^Cti AN INDEX OF DIFFERENTIAL DIAGNOSIS OF MAIN SYMPTOMS €JJ/'J /f/Y/rVr/y/ ' //'.^/-tTt'/' 9/'T>y^//////'f//Y. Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/indexofdifferent1912fren AN INDEX OF Differential Diagnosis of main symptoms BY VARIOUS WRITERS HERBERT FRENCH, M.A., M.D. Oxon, F.R.C.P. Lond. Assistant PJiysiciaii to Gicy's Hospital WITH SIXTEEN COLOURED PLATES AND OVER TWO HUNDRED ILLUSTRATIONS IN THE TEXT 1^10. WILLIAM WOOD AND COMPANY MDCCCCXII JOHN WRIGHT AND SONS LTD. PRINTERS AND PUBLISHERS. BRISTOL PREFACE This book is a treatise on the application of differential diagnosis to all the main signs and symptoms of disease. It aims at being of practical utility to medical men whenever difficulty arises in deciding the precise cause of any particular symptom of which a patient may complain. It covers the whole ground of medicine, surgery, gynaecology, ophthalmology, dermatology, and neurology. Whatever the disease from which a patient is suffering, the import- ance of diagnosing it as early as possible can hardly be over-rated. The present volume deals with diagnosis from a standpoint which is different from that of most text -books, having been written in response to requests for an Index of Diagnosis as a companion to the pub- lishers' Index of Treatment, issued in 1907. The book is an index in the sense that its articles on the various symptoms are arranged in alphabetical order ; at the same time it is a work upon differential diagnosis in that it discusses the methods of distinguishing between the various diseases in which each individual symptom may be observed. Whilst the bod\' of the book thus deals with symptoms, the general index at the end gathers these together under the headings of the ^•arious diseases in which they occur. The Editor lays particular stress upon the importance of using these two parts of the book together. Unless reference is made freely to the general index, the reader may miss a number of the places in which is discussed the diagnosis of the disease with which he has to deal ; for while each symptom is considered but once, each disease is likely to come up for discussion under the heading of each of its more important symptoms. The guiding principle throughout has been to suppose that a particular symptom attracts special notice in a given case, and that the diagnosis has to be established by differentiating between the various diseases to which this symptom may be due. One of many difficulties arising during the construction of the work was that of deciding where to draw the line as regards symptoms themselves. The exclusion of many borderline headings such as " Dullness at the base of one lung," " Inability to breathe through the nose," and various signs such as Romberg's, Stellwag's, von Graefe's, and so forth, may perhaps seem arbitrary ; but reference to the minor vi PREFACE sjTnptoms and physical signs which have not been thought suffi- ciently important to merit separate articles will be found in the general index at the end of the volume. Treatment, pathology, and prognosis are not dealt with except in so far as they may bear upon differential diagnosis — the emplo5''ment of salic3"lates, for instance, in distinguishing acute rheumatic from other forms of arthritis ; the use of the microscope in distinguishing malignant neoplasms from inflammatory or other tumours ; the value of the lapse of time in distinguishing between tuberculous and meningococcal meningitis. Coloured plates and other illustrations ha\"e been introduced freely wherever it was thought they might be helpful in diagnosis. Most of them are original, but a few are reproduced from other sources, and thanks are due to the authors and publishers who have kindly lent them. So far as the Editor is aware, although there exist indices of s^-mptoms, and medical works in which various maladies are discussed in alphabetical order, the present Index of Differential Diagnosis of Main S5^mptoms is unique in medical literature. It rests with the medical profession to decide whether it strikes the mark at which it aims. There must be room for improvement in many respects, notwithstanding the great amount of time and labour that have been bestowed upon it. However this ma}- be, the work undoubtedl}^ owes much of what value it possesses to the suggestions and kindty help of the manj' contributors who have assisted in its making ; and to the prac- titioners and the authorities of various institutions ^^■ho have generously lent the material lor many of the illustrations. Indeed, it is difficult to see how the book could have been produced in its present completeness wthout their willing collaboration : they are enumerated elsewhere, and to all of them the Editor tenders his sincere thanks. Criticisms and suggestions are invited, and will be received with gratitude by the Editor, Herbert French. 62, Wimpole Sired, London, W. MarcJi^ 1912. LIST OF CONTRIBUTORS William Cecil Bosanquet, m.a., m.d. Oxon., e.r.c.p. ; Physician to Out- Patients, Charing Cross Hospital ; Assistant Physician, Brompton Hos- pital for Consumption and Diseases of the Chest. E. Farouhar Buzzard, m.a., m.d., b.ch. Oxon., f.r.c.p. ; Physician to Out- Patients at St. Thomas' Hospital and at the National Hospital for the Paralysed and Epileptic, Queen Square ; Consulting Neurologist to the Royal Free Hospital and to the Hospital for Diseases of the Throat, Golden Square. Percy John Cammidge, m.d. Lond., d.p.h. Camb. Herbert L. Eason, m.d., m.s. Lond.; Senior Ophthalmic Surgeon, Guy's Hospital. John W. H. Eyre, m.d., m.s. Durh., d.p.h. Camb.; Director of the Bacterio- logical Department, Guy's Hospital ; Lecturer on Bacteriology to the Medical School and Dental School, Guy's Hospital. Herbert Morley Fletcher, m.a., m.d. Camb., f.r.c.p. ; Physician in charge of Out-Patients, and of Diseases of Children Department, St. Bartholomew's Hospital ; Physician, East London Hospital for Children. Herbert French, m.a., m.d. Oxon., f.r.c.p. ; Assistant Physician, Guy's Hospital. Archibald Edwd. Garrod, m.a., m.d. Oxon., f.r.c.p., f.r.s. ; Physician, with charge of Out-Patients to, and Lecturer on Chemical Pathology at, St. Bartholomew's Hospital ; Physician to the Hospital for Sick Children, Great Ormond Street. George Ernest Gask, f.r.c.s. ; Assistant Surgeon, St. Bartholomew's Hospital ; Demonstrator of Operative and Practical Surgery, St. Bar- tholomew's Hospital Medical School. Hastings Gilford, f.r.c.s., ; Consulting Surgeon, Reading Dispensary and Kingwood Sanatorium. Arthur Frederick Hertz, m.a., m.d. Oxon., f.r.c.p. ; Assistant Physician and Physician for Nervous Diseases and to the Electrical Department, Guy's Hospital. Robert Hutchison, m.d., cm. Edin., f.r.c.p. ; Physician to the London Hospital, and Assistant Physician to the Hospital for Sick Children, Great Ormond Street. Arthur John Jex-Blake, m.a., m.b., b.ch. Oxon, m.r.c.p. ; A.ssistant Physician, St. George's Hospital ; Assistant Physician, Brompton Hospital for Con- sumption. Sir Malcolm Morris, k.c.v.o., f.r.c.s. Edin. ; Consulting Surgeon, Skin Department at St. Mary's Hospital ; Surgeon, Skin Department, Seamen's Hospital. Robert P. Rowlands, m.b., m.s. Lond., f.r.c.s. ; Assistant Surgeon and Surgeon in charge of the Orthopaedic Department, Guy's Hospital ; Demon- strator of Operative Surgery and Surgical Pathology, Guy's Hospital Medical School, oj> ^ i:' LIST OF CONTRIBUTORS James E. H. Sawyer, m.a., m.d., b.ch. Oxon. ; Assistant Physician, General Hospital, Birmingham. Frederick John Smith, m.a., m.d. Oxon., f.r.c.p., f r.c.s. ; Physician, London Hospital ; Consulting Physician to the City of London Dispensary and to the National Orthopaedic Hospital. Thomas George Stevens, m.d., b.s. Lond., m.r.c.p., f.r.c.s. ; Physician, Hospital for Women, Soho Square ; Physician to Out-Patients, Queen Charlotte's Hospital ; Obstetric Physician, Surrey Dispensary ; Obstetric Tutor, St. Mary's Hospital Medical School. Russell H. Jocelyn Swan, m.b., m.s. Lond., f.r.c.s. ; Surgeon, Cancer Hospital, Brompton. Frederick Taylor, m.d. Lond., f.r.c.p. ; Consulting Physician, Guy's Hospital, and Evelina Hospital for Sick Children ; Physician, Seamen's Hospital, Greenwich. Philip Turner, b.sc, m.b., m.s. Lond., f.r.c.s. ; Assistant Surgeon, Guy's Hospital ; Demonstrator of Operative Surgery, Guy's Hospital. William Hale White, m.d. Lond., m.d. Dub., f.r.c.p.; Senior Phj'sician and Lecturer on Medicine, Guy's Hospital. The book owes much to all its contributors, and in addition the Publishers wish to acknowledge the courtesy and valuable assistance they have received from the following medical authorities, practitioners, publishers, and others in various ways : — Dr. A. J. Jex-Blake, Dr. W. J. H. Pinniger, and Dr. A. Rendle Short, for help and suggestions which have lightened the labour of passing the sheets through the press, and constructing the General Index. The Authorities at St. Bartholomew's, St. George's, and Guy's Hospitals, a.nd the Bristol Royal Infirmary, for many illustrations, negatives, and drawings ; Sir Dyce Duckworth, Dr. Garrod, and the Royal Society of Medicine for Plate IX ; Dr. A. C. Jordan and Mr. Hugh Walsham for valuable skiagrams ; Dr. D. S. Davies, M.O.H. Bristol, for photographs of eruptive fevers ; Dr. Armauer Hansen, Inspector General of Leprosy in Norway, for Figs. 124, 140 ; Dr. Boycott and Dr. Haldane for negatives of the ova of Ankylostomum duodenale ; Dr. Adams, of the Clinical Research Association, London, for great pains in furnishing material and assistance in drawing Plates II and XII. Mr. C. F. Walters, of Clifton, kindly gave some of the coloured sketches for Plates V and VI. Mr. H. A. Wilson they have to thank for permission to reproduce his drawing of Bilharzia hcsmatobia, and Mr. Pillischer, of New Bond Street, for the fine specimen of the head of a Tcsnia solium which appears in Fig. 150. They are specially indebted to Dr. Farquhar Buzzard for the series of photo- graphs illustrating facies in disease, and for several original carefully worked- out diagrams ; and to Professor Rutherford Morison, Sir Malcolm Morris, Dr. Llewellyn Jones, and others for permission to use various illustrations from works written by them. They also have to thank Messrs. Bailliere, Tindall and Cox, Cassell & Co., Macmillan & Co., Rebman, and the Editors of the Medical Annual, Allbutt and Rolleston's System of Medicine, The Journal of Hygiene, The Quarterly Journal of Medicine, Guy's Hospital Reports, and others, for sinailar permission, which has, they believe, been acknowledged in the text in each case. The volume has been fortunate in having at its service the artistic and technical ability of Mr. A. W. Head for the drawings of the fundus oculi, and of Messrs. Shiells and Ford for many of the other coloured illustrations, LIST OF ILLUSTRATIONS COLOURED PLATES PLATE I.- II.- III.- IV.- V. I VI. J VII. I VIII. J IX.- X.- XI.- XII.- XIII.- XIV.- XV.- XVI.- -Renal tube casts ..... -Red and white blood corpuscles -Symmetrical gangrene of the fingers in Raynaud's disease -Gangrene of the foot ..... Bladder appearances seen through the cystoscope Ophthalmoscopic appearances .... -Intestinal sand, true and false .... -Pityriasis rubra ..... -Diagram showing the radicular sensory areas of the human body ..... -Bacteria and blood parasites . . - . -Popliteal aneurysm . . . . . -Cirsoid aneurysm . - . -Early stages of carcinoma of the tongue -Varicose abdominal veins .... Facing page 281 284 308 310 . 461 . 463 , 652 658 663 , 696 . 762 . 764 814 , 824 ILLUSTRATIONS IN THE TEXT 13- I4-- I5-- 16.- 17- 18. 19. 26.- 27. 28. 29.- -The hand of tetany ..... -Pseudo-leukaemia infantum (von Jaksch's disease) -My.xcedema : the same patient as (4) prior to the attack -Myxoedema : the characteristic facies -Myxcedema : characteristic hands -Echinococcal booklets . . . . - -Infantile paralysis of the left shoulder and upper arm -Tooth's peroneal type of neuro-muscular dystrophy (early) -Tooth's peroneal type of neuro-muscular dystrophy (later) -Primary syphilitic sore on lower lip - -Cancrum oris ...... -Amceba histolylica and Amceba coli - - - -Ova of Bilharzia hfematobia .... -.•Vnkylostomum duodenale .... -Ankylostomum duodenale, ova at different stages -Ankylostomum duodenale, two-cell stage of developing ovum -Spectral absorption band : oxyhaemoglobin -Spectral absorption band : reduced haemoglobin -Spectral absorption band : carboxyha?moglobm -Spectral absorption band : haematin in alkaline solution -Spectral absorption band : acid heematin -Spectral absorption band : methaemoglobin -Spectral absorption band : urobilin -Diagram of bruits of mitral stenosis -Diagram of heart to explain Flint's murmur -Charcot-Leyden crj'stals - - - . - -Skiagram showing mottled lung apices produced by phthisis -Cheyne-Stokes' breathing .... -Claw-foot 3 42 43 43 43 57 70 71 71 86 SS 91 93 94 94 94 95 95 95 95 95 95 95 108 109 117 120 124 126 LIST OF ILLUSTRATIONS FIG- PAGE 30. — Syringomyelic claw-hand ...... ^^7 31. — Clubbed fingers due to congenital pulmonary stenosis - - 129 32. — Habitual constipation ....... j^j 33. — Dyschezia - ---.... 142 34. — Normal large intestine .----.- 143 35. — Post-dysenteric atony and paresis of the colon - - . . 144 36. — Constipation due to lead poisoning ..... j^^ 37- — Constipation with niuco-membranous colitis - . . . 145 38. — Skiagram : obstruction due to carcinoma coli .... 146 39. — Skiagram : ptosis of caecum and transverse colon - - . 147 40. — Colon in a case of Hirschsprung's disease .... 148 41. — Visceroptosis ........ 14^ 42. — .\thetosis --...... 1^4 43. — Volkm arm's ischa;nuc paralysis ...... 166 44. — Dupuytren's contracture ...--.. 167 45. — Cicatricial contracture after a burn - - - - - 168 46. — Curschmann's spirals from asthmatic sputum .... lyq 47. — -Osteitis deformans in a man ...... 182 48. — Osteitis deformans in a woman -.--.. 182 49. — Myopathic lordosis ....... 183 50. — Morbus caeruleus ._.--.. 184 51. — Cystin. crystals - - - - - - - - 187 52. — Politzer's acoumeter - - - - - - .188 53. — Tuning fork, with foot for testiug hearing .... 189 54. — Galton's whistle ....... jSg 55. — Cyrtometric tracing of rickety chest ..... 192 56. — Cyrtometric tracing of normal adult chest .... ig2 57. — Cyrtometric tracing of pigeon chest - ■ - - - 192 58. — C}Ttometric tracing of fibrosis of lung .... - 192 59. — CjTtometric tracing of emphysematous chest .... 152 60. — Diagram of homonymous double images - - - - 199 61. — Diagram of crossed double images ..... igg 62. — Transillumination of the antrum ..... 205 63. — Dwarfism : extinct rickets ...... 212 64. — Dwarfism : achondroplasia - - - - - - 213 65. — Dwarfism : osteogenesis imperfecta . . - . . 213 66. — Dwarfism : anangioplastic infantilism - - - - - 215 67. — Dwarfism : cretinism ....... 216 68. — Dwarfism: mongolism ........ 217 69. — Dwarfism : ateleiosis - . - - - - - - 217 70. — Dwarfism : progeria ....... 218 71. — ^Tooth-plate impacted in the larynx ..... 223 72. — Obstruction to superior vena cava by an aortic aneurysm - - 234 73. — Obstruction to superior vena cava by an aortic aneurysm - - 235 74. — Skiagram of a large saccular aneurysm of the aorta - - - 236 75. — Meningocele projecting into the face from base of skull • - 254 76. — Myxoedema - - ...... 258 77. — ^The same patient as 76 prior to the disease .... 258 78.— Congenital syphilis: prominent forehead and depressed nasal bridge - 259 79. — Congenital syphOis : notched teeth and sore angle of mouth - - 259 80. — Congenital syphilis : Hutchinsonian notched teeth - - - 260 81. — Myopathic facies : the loose pout ..... 260 82. — Myopathic facies : the transverse smile .... 260 83. — Myasthenic facies : the appearance of fatigue .... 261 84. — Myasthenic facies : the nasal smile, one-sided - - . . 261 85. — Exophthalmic goitre ....... 261 86. — Paralysis agitans ....... 262 87. — Tabetic facies ........ 262 88. — .\cromegaly : facies and hands ---... 263 89. — .Achondroplasia ..--.... 263 90. — Mongolian idiot in infancy ...... 264 91. — Mongolian idiot, older ....... 264 92. — Sarcinae ventriculi • - ■ - - - 267 93. — Favus .-....-.. 271 94. — Cholesterin crystals - - - - - ■ - 281 95. — Raynaud's disease : stage of local asphyxia .... 283 96. — Raynaud's disease : recurrent necrosis of the fingers - - - 284 97.— Skiagram of calculus in dropped left kidney .... 309 LIST OF ILLUSTRATIONS VU:. PAGE g8. — Skiagram of coinpositc vesical calculus ----- 312 99. — Skiagram of lobar pneumonic consolidation of left lung - - 321 100. — Skiagram of hydatid cyst of the thorax - - - ■• - 323 loi. — Hemianopsia: diagram showing optic nerves and tracts - - 334 102. — Hemianopsia : diagram showing optic nerves and tracts - - 334 103. — -Hemianopsia: diagram showing optic nerves and tracts - - 335 104. — Hemianopsia : diagram showing optic nerves and tracts - - 335 105. — Skiagram : bismuth shadow of a dropped dilated stomach - - 353 106. — Chart : pyrexia and rapid pulse of rheumatoid arthritis - - 377 107. — -Acute rheumatoid arthritis ..-.-- 378 108. — Skiagram : severe rheumatoid arthritis, showing ulnar deflection - 379 109. — Heberden's nodosities ------- 380 no. — Skiagram: rheumatoid arthritis, transparency of ends of bones - 381 III. — -Henoch's purpura .-..--- 382 112. — -Chronic gout : urate of sodium deposits . - - . 382 113. — Skiagram: chronic gout, showing sodium urate deposits - - 383 114. — Pads over finger-joints ------- 385 115. — Skiagram of the pads in (114) ---.-- 385 116. — Charcot's disease of the knee-joint . . - . . 387 117. — ^The hands in pulmonary osteo-arthropathy - - - - 369 118. — Pulmonary osteo-arthropathy -..-.- 390 119. — Hodgkin's disease - - - - - ■ - 4i7 120. — Still's disease -------- 418 121. — Macular S3'philides ....... 425 122. — Hirschsprung's disease : idiopathic dilatation of colon - • ■ 432 123. — Tubular mucous cast of large intestine . - . . ^^^ 124. — Nodular leprosy in a Norwegian ..... 451 125. — Girl suffering from hypernephroma - ... - 453 126. — Girl suffering from h3'pernephroma - - ■ - - 454 127. — Milroy's or Meige's disease - - ■ , - - - 45^ 128. — Angioneurotic oe.dema of eyelids - - . ... 458 129. — Bilateral hereditary trophoedema of the legs .... 460 130. — Crystals of calcium oxalate - - .... 470 131. — Skiagram : aneurysm of innominate artery • - - - 483 132. — Segmental areas of head and neck and their maximal points - 497 133. — Segmental areas of head and neck and their maximal points ■ 497 134. — Segmental areas of head and neck and their maximal points - 497 135. — Segmental areas of head and neck and their maximal points - 497 136. — Paralysis of the right side of the face - - - - - 534 137. — Post-paralytic contracture of left side of face - - - - 535 138. — Same patient as (137) closing her eyes ----- 535 139. — Same patient as (137) smiling ------ 535 140. — Bilateral facial palsy ------- 535 141. — -Hemiatrophy of left side of face (early stage) - - - - 537 142. — Brown-Sequard paralysis - - - - - - 54© 143. — Diagram of lumbo-sacral plexus and its branches - - - 544 144. — Paresis of the arms in lepra maculo-ansesthetica - - - 551 145. — Diagram of the cervico-brachial plexus and its branches - - 553 146. — Diagram of sensor}^ localization in the spinal cord - - - 566 147. — Diagram of localization of reflex centres in the spinal cord - - 566 148. — Head of Ta3nia solium ....--- 568 149. — ^Head of Tasnia solium, semi-diagrammatic _ . - - 568 150. — Head of Ta3nia mediocanellata ------ 568 151. — Head of Bothriocephalus latus ------ 568 152. — Ovum of Ta3nia solium ------- 569 153. — Ovum of Ascaris lumbricoides ------ 569 154. — Ovum of Trichocephalus dispar ------ 570 155. — Triple phosphate crystals ...... 573 156. — Paralysis of left third ner\-e : face at rest . - - - 589 157. — Paralysis of left third nerve : patient looking to right - - - 5'89 158. — Paralysis of third and seventh nerves : face at rest - - - 589 159. — Effort to show teeth and close eyes in case 158 - - - 5'89 160. — Smallpox ; confluent arid discrete varieties, 2 views (stereoscopic) _ - 606 161. — Septic dermatitis wrongly diagnosed as smallpox, 2 views (stereoscopic) 6o'8 162. — Temperature chart : typhoid fever - - - - - 61:1 163. — Temperature chart : Malta fever . . - - - /6i-2 164. — Temperature chart : malignant endocarditis - - - - 613 165. — Temperature chart : pyasmia - - - - - - 6^:3 LIST OF ILLUSTRATIONS FIG. i66. i67.- i68.- 169. 170. 171. 172. 173- 174- I75- 176.- 177.- 178.- 179.- 180.- 181.- 182.- 183.- 184.- 185.- 186.- 187.- 190.- 191.- 192.- I93-- 194.- I95-- 196.- 197.- 198.- 199.- 200.- 201.- 202.- 203.- 204.- 205.- 206.- 207.- 208.- ^09.- ^10.- jii.- 212.- 213.- -Temperature chart : facial erysipelas _ . . . . -Temperature chart : pernicious anaemia . . . . -Temperature chart : Hodgkin's disease . . . . -Temperature chart : sarcoma of the neck and mediastinum -Diagram of malformations of rectum . - - - . -Diagram of malformations of rectum . . - - - -Diagram of malformations of rectum - . . . - -Diagram of malformations of rectum . - - - . -Diagram of the distribution of sensory nerves in the skin -Peripheral neuritis : glove and stocking anaesthesia -Division of ulnar nerve at wrist — area of impaired sensation -Sensory paths in the peripheral nerves and spinal cord -Loss of sensibility from comminuted fracture of sacrum -Loss of sensibility from dorsal myelitis - . - - . -Loss of sensibility from fracture-dislocation of cervical spine - -Brown-Sequard paralysis ...... -Loss of sensibility in syringomyelia . . . . . -Loss of sensibility in early tabes dorsalis . . . . -Loss of sensibility from thrombosis of posterior inferior cerebellar artery -Diagram of left cerebral hemisphere, with speech centres -Splenic anaemia ...--- -Elastic fibres from sputum .... -Temperature chart : lobar pneumonia - -Plan of regions of the abdomen -Idiopathic dilatation of the stomach -Idiopathic dilatation of the bladder -Skiagram : chronic periostitis of the ulna -Skiagram : tuberculous dactylitis -Skiagram : cancellous exostosis of the femur -Skiagram : enchondroma of fifth metacarpal bone -Skiagram : periosteal sarcoma of tibia -Skiagram : myeloid sarcoma of radius - -Skiagram : myeloid sarcoma of radius -Skiagram : myeloid sarcoma of radius - -Diagram of the cutaneous nerve supply of the scalp -MoUuscum fibrosum — early stage -Segmental areas of the scalp .... -Segmental areas of the scalp .... -Area of referred spinal pain and tenderness -Graphic record of movements in intention tremor -Graphic record of movements in ataxy - -Perforating ulcer of foot -Diagram of gummatous ulcer -Diagram of tuberculous ulcer -Diagram of epitheliomatous ulcer -Diagram of rodent ulcer -L'ric acid crystals -Smallpox : showing distribution of the eruption PAGE 614 616 617' 617 637 637 637 637 659 660 661 662 663 663 663 664 66=; 665 666 683 694 701 702 723 728 730 751 752 753 754 754 755 756 756 781 782 783 783 788 799 799 809 811 811 811 811 816 833 INDEX OF DIFFERENTIAL DIAGNOSIS OF MAIN SYMPTOMS ACCENTUATION OF HEART SOUNDS. — It often happens that, without there being any cardiac bruit, one or other of the heart sounds is much louder than it ought to be. Such accentuation generally has important chnical sig- nificance. Roughly speaking, it is the first sound that is likely to be either accentuated or prolonged at the impulse ; whilst in the second right, or second and third left intercostal spaces close to the sternum, it is the second sound that is likely to be accentuated rather than the first. It is very unusual to find the first sound accentuated at the base or the second sound at the impulse, unless there is at the same time still greater accentuation of the first sound at the impulse, and of the second sound at the base respectively. Hence the three conditions under which accentuation of a cardiac sound becomes chnically important are : (i) When the second sound is unduly loud in the second right intercostal space close to the sternum ; (2) When there is an accentuation of the second sound with maximum intensity in the second or third left intercostal space- close to the sternum ; (3) When there is accentuation of the first sound with maximum intensity at or near the impulse. Accentuation of the second sound with maximum intensity in the second right intercostal space close to the sternum nearly always indicates that the systemic blood-pressure is above the normal. The latter can only be determined with certainty by actual measurement of the systemic blood-pressure instrumentally. The causes of the increase will probably be one or other of the following : — Age. — Even healthy patients over forty begin to show a slight but definite increase of Blood-pressure {q.v.) as the years go on. In people over fifty, therefore, the aortic second sound begins to get relatively louder than the first. Arteriosclerosis or granular kidney. These can be discussed together, because it is extremely difficult to tell where the one ends and the other begins. In both there is cardiac hypertrophy, increase in the blood-pressure, prolongation of the first sound at the impulse, and possibly a blowing systolic bruit there, a ringing or clanging aortic second sound which may ultimately change into the diastohc puff of sHght aortic regurgitation, albuminuria, a tendency to heart failure as time goes on, with all its concomitant symptoms, and albuminuric retinitis. It is sometimes stated that the accentuation of the aortic second sound is due to local atheroma ; but this is inaccurate, for atheroma by itself, though it may easily produce an aortic systolic bruit, does not accentuate the second sound ; and when in the second right intercostal space there is a .soft systolic D I ACCENTUATION OF HEART SOUNDS bruit replacing the first sound, and a clanging second sound, the former indi- cates atheroma of the aortic valves, and the latter arteriosclerosis. These two absolutely distinct vascular lesions often coincide in the same patient, atheroma affecting the aorta, and the coronary and cerebral arteries, whilst arteriosclerosis affects the middle-sized arteries, especially of the splanchnic area. There is often extensive visceral arteriosclerosis when the radial artery does not feel abnormal to the fingers. Accentuation of the second sound with maximum intensity in the second or third left intercostal space close to the sternum, generally spoken of as accentuation of the pulmonary second sound, indicates a higher pressure than there should be in the pulmonary circulation, except in children, in whom it is not uncommon to find the pulmonary second sound normally much louder than the aortic. The most important cause of pathological accentuation of the pulmonary second sound is disease of the mitral valve ; it occurs more markedly with mitral stenosis than with mitral regurgitation. It may sometimes be a marked feature of the latter, whether due to organic changes in the naitral valve itself, or secondary to dilatation ot the otherwise normal orifice as the result of heart failure from aortic disease, myocardial degeneration, arterio- sclerosis, or granular kidney. Sometimes, instead of accentuation of the pulmonary second sound, the latter may be reduplicated ; the significance of its reduphcation is identical with that of its accentuation, the probable reason for the reduplication being that when the pressure in the pulmonary circulation is relatively very much above the normal, the pulmonary semilunar valves close sooner than the aortic, the first part of the reduplicated second sound being due to closure of the pulmonary valves, whilst its second part is due to closure of the aortic valves. The cause of an accentuated or reduplicated pulmonary second sound will generally be obvious if the other cardiac physical signs are observed carefully ; one way in which it may have particular significance is in distinguishing between old and recent changes in the mitral valves ; when, for instance, a systolic and mid-diastolic bruit at the impulse are due to recent endocarditis which may possibly clear up, there is very much less accentuation of the pulmonary second sound than there would be if the same bruits were due to mitral stenosis and regurgitation due to old fibrotic changes. The greater the accentuation of the pulmonary second sound, the greater the mitral leakage or obstruction. Accentuation ot the first sound at the impulse may have one or other of two entirely' dift'erent characters ; it may be an accentuation of very short duration, difficult to describe in words, though obvious enough when heard, and often spoken of as a " slapping " first sound at the impulse : this is one of the most characteristic physical signs in many cases of mitral stenosis. It may occur when there is neither a presystolic nor a mid-diastolic bruit, though even when there is a bruit the slapping character of the first sound is still to be distinguished. When there is failure of compensation in a mitral case, the driving power of the heart may become so feeble that bruits are no longer audible, and the heart's action is quite irregular ; in such cases, the occurrence of this slapping character of the first sound, clearly audible here and there in an otherwise tumbling rhythm, is highly suggestive of mitral stenosis. The second variety of accentuation of the first sound at the impulse consists in its being very much longer than it ought to be — a marked prolongation of the first sound as distinct from there being any bruit. This prolongation is obvious enough when heard. It indicates that there is considerable hypertrophy of the left ventricle, and therefore, in the absence of bruits, nearly always points to a high blood-pressure such as results from either arteriosclerosis, granular kidney, ACCOUCHEUR'S HAND or the two combined ; it is repeatedly met with in cases in which there is accentuation of the aortic second sound at the same time. In a person of middle age or over, in whom there is a prolonged first sound at the impulse — sometimes spoken of as a " lumpy " first sound — and a clanging aortic second sound, with or without Albuminuria [q-v.], a diagnosis of arterio- sclerosi or of granular kidney is very probably correct, and instrumental determination of the blood -pressure will generally show that it has risen from the normal 120-150 mm. Hg to something between 200 and 300 mm. Hg, or even more. It is noteworthv that transient accentuation of the first sound at the impulse mav occur in nervous young patients examined while their hearts are acting rapidlv ; it vanishes in a few minutes when the patient becomes less nervous and the heart slower. The phenomenon is common in connection with life insurance examinations. Herbert French. ACCOUCHEUR'S HAND. — Accoucheur's hand is seen most characteristically in tetany {Fig. 1), though it may also occur in a few cases of other spasmodic neuro-muscular affections such as athetosis. In a typical case, the attitude of the fingers is almost pathognomonic. There is full ex- tension of all the fingers and of the thumb at the interphalangeal joints, the four fingers are adducted firmly towards the middle finger, so as to form a cone, they are semi- flexed at the metacarpo-phalangeal joints, and the thumb is strongly ^,V i._The hand of tetany. adducted and opposed to the cone of which the middle finger forms the apex, or else into the palm of the hand. The spasmodic muscular contraction seldom ceases here, but generally affects the rest of the arm also, the wrist being strongly flexed and abducted towards the ulnar side. The elbow is flexed to a right angle, and the arm inwardly rotated and adducted so as to lie in contact with the trunk. The aft'ection is symmetrical. The feet and ankles are apt to show similar spasmodic contractions, the ankle being fully plantar-flexed, the toes and the distal half of the feet being inwardly rotated, the knees rigidly extended, and generally the thighs also. The contractions may be limited to the hands and feet — the so-called carpo-pedal spasm — especially in the tetany of young children suffering from rickets, or from gastro-intestinal disorder such as diarrhoea. WTien adults are affected, the symptoms spread from the limbs to the trunk, the whole body being kept rigidly extended, the paroxysms lasting from a few minutes to many hours, and recurring for days, weeks, or even months. So far as the tetany itself is concerned, recovery is invariable, though the patient may sometimes succumb to the associated malady, tetany itself generally being not a primary disease but a comphcation of gastric ulcer, gastrectasis, colitis, intestinal fermentation or putrefaction, thyroidectomy or pregnancy. The diagnosis is seldom difficult. One remarkable feature of the case is, that in the intervals between the spasms, if the upper arm is firmly grasped between the observer's two hands, and the pressure maintained, the hand and wrist may be forthwith sent into the typical spasm, a sign described as Trousseau's. Herbert French. ACETONURIA ACETONURIA. — This term denotes the occurrence of acetone in the urine in amounts to be detected b}' ordinary chnical tests. In practice the laboratory method of distilHng a quantity of urine to get a concentrated solution of any acetone that may be present takes too long, and yet without distillation it is difficult to apply the iodoform tests for acetone. An easier and more usefuLplan is Legal's nitroprusside test, or Rothera's modification of it. Legal's test consists in taking 5 cc. of urine in a test-tube, adding a few drops of liquor sodae, then a few drops of fresh nitroprusside solution made by dissolving a crj-stal or two of this salt in ordinary water, and finally acidifying with strong acetic acid. The liquor sodse causes no change of colour, or at most an opalescence from the precipitation of phosphates ; the sodium nitroprusside produces a red or reddish-brown colour in almost all urines owing to the presence of creatinine ; if the red colour is due to creatinine only, it is discharged on adding acetic acid, whereas the latter in the case of acetone deepens the red into a rich burgundy that is unmistakable. Rothera's modification of this test consists in adding a few drops of fresh nitroprusside solution to 5 cc. of urine, hquor ammoniae till the mixture is decidedly alkaline, and then ammonium sulphate crystals in excess ; as the solution becomes saturated with the latter, a colour like that of potassium permanganate develops if acetone is present, the maximum being reached in about fifteen minutes. Acetone is often associated with diacetic acid, oxybutyric acid, and amido- oxybutyric acid ; the detection of these, however, affords no clinical information that is not afforded by the acetone alone, so that it generally suffices to test for the latter, and possibly for diacetic acid also. The tests for the butj^ric acids are difficult. When these substances are being produced, the patient is said to be suffering from acidosis, the result of unnatural metabolism. Aceton- uria is indeed the chief practical evidence of acidosis. It occurs in the most extreme degree in certain cases of diabetes mellitus ; indeed, from the point of view of prognosis all cases of glycosuria may be divided broadly into two classes, namely, those with, and those without, acetonuria. The same patient may, of course, be passing acetone in his urine at one time and not at another ; the prognosis is always graver, however, when acetone is present, for it is the acidosis that causes the serious results of diabetes and glycosuria. A patient without acetonuria is in no immediate danger of coma, whereas, when acetone is present as well as sugar, coma may supervene at any time. Broadly speaking, once glycosuria has been diagnosed, it is more important to test the urine for acetone from time to time than it is for sugar, and that treatment which reduces the acetone to a minimum is, generally speaking, doing most good, whatever quantities of sugar may be passed. Acetonuria may occur, however, without any glycosuria, and it is important to remember that even a healthy person who is starved of carbohydrate food is apt to pass acetone and diacetic acid in the urine. This explains why it is that acetonuria occurs in such conditions as gastric ulcer ; gastric carcinoma ; gastrectasis ; oesophageal stenosis ; intestinal obstruction ; cachexia, whether tuberculous, malignant, syphiliti: or malarial ; in cases of persistent vomiting of pregnancy ; uraemia ; severe migraine ; infantile diarrhoea and vomiting ; and probably in many other conditions in which there is either actual or virtual starvation. The same applies to surgical operations under anaesthetics — the patient is often starved beforehand, and may then be persistently sick after- wards ; almost all patients who have been under a general anaesthetic for any ength of time have acetonuria, and in some the acidosis increases instead of being transient, this being to a large extent the pathology of so-called delayed chloroform poisoning. ALBUMINURIA The chief importance of acetonuria therefore from a diagnostic point of view Ues, not so much in distinguishing one disease from another, as in detecting the existence of acidosis. The importance of this from the point of view of prophylaxis and treatment will be obvious when it is remembered that acidosis does not occur until the liver and tissues have lost their glycogen, and that glycogen storage depends largely upon the ingestion of carbohydrates either by the mouth, the rectum, or hypodermically. Herbert French. ACIDOSIS. — (See Acetonuria.) ACROPARffiSTHESIA.^(See Sensation, Abnormalities of.) ALBUMINURIA. — This term is used to denote the passage in the urine of proteid that is coagulable on boiling. More than one substance is included in the word albumin in this sense, and there are varying proportions of serum albumin and serum globulin in different cases. So variable may be the relative amounts of these, not only in different diseases, but also in different cases of the same disease, and in the same patient at different times, that there is little useful clinical information to be obtained by dealing with the albumin and the globulin separately, at any rate so far as present knowledge goes. Nucleo-proteid or nucleo-albumin {q.v.) comes in quite a different category. Although a large number of different tests for albumin have been devised and advocated, for clinical purposes there is little need to trouble about more than the two common ones, namely the acetic acid and boiling, and the cold nitric acid tests. It is true that each of these has fallacies ; but the latter are not common to both, and therefore, if there is any doubt in the interpretation of one of the two tests, it can readily be confirmed or otherwise by the other. It is alleged that more delicate tests exist, but there is such a thing as too great delicacy in a clinical method. One does not want to find albumin in minute traces where it does not matter ; and it seldom matters until its amount is sufficient to give both the common tests. The Acetic Acid and Boiling Test — A test-tube three parts full of urine — cleared if need be by filtration — is held by its lower end, whilst its upper part is carefully heated to boiling point. It is best not to add any acetic acid before boiling unless the specimen is distinctly alkaline, in which case it may be just acidulated with a drop of acetic acid. After boiling, the tube should be held in a good surface-light against a dark background, such as the sleeve of one's coat ; any opalescence will be obvious at once, and there ma}^ be a dense white cloud. Except in very rare cases of Bence- Jones' albumosuria (p. 21), this cloud will be due to one or more of three things, namely, calcium and magnesium phosphate, calcium carbonate, or coagulated albumin. One, two, or more drops of acetic acid solution (B.P.) are now added ; if the cloud disappears entirely, quickly, and at once, it was due to earthy phosphates, and no albumin is present ; if it disappears entirely but with brisk effervescence, the latter is due to calcium carbonates amongst the phosphates, and no albumin is present ; if, on the other hand, the cloud clears up but partially, or remains unaltered, or actually increases and becomes more fiocculent, albumin is almost certain!}' present. There is only one serious fallacy remaining, and that is in regard to nucleo-proteid ; this is precipitated by acetic acid, and it is possible for a cloud of phosphates to be cleared up by the latter and yet for a faint cloud of nucleo-proteid to come down in the place of the phosphates in such a way as to suggest that the original cloud was not wholly soluble in the acid, and therefore that albumin is present when it is not. There are three ways of obviating this source of fallacy : the first is to add a single drop of dilute non-fuming nitric acid to the suspicious ALBUMINURIA cloud that remains after the addition of acetic acid ; if it is due to albumin it will persist or even increase, whilst if it is due to nucleo-proteid the nitric acid will disperse it ; the second is to perform the cold nitric acid test for albumin as described below — nucleo-proteid will not give a definite localized white ring with it ; and thirdly, a control test maj- be done, acetic acid being added to another specimen of the urine without boiling, and the cloud due to any nucleo-proteid present compared with the cloud in the acidulated and boiled specimen. Heller's Cold Nitric Acid Test — About an inch and a half of urine is poured into a test-tube, the latter is held much inclined, and colourless nitric acid is allowed to flow gently down the side, until about one-third as much as the urine has been added. The nitric acid is heavier than urine and goes to the bottom ; if albumin is present a white ring forms at the junction of the two fluids. Some prefer to pour the nitric acid into the test tube first and then to add the urine carefully with a pipette. It is important not to shake the tube, or the nitric acid and urine will mix, and there will be no definite line of junction between them. Fuming nitric acid must be avoided, because the nitrous oxide fumes cause decomposition of the urea, and the resultant bubbles mix the fluids ; sometimes there is bubbling even when the nitric acid is colourless, in which case this is due to CO^ set free from carbonates. The test is very delicate ; if any large quantity of albumin is present, the ring appears at once ; if there is only a trace, the white ring may not appear for a little, and the tube should be set aside and looked at again in a few minutes. Broadh- speaking, it takes three minutes for it to develop when the amount of albumin is i part in 30.000. This test is open to more fallacies, however, than the acetic acid and boiling test, so that the nitric acid test should not be trusted to alone, unless it is negative. In concentrated urines it is common to get a dark-brown, reddish- brown, or violet-brown ring of colour at the junction ; this is nothing to do with albumin ; it is general!}- most marked in cases of Indicaxuria [q-v.). White rings, more or less like that due to albumin, may also be due to any of the following : — 1. Resin. — If the patient is taking copaiba resin, or other similar drug, enough of the resin may be excreted in the urine to form a difl'use white cloud above the nitric acid. This source of fallacj- is best avoided by bearing it in mind, and checking the nitric acid test by the heat test ; this latter safeguard applies to all cases of suspected albuminuria. 2. Albumoses. — These generally occur in association with albumin ; should the}' occur alone, the ring will disappear with warming, to reappear with cool- ing, and there will be no cloud with the heat test. 3. Bence-Jones' Albiimose. — This occurs without albumin, gives a ring with nitric acid that disappears on warming, to reappear on cooling ; with the heat test, a dense cloud appears about 60- C, to disappear on further heating to boiling-point. 4. Nucleo-albumin. — The ring with this is not in contact with the nitric acid, but higher up, and diffuse ; it may be a real difficulty in diagnosis from albu- min, for it is also precipitated by acetic acid, and may therefore give a cloudi- ness with the boiling test (see above). 5. Urates. — These may form a cloud near the nitric acid if the urine is very concentrated ; the cloud will disappear on gentle warming, to reappear on cooling, so that it may also be mistaken for albumose ; the fallacy may be avoided by diluting the urine with plain water before the nitric acid test is employed. 6. Urea nitrate. — If the urine contains a large percentage of urea, a crystalline deposit of urea nitrate may form at the junction ; as a rule, the crystalline nature '^. « * ^'ig-- c. FLA TE I. RENAL TUBE CASTS & c ^ig- E. i^4-. D. ^r ^ '^ -- H. A. Hyaline casts. B. Waxy casts C. Hyaline cast containing small crystals of calcium oxalate. D. Blood'casts. E. A leucocyte cast. F. Epithelial casts. G. Granular casts. H. Fatty casts. INDEX OF DIAG.NOSIS ALBUMINURIA 7 of the ring is obvious on inspection ; but in case of doubt the urine should be diluted and the test repeated. It does not matter which test is most relied upon when the result is negative ; but before the positive deduction that a urine contains albumin is drawn, both the acetic acid and boiling, and the cold nitric. acid tests, should be positive. In arriving at a diagnosis of the precise cause of albuminuria in any given case, it is essential that a microscopical examination of the centrifugalized deposit from the urine should be made. Whatever else may be found, the first question to be answered is : Are renal tube-casts present, as well as albumin, or not ? All cases of albuminuria may be divided into two main groups, namely : (I.) Cases with renal tube-casts ; (II.) Cases without renal tube-casts. Renal Tube-casts. — When one speaks of renal tube-casts in this respect, however, one has to bear in mind the fact that modern methods of centrifugalizing with electrically-driven machinery have reached so high a degree of perfection, that hardly anything that a given specimen of urine contains escapes detection ; technique has become almost too perfect ; for when clinical methods become too delicate they begin to lose some of their clinical value. The result, in connection with casts, is that even in a great many normal urines an occasional renal tube-cast and an occasional red blood corpuscle are found ; therefore when one speaks of cases of " albuminuria with tube-casts," one means " with enough renal tube-casts to be pathological." The observer learns from previous experience to know when the " occasional " tube-cast is inside or outside the normal limits. More than one examination may be required, and the urine should be as fresh as possible, for casts disintegrate on standing, especially in hot weather and in alkaline urines. Renal tube-casts are of various sorts {Plate I), and a certain amount of help can be derived from a knowledge of the particular kinds of casts present in a given case. Their matrix or foundation is a structureless material whose origin is obscure, though thought to be due to some kind of proteid coagulation. Some- times the casts consist of this structureless matrix only, and according as they are then less or more highly retractile, they are spoken of as hyaline casts or waxy casts respectively. The hyaline form is commoner than the waxy, but neither is characteristic of any particular disease. Embedded in the hyaline matrix there may be various substances or structures ; and according to the main features of the embedded substances, the casts receive different descriptive names. If renal epithelial cells predominate, the cast is called an epithelial cast ; if leucocytes or pus corpuscles, a leucocytic cast ; if red blood corpuscles, a blood cast ; if bacteria, bacterial casts ; if fat globules, probably derived from degenerated renal cells or leucocytes, fatty casts ; if non-fatty granular debris, granular casts. It is not at all uncommon to find a long cast which in one part is simply hyaline, at one end is granular, and at the other epithelial — a mixed cast. Upon the whole one may say that the hyaline cast occurs in all forms of nephritic conditions, whether acute or chronic ; that epithelial and leucocytic casts indicate active catarrh ; that granular casts tend to occur along with epithelial casts, but that when they occur alone or in association with hyaline casts, they are evidence of at least less acute mischief than are epithelial casts, whilst fatty casts come between the two. Blood casts may occur in almost any variety of renal haemorrhage, and by themselves they are not evidence of inflammation, though in association with other casts they indicate very acute inflammatory changes. ALBUMINURIA I. — Albuminuria with Renal Tube-Casts. When it has been decided that there ai'e a pathological number of renal tube casts as well as aibumin in the urine, it is almost certain that there is an inflam- mator\^ lesion of the kidney. The next step in the diagnosis is to decide by microscopical examination whether pus is present also ; in other words, the cases may be subdivided into two main sub-groups, namely : {A) Albuminuria zi'ith renal tube-casts without obvious pus ; and {B) Albuminuria it'ith renal tube casts and obvious pits. There are, of course, a few border-line cases in which leucocytes are present in excess, and yet not in sufficient numbers to constitute pus. There will generally be other points about such a case that will lead one to decide whether it comes rather in the pyuric or in the apyuric group. The differential diagnosis of the former is discussed under Pyuria, so that it only remains here to discuss : — (A) The di-fferential diagnosis of albuminuria with tube-casts without obvious pus. The causes of this condition may be classified as follows : — 1. The various forms of Bright's Disease : — ia) A primars' acute nephritis. ib) An acute exacerbation upon an underhung chronic nephritis, (c) Chronic nephritis of young people : — (i). Arising out of a known attack of acute nephritis. (ii). Arising without any known previous attack of acute nephritis. (iii). Chronic nephritis of old people — cirrhosis of the kidneys. iv). Arteriosclerosis. (v). Cvstic disease of the kidneys. 2. Nephritis of Pregnancy. 3. Chronic Ascending Nephritis, leading to scarred contracted kidneys, the result of : — ■ [a). Obstruction to outflow bj- : — (i). Urethral stenosis. (ii). Enlarged prostate, (iii). Displacement of the womb. (iv). Fibromyoma, ovarian cyst, or other pelvic tumour. (v). Pregnancies. (vi). Undue mobility of the kidney and kinking of the ureter, (vii). Rarities, such as abdominal aneuiy^sm obstructing a ureter. <[b). Irritation ascending from the pelvis of the kidney, the result especially of calculus, but also sometimes of chronic tuberculous lesions. 4. Lardaceous Disease of the Kidneys. 5. Infarction of the Kidneys, especially when the result of embolism in cases of fungating endocarditis ; but also due to thrombosis, as in some blood diseases. 6. Thrombosis of the inferior vena cava involving the renal veins. 7. New Growth of the Kidney, some cases. In man}^ instances the diagnosis soon becomes obvious, but in some there may be great difficulty. The 1r\vo following cases may serve to indicate how such difficulties may arise : A patient of middle age, who had not been strong for a long time, began to suffer from oedema of the ankles, which rapidly increased and spread to her back, genital organs, thighs, and legs. She did not see a doctor at once ; but within a few days her abdomen began to swell, and she began to pass very little water, and what she did pass was the colour of blood. Upon examina- tion the urine had a specific gravity of 1030, and was loaded with albumin and blood ; whilst microscopically there was an abundance of red corpuscles, renal ALBUMINURIA epithelial cells, leucocytes, and epithelial, fatty, granular, and blood casts, without pus, crystals, or bacteria. It seemed almost obvious that she must be suffering from acute Bright's disease ; but there was no oedema of the eyelids, and there was definite enlargement of the left supraclavicular lymphatic gland ; the discovery of the latter led to a very careful examination for malignant disease ; and a latent and quite unsuspected carcinoma of the rectum was dis- covered. The diagnosis was carcinoma recti, secondary deposits in the retro- peritoneal glands, obstruction and thrombosis of the inferior vena cava and of the renal veins, with consequent albuminuria, haematuria, and renal tube-casts from asphyxial nephritis, simulating acute Bright's disease. Another case was that of a girl of i6, who began to suffer from increasing anaemia, shortness of breath, oedema of her ankles and face, and slight pyrexia. The heart seemed to be a little enlarged, and there were soft systolic bruits that were regarded as secondary to the anaemia. The urine contained blood and albumin, with renal epithelial cells and tube-casts in abundance. Ascites developed, with increasing general oedema ; there were also retinal hcemor- rhages and neuro-retinitis. The diagnosis of acute nephritis, however, was onl}?- in small degree correct ; for she was really suffering from malignant endocarditis of a subacute type, the nephritis being due to infected emboli of the kidney producing inflammatory changes around multiple renal infarcts. These two cases will serve to show how it may be impossible to arrive at a correct diagnosis except by a thorough examination of all the svstems, by watch- ing the case carefulh', and by repeating the full systemic examination at intervals. We wiU now deal with the main headings in the above table in their reversed order. If there is New Growth in a kidney the number of renal tube-casts is likely to be small ; sooner or later a microscopic fragment of new growth will probably be detected in the centrifugalized urinary deposit. Albuminuria will not be extreme unless the renal veins and the inferior vena cava become involved, the same applying also to the oedema of the legs and trunk ; haematuria is likely to occur at intervals, the attacks being separated by many weeks sometimes, and being relatively painless ; there may be an increasing renal tumour ; cystoscopic examination may show the blood-stained urine (see Plate V, Fig. A) to be coming from one ureter only ; and finally, when suspicion of new growth has been aroused, laparotomy may be indicated and the diagnosis thereby confirmed. Thrombosis of the Renal Veins and Inferior Vena Cava has been referred to above, as a condition that ma^' simulate acute nephritis. Points to lay stress on in arriving at the diagnosis are : (i) To make a ver}^ careful and systematic examination, including that of rectum and vagina, in order not to miss anything, such as some latent growth whose secondary deposits are obstructing the veins ; (2) To enquire carefully into the history — a great many cases of inferior venacaval thrombosis are due to extension upwards from iliac or saphenous clots, in which case there will nearly always have been swelling of one leg only to start with, followed later by extension to the back and to the other leg ; (3) To note that although the oedema of the legs and back may be extreme, there is a definite upper level to it, and no swelling of the eyelids or scalp ; and (4) To note that if there are any distended or varicose veins upon the abdoininal wall (see Veins, Varicose Abdominal, Plate XVI), the blood-current in them has become reversed — to being from below upwards instead of from above downwards . Infarction of the Kidneys may be either embolic or thrombotic. By far the commonest cause of embolic renal infarction is infected or fungating endocarditis. Each embolus gives rise to the sudden appearance of blood in the urine which may have contained none previously, or to a sudden marked increase in any ALBUMINURIA existent hsematuria ; there may or may not have been a sudden pain in the back at the same time. Around each infarct there develops acute nephritis, so that in some cases all the characters of the latter malady may be superposed upon those of the fungating endocarditis. If the patient is already known to have heart disease, the diagnosis is easy enough ; the difficulties arise in cases in which, notwithstanding the fungating endocarditis, there is no bruit. If fungating endocarditis is suspected, the points that confirm the diagnosis are : pyrexia, which may be of any type — though absence of pyrexia does not exclude the disease ; enlargement of the spleen ; cutaneous, retinal, or other haemor- rhages ; progressive anaemia ; definite cardiac bruits, especially if the latter at any time undergo any radical change in their character, such as becoming musical instead of blowing, or vice versa ; optic neuritis ; and multiple embolism, for instance, in the brain, spleen, or a peripheral artery. There is no marked leucocytosis as a rule. Venous blood may be cultivated bacteriologically as a means of confirming the diagnosis. Thrombotic infarcts are less severe in their effects ; they may produce no hsematuria at all, and the albuminuria may be slight, and unaccompanied by tube-casts. They generally arise in cachectic conditions, or in blood diseases such as leukaemia or pernicious anaemia, in which cases the diagnosis will be arrived at on other grounds, and albuminuria will not be the prominent feature of the case. Lardaceous Disease of the Kidneys used to be common enough in the days- of septic surgery, but it is decidedly uncommon now. It is a risky diagnosis to make, therefore, unless there is some obvious cause for it, such as long-standing suppuration in association with a spinal, hip-joint, or empyema sinus, bronchi- ectasis, phthisis with cavitation, or the like ; or else clear evidence of tertiary syphilis of the viscera with cachexia. There is nothing characteristic about the urine, although statements are made to the contrary. In the earlier stages there may be but a trace of albumin in an otherwise normal urine ; later, the albumin increases, and it may reach very large amounts, such as 20 parts per 1000, casts being very few in proportion, the total amount of urine increased, its colour pale, and its specific gravity low — 1005 to 1012 ; later still, possibly as the result of a superposed nephritis, the amount of urine falls until only a few ounces may be passed each day, of high colour and specific gravity 1020 to 1035, loaded with albumin, and now containing hyaline, waxy, granular, fatty, and epithelial casts. Lardaceous casts may or may not occur, but they are not diagnostic, for they have also been found in cases of nephritis without lardaceous disease, hj'aline degeneration of the renal tissue being not uncommon in cases of chronic nephritis. Indeed, the diagnosis of lardaceous kidney resolves- itself into one of guesswork in a case in which there has been prolonged suppura- tion or severe syphilis to give rise to it, and in which there maj' be smooth firm enlargement of the liver, moderate enlargement of the spleen, and more or less- severe diarrhoea, to indicate corresponding lardaceous change in the other organs that are generally affected at the same time as the kidneys. Chronic Ascending Nephritis arises from precisely the same causes as acute- ascending nephritis or surgical kidney, and probably results from recurrent focal inflammations which heal, each leaving behind a smaller or larger scar ; with the result that, in the course of months or years, the kidneys are converted into a mass of irregular fibrotic scars, which together produce the same local and general changes and effects as are to be found in cases of ordinarj' red granular contracted kidney. This is not always kept clearly in mind. At first sight it might seem that there could be little connection between prolapsus uteri and cerebral haemor- rhage ; but the latter may be due to the former, by the following sequence of ALBUMINURIA events — the displacement of the womb and bladder sometimes produces a bend or kink in the ureters a short distance above their vesical ends ; this obstruction, persisting for years, tends to produce chronic ascending nephritis ; the fibrotic changes in the kidneys that result from this may lead to thickening of arterioles, high blood -pressure, and hypertrophied heart, with tendency to apoplexy, just as other forms of granular kidney do. It is true that this sequence of events is not very common ; but this is because prolapse of the uterus, fortunately, is not generally left untreated when it is of sufficient degree to cause the ureteral obstruction referred to above. Nevertheless, it is important to bear in mind that any cause of prolonged obstruction to the urine outflow may cause granular kidney with albuminuria, without pus, but with casts, in a pale and abundant urine of low specific gravity. The diagnosis will generally be obvious when the obstruction is due to urethral stricture ; it is more apt to be overlooked in other cases, though if one bears in mind the kind of causes mentioned in the list above, the methods of diagnosis will generally be obvious. One would only mention in particular, that uterine tumours or displacements are a very common cause for slight albuminuria and a few renal tube-casts in women ; and that in men of sixty and over, enlarge- ment of the prostate causes a precisely similar condition long before there is any definite pyuria. Pregnancy Nephritis is sometimes spoken of as though it were an altogether different thing to nephritis of the Bright's disease ty^pe in general. I do not subscribe to this view. I hold that Bright's disease has man}- different causes and manv different types. It may be due to scarlet fever, in which case it is very possibly streptococcal ; it may be due to pneumonia or empyema, in which cases it may be pneumococcal ; it may be due to various other micro-organisms ; it occurs in some cases of cholera, and in severe secondary syphilis ; it may be due to chemical substances, such as turpentine, cantharides, or oxalic acid ; it very often seems to come on from no known cause at all, though in such cases there must be a microbial or other cause that is not discovered ; it m-ay be due to pregnancy, in which case it is ascribed to unknown toxins. In all these cases, the types of reaction on the part of the kidney are similar, and one can only regard pregnancy nephritis as a variety' of non-suppurative nephritis in general. Very likely it is only a matter of degree whether it is non- suppurative or merges into the t^'pe in which there is pyuria as well as albumin- uria — pyelitis of pregnancy. Pregnane}- may cause a primary acute nephritis, which may recover either completely, or but partially and persist as chronic nephritis ; or maj^ seem to recover, when in reality it is merely latent, or even slowly and insidiously progressive ; it may produce what seems to be a primary acute nephritis which is really but an exacerbation superposed upon a chronic nephritis that has been unsuspected ; and very possibly it may produce nephritic changes which are not associated with definite symptoms at the time, but which ultimately result in what is spoken of as chronic interstitial nephritis. When, therefore, albuminuria with renal tube-casts, but without pyuria, occurs during pregnancy, it matters little what name is given to the condition, pro- vided it is realized that just the same difficulties offer themselves here as in Bright's disease in general, in arriving at a conclusion as to whether the renal lesion is acute, chronic, or acute on chronic. Various forms of Bright's Disease. — Of all these, the hardest to diagnose with certainty is primary acute nephritis in the adult. The majority of adult cases that are labelled acute Bright's disease are really suffering, not from primary acute nephritis, but from an acute exacerbation upon the top of already existent but possibly latent chronic nephritis. The difficulty is to arrive at the diagnosis between these two, particularly since many of the points mentioned in text- ALBUMINURIA books as occurring in acute nephritis are really due, not to the acute attack, but to the subacute or chronic renal lesion which has, until then, been unsuspected. The best examples of primary acute nephritis are to be seen in cases that are already under observation for some other disease, notably scarlet fever or lobar pneumonia. Sometimes the onset of the nephritis is indicated bj- general oedema, especially of the eyelids and face, ankles, genital organs, and loins ; but it cannot be too strongly insisted upon that oedema is not essential, man}- cases of acute nephritis having no oedema at all, especially if the patient is ahead}- in bed when the kidne}- inflammation begins, as in scarlatina cases. If the urine were not examined, the renal lesion would often escape recognition altogether ; and there can be no doubt that many cases of primary acute nephritis do escape recognition in this way, coming under observation later, when they present symptoms of chronic nephritis, or an acute exacerbation on chronic nephritis. The essential point in the diagnosis is urine examination. According to the severity of the nephritis there will be more or less diminution in its total dail}^ quantity ; it is common for less than 20 oz. to be passed in the twenty-four hours, and often the amount falls to 10 oz., 5 oz., or even to none at all for a whQe. The specific gravity is raised to 1025, 1030, or even to 1035, but rarely to 1040. The reaction is generally acid at first, but it soon becomes alkaline on standing. The colour is extremely variable, according as little or much blood is present ; sometimes it is almost normal or merely that of a concen- trated urine ; more often there is some tinging with blood, varying from bright red to brownish, brown, brown-black, or to that peculiar blackish tint which is described as smoky. There is a general cloudiness of the specimen, and on standing, it deposits a heavj^ sediment which often has a dark brownish tint, owing to the phosphates carrying the blood pigment down with them. Microscopically, the centrifugalized deposit consists partly of amorphous debris due to earthy phosphates, and to the disintegration of cells and tube-casts ; and one expects to find an abundance of red corpuscles, renal epithelial cells, variable numbers of epitheUal, fatty, granular, hyaline, and blood-casts, an excess of leucocytes, an occasional crj^stal of calcium oxalate or uric acid, and irregular granular masses which are not definiteh- tube-casts. It is noteworthy, how- ever, that in the very acute stages there may be no tube-casts, though shed renal epithelial cells are abundant ; in such a case, tube-casts will show them- selves in a few daj'S. It is important that each specimen should be examined as fresh as possible, owing to the tendency' to alkaline reaction and disintegration of casts and cells on standing. In addition to red corpuscles there is often a considerable amount of free haemoglobin ; the tincture of guaiacum test will be positive, and the spectroscope will show the bands of oxyhaemoglobin or of methaemoglobin. Coagulable proteid is generally present in abundance, the proportions of globulin and albumin varying greatly, but together amounting to anything between 2 and 20 parts per thousand — often about 15 parts per thousand at first, rapidly dropping to less after the first few days of treatment, until at the end of from a fortnight to a month it ma}' be i part per thousand or less, or even absent altogether. In a few cases, however, there is vpry little coagulable proteid but an abundance of albumose, so that the boiling test gives but a faint cloud, whilst the nitric acid test j-ields a dense white ring, soluble on warming, to reappear on cooling. There is generall}' an excess of nucleoproteid also. The urea, chlorides, and phosphates all fall below the normal totals, though their per- centages may be increased if the urine is very concentrated. With this condition of urine there will be little doubt as to the presence of acute nephritis ; the only question being whether it is primary, or whether it is an exacerbation upon chronic nephritis. The former is probable if it is ALBUMINURIA 13 known that the urine was free from albumin up to the time of the attack, if the patient is known to have suffered recently from scarlet fever, pneumonia, diphtheria, secondary syphilis, or some other similar fever ; if the heart is of normal size and its sounds natural, the blood-pressure natural, and the retina: healthy. It may be that the patient himself may have been exposed to scarla- tinal infection, and without having had the rash, may develop nephritis ; the association of peeling of the skin, or recent sore throat with enlarged glands in the neck, or otitis media, might suggest the diagnosis in these mild cases of scarlatina, though sometimes acute nephritis in a child may be the sole evidence of the disease. The course of the malady will also assist the diagnosis ; the albuminuria of primary acute nephritis may clear up entirely in from a fortnight to six weeks, though in unfavourable cases it persists, and chronic nephritis develops out of the acute. If, on the other hand, it is found that, in a case of apparently recent acute nephritis, with general oedema, haematuria, and the other urinary changes described above, there is cardiac hypertrophy, with a prolonged lumpy first sound at the impulse, a ringing aortic second sound, a blood-pressure of more than 150 mm. Hg, and possibly albuminuric retinitis, the probability is that the acute nephritis is not primary, but an acute exacerbation of an unsuspected chronic nephritis. There is often a history of former scarlet fever or of syphilis in such cases ; the patients may be of any age, from child- hood to past middle life. If the patient survives, one or other of two conditions usually results : either the albuminuria, the scanty urine, and the tube-casts persist, whilst the patient remains waterlogged until the end comes in a few weeks or months, or else the acute exacerbation subsides and the clinical characters of chronic nephritis remain. Some of these, but by no means all of them, are examples of primary acute nephritis, persisting and becoming chronic. It must, however, always be very difficult, and indeed almost a matter of opinion in many cases, to decide whether a patient is suffering from a chronic nephritis which is the result of a primary acute nephritis that has not cleared up, or from a chronic nephritis which was present but unrecognized before an acute exacerbation drew attention to it ; but my own view is that many cases in which young adults seem to develop acute nephritis from no more definite cause than exposure to damp or cold, are really examples of acute on chronic, and not of primary acute, Bright's disease. The albuminuria in these cases does not clear up, and it is a mistake to restrict the diet or the daily occupation after the acute exacerbation has subsided. In spite of the persistence of albuminuria, these patients do best if they are given iron and allowed to go about their ordinary avocations ; they have diseased kidneys, and they will not live many years, but there is no need to adopt treatment which constantly reminds them of the fact. As the acute exacerbation subsides in these cases, the amount of urine rises rapidly to 60 or 70 oz. or more per diem, and remains increased even after all oedema has passed away ; the specific gravity falls to 1012, loio, or 1008 ; the albumin persists to the extent of anything between 0-5 and 8 parts per thousand ; blood is absent, though an occasional red corpuscle may be seen under the microscope ; and there are moderate numbers of hyaline, granular, or even fatty casts, with an occasional renal epithelial cell. It not infrequently happens that a young patient suffering from chronic nephritis comes under observation for shortness of breath, palpitations, anaemia, or for inflammation of one or other of the serous membranes, without ever having had any symptoms of acute nephritis at all. The kidneys that would be found in such cases differ from the granular contracted kidneys of older people in that they are pale instead of red. They are pale granular contracted kidneys, preciselj^ similar to those which may result from a long antecedent acute nephritis that 14 ALBUMINURIA has not entirely cleared up. When they develop without any known preceding attack of acute nephritis, they have been referred to as Rose-Bradford kidneys. It is by no means impossible that they are really the result of a preceding acute nephritis which escaped recognition, because there was no oedema to attract attention to the need for urine examination. The patient may be of any age, though generally between five and thirty-five. There may be no sign of any- thing wrong until acute uraemia, with convulsions, leads to rapid death. On the other hand, in a typical case, in addition to the urine changes mentioned above, one expects to find some of the following symptoms or signs : a great increase in the size of the left ventricle, as evidenced by displacement of the impulse downwards and outwards into the sixth left intercostal space below or outside the left nipple, with increase of the precordial impairment of resonance outwards to the left without corresponding increase upwards or to the right ; a ringing exaggerated second sound in the second right inter- costal space close to the sternum, and a prolongation of the first sound at the impulse, or its replacement by a more or less localized blowing systolic bruit ; more or less anaemia, sometimes very considerable and of the chlorotic type ; a maximum systolic blood-pressure, of 175 mm. Hg or more, sometimes over 300 mm. Hg, even when the pulse feels comparatively soft to the finger ; albuminuric retinitis ; a tendency to haemorrhages, especially to epistaxis ; headache ; insomnia ; breathlessness on exertion ; and inability to work with the usual energy, either mentally or physically. The chronic nephritis of old people is diagnosed more often than it exists, if one understands by it the disease associated with small red granular contracted kidneys. On the other hand, the kidneys of most old people exhibit a certain amount of interstitial fibrosis, with occasional retention cysts and some granu- larity of the surface when the capsules are stripped off, without there being any material diminution in their size. Where senile changes that are almost normal end and chronic interstitial nephritis begins, is difficult to determine. The same applies to arteriosclerosis and the renal changes associated with this arterial degeneration. Some regard arteriosclerosis and chronic interstitial nephritis as essentially different maladies ; others regard the arterial secondary to the renal changes ; others hold that arteriosclerosis leads to a variety of red granular kidney that is not the same as the red granular contracted kidney of chronic interstitial nephritis ; whilst others again favour what seems a likely view, namely, that arteriosclerosis and sclerosis of the kidneys both have a common cause, and that it is more or less of an accident whether the patient, on post- mortem examination, presents more arterial than renal changes, or about the same degree of both. During life the differential diagnosis between them is sometimes impossible. In either case there will be a hypertrophied left ventricle, a loud lumpy first sound, or a blowing systolic bruit at the impulse, a markedly accentuated aortic second sound, a systolic blood-pressure somewhere between 150 and 320 mm. Hg, with a tendency to shortness of breath; giddiness, especially on sudden change of posture ; singing in the ears ; difficulty in con- centration of mind ; and very possibly cardiac symptoms, varying from a mere consciousness of the existence of the heart, to precordial pain of varying severity, or even extreme heart-failure, with oedema of the lips, ascites, nutmeg liver, orthopnoea, and pulmonary congestion. In the latter case the great difficulty will be to decide whether the heart failure is due to primary renal or arterial, primary cardiac, or to primary pulmonary disease, and the only sure methods of deciding that there is a renal lesion are, first, the discovery of more than an occasional granular and hyaline tube-cast in the urine ; and secondly, the detection of albuminuric retinal changes. Sometimes inflammation of one of the serous membranes is the first symptom : subacute or chronic ALBUMINURIA 15 peritonitis with ascites ; pericarditis ; or pleuritic effusion. On the other hand, the patient may seem to have been in robust health until the nature of the case is suggested by a sudden apoplectic seizure due to cerebral haemorrhage, followed by hemiparesis or aphasia. In yet another group of cases the malady is discovered accidentally as the result of examination for life insurance. It is not very uncommon to find glycosuria as well as albuminuria, the sugar occurring in a urine of normal specific gravity, without any associated acetone or diacetic acid. The degree of albuminuria is very variable indeed ; when there are signs of cardiac failure, there may be oliguria, with much albumin and not a very large number of casts ; when there is no heart failure, there is generally polyuria, the patient having to rise several times in the night, passing from 60 to 120 oz. of urine in twenty- four hours. It is pale, of specific gravity 1008 to 1012, often containing only a trace of albumin, and even that not constantly ; there are intermediate cases in which the amount of albumin varies from o'25 to 4 or 5 parts per thousand. Upon the whole one may say that, if the increased albuminuria due to heart failure on the one hand, or to a super-added acute attack of nephritis on the other, can be excluded, the more the disease approaches the type of red granular contracted kidney, the more likely is the albumin to be small in amount and intermittent ; whilst the more the disease approaches in type to arterio- sclerosis with renal changes on the one hand, or to pale granular contracted kidneys on the other the greater will be the amount of albumin, if anj^ is present. There will be tube-casts, chiefly granular and hyaline, most numerous with pale granular contracted kidneys, fewest with arteriosclerosis, and inter- mediate in numbers with red granular contracted kidneys. It need scarcely be added that the absence of albuminuria does not exclude arteriosclerosis ; but we are here dealing only with cases in which albuminuria occurs. Cystic Disease of the Kidneys is found in three entirely different types of patients, namely, "(i) the newly born, (2) the young, and (3) the elderly. In the newly born, the main symptom is abdominal distention, which may be so extreme as to have caused difficulty in delivery ; the bilateral cystic tumours can be felt, and the diagnosis in extreme cases is by no means difficult. Minor cases escape detection at birth, and it may be that several years have elapsed before the diagnosis is arrived at, as the result of finding bilateral uneven renal tumours associated with the passage of abundant pale urine of low specific gravity con- taining traces of albumin, a few granular and hyaline tube-casts, and an occasional red corpuscle. Sometimes, a sudden and severe attack of haematuria is the first symptom in the case. The discovery of bilateral irregular renal tumours is the clinching point in the diagnosis. In at least one case they were so large as to meet in the middle line, so that a loop of intestine, having passed in between and behind them, could not get out again, and the patient came under observation for acute intestinal obstruction. The third type of cystic disease of the kidneys, which occurs in old persons, is but a variety of chronic interstitial nephritis in which the agglomeration of retention cysts has reached an extreme degree ; the enlargement of the kidneys in these cases is very much less than in young persons, where the lesion is probably congenital ; and the symptoms and urinary changes are precisely similar to those that may occur in cases of red granular contracted kidneys already described. [B) Albuminuria with renal tube casts and with pus. — When pus is present in the urine, along with albumin and renal tube-casts, the differential diagnosis resolves itself into that of pyuria that is partly or wholly of renal origin (see Pyuria). It only remains to add : first, that it is by no means sufficient to rely upon the naked-eye characters of the urine, or upon chemical tests, in 1 6 ALBUMINURIA excluding minor degrees of pA^uria ; microscopical examination of the centri- fugalized deposit is essential, especially in the detection of acute pj^elitis and pyelonephritis, the result of coli-bacilluria in children, pregnant women, and others ; secondly, that the amount of albumin actually due to pus itself is small, so that if there is any measurable quantity of albumin present it indicates that the kidneys are themselves affected, this being further confirmed when casts are also found ; and thirdly, that blood, like pus, is in itself responsible for relatively little albumin, so that when there is considerable albuminuria associated with blood, there is strong ground for believing that the albumin is by no means all due to the blood. The presence or absence of ver\- small quantities of blood does not assist the differential diagnosis of the cause of albuminuria so much as might be expected ; the occurrence of much blood with much albumin and man}' renal cells and tube-casts indicates acute nephritis, but by itself does not decide between primary acute nephritis, acute exacerba- tion of a chronic nephritis, or the effects of embolic infarction in cases of malignant endocarditis. Renal growths, calculus, or tuberculosis may all cause haematuria and pyuria with albuminuria, and a variable number of granular, hyaline, fatty, epithelial, leucocyte, or blood casts ; and occasionally, when the amount of pus is small, it may be difficult to distinguish between these and acute nephritis. Their differential diagnosis is discussed under H.i;jiaturia. II. — Albuminuria without Tube-Casts. Turning now to the question of the occurrence of albuminuria without renal tube-casts, one would first emphasize the fact that more than one microscopical examination may sometimes be required, for if the urine is alkaUne, or has stood for any length of time, casts, originally present, may have become unrecognizable ; besides which, even with definite nephritis, there may be very few casts at one time, many at another. This apphes particularly to the ver\' acute cases on the one hand and the very chronic on the other. Assuming, however, that no cast, or not more than a very occasional cast, is found, the chief conclusion that can generally be drawn is, that the albuminuria is not in.dicative of organic renal disease. The cases may then be subdivided into : (i) Those in which the urine presents some other definite abnormality besides albuminuria, especially (a) p5ruria, ib) haematuria, (c) hsemoglobinuria. or [d) glycosuria ; (2) Those in which, were the albumin removed, the urine would be normal. 1. These cases need not be further discussed here ; the differential diagnosis will be found under Pyuria, H-5;maturia, H.^moglobinuria, and Glycosuria respectively. 2. These are clinically of importance, in that, until the absence of casts has been determined, the absence of organic renal changes cannot be concluded. Even when casts are absent, a trace or a small amount of albumin may be the first evidence in elderh- persons of enlargement of the prostate, chronic inter- stitial nephritis, or arteriosclerosis ; or in younger persons of chronic ascending nephritis, the result of such things as former gonorrhoea, repeated pregnancies, uterine prolapse or other displacement, chronic vesical catarrh, or urethral stricture. The chronic effects on the kidneys of interference with the urine out- flow are apt to be overlooked, though if they are borne in mind they are generally easy of diagnosis. The following are a number of other conditions which may cause sUght degrees of albuminuria without tube-casts, but which are obvious, or else diagnosed by other si.gns that are discussed elsewhere : burns, scalds, chronic alcoholism, cirrhosis of the liver, diabetes meUitus, exophthalmic goitre, gout, lead-poisoning, mumps, secondary syphilis, morphinism, mercuriali.sm, vasomotor neuroses ALBUMINURIA 17 such as Raynaud's disease or angeioneurotic oedema, obstruction to the vena cava interior by thrombosis or by external tumours, the pressure of considerable ascites, ovarian cysts or solid tumours, pernicious anaemia, Hodgkin's disease or lymphadenoma, lymphosarcoma, lymphatic or splenomeduUary leukaemia, splenic anaemia, pemphigus, phosphorus poisoning, chronic arsenical poisoning, pregnancy, severe anaemia the result of syphilitic, malarial, malignant, tuber- culous, or phthisical cachexia, ankylostomiasis, or infection with other parasites such as Bothriocephalus latus or Trichina spiralis. There remain three other groups of conditions in which albuminuria and its differential diagnosis are often important, and these are : (i) Febrile conditions ; (:) Heart-failure conditions ; and (3) So-called " physiological " albuminuria of young males. I. Febrile Conditions. — In nearly every fever there is some cloudy swelling of the parenchyma of various viscera, especially the kidneys ; consequently most fevers may sometimes be associated with albuminuria, and, broadly speaking, the higher the patient's temperature, the greater is the liability to it. The amount of albumin present is generally not great. We need not enumerate all the various fevers in this connexion, nor discuss the causes of Hyperpyrexia iq.v.). Suffice it to say that albuminuria is relatively common in scarlatina, diphtheria, variola, erysipelas, pyrexial phthisis, cholera, dysentery, Weil's disease, severe malaria, and yellow fever ; not so common in lobar pneu- monia, bronchopneumonia, typhoid fever, and empyema ; and relatively uncommon in other febrile conditions, such as acute rheumatism, influenza, meningitis, measles, German measles, follicular tonsillitis, and so on. The albuminuria may, of course, be already present in a person who develops an intercurrent fever ; the diagnosis then depends upon considerations men- tioned above. If, on the other hand, the albuminuria is known to have developed coin- cidently with the febrile illness, the chief point to decide will be whether it indicates actual nephritis or not. Many consider there is an essential difference between " febrile albuminuria " and actual nephritis. This may or may not be so, but it is extremely difficult to be sure of the distinction clinically. It may be urged that — to take scarlet fever as an example — the albuminuria of the first few days is " febrile," whilst that of the second or third week is " nephritic." As a matter of fact, in not a few cases in which death has occurred in the first week, the " febrile " albuminuria has been associated with large mottled acute nephritic kidneys, even when there has been no oedema, no haematuria, and no very large numbers of renal tube-casts. Probably there are all degrees of acute nephritis, from very slight and transient, to very severe and possibly fatal ; and it is a mistake to try and make a distinction in kind. The great majority of cases of albuminuria during fever recover completely ; some seem to recover, but come under observation years later with pale granular contracted kidneys ; others die during the acute attack. The degree of albuminuria is not a direct measure of the renal changes unless the amount of albumin is large ; a small amount of albumin does not necessarily indicate trivial nephritis. Absence of oedema is the rule. Micro- scopical examination of the centrifugalized urinary deposit is essential : the more the renal epithelial cells, red corpuscles, leucocytes, and various renal tube-casts, the more conclusively can some degree of actual nephritis be diagnosed. When doubt lies between scarlatina and measles or German measles, or betweeij diphtheria and other forms of sore throat, the existence of albuminuria some- times assists in arriving at the diagnosis of scarlatina in the one case or of diph- theria in the other. D 2 ALBUMINURIA In pneumonia, albuminuria has become much less frequent since blistering with cantharides has gone out of fashion in treating this disease. 2. Heart-failure Conditions — The right side of the heart may fail owing to many different causes, which may be arranged under four main headings, as follows : [a) Valvular disease ; [b) Obstructive lung affections ; (c) Myocardial affections ; {d) Granular kidneys and other high blood-pressure conditions. Each of these main headings has many sub-headings which need not be repeated in detail (see (Edema). Any one of them may result in albuminuria, though the amount of the latter is extremely variable, some cases of severe heart failure exhibiting no albuminuria at all, whilst others may have as much as lo parts per looo, or more. The first step in the differential diagnosis is to exclude primary renal conditions by negative microscopical examination of the centrifugalized urine deposit for casts, examination of the retinae, and exact determination of the blood-pressure. Curiously, even with feeble irregular pulses, such as are found in panting cases of mitral stenosis, the blood-pressure is considerably higher than normal, doubt- less owing to partial asphyxia ; so that merely finding a systolic blood-pressure of 150 or 160 mm. Hg is no proof of granular kidney or arteriosclerosis ; some- times, however, the reading is as high as 200, 250, 300, or even 320 mna. Hg, and then the diagnosis of one or other of the latter is almost certain. If renal and arteriosclerotic conditions can be excluded, the diagnosis lies between the other three main groups. The cardiac bruits, the history of grow- ing pains, chorea, and acute rheumatism, the youth of the patient, the family history of heart disease or rheumatic fever, the association of other rheuraatic affections, such as recurrent tonsillitis, subcutaneous nodules, or erythema, will often serve to point to primary valvular disease and its nature ; in older patients, especially in men between forty and fifty, there may be aortic disease and a history of syphilis and not of acute rheumatism. In severe heart failure in children under puberty, the result of mechanical difficulty with the circula- tion, an adherent pericardium is generally found, and clinically, the heart is large out of proportion to the general physical signs. When there is a definite history of recurrent winter cough in an elderly person, with a hyper-resonant and over-expanded chest, the likelihood of emphysema and bronchitis will at once suggest itself. Similarly fibroid lung, or fibroid lung and bronchiectasis, as a cause of heart failure and albuminuria, only needs mentioning, the diagnosis generally being obvious from the physical signs, the clubbed fingers, and, in the bronchiectatic cases, the abundant intermittent, and fre- quently foul, expectoration. Myocardial affections, such as fibroid, fatty, or primary alcoholic heart, are generally diagnosed by guessing at them when other causes of heart failure can be excluded. The patients are generally middle-aged, with precordial pain and even angina pectoris occupying a prominent position amongst their cardiac symptoms ; there may or may not be a high blood-pressure, the albuminuria is not associated with renal tube-casts, there is often no cardiac bruit, or at most a more or less localized blowing systolic bruit at the impulse ; at the same time the heart is clearly enlarged, and it may be beating rapidly and irregularly ; there may be a history of syphilis or of chronic alcoholism ; the patient may be very stout in the fatty, though generally not so in the fibroid, cases. There may be a history, either of an extremely sedentary life upon the one hand, or of over-use of the heart by strenuous hard physical work — as a blacksmith, an athlete, and so forth — on the other. Needless to say, the exact nature of the cardiac lesion remains obscure or uncertain in many of these cases, many a patient who really has mitral stenosis being regarded during life as suffering rom chronic bronchitis and emphysema, and so on. ALBUMINURIA 19 3. "Physiological" Albuminuria. — Finally, we come to that large group of cases of albuminuria in apparently healthy males and females between the ages of fifteen and thirty. The condition was unknown until medical examina- tions at schools or for life insurance, for the army, navy, and civil services became common ; and it has received a large number of different names, of which the following are some : "accidental," "essential," ''postural," "cyclic," " orthostatic," " intermittent," " physiological," " functional," " orthotic " albuminuria, Pavy's disease, albuminuria " of adolescence " or " of puberty." It derives its chief importance from the fact that young males who suffer from it are looked at askance by the older examiners for life insurance or for the "services," and are very liable to be rejected altogether. The reason for this was the fear that they were sufferers from some form of nephritis. A precisely similar condition occurs in perfectly healthy females of a similar age, but its occurrence in the female sex is detected less often than it is in males, because one has less frequent occasion to examine the urines of healthy girls than is the case with boys and youths. Collier and others have thrown much light upon the nature of the affection by their investigations upon the urines of rowing men. It is found that the urine voided just before a boat-race being free from albumin, that voided immediately afterwards is generally loaded with it. A few hours later this albuminuria is gone again. Now university oarsmen are, upon the whole, long lived, hence this recurrent albuminuria cannot matter in them ; and the same applies to the albuminuria of many adolescents. A prominent feature of such a case is, that the urine first voided in the morning is quite normal, whilst that passed later in the day may contain anything from a trace to five parts per thousand of albumin ; the more the youth has exerted himself physically by walking or otherwise, and the more he has exposed himself to cold, for instance, during a train journey to the city on a winter's day, or in a cold bath, and so on, the greater is the liability to this unimportant but possibly alarming albuminuria. Some youths are so liable to it that they may pass albumin for days together before an interval of freedom from it occurs. Sometimes they appear to be in robust health, sometimes they look a little pale, as though they had been over- working at an indoor occupation ; they may be nervous, but often they are not. A natural nocturnal emission is supposed to predispose to albuminuria next day. The point is that these individuals have to be differentiated from sufferers from Bright's disease. The method of diagnosis is as follows : a complete routine examination is carried out, and no obvious affection of the heart or other viscera can be detected ; the blood-pressure is normal ; the albumin having been discovered, the patient is directed to supply a series of samples, at intervals of a few days, and preferably passed immediately after rising in the morning. If all samples contain albumin, it will be very difficult to exclude organic disease ; if some contain albumin in abundance, however, and others none at all, the presumption will be that it is " functional ; " before being finally satisfied, however, it is important that a careful microscopical examination of the centrifugalized deposit from a specimen containing albumin should be made, no casts or other abnormal constituents being found. The administration of calcium chloride greatly diminishes the tendency to this form of albuminuria. In an adolescent male who has no symptoms, albumin- uria discovered accidentally, present after exertion or after exposure to cold, but absent after rest in bed, and when present not associated with renal tube-casts or with signs of arterial, cardiac, or other diseases that should be detected by physical examination, is almost certainly a " physiological " albuminuria which needs no treatment and is not indicative of any underlying disease. Herbert French. ALBUMOSURIA ALBUMOSURIA. — The occurrence of albumose in the urine used to be termed peptonuria. For clinical purposes it may be subdivided under two main headings, namely, (i) Ordinary Albumosuria, which is not ver}'' uncommon, but is of little clinical importance ; and (2) Bence-Jones' Albumosuria, which is rare, but is clinically important. Ordinary Albumosuria is seldom' recognized because the albumose generally occurs along with albumin, and it cannot be recognized until this albumin has been removed bj" acidulating with acetic acid, boiling thoroughly, and filtering. Albumose maj^ be recognized in the filtrate bj- the fact that with Heller's nitric acid test it gives a cloud which disappears on warming, to reappear on cooling ; and its presence may be confirmed by the violet-red colour it gives with the biuret test, which consists in adding excess of caustic soda to a drop of dilute copper sulphate solution, adding this mixture in drops to the urine, from which all albumin has been removed, and warming. Another test for albumose is Hofmeister's, which consists in acidulating the urine with acetic acid, and then adding phosphotungstic acid ; albumoses give a milky cloud with the latter. The deutero-albumose that gives these tests occurs in the urine under a great variety of circumstances ; apparently the one essential factor is cell destruction within the body. It wiU suffice to mention some of the many diseases in which it has been found : — (a). " Febrile " Albumosuria : in severe cases of infective fevers, such as t^^phoid fever, scarlet fever, small-pox, measles, acute rheumatism, lobar pneu- monia. (b). "Pyogenic" Albumosuria: in empyema, phthisis with cavitation, bron- chiectasis, appendicular abscess, pyosalpinx, subdiaphragmatic or hepatic abscess, suppurating gall-bladder, suppurative periostitis, arthritis or osteo- mj'elitis, gangrene of the lung, gangrene of the leg, breaking-down cancer, acute peritonitis. (c). "Hepatogenous " Albumosuria: in cancer of the liver, cirrhosis, catarrhal jaundice, phosphorus poisoning, acute yellow atiophy, infective cholangitis, suppurative p^'lephlebitis. (d). "Alimentary " Albumosuria : in cases of gastric or duodenal ulcer, car- cinoma of the colon or stomach, ulcerative colitis, tuberculous ulceration of the bowel, acute and chronic d\•senter3^ (e). " Hcsmatogenous " Albumosuria: in spleno-meduUarj^ or lymphatic leukaemia, scurvy, purpuric conditions, and as the result of internal hasmato- mata, such as pelvic haematocele. (/). "Albuminuric" Albumosuria: many cases of acute nephritis, S5'p)hilitic albuminuria, cardiac and other forms of albuminuria, are associated with albu- mosuria. There is some doubt, however, as to whether the chemical reagents employed do not themselves convert some of the albumin into albumose during the course of the qualitative analysis. (g). Albumosuria due to ttnclassified causes : such as pregnancy, especially if the foetus has died, though sometimes even without this. The amount of albumose present in any of the above conditions is seldom large, and diagnostically it has little if any significance except when it occurs apart from albumin. Even then, its main importance lies in the necessity of not mistaking it for albumin. This error would only arise with the nitric acid test, for albumose does not form a cloud on boiling with acetic acid. It is urged by some, that the presence of albumosuria in an appendicitis case points to abscess rather than to simple inflammation ; that in a pleuritic case it points to emp3^ema rather than to serous effusion ; that in a meningitic case it points to the suppurative or epidemic cerebrospinal forms rather than the tuberculous ; and so on ; but it is very doubtful if the symptom can carry so much weight as this ALLOCHEIRIA In a given case the presence of ordinary albumosuria points to a graver prognosis upon the whole than if no albumose were present, but it is not particularly help- ful in differential diagnosis. Bence-Jones' Albumosuria, on the other hand, though rare, is clinically im- portant. The nature of the proteid present is still undecided, and certainly is not ordinary albumose. Its most striking characteristic appears when the urine is warmed after acidulation with acetic acid to prevent precipitation of phosphates : long before the urine boils, a dense milky precipitate appears, suggesting at first sight either phosphates or coagulated albumin ; it attracts attention at once, from the fact that on further warming it begins to clear up again, and after boiling it almost or completely goes. It will be realized that the precipitate cannot be albumin or phosphates, for not only would neither of these clear up at boiling-point in this way, but also the acidulation of the urine has been sufficient to prevent phosphates from coming down, whilst the temperature at which the dense sticky precipitate appears (about 60° C.) is far lower than that at which albumin coagulates. If any albumin is present at the same time, the clearing at boiling-point will be but partial ; the albumin should then be removed bj' boiling and filtration, when nitric acid added to the filtrate will give a white ring which redissolves on warming, to reappear on cooling, like that of albumose. This Bence-Jones' proteid, when it occurs at all, is generally present in very much larger amounts than ordinary albumose ever is, so that it is seldom over- looked unless it is mistaken for albumin. It may amount to anything between I and 20 parts per thousand, or more. It may be present on some days and not on others. It indicates, almost with certainty, that there is some affection of the bone-marrow ; it might be due, for instance, to secondary deposits of malignant disease in bones, or to leukemia ; but in the great majority of cases it has occurred in connection with multiple myelomata — Kahler's disease or myelopathic albumosuria of Bradshaw. Unless there is other evidence to the contrary, the occurrence of abundance of Bence-Jones' proteid in the urine indicates multiple tumours of the bone-marrow. Herbert French. ALKAPTONURIA.— (See Urine, Abnormal Coloration of.) ALLOCHEIRIA — Literally means "other handness." It sometimes happens that when a patient is touched upon, say, the back of his right foot, and is then asked where he has been touched, he says, " Upon the back of my left foot." This reference of sensations to exactly corresponding parts of the limbs or body on the wrong side is known as allocheiria. Experiments have shown that complete allocheiria results from transverse hemisection of the spinal cord. It seems that sensory impulses travel much the more readily up their own side of the cord, but can also pass by the opposite side if necessary ; when they are compelled to do so, the brain interprets them as coming from that side of the body which usually sends impulses up this particular side of the cord. When a patient exhibits allocheiria, therefore, it generally indicates that there is a lesion affecting one side of the spinal cord, or the upward extensions of the tracts which convey sensory impulses from the cord to the brain, more than the other. It is necessarily a rare symptom. It might result from a stab or a bullet wound damaging the cord unilaterally ; or from a gumma or neoplasm of the spinal meninges ; it may be functional ; rarely it may result from the cord becoming compressed more on one side than on the other by spinal caries, a new growth, callus, or a fracture- dislocation ; and occasionally it may be noticed when there is a cord disease which, though usually bilateral, happens to have advanced more rapidly on one side than upon the ALLOCHEIRIA other^ as in exceptional cases of disseminated sclerosiSj locomotor ataxy, or softening from sj-philitic endarteritis and thrombosis. It is clear that, except in functional cases, allocheiria will seldom if ever be the only, or even the chief, symptom in the case ; paresis, pain, or some other symptom will certainly be present also, and will afford greater assistance in the diagnosis than will the allocheiria itself. Herbert French- ALOPECIA.— (See Baldness.) AMAUROSIS. — (See Vision, Defects of.) AMBLYOPIA. — (See Vision, Defects of.) AMENORRHCEA- — The time at which menstruation first appears is very variable within certain limits, being influenced very largely by climatic and racial pecuharities ; in this country, about the age of fourteen years may be taken as the average. When the menstrual flow has not become established it is usual to speak of primary amenorrhcea, whilst cessation of the flow after it has once been regularly established is known as secondary amenorrhcea. From a perusal of the table of the causes of amenoirhoea (page 23), it will be seen at once that some of them must of necessity give rise to primary amenorrhcea, whilst others more commonly produce the secondary variety. In the investigation of cases, therefore, it is important to ascertain first whether the condition is primary or secondary, and next whether it is real or only apparent. The latter condition, more strict^ known as cryptomenorrhoea, implies that the menstrual flow takes place, but is unable to escape externally because there is some closure of a part of the genital canal. The congenital form of crj^pto- menorrhoea is the only variety at all commonly met with, acquired closure of a part of the genital canal being an exceedingly rare condition. Stenoses of the vagina are not uncommonly produced as a result of injur}^ and infection ; but a small sinus is usually left which suf&ces for the escape of the menstrual fluid. We are commonly led to suspect cryptomenorrhoea when the patient volunteers the statement that she has pelvic pain, headache, and possibly vomiting, of monthly occurrence, in fact, the usual menstrual molimina un- accompanied by any visible flow. A physical examination should be made at once in such a case, including abdominal palpation, inspection of the vulva, and a recto-abdominal bimanual examination. The common form is that in which the hymen is imperforate, a condition not always self-evident on inspection, The complete examination in such a case will reveal a fluctuating swelling reaching from the vulva to the pelvic brim, above which the uterus can often be palpated and moved about. It is further of considerable importance to make out whether the uterus and Fallopian tubes are distended with menstrual products along with the distended vagina, for in the presence of haemato- salpinges the treatment is considerably modified. Abdominal section is required in such a case to avoid rupture of the tubes when the vagina collapses after incision of the hymen. Distention of the vagina or haematocolpos is complete in this case, but may be partial where the lower part of the vagina is absent, and then is more than likely to be accompanied by distention of the uterus (haematometra) and ha;matosalpinx. Complete absence of the vagina can only be inferred from a physica examination, when the distended organ appears to be only the uterus. Although a secondary phenomenon, acquired cryptomenorrhoea produces the same symptoms and requires the same kind of investigation as the con- AMENORRHCEA 23 genital cases. It must not be forgotten that acquired closure of the vagina following the vaginitis of specific fevers may occur in infancy, and will then, of course, produce primary amenorrhoea. CAUSES OF APPARENT AMENORRHCEA. COXGENITAL. Imperforate hymen Imperforate vagina Absence of the vagina Imperforate cervix Double uterus with retention Hasmatocolpos Haematometra Hematosalpinx Acquired. Closure of the vagina : Due to specific fevers Due to injury Closure of the cervix : Due to injury Following operations CAUSES OF REAL A:MEX0RRHCEA. Physiological Before puberty After the menopause During pregnancy During lactation Pathological. Generative System : Absence of essential organs Infantile uterus Small adult type of uterus Deficient ovarian activity Destruction of both ovaries : By double ovarian growths By pelvic inflammation Superinvolution of the uterus Circulatory System : Chlorosis Anaemia Leucocythaemia Hodgkin's disease Wasting diseases : Malignant growths Tubercle Prolonged suppuration Diabetes Late stages of nephritis Late stage of some forms of heart disease Late stage of cirrhosis of the liver Nervous system : Imbecility Cretinism Various forms of insanity Cold just before or during menstruation Suggestion — fear of pregnancy Anorexia nervosa Altered internal secretion'^ : Myxoedema Exophthalmic goitre Addison's disease Acromegaly Obesity Change of habits Toxic : After specific fevers Chronic poisoning by morphia, alcohol Note: — Real amenorrhoea maybe (i) prirr.arywith delayed onset; {2) primary and permanent (3) secondary. lead, mercury, In considering the diagnosis of the causes of real amenorrhoea, the primary and secondary forms afford us an important clue to the possible causation. Suppose, for instance, that menstruation has once been regularly estabhshed, it is clear that there cannot be any serious congenital anomaly of the generative 24 AMENORRHCEA system ; the uterus and ovaries must at least be present and functional. We then must make a systematic examination of the generative, circulatory, nervous, and ductless gland systems, in order to lea.rn by a process of exclusion which group of causes we have to deal with. If, however, the amenorrho2a is primary and real, that is, the patient has no molimina, our examination must first be directed towards finding out whether the essential organs, namely, uterus and ovaries, are present, and are normal in size and shape as far as a bimanual examination can ascertain. If necessary, an anaesthetic may be given for this purpose, for it is often a matter of considerable difficulty to decide the question. If the fact of absence of the essential organs can be estabhshed, we are clearly justified in considering the amenorrhoea to be permanent, and the patient or her friends should be told of this. Apart from congenital anomalies, it is somewhat remarkable how few lesions of the generative organs there are which produce amenorrhoea. Only those diseases which completely destroy both ovaries or render the uterus functionless can cause amenorrhoea, and under this heading we find only double ovarian growths, the late stages of pelvic inflammation (salpingo-oophoritis) and super- involution of the uterus. A tumour destroying one ovary as a rule has no effect on menstruation at all, provided the other is present and functionally perfect. It is possible for one ovary only to be functional ; for instance, that on the same side as the undeveloped half of a unicornuate uterus may be quite atrophic and functionless. The presence of two tumours in the abdomen symmetrically arranged with regard to the uterus will sometimes permit of the diagnosis of double ovarian destruction, but quite commonly one tumour is much larger than the other, and the double nature of the lesion cannot be established until the abdomen is opened. Superinvolution of the uterus is not difficult to recognize when we remember that it always follows pregnancy, and the small size of the uterus can be readily made out by bimanual examination and the passage of the uterine sound. The organ sometimes only measures i ^ inches by the sound. It must not be forgotten that even in these cases the primary lesion may be an ovarian atrophy, but very little is known on this point. The term " deficient ovarian activity " is a time-honoured one, and must be taken to mean the absence of the internal secretion of the ovary. It is obvious that this condition cannot be diagnosed by any physical exami- nation, and its presence can only be inferred when absolutely no other lesion of any system can be found to account for amenorrhoea, either primary or secondary. It is impossible in the space at our disposal to draw up any detailed method by which the various diseases under the circulatory, nervous, etc., systems, can be diagnosed ; these come naturally within the province of general medical diagnosis. It is, however, not out of place here to note that amenorrhoea caused by general diseases, unconnected with the generative system, depends upon: (i) Alterations in the blood itself; (2) Alterations in blood-pressure ; (3) Altered relation of the nerve impulses which form part of the stimulus for menstruation ; (4) Altered relations between the internal secretions of the ovary and the thyroid glands on the one hand, opposed to the suprarenal and pituitary glands on the other. Finally, with regard to pregnancy, which is the commonest of all causes of secondary amenorrhoea. it may be formulated as an axiom that an otherwise healthy woman who has had perfectly regular menstruation is probably pregnant if she has a period of absolute amenorrhoea. Nevertheless, the presence of pregnancy must never be assumed without a most careful consideration of the history, combined with a complete physical examination. The diagnosis of pregnancy must always be made upon a complex of symptoms rather than upon any one ; the AMNESIA 25 combination of amenorrhoea, secretion to be squeezed from the breasts, morning sickness, vaginal discoloration, and an abdominal tumour, can only mean pregnancy in the vast majorit}' of cases. The addition of foetal movements and the fcetal heart are only required to make the diagnosis absolute. 7". C. Stevens AMNESIA. — Loss of memory. Memory is one of the higher lunctions of the brain, and presents wide variations in its degree of development in different individuals. The physiological range being so extensive, it is almost impossible to say whether an apparently poor memory is pathological or not, when the condition is of long standing and stationary. Slight degrees of impairment of memory are of interest to the psychologist, but to the majority of medical men the loss must be of considerable extent or of pecuUar character before it assumes a position of diagnostic importance. In the analysis of any mental disease, the condition of the memory must be submitted to test. In some forms of excitement there may appear to be an exaltation of memory (hypermnesia) ; events are recalled and magnified in importance, which, in normal states, would never have reached the surface of conscious memory. In all forms of dementia, on the other hand, memory becomes impoverished (hypomnesia), and may eventually fail altogether (amnesia). Reference can be made to only a few states in which the condition of memory may be of service in diagnosis. Dementia. — In all forms of dementia — senile, general paralytic, toxic, etc. — memory is impaired, and it is the rule to find that recent events are lost before those belonging to distant years. Even when memory is obhterated almost completely, a few isolated events in the past may be recalled distinctly without their surroundings, and may take a prominent place in the patient's personality. These traits are generally recognized in connection with senility, but are also to be found, when looked for, in other demented states. Epilepsy. — Amnesia is an important feature of the epileptic seizure. In the majority of epileptics, no memory is preserved of the convulsion, although events immediately preceding it may be clearly retained, as well as those which follow the return of consciousness. In other cases the amnesia may cover a period preceding the attack (retrograde amnesia), while in others, actions are performed after the attacks, in an apparently conscious state, which the patient is quite unable to recall later on. To this phenomenon may be appUed the term antegrade amnesia in association with post-epileptic automatism. From the diagnostic point of view, epileptic amnesia is often of importance in connection with medico-legal questions and criminology. In addition to temporary lapses of memory, the majority of epileptics suffer from the progressive hypomnesia common to all forms of dementia. It is one of the first signs of their intellectual deterioration. Trauma. — Severe falls or blows on the head are not infrequently the cause of complete amnesia, and the latter may cover not only a period of unconscious- ness, but also a period preceding or following it, or both. As in cases of epilepsy, the amnesia may be retrograde, anterograde, or antero-retrograde. Korsakow' s Syndrome. — This condition, generally the result of alcoholism, is characterized by hypomnesia, disorientation, and pseudo-reminiscences. The patient loses memory for recent events, has no appreciation of time or place, talks freely and often plausibly about events which have never occurred, and yet may retain a very natural attitude of mind towards his surroundings. So natural may be his manner of talking and his behaviour, that the above- mentioned mental deficiencies may escape notice unless the medical man applies himself to their discovery. 26 AMNESIA Toxcsmia. — In many infective diseases, such as enteric fever, the return of health may reveal a state of amnesia covering a considerable part of the patient's illness, and this blank, the result of intoxication of the higher cerebral centres, may be permanent. Hysteria. — Amnesia is probably quite complete in connection with some forms of hysterical " fits." The patient in the interval between attacks has no recollection of the latter, although they are not associated with loss of conscious- ness. This fact underUes the theory which assumes a double consciousness ; the person in one state of consciousness has no memory for events which occur in the other. E. Farquhar Buzzard. ANEMIA. — Ansmia is a general and inexact term, which may include one or more, or even all, of several different changes in the blood, but of which the main criterion from a clinical point of view is diminution in the amount of haemoglobin contained in a given volume, usually but not invariably associated with a diminution in the total number of red corpuscles per c.mm. of blood. The leucocytes may vary or not without changes in them being essentially related to anaemia, though their behaviour affords a means of diagnosing some forms of anaemia from others. Various terms have been used to denote different ways in which the blood may depart from the normal, and these may be defined shortly, though they seldom become important from a clinical point of view. OligocythcBmia or hypocythcBmia. both signify a diminution of the number of red corpuscles below the normal per c.mm. of blood — ^5,000,000 in a man, 4,500,000 in a woman. OligcBmia means a diminished total amount of blood in the body ; hydrcBwiia, an increased percentage of water in the blood ; poly- plasmia, an increase in the volume of the plasma of the blood such as is supposed to occur in chlorosis ; oligochromannia, a diminution in the amount of haemoglobin per c.mm. of blood. For purposes of comparison of one case with another, one speaks of the red corpuscles and of the haemoglobin as being normally 100 per cent in health. It is possible for an anaemia to be such that the hsemoglobin is greatly diminished without a corresponding diminution in the red corpuscles ; it is also possible for the haemoglobin and the red corpuscles each to be diminished in equal proportions ; and thirdly, it is possible for both the haemoglobin and the red corpuscles to be diminished, but for the haemoglobin to be relatively less diminished than are the red cells. The red corpuscles contain relatively less haemoglobin than they ought to in the first variety of anaemia, which is probably the commonest of all ; in the second group, although there is anaemia, each red corpuscle contains its full quantity of hemoglobin ; whilst in the third group, although there is anaemia, each corpuscle contains more haemoglobin than it normally should. As a means of expressing these facts shortly, one speaks of the colour index : this is the ratio of the haemoglobin to the red corpuscles ; if the red corpuscles and haemoglobin are each 100 per cent of normal, the colour index is j-{J-|}, or i. If the haemoglobin were diminished to 40 per cent of normal, whilst the red corpuscles were only diminished to 80 per cent of normal, the colour index would be i^, or 0-5 — the chlorotic type, in which the index is less than I. If the haemoglobin and the red corpuscles were both diminished to 50 per cent of normal, there would be anaemia with a normal colour index of ^-, or I. If the haemoglobin were diminished to 30 per cent of normal, whilst the red corpuscles were diminished to 20 per cent of normal, the colour index would be if}}, or 1-5 — that is to say, greater than i, a condition which is spoken of as the pernicious type of colour index, because it is almost pathognomic of pernicious anaemia. ANEMIA 27 Pallor may or may not be an indication of anaemia. There are many persons who look almost white, and yet whose blood is not in an abnormal condition. Pallor is normal in night-workers and in those who work underground. Even in some daylight workers, the distribution of the cutaneous capillaries seems to be such that the superficial skin has little, if any, of the normal colour of blood, and yet the individuals are not anaemic in the sense of having any diminution of the haemoglobin or the red corpuscles. It is important not to mistake mere pallor for anaemia ; this error is to be avoided by means of a blood-count, which in all cases should include the estimation of the percentage of haemoglobin, and of the total number of red corpuscles per c.mm. ; and inmost cases should also include a determination of the number of leucocytes per c.mm., a differential leucocyte count and an examination of the characters of the red corpuscles in stained bloodfilms. Corpuscles are best counted by means of the Thoma-Zeiss or Thoma-Leitz hcemo- cytometer ; hjeraoglobin is most accurately measured by the Haldane-Gowers h^mo- giobinometer ; and blood lilms are best fixed and stained simultaneously bj' means of Jenner's stain, or, when hsematozoa are to be looked for, by Leishman's stain. Ful directions as to the use of these instruments and stains are generally issued with them, or one of the many small handbooks on laboratory methods may be referred to. TRUE ANEMIAS. Having definitely proved that the patient is suffering from real anaemia, that is to say from a diminution in the percentage of haemoglobin, and probably from a diminution in the red corpuscles also, the next step in the diagnosis is to determine what is the nature of the anaemia. Attempts are sometimes made to fit all cases of anaemia into one or other of two main groups, labelled primary and secondary respectively ; but this is not really very helpful clinically. In many cases the nature of the anaemia is obvious at once — it may be second- ary to post-partum haemorrhage or other blood loss, or the later stages of phthisis, syphilis, cancer, or nialarial cachexia, and so on — the diagnosis being arrived at directly without any difficulty. Sometimes, however, even though anaemia is really du'e to a cause which in some patients is obvious, it is not obvious in the patient with whom one happens to be dealing at the moment, and then the diagnosis has to be arrived at by a process of exclusion. One need but mention as examples, perhaps, the difficulties that arise sometimes in diagnosing between fungating infective endocarditis, gastric carcinoma, and pernicious anaemia ; or between anaemia due to blood-loss and blood-loss due to anaemia. In arriving at the diagnosis, it is important in the first instance to exclude those conditions in which the blood picture is itself positive. A division of all cases of anaemia into {A) AncBinias with a positive blood picture ; and {B) Ancemias with an indeterminate or negative blood picture, is probably more helpful clinically than any other classification. The only anaemias in which the blood picture can be described as itself positive — that is to say in which the diagnosis is indicated directly by the results of blood examina- tion — are {a) pernicious anaemia, {b) spleno-meduUary leukaemia, (c) lymphatic leukaemia, {d) mixed varieties of leukaemia, (e) parasitic anaemia, associated with eosinophilia, and (/) pprasitic anaemia associated with parasites in the blood. Blood changes common to all severe ansemiaSo — In any severe anaemia, whether it is of that definite variety known as pernicious anaemia or not, there are certain blood changes which are almost always to be found, which are not characteristic of any one variety of anaemia, but which, seeing that pernicious anaemia in its later stages is probably the profoundest of all the anaemias, are perhaps better seen in it than in any other disease. These are : — • 28 A X.EM I A (a). A ver^,- great diminution in the number of red corpuscles, down even to so low a figure as 600,000 per cmm. (fc). Great variation in the shapes of the red corpuscles seen in blood films — poikiloc],-tosis ; poikiloc\-tes {Plate II, Fig. E), always retain a smooth, curved outUne. but instead of being flat circular discs, hke normal corpuscles, they may be oval or pear- or hour-glass-shaped, and so on. It is important not to mistake crenated corpuscles [Plate II, Fig. D), or red cells that have become polygonal by reason of mutual moulding when fixed in too close apposition with one another (Plate II, Fig. C), for poikilocytes. (c). Alterations in the sizes of the corpuscles. In normal blood the red cells are almost aU of the same diameter, about 7 yu ; in any se\-ere anaemia they may vary considerably in size, many being much smaller than normal — microcytes {Plate II, Fig. B) ; some larger than normal — macrocytes or megalocytes [Plate II, Fig. B). (d). The presence of nucleated red corpuscles, formally none are present in the blood even in infancy ; in any severe anaemia they may appear in varying numbers, and according to their sizes they are termed microhlasts, normoblasts, megaloblasts, or gigantoblasts [Plate II, Fig. F) — the latter containing more than one nucleus, the others only one. It has sometimes been stated that the greater the number of nucleated corpuscles, the less favourable the prognosis ; but this is not necessarily- the case, except in so far that it is unusual for nucleated forms to appear until a severe stage of the anaemia is reached. Xone of the above changes, one must repeat, are diagnostic of anj- particular variety of severe anaemia, though the}- are perhaps most marked in the later stages of pernicious anaemia. The Differextial Leucocyte Count. I. — Normal Varieties of White Corpuscles. — It often happens that variations in the relative proportions of the difierent leucocj-tes in the blood afford means of differential diagnosis. Before changes from the normal can be understood, it is necessary- to say a word or two about the normal varieties of white cells ; these number an\-thing from 5,000 to 10,000 per cmm., the total changing considerably at different times of the day. ^^TLen films are made it is found that four easily distinguishable varieties are to be seen. These have received very different names at the hands of different observers, but they are so distinct that names hardly matter, and the}- might be termed quite well t\-pes A, B, C, and D respectively. If, hoM-ever, one has to choose between the different names that have been given to them, the following may perhaps be selected as the most frequently employed : — (i) Small lymphocytes ; (2) Large lymphocytes ; (3) Polymorphonuclear cells ; (4) Coarsely granular eosinophile corpuscles. 1. The small lymphocytes [Plate II. Fig. H) stain blue with Jenner's stain, both as to nucleus and protoplasm. The nucleus is round, and the protoplasm is relatively small in amount and free from granules. 2. The large lymphocytes, or hyaline corpuscles {Plate II, Fig. J), stain blue, both as to nucleus and protoplasm. The nucleus is more or less kidney-shaped, and the protoplasm relatively large in amount and free from granules. 3. The polymorphonuclear cells {Plate II, Fig. K) stain blue as to the multi- lobed nucleus, red as to the relatively abundant protoplasm, which under the high power is seen to be speckled with %en.- fine red granules. 4. The coarsely granular eosinophile corpuscles {Plate II, Fig. L) stain blue as to the multi-lobed nuclei, red as to the protoplasm, the amount of which is approximately the same as in the polymorpho-nuclear cells, but differs from the latter in that it is studded with very striking large eosinophile granules. The onlv difi&cultv that arises in making a differential leucocvte count in PLA TE II. RED AND WHITE BLOOD CORPUSCLES As seen under ihe :j'.,th-inch nil-ininier.sion lens A, Normal red corpuscles ; B, Megalocytes and microcytes ; 0, Normal red corpuscles made angular b}' imperfect fixation; D, Crenated red corpuscles; E, Poikilocytes ; F, Nucleated red cor- puscles, (i) Normoblasts, (2) Megaloblasts, (3) Gigantoblasts ; G, Punctate basophilia and poly- chromasia ; H, Small lymphocytes; I, Indeterminate lymphocyte; J, Large hyaline lymphocyte; K, Polymorphonuclear corpuscle; L, Coarsely granular eosinophile corpuscle; M, Myelocyte; N, Eosinophile myelocyte; O, Basophile corpuscle. Cflpyiight INDEX OF DIAGNOSIS /. R. Ford, del. AN MM I A 29 normal blood is that whereas the small lymphocytes usually become fixed in such a way as to cover relatively small areas, so that the cells seem to consist mainly of nucleus, at other times they spread out ilatter over larger areas, and then the rounded nucleus seems to be surrounded by much protoplasm {Plate II Fig. I). When the small lymphocyte becomes flattened out in this way, it is apt to be called either a large lymphocyte by those who do not insist upon the reniform nucleus of the latter, or a transitional lymphocyte by other observers. There is no deduction of particular clinical value to be obtained by distin- guishing these cells from small lymphocytes ; it is better that they should be grouped with the small lymphocytes for chnical purposes at any rate, only undoubted large hyaline cells with reniform nucleus being included in the group of large h'mphocytes or hyaline corpuscles. The relative proportions of these cells differ according as the individual is a child or a grown-up person ; for an adult one may say that, roughly speaking, out of 100 leucocytes about — 25 will be small lymphocytes S will be large hyaline lymphocytes 65 will be polymorphonuclear cells, and 2 will be coarsely granular eosinophile corpuscles. 100 In children, the tendency is for the small lymphocytes to be relatively more numerous in health, and still more so in any illness — up to 40 per cent or even more — whilst the polymorphonuclear cells are correspondingly diminished. Some observers prefer to represent the different varieties of white corpuscles not as percentages but as total numbers per c.mm. of blood ; but this has not yet become a widely extended custom. II. Abnormal Varieties of White Corpuscles. — It remains to add that, whereas the above are the only kinds of white corpuscles seen in the blood during health, in certain diseases the following abnormal white cells may be met with : — Myelocytes. — These are large corpuscles [Plate II, Fig. M), comparable in size to the polymorphonuclear cells, but differing from the latter in having either a perfectly round, an oval, or possibly a shghtly kidney-shaped nucleus rather than a multilobed one. There are all gradations of these cells, and at the two extremes it is difficult to differentiate some from large lymphocytes and others from polymorphonuclear cells. They are to be distinguished from the latter by the roundness of the nucleus, and from large lymphocytes by the granularity of the protoplasm. The granules in question are sometimes stained brightly with eosin — eosinophile myelocytes {Plate II, Fig. N), distinguishable at once from the ordinary eosinophile corpuscles by their nuclei being nearly spherical ; more often, however, the granules stain blue, or some colour between blue and red — ordinary or neutrophile myelocytes. No useful clinical information can, so far as is at present known, be obtained by laying any particular stress upon these differences in the staining reactions of different myelocytes, so that these cells are usually counted together simply as myelocytes. There is only one condition in which they are very numerous, and that is spleno-meduUary leukaemia • but they may occur in small num.bers in various other affections also, particularly in lymphadenoma, Hodgkin's disease, pernicious anaemia, and aplastic ansemia. Basophile Corpuscles {Plate II, Fig. 0). — These are much smaller than myelo- cytes, their size being comparable i-ather to that of small lymphocytes ; they differ from the latter, however, in that the protoplasm, instead of being homogeneous, contains small numbers — from 2 or 3 to perhaps 20 or more — of very large granules which stain deep blue with Jenner's stain. They are unmistakeable. No definite clinical deductions can be drawn from their 30 ANEMIA presence beyond the fact that, if there are more than i or 2 per 1,000, the blood is abnormal. They may be present in manj^ different varieties of anaemia, but they are not characteristic of any ; thej' seldom amount to more than 2 or 3 per cent, and often to no raore than 0-5 per cent, even in disease. Punctate Basophilia. There are certain conditions, particularly pernicious ansemia in its later stages, leukaemia, and lead poisoning, in which the red corpuscles, instead of staining uniformly pink with the eosin of Jenner's stain, present large numbers of very small blue specks or granules in their protoplasm {Plate II, Fig. G), a condition known as punctate basophilia. In a case of doubt, when pernicious anamia has been excluded by there being a low colour index, and when leukaemia is contraindicated by the fact that there is a normal leucoc5'te count, the presence of extensive punctate basophilia sometimes affords confirmative evidence of plumbism. (J).— AX.EMIAS WITH POSITIVE BLOOD PICTURES. We may now pass on to consider the commoner varieties of anaemia, deahng first with anaemias with positive blood pictures. Pernicious Anaemia is a disease of insidious onset in adults, the main s^Tiiptoms being progressive loss of muscle-power and increasing pallor, with loss of weight, but with relatively less loss of body volume. A large number of other symptoms may be associated with these, or no others may be present. The diagnosis is seldom made until a relatively late stage of the malady has been reached, by which time there is a great diminution in the haemoglobin, down perhaps to 30 per cent of normal or less, and a still greater diminution of the red corpuscles down perhaps to 25 per cent, 20 per cent, or even 10 per cent of normal ; con- sequently the colour index is high, and this is the pathognomonic sign of the disease. There is no leucocytosis, but rather leucopenia {q.v.) ; the differential leucocyte count shows a relative increase in the small leucoc^-tes, a corresponding diminution in the poh-morphonuclear cells, normal numbers of eosinophile corpuscles and large lymphocytes, occasional basophile corpuscles, and one or two myelocytes. Blood films also show all the changes described above as common to the severe anaemias with a particularly large relative number of megalocytes. When these blood changes are all present there can be httle or no doubt about the diagnosis, and therefore Ave need not enter here into all the other SA^mptoms that maj^ be presented by the patient. It is important to remember, however, that there is one group of the cases in which nerve symptoms predominate long before the anaemia is pronounced. The diagnosis of pernicious anaemia cannot be made without a blood-count, and it can be made absolutely with one ; only one word of warning is required, and that is that the colour index is not continuously high in every case of pernicious anaemia, so that perhaps several blood-counts may be required at intervals. It should also be noted that the power of temporary recuperation is considerable, and when the patient's condition improves the blood ma}? return partly or whoUj^ to normal ; and during this remission of the disease the colour index, instead of remaining greater than i, becomes i or less than i. It is on this account that pernicious anaemia in its earher stages is exceedingly difficult to detect, and indeed at present it is generally mistaken for something else until the anaemia has reached such a stage as to be obvious. There are certain cases of very severe anaemia which some would include under the heading of pernicious anaemia, although the colour index is persistently less than i. It is more useful, however, from a clinical point of view to leave AN.^MIA 31 these cases unlabelled, or at any rate not to call them pernicious anaemia, which has so characteristic a blood picture. One variety has recently become separated from the rest under the title of aplastic ancemia, the chief characters of which are a profound, progressive, and ultimately fatal anaemia for which no cause can be found, which seems in many respects to simulate pernicious anaemia, but which is persistently associated with a low instead of a high colour index. Spleno-medullary Leukaemia. — In the earlier stages of this disease there is no anjemia at all, though later diminution both in the haemoglobin and in the red corpuscles may be profound. The essential point in the diagnosis is the occurrence of a very great increase of the total number of leucocytes, not at all uncommonly up to such a figure as 200,000, and sometimes up to 600,000 or even 1,000,000 per c.mm. of blood. There is only one other condition which can produce so extreme an increase in the total nvimber of leucocytes, and that is lyiiipJiatic leukcsmia. The two are immediately distinguishable from one another by the differential leucocyte count, the characteristic point about which, in spleno-medullary leukaemia, is the large number of myelocytes present. These may amount to 30, to even 50 per cent, or more, of all the corpuscles present, with the consequence that there is a relative but not an absolute diminution in the other varieties of white cells. Occasionally basophile cells are seen ; but whatever may be the proportion of these or other leucocytes, the main point in the diagnosis is the large relative number of myelocytes, in association with an enormous increase in the total leucocyte count. When anaemia ultimately ensues it is of the chlorotic type ; that is to say, the haemoglobin falls before, and to a greater extent than, the red corpuscles. The disease generally lasts from one to three j^ears before ending fatally, and in the later stages all the blood- changes characteristic of severe ana;mia may be found. Clinically, the other main feature of the complaint is the enormous enlargement of the spleen, which here reaches dimensions bigger than in any other disease, the viscus often extending right across the middle line to the right iliac fossa or down into the pelvis. It is noteworthy that in patients treated with the ;i;-rays the spleen verj^ often becomes greatly reduced in size, and the blood picture may return nearly to normal, though it seldom if ever happens, even when the number of leucocytes per c.mm. has reached the normal, that there is an absence of myelocytes in the differential leucocyte count. Notwithstanding this apparent improvement in the blood and in the spleen, the length of time the patient survives does not seem to be increased. The splenic enlargement is not associated with enlargement of the lymphatic glands. Lymphatic Leukaemia. — There is no age at which any form of leukaemia may not occur ; but upon the whole, the spleno-medullary form rather affects adults than children, whereas the lymphatic form affects children rather than adults. Its course is usually rapid and invariably fatal, death resulting, as a rule, within three or four months from the first definite symptoms. Anaemia is much more rapid in its development in the lymphatic than in the spleno-medullary form. The first symptoms may be either those of anaemia, or the development of obvious lymphatic glandular enlargements in the neck, axillae, and groins, or the occurrence of purpura, epistaxis or other forms of haemorrhage, or in certain cases a complete change in the child's temperament in the direction particularly of excessive irritability of temper, with loss of appetite and obvious and progres- sive illness. There are cases in which there is no glandular enlargement at all, and in which the diagnosis would not be at all obvious without a blood-count. More often there is the general enlargement- of the lymphatic glands, visceral and peripheral, sometimes associated with similar increase in the size of other glands, particularly the salivary and lachrymal, and upon examination the spleen is nearly always palpable and sometimes decidedly large, though 32 ANEMIA seldom so big as it is in the spleno-medullary form of the disease. Serous inflammations are common, and there is apt to be pyrexia, just as there is in other severe ansemias, especially in spleno-medullary leukaemia, Hodgkin's disease, and pernicious anemia. The diagnosis is at once afforded by the blood- count in the great majority of cases. There is a varying degree of increase in the total number of leucocytes per c.mm. of blood, sometimes reaching no higher than 20,000 or 30,000, more often 80,000 to 100,000, and sometimes, but more rarely, to much higher figures, such as 200,000, 600,000, 800,000 or even 1,500,000 per c.mm. Whatever the total number of leucocytes, however, the most striking feature in these cases is the enormous relative increase in the number of small lymphocytes in the differential leucocyte count. Out of every hundred leucocytes it is not at all uncommon to find that 90, or even 95 or 98 are lymphocytes ; so that there is an enormous relative and sometimes absolute reduction in the other corpuscles of the blood. When a very large number of cells are examined, amongst them will be found an occasional myelocyte and one or two basophile corpuscles. The red cells and the hasmoglobin become progressively diminished, and the former may exhibit all the other changes described above as characteristic of any very severe anaemia. It is worthy of note that whereas in most cases the colour index becomes less than i as the disease progresses, in a few instances, especially some time before the end, the colour index has been found to be greater than i, as it is in pernicious auEemia. There is no likelihood of mistaking one condition for the other however, on account of the changes in the white cells. There are some authorities who describe two varieties of lymphatic leukaemia, according as the lymphocytes seen in the films are of relatively large or small size ; as has been explained above, however, there is always difficulty in deciding whether differences in apparent size of the lymphocytes constitute differences in kind, and there is no very great clinical purpose served in drawing the distinction here, unless perhaps that upon the whole the larger the lympho- cytes present, the greater the number of weeks the patient is likely to survive. The chief difficulties that arise in the diagnosis occur in two ways : namely, first, that there are a few instances in which lymphatic leukaemia has run its course without any actual increase in the number of leucocytes per c.mm. of blood, the diagnosis being afforded only by the enormous relative increase in the small lymphocytes ; and secondly, from the fact that children normally have a relatively high leucocyte count, from which it happens that lymphatic leukaemia may sometimes be suspected when it is really not present at all. Suppose, for instance, that a child suffering from an obscure illness associated with anaemia had the chlorotic type of changes in the blood-cells and haemo- globin together with an increase in the total number of leucocytes up to 25,000' per c.mm., and a relative increase of the small lymphocytes up to 55 per cent, would one be justified in making a diagnosis of lymphatic leukaemia ? One might do so if there was general enlargement of the lymphatic glands together with enlargement of the spleen ; but otherwise both the leucocytosis and the relative increase in the lymphocytes might be due to some other com- plaint, and the only means of arriving at the diagnosis might be by awaiting developments. It is not safe to insist upon a diagnosis of lymphatic leukaemia unless there is either a very large increase in the total number of leucocytes, or a relative increase in the small lymphocytes up to 90 per cent or over, or both these changes at the same time. Mixed Forms of Leukaemia. — Ahhoughthe great majority of cases of leukaemia belong either to the spleno-medullary or the lymphatic form, there are cases in which the symptoms and the blood changes partake of the characters of both. Either the splenic enlargement or the lymphatic glandular enlargement, or both. AN JEM I A 33 may be well marked ; there may be no anaemia until the disease has passed its earher stages, when the red cells and haemoglobin pass through the chlorotic type of changes until they reach those severe alterations characteristic of all anaemias in their last stages ; the white corpuscles show more or less increase in their total numbers, and the differential leucocyte count shows not only consider- able numbers of myelocytes, such perhaps as 20 per cent or more, but also a great relative increase in the Ij-mphocytes up to, it may be, 60 per cent or over. The occurrence of these cases of " mixed " leukaemia would seem to indicate that there is really no absolute difference in kind, but rather onh^ a difference in tvpe betAveen the lymphatic and the spleno-medullary forms already described. Parasitic Anaemia associated with Eosinophilia. — Many varieties of the parasites that affect man produce hardly any blood changes at all — Tricho- cephalus dispar, Oxyuris verniicularis, Ascaris lumbricoides . Other parasites, however, produce very marked changes in the blood, and one may mention in particular Bothriocephalus latus, Ankylostomum duodenale, Trichina spiralis, Bilharzia hcematobia, and not a few cases of hydatid disease. The anaemia which results may be very profound, and the blood may exhibit all the changes described above as common to the severest anaemias. The colour index is usually less than I, but sometimes it may be greater than i, and so simulate pernicious anaemia ; but whatever the total number of leucocytes in the blood, the differential count very commonly presents a considerable increase in the coarsely eosinophile corpuscles, and this Eosinophilia [q.v.) in association with severe anaemia is highlv suggestive of the presence of some toxic parasite. It does not indicate which parasite is present, however, this being determined by careful examination of the faeces, urine, and so forth. (See Parasites, Intestinal.) Parasitic Anaemia associated with Parasites in the Blood. — The four best known varieties of disease in which human beings have parasites in the blood are : malaria, filariasis, trypanosomiasis, and relapsing fever. In all of these con- ditions there may be much destruction of the red corpuscles with consequent anaemia of the chlorotic type. It is probable that in most cases the history, particularly of residence in some tropical country where the disease in question is hkely to occur, will suggest the diagnosis in the first instance, and the exami- nation of the blood, either fresh or in films, will merely be confirmative. Relapsing fever used to be prevalent in various parts of Great Britain, and it still occurs in epidemic form in times of famine in association with uncleanness. It is commoner abroad. It is due to infection by the spirochaete of Ober- meier [Plate XII, Fig. I). This is a long spiral organism, 40 fi long and I jj. broad, which is actively motile in fresh blood, but is best seen in films stained with Leishman's stain. They first appear a day or two before the paroxysms of fever, and may reach large numbers. In the intervals between the paroxysms they are not to be found. The course of the disease is usually very suggestive of the diagnosis, there being outbursts of pyrexia associated with extreme prostration and severe illness, lasting about a week or rather less, with complete intermissions of about the same length. There may be an indefinite number of relapses before the patient either dies or recovers. Filariasis may be latent for a long time before it produces actual symptoms. Its best known effects are elephantiasis of the legs or genital organs, with or without chyluria. It occurs in many parts of the tropics, particularly in some of the Pacific Islands, such as Fiji ; and in certain parts of China. The elephantiasis and chyluria are due to mechanical obstruction to the pelvic lymphatics by the mature worms. The blood exhibits more or less anaemia of the simple chlorotic type, together Avith a varying degree of eosinophiUa, whilst at certain times of the day or night, the peripheral blood also contains the long but narrow filarial embryos (Plate XII, Fig. F). There are probably D 3 34 AN JEM I A different varieties of the organism, but they cannot be distinguished easily by the appearance of these embryos alone. Without laying stress upon generic differences, it is important to know that in most cases they are to be found in the peripheral blood only at night {Filaria nocturna bancrofti) ; during the day in these cases they seem to retreat into the deep vessels ; there are other cases, however, in which embryos, very similar in appearance, occur in the peripheral blood in the daytime and not at night {Filaria diurna) ; whilst in Filaria Persians they are present in the blood both day and night. Roughly speaking one may say that each embryo when stretched out is 200 f.i long and 4 to 5 ju wide, and they stain by Leishman's method. The parasites may be found in the blood of patients who have returned to England from foreign parts in which they have contracted the disease. Trypanosomiasis. — -This is the cause of sleeping sickness. Trypanosomes of many different kinds are known to affect various animals, birds and fish, but the only one which is important in man is the Trypanosoma gambiense {Plate XII, Fig. G). It is to be found in blood films stained by Leishman's method in infected patients, months or years before it finds its way into the cerebrospinal fluid to produce sleeping sickness. It has a large and definite nucleus about its middle, surrounded by protoplasm which becomes prolonged into a relatively long undulating membrane terminating in a flagellum. It is an extra-corpuscular organism readily distinguishable when seen in its mature stage. It occurs particularly in people who have been resident in Uganda or other district in which the fly Glossina palpalis abounds which spreads the disease. The diagnosis is much less easy when the blood contains only imma- ture forms. In this connection it is worthy of note that one variety of severe anaemia occurring in Assatn, associated with pyrexia and enlargement of the spleen, and formerly thought to be a variety of malaria, has been shown to be due to a variety of trypanosomiasis in which only immature forms of the parasite (Leishman-Donovan bodies) have been found [Plate XII, Fig. H) ; and here not in the general blood stream, but in the fluid obtained by splenic puncture. The disease is termed Kala-azar. Malaria. — Malaria is not essentially associated with anaemia ; but in patients who have had recurrent attacks blood destruction by the parasites leads to considerable reduction both in the red cells and in the haemoglobin, the colour index generally being of the chlorotic type. The changes in the white corpuscles are described above. The diagnosis can often be surmised when a patient who is, or has been, resident in a malarial district suffers from the typical periodic rigors with pyrexia. Theoretically, there are two main types of the disease, — the tertian, in which the paroxysms come on every alternate day with complete freedom every intermediate day ; and the quartan, in which there are two-day intervals, so that the paroxysms occur every fourth day. What happens in a malarial district, however, is that after a patient has been infected by one set of mosquito bites with a tertian or quartan ague, he becomes sub- sequently infected upon different days by other mosquitoes with other tertian or quartan parasites, so that there is a mingling together of the effects of different sets of haematozoa. For instance, if a patient had become infected by two tertian parasites, the one producing rigors upon Monday, Wednesday, Friday, and Sunday, and the other similar attacks upon Tuesday, Thursday, Saturday, and Monday, this patient would have a paroxysm every day, the type being then spoken of as quotidian. If he were infected by two quartan parasites, the one producing attacks upon Monday, Thursday, and Sunday, and the other upon Tuesday, Friday, and Monday, the occurrence of the paroxysms becomes less obviously regular, for the patient would have a rigor upon Monday, another on Tuesday, none on Wednesday, a rigor upon Thursday and Friday, but none on AN.¥.MIA 35 Saturday, and so on. Each infection by a fresh brood of malarial parasites complicates the clinical picture, until finally, in those who have been long in malarial districts, the attacks of pyrexia may be quite irregular or even almost continuous. Each paroxysm has three characteristic stages, any one of which may last from half an hour to two or three hours, or even more. During the first or cold stage, the patient shivers with a severe rigor, feels cold, looks blue and pinched, but nevertheless has a rise of temperature to 102° F. or 103° F. The teeth chatter and the patient wraps himself up to try and keep warm. This is followed by the hot stage, which begins with flushing of the face, severe headache, pains in the back, further rise of the temperature to 104° F. to 106° F., and a sensation of such heat that the patient throws oft the clothes and calls for cooling drinks. This ends in the third or sweating stage, during which the skin, previously dry, breaks out into perspiration so severe that all the bed-clothes may become wringing wet. The temperature now falls, and the patient, more or less exhausted, sleeps, and on waking feels comparatively well except for a sense of weakness ; he may be able to do his ordinary work until the next paroxysm comes on. Onlv in a few cases do much severer symptoms supervene if proper treatment be adopted. In the absence of treatment, however, malaria may lead to h^•perp^^:exia (107° F.-ii2° F.) ; to coma; or to a condition of algidity and collapse ; any one of which may end in death. The diagnosis may be confirmed to some extent by finding that the pyrexial outbursts diminish or cease altogether under the administration of quinine, but the only real proof of the nature of the complaint is the discovery in the blood of the malarial parasites (Plate XII, Figs. A, B,C, D, and E). In this connection it is important to note that the administration of quinine renders it difficult or impossible to find these in blood films, and then the behaviour of the leucocytes (see above) may be very helpful. For a detailed account of all the stages and appearances of various malarial parasites, text-books of tropical medicine should be consulted. There are two main t^^es to be seen in films stained by Leishman's method — the ring-form and the crescent-form. The latter are perhaps the rarer, though the severer t^'pes of malaria, particularly the sestivo-autumnal form met with on the West Coast of Africa, are generally due to it ; the crescentic parasites cannot be mistaken for anything else. The ordinary tertian and quartan agues are due to the ring form of parasites, which, though the two types are distinct from one another, are sufficiently similar not to be distinguishable in films except by experts. In either case the Hcemamceba malaria;, tertian or quartan as the case may be, has a double hfe cycle, half of which is spent in the mosquito, the other half in man. The bite of an infected mosquito introduces spores into man's blood, where they grow, become amceboid, and invade red corpuscles, enlarging at the expense of the haemoglobin, producing pigment granules, finally segmenting, and then breaking up into spores again, which in their turn invade fresh corpuscles, and repeat the cycle, which lasts 48 hours in the case of the tertian, and 72 hours in the case of the quartan parasite. Plate XII, Fig. A represents the first stage in which the haemamoeba spore has invaded a red corpuscle ; Plate XII, Fig. C represents it when it is approaching maturity within the red cell ; and Plate XII, Fig. D represents it when ready to break up into spores. If blood is examined at the very beginning of the rigor, the stage most commonly seen is that of Plate XII, Fig. B. The two chief points of morphological distinction between tertian and quartan parasites are, first, that the pigment granules are much blacker and fewer in number with the quartan than the tertian, and secondly, that in the rosette stage, the quartan segments are fewer than the tertian. One remarkable feature about malaria is that it may remain latent for many years, and yet recur in those who have long since returned to Great Britain from the tropics. What has happened to 36 ANEMIA the parasites in the interval is not known, but their re-appearance is brought about by such conditions as general depression of health from overwork or worry, or as the result of some intercurrent malady. (B).— ANEMIAS WITH AN INDETERMINATE OR NEGATIVE BLOOD PICTURE. The diagnosis of the fact of anaemia is made by means of a blood-count, but the cause of the anaemia itself is not indicated by the blood condition in the great majority of cases. The differential diagnosis has to be made on other grounds. One may subdivide Group B into four sub-groups, namely, (i) Those cases in which the anaemia is slight and in itself not a very prominent symptom ; e.g., in an indoor worker or a convalescent : (2) Those cas'es in which, though the anaemia may be severe, the routine examination of the patient discovers some more or less obvious and not absolutely uncommon cause for it ; e.g., chronic tubal nephritis : (3) Those cases in which, though the anaemia naay be severe, no obvious lesion can be discovered, but in which there is nothing about the case to suggest that the condition is a rare or unusual one ; e.g., chlorosis : (4) Those cases in which the anaemia may be more or less severe, in which there may or may not be obvious lesions to account for it, but in which the circum- stances of the case suggest that the disease is unusual or rare ; e.g., chloroma. 1. Cases in which the anaemia is slight and in itself not a very prominent symptom. — It is quite clear that before a so-called anaemia reaches its severe stage it must pass through a phase when it would be regarded as slight or mild. This group therefore really includes all the other groups at some stage of their development, and it is clear that the diagnostician will often label a case to start with as comparatively mild or unimportant, when the course of events ultimately shows that this was wrong. For instance, a case of pernicious anaemia may exhibit what seems to be unimportant symptoms for months or years before the anaemia reaches so definite and severe a stage as to be diagnosed correctly. For the purpose of the present work, the group now under discussion is meant to include only such slight degrees of anaemia as are themselves not important in the matter of diagnosis ; for instance, in people who live too much indoors, in those who are convalescent from some acute or subacute illness, in those who suffer from chronic indigestion, constipation, obesity, some forms of chronic intoxication by microbial products, as in cases of infective synovitis and arthritis, pyorrhoea alveolaris and oral .sepsis, uterine or ovarian disease, the earlier stages of phthisis, latent or deep-seated caseous glands or tuberculous affection of joints, vertebrae or peritoneum in children, the milder cases of plumbism, and so on ; in all these cases there may be a sufficient degree of anaemia to attract some attention, but the diagnosis will rest upon other symptoms and signs than those connected with the blood, and in most cases the anaemia will not be extreme. 2. Cases in which, though the anaemia may be severe, a routine examina- tion of the patient discovers some more or less obvious and not absolutely uncommon cause for it. HcBmorrhage. — Some of the most striking cases of anasmia in this group are those in which there has been recurrent or severe loss of blood. When the latter has been lost by epistaxis, haemoptysis, haematemesis, haematuria, menorrhagia, metrorrhagia, metrostaxis, purpura, or by the escape of blood per rectum, the nature of the anaemia will generally be obvious, and the differential diagnosis will depend upon the cause of the particular haemorrhage in question (see Epistaxis, etc.). One should insist upon the necessity for a complete blood-count in all these cases, however, in order to exclude pernicious anaemia. AN MM I A 37 leukaemia, and the other conditions in which the blood-picture is positive, lest the bleeding be due to the blood state and not the blood state to the bleeding. The possibility of meljena should also be borne in mind, for without examination of the faeces the extreme pallor resulting from loss of blood from such a lesion as a duodenal ulcer may not be diagnosed correctly. The possibility of hcsmo- philia should not be forgotten, though the way in which the patient bleeds excessively from sUght scratches or cuts will generally point to the diagnosis, especially if there is a family history of a similar condition, males being affected more than females. The blood-picture in cases of haemophilia is entirely negative, the anaemia that results from the bleeding being of the chlorotic type. It is sometimes stated that the result of blood-loss is to produce an anaemia in which the red corpuscles and the haemoglobin are equally reduced, so that the colour index remains more or less normal. This may be true of an acute bleeding such as venesection or post-partum haemorrhage, but the effect of recurrent blood-loss is to produce the chlorotic type of anaemia, in which the red corpuscles are less diminished than is the haemoglobin. Cachexia. — A similar blood picture, namely an anaemia of the chlorotic type more or less severe, but without anything which may be called pathognomonic, either as to the red cells or the leucocytes, is to be found in almost all forms of cachexia, whether due to s^^hihs, tuberculous or maUgnant disease, malaria, oesophageal stenosis, or starvation. A careful physical examination of the patient and enquiry into his symptoms, may point to the correct diagnosis ; but it is to be borne in mind how difficult it sometimes is to detect phthisis, or some cases of carcinoma or sarcoma, even when far advanced. Sputum analysis should not be omitted ; rectal examination should not be forgotten ; the ;ir-rays may serve to detect lesions within the thorax, and Wassermann's serum reaction may be employed when syphilis is suspected. It is remarkable how little anaemia may result from some varieties of cancer, particularly carcinoma of the breast ; whilst other varieties, especially perhaps carcinoma of the stomach, produce progressive anaemia comparatively early. It is noteworthy that, whereas in former times the absence of free hj^drochloric acid from the gastric juice at the proper interval after a test meal, was regarded as good evidence in favour of a carcinoma ventricuU, it has now been firmly established that the hydrochloric acid may be very deficient or entirely absent in a great many other conditions also ; it is absent in almost all cases of advanced carcinoma, whether of the stomach or not ; and in many chronic maladies associated with ill-health all the secretions of the body suffer, and amongst them the hydrochloric acid of the gastric juice. It follows therefore, that it is only when the diagnosis has been narrowed down to there being some lesion of the stomach, that the discovery that the hydrochloric acid is very deficient or absent affords evidence that the lesion is a carcinoma. Parasitic affections sometimes escape recognition, even w^hen they have led to sufficient anaemia to attract attention (see Parasites, Intestinal). The two varieties most apt to be associated with anaemia are Ankylostomum duodenale and Bothriocephalus latus. Bilharzia hcsniatobia may also lead to severe anaemia, but generally does so on account of the H.^maturia [q.v.) that it produces. Certain drugs are apt to produce anaemia of the simple chlorotic type if their administration is continued over a long period ; one may mention in this connection particularly mercury, arsenic, lead and salicylates. Acute mercurial- ism is more commonly associated with severe stomatitis and saHvation, but in chronic cases, in addition to anaemia there is very apt to be a motor type of peripheral neuritis, affecting the limbs and associated with a remarkable tremor, particularly of the hands. The diagnosis is generally arrived at from the ANEMIA fact that the patient has either been receiving mercury inedicinall}', or else is employed in some work in which mercury is used, such for instance as the making of thermometers, mirrors^ and so forth, or the curing of rabbit skins for the manufacture of hats. Arsenical poisoning seldom gives rise to anaemia as its sole symptom ; but it is noteworthy that although hquor arsenicalis is an admirable remedy for the rehef of pernicious anaemia, arsenic itself is also a cause of ansemia amongst those who work in it. As a rule, in addition to anaemia there is marked pigmentation of the skin, and on this account Addison's disease may be simulated. In the latter, however, the pigmentation occurs on the mucous membranes, particularly of the lips and cheeks, as well as upon the skin, and this — though in very excep- tional cases a similar pigmentation within the mouth has been observed in pernicious anaemia, and perhaps after taking arsenic for long periods — is always very suggestive of Addison's disease, and the diagnosis may be confirmed by finding a slight degree of eosinophiha, a remarkably low blood-pressure, down even to 80 mm. Hg or less, attacks of vomiting, syncope, and remarkable asthenia. If there is active tuberculosis of the suprarenal capsules, Calmette's or von Pirquet's reactions with tubercuhn may be positive, but these two tests are now less rehed on than formerly. In arsenical cases it is very possible that there may also be evidence of peripheral neuritis and of hyperkeratosis of the soles and palms. Analysis of the hair will discover an abnormalh^ high percentage of arsenic. The chlorotic type of anaemia in lead poisoning may be very pronounced, but the diagnosis will depend upon other symptoms of which any or all of the following may occur : — a blue line upon the gums ; constipation ; abdominal colic ; a tendency to repeated abortion in women ; peripheral neuritis, particularly of the wrist-drop type ; various cerebral symptoms of anj^ degree between mere headache or insomnia and epileptic convulsions or acute mania ; optic neuritis ; ophthalmoplegia, chiefly affecting the sixth cranial nerve ; a tendency to gout, to albuminuria and granular kidney, and the secondary effects of the latter. The absence of a blue line on the gums does not exclude lead poisoning in those whose teeth are clean ; nor does its presence prove lead poisoning, for most workers in lead exhibit a blue line, whether they have other symptoms or not. In cases of doubt, it may be necessary to collect an abund- ance of urine, evaporate it, and apply the ordinary tests for inorganic lead. The occupation of the patient will often suggest the diagnosis. Salicylates are said to produce anaemia if their administration is continued for a long period ; but it is also possible that the anaemia may be due to the con- dition for which the salic^dates are being given, namely acute rheumatism. The diagnosis is generally obvious. In addition to the anaemia that may result from acute rheumatism itself, there is apt to be pronounced anaemia in some forms of valvular heart disease, particularly in affections of the aortic valves, whether rheumatic or syphilitic. Mitral valvular disease, particularly mitral stenosis, is more likely to cause polycythaemia, unless there is fungating infective endo- carditis. The occurrence of a progressive anaemia in chronic heart cases always arouses suspicion of the latter ; most cases of fungating endocarditis present symptoms of failing compensation, which are often very difficult to distinguish from those due to the mechanical effects of chronic valvular disease ; so that it is very difficult to distinguish a heart case without fungating endocarditis from a similar case in which fungating endocarditis has supervened. In addition to the anaemia, the following points would be in favour of the latter : sijdden and radical changes in the character of the heart bruits, for instance from musical to blowing, and vice versa ; enlargement of the spleen ; the occurrence of haemorrhages, particularly subcutaneous or retinal ; optic neuritis ; p5='rexia, whatever its type, provided it cannot be explained by any intercurrent affection ANEMIA 39 such as tonsillitis or pleurisy ; and symptoms of infarction or embolism in the spleen, kidney, brain, intestine, retinal or peripheral vessels. It is noteworthy that there is but little leucocytosis in infective endocarditis. Cultivations from the blood obtained by aseptic venesection may serve to clinch the diagnosis, and also to indicate what serum or vaccine treatment should be employed. It is in some cases very eas}', but in others relatively difficult, to be sure of the diagnosis of subacute nephritis. Anaemia is a prominent symptom in the chronic nephritis of young people, though the reverse is generally the case in the red granular kidney of later Hfe ; for the differential diagnosis, see Albuminuria. The old aphorism of " the large white person being associated with the large white kidnev " may sometimes suggest the nature of the malady. The anaemia of fungating endocarditis is probably due to the direct or indirect effects of bacteria. Many other subacute or chronic maladies associated with a continual absorption of microbial toxins may have anaemia as a prominent sj^mptom. One may mention, for instance, chronic colitis, whether muco - membranous, " simple " ulcerative, or tropical dj'senteric (see Diarrhcea) ; deep-seated suppuration acts in the same wa}-, and one is familiar with the pallor of patients suffering from empyema ; the development of this anaemia after the crisis of lobar pneumonia, or in connection with broncho-pneumonia in children, not infrequently suggests that an empyema has developed ; the diagnosis will be confirmed to some extent by the physical signs, but it will be chnched by finding pus when the chest is needled. The occurrence of leucocytosis or of a relative increase in the polymorphonuclear cells does not help in determining the presence of pus in the case of empyema so much as in other cases of suppuration, because empyema is nearly ahvays secondary to lobar or lobular pneumonia, and in each of these there is also a polymorphonuclear leucocytosis. Other examples of chronic sepsis which may produce severe ansemia are chronic appendicular abscess ; pyosalpinx ; hepatic abscess ; the breaking down of ovarian or uterine tumours ; chronic endometritis ; pyorrhoea alveolaris ; infection of sinuses connected with bones or joints, particularly in association with unclean tuberculous hip or knee- joints ; psoas abscess ; suppurative periostitis or osteomyehtis, with necrosis of bone ; secondary coccal infections in phthisis with cavitation, or in bronchiectasis. In all these cases there will be fear lest chronic sepsis may be producing lardaceous disease, which itself is also a cause of profound anaemia, with a pecuhar pale yellowish or transparent appearance of the skin, though its diagnosis is exceed- ingly difficult in any but advanced cases. It is guessed at, as a rule, on account of there being a chronic purulent discharge from lung, joint or limb, or else severe tertiary syphilis. There may be enlargement of the Liver and spleen, albuminuria, and a tendency to diarrhoea ; but even when all these symptoms are present, it not infrequently happens that the post-mortem examination shows that there was no lardaceous disease at all. Rheumatoid arthritis is an indefinite group of joint diseases which differ essentially from osteo-arthritis, in that whereas in the latter there are extensive bony as well as joint lesions and few- constitutional symptoms, with the former the changes affect the bones very little compared to the synovial membrane, hgaments and tendons, and there are more or less severe constitutional svm- ptoms, including slight pyrexia, loss of appetite and weight, pigmentation of the skin, and anemia. The nearest lymphatic glands, e.g., the epitrochlear, when the hands are affected, are often enlarged and tender. The diagnosis seldom depends upon the anemia, however. Probably there are manv varieties of rheumatoid arthritis which will some day be classified upon a bacteriological basis into those due to gonococci, streptococci, staphvlococci, pneumococci, Bacillus coli communis, SpirochcBta pallida, and so on. There are two particular 40 ANEMIA types of rheumatoid arthritis in which anaemia is particular!}^ hable to be pronounced, and these are, first, the form in which there is marked spindle- shaped enlargement of all the first interphalangeal joints in adults, whatever other joints may be affected at the same time ; and secondly, a general destruc- tive affection of the joints in children, associated with emaciation, anaemia, enlargement of the spleen and of the h-mphatic glands, and known as Still's disease. (See Joints, Affections of.) Cirrhosis of the liver, sooner or later, leads to more or less anaemia of the chlorotic type, although in the earher stages the alcoholic patient may have a rubicund complexion ; b^' the time the anoemia is produced there would almost certainly have been other symptoms of the complaint, particularly Hfmatemesis {q.v.), Jaundice [q-v.), or Ascites {q-v.). Patients suffering from cirrhosis of the liver often have some degree of evening p^Texia, and they also tend to undue pigmen- tation of the skin. Hyperlactation is a prominent cause of anaemia and general ill-health, especially in women in towns. It is stated that the cause for prolongation of the period of lactation is an idea that pregnancy will not recur whilst the last infant is being suckled. The diagnosis is generally obvious if its possibility is borne in mind. Gastric ulcer, or rather the symptoms which are often stated to be those of gastric ulcer, is frequently associated ^\dth anaemia ; the latter in a few cases is the result of direct loss of blood by H.5Matemesis (q-v.), or, in the case of duodenal ulcer, Mel-bna {q.v.) . A duodenal ulcer may sometimes simulate gastric ulcer, but more often it produces s^'mptoms which are apt to be mistaken for gall-stones, the pain being referred to a spot about an inch below the tip of the ninth right rib. As a rule, the pain in cases of duodenal ulcer bears a definite relationship to food, being greatest when the patient is beginning to be hungry, and reheved by the taking of food. Gastric ulcer, on the other hand, is much more difficult to diagnose, for even when the patients have suffered from epigastric pain coming on immediateh^ after food, from vomiting Avhich relieves the pain, and from one or more attacks of haematemesis, it is possible for the latter to be due to generalized oozing from the gastric mucosa — Hale White's " gastrostaxis " — rather than a definite measurable ulcer. AATien there has been no haematemesis, the diagnosis is still more difficult, though it is noteworthy that in nearly half the cases in which the presence of an ulcer has been proved by operation, there has been no history of haematemesis. It was formerly stated that gastric ulcers are common in the female sex between the ages of fifteen and thirt}.', especially in the unmarried and the ansmic ; notably amongst the servant class ; operative demonstrations of gastric ulcers, however, would seem to show that they are really commoner in later fife, and affect men as often as women, so that there is a very decided possibihty that the gastric symptoms of anaemic women are not in fact due to ulcer. One meets with patients who have pain the moment they take food, in whom vomiting after meals is persistent, in whom the diagnosis of gastric ulcer would certainly have been made in former j'-ears, but in whom that diagnosis is made now onh^ with considerable caution. It has become increasingly recognized that the vomiting and the gastric signs are often due to the anaemia itself, and it is possible that they are in some way related to anaemic dilatation of the heart. In diagnosing betAveen this condition and that of true gastric ulcer, one of the best plans is to put the patient to bed, and when she has been recumbent for twenty-four or thirty-six hours, to see what is the effect of giving her full diet. Full diet will be borne quite well in cases of severe anaemia associated with gastric symptoms without ulcer, so long as the patient remains in bed ;.but if she gets up and returns to work before the anaemia is cured, the gastric symptoms come on again directly. The vomiting and the epigastric pain seem to be related not so much to food as to work in ANEMIA 41 these cases. When there is an ulcer, however, an attempt to adopt full meat and vegetable diet on the second day of resting in bed nearly always fails if there have been severe symptoms up to that time. 3. Conditions in which, though the anaemia may be severe, no obvious lesion can be discovered, whilst at the same time there is nothing to suggest that the case is a rare or unusual one. Chlorosis is almost the only malady which comes under the above heading, provided one also includes the milder anaemias of girls and young women, as well as tho.se severe cases of yellow-green sickness to which the term should strictly speaking be limited. The cases of ansemic vomiting just discussed might also come under the same heading. Chlorosis and simple chlorotic anaemia, without obvious organic lesions, are affections of the female sex — absent before puberty and common immediately after, seldom lasting after thirtj^ years of age, and generally not so long ; cured as a rule by marriage ; never fatal even when severe ; an affection of all classes, but mostly of indoor workers such as servant girls, and not often affecting those who are employed in outdoor pursuits. The diagnosis is generally easy. The patients are comparatively well covered though they often eat very little. Emaciation is rare in chlorosis, and this is probably due to the fact that the blood is less deficient in quantity than diluted by excess of water. The leucocytes are normal both in total number and in their differential count. The red corpuscles are often much less diminished than might be expected from the appearance of the patient, the chief feature of the complaint being the great reduction in the haemoglobin, so that the colour index may fall to 05, 0-3, or even less. As the condition improves, the red cells return to normal fairly quickly, and the haemoglobin rises steadily but less rapidly. The way in which the patients react to treatment by rest in bed, by the giving of iron, by keeping the bowels open, and by living in a sunny atmosphere, is remarkable, and helps to clinch the diagnosis in any case of doubt. It has been mentioned above that there are many blood changes which are common to severe anaemias ; it should be noted that even when the haemoglobin has fallen to 30 per cent of normal in a severe case of chlorosis, the changes in the blood-cells enumerated on page 27 seldom appear. Chlorosis, more often than any other form of anaemia, leads to haemic cardiac bruits, particularly a blowing systolic bruit in the pulmonary area and a bruit de diable in the neck. The patients are nearly always more or less constipated, and are apt to suffer from menstrual irregularity, particularly amenorrhoea which may last for months, and a tendency to oedema of the feet. Examination of the viscera discovers no abnormality in any of them. Chlorosis, unlike many other forms of severe anaemia, seldom produces albuminuria. 4. Cases in which the anaemia may be more or less severe, in which there may or may not be obvious lesions to account for it, but in which the circum- stances of the case suggest that the disease is unusual or rare. Hodgkin's disease is often spoken of as though it were an affection in which the blood-count indicates the diagnosis. This is not the case, however, the blood changes being merely negative, though a blood-count is essential in order to exclude leukaemia by finding that there is no leucocytosis. At first there is no anaemia ; later there is progressive anaemia of the chlorotic type, with finally all the changes in the red cells common to the severe anaemias (see above). There is no leucocytosis, or none of moment. The differential leucocyte count may be like that of a normal person ; more often, however, there is some relative increase in the lymphocytes with proportionate relative diminution in the polymorphonuclear cells, and when a large number of white corpuscles are examined, it is probable that an occasional myelocyte and one or two basophile corpuscles will be detected. The diagnosis is made 42 AX.EMIA upon the enlargement of the Lymphatic Glands (q-v.) and of the Spleen (q-v.), and in a negative way upon the blood changes. Splenic aiiiBmia is a malady in which there is considerable enlargement of the spleen, progressive and persistent anaemia of the simple chlorotic type, and no other verj' obvious evidence as to what is wrong with the patient. It is very probable that more than one condition is at present labelled splenic anaemia ; a considerable number of the cases turn out ultimately to be cirrhosis of the hver, in which enlargement of the spleen happens to have been the first symptom to attract attention, ver}' likely years before the other effects of cirrhosis manifested themselves. \Mien splenic anaemia is the original diagnosis in a case which ultimatelj' proves to be cirrhosis of the hver, the condition is often spoken of as Banti's disease. Aplastic ancFmia has been mentioned above, and there are a considerable number of obscure cases of severe anaemia to which up to the present no definite labels can be attached. Some of these simulate pernicious anemia, but all differ from the latter in having a colour index persistently less than i. One can only refer to them as severe and even fatal un-named anaemias. Pseiido-lenkizmia infantum is a condition in which enormous enlargement of the spleen takes place in a young child or infant {Fig. 2) , associated as a rule with more or less ascites and huge enlargement of the abdomen. So great is the splenic enlargement, that the condition at first suggests leukaemia ; but when a blood-count is made, although the red cells ma}^ be very much diminished and exhibit all the changes- characteristic of severe anaemia, there is no leucocytosis, so that the condition cannot be classified as a leukaemia, and hence is termed ' pseudo- leukaemia infantum.' From its first de- scriber, it has also been called ' von Jaksch's disease.' It generally begins at an age of less than two years. The hver is enlarged, but less so than the spleen. There may be severe haemorrhage from the mucous membranes, and there is often periodic pyrexia. The disease may be mistaken for rickets or for congenital S5'phihs ; indeed some authorities think that it is really due to one or other or both of these causes in an exaggerated degree. Others, however, consider this not to be the case. "WTiether this is so or not, the prognosis is fair even when the ansmia has reached a severe degree. The ascites ma}' disappear, the huge spleen may become restored to its normal dimensions, and the patient recover completely in the course of months. Myxcedema is a condition which is often mistaken in its earlier stages' for simple anaemia, and consequently it is apt to be overlooked, particularly at that stage which merits the term ' hii'pothyroidism ' rather than myxoedema. It is an affection of women rather than of men ; it comes on verj' slowh" and some- times it can be diagnosed only by watching the beneficial effects of th}-roid treatment. There is general!}'' excess of subcutaneous tissue of a gelatinous nature, which gives the patient the appearance of being puffy or oedematous. J^!£: 2. — Pseudo-leukaemia infantum (von Jaksch's disease). The black line demarcates the spleen. A N.'EMIA 43 especially in the face (Fig. 4), ha.nd?r{Fig. 5), and lower limbs, so that not a few cases are mistaken for nephritis. The urine is copious and of low specific I^ig. 3. — The same patient as Fig^. 4, previous to the development of rayxoedema. Fig. 4. — Myxo?denia : the character- istic facies, illustrating the broadening of the features and the malar flush, (Com- pare Fig: 3). ■ gravity, but it does not necessarily contain albumin. The apparent oedema does not pit on pressure, or pits far less easily than it would if it were ordinary Fig^. 5. — Hands of a patient suflFering from myxoedema, illustrating the swelling of the soft parts, the broadening of the fingers, and their consequent stumpy or podgy appearance. oedema ; the skin becomes thickened, and the hair decreases in quantity and becomes brittle. Physical movements are lethargic, and the intellect dull, so 44 A X.EM I A that there is a slowness of action both of the body and of the mind, symptoms that disappear in a remarkable way under th\Toid treatment. The chlorotic type of ana;mia which accompanies it may be masked by a local flush over the malar bones, not unhke that of mitral stenosis. Scurfy is a rare disease, which may lead to the most profound anaemia, though it seldom does so without also producing extensive haemorrhage into the skin, beneath the periosteum of bone, from mucous membranes, and especially from the spongy and foetid gums. It is not a common disease now-a-days, except in a mild form in children, in which the tenderness of the bones associated with anaemia, often mistaken for rickets, is the main symptom. The ten- derness in question is due to local sub-periosteal haemorrhage, and the way in which the complaint rapidly gets better under suitable treatment with fresh vegetable diet helps in chnching the diagnosis. The severer forms of scurvy are due to prolonged deprivation of fresh food, such as is rare in modern practice, though it used to be common on board ships. Chloroma is a very rare affection, related to honphatic leukaemia on the one hand and to hinpho-sarcoma on the other. It is associated with the formation of multiple tumours, especially in connection with bones, and a progressive and severe anaemia of indeterminate t^.'pe. The condition is fatal, and the diagnosis is at once suggested by the green colour of the neoplastic deposits. Herbert French. ANESTHESIA. — (See Sexsatiox, Abnormalities of.) ANALGESIA. — (See Sexsatiox, Abxormalities of.) ANASARCA.— (See CEdema.) ANKLE-CLONUS. — Is best elicited when, the patient lying on his back with his knees slightly flexed, the observer quickly but not violently, dorsifiexes the foot by pressing it firmly upwards, the hand being applied along its outer border in such a way as to keep it well outwardly rotated. The result, when ankle- clonus is present, is a series of rhythmical jerks at the ankle-joint, at the rate of about 7 per second — the contractions continuing as long as the pressure is maintained. The last proviso is important, because it often happens that a few ankle- jerks are obtained, var\-ing in number from two or three to as many as twenty or thirtj^, but gradually tailing off and ceasing, although the pressure on the sole is maintained. This is sometimes spoken of as a " tendency to ankle-clonus," but for clinical purposes it is not ankle-clonus at all, and indicates nothing more than hj-persensitiveness of the nervous s^'stem, and not organic disease. Ankle-clonus, on the other hand, denotes changes in connection with the corresponding crossed p}Tramidal tract, and it is to be expected in association with increased knee-jerk and extensor plantar reflex. Its chief value lies in determining between functional and organic exaggerations of the knee-jerk ; the latter may be very brisk as the result of pure nervousness, but if it is associated with either an extensor plantar reflex or ankle-clonus, or both, the exaggeration is due to organic disease of the upper neurone, hemiplegic or paraplegic as the case may be (q.v.). Whereas, however, the presence of maintained ankle-clonus is conclusive proof of an upper neurone affection, the absence of such clonus does not exclude such lesion ; ankle-clonus is not met with until there is a relatively large amount of lateral column change ; it comes later, as a rule, than the extensor plantar reflex. . Herbert French ANOSMIA. — (See Smell, Abnormalities of.) ANURIA 45 ANURIA — or complete suppression of urine — may arise from a variety of causes, as a complication of surgical disorders of the urinary apparatus, or as a late symptom in a progressive incurable disease. From whatever cause it arises, anuria is a symptom of grave import, requiring urgent surgical measures to reheve any obstruction to the passage of urine from the kidney that may exist if impending death from uraemia is to be avoided. Anuria may be complete, or occasionally, after a period of suppression, a small quantity of urine may be secreted again, to continue in sufficient amount to meet the requirements of the patient, or again to return to complete anuria. It must be distinguished carefully from retention of urine, in which urine is secreted from the kidneys, but is retained in the bladder from some lesion causing obstruction to the urethra, as in urethral stricture or prostatic obstruc- tion in the male, or from the pressure or drag upon the urethra by a large pelvic tumour or by a retroverted gravid uterus in the female. Retention of urine may also occur in either sex without any urethral obstruction, in various forms of disease of the spinal nervous system affecting the lumbar centres. In retention of urine there is pain above the pubes, constant and urgent desire to pass urine, and the distended bladder can be felt as a tense, oval, dull tumour above the pubes in the middle line, and rising from the pelvis. In many cases a previous history of obstruction to the urinary flow will be obtained, whilst in others the involuntary dribbling of urine from the urethra from an over- distended bladder will readily distinguish the case from one of anuria. CAUSES OF ANURIA. A. — Obstructive : — Calculus in kidney or ureter Vesical carcinoma involving the ureteric orifices Uterine carcinoma Large pelvic or abdominal tumours. B. — Non-obstructive : — Toxic, in acute fevers In renal disease, nephritis, lardaceous disease, tuberculosis, polycystic disease, suppurative pyelonephritis Reflex, after operations or trauma In poisoning from mercury, lead, phosphorus, or turpentine In severe collapse Hysteria. Anuria may occur and be complete without any other symptom, and it is a remarkable fact that in the obstructive forms, especially perhaps with calculus, anuria may be complete for several days without any other symptom — latent uraemia. In the non-obstructive forms, anuria may be accompanied from the earliest onset by the various symptoms of uraemia, such as vomiting, convulsive muscular twitchings, dyspnoea, and headache. In the obstructive form of anuria, there may be total absence of any urine secreted, or a small quantity may be passed of low specific gravity, and containing very Little urea or solids. Albumin is absent unless there be haematuria or cystitis, when pus may be present also. The patient may complain of aching in one or both lumbar regions, but, with the exception that no urine is passed, seems to be in ordinary health. The appetite is good and the mental state quite clear ; but after a variable period, from seven to ten days, the patient becomes drowsy, the tongue dry, temperature subnormal, appetite deficient, and pupils small. There may be muscular twitching ; but the drowsiness gradually becomes deeper, without any true urasmic convulsions, and death may be postponed for as long as twenty days from the onset of the anuria. This sequence is very different from that seen 46 ANURIA when anuria occurs from non-obstructive causes, when there is frequently marked disturbance of the nervous system ; headache and giddiness are rapidly followed by convulsions, dehrium, and dyspnoea, with vomiting and small pupils, the patient rapidly becoming comatose and dying in a few days. It remains to consider the diagnosis of any case in which anuria is a symptom. A. — Obstructive Anuria. Calculous Disease is the most frequent cause of obstructive anuria. It may occur at any age, but is more common in men about forty years of age. Suppression of urine may arise from the impaction of a small calculus in the ureter of a kidnQj which is practicallj' normal in structure, or may be due to the total destruction of the renal secreting substance, which has progressed gradually and without marked symptoms. Between these two extremes there may be many stages, and the two conditions, namety, ureteric impaction and renal destruction, ma^' exist at the same time. Chnically, it is rare to find that calculous anuria is due to the simultaneous blockage of both ureters by calcuU, but rather that one kidney has been previoush^ destroyed b}^ previous disease or is absent, whilst the ureter of the remaining functional organ has become obstructed. Exceptionally, the blockage of one ureter by stone may cause a reflex suppression of urine in the other kidney, especially if the function of the latter is already impaired by disease and so rendered more susceptible to nervous influences ; but in these cases the anuria is usually but temporary. Calculous anuria may occur suddenly, and in patients who are apparently- in good health, for it is no uncommon thing for a patient to go on in good health when he possesses only one functionally active kidney, the other having been destroyed by slow disease, or being absent. Though, as a rule, there is an old-standing disease in one kidnej^ before the other functional organ becomes obstructed, yet the damaged organ carries on a certain amount of excretion until the sudden obstruction to the sound kidney occurs ; the additional stress thrown upon the damaged kidney proves too much for it, and complete suppression occurs. Calculous anuria may occur suddenly in a patient who has thought himself pre\dously well, or there may be a history of previous lumbar pain, haemat- uria, p^Tiria, or the passage of calcuU. At the onset of anuria there is usually pain in the lumbar region along the course of the ureter of the side most recently affected ; it commonly lasts a day or so and then subsides, or it may last throughout the period of anuria. In addition, there is frequently a constant desire to micturate, although no urine is passed, or if the anuria is intermittent, urine of pale colour and low specific gravity, sometimes blood-stained, may be passed. If the anuria remains complete, no other symptoms may occur . for several days, a feature which is common to the obstructive forms of anuria, but is in marked contrast to the non-obstructive variety. After a period of anuria lasting from seven to ten days, the patient becomes drowsy, the tongue is dn,-, there is disinchnation for food, and the general symptoms of uraemia may come on ; but in many cases the patient maj' die before any symptoms of uraemia occur. Thus, it is usual to speak of a tolerant and a urcemic period in obstructive anuria. The tolerant stage of obstructive anuria may be even further prolonged if the functional kidney be already hydronephrotic from previous intermittent obstruction, even to twenty days. The sudden obstruction to the urinary flow in a comparativel}^ normal kidney causes complete suppression, whilst a partial or intermittent obstruction causes dilatation of the kidney. If such a kidney be the functionating organ, and become completely obstructed, the dilatation will increase ; thus the presence of a lumbar tumour with anuria indicates that urinary secretion is still going on, and, although ANURIA 47 insufficient to maintain life, yet enough to form an important element in prognosis, and an indication for immediate operation. If there have been previous attacks of renal colic, accompanied or followed by the passage of blood or of a calculus, the sudden onset of pain in one loin and anuria suggest obstruction of a calculous form. If there is any swelhng or pain on pressure over the kidney or along the course of the ureter, the diagnosis is strengthened, or there may be evidence in the history pointing to disease of one kidney, or information obtained by an operation or previous skiagraphic examination. In some cases in which one kidney has been destroyed gradually without pain, and anuria occurs, there may be great difficulty in determining which of the two kidneys is the functional organ which has recently become obstructed, so that appropriate surgical measures may be undertaken to relieve it. In these cases, the onset of pain in one side points to the side more recently affected, and it is a good rule to operate upon the side on which the pain has most recently occurred. Assistance may be obtained by the palpation of the ureter through the abdominal parietes, if the patient is not too stout, when a distinct area of pain may be obtained over a calculus impacted in the course of the ureter ; or by a careful rectal or vaginal examination, a calculus impacted in the vesical end of the ureter may be felt. If the case is seen early, evidence of ureteric calculus may be obtained by inspection of the ureteric orifice by the cystoscope, or a ureteric bougie impermeable to the Rontgen rays may be passed into the ureter and a skiagram obtained, but it is only exceptionally that this can be carried out. In any case one may strongly urge the necessity of operation upon the side of the recent pain, when the kidney can be opened and drained, and opportunity taken to explore as much of the ureter as can be felt by the_ parietal incision and by catheterization from above. In a recent case of partial calculous anuria under the writer's care, one kidney had been unsuccessfully explored for calculus two years previously. The patient complained of pain on the other side, and per rectum a calculus could be felt in the lower end of each ureter. As the anuria was not complete, a skiagram was obtained, and the diagnosis confirmed. The calculi were removed, with an excellent result. Anuria from Vesical Carcinoma. — Anuria occurring from vesical carcinoma implies that either both ureteric orifices must be involved in the disease, or that the ureteric orifice of the only functional kidney is implicated. The condition is uncommon as a pure obstructive anuria, for in most cases the kidneys are already the seat of changes due in part to the back pressure and in part to sepsis, so that when anuria terminates a case of vesical carcinoma, it is more.often due to renal disease than to ureteric obstruction. If the bladder has remained uninfected by septic organisms, the gradually increasing ureteric obstruction may first cause hydronephrosis, so that when the obstruction becomes complete, the renal distention may increase quickly, and the sym- ptoms of uraemia be delayed. In cases arising from vesical carcinoma, it is very rare for the anuria to occur before any symptoms of vesical growth are apparent, such as haematuria, pyuria, increased frequency and pain on micturi- tion, but in the infiltrating type of carcinoma, haematuria and frequency of micturition may be absent for a long time. In all cases, a careful vaginal or rectal examination will detect a distinct infiltration and thickening of the base of the bladder. Uterine Carcinoma. — Anuria is a very frequent symptom in the terminal stage of uterine carcinoma, when the growth has extended into the cellular tissues of the broad ligament and involved the terminal portions of the ureters, or when the orifices of the latter are implicated in the direct infiltration of the growth into the bladder base. In the very large majority of cases dying from 48 ANURIA uterine cancer in the inoperable wards of the London Cancer Hospital, the kidneys are found to be hydronephrotic, the renal pelvis dilated, or the renal secreting tissue sclerosed, apart from the frequent infection with septic micro- organisms. In all cases the growth has reached an advanced stage, and the disease has been apparent, but it has been recorded that anuria has occurred before the patient has complained of any symptom pointing to the uterine con- dition. These cases might simulate other forms of obstructive anuria, but the diagnosis would be apparent upon the vaginal examination. Pelvic or Abdominal Tumours, such as uterine fibromyomata or ovarian carcinomata, may cause anuria from the direct pressure on the ureters, especially if a part of the tumour is impacted in the pelvic cavity. The cause of the anuria will be apparent on examination of the abdomen and of the pelvic organs. B. — Non-obstructive Anuria. Marked diminution in the amount of urine or complete anuria, may occur without any obstructive lesion of the urinary apparatus, due in many instances to disease of the renal secreting tissues. In many of these cases the symptoms differ in a remarkable manner from those seen in obstructive anuria, in that the occurrence of anuria is accompanied by marked symptoms of urEemia in a short time, and not after an interval of days, as in the obstructive cases. Anuria may occur under certain toxic conditions, as in acute fevers, or in acute poisoning by mercury, lead, phosphorus, or turpentine ; the history and accompanying symptoms of such cases are usually sufficient to point to the nature of the urinary suppression. Anuria in Renal Disease. — In acute nephritis, anuria may occur early or after the disease is well established, and is usually accompanied by marked disturbance of the nervous system. The sudden onset of the disease after exposure to cold, or in the course of an acute specific fever such as scarlet fever, associated with pallor, backache, puf&ness of the face and ankles, and shght p3''rexia, together with the small amount of urine passed before the suppression becomes complete, are points all suggesting acute nephritis. If the urine has been tested before the onset of anuria, it is often of reddish-brown colour from the presence of blood, and contains abundant albumin, together with renal, epithehal, and blood-casts. In chronic nephritis, anuria may occur as a late sj^mptom in the disease, and is occasionally preceded by a period in which polyuria is marked. Anuria in chronic nephritis is accompanied by prominent sjonptoms of uraemia, such as headache, giddiness, convulsions, stertor, and coma, and unless the flow^ of urine is quickly re-estabhshed, death rapidly ensues. The previous histor}' of the case, high arterial tension, cardiac hypertrophy, retinal changes, and signs of back-pressure, with or without ascites and anasarca, will point to the nature of the anuria. In other diseases of the kidney, such as lardaceous disease, suppurative pyelonephritis, or in bilateral tuberculosis, anuria may be preceded by general failing health, with loss of appetite, subnormal temperature, a dry brown tongue, and headache ; frequentl}^ there may be pohnaria before suppres- sion occurs. In these cases the anuria is a terminal symptom of the case, when in all probabihty the condition of the kidneys has been known previously. With the occurrence of anuria there may be great restlessness, with muscular twitch- ing, loss of sphincteric control, convulsions, and a gradual lapse into coma. Polycystic disease of the kidneys frequently terminates in anuria and uraemia, but the diagnosis of the disease has probably been arrived at previousl}'. The symptoms resemble in a great measure those of chronic nephritis, with the exception that ascites and oedema of the extremities are uncommon. Headache, flatulence, and digestive troubles, sickness, and general lassitude are symptoms APPETITE, ABNORMAL 49 of renal inefficiency, whilst arteriosclerosis, a bilateral renal tumour, and a low-specific-gravity urine in increased quantity, would suggest polycystic disease. Anuria following Operations or Trauma. — Anuria may occur in patients who have undergone an operation and who are the subjects of renal disease, or may occur occasionally even when no renal disease is present. Any extensive operation which involves a good deal of shock in a patient with renal disease, or in whom the kidneys have been subjected to back-pressure, as in uterine m.yomata, may succumb to anuria unless appropriate measures are undertaken, whilst on the other hand an apparently trivial operation on the urinary organs may cause acute suppression of urine. This must be differentiated carefully from the retention of urine in the bladder often seen after operations, such as for haemorrhoids or for hernia. Acute suppression of urine may follow operations upon the lower urinary tracts, such as the passage of instruments, and in one case under the writer's care it occurred in a patient with apparently healthy kidneys, after internal urethrotomy. Anuria is particularly liable to occur when a catheter is passed to relieve an over-distended bladder in a case of prostatic enlargement or urethral stricture, in which the kidneys are already distended from back-pressure or infected with septic processes, and it must be laid down as a golden rule, that if a catheter is passed in these cases, the urine must be withdrawn very gradually, so as to allow the kidneys to maintain their function under the altered condition of pressure. Anuria following operations upon the lower urinary tract is diagnosed by the direct relationship between the operation and the onset of symptoms ; by the rigors, pyrexia, and the profound prostration, rapidly followed by convulsive move- ments and coma. Anuria may also occur in the severe collapse following an injury, in the late stages of cholera or yellow fever ; and occasionally as a manifestation of hysteria ; or it may be due to fraud. R. h. Jocelyn Swan. APHASIA (See Speech, Abnormalities of.) APHONIA. — (See Speech, Abnormalities of.) APPETITE, ABNORMAL. — Appetite may be : (i) Increased ; (2) Diminished ; (3) Perverted. 1. Increase of Appetite sometimes occurs in cases of hyperchlorhydria. The general condition is then well maintained, there is usually pain or discomfort in the later period of digestion, relieved (temporarily) by the taking of more food. A test meal shows excess of hydrochloric acid. In diabetes, especially in its earlier stages, there is often an abnormal craving for food ; but in spite of large meals the patient wastes. Examination of the urine will establish the diagnosis. Intestinal parasites (round-worms and tape-worm) are believed to be a cause of excessive appetite in some cases. This is doubtful ; but in any case the point can always be cleared up by giving an anthelmintic. In some cases of hysteria an excessive appetite is present (bulimia). The patient is usually a young woman, and other stigmata of hysteria are present. 2. Diminution of Appetite occurs in many forms of dyspepsia, especially when associated with a lessened gastric secretion. Thus it is almost constantly present in gastritis, except, perhaps, in the acid form. If renal disease, advanced mitral disease, or cirrhosis of the liver be present, secondary gastritis may be diagnosed. If there be a history of the abuse of alcohol or tobacco, or of indiscre- tions in diet, or if there be a marked defect of the chewing apparatus, there is probably primary gastritis. In any case, the tongue will probably be furred, D 4 50 APPETITE, ABNORMAL and a test meal shows diminished acidity and probably an excess of mucus, but the examination of the stomach otherwise is negative. (See also Indigestion.) Loss of appetite is also an early symptom in cases of gastric carcinoma, and should lead, especially in elderly subjects, to careful examination for other signs of that disease. There is frequently a special distaste for meat in such cases. (See Indigestion.) In children a profound anorexia is sometimes an early symptom of tuberculosis. In hysterical young women complete disinclination for food {anorexia nervosa) is sometimes met with. The diagnosis is based upon the absence of other causes of the symptom, the presence of other signs of hysteria, and the history of mental or emotional shock. The loss of appetite in such cases may amount to a complete refusal of all food, and the patient may emaciate to a dangerous degree. Obstinate constipation is usually present as well. Allied to these cases is the loss of appetite which occurs in melancholic forms of insanity. In such a case delusions may be present. 3, Perverted Appetite may occur in the course of pregnancy , and is of no special significance. It is met with, too, in nervous, anaemic children, in whom it often takes the form of dirt-eating {pica) . Here, also, it is not a sign of any diagnostic value. Perverted appetite is also a common occurrence in insanity ; but other evidence of mental disturbance is always present as well. Robert Hutchison. ASCITES.^ — Ascites, or the accumulation of serous fluid in the peritoneal cavity, is an indication of disease, and it may be the main symptom in a particular case ; but it is not a disease in itself. It may be produced by a great variety of conditions — Bright's disease, cirrhosis of the liver, tuberculous peritonitis, cardiac disease. It is easy to determine its precise cause in some cases ; in others it may be almost impossible to say what is the primary condition pro- ducing the ascites. One may discuss (I) Its physical signs ; (II) How to distinguish it from other conditions which may simulate it ; (III) A classified list of its causes ; and finally, (IV) The chief points about each particular variety which will help in arriving at a correct difjerential diagnosis when a case is met with in practice. I. — The Physical Signs of Ascites. Inspection. — The abdomen is uniformly distended, the degree varjdng with the amount of fluid. If the quantity is large, and its accumulation has been rapid, the abdomen presents a rounded, globular appearance, the umbilical region being the most prominent. The skin is tense and shiny. If the quan- tity of fluid is large, but its accumulation has been gradual, bulging of the flanks is the most prominent feature of the general distention. Large effusions cause well-marked linese albicantes in the lower half of the abdominal wall, the lower ribs may be somewhat pushed outwards, and the epigastric angle widened. If the quantity of fluid is small, only a slight bulging of the flanks may be noticed. The appearance of the abdomen depends a good deal on the position of the patient. If lying on one side more than the other, the most dependent part is the most prominent, owing to the fluid gravitating to that side of the abdomen. If the patient stands or sits upright, the hypogastric and iliac regions will be most bulged. The umbiUcus becomes stretched transversely and flush with the surface, or even protruded ; it retains its position in the median abdominal line, and remains nearer to the pubes than to the ensiform cartilage. In tuberculous peritonitis the skin in its immediate neighbourhood may be reddened, inflamed, and ASCITES 51 oedematous, or there may even be a small fajcal fistula here. In cirrhosis of the liver, the veins around the umbilicus are said to be dilated, but the so- called ' caput medusae ' is of extreme rarity. The superficial veins all over the abdomen and lower part of the chest may be dilated, the blood flowing in an upward direction, this reversal of the stream occurring mainly when the inferior vena cava is obstructed either by the tension of the ascites or by something related to its cause. (See Veins, Varicose Abdominal.) The abdominal respiratory movements may be absent or much diminished. The cardiac impulse may be displaced upwards and outwards. The legs and thighs may be oedematous, and so may the loins. Palpation. — The abdomen may be anything between quite flaccid and very tense. A fluid thrill may be obtained by placing the palm of one's hand flat against one of the lumbar regions, and gently flicking the other flank with the fingers of the other hand ; the possibility of a thrill being transmitted in the abdominal wall should be eliminated by getting the patient or an assistant to place the side of his hand on the front of the abdomen, so as to stop the mural thrill at the point of contact of the hand with the abdominal wall. If the above precaution is taken and a thrill is still obtainable, it denotes the presence of fluid. If the liver or spleen have enlarged, they sink backwards, so that between these organs and the abdominal wall a layer of fluid is present ; if the hand placed on the abdomen, in the right or left h^'pochondriac regions, as the case mav be, is suddenly depressed, this fluid is displaced, and the surface of the enlarged organ can then be felt. This phenomenon of " dipping " is almost pathognomonic of ascites. The direction of the blood-flow in dilated veins, the position of the cardiac impulse, and the diminished respiratory movements may be confirmed by palpation. Percussion. — When the patient lies flat on his back the fluid gravitates to the posterior part of the abdomen, and the air-containing viscera float to the anterior part, so that the percussion note is resonant in front and dull in the flanks. As the fluid increases in quantity, the line of dullness creeps forward from the flanks and upwards from the pubes, and keeps a concave upper border ; in extreme cases the abdomen may be dull all over, particularly in children. One of the most prominent physical signs of ascites is the effect produced on the percussion note by a change in the posture of the patient. If, after examining him lying on the backhand finding dullness in the flanks and resonance in the front, he be turned on one side, the uppermost flank becomes resonant and the line of dullness on the other side rises nearer to the median abdominal line. This phenomenon is due to the fluid gravitating to the most dependent part. In some cases, especially of tuberculous peritonitis, shortening of the mesentery is apt to be associated with the ascites ; the intestines cannot then rise, and the result is dullness all over the abdomen. Chronic peritonitis may cause the fluid to be loculated through matting together of the intestines. The abdominal distention may then not be uniform, and change of posture may not alter the character of the percussion note. If only a very small quantity of fluid is present, the abdomen may be resonant all over when the patient hes on his back ; but if he is percussed in the knee- elbow position, the umbilical region may be found to be dull. Mensuration. — The abdomen should be measured, fixed points being taken in front and behind, e.g., the umbilicus in front and the tip of the third lumbar spine behind. This is important in order to watch the effect of treatment. The distance of the umbihcus from the ensiform cartilage, pubes, and anterior superior iliac spines should also be noted. In ascites, the navel is nearly always 52 ASCITES nearer the pubes than the ensiform cartilage, and equidistant from the two anterior superior ihac spines when the patient hes flat on his back. It is always important to examine the abdomen carefull}^ after paracentesis has been performed. The diagnosis of the cause of the ascites can often be made or confirmed in his way, tumours, or enlargements of organs being made out which previously- were hidden or obscured by the tenseness of the abdominal waU. II. — The Diagnosis of Ascites. Ascites has to be distinguished from other conditions which maj- give rise to general abdominal distention, especiall]/ from : — (i) Tympanites ; (2) Ovarian and parovarian cysts ; (3) Gravid uterus with hydrops amnii ; {4) Distended bladder ; (5) Distention associated with obesity ; (6) Phantom tumour ; (7) Large abdominal cysts and solid tutnoiirs. 1. Tympanites is distinguished from ascites b}^ the following signs : — The outhne of distended coils of intestine may be visible, and peristaltic move- ments ma}' be noticed. There is no fluid thriU if precautions to prevent a thrill being transmitted by the abdominal w-all are taken. The abdomen is resonant all over, both in front and in the flanks. 2. Ovarian Cyst. — There ma}' be a historj' of the enlargement of the abdomen having been noticed at an earl}^ date to be more on one side than the other, and to have arisen from the pelvis. The umbihcus may be nearer to the ensiform cartilage than the pubes, and nearer to one anterior superior iliac spine than the other. A fluid thrill may not be obtained far back in the flanks, but only in front of the mid-axiUary lines. There is usually dullness in front, with resonance in the flanks. The outhne of the cyst may possibly be noticed during the respiraton,- movements. On measuring the abdomen the greatest circumference is usuallj' below the umbilicus ; whereas in ascites it is generally at the umbihcus. A vaginal examination may reveal that the uterus is drawn upwards and that its mobihty is impaired ; whereas in ascites it is low down and movable. If paracentesis has been performed, the nature of the ovarian fluid is characteristic, being usually thick, tenacious, \ascid, and of a brownish or greenish colour ; whereas ascitic fluid is yellowish, hmpid, and clear. iluch difiiculty arises when there are both ovarian cyst and ascites, owing to infection of the peritoneum b}' secondary deposits from the ovary. Even without this, however, it is by no means alwaj^s easy to distinguish between ovarian cyst and ascites, particularly when the resultant abdominal distention has become extreme. 3. A Gravid Uterus with Hydrops Amnii. — In this condition it maj- be possible to make out : — The outhne of the enlarged uterus ; and the tumour may varj- in consistency as the uterine wall contracts and relaxes. On vaginal examination, the cervix is soft and patulous and the uterus is enlarged. The presence of other signs of pregnancy, the characteristic condition of the breasts, foetal movements and heart sounds, and the histor}^ of amenorrhoea. There will be dullness in the front of the abdomen, resonance in the flanks. 4. A Distended Bladder may reach well above the level of the umbihcus. This condition occurs most frequently in women as the result of a retroverted gravid uterus, or in men over sixty as the result of enlargement of the prostate. The most important symptoms are : incontinence of urine from over-distention and overflow, and abdominal distention. There is generally a globular mass to be palpated in the middle Hne above the pubes and reaching up to the umbihcus or higher ; it is dull to percussion in front, with resonance in the flanks. The passage of a catheter should clear up all doubt. ASCITES 53 5. General Obesity may cause much abdominal distention. The mesentery, omentum, and abdominal wall may be very much thickened with fat ; under such conditions it is very difficult to make a satisfactory examination, and it may be almost impossible to determine with certainty the presence of a small or even a moderate amount of fluid. 6. Phantom Tumour. — The abdomen may occasionally be much distended in women, especially at the time of the climacteric. Such a distention may present difficulties in diagnosis, and may be mistaken for ascites, ovarian tumour, or pregnancy. If an ansesthetic is administered it often disappears, the rigid abdominal wall becomes flaccid, and it can be determined with certainty whether fluid in the peritoneal cavity or any abdominal tumour is present or not. 7. Large abdominal Cysts may occasionally simulate ascites, e.g., hydro- nephrosis, pancreatic cyst, and hydatid cyst ; they do not, however, cause uniform distention of the abdomen as a rule. They are most likely to be mistaken for simple chronic peritonitis, in which case local collections of fluid may occur, owing to matting together of the intestines. Hydronephrosis may be distinguished by its position and by the fact that it may vary in size, a decrease being associated with an increase in the amount of urine passed. Pancreatic cyst may be differentiated by its position in the upper part of the abdomen and by its more or less spherical outline. If paracentesis abdominis has been performed, the character of the fluid and its ferments would point to the nature of the disease. III. — The Causes of Ascites. Having made up one's mind that the general abdominal distension is due to the presence of fluid in the peritoneal cavity, one must next differentiate the cause of the ascites. The following is a classified list of its causes :■ — ■ 1. Diseases of the Peritoneum. Non-suppurative acute peritonitis " Simple " chronic peritonitis Tuberculous peritonitis Malignant peritonitis, generally secondary to a primary growth elsewhere Hj^datid cysts in the peritoneal cavity. 2. Obstruction to the main Portal Vein by : — Non-suppurative thrombosis. Enlarged portal lymphatic glands : — Malignant I Tuberculous Lymphadenomatous | Lymphatic leuksemic Tumours of adjacent organs, such as : — Liver Duodenum Pancreas Colon Kidney Suprarenal capsule Stomach Aneurysm of hepatic artery. 3. Diseases of the Liver. Cirrhosis Perihepatitis, really part of chronic simple peritonitis Carcinoma / Doubtful causes if the lesions are confined to the Sarcoma I liver ; i.e., if there is ascites, it is probably not due „ , .,. -[ to the carcinoma, etc., in the liver, but to simul- bypnuis . taneous affection either of the peritoneum or of the Hydatid disease ( portal lymphatic glands. 54 ASCITES 4. Obstruction of the Inferior Vena Cava above the Hepatic Veins by :— Thrombosis Stenosis by chronic mediastinitis Occlusion by mediastinal growth. 5. Chronic Failure of the right side of the Heart (" backward pressure ") the result of : — VahTilar disease : — • ]\Iitral stenosis antral regurgitation Aortic stenosis or regurgitation with secondary mitral regurgitation : — - Rheumatic or s^-phihtic Congenital pulmonar}" stenosis (rarely). Chronic myocardial affections : — • Fatt}' degeneration 1 Fibroid heart Fattv infiltration ' Primarj- alcoholic heart. Fatty superposition j Adherent pericardium. Chronic lung afl'ections, especiall}' : — Emphvsema 1 „ ,, • . j ^ ^ - , , . .,. -Generally associated Recurrent bronchitis ' Fibroid lung. Chronic high blood-pressure conditions : — Red granular contracted kidneys Pale contracted kidneys Arteriosclerosis. 6. Bright's Disease. In Bright's disease ascites may be caused in at least four different ways, namel}^, as the result of : — Part of a general dropsj^ Acute peritonitis Chronic peritonitis Secondar}^ to h^-pertrophy and dila- tation of the heart, followed by failure of compensation. 7. Severe Anaemias, in which the ascites is usually no doubt the result of acute, subacute, or chronic intercurrent peritonitis, as in : — Splenomedullar}- leukaemia Lj-mphatic leukaemia Hodgkin's disease Splenic anaemia Pernicious anemia Aplastic anaemia. IV. — -The Differential Diagnosis of the Cause of Ascites. If ascites is the only fluid accumulation present in the patient ; if, although there is also swelhng and oedema of the legs, the ascites is known to have appeared first ; or if the ascites is out of proportion to dropsy elsewhere ; it is most probably due either to some form of peritonitis, to portal obstruction from thrombosis of or pressure on the portal vein, or to cirrhosis of the hver. If it is associated ^\ith general anasarca, that is to say, with oedema of the legs, body, and face, perhaps even of the scalp, and possibly with other serous effusions, the probable cause is acute, or acute on chronic, Bright's disease. If swelling and oedema of the legs were first noticed and the ascites followed, heart failure from one of the causes in Group 5, or obstruction of the inferior vena cava above the hepatic veins, would be the most likeh- cause ; it is impor- tant to remember, however, that in the slighter cases, or in those of long stand- ing, the patient is often uncertain which swelled first, his legs or his abdomen, and his statements on the point may be misleading. If jaundice is associated Avith the ascites, it points to some form of portal ASCITES 55 obstruction as the cause, either cirrhosis of the Uver, or, if the jaundice is intense, to some actual pressure on the portal vein and common bile ducts. If enlargement of the liver is associated with the ascites, this may be due to carcinoma, sarcoma, cirrhosis, perihepatitis, syphilis of the liver, or to nutmeg change the result of backward pressure from chronic heart or lung disease. If the ascites is associated with multiple abdominal tumours, it suggests tuberculous or malignant peritonitis, or in rarer cases hydatid disease of the peritoneum. Diseases of the Peritoneum. Acute Nonsuppurative Peritonitis. — By this is meant an acute inflammation of the peritoneum analogous to acute ' simple ' pleurisy with serous effusion. One seldom speaks of ascites, however, in connection with acute infective peri- tonitis such as would certainly lead to pus formation if immediate laparotomy were not resorted to ; and it is difficult to draw a decided line between acute peritonitis in which the fluid should be called ascites, and other conditions of acute generalized peritonitis to which the term would not be applied. There are, however, cases in which acute serous effusion due to non-suppurative peritonitis occurs in acute and chronic Bright's disease ; acute tuberculous peritonitis almost simulating general suppurative peritonitis is also familiar, and both pneumococcal and gonococcal peritonitis may be acute in onset, and yet take the form of an ascitic effusion, recovery occurring without the necessity for laparotomy. It is probably a question of the dose of the micro- organism that affects the peritoneum, and it is by no means impossible that, whereas the perforation of a gastric ulcer, duodenal ulcer, dysenteric, typhoid, or tuberculous ulcer of the intestines, or leakage from a pyosalpinx, an appen- dicular abscess, stercoral ulcer of the colon, or a perirectal or prostatic abscess, generally gives rise to acute general peritonitis which would prove suppura- tive if it were not operated on, the same conditions may in some cases lead to a slighter affection with a severe but non-suppurative ascitic effusion ending in spontaneous recovery. Whether laparotomy is indicated or not in any given instance, must depend upon the individual circumstances of the case ; but it is probably much safer for the patient to be operated upon for acute non-suppura- tive peritonitis of the type of which we are now speaking, than for general suppurative peritonitis to escape operation. Simple Chronic Peritonitis. — By this is meant a chronic inflammation that is not tuberculous or malignant. It may follow simple acute peritonitis, but its two commonest causes are first, a former tuberculous peritonitis from which the tubercles have disappeared ; and secondly, the chronic inflammation which results from repeated paracentesis abdominis for any other variety of ascites. The latter is important to remember, for it sometimes happens, in a heart case for instance, that both oedema of the legs and ascites have been promi- nent symptoms, paracentesis abdominis being indicated on account of the cardiac distress ; the tapping of the abdomen may have had to be repeated many times, and yet ultimately the cardiac compensation may have been restored, the patient's general condition becoming quite good and the oedema of the legs disappearing ; yet in spite of this general improvement, ascites may still persist and require further tapping at intervals. In such a case, whereas at first the ascites was due to backward pressure from the failing heart, it ultimately becomes due to chronic peritonitis, the result of the repeated tappings. It is usually associated with perihepatitis, which indeed is only one of the local manifestations of chronic peritonitis. Even when all inflammation has ceased, the great thickening of the peritoneum over the diaphragm, liver, and spleen may have blocked up those pores through which the peritoneal secretions naturally drain away, so that the fluid keeps on re-accumulating, 56 ASCITES and necessitates repeated tapping, which in some cases has been performed over three hundred times. The peritoneum becomes generally thickened, and the intestines bound down and matted together. There may be local or general abdominal distention, depending on whether loculi are formed or not by the adhesions. On account of the shortening of the mesentery and matting together of the intestines, there may be dullness all over the abdomen, so that this form of ascites is particularly liable to be mistaken for ovarian cyst or tumour. Albuminuria is a frequent symptom on account of the interference with the renal circulation, and there may even be a few tube casts ; there inay or may not be actual renal disease, but this should not be diagnosed from the albumin- uria unless there is also a high blood-pressure, retinitis, or other confirmatory sign. Abdominal pain is generally slight, and although there may be vomiting or constipation, there is usually neither. Tuberculous Peritonitis. — This is the most common cause of ascites in children. There are several varieties, of which the following may be distinguished : — 1. The acute ascitic form, which may simulate acute general peritonitis due to perforation of a viscus (see above). 2. The peritoneum may be studded all over with miliary tubercles without there being any caseous masses. The physical signs of this form are those of ascites without any abdominal tumour, and it is not difficult to mistake it when it occurs in an adult for cirrhosis of the liver or for malignant peritonitis, especially that form which is secondary to ovarian tumour. In a child, the occurrence of ascites without oedema of the legs at once suggests tuberculous peritonitis, whilst in an older person tuberculous peritonitis is much less common. 3. The omentum may be contracted and thickened from infiltration with caseous or fibro-caseous material, and a hard abdominal tumour simulating an enlarged liver may be felt. It may be distinguished, however, by the presence of a resonant percussion note between its upper limit and the costal margin, and it may be possible to feel the edge of the liver itself distinctly above the omental mass which simulates it. Ascites in cases of this kind is generally less in amount than in the miliary tuberculous form. 4. The intestines may be matted together and the adhesions thickened and infiltrated with tuberculous deposits, so that the peritoneal cavity may be divided into several loculi of fluid, the abdominal distention being not uniform, and paracentesis only removing part of the ascites. 5. The mesentery may be thickened and contracted, and the intestines bound down to the posterior parts of the abdominal cavity, so that if there is ascites there will either be dullness all over the abdomen, or dullness in front with resonance in the flanks, suggesting ovarian cyst rather than tuberculous peritonitis. After paracentesis, a more or less defined irregular deeply situated tumour may often be felt. 6. When the caseation affects the mesenteric glands in particular, multiple irregular tumours are felt, sometimes but not always associated with ascites. 7. Occasionally local thickenings in the abdominal wall are to be felt as the result of subperitoneal inflammatory deposits, a condition which may often be mistaken for rigid contraction of the recti muscles or for disease of the parietes rather than of the peritoneum ; if, however, there is ascites at the same time, tuberculous peritonitis would be very probable, particularly in a child. It will naturally depend upon the acuteness of the tuberculous process whether there will be pyrexia or not, and whether there will be abdominal pain and tenderness. In the caseous varieties, whether of the glands, omentum, mesentery, or abdominal wall, pain and tenderness are the rule, and the temperature generally rises to io3°F. or io4°F. each evening. It is not at all uncommon in such cases for redness and oedema to develop for some little ASCITES 57 distance round the umbilicus, and for a purulent discharge to occur from the latter, or for a fascal fistula to develop. The commonest cause for spontaneous fzEcal fistula of the umbiUcus is tuberculous peritonitis. When the active tuberculous process has become quiescent, there may still be ascites, though the temperature is subnormal. When paracentesis is performed, it is advisable that some of the fluid should be injected into a guinea-pig, to see whether the latter develops general tuberculosis or not. The nature of the case may some- times be suggested by the presence of tuberculous lesions elsewhere in the patient's body; for instance, in the spine, kidney, a joint such as the hip or knee, glands in the neck, or lupus, though very often tuberculous peritonitis is the only objective lesion. Ascitic Fluids. — It has been stated that chemical analyses of ascitic fluid often afford material assistance in arriving at a diagnosis of its cause ; but in practice only the broadest conclusions can be drawn. The higher the specific gravity, the larger the percentage of albumin, and the greater the tendency to spontaneous coagulation, the more definitely can one conclude that the condition is an inflammatory exudate, e.g. specific gravity 1,025, twenty parts per thousand of albumin with a spontaneous coagulation. The lower the specific gravity, the smafler the percentage of albumin, and the more definite the absence of spontaneous coagulation, the more likely is the condition to be a non- inflammatory transudate, e.g., specific gravity 1,005, Ave parts per thousand of albumin and no coagulation. There are, however, a large number of intermediate cases in which chemical investigation of the fluid leaves one in doubt as to whether the condition is inflammatory or not. It has also been stated that differential analyses of the proteids are helpful, notably as to whether there is more globulin or more albumin present ; but it is doubtful whether this really is so. Microscopical examinations are of considerably more value <^~^ '^ than chemical ; the centrifugalized deposit should always ^O:^ ^ be examined under the high power, and it may exhibit ^ either many leucocytes in inflammatory conditions, poly- ^ 1(\ morphonuclear cells predominating in acute inflammations, ^ and small lymphocytes in subacute or chronic affections ^^^ o p^ such as tuberculous peritonitis ; or peritoneal cells in cases ^^i' \^ y^'^^ of inflammation ; and in rare instances it is possible to /T ^ clinch the diagnosis by finding actual fragments of new v|j growth or hydatid booklets [Fig. 6). The deposits may '^''^ also be stained for bacteria, and sometimes tubercle bacilli or even streptococci, staphylococci, gonococci, or pneumo- Fig. 6. — Echinococcal cocci may be found. When investigating ascitic fluid booklets, bacteriologically, however, it is probably better to resort to cultural or inoculation methods than to rely solely upon films prepared from the deposit. Cancerous Peritonitis usually occurs in patients over forty years of age, and the growth is practically always secondary. Primary carcinoma of the peri- toneum is very rare, and it is usually colloid and not associated with ascites. In secondary cases the omentum may be thickened and infiltrated, the umbilicus fixed, the urachus palpably infiltrated, and nodules and masses may develop all over the peritoneum. Rapid emaciation and marked cachexia are the rule. A large quantity of fluid may be present, and if it is blood-stained at the first tapping it is very suggestive of malignant disease. Ascites may be the first and only evidence of growth, and it may be mistaken for tuberculous peritonitis or cirrhosis of the liver, especially when the abdominal distention is so marked that no nodules can be felt. Evidence of a primary growth should always be looked for with care, especially in connection with the stomach, pancreas, colon, rectum, or ovaries. Rectal examination should never be omitted, and if need be the sigmoidoscope may be used. It should not be forgotten that useful indication of intra-abdominal malignant disease is some- times afforded by there being enlargement of the left supra-clavicular lymphatic glands by secondary deposits. 58 ASCITES There is one variety of secondary malignant peritonitis which merits special mention — namely, that which may result from a proliferating papillomatous ovarian cyst. The mahgnancy of the latter is sometimes relative, so that although there may be thousands of papilloma deposits on the peritoneum, causing ascites that may need tapping scores of times at short intervals, there may be no other secondary deposits anj^where. The diagnosis may be made as the result of careful vaginal examination, or b}^ finding fragments of the malig- nant papillomata in the ascitic fluid, or perhaps the case may be regarded as chronic " simple " peritonitis until the abdomen is opened. Hydatid Cysts in the peritoneal cavity may be primary, but more often they are secondary to hydatid disease of the liver. The malady is rare in this country, though commoner in Australasia and elsewhere. The patient is generally an adult and the diagnosis is often obvious, though sometimes it may be very obscure. There may be a large globular tumour in the liver, rarely giving the tj^pical hydatid thrill ; there may be Eosinophilta (q-v.), and an investigation of the blood serum in special laboratories may show the specific h3^datid serum reaction. In some cases in which there are hydatid cysts associated with ascites, it is possible to make the diagnosis certain by rectal examination. One has felt globular bodies about the size of grapes in front of the anterior rectal wall, and when one has pressed upon these to investigate them more fully, they have slipped away from under one's finger through being pushed up into the ascitic fluid ; after waiting a moment the finger has felt them come back into Douglas' pouch. Similar mobihty of spherical masses in the ascitic fluid may be noted elsewhere — for instance, in an iliac fossa. The ultimate diagnosis depends upon the detection of booklets {Fig. 6) in the fluid obtained by para- centesis or by laparotomy. It is important to bear in mind, however, that the absence of booklets does not exclude hydatid disease, the cysts sometimes being sterile, and in that case not producing booklets. Chylous Ascites is not in itself a specific malady, for there is more than one condition in which the ascitic fluid may be loaded with fat droplets so as to appear like milk. This is generally the result of obstruction to the main abdominal lymphatics, particularly the receptaculum chyU and thoracic duct. Occasionally this is due to rupture after an injury to the abdomen ; more often the condition is associated in this country, in some way which is not fully under- stood, with the peritonitis of chronic Bright's disease. The best known tropical cause for chylous ascites is Filaria sanguinis hominis, producing elephantiasis. In rare cases the secondary deposits of malignant disease may be such as to obstruct the thoracic duct, and so produce the chylous condition of the ascitic fluid. Chyluria may or may not occur at the same time. Obstruction to the Main Portal Vein. — This is most commonly due to enlarge- ment of the portal lymphatic glands by secondary deposits of malignant disease ; it is common for the main bile-ducts to be obstructed at the same time, so that an increasing depth of jaundice accompanies the ascites. When there are masses of secondary growth in the hver associated with jaundice, or ascites, or both, it is seldom that the hepatic masses are themselves responsible for the symptoms, these being more often due to the associated deposits in the portal lymphatic glands. The diagnosis is made as the result of discovering a primary growth, which is more often a carcinoma than a sarcoma. It is much rarer for the lymphatic glandular enlargement to be lymphadenomatous, tuberculous, or due to lymphatic leukaemia. If ascites were a prominent symptom in any of these conditions, it would be regarded as consequent on affection of the peritoneum rather than on obstruction to the portal vein, unless there were deepening jaundice at the same time. In the latter case itialignant disease ASCITES ■ 59 would be simulated. General enlargement of the lymphatic glands in the axillae, groins, and neck, with or without evidence of enlargement of those in the thorax or abdomen, together with enlargement of the spleen, would suggest either lymphadenoma or Ij^mphatic leuka3mia ; the absence of positive blood changes would render the former more likely, for in lymphatic leukaemia there is more or less considerable leucocytosis with a great relative increase in the small lymphocytes up to go per cent or more. Only in very rare cases do tuber- culous portal glands cause ascites, and when they do the diagnosis must be one of guess-work onl}^, unless in association with definite tuberculous peritonitis there were jaundice suggesting obstruction to the common bile-duct and to the portal vein at the same time. Thrombosis of the portal vein may be suppurative, in which case there is no ascites, but rather a pyrexial condition with rigors and possibly jaundice, which is diagnosed as a rule only when there has been some definite inflammatory or suppurative focus in the portal area, such as appendicitis, which might lead to infection of the portal vein. Primary thrombosis of the portal vein is relatively rare, and its diagnosis can seldom be more than guessed at. It leads to marked ascites, possibly with simultaneous increase in any tendency there may be to piles, and without evidence of tuberculous or malignant disease of the peritoneum or cirrhosis of the liver. It is by a process of exclusion that the diagnosis of portal vein thrombosis might be arrived at, especially if the ascitic fluid with- drawn by paracentesis, when examined chemically, were found to contain a relatively very high proportion of coagulable proteids without any particular tendency to spontaneous coagulation, and without those polymorphonuclear cells or h'mphocytes in the centrifugalized deposit that would be found if the high percentage of proteid were due to the ascites being inflammatory. Tumours of adjacent organs seldom obstruct the portal vein enough to cause ascites without presenting other symptoms which suggest the diagnosis. Some- times, however, unless the tumour can be felt, great difficulty may be experienced in determining the nature of the case. Carcinoma of the pancreas may be accompanied by glycosuria and the passage of fatty stools, together with deepen- ing jaundice, progressive enlargement of the gall-bladder, and a positive Cammidge's Pancreatic Reaction (q-v.). Onaccountof the relation of the tumour to the aorta, marked transmitted pulsation may be felt in it, and by inflating the stomach it may be demonstrated that the tumour lies posterior to the latter. Renal tumours may be difficult to distinguish from enlargement of the liver when they are big ; but they are generally associated with Albuminuria (q.v.), H.5MATURIA (q.v.), or Pyuria (q.v.). Carcinoma of the stomach, duodenum, colon, or suprarenal capsule would be suggested by the position of the mass, or by the gastric or intestinal symptoms ; if there were ascites accompanying them, it would generally be attributed not to the primary tumour itself, but to secondary deposits either in the peritoneum or in the portal lymphatic glands. Aneurysm of the hepatic artery is a pathological curiosity, though in recorded cases it has produced ascites and jaundice. The commonest cause of aneurysm of the hepatic artery is fungating endocarditis with embolism. Diseases of the Liver. — Cirrhosis of the Liver. — When ascites is due to this cause, the diagnosis is sometimes very easy on account of the history of chronic alcoholism, and very possibly of former hsematemesis, metena or jaundice. There may also be acne rosacea and telangiectases on the cheeks, a furred and tremulous tongue, a history of morning sickness, cramps in the legs at night and loss of appetite, epistaxis, perhaps the presence of distended veins around the umbilicus, enlargement of the liver, the surface of which is hard and rough, and the edge irregular and perhaps beaded, enlargement of the spleen, icteric tinge of the conjunctivae, and a peculiarly sallow, slightly 6o ASCITES pigmented facies, which is almost characteristic in the later stages of the malad5^ Cirrhosis is a slowly progressive disease sometimes extending over twenty j'ears or more, producing a large, smooth, unilobular cirrhotic liver, associated with jaundice and a tendency to haematemesis in its earlier stages ; but later a small liver in which, in addition to the unilobular iibrous tissue, there has developed a much coarser multilobular meshwork which, by progressive contraction, has led to the previously large, smooth organ becoming smaller, rougher, and harder, until it may sometimes be so small as to be no longer palpable. Only in the very last stage does it produce ascites. People have been known to be total abstainers for as long as eighteen years or more after the first symptoms of cirrhosis have developed, and yet to die with a granular, contracted, " hob-nail " liver and ascites. Perihepatitis. — It is generally stated that a case of cirrhosis of the liver seldom survives long after it has first become necessary to tap the abdomen, and that therefore when paracentesis abdominis has to be performed more than once or twice in a case supposed to be cirrhosis of the liver, this points to the diagnosis being wrong, the case being one, not of cirrhosis, but of perihepatitis. As a matter of fact, however, this is not always so, for it sometimes happens that even when the ascites was originally due to cirrhosis, the repeated tapping pro- duces perihepatitis, the greatly thickened capsule of the liver being the result of multiple tappings for what was at first cirrhotic ascites. It is exceedingly difficult to be certain of the diagnosis of simple perihepatitis ; the condition is really only part of a chronic peritonitis. The capsule of the liver becomes much thickened, and it contracts and distorts the organ, and rounds the edge, or else turns it up or under, in a way which is characteristic. It is only if this curled-under or turned-up edge can be detected that the diagnosis of perihepatitis can be made with certainty. It is possible that syphilis is the cause of the malady in some cases. Ascites associated with carcinoma or sarcoma of the liver is usually accom- panied by intense jaundice, and there will always be doubt as to whether these symptoms are not due rather to coincident affection of the portal lymphatic glands than to the deposits in the liver itself. The latter becomes much enlarged, very hard, the edge often coming well below the umbilicus. Probably the largest livers that occur are due to secondary carcinoma or sarcoma. They may reach a weight of 22 lb. or more. Besides being very hard, the liver may be tender, and umbilicated nodules may be felt on its surface. Primary growth of the liver is exceedingly rare, and though it leads to progressive and deepening jaundice, it does not often produce ascites. Secondary growth is so much more common, that it is always most important to look for the primary growth else- where with great care before primary growth in the liver is diagnosed. Rectal examination should not be omitted ; and Cammidge's pancreatic reaction in the urine should be tested, in case the primary growth be in the pancreas. Syphilis may produce local peritonitis over a gumma ; it may also lead to general chronic peritonitis and thus to ascites. The diagnosis is made upon the history, upon the signs of syphilis elsewhere, and upon Wassermann's serum reaction. Hydatid disease of the liver seldom of itself causes ascites, though it may be associated with coincident affection of the peritoneum with ascites. We may now pass on to consider those cases in which, if the history is correct, there has been swelling of the legs before, or at any rate not later than, swelling of the abdomen ; and if one continues the classification as given on pages 53 and 54, one comes next to — Obstruction of the Inferior Vena Cava above the Hepatic Veins. — This is ASCITES 6r a very rare cause of ascites, and it will seldom, be diagnosed unless there is either (i) clear evidence of extension of thrombosis to the inferior vena cava from a previous thrombus in one leg, associated with extension of oedema up the back, followed by albuminuria and perhaps hsematuria when the renal veins are involved, and then by ascites, together with varicose distention of the abdominal veins and alteration in the blood-stream in them, or (2) a history or the physical signs of chronic mediastinitis, which generally results from recurrent attacks of pleurisy and pericarditis, especially rheumatic, or of intrathoracic new growthy which is distinguished from chronic mediastinitis by the shorter history and by the ,Y-ray appearances. (See Veins, Varicose Thoracic ; and Veins, Varicose Abdominal). Chronic Failure of the Right Side of the Heart (Backward Pressure). — Ascites as the result of backward pressure in chronic heart and lung disease is nearly always preceded by swelling and oedema of the legs. Careful examination of the heart and lungs, a history of acute rheumatism, or of recurrent winter cough, or an abundant and offensive periodic expectoration, may suggest valvular disease of the heart, chronic bronchitis and emphysema, or fibroid lung with or without bronchiectasis, to account for the ascites. It should be remembered that enlargement of the liver — nutmeg liver — also results in these cases, the enlargement varying pari passu with the degree of heart failure, the surface of the organ being smooth, sometimes pulsating synchronously with the heart, tender, with a Avell-defined edge which may reach to below the level of the umbilicus in the right nipple line. The urine is apt to contain albumin, and when the heart failure has reached an advanced degree it may be exceedingly difficult to say whether it is due to primary valvular disease, primary lung disease, primary kidney disease, primary arterial disease, or to primary affec-; tion of the muscle of the heart. The iraportance of casts in the urine in the differential diagnosis has been referred to under Albuminuria (q-v.), where the significance of the blood-pressure, of retinal changes, and so forth, are also discussed. The valvular heart lesion most apt to be mis-diagnosed in connection with ascites is mitral stenosis-, for by the time the heart failure has reached a sufficient degree to cause ascites, characteristic bruits, especially the presystolic, become no longer audible in many cases. The heart beats very rapidly and very irregularly, so that no bruits may be audible at all. Mitral stenosis may still be suggested by the characteristic appearance of the face, with its yellowish pallor of the forehead, and around the nose and mouth, with bright or dark red coloration over the malar bones and upper portions of the cheeks and lips ; or by the history of acute rheumatism or chorea, though absence of such a. history by no means excludes the possibihty of valvular heart disease. It may, however, be impossible to say whether there is mitral stenosis or not until the patient has been kept in bed, given digitalis, and watched for a week or more, until there is some degree of recovery of the cardiac compensation ; by which time the characteristic bruits of mitral stenosis very often return with increasing force of the heart's beat. Some of the hardest of heart-failure cases to diagnose with certainty are those due to chronic affections of the myocardium or to adJierent pericardium. In each case the diagnosis is mainly arrived at by a process of exclusion. Chronic myocardial degeneration seldom occurs in young people, or at any rate it is much commoner in middle life and later. The symptoms are those which are common in all varieties of chronic heart failure, whatever the cause of the latter. There may or may not be the systolic bruit of mitral regurgitation, or an aortic systolic bruit due to atheroma of the aortic valves, but upon the whole, the physical signs do not suggest valvular disease ; the urinary changes and the 62 ASCITES absence of casts do not suggest nephritis or granular kidney; the blood -pressure may or may not suggest arteriosclerosis ; the lung signs do not suggest bron- chitis and emphysema^ or fibroid lung : so that some myocardial affection is all that is left to diagnose. If there has been a history of the drinking of much alcohol, particularly beer, primary alcoholic heart may be suspected, though this is much less common in England than it is said to be in Germany. Fatty superposition would be suggested if there was general obesity of the patient with shortness of breath on ordinary exertion ; whilst overloading of the surface of the heart seldom occurs without some fatty infiltration at the same time. Fatty degeneration is more likely after a long febrile illness, or chronic poisoning by phosphorus, arsenic, or by the supposed toxins of severe anccmias, such as pernicious anaemia, or aplastic anaemia. Fibroid heart is very difficult to distinguish from fatty heart, but it is the more likely diagnosis in a syphilitic patient, particularly if the patient is not obese and if there is a history of syphilis or evidence of syphilitic atheroma leading to aortic regurgitation or angina pectoris. Adherent pericardium is not in itself an explicit term, for there are three different conditions which come under the one heading ; thus there may be (i) Adhesions between the parietal and visceral layers of the pericardium ; (2) Adhesions between the parietal pericardium and the structures around it, particularly the pleuree, diaphragm, and chest wall ; and (3) Adhesions both of the parietal and visceral layers of pericardium and of the parietal layer to the structures outside it. It is quite clear that the physical signs will be different according to which of these three things has happened. That which ought to be implied strictly by the term adherent pericardium, is adhesion of the parietal to the visceral layers, without any other adhesions whatever, and of this condition there are no positive physical signs at all, nor need there be any symptoms. The diagnosis is generally made by guess-work, the patient being known to have had pericarditis, or being suspected of having had it because of having suffered from acute rheumatism with severe compli- cations, and the heart now being found much larger than it ought to be in proportion to the apparent valvular disease as indicated by the bruits. It is quite possible, however, for the parietal and visceral layers of pericardium to be universally adherent to one another without the heart being big, and without there being any ill effects at all, the condition being met with not uncommonly in the post-mortem room in patients who die of something entirely different. It is only when the parietal layer has become adherent to the visceral layer when the heart was already dilated at the time of the pericarditis, that symptoms subsequently accrue, the result rather of the inability of the already big heart to maintain its dilatation and hypertrophy than of any intrinsic interference with its action by the adherent pericardium itself. It quite often happens, indeed, that when there has been rheumatic myocardial affection without pericarditis, the big heart that results is out of all proportion to the valvular disease, and yet in the post-mortem room no abnormality of the pericardium is found. The three following points in connection with heart disease in children are as true as most aphorisms. First, mitral stenosis is almost unknown before puberty, whatever the bruits that suggest it. Secondly and thirdly, heart disease never proves fatal before puberty unless as the result either of the severity of the acute inflammation of valves, muscle, or pericardium, or else from adherent pericardium. Fatal mechanical failure of the heart before puberty, therefore, in a patient who presents no symptoms of rheumatic reinfection, points to there being adherent pericardium in the sense of there being adhesions between the parietal and visceral layers. ASCITES 63 Adhesions between the parietal pericardium and the structures outside it, without there being any adhesions between the parietal and visceral layers within the pericardium, are of exceedingly common occurrence, generally result- ing from former pleurisy. The former inflammation must have extended outside both the pericardium and the pleurae, so that it was really a mediastinitis ; but clinically the condition is seldom spoken of as mediastinitis, because it is of very little importance, and in itself it produces no symptoms at all ; the physical sign which might suggest it would be deficiency in the degree of movement of the position of the cardiac impulse to the left or to the right, as the case might be, as the patient rolls from one side to the other. The third variety of adherent pericardium, namely, that in which there are adhesions between the parietal and visceral layers, and between the parietal layer and the chest wall, pleurae, and other structures outside it, is really a combined condition of adherent pericardium and mediastinal adhesions which, when an extreme degree is reached, becomes what is known as chronic medias- tinitis. Here again, it is possible for neither symptoms nor physical signs to present themselves, the condition being found unexpectedly in the post-mortem room. It is this condition which is generally diagnosed under the name of adherent pericardium. There will be a history of former pericarditis, pleurisy, or both, probably of a rheumatic nature. The heart will be large out of all proportion to any valvular disease that is present, without there being other obvious cause for its hypertrophy and dilatation, such as nephritis, arterio- sclerosis, hard work, alcoholism, fatty or fibroid heart, or chronic lung disease. If the parietal pericardium is firmly adherent both to the pleurse and to the diaphragm — particularly the latter — there will very likely be retraction of the lower ribs in the left axillary line synchronously with the heart-beat ; it is this physical sign — systolic retraction of the lower left ribs — which is generally regarded as pathognomonic of adherent pericardium ; it is really evidence, of course, of adhesions outside rather than within the pericardium. Another physical sign which is regarded by some as indicative of general pericardial adhesions, is an ingoing impulse of the third or fourth intercostal space half way between the left nipple and the left border of the sternum, synchronous with an out- going impulse nearer the apex, giving an oscillating or see-saw appearance to the precordial region — some of the intercostal spaces moving inwards at the same time as others move out with the heart-beat. As a matter of fact, the probable explanation of the ingoing movement nearer the sternum when the part of the heart which is nearer the apex causes the ordinary outgoing impulse, is the visible withdrawal of the hypertrophied right ventricle as it contracts. This see-saw appearance in the precordial region is indicative therefore of great hypertrophy of the right ventricle ; it does not indicate what is the cause of this hypertrophy, though amongst its causes would be adherent pericardium. A similar appearance is often seen in cases of extreme mitral stenosis of long standing, even when there is no adherent pericardium. Bright's Disease may produce ascites in more ways than one ; the effusion may, for instance, simply be part of a general anasarca, the accumulation of the ascitic fluid in the peritoneal cavity corresponding precisely with its accumulation in the subcutaneous tissues ; or the Bright's disease may lead to acute or chronic peritonitis of the types described above ; or, especially in chronic cases associated with pale or red granular contracted kidneys, there may be failure of the dilated and hypertrophied heart, with ascites, which it may be very difficult to distinguish from that of primary heart disease, especially as the greater part of the albuminuria which may be associated with the ascites and the failing heart, is now the result of the heart failure rather than of the renal sclerosis, so that the number of casts may seem to be unduly few in 64 ASCITES relation to the albumin. If the blood-pressure is very high, the diagnosis is in favour of arteriosclerosis or granular kidney rather than primary heart-failure, though, curiously enough, the blood-pressure is always above normal in heart- failure from any cause, even when the pulse is as irregular and feeble as it often is in the late stages of mitral stenosis. This terminal rise of blood-pressure in heart cases probably results from the partial asphyxia. Severe Anaemias often cause ascites, but they do not give rise to much difficulty in diagnosis, because the sub-acute or chronic peritonitis which is the cause of the ascitic exudate in these cases, arises, as a rule, comparatively late in the disease, after the diagnosis has been made on other grounds, by blood- counts and otherwise. (See An.^mia ; Spleen, Enlargement of ; Lymphatic Gland Enlargement.) One need not do more here than refer to the huge enlargement of the spleen without lymphatic glandular enlargement, and the great leucocytosis Avith a large portion of myelocytes, in splenomedullary leukcsmia ; the considerable leucocytosis, the enlargement of the lymphatic glands and probably of the spleen, and the great relative increase of the small lymphocytes, in lymphatic leukcBinia ; the enlargement of the lymphatic glands and of the spleen, and the absence of any positive blood changes, beyond anaemia of the chlorotic type without leucocytosis, in Hodgkin's disease ; the enlargement of the spleen, the absence of lymphatic glandular enlargement, and the occur- rence of a progressive and ultimately severe anaemia, of the simple chlorotic type without leucocytosis, but with an occasional myelocyte and basophile corpuscle, in splenic ancemia (which often, as the course of the disease goes on, turns out to be cirrhosis of the liver) ; the profound anaemia and the high colour-index without leucocytosis, in pernicious ancemia ; the severe anaemia suggestive of pernicious anaemia but with a persistently low colour-index, in aplastic ancBwiia ; and the splenic enlargement with profound chlorotic anaemia without leucocytosis, in pseudo-leukcemia infantum. Herbert French. ATAXY. — ^Ataxy is the term used to describe voluntary movements which are imperfectly controlled or co-ordinated. It is displayed in its simplest form by infants under the age of one year. With excellent muscular power, and with the ability to make their limbs assume any position, they are yet unable to carry out any action requiring the careful adjustment of force to a particular end. They are clumsy with their fingers, and lack stability on their feet. Ex- perience eventually teaches them unconsciously to utilize the information which their higher nervous centres receive from the peiiphery of their bodies, for the purpose of adapting their expenditure of muscular energy to the accomplishment of the object in view. Subconscious memories of the afferent impressions produced by any particular movement are gradually stored by the higher centres, with the result that each repetition of that movement is kept more and more under guidance and control, and some degree of economj' is established in carrying on the business of voluntary action. In pathological states, ataxy is often a symptom of great diagnostic import- ance ; but before its value as a localizing sign of disease can be utilized, it is necessary to appreciate broadly the physiological mechanism by which co- ordination is brought about, and the possible situations where a lesion is able to disturb the smooth working of that mechanism. For the proper co-ordination of voluntary movement, impulses from the muscles, tendons, joints, and skin of the part which is moved must reach the brain. It is expedient to regard these impulses as being of two kinds : — I. Sensory afferent impulses which are carried to the cerebrum by way of the peri- pheral nerves, the posterior columns of the cord, the fillet in the brain-stem, and finally- some path from the basal ganglia to the cortex in the neighbourhood of the motor area ATAXY 65 These impulses cross from one side of the body to the opposite hemisphere, the crossing taking place in the medulla. The path is not an uninterrupted one ; that is to say, the impulses are not carried bv fibres which stretch from the peripheral tissues to the cere- brum. On the contrary, there are probably at least two points where one neuronic system ends and its work is taken up by another. 2. Non-sensory afferent impulses, so-called because they never reach consciousness, pass from the peripheral structures concerned in movement, by way of the peripheral nerves and the ascending cerebellar tracts of the cord, to the cerebellum, and principally to the cerebellar lobe of the same side of the body. In some manner which is not per- fectly understood, but in which preservation of muscular tone is probably concerned, the co-operation of the cerebellum is required if movements initiated in the motor area of the cerebrum are to be carried out in a co-ordinate manner. Not only must these two sets of impulses reach the brain, but the parts of the brain, cerebral and cerebellar, \vhich form their destination, miust also be intact if vcluntary movement is to be carried out with accuracy and co-ordination. From the clinical point of view it is necessary to ascertain in the first place whether a patient is ataxic, and in the second whether the ataxy can be attributed to the loss of the sensory or non-sensor}^ afferent impulses. In some cases the ataxy is obvious ; in others its presence can be detected only by the careful application of certain tests. For instance, a patient may walk into a \vell-lighted room with perfect ease and without anything remarkable in liis gait, but if he is asked to walk along a line, placing one foot exactly in front of another, he may at once display his lack of co-ordination. Such ataxy is just as important from a diagnostic standpoint as the imperfect attempts of an advanced tabetic patient to walk even when supported by companions on either side. It is the quality and not the quantity of a defect which gives the needed information. The co-ordination of movements performed by the upper extremities must also be investigated with the same care. The patient may handle his stick in quite a natural manner, but if asked to unbutton and button his coat, to touch the tip of his nose with the tip of his finger, to write, etc., he may fail to convince the observer that his control of fine movements is up to the normal standard. Having ascertained the existence of ataxy, the next step is to decide whether it is dependent on the loss of sensory or non-sensory afferent impulses, or on the imperfect function of the cerebrum or cerebellum. If the ataxy is due to loss of sensorv impulses, it wall be increased by the loss of visual impulses brought about bv closing the eyes. It will also be possible to demonstrate the loss of sensorv impulses by asking the patient to describe the position of a limb with his eyes closed after it has been moved by the observer. When these two tests are positive, it may safely be assumed that the lesion affects the first set of impulses or their cerebral destination. If, on the other hand, the ataxy is uninfluenced by closing the eyes and the patient is perfectly accurate in describing the position of his limbs, it is probable that the cerebellar tracts or the cerebellum itself is at fault. For further localization of the lesion in any particular case it will be necessarj' to take into account concomitant phenomena, and for this purpose it is advisable to consider different parts of the nervous system separately. It is clear, from what has been stated above, that interference with the passage of impulses necessary for proper co-ordination may be provoked by lesions in (i) The peripheral nerves; (2) The spinal cord; (3) The brain-stein; (4) The cevebrum ; and (5) The cerebellum. Let us now consider the effect of lesions in these different regions, and the diagnostic evidence afforded by ataxy of their localization. I. Peripheral Nerves, — A severe lesion of a peripheral nerve must necessarily lead to ataxy of movements performed by the muscles to which it is distributed. It is obvious, how^ever, that a severe lesion will also paralyze the muscles and D 5 66 ATAXY thus effectually prevent any ataxy being demonstrated. Less severe lesions, such as occur in slight cases of peripheral neuritis, allow of some volun tary movement, with the result that ataxy becomes a demonstrable physical sign. Thus a case of peripheral neuritis of alcoholic or diphtheritic origin may show impaired strength, together with ataxy in all four limbs. The diagnosis of a peripheral nerve affection in such a case will depend on the following points : In the first place, the symptoms will be found to be symmetrical, and in the affected limbs the impairment of strength will be most marked in the extensors of the wrists and ankles. Secondly, slight ansesthesia to cotton-wool may be detected over the glove and stocking areas. With regard to pain, there may be blunted cutaneous sensibility to the prick ot a pin over the same area, but, almost constantly, deep pressure on the affected muscles will establish the fact that these tissues are abnormally sensitive. This is a most important point in diagnosis, because it strikes an essential distinction between cases of ataxic peripheral neuritis, sometimes described as pseudo-tabes, and cases of true spinal tabes, in which it is an almost invariable rule to find diminution or loss cf painful sensibility on squeezing the muscles. In the third place, the tendon reflexes will be markedly diminished or completely absent, while the plantar reflexes will probably be unobtainable. Finally, the use of electrical currents upon the muscles will show that the response to faradic currents is materially lessened or abolished, and that the contraction excited by the make and break of the galvanic current may be of the slow, worm-like type so characteristic of the reaction of degeneration. The ataxy of peripheral neuritis has no reliable characteristic to distinguish it from what may be observed in the ataxy due to spinal disease. The gait is unsteady, and the patient keeps his legs apart in order to lessen the tendency to lose his balance. The clumsiness of the upper extremities may be demion- strated by his inability to bring the first finger of one hand accurately into apposition with that of the other, or to touch the tip of his nose with either. Both the unsteadiness of gait and the awkwardness of the fingers are exaggerated if he attempts to walk, or carry out movements with his hands, when his eyes are closed. A tendency to high-steppage will be noticeable in walking if, in addition to the ataxy, there is well-marked paresis of the dorsifiexors of the ankles. In such a case the patient is obliged to lift the feet to an unusual height in order to clear the ground. We conclude, therefore, that ataxy is due to a lesion of the peripheral nerves, not from the nature of the ataxy, but from the presence of other symptoms also referable to interference with the functions of the nerves. 2. Spinal Cord. — -The ataxy due to disease of the spinal cord is seen best in cases of tabes dor sails or locomotor ataxia, in which malady degeneretion of the posterior column ascending tracts is ah early pathological feature, and in which, conse- quently, the patient does not receive the normal impulses from the muscles, tendons, and joints so necessary for the preservation of his sense of position and movement. Contrary to popular ideas, gross ataxy is only met with in a small proportion of the cases of this disease, and it is often necessary to apply delicate tests to demonstrate its presence in slighter degrees. The patient's gait may not be remarkable in good daylight, but he may complain of its un- certainty in the dark, or he may be obviousl}^ ataxic with his eyes closed. Another patient may have noticed nothing amiss with his walking in the ordinary way, but if he is asked to follow a line on the carpet of the floor, placing one foot exactly in front of the other, his impaired power of balance will become apparent at once, especially if he is directed to accomplish this test with his head raised and his eyes fixed on something in front of him instead of upon his feet, whither they will incline to wander. ATAXY 67 In cases of moderate ataxy the gait and stance of the patient are remarkable for the wide base he assumes, and his tendency, as it were, to guide his feet by means of his vision. Romberg's sign can be obtained easily. This sign is not diagnostic of tabes, as is so often assumed, but is merely used for the purpose of ascertaining whether the removal of visual impulses will convert a condition of stability into one of instability. Many students, and perhaps some medical men, if asked to describe Romberg's sign, at once reply, " You direct the patient to put his feet together and close his eyes ; if he sways or falls, the sign is present." This is obviously incorrect, because the patient may sway even before his eyes are closed. In order to test a patient for this sign, he must be directed to stand with his feet as near together as he is able to do with steadiness, and, having esta Wished his stability in that position with open eyes, he must be told to close the latter. If he sways or tends to fall, it is clear that he had been depending, in part at. any rate, on his visual impulses, and that, without their aid, the impulses derived from his legs and trunk were insufficient for the preservation of his equilibrium. We have in this test, therefore, a valuable method of ascertaining whether the function of the posterior columns is being carried out normally. To judge from the descriptions given in some text-books, the typical gait of tabes is one in which the legs are thrown into the air and the feet brought to the ground with a more or less noisy stamp. As a matter of fact, this type of gait is only seen in a small proportion of cases, and is rarely observed except when the patient is depending for support either on a couple of sticks or on one or two attendants. In other words, he has become so ataxic that he cannot walk unsupported, and, being supported, he no longer attempts to control the exuberance of his leg movements by means of his sight. The exuberance of the movements may be explained on the ground that excessive muscular action is necessary before the patient becomes aware that the parts are being moved. Tabetic ataxia in its moderate and extreme degrees can be demonstrated, when the patient is at rest in bed, by asking him to carry out accurate movements with his hands and feet, with and without the aid of his vision. In slighter degrees, the fact that the ataxia is dependent on interference with his sense of position and movement may be proved by asking him to describe the position of a finger or toe which the observer moves in different directions. Sometimes it is as well in testing this sense in one limb to ask the patient to place the corres- ponding limb in the same position, when the error will be made more obvious. The diagnosis of tabes cannot be made from the character of the ataxy alone, since in other diseases, such as Friedreich's ataxy, disseminated sclerosis, or combined degeneration of the cord, there is or may be sclerosis of the posterior columns resulting in similar inco-ordination. It is important, therefore, to remember that in tabes the posterior roots are affected also, and that there is practically always some interference with other sensory impulses, especially those which convey sensations of pain from the muscles and skin. Thus, in this disease one of the earliest symptoms is relative analgesia to pin-pricks and to deep pressure on the muscles in the lower extremities. In Friedreich's ataxy, disseminated sclerosis, and other spinal disease, as well as in some cases of tabes, the ataxy due to the lesion of the posterior columns may be complicated and intensified by the fact that there is also interference in the path of the non-sensory afferent impulses, which, as has already been pointed out, pass from the extremities to the cerebellum via the ascending cerebellar tracts in the spinal cord. If this form of ataxy is present, the help which the patient derives from vision for the purpose of controlling his inco- ordinate movements is largely discounted, and he may be as markedly ataxic with open as with closed eyes. 68 ATAXY In some lesions, such as those resulting from syringomyelia or new growths, only one side of the cord may be affected, and a Brown-Sequard form of paralysis be exhibited. In this case the loss of sense of position and movement is on the same side as the paralysis, and on the opposite side to the loss of other sensory impulses such as those of touch, pain, and temperature, owing to the fact that the former do not cross with the latter to the other side of the cord. If the paralysis is not complete, some ataxy may be observed in the paretic limb, and in any case the loss of sense of passive position and movement may be demon- strated by the means already referred to. 3. The Brain-stem. — Lesions of the medulla, pons, or crura may produce ataxy if they interfere with the passage, either of sensory afferent impulses to the cerebrum or of non-sensory afferent impulses to the cerebellum. The cerebellar impulses can only be interfered with at the medullary level ; that is to say, before they have passed into the cerebellum via the inferior peduncle. A good example of hemiataxia of this origin is afforded by any case of thrombosis of one posterior inferior cerebellar artery. This uncommon condition affects the structures on one side of the medulla, and is characterized by hemiataxia of the homolateial limbs, together with loss of sensibility to pain, heat, and cold, on the contra- lateral side. The ataxy is of the cerebellar type ; that is to say, it is not associated with loss of sense of position and movement in the affected limbs, and is little influenced by closure of the eyes. Above the medulla, lesions which are capable of producing ataxy by interfering with the sensory impulses from the muscles, joints, and tendons, usually cause paralysis of the same parts, so that the co- ordination is, if we may use the term, more latent than real, and therefore of little diagnostic importance. 4. The Cerebrum. — From the basal ganglia to the cortex, the path of the afferent impulses which are so necessary for co-ordinate movements lies near to that of the efferent impulses from the motor area, and it is only rarely that lesions affect the sensory fibres and leave the motor ones intact. Every now and then, however, a patient complaining of loss of use of the limbs on one side, is found on examination to be suffering from impaired sense of position and movement in those limbs rather than from paralysis. His co-ordination may be fairly good so long as he can utilize his vision, but with closed eyes he has no notion of the position of his arm or leg, and no knowledge of the nature of objects placed in his hand [aster eognosis). This may even be the case when other sensory stimuli, such as those of touch, pain, and heat, are appreciated perfectly. A similar condition may be observed during recovery from a slight hemiplegic " stroke," the patient displaying a degree of clumsiness and awkwardness with his fingers quite out of proportion to his loss of voluntary power. A process of re-education for finer movements, similar to the education of early life, is necessary before he is able to overcome this form of ataxy. Ataxic movements are not uncommon in the subjects of infantile hemiplegia. The hand on the affected side may be permanently clumsy and incapable of carrying out the delicate manipulations necessary for writing, seM'ing, etc. In other cases all voluntary efforts are interfered with by the constant presence of involuntary movements of an athetotic, choreiform, or tremulous character, sufficient to prevent their attaining any dexterity. Whatever the nature of the lesion, cerebral ataxy is generally characterized by its hemiplegic distribution, and by the fact that it is increased when the eyes are closed ; generally the loss of impulses subserving the sense of position and movement, and often of other sensory impulses, can be demonstrated by suitable tests. 5. The Cerebellum. — Cerebellar ataxy may be unilateral, as in some cases of tumour of one lateral lobe, or bilateral, as in the acute cerebellar ataxia of children ATROPHY, MUSCULAR 69 due to encephalitis. In unilateral cases the ataxy is most marked on the same side as the lesion, and is associated with hypotonia and some paresis of the affected limbs. On the other hand, it is important to note that the reflexes on the affected side are normal, that the ataxy is not accompanied by any loss of sense of position and movement, and that closure of the eyes does not materially increase the patient's disability. The ataxy often differs from that due to disease of the posterior spinal column in the fact that it is complicated by vertigo. This may take the form of a sensation of rotation on the part of the patient, or of rotation of surrounding objects, sometimes of both. The vertigo and the ataxy are generally much less noticeable when the recumbent position is assumed. The so-called cerebellar gait resembles that of a drunken man ; the patient reels from side to side, with a general tendency to deviate or fall to the side of the lesion if only one lobe is affected. He is unable to balance himself properly on the homolateral foot, and his manual dexterity is greatly impaired, so that he may be quite unable to feed or clothe himself. The ataxia is not always limited to the trunk and limbs, but may affect the tongue, lips, palate, and vocal cords, so that their movements may be imperfectly controlled and a characteristic " cerebellar articulation " attract the observer's attention. Finally, a lesion of the cerebellum sufficient to cause ataxy is nearly always responsible for nystagmus, which, in disease of one lobe, is more marked during deviation of the eyes to that side. 6. Hysterical Ataxy. — Ataxy is sometimes hysterical, and may then be the only disorder of function exhibited by the patient, or may be associated with hysterical hemiplegia, paraplegia, hemianaesthesia, etc. The diagnosis of hysterical ataxy depends partly upon the absence of signs of organic disease, partly on the presence of other hysterical stigmata, and partly on its character. For example, we may cite the case of a boy who, when lying in bed, was able to feed himself and to carry out all movements of his upper and lower limbs with perfect accuracy, but who, when placed on his feet and told to walk, displayed the wildest inco-ordination and loss of equilibrium. It was noticeable, however, that he always reached some chair or bed on which to collapse finally, even when placed in the middle of the room at some distance from any support. It would, of course, be unjustifiable to apply this last test before the observer was satisfied from careful examination that there were no signs of organic disease. E. Farquliar Buzzard ATHETOSIS — (See Contractions.) ATROPHY, MUSCULAR. — Muscular atrophy is often merelv a part of a general wasting of the whole body, the result either of chronic lesions, such as carcinoma, sarcoma, tuberculosis, syphilis, malaria, ulcerative colitis, marasmus, starvation, hepatic abscess, cirrhosis of the liver, diabetes, anorexia nervosa , or from acuter maladies, such as diarrhoea and vomiting, ptomaine poisoning, typhoid fever, dysentery, cholera, and so forth. The history, and the other symptoms in the case, will usually serve to indicate the diagnosis. If any doubt remains as to whether the atrophy is neurotrophic or not, the electrical reactions will be tested ; there will be no reaction of degeneration (R.D.) when the atrophy is merely part of a general wasting, whereas if — as might be the case in a dia- betic patient, for instance — there is peripheral neuritis in addition, this will be indicated by a partial or complete R.D. (See Reaction of Degeneration.) In the next place, the atrophy may be the result of disuse, especially in the legs. Organic disease of the nervous system may or may not be present at the same time ; the patient may be bedridden from locomotor ataxj^ for example, or from general paralysis of the insane : and the muscles of the limbs may consequent!}' become so thin that peripheral neuritis or degeneration of the 70 ATROPHY, M use ULA R anterior cornual cells may be simulated, and a determination of the absence of R.D. mav be the only means of excluding these. It is important to remember that in the primary muscular dystrophies, whether of the pseudo-hypertrophic, the juvenile, the infantile, the facio-scapulo-humeral or Landouzy-Dejerine or other types, there is no reaction of degeneration, the electrical responses and the superficial and deep reflexes remaining normal in type,' though they diminish in degree as the amount of muscle grows less and less, until finally there is no muscle to respond at all. The primary muscular dystrophies are comparatively easy to diagnose, however, on account of their insidious onset in children, their slow but progressive downhill course, their occurrence in different members of the same familv, the absence of sensory disorder, and the F/'s: 7-- -Atrophy of the muscles of the left shoulder and upper arm, the result of former acute anterior poliomyelitis — infantile paralysis. absence of reaction of degeneration. Thej^ are distinguished from the infantile parah'sis which results from acute anterior poliomj'elitis {Fig. 7) bj- the sudden onset of the latter, the R.D. at its height, and by the fact that the resultant wasting does not advance beyond a certain point, but rather tends to remain stationary, after recovering to a certain degree. Peripheral neuritis is to be distinguished from primary muscular dvstrophv by the history and course, and by the presence of R.D. at some period of the malady. Two other affections that may be confused with a primary muscular dystrophy, particularh^ as they also are hereditary, that begin insidiously at an earlv age, and slowly advance — are Friedreich's ataxy, and Tooth's peroneal tvpe of ATROPHY, MUSCULAR 71 progressive muscular atrophy. Each of these may cause tahpes, moreover, and therefore simulate infantile paralysis, except that in the latter the talipes is generally one-sided, whereas in the other two it is bilateral. In Friedreich's ataxy there is no real wasting, but rather a lack of development; the knee-jerks are lost, the big toes are permanently erect, there is no Argyll- Robertson pupil, the bladder and rectum are not involved until quite late, there is no R.D., and although the legs are chiefly affected, there may also be ataxic movements of Fi^. 8. — Tooth's peroneal type of neuro-niuscular dystrophy — early : the patient is the younger brother of the girl in Fig. 9. Fig-, g. — Tooth's peroneal typeof neuro-muscular dystrophy : the patient is sister to the boy in Fig. 8 ; her malady is in a much more advanced stage than is his. the hands, and the eyes may present nystagmus and even optic atrophy. In Tooth's peroneal type of progressive muscular atrophy, the illness is apt to come on after some febrile malady such as measles or whooping-cough, the first thing to be noted being an inability to dorsifiex the big toe, which hangs down in a way that is the exact converse of its erect position in Friedreich's atax}- {Fig. 8) ; the paresis takes months or years to spread to the rest of the legs, and finally to the hands [Fig. 9), the slowness of the progress and the absence of ATROPHY. MUSCULAR sensory symptoms showing that it is not peripheral neuritis, whilst the R.D. in the affected muscles excludes a primary muscular d3'Stroph^^ The lesion is in the anterior cornual cells and starts in the lumbar enlargement. The knee- jerks are retained until the quadriceps of the thigh is involved. Local muscular atrophj' may be due to disease of the parts beneath, as in the case of the pectoralis major, the supraspinatus, the deltoid, the infra- spinatus, and other shoulder muscles when the underlying lung is the site of active phthisis. Similar local atrophy results very quickly from acute and subacute affections of joints, especially in the muscles whose origin is above the affected joint. The gluteal atrophy associated with tuberculous hip- joint is well known ; similarly, knee-joint disease leads to thigh atrophy, elbow disease to atroph}^ of the muscles of the upper arm, and so on. The same applies to the effects of fractures, new growths, sprains, and splints ; the atrophy is some- times so rapid that some think it cannot be due simpl}^ to disuse, but must have a neuropathic factor also. The affected muscles present no R.D., however. One particular form of paralj'sis associated with the use of splints merits special mention, namelj^, Volckmann's paralysis of the forearm. (See Paralysis of THE Upper Extremity.) Hemiatroph}' of the face or trunk is generally congenital, and the diagnosis is not difficult. If it can be decided definitely that there is some nervous cause for muscular atrophy, the best proof of which is the detection of partial or complete R.D. in the affected muscles, the diagnosis lies between one or other of the following conditions : — 1. Causes in the Spinal Cord. — Progressive muscular atrophy. Am j^o trophic lateral sclerosis. A few cases of transverse m^^elitis. Syringomyelia. Tooth's peroneal type of progressive muscular atrophy. Acute anterior poliomj^elitis. 2. Causes in the Peripheral Nerves. — Tumours of the cauda equina Pelvic tumours involving the lumbo- sacral plexus Sciatica Aneurysm New growth Accessory cervical rib, etc., pressing on the brachial plexus Gummata, etc., involving the cranial or other nerves Injury to peripheral nerves, including the effects of callus after fractures Peripheral neuritis, of which the following are some of the causes :- Certain inorganic chemical sub- stances, notably Lead Arsenic Mercury Certain organic chemical com- pounds, notably Alcohol Ether Carbon bisulphide Naphtha Certain severe anaemias : Pernicious anaemia Spleno-meduUary leukaemia Lymphatic leukaemia Hodgkin's disease Splenic anaemia Certain microbial or allied toxins : Diphtheria Leprosy Malaria Chronic p3'aemia Infective endocarditis Beri-beri Syphilis Tj'phoid fever Influenza Oral sepsis Certain constitutional diseases, some- times attributed to endogenous poisons : Gout Diabetes mellitus Pregnancy Other causes as j'et undetermined. ATROPHY, MUSCULAR 73 In arriving at a diagnosis in a particular case, it is important not to use the term " neuritis " until all the other possible lesions have been excluded. Tooth's peroneal type of progressive muscular atrophy and acute anterior poliomj'elitis have already been discussed. The latter is sometimes regarded as essentially a disease of earlv life, but it is important to remember that it is by no means impossible for it to affect an adult, in whom the symptoms and results may be preciselv similar to what they would be in a child. Progressive muscular atrophy is a disease of adults. It shows no particular tendency to occur in several members of the same family. It begins insidiously, and advances slowly for months and years, affecting first the small muscles of the hands, causing atroph}' with R.D. in the interossei and in the muscles of the thenar and hypothenar eminences ; the peculiar deformity described by the term " main-en-griffe " results. In the course of months the paresis spreads from the hands to the forearm muscles, and later to those of the upper arm. Disease of the peripheral nerves, such as the ulnar, is excluded by the fact that the paralyzed muscles are not all supplied from the same nerve trunk — the thenar muscles supplied by the median being affected equally with the hypo- thenar supplied by the ulnar. All the muscles below the wrist are involved more or less together, then all the muscles below the elbow, and so on ; this paralysis of associated groups of muscles, as distinct from muscles supplied by the same nerve, at once suggests a progressive degeneration of the anterior cornual cells of the cervical enlargement of the cord. Disease of the brachial plexus would be excluded first by the fact that the lesion is bilateral and symmetrical, and secondly by the absence of pain or other sensory disturbance. The pathology of the disease is analogous to the nuclear cell degeneration in the medulla oblongata that leads to bulbar (labio-giosso-pharyngo-laryngeal) paralysis ; and indeed, progressive muscular atrophy may either follow or be followed by bulbar paralysis. If, at the same time that there are the signs of progressive muscular atrophy in the hands, there is also spastic paresis of the legs, with no wasting, but increased knee-jerks, ankle clonus, and extensor plantar reflexes, the onset having been quite gradual, without sensory disorder, and without bladder or rectal trouble unless the disease has reached quite a late stage, the condition is amyotrophic lateral sclerosis. It is important that the character of the onset and the absence of sensory symptoms be insisted on, in order to exclude syringomyelia and anomalous cases of transverse mj-elitis. Syringomyelia is rare, but it has one very character- istic feature, namely, the preservation of ordinary cutaneous sensibility with the loss of power of distinguishing heat from cold, or pain from touch, in some part of the limbs or trunk. There need be no other symptom than this dissociation of sensations, or skin lesions in the paresthetic parts may be a prominent feature — Morvan's disease ; if the enlargement in and around the central canal of the cord displaces and destroys the anterior cornual cells in the lower part of the cervical enlargement, progressive muscular atrophy is simulated ; if at the same time the bulging of the central canal and the changes around it cause compression of the crossed pyramidal tracts, there will be all the motor symptoms and signs of amyotrophic lateral sclerosis, the diagnosis being only possible when the sensory symptoms are typical. It is generally stated that transverse myelitis causes spastic paraplegia without muscular wasting or R.D. This is in the main true, because the few anterior cornual cells destroyed by the transverse softening of the cord in the commonest site, namely, the dorsal region, correspond to an intercostal or abdominal segment, the wasting of which is difficult to detect. If, however, the transverse myelitis occurs so high up as to involve the lower part of the cervical enlargement — to 74 ATROPHY, MUSCULAR involve the cord yet higher up is incompatible with life, because both the intercostals and the phrenic nerves would be paralysed — a certain number of the anterior cornual cells sending motor nerves to the hands and arms would be destroyed, the result being a main-en-griffe like that of progressive muscular atrophy ; and the simultaneous interference with the crossed pyramidal tracts would produce a picture identical at first sight with amyotrophic lateral sclerosis. Not onh^ however, would there very likely be impairment of all forms of sensation as well as paresis, in a case of transverse myelitis, but instead of the onset being very gradual and the progress a steady advance downhill, as in progressive muscular atrophy or amyotrophic lateral sclerosis, the onset would have been a comparatively rapid one, followed by a cessation or even by an improvement if the patient lived. Similarly, if transverse mj^elitis occurs so low down as to involve the lumbar enlargement of the cord, it would cause, not spastic paraplegia with increased knee-jerk, ankle clonus, extensor plantar reflex, no wasting and no R.D. ; but absence of knee-jerk, no ankle clonus, no extensor plantar reflex, marked muscular atrophy of the legs, with R.D., paraesthesia, bladder and rectal trouble. The involvement of the sphincters in such a case would be of considerable aid in excluding peripheral neuritis ; whilst Tooth's peroneal type of progressive muscular atophy and acute anterior poliomyelitis would be excluded not only by the paraesthesia, but also by the history of the mode of onset and the course of the malady. • A tumour involving the cauda equina is rare, but it is not altogether difficult to diagnose. It may be more difficult to determine the nature of the mass — gumma, glionaa, primary sarcoma, secondary sarcoma or carcinoma — than its site. The onset of symptoms is generally gradual, and one leg is affected either earlier than, or more than, the other. Weakness in the leg, together Avith severe pains both in it and in the lower part of the lumbar region of the spinal column, will be followed by muscular atrophy and R.D. Sciatica may at first suggest itself, until it is found that neither the pains nor the paresis correspond to one single nerve ; and when the disease progresses and the other leg is affected, anaesthesia supervenes upon the paralysis. The site of the pain over the region of the Cauda equina is an important point in the diagnosis, whilst rectal and possibly vaginal examinations are essential for the exclusion of a pelvic mass — such as carcinoma of the rectum, uterus, or ovary, a fibromyoma, a cyst, a sarcomatous,' gummatous, tuberculous, or inflammatory mass, or even a displace- ment of the womb — which, by interfering with the nerves at the back of the pelvis, might produce very similar symptoms. Sacro-iliac joint disease can generally be excluded by the fact that the pains are not definitely referred to the joint, whilst any wasting that might be associated with disease of that joint would not be accompanied by R.D. Sciatica does not always give rise to wasting of the corresponding muscles ; but sometimes it does, and occasionally it may do so bilaterally, with R.D. The localization of the pain, tenderness, and atrophy to the parts supplied by the great sciatic nerve, without affection of other nerves and muscles in the leg or calf, would point to sciatica, especially if the lesion was unilateral, and if the patient, though unable to flex his thigh to a right angle with his abdomen at the same time that he keeps his knee extended, can extend his leg back- wards at the hip-joint in a way that would be impossible if he had a psoas abscess ; and if he is able to bear firm backward pressure on the knee when the leg of the affected side is flexed and outwardly rotated in such a way that the foot lies across the opposite knee — a test which will exclude hip-joint disease. When the lesion is a thoracic aneurysm or neoplasm, or an accessory cervical rib pressing on or involving the brachial plexus, the wasting is almost certain to affect one arm only, or one arm much more than another, and the diagnosis ATROPHY, MUSCULAR 75 will be made by physical examination of the thorax, assisted by the use of the ;ir-rays. The only cranial nerve paralyses that are likely to be associated with marked atrophy of muscles, are those of the seventh with facial atrophy, and of the twelfth with atrophy of the tongue. Injuries to peripheral nerves, or inclusion of the latter in callus, will generally be diagnosed by the history, and by the fact that in distribution the muscular atrophy and R.D. correspond accurately with one or more of the peripheral nerves that may have been divided or otherwise injured. If all the conditions described above can be excluded, it is probable that the cause of the muscular atrophy is some variety of peripheral neuritis. To merit this diagnosis, the affected muscles should be multiple and symmetrical ; partial or complete R.D. should be obtained ; there may or may not be sensory changes ; the reflexes, both superficial and deep, are for a short time exaggerated, and then become deficient or disappear altogether for the time being. Wasting may be extreme, but the tendency is for slow recovery to ensue, improvement beginning to set in some three or four months after the neuritis ceases. Some- times the nature of the case is obvious, but it is often easier to diagnose peripheral neuritis than to discover its exact cause. The different conditions that may produce it are enumerated above. In diagnosing between them the history is very important. If the patient has never been abroad leprosy and beri-beri are unlikely, whereas if he has been abroad amongst lepers, and if he has areas of anaesthesia without much paresis, with or without the characteristic nodules and bosses of subcutaneous infiltra- tion," followed by ulceration and necrosis, the diagnosis of leprosy will at once suggest itself. The chief difficulties wall perhaps be to exclude syringomyelia on the one hand and tertiary syphilis on the other. The good effects of treat- ment by potassium iodide and mercury may assist in detecting syphilis, and Wassermann's reaction may also be positive ; in syringomyelia there is little or no loss of cutaneous sensibility like there is in leprosy, though there is loss of power to distinguish heat from cold, and pain from touch. The ultimate test of leprosy would be to excise a small portion of the affected tissue and to examine it for the acid-fast leprosy bacillus. Beri-beri is sometimes seen in this country, generally in patients who have come into port in a ship from the East ; several of the crew have generally been affected at the same time, some may have died ; the peripheral neuritis and muscular wasting will often be associated with subcutaneous oedema, and there is often a history that the dietary has consisted of rice that has not been absolutely fresh. The presence or absence of glycosuria will serve to diagnose or exclude diabetic neuritis. Loss of knee-jerk in diabetes mellitus is comparatively common, but extensive peripheral neuritis is much rarer. It is associated with pain and parsesthesia as well as paresis and muscular atrophy, and it affects the limbs, especially the legs, rather than the trunk. Gout as a cause of peripheral neuritis is always open to doubt, for there is often a possibility that the neuritis of a gouty subject may really be due to the same indulgences that brought on the gout. Difficulty may also arise in attributing a neuritis to pregnancy even when the patient is, or has been recently, pregnant. In the case of blood diseases it is important to bear in mind that these are usually treated with arsenic, so that the peripheral neuritis may be due to the Treatment rather than the disease. This will be rendered the more probable if there are or have been other symptoms of subacute or chronic arsenical poisoning, such as corvza, nausea, vomiting, abdominal colic, diarrhoea, 76 A TROPH Y, M USC ULA R headache, pigmentation of the skin not unhke that of Addison's disease, hyper- keratosis of the pahns and soles, or herpetiform eruptions. With arsenical neuritis, the limbs are involved most, particularly the legs, and there are pains and paraesthesia as well as paresis. It is held by some, however, that the blood diseases may themselves cause peripheral neuritis, and there seems no reason wh}- this should not be so, for it is well known that the severe anaemias such as pernicious ansemia may cause degeneration in other parts of the nervous system also, notably in the long tracts in the spinal cord, with consequent sensorjr, ataxic, or paretic s\-mptoms, varjdng with the parts involved. If the peripheral neuritis occurs early in the blood disease, the latter may not come to mind as a possibihty. A blood-count is essential. Oligocythaemia with high colour index, no leucoc]ii;osis, a relative h-mphoc^^osis, and the presence in blood films of a preponderance of megaloc}^:es, are changes characteristic of pernicious ancBtnia, in addition to which the primrose-yellow skin may be tjrpical. Great increase in the total number of leucocytes up to an3rthing from 50,000 to 1,000,000 per c.mm. would suggest leucocythcemia : if this were the spleno- meduUar\' form, myelocytes would probablj^ be 30 per cent or more of all the white cells seen in films, whilst in the Ijnnphatic form the Ij^mpho- cytes w^ould similarly amount to 90 per cent ; in both forms, particularly^ the spleno-medullarjr, the spleen and liver would be big, whilst in the lymphatic t^-pe there would probably be general enlargement of the lyra.- phatic glands. Hodgkin's disease or lymphadenoma suggests itself when the spleen and many of the l\Tnphatic glands are enlarged, without any characteristic blood changes — at most a simple anaemia without leucocytosis, with relative l5?mphocytosis, and an occasional mj-eloc^rte, basophUe corpuscle, and nucleated red cell in films. Splenic ancsmia is a doubtful entity?', the name being apphed when there is simple anemia A^ith apparently idiopathic enlargement of the spleen. Many such patients ultimately turn out to have cirrhosis of the liver — Banti's disease. Peripheral neuritis in such a case may well be alcoholic. Malaria or ague will be diagnosed by the history, and by the discovery of the haematozoa in the blood during an attack. The difficult}' may be to exclude alcohol as a cause for the neuritis in a patient who has also suffered from severe malaria. Infective endocarditis is sometimes so chronic and insidious that it escapes detection. Points to la}- stress on are the presence of a cardiac bruit or bruits, especiaU}' if the latter change radically in character under observation, pro- gressive anaeraia, p^Texial periods, enlargement of the spleen, evidence of embolism or infarction, retinal, subcutaneous or other haemorrhages, and optic neuritis. It may not be easy to convince oneself that some other cause of chronic pycemia, whether uterine, pelvic, pulmonar}^, oral, or otherwise, is the cause of peripheral neuritis in a given case. The same applies to syphilis, especially if the patient is also addicted to alcohol. Jniluenza is not to be diagnosed as the cause until ever}' other possible explanation has been exhausted ; it is too easy to attribute things to influenza. Peripheral neuritis in connection with typhoid fever generall}^ arises as a direct sequela of a ts'pical attack confirmed by Widal's test, so that the diagnosis is not difficult as a rule. It has the same t^-pe, sensor}- and motor, as arsenical neuritis. Diphtheria is one of the most important of all the causes, and if the diphtheria itself has been slight it may have been entirely overlooked, especially as the neuritis develops two or three weeks or longer after the sore throat. It is important, therefore, to lose no time in taking cultivations from the throat in ATROPHY, MUSCULAR 77 all doubtful cases of peripheral neuritis, lest it be still possible to find the causal organisms in swabbings. The nature of the case may be suggested at once, however, if there has been a nasal alteration in the voice, or if there is an inability to swallow liquids owing to 'their regurgitation through the nose — evidence of paralysis of the palate that is almost characteristic of diphtheria ; the pupil reflexes are also apt to be affected, and the patient may be thought to have an error of refraction because paresis of the ciliary muscle renders accommodation difficult or impossible for the time being. The symptoms may stop at the palate and eye ; but in bad cases — perhaps as the result of a toxin different from that which directly affects the palate — paralysis and extreme atrophy of the limbs, without much sensory disorder, follows too. The vagus nerves may be involved, causing tachycardia, and perhaps death ; equally serious may be the involvement of the phrenic nerves, with weakness or paralysis of the diaphragm. In regard to the various chemical substances that may produce peripheral neuritis, inquiries into the patient's occupation may assist the diagnosis. Workers amongst indiarubber come in contact with carbon bisulphide fiimes, this compound being used to dissolve the rubber. Naphtha is extensively used in some trades. The use of a chemical may not always be obvious until careful inquiries are made — for instance, one may not at first see what a person who prepares rabbit skins for conversion into hats has to do with mercury, until it is learned that mercurials are used to preserve the pelts. Mercurial neuritis is characterized by a remarkable tremor of the hands and arms, in addition to the muscular atrophy in the arms and legs ; there are not many sensory symptoms as a rule. Lead neuritis is easily diagnosed when it causes the characteristic wrist-drop ; all the muscles supplied by the musculo- spiral nerve beyond the triceps become paralyzed, except the supinator longus and the extensor ossis metacarpi pollicis, and there is no sensory disorder ; the diagnosis is confirmed by finding a blue line upon the gums and the other signs of lead poisoning, particularly abdominal pains and colic, anaemia, constipation, nausea, vomiting, headache, impairment of sight, a tendency to abortion in women, gouty joint pains, albuminuria, and even epileptiform convulsions and other serious cerebral symptoms that are spoken of as saturnine encephalopathy. The difficulty arises in those less typical cases in which the lead causes generalized peripheral neuritis in both legs and both arms, perhaps without any other symptoms, without even a blue line upon the gums if the teeth are kept clean. The source of the lead may be very far from obvious — it may be some obscure thing, such as a hair- wash, or the result of water contamination due to electrolysis in w-ater-pipes, the result of leakage in an electric main. In case of doubt it may even be worth while to evaporate down a large bulk of urine and apply the ammonium sulphide test for lead to the residue : a drop or two of the latter, allowed to fall into a tall glass full of ammonium sulphide, will cause a white trail to develop in the fluid as the drop descends. Arsenical neuritis has been mentioned above ; it may arise in patients who are taking arsenic in medicinal doses, for instance for chorea or pernicious anaemia, or the poison may be taken unawares, as in the Manchester epidemic, in which fatal results followed contamination of beer wdth arsenic. It has even been held that alcohol itself is no cause of peripheral neuritis, and that those patients who have developed it as the result of long-continued drinking to excess —possibly without a single actual intoxication in the popular sense — owe the nerve trouble and generalized muscular atrophy, not to the chemical substance C.,HgO, but to other bodies associated with it. Clinicalh^ however, it is sufficient if the diagnosis of the cause of peripheral neuritis can be narrowed down to alcohol in some form or other, and for this to be possible an accurate ATROPHY, MUSCULAR history is essential. The greatest dif&culty arises in the case of secret drinkers, especially women who may appear to be above suspicion. The neuritis is ushered in with pains and cramps in the limbs, followed by wasting, which may reach an extreme degree ; the trunk and limbs so'metimes look like those of a person who has been starved to death. Associated signs of alcoholism should be looked for. It only remains to add that there will always be some cases in which the cause of the peripheral neuritis fails to be found ; if arsenic is suspected, a portion of hair should be sent for chemical analysis ; for it has been shown that the hair of a person taking arsenic stores the latter in proportions sufficient to allow of its detection. Herbert French ATROPHY, OPTIC. — (See Ophthalmoscopic Appearances, Xotes on.) ATROPHY, TESTICULAR.— When the fact that one testicle is smaller than the other is a prominent feature in a case, it is, in the first place, necessary to determine which of the two organs is the abnormal one ; for when one testicle is shghtly enlarged, one may sometimes be led into the error of regarding the enlarged organ as normal and the other as too small. The next point to remembej: is that the condition may be physiological ; a certain amount of inequaH1r\- of the two organs is not an uncommon result of developmental difierences here, just as in the case of paired organs generally. Further than this, atrophy of one testicle is seldom in itself of serious import even when it has a pathological basis. It may be of some value in its bearing upon other features of the case, however, so that it may be important to deter- mine why the patient presents the symptom. Deahng first with the question of a testicle which is in an abnormal position, such as one that has been retained in the inguinal canal or elsewhere, it is clear that in addition to such causes of atrophy as the normally situated testicle may be subject to, there is here another and a special factor, namely, inhibition of gro%vth owing to compression by the surrounding parts. A retained or misplaced testicle is frequently undersized. At the same time it should be remembered that inflammatory and other lesions which may- produce atrophy of a normally situated testicle, may also affect one that is retained or misplaced. In speaking of testicular atrophy it is important to take into consideration the age of the patient, because a physiological atrophy of the testicles is apt to occur in advanced life. This senile change may begin as early as the fiftieth year, but on the other hand, there are many quite old men whose testicles are no smaller than when they were young. Atrophy of a normally situated testicle is nearly always due to one or other of three main groups of causes, namely, either : (I) Interference with its blood- supply ; (II) A preceding inflammation ; or (III) A neurotrophic cause. The following is a list of causes arranged under these main headings : — I. — Interference with the Blood Supply : — Compression of the spermatic cord, as by an inguinal hernia or by a spermatocele. \'enous stasis, the result of varicocele. Compression of the testicle by affections of the tunica vaginahs, such as hydrocele or haematocele. The wearing of an ill-fitting truss in the inguinal region. As a sequela of operations in the region of the spermatic cord, such as those for the cure of varicocele, spermatocele, or hernia. Elephantiasis ATROPHY, TESTICULAR 79 II. — Atrophy, the result of Orchitis, due to such causes as the following : — Gonorrhoea Injury Syphilis Mumps Typhoid fever Tubercle Gout Strain X-rays Rheumatism Influenza III. — Neurotrophic Causes, especially after injury to the brain or spina cord. It has been stated that atrophy of a testicle may result from the administration of iodide of potassium ; but this is exceedingly difficult to prove, for it will seldom happen that this drug will be given unless there is already present some other possible cause of testicular atrophy, particularly syphilis or an orchitis. Dealing now with the differential diagnosis of the above causes in greater detail, it will be clear that the history of the case will in most instances have a very important bearing upon it. Group I. — The cause in any of the cases in this group will generally be obvious. It is only necessary to bear in mind that an operation for varicocele, for instance, may have been successfully performed, and the patient may there- after contract an orchitis followed by testicular atrophy, for which the operation may then be unjustly blamed. As regards Group II, one may say at once that it is very doubtful whether either influenza or rheumatism ever really produced either orchitis or testicular atrophy. There may be a definite history of the orchitis itself, which preceded the atrophy, and then diagnosis should not be difficult, provided it is remembered that by no means every orchitis is gonococcal. If mumps, typhoid fever, gout, and injury are borne in mind, these causes of orchitis and testicular atrophy will be recognized more often than they are. Mumps is particularly apt to be overlooked, and yet it is well known that orchitis may be the sole evidence of this complaint. If the patient has been seen when the orchitis was active, bacteriological examination of any urethral discharge is essential to the diagnosis, which depends on whether gonococci are detected or not. If gonorrhoea can be excluded, then the diagnosis of the nature of the orchitis is arrived at by considering the evidence as to gout, mumps, and so on. It is sometimes stated that orchitis may result from strain, atrophy resulting in due course. There are a few reported cases where, apparently as the result of great bodily exercise, especially the lifting of heavy loads, inflammation of the testicle followed ; but it is difficult to say that in these cases the strain alone produced the symptoms ; there is the possibility that a residual gonorrhoea may have been present in the prostate or posterior urethra, the action of the strain being merely to light up the latent inflammation. There remain a large number of cases, however, in which there is no clear history of any orchitis, the latter having been relatively slight. Testicular atrophy will then seem to have arisen idiopathically, and it will be very im- portant to remember how often it is the result of former injury, such as a kick at football, a blow from a cricket ball, contusion from falling astraddle on a fence or bicycle, and so on. The injury may date back to boyhood, many years before testicular atrophy is noticed, and it will often be difficult to prove that the latter was really due to the former. It is noteworthy that, apart from obviously tuberculous epididymo-orchitis, it not infrequently happens that transient enlargement of a testicle is to be 8o ATROPHY, TESTICULAR obser\-ed, if looked for, in tuberculous subjects, and whether this can be regarded as a definite tuberculous orchitis or not, it sometimes results in atrophy. In a consumptive patient some degree of atrophy of one testicle is not infrequent ; so that when a thin patient presents himself for exam- ination, and one testicle is found to be unduly sniall without obvious cause, the examination of the lungs, and if necessarj^ of the sputum, should be made with particular care. The ;t;-rays as a possible cause of testicular atrophy should not be forgotten, and all users of ^--rays should be careful to have a suitable lead shield. That sterility can result from repeated applications of these rays is well known. Group III. — Here, the history of the cases as a rule gives the diagnosis. Remarkable instances have been recorded in which, within a few months of injury to the brain or spinal cord, particularly after injury to the lumbar vertebrae, or the occipital region of the skull, the glandular elements of the testicle have disappeared. A case of Kocher's exemplifies this very well : A man, ast. 41, the father of four children, fell on his head from a consider- able height. At first he did not appear to be greatly damaged, but presently twitchings occurred, and the patient became unable to work. From this time on his sexual powers greatly diminished, and his beard and pubic hair fell out. Eighteen months later this hair was completely gone, and about five years after the accident the left testicle was the size of a hazel nut, and the right one the size of a bean. Herbert French. AURA is the term applied to the immediate prelude of an epileptic seizure. It is recognized in some form or another in about 30 or 40 per cent of epileptics, and with rare exceptions alwaj^s takes the same shape with every attack in each individual. An aura may be motor, sensory, psychical, visceral, or related to some special sense. A motor aura may be represented by an involuntary^ movement of a limb or a part of a limb ; in other cases it takes the form of a general movement such as running. A sensory aura is common, and is described as a pain, a numbness, or a tingling in some part of the patient's body. A psychical aura is often expressed as a vague apprehension, or an indescribable feeling, or a sense of unreality. A visceral aura is frequently present, usually as an " epigastric sensation " or queer feeling starting in the region of the stomach and rising to the throat, or less often as a peremptory desire to go to stool. An aura of special sense may be oljactory, visual, auditory, or gustatory. In one case a pleasant or unpleasant odour or flavour may be perceived by the patient. In other cases some alteration in vision or other special sense may be realized by him, warning him of the onset of a seizure. In the case of an auditory aura it is customary for the patient to hear voices or some particular kind of sound. The aura of epilepsy is, in relation to diagnosis, important from at least two points of view. In the first place, it often affords a clue to the particular locality in the brain from which the " fit " or " storm " originates and spreads. This may not be of much value in the case of idiopathic epilepsy, because there is no method at present known to us by which the seat of the disease can be successfully treated. In the case of Jacksonian epilepsy, on the other hand, the knowledge of the locality in which a fit is generated sometimes, although unfortunately not often, allows of benefit being obtained from surgical assist- ance. For instance, an aura ma}'' be the first symptom of the presence of an intracranial growth. A tumour of the uncinate region of the temporo-sphenoidal lobe may be revealed by the presence of signs of increased intracranial pressure and the repeated occurrence of an olfactory aura, followed by a vague, dreamy state of consciousness. A lesion of one occipital lobe may be suspected from BABINSKFS SIGN the occurrence of epileptiform fits, immediately preceded by an aura in which there is loss of sight in the opposite visual field. An aura of pain starting in the left foot, spreading up the left side of the body, and terminating in a generalized convulsion, suggests a lesion in the post-Rolandic region of the right parietal lobe. Such instances of the importance of an aura as a local- izing sign in diagnosis might easily be multiplied were it necessary; but a general knowledge of the functional anatom^^ of the brain will suffice to supply other examples of a similar kind to the reader's mind. In the second place, the importance of recognizing a subjective sensation as an aura, and so recognizing the existence of epilepsy in its simplest and some- times earliest form, can hardly be over-estimated from the point of view of treatment. When a patient describes himself as being liable to subjective sensations occurring at intervals, and for which he cannot account, careful inquiry should be made as to their nature. The chief characteristics of an aura are : (i) Its spontaneous development without cause, generally during good health ; (2) The suddenness of its onset ; and (3) The identity of each sensation with the last. It should be understood clearly that an aura may occur alone, or may be followed by momentary loss of consciousness (petit mal), or by loss of conscious- ness with convulsions (grand mal). In some cases an aura may be repeated with frequency for many months before a typical epileptic seizure supervenes, and if recognized as such during this stage, it is reasonable to expect that treat- ment will have more chance of success than at a later period, when the " habit " of convulsions has been firmly established. Finally, it should be emphasized that in cases of epilepsy the recurrence of an aura, even without further manifestations of the disease, must be regarded as evidence that the morbid tendency is not completely controlled, and that discontinuance of treatment must inevitably lead to the reappearance of more serious attacks. E. Farquhar Buzzard. BABINSKI'S SIGN — consists in a modification of the plantar reflex. In testing the latter the patient should be lying upon his back, with his legs very slightly flexed and each foot everted so that its outer border lies comfortably in contact with the bed or couch ; the sole should be warm and dry ; the ankle should be gently but firmly grasped by one of the observer's hands, to prevent the undue dorsiflexion of the whole foot which often makes it difficult to decide which way the toes themselves move, whilst the outer side of the sole is firmly and steadily stroked from the heel forwards with some such instrument as the butt end of a pencil. In healthy adults the big toe and the other toes will become plantar-flexed ; when the great toe becomes dorsiflexed instead, it presents the extensor plantar reflex, or Babinski's sign. It is important to bear in mind that whichever way the other toes move, it is with the direction of movement of the big toe alone that Babinski's sign is concerned. It is also noteworthy that if Babinski's sign is present, the fact is usually ascertained with ease ; when there is any doubt as to which way the great toe moves, the plantar reflex is seldom really extensor. The great value of the sign is in distinguishing between certain functional and organic affections of the nervous system. If the patient is an adult who is fully conscious, and presents symptoms of paresis of one or both legs, the existence of an extensor plantar reflex is proof that the lesion is organic. The converse is not true ; for with locomotor ataxy, and with lower neurone affections, such as infantile paralysis. Tooth's peroneal type of progressive muscular atrophy, peripheral neuritis, Landry's acute ascending paralysis, and primary' D <3 82 BABINSKVS SIGN muscular dvstrophies, the plantar reflex is flexor so long as it is obtain- able at all. It is when there is a lesion in any part of the crossed pyramidal tracts that Babinski's sign is best seen. Thus, it is present in cases in which tumour, abscess, haemorrhage, thrombosis, or embolism have caused hemiparesis or hemiplegia by affecting either the pyramidal cells themselves in the motor cortex, or the pyramidal fibres in the internal capsule ; in cases of cerebellar tumour, owing to the fact that this, by compressing the medulla, nearly always •causes lateral sclerosis of the cord as well ; and in cases of disseminated sclerosis, transverse mvelitis, either primarj^ or due to compression, ataxic paraplegia, Friedreich's ataxv, amvotrophic lateral sclerosis, primary lateral sclerosis, some cases of syringomA'elia, and in those cases of irregular sclerosis of the cord that may be associated with severe oligoc^j-thaemias, such as pernicious anaemia. The ■differential diagnosis of these conditions will be found under Hemiplegia (q.v.) and Paraplegia (q.v.). Babinski's sign is not found in those cases of hysteria that sometimes simulate one or other of the above conditions ; provided always that the patient is a conscious adult. This is an important proviso, because the plantar reflex may be extensor without there being any decided changes in the cord or brain in infants and quite young children ; and also sometimes in adults, during deep sleep, or under conditions of unnatural unconsciousness, such as that due to a general anaesthetic, or acute alcoholic intoxication, or such affections as epilepsy, uraemia, concussion, saturnine encephalopathy, and in some other forms of coma. These exceptions, however, scarcely detract from the great value the sign has as a means of distinguishing between organic and functional paralysis of the legs of the upper neurone tT,-pe. Herbert French. BACILLURIA (See Bacteriuria.) BACTERIURIA (see Plate XII) is a comprehensive term employed to indicate that the urine when freshly voided contains micro-organisms derived from some portion of the genito-urinary tract. Bacilluria is a term of similar import, but is restricted to those cases in which rod-shaped bacteria are present. The normal urethra (male and female) is the habitat of certain non-pathogenic bacteria (chiefly cocci, such as Streptococcus brevis, Staphylococcus albus, also varieties of Bacillus xerosis, etc.), Avhich are, of course, present in urine obtained under ordinarj- conditions. Bacteriuria as a pathological condition can onlj- be recognized with certainty bj' the examination in the laboratory of a catheter specimen of the urine collected with the most scrupulous attention to asepsis ; for, on the one hand, a perfectlj^ clear acid urine xsia.y be heavily loaded with bacteria, and, on the other, a urine may owe its turbidity either to purely physico-chemical causes, or to the growth in it of bacteria which have gained access after its exit from the urethra. Moreover, although the identity of the infecting organism may be suspected from general clinical considerations, cultivation experiments are essential in order to settle the matter beyond doubt. Bacteriuria may indicate either general or local infection. It is a rare symptom of general infection, save one of such intensity that an acute nephritis, associated with a definite haematuria, has supervened. Usualh' its appearance indicates a purely local infection ; it then occurs with greatest frequency in young children and pregnant women, when the micro-organism concerned is usually B. coli, and the site of the infection the pelvis of the right kidne3^ It is, however, met with at all ages and in both sexes, and many different bacteria have been recorded as the causative factors. BACTERIURIA 83 Bacteriuria may be a symptom in :— A. General Infections due to : — Streptococcus pyogenes longus Pneumococcus Micrococcus melitensis Gonococcus Staphylococcus pyogenes aureus B. typhosus B. coli communis B. paratyphosus B. Local Infections :^ I'ith or without associated nephritis. Nephritis | Pyelo -nephritis - Ureteritis ) Cystitis Prostatitis Urethritis due to- due to due to- due to B. coU B. tuberculosis B. pyocyaneus B. pneumoniae (Friedlander's bacillus) Streptococcus pyogenes longus Pneumococcus. B. coli B. tuberculosis B. typhosus Streptococcus pyogenes longus. B. coli Gonococcus Staphylococcus pyogenes aureus Streptococcus pyogenes longus. Gonococcus Staphylococcus pyogenes aureus or albus Pneumococcus Streptococcus pyogenes longus Micrococcus catarrhalis. Finally, a slight and transitory bacteriuria due to B. coli communis, and usually passing oirf without any treatment, can frequently be observed following operative measures upon the rectum or anus, or the organs of generation. In general infections the urine is either normal in appearance, or by reason of its admixture wdth blood may present any tint from " smoky " to bright red. The reaction is acid, albumin is present, varying in amount from a trace to 7, 8, or more parts per thousand, and microscopical examination of the centri- fugalized deposit shows the presence of blood-cells, renal tube-casts, and renal epithelium, in addition to the infecting bacterium. The clinical symptoms presented by the patient are those of the general systemic infection. In local infections of the genito-urinary tract where infection is due to one species of micro-organism only, the urine presents a somewhat similar appear- ance ; blood, however, may be entirely absent, while pus is usually present in larger or smaller amount, and when measured by the help of the centrifuge may vary in volume from a trace to 10 or 20 per cent of the total bulk of urine. In the early stages of a local infection, however, the microscopical examination of the deposit may merely show the presence of leucocytes slightly in excess of normal, so that without the use of the microscope the fact of pyuria may easily be missed altogether. Occasionally, and particularly in adult cases, it may be noted that the urine passed during the day is neutral or faintly alkaUne — ^the change in reaction then being due to physiological causes. In those cases where the urine is strongly 84 BACTERIURIA alkaline, the alkalinity is due to ammonia resulting from the decomposition of urea, not bv the pathogenic infecting organism, but bj- non-pathogenic sapro- phytes which have gained access to the urine, either after it has been voided, or whilst still intra vesicam. In the latter instance the contamination may have taken place as a result of careless instrumentation, or (as in the female) b}^ con- tinuit}- of surface, but it also frequently occurs o-v\ing to the passage of micro- organisms through the inflamed bladder walls from the lumen of the adjacent large intestine. The chnical s^-mptoms associated with bacteriuria due to local infection \-ary enormously \^ith different patients. Frequencj^ of micturition, scalding, dull aching pains in one or both loins, with tenderness on deep pressure over the kidne\-, pains in the perineum and h\-pogastrium (according to the situation of the primary,- infection), severe rigors, p^Texia, anorexia, nausea, and vomiting are amongst those commonly observed. It is important to remember its rela- tivelv common occurrence in children, in whom the constitutional symptoms may be prominent ^\ithout any special urinary s^-mptoms attracting notice. The urine generallv contains onlj- a trace of albumin, and no obvious pus ; the diagnosis depends upon bacteriological investigation of a catheter specimen, the need for which A\-ill be suggested hy the discovery of a decided excess of leucoc\-les in the centrifugahzed deposit. /no. Eyre. BALDNESS. — Alopecia, or baldness, may vary in degree from shght thinning to the complete loss of hair. There are three main varieties of simple baldness, namely (i) Congenital, (2) Senile, and (3) Prematiire alopecia. 1. In the congenital variet3^ the baldness is seldom complete, and the hair may be lanugo-hke. In the latter case the diagnosis is certain, as it also is when the baldness is accompanied by developmental defects in the skin or its appendages. 2. Senile alopecia needs neither description nor diagnosis. 3. Premature alopecia may be (a) idiopathic or (6) symptomatic. The former, much less frequent than the latter, and due to no recognizable cause except heredity-, usually begins between the ages of tsventy and thirty-five ; in man}- cases at the vertex, hke senile baldness, but often at the temple, when it extends backwards elHptically. S\-mptoinatic premature baldness may be either temporar\- or permanent, gradual or rapid, and is dependent upon a great variety- of local or constitutional causes, including seborrhcea of the scalp, psoriasis, chronic eczema, erysipelas, ringworm, favus, lupus erythematosus, syphilis ; it is also a sequela of fevers or other acute systemic diseases. \Mien it occurs as a sequel to fevers, in syphilis, ring^vorm (except after severe kerion), er\-sipelas, and eczema, the loss of hair is usually but temporary- ; in seborrhcea, favus, lupus erythematosus, morphoea, and folliculitis decalvans, it is generally permanent, and is alwaj'S so, of course, when the hair-folhcles have been destroyed. The most important form of symptomatic baldness is that which is associated with seborrhcea, whether of the oily or of the dry kind. Seborrhoeic alopecia has the same distribution as idiopathic baldness, as described above. Another form of symptomatic baldness is the condition known as alopecia areata, in which the hair falls out in patches, generally of irregular distribution. Usually the patches continue to spread for a time, and may run into others, denuded areas thus being formed, of irregular outhne, with a surface white and smooth as a billiard ball. The hairs at the edges of the patches are looser than the others, and among them may be seen short hairs that show signs of atroph}- close to the root, so that the}' resemble a note of exclamation (?) . In rare cases, the hair falls out not in patches but more generalh', and very rapidly ; and soon the whole .scalp may be bared, and even the hair of the whole body may be lost, and with BLEEDING GUMS 85 it the nails of the fingers and toes. The affection with which alopecia areata is most easily confounded is ringworm of the trichophytic variety : the differential diagnosis between the two affections will be found under Fungoid Affections OF THE Skin. Alopecia areata may also be confused with another form of symptomatic baldness, namely, alopecia cicatrisata, the pseudo-pelade of Brocq, in which depressed islands of baldness, round or of irregular shape, occur on the scalp, the patches usually spreading and coalescing into large, smooth, shiny areas. But here the patches are cicatricial ; there is destruction of the follicles, so that the hair is never restored ; there are normal-looking hairs on the bald areas, and the note-of-exclamation stumps of alopecia areata are absent. The bald patches sometimes met with in secondary syphilis may be distinguished from those of alopecia areata by the co-existence of other s\'philitic symptoms, and by the effects of specific treatment. The bald areas of lupus erythematosus are in greater or less degree cicatricial, there is destruction of the folhcles, and a border which is slightly or distinctly inflamed. Folliculitis decalvans is cicatricial also, and at the edge of the bare patches a small red papule or patch of erythema can be seen surrounding each follicle. Malcolm Morris. BEARING-DOWN PAIN (See Pain, Bearing-down.) BLEEDING GUMS. — A spongy, bleeding condition of the gums, attaining such a degree that the teeth became covered over by the exuberant blood-oozing tissues, was a prominent feature of scurvy, a serious and often fatal disease which used to be common on sailing ships when fresh food was necessarily absent from the diet for weeks or even months at a time. It is now, fortunatel}-, very rare in its full development, but is still found in a mild form amongst children — infantile scurvy, or Barlow's disease — as the result of long-continued feeding with tinned milk without fresh food. Its chief features are aneemia and tender- ness of the long bones due to haemorrhages under the periosteum ; in severer cases, there may be purpura and other obvious haemorrhages, including sponginess and bleeding of the gums, with a more or less general condition of stomatitis. The diagnosis is suggested by the history of tinned-milk diet, and confirmed by the benefit that follows the addition of fresh milk and, in older children, fresh vegetables. A similar condition may arise in adults whose circumstances compel them to live on tinned foods. There are, however, many other causes of bleeding of the gums besides scurvy. The differential diagnosis is generally easy, but sometimes may be very difficult. The first point to determine is whether the gum condition is due to local changes only, or whether it is part of a more general condition. {A). Bleeding Gums due to General Conditions or preceded by Lesions else- where than in the Mouth : — Scurvy Splenomedullary leukaemia Lymphatic leukaemia Hodgkin's disease Pernicious anaemia Aplastic anaemia Splenic anaemia Haemophilia Iodide poisoning Phosphorus poisoning Arsenic poisoning Lead poisoning Tuberculous gingivitis Febrile or asthenic states accom- panied by sordes, e.g., pneu- monia, the later stages of Purpura, whether due to any of malignant cachexia, general the above causes, or to others ; paralysis, acute yellow atrophy (see Purpura) Syphilis Mercurialism of the liver, and so forth Dyspepsia. BLEEDING G UMS (B). Bleeding Gums due to purely Local Conditions Injury, e.g., by tooth brush ; the result of bee or wasp sting ; and so forth Dental caries Tartar Pyorrhoea alveolaris Alveolar abscess Papilloma Epulis Myeloid sarcoma Epithelioma Actinomycosis Acute or chronic stomatitis, not obviously due to any of the causes already mentioned ; e.g. : Aphthous stomatitis Ulcerative stomatitis Gangrenous stomatitis (can- crum oris, phagedsena oris, or noma oris) Erythema buUosum, dermatitis herpetiformis, pemphigus, affect-, ing the mouth as well as the epidermis A. Bleeding Gums due to General Conditions. — Many of the above conditions are discussed under other and more prominent symptoms, so that here we need refer but briefly to them (see Spleen, Enlargment of ; Anaemia ; Purpura ; etc.). A blood-count may be required, in order to diagnose or exclude spleno- medullary or lymphatic leukcBwiia, or pernicious ancemia. The family history may suggest hcsmophilia. Splenic ancsmia, Hodgkin's disease, and aplastic ancemia attract attention more on account of the enlargement of the Spleen iq.v.), or of the Lymphatic Glands {q.v.), or of the Anemia [q.v.), than because of spongy gums. Purpura (q.v.) is itself a symptom and not a disease. Syphilis, particularly in its secondary stage, may produce stomatitis, pharyn- gitis, laryngitis, and gingivitis, with more or less tendenc}^ to bleeding, even /•'I'g: lo — Primary syphilitic sore on the lower lip. when no mercurial treatment has been adopted ; the secondary roseola may still be present, or the history may be obvious. Difficulty arises mainly in women and children, and when the chancre has been extragenital {Fig. lo). Wasser- mann's serum test may be tried, or the Spirochceta pallida [Plate XII, Fig. J) looked for in scrapings from the mucous lesions. Mercury is very liable to cause profuse salivation and acute stomatitis, with most distressing and painful swelling of lips, gums, tongue, and cheeks ; swallow- ing may become impossible, the glairy saliva hangs in strings from the protruding tongue and bulging lips, the mucosa bleeds on the slightest touch, and the patient is the picture of abject misery. Some persons are far more susceptible than others to the effects of mercury ; but its worst effects have occurred when the remedy has been employed in excess in the treatment of syphilis, especially when the teeth are carious, or when the mouth has not been kept clean with a tooth-brush after each meal, and when there is albuminuria (syphilitic nephritis) at the same time. The diagnosis depends upon a knowledge of the drugs that are being given or, in occupation cases, of the chemicals that the patient has been working with. BLEEDING GUMS 87 Iodides may cause profuse coryza, due to conjunctival, nasal, and oral catarrh, but the amount of bleeding that accompanies it is slight. The nature of the drugs being taken will suggest the diagnosis, or if there is doubt as to the drugs, the urine may be tested for iodides. Phosphorus used to produce very severe stomatitis, going on to necrosis of the jaw — " phossy jaw " — not infrequently ending in death as the result of fatty degeneration of the liver and heart ; this is uncommon since restrictions have been laid upon the use of crude yellow phosphorus in the manufacture of matches. The occupation generall}^ serves to suggest the diagnosis. Arsenic and lead are both rare causes of bleeding gums ; occupation, or medical prescription, or habits as regards drinking, may suggest the diagnosis, and there may be other signs of the poisoning, particularly pigmentation of the skin, vomiting, diarrhoea, hyperkeratosis of the soles and palms, and generalized peripheral neuritis in the case of arsenic ; and the symptoms given elsewhere in the case of lead. Arsenic may be found in excess in the hair, or lead may be detected in the residue from a bulk of urine. Tuberculous gingivitis is rare, but when it does occur it is very severe. The nature of the bleeding gums will be suggested by the co-existence of phthisis with cavitation, and abundant sputum teeming with tubercle bacilli ; the latter may also abound in scrapings from the gum. Febrile and asthenic states onlv cause sordes and bleeding gums when the patient has already been ill some while, or when the nursing has been remiss • the diagnosis will depend on symptoms other than those connected with the gums. Dyspepsia is a recognized cause for sponginess of the gums, shallow peptic ulcers, and bleeding on sUght provocation ; but there is often difficulty in being' sure that the dyspepsia is not due to the swallowing of septic products from infected teeth and gums, rather than the gum condition secondary to the stomach. B. Bleeding Gums due to Local Conditions. — When care has been taken to exclude general causes of bleeding of the gums, differentiation between the various local causes is not difficult. Some patients are alarmed by the symptom when its cause is nothing more than the use of a new tooth-brush, whose bristles have slightly lacerated gums that are accustomed to an older and softer brush. The history will indicate other forms of local injury — an ill-fitting tooth-plate, perhaps. Dental caries inay be obvious, or it may be hidden away between adjacent teeth and yet be irritating the gum enough to cause it to bleed with undue readiness, for instance when the teeth are brushed. Tartar will be obvious on inspection. Pyorrhoea alveolaris, also known as suppurative gingivitis or Rigg's disease, is the result of septic infection around the teeth extending down into the sockets and loosening" them, causing the gum margins to recede by a process of erosion, and leading to a purulent discharge from between the gums and the teeth. It is possible for this condition to be present, even when the external aspect of the teeth seems perfect ; a very fine probe may sometimes be passed painlessty down into the tooth-socket between adjacent teeth, where the sup- purative process has been progressing unsuspected, and out of the reach of the tooth-brush as used in the ordinary way. The gums bleed with the greatest ease in severe cases, the breath is foul, and the constant swallowing of pyogenic organisms and their products leads to dyspepsia, anaemia, chronic ill health, listlessness, functional nerve disorders, and sometimes more acute symptoms of general pyaemia, especially multiple infective synovitis and arthritis. Neur- asthenia and depression ultimately ensue in many cases, and sometimes very severe and even fatal anaemia. The diagnosis of alveolar abscess is generally obvious, though infection of a benign or malignant new growth may simulate it for a time. Microscopical BLEEDING GUMS examination of the excised tumour is the only certain way of diagnosing the nature of an odontoma, papilloma, simple epulis, myeloid sarcomatous epulis, myeloid sarcoma of the jaw, or epithelioma of the gum. Actinomycosis is a very rare lesion in man ; but the jaws, gums, or cheeks are parts that are least uncommonly affected. The chronic nature of that which partakes of the characters partly of a neoplasm and partly of an abscess, in a person who has had occasion to put straws, cotton, or other vegetable products into his mouth or between his teeth, may suggest the diagnosis, which will be confirmed by the finding of the ray fungi in the purulent discharge, or in sections from parts excised. Minute grey or yellowish-grey specks in the pus are said to be characteristic, but they are not always to be seen, and it is only by micro- scopical examinations that the diagnosis can be made with cer- tainty (see Plate XII, Fig. S). Stomatitis in its various degrees may have a general cause, such as mercurialism (see above) ; or it may be due to purely local infec- tion with micro-organisms. It might perhaps be classified bac- teriologically — the variety spoken of as thrush being due to the oidiimi albicans, for instance. Clinically, however, it is more often classified by its degree, into acute catarrhal, ulcerative, and gangrenous. All these affect the mucosa of cheeks, lips, tongue, and palate, in addition to the gums, and any of the inflamed parts bleed readily. The first degree is characterized by redness, swelhng, tenderness, and pain, with inability to move the tongue about in order to eat and swallow, swelling and protrusion of the hps, foulness of the breath, and very often saliva- tion. There may or may not be localized greyish or white aphthous patches ; these are commoner in children. When ulcers occur, these are generally multiple and shallow, very painful, with more or less glazing of the ulcerated surface, and acute hyperaemia of the margins. The gangrenous form is better known by the title cancrum oris (Fig. ii), fortu- nately rare, though sometimes seen in ill-cared-for children who have contracted measles or some other acute debilitating fever. The cheek is the first affected by the gangrene, acute generahzed stomatitis being followed by the appearance of a black spot within and without, rapidly spreading and leading to sloughing and perforation of the cheek, gangrene of the gums and jaw, falling out of the teeth, a very foul nauseating odour of the breath, and death from utter exhaustion. The diagnosis is generally obvious. Erythema bullosum, dermatitis herpetiformis, and pemphigus — particularly the first of these — may affect mucous membranes as well as the skin, especially the mouth, colon, and vagina. The result as regards the mouth is very distressing ; the crusts and resultant inflammation of lips, gums, tongue, cheeks, palate, fauces, and pharynx, may make it impossible for food to be taken orally, and -Cancrum oris. BLOOD PER ANUM 89 the patient rapidly loses weight and becomes very ill. The mucous membrane everywhere bleeds on the slightest touch, and the condition is pitiable. There is generally pyrexia. The diagnosis is, as a rule, easy, for the mucous membranes are very seldom attacked unless the skin is affected also (see Bull.;^, and EosiNOPHiLiA). Herbert French BLINDNESS.— (See Vision, Defects of.) BLISTERS. — (See Bull.e.) BLOOD PER ANUM. — Blood may be passed per anum whenever bleeding takes place from any part of the alimentary canal. If it comes from a point high up, as from the stomach or duodenum, it is usually altered in appearance, so that black, tarry stools are passed (melaena) ; whereas, if it comes from the large intestine or from the lower end of the ileum, it is passed as red blood, easily recognizable as such. If the quantity is very large, it may be bright red, even in the case of highly situated lesions ; the colour depends on the rapidity of passage through the bowel and the consequent extent to which the digestive juices have acted upon it. Recognition of the actual presence of blood, pure or mixed with the motions, is not often difficult, except when the quantity is small. The typical tarry stools of haemorrhage high up in the alimentary tract are unlike anything else. The black colour is much more pronounced than in such conditions as pigmentation of the stools with iron or bismuth sulphide, which produce rather a slatey or dirty greyish-black tint ; while the viscid consistency of the haemor- rhagic stool is also characteristic. Administration of charcoal by the mouth may produce deep black stools, and eating bilberries is also said to do so. In case of doubt, the chemical and spectroscopical tests for blood may be applied ; for which purpose it is best to acidulate the faeces strongly with acetic acid and to extract the acid mixture with ether ; a clear solution of blood-pigment is thus obtained, suitable for the spectroscope or for the guaiacum test. In some cases blood-corpuscles may be recognizable under the microscope, if a portion of the faeces is rubbed up with physiological saline solution. Grains of charcoal will be distinguishable under the microscope if this substance has been taken. The conditions associated with the passage of blood per anum may be most conveniently divided for diagnostic purposes into : (i) Those in which large quantities of altered blood are passed (true melaena) ; (2) Those in which large quantities of red or unaltered blood are voided ; (3) Those in which small amounts of such blood are seen ; and (4) Cases of so-called occult hcemorrhage only recognizable by chemical or other special tests. The conditions classed under headings (2) and (3) necessarily overlap, inasmuch as the exact quantity of blood discharged is very variable ; the former comprises, roughly speaking, affections of the bowel ; the latter, lesions about the rectum and anus. I. Large quantities of blood may escape in cases of ulceration of the stomach or duodenum. It is usually mixed with acid gastric juice, and thus blacketied. Such cases are generally associated with pain after meals, vomiting, haemat- emesis, and increased acidity of the gastric juice. Tenderness will be elicited on pressure over the epigastrium, most often at a point rather to the right of the middle line and about four inches below the xiphisternal junction in the pyloric region. Distinction between the two lesions is difficult : but in gastric ulcer- ation the pain usually arises within an hour after meals, and is relieved by vomiting ; in duodenal ulcer, the pain often reaches its acme about three or four hours after a meal, and it may at first be relieved by taking food. In gastric ulcer, the greater part of the blood which escapes is likely to be vomited ; in duodenal, most of it to be passed per anum. Duodenal ulceration is most common in 90 BLOOD PER ANUM men. The symptoms of gastric ulcer are much more common in women, but it has been shown that in many such instances no actual ulcer can be found, the blood escaping apparently by a process of oozing through the mucous membrane — a condition referred to by Dr. Hale White as gastrostaxis. 2. Large quantities of unaltered or but slightly altered blood may be due to ulceration of the small intestine, as in enteric fever, tuberculosis, or the peculiar lesions associated with chronic interstitial nephritis. The phenomena of enteric fever need not be detailed at length — initial headache, epistaxis, and fever ; fullness of the abdomen and possibly diarrhoea, rose spots, enlargement of the spleen mental dullness or delirium ; leucopenia, and Widal's agglu- tinative reaction in the blood. Tuberculous ulceration of the intestine seldom, . if ever, occurs apart from tuberculosis of the lungs, and it is a rare cause of profuse intestinal haemorrhage. It is associated with pain and tenderness in the abdomen, and with emaciation and signs of pulmonary disease. Chronic Bright's disease may be associated with haemorrhage from the bowel as from other parts of the body. The absence of other causes, such as ulceration ; the existence of high blood-pressure and enlargement of the left ventricle, the cardiac impulse being displaced outwards and downwards ; polyuria ; and the constant or occasional appearance of albumin and renal tube-casts in the urine, with weakness, anaemia, and perhaps epistaxis, will point to this cause. Bleeding into the pancreas and embolism or thrombosis of one of the mesenteric vessels may both lead to moderate haemorrhage from the bowel. In both alike, there will be symptoms of sudden abdominal pain and constipation, with collapse, closely resembling the phenomena of intestinal obstruction. A certain diagnosis can hardly be made without laparotomy. Patients who suffer from pancreatic apoplexy are usually fat. Blocking of a mesenteric vessel by embolism is most likely to occur in sufferers from some form of cardiac disease, especially malignant or ulcerative endocarditis. A good deal of blood may be passed per anum in some cases of general hcemorrhagic conditions, such as profound anaemia, leukaemia, and purpura haemor- rhagica. The general appearance of the patient, and examination of the blood, will suffice to distinguish the two former ; and in the last there will probably be visible haemorrhages in the skin and bleeding from other mucous surfaces. In the peculiar condition known as Henoch's purpura there occur attacks of colic, constipation and vomiting, with passage of blood per anum. The symptoms may closely simulate intestinal obstruction or intussusception, and may be indistinguishable from mesenteric embolism. A diagnosis may some- times be made when other phenomena of bleeding are present, such as haemat- emesis, haematuria, petechiae in the skin, or epistaxis, or by concomitant affections of joints (haemorrhagic arthritis) : the patient is generally 3'oung ; a history of previous attacks may also be obtained. The possibility of the rupture of an aneurysm into the stomach or bowel may be mentioned for the sake of completeness ; a diagnosis can only be made by recognition of the pulsating aneurj^smal swelling, and the condition will probably be rapidly fatal. In infants, considerable quantities of blood may be passed per anum owing to septic infection of the umbilical cord, the haemorrhage arising either from an actual ulcer of the stomach or duodenum, or from a purpuric condition caused by bacterial toxaemia. 3. Haemorrhage of moderate degree is usually associated with disease of the large intestine, though occasionally profuse bleeding may occur in such affections. The blood is bright in colour and generally mixed with mucus. In tropical dysentery there is severe tenesmus and great frequency of defaecation, only blood-stained mucus in small quantities being passed when the disease is well BLOOD PER ANUM 91 established. In ulcerative colitis, which appears to be a bacillary dysentery of temperate cHmates, there are the same diarrhoea, frequency of defaeca- tion, and wasting, as characterize the tropical malady, but tenesmus is less marked and the stools are usually more faecal. Some cases of ulcerative colitis closely simulate enteric fever ; they may be distinguished by absence of Widal's reaction, and by recognition of the ulcers in the lower part of the large bowel by means of the sigmoidoscope. Examination of the stools in cases of tropical dysentery may reveal the presence of the Amoeba histolytica {Fig. 12). This large organism measures some 30 to 40 J.L in diameter, and is distinguished from the harmless A moeba coli by its well-developed clear outer layer of ectoplasm, by its small and eccentric- ally placed nucleus, and by the presence of ingested blood-corpuscles within its substance. In bacillary dysentery the pathogenic organisms belong to a group of closely allied bacteria grouped under the title B. dysenteries. They are short, rod-shaped bacteria, with rounded ends, somewhat resembling B. typhosus, but N ct N N i? Fig. 12. — {aa) Ainceba histolytica (after Jiirgen.s) ; (i^) Auiceba coli, motile form ; {b') Aviceba coli, encysted (after Casagrandi and Barbagallo. (N) Nucleus ; (N') Nuclei atter division ; (C) Blood corpuscles. (High power of the microscope.) non-motile. These bacilli grow on ordinary laboratory media, do not coagulate milk, and do not form indol. They are not stained by Gram's method. The exact bacteriology of ulcerative colitis is undetermined. Malignant disease 0/ the intestine may give rise to some degree of haemorrhage. In a typical case of cancer of the large bowel, an elderly person has suffered from gradually increasing weakness, wasting, and constipation. Attacks of colicky pain may supervene, and some enlargement of the abdomen may be noticed. Blood may be present in the motions from time to time, but is not often a marked eature ; rarely, a moderate degree of haemorrhage may occur. Examination of the abdomen may reveal vermicular movements of the hypertrophied bowel, which tend to pass in a definite direction along the course of the colon, and to cease at a particular point. Here a definite tumour may be palpable ; but as the flexures of the colon are favourite seats for neoplasms, it often happens that the growth is situated deeply in the pelvis or beneath the lower ribs, and cannot be felt. There is little or no fever unless there are extensive secondary 92 BLOOD PER ANUM deposits, especially in the liver. Acute intestinal obstruction may finally occur. As contrasted with the above, non-malignant ulceration of the colon is likely to have a more marked onset, with pain, frequency of defaecation, and loose motions. The stools often contain considerable quantities of blood mixed with mucus. The bodily temperature is raised, often to a high degree (103° F.), pain is more constant, and tenderness may be elicited all along the course of the large intestine. Often the ulceration extends into the sigmoid flexure of the colon, and may be visible on examination with the sigmoidoscope. In intussusception, blood and mucus are passed without fsecal matter accom- panying them. The condition is commonest in infants and young children. There are usually symptoms of severe illness, with screaming, drawing up of the legs, frequent pulse, and some collapse ; rarely the condition may be encountered with but few grave signs ; a rectal examination is essential in case the intus- susceptum may be felt with the finger ; a careful palpation of the abdomen will usually reveal an elongated tumour, which may sometimes be felt to harden and relax again with the peristalsis of the gut. In infants, simple colitis may give rise to the appearance of blood and mucus in the motions, but there is generally some faecal material passed at the same time, which is not the case in intussusception after the contents of the colon below the intussusception have been evacuated. In simple colitis, the motions are frequent and loose, and they may contain mucus. In milder cases they may be green and slimy, but in the more severe they are brownish and very offensive, and in the worst cases consist of little more than a dirty serous discharge. The child's temperature will probably be raised ; the pulse is frequent, and there may be vomiting. A collapsed condition may occur at a late period of this malady — rarely, in acute choleraic cases it may ensue within the first twenty-four hours. In intussusception, on the other hand, collapse usuallv occurs quickly ; and there is absolute constipation, with passage only of a small amount of blood-stained mucus. The only cases which can give rise to a difficulty of diagnosis are the rare instances in which intussusception is present without severe symptoms ; and here a rectal examination will probably reveal the true condition of affairs. By means of rectal examination in an infant a considerable area of the abdomen can be investigated, especially if an anaesthetic be administered. In all cases of doubt in intestinal affections accompanied by bleeding, this procedure is urgently demanded. The intense diarrhoea accompanying arsenical poisoning may be accompanied by the passage of traces of blood and mucus. The condition will be distinguished by its rapid onset, some half-hour or so after a meal, by the epigastric pain, tenderness, and vomiting, followed by collapse, with rapid irregular pulse, and clammy skin. A chemical examination of the vomited matters should be made in suspected cases, either by Reinsch's or Marsh's test. Traces of blood smeared over the motions are suggestive of piles, which may be seen on inspection if external, and felt by the examining finger if internal to the sphincter. Occasionally a sharp attack of bleeding may occur from this cause, if a varix be ruptured. The condition is usually accompanied by a sense of fullness, weight, and even pain in the rectum, and the patient may be conscious of " something coming down" and having to be replaced after defaecation. Some amount of blood may arise from an anal fistula, which may also lead to a discharge of mucus and of pus. Inspection and digital examination will readily discover this affection, the external opening of the fistula being close to the margin of the anus, the internal often just above the border of the sphincter. Cancer of the rectum does not usually give rise to much haemorrhage, but traces of blood may be passed from time to time, and sometimes a sanious discharge BLOOD PER ANUM 93 occurs. The main syniptonis are usually wasting and cachexia, gradually increasing difficulty in defecation ; and rarely, alteration in the size and shape of the fecal masses, which may be thin or ribbon-like. Pain in the sacral region generally occurs at some period of the disease, and it may radiate down the thighs. The growth may be seen by means of the speculum or sigmoidoscope, and also felt by the examining finger. Rectal polypi are common in children, and may rarely be encountered in adults. They give rise to frequent bleeding, which may occasionally be considerable in amount. The patient may be conscious of something present in the rectum, giving rise to a sensation of fullness and frequent desire to defsecate. Digital examination will reveal the existence of a pedunculated tumour, or rarely of multiple tumours. Occasionally a polypus may protrude at the anus after defascation. Another condition affecting the rectum which may be signalized by free bleeding is that of papilloma or villous tumour. The symptoms will closely resemble those described under rectal polypi, but the blood is likely to appear in large quantities. Digital examination may discover a soft, velvety patch on the rectal wall, and the examining finger will be withdrawn covered with blood. The growth may be seen by means of a speculum as a soft, vascular mass, bleeding on the slightest touch. The condition is uncommon. It is likely to occur at an earlier age than cancer, but the latter is not unknown in persons under 20 years of age. Simple prolapse of the anal mucosa will lead to slight haemorrhage. The condition is often seen in children, and may be recognized on inspection of the anus, when a red globular swelling of everted mucous membrane is visible. Adults will be conscious of having to push the part back after passing a motion. Such prolapse often accompanies piles. Ulceration of the rectum, of venereal origin, occurs chiefly in women. Bleeding is not usually a very marked feature, but attacks of haemorrhage may take place. The condition is recognizable by digital examination, and by inspec- A tion through a rectal speculum or p. /""■ the sigmoidoscope. The ulceration \ -^ usually extends right down to the anus, whereas there is nearly always - "- ■ ' \ an interval of normal mucosa be- ' \ ■ ■• tween the anus and an ulcerating ' ^ ^ / cancer of the rectum. The parasite called Bilharzia hcBmatobia may occur in the rectum, .' , - X though less frequently here than in ' / the bladder. Its presence gives rise ~ — =^ — — ^ %^ to the passage of mucus and blood Fi^i^. 13.— t)va of Bilharzia hannatobia: one per anum. There may be discom- e>^hibiting a terminal spine— the common form: ^ •' the other presenting a lateral spme. (High power fort in the rectum and frequency of of the microscope). defaecation. Infection is contracted abroad, especially in Egypt — a fact which may lead to a suspicion of the presence of the affection in patients who have resided out of England. Diagnosis can only be made by finding the ova of the parasite in the faeces. Their well-known shape — oval with a pointed spike at one end, or rarely at the side {Fig. 13) — renders them unmistakeable objects under the microscope. In children the presence of thread-worms (Oxyuris vermicular is) in the rectum may lead to the discharge of small amounts of mucus coloured by a trace of blood. The worms will be readilj' seen on inspection of the child's motions. They 94 BLOOD PER ANUM are white, about the thickness of coarse thread, and some ^ to ^ in. in length. 4. Occult haemorrhage is the term applied to the presence of minute traces of blood in the motions, revealed only by chemical or micro- scopical examination. It may occur in any lesion of the alimentary canal in which there is breach of surface, as in ulcer, cancer, or severe infiam- mation. Such haemorrhage will also be present constantly in cases of infection with the parasitic worm Ankylostomum duodenale (Fig. 14). This condition, which is met with in persons who have worked in mines or tunnels, leads to profound anaemia ; and the ova of the worms may be found in the faeces by microscopical exann- ination (Figs. 15 and 16). The tests for occult bleeding may be applied in cases of difficulty when there is reason to suspect ulceration or can- cer. No meat or meat- extracts must be administered for a day or two before the test is made, lest the haemoglobin present in them should vitiate the results. The existence of any bleeding from the gums must also be excluded. One of the simplest methods of detecting occult haemorrhage is to rub up J^y^. I4. — Ankylostoimiin diiodcnalc. A Head 'ith hooks ; B Tail ; C Entire worm (low power). (From Medical Laboratory Methods. Dr. Herbert French.) »r^'f-rv. ^jo- ^ >i"< V i^\ Fi^^. 15. — Ankylostomum duodenale. Ova at different stages. Near the centre is an ovum of I'ricliocephalKs dispar (x 50). By permission from Dr. Haldane and Dr. Boycott's paper in The Jourjial of Hygiene, Vol. III. Fig. 16. — Ankylostomum duodenale. Two-cell stage of developing ovum ( X 200). By permission from Dr. Haldane and Dr. Boycott's paper in 'I he Journal of Hygiene, Vol. III. some of the faeces with water, acidify with strong acetic acid, and then shake out with about \ volume of ether ; the latter extracts the haematin, and the BLOOD-PRESSURE [ABNORMAL) 95 characteristic bands mav be detected in the ethereal extract by means of the spectroscope (see Figs. 20 and 21). SPECTRAL ABSORPTION BANDS. ■ IT ^^H Fig-. 17. — Oxyhaemoglobin. ■ ■ ^^^H Fig. iS. — Reduced haemoglobin. ■ II ^^H Fig ig. — Carboxyhcemoglobin. I 1 ^^^B^B J'lg. 20. — Haeinatin in alkaline solution. ■1 l^^^^^^l Jug. 21. — Acid hajmatin. Fig. 22. — Methaemoglobin. E Fig. -Urobilin. ir. Cecil Bosanquet. BLOOD -PRESSURE (ABNORMAL). — Blood-pressure cannot be gauged accurately with the finger ; when instruments of precision are used to verify opinions expressed as the result of merely feehng the pulse, it is astounding how erroneous digital impressions of pulse-tension and blood-pressure are found to be. Thev may be more than 100 mm. Hg out ; and it is most important not to diagnose an abnormality of blood-pressure until the latter has been accurately measured instrumentally. There are four main kinds of blood-pressure, namely, maximum systolic systemic arterial pressure ; minimum arterial blood-pressure ; 96 BLOOD-PRESSURE (ABNORMAL) mean arterial blood-pressure ; and venous blood-pressure. Instruments have been devised for measuring all of these, but for clinical purposes the only variety which is really important is the maximum systemic arterial blood-pressure. This may be either abnormally low or abnormally high, but no stress should be put upon any but considerable departures from the normal. Healthy individuals who have not been kept in bed, have an average pressure in early adult life of 1 20 to 130 mm. Hg. Children have less than this, though at this early age it very seldom happens that anything is to be learned by measuring the blood- pressure. As years advance, the blood -pressure tends normally to rise, so that in a person of lifty or sixty, a reading of 150 or 160 mm. Hg, or thereabouts, which in a younger person would indicate disease, would be normal.. Abnormally high blood-pressure may reach figures such as 320 mm. Hg, and anything from 170 mm. Hg upwards is essentially abnormal, whatever the age of the patient. It nearly always indicates rigidity of the vessels as the result of arteriosclerosis , and it is very often associated with renal degeneration, which, as time goes on, ultimately becomes red granular contracted kidney. Curiously enough, and contrary to what might be expected, the maximum systolic blood-pressure is higher than normal in cases of heart failure such as result from mitral stenosis, even when the pulse is so irregular and feeble that it can only be felt with certain beats, and when one would have thought that there must be a fall in the blood-pressure ; the cause for the rise in such cases is probably the partial asphyxia acting upon the vasomotor centre. Provided the fact is borne in mind, little difficulty in diagnosis will arise from it. The chief importance of high blood-pressure is in diagnosing arterial or renal degenera- tion, with consequent tendency to apoplexy, in patients in whom there may not be any other very obvious signs of disease. It should be remembered, however, that any patient who is kept at rest in bed, tends to have a diminution in the blood-pressure, and this applies to arteriosclerotic patients as well as others. Indeed, a person may have a blood-pressure of 250 mm. Hg or more when up and about, and yet when he is kept in bed the pressure may fall to 150 mm. Hg, to rise again when the patient returns to active life. Prolongation of the first sound at the impulse or a ringing accentuation of the aortic second sound, may sometimes serve to indicate that there is a high blood-pressure when no instrument is at hand to verify the fact. A clinical fact which may sometimes prove helpful is, that cases of melancholia have abnormally high blood-pressures, and that when the melanchoha begins to improve, the pressure falls, and may return to normal when the patient recovers from the mental symptoms. Abnormally low blood-pressures may be observed in many different cir- cumstances associated with asthenia, but without renal or arterial degeneration. In itself a low maximum systemic blood-pressure is seldom of diagnostic sig- nificance excepting in Addison's disease. In a case in which the degree of pigmentation of the skin or of mucous membranes may leave it still in doubt as to whether Addison's disease is the diagnosis or not, the discovery of a blood- pressure so low as 80 mm. Hg would be confirmative of the diagnosis, although there are cases of Addison's disease in which the blood-pressure may be no lower than no mm. Hg. Herbert French. BOILS. — (See Pustules.) BORBORYGMI are gurgling noises in the abdomen produced by peristaltic movements of the bowel acting upon, their mixed gaseous and fluid contents. They are probably more frequent in the small intestine than elsewhere ; but they may sometimes be gastric or colonic. With the stethoscope applied to BRADYCARDIA 97 the abdomen, they may be heard in all normal persons, varying in intensity at different times of the day according to the different phases of digestion. When a meal has been taken after a period of fasting, the passage of the intestinal contents through the ileoczecal valve may be heard distinctly with the stethoscope placed over the right iliac fossa some six or eight hours after the meal ; but it is seldom possible to decide what precise portion of the bowel is responsible for the production of borborygmi heard elsewhere. Normally, these sounds should not be audible either to the patient or to other persons ; but occasionally even in health they may be heard quite loudly. In some individuals indeed, especially in women, the sounds become annoyingly obtrusive, and they may even acquire a pathological degree. It may be very difficult, however, to decide exactly as to their cause ; sometimes the patient seems to be otherwise perfectly healthy, so that they might be called a normal abnormality in such a case. More often there is more or less evidence of functional nerve disorder or hysteria, so that the borborygmi may be due to functional errors in the intestinal peristalsis or in the secretions within the bowel. They may be associated with Flatulence {q-v.), though this is by no means necessarily the case. When there is excess of gas in the alimentary canal, observation of the patient may detect air-swallowing ; intestinal putrefaction is said to be indicated by the presence of excess of indican in the urine, or by there being a high ratio of organic to inorganic urinary sulphates ; fermentation of carbohydrate is suggested when there is no evidence of air-swallowing, when the urine analyses do not confirm any suspicion of proteid putrefaction, and when the borborygmi are increased by the giving of carbohydrate foods. The absence of borborygmi may sometimes be a sign of clinical importance, for one of the first effects of peritonitis is to inhibit the peristaltic movements of the bowel ; in the absence of peristalsis borborygmi cannot be produced, and therefore, in a case suspected to be one of peritonitis, the presence of well-marked borborygmi upon auscultation of the abdomen is an argument against there being general peritonitis, whilst complete silence of the abdomen is in favour of this diagnosis. Borborygmi may be increased in asphyxial conditions, so that they may be a very marked symptom in cases of heart failure with cyanosis. Herbert French. BRADYCARDIA, or undue slowness of the pulse-rate, is not incompatible with health, some individuals having a normal pulse-rate of 50 per minute, whilst in a few it does not exceed 40 or even 30 per minute. Occasionally bradycardia of this kind is found in more than one member of the same family. It is important to auscultate the heart in order to exclude the possibility of the rate of the pulse as felt at the wrist not being the same as the rate of the heart-beat ; it sometimes happens, particularly when there is mitral stenosis, that by no means every pulse wave becomes palpable at the wrist, and the rate may then seem to be slow when perhaps in reality it is twice the apparent rate. Absolute slowness of the pulse-beat, as distinct from its relative slowness in proportion to the pyrexia, is best seen in that symptom-complex which has been termed Stokes- Adams' disease, the phenomena of which are attacks of unconsciousness associated with one or several epileptiform convulsions, coma, stertor, and cyanosis, the rate of the heart-beat being found to have dropped to a half or even to less than half of that which is natural. These symptoms are due to difficulty in the transmission of the contraction-stimulus from the auricle to the ventricle along the auriculo-ventricular bundle of His. The inhibitory factor is not the same in all cases, but is very often associated with arteriosclerosis and degenerative changes in the bundle of His, together with myocardial degeneration and atheroma of the coronary arteries ; less D 7 gS BRADYCARDIA often it is due to syphilis of the bundle of His or to destruction of that bundle by a gumma, sarcoma, or carcinoma. The diagnosis is apt to be that of epilepsy until the fact has been established that the pulse-rate falls during an attack to about half the normal ; but when this observation has been made, the difference between Stokes- Adams' disease and ordinary epilepsy is clear. ' Increased intracranial pressure is another cause for bradj^cardia ; it may thus be observed in cases of cerebral haemorrhage, cerebral tumour, cerebral abscess, and in the early stages of tuberculous meningitis ; but in other forms of meningitis and in the later stages of tuberculous meningitis the initial bradycardia changes to tachj-cardia. If in a given case there is otitis media or some other local infective focus which might produce a cerebral abscess, the occurrence of pyrexia with a pulse-rate of 50, 55, or 60 per minute is an argument in favour of intracranial abscess ; for the other complications of otitis media, especially lateral sinus thrombosis, mastoid abscess, or suppurative meningitis, produce a rapid pulse-rate instead of a slow one ; the reverse is not true, that is to say, it is not possible to exclude cerebral abscess merely on the ground that there is no bradycardia. Cerebral tumour can generally be distinguished from cerebral abscess by the greater length of the history, the more pronounced optic neuritis ; or by the absence of predisposing cause to cerebral abscess, for instance otitis media, or bronchiectasis ; whilst cerebral haemorrhage is much more rapid in its onset, is less likely to have marked optic neuritis, and if there is pyrexia it is apt to be extreme, reaching the level of hyperpyrexia ; generally the patient is an elderly man who has either high blood-pressure, albuminuria or other evidence of degenerated arteries or granular kidneys. Myxoedema is a disease in which the pulse-rate is not fast, but in which it seldom becomes absolutely slow. Certain drugs are apt to slow the heart very markedly when they have been administered in full doses over a long period ; amongst these the two most important are digitalis and strophanthus, while sodium salicylate also is likely to have a similar effect: the diagnosis will depend upon the knowledge of the medicine the patient is taking. Jaundice is generally stated to be a cause for marked slowing of the pulse- rate : it is true that the artificial introduction of bile salts and pigments into the circulation in animals slows the heart, but clinically in man it is rare to find jaundice and absolute bradycardia associated. Herbert French. BREATH, FOULNESS OF THE. — This is due to one or other of four main groups of conditions, namely, septic and putrefactive changes within the mouth or nose ; septic or putrefactive changes within the lungs ; the ingestion of certain substances such as tobacco smoke, garhc or onions, whose products are excreted by the lungs or saliva ; and severe toxic conditions, especial^ those affecting the alimentary canal or peritoneum. When the foulness of the breath is not habitual, but occurs as the result of a recent illness, there will be symptoms of the latter Avhich point to the diagnosis quite apart from the condition of the breath ; so that one need not do more than indicate as possible causes of the symptom such things as typhoid fever, general peritonitis, post-puerperal sepsis, intestinal obstruction, and a host of other conditions of this kind in which, even though the mouth be clean, there may be foulness of the breath, such tendency to foulness being greatly exaggerated if sordes have been allowed to collect. Foulness of the breath due to the ingestion of foodstuffs such as onions or garlic, is familiar enough, and it only remains to add that there are certain drugs, for instance guaiacol, which may produce a similar symptom without the patient's friends realizing whv the breath should be so tainted. BREATH, FOULNESS OF THE 99 Foulness of the breath due to lung conditions will nearly always be indicated either by the abundant and putrid sputum, or by the abnormal physical signs in the thorax. The condition may be due to phthisis with secondary infection of the cavities by pj'Ogenic organisms, fcetid bronchitis, bronchiectasis, gangrene of the lungs, empyema or other abscess which has ruptured into the lung. The only cases which give rise to difficulty in the differential diagnosis, are those in which an empyema has been situated deeply, for instance between the lower lobe and the diaphragm, or between two lobes, without reaching the surface ; in such a case there ma}^ be absolutely no abnormal physical signs, and the diagnosis has to be made from the symptoms and history. The patient has generally had some obscure febrile illness, possibly with cough, but without much expectora- tion, until one day, after a particularly severe bout of coughing, a large quantity of pus — perhaps a teacupful or even more — has suddenly been brought up at one time, since when, at intervals of hours or days, there has been similar expectoration of large quantities of putrid pus. This condition of deep-seated empyema without abnormal physical signs most resembles bronchiectasis or bronchiolectasis, but is distinguished by the sudden way in which the first large quantity of purulent expectoration came on. In both cases there may be clubbing of the fingers ; and in both, the sputum contains pus corpuscles, and pyogenic and non-pyogenic micro-organisms other than tubercle bacilli, but no elastic fibres indicative of lung destruction. Gangrene of the lung produces an unmistakable stench of the worst kind ; if any doubt remains as to the diagnosis, the detection of abundant elastic fibres in the sputum, after boiling with caustic soda to destroy the other tissue elements present, will clinch the diagnosis. Phthisis with cavitation may produce foulness of the sputum, but hardly ever the stench of gangrene, unless'gangrene has supervened. It is distinguished from bronchiectasis and from hidden empyema by the discovery of tubercle bacilh in the sputum. The chief difficulty in the diagnosis arises when the tuberculous part of the malady has ceased, the cavities formerly excavated by the tuber- culous process being now occupied only by pyogenic organisms that have secondarily infected them. Xone of the above conditions need be considered at all in arriving at the diagnosis of the cause of foulness of the breath in many cases, inspection of the mouth at once indicating the nature of the trouble in the form of tartar, septic gums, carious teeth with decomposing food particles in them, pyorrhcea alveolaris, or even more extensive stomatitis, the different varieties of which are dealt with under that heading ; or it may be that the nose or throat are at fault rather than the mouth, necrosis of the nasal bones, purulent hypertrophic or atrophic rhinitis, ozisna, septic tonsillitis or other varieties of Sore Throat [q-v.), with more or less extensive inflammation of the tonsils, fauces, or pharynx, being generally obvious on inspection, or on bacteriological examination for the Klebs-Loffler bacilli of diphtheria, or the fusiform bacilli and spirilla of Vincent's angina {Plate XII, Fig. M). Some of the worst cases of foulness of the breath are to be met with when there is inoperable squamous-celled carcinoma of the mouth or tongue. It is only when all such local conditions have been excluded, and when there is no acute illness nor an}^ lesion of the lungs, that one can attribute foulness of the breath to that ill-defined malady dyspepsia. It is sometimes very difficult to find out why the patient's breath is not sweet, and indeed there are some persons in whom all the functions of the body seem to be perfectly good, and the mouth perfectly clean, and yet the breath is foul. If there are any symptoms of gastro-intestinal disorder, especially flatulence or constipation, one is inchned to attribute the condition of the breath to the stomach or the bowels ; but when there are no symptoms of any error in these, it is more than hkely that BREATH, SHORTNESS OF the trouble is due to some local condition "which has not been discovered upon ordinary inspection, particularly the accumulation and putrefaction of food particles between the teeth, where they may become impacted even in persons who vigorously use both tooth-brush and mouth-wash daily. Herbert French. BREATH, SHORTNESS OF. — This is a very common complaint which, in our opinion, should be differentiated carefully from difficulty of breathing, the latter term being reserved entirely for cases of obstruction in the main air- passage, the larvmx, and trachea — using it as a lar\-ngological expression in fact — diphtheria, growths, and, very much more rarely, pressure from without being the main causes. Shortness of breath is, in the patient's mind, a conscious quickening of the respiratory movements to supply a conscious need of air. The following are the chief causes of the symptom : — Increased Need for Oxygen. — Fevers and other septic processes inducing exces- sive oxygen requirements. Exercise in health. Temporary shortness of breath. Diminished Supply of Oxygen. — (i) Blood conditions in which the red corpuscles cannot carry a sufficient charge, or do not yield up their supply with sufficient ease ; (2) Cardiac conditions of inefficiency of circulation ; (3) Pulmonary con- ditions of diminished surface of contact, or ease in contact, of air and blood in alveoli ; (4) Atmospheric conditions of diminished partial oxygen pressure in the alveoli of the lung ; (5) Deformities of the chest mechanically preventing the expansion of the lung. The diagnosis of these conditions is not difficult when once attention is drawn to the possibility of their occurrence, but we must briefly advert to each of them to indicate the guides to the cause in a case not at once obvious. Fevers and Septic Conditions. — The thermometer and the obvious illness of the patient will generally give sufficient indication of these ; nor indeed is shortness of breath a common complaint in such patients, their minds being filled with other ideas. Exercise in Health. — Here it is necessary to be sure of the health ; it may, or may not be, that the person is merely out of condition, and undertakes exercise which only a trained athlete can properly perform. The only way to avoid mistakes is to ask. Does the shortness of breath soon disappear ? and then to make a careful examination of the patient to see if anj- of the undermentioned causes are at work. 1. Blood Conditions.- — These include: (i) Simple loss of blood; (ii) Ansemia simplex ; (iii) Anaemia, severe or pernicious ; (iv) Polycythsemia ; (v) Some pathological constituent, as in diabetes, ursmia. Graves' disease, etc. ; (vi) All forms of leukemia. The actual laboratory diagnosis of the blood condition is simple enough if we decide to have it examined. The points that may lead us to have this done would naturally come in the following order. A history of loss of blood is pretty sure to be volunteered — piles, excessive menstruation, obvious trauma, loss at parturition, etc. ; suspicion is very likely to be aroused b}' the colour of the patient's face, especiallv when coupled with a primary complaint of shortness of breath. Diabetes and uramia are likely to show other signs, and the urine will give the clue to the diagnosis ; but great caution is required never to omit to have the blood examined if the cause of a shortness of breath is not apparent on simple physical examination ; indeed, one must go farther, and say if some easily diag- nosable condition is not present ; for it must be remembered that blood conditions are the very ones to be the exciting cause of cardiac inefficiency, which by itself is often hard to diagnose if there be no obvious bruit or irregularity in rhythm. 2. Cardiac Conditions. — Inef&ciency in circulation. These include : (i) Valvular BRUITS, CARDIAC disease (acute and chronic) ; (ii) Muscular weakness (fatty, fibrosis, etc.) ; (iii) Nerve conditions (arrhythmia ?) ; (iv) Pericarditis and pericardial effusion. i. Valvular disease. — If a bruit be present, it may fairly be assumed that the heart is a factor in causing shortness of breath, but unless some other tell-tale sign be present it must not be assumed that it is the only factor, for it is very common to find patients with bruits who will not confess to shortness of breath. ii. Muscular Weakness. — We cannot under the present heading give all the points in connection with " morbus cordis sine murmure " ; it must, however, be stated that a diminution in the muscular energy of the heart is a most important contributory factor in producing shortness of breath in all pathological conditions of the blood, including renal affections and diabetes, in convalescence from acute disease, and in acute pericardial affections ; it is, perhaps, the commonest cause of all of shortness of breath. Want of tone in the sounds, likeness of the first to the second sound, and irregularities in rhythm, are the principal points to look for. The urine should be examined with care, both for albumin and tube- casts ; the ophthalmoscope should be used in the detection of albuminuric retinitis ; and it is often wise to measure the systemic blood-pressure to find out whether it is greatly above the normal or not. iii. Nerve Conditions. — Local pressure on the nerves may cause cardiac arrhyth- mia and breathlessness, but these will have other signs and symptoms easily discoverable ; general nervousness and neurasthenia are often characterized by shortness of breath on exertion or excitement, there being frequency of the beat without any arrhythmia. iv. Pericardial Diseases. — A differential diagnosis between these and a hyper- trophy or dilatation of the ventricles may be demanded for other reasons, but qua shortness of breath, there is no difficulty in determining that either cardiac or pericardial trouble is the cause. 3. Pulmonary Conditions.— These, again, will be fairly obvious on proper exami- nation, including, as they do, every disease of the lung ; but we would specially draw attention to the possible presence of a quiet pleural effusion, which not very infrequently is so insidious as to give rise to no complaint but that of shortness of breath. Again, in the early days of phthisis, it may be that a cough and shortness of breath are nearly all that is complained of. Bronchitis, advanced tubercle, bronchopneumonia, lobar pneumonia, and acute pleurisy, are all easily recognizable causes of shortness of breath. The only intrinsic affection of the lungs not at once easily discoverable is emphysema without its usually accompanying bronchitis ; the shape of the chest, the absence of vesicular sounds, the increased resonance to percussion will, however, generally give a clue. 4. Atmospheric Conditions need no diagnosis ; partial asphyxia by bad air, high mountains, and caisson work, are the three chief alterations in gaseous surroundings. All are obvious. 5. Deformities of Chest are again obvious ; Pott's curvature is the chief one. They derive their importance from the fact that commonly one lung is hers de combat almost to start with, and hence a very slight affection of the other may cause great difficulty in breathing. Fred J. Smith. BRUITS, CARDIAC. I. — Systolic Bruits. {A). Systolic Bruits over the Mitral Area, which corresponds to that portion of the chest wall lying immediately over the cardiac apex. When a definite systolic bruit is audible over the mitral area, its cause is sometimes perfectly obvious. If, for example, a person who some time previously had an attack of rheumatic fever presents a bruit, with its point of maximum intensity over the cardiac apex, and the bruit is conducted outwards into the left axilla, BRUITS, CARDIAC there being lost, and heard again in the neighbourhood of the inferior angle of the left scapula ; then such a bruit is almost certainly due to old-standing organic disease of the mitral valve, which has caused regurgitation through it. This opinion is confirmed by finding that the heart is enlarged, as demon- strated by the area of cardiac dullness being increased, and by the apex beat of the heart being displaced downwards and to the left. Such an enlargement of the heart points to the cardiac condition not being of recent origin ; and any bulging of the praecordia, which very often occurs in children when the heart is enlarged, is additional evidence in the same direction. In some cases, however, the diagnosis is not nearly so obvious, and in order that a definite conclusion may be arrived at, it is necessary to consider all the conditions which maj' produce a systolic bruit in the mitral area. The following are the possible causes : — (i). Mitral regurgitation, due to chronic organic disease of the mitral valve. (2). Acute endocarditis ; {a) Simple; (b) Ulcerative or malignant. (3). Mitral regurgitation where there is no disease of the mitral valve, but dilatation of the left ventricle as the result of [a) Disease of the aortic valve ; (b) Disease of the myocardium, such as mj'ocarditis, parenchymatous degenera- tion, fatty heart, fibroid heart, and other degenerative changes in the cardiac muscle secondary to disease of the coronary arteries ; (c) Disease external to the heart, causing hypertrophy and dilatation of the left ventricle, such as arterial sclerosis and interstitial nephritis ; [d) Adherent pericardium, which is a very important factor in causing dilatation of the ventricles, but is very frequently associated with organic disease of the valves. (4). Functional bruits. (5). Congenital malformation of the heart. (6). Aneurysm of the heart. (7). Acute pericarditis. I. The following points are in favour of the bruit being due to organic disease of the mitral valve of long standing : — {a). An enlargement of the heart, as shown by displacement of the apex beat and by an increase in the area of cardiac dullness. In mitral regurgitation the enlargement of the heart is due in the first instance to hypertrophy and dilata- tion of the left ventricle ; but the left ventricle may become enlarged from other causes, such as disease of the aortic valve, adherent pericardium, arterial sclerosis, and chronic renal disease ; these causes must be excluded before the diagnosis of mitral regurgitation due to organic disease of the mitral valve is made. Lesions of the aortic valve producing enlargement of the left ventricle would be excluded by the absence of systolic and diastolic bruits at the second right costal cartilage or down the left side of the sternum. An adherent pericardium, causing dilatation of the left ventricle, and therefore producing regurgitation through the mitral orifice, is often very difficult to diagnose correctly, as it is almost impossible to ascertain that there is not disease of the mitral valve. The absence of systolic retraction at the apex points to the pericardium not being adherent. Arterial sclerosis is not likely to be present without anj^ thickening of the radial arteries. Xo accentuation of the aortic second sound over the right second costal cartilage indicates the absence of arterial sclerosis, as in this condition the blood-pressure is higher than normal, thereby making the aortic cusps close more forcibly. In chronic renal disease, high arterial blood-pressure, arterial sclerosis, polyuria of low specific gravity with a trace of albumin, and often retinal changes, are present ; if these be not found, chronic renal disease can be excluded as cau.sing the enlargement of the left ventricle. (b). A previous history of rheumatic fever is greatly in favour of the mitral regurgitation being due to organic disease of the mitral valve of long standing. BRUITS, CARDIAC 103 (c). The age of the patient is also an important factor in the diagnosis, for in children and young adults, mitral regurgitation is far more likely to be the result of a previous endocarditis than of dilatation of the mitral orifice due to. the causes just mentioned. [d). The absence of p^-rexia helps in excluding a recent endocarditis ; but it must be remembered that in children suffering from rheumatic endocarditis the temperature is often normal while they are being treated with salicylates. In cases of recent endocarditis there may be no physical signs of any great enlarge- ment of the left ventricle, and usually the apex beat is found close to its normal position. 2. Acute endocarditis is nearly always associated with some other affection. For example, there may be acute rheumatism or chorea, or the patient may be suffering from pneumonia or some other infectious process, such as erysipelas, septicaemia, or puerperal fever. Whatever be the cause of the acute endo- carditis, it will be a part of a general blood-infection. The heart is not found to be enlarged, or only to a slight extent, provided that the condition is not one of an acute endocarditis affecting old sclerotic valves. In malignant endocarditis the constitutional disturbances are severe, for irregular pyrexia, rigors, sweating, and even delirium are likely to be present. The patient is so ill that the bruit is not likely to be mistaken for one due to old-standing mitral regurgitation. Symptoms pointing to emboli in various organs help to confirm the diagnosis of malignant endocarditis. 3. The points in favour of mitral regurgitation due to dilatation of the left ventricle are : — {a). Age of the patient, for myocardial degenerations, except those occurring in infectious processes, are not likely to be present before middle life. {b). The presence of arterial sclerosis and chronic interstitial nephritis, as determined by increased arterial blood-pressure, accentuation of the aortic second sound, thickening of the radial arteries, retinitis, and polyuria with a trace of albumin. (c). Aortic obstruction and regurgitation, which cause hypertrophy and dila- tation of the left ventricle. (d). Attacks of angina pectoris. (e). Shortness of breath, and cardiac distress upon exertion, without any obvious cardiac lesion. If the bruit be associated with oedema of the legs, engorgement of the lungs, and enlargement of the liver, as the result of cardiac failure, the lesion may be due to organic disease of the mitral valve or dilatation of the mitral orifice as the result of myocardial degeneration. These signs of failing compensation are not likely to occur in a recent endocarditis, for they make their appearance after the cardiac lesion has been present for a considerable time. If the bruit be due to dilatation of the left ventricle as the result of fatty infiltration of its walls, the patient may be corpulent, the cardiac condition being part of a general obesity. Regurgitation through the mitral valve may be caused by a dilatation of the left ventricle dependent upon an adherent pericardium. The following signs of adherent pericardium must be looked for : (a) Systolic retraction, which is best determined by inspection of the chest wall from the side, and is due to an indrawing of the intercostal spaces during the ventricular systole. When this is situated near the ape.x beat it is due to an adherent pericardium : it may also be noticed over the lower sternal region, and even at the ensiform cartilage. Systolic retraction is not always due to an adherent pericardium, for in thin persons and in children, a systolic indrawing of the third and fourth left intercostal spaces close to the sternum is often seen, and is produced by I04 BRUITS, CARDIAC the normal recession of the base of the heart during each ventricular systole. Systolic retraction due to adherent pericardium is often followed by (6) the diastolic shock, which can be felt upon palpation and is due to the sudden relaxation of the ventricular wall, (c) Diastolic collapse of the veins of the neck, or Friedreich's sign, which is produced during the ventricular diastole, is an indication of an adherent pericardium ; it is found chiefly in this con- dition, but does not always occur, and is sometimes seen without any pericar- dial adhesions being present, [d) The pulsus paradoxus is chiefly found in adherent pericardium, and is due to the cardiac beats becoming more feeble at the end of inspiration, so that during each inspiration the pulse-beat becomes very weak, or is lost. 4. A systolic bruit at the cardiac apex may be functional in origin, in which case it is localized to the mitral area, being conducted only for a short distance into the axilla, and not heard posteriorly. The condition is associated with anagmia and other debilitating conditions. Other functional bruits may be associated with it, especially one in the pulmonary area and also a bruit de diable in the neck. The history helps greatly in the diagnosis. 5. A congenital systolic bruit, when heard in the mitral area, is always part of a loud bruit with its point of maximum intensity nearer the base of the heart. When such a murmur is heard in children, with little or no displacement of the apex beat, and the area of cardiac dullness is increased to the right of the sternum, the condition is always congenital. The lesion will generally be either patent septum ventriculorum, pulmonary stenosis, or patent ductus arteriosus, which are discussed elsewhere. Mitral regurgitation due to a congenital defect prac- tically never occurs. 6. An aneurysm at the cardiac apex is rare, and is scarcely possible to diagnose, so that it need not be taken into account when considering the differential diagnosis of apical bruit. 7. When acute pericarditis is present, a systolic bruit which is part of a "to-and-fro" friction murmur may be heard in the mitral area. Such a murmur changes its character with the pressure of the stethoscope and with the different phases of respiration ; and it is not conducted into the axilla. Other signs of pericarditis are usually present, so that the diagnosis should not cause any difficulty. {B). Systolic Bruits over the Pulmonary Area, which corresponds to that portion of the chest wall lying over the second left intercostal space close to the sternum. When a systolic bruit is heard over the pulmonary area, with its point of maximum intensity in the second costal space close to the left border of the sternum, and conducted upwards and outwards towards the left shoulder, it may be caused by the following conditions : — (i). Congenital cardiac malformations, especially pulmonarj^ stenosis and patent ductus arteriosus. (2). Functional bruit. (3). Acquired pulmonary stenosis, which is a very rare lesion. To distinguish between an organic and congenital defect and a functional condition is usually quite easy. Pulmonary stenosis is nearly always a congenital defect, and is therefore found for the most part in children ; and its presence is confirmed by other signs of congenital heart disease, such as little or no displacement of the apex beat with considerable enlargement of the right side of the heart, together with cj^anosis of varying degree, and clubbing of the fingers and toes. With a patent ductus arteriosus the bruit is often similar, although cyanosis and clubbing of the fingers and toes are usually absent. Generally, instead of the murmur being definitely' either systolic or diastoHc in time, a long rumbling bruit, commencing during systole and passing on into the BRUITS, CARDIAC 105 diastole of the ventricles, is heard. Such a bruit is considered to be patho- gnomonic of this congenital defect, as it is impossible for a bruit extending from sjj'stole into diastole to be produced within the heart. Other congenital malformations may produce a systolic bruit in the pulmonary area, such as a patent interventricular septum, though here the maximum intensity of the abnormal sound is lower down on the left of the sternum ; in many cases the differential diagnosis of these congenital malformations is quite impossible. 2. The functional pulmonary bruit is common in chlorosis and other anaemic and debilitated conditions, and in exophthalmic goitre ; it is also frequent in school-children set. 5-15. The bruit alters with the position of the patient, being louder in the recumbent than in the erect posture, whereas in congenital defects, the position of the patient has very little influence upon the loudness of the bruit. The presence of a bruit de diable in the neck confirms the diagnosis of the functional origin of the bruit. When the bruit is due to functional conditions, there is no such increase of cardiac dullness to the right of the sternum as occurs in congenital malformation and acquired pulmonary stenosis. A systolic thrill may be present in the pulmonary area both in organic and functional conditions, but is more common in the former, and therefore in favour of pulmonary stenosis. 3. Pulmonary stenosis may be an acquired lesion, although very rarely ; if in a young adult such a bruit as has just been described is present, and if there is a past history of rheumatic fever, together with lesions of the other valves, especially the mitral, then it may be fairly presumed that the bruit is due to an acquired pulmonary stenosis. The history helps greatly in the diagnosis, for if the stenosis were a congenital malformation, there would be symptoms of its presence dating back to infancy. Systolic bruits due to other valvular lesions may also be heard over the pulmonary area ; but they have their point of maximum intensity over other portions of the praecordia, and are only heard over the pulmonary area on account of their loudness. These bruits are not likely to be mistaken for those that have just been described. (C). Systolic Bruits over the Aortic Area, which corresponds to that portion of the chest wall overlying the second right costal cartilage. When a systolic bruit is heard with its point of maximum intensity in the aortic area, and is conducted upwards into the vessels of the neck, it arises either at the aortic valve or in the ascending portion of the aorta. The chief point in the diagnosis between these two conditions is the character of the aortic second sound. If the bruit be due to changes in the valves causing obstruction, then the second sound will be altered in character, being muffled and sometimes inaudible, as the rigidity of the aortic cusps prevents them closing suddenly in the normal manner. The presence of an aortic diastolic bruit would make quite clear the valvular origin of the systolic bruit. When the bruit is due to changes in the aorta, in consequence of atheroma, dilatation, or aneurysm, and not to stenosis of the semilunar valves, then the second sound is usually clear. The presence of a pulsating tumour, pulsation in the second right intercostal space without a tumour, or dullness in this region, would confirm the diagnosis of the bruit arising in the aorta. A systolic bruit over the aortic area is of frequent occurrence ; but for the purpose of diagnosis it must be remembered that such a bruit is rarely due to stenosis, and frequently results from a progressive sclerosis of the aortic valve, or from changes in the aorta. Before aortic stenosis is diagnosed, there should be a loud systolic bruit in the second right intercostal space, together with a systolic thrill, and evidence of hypertrophy of the left ventricle. If the bruit is due to an acute endocarditis, with vegetations on the semilunar valves, then the left ventricle is not enlarged to such an extent as occurs in io6 BRUITS, CARDIAC aortic obstruction, or in atheroma of the aorta, which is most frequently part of a general arterial sclerosis. A functional bruit confined to the aortic area is very rare, but may be distinguished by there being no enlargement of the left ventricle, and by the presence of other functional bruits, especially a hruit de diable. If marked ansemia exists, either from some primary blood-disease or secondary to a cachectic condition, due to malignant disease, tuberculosis, malaria, a large haemorrhage, etc., then the diagnosis of a functional bruit is confirmed. {D). Systolic Bruits over tlie Tricuspid Area, which corresponds to that part of the chest wall overlying the lower portion of the sternum. A bruit heard over the tricuspid area is of diagnostic importance in that it indicates tricuspid regurgitation, which is nearly always due to dilatation of the right ventricle. That the bruit is due to tricuspid regurgitation is confirmed by finding the cardiac dullness extending to the right of the sternum, fullness and pulsation in the veins of the neck, and evidence of failing cardiac compensation, as shown by oedema of the legs, and enlargement and pulsation of the liver. Many bruits wliich are systolic in rhythm and produced at the tricuspid valves are best audible in the neighbourhood of the cardiac impulse, but the}^ are not Conducted outwards into the left axilla like bruits produced at the mitral valve. On the other hand, when a mitral systolic bruit is loud enough, it may be audible in the tricuspid area, but there would not be the signs of passive congestion, unless there was general failure of compensation. It should be borne in mind, of course, that tricuspid regurgitation often occurs without producing any bruit at all, so that absence of systolic bruit does not exclude tricuspid leakage. II. — Diastolic Bruits. A diastolic bruit heard over the precordia is always due to organic disease of the heart. If it be present over the aortic area, that is, over the second right costal cartilage close to the sternum, and conducted downwards along the left border of the sternum, and sometimes outwards towards the cardiac impulse, then the bruit is due to aortic regurgitation. Sometimes the point of maximum intensity of the bruit is in the aortic area, sometimes to the left of the sternum in the third intercostal space. An examination of the pulse confirms the diagnosis, for the " water-hammer " pulse is found only with aortic regurgitation. Capillary pulsation is also present, and is best demonstrated by placing a glass slide on the everted lower lip, or by pressing the finger nail so that the proximal half of it remains pink and the other is blanched. Capillary pulsation is found also in cases of marked anaemia, and in the normal person in a Turkish bath. As the diastolic bruit of aortic regurgitation is frequently associated with a sj^stolic one, the result of aortic obstruction, a " to-and-fro " murmur is pro- duced Avhich may sometimes be mistaken for pericardial friction sound. In pericardial friction the systolic and diastolic sounds do not commence accurately with the first and second sounds of the heart, are not conducted in the recognized direction of an endocardial bruit, and are altered in intensity by the pressure of the stethoscope. Having decided that the bruit is due to aortic regurgitation, it must be remembered that such a lesion may be the result of : — 1. A progressive sclerosis of the- aortic segments, being part of a general arterial degeneration, or due to a localized syphilitic lesion. 2. Endocarditis, either simple or malignant. 3. Rupture of a segment, due to either excessive strain on an already diseased valve, or to malignant endocarditis. 4. Dilatation of the aortic ring, secondary to dilatation or aneur^'sm of the ascending portion of the arch of the aorta. 5. Congenital malformation. BRUITS, CARDIAC 107 The age of the patient helps greatly in the differential diagnosis ; if the lesion be found in a child or young adult, the condition is almost invariablj^ the result of endocarditis ; if, on the other hand, aortic regurgitation occurs in middle life, it is nearly always due to sclerosis of the aortic valve, and the diagnosis is confirmed by finding degenerative changes in the arteries, chronic renal disease, and considerable hypertrophy of the left ventricle. If the regur- gitation be due to dilatation of the aortic ring, it can only be diagnosed when the existence of dilatation, or aneurysm of the ascending portion of the arch of the aorta, is indicated by dullness in the second right intercostal space close to the sternum, and by pulsation or a pulsating tumour in this area. An x-ray examination is also useful in confirming the presence of an aneurysm. Some- times an aneurysm may be situated just above the sinuses of Valsalva, and, while producing aortic regurgitation by causing dilatation of the aortic ring, may give no other physical sign of its presence. It may be very small, and yet may cause sudden death by rupture into the pericardial sac. A diastolic bruit heard only down the left border of the sternum is nearly always due to aortic regurgitation, but occasionally may be produced by pulmonary regurgitation as the result of endocarditis, dilatation of the pulmonary ring, or a congenital defect. Pulmonary regurgitation more frequently occurs secondarily to mitral stenosis, and it is then due to dilatation of the pulmonary orifice as the result of increased blood-pressure in the pulmonary circulation. The other two forms of pulmonary regurgitation are very rare, and difficult to distinguish from aortic regurgitation. In this cardiac lesion there is no evidence of enlargement of the left ventricle, while the right side of the heart is enlarged, and there is no " water hammer " pulse as in aortic regurgitation. Diastolic bruits audible at the cardiac impulse are due either to endocarditis of the mitral valve, to mitral stenosis, or to aortic regurgitation. An aortic diastolic bruit is often conducted as far as the cardiac apex, and replaces the second sound here ; sometimes, however, the diastolic bruit, which is heard in the aortic area, is lost on being traced down the left border of the sternum, to reappear at the apex. The diastolic bruits of mitral stenosis can be distin- guished by their appearance later in the diastolic period, and the most common is presystolic in rhythm — a crescendo murmur ending in a loud slapping first sound. An aortic regurgitant bruit is blowing in character, whereas the bruit of mitral stenosis is rumbling. Early diastolic, mid-diastolic, and late diastolic bruits, also occur in mitral stenosis ; but none of these should be mistaken for the bruit of aortic regurgitation, as the latter condition would be associated with hypertrophy and dilatation of the left ventricle, the apex beat being displaced outwards and downwards, usually to the sixth intercostal space, and would be confirmed by the characteristic " water-hammer " pulse. In mitral stenosis without mitral regurgitation, there is very little displacement of the apex beat, because the left ventricle is not enlarged. The bruit of mitral stenosis is often associated with a presystolic thrill, whereas that of aortic regurgitation is not. In order to understand the various bruits which occur in mitral stenosis, the manner in which they are produced must be discussed. They are caused by the blood being forced through the stenosed mitral valves. The two forces which produce this are the contraction of the walls of the left auricle and of the right ventricle. The suction action of the left ventricle during its diastole is probably not sufficient in itself to cause the bruit, but simply helps in the work of the left auricle and right ventricle. The presystolic bruit of mitral stenosis occurs during the end of the ventricular diastole, and corresponds to the systole of the left auricle. A mid-diastolic bruit sometimes occurs in mitral stenosis. This may be the only bruit present, but there may be a presystolic bruit as well, resulting in two distinct bruits during the ventricular diastole. These two io8 BRUITS, CARDIAC bruits may be fused into one, when the contractions of the right ventricle and left auricle are vigorous. The mid-diastolic bruit is probably due to the previous contraction of the right ventricle increasing the blood-pressure in the lungs and left auricle, and so forcing the blood through the stenosed mitral valve. The mid-diastolic bruit varies slightly in its situation in the ventricular diastole, and this may depend upon the time when the force of the contraction of the right ventricle makes itself felt on the left side of the heart. This bruit in consequence may become an early or late diastolic bruit. When the force of the contractions of the left auricle begins to fail, the presystolic bruit often disappears. In mitral stenosis there may therefore be a presystolic bruit, or a mid-diastolic bruit, or mid-diastolic and presystolic bruits, or a bruit which occupies almost the whole of the ventricular diastole. With all these bruits the first sound at the apex is usually slapping or thumping in character. This alteration in the first sound may be present without any of the above-mentioned bruits, and is in itself very characteristic of mitral stenosis. In some cases the second sound is reduplicated at the cardiac apex, while in others — and this in the majority of the cases — it is inaudible. The pulmonary second sound is accentuated. The bruit may be accompanied by a mitral systolic bruit, as regurgitation often occurs through the stenosed orifice. Accentuation of the first sound in all varieties. n H Short presystolic bruit. Longer presystolic bruit. L Mid-diastolic bruit. JNIid - diastolic and pre- systolic bruit. n Mid - diastolic and pre- systolic bruits fused into one. Fig-. 24. — Diagram of the bruits 01 mitral stenosis (Sawyer's Physical Signs). A presystolic bruit in the mitral area is usually due to mitral stenosis, but it also occurs in aortic regurgitation and in dilatation of the left ventricle, when the bruit is spoken of as Flint's murmur. To distinguish bet^veen the two conditions BRUITS, CARDIAC 109 may be difficult ; in an uncomplicated case of mitral stenosis the apex beat is normal in position, but when Flint's murmur is present, the apex beat is greatly displaced on account of the enlargement of the left ventricle. The presence of any aortic disease also points in the direction of the bruit being Flint's murmur. This bruit is often considered to be caused by the vibration of the anterior curtain of the mitral valve, as it lies between the regurgitating blood-stream through the aortic orifice and that flowing into the ventricle from the left auricle. If this were the true explanation of Flint's murmur, it should occur early in diastole instead of being presystolic, as it invariably is. Another view is that the blood regurgitating through the aortic orifice lifts the anterior curtain of the mitral valve and so obstructs the mitral orifice at the end of the ventricular diastole. Neither of these explanations seems to be sufficient to account for the murmur. In a normal heart the ratio of the diameter of the mitral opening to that of the left ventricle is about i to 2 ; in mitral stenosis, on account of the contracted orifice, the ratio is about -} to 2, the size of the left ventricle remaining the same. In this latter condition, a presystolic bruit occurs, and it is probably this alteration in the ratio which produces it. In aortic! regurgitation, although the diameter of the mitral orifice remains the same, yet the diameter of the left ventricle is greatly increased on account of its dilatation. The ratio between the diameter of the mitral opening to that of the left ventricle would probably be I to 4, or exactly the same ratio as occurs in mitral stenosis. There would be a relative mitral stenosis when the size of the mitral opening is compared with that of the left ventricle. The two conditions, therefore, may be similar, although the one is on a larger scale than the other ; and as the altered ratio of these two diameters produces in raitral stenosis a presystolic bruit, it is probable that the same ratio, although the factors are on a larger scale, produces in aortic regurgitation a Flint's murmur — which is also presystolic in time. A presystolic bruit is sometimes present without any aortic regurgitation, and without mitral stenosis, but always with an enlarged left ventricle • and this seems to point to the regurgitation of the blood through the aortic valves not taking any direct part in the production of the bruit. The following diagrammatic drawings of the heart are constructed to show the probable mode of production of Flint's murmur : — Normal heart. IMitral stenosis. Dilated left ventricle. Ratio of diameter of Ratio about i to 2. Ratio about i to 4 ; same proportion mitral valves and dia- Presystolic bruit. as in mitral stenosis. Presystolic jueter of left ventricle, bruit (Flint's), about I to 2. Fig-. 25. — Diagram to explain the origin of Flint's murmur Sawyer's Physical Signs). BRUITS, CARDIAC Diastolic bruits are heard only very occasionally over other areas of the pre- cordia, but it is possible for a presystolic bruit to occur in the tricuspid region as the result of tricuspid stenosis ; such a bruit is rareh^ present without valvular disease of the left side of the heart. A functional bruit is never diastolic in rhythm ; but it is important to distinguish the mid-diastolic bruit of acute endocarditis from the similar bruit of fibrotic stenosis. During endocarditis there is some thickening of the valve-fiaps from inflammatory oedema; and this leads to bruits not unlike those of fibrous stenosis. The diagnosis depends upon (i) The development of the bruit under observation : if in a case of acute rheumatism a mid-diastolic bruit is noticed to develop rapidly, it cannot be due to fibrosis, and must result from acute inflammation of the valve ; (2) The course of the bruit : if it is due to fibrosis it will persist, if to endocarditis it will change with time, becoming less definite if the endocar- ditis resolves, more definite if the inflammation goes on to scarring and stenosis ; (3) The age of the patient : mitral stenosis does not occur commonly before puberty, so that it is most risky to interpret a diastolic apical bruit in a child as being due to mitral stenosis. /. E. H. Saivvcr. BULLffi. — A bulla is literally a water-bubble ; as applied to skin diseases, it is synonymous with bleb or blister ; it differs from a vesicle only in its size, which may be from half an inch in diameter to that of a tangerine orange. It is possible for almost any vesicular skin disease to be of bullous degree occasion- ally ; on the other hand, there are certain diseases in which bullae are character- istic ; and there are yet other affections in which, although bullae are not always present, they may occur in a marked degree occasionally. The following are the chief conditions under which bullae are, or ma^^ be, a prominent feature of the case : — A. Conditions in which Bull.^ are usual; — Pemphigus Erythema bullosum Dermatitis herpetiformis Herpes gestationis Er^'thema iris Epidermolysis bullosa Pemphigus neonatorum Local application of vesicants, such as cantharides, arnica, rhus tcxico dendron, croton oil, nitric acid, scalding water, or hot solids Cheiropompholyx Local friction by splints after fractures ; or by boots, oars, tools, etc. Some cases of gangrene, and Raynaud's disease. B. Conditions in which Typical Bull.^ may occur, though they are NOT USUAL : Erysipelas Impetigo contagiosa lodism Bromidism Glanders Syphilis Cases of extreme oedema from Bright's disease or heart failure Syringomyelia Workers amongst turpentine, chrysarobin, varnish, aniline dyes, and other chemicals ; tar products, resin, volatile oils ; satin-wood, primula obconica, and perhaps some other plant products. BULL/E III ' The diagnosis is sometimes obvious ; for instance, herpes gestationis — which is also known as hydroa gestationis, erythema gestationis, and dermatitis pruriginosa polymorpha recurrens graviditatis — is the probable lesion whenever a bullous eruption develops in a pregnant woman ; and this diagnosis becomes certain if there is a history of former pregnancies, each associated with a similar eruption, whilst between the pregnancies there has been complete freedom from the complaint. The eruption itself is precisely similar to that of dermatitis herpetiformis, which is described below. It only remains- to add that, whereas in most cases the trouble begins in the later months of pregnancy, there is a tendency for it to develop earlier in each successive pregnancy ; and that, whereas in most cases it subsides rapidly when the child is born, in a few instances it may last into the puerperium, or even develop only during that period. The most troublesome part of the complaint is the itching and irritation, that often amount to actual pain. It is conceivable that a person who is subject to pemphigus or erythema bullosum might develop an attack during pregnancy ; but herpes gestationis is excluded if recurrence takes place apart from pregnancy, whereas the occurrence of the bullous eruption solely in association with preg- nancy makes the diagnosis obvious at once. Again, bullae in a new-born infant will generally receive the term pemphigus neonatorum. The two main points to be borne in mind are, first that the eruption is not related to that of ordinary pemphigus, so that it is a pity the word pem- phigus is employed at all ; and secondly, that, uncommon though it may be, there are nevertheless two distinct kinds: (i) That in which the bullae are chiefly on the "hands and feet, when they are one of the manifestations of a severe and generally fatal type of congenital S3rphilis — a type in which the eruption appears almost immediately after birth instead of after an interval of days or weeks as in other cases ; and {2) That in which there is an infection of the skin of the nature of an impetigo — generally staphylococcal, but in some cases due to less usual organisms such as the Bacillus pyocyanens — producing bullae instead of the more usual pustules ; the latter is an affection of poverty- stricken districts, occurring in more or less epidemic form, sometimes closely related to the practice of a particular midwife, and fortunately rare now-a-days. Cheiropompholyx is another condition that may generally be recognized at once. It is a dysidrosis, and the sweat-glands of the palms of the hands and the soles of the feet are most affected, though those of the forehead, chest, back, and so on, may sometimes be affected too. As a rule, the sweat retained in the glands produces subcutaneous vesicles that are barely larger than sago grains ; as the superficial epidermis becomes worn off, the little sweat-cysts reach the surface, a process assisted by the scratching that usually results from the irrita- tion arising in the parts. After each cyst bursts there is desquamation of such a degree that scarlatina may sometimes be simulated. The malady occurs in summer weather, or in tropical climates, especially in those who are apt to perspire freely. The blisters that are produced by the external application of vesicants to the skin are diagnosed readily enough when it is known that any application is being used. Difficulty arises mainly in two classes of persons ; namely (i) In those who live in houses upon which the rhus toxicodendron is grown as a Virginia creeper, the nature of the case being usually discovered from the fact that the patient is always affected when at home, and never when away ; and (2) In hysterical patients, or in malingerers, who purposely but surreptitiously produce the skin eruption. If the latter is suspected, it is generally possible to place the patient under conditions which preclude self-application, when the disappearance of lesions confirms the diagnosis ; or the actual vesicant employed may some- times be discovered, liquor epispasticus for instance, or some other preparation 112 BULL.^ of cantharides ; croton oil ; capsicum ; carbolic acid ; m^'labris ; iodine ; or one of the strong mineral acids, especially nitric acid. The relationship of occupation to a bullous dermatosis will often become obvious from the wa^' the skin trouble recurs whenever an^^ particular work is resumed ; the list above indicates the kind of occupations that are liable to produce it ; it should be remembered, however, that nearty aU these produce bulte far more seldom than they do a vesicular dermatitis. Extremelv oedematous tissues are very easily blistered, and on this account one must be char\- of diagnosing anything but simple blisters when bullae develop upon oedematous legs or other parts in association, for instance, with Bright' s disease, or in chronic heart cases with failing compensation. The same applies to the blebs arising on the skin of fractured limbs, and also in the region of a local gangrene ; or necrosis of the soft parts due to such causes as frost-bite, or Raynaud's disease, or scurv'y. The diagnosis in these cases will nearly always be clear enough, and so will it be in cases of simple blisters due to friction or irritation. Having thus excluded all the more or less obvious cases, there remain the following : pemphigus, en,-thema buUosum, dermatitis herpetiformis, erythema iris, epidermolvsis bullosa, en,-sipela.s, impetigo contagiosa, iodism, bromism, glanders, svphilis, and s\-ringomyelia. Of these, acquired syphilis is so very seldom bullous that it would not be diagnosed unless there was strong collateral evidence of the nature of the complaint, either in the historj' or in the other clinical evidence presented by the patient. S\-Tingomyeha is ver\' rare also, and buUae occur in but a ver^'- small propor- tion of the cases ; should they do so they would attract attention from their distribution being probably confined to quite a local area, the fingers and hands for instance, leaving the rest of the person free. The diagnosis would be con- firmed bv finding cutaneous sensibility natural, though the patient cannot distinguish pain from touch, or heat from cold, in the affected parts. The cutaneous affections of s^-ringom^-eUa are sometimes known as Moi^van's disease. The lesions are due to injuries produced because the skin is in- sensitive to things that are painful enough or hot enough to produce sores and blisters. The patient's occupation would ver^^ likel^^ suggest the nature of the complaint in a case of bullous glanders ; it might actually be known that a horse with, which the patient had had to do was affected with the complaint. The skin eruption is sometimes quite a late manifestation of a prolonged and obscure febrile illness when the glanders infection has started internally, for instance in the lungs. The Bacillus mallei may be found either in direct smears from the contents of the bullae themselves, or in cultures made from them. Bacterio- logical methods afford the final criterion of glanders. Both bromides and iodides mav produce many different t\'pes of skin eruptions. The commonest by far is that of simple acne ; but in other patients there may be,, instead of acne, either a patch}- er\-thema with cutaneous infiltration ; or nodular swelling studded with yellow points from which thick puriform fluid can be expressed ; or a confluent f uruncular lesion ; or, finally, a true bullous eruption or hydroa. The latter is decidedly rare, but the possibilit\' of its occurrence should be borne in mind, and enquir\- should be made as to an}- drugs that the patient may be taking ; in the case of iodides the urine will give a bluish-green colour with the guaiacum test, though no blood is present, and if there is still doubt a quantity- of urine may be evaporated down, and either bromine or iodine detected by ordinar\- chemical tests. It is noteworthy- that bromide and iodide eruptions have been recorded in infants at the breast when the mother has been taking' the drug without herself presenting an}- cutaneous symptoms. The causal BULL^ 113 micro-organism is generally a staphylococcus, but occasionally it has been found to be the Bacillus pyocyaneus. Bullous impetigo contagiosa is a variety of impetigo. Fluid seems to accumu- late in the infected spots so quickly that at first it does not appear to be purulent but rather to take the form of single big vesicles or bullae. These often become pustular, and as they dn,' up the crusts over them have a characteristic yellow- honey-like appearance. The condition can be diagnosed, as a rule, from the fact that other parts of the body present the typical lesions of ordinary impetigo ; there may be other patients affected in the same house or school, and the condi- tion is as readily curable by antiseptic measures as is impetigo. There is a very rare and extremely grave disease described as impetigo herpetiformis in pregnant women ; but this seems to be an aggravated form of dermatitis herpetiformis or herpes gestationis become purulent and contagious. It is found in Austria, but not, apparently, in England. Erysipelas as a cause of bullje is well known, and when blebs are present upon the tjrpical tender, slightly raised, and well demarcated red skin at the height of the affection, in association with the constitutional symptoms and pyrexia, there can seldom be any difficult}^ in the diagnosis. It is when the erysipelas is subsiding or has subsided, whilst the bulls, or the remains of them, are still obvious, that a difficulty might arise. Streptococci may be detected bacterio- logically. If, on due consideration, all the conditions described above can be excluded and it has been found that the patient is suffering from a disease of which bulls with more or less erythema are the chief manifestation, then the diagnosis has been narrowed down to one or other of the following : pemphigus, erythema bullosum, dermatitis herpetiformis, erythema iris, and epidermolysis bullosa ; there is evidence to show that these are closely related in some respects, the different names applying to affections that differ more in type than kind. If the patient develops bullae on various parts of the trunk and limbs without any erythema, or at any rate without any erj^thema until the bullae have been present a longer or shorter time, the condition is then described as pemphigus. If the bullae develop, not on normal-looking skin, but upon places where there has already been erythema, associated with more or less itching, or even pain, before the bullae develop, and if the whole eruption consists of this combined condition of erythema and large bulls, the name used to designate it is erythema bullosum. If the bullae tend to dry up at their central parts and then to be followed by a secondary ring of vesicles or blebs around the original one, these secondary vesicles being followed in turn by others upon a yet larger ring outside them, the condition is referred to as herpes iris or as erythema iris, according as there is little or much er^-thema before the first vesicles or bulls appear. When the bulls are apt to develop on any part of the body from a degree of rubbing or scratching which in the ordinary individual would be quite unlikely to produce blisters, this undue tendency to blister formation, from what ought to be inade- quate causes, is spoken of as epidermolysis bullosa, a condition which may persist throughout life without necessarily leading to any other untow-ard sym- ptoms in the patient ; it is probably related to factitious urticaria. Dermatitis herpetiformis is a polymorphous eruption, of which bulls form but a part ; the trouble begins with itching of the skin, and more or less general disturbance, part of which arises from the loss of sleep entailed b}' the irritation. In various parts of the body or limbs er^-thematous and urticarial patches supen.'ene, some of wtiich subside without further development, whilst upon others clusters of vesicles soon appear. Many of the clusters contain twenty or thirty vesicles upon a single inflamed base ; some, fewer vesicles of larger size ; whilst yet others, in the place of clusters of small vesicles, develop into typical blebs varjang D ' S 314 BULLM in area from that of a sixpence to that of a half-crown. No region of the body is exempt. The characters of the lesion are precisely similar to those found in pregnant women suffering from herpes gestationis, but there must be a difference in causation, for the latter^ though it occurs with every successive pregnancy in the same woman, remains in complete abeyance between the pregnancies, w^hilst dermatitis herpetiformis — Diihring's disease or hydroa — may occur in either sex and at almost any age, though it is less common in children than in adults. It is probablj' due to the action of some poison circulating in the blood, derived perhaps from the food in some cases ; it is possible for two persons to be taken ill after partaking of the same food, one with acute gastro-intestinal symptoms, such as diarrhoea and vomiting ; the other with acute pemphigus ; it looks, therefore, as if pemphigus and its allies may be related to the acute urticaria that is so familiar in certain cases of shell-fish poisoning ; it may be due to ptomaines. Any one of the bullous dermatoses may be either acute, subacute, or chronic, in any of these degrees there may be, practically, no constitutional disturbances on the one hand, or the patient may be so ill, with more or less pyrexia and constitutional disturbances, as to require to stay in bed ; while not a few cases, •especially those of the type to which the term pemphigus can be strictly applied, may prove fatal. In all the bullous dermatoses the eruption may be restricted to the cutaneous surface ; but they may also occur upon the mucous membranes, especially of the mouth, palate, oesophagus, nose, colon, rectum, and vagina. If recovery has taken place upon one occasion there is a decided tendency for subse- quent attacks to occur. Finally, it may be mentioned that although it is often stated as a general rule that many skin diseases may be associated with eosinophilia, as a matter of fact few skin diseases other than the bullous dermatoses produce any marked degree of eosinophilia, so that a differential leucocyte count may afford valuable dia- gnostic evidence. The absence of eosinophilia by no means excludes pemphigus or erythema buUosum or any other bullous dermatosis, but the presence of eosinophilia in a doubtful case increases the probability of the condition being one of these ; it is noteworthy, moreover, that whereas the cells in the contents of the bullae themselves are, to a considerable extent, coarsely granular eosino- phile corpuscles, those which occur in a blister produced artificially in the same case present no such tendency to eosinophilia. Herbert French. BUZZING IN THE EARS.— (See Tinnitus.) CACHEXIA literally means " a bad habit," and is an ill-defined term used to include almost any depraved condition of the body in which nutrition every- where is defective. Formerly it was synonymous with chlorosis. It is generally applied to patients who exhibit at the same time progressive loss of weight, and change of complexion in the direction of sallowness or actual anjemia. (See Weight, Loss of ; and Anaemia.) The word is generally prefixed by a qualifying adjective, such as cancerous cachexia, syphilitic cachexia, malarial cachexia, tuberculous cachexia, the dia- gnosis generally being indicated by other symptoms or by the history. Other varieties of cachexia that may be given special mention, and which, if they are borne in mind, are not as a rule difficult of diagnosis, are C. splenica, including blood diseases such as leucocythemia, in which with progressive loss of weight and anaemia there is enlargement of the Spleen {q.v.) ; C. utevina, with chronic non-fatal lesions of the uterus or other pelvic organs, notably with leucorrhoea, chronic endometritis, or fibroid tumoiirs ; and often accompanied by brown disfiguring pigmentation (chloasma uterinum), especially on the forehead and round the eyes ; C. parasitica, due to infection by the more serious intestinal or CAMMIDGE'S PANCREATIC REACTION 115 other parasites, especially Ankylostomum duodenale, Bothriocephalus latus, Bilhar- zia hcsmatobia, and Trichina spiralis ; C. chlorotica, a synonj^m for chlorosis ; C. mercurialis, attributed to the effects of mercury, though perhaps really due to syphilis, seeing that the condition is commonest in tertiary cases in which mercury has been given in large quantities ; it was much commoner in former days, when iodide of potassium was not employed, and great destruction of the tissues of the legs, scalp, palate, and other parts was common ; C. exophthalmica, the cachexia that is sometimes associated with exophthalmic goitre ; C. palustris, or marsh cachexia, due either to actual malaria or to constant living in un- healthy, damp surroundings ; C. alkalina, the bad health caused by taking large quantities of alkalies for a long period, and evidenced by pallor, breathlessness, emaciation, and anaemia ; C. aquosa, also called pica, and C. afrtcana, a term given to an anaemic condition leading to serous effusion, and often accompanied by perversion of appetite, seen in hot climates and especially among negroes; it has received many names, such as white tongue, stomach disease of negroes, negro cachexy, intratropical anaemia, dirt-eating disease, and many others. Doubtless many different disorders have been included under this name, including the results of malaria or of intestinal worms ; C. renalis, which results from prolonged albuminuria, especially in subacute tubal nephritis ; C. scorbutica, a condition formerly described as associated with rickets, though more likely related to the infantile scurvy of Barlow, nutrition being impaired, the head and upper part of the body perspiring profusely during sleep, anaemia developing, and the patient being intolerant of bed-clothes owing to tenderness or actual painfulness of the bones : there may or may not be bleeding gums ; the bone tenderness is thought to be due to subperiosteal haemorrhages ; C. saturnina, which results from chronic lead poisoning. Herbert French CAMMIDGE'S PANCREATIC REACTION.— The improved pancreatic re- action primarily depends upon the fact that when the urine of a patient suffering from pancreatic inflammation is hydrolysed by boiling with dilute HCl, a sugar having the reactions of a pentose is set free, and may be recognized by conversion into its osazone crystals by treatment with phenylhydrazine. A golden yellow flocculent deposit of flexible hairlike crystals forms, arranged in microscopic sheaves, readily soluble in dilute sulphuric acid. The appearance and solubility of the crystals are very characteristic, but as glycuronic acid, which is set free to a greater or less extent in all urines during the hydrolytic process, also forms a crystalline compound with phenylhydrazine, it is removed by treating the still acid urine with tribasic lead acetate, after the excess of hydro- chloric acid has been neutralized with lead carbonate. The lead that goes into solution has also to be removed by converting it into an insoluble sulphide or sulphate before the phenylhydrazine test is applied. The results, both of five years' clinical experience, and of many animal experi- ments, have demonstrated that a positive " pancreatic " reaction is strong presumptive evidence of a disturbance of function and of active degenerative changes in the pancreas. In most cases these are consequent on inflammation, either acute or chronic, but in a few instances a positive reaction seems to arise from abnormal physiological activity. The latter may, however, be neglected for all practical purposes, for it is not associated with symptoms suggestive of pancreatic disease. It has been pointed out repeatedly that the pancreatic reaction is not patho- gnomonic of pancreatitis, and the writer must again insist that the results of the test must be considered in conjunction with the clinical symptoms and the evidence to be obtained by a complete analysis of the urine and faeces. By doing so one can not only obtain confirmation of the indications given by this ii6 CAMMIDGE'S PANCREATIC REACTION special method of examination, but also infer the probable cause of the changes in the pancreas, which is a most important point, for pancreatitis is rarely, or never, a primary' disorder, but is usually secondary to an ascending catarrh from the duodenum, gall-stones in the common bile-duct or in the ampulla of Vater, invasion of the pancreas by a duodenal or gastric ulcer, malignant disease either primary in the pancreas or secondary to some other organ, back-pressure from disease of the heart or lungs, arteriosclerosis, alcoholism and cirrhosis of the liver, sj^hilis, tubercle, influenza, typhoid fever, mumps, etc., etc. In many of these the chnical signs and symptoms alone are sufficient to indicate the cause of the pancreatitis, but in others they are so indefinite or obscure that it is only by considering the results of a complete quantitative and qualitative analysis of the urine, and faeces also, that a correct diagnosis can be arrived at. A single negative pancreatic reaction does not exclude chronic pancreatitis, or rather the results of inflammation of the pancreas, for the reaction is only given when there are active degenerative changes in the gland at the time when the urine is being excreted. Cirrhosis of the pancreas due to past inflammation does not, therefore, cause a reaction after the inflammation has subsided. Cancer of the pancreas too is associated with a positive reaction in only about 25 per cent of cases, the presence of the growth being apparently unattended by any inflam- matory changes in the pancreas in the remaining 75 per cent. Other points to be noticed in examining the urine from suspected cases of pancreatic disease are : — 1. The presence of calcium oxalate crystals (see Oxaluria) in the centrifu- gahzed deposit ; these are met with in 63 per cent of cases of chronic pancrea titis, or 73 per cent if jaundiced cases are excluded. 2. A pathological excess of urobilin (see Fig. 23, p. 95) ; this is a very constant indication of cholangitis, and a particularly useful sign of gall-stones in the common bile-duct, whether accompanied by jaundice or not. 3. A well-marked indican reaction : pointing to a catarrhal condition of the intestinal mucous membrane, with abnormal putrefactive changes in the contents of the intestine, and possibly a duodenal or gastric ulcer. 4. Bile pigment in the urine : showing that there is some obstruction to the free flow of bile into the intestine, due to impacted gall-stones, gripping of the common bile-duct by the inflamed head of the pancreas, which surrounds the duct in 62 per cent of cases, malignant disease of the head of the pancreas, or a growth in the common bile-duct. For the purposes of a further differential diagnosis, the results of a qualitative and quantitative analysis of the faeces are most important. In carrying out the analysis the points to be noticed particularly are : — 1. The presence or absence of stercobilin ; in gall-stone obstruction, traces at least are nearly always met with, whereas in malignant disease of the head of the pancreas, total blocking of the duct is the rule, although the soft growths occurring primarily in the common duct usually allow some bile to filter through, so that traces of stercobilin are met with in the faeces. 2. The percentage of unabsorbed fat : in cancer of the pancreas this is always very high, 70 to 80 per cent ; it is usually somewhat less in growths of the common duct, averaging 60 to 70 per cent, and varies from a subnormal percentage in early catarrh of the pancreas to as much as 50 or, rarely, even 80 per cent in advanced chronic pancreatitis. 3. More important still, however, is the relation of the unsaponified to the saponified fats, for whereas the former are in excess in diseases that interfere with the digestive functions of the pancreas, such as cancer of the gland and advanced chronic pancreatitis, the latter predominate in obstruction of the common duct by gall-stones, without pancreatitis, and in malignant growths CHARCOT-LEYDEN CRYSTALS 117 not involving the pancreas. It must be borne in mind, however, that, owing to the abnormal activity of fat-splitting bacteria in the lower bowel, such as is met with in some cases of intestinal catarrh, an excess of saponified fat may be found in cases of chronic pancreatitis, where the disease is due to an infection spreading from the duodenum along the pancreatic ducts. A similar excess is often met with in early catarrhal pancreatitis, owing probably to an increased flow of pancreatic juice analagous to the salivation met with in parotitis. 4. Microscopical examination of the faeces for fat globules, fatt}- acid cr^'stals, undigested muscle fibres, connective tissue, etc., should not be omitted : a large excess of fat globules and free fatty acid crystals, with numerous isolated undigested muscle fibres, pointing to cancer of the pancreas o,r advanced cirrhosis of the gland, whereas muscle associated with connective tissue points to defective gastric digestion. 5. An acid reaction of the fresh stool is in favour of a diagnosis of pancreatic disease ; in simple gall-stone obstruction, the faeces are usually alkaline. 6. Occult blood, when constant^ present in the faeces (see p. 94), is suggestive of malignant disease or, more rarel}', advanced pancreatitis, in which it is now well known that there is a haemorrhagic tendency ; while the discovery of blood intermittently points to a gastric or duodenal ulcer, which may be invading the pancreas and setting up pancreatitis. By carefully considering all the facts thus obtained, and interpreting them in the light of the clinical signs and symptoms, it is possible, not only to diagnose correctly the existence of disease of the pancreas, but also to arrive at a satis- factor)' conclusion as to its probable cause. Affection of the pancreas is much commoner than is generally supposed, and many try'ing cases of chronic indiges- tion, recurring or persistent jaundice, and obscure affections of the upper abdomen would be explained, and satisfactorily treated, if investigated as above. Undiagnosed, and consequently untreated, pancreatitis, is probably the most common cause of diabetes. If this were more widely recognized much might be done to stay the further increase of that disease. p. j . Cammidge. CARDIAC BRUITS.— (See Bruits, Cardiac.) CARDIAC IMPULSE DISPLACED.— (See Heart Impulse Displaced.) CARDIAC THRILLS. — (See Thrills, Precordial.) CASTS IN THE URINE.— (See Albuminuria.) CEPHALALGIA.— (See Headache.) ^:j^ CHARCOT-LEYDEN CRYSTALS.— Charcot- Ley- den crystals were at one time supposed to consist of spermin, but now there is considerable doubt as to their exact chemical nature. Their chief importance from a clinical point of view is that they are more common in certain conditions than in others. They may be found either in the sputum, the blood, or in the stools. The crystals themselves are of microscopic size, needing the high power for their detection. Each resembles a very elongated diamond {Fig. 26), with clear-cut edges, without colour, but with a slightly yellow appearance when seen obliquely. They stain with eosin, and are soluble in hot water, in mineral acids, and in alkalies, so that for their detection a fresh specimen is required. In the sputum, they are far more common in asthma than under anv other I^/^. 26. — Charcot-Leyden crys- tals and leucocytes under the high power of the microscope. (From ISledical Laboratory Methods. Dr. Herbert French.) ii8 CHARCOT-LEYDEN CRYSTALS circumstances — true spasmodic asthma, such as also gives rise to Curschmann's Spirals [q.v.) and eosinophile corpuscles in the sputum at the same time. As a means of determining whether a given case is one of paroxysmal dyspnoea, cough, or bronchitis on the one hand, or true asthma complicated by bronchitis, upon the other, the detection of large nurabers of Charcot-Leyden crystals in a fresh specimen of sputum affords considerable evidence in favour of the latter diagnosis. Small numbers of the crystals may be found in bronchitis and in association with bronchiectasis, but in true asthma their numbers may be quite large. The occurrence of Charcot-Leyden crystals in the blood is of little diagnostic value. They are seldom if ever found in fresh blood ; but when the latter has. stood for some time in bulk they develop, particularly in certain diseases in which leucocytes are breaking down rapidly, especially in cases of leukcBvnia. Some authorities have tried to draw important clinical deductions from the development of these crystals in blood, but it is doubtful whether they really have any significance of value. In the stools, Charcot-Leyden crystals have been found in a great variety of diseases, but whether or not clinical deductions can be drawn from their presence is doubtful. It is stated that, when they abound, the patient is probably suffering from an animal parasite ; but it affords no indication of the nature of the parasite present. Their occurrence should lead one to examine the fasces for parasites or their ova with even greater care than usual. Herbert French. CHEST, BLOODY EFFUSION IN When, on needling a chest containing fluid in the pleural cavity, this fluid is found to be obviously blood-stained, the fact is always very suggestive of one of three things : either the inflammation of the pleura has been exceedingly acute ; or the chest has already been tapped not long previously, so that there has been haemorrhage into the residual fluid ; or there is malignant disease of the pleura, either primary or secondary,, carcinoma or sarcoma. The history of the case may at once indicate whether the inflammation is very acute or not ; the symptoms would have been of short duration and associated with much pyrexia, whilst the fluid itself would be of high specific gravity, would contain a large amount of albumin, would probably coagulate spontaneously, and microscopically would exhibit numerous poly- morphonuclear cells and lymphocytes, as well as an abundance of red corpuscles,, but no particles of growth in the centrifugalized deposit. If blood is found in pleuritic fluid at a second tapping, when it was not present at the first, the fact is by itself of little value in difterential diagnosis, for the bleeding has probably been caused by the act of paracentesis. When there is a new growth, and the effusion contains obvious blood at a first tapping, it is likely that the symptoms will have been of gradual onset, there will not be marked pyrexia, there may not be signs of obstruction to a bronchus or to the intrathoracic veins ; but the diagnosis may be cleared up by finding fragments of new growth in the centrifugalized deposit. It is of course by no means every case of malignant disease affecting the pleurae that produces a blood-stained effusion ; but when the effusion is blood-stained at a first tapping, in a case that has not run a very acute course, one should be very suspicious of new growth. In not a few such cases there have also been comparatively large numbers of coarsely granular eosinophile corpuscles in the effusion. Herbert French. CHEST, DEFORMITY OF.— (See Deformity of the Chest.) CHEST, PAIN IN (See Pain in the Chest.) CHEST, PUS IN iig- CHEST, PUS IN. — When, on needling the chest, pus wells up into the exploring syringe, it is exceedingly probable that the patient is suffering from an empyema. Other lesions may simulate empyema, however, and even when empyema is actually present it is important not to let the diagnosis rest at empyema ; but rather to regard it as a symptom and try to diagnose its cause. It by no means follows, of course, that when the exploring syringe fails to detect pus, an empyema is not present, for sometimes it is situated either between the lower lobe and the diaphragm, in front of the lung or between the lobes,, or in some other position in which it is difficult to hit it off with the needle. When pus is found but the amount is only quite small, there may be doubt as tO' whether it came from an empyema outside the lung, from a bronchus, or an abscess cavity in the lung substance. The nature of the case may remain undecided until a subsequent puncture, or a resection of a rib, conclusively discovers intra- pleural pus. Even when pus wells up in the exploring syringe it is sometimes possible to- mistake for empyema a collection of pus which is below the diaphragm. A subdiaphvagmatic abscess and an abscess within the liver are the two conditions most liable to simulate empyema in this way. If, however, the history, the symptoms, and the physical signs do not serve to distinguish between these different conditions, it will still be clearly necessary to evacuate the pus, and the surgeon's finger inserted through the wound will be able to feel whether the diaphragm is above or below the collection. Even then there is one possible source of error, namely, when there is pus both above and below the diaphragm. A subdiaphragmatic abscess, secondary perhaps to appendicitis upon the right side, or to a leaking gastric ulcer upon the left, may have infected the pleura through the diaphragm, causing first a serous and then a purulent effusion, separated from that below the diaphragm merely by the thickness of that muscle. It may be very difficult indeed to be sure of this condition, even at the time of operation, the nature of the case not being fully cleared up until, when one of the pus-containing cavities has been evacuated, the abnormal physical signs persist, and a second collection of pus, above or below the diaphragm as the case may be, is found at a subsequent exploration. The ;r-rays may be of considerable assistance sometimes in showing whether the diaphragm is above the pus or below it If, however, the physical signs, symptoms, and the result of needling, all conclusively prove that the chest contains an empyema, it is still necessary to- decide as far as possible the nature of the latter. Its commonest cause is pneumococcal infection, nearly always preceded by lobar pneumonia in adults, in children sometimes by bronchopneumonia, but not infrequently arising insidiously. It is probable that many of the so-called latent empyemata of children have really been preceded by undiagnosed bronchopneumonia. Difficulty very often arises from the fact that the amount of pus present is not great, so that though it compresses the lung sufficiently to render the alveoli airless, the bronchial tubes still remain patent, and there is no complete dullness at the base or wherever the empyema may be ; and over the affected area there may be bronchial breathing and crackling rales, instead of the absence of breath- sounds and of voice-sounds that usually accompanies empyema in adults. If there is doubt as to the nature of the empyema as judged by the history, bacteriological examination of the pus will often indicate its origin. The commonest organisms to be found are pneumococci, streptococci, and staphylo- cocci, though Bacillus coli communis , typhoid bacilK, and the Bacillus pyocyaneus also occur, and it is not improbable that other organisms also may be present in some instances. The mode of infection is generally either via the lung, or from beneath the diaphragm ; and careful inquiry into the history and symptoms CHEST, PUS IN ■^vill generally indicate which of these two paths has been the more hkely. When infection from any peritoneal condition such as appendicitis, leaking gastric ulcer^ or sub-diaphragmatic or hepatic abscess, can be excluded, when there has been no injur}' to the chest with broken rib, or a wound communicating with the exterior, and when there is nothing to indicate whether the infection has succeeded pneumonia or is itself pneumococcal, suspicion will arise that the patient has, been suffering- from phthisis, which has caused a. pleurisy which was at first non-purulent, but which became converted into an empyema as the result of secondary infection with pyogenic organisms, especially if there is a tuberculous family history, or if the patient has himself been weakly for some J^ij^. 27. — .^Kiagram snowing tne mottling 01 the lung apices produced by phthisis. Posterior view. {By Dr. A. C. Jordan.) time. The sputum should be examined ^\'ith particular care, and Ar-ray examination may pro\'e very helpful ; for even when the compression of the lung by empyema has led to marked opacitj^ at the base, it ma}' still be possible to make out that apical mottling which is almost pathognomonic of phthisis (Fig. 27). Rarer causes of empyema than those mentioned above will generally have been accompanied by other symptoms, or by a history which suggests the nature of the individual case. Herbert French. CHEST, SEROUS EFFUSION IN.— When exploratory needhng of the chest discovers clear serous fluid in the pleural cavity, it is most important to regard the fact merely as a symptom, for there are many different causes to which it may be due, and, whenever possible, one should decide what is the actual cause in each particular case. In the first place, the effusion may be inflam- mator}^ or merely a transudate ; the pleuritic must be distinguished from the pleural effusion. Clinical points indicating that the effusion was inflam- matory rather than passive would be : its being unilateral, not bilateral and symmetrical ; not being associated with a general water-logging of the patient ; and the non-existence of the more common causes for passive effusion, particularly chronic heart failure or acute nephritis with general anasarca.. Physical, chemical, and microscopical analyses of the fluid might also serve to CHEST, SEROUS EFFUSION IN indicate whether the effusion was active oi* passive (see Ascites). There are cases, of course, in which there ma}' be doubt, but it is generally easy to deter- mine whether the effusion is due to pleurisy or not. Pleural effusions net due to pleurisy occur late, and the diagnosis will have been made already from the existence of prominent symptoms earher in the disease, for instance. Albumin- uria {q.v.), Orthopncea [q.v.), CEdema {q.v.), and so forth. Pleuritic effusion; on the other hand, may sometimes be the most prominent symptom, and it is not always easy to determine the cause of the pleurisy. It should be an invariable rule to have the effusion examined microscopically, both for cells and for micro-organisms, and sometimes to have guinea-pigs injected with it in order to see whether in six weeks' time the inoculated animals have developed general tuberculosis or not. The commonest cause for apparently simple and idiopathic pleuritic effusion, is latent or undiagnosed tuberculosis of the lung ; there may be no sputum ; ;tr-ray shadows may be indeterminate ; there may be no abnormal apical physical signs ; there may be too few bacilh for them to be detected on direct examination of the deposit, even when it has been most carefully centrifugalized, and yet inocu- lated guinea-pigs may develop typical tuberculosis and thus indicate the nature of the pleurisy. Intrathoracic new growth, whether of the mediastinum, lung, or pleura, is fortunately uncommon ; but when it occurs, the symptoms and physical signs to which it gives rise are often very difficult to interpret. The growth may obstruct a bronchus and give all the physical signs of fibroid lung, with or with- out bronchiectasis ; it may cause a big mass, bodily displacing the lungs and heart ; it may cause multiple nodules which, unless they obstruct the superior vena cava and produce obvious varicose veins on the chest wall or other prominent symptoms, may give rise to no very definite signs or symptoms at all ; or, what is not at all infrequent, the growth may lead to pleuritic effusion which may at first seem to be simple, or even be taken to be tuberculous, growth not being suspected until the rapid recurrence of the eftusion, repeated tappings, and rapid downhill course of the disease ultimately suggest its nature. Microscopical examination of the centrifugalized deposit of the pleuritic fluid sometimes leads to the detection of particles of new growth which clinch the diagnosis, whilst if the fluid in a case which is not absolutely acute, is blood-stained at a first tapping, this by itself is highly suggestive of neoplasm. Acute rheumatism, particularly between the ages of five and twenty, is not an uncommon cause of pleurisy with eflusion. It may occur when there have already been joint-pains, or other symptoms of acute rheumatism, such as chorea, recurrent tonsilUtis, pericarditis, endocarditis followed by valvular disease, skin affections such as erythema multiforme, erythema nodosum, pehosis rheumatica, or subcutaneous nodules. In such cases the diagnosis is not difficult ; but it is less easy when the pleuritic effusion is itself the main symptom in the case. The youth of the patient, the absence of anaemia or of previous ill-health of some duration, the absence of abnormal apical lung signs, of a family history of phthisis, the presence of a cardiac bruit, the occurrence of heart disease, acute rheumatism, or chorea in other members of the same family, the rapid onset of the disease, and the almost equally rapid resolution of the effusion, even when no particular treatment is adopted, are points in favour of acute rheumatism rather than tuberculosis. When in doubt, the negative results of guinea-pig inoculation would point in the same direction, and von Pirquet's skin reaction would be negative. There are, however, many cases of pleuritic effusion in young people, in whom it is impossible to allocate the cause either to rheumatism or phthisis, and such cases are sometimes spoken of as examples CHEST, SEROUS EFFUSION IN of "simple" pleurisy; doubtless -most of these are either tuberculous or rheumatic, the majority ultimately proving to be the former. Pneumococcal lesions of thr lung generally produce pleurisy ; lobar pneumonia indeed, never occurs without it, though bronchopneumonia, even when it is pneumococcal, often does. It is less common, however, for pneumococci to cause a serous effusion than either a dry pleurisy or an empyema, although pneumococcal pleuritic effusion is met with now and then, the diagnosis being confirmed by the discovery of pneumococci in the fluid. It is even possible for pneumococcal pleuritic effusion to occur without there having been any definite lobar pneumonia or bronchopneumonia preceding it — primary pneumo- coccal pleurisy. It is difficult to say where pneumococcal serous effusion stops and pneumococcal empyema begins, the two merging into one another, and the same case often exhibiting clear fluid at one exploration, cloudy fluid a few days later, and pus later still. Bright's disease may cause either a passive effusion as the result of heart failure in chronic cases ; or a simple accumulation of oedema fluid in the pleural cavities without heart failure, in cases in which the general oedema of Bright's disease is extreme ; or actual pleurisy with serous effusion, probably the result of intercurrent infection by some low type of organism, corresponding with the peritonitis with Ascites {q.v.) and with the pericarditis which may also occur in these cases. The diagnosis will be indicated by the Albuminuria {q.v.), associated with renal tube-casts ; and if there is bilateral effusion without universal oedema, but with signs of heart failure in the form of orthopnoea, oedema of the legs, and perhaps ascites, the effusion is passive ; it belongs to the second category if there is universal oedema, as in some cases of subacute nephritis of some standing ; whilst if the effusion is inflammatory it will probably be unilateral, or else more marked in one side of the chest than in the other. In a few cases, an extensive pleuritic effusion in a middle-aged or elderly person is the very first indication that there is anything renal the matter, the diagnosis of red granular contracted kidney being confirmed by the urinary changes, big heart, ringing aortic second sound, high blood-pressure, or by albuminuric retinitis. Any of the severe blood diseases, particularly Hodgkin's disease, lymphadenoma, lymphoma, lytnphatic leukemia, splenomedullary leukcsmia, splenic ancBmia, pseudo-leukcsmia infantum, and to a less extent pernicious ancemia, may give rise to inflammation of any of the serous membranes, and thus lead to ascites, pericarditis, or pleurisy with effusion. The latter is seldom an early symptom in such cases, however, and the diagnosis will generally be known already by the presence of pronounced An/emia {q.v.), enlargement of the Lymphatic Glands ((/.w.), or enlargement of the Spleen (5'.z;.),withor without pathognomonic blood-changes already discussed under these various headings. Pleuritic effusion may sometimes be secondary to infection of the pleurae from inflammatory changes below the diaphragm ; thus appendicitis may lead to micro- organisms tracking up behind the ascending colon to reach the diaphragm, there perhaps producing a small subdiaphragmatic abscess, or a local inflammation which, stopping short of pus formation, ultimately subsides. The bacteria in contact with the lower surface of the diaphragm seem able to pass through the latter and infect the pleura without there being any actual hole in the diaphragm muscle ; they seem to pass through the normal stomata, and it is noteworthy that passage of micro-organisms in the reverse direction is so rare as almost to be negligible ; acute peritonitis often produces acute pleurisy, but the latter, or even empyema, seldom produces peritonitis. Anj^ inflammatory mischief below the diaphragm may lead in this way, sometimes to dry pleurisy, sometimes to pleuritic effusion, and sometimes to empyema. One need not enumerate all such causes, but they should be borne in mind as possibilities. CHEST, SEROUS EFFUSION IN 123 There may have been acute general peritonitis, or a more local inflammation of the peritoneum, tracking in the manner already described in connection with appendicitis. This is possible when there is a leaking from a gastric or duodenal ulcer ; local infection from the gall-bladder ; pyosalpinx ; pelvic peritonitis due to whatever cause ; perinephric inflammation secondary to renal calculus or injury, or tuberculosis of the kidney ; hepatic abscess or other inflammatory changes in or about the liver, such as infective cholangitis, suppurative pyle- phlebitis, or the softening and breaking down of new growth, gumma, or hydatid cyst. When the possibility of a pleuritic effusion being secondary to an abdominal lesion of some kind is borne in mind, the diagnosis of the case is generally indicated, at least approximately, by the preceding history and symptoms. If the fluid obtained smells as though it were infected with Bacillus coli communis, this would be an additional argument in favour of some sub- diaphragmatic cause. Infarction of the lung, whether thrombotic or embolic, is very apt to be associated with pleurisy, the latter often being dry ; but if the infarct has been extensive, or is due to embolism from some septic source such as a lateral sinus or jugular vein thrombosis in connection with otitis media, or other similar lesions causing venous clotting, the inflammation of the pleura tends to go further and produce an effusion which, at first serous, may later become purulent. The diagnosis is sometimes obvious ; but when after an operation, perhaps for excision of an inflamed appendix, the patient a few days later develops pleurisy with efl'usion, it may not occur to one that a possible explanation of the trouble is that more than one systemic vein in the region of the right iliac fossa has become inflamed and thrombosed, and that portions of the clot have been detached and carried to the lung, where multiple infected emboli have led to pleurisy and serous effusion, without going so far as to produce either abscess in the lungs or empyema. Should haemoptysis occur in such cases, as it sometimes does, phthisis may be feared ; but it will be excluded by the absence of tubercle bacilli on repeated examination of the sputum. Multiple serositis or polyorrhomenitis is a term used to express any condition in which there is recurrent inflammation and serous effusion into more than one serous membrane. It generally affects the peritoneum, pericardium, and both pleurae either simultaneously or successively. It is not a disease in itself, so that the differential diagnosis of the cause of the combined effusions has to be made upon the same lines as that described for each separately. There are cases in which, even when the patient dies, the precise nature of the multiple serous inflammations and effusions is obscure ; it is very possible that the original microbial cause has disappeared, leaving behind it so much fibrotic thickening of the membranes that even the normal secretions are unable to drain away as fast as they should. The result is, that recurrent tapping at comparatively short intervals becomes necessary, and the patient ultimately dies of exhaustion, nothing being found post mortem except fibrous thickening of the peritoneum, pericardium, and pleurae, with more or less extensive peri- hepatitis, perisplenitis, adherent pericardium, and chronic mediastinitis. The general opinion is that the primary cause in these cases has been either acute rheumatism or tuberculosis. Sometimes secondary malignant disease affects more than one of the serous membranes at the same time, and produces a clinical picture which at first simulates chronic simple polyorrhomenitis ; there are generally symptoms due to the primary growth ; but occasionally, especially in connection with diffuse carcinoma of the stomach — " indiarubber-bottle " stomach — the primary growth causes no symptoms, and the nature of the multiple serous effusions may be obscure unless particles of new growth can be 124 CHEYNE-STOKES RESPIRATION detected in the centrifugalized deposit, or secondary masses can be found in the hver or lymphatic glands. The left supraclavicular glands should be care- fully examined. Sometimes the diagnosis is not arrived at until a post-mortem examination is made. Besides chronic tuberculous, rheumatic, and mahgnant polyorrhomenitis, a similar condition may be due to Bright's disease or any of the severe anaemias ; the differential diagnosis of the serous effusions to which these may give rise has already been discussed. Careful examination of the blood and urine, together with estimation of the blood-pressure, examination of the optic discs, and routine physical examination of the various bodily systems, are essential before the correct diagnosis can be arrived at. Herbert French. CHEST, VARICOSE VEINS ON (See Veins, Varicose Thoracic.) CHEYNE-STOKES RESPIRATION, or periodic breathing, consists in the occurrence of a series of inspirations, beginning with a hardlj^ perceptible movement increasing to a maximum, and then declining in force and length until they cease in a period of apnoea of some seconds' duration, during which the patient may appear to be dead, but at the end of which a low inspiration followed by one more decided, and then others of increasing depth, mark the beginning of a new ascending series of inspirations which in their turn, when the maximum has been reached, become progressively smaller again to end in another period of apnoea ; and so on with more or less periodicit}^ {I^^g- 28). The vvr---^ Fig: 28, — Cheyne-Stokes Breathing. A graphic record from a case of arterial degeneration and softening of the medulla oblongata. The two curves were completed in 143 seconds. duration of each period varies from half a minute to two minutes or even more. There is a pecuhar variety of periodic breathing in which, instead of a waxing and waning sequence, only two or perhaps three rapid deep breaths are made at a time, with long periods of apnoea between them- — a variety of periodic breathing which is sometimes spoken of as Blot's. Periodic breathing occurs during sleep both in the very young and in the very old, without there being any actual disease. In other persons Cheyne- Stokes breathing is generally a late phenomenon, having been preceded by other symptoms, particularly ursemic or cardiac, though in a few cases of progressive softening secondary to arterial degeneration in the medulla oblongata Cheyne-Stokes respiration may be the most saUent symptom in the case. Broadly speaking, one ma}^ classify the chief causes of periodic breathing under headings, as follows : — 1. Arterial, especially when there are Degenerative Changes in the Medulla Oblongata : — Arterio-sclerosis Senile degeneration, especially changes associated with granular kidney. 2. Ursemic, in cases of : — Acute nephritis Chronic nephritis Calculous disease of the kidney Tuberculous disease of the kidney Ascending nephritis, acute or chronic Cystic kidneys Carcinoma of the kidney Sarcoma of the kidney. CH ORDER 125, 3. Chronic Heart Failure : — Secondary to valvular heart disease Secondary to myocardial degeneration, especially fatty or fibroid heart Secondary to chronic obstruction in the lungs, especially from emphysema and bronchitis, and fibroid lung Failure associated with very high systemic blood-pressure due to arterio- sclerosis or granular kidney. 4. Narcotic Poisoning, especially from Morphia Butyl chloral hydrate Opium Veronal Chloral Sulphonal. 5. Macroscopic Lesions of the Brain or its Coverings :— Tuberculous meningitis Suppurative meningitis Posterior-basal meningitis Cerebrospinal meningitis Hydrocephalus Tumour of the brain, especially of the pons or medulla Hemorrhage Softening of the brain secondary to : Chronic arterial degeneration Syphilis Caisson disease Embolism General paralysis Acute specific fevers, such as pneumonia, cholera, diphtheria, typhoid fever, malaria, infective endocarditis". ^ ■".. • The differential diagnosis of these' various conditions will be* indicated by symptoms and signs other than the Ch^syjie-Stpkes . respiration, for the latter will have occurred late in the great majority "of the cases. The urine will be examined, the blood-pressure measured, the physical signs of the 'heart particu- larly noted, the retina examined for retinitis, optic neuritis, or for choroidal tubercles, and careful inquiries will, be made into the history. ■ Wheye nqtcotfc poisoning may be suspected, the gastric contents may be recovered and analyzed, bottles found under suspicioxis circumstances anay be examined -in .the same way, or evidence of hypodermic*injections sought for on the patient's body or ' limbs. When Cheyne-Stokes respiration occurs as the main symptom in the case, the great probability is that there are degenerative changes in the medulla oblongata, nearly always secondary to arterial degeneration, either senile, syphilitic or sclerotic. When there have been obvious symptoms of some, other kind before Cheyne-Stokes respiration develops, the latter is far more important from the prognostic than from the diagnostic -standpoint. Herbert French. CHORDEE. — -A condition in which, during erection, the penis, instead of remaining straight, becomes curved like a banana, either downwards Or to one or other side. It is nearly always due to gonorrJieea, though, in rare cases it has been noticed as the result of injury without gonorrhoea. The dift'erential diagnosis will depend upon the history and the ^xisten(^e or otherwise of a urethral discharge containing, gonococci. The cbndition itself is probably due to inflammatory effusion into one or other corpus cavernosnm,-or the corpus spongiosum, as the case may be ; or, in the absence of inflammation, to the bursting of one or more blood-vessels, with consequent blood extravasation. There are cases on record in which fracture of the penis has occurred during resisted coitus, the diagnosis depending on the history and upon the obvious break that is palpable in the penis during erection. Herbert French, 126 CHYLURIA CHYLURIA. — The passage of milky-looking urine, due to the admixture with it of emulsified fat, is known as chyluria. It is not likely to be mistaken for phosphaturia, even when the latter, especially after the largest meal of the day, causes the urine to be almost Hke thin milk from the spontaneous deposition of the excess of phosphates whilst the urine is still in the bladder. The opacity in the latter case disappears on the addition of a drop or two of acetic acid, whilst the fat droplets of chyluria do not clear up with acids, are obvious under the microscope, and may be brought out still more clearly by the use of special fat stains, such as osmic acid, sudan III, or saffranin. As a rule, the urine coagulates on standing, and subsequently liquefies again, when it throws up a fatty scum and deposits a sediment. The fat is most plentiful after meals which contain fat, and the degree of chyluria consequently varies considerably in the same patient, and may sometimes be almost absent. The commonest cause for the symptom is infection hyFilaria sanguinis hominis in the tropics, adults being affected more often than children, and females more often than males. There may. or may not be elephantiasis at the same time ; the diagnosis may be suggested by eosinophiha and confirmed by the discovery of the embryos in the blood {Plate XII, Fig. F) . Chyluria may also occur, however, in those who have never been abroad, and it is sometimes associated in some way that is not yet fully understood with sub-acute nephritis ; there may be chylous ascites at the same time. The diagnosis depends upon the history, the general oedema, the anaemia, cardiac hypertrophy, and upon the discovery of an abundance of albumin with renal epithelial cells and tube-casts in the centrifugalized urinary deposit, as well as fat droplets in the supernatant fluid. Sonaetimes chyluria develops quite apart from any renal lesion, either spontaneously or as the result of abdominal injury; and it has generally been found in these rare cases, that there has been either rupture of the receptaculum chyli, or else a blockage in the thoracic duct. The latter some- times results in cases of malignant disease, especially carcinoma of some intra-abdom- inal organ. The development of chyluria in such cases would be a late symptom, and the diagnosis would probably have been made already on account of other symptoms, especially the discovery of a primary tumour. It is important not to forget rectal and vaginal examination, lest the growth should be pelvic. Herbert French. CLAW-FOOT, pied-en-griffe, Krallen der Zehen [Fig. 29), is much less common than Claw-hand {q.v.), but it may arise from similar causes. The internal popliteal nerve, which supplies the interossei and lumbricals of the foot through its ex- ternal plantar branch, is homologous to the ulnar nerve in the upper extremity. Its buried course in the leg does not, however, expose it to the same chances Fig. 2g. — Claw-foot. CLAW-HAND 127 of injury as the more superficial ulnar nerve, and consequently claw-foot is not often the result of trauma. Disease or injury of the first and second sacral segments or spinal roots may produce the characteristic deformity of the toes, in which case there would probably be disturbances of sensibility in the cor- responding cutaneous areas. In acute poliomyelitis affecting those segments, the diagnosis depends on the history of onset, as in the cases of claw-hand of similar origin. £. Farquhar Buzzard. CLAW-HAND, main-en-griffe, Krallenhand, is the name used to describe a hand characterized by a claw-like p'osition of the lingers [Fig. 30). In such a hand the lingers are extended at the metacarpo-phalangeal joints and flexed at both inter-phalangeal joints. This position of the fingers is the result of the over-action of the extensor communis digitorum and flexores digitorum when unopposed by the normal antagonism of the interossei and lumbricales. It is not symptomatic of any particular disease, but results from any morbid condition which produces atrophic paralysis of the intrinsic hand muscles so long as the long extensors of the fingers remain intact. Progressive muscular atrophy, ulnar paralysis, syringomyelia, cervical pachymeningitis, acute poliomyelitis, peroneal atrophy, and supernumerary ribs are among the conditions which may give rise to claw-hand to a lesser or greater degree. In any particular case the diagnosis of the condition underlying it must depend on the result of further investigation. Fig. 30. — Syringomyelic claw-hand. In progressive muscular atrophy, wasting of the intrinsic hand muscles is often an early symptom, and a claw-hand may develop before the long extensor muscles of the fingers have become involved in the disease. All four fingers are usually affected to an approximately equal extent, and there is often marked wasting of the thenar and hypothenar eminences. When the abductor pollicis is also involved, the thumb tends to come into line with the fingers and gives an appearance to the hand resembling that of the ape (ape's hand). The flexors of the wrist often become involved before the extensors, with the result that the wrist is hyperextended, and a " preacher's hand " results. The absence of pain and of all sensory disturbance, the gradual onset, and the general exaggeration of the deep reflexes, serve to distinguish this condition from some of the other causes of claw-hand. In ulnar paralysis the claw-position is more marked in the ring and little fingers than in the middle and first fingers, owing to the fact that the two outer lumbricals are supplied by the median nerve. The adductor pollicis is the only thenar muscle to suffer, but the hypothenar eminence is wasted. If the injury CLAU'-HAXD to the nerve is above the point where it gives off the branch to the flexor carpi ulnaris, the latter muscle \yiil also be paralyzed, and flexion of the -n-rist will be carried out with a leaning towards the radial side. In ulnar paralysis the palsy is limited to the muscles supphed by the ulnar ner\-e, and there is usually some sensory loss in the area of skin innervated b}- the latter. The claw-hand of syringomyelia [Fig. 30) resembles that of progressive mus- cular atrophy in general appearance, and may show the modifications to which the term " ape's hand " and " preacher's hand " have been applied. The mus- cular atrophy is not limited to the distribution of a single ner\-e, but involves the musculature inner^-ated by the eighth cervical and first dorsal spinal seg- ments, the segments, in fact, in which the gliosis frequently begins. The diagnosis depends on the presence of dissociative anaesthesia, trophic and vasomotor disturbances such as whitlows, glossy skin (peau lisse), main succulente, and is often corroborated bv the occurrence of oculo-pupillar\- phenomena, nystag- mus, scoUosis, and e\-idence of spastic paralysis in the leg of the same side. Cervical pachymeningitis ovly leads to a claw-hand when it interferes with the function of the eighth cervical and first dorsal anterior roots and leaves uninjured the sixth and seventh cervical roots. The condition is generally bilateral with some as\Tnmetr\-, and it is usually associated with pain and ill- defined disturbances of sensibility in the two arms. An acute poliomyelitis affecting the eighth cervical and first dorsal segments, and leaWng intact the sixth and seventh cer\dcal segments, is of uncommon occurrence. The history- of acute onset, with constitutional s\-mptoms such as headache, fever, vomiting, and con^■ulsions, affords a clue to the diagnosis. The absence of sensory- loss, and the possible presence of atrophic palsies in other parts of the body, form additional data in these cases. Peroneal atrophy is another condition in which a claw-hand may develop, owing to the slow progressive wasting of the intrinsic hand muscles. The diagnosis depends on the s^-mmetrT.- of the affection and the preceding or con- comitant atrophv of the leg muscles, generally beginning in those supplied by the peroneal nerve (see Figs. 8 and 9, p. 71). Supernumerary cervical ribs may lead to the production of a claw-hand when they cause neuritic changes in the trunk formed by the eighth cervical and first dorsal contributions to the brachial plexus. The muscular atrophy is preceded b}^ pain in the arm and neck, and sometimes by vasomotor changes and diminu- tion of the radial piilse. Analgesia in the distribution of the eighth cervical and first dorsal-root areas may also be detected, but the diagnosis must depend mainly on the skiagraphic discovery of the rudimentarj- ribs. E. Farqiihar Buzzard. CLONUS, ANKLE.— (See Axkle-Cloxus.) CLUBBED FINGERS. — This condition denotes bulbous enlargement of the soft parts of the terminal phalanges, \^-ith over-cur\-ing of the nails both transversely and lon.gitudinally, seen characteristically in morbus cseruleus, and also in asso- ciation M,-ith fibroid lung. It is readily distinguished from enlargement due to bonv changes, such as those of acromegaly and pulmona.r\- osteoarthropathy. Minor degrees of clubbing of the fingers may occur with almost any disease that leads to persistent congestion of terminal parts, such as mitral stenosis, mitral regurgitation, emphysema, chronic bronchitis, pleurisy with effusion, empyema, chronic phthisis, some forms of aortic aneur\-sm, asthma, pericarditis, adherent pericardium, mediastinitis, or mediastinal neoplasm. In such cases, however, the clubbing has to be looked for — it does not thrust itself upon one's notice ; it may also pass away again when the cause is removed, for instance, when an empyema is cured by operation. CLUBBED FINGERS 129 Obvious and extreme finger-clubbing has only two main causes — con- genital heart disease with cyanosis (Fig. 31), especially pulmonary stenosis with or without a perforated interventricular septum ; and fibroid lung, especially if associated with bronchiectasis. The distinction between these two will generally be obvious. The former dates from infancy and is associ- ated with extreme cyanosis and a loud pulmonary systolic bruit and thrill ; the latter develops later in life, is seldom associated with such extreme cyanosis except when the patient is in extremis, and is accompanied by displacement of the heart and other signs of fibrosis of the lung, with or without bronchiectasis. Difficulty may arise in those rarer cases of congenital heart disease in which there is no bruit — cases, for instance, in which the heart gives off a single large vessel, the place of the pulmonary arteries being taken by intercostal vessels — Fig: 31. — Clubbed fingers in a case of congenital pulmonary stenosis with e.vtreme cyanosis. but even here the fact that the lividity is out of proportion to the dyspnoea, and the history that the cyanosis and the finger-clubbing date from soon after birth, afford immediate clues to the diagnosis. Congenital heart disease without cyanosis — patent ductus arteriosus for instance — does not give rise to clubbed fingers. In lung cases the diagnosis is either obvious from the physical signs ; or else, if the abnormal physical signs are so slight as by themselves to suggest little more than bronchitis, the existence of marked clubbing of the fingers is important evidence that the lung trouble is much more extensive than this, and that there is really much fibrosis, and probably bronchiectasis, too deep-seated perhaps to permit of the usual physical signs being detected at the surface of the chest. A moderate degree of clubbing of the fingers is sometimes observed in case's of cirrhosis of the liver, particularly in that type which begins as splenic anaemia — Banti's disease. This suggests that the changes in the finger tips have a chemical as well as a mechanical factor in their causation. Herbert French. D 9 I30 CLUB-FOOT OR TALIPES CLUB-FOOT OR TALIPES. — Any deformity of the foot not limited to the toes commonly goes under the name of club-foot or tahpes. The diagnosis of the dilierent forms of talipes is extremelv difhcult, owing to the number of causes and the compUcated nature of the deformities. It may be -well, therefore, to define briefly the chief varieties of simple deformity-. 1. Talipes Equinus. — In this condition the fore part of the foot cannot be raised to the normal degree. Any healthy adult is able, with the knee straight, to dorsiflex the ankle to such an extent that the baU of the great toe is two or three inches higher than the prominence of the heel. The degree of dorsiflexion is even greater in infants, but with advancing years the movement becomes hmited, so that old people may hardly be able to dorsiflex the foot beyond the right angle. 2. Talipes Calcaneus, — In this condition the heel is depressed and the fore part of the foot elevated. Extension of the ankle is Hmited, so that the fore part of the foot may not touch the ground in w-alking. 3. Talipes Valgus. — The foot is everted and abducted at the ankle joint, so that the inner malleolus is too prominent. '4. Talipes Varus. — The foot is inverted and adducted at the ankle joint, so that the outer malleolus is too prominent. In this condition, however, there is more serious deformity at the medio-tarsal joint, at which the fore part of the foot is adducted and inverted. (;). Talipes Cavus. — The arch of the foot is too high or hollow. This may be due to depression of the fore part of the foot, of the heel, or of both. Club-foot may be di^•ided into (I) The Congenital, (II) The Acquired. I. CoxGEXiTAL Talipes. Congenital tahpes is usually quite easy to diagnose, because of the history of the presence and the nature of the deformity- at birth. There are two chie varieties of it : (a) Equino-varus ; [b] Calcaneo-valgus. Sometimes the histor\" may be lacking or misleading, and the shape of the feet may have been so altered by treatment or neglect that it may be ver\- difficult to distinguish the condition from paralvtic tahpes, especially that due to paralysis of the lower neurone. In making the distinction it is important to remember that the shortening is usually ver\- much less in congenital cases, and that wasting of the muscles, apart from tight splinting, is also much less. Trophic ulcers, and cold and blue feet, which are common in cases of paralysis, do not occur in congenital talipes. Moreover, the toes are not h^^per-extended at the metatarso-phalangeal joints, a condition commonly present in paralytic talipes. The reaction of degeneration is not present in congenital cases, thus distinguishing it from tahpes due to comparatively recent paralysis of the lower neurone. The reflexes are not exaggerated, thus distinguishing it from talipes due to paralysis of the upper neurone. In congenital equino-varus the small conical heel is nor only raised but also turned inwards in a characteristic way, and it is generally separated from the inner aspect of the foot by a deep furrow. There is also a curious flattening on the outer side of the foot, just in front of the external maUeolus. where the skin is dmipled and loose. There is also a furrow on the inner side of the foot opposite the medio-tarsal joint. The varus is alwavs worse than the equinus, whereas in paralvtic cases the equinus is usually worse than the varus. With care the overstretched and therefore weak muscles can be shown to be capable of voluntary- contraction. II. Acquired Talipes. This condition may be subdi\"ided as follows: (i) The parah-tic, due to {a) Disease of the upper neurone ; (b) Disease of the lower neurone ; (c) Primary- muscular disease ; (2) Postural, e.g., talipes valgus ; (3) Due to fibrosis of CLUB-FOOT OR TALIPES 131 muscle, with retraction ; (4) Due to bone disease ; (5) Due to joint disease 6) Due to contracting scars ; (7) Due to hysteria. I. The Paralytic. — [a) In talipes due to destruction of the upper neurone the reflexes are exaggerated and the plantar reflex is extensor ; whereas in talipes due to disease of the lower neurone the reflexes are unchanged, diminished, or lost. Reaction of degeneration may be present with lesions of the lower neurone, and absent with lesions of the upper. Coldness and blueness of the feet are only common in lesions of the lower neurone, and the same is true of trophic ulcers. The shortening and wasting are generally much greater in lesions of the lower neurone, and the distribution of the paralysis is much more irregular than in those of the upper. When the disease of the upper neurone is in the brain, it is usual for the arm as well as the leg to be paralyzed (infantile hemi- plegia), or both feet may be symmetrically involved {congenital spastic para- plegia). Occasionally there may be a cerebral monoplegia. In any case the deformity due to disease of the upper neurone is almost characteristic, and is mostly equinus, usually with a little valgus, but occasionally with slight varus ; whereas when the lower neurone is affected the deformity is nearly always equino-varus or talipes valgus. In distinguishing various destructive lesions of the upper neurone, the history and the nature of the deformity may help. In hemiplegia or monoplegia there may be a history of difficult labour, with delivery by forceps, indicating injury to the cerebral cortex, or meningeal haemorrhage with secondary fibrosis of the motor area. The deformity may not be obvious for a year or more after birth, and it is usually first noticed when the child begins to walk. In other cases it may be due to thrombosis of the cerebral veins following measles or influenza, or to rupture of some of the cortical veins during whooping-cough or violent fits of passion. Congenital spastic paraplegia is distinguished by its symmetry, by the amount of spasm as shown by the unexpected degree of flexion of the ankles that can be produced by firmly pressing upwards the fore-parts of the feet. Moreover, there is usually some mental incapacity, and often the history of nervous disease in the family. When the lesion is in the spinal cord, there may be a history of spinal injury or the evidence of spinal caries, or of growth causing a spastic paraplegia. In amyo- trophic lateral sclerosis there are signs of paralysis and wasting of the upper limbs. Friedreich's disease^ or hereditary ataxy ^ is an occasional cause of talipes equinus or equino-varus. It can be recognized by the inco-ordination, the nystagmus, the slurring of speech, the age of onset, which is usually about six to nine years, the absence of knee-jerk, and the hallux erectus. {b). Lesions of the lower neurone may be in the cord (infantile paralysis), or in the Cauda equina (spina bifida), in the lumbo-sacral cord or sacral plexus (e.g., carcinoma of the rectum), or in the peripheral nerves (peripheral neuritis, injured sciatic nerve, or Tooth's neuro-muscular paralysis). Infantile paralysis results from acute anterior poliomyelitis, and is distinguished by its irregular distribution, reaction of degeneration, and its vasomotor and trophic lesions. It is frequently possible to show that the patient is unable to use certain muscles or groups of muscles, especially the anterior tibial and peroneal group. It is quite unusual for the paralysis to be limited to the leg ; the thigh is often affected to some extent, and often the opposite leg. It is important to examine for spina bifida ; talipes due to this is not necessarily symmetrical ; one foot may be involved more than another, and the deformity is often progressive. I have seen several cases of talipes calcaneo-valgus associated with it, and also pure cavus, and one very bad case of equino-varus of one foot, and equino-valgus of the other. The foot may drop in peripheral neuritis due to diphtheria, lead poisoning, or alcoholism. In each of these conditions there is other evidence of the disease. In many cases of growth in the pelvis the foot may drop owing to invasion of the 132 CLUB-FOOT OR TALIPES sacral plexus by the growth, which may be either sarcoma of the pelvis or carcinoma of the rectum. Wounds of the thigh, or the pressure of tight splints in the treatment of fracture, or the forcible extension of a contracted knee, may lead to paralysis of the sciatic nerve, especially of its external popliteal branch. This may lead to talipes equino- varus. A similar deformity may follow injury of the lumbar spine with secondary haemato-rhachis, or growth anywhere in the course of the sciatic nerve. I have known it follow the use of a Hodgen extension apparatus. Tooth's neuro-muscular paralysis (Figs. 8 and 9, p. 71) causes paresis of the anterior tibial and peroneal muscles, with talipes equino-varus and marked cavus, and deformity of the toes. It may be distinguished from infantile paralysis by the symmetrical affection of both feet, by the wasting of the thenar eminences, and the history of similar deformity in the family, and from the primary muscular dystrophies by the occurrence of reaction of degeneration. (c). Primary Muscular Disease. — In primary muscular paratysis (see Atrophy, Muscular) talipes may be developed late in the disease ; but as a rule the patients do not live long enough for the deformity to become a striking feature of their condition. The family history assists the diagnosis, and in the pseudo-hyper- trophic form there is the characteristic way in which the patient raises himself from the supine position by rolling into the prone position, and then lifting himself on his toes and hands, and working his hands up the fronts of the thighs. 2. Postural. — Acquired talipes valgus may be due either to posture or to paralysis of the tibiales muscles. When a patient attempts to adduct and invert the fore-part of the foot, the tendons of these muscles can be seen to stand out when they are not paralyzed. The foot may be forced into a cramped position by tight boots, and a form of talipes cavus may thus develop, with marked deformity of the toes, which are hyper-extended at the metatarso-phalangeal joints and flexed at the others. This condition must not be confounded with a similar one due to paralysis of the small muscles of the foot, especially of the interossei and lumbricales. 3. Fibrosis and Contracture of tlie Muscles of the Calf. — Very rarely the calf muscles may contract as a result of an ischaemia analogous to that occurring in the fore-arm, and leading to contracture of the wrist and fingers (Volkmann's contracture). The same condition may develop as a result of cellulitis of the calf muscles, often associated with compound fracture of the leg, or with acute necrosis of the tibia. In all these conditions it is important to prevent the development of talipes equinus. 4. Bone Disease. — Injury or inflammation of the tibia near the epiphysial lines in youth may lead either to arrest or over-growth of the affected bone. This is not uncommonly a cause of talipes, which can be recognized if care be taken to make comparative measurements and ;v-ray examinations of the bones. 5. Joint Disease. — In fractures into the ankle joint, such as Pott's and Dupuytren's fractures, a very bad form of talipes equino- valgus may form unless care be taken to correct the deformity and to keep the ankle moving. Talipes equinus may arise as a result of the maltreatment of sprains, and it may also follow arthritis of the ankle, either septic or tuberculous, unless care be taken to keep the joint dorsi-flexed during treatment. 6. Contracting Scars. — Occasionally talipes equinus follows severe burns or lacerations of the skin of the leg or foot. The diagnosis is usually obvious enough from the scars. There may be some wasting of the muscles from want of growth of the limb from disuse. 7. Hysteria. — Hysterical club-foot may be suspected from the associated symptoms and confirmed by the absence of any change in the electrical reactions, COLIC 133 by the variation of the deformity, and the disproportionate amount of spasm, which passes off during sleep and under an anaesthetic. Finally, it is to be remembered that if a normal muscle is left in one position over a long period with its points of origin and insertion unduly approximated, it may presently be found to be impossible to lengthen it out properly again ; it is in this way that contractures of muscles are apt to occur during the course of long febrile illnesses — enterica for instance — when the patient may remain curled up in bed for weeks. If the limbs are passively extended and flexed each day, no contracture results, but it sometimes happens that the neglect of this precaution is followed by persistent contracture of what had hitherto been normal muscles, and one of the likely results of this is club-foot. R. P Rowlands. COLIC. — This is a word often used verj- loosely for any severe abdominal pain which tends to wax and wane in intensity. Such pain may be associated with disease in almost any one of the abdominal viscera, and the word colic is actually applied quite commonly to the pain caused by the passage of a calculus down the bile-duct (biliary colic) or the ureter (renal colic). The name " mucous colic " is also used by some writers for the disease usually known as muco- membranous colitis. It is better, however, to restrict the term colic, used without a qualifying adjective, to pain caused by contraction of the intestine, of a cramp-like nature, caused bjr local irritation or by general poisoning, in the absence of any organic disease of the bowel. Diagnosis therefore mainly consists (i) In excluding such organic affections; and (2) In ascertaining, so far as possible, the cause of the local spasm. I. In order to exclude organic disease a careful examination of the whole abdomen is needed, as well as observation of the general condition of the sufferer. It must be remembered that in simple colic there may be vomiting, sweating, and some degree of collapse owing to the severity of the pain. The patient's temperature is not, however, usually raised ; the abdominal walls move freely on respiration ; and there is little or no local tenderness, pressure being often a relief to the pain, so that the sufferer tends to press his abdomen against a pillow or other support. Though the face exhibits an expression of pain, there is not the pinched, anxious facies so characteristic of grave abdominal troubles ; and the patient is likely to throw himself about instead of lying still as in such conditions as peritonitis or intestinal obstruction. The pulse is not often markedly affected : it may even be unduly slow, but in nervous subjects the anxiety and pain may cause some rise in its frequency. It will be convenient to enumerate the different affections which may give rise to abdominal pain liable to be called colic by patients. These are : Acute intestinal obstruction, intussusception, appendicitis, and possibly even perfora- tive peritonitis ; colitis and ulcerative diseases of the colon ; malignant disease of the intestine ; pancreatic disorders, acute and chronic ; gastric pain, especially that encountered in cases of pyloric obstruction ; intestinal neuralgia, and referred pains in spinal caries and in cases of pressure by tumours or aneurysms ; gastric and intestinal crises in locomotor ataxy ; and renal and biliary colic. Taking the diagnostic features separatel}' : — Rise of temperature above 100° F. will indicate the existence of some inflam- matory affection, such as appendicitis. The possibility of thoracic disease, such as pneumonia or diaphragmatic pleurisy, causing abdominal pain, must be borne in mind ; but such pain is not really colicky in character. (See Pain, Abdominal.) Vomiting that is repeated and severe does not occur in simple colic. It suggests the existence of intestinal obstruction, if the temperature of the patient 134 COLIC is normal or subnormal, or of some form of peritonits if there be fever. In the former condition, a faecal odour may be noted in the vomit ; in the latter, large quantities of fluid may be brought up with little effort ; but these signs occur late in the course of these conditions (see Vomiting). The colicky pains associated with gastric dilatation due to pyloric obstruction are likely to end with the expulsion of a large quantity of foul fermenting material. The dilatation of the stomach may be ascertained by noting the existence of splashing in the organ when the fingers are " dipped " sharply in the epigastric region ; by eliciting an increased area of tympanitic resonance ; by observing the peristaltic movements of the hypertrophied walls of the stomach, as seen by inspection of the abdomen ; by discovery in the vomit of food taken some days previously, as well as of organisms of fermentation (torulse and sarcinae), the vomited matter being generally foul and frothy ; and by examination with the AT-rays after exhibition of a bismuth meal. Tenderness and rigidity of the abdominal wall are usually absent in colic. When conjoined, they point to affection of the peritoneum ; tenderness alone indicates disease of some viscus, as in colitis, when it is found along the course of the colon, in intestinal or gastric ulceration, and so forth. Slight fullness of the abdomen may exist in cases of colic, but it is usually inconspicuous ; more often the abdominal walls may appear retracted. Con- siderable degrees of distention indicate some organic trouble, such as cirrhosis of the liver, intestinal obstruction, or peritonitis. A contracted portion of bowel may sometimes be felt in cases of colic. This must be distinguished from an actual tumour or inflammatory mass, and from the elongated swelling felt in intussusception. The spasmodically contracted gut of colic is of small diameter, and may be felt to relax as the pain subsides and to harden again with a fresh exacerbation. Constipation is the rule in patients suffering from colic, and if a motion is passed it is small and hard. The appearance of diarrhcea will point to some affection of the bowel, such as colitis. In mucous colitis, which is associated with severe pain, hard scybala may be passed along with casts of the intestine or large shreds of mucus. The rolls of this substance may resemble segments of tape-worm, but can easily be floated out if placed in water. The appearance of any blood per anum will show that something more than mere colic is present (see Blood per Anum). Intestinal neuralgia may be difficult to distinguish from colic, as both are alike functional disorders without organic disease. Neuralgia is likely to occur in an anaemic, ill-nourished person ; it arises without obvious exciting cause, and may recur at the same time of the day with some regularity. The pain has not the cramp-like character of colic, but is aching, boring, or darting. It is a very rare disorder. The gastric or intestinal crises of locomotor ataxy may be indistinguishable from colic, except by recognition of the other symptoms of the disease — absence of knee-jerks, with ataxy, and Argyll Robertson pupils. In children, who are specially liable to suffer from attacks of colicky pain due to indiscretions in diet, it is important to bear in mind the possibility of appendicitis, on the one hand, as a cause of abdominal pain, and on the other of Pott's disease, which may give rise to pain referred to the front of the abdomen. Examination of the spine in these latter cases may reveal the existence of rigidity and tenderness, and perhaps some prominence of one or more vertebral spines. Appendicular Colic This term is sometimes applied to attacks of pain in the right iliac fossa. Their association with disease of the appendix is doubtful. Appendicitis may subsequently ensue, but it is as likely that the original attacks COLIC 135 may have been due to colitis (typhlitis), which afterwards spread to the appendix, as that this organ was at fault throughout. Unless the signs of appendicitis are present — pain, vomiting, fever, tenderness and rigidity of the muscles in the right iliac fossa — the condition cannot be recognized with certainty. In all cases of doubt as to the cause of colicky pains, an examination per rectum is advisable ; it may reveal the presence of inflammation in the appendicular region, or of an intussusception, in quite unsuspected cases. Biliary Colic. — The passage of a calculus down the bile-ducts gives rise to severe and even agonizing pain in the right hypochondrium. It is of a colicky character, but it is apt to be more intense than that of simple colic. It may be accompanied by vomiting, sweating, and collapse. Shivering is frequently seen, and if present is suggestive of this trouble. The pain is likely to pass round into the right side and to the angle of the right scapula ; it may even be referred to the tip of the right shoulder. If the calculus lodge in the common bile-duct, jaundice will result. Its depth will vary with the degree of obstruction, and while the colic lasts it is not likely to be very intense. Palpable enlargement of the gall-bladder is quite exceptional in cases of gall-stones. Actual proof of the cause of the colic may sometimes be obtained by finding a stone in the faeces, which may be done by passing them through a coarse sieve, under a current of water. Attacks of gall-stone colic are liable to recur, and a history of previous illness of the same kind may aid in the diagnosis. Women are rather more subject to gall-stones than men, and fat subjects suffer more than thin. The malady is most often encountered in middle life. Pancreatic Colic, due to passage of a calculus along one of the ducts of the gland may occur, but can scarcely be diagnosed. It is characterized by severe, deeply seated pain in the epigastrium, sometimes extending to the back and loins. Exactly similar attacks of pain occur in chronic pancreatitis, and may be accompanied by shivering, or actual rigors. Intense jaundice may also be seen in this malady, and an enlarged gall-bladder can usually be felt. The condition can only be recognized when there are present other signs of pancreatic disease — wasting, pigmentation of the skin, and the passage of bulky, offensive stools, containing large quantities of fat. Chemical examination may show that much of this fat is neutral (unaltered) fat, with less than the usual proportion of fatty acids (p. 116). Microscopical examination may reveal the presence of unaltered meat-fibres in the motions. The urine may contain sugar, and Cammidge's Test (q.v.) may be applied to it, though the trustworthiness of this reaction is not yet established. Renal Colic. — The distinguishing features of the passage of a calculus down the ureter are similar to those of biliary colic, but the pain starts in one loin and radiates downwards to the thigh and to the testicle in the male, to the labium majus in the female. The urine may contain blood, and also epithelium from the pelvis of the kidney and from the ureter. Frequency of micturition is often marked, but the quantity of urine may be small ; it may even be temporarily suppressed. If the calculus become impacted in the ureter, a swelling may subsequently appear in the loin, due to the formation of a hydro- nephrosis. The pain may cease suddenly when the stone passes into the bladder. The ;\;-ra3^s are of considerable value in detecting the concretion, provided the bowels be empty so that shadows due to scybala can be avoided. The pain due to the presence of a calculus in the kidney can hardly be mistaken for colic, but occasionally the symptoms of this condition may precede an attack of renal colic. A history, therefore, of pain in the loin, frequency of micturition, and the appearance of blood in the urine, may help in the diagnosis of the latter condition. Tuberculous disease of the kidney, in which the symptoms may be very similar, though apt to be accompanied by more wasting and by evening 136 COLIC pyrexia, may give rise to colicky attacks if blood-clots or caseous masses lodge in the ureter. Pus and tubercle bacilli may be found in the urine. 2. A diagnosis of the cause of the colic is also necessary. Its principal causes are indigestible food, alcoholic excess, and lead-poisoning. This last should be eliminated first. It is characterized by the great severity of the pain, by the obstinate constipation which accompanies it, by the anaemic appearance of the patient, and by the presence of a blue line along .the margin of the gums, though the absence of the blue line in a patient whose teeth and gums have been kept clean does not exclude plumbism. Lead may be found by chemical examination of the urine, but usually only in minute traces. There will usually be a history of some occupation involving contact with lead — painting, glazing, type-setting, or manufacture of some compound of lead ; but the possibility of poisoning by drinking-water or by beer which has stood in contact with leaden pipes must be remembered — the latter especially in potmen. The part played by alcohol in inducing colic can only be inferred from the appearance of the patient and such signs as tremor of the hands, furred tongue, pharyngitis, and so forth. In cases due to indigestible food, a history of the consumption of fried fish, shell-fish, pork, raw fruit, or other suspicious matter may be obtained. The pain is more likely to move along the course of the colon than to remain fixed in the centre of the abdomen or at some special point, as it usually does in lead colic. In infants, colic may be caused by hard curds of milk, and be indicated by drawing up of the legs and screaming. In older children, unripe apples, plum-stones, and similar delicacies are often the source of the trouble, and fruit-stones may be discovered subsequently in the motions. w. Cecil Bosanquet. COLOUR BLINDNESS.— (See Vision, Defects of.) COMA is a state of unnatural,' heavy, deep and prolonged sleep, often accom- panied by slow stertorous or irregular breathing, and frequently ending in death. It may be due to a large number of different causes, which may be classified into two main groups, nam.ely : {A) Cases in which coma is not a prominent symptom early in the malady, but only in a late stage, when the nature of the disease has already been suggested by other symptoms ; and {B) Cases in which coma comes on early and may be the most prominent feature of the case. Group A includes — 1. Certain Severe Fevers in which coma may occur as a terminal phenomenon : Typhus fever Yellow fever Typhoid fever Blackwater fever Cholera Malignant malaria. Dysentery I 2. Acute Inflammatory Lesions of the Brain or the Cranial Meninges : Suppurati\'e meningitis Epidemic cerebrospinal menin- Tuberculous meningitis [ gitis, or spotted fever Posterior basal meningitis ! Acute encephalitis. 3. Certain Less Acute Lesions of the Central Nervous System : Cerebral tumour Cerebral abscess Post-epileptic state General paralysis of the insane Disseminated sclerosis Syphilis of the brain. 4. Diseases in which General Metabolism is probably at fault : Uraemia Diabetes Cholaemia Addison's disease Raynaud's disease. COMA 137 Group B includes the following conditions — The Results of Head Injury : Concussion j Compression by meningeal hsemorrhage | Vascular Lesions of the Brain : Embolism Haemorrhage Depressed fracture Fracture of the base skull. of the The Acute Effects of Drugs, particularly : Alcohol Carbon monoxide Thrombosis : (a) arterial, (fo) of a venous sinus such as the superior longitudinal. Trional Tetronal Bromides Chloroform and other anaesthetics. 6. 7- Excessive cold. Duodenal bleeding Intestinal bleeding Ruptured aneurj'sm. Opium Absinthe Morphia Chloral hydrate Carbolic acid Veronal Oxalic acid Sulphonal The Chronic Effects of Drugs or Chemicals, especially plumbism leading to : Saturnine encephalopathy. The Effects of Extremes of Temperature : Heat stroke | Excessive Loss of Blood from : Ruptured tubal gestation ' Post-partum haemorrhage Haemoptysis 1 Haematemesis I Hysterical Trance. Although it is generally possible to make a broad distinction betAveen the two groups enumerated above, it is necessary perhaps to point out that some con- ditions which usually give rise to other symptoms before they produce coma, sometimes pass unrecognized until coma supervenes. This apphes, for example, to certain cases of diabetes mellitus, uraemia, suppurative meningitis, or cerebral abscess or tumour ; whilst, conversely, some conditions which usually exhibit coma early, may not do so until after there have been other symptoms to indicate the nature of the case. It is not necessary to enter into the differential diagnosis of those conditions in which other prominent symptoms have preceded coma. When coma is either the first or the most prominent sj'mptom in the case, however, it is very important to arrive as near the correct diagnosis as may be at the earliest possible moment, for any given case is to be relegated to one or other of the following four classes, which differ from one another radically as regards treatment : — 1. Cases in which immediate trephining is required, for instance for meningeal haemorrhage. 2. Cases in which active treatment by lavage of the stomach or bj- the administration of antidotes is required, as in opium or other poisoning. 3. Cases in which active medicinal or phvsical treatment is required : for instance, diabetic coma requiring the administration of alkalies, or uraemia requiring venesection, and so forth. 4. Cases in which absolute rest is indicated, especialh' in cerebral haemorrhage. When investigating a case, notice first whether there is any evidence of unilateral paralysis : the pupils may be markedly unequal, one cheek may be more puffed out on expiration then the other, one arm or leg may fall more hmply than the other ; there may be differences between the two knee-jerks or the two plantar reflexes. There may be conjugate deviation of the eyes. If there is 138 COMA distinct evidence of unilateral paresis or paralysis, there is almost certainly a cranial or intracranial lesion, either haemorrhage, embolism, fracture, tumour, abscess, or thrombosis. Next, examine the head with particular care to see if there are any signs of injury ; the presence of a scalp wound or even of a fracture does not of course prove that this is the primary cause of the coma, for the patient may have become unconscious, from a cerebral hsemorrhage for example, and in falling may have struck his head, in which case the injury is due to the coma, and not the coma to the injury. Some of the very greatest difficulties in diagnosis arise on this account, particularly when the patient has previously taken sufficient alcohol for his breath to smell of it, and to suggest that he is drunk. Careful observation for several hours may be required before the diagnosis can be settled, and even then errors are sometimes unavoidable. A clear history is generally lacking, but if it is available it often assists materially in deciding the nature of the case. The ears and nose should be examined with particular care to see whether cerebrospinal fluid or blood is coming from either, as an indication that there is a fracture at the base of the skull ; and blood coming forward into the subconjunctival tissue may afford evidence in the same direction. Cerebral hcBmorrhage is much more common in an elderly than in a young person, whilst the reverse is true of embolism. The latter may occur instantaneously, whilst haemorrhage produces coma rather more gradually ; and thrombosis, syphilitic or otherwise, often leads to hemiplegia so gradually that no coma occurs. The presence of albuminuria with casts, with a high blood-pressure as measured instrumentally ; the history, in an elderly man, of ajprevious seizure of a similar kind with definite hemiplegia, especially if there is also an enlarged heart with a lumpy first sound at the impulse, or perhaps a local systolic bruit there, and soft systolic aortic bruit with a ringing aortic second sound, would all indicate cerebral haemorrhage, associated with defective arteries and perhaps with granular kidney. Albuminuric retinitis should be looked for. Strong evidence in favour of cerebral embolism would be afforded by a previous history of acute rheumatism and the existence of a presystolic or other bruit indicative of organic mitral or aortic disease, especially if there has been any pyrexia, progressive anaemia, enlargement of the spleen, infarction elsewhere, or a tendency to purpura, epistaxis, or other bleeding suggesting that fungating endocarditis has developed upon the top of a chronic valvular lesion. Supposing there is no evidence of a unilateral paralysis, it does not immediately follow of course that none of the above conditions are present ; one form of cerebral haemorrhage in particular that may cause no unilateral paralysis is pontine hcBmorrhage ; this might be suggested at once by the very small, almost pin-point pupils, though similar pin-point pupils may be due to opium poisoning. The thermometer affords a means of diagnosis between these, for opium poisoning leads to a subnormal temperature, whilst haemorrhage into the pons Varolii rapidly causes the temperature to rise even to the point of hyper- pyrexia. The diagnosis of other varieties of coma due to poisoning can seldom be arrived at accurately unless the circumstances of the case either allow of an analysis of the gastric contents, or else point to the patient having ta,ken an over-dose of one of the drugs mentioned in the above list, either accidentally or with suicidal intent. The bottle may be found near the patient. Coma due to poisoning by carbon monoxide is generally obvious at once ; the patient has a peculiar bright cherry-red colour ; it is impossible to convert the carboxyhaemoglobin in his blood into reduced haemoglobin by the ordinary ammonium sulphide method ; and there is generally direct evidence of the mode of poisoning, such as the fact that the patient is found in a room with the COMA 139 windows shut and the gas turned on, or has been subjected to the fumes of slow combustion from a stove, brazier, limekiln, or some other fire which has been burning with an insufficient supply of oxygen. Saturnine encephalopathy is very variable in its symptoms ; it may take the lorm of epileptiform convulsions ; more or less dementia ; continued coma ; acute mania ; indeed, its multiformity is one of its chief features. The occupation of the patient may point to the diagnosis forthwith in some cases, or there may be a blue line upon the gums or other signs of lead poisoning. Not infre- quently, however, the nature of the case gives rise to much perplexity before the diagnosis is ultimately made. One method of arriving at the latter is to collect an abundance of urine, evaporate it to dryness, and apply the tests for lead to the residue. The case is apt to be mistaken for either cerebral haemor- rhage, cerebral tumour, or general paralysis of the insane. Optic neuritis may be directly due to plumbism, and this makes the differential diagnosis still more difficult, unless there is clear collateral evidence of lead poisoning. Coma due either to heat stroke or to exposure to excessive cold is generally indicated by the collateral evidence, especially as regards the temperature of the patient's surroundings, or his having been exposed to very strong sun's rays when at work. The chief difficulty will be to make certain that there is not any vascular lesion of the brain. When there is doubt, the course of the case may, however, indicate its nature, heat-stroke generally recovering rapidly, or ending fatally with hyperpyrexia ; but sometimes, even in a fatal case, the diagnosis may remain in doubt until a post-mortem examination has been made. Acute encephalitis is a disease of children rather than of adults ; its general symptoms are those of acute meningitis ; the patient becomes unconscious more rapidly, however, than is usual with the latter, and yet, notwithstanding the apparent severity of the illness, recovery may occur, either within a few days or a week or two. The diagnosis rests upon the course and recovery, for in the earlier stages it will nearly always have been regarded as acute meningitis. The same applies to acute thrombosis of the superior longitudinal sinus, the diagnosis between which and acute encephalitis or meningitis, is generally one of opinion only, unless operative measures are resorted to, or a post-mortem examination made. Optic neuritis, as well as headache, vomiting, and general convulsions, occur in all three. General paralysis of the insane does not as a rule give rise to coma and epilepti- form convulsions until the nature of the case has already been indicated by the mental and physical changes — particularly the ideas of grandeur, the loss of highest cerebral control in one way or another, the changes in disposition, and the inability to perform the finer movements required for writing, dancing, playing the piano or violin, painting, and so forth, in which the patient may at some time previously have been an adept. Occasionally, however, notwith- standing some alterations in the mental character, the diagnosis of general paralysis may not have entered one's mind in a given case until a sudden syncopal seizure, with or without convulsions, attracts particular notice to it. It is not impossible that such a case may even then be mistaken for one of severe cerebral haemorrhage, and it may be treated as such until it is found that the coma, severe though it may have been, rapidly passes off in a way that would not have been the case had it been a haemorrhage of corresponding severity. The recurrence of these attacks will make the diagnosis certain, even if it remains in doubt for a time, and it is stated that examination of the cerebrospinal fluid for excess of small lymphocytes or for Wassermann's serum reaction will serve to clinch the diagnosis in most cases. Severe hcemorrhage other than cerebral as a cause for coma is usually indicated at once by the sudden extreme blanching, not only of the patient's cheeks, but I40 COMA also of his lips and mucous membranes. The pulse-rate rises to loo, 120, or even 150, according to the amount of blood that has been lost ; if there has been external evidence of the haemorrhage, the differential diagnosis will be arrived at as discussed under such headings as H.^matemesis, Hemoptysis, Metrorrhagia, etc. If the bleeding has been internal in a healthy person, the commonest cause is duodenal ulcer in a man, pelvic hasmatocele or ruptured tubal gestation in a woman ; similar blanching in cases of typhoid fever would point to intestinal bleeding. The coma in such cases comes on suddenly, but it does not long remain profound. It is often preceded by amaurosis, and may be accompanied by epileptiform convulsions, so that acute urjemia may be simulated. When an aortic aneurysm ruptures either into a bronchus, the oesophagus, trachea, stomach, or bowel, the amount of blood-loss seldom leads to coma, but rather to sudden death ; sometimes, however, when the bleeding is into some closed space such as the mediastinum or retroperitoneal tissue, the blood-escape is checked to some extent, and acute blanching with coma precedes further bleeding and death. Rupture of an aortic aneurysm into the pericardium causes sudden death before the amount of blood lost has been sufficient to produce marked blanching. Hysterical or functional trance is an affection of young women, and it is not very common ; the diagnosis is arrived at by a process of exclusion, and until the case has been watched for some time, its nature may not be obvious, unless there have been other hysterical symptoms previously. It is a dangerous diagnosis to make until every other possible cause for coma has been considered and satis- factorily excluded, for it is not difficult to jump to the conclusion that coma in a girl or young woman, really arising perhaps from a cerebral tumour or abscess, is due to a neurosis. It is most important to examine the optic discs with great care, lest there should be optic neuritis, the latter never being functional. Herbert French. CONJUNCTIVITIS. — (See Eye, Acute Inflammation of.) CONSTIPATION I.— CHRONIC CONSTIPATION. In normal individuals the indigestible residue of a meal reaches the descending colon in less than sixteen hours, and in defaecation all the contents of the large intestine beyond the splenic flexure are excreted. Consequently some of the residue of a meal taken eight hours after defsecation should be excreted at the next defaecation in individuals whose bowels are opened every twenty-four hours. If, however, the bowels are only opened on alternate mornings — a condition which is not necessarily pathological — forty hours instead of sixteen would elapse before some of the residue of the meal would be excreted. Constipa- tion may therefore be defined as a condition in which none of the residue of a meal, taken eight hours after defcecation, is excreted within forty hours. In doubtful cases constipation thus defined can be recognized by giving three charcoal lozenges with some food eight hours after defaecation ; if a blackened stool is not passed within the next forty hours, the patient must be regarded as constipated. The abnormal action of the bowels in constipation may manifest itself in three different ways : — 1. DefcBcation may occur with insufficient frequency. A daily action of the bowels is merely a matter of convenience, and many people in perfect health only defaecate once in two or three days. As a rule, however, an individual may be regarded as constipated if his bowels are not opened at least once in forty-eight hours. 2. The stools may be insufficient in quantity and a certain amount of fcBces is retained, although the bowels may be opened once daily or more often. This condition CONSTIPA TION 141 (cumulative constipation) can be differentiated readily by the charcoal test from that in which the bowels are properly emptied, but the faeces are very small in quantity owing to the diet or to the unusually active absorptive power of the intestines. 3. The bowels may be opened daily, yet the fcsces are hard and dry, owing to prolonged retention before excretion ; the deficient quantity of water in the stools also renders them less bulky than normal. The stools may be similar in character when an excessive quantity of fluid is lost by other channels, as in diabetes. By means of the charcoal test it is easy to determine whether con- stipation is also present. After the diagnosis of constipation has been made, it is necessary to determine its cause. The first essential is to distinguish between two great classes of constipation : that in which the passage through the intestines is delayed, whilst defaecation is normal — Intestinal Constipation ; and that in which there is no delay in the arrival of faeces in the pelvic colon, but their final excretion is not adequately performed — Pelvi-rectal Constipation or Dyschezia. A. — Diagnosis between Intestinal Constipation .^nd Dyschezia. A rectal examination should be made in the morning, after an attempt has been made to open the bowels without the assistance of medicine, enemata, or suppositories. If more than a very small quantity of faeces is found in the rectum, dyschezia may be diag- nosed. If the rectum is almost or quite empty, the constipation must be due to delay in the passage through the intestines, except in the uncommon cases of dyschezia in which there is inability to pass fasces from the pelvic colon into the rectum. The latter condition can be recognized on rectal examina- tion, if the pelvic colon is felt through the front wall of the rectum to be filled with solid faeces ; the presence of faeces in the pelvic colon can also be proved if a sigmoidoscopic ex- amination is made at once with out further preparation of the patient by washing out his bowels. At the same time the abdomen should be palpated. If scybala are felt in any part of the colon, intestinal constipation must be present. This is, however, not necessarily the case if faeces are felt in the iliac or pelvic colon, as the rectum in dyschezia may be so full of faeces that retention occurs secondarily in the pelvic colon and rectum ; such a condition would be recognized by the rectal examination. When a patient feels that there is something in his rectum which he cannot Fi^: 32. — Habitual Constipation. Twenty-four hours after bismuth breakfast. No bismuth has reached beyond the first two inches ot the transverse colon. Subsequent examinations showed that a similar delay occurred along the whole of the large intestine. 142 CONSTIPA TION expel at all, or that after defgecation the relief is incomplete, dyschezia is probabl3' present. The absence of this symptom does not exclude the possibility of dyschezia, as the rectum is often so insensitive in such cases that no sensation is experienced, even when it is filled tightly with faeces. The frequent passage of very small pieces of hard faeces (fragmentary' constipation), or the occurrence of pseudo-diarrhoea — in which small fluid stools, sometimes containing hard fragments of faeces, are passed, although the charcoal test shows the presence of constipation — are both symptoms suggestive of dyschezia. Some indication, which is not, however, absolutely reliable, can be obtained from the results of previous treatment. Patients, who have found that diet and mild aperients readily give them relief, are probably suffering from intestinal constipation. Those who have obtained better results with enemata, and particularly with suppositories, probabl}^ have dyschezia. Dyschezia is of course also present in those patients who have to dig out the faeces from the rectum with their fingers. Examination with the x-rays is the only method by which the two classes of constipation can be separated with absolute certainty, and by which the predominant condition can be discovered in cases in which both are present together. Two ounces of bismuth oxychloride mixed with porridge or bread and milk are taken at breakfast, and observations are made at intervals during the next two or three daj^s of the shadow produced on the fluorescent screen. The colon should be emptied as completely as possi- ble by aperients and enemata for two or three days before the examination, and if the bowels have not opened naturally on the morning of the bismuth breakfast, an enema should be given at once. During the period of observation no aperients or enemata should be given, and the patient should be allowed to continue his usual occupation and to take his ordinary diet, in intestinal constipation, delay is observed in the passage through some part or all of the colon, and occasionally the small mtestine ; in dyschezia there is no delay in the intestines, but the act of defaecation does not empty the pelvic colon and rectum completely {Figs. 32, 33). B. — Diagnosis of the Cause of Intestinal" Constipation. Intestinal constipation may be due to (i) The motor activity of the intestines being deficient ; or (2) The force required to carry the fcBces to the pelvic colon being excessive. In the first group of cases aperients are generally much more effective than in the second ; in the latter there may be a history that Fig. 33. — Dyschezia. Twenty-four hours after bis- muth breakfast. All the bismuth has collected in the dilated pelvic colon and rectum, except traces which remain in the transverse colon. In spite of this the patient felt no desire to defeecate. CONSTIPA TION 143 purgatives are producing less effect than formerly, or that they now completely fail to act, but that enemata still give a more or less satisfactory result. The increased activity of the intestines in their attempt to respond to the excessive demands in the second class often leads to colic. I. Deficient Motor Activity may be due to : — • (a). Weakness of the Intestinal Musculature (Atonic Constipation). When constipation has existed from infancy, especiall}'' if it is present in several members of the family, it is likely to be due to congenital hjrpoplasia of the intestinal musculature. Constipation developing gradually as old age is approaching, is generally due in part to senile intestinal hypoplasia. When constipation occurs in chlorotic girls, in cachectic conditions, in rickets, and in fevers, it may generally be assumed to be due to weakness of the intes- tinal musculature, secondary to these conditions. When the abdomen is constantly distended and tympanitic, and the patient complains of attacks of colic, which are relieved by the passage of flatus, it may be assumed that the constipa- tion is due, in part at least, to the incapacitating effect of distention on the intestinal musculature. The Flatu- lence (q.v.) may be primary, or it may be secondary to the constipation, in which case some other cause of the con- dition must be looked for. The constipation of fat people is due in part to the inefhciency of the intes- tinal musculature resulting from fatty infiltration. In all these conditions the atony of the colon can be recognized with the ;ir-rays by its abnormally large lumen in addition to the slow pass- age of faeces {Figs. 34 and 35). (b). Deficient Reflex Activity of the Intestines. Insufficient Stimulation of Intestinal Movements. — Careful enquiry should be made into the patient's diet and habits, as many cases are due to too little food being taken, or to the food containing too little mechanical or chemical peristaltic stimulants, and some are due to deficient exercise. Other cases result from a " greedy colon," the absorption of food being unusually complete. In spite of enough food of a sufficiently stimulating character being taken, and in spite of the fact that the abdomen is retracted and no accumulation of faeces can be felt in either the colon or the rectum, yet a very deficient quantity of faeces is excreted. This is the type of case in which benefit results from the use of agar-agar or petroleum. In constipation due to an unsuitable diet or to a greedy colon, the stools are generally small, dark, and dry, and smell less strongly Fig-. 34. — Diagram of the normal large intestine. The numbers represent the hours after a bismuth breakfast at which the different parts of the colon are reached. C, Ca;cum ; AC, Ascending colon; HF, Hepatic flexure; SF, Splenic flexure ; DC. Descending colon ; IC, Iliac colon ; PC, Pelvic colon; R, Rectum; U, Umbilicus; P, Pelvis. 144 CONSTIPA TION than normal. In oesophageal and pyloric obstruction constipation is always present owing to the small quantity of food-residue which reaches the colon. The other symptoms generally prevent a mistake in diagnosis being made ; but occasionally in pyloric obstruction the patient complains of nothing but some slight indigestion or weakness in addition to the constipation. The passage of a stomach-tube twelve hours after a large meal, when the stomach should be completely empty, and an ;i;-ray examination, will clear up the diagnosis in doubtful cases. Deficient Sensibility of the Intestinal Mucous Membrane. — This is the probable cause of the constipation when there is a history of excessive tea-drinking or of the long-continued use of large doses of aperients ; it is also partly respon- sible for the constipation associated with catarrhal colitis — in which excess of mucus is passed with the stools — whether this is primary or a result of constipa- tion of other origin. Depression of the Nervous System. — In neurasthenic, hypochondriac, and insane patients, the condition of the nervous system is the chief cause of the constipation which is almost invariably present ; but an improper diet is gener- ally an additional factor. (c). Inhibition of the Motor Activity of the Intestines. This group of cases can often be recognized by the fact that sedatives, such as opium and belladonna, give relief, whilst purgatives are required in un- usually large doses, and pro- duce an unusual amount of colic unless given with a seda- tive. The x-rays show that the small intestine as well as the colon is traversed slowly ; this is unusual in other forms of constipation {Fig. 36). In- hibition may be direct, central, or reflex. Direct Inhibition in Dead Poisoning. — The diagnosis is siTggested by the occupation of the patient, a blue line on his gums, the presence of anaemia and sometimes of arteriosclerosis and granular kidney, or a previous history of colic or lead palsy. Central Inhibition. — A history of a recent shock, annoj'ance, or worry is obtained. Reflex Inhibition. — Constipation is a frequent symptom of painful diseases of abdominal and pelvic viscera, other than the intestines themselves. It can then be cured only by treating the primary condition, so that it is essential to ascertain the cause of the pain. Constipation is particularly liable to result from disease of the vermiform appendix, female genital organs, stomach, duodenum, and gall-bladder. {d). Irregular Spasmodic Contraction of the Intestine: Spastic Constipation : Enterospasm. When constipation is associated with pain, especially if the pain comes on in P'g- 35. — Post-dysenteric atony and paresis of the colon. Compare the lumen of the colon and the slow passage of feeces through it with Fig^. 34. CONSTIPA TION 145 attacks, during which the difficulty with the bowels is increased, the possibility that it is due to spasm of the colon must be considered. The pain is situated in the course of the large intestine, most frequently in the iliac and pelvic colon, but occasionalh' in other parts. The affected parts of the colon can generally be felt as a contracted, tender cord, in which scybala may be detected and the narrow lumen can be recognized with the ;v-ray3 [Fig. 37). When the pain is in the right iliac fossa, appendicitis may be simulated ; the long duration of the attacks without any p}"rexia, the occasional his- tory of similar pain on the opposite side, and the contracted condition of the ascending colon and sometimes of the caecum (though in other cases the csecum may be distended and tympan- itic), are distinctive features of spastic constipation. When the pain is in the left side, a tumour of the descending or iliac colon may be suspected : the long history, the absence of visible or palpable peristalsis and of dis- tention above the contracted part, and the absence of occult blood from the stools, are points which distinguish spastic constipation from cancer of the colon. In cases of spastic constipation the stools should always be examined for the presence of mucus, as the spasm, especially when it occurs in neurotic women, is often only a symptom of muco- membranous colitis, shreds or membranes of coagulated mucus being passed by the patient. 2. — Constipation due to Excessive Force required to carry the f.^ces to the Pelvic Colon may be due to : [a). Obstruction by Faeces. Dry, hard f^ces, which re- quire abnormally strong peri- stalsis to carry them to the pelvic colon, result from : (i) Insufficient consumption of water — a common cause of con- stipation in women ; (ii) Ex- cessive loss of water by other channels — one cause of the constipation of diabetics, and a possible cause in individuals who perspire freely and are only constipated in hot weather. J'/g^. 36. — Constipation due to lead poisoning. The passage through the small intestine as well as the colon is slow, owing to the inhibitory action of the splanchnic nerves. ■FiS^. 37. — Constipation with muco-membranous colitis, showing spasm of descending and iliac colon. 146 CONSTIPA TION (b). Narrowing of the Intestinal Lumen. Organic stricture. Unless this is due to a palpable tumour, it may be very- difficult to distinguish from constipation due to less serious causes. More or less colic is generally present, and its situation often gives a clue to the localization of the obstruction. An ^r-ray examination should be made : the shadow of the colon is soon visible as far as the seat of the obstruction, beyond which no bis- muth passes for a considerable time. Sometimes the actual narrowing of the intestine can be observed {Fig. 38). Non-malignant strictures of the colon are rare. If there is a history of tuber- culous or dysenteric ulceration, the possibility of obstruction due to cicatrization should be considered, though this is a very unusual occurrence. Hyperplastic tuberculous infiltration of the intestine, especially of the caecum, causes obstruction, but the tumour present is clinically indistinguishable from cancer. Obstruction to the iliac or pelvic colon may follow the pericolitis which results from the formation of diverticula in old people who have long suffered from constipation. This condition may also be indistin- guishable from a growth, but the possibility should be borne in mind in the case of elderly patients with a tumour in the iliac or pelvic colon, where there is a long history of constipation : the sigmoidoscope may help in the diagnosis. If a vesico-colic fistula develops in association with chronic constipation, it should be remembered that pericolitis • due to ulceration of diverticula is a more frequent cause of this condition than cancer. Organic stricture of the colon is most commonly due to cancer. The possibility of cancer should always be considered when an individual above the age of forty, whose bowels have been regular previously, develops constipation of increasing severity without change of diet or habits, or when a patient, who is habitually constipated, becomes more so without obvious reason. The con- stipation is at first intermittent and may alternate with diarrhoea ; drugs become steadily less effective, and enemata, which at first give greater relief than drugs, also lose their effect slowly. A tumour is palpable in less than half the cases ; it may vary in size, and even disappear after the bowels have been opened well, because a mass of faeces may become impacted above a cancerous stricture which is itself impalpable. Hence, although the presence of a tumour is an important aid in diagnosis, its absence or disappearance does not exclude the possibility of cancer ; only when its disappearance under treatment is accom- panied by complete and lasting cure of all symptoms, can cancer be excluded. /•'/X. • . — ^l.iaLjr.Lin showing incomplete intestinal obstruction, due to cancer of ascending colon. Taken nine hours after a bismuth meal. C, Caecum; T, The palpable tumour, marked out with a wire placed on the patient's abdomen ; AC, Strictured ascending colon ; TC, Transverse cqlon ; A, Appendix, which is rarely seen so clearly; U, Umbilicus, marked by a coin; IC. Iliac crest. Skiagram by Dr. A. C. Jordan., reproduced by permission from "The Archives of the Roentgen Ray." CONSTIPA TION 147 The tumour is hard, and cannot be altered in shape by pressure, as is the case with fascal tumours. Slight attacks of colic occur frequently, but they are not often severe until the obstruction is almost complete ; the colic may be accom- panied by visible and palpable peristalsis and spasmodic contractions of the intestine. The latter is a most important sign, as it never occurs in colic associated with lead-poisoning or colitis, and very rarely with obstruction due to fsecal impaction. Progressive loss of weight and strength, anorexia, and anaemia are late -symptoms, and it is important to make a correct diagnosis before they have appeared. The obvious presence of blood in the faeces is an important symptom, but it is often absent. Much more frequently traces are found which are only recognizable by chemical tests. In the absence of haemorrhoids and of haemorrhage from the mouth, throat, or nose, the presence of " occult " blood in the fasces is strong evidence that ulceration is present in the stomach or intestines ; when symptoms pointing to gastric or duodenal ulcer and gastric carcinoma are absent, and constipation is present, a suspicion of cancer of the intestine receives important confirmation. In doubtful cases a sigmoidoscopic examination should be made, as cancer is much more com- mon in the rectum and pelvic colon — which alone can be investigated by this method — than in any other part of the intestine. A kink of the colon is a very unusual cause of consti- pation. It is sometimes partly responsible for the constipa- tion which is almost always present in visceroptosis [Fig. 39), and it should be suspected when an attack of localized peritonitis, due particularly to disease of the female genital organs, appendicitis, or leak- age from a gastric or duodenal ulcer, is followed by constipa- tion. An x-r2t.Y examination should, however, always be made before advising surgical interference, as, in the vast majority of cases, even if adhesions are present they have nothing to do with the obstruction. The ;ir-rays show whether the delay takes place in the neighbourhood of the supposed adhesions, and the presence or absence of adhesions can also be ascertained by seeing how movable the colon is, and whether the two limbs of the various flexures can be separated from each other. Whatever may be the primary cause of Hirschsprung' s disease (wrongly called "congenital idiopathic dilatation of the colon"), it is probable that a kink is produced after the dilatation has reached a certain degree by the over- hanging of the dilated part of the colon over the undilated section {Fig. 40). There is always a history of constipation dating from the first few months of life, although sometimes the bowels may be opened daily but insufficiently. Soon after birth the abdomen becomes greatly enlarged, the size varying from Jiig;. 39. — Skiagram taken by Dr. A. C. Jordan, showing ptosis of csecum and transverse colon. 148 CONSTIPA TION time to time. The outline of the distended colon can be seen, and peristalsis is often visible. The abdomen finally becomes enormous ; it is then tense and tympanitic. Attacks of obstruction are liable to occur, and death takes place most frequently between the ages of three and eight. When a large abdominal tumour is present, constipation may be produced by its pressure on the colon. Chronic intussusception may give rise to symptoms similar to those produced by a stricture ; attacks of colic accompanied by visible peri- stalsis occur with increasing frequency and severity, and they are often brought on by food or aperients. An intussusception should be sus- pected under these circumstances when a sausage-shaped tumour is palpable, especially if blood and mucus are passed at frequent inter- vals. In one-third of the cases, the apex of the intussusception can be felt on rectal examination. Pi^. 40. — Colon in a case of Hirschsprung's Disease. AC, Ascending colon ; TC, Transverse colon; DC, Descending colon; I C, Iliac colon; PC, Loop of pelvic colon ; R, Rectum. The dotted lines represent the costal margins. C. — Diagnosis of the Cause of Dyschezia. Dyschezia is due to a want of proper proportion between the power of expelling the faeces from the pelvic colon and rectum, and the force required to do this completeh'. It may therefore be due to (i) Inefficient DefcBcation ; or (2) An Obstacle to efficient Defcecation. I. Inefficient Defjecation may be due to : — (a). Weakness of the Voluntary Muscles of Defaecation. This should always be suspected when constipation dates from pregnancy, or is associated with ascites, large abdominal tumours, or great obesity. It is often easy to ascertain the condition of the abdominal muscles by simple palpation in the horizontal position ; the discovery of a movable kidney or a dropped liver would also suggest that the abdominal muscles are weak. The patient should next be told to raise her head from the couch ; the recti muscles contract and their strength can be ascertained, and any separation between them recognized. Finally, the patient should be examined standing up ; bulging of the abdomen below the umbilicus {Fig. 41) shows that visceroptosis is present and that the abdominal muscles are weak. The patient often complains of abdominal discomfort, which is relieved by lying down or by pressing the lower part of the abdomen upwards. In all cases in which a woman, whose bowels have previously been regular, becomes constipated after the birth of a chUd, the condition of the pelvic floor should be investigated, as well as that of the abdominal wall. The anus is normally slightly retracted ; the retraction is increased and the anus moves slighth' forward when the levator ani muscles are contracted by making the movement which is required when it is attempted to restrain a commencing defaecation. If thej^ are weak, the retraction in the condition of rest is absent or diminished, and on contracting the levator ani muscles, the retraction and CONSTIPA TION 149 forward movements are slight or absent. On straining, the whole perineum projects much further than it should do, and in severe cases the uterus may be more or less prolapsed : in such cases no further evidence is required to show that the dyschezia is partly due to weakness of the levator ani muscles. When constipation is present in asthmatic or very emphysematous people, it is partly due to the fact that the great rise in intra-abdominal pressure required in defaecation cannot be produced by contracting the diaphragm, as the latter is already almost as low as it can go. (fe). Habitual Disregard of the Call to Delsecation. When dyschezia is not associated with weakness of the muscles of the abdominal wall or pelvic floor, the history will generally show that it has resulted from habitual disregard of the call to defaecation — a very common cause in girls, and a not uncommon one in schoolboys and business men, who allow themselves too little time between getting up and beginning the day's work. The call is often neglected also if for any reason defaecation is painful. [c). Unfavourable Posture during Defae- cation. Enquiry should be made as to the height of the seat in the water-closet, as when this is too high it is impossible to assume the proper crouching position, and defeecation may consequently be inefficient. Weakness of the voluntary muscles of defaecation, habitual disregard of the call, and the assumption of an unsuit- able position during the act, all lead to the same results — the loss of the defaeca- tion reflex, and atony and paresis of the musculature of the pelvic colon and rectum. The loss of the defaecation reflex is shown by the fact that the patient never experiences a desire to defaecate, even when examination shows that the rectum is full of faeces. The atony of the rectum is shown by its abnormally large size and the very slight resistance offered when the finger presses upon its walls ; the atony of the pelvic colon is shown by the abnormally large shadow it forms when examined with the ^r-rays [Fig. 33, p. 142). The paresis of the pelvic colon and rectum is shown by the patient's inability to defaecate by an effort of will, when the rectum isfvdlof faeces. {d). Primary Weakness of the Defaecation Reflex. This is sometimes the cause of constipation in infants ; it is probably the case when defaecation occurs immediately if the natural stimulus is exaggerated by the mechanical effect of the introduction of a finger into the rectum, or by the combined mechanical and chemical effect of the introduction of a piece of soap. {e). Organic Nervous Diseases. When constipation occurs in the course of organic nervous diseases, such as tabes dorsalis, myelitis, or meningitis, it is due to disturbance in the defaecation centre in the lumbo-sacral cord or the tracts connecting it with the brain. When Fig. 41. — Visceroptosis. I50 CONSTIPATION constipation and difficulty in micturition appear simultaneously, the possibility of some organic nervous disease, such as tabes, should be considered, even if no other symptoms are present. (/). Hysteria. When dyschezia occurs in hysterical individuals, it is often due to the patient having suggested to himself that he cannot open his bowels at all, or unless he takes a purgative or an enema. The diagnosis can be confirmed hy the result of treatment : if such a patient can be persuaded after a thorough examination that there is really' no reason whate^'er why he should not obtain a dail^r action of the bowels without artificial aid, he will have no difficult}^ in curing himself at once. 2. Obstacles to Efficient Def.ecation may be due to : — {a). Hard and Bulky Fseces. When the faeces are abnormally- hard as a result of intestinal constipation or of the excessive loss of fluid from diarrhoea, haemorrhage, or other cause, the force required to expel them maj^ be so great, especially if the}^ are bulky, that dyschezia results. This condition can be recognized easily hy a rectal examina- tion, which shows that faeces of abnormal hardness are impacted in the rectum. [b). Spasm of the Sphincter Ani. ^■^^len defaecation is painful, it is rendered difficult as well as painful hy reflex spasm of the sphincter ani. The anal canal and rectum should be examined after the introduction of a cocaine suppository-, or — if necessarj^ — under a general anaesthetic, so that any local cause of the pain, such as an anal ulcer or inflamed haemorrhoids, may be discovered. In the absence of these, the genito-urinary organs should be examined thoroughlj^ for reflex causes of spasm. (c). Organic Stricture of the Rectum and Anus. In every case of constipation a digital examination of the rectum should be made, and in cases of doubtful origin the rectum and pelvic colon should be examined with a proctoscope and sigmoidoscope. Congenital narrowness of the anal canal is easHj^ recognized ; it is a rare condition, but may give rise to no symptom until several years after the child is born. Fibrous stricture of the rectum is an occasional cause of dyschezia, especially in women ; it is never due to s\-philis, but results from an inflammatory infiltration of the submucous tissue, secondary to infection of an abrasion of the mucous membrane. The condition is generally painful, and often associated Avith active inflammation and ulceration ; it can be distinguished readily- from malignant stricture b}^ means of the proctoscope. Cancer of the rectum or pelvic colon is a common cause of dyschezia ; when constipation deA-elops after the age of forty without anj^ obvious cause, especiall}- if it is accompanied by a sense of fullness in the rectum and of incomplete relief after defaecation, b3^ loss of weight and strength, or b}^ dis- charge of mucus and blood, the possibility of cancer of the rectum should alwaj^s be considered, and a thorough examination made. by the finger and proctoscope or sigmoidoscope. {d). Pressure on the Rectum from Without. Pressure on the pehic colon and rectum by a gravid uterus alwa3^s produces some dyschezia. Apart from this, the possibility of a pelvic tumour, such as distended tubes, cancer and fibroid of the uterus, and ovarian tumours, should be remembered in dyschezia occurring in women, especialty if there is a.ny pelvic pain. The presence of a retroverted but otherwise normal uterus cannot be regarded as a sufficient explanation of dA'schezia. {e). Invagination, When a constipated patient, whose general health is so good that cancer seems improbable, complains that after defaecation he feels as if something were CONSTIPATION 151 still present in the rectum, especially if mucus and occasionally a little blood is passed, the dyschezia may be due to the obstruction caused by the invagination of the mucous membrane of the upper part of the rectum into the lower part. The condition is generally associated with lumbar pain. On digital examination the invaginated mucous membrane can be felt, especially when the patient strains. II.— ACUTE CONSTIPATION. Acute constipation may be (i) Due to acute intestinal obstruction; or (2) A symptom of (a) some general disease, or {b) some other acute abdominal disease. I. Acute Intestinal Obstruction. A. The following points help in the distinction between acute intestinal obstruction and severe cases of acute constipation of other origin : — (i). Visible and palpable peristalsis or stiffening of the intestines is never present except in obstruction. (11). Vomiting is never fseculent, except occasionally at a very late stage, in non-obstructive cases. (Hi). In other conditions the constipation is incomplete : — {a). Flatus, and even a small quantity of faeces, may be passed spontaneously. (6). A purgative may give a result ; it is, however, very unwise to administer purgatives in such cases, but frequently the patients have already tried them on their own responsibility. (c). A rectal examination should always be made. In organic Intestinal obstruction the rectum is empty ; if it contains faeces there may be obstruction due to faeces, but It is exceedingly rare for this to produce symptoms at all com- parable in severity with those due to acute obstruction. With this exception, the presence of any quantity of faeces would show that there was no intestinal obstruction. (d). In doubtful cases two enemata should be given, with an Interval of an hour : the first generally brings away a certain amount of faeces, even if obstruction is complete ; the second only results in the passage of faeces or flatus if there is no complete obstruction or if the obstruction is very high in the small intestine. If there is complete obstruction, the second enema is either retained or escapes unaltered and with abnormally small force. B. Before considering any other possibility, all the hernial apertures should be examined, even in the absence of local pain, as a strangulated hernia gives all the signs of acute intestinal obstruction. C. The following points should then be considered in determining the cause of the acute Intestinal obstruction : — (1). Age. — Intestinal obstruction in the new-born is almost invariably due to a congenital malformation : as this is generally in the rectum, the latter should be examined first, and only aftet it has been found to be normal should the possibility of congenital obstruction In the duodenum or ileum be considered. In infants the common cause of intestinal obstruction is intussusception ; at a somewhat older age obstruction may arise in connection with a Meckel's diverticulum ; but In children and young adults the most common cause is obstruction by bands or adhesions resulting from local peritonitis, due to appendicitis, tuberculous peritonitis, or caseous mesenteric glands. Acute obstruction occurring In an Infant or child under ten years of age, in whom there is a history of constipation and abdominal distention dating from soon after birth, is most probably due to Hirschsprung's disease. After the age of forty the possibility of cancer of the colon should always be remembered, and in fat patients, especially women, obstruction by gall-stones. In patients CONSTIPATION over sixt\- acquired diverticula of the colon are likely to give rise to symptoms and signs which are generally mistaken for cancer. (ii). History. — A previous attack of appendicitis, or a history of tuberculous peritonitis or of inflammatoni- pelvic disease in females, suggests the possibHitv of obstruction by bands or adhesions ; the same diagnosis should be considered if the patient has some weeks or months before had a strangulated hernia reduced. A history- of biliary colic or of the less striking s^nnptoms which may result from cholelithiasis indicates that obstruction may be due to impaction of a gall-stone. "\Mien acute obstruction follows a period of increasing constipa- tion in middle-aged patients, cancer is probablv present. (ui). State of the Bowels. — ^The passage of blood and mucus without any faeces is ver^- suggestive of an intussusception. In older patients it may be due to cancer. The passage of stools during the early stages in spite of other evidence of obstruction, indicates that the latter is situated in the small intestine. (iv). Abdominal E-vamiviation. — («). Distention. — Great distention generally means that the obstruction is in the colon : if it is present very soon after the onset of sjinptoms, it is probably due to cancer or vol\"ulus ; if it has been present to a less extent for some time before the onset of acute sj-mptoms, a growth is likelj' ; but if it has de\"eloped ver\- acutely, a volvulus is more probable. In infants and smaU children great distention suggests Hirschsprung's disease, if the abdomen is t\Tiipanitic ; if it is partially dull, and if free fluid or irregular masses are present, tuberculous peritonitis is the probable diagnosis. Well-marked distention in both flanks suggests origin in the pelvic colon or rectum ; if in the right flank only, in the hepatic flexure or transverse colon ; if the flanks are comparatively undistended, and the central part of the abdomen is most affected, the obstruction is likely to be in the fleum or the caecum ; distention is slight when the obstruction is in the duodenum or jejunum. (6). Visible Peristalsis and Stiffening of the Intestine. — ^The position and direc- tion of %-isible peristalsis and the position of stiffening coils of intestine may show the localization of the obstruction. \\Tien a series of more or less parallel con- tracting coils is \"isible in the central part of the abdomen, the obstruction is in the smaU intestine ; if it appears to culminate in the right iliac fossa, this is likely to be the seat of disease. Stiffening of a length of intestine, which can be seen to rise up and felt to harden, most often occurs in the colon, and especially when there is a g^o^vth near its lower end. The most marked peristalsis and stiffening occur when acute obstruction is a sequel of chronic obstruction ; they may be completely absent in verj^ acute primarj^ cases. (c). Tumour. — The diagnosis of intussusception can be made with certainty only when the characteristic sausage-shaped tumour situated somewhere in the course of the colon is felt. In acute obstruction due to cancer, the tumour is often not palpable, as it is generally hidden by the dilated intestine. But large tumours are sometimes felt, especially when present in the right or left iliac fossa : the former are generally due to cancer of the caecum, the latter to cancer of the iliac colon and inflammaton,* thickening round acquired diverticula — a condition which may closely simulate cancer. Gall-stones can hardly ever be felt. (v). Rectal Examination. — A growth of the rectum can be recognized easily, and sometimes a growth of the pelvic colon can be felt through the front wall of the rectum. In infants, the end of an intussusception may be felt in the lumen of the rectum, and more frequently the tumour can be felt on bimanual examination. Obstruction due to pelvic adhesions can often be recognized by the presence of tender masses and the lixit\- of some of the pelvic viscera. The presence of more than traces of faeces in the rectum in cases of undoubted obstruction indicates that its situation is probablj- high up in the small intestine. A very CONTRACTIONS 153 ballooned rectum suggests obstruction high up in the rectum or in the pelvic colon, but this is not an invariable rule. (vi). Pain. — When the pain is localized, or moves in a definite direction to reach its greatest severity at a certain point, the latter is likely to be near the seat of the obstruction. When the pain is situated in the middle line, the obstruction is probably in the small intestine if it is above the umbilicus, and in the colon if below. (vii). Vomiting. — The more frequent the vomiting and the earlier the onset of faeculent vomiting, the higher in the intestine is the obstruction likely to be. It is most severe in small intestine obstruction due to bands or internal hernia ; its onset is later and its occurrence less frequent and sometimes only after food in cases of growth and vohailus. (viii). Borboyygmi are sometimes most marked over the seat of the obstruction. (ix). Shock and Collapse are more marked the higher the obstruction. They are also much greater when obstruction is accompanied by strangulation owing to bands or hernia than when strangulation is absent, as with gall-stones and cancer. 2. Symptomatic. In Acute General Diseases. — Constipation beginning acutely, is a frequent symptom of a large variety of acute infective and other diseases. It is never so severe that it cannot be overcome by purgatives or enemata, and the other symptoms are so much more striking in the majority of cases that the presence of constipation has little influence in forming a diagnosis. In Acute Abdominal Conditions. — Constipation is a prominent symptom in most acute abdominal conditions. Other symptoms are often so well marked that the question of intestinal obstruction hardly arises. Thus, the diagnosis can generally be made by the early tenderness and rigidity, its localization, and the early pyrexia in acute peritonitis due to appendicitis or the perforation of an ulcer ; the characteristic situation and radiation of the pain in renal and biliary colic, and the frequent haematuria in the former and jaundice in the latter ; the presence of a tumour when an ovarian cyst is twisted ; the melaena and occasional hsematemesis, and the presence of a primary disease in the heart or abdomen in mesenteric embolism and thrombosis respectively. Some cases of acute pancreatitis are clinically almost indistinguishable from intestinal obstruc- tion, but flatus is generally passed ; there may also be a history of biliary colic, and the patient is generally fat, middle-aged, and alcoholic. The diagnosis is seldom made with certainty until the typical fat-necrosis is seen on opening the abdomen. In lead colic the constipation is not absolute, and the occupation of the patient and the blue line on the gums suggest the correct diagnosis. Arthur F. Hertz. CONTRACTIONS, Athetotic, Choreiform, Fibrillar, Spasmodic, and Tetanic- are all to be defined for present purposes as involuntary and painless contrac- tions occurring in the voluntary muscles. From Contractures {q.v.) they may be distinguished by their short duration, longer or shorter intervals in which the affected muscles are relaxed occurring between the separate contractions. From cramps they differ by being painless, or comparatively so, and also by their short duration. But in many cases it is impossible and also unnecessary to draw any hard-and-fast line showing where, for example, tetanic contractions cease and tetanic cramps begin. In all cases the occurrence of the contractions mentioned above may be taken to indicate some disease of the nervous system, usually organic but sometimes functional. 154 CONTRACTIOXS Athetotic ContractioxSj Athetosis, or Mobile Spasm. Athetosis is a form of involuntary movement affecting the fingers, hands, and A\Tists most often ; less often the toes and feet, and in rare instances the face. It is usually unilateral, but in exceptional cases bilateral — the " double athetosis " of French neurologists. The movements are spontaneous and incessant, and may even continue while the patient is asleep ; in other instances they tend to cease, but are started anew or exaggerated when voluntary move- ment is attempted. In the hand, the movements consist of a succession of slow and serpentine flexions, extensions, h\'perextensions, and lateral motions, all combined to cause the fingers and thumb to execute the most curious and complex clutching or spreading movements [Fig. 42). The vcrist is held more or less flexed ; the fingers may move about together, or wander each individually. Analogous movements are observed when athetosis occurs in the lower extremity, or the mouth and face. Xo great regularity characterizes the motions of athetosis, and as a rule they are steady rather than violent. In all cases, a large amount of voluntary control over the affected parts is retained ; mobile spasm must be attributed to varpng degrees of central irritation of muscles that are incompletely paralyzed and somewhat spastic. Primary, idiopathic, or primitive athetosis is a rare disease of child- hood or of adult life, in which bi- lateral athetotic contractions first make their appearance in a pre- viously healthy person, either for no particular reason, or after a chill or a ner\-ous shock. It may or may not be associated ^\'ith epilepsy or insanit}'-. This form of athetosis appears not to be con- nected with any definite changes in the nervous system, and so is to be distinguished from all other con- ditions in which athetosis is seen. Athetosis is common in the various spastic paraplegias of infants and children, which may be either congenital or acquired : Congenital cerebral diplegia, also known as Little's disease when the legs are the part chiefly affected, is a condition in which the nervous structures suffer from an inherited taint (alcoholism, syphilis, insanity), and either fail to develop proper h', or degenerate earl}- in hfe. The onset of Little's disease is gradual, and usuallj^ early, but it may be delayed until the child is as much as six or eight years old. The patient is found to be backward or mentally deficient, probably unable to walk, and afilicted with bilateral spastic paralysis. The paralysis may affect the legs, the legs and arms, or even the whole bod}', and may be more marked and more spastic on one side of the body than on the other ; speech is defective, optic atrophy common, and the gait is clumsy and stiff, " cross-legged " or " scissor." In- voluntary movements occur in the affected members, and are athetotic or choreiform ; tremor or intention-tremor may also be niet with not in- frequently. Fi£^. 42. — The hand in athetosis. CONTRACTIONS 155 Although it may not appear for some years after birth, this form of cerebral diplegia is really a congenital disorder ; and it is to be distinguished, for reasons connected with its pathological anatomy and etiology, from certain other forms of spastic paralysis in infants and children that may closely resemble it from a clinical point of view. These are the acquired cevebral paralyses of infants, the spastic infantile hemiplegias, monoplegias, diplegias, triplegias, paraplegias, that result from more or less localized cerebral inflammations or haemorrhage occurring at birth or in infancy. Porencephaly , or the occurrence of lacuna in the tissues of the cortex or brain, may be found in either the congenital or the acquired cerebral paralyses ; it is really a post-mortem-room term, and requires no special consideration here. The acquired spastic paraplegias fall into two categories, according to their etiology : — 1. Birth palsies : due to meningeal or cortical hsemorrhage caused by prolonged labour or the use of instruments. Many of these infants have been born prematurely. 2. Acquired palsies : due to — Encephalitis occurring after an acute specific fever, or suppurative in origin. Polio-encephalitis, the cerebral analogue of acute poliomyelitis in the anterior cornua of the cord. Cerebral embolism. Cerebral or meningeal haemorrhage or thrombosis. The birth palsies are due to injuries received in the process of birth, and the rupture of meningeal or cerebral blood-vessels, with the escape of blood ; they develop at once, and the history of the case should make diagnosis easy. The diagnosis of the exact cause of an acquired spastic paralysis in an infant or child may be less easy. The paralysis due to encephalitis generally appears during the first two or three years of life, but may come on at almost any age. Cerebral thrombosis in children, is said to happen oftenest at about the age of six. Cerebral embolism is likely to be seen in infants or children with acquired heart- disease, the embolus being derived from vegetations on the mitral or aortic valves, or from thrombi that have formed in backwaters of the dilated left auricle or ventricle. These infantile hemiplegias or diplegias are of sudden onset, and are characteristically spastic. Athetotic movements, with or without choreiform contractions, trophic lesions, and tremors, are common in the affected limbs ; the children often grow up to exhibit mental defect, imperfect speech, or epilepsy. As a rule, the face is less involved than the arm or leg, and the athetotic movements, confined to the affected parts, may not be developed until years after the occurrence of the original cerebral lesion. Post-hemiplegic athetosis, which cannot be sharply marked off from post- hemiplegic chorea (see p. 157), is an uncommon sequela of hemiplegia in the adult ; but common — being seen in about a third of the cases — in the congenital and acquired hemiplegias just considered. In the adult, it occurs oftenest when the lesion is situated near the posterior part of the internal capsule or the optic thalamus. These athetotic movements of the extremities have been described already ; in the adult, they may be combined with choreiform contractions involving the whole arm and shoulder, and the face. The diagnosis should not be difficult, as the history of a stroke will be obtained and the physical signs of a hemiplegia will be present. Choreiform Contractions. These are similar to the contractions seen in chorea. They are involuntary and inco-ordinated movements, purposive in character, but aimless and ineffective in performance. They are jerky, rapid, and highly irregular • 156 CONTRACTIONS groups of muscles are successively put into action, as if the original intention were given up, or changed, as soon as the complex movement began. They may affect one side of the body only, or both. When mild, choreiform movements amount to no more than excessive fidgetiness, involving perhaps only the hands and arms, or the hands, arms, and face, in ^vriggling and grimacing. When severe, they give the patient no rest ; he is tossed about, perhaps with the utmost violence, by combined but irregular contractions in which any of the voluntary muscles may participate. Choreiform contractions bear no resemblance to tremors, whether coarse or fine. From intention-tremors they are distinguished by the facts that they continue when the patient is at rest, that they are purposive, and resemble ordinary voluntary movements misapplied. From ataxia they are distinguished by occurring at rest as well as on attempted movement ; the muscular contractions of ataxia are merely inco-ordinated, apparently ill-designed and clumsily executed, types of normal movements. Choreiform contractions are seen in the following conditions : — Chorea, chorea minor, acute chorea, or St. Vitus's dance Chronic degenerative or Huntington's chorea Chorea major or pandemic chorea Hysteria Pre-hemiplegic chorea Post-hemiplegic chorea Congenital and acquired spastic paralyses of infants Cortical sclerosis Chorea electrica (Henoch). Chorea, chorea minor, acute chorea, or 5^. Vitus's dance, is an acute disease of childhood or adolescence, commoner in girls than boys, and closely connected with a history or a family history of rheumatism, and with rheumatic endocarditis. It may also occur in adults in connection with pregnancy, when it is sometimes of a severe type and may run on into insanity. The movements may be confined to one side of the body — hemichorea — or may affect both sides ; the muscles are, in general, weak, speech may be interfered with, respiration is often jerky, and the patient is often unduly irritable and emotional. Except in the severest cases of chorea, the movements cease during sleep ; the disease tends to recovery in the course of perhaps two or three months. Mild cases of chorea, in which the face is most affected, may present a certain resemblance to the more chronic and quite unconnected disorder known as habit-spasm, habit-chorea, or convulsive tic (see Spasmodic Contractions, p 159). A facial tic is controlled for a time by strong efforts of the will, whereas the facial movements of chorea will usually be increased by the concentration of the attention on them ; the facial movements of chorea are irregular, representing a succession of various purposive but uncompleted actions, while the facial tic consists in the repetition of a single definite and purposive movement originally designed, no doubt, to give relief to some local irritation. Chronic, degenerative, or Huntington's chorea is a rare hereditary disease coming on at the age of thirty or forty, associated with slow and difficult speech and with insanity. The involuntary movements are slower and more ataxic than those of acute chorea, and can often be suppressed for a time by exercise of the will. They affect the extremities and face, are continuous, cease during sleep, and are accentuated by excitement, so that at first sight acute chorea may be imitated fairly closely. The diagnosis between this chronic chorea and an acute chorea that had become chronic, as sometimes happens, would turn on the family history, mental symptoms, age at onset, and the course of the disease. Chronic chorea is incurable, and may take twenty years CONTRACTIONS 157 or more to run its course ; mental failure occurs early, and is progressive ; and a family history of chronic chorea can always be obtained. Chorea major, or pandemic chorea, is an epidemic hysterical manifestation occurring in the more emotional races of Europe under the influence of religious excitement. Choreiform movements are among the less conspicuous of its motor phenomena, and it need not be considered further, for it is unknown to the more phlegmatic Northern races. In hysteria the motor phenomena are notoriously protean. Should a hysterical patient have had chorea herself, or should she have had the opportunity of observing it in others, she may reproduce its characteristic movements with the greatest accuracy. The diagnosis here may be very difficult for a time, particu- larly if the patient's previous history be not known, and hysteria not suspected. The hysterical patient's temperament will probably lead her to develop other signs or symptoms that will suggest the true diagnosis in these cases ; such as tremors, paralyses, contractures, hemi-anssthesia, anaesthesia of the stocking and glove distribution, exaggeration of the deep reflexes, or attacks of hysterics. Remission of the choreiform movements and of the local symptoms generally may occur when the hysterical patient thinks she is no longer under observation, or when her attention is diverted elsewhere. In a word, the hysterical patient simulating chorea or hemichorea, is likely to overdo the part. Choreiform movements may occur in connection with hemiplegia in two forms. Pre-hemiplegic chorea has been recorded in a few cases, twitchings or even choreiform movements being initiated in the limbs of one side of the body shortly before the onset of an apoplectic stroke. Post-hemiplegic chorea is commoner, and is more often seen in children than in adults. After a hemiplegia, more or less muscular spasm and movements of one kind or another are habitually seen on the affected side of the body. In many patients these movements take the form of tremors, flne or coarse ; in others they are athetotic ; in others again they are ataxic, occurring only when voluntary movements are attempted ; and in yet others they are choreiform. Which of these forms of muscular contraction is likely to occur in any given case it is impossible to say ; they are all due to combinations of cerebral irritation, muscular spasm, and muscular paralysis, mixed together in varying proportions. The choreiform movements occurring in the spastic paraplegias of infants and children, conditions that have been more vaguely described as cortical scleroses on the strength of their post-mortem appearances, are to be regarded as variants of the athetotic contractions already considered above. Henoch's chorea electrica is considered below : it is the muscles of the neck and shoulder that are chiefly involved in this rare disorder. Fibrillar Contractions. Fibrillar contractions of the muscles, or fascicular muscular twitchings, are small spontaneous contractions visible on the surfaces of muscles, rhythmical or irregular, involving not the whole muscle, but only single muscular bundles in it. They may be confined to a few of the bundles, or may occur irregularly in any of the bundles composing a muscle. They are almost always too small and feeble to produce any visible movements at the joints. These muscular flickerings are increased in fatigue, and when the muscle is mechanically stimulated. Similar, but coarser, twitchings may be seen in normal muscles when they are over-fatigued, or on exposure to cold. The finest fibrillar contractions are said to occur only in cases of organic disease in the central nervous system. They are seen most freely in muscles that are degenerating or undergoing atrophy, or are shortly about to atrophy, as the result of disease in the lower motor neuron ; they cease to appear when 158 CONTRACTIONS the muscle is much wasted. They are most evident in the extremities and tongue, and no doubt are due to irritation of motor nerve-cells in the cord or bulb that are hyper-excitable because they are degenerating. From a diagnostic point of view, fibrillar contractions are important, because for practical purposes they do not occur in the myopathies or primary muscular dystrophies that are due to lesions in the muscles themselves and not in the spinal cord. In only a few recorded cases have these fibrillations been seen in cases of myopathy where lesion of the central nervous system could be excluded. Neurologists and myologists have devoted much attention to primitive myopathy, with the result that it has become burdened with a highly elaborate classification and nomenclature. Thus the condition generally has been described as — Primary progressive myopathy Progressive muscular dystrophy (Erb) Idiopathic muscular atrophy and hypertrophy Primitive progressive myopathy Muscular dystrophy Myopathy. Special forms of it have been raised to the dignity of " types," the chief of which are the — Simple atrophic (Erb) Pseudo-hypertrophic Juvenile (Erb) Facio-scapulo-humeral (Landouzy and Dejerine) Distal (Gowers) Myotonia atrophica Mixed and transitional (Leyden and Moebius) (Zimmerlin). Distinctions between these various forms must be sought in special manuals. Their importance for present purposes consists in this — that fibrillary contractions may occur as a rare exception in most of them. Contrariwise, fibrillar contractions are habitually observed in the course of the progressive muscular atrophies of neuropathic origin, variously known under such names as — Chronic anterior poliomyelitis Amyotrophic lateral sclerosis (Charcot) Progressive bulbar paralysis Progressive muscular atrophy Toxic degeneration of the lower motor neuron Werdnig-Hoffmann progressive muscular atrophy of infants, according to their special characters. In all of these, the lower motor neurons are primarily at fault, exhibiting slow or rapid degeneration ; in many cases the upper motor neurons are also affected, either simultaneously, or before or after the lower. As a rule, no cause for the degeneration can be discovered ; but many — perhaps a half — of the patients have previously had acute polio- myelitis. Occurring in infants or children, this neuropathic muscular atrophy is generally of the Werdnig-Hoffmann type, affecting the legs first, and spreading upwards to the body and arms ; the hands and feet are affected late, and the deep reflexes vanish. The condition may at first sight resemble rickets, but in rickets there is no real muscular atrophy, the deep reflexes are retained, and fibrillar contractions do not occur. It may be indistinguishable from one of the primary myopathies considered above ; but the occurrence of fibrillar contrac- tions would make the diagnosis of neuropathic muscular atrophy the more probable. CONTRACTIONS 159 In adults the disease may conform to one of several types, according to the distribution of the atrophy. In some instances, the lower motor neurons of the hand, arm, and neck are attacked, when the Claw-hand {q.v.) may result ; in others, the lower extremities may first show the degeneration. Charcot's amyotrophic lateral sclerosis is characterized by spasticity of the legs combined with atrophy of the muscles of the hands and arms. In making the diagnosis of neuropathic muscular atrophy, it must be remembered that the onset is gradual, that fibrillar conti-actions are present, that the atrophy proceeds pari passu with the loss of power, and that sensation and the sphincters are not involved. The electrical changes in the muscles are of assistance, too, the partial Reaction of Degeneration [q.v.) being exhibited ; the nerves react normally to faradism, and to galvanism so long as there are muscle fibres left to respond to the stimulation, while the muscles react sluggishly, and A.C.C is often greater than K.C.C. Bulbar paralysis is due to lesions of the medulla oblongata, and the nerves mainly affected are the motor part of the fifth, the seventh (facial), the eleventh (spinal accessory) and twelfth (hypoglossal). In other cases, ophthalmoplegia is observed as well. It is only in the chronic cases of bulbar paralysis that fibrillar contractions are seen, and they are particularly well shown in the tongue, which has been described as looking " like a bag half full of worms." The main symptoms will be difficulty in articulation, phonation, mastication, and, most of all, in swallowing. Spasmodic Contractions. In general parlance, the epithet " spasmodic " implies suddenness and short duration. These characteristics are not implied by the word as it is used clinically. Hence it is necessarj^ to distinguish between spasmodic contractions or muscular spasms of three kinds, according as they are : — (i) Short and single — the muscular twitch ; (2) Short and repeated — clonus or clonic spasms ; (3) Tetanic — commonly and improperly known as tonic spasms ; these are long-sustained. I. Single Spasmodic Contractions of a muscle or group of muscles, over in a fraction of a second, may occur in normal persons who are suffering from great fatigue, overwork, or nervous exhaustion. For no apparent reason, and fre- quently just as the person is going off to sleep, a sudden violent twitch in one or more of the limbs occurs, and wakes him up. In other cases these sudden starts may occur when the patient is resting by day. In abnormally nervous or excitable patients such sudden spasms are more frequently seen, and often result from some sudden and unexpected sensory impression — a sound, sight, or touch. The diagnosis of such spasms in nervous or jumpy patients should not be difficult, the affection being very chronic, and no doubt familiar to the patient and the patient's entourage. Coming on suddenly, this jumpiness may be a minor sign of various nervous disorders, such as hysteria, acute chorea, delirium tremens, general paralysis. Graves' disease, and so forth. Single twitches of muscles or of groups of muscles, form the outstanding featm-e of the simpler forms of a series of affections known as habit spasms or spasmodic tics. A habit spasm consists in the involuntary repetition of some ordinary co-ordinated purposive act. In many instances, the tic was at first a natural reflex act, designed to allay some transient irritation. Thus a blinking tic may have been initiated by the pain caused by a foreign body in the eye, or conjunctivitis ; a sniffing tic by some temporary itching about the nares ; a shoulder-shrugging tic by some irritation of the neck due to a tight or rough collar. By voluntary repetition such an act ultimately becomes automatic, when it is spoken of as a habit spasm or tic. These motor tics exist in great i6o CONTRACTIONS variety, oftenest affecting the face, less often the jaws, neck, or limbs ; they are so common as to escape comment in their minor manifestations — mannerisms and stereotyped acts — being set down merely to " individualit5^" Most tics can be controlled by mental effort with some distress, are increased by emotion, cease during sleep, and are curable only with great difficulty when well established. In all cases, the patient is supposed to exhibit a certain psychical weakness. More violent and shock-like muscular spasms are seen in the rare condition known as myoclonus or paramyoclonus multiplex. Mj^oclonic movements are particularly sudden and violent, occurring bilaterally, or first on one side of the body and then on the other ; they are painless, but may give rise to much inconvenience by their violence. They are increased by eraotion and cease during sleep. They may be single, but more often are clonic, repeated perhaps fifty or a hundred times in a minute. In paramyoclonus multiplex there are no mental, sensory, or sphincter changes. In hysteria, myoclonus is excep- tionally seen, and is accompanied by other hysterical manifestations. In certain rare forms of epilepsy, the so-called myoclonic epilepsy, these parox^^smal asynchronous bilateral lightning-like movements have been recorded ; the diagnosis will be easy here, as the patient exhibits the phenomena of major epilepsy — loss of consciousness, relaxation of the sphincters, etc. — in addition to the sudden and forcible mj^oclonic movements. In certain cases of minor epilepsy or petit mal, the affection may take the form of spasmodic twitches of the muscles of a limb, or of the face. 2. Clonic Spasmodic Contractions, clonic spasms, or clonus, are in realitj^ interrupted tetanic contractions, consisting in the rhythmical and more or less rapid repetitions of the single brief muscular spasm or twitch. A typical clonus of muscles in the arms or legs may often be produced in health by the adoption and maintenance of some strained position. Thus ankle-clonus is soon produced if a normal person sits in a chair and strains the heels up while the toes are held pressing on the floor. Such clonus is physiological, being due to heightening of the muscle tone or normal state of tonic muscular contraction by the application of mechanical tension to the calf muscles. Pathologically, clonic spasms are typically seen in the second or clonic stage of major epilepsy, where they succeed the initial tetanic (or tonic) stage. Here they are universal and bilateral as a rule, although one side of the bodj' may be more involved than the other, or the arms more than the legs. Consciousness is lost, and the sphincters are often relaxed in the second stage of epilepsy ; very similar convulsive seizures may be met with in patients with chronic nephritis [urcBmic convulsions) and in pregnant women (eclampsia). The clonic stage of epilepsy may be imitated unconsciously by patients with hysteria, or frankly mimicked by the malingerer. In hysteria the onset of the fit is gradual, not sudden ; consciousness is impaired, not lost ; the pupil reacts to light, and is not immobile as in epilepsy ; screaming and purposive movements occur throughout, and the fit is often protracted ; the sphincters are not relaxed, and the tongue is not bitten. The malingerer is red and heated by the effort of producing the clonic spasms, his consciousness is fully preserved, and he reacts at once to the application of painful stimuli that leave the epileptic unmoved. Both the hysterical patient and the malingerer show quivering of the ej'elids, and are likely to resist attempts to open the eyes. Mild and limited clonic spasms of a few muscular groups, without loss of consciousness and lasting for only a few seconds, may be seen in patients with major epilepsy, and are often described by them as "warnings." Such attacks are identical with those of minor epilepsy. In certain patients they seem to be to some extent under control, so that their threatened onset can be prevented if the patient can sit or lie down, for e.xample, or can press on or con.strict the CONTRACTIONS i6i limb in which, the spasms are about to appear. The diagnosis of hystero- epilepsy is sometimes made in these patients ; but the term is not a good one, and is often misleading. In Jacksonian epilepsy, clonic convulsions occur without loss of consciousness ; they are usually unilateral, starting in some given muscle and spreading thence until both limbs or half the body are convulsed. Transient paresis from exhaustion may be noted afterwards in the affected muscles. In severe or long- established cases the whole body may be convulsed, or a tetanic stage may occur after the clonus ; in these instances consciousness may be lost. Jacksonian or focal epilepsy may result from any form of local irritation of the motor cortex — trauma, haemorrhage, new growth, the effects of syphilis, chronic inflammation. It leads in the long run to paresis and atrophy of the affected muscles. As the names imply, myoclonus and paramyoclonus multiplex exhibit tj^ical clonic contractions. The clonus occurs in single muscles or muscle-groups, such as the biceps and supinator longus, the quadriceps femoris and semi- tendinosus ; rarely in the face : up to loo contractions a minute may occur. Henoch's chorea electrica is the same as myoclonus. It is said that animals from which the parath^Toid glands have been removed may exhibit identical spasms. For the diagnosis of myoclonus, see above. Clonic spasms of the neck-muscles, particularly the sternomastoids, are common in torticollis or wry-neck. 3. Tetanic Contractions, tetanic or the so-called tonic spasms. Physio- logists and clinicians both make use of the tAvo terms " tetanic " and " tonic," but unfortunately employ them in different senses. Physiological " tetanus " is the apparently steady state of muscular contraction exhibited by the voluntary muscle at work, maintained by the fusion of separate muscular twitches or spasms due to a rapid succession of nervous (or other similar) stimuli. It may be seen in a single muscle or in many together. Clinically, however, " tetanus " or " tetanic contractions " have come to be associated with pain, besides being of some dviration, and the terms are used only when a large number of muscles are simultaneously involved ; tetanus of a single muscle is referred to clinically as a cramp (q-V.). To the physiologist, the normal resting muscle is already in a state of " tonic contraction," and exhibits " tonus." This muscle-tone is maintained partly by local or peripheral stimulation (mechanical tension, the venosity of the blood, drugs such as digitalis or veratria) ; and partly by nervous impulses that reach the muscles more or less continuously from the motor neurons of the central nervous system. This central element of muscular tonus is really of reflex origin and due to posture, the maintenance of the erect attitude ; the motor impulses descending in answer to ascending impulses received by the central nervous system from the muscles and joints concerned. But the clinician applies the terms " tonus " and " tonic contractions " to the severe and pathological muscular contractions seen, for example, in the iirst stage of major epilepsy, which are physiologically and scientifically speaking tetanic, not tonic. This clinical misuse of the word " tonic " is, of course, well established and time- honoured, but only serves to promote confusion. The terms " tonic spasm " and " tonic contraction " should be reserved for states of muscle-tone that are raised only within physiological limits, and are not pathological. The contrac- tions or spasms that the clinician calls " tonic " are almost always pathological, and in the interests of uniformity should be described as " tetanic," not " tonic." Exaggerated states of physiological tone and the milder degrees of pathologically heightened muscular tonicity are described clinically as spastic states or spasticity, falling short of tetanus in degree, and differing from both tetanus and cramp by being painless. They are detailed under the heading CoN- TR.\CTURES {q.'O.). Tj'pical tetanic (or tonic) spasms are seen in tetanus. Here the patient has i62 CONTRACTIONS become infected by Bacillus tetani {Plate XII, Fig. T), through some known or unknown wound. He first notices stiffness of the neck and jaws; soon, increasing tetanic spasm of the muscles of mastication brings on trismus or lockjaw. Spasm of the facial muscles next brings on the painful grin known as the nsMS sardonicus, and presently paroxysmal tetanic spasms of great violence occur in practically all the voluntary muscles. If the spasms are strongest in the extensors of the back, the body is arched backwards till, perhaps, the heels touch the head (opistho- tonus). If the flexors contract most powerfully, the body is bent forwards (emprostho tonus) ; in some cases the body remains straight and stiff (orthotonus) when the flexors and extensors are balanced. These acutely painful paroxysms last for perhaps a few seconds, and recur at varying intervals on any kind of stimulation ; they may cause death by asphyxia or heart-failure. In the intervals between these severe paroxysms, a milder but still painful tetanic (the so-called tonic) contraction of the muscles is maintained ; or, in milder cases, nothing more than an exaggerated physiological muscle-tone may be observed between whiles. In mild or chronic cases of tetanus, the signs and symptoms ■will be far less severe than those described above ; but trismus and painful muscular contractions will still occur. In some chronic cases, the chief sign may be a recurring but transient risus sardonicus, perhaps with some stiffness of the neck ; not a few of these patients have been treated for habit-spasm or hysterical grimacing for a time, until the suspicion of tetanus arose, or spread of the tetanic spasms to the trunk-muscles made the diagnosis more obvious. The diagnosis of tetanus may have to be made in other instances from impacted wisdom tooth or from muscular rheumatism, which may cause stiff-neck but is hardly likely to set up trismus ; or from spinal meningitis, in which there is fever, while the tetanic spasms occur on exertion, and do not primarily affect the muscles of the jaws, and great pain is felt on moving the head and neck. The spasms of tetanus must be distinguished from those of strychnine poisoning. In this, trismus is absent or occurs very late, the extremities are first and most markedly affected, the muscles are quite relaxed between the paroxysms, and the symptoms develop rapidly — within an hour or two of the administration of the drug. In tetany the distribution and duration of the tetanic contrac- tions should suffice to prevent any confusion with tetanus. In hydrophobia there should be a history of a bite by some animal, most often a dog ; mental symptoms are prominent, and the spasms affect the muscles of respiration and deglutition most, while trismus is absent. In hysteria a patient may exhibit trismus, tetanic spasms, and opisthotonus ; but no true picture of tetanus will be presented, and no doubt abundant evidences of hysteria will be found on examination of the patient, or will develop if the case be kept under observation. • a. J. J ex-Blake. CONTRACTURES — are lasting bodily deformities resulting from a great variety of causes. For clinical purposes they may be roughly divided into two classes, according as they are (i) Active, or (2) Passive. The division between the two is not sharp, as active contractures when long established tend to become passive. I. Active Contractures : resulting: — • (a). From lesions of the upper motor neuron : Cortical lesions Subacute combined degeneration Hemiplegia Lateral sclerosis Friedreich's ataxia Spastic ataxia Myelitis Spastic paraplegia Transverse lesions of the cord CONTRACTURES 163 {b). F/om lesions of the lower motor neuron : Acute poliomyelitis Neuritis Chronic poliomj-elitis Trauma of nerves Progressive muscular atrophy (c). From disuse : Hysteria Torticollis 2. Passive Contractures : seen in : — Late stages of the active contractures Local organic diseases of the bones, joints, muscles, fasciae, etc. I. Active or Spastic Contractures. — In these, certain groups of muscles are thrown into a permanent state of contraction, or else the balance of power between antagonistic sets of muscles is upset. In either case bodil}^ deformity (iiexion, extension, curvature) results ; but the deformity can be redressed temporarily either by steadily maintained mechanical traction, or by the forcible electrical stimulation of the weaker set of the antagonistic muscles involved. In passive contractures, on the other hand, no amount of electrical or other stimulation avails to correct the deformity, nor can the application of force without rupture of the tissues. Active contractures must be distinguished from certain other forms of muscular contractions, particularly cramps and tetanic (or so-called tonic) contractions or spasms of the voluntary muscles. Cramps may resemble contractures by their relatively long duration ; thus the cramps of tetany have been known to persist for days and even weeks. But pain is a constant feature of cramp, whereas it has no connection at all with contractures per se. Tetanic contractions of muscles (see Contractions) — commonly called tonic by the misuse of a word that already has a definite and different physiological meaning — resemble cramps by being painful, and differ from them only by being more generalized. The normal resting muscle is, physiologically speaking, in a constant state of tonic contraction, and exhibits a certain reflex tone or tonus (muscle-tone) due to the combined action of two factors, one local and one nervous. The local or peripheral component is inherent in the muscle-tissue, and may be increased by such influences as mechanical tension of the muscle-fibres, augmented venosity of the blood, the action of drugs like digitalis or veratria. The nervous or central factor consists of efferent nerv'ous impulses from the motor neurons, sent down no doubt in response to afferent impulses coming up from the muscles and joints, and determined largely in man by the habitual maintenance of the erect posture. Any muscular spasm, rigidity, or spasticit}^ set up by increase of this normal tone within physiological limits, may properly be referred to as a condition of tonic contraction. But when a spasticity is pathological, as are all the " tonic contractions " of the clinician, it should no longer be referred to as a state of tonic contraction, especially as it corresponds satisfactorily with the physiological " tetanic contraction "or " tetanus." A typical pathological spasticity or active contracture is seen in Sherrington's " decerebrate rigidity," the extensor spasm observed in the limbs of the cat or rabbit after removal of the cerebral hemispheres and basal ganglia. This rigidity lasts for several days, and is due to the removal of the inhibitory impulses normally reaching the cord from the cortex and thalamus. A similar rigidity, though, of course, with a different distribution, is seen in such disorders as hemiplegia, cortical losses, lateral sclerosis, Friedreich's ataxia, subacute combined degeneration, and transverse lesions of the cord. The active contractures following hemiplegia or cortical lesions in the motor area are confined to the affected side of the body, and should not be difficult to diagnose. Gowers described three varieties of rigidity after hemiplegia, but 164 CONTRACTURES only the last of these is usually described as a contracture : (i) Initial rigidity, present at the outset and lasting only for a few hours ; (2) Early rigidity, beginning within a few days of the stroke and lasting for a week or a few weeks, possibly due to the irritation of blood-clot at the site of the cerebral lesion ; (3) Late rigidity or contracture, first appearing several weeks or months after the stroke, and due to the fact that while all the muscles are spastic, certain groups of them are stronger than their antagonists. Thus the thumb is flexed and pressed into the palm ; the fingers are clenched ; the wrist and elbow are flexed, the forearm is pronated, and the arm is adducted. The thigh is adducted, the knee extended ; the heel is drawn up, the foot inverted, and a characteristic spastic gait results. The deep reflexes are increased on the hemiplegic side, where, too, ankle-clonus and Babinski's extensor reflex can be obtained. The lapse of years converts these active contractures into passive, as has been noted already, in consequence of structural changes in the muscles and fasciae, and in the joints. Contractures are highly characteristic of the congenital and the acquired cerebral diplegias or hemiplegias due to cortical lesions, cortical sclerosis, or porencephalus (see Contractions, Athetotic). The patients show bilateral spastic paralysis ; one side is sometimes more severely affected than the other. If the legs only are affected, the condition is known as Little's disease, and the gait is " cross-legged " or " scissor," the feet being pointed and inverted, and the thighs adducted. Kyphosis is often seen, and the arms, if involved, are held in the position of a hemiplegic arm (see above). In the acquired cases the spastic paresis is oftener unilateral than bilateral ; the nutrition of the affected limb suffers conspicuously, and its growth is retarded and incomplete. In Friedreich' s disease, a familial disorder beginning usually between the ages of seven and seventeen, and seen oftenest in males, characterized by ataxia, inten- tion-tremor, nystagmus, and hesitating or syllabic speech, active contracture sets up scoliosis or scoliokyphosis, pes varus or equino-varus, and "main bote" — an analogous deformity of the hand with hyperextension of the terminal phalanges. These contractures are partly due to muscular atrophy, partly (in the case of the foot) to overuse of certain muscles in attempts at equilibration ; the heel is drawn up, the dorsum of the foot arched, the sole hollowed out, the toes flexed at the interphalangeal joints and hyperextended at the metatarsophalangeal ; hypertrophy of the prominent extensor longus hallucis has been found. In subacute combined degeneration, in which may be included lateral sclerosis if the degeneration mainly affects the upper motor neurons, there wfll be contractures. The earliest symptoms are connected with sensation ; but the patient, usually an anaemic adult in the second half of life, presently develops spasticity in his legs. The limbs tend to draw up as he lies in bed, from flexor spasm ; the gait becomes spastic, and walking is soon impossible — the condition becoming one of spastic paraplegia. The deep reflexes are increased, and Babinski's sign is present ; segmental areas of anaesthesia can be made out, and control over the sphincters is weakened. After some months, this spastic stage gives place to flaccidity, control over the sphincters is lost, and the patient rapidly runs down hill. In cases of transverse myelitis or transverse lesions of the cord, spasticity with increased deep reflexes, loss of sensation, and loss of control over the sphincters is the rule. The diagnosis is facilitated by the fact that no symptoms occur in parts of the body innervated from above the cord lesion ; at the level of the lesion there is evidence of nerve-irritation (girdle pain, hyperaesthesia) . In these cases the flexors of the leg overpower the extensors ; the limbs draw themselves up again, sooner or later, as often as they are extended for the patient. So far, the active contractures considered have all been due to lesions of the CONTRACTURES 165 upper motor neuron. A second class contains those resulting from lesions of the lower motor neuron and the subsequent muscular atrophy. These conti'actures arise either from the unbalanced action of the muscles that normally antagonize those that have atrophied, or from late shrinkage of the paralyzed muscles themselves ; and a spinal curvature may come on from the adoption of some posture that facilitates locomotion or the occupations of life when the spinal muscles are intact. Acute and chronic poliomyelitis, neuritis, and lesions of the nerves have to be discussed in this connection. Acute poliomyelitis, or infantile paralysis, begins suddenly with malaise, pains, and an acute febrile attack ; the flaccid paralysis appears early, and contractures begin to show themselves within a few months, as a rule. The limbs are most involved, isolated muscles or groups of muscles being paralyzed ; and it should be noted that the parah^sis is distributed in accordance with the nuclear grouping of the muscles in the anterior cornual regions of the cord. Sensation is affected only in the rarest instances. If many muscles in a limb are paralyzed, its growth is much impaired. Contractures are common in chronic poliomyelitis and the various forms of progressive muscular atrophy of neuropathic origin (see Contractions, Fibrillar), the hands and feet being mainly involved, with the production of various forms of club-foot and claw-hand. All the muscles are involved together, and there is no selection of certain groups for paralysis as is the case in acute poliomyelitis. In addition, fibrillar contractions can be seen in the degenerating muscles, provided that they are not too thickly covered with subcutaneous tissue. The onset is insidious, and the disease occurs most often in middle age ; the commonest type is that in which the hands are first and most involved, but in other cases the legs, and in others the upper arm and shoulder, first give evidence of the disease. Contractures are seen occasionally in alcoholic neuritis of the motor type, and more frequently in arsenical neuritis, talipes equinovarus or flexor contracture of the wrist, with excessive muscular hypersesthesia, being noted ; such deformities are rare in other forms of neuritis, such as those due to lead, diabetes, influenza, diphtheria, etc. For example, secondary contracture of the muscles on the affected side in Bell's facial paralysis may occur, and gives rise to the impression that the sound side of the face is paralyzed while the face is at rest, for the face as a whole is pulled over to the affected side : on voluntary movement, however, the healthy side will be found to move normally, while the paralyzed side remains comparatively still. Contractures usually follow severe trauma of nerves, unless satisfactory healing of the wound and regeneration of the nerve-trunks take place. Active contractures from disuse may occur in otherwise healthy subjects who for any reason may have been kept too long in one position. Patients who have lain on their backs in bed for long periods may have a temporary talipes equinus when they get up — an active contracture due to the weight of the bedclothes resting on the toes and keeping the feet extended. Fractured or injured limbs that have been splinted and kept too long in one position, often exhibit active contractures when the splints are removed (e.g., Volkmann's ischaemic contracture of the forearm, Fig. 43). In some cases, the contracture is due to fixation of the muscles, tendons, or muscle-sheaths by inflammatory products that have become organized, in others to adhesions or bony deposits that have formed themselves in or about the joints, while in others mere disuse, without inflammatory changes, may be supposed to underlie these contractures : all of these would be avoided by the timely use of massage and movement. Paralyses occur in perhaps 25 per cent of all patients with hysteria, in two main types : the rarer flaccid, the commoner spastic, and often marked enough to produce active contracture. In hysterical contracture the affected muscles 1 66 CONTRACTURES are not wasted except in severe cases of long duration ; the deep reflexes are increased ; ankle-clonus may be present ; but Babinski's sign in all probability is never observed. The limbs are most affected (hemi-, mono-, or paraplegia), less often the muscles of the face, e^-elids, lips, or tongue. Certain attitudes are-lhighlj' characteristic of hysterical spastic paralyses ; the elbows, ^msts, and fingers are kept flexed, the arms are adducted ; the hip and knee are extended, and the foot is held in a position of talipes equinovarus ; ptosis mav be seen, from spasm of the orbicularis ; torticollis from contracture of the sternomastoid. In the less severe cases, the stiffness and paresis are neither complete nor marked enough for the condition to be referred to as a contracture. In all instances the deform- ity produced is the result of active mus- cular spasm, and in the severe cases it cannot be overcome by exercise of the patient's will, galvanization, or by the application of mechanical force. The contracture often persists during sleep, and is abolished only bj^ deep anaesthesia — a character distinguishing h^'sterical contractures from those due to organic disease. Hysterical contractures often last for months, or even years: and in cases of long standing, muscular atrophy and structural changes about the joints may establish permanent passive contracture from disuse. Highly characteristic of h^'sterical contracture is the patient's use of antagonistic muscles to prevent passive or active correction of the deformity ex- hibited. If, for example, the arm is semi- flexed by contractmre of the biceps, the triceps can be felt to contract and resist the movement when the attempt is made to flex the arm fmrther. A similar con- traction of the triceps can be felt or seen if the patient is asked to bend the joint for herself ; with the result that the joint remains unmoved, although all signs of great effort to bend the arm ma3^ be displayed. Pain and tenderness in the contracted muscles are usuall}' found ; and other hj^sterical stigmata such as hemiansesthesia, paraesthesia, cla\Tis or globus hystericus, and the hysterical temperament generall}^, will not be want- ing. Special forms of hysterical contracture may give rise to great trouble in diagnosis by imitating definite conditions or diseases. Thus a painful " hys- terical hip " or " hysterical knee " may pass on from surgeon to surgeon, until one is found to operate upon the normal joint for tuberculous arthritis ; hys- terical spasm of some of the abdominal muscles may lead to the diagnosis of pregnancy even in rovalties in search of an heir, when the condition is one of pseudocj'esis ; hysterical contracture of muscles in the neck or shoulder may f/g-. 43. — Volkinann's ischaemic paralysis following the use of an anterior splint for fracture of the bones of the forearm. Note the clenched fingers and the trophic sore on the forefinger. (Reproduced by permission from a paper by Mr. R. P. Rowlands in the Guy's Hospital Gazette. ) CONTRACTURES 167 be diagnosed as new growth, the palpable tumour vanishing only when the patient has been anaesthetized and is on the operating-table awaiting incision. Torticollis, which may be regarded as a functional disease, and is a form of tic, is characterized in its later stages by contracture of the affected muscles of the neck. Its clonic variety is easy to diagnose ; but where the spasms are tetanic (or tonic) rather than clonic, the diagnosis must be made from such conditions as cervical caiies, rheumatic myositis, or deep inflammation in the glands of the neck. Congenital torticollis dates from birth, usually affects the right sternomastoid muscle, and is often associated with facial asymmetry — when it is perhaps due to congenital defect of the centres in the bulb. The face is smaller on the side of the affected sternomastoid. 2. Passive Contractures are those due to affections of the bones, joints, or soft tissues, that mechanically obstruct correction of the deformities they produce. The contracted limbs can only be straightened by surgical measures, or by manipulations severe enough to rupture the obstructions. -/■VV 44. — Dupuytren's Contracture. Passive contractures often result from long continuance of the active con- tractures considered above, by a gradual process of transition : these will not be considered further. Passive contractures may result from the most varied local organic diseases of the affected parts. Dupuytren s Contracture of the palmar fascia, leading to deformity of the little and ring fingers [Fig. 44) is so characteristic that it can seldom be mistaken. It is prone to occur in gouty subjects and in those who use the palms of their hands most, as in the case of coachmen and those who use spades, etc. In diseases of the joints, such as rheumatism, rheumatoid arthritis, spondylitis deformans, tuberculosis, gonorrhoea, etc., the patient may lie in bed or go about for weeks or months in some bent or contorted position that involves the minimum of discomfort; ankylosis of the affected joints often results, from the gi'owth of adhesions, ecchondroses, or exostoses in and about the edges of the joints, that permanently limit their range of movement. Corres- ponding shortening will take place in the muscles that are relaxed, and a passive CONTRACTURES contracture results. The growth of a tumour in or about a joint may produce identical results. Traumatic or inflammatory^ lesions about the muscles or their tendons may establish inflammatory products locally that permanently limit the movements of these structures. Large superficial scars due to extensive burns or losses of skin and the superficial tissues, being composed mainly of fibrous tissue, maj" contract, and so bring about marked contractures (see Fig. 45). Fig. 45. — Cicatricial contracture after a burn. (From Professo hitroduction to Su}-gc?y.) Rutherford Morison's The diagnosis of the cause of a passive contracture will obviously depend upon the results of the physical examination of the affected part, and upon the success with which a true history of the onset and course of the case can be elicited. A. J. J ex-Blake. CONVULSIONS, or CONVULSIVE SEIZURES, are paroxysms of involuntary muscular contractions. They may be divided into two classes, according as they are local or general ; local convulsions have been considered under the heading Contractions, Spasmodic {q.v.), and the following account will deal mainly with general convulsions. The general convulsions without loss of consciousness that constitute Rigors are described under that heading {q.v.) ; with this exception, general convulsions are almost always accompanied by loss of con- sciousness, excepting in some few cases of partial epilepsy and of hysteria. In most cases of convulsions, both sides of the body — face, neck, arms, trunk, and legs — are convulsed equally. But it sometimes happens that though their cause is apparent!}^ a general one, the movements are unilateral or are much more marked on one side of the body than the other ; for present purposes such convulsions may still be termed general. Usually convulsions are clonic, less often tetanic or tonic. " Fits " may be defined roughly as any sudden paroxysms or seizures occurring in the course of any disease. In common usage, however, a " fit " is a convulsive fit, or fit of convulsions, and if unqualified, the term usually means an epileptic fit, but not always. Certain clinical features are common to almost all convulsive seizures in which consciousness is lost. If the onset is sudden, as it usually is, the patient is apt to fall down and injure himself unless already recumbent. If the muscles of the mouth and jaws are involved and saliva is freely secreted, the mouth foams ; if the tongue or cheeks are bitten, the foam becomes stained with blood. CONVULSIONS 169 Clenching of the jaws will make the breathing laboured, stertorous, and ineffec- tual. If the muscles of respiration are greatly affected, much cyanosis, with congestion of the face, neck, and exposed parts, will be observed. The convulsive movements are typically clonic, limited in range, purposeless, and accompanied by more or less rigidity. If the rigidity is marked, the amplitude of the move- ments will be correspondingly reduced, so that the condition may even become one of stiffness and tetanic (or so-called tonic) spasm. It is characteristic of epilepsy that the fit should consist of a brief tetanic stage followed by a longer stage of clonus. Control over the organic reflexes of micturition and defaecation is often lost, with the result that the bladder and rectum may be emptied involun- tarily. As a rule the reflexes cannot be obtained while the convulsions last, and are lost or diminished for some hours after they are over, or are unequal on the two sides of the body. When the fit is over and the patients have re- covered consciousness they often complain of headache and lassitude, showing diminished sensibility to all impressions, mental hebetude, and great sleepiness. Less often, the patient becomes excited or terrified after a fit, or even maniacal, and he may also exhibit automatism for hours or even days ; in none of these conditions will he be responsible for his actions. The duration of general con- vulsions is commonly to be measured in seconds or minutes ; but in severe cases they may go on for hours if untreated, and in the status epilepticus may last for days with only brief intermissions. Prolonged convulsions due to any cause may raise the temperature several degrees ; when they are unilateral, the temperature is raised more on the affected side than on the other. Albu- minuria after a fit is very common, and may last for a day or two ; it is in no way evidence that the fit was due to renal disease and uraemic in character. The morbid conditions in which local or partial convulsions, and in rarer instances general convulsions also, occur without loss of consciousness, have been sufficiently considered under Contractions, Spasmodic {q.v.), but for the sake of clearness may be recapitulated : — Fatigue Nervous exhaustion Habit spasm Spasmodic tic Myoclonus Hysteria Jacksonian epilepsy Chorea electrica (Henoch) Tetany Tetanus Hydrophobia Strychnine poisoning Malingering. The convulsions commonly accompanied by loss of consciousness will be considered here under the following heads : — I. General Convulsions of Infants and Children, seen in : — Hereditary syphilis Congenital heart disease Cerebral paralysis Onset of acute fevers Meningitis Drug poisoning Enlarged thymus Idiocy Rickets Epilepsy, minor and major. 2. General Convulsions of Adolescents and Adults, seen in :- Epilepsy, minor and major Jacksonian epilepsy Epileptiform convulsions — Uraemia Pregnancy Severe heart disease Asphyxia Stokes-Adams' disease Cerebral lesions : — Apoplexy Meningitis Intracranial growth General paralysis Chronic alcoholism Cerebral syphilis Hysteria Malingerins:. 170 CONVULSIONS Epilepsy, major and minor Jacksonian epilepsy Disseminated sclerosis. 3. Unilateral Convulsions, seen in : — Apoplexy Intracranial growth Meningitis I. General Convulsions of Infants and Children. — Among the commonest of all convulsive seizures are those occurring in children of tender age, known as infantile convulsions. The sexes are affected equally ; about a third of the cases take place during the first year of life, two-thirds during the first two years ; and they are rare, apart from epilepsy, after the age of five or six. They are of more serious import in infants under six months than in older children, and also in ansemic and weakly infants. In hereditary syphilis convulsions often prove fatal during the first few weeks of life. For the rest, in about half the patients rickets is the predisposing cause ; in many of the others some local irritation, such as inflammation of the gums in dentition, diseases of the nose or ears, the presence of irritating food or worms in the intestine, renal or vesical calculus, or phimosis, can be found ; while convulsions at the onset of acute infectious diseases, such as scarlet fever, pneumonia, measles, whooping-cough, or during their course, and in nephritis, are not infrequent. Overdosing with drugs — strychnine, atropine, santonin, morphia, etc. — or with alcohol, may bring on convulsions. Fright and over-strong emotions are included among the causes of infantile convulsions ; how far inheritance, the neurotic or neuropathic taint, is responsible for them is uncertain. They occur in children with enlarge- ment of the thymus gland, the so-called status lymphaticus, and in these not infrequently a fit has a fatal issue. Finally, it must be remembered that in any child they may be early evidence of epilepsy, or of organic disease of the brain. Their diagnosis demands a very careful examination of the child, and also of its diet and the hygiene of its daily life. They may be due to congenital heart disease, when there will be enlargement of the heart, a cardiac murmur or naurmurs, and some degree of cyanosis. In children with organic disease of the brain {porencephalus, congenital or acquired cerebral paralysis, spastic para- plegia, etc.) there will be paralysis, spasm, and muscular atrophy, and probably mental defect. If the convulsions are due to the onset of some acute infectious disorder, they will come on suddenly in a child previously well, and will be accompanied by high fever and followed by the characteristic rash ; a history of exposure to infection is often unobtainable. Similar convulsions and fever may occur in meningitis, usually towards the end of the disease. They are not rare in whooping-cough, particularly in rachitic infants, being precipitated by the asphyxia resulting from the whooping, and not rarely causing death. The diagnosis of fits due to drugs or alcohol, taken either by the child, or by the mother if the child is being suckled, will depend upon obtaining an adequate history of the case. In what way enlargement of the thymus brings about con- vulsions is not known ; the condition is fortunately rare, and is hardly ever diagnosed during life. The fits occurring in hydrocephalus and the various degrees of mental defect need only be mentioned. It is to rickets that one must look for the explanation of most convulsions occurring between the ages of three months and four or five years. The nervous system is unstable in all young children, the power of cerebral inhibition not being acquired for several years. In rickets this instability is much increased, and finds expression in irritability, fits of screaming, restlessness, the inability to sleep well at night, and in the more serious troubles of tetany, laryngismus stridulus, and convulsions. Any child with fits should be scrutinized for evidence of rickets — for exaggerated curvatures in the long bones, the rickety rosary, a Harrison's sulcus on the sides of the chest, the large and bulging rickety head, CONVULSIONS 171 thinness of the hair on the back of the head (due to head-rolling), a tumid and flaccid abdomen, lateness in the closure of the anterior fontanelle, and general muscular debility. Enquiry should be made for other symptoms common in rickets that will come under the observation of the mother or nurse — tenderness of the bones and skull on handling and washing, head-rolling due to tenderness of the skull, much sweating about the head in sleep, broken slumber, proneness to gastro-intestinal upsets, constipation and mucous stools or constipation alternating with diarrhoea, unusual liability to- coryza and bronchitis (or " catching cold "). The feeding and hygiene of the child must be gone into : in low life, rickets is mainly due to deficiency of fat and protein in the diet, with excess of carbohydrate food, whereas in high life the diet is more likely to err by lack of freshness due to too careful sterilization or to the use of patent foods ; rickety children all suffer from want of enough exposure to fresh air and sun- shine. But if rickets is the main predisposing cause of infantile convulsions, it must be remembered that they are actually brought on by some secondary exciting cause, such as a gastro-intestinal disturbance with diarrhoea or vomiting, or reflex irritation of an}- sort. Whether dentition is in itself enough to account for convulsions is extremel}^ doubtful, although that " teething-fits " do occur is one of the things that every woman knows. Epilepsy is one of the last causes of infantile convulsions that should be thought of, except when the fits occur for the first time in tolerably healthy children more than three or four years old. A bad family historj' of fits or of insanit}^ in the parents or the brothers and sisters would make epilepsy more probable ; so would the occurrence of an aura before the fit, and the division of the -fit into a tonic and a clonic stage, with biting of the tongue or cheeks. The repetition of fits for which there is no local or general cause, such as those described above, would be in favour of epilepsy, particularly if they extended over a long period of time. But one fit undoubtedly facilitates the occurrence of another soon afterwards, so that the recurrence of convulsions for a few days or weeks in a rickety child is not enough to justify the diagnosis of epilepsy. 2. General Convulsions of Adolescents and Adults. — The convulsions of epilepsy, including both the major and the minor forms, are very variable in extent and duration. In the minor degrees, or petit nial, there is usually brief tonic or tetanic spasm, with loss of consciousness, but without clonus or con- vulsions. In severer cases this is known as tetanoid epilepsy, a tetanic spasm convulsing the patient for some seconds, or even for a minute or two, with great risk of death by asphyxia. In partial epilepsy the convulsions are confined to part of the body — the face, perhaps, or the arms and face. Midway between minor and major epilepsy Gowers places '^ epilepsia media, in which there is muscular spasm of tonic character, without the clonic spasm which follows when the tonic spasm is more severe." In major epilepsy the typical picture is as follows : after experiencing an aura or warning of some sort for a few seconds, the patient is seized with a general tetanic spasm, cries out, and falls to the ground, this tetanic or tonic stage lasting for from five to thirty seconds. This then gives place to the clonic stage, or convulsions, with foaming at the mouth, and clonic jactitations that are often unequal on the two sides of the body. After a few minutes the clonus dies away and the patient is left comatose or stupefied, with a headache that is slept off in the course of the next few hours. Consciousness is always lost in true epilepsy ; the extent and duration of the convulsions, however, are highly variable. The fits of Jacksonian epilepsy are rarely generalized ; the condition is considered below. In true epilepsy there is no known organic lesion of the brain ; the loss of consciousness and the convulsions are due to some unknown functional disturbance of its action. But apparently identical fits may occur in the course of a number of diseases in 172 CONVULSIONS which organic lesions are present, either in the brain or elsewhere, and to these the name epileptiform convulsions is given. They are seen most often in urcBmia, in which the kidneys are severely diseased and toxaemia results ; the patient exhibits the characteristic picture of advanced renal disease, with headache, high blood-pressure, hypertrophied heart, albuminuria, probably retinal changes, and anaemia. It must not be forgotten that transient albuminuria is commonly present after fits due to any cause whatever. In the intervals between uraemic convulsions the patient may remain unconscious. The convulsions occurring in connection with pregnancy are known as eclamptic Ms, the condition as eclampsia. The majority of such convulsions come on before labour, some during labour, and 15 or 20 per cent during the first week after parturition ; any fits occurring after this are probably due to some cause — -uraemia, for example — other than pregnancjr or parturition. In many cases the fits occur suddenly and without any warning, or after no more than a brief period of headache or restlessness, or after vomiting. Eclampsia appears to be an auto-intoxication accompanied by a profound disturbance of the protein metabolism ; its primary cause is to be sought in the placenta, and it is brought about by the increased activity of the placental and other proteolytic enzymes. Its diagnosis can rarely be a matter of difficulty. There is nearly always albuminuria, and some observers regard puerperal eclampsia as one variety of uraemia. EpileptiforiTi convulsions may occur in severe heart or lung disease, and, indeed, in the terminal stages of many disorders, due in part to asphyxia, in part to toxaemia. Like certain obstinate infantile convulsions, they may often be stopped by the administration of oxygen to breathe. In Stokes-Adams' disease, epileptiform or apoplectiform convulsive seizures occur from time to time, no doubt due to the asphyxia and cerebral anaemia resulting from temporary cessation of the heart's action. The pulse is habitually slow in this disorder, beating about thirty times to the minute ; the cardiac auricles, on the other hand, beat at the normal rate. The patients are usually arteriosclerotic people in the second half of life ; if they are seen in their con- vulsions, the diagnosis of apoplexy will probably be made, only to be corrected later when it is found that the attack leaves no paralysis or paresis behind it, that similar seizures have occurred before, and that the pulse is slow. General convulsions due to direct irritation or to disease of the brain may occur in a large number of cerebral lesions, whether these are unilateral or bilateral, though, of course, most commonly in the latter case. In most of these there will be other well-marked signs or symptoms of disease, especially optic neuritis,- that should suffice to clear up the diagnosis. Such convulsions may be seen in meningeal, subdural, or arachnoid hcBmorrhage ; in meningitis due to the B. tuberculosis, Weichselbaum's meningococcus, or other microbes ; in cerebritis, or inflammation of the brain ; in congenital anomalies of the brain such as porencephalus, hydrocephalus, and the abnormalities met with in idiots and mentally defective children generally ; and in cerebral or cerebellar abscess, tumour, or aneurysm, when sufficient growth has taken place to raise the intra- cranial pressure generally. In another group may be placed those cases in which extensive degenerative changes have taken place in the brain ; fits are common in the second and third stages of general paralysis of the insane, when other signs, such as defective memory and judgment, grandiose ideas, inequality or reflex immobility of the pupils, blurred speech, tremors of the tongue and face, loss or exaggeration of the deep reflexes, and muscular weakness may be looked for ; in the insanity of chronic alcoholism, with its tremors and inco- ordination, its marked sensory perversions, and its paramnesia or illusions of memory ; and in cerebral syphilis, where the lesions may be either vascular, CONVULSIONS 173 gummatous, meningeal, diffuse, or a combination of any or all of these, and the main sjmiptoms are headache, insomnia, attacks of aphasia and hemiplegic or epileptifonn convulsions, paralysis of cranial nerves, and in addition dementia in the diffuse cases. Chronic plumbism may produce cerebral symptoms of the most varied kind {saturnine encephalopathy) , from simple headache to acute mania, and amongst the phenomena, convulsions of epileptiform type may be prominent. The diagnosis is based upon the history, the occupation, the other symptoms of lead poisoning, and perhaps upon analysis of the urine. Lastly must be mentioned the general convulsions of the hysterical and of malingerers. In hysteria, the fits are noisy and protracted performances, the movements are more or less purposive and quite unlike clonus ; the patient becomes red in the face rather than blue or white ; consciousness is not lost, attempts to open the eyes are resisted, pressure into the supra-orbital notch causes withdrawal of the head, the sufferer's hand is withdrawn if pressure is made between a nail and its matrix ; the sphincters are not relaxed, and the tongue or cheeks are rarely bitten. The convulsions are brought on by some emotional upset, and tend to cease when unsympathetically received. The malingerer may display no little art and skill in his convulsions, which are modelled on those of epilepsy ; here again, the sufferer is red in the face rather than blue, although he may breathe stertorously, and, with the help of a little soap, foam at the mouth ; consciousness is not lost, the corneal reflex is present, the head and hand are withdrawn from painful impressions ; the sphincters are not relaxed ; perspiration is usual ; it is said that in epilepsy, if the hands are clenched, the thumb is buried in the palm, whereas the malingerer clenches it outside the fingers ; and on the detection of its character, the simulated fit ends as suddenly as it began. 3. Unilateral Convulsions. — The convulsions in apoplexy are habitually limited to one side of the body. The onset of apoplexy, more often gradual than sudden, is generally preceded by headache, dizziness, and tingling or weak- ness in some part of the body ; and it is more marked in cerebral haemorrhage than in embolism or thrombosis. The loss of consciousness comes on earlier and persists longer in cerebral haemorrhage than in the other two conditions ; in all cases where it occurs — 50 to 75 per cent — it is brought about by cerebral anaemia. When the convulsions are prominent the case is described as one of epileptiform apoplexy. The diagnosis of apoplexy is discussed under Coma [q.v.) ; it is sufficient to say that cerebral hcBmorrhage is commoner in middle- life, in persons with high blood-pressure and hypertrophied hearts, and in the subjects of arteriosclerosis ; cerebral embolism is associated with endocarditis or intracardiac thrombosis, and occurs oftenest in young patients with heart- disease ; cerebral thrombosis is seen in syphilitic patients, and in those with vascular disease, and is characteristically of slow onset after premonitory warnings. In cerebral abscess and cerebral tumour convulsions are not very common, and usually appear only after the diagnosis has been made clear by the occurrence of such cardinal symptoms as headache, vomiting on change of position, optic neuritis (choked disc), and localizing signs pointing to intracranial tumour. But it may happen that an epileptiform fit with unilateral or bilateral convul- sions is the first sign that anything is wrong, or at any rate maj^ be the first thing that makes the patient consult a medical man. The headache that follows a convulsive seizure is likely to be very severe and prolonged if the fit is due to intracranial new growth or abscess, and vomiting and choked disc will probably be observed, with localizing signs. Of the two, cerebral abscess is the more likely in patients with chronic suppurative disease of the ear or nose, or of the facial and frontal sinuses. Meningitis — especially tuberculous meningitis in its 174 CONVULSIONS later stages — often exhibits unilateral or bilateral convulsions ; squint and other local paralyses, more or less coma or mental apathy, gastro-intestinal symptoms, Cheyne-Stokes breathing, and irregularity of the pulse and tem- perature, are likely to be noted in these cases. The unilateral convulsions of J acksonian epilepsy are rarely difficult to diagnose. The patient usually gives a history of head injury, and often a cranial scar or irregularity is to be found. There is no loss of consciousness during the attack, except in very severe and inveterate cases ; usually only one limb is involved, and an aura of some sort usually precedes the convulsions, which exhibit a characteristic " spread " — ^beginning in a single muscle or group of muscles, and spreading thence to the muscles whose cortical areas of representation adjoin that of the muscle first involved. In Jacksonian epilepsy there is almost always an irritative lesion of the motor cortex or its immediate vicinity, due to trauma, syphilitic meningitis, or new growth ; paresis or paralysis of the affected muscles follows the convulsions, and in the course of time becomes marked. The " spread " is frequently characteristic ; if the face is involved first, the arm follows, and then the leg ; if the hand is attacked first, the con- vulsions spread up the arm, then to the face, last to the leg. In the severer cases, where the whole side of the patient is convulsed, consciousness is lost, and then the convulsions may become bilateral. It is not often that unilateral convulsions occur in epilepsy or infantile con- vulsions, or epileptiform convulsions, and when they do there is a danger lest the diagnosis of apoplexy or some focal organic lesion of the brain be made. There is nothing in the character or distribution of the convulsions in these cases that enables a diagnosis to be made, and it is only after they are over, and when it is found that no evidence of organic cerebral mischief is left behind, that their functional nature can be established. They are not followed by any permanent paresis, paralysis, or atrophy of the muscles on the affected side. It must be remembered that unilateral convulsions, the so-called " apoplecti- form " convulsions, may occur exceptionally in a number of the conditions detailed under Group 2. In disseminated sclerosis, hemiplegic apoplectiform attacks like those seen in general paralysis are not rare, often accompanied by aphasia. These attacks are both transient and recurrent. The patients are likely to exhibit other evidences of disseminated sclerosis — a childish and optimistic mental attitude, optic atrophy, nystagmus, impaired articulation, intention tremor, undue muscular fatigability ; the deep reflexes are commonly increased, Babinski's extensor plantar reflex is present, sensation is but little affected, and control over the sphincters is rarely lost until late in the disease. A. J. J ex-Blake. CORYZA.— (See Discharge, Nasal.) COUGH. — Cough is a signal that something is irritating a branch of the vagus nerve or the cough centre, and is, in fact, nature's effort — often ill directed — to remove that something. Hence, to diagnose the cause of a cough it is necessary to know the branches of the vagus ; they are as follows : — 1. A small meningeal branch, of no interest as causing cough, though it may possibly account for vomiting in meningitis. 2. Arnold's branch to the ear — a cause of cough, though a rare one, due to affections (wax, eczema, etc.) of the external ear. 3. Pharyngeal branch — a frequent source of cough. 4. Superior laryngeal branch — sensory to base of tongue, larynx, etc., the most frequent source of cough, with or without visible changes. 5. Inferior laryngeal branch — motor for action of coughing, not a cause of cough, but of inefficiency and other peculiarities in the act of coughing. COUGH 175 6. Cardiac branches — indirect causes through circulatory failure. 7. Pulmonary branches — concerned in the cough of gross pulmonary or pleural diseases. S and 9. (Esophageal and pericardial branches — possible but most rare causes. 10. Gastric branches — occasionally dyspepsia causes a cough. The irritants to which the surfaces of the distribution of these nerves are exposed may be classified into : — 1. Foreign bodies,, e.g., dust, food, tobacco smoke, etc. 2. Excess of natural secretion. 3. Pressure and inflammation. 4. Acute or chronic simple debility or increased irritability, e.g., after influenza, etc. In dealing with the treatment, there is no better division of coughs than into those which are helpful and those which are not, and the same division is most useful in arriving at a diagnosis of the cause of a cough, for if the cough succeeds in its object — the removal of the offending material — we can see, or at least enquire about, its nature, and this will at once give a strong clue to the locality of the irritable point, and very possibly also to the morbid process going on. Hence the first questions to ask a patient with a cough are : " Do you bring anything up ? " " What do you bring up ? " Cough without Expectoration. — If the answer to the first question be, " No, the cough is just a troublesome dry cough with no expectoration at all," we at once begin to think of some of the purely reflex coughs produced by an irritant which the cough itself is powerless to remove, and though we may very often make a short cut to a diagnosis by other means of investigation, or observation of the general condition, the following routine should be followed if no prominent clue offers itself : — 1. Examine the external ear for wax, eczema, etc., although this is a com- paratively rare cause of cough, except in the special experience of aurists. - 2. Enquire whether any ordinary irritant, such as tobacco smoke, etc., brings it on ; this, of course, at once raises the suspicion that the nasopharynx or larynx is unduly sensitive, and should lead to a careful examination of the region, whereupon a cause may be detected directly, such as chronic inflammation of any sort, or a long pendulous uvula, somewhat oedematous, or showing other signs of acute inflammation. Conditions of undue irritability without anything to see occur after influenza or whooping-cough, and indeed remain long after the acute trouble has passed away from the regions ; therefore enquiry must be made for some such illness. Such a cough is often seen when convalescents go into a cold bedroom, or get into cold sheets at night. 3. Ask the patient to cough voluntarily ; the curious barking or rough cough of laryngitis and of pressure on the trachea from aneurysm or growth, also the very striking cough of paralysis of the vocal cords, at once betray themselves. 4. Examine the chest carefully for heart disease or early phthisis ; the cough of both these conditions is commonly dry ; so too is the cough of the early hours of an oncoming bronchitis or pneumonia, but these can scarcely fail to give other indications. 5. If no cause reveals itself by now, the stomach must be thought of, and its functional and physical conditions enquired into and examined, and only after negative results from all these enquiries and procedures may we think of a simple hysterical cough. Cough with Expectoration. — Expectoration generally makes the task of dia- gnosis much easier, and from the simple inspection of a spittoon it is frequently possible to make an almost complete diagnosis of a case : the very sticky sputum of any acute inflammation in its early stages, the rusty sputum of 176 COUGH pneumonia, the stink of abscess or gangrene of the lung and of bronchiectasis, the nummulation of phthisical sputa, the frothy sputum of bronchitis, are very commonly quite typical and unmistakeable. Small blood-clots make us apprehensive of early — but well-marked — phthisis, or of pharyngeal conditions ; streaks of blood point to acute laryngitis or bronchitis ; profuse haemoptysis almost diagnoses acute phthisis in the absence of signs of an aneurysm or growth. Pus is a factor common to all inflammations of mucous membranes, and there- fore in itself is of but little diagnostic value, though its quantity, colour, and odour may be very suggestive of abscess or excavation, or of an hepatic abscess ruptured into the lung, of gangrene, or stinking empyema. With hepatic abscess the sputum sometimes has an almost pathognomonic anchovy-sauce appearance. In any case of cough with sputum it is wise to have a microscopical examination of the latter, particularly for tubercle bacilli. The Age of the Patient. — In babies and quite young children most of the more unusual causes of cough can be at once excluded on the mere fact of age, but the presence of a foreign body in the larynx is one of the unusual ones to be remembered, especially if the cough has come on suddenly in the midst of health. Bronchitis, bronchopneumonia, tubercle, pneumonia, whooping- cough, and diphtheria, are far and away the most common causes in these young subjects, and owing to the absence of expectoration they do not reveal their presence without careful examination of the chest and throat. From infancy to middle life, the age of the patient, gives but little assistance in determining the dia- gnosis ; but about middle age chronic bronchial troubles, quiet pleurisies, growths, aneurysms, etc., become increasingly obtrusive, giving rise to a persistent cough, and only careful routine examination of the chest will reveal their presence. An enlarged caseous gland may be thought of in youth, but I doubt if it can ever be diagnosed certainly. How long have you had the cough ? Much information may be derived from the answer to this question, for a cough that has only lasted a few days, but in that time has become sufhciently severe to cause the patient to seek advice, is practically certain to belong to the group caused by acute trouble, easily detectable when the chest is carefully examined ; whereas, on the contrary, a cough that has lasted some months, and yet seems to the patient uncertain in its causation, is very likely to be due to some of the obscurer conditions, pressures of aneurysms or glands, etc., which need care to discover. The Rontgen rays are of considerable value in detecting thoracic aneurysms and new growths, and they are also of service in demonstrating phthisical and other lesions in many cases ; skiagraphic evidence must never be relied upon by itself, however ; it should always be interpreted in terms of the other clinical data and physical signs. When does the cough come on ? A cough in the morning only, is suggestive of bronchial catarrh with slight accumulation of secretion during sleep. A cough on getting into bed suggests laryngeal irritability or a long pendulous uvula ; but one that wakes the patient after he has gone to sleep makes one apprehensive of phthisis, in the absence of other indications of obvious acute chest changes. A cough on exertion suggests heart weakness, and in determining the presence of this, the finest discrimination is required in auscultation, for these are typically the cases of morbus cordis without a bruit in which frequency of rhythm and good differentiation of the first and second sounds are all important for a diagnosis. Shortness of breath will generally be a marked symptom associated with the cough in these cases (see Breath, Shortness of). Has the voice altered since the cough appeared ? Laryngeal inflammations or paralysis of a vocal cord are suggested by an affirmative answer, and the larynx must be carefully examined, the more carefully the more nearly the patient is approaching to the period of life when growths are more common. Fred. J . Smith. CRAMPS 177 CRACKLING, EGG-SHELL — This is a condition closely allied to Crepitus {q.v.) ; if subcutaneous emphysema, arthritis, and tenosynovitis can be excluded, it is nearly always a symptom either of osteosarcoma, if it occurs in connection with a long bone, or of hydrocephalus or craniotabes in the case of the occipital or other cranial bones. The ;ir-rays may often assist the diagnosis ; if there is a tumour connected with the end of a long bone which exhibits egg-shell crackling with or without pulsation, it is almost certainly an osteosarcoma. Herbert French. CRAMPS. — These are involuntary tetanic muscular contractions accompanied by sharp pain in the voluntary muscles involved. Temporary paralysis of move- ment, partial or complete, is often associated with cramp. Similar painful spasms of the involuntary muscles are referred to as colic. In most instances, cramps result from over-exevtion of the affected muscles. The cramp comes on at once, or after a short delay, or when the attempt is next made to use the muscles involved. The most striking example of this is swimmer's cramp ; in this the victim is suddenly overtaken by painful spasm and paralysis of the muscles of the leg or legs, or of the legs and arms. If in deep water he is likely to drown unless help is speedily forthcoming. Similar but less extensive cramps are not rarely experienced by persons taking part in the more violent of outdoor games — football, hockey, lacrosse, etc. In these, any particularly sudden or violent muscular effort may be followed by cramp in one or more of the thigh- or calf-muscles. Cramps of the legs are not rare in rowing men, whose pleasure it is to perform very heavy muscular work while seated in positions of great confinement and constraint. Ballet-dancers who are constantly on tip-toe are very prone to cramps in the calves of the legs. Certain people seem to have a great proclivity to cramp, which seems to return with less and less provocation the more often it is experienced. The diagnosis of cramps due to over-exertion, directly associated as they are with a definite history of muscular strain, should not be difficult. They rarely become so severe as to prevent their victims from continuing to take part in the occupations that provoke their occurrence. It is quite otherwise, however, with patients who are afflicted with the so-called professional cramps or occupation neuroses, that result from chronic strain and over-use of certain groups of muscles. They occur in such persons as writers, typists, telegraph operators, compositors, painters, tailors, seam- stresses, dairymaids (from milking cows), pianists, flute-players, violinists, 'cellists, drummers, blacksmiths, cigarette-rollers, and so forth. In all these employments, the muscles of the arms, forearms, or fingers are in constant and special employment. If they are overworked, they may become the seat of cramps and aching pains — professional cramps — as soon as they are used ; their movements lose their delicacy, and become inco-ordinated and spasmodic. A fine tremor is very commonly to be observed in the affected linab. It is probable that over-use alone is not enough to set up these cramps. Anxiety, ill-health, local injury or disease, and the inheritance of a neurotic temperament, all contribute to the establishment of professional cramps. These cramps have also been recorded in other occupations, and as affecting other groups of muscles : in treadler's cramp the hamstring muscles and glutei are affected ; in cornet player's the tongue, in watchmaker's the orbicularis oculi, may be attacked. As a rule, the diagnosis of a professional cramp is not hard, but it is necessary to make sure that neither organic nervous disorder nor local disease is present. Thus the physical signs, though hardly the symptoms, of writer's cramp may be present in such diseases as paralysis agitans, dissemin- ated sclerosis, tabes, general paralysis ; brachial neuralgia might simulate the neuralgic forms of occupation neurosis, but it is free from cramps. Again, D 12 178 CRAMPS affections of the joints or of the tendons at the wrists, such as chronic rheumatism, rheumatoid arthritis, tenosynovitis, tuberculous infection, may all give rise to pain in, and interfere with the movements of, the hand. Again, writer's cramp may be so much feared by nervous patients, that their right hand may become so stiff, or weak, or painful, that they can no longer write : objective signs of the cramp, however, are lacking in such cases, which are cured by the re- establishment of the patient's self-confidence. Cramps are the main feature of tetany, a disease characterized by the occurrence of paroxysmal or continued tetanic spasms of the extremities (see Fig. i, p. 3), and increased excitability of the nerves and muscles to electrical or mechanical stimulation. Tetany occurs in many different conditions, and at any age. In infants and young children it is a complication of rickets and improper feeding. In children it may result from acute gastro-intestinal disorders, either with or without diarrhoea and vomiting. Epidemics of tetany in young adults, probably resulting from food-poisoning, have been described as occurring on the Con- tinent, though not, apparently, in Great Britain. In nursing women, tetany may follow prolonged lactation ; or it may develop during pregnancy and recur in successive pregnancies. It may result from the removal of too much or all of the thyroid gland in either sex ; this may be regarded either as a consequence of thyroid insufficiency, or as evidence of parathjrroid insufficiency, for there can be no doubt that the parathyroid glands are lost when the bulk of the thyroid is removed. Tetany complicates a certain proportion of the cases of gastrectasis, occurring whether the dilated stomach has been washed out or no. A few instances are on record in which tetany followed the acute specific fevers, enteric fever, or poisoning by chloroform, lead, or ergot. In fine, it may be said that tetany is usually due to acute or chronic digestive troubles, the painful spasms being evidence of the absorption of some toxin from the gastro-intestinal tract in most cases. The cramps of tetany are mainly in the extremities and paroxysmal ; they may continue, however, for hours or days, and are very painful. During the spasms, the fingers are extended at the terminal and flexed at the metacarpophalangeal joints and pressed together, while the thumb is adducted and flexed into the palm, so that the so-called " accoucheur's hand " is produced. The wrist and elbow are flexed, the arms being usually folded over the chest ; exceptionally the elbow may be stiffly extended. The toes are drawn together and flexed, the foot is arched and turned inwards, and the ankles and knees are held extended. Usually only the limbs are involved ; but in severe cases, cramps occur in the face, neck, and even the trunk, when respiration may be seriously embarrassed. The rigid muscles are very tender to the touch. Three special signs are present in the intervals between the attacks of tetany, and are valuable in diagnosis : these are Trousseau's sign, or reproduction of the paroxysm by compression of the nerves or blood-vessels supplying the affected parts ; Erb's sign, or hyperexcitability of the motor nerves to electrical currents (o'5 to 2-0 milliamperes) ; and Chvostek's sign, or reproduction of the spasm in the facial muscles by tapping either on the muscles themselves or on the facial nerve. Tetany must be diagnosed from tetanus, in which the spasms begin in the head and neck, while trismus is an early symptom ; and from strychnine poisoning, where the spasms are clonic rather than tetanic, and affect the whole body and not the extremities primarily or principally. In the carpo-pedal spasms of rickety children or of infants with severe gastro- intestinal catarrh, the cramps are similar to those of tetany, but are transient, and perhaps affect the hands only, or the hands and arms. Such spasms may justly be regarded as identical with those of mild tetany. Hysterical tetany occurs, and is to be distinguished from true tetany by its association with other hysterical stigmata on the one hand, and on the other by the absence of Trousseau's CURSCHMANN'S SPIRALS 179 and Chvostek's signs. Hysterical tetany may also, perhaps, be distinguished by its failure to respond to the exhibition of calcium salts ; the most recent view of true tetany regards it as the expression of the hyperexcitability of the nerve- cells due to lack of calcium salts, and connects it with the parathyroid glands by supposing that they control the calcium-metabolism of the body. Reference may again be made to the fact that cramps are prone to occur in patients debilitated by the acute fevers or enteric fever ; severe cramps in the legs and arms are often a highly troublesome feature of the convalescence from cholera. In many chronic diseases nocturnal cramps may give rise to no little distress, or may interfere seriously with sleep : in gout, chronic Bright's disease, alcoholic neuritis, and almost any chronic wasting disorder, complaint of cramp is not infrequent. But in such instances more serious signs or symptoms of disease will no doubt have made themselves evident. A. J. J ex-Blake. CREPITUS is a term generally used to denote the grating or crackling sensation and noise produced when two ends of a broken bone grate together. It is the most conclusive sign of a fracture ; but it causes the patient so much pain that, whenever the x-rays can be employed, attempts to obtain crepitus should not be made with any vigour. Apart from fracture of a bone, crepitus is also to be felt and heard in joints affected by dendritic synovitis, or still more so in cases of osteo-arthritis ; the term " silken crepitus " has been used for the sensation felt on moving such a joint, comparable to the rubbing together between the fingers of two pieces of stout silken ribbon. Tenosynovitis, especially around the flexor tendons at the wrist, may also produce a very marked feeling of crepitus, especially in cases where the tendon sheaths contain melon-seed bodies. When there is an enlargement of a bone without fracture, and when on palpation a feeling of crepitus or egg-shell crackling is obtained, it is an indication that the tumour is a rarefying osteosarcoma, which may sometimes be felt to pulsate also. The diagnosis may be assisted by the use of the ;tr-rays (see figures in article on Swelling on a Bone). Rarefaction of the bones of the skull, either as the result of syphilitic lesions in adults, or of hydrocephalus or craniotabes, especially in the occipital region of congenital syphilitic and rickety infants, may make the skull bones so thin that they readily bend on pressure, and sometimes the result is a sensation of crepitus. The diagnosis is generally obvious. Quite apart from bony, arthritic, or synovial changes, a characteristic feeUng of crepitus may be felt beneath the skin when gas or air has accumulated in the subcutaneous tissues as the result of surgical Emphysema (q.v.). Herbert French CROSSED PARALYSIS.— (See Hemiplegia.) ^,. CRUSTS ON THE SKIN.— (See Scabs.) CUD-CHEWING.— (See Merycism.) CURSCHMANN'S SPIRALS consist of a highly re- fractile central fibre, and a sinuous wavy sheath of T^v;?- 46- -Curschmanns mucus {Fig. 46). They may be half an inch in length, spirals from asthmatic but they are very slender. Thev occur in the sputum ^'""'JT fTV''' . of patients suffering from true spasmodic asthma, and Methods, Dr. Herbert they may be associated with eosinophile corpuscles French.) and Charcot-Leyden crystals. They are best seen in fresh sputum, and are pretty objects ; but their diagnostic significance is very hmited, first because they are so often absent in cases of undoubted asthma, and secondly because they have been found in bronchiolitis without asthma. They seem to be casts 1 80 C URSCHMA NN' S SPIRA LS of the finest bronchioles. It is probable that^ if there were doubt as to whether a given case were one of primary emphysema and bronchitis, or of spasmodic asthma that had led to emphysema and bronchitis, the occurrence of t^-pical Curschmann's spirals would point to the latter. There are, however, other means of arriving at the same conclusion, particularly the historj^, the age at which the first attack began, and the presence or absence of Eosinophilia [q.v.) Herbert French. CURVATURE, SPINAL — In the diagnosis, the first thing is to distinguish between lateral and antero-posterior deformities ; but in a good many cases scoliosis or lateral curvature is complicated by antero-posterior deformity, kyphosis, or lordosis as well, and in a few instances of angular kj^phosis due to caries, there is some lateral deviation, Avhich is generally much more abrupt than is the curve of scoliosis. A good way of demonstrating lateral curvature is to pencil the skin over the spinal processes. Lateral Curvature. The following are the most important causes of lateral curvature : — 1. Inequality in the lengths of the lower limbs. 2. Weakness of the muscles of the back associated with bad habits of standing or sitting. 3. Carrying heavy weights with one arm or on one shoulder. 4. Rickets. 5. Paralysis of the muscles of the back, as in infantile paralysis, peripheral neuritis, especiall}^ that following diphtheria, and some of the muscular dystrophies. 6. Shrivelling of one side of the chest as the result of empyema or fibroid lung. 7. Wry-neck, or other causes of asymmetry of the head and shoulders, such as Sprengel's shoulder. 8. Hysteria. Inequality of the lengths of the lower limbs is one of the commonest causes of lateral curvature ; therefore it is very important to find out at once if the legs are equal. The most reliable and easy method of determining this is to get the patient to stand up with both knees straight and without resting a hand upon anything. The observer then stoops in front of the patient and places his thumbs, with their extremities upwards, exactly upon the prominence of each anterior superior spine. The eye can then detect the slightest difference in the level of the two spines. This method is far more reliable than measmrement from the anterior superior spines to the malleoli. Moreover, the latter method does not show the shortening that is due to the fiexion and adduction of the hip joint. Further, the foot may be fixed in a position of talipes equinus, which may make a short limb apparently longer than its fellow, so that the anterior spine on the corresponding side may be elevated. When the anterior spines are on a different level, the body leans towards the lowest spine, but in order to maintain the erect position, the upper part of the body becomes flexed to the opposite side. Thus, the spine in the lumbar region develops a curve with its convexity to the side of the short limb. Lateral curvature due to a shortened limb, in its early stages, is at once corrected by compensating the shortened limb, and it also disappears when the patient sits on a flat level surface. In the absence of inequality of the limbs, muscular weakness is by far the most common cause of lateral curvature. The spine does not become straight when the patient sits on a flat level surface ; but in the early stages of the deformity the shape can be somewhat corrected by muscular effort. Asymmetry of the chest following upon empyema or fibroid lung is easily CURVATURE, SPINAL i8i detected. The shrivelled side is generally less resonant on percussion, and there are other signs of pulmonar}^ disease. Scoliosis secondar\- to wry-neck is usually slight, and limited to the spinal and dorsal regions. In growing youths the carrying of heavy weights with one arm or upon one shoulder is a common and important cause of scoliosis, and it is therefore necessary to go into the question of occupation and habits. For instance, nursery-maids and butchers' boys are very apt to develop lateral curvature as the result of carrying burdens upon the right arm. The lateral curvature due to rickets is recognized by the unusually early onset, during the first or second year, and the signs of rickets in other parts, especially thickening of the lower end of the radius. The direction of the primary curve is sometimes explained by the pressure of the arm of the nurse who carries the baby too exclusively on one arm. Actual paralysis of the spinal muscles is a rare cause of scoliosis, and is to be recognized by the wasting of the spinal muscles, especially when this is more marked on one side. The sinking of the muscles due to rotation of the spine must not be mistaken for wasting. There is usually paralysis of other muscles, especially those of the leg. Scoliosis is often seen in the various primary muscular atrophies, and in Friedreich's hereditary ataxy. Peripheral neuritis as a cause is nearly always due to diphtheria or sore throat. The history may indicate this, or there may have been other post-diphtheritic paralyses, notably that of the soft palate^ with nasal voice and regurgitation of fluid through the nose. Cultivations should be taken from the throat, and the Klebs-Loffler bacillus (Plate XII, Fig. L) may be found if sought early enough. Occasionally the abdominal muscles may also be paralyzed in these cases, and this is a contributory cause of the curvature. Antero-Posterior Curvatures. These may take the form of (i) Kyphosis, (2) Lordosis. I. Kyphosis, or " hump-back," means a bending forwards of the upper part of the back on to the lower. The curve may be (a) Angular, and limited to a small portion of the back ; or it may be {b) Diffuse, or even general, extending from the coccyx to the cranium. [a) Angular Kyphosis. — The causes of angular kyphosis are : — (i) Tuberculous caries of the vertebrae ; (ii) Growth of the spine ; (iii) Hydatid disease of the vertebrae. (i). Caries is by far the commonest cause, and it is very important to recognize the disease before the deformity becomes well marked. Unfortunately, it may be treated for a long time as stomach-ache or intercostal neuralgia, because the pain is referred to the abdomen and the intercostal regions. During its active stages it is easy to recognize it from its classical symptoms and signs. The patient avoids all jerky movements, walks with a stooping gait, and grasps with the hands any convenient article of furniture. The spine is tender on percussion, also on pressure upon the head or shoulders. Local rigidity of the back is noticed when the patient attempts to stoop. In later cases, paralysis of the legs may complicate the deformity. In the quiescent stages, the diagnosis is based on the characteristic local deformity and rigidity. Skia.grams, especially those taken from side to side, may afford material help by showing evidence of destruction of the bodies of the vertebrae. In some cases, lateral curvature may complicate or follow caries, and then the diagnosis is not easy. The disease may have affected the bodies of the vertebrae unev-enly, leading to some lateral deviation, which is usually rather abrupt and associated with the local rigidity characteristic of caries. (ii). Growth of the spine is a rare cause of angular curvature. Rapidly developed curvature in a patient after middle age may be due to secondary I82 CURVATURE, SPINAL carcinoma in the bodies of the vertebras, and bearing this possible cause in mind, the surgeon should go carefully into the history, and examine every possible source of primary carcinoma, particularly the breast. Primary or secondary sarcoma may also lead to deformity of the spine, and in some cases an ;i;-ray examination may give evidence of the development of new bone in the growth, or of the absorption of the vertebrae. (iii) . Hydatid disease is a very rare cause of spinal curvature, and it is usually not limited to the spine. J^Jg: 47. — Osteitis deformans in a man. J^/g: 48. — Osteitis deformans in a woman. (6). Diffuse Kyphosis. — The back maj^ be bent forwards in a uniform curve extending from the coccyx to the cranium. This variety is common in rickets, owing to the premature assumption of the sitting position when the bones are soft and the muscles of the back are weak. When the patient is lying prone, the deformity can easily be corrected by raising the legs. Moreover, there are other signs of rickets, such as enlargement of the lower end of the radius, beading of the ribs, and delay in the eruption of teeth. A similar deformity arises from muscular weakness due to other causes, such as idiocy and congenital spastic paraplegia. In all of these there is an entire absence of rigidity of the spine. CURVATURE, SPINAL 183 An extensive and uniform curve, affecting the cervico-dorsal region is common during adolescence, and is due to muscular weakness, lazy habits, and the carry- ing of heavy weights. In its early stages the deformity is easily reducible, and as a rule is compensated by a marked lordosis in the lumbar region, and some tilting backwards of the occiput. It is often associated with lateral curvature, and in some cases may be partly due to shortness of sight. The condition is distinguished from caries by the diffuseness of the curvature, the absence of pain and local tenderness, and the comparative suppleness of the back. Kyphosis due to spondylitis deformans or to osteitis deformans {Figs. 47 and 48) is of a more uniform character without complicating lordosis, and the deformity is irreducible. There is generally evidence of the disease in other parts, such as osteo-arthritis, or the bending of the legs, and increase of the size of the head, which are due to osteitis deformans. Porters carrying heavy weights on the upper part of the back, prema- turely develop the kyphosis which is usually associated with old age. They frequently have a bursa over the seventh dorsal spinous process. 2. Lordosis, Hollow-Back This deformity is only common in the lumbar and lower dorsal region. The natural hollow of the loin is exaggerated, and usually there is either primary or compensatory kyphosis in the cervico-dorsal region {Fig. 49). Lordosis is rarely primary, but it may be so in the early stage of lumbar or lumbo-dorsal caries in children, when the real cause of the deformity is apt to be overlooked. The abdomen is very prominent, and the back is not only hollow, but rigid and tender. Pressure upon the head also causes pain in the back. In some cases the deformity is exaggerated by induration or suppuration in the psoas muscle, which complicates this disease. Lordosis is not uncommonly due to weakness or paralysis of the muscles of the back {Fig. 49). It is particularly important to look for other evidence of primary muscular dystrophy. The upper part of the back is then thrown backwards to facilitate the maintenance of the erect position. Lordo- sis is often secondary to the flexion of hip disease, which must not be overlooked. Limitation of move- ment — especially of rotation of the hip joint — and wasting of the thigh, serve to demonstrate the existence of this disease. Lordosis and the waddling gait may be the first indications of congenital dislocation of the hip. In this condition, which is almost confined to the female sex, the erect position is maintained only by throwing the shoulders backwards to an unusual degree in order to bring the trunk in a line with the heads of the femora, which are dislocated backwards. The suspicion of con- genital dislocation of the hip may be confirmed by skiagraphy, by the gliding movements of the head of the femur upon the pelvis, the unnatural width of the hips, the hollow appearance of Scarpa's triangle, and by palpation of the head of the femur upon the dorsum ilii when the thigh is flexed, strongly adducted, and inverted. Contortionists usually have a good deal of lordosis owing to the unnatural suppleness of the lumbar spine and the elongation of the hamstrings. In all these conditions, the back is supple, and 'can be restored to its natural shape by placing the patient in the supine position and flexing the thighs. R. P. Rowlands. Fig. 49. Myopathic lordosi.s. 1 84 CYAXOSIS, EXTREME CYANOSIS, EXTREME. — Extreme cyanosis, blueness, or lividitv, is generally most marked in the face ; next most clearh' in the extremities, especiallj' the hands, feet, ears, and penis ; and least marked in the trunk. Cases in which it is a prominent symptom maj* be divided into t:\vo main groups according as the cyanosis was present at or soon after birth, or occurred later in the hfe of a patient Avho was originally quite free from it. Congenital cyanosis of extreme degree is nearlj- always due to malformation of the heart, particularly pulmonary stenosis (Fig. 50). Patent septum ventriculorum may also produce the symptom, though not in so marked a degree, whilst patent ductus arteriosus, when it occurs by itself, is generally not associated with cyanosis at all. These three conditions ail give rise to loud universal bruits, of which that due to pulmonary stenosis is pureU' systolic, with its maximum intensitj^ in the second left intercostal space close to the sternum ; that due to patent septum ventriculorum is also sj-stolic, but has its maximum intensity lower down the sternum, usuall}^ between the tivo third spaces or fourth ribs ; whilst the bruit of patent ductus arterio- sus is not purely systoUc, but continues through both systole and diastole, with its maximum intensity at the time of the second sound, and it is best heard in the third left intercostal space, about half an inch out from the sternum ; all these bruits may or may not be accompanied b}- a corresponding thrill, the latter generally being least marked with patent septum ventriculorum. Extreme Club- bing OF THE Fingers [q.v.) and of the toes accompanies the cyanosis in most cases [Fig. 31, p. 129). In addition to these three tj^es of congenital heart disease, there are other cases in which extreme cj-anosis, with or without club- bing of the fingers, occurs without any definite bruits, and the diagnosis of the nature of the lesion can only be guessed at. There may or maj^ not be trans- position of the great vessels or of the \'iscera at the same time. Sometimes there is a single large vessel, the pul- monary artery coming off from the aorta ; or there may be only one ventricle, or a single auricle. It is almost impossible to decide between the various possible lesions, unless there is one of the definite bruits just described. Anomalous cases seldom survive, but some cases of pulmonary stenosis or patent septum ventriculorum survive to adult life, and patent ductus arteriosus often gives little inconvenience to the patient at all. It is to be remembered that patent foramen ovale is quite undiagnosable, that it causes no sj'mptoms, and is present in a large percentage of normal people. Cyanosis developing in children or adults who have hitherto been healthy, is generally due either to laryngeal obstruction, to lung lesions, cardiac failure, obstruction to the superior vena cava, or to some alteration of the blood itself, such as is found in splenomegahc polycythaemia, methaemoglobinaemia, sulph-haemo- globinaemia, or the later stages of diseases associated with extreme loss of fluid from the tissues, especially cholera maligna. The differential diagnosis is usually easy up to a certain point. The fact of laryngeal obstruction is generally obvious ^'M- 5^- — -■^ case of morbus coeruleus : con- genital pulmonary stenosLs with extreme c^'anosis. CYANOSIS, EXTREME 185 from the stridor, and from the way in which the larynx moves forcibly up and down with respiration. The cause of the obstruction may be less easy to deter- mine. In a child, a digital examination of the back of the mouth should not be omitted, lest there be a post-pharyngeal abscess or a foreign body ; in the absence of this, the most probable cause is diphtheria ; though it may be difficult to diagnose forthwith between laryngitis with intermittent spasm, laryngismus stridulus, acute obstructive laryngitis, and diphtheria. Swabbings should be taken from the throat as far back as possible, and examined bacteriologically. The Klebs-Loffier bacillus of diphtheria {Plate XII, Fig. L) may be found on direct examination of films stained by Neisser's method ; but sometimes they cannot be found until cultivations have been made, and this takes upwards of twenty-four hours. If there has been no obvious cause for catarrhal laryngitis, such as the inhala- tion of irritant gases or a recent attack of acute bronchitis affecting the large tubes, it is better to assume that the condition is diphtheria until it is proved not to be so. The occurrence of other cases in the same house, or in the neighbourhood, may assist the diagnosis. In an older person, acute suffocative laryngitis due to pneumococci or streptococci is associated with an extreme cyanosis of rapid onset. Tracheotomy is necessary, and the diagnosis is arrived at upon bacteriological grounds. It is difficult to inspect the vocal cords in a child ; but in an adult this is easier, and direct examination serves to distinguish between acute or ulcerative lesions of the larynx and laryngeal paralysis ; the, latter sometimes the result of syphilitic degeneration of part of the vagal centre in the medulla, is apt to produce bilateral abductor paralysis with adductor spasm, which may come on acutely and simulate acute asphyxia from a foreign body. Tuberculous, syphilitic or malignant, variolous, leprous, lupoid, and trau- matic ulceration of the larynx, may any of them become acutely infected by inflammatory organisms, and lead to comparatively sudden and severe laryngeal stenosis with acute cyanosis ; the diagnosis will depend in part upon the history, bacteriological examination, and direct examination of the vocal cords. Bright' s disease has sometimes caused similar symptoms, due to acute oedema of the larynx, and potassium iodide may do the same in those who are particularly prone to iodism. Knee-jerks should be tested, and the pupils examined, lest acute attacks of dyspnoea with cyanosis simulating laryngeal obstruction, are due to the laryngeal crises of locomotor ataxy. , Growths of the lung, particularly if they give rise to pleuritic effusion or to obstruction of a bronchus, may cause progressive cyanosis ; the diagnosis is not as a rule easy in the earlier stages, but if there is evidence of progressive inter- ference with the structures within the thorax, with ultimate stenosis of the superior vena cava, and the results of this, namely, oedema of the face and arms, together with cyanosis of these parts out of proportion to any similar change in the legs, the diagnosis lies between growth, aneurysm, and mediastinal fibrosis. The ;v-rays will sometimes be of material assistance in deciding. Phthisis, in the later stages, particularly when it advances rapidly and leads to generalised caseous bronchopneumonia, causes extreme cyanosis in some instances. The diagnosis will generally have been made long previously, from the symptoms, such as haemoptysis, cough, and wasting ; from the abnormal physical signs which started at the apices of the lungs and were progressive ; and from the discovery of tubercle bacilli and elastic fibres in the sputum. Pneumothorax [q.v.), when it comes on suddenly in a patient who has had no symptoms hitherto, leads to acute dyspnoea and cyanosis, which presently pass off ; the physical signs are pathognomonic, and the cause is generally tubercle. Embolism of the lung, if the artery occluded is of large size, may cause sudden death so rapidly that the patient hardly has time to become cyanosed ; when the embolus blocks a smaller vessel, lividity, dyspnoea, intrathoracic pain, and 1 86 CYANOSIS, EXTREME haemoptysis are the most prominent symptoms ; the diagnosis is suggested by the suddenness of the onset in a case in which there is a cause for embohsm^ particularly either thrombosis of a vein such as the femoral or iliac, or a recent surgical operation in the neighbourhood of a large vein such as those in the abdomen, or otitis media with a possibiUty of lateral sinus thrombosis, or a cardiac lesion such as infective endocarditis of the right side of the heart. There may be no abnormal phj^sical signs at all ; but when the embolus is large, it generally results in an infarct which may be detected by the impairment of percussion note, the deficient vesicular mumaur, and the development of a rub over it. In childhood, the commonest lung affection to produce extreme cyanosis is bronchopneumonia ; the diagnosis is generally obvious, though it is not alwaj^s easy to determine whether, in a case in which there is some evidence of laryngitis at the same time, the cyanosis is due mainl}^ to the laryngeal obstruction or to the intra-pulmonarjr lesions. Each may cause extreme sucking in of the intercostal spaces and convulsive movements of the chest as a whole ; but the best measure of the degree of larnygeal obstruction is the violence of the up-and-down move- ments of the larjmx itself. There may or may not be empyema associated with bronchopneumonia ; but the degree of cyanosis will not help to distinguish between these two ; exploratory^ needling of the chest will probably be resorted to when there is sufiicient clinical ground for supposing that empj^ema may be present. Severe bronchitis and emphysema in middle age often lead to very severe cj^anosis and orthopnoea, owing no doubt to the failure of the right side of the heart to w'hich the lung trouble gives rise. The over-distended condition of the chest, its great girth, its small difference between maximum inspiratory and maximum expiratory girths, the deficiency of the vesicular murmur, the occur- rence of sibilant or sonorous rhonchi all over, and perhaps non-consonating rales at the bases, w^ould indicate the diagnosis, particularly if the patient has inelasticity of the skin of the back of the hands, and has suffered from similar attacks for some years past, especially in the winter. The chief difficulty will be to determine whether the cause of the cyanosis is pulmonary or cardiac (see below). Lobar pneumonia, as a cause of acute cyanosis, is diagnosed chiefly by a historj' of sudden onset, the continuance of pyrexia for a week or ten days and ending by crisis, the rapid respiration-rate in proportion to the temper- ature, the viscid rust}' character of the sputum, and the herpes labiaUs. Sometimes the diagnosis is made when no abnormal physical signs can be detected ; but if over a large portion of a lobe there is at the same time impair- ment of note, with bronchial breathing, bronchophony, pectoriloquy, without rales at the height of the malady, but with fine crepitations at the beginning of the attack, and with redux crepitations as the bronchial breathing disappears after the crisis, the diagnosis will be obvious, especially if during the fever there is a great deficiency or complete absence of chlorides from the urine. Asthma is sometimes ver^^ difficult to distinguish from bronchitis and emphy- sema, because it ultimately gives rise to both the latter. It may produce extreme cj^anosis during an attack. Cardiac causes for extreme cyanosis include any of the conditions which lead to chronic failure of the right side of the heart. These may be classed into one or other of four main groups, nameh'' : primary valvular disease of the heart ; affection of the muscle of the heart or pericardium ; failure of the heart as the result of chronic lung lesions, especially emph^^sema, bronchitis, fibroid lung and bronchi- ectasis ; and cardiac failure when the heart is unable to maintain the high blood- pressure due to granular kidney or arteriosclerosis. When a late stage in the failure of compensation has been reached, it is often difficult to determine whether the primary condition is kidney, heart, lungs, or arteries ; the differential diagnosis between these is con.sidered on page i8. CYSTINURIA Cyanosis due to splenomegalic polycythemia is slowly progressive, and the diagnosis is arrived at by finding in the patient a big spleen with Poly- CYTH.^MiA (q.v.), and no other very definite lesion. Cyanosis due to inspissation of the blood as the result of loss of fluid from the tissues in fevers, such as cholera, dysentery, yellow fever or tj^phus, is a late symptom in a disease that will generally have been diagnosed upon other grounds. MethcBinoglobincBmia and sulph-hcBnioglobincBmia are diseases which have been grouped together under the term enterogenous cyanosis. Both are exceed- ingly rare. The tint of the skin is distinctive, and by itself suggests the diagnosis, being altogether different from that of ordinary cyanosis, and yet not to be mistaken for pigmentarj^ affections such as Addison's disease, argyria, ochronosis, or haemochromatosis. There is no polyc;^^h3emia. The diagnosis is established by spectroscopic examination of the patient's blood, a suitabh" diluted specimen exhibiting a well-defined absorption band in the red [Fig. 22, p. 95) in addition to the two bands of oxyhsemoglobin between the D and E lines [Fig 17, p. 95) ; the distinction between sulph-hasmoglobin and methsemo- globin is not easy except in the hands of experts in blood chemistry and spectroscopy. Some cases arise without any obvious external cause, and are to be distinguished from cases in which the blood-changes are directly attribut- able to the effect of taking chlorate of potash, anihne derivatives, and possiblv other drugs. Herbert French. CYSTINURIA is the term used to indicate the presence of cystin (Cj,H,. NSO._,) ., in the urine. The urine is usualty pale, turbid, and oily in appearance when passed, of a sUghtly acid reaction, with a pleasant aromatic odour resembling sweetbriar ; after standing, alkaline decomposition may take place, with the formation of sulphuretted hydrogen and a change in colour from yellow to green. It forms a light-j^ellowish deposit, which on microscopical examination is seen to consist of colourless hexagonal plates [Fig. 51). The condition is hereditary, and mereh' indi- cates a pecuUarit^^ of metabolism. The crystals have occasionally given rise to calcuh, which are of a light fawn colour when first passed or removed, changing to green when they are exposed to the air. Cj^stin is not dissolved on heating the urine or by adding acetic acid, but ^^^Ir-si-— Cystin crystal (high power), it is by mineral acids and by ammonia ; from the latter it can be recovered by evaporation : a chemical test that has been recommended is to boil some urine with acetate of lead and caustic potash ; if cystin be present, a dark precipitate should form, as the result of the formation of lead sulphide. The best evidence of the condition, however, is the discovery of the typical crystals in the urine microscopically. Herbert French. DEAFNESS. — This is the most constant sjmiptom of disease of the ear. It may be present in one or both ears, and may vary from a slight deficiency, which may be unnoticed by the patient, to a complete loss of hearing. The cau.ses of defective hearing are many. In some cases it can be easily relieved ; in others the prognosis may be absolutely hopeless. The organ of hearing consists of two main parts. The first is a conducting portion consisting of the external ear — external auditor}' meatus, tvmpanum. DEAFNESS drum and ossicles — the function of \vhich is to collect the sound waves and transmit the vibrations to the endolymph of the internal ear. The second portion contains the labyrinth, consisting of cochlea, vestibule, and semi- circular canals, in which are situated the terminations of the auditory nerve. Deafness maj' be caused bj' some lesion either of the conducting portion of the auditory apparatus, or of the internal ear, which contains the receptive mechanism. The latter — known as labyrinthine or nerve deafness — is the more serious and usually the more severe, but the former is much the more common. Rarely, deafness maj- be due to some disease of the auditory nerve or to some tumour of the brain involving the fibres of the nerve in their intracerebral course. Tests for Hearing. — In the examination of a deaf patient, a careful investi- gation of the sense of hearing is necessar}-, for two reasons : (a) To estimate the severity of the deafness ; (b) To ascertain whether the lesion is situated in the conducting apparatus, or in the labjTinth or auditor}^ nerve. Before carry- ing out these tests it is well to examine the external auditory meatus with a speculum, to make sure that the deafness is not due to the presence of a plug of cerumen, in which case elaborate hearing tests are unnecessary. The following are the tests usually applied : — 1. The Whispered Voice Test. — This consists essentially in noting the distance at which whispered words are heard. Vowel sounds are usually heard better than con- sonants. The examiner must culti- vate a whisper of uniform intensity, and the patient's eyes should be covered to avoid the possibility of "lip reading." Each ear must be tested separately', the other external auditory meatus being covered by a finger. 2. The Watch Test. — Here, the distance is measured at which the ticking of a watch is heard. The same precautions must be taken as in the voice test. The observer must first measure the distance at which it can be heard by a normal person. Suppose this to be 30 in., and the patient hears it at a distance of 12 in. The patient's hearing is then described as i=-. Instead of a watch, Politzer's acoumeter {Fig. 52), an instrument which produces a uniform tapping sound, may be used. 3. Tuning-fork Tests are of the greatest importance, since it is chiefly by these that labyrinthine or nerve deafness can be distinguished from deafness due to a lesion of the external or middle ear. In the latter case, the sound waves are obstructed on their way to the receptive apparatus, and cannot be heard when the fork is near to, but not in contact with, the ear ; whilst, if the base of the fork is applied to the mastoid process, forehead, or chin, the vibrations are readily heard, because thej' are now convej^ed to the normal receptive mechanism directly through the bone. In nerve or lab\Tinthine deafness, on the other hand, though the vibrations are transmitted by the bone, the sound is heard poorly or not at all, for the receptive apparatus is at fault and is unable to respond properly to the stimulus of the sound waves, whether they reach it via the external and middle ear, or through the bone. s acoumeter. DEAFNESS The tuning-fork used should be one which vibrates 256 times per second (C^). It should have a flat foot-piece {Fig. 53), so that it can be applied conveniently to the bone, and it may with advantage be fitted with a contrivance to prevent the occurrence of overtones. In addition, tuning-forks vibrating 64 times per second and 1028 times per second should be at hand, for testing the perception for high and low tones. In an elaborate investigation, still higher pitched tuning forks may be necessary. The following are special tests used in testing-bone conduction in a deaf patient : — 1. Rinne's Test. — The tuning-fork is struck lightly, and the flat foot-piece is held steadily against the rnastoid pro- cess. Directly the patient ceases to hear the sound, he raises his hand, and the fork is then held close to the external auditory meatus. If the sound is heard again, the result is positive ; if it is inaudible, the result is negative. The test may also be carried out by holding the fork opposite the external auditory meatus first, and then, when it is no longer audible, applying it to the mastoid. A useful modifi- cation of this test is for the examiner to wait until the fork is no longer heard by the patient through the mastoid, and then to transfer it to his own mastoid. In this way the bone conduction of the patient is compared with the bone conduction of a normal individual. 2. Weber's Test. — This is especially useful in unilateral deafness. The vibrating fork is applied by the flat foot-piece to the middle of the forehead. The patient is then asked in which ear the sound is heard best. If the deafness is in the external or middle ear, the sound will be best heard on the deaf side (positive) ; if due to a lesion of the internal ear or auditory nerve, it will be heard in the good ear (negative). Great care has to be exercised in this test to get the correct reply from the patient, as there is often unwillingness to admit hearing in the affected ear. 3. Gelle's Test. — The air-pressure is increased in the external auditory meatus by means of a Siegle's speculum. The vibrating fork is then applied to the mastoid, or to the middle of the forehead. In a normal person, bone conduction is diminished. When it is un- affected it is generally considered that the foot of the stapes is fixed. The hearing of high or low tones is ascertained by using tuning-forks of a rapid or low rate of vibration. Galton's whistle {Fig. 54), which produces very high notes, is also used for this purpose. To sum up, labyrinthine deafness is indicated when bone conduction is diminished markedly, i.e., when Rinne's test is positive and Weber's is negative. Generally speaking, in this form of deafness the perception of high-pitched sounds is diminished. Deafness due to some error in the conducting apparatus is indicated when bone conduction is good, i.e., when Rinne's test is negative and Weber's positive. There is also likely to be poor perception of low-pitched notes. In carrying out these tests, however, it must be remembered that, in a patient §'. 53. — Tuning-fork with foot-piece._ Galton's whistle. igo DEAFNESS over fifiA", bone conduction is normally' diminished, so that the tests are often inconclusive in an elderly patient. Deafness due to a Lesion of the Sound-conducting Apparatus. — ^WTien this is the case, the external ear or middle ear may be at fault. An examination with the speculum -w-ill readily reveal the presence of a plug of cerumeyj, polypi, or a foreign body, such as a mass of -wool, which is not infrequently inserted and forgotten b}- the patient. The cause of middle-ear deafness ^^-Ql be diagnosed by considering other symptoms which may be present, such as pain and tinnitus, together \\-ith an examination of the t^-mpanic membrane, and of the nose and naso-pharynx. Deafness is more or less marked in all inflammatory diseases of the iniddle ear, acute or chronic, suppurative or nonsuppurative. It must be remembered that there is not necessarily a correspondence between the intensity- of the deafness and the abnormal appearance of the membrane. The latter may be destroyed and hearing may remain fairly good, while with a small perforation, or in chronic non-suppurative otitis media, the deafness may be very profound. Catarrh of the Eustachian tube, or obstruction to this passage by the presence of adenoids or enlarged tonsils, is a common cause of deafness, especially in children. In some cases of middle-ear deafness, especially in otosclerosis, where the foot-plate of the stapes is fixed, the patient may hear ordinary speech better in a noisy place than in a quiet room. This is known as paracusis Willisii. In disease of the conducting apparatus, the patient, though deaf, not infre- quently hears his own voice very loudly, and also noises in the nasopharynx such as occur on swallowing. This is known as autophonia. HypercBsthesia acustica is a term applied when sounds produce an actual painful sensation in the ear. It may be present in acute inflammation of the middle ear, fevers, and migraine. In Nerve or Labyrinthine Deafness it is of the greatest importance to ascertain the cause of the trouble. It may be due to a lesion of the auditory nerve itself, -which may be involved in a growth of the temporal bone, or may show degenera- tive changes in locomotor ataxy. It may also result from a de fini te intra- cranial lesion such as a tumour of the mid-brain or pons. A diagnosis in these cases will be made from the coexistence of other nervous sxTiiptoms associated with cerebral tumour. In lab}-rinthine deafness the following actual pathological changes have been found : — 1. Degenerative changes in the organ of Corti. 2. Haemorrhages. 3. Organized inflammatory products. 4. Some cases are probably due to a rise in pressure in the endolymph. The follo%ving are the chief causes of lab^•rinthine deafness : — 1. Extension from disease of the middle ear, suppurative (pyo-lab}Tinthitis) or non-suppiurative (occasionally in otosclerosis). 2. Apoplectic deafness or ^Meniere's disease, which may be due to haemor- rhage or a sudden rise of intracranial pressure. 3. Following the specific infectious fevers, especially mumps, tut also influenza, t^-phoid, measles, scarlet fever, and others. 4. Sj'philis. In the acquired disease, deafness ma^" occur almost at any stage. The onset is usually sudden, and may have ah the characters of Meniere's disease. The trouble is usually unilateral. In congenital s\-philis the trouble usually begins between the ninth and sixteenth years. Eustachian obstruction and retracted membranes are fre- quently present, but the deafness progresses and is lab}.Tinthine in character. Other signs of congenital 5}-philis wiU be present to assist in the diagnosis. DEFORMITY OF THE CHEST 191 5. In Bright's disease, leukaemia, pernicious and other anaemias. A haemor- rhage is frequently the cause of the trouble here. 6. Certain drugs cause transient deafness of labyrinthine character : notably quinine, and sodium salicylate ; possibly alcohol and tobacco. Mercury and lead also are stated to cause deafness sometimes. 7. Traumatic. Labyrinthine deafness may follow blows, falls, or fracture of the base of the skull. 8. Occupations, such as caisson workers, or workers in a continuous loud noise (boiler-makers' deafness). 9. In certain diseases, such as meningitis, especially cerebrospinal meningitis ; and occasionally in epilepsy. Deafness may also occur in hysterical individuals. This may usually be recognized by the manner and aspect of the patient, and by the absence of any abnormal physical signs on examination. Lastly, it must be remembered that deafness is occasionally complained of by a malingerer. In this case the fraud is usually exposed by contradictory replies to hearing tests with the eyes bandaged, or by speaking into the chest- piece of a bimanual stethoscope with the tube to the sound ear plugged with wool. The probability is that the patient will say he hears words spoken into the stethoscope, but on removing this and covering the sound ear with the finger, he will say that he hears nothing. Philip Turner. DEFORMITY OF THE CHEST.— In considering the differential diagnosis of alterations in the form of the chest, it must be remembered that there are many slight deviations from its typical form which are not produced by disease. A long narrow chest {alar chest), or one flattened anteriorly {flat chest) is often found in persons predisposed to phthisis ; but these also occur in individuals who are never affected by this disease. A long neck and sloping shoulders are also associated with this condition, while a short, thick neck with high shoulders is found in persons subject to apoplexy. The alterations in the form of the chest which may result from disease are very numerous, and are best considered under the following headings : — (i). Deformities the result of rickets ; (2). General changes in the form of the chest : (a) The barrel-shaped, {b) Uni- lateral enlargement, (c) Unilateral shrinking ; (3). Local changes : (a) Bulging, (b) Retraction. 1. Rickets. — The following deformities of the chest in an infant are due to rickets. The chest is somewhat pear-shaped on transverse section, and a long vertical groove is often seen on each side of the sternum. Beading of the sternal ends of the ribs takes place, giving rise to the rickety rosary. The pigeon chest, in which the ribs are flattened on each side in front, so that the sternum becomes unusually prominent, making the chest appear somewhat triangular on transverse section, is always due to rickets {Fig. 57). Harrison's sulcus, which is a horizontal groove in the lower part of the rickety chest, is due to the sinking in of the ribs above the attachment of the diaphragm. This groove is exaggerated because the lower ribs are pushed out by the increase in size of the abdominal viscera. All these deformities of the chest are usually associated with other signs of rickets in the child, which make the diagnosis easy. 2. General Changes. — {a). The Barrel-shaped Chest is found in patients suffering from pulmonary emphysema {Fig. 59). The chest is enlarged in all directions, and gives the appearance which is assumed by the normal chest only after deep inspiration. The an tero- posterior diameter is greatly increased. The shoulders are higher than in health, and the intercostal spaces are enlarged and bulging, while the dorsal curve of the spine is exaggerated and the back rounded. The move- 192 DEFORMITY OF THE CHEST ments of the chest during respiration are extremely restricted on account of the rigidity of the costal ligaments, which become ossified. There is very little expansion of the chest during inspiration, but there is elevation of the chest as a whole. The epi-sternal fossa is deep, the clavicles stand out prominently unless the patient is stout, and the neck appears abnormally short. The apex beat of the heart cannot be felt, as it is covered by the lung. Vocal fremitus is diminished. On percussion, the note over the lungs is hyper -resonant, the cardiac dullness is greatly diminished and often obliterated, and the upper level of the hepatic dullness is lowered. The breath-sounds upon auscultation are enfeebled, and expiration is markedly prolonged. If bronchitis be present also, adventitious sounds are heard, especially sonorous and sibilant rhonchi, and coarse bubbling rales. The heart-sounds are obscured, the pulmonary second sound is accen- tuated, and there are signs of engorgement of the right side of the heart. ^./"^^ ~^^ [2% 2V^ \ \~-- 's/ Fi,s;. 55. — Rickety chest — child, aged 15 months. Fig. 57. — Pigeon chest — child, aged 14 months. Fig. 56. — Normal adult chest. i-''^-' ~^=*1 // U 5Vz ^ ^^ \ 1 , \ ; \ * 1 ^^ 1 1 / 1 / ; \ \ 1 * / / \^ , y J x:—-;'- _^-' },'ig_ 58.— Fibrosis of the left lung— man, Fig. 59.— Emphysematous chest, aged 30 years. Cyrtometric Tracings of Various Forms of Chest Transverse sections of various forms of chest at the level of the sterno-xiphoid articulation, reduced from cyrtometric tracings. The dotted lines indicate the natural shape at the same age. The figures represent the- measurements in inches. (Sawyer's Physical Signs, igo8.) Whenever any loss of symmetry in the two sides of the chest is found, the vertebral column must be carefully examined, as the alteration may be due to a spinal curvature. (5). A Unilateral Enlargement of the chest can be produced by an extensive pleuritic effusion, a large empyema, pneumothorax, and when an intrathoracic tumour affects the greater part of one side of the chest. The cause of the enlarge- ment is ascertained by the physical examination ; thus, with pleuritic effusion, either serous or purulent, the movements of the affected side during respiration are restricted, while those of the opposite side are exaggerated. Dullness is found over the effusion, while above the effusion the percussion note is usually of higher pitch than normal, and often skodaic. Vocal fremitus and resonance are DEFORMITY OF THE CHEST 193 absent over the dull area, and the breath-sounds are diminished or absent. .Egophony may be present at the upper level of the fluid, most frequently in the neighbourhood of the inferior angle of the scapula. The lung is compressed by the effusion, so that the breath-sounds are frequently tubular at the upper level of the fluid. The presence of the fluid is further confirmed by finding the heart pushed over to the opposite side, and the liver depressed when the right pleura is involved. When a pneumothorax is present, there is usually a history of a sudden onset, accompanied by a severe pain in the chest. The affected side does not move as freely as the other with respiration. The heart is displaced towards the opposite side, and vocal fremitus and resonance are diminished or absent. The note over a pneumothorax may be resonant, provided the distention is not great ; but if the distention is excessive, and the cavity contains serum or pus, in addition to air the note is usually dull or greatly impaired at the base of the lung, with hyper-resonance, but absence of breath-sounds above. When much fluid is present, the note changes considerably with the position of the patient. Signs of compression of the lung are present as in pleuritic effusion. The metallic tinkling of Laennec is heard over a pneumothorax, and coughing is generally required for its production. It resembles the sound which occurs when " a drop of water falls on the surface of a fluid contained in a half-filled decanter." The bell sound or the " bruit d'airain " is very characteristic of a pneumothorax. To hear it, auscultation is performed over a portion of the pneumothorax, and a coin is placed on another portion and is struck with a second coin ; the sound has a ringing metallic quality like that of the tinkling of a small bell, or like the ring that accompanies hammering upon a blacksmith's anvil. Hippocratic succussion may also be obtained when the observer's ear is applied to the chest, while the patient's body is shaken or jolted. (c) . Shrinking of the whole of one side of the chest is due to contraction of one lung, either as the result of a previous compression by a large pleuritic effusion, and especially by an empyema, or on account of fibrosis of the lung (Fig. 58). The history of the patient often indicates clearly the cause of the contraction of the lung ; a large effusion may have been aspirated, or an empyema may have been drained by surgical means, leaving the scar of the operation. In other cases, the empyema may have burst into the lung, and there may be a history of a large amount of pus having been expectorated. With fibrosis of the lung, the affected side is retracted and shrunken, the intercostal spaces are very narrow, and the ribs may even overlap. The shoulder is lower on the affected side, and the vertebral column is deviated towards the diseased lung. The heart is drawn over to the affected side, in which there is very little movement during respiration. If the left lung be affected, the heart wfll be less covered by lung than normally, and so there may be a large area over which cardiac pulsation is visible. The note over the contracted lung is dull, while on the opposite side it is hyper- resonant. The breath-sounds are deficient or absent, and may be tubular or cavernous, while at the base there are numerous coarse bubbling rales, especially if there is bronchiectasis. Vocal fremitus may be decreased or exaggerated. The expectoration is generally copious, semi-purulent, and often foetid. There is often marked clubbing of the tips of the fingers. 3. Local Changes. — {a). Bulging of any portion of the chest wall may occur, and be difficult of diagnosis. Sometimes its cause is quite obvious, as when an empyema points externally. Even this is sometimes mistaken for a localized abscess of the chest wall, but a careful examination reveals the fact that a large empyema is present. Local bulging and deformity are very common in rickets. In pulmonary emphysema, bulging is often present in the supra- clavicular and infraclavicular regions. Bulging may also be due to an intrathoracic tumour, to an aneurysm of the aorta, and to a tumour or abscess of the chest wall. D 13 194 DEFORMITY OF THE CHEST The most common situation on the chest wall for an aneurysmal swelling is to the right of the sternum in the first, second, and third intercostal spaces. An aneurj^sm may erode the upper part of the sternum and so produce a swelling there, while in rare instances it may produce a prominence on the left of the sternum. A bulging to the left of the vertebral column may be due to an aneurysm of the descending thoracic aorta. The expansile character of the pulsation which occurs in these situations proves the existence of an aneurysm. A tumour or abscess of the chest wall may occur in any situation. The praecordia becomes prominent in children in cases of pericardial effusion, or when the heart is enlarged, and the situation of the prominence indicates at once its cardiac origin. An enlargement of the liver may also produce a prominence of the ribs under which it lies. A hepatic abscess, a subdiaphragmatic abscess, or an emp3^ema, sometimes point over the lower part of the chest in front, while a psoas abscess may point over the lower ribs posteriorly. A prominence over the spinal column in the dorsal region may be due to spinal caries, or to a malignant new growth of the spine. An angular curvature of the spine is most commonly due to spinal caries, and any swelling which is associated with it may be produced by an abscess arising from the disease. Bulgings which give an impulse on coughing, and which wax and wane with respiration, suggest hernia of the lung, sometimes of considerable size, in marasmic children suffering from whooping-cough, or in emaciated phthisical subjects with incessant cough. {b) . Retraction or localized shrinking of the chest wall occurs in any condition in which there is a portion of lung contracted by disease. When present over one or both apices of the lungs, as shown by retraction in the supra- and infra- clavicular regions, it is nearly always due to phthisis, active, latent, or healed. It is also found in fibroid conditions of the lungs which are not tuberculous. After the absorption of a pleuritic effusion or the removal of the pus from an empyema, the lung is sometimes unable to expand, and a local shrinking of the chest wall occurs in consequence. j , e. H. Sawyer. DELIRIUM. — Sydenham's Dictionary defines delirium as raving, which does not help us much in diagnosis, for it draws no distinction between the casual delusions of a chronic lunatic while these are being verbally expressed, and the same delusions being verbally expressed by a patient severely ill with delirium tremens or typhoid fever. The definition is, however, comparatively immaterial, for in practical medicine the point to be decided is what has caused a given mental obfuscation, and not the particular form it may take. An overwhelmingly large proportion of such cases occur in the course of some well-known disease, commonly pyrexial, and beyond the fact that the condition itself in such diseases is a symptom of somewhat serious import, nothing need be said as regards the diagnosis. There are, however, a few prognostic points worthy of mention in connection with such cases. Thus, in typhoid during the height of the fever, in measles, and in scarlet fever, the delirium is commonly in proportion to the pyrexia in its violence, and can usually be controlled by controlling the pyrexia, if necessary ; in the later stages of typhoid, a low mutter- ing delirium is of very serious import. In pneumonia, on the other hand, some degree of delirium is an almost constant factor, no matter what the temperature may be, and its significance depends upon the previous (alcoholic) history of the patient, upon the violence or severity, and duration or persistence of the mental phenomena, which cause proportionate exhaustion. In rheumatic fever (unless due to salicylates, vide infra) delirium is of extremely grave significance, being commonly associated either with hyperpyrexia or with definite intracranial inflammation, neither of which is at all common. In influenza, too, it is a symptom causing great anxiety. DELIRIUM 195 The difficulties of diagnosis arise chiefly when we are called to a case of delirium of which we have no previous knowledge, where in fact our services are sought primarily because the patient has "gone off his head and is talking nonsense," and we must consider to what different factors this may be due. The following table embraces causes ordinarily met with. These may first be divided into those cases in which changes in the brain-cells are the primary cause, and those in which some poison circulating in the blood is the primary cause of the altered brain function ; this is practically accurate, though theoretically it is conceivable that the first class is really due to the second cause. The second group may be subdivided according to whether the poison is developed in the body {a) by its own activities, or {b) by microbic agency, or whether it is due to some definite chemical poison introduced into the body from without. Thus in tabular form we have : — Delirium due to intrinsic brain- ( Mania or lunacy in all its forms. cell changes or to pure nerve -. Pain, occasionaily so severe as to produce it. influences. i Shock, ditto. / Uraemia. ' T^ 1- ■ J , • ■ ■ Diabetes. Delirmm due to poison arismg { Anaemia in the body (autogenetic). ", poiycythaemia ? V Impending death from any cause. -ni„i;„-„^ ^, „ 4- „•„ 1,- Fevers of any and everv kind, known and Delirium due to microbic I , ^ xu ■' ■£. ■ u- unknown as to their specific microbic origin. Belladonna, hyoscyamus, and their allies alcohol and other less common intoxicants, i-i„i;r,-„™ A„r. j.^ „u„^;„.,i „ J. I anaesthetizing substances, and hvpnotics. Delirium due to chemical agents i t j j ^u i. 1 ' • n ^ ^ Lead, and other metals occasionally. Exceptionally, it arises from almost any poison or drug, most typically, perhaps, from artificial salicylate of sodium. activities. introduced from without. Like all other complete tables of diagnostic problems, the difficulties are much greater on paper than in practice, for in almost every case there is some one overwhelming and outstanding fact in the history which settles the matter off-hand. It is well, however, to have some fixed order of procedure laid down, which may take the following lines : — 1. Make strict enquiries as to anything unusual having been lately taken or applied. Medicines containing belladonna, drops put into the eyes, or some strange or unusual vegetable eaten, are the most likely things. 2. Enquire as to the recent health of the individual bearing on the urinary secretion, anaemia, etc. ; also enquire about incidents that might have caused shock, and incidents suggestive of a simple idiopathic mental disorder. 3. Take the temperature ; if materially raised it suggests some form of microbic influence, although in some, such as rabies, the pyrexia may not be great. 4. Note the pupils : if dilated and fixed, they suggest belladonna or perhaps alcohol — delirium tremens can hardly occur without a definite history of soaking," or an accident ; contracted and immovable pupils suggest uraemia ; unequal pupils, general paralysis of the insane. 5. Test the urine ; this will go far in clearing up urinary causes. Further details must be sought under the appropriate headings. 6. Note the skin, whether dry or sweating, whether flushed or pale ; in poison- ing by belladonna, etc., it is often dry and flushed ; if connected with other dangerous chemical poisons, it is commonly pale and sweaty. Fred. J . Smith. 196 DIACETURIA DIACETURIA — or the passage of diacetic acid in the urine — occurs under precisely similar circumstances to Acetonuria {q.v.). It only remains to mention- the following clinical test for diacetic acid : — To one inch of urine in a test-tube add liquor ferri perchloridi (B.P.) drop by drop. For a moment a white precipitate of iron phosphate forms, and then, if aceto-acetic acid be present, the liquid becomes deep purple-red, this colour being discharged on warming. If carbolic acid, salol, salicin^ or salicylates are being taken, the urine contains phenyl compounds which give a similar reaction with ferric chloride, but when the colour is due to these it does not disappear on warming. Herbert French DIARRHCEA. — Diarrhoea is a symptom which may be due to many different causes which it is important to differentiate if possible. It is convenient in the first place to divide cases into the two groups : (i) Acute, and (2) Chronic. 1. Acute. — The history is of great importance. It may elicit some indiscretion of diet (the eating of unripe fruit, etc.) , or the consumption of some toxic article of food {ptomaine poisoning). In such cases vomiting is often present as well. In toxic cases there is great depression, and a feeble and, perhaps, irregular pulse. If there be fever, one should think of an infective cause, such as summer diarrhoea (in children), typhoid fever, or dysentery. In the case of typhoid, enlargement of the spleen is an early confirmatory sign, but is sometimes absent ; spots should also be looked for. The presence of leucopenia may be of help, and the pulse-rate is low in proportion to the temperature. The agglutination reaction is not usually obtainable until the end of the first week. In dysentery there will be tenesmus, with blood and mucus in the motions. In the amoebic form, the Amceba coli may be found in the stools (see Fig. 12, p. 91). In the specific form, the blood serum agglutinates Shiga's bacillus. Similar symptoms to those of dysentery are produced by acute colitis, especially of the ulcerative form. It should also be remembered that in young children intussusception produces diarrhoea, with blood and mucus in the motions ; the characteristic sausage-shaped tumour should therefore be looked for, and a careful rectal examination made. The presence of any faecal colouring matter in the discharge usually negatives intussusception. Appendicitis may begin with acute diarrhoea, and the possibility of this should be borne in mind. In pernicious ancBmia and in Addison's disease, periodic attacks of acute diarrhoea are apt to occur. The other characteristic signs and symptoms of these affections will be present. (See Anaemia ; and Pigmentation of the Skin.) Finally, it should be remembered that even although diarrhoea is due to a new growth in the bowel, it may begin acutely, and a rectal examination should never be omitted. 2. Chronic. — In all cases of chronic diarrhoea the lower bowel should be carefully examined, preferably with the sigmoidoscope. This will enable one to exclude local conditions in the rectum, chronic intussusception, and catarrhal, or ulcerative colitis, as causes. A test-meal should also be given, for many cases of chronic diarrhoea are due to deficient secretion of gastric juice, or to its total absence (achylia) ; such cases are spoken of as gastrogenic diarrhoea. (See also Indigestion.) The stools should also be examined both with the naked eye and the microscope. In order to examine the stool a portion the size of a walnut should be rubbed up with distilled water to a fluid consistency, and examined with the naked eye against a dark background. Normally one sees a homogeneous fluid made up of very small dark-grey particles. In pathological conditions one may recognize mucus, pus, blood, parasites, the remains DIARRHCEA 197 of connective tissue in the form of yellowish-white shreds, brown muscle fibres, and the residue of potatoes in the form of glossy granules. For microscopical examination one prepares three specimens. The first is examined as it is ; to the second one adds a few drops of 30 per cent acetic acid and heats a little to dissolve fat ; to the third is added a little iodine solution. A normal stool shows in the first preparation a few muscle fibres, some yellow lumps of lime salts, and a few empty potato cells. In the second preparation, a few fatty crystals ; in the third a very few violet-tinted starch grains. In pathological conditions one may find in the first preparation many well-preserved muscle fibres, numerous fat droplets and fatty crystals, and abundance of potato cells ; in the acetic acid preparation, numerous masses of crystals of fatty acids ; in the iodine preparation, an excess of starch. In order to test for Bile, mix some of the stool with concentrated corrosive sublimate solution and allow to stand for twenty-four hours. Normally it turns red from the presence of urobilin ; greenish particles show the presence of unaltered bilirubin ; absence of green or red colouring shows that bile is not present at all. Reaction of the Stool. — A drop of the stool prepared as above by rubbing up with water is applied with a glass rod to a piece of moistened litmus paper. The reaction can easily be seen on the other side of the paper. A normal stool is nearly neutral ; marked alkalinity indicates putrefaction ; acidity shows carbohydrate fermentation. Test for " Occult " Blood. — The patient must have eaten no red meat for two or three days. A portion of the stool the size of a hazel-nut is rubbed up with 2 c.c. of distilled water in a mortar and placed in a test-tube. Add half its volume of glacial acetic acid, and shake. Then nearly fill the tube with ether, and reverse several times. To about one inch of the resulting yellow, translucent, ethereal solution, add : (a) a few drops of glacial acetic acid, (b) one inch of freshly prepared saturated solution of benzidin in rectified spirit, (c) one inch of liq. hydrog. perox. Shake, and pour a few drops on to a porcelain slab. If blood be present, a blue colour appears. White stools containing excess of fat point to disease in the pancreas (pan- creatic diarrhcea) ; blood and mucus, to some form of coUtis ; the presence of meat fibres and connective tissue in excess, to gastrogenic diarrhoea ; unaltered starch grains, to fermentative diarrhcea from mal-digestion of starch ; yellow stools con- taining microscopic particles of bile-stained mucus, to catarrh of the small bowel. If all these causes can be excluded, one may have to deal with a case of nervous diarrhoea, which is characterized by a tendency for the bowels to act immediately after a meal {lientery), and on excitement, or under emotional influences. A good many cases of so-called " morning diarrhcea " are of this type. The history, the presence of other evidences of nervous irritability, and the fact that the general nutrition is well maintained, all yield confirmatory evidence. In patients who have lived in the East the possibUity of sprue has to be con- sidered. The pale, frothy, and copious stools are characteristic, as well as the presence of a painful stomatitis involving the tongue and lining of the cheeks. If the indications point to a chronic catarrh of the intestine, phthisis (see Cough) cirrhosis of the liver (see Liver, Enlargements of), and renal disease (see Indigestion), should always be looked for, and the question of possible alcoholism gone into, as all of these conditions are apt to be attended by a chronic diarrhoea, which may be the first symptom to bring the patient to his doctor. Amyloid disease is a rare cause of chronic diarrhoea. There may be a history of prolonged suppuration, or of tertiary syphilis, and signs of amyloid disease in other organs (e.g., albuminuria, with a low gravity urine, enlargement of the spleen, etc.). One should also remember to enquire into the possibility of chronic irritant poisoning, e.g., by arsenic or antimony. Robert Hutchison. DIAZO-REACTION. — The diazo-reaction of Ehrhch is obtained in certain urines on testing them with the following solutions : — (i) Sodium Nitrite - - o'5 gram. \ (2) Sulphanilic Acid - - o'5 gram. Distilled Water - - 100 c.c. ' Hydrochloric Acid - '5 c.c. Distilled Water - - 100 c.c. A strong solution of ammonia is also required, and all should be freshly pre- pared. To a drachm of sulphanilic acid solution add a drop of sodium nitrite DIAZO-REACTION solution^ mix with a drachm of the urine, and add ammonia to excess. A normal urine turns brownish-yellow ; when the reaction is positive the mixture turns deep red, and, most characteristic of all, the froth produced on shaking the test tube is rosy red. It is often regarded merely as an obsolete test for typhoid fever ; but it occurs in a great many other conditions — as will be obvious when it is realized that it is merely an indication of abnormal protein metabolism, leading to the elimination of certain aromatic substances which react in this way to diazo compounds. The following are some of the conditions under which the diazo- reaction has proved positive : — Many fevers, such as diphtheria, erysipelas, measles, pneumonia, scarlet fever, typhoid, typhus ; cachectic states, such as advanced phthisis, cancer, cirrhosis, syphilis, malaria, grave anaemias ; and as the result of poisoning by certain drugs, such as chrysarobin, guaiacol, carbolic acid, or opium. Clearly a reaction which is found to occur under so many different circum- stances can have but a limited value. There are some who say that it has no value at all ; others, however, find it of clinical use in the following respects : (i) It is never normal ; (2) It is more constantly present in cases of typhoid than in any other fever, so that, other things being equal, the presence of the diazo-reaction may help in diagnosing typhoid fever, though the converse is not true ; (3) In cases of phthisis a positive diazo-reaction is a sign of ill-omen, whilst should the diazo-reaction disappear after it has been present, it is evidence of material improvement, even though the physical signs remain the same. Herbert French. DILATATION OF THE HEART.— (See Enlargement of the Heart.) DIPLOPIA, or double vision, may be either monocular or binocular ; that is to say, an object may be seen double either with one eye alone, or only when both eyes are open. To distinguish between the two conditions it is only necessary to close each eye in turn. If with either eye the object is still seen double, the diplopia is monocular ; if, on the other hand, the object is seen singly with each eye, and only seen double when both eyes are open, the double vision is binocular. Monocular diplopia may be due to : — (i) Dislocation of the lens; (2) Incipient cataract ; (3) Low degrees of astigmatism ; (4) Double pupillary apertures when the eyes are not in accurate focus. 1. In dislocation of the lens when its edge crosses the pupil, images of an object may be formed both by the rays passing through the periphery of the lens and by those passing beside it. Owing to the prismatic shape of the edge of the convex lens, the images will be cast on different parts of the retina, and diplopia will result. Dislocation of the lens may be recognized by the presence of the crescentic edge of the lens, which appears dark in the illuminated pupil, by tremulousness of the iris, and by irregularity in the depth of the anterior chamber. 2. In incipient cataract, especially the cortical variety, the lens may be broken up into sectors of varying refrangibility by radial striae, both opaque and trans- parent. In this condition diplopia, or more commonly polyopia, may result. A candle or other bright object appears double or multiple. The condition can be recognized easily on examination of the dilated pupil with the ophthalmo- scope. 3. Monocular diplopia is a fairly common symptom of low degrees of astigmatism, particularly where the curvature of the cornea is slightly irregular. Letters and test types are accompanied by faint " ghosts," placed either above or to the side of the real letters, and in some cases overlapping DIPLOPIA 199 them. The cause of this condition can be ascertained only by a careful examination of the refraction, and the diplopia is cured by the prescription of suitable glasses. 4. When the eyes are accurately focussed, a double pupillary aperture, whether congenital or traumatic, does not produce diplopia, all rays passing through either aperture being concentrated on the same spot. When, however, the eyes are not focussed accurately, two images result, one being formed by the rays passing through each aperture. Binocular Diplopia may be : — (i) Physiological; (2) Pathological. I. Physiological diplopia occurs unnoticed in all binocular vision, owing to the dissimilarity of the retinal images formed in the two eyes viewing the same object from a slightly different standpoint. The diplopia is not apparent, however, as the two dissimilar images are combined by the higher visual centres in the brain to form a single solid conception of the object viewed. The amount of dissimilarity in the retinal images gives the impression of space and distance, near objects causing images more unlike than those formed by things remotely F/'g. 60. — Homonymous double images. Fi,s:. 61. -Crossed double images. placed. The dissimilarity of the two retinal images in normal binocular vision, giving the idea of space, is termed in psychology " disparation " or " disparateness." When, however, owing to some failure in the centre which controls the fusion of the two ocular images, they are not combined, or when some disturbance of the accurately balanced muscular mechanism upsets the automatic fixation of the two eyes upon the same object, pathological or obvious diplopia results. 2. Pathological diplopia. — Before discussing the various forms and causes of this condition, it is necessary to have a clear idea of the process of visually localizing objects in space — projection, or orientation. In looking at any object the eye is so turned that the image falls upon the central point of the retina — the macula or yellow spot. All other objects form images upon the retina which are more or less peripheral, and from experience of such sensations and their locality on the retina, objects are accurately placed in space — projection. An image falling upon any particular portion of the retina will always be projected to the same point in space in relation to the 200 DIPLOPIA position of the eyes. In binocular vision, however, it must be remembered that images of the same object do not fall upon corresponding areas of both the retinas. The image of an object to the right of the two eyes falls upon the nasal side of the right, and the temporal side of the left, retina. These areas, which are symmetrically placed in the two retinse, are always stimulated simultaneously under normal circumstances by objects in the same position, and from these two images is derived the idea of the position of the object in space — orientation. Any disturbance of binocular vision causes diplopia. For example, in Fig. 60 the left eye fixes the object 0, while the right eye is rotated inwards. In consequence, the image of the object falls upon an area of the right retina, a, internal to the macula or fovea, /. Under ordinarj? circumstances, with parallel binocular vision, the object whose image fell upon the spot a would be to the right of the object O ; hence the right eye under these conditions projects the object to the position O', causing a diplopia in which the right of the two objects is seen by the right eye, and the left by the left eye. This is termed homonymous diplopia. Fig. 61 shows in a similar manner the formation of crossed diplopia. It will be seen from the figures that, in lateral deviations a convergent squint causes homonymous, and a divergent squint crossed, diplopia. In ocular paralyses the diplopia will increase if the two eyes are carried in the direction of the usual action of the paralyzed muscle. As an example, Fig. 60 may be chosen as a diagrammatic representation of a paralj'sis of the right external rectus muscle. The more the ej'es are turned to the right the greater will be the convergence, owing to the inability of the right eye to turn to the right to the same extent as the left ; the greater therefore wiU be the diplopia as the image of the object falls farther and farther round on the nasal side of the right retina, the object being projected farther and farther to the right. It will also be seen from this consideration that the farthest displaced image always belongs to the paralyzed' eye. The two images are not equally distinct. That in the unafiected eye falls upon the macula and is most distinctly seen ; this is called the real image. That falling upon the retina of the affected eye is more peripheral, and therefore not so distinctly seen, and is termed the false or apparent image. With the above considerations in view, and with a knowledge of the individual actions of the ocular muscles, it is easy to elucidate cases of simple paralysis of one or more ocular muscles, but for convenience of reference the chart giving the position of the images in paralysis of the various ocular muscles is repro- duced on the opposite page. Binocular diplopia may be caused, as suggested above, by paralysis of ocular muscles (see Strabismus), but it may also arise from the bodily displacement of one eye from an orbital growth, abscess, or kcsmorrhage. It may also occur after some operations for tenotomy. Cases of displacement of the eye can usually be distinguished from those of ocular paralysis by the indeterminate character of the diplopia, which is accom- panied by more or less fixation of the eyeball, and by proptosis. Isolated paratyses of individual ocular muscles or groups of muscles are nearh^ alwaj's nuclear in origin ; basal growths rarely cause ocular paralj'ses of any extent on one side only, the affection sooner or later becoming bilateral. In some rare cases of convergent or divergent squint with absence of binocular vision and good vision in each eye, there may be the power of alternate fixation with more or less evident diplopia. As a rule, however, the individual has the power of suppressing the image of the squinting eye, obtaining monocular vision. DISCHARGE FROM THE NIPPLE 20I I,eft-sided Paralysis. Behaviour of the Double Images in Paralyses of the Ocular Muscles. Right-sided The dotted lines repycsent the appare7it image. (After Fuchs). External Rectus. Diplopia appears in looking toward the paralyzed side. The lateral separation of the images increases as the paralyzed eye is abducted. Paralysis. Internal Rectus. Diplopia on looking towards the sound side. The lateral separation of the images increases in ad- duction of the paralyzed eye. Superior Rectus. « Diplopia on looking up. \ The vertical distance between the images increases as • the paralyzed eye is elevated and abducted. • The obliquity increases in adduction. The lateral separation of the images diminishes when the eyes are turned laterally in either direction. Inferior Rectus. Diplopia on looking down. The vertical distance between the images increases as the paralyzed eye is depressed and abducted. The obliquity increases in adduction. The lateral separation of the images diminishes when the eyes are turned laterally in either direction. Superior Oblique. Diplopia on looking down. The vertical distance between the images increases as the paralyzed eye is depressed and adducted. The obliquity increases with the abduction. The lateral distance between the images diminishes when the eyes are turned laterally in either direction. \ Inferior Oblique. Diplopia on looking up. The vertical distance between the images increases as the paralyzed eye is elevated and adducted. The obliquity increases with the abduction. The lateral distance between the images increases as the eve is elevated and abducted. DISCHARGE FROM THE EAR.— (See Otorrhcea. Herbert L. Eason. DISCHARGE FROM THE NIPPLE.— Discharges from the nipple may be divided into three classes : — (i) Normal discharges. (2) Normal discharges at abnormal times. (3) Abnormal discharges. I. Normal Discharges. — It is quite natural for a woman during the period of pregnancy and lactation to have a discharge of milk from the breast. It is usually of small amount, except when the child is put to the breast, but occasion- ally the flow at other times may be sufficient to be distressing. DISCHARGE FROM THE NIPPLE 2. Normal Discharges at Abnormal Times. — Milk may come from the breast at other times than during pregnancy and lactation. In infants it may be found as the result of undue stimulation on the part of the nurse, and it has been noted in the breasts of both sexes at the time of puberty. No great importance attaches to it. 3. Abnormal Discharges. — Blood or Blood-stained Discharge. This is a very significant sign and should not be neglected, for it almost always indicates the presence of some abnormal condition in the breast which requires careful investigation. The commonest is some growth involving the larger ducts in the neighbourhood of the nipple. This may be either innocent — a duct papil- loma ; or malignant — duct carcinoma, scirrhous carcinoma, or sarcoma. It behoves one therefore never to neglect such a significant sign. In cases in which a well-marked lump is easily felt, the diagnosis can usually be made without difficulty, and for this the reader is referred to the article on Swelling, Mammary. Difficulty arises when there is no obvious swell- ing. In these cases the breast must be palpated carefully with the flat of the hand and also with the tips of the fingers, special attention being given to the part immediately subjacent to the nipple. If no swelling can be made out, and the bleeding remains a persistent sign, it may become necessary to make an incision into the breast for diagnostic purposes, recognizing the fact that a papilloma may be so delicate as to escape detection with the finger. Probably the commonest cause of bleeding is a duct carcinoma (columnar- celled carcinoma), and after that duct papilloma and scirrhous carcinoma, and last of all sa,rcoma. A Purulent Discharge. — Acute suppurative mastitis. Now and again in this condition there may be a discharge of pus, or pus mixed with milk, from the nipple. This is rare, and the other signs of abscess are so well marked that there is no difficulty in arriving at a diagnosis. Tuberculous mastitis. A discharge of tuberculous pus is rare in this disease, but should it occur, this may help to distinguish it from carcinoma with which it is often confused. A Discharge of Serum. — Chronic interstitial mastitis with cyst formation accompanied by discharge of serum, is so rare as only to call for passing mention. Hydatid Fluid. — It has been recorded that a hydatid cyst has discharged itself at the nipple. George E. Gask. DISCHARGE, NASAL. — A discharge from the nose may be acute, subacute, or chronic, and it may consist of clear fluid almost like water, of mucus, muco-pus, pus, food regurgitated through the nose, or blood. For the differential diagnosis of the causes of haemorrhage from the nose, see Epistaxis. Regurgitation of Food through the Nose may be due to a congenital condition, especially cleft-palate ; to acquired perforation of the palate, especially syphilitic ; to post-diphtheritic paralysis ; or to much rarer neuro-muscular lesions, such as bulbar paralysis, pseudobulbar paralysis, or myasthenia gravis, all of which conditions are discussed elsewhere. Serous, Mucous, and Muco-purulent Discharges differ from each other chiefly in degree, for that which may begin as serous may later become muco-purulent and then purulent, as is seen during the course of a common cold. A watery discharge is sometimes spoken of as corj^za, though for the latter to be typical there should at the same time be watering of the eyes ; it is generally acute in onset, and the diagnosis of its cause is not difficult as a rule. It may be due to the following different conditions : — DISCHARGE, NASAL 203 Common cold, early stage {Micro- | Local irritants such as snuff, coccus catavrhalis) 1 ammonia vapour, sulphur di- Lachrymation Hay fever {coryza e feno) Measles lodism Arsenic oxide, and other irritating gases Fog Some cases of spasmodic asthma Some cases of trigeminal neuralgia. The differential diagnosis of these conditions needs little discussion, a careful inquiry into the circumstances of the case generally pointing to its nature at once. Measles probably presents the greatest difficulty, for the coryza precedes the macular eruption, and the patient, generally a child, may seem to be suffering merely from a severe cold, when in reality it is in the most infectious stage of measles. Examination of the buccal mucous membrane for Koplik's spots may sometimes serve to distinguish this malady as long as two days before the eruption appears. The coryza resulting from iodide of potassium or from arsenic may be very severe, and the patient generally complains of constantly catching cold, when in reality the symptoms are due to the drug. The term influenza is sometimes applied to severe febrile colds associated with running of the eyes and dripping at the nose, but it is often inaccurate to apply the term influenza here, for the symptoms are more often due to the Micrococcus catarrhalis. Bacteriological detection of the Bacillus influenzce in the discharge is essential if influenza is to be diagnosed with accuracy. Excessive secretion by the lachrymal glands apart from emotion may, in some instances, lead to constant dripping of water from the nose as the result of neurosi^. One rare form of watery discharge from the nose is the escape of cerebrospinal fluid ; this fluid is perfectly transparent, like water, and it may be difficult to recognize its true nature unless there is a clear history of the commonest cause for the symptom, namely, an injury to the head leading to fracture through the base of the skull, involving one of the anterior fossae. The fluid may drip steadily, at the rate of a certain number of drops per minute, and if it is collected in a test-tube it may be found to reduce Fehling's solution, though the reducing substance is related to pyrocatechin and not glucose, and therefore will not give the phenyl-glucosazone reaction. A purulent discharge from the nose may result from that which has been in the first place serous, mucoid, or muco-purulent ; or it may have been purulent from the beginning. If it is acute and bilateral, it is probably due to a local infection by some pyogenic micro-organism, and even when it may seem to be due to nothing more than a common cold, not a few different organisms may be discovered if bacteriological methods of diagnosis are adopted. Thus staphylo- cocci, streptococci, and pneumococci (see Plate XII) are associated not at all infrequently with the Micrococcus catarrhalis. Influenza bacilli may be found. In rare cases, especially when the purulent discharge persists longer than it ought if it were the result merely of a cold, and especially in cases in which the discharge is so acrid as to produce superficial excoriation and extreme soreness of the edges of the nostrils and the upper lip, diphtheria bacilli will be found more often than might be expected. Nasal diphtheria, indeed, is not altogether uncommon, but it is difficult to recognize except by bacteriological examination of the nasal discharge. The same applies to two very much rarer purulent lesions of the nose, namely those due to gonococci and to glanders. There may be a urethral infection or a vaginal discharge to point to the diagnosis in the former case, the patient having transferred gonococci directly from the genital 204 DISCHARGE, NASAL source to the nose by means of the fingers or a towel. Purulent rhinitis due to g'/aw^^ers is fortunately rare, though when it does occur it may entirely escape recog- nition in its curable stage unless the patient's occupation as a groom or horse- dealer suggests the source of the infection, or unless bacteriological methods' are resorted to in all cases of nasal discharge that are not perfectly straightforward. Chronic purulent nasal discharges are for the most part due either to lesions of the mucous membrane or to the emptying into the nose of purulent collections derived from an accessory sinus of the nose, the antrum of Highmore, frontal, ethmoidal, or sphenoidal sinus, or from necrosis of the nasal bones. The diagnosis may be obvious enough, but very often it is by no means easy. It is essential that both nasal cavities should be inspected directly in a good light by means of a speculum and mirror ; the various kinds of chronic rhinitis may be recognized in this way ; in chronic atrophic rhinitis the amount of discharge is usually small, the cavities of the nose are relatively spacious, the smell offensive (ozaena), and there are generally crust -like deposits upon the mucous membrane. Chronic hypertrophic rhinitis may also produce a very offensive smell, and a considerable purulent discharge, with difficulty or even inability to . breathe through the nose owing to the bulging of the inflamed mucous membrane. There may or may not be polypi at the same time, and perhaps adenoids and enlarged tonsils owing to the necessity for breathing through the mouth. Membranous rhinitis is not a distinctive variety, it being more or less an accident whether the inflaraed mucous membrane produces a membranous exudate or not ; the discovery of membrane would suggest diphtheria, but bacteriological examination alone can determine whether the lesion is diphtheritic or not. Syphilis is responsible for a large number of the cases of ozsena and chronic rhinitis, especially of the atrophic form, but it is not responsible for all, and the diagnosis as to whether the lesion is syphilitic or not will rest upon concomitant signs elsewhere, upon the history, and perhaps upon the result of Wassermann's reaction. Necrosis of the nasal bones, if it occurs spontaneously, is often syphilitic, but it may also be the result of injury, such for iastance as a blow upon the bridge of the nose at football ; the deformity which results from the falling in of the bridge of the nose is characteristic. -Tuberculous rhinitis is rare. Rhinoliths, although they may cause persistence of a nasal discharge, are not in themselves a primary condition, but rather the result of preceding rhinitis. Endothelioma, carcinoma, or sarcoma affect- ing the nose are not common except as the result of direct spread to its interior from the lip, jaw, cheek, or forehead. Sometimes, however, consider- able nasal discharge may result from the growth of a semi-malignant tumour known as recurrent fibroma or fibro-sarcoma arising from the external periosteum of the basi-sphenoid bone, thus affecting the back of the nose, and detected by a digital examination via the back of the mouth. A foreign body inserted into the nose by a child or by an insane person may produce considerable damage, associated with a purulent discharge, which may persist even after the foreign body has been detected by direct examination and removed. Lupus of the nose is hardly ever primary, and although it ma}'' destro}- the margins and lead to a purulent discharge from the nostrils, the diagnosis is generally clear from the apple-jelly deposits in the adjacent skin of the cheeks. Empyema of one antrum of Highmore may cause most troublesome purulent discharge from the rtose, but it is not altogether difficult to diagnose when the symptoms are definite. The patient generally complains that the pus invariably comes down one nostril ; that it is associated with an odour which is offensive to himself in a way not common with ozsena generally ; that he can often produce the discharge by tilting his head sideways in the opposite direction to DISCHARGE, NASAL 205 that from which the discharge comes, in such a way as would naturally tilt pus down through the opening from the antrum of Highmore into the nose ; and that he experiences dull aching pain in one side of the face, often spoken of as neuralgia, but upon investigation proving to be associated with tenderness located mainly in the corresponding superior maxilla. There may be a carious tooth or stump, particularly a canine, from which infection of the antrum may have taken place, though in a small number of cases a more serious cause for the empyema exists, namely, carcinoma or endothelioma of the antrum, which can seldom be diagnosed until either an operation is undertaken or the growth Fig^. 62. — Transilluminations of the antrum. A shows the normal appearance. B shows no illumination of right side, owing to purulent contents. (From Medical Annual^ 1906.) itself begins to cause a protuberance either into the nose or through the face ; the nature of these growths will be determined by histological examination. Examining the patient in a dark room by the introduction of an electric lamp into the mouth or posterior nares, may reveal empyema of the antrum by the transillumination of the superior maxilla of the normal side and the opacity of the other in which the antrum is full of pus (Fig 62). Empyema of a frontal sinus has generally been preceded by acute nasal catarrh, which has led subsequently to severe aching above one or other eye, with tender- ness on percussion over the region of the affected frontal sinus, and with so much pain in this region that the patient may be compelled to hold his head before he is able to cough or blow his nose, because of the increased pressure 206 DISCHARGE, NASAL within this sinus due to either of these acts. The condition nearly always starts acutely, though if untreated it may become chronic and come under observa- tion only when the infection has tracked its way through into the subcutaneous tissue, so as to point above the eye or in the angle between the latter and the nose. Suppuration in connection with the ethmoidal or sphenoidal sinuses can be little more than guessed at unless special skill has been acquired in the direct examination of these air-cells. If, however, there is a purulent discharge from the nose coming apparently from high up in a patient who has neither antral disease nor infection of the frontal sinus, and in whom local conditions of the mucous membrane of the nose itself can be excluded, infection of the sphenoidal or of the ethmoidal cells is to be suspected. Herbert French. DISCHARGE, URETHRAL. — Any inflammatory process in the urethra causes a discharge. Although in the greater number of cases a urethral dis- charge is the direct result of infection by the gonococcus, it does not necessarily follow that every urethritis is of this nature, and, with the present methods of bacteriological examination, it is found that other organisms besides the gonococcus may produce a urethral discharge and the same symptoms as an acute gonorrhoea. Further than this, a discharge may occasionally occur in which no micro-organisms can be found, as for instance, when the urethra has been subjected to irritation by the injection of strong solutions, trauma, or the presence of a foreign body, such as a calculus or a retained catheter. In these cases there is a purulent discharge of greater or less severity in which bacteria are at first absent, and which rapidly clears up on the removal of the causative element, or after the use of a few injections of a weak astringent lotion. It is stated that a urethral discharge may be associated with gout and rheumatism ; but although a few cases of the former have come under my care, I have been unable to prove that the small amount of discharge was not the remains of a former uncured urethral infection, or that it was directly due to the same source as the arthritic symptoms. There is no doubt that an acute urethritis may be caused by other organisms than the gonococcus, and sometimes there is considerable trouble in completely curing it. These cases may cause complications in the genito-urinary organs similar to those due to the gonococcus, such as prostatitis, epididymitis, or cystitis. They may arise by the infection of the urethra by septic instrumenta- tion or by connection with a patient the subject of a leucorrhceal discharge, so that if any doubt exists as to the nature of the discharge, a careful bacterio- logical examination should be made. It is important that the existence of a septic urethritis should be remembered, as more than once the reputation of a wife has been at stake until it was proved that the husband's urethritis was of a staphylococcal and not gonorrhoeal origin. Gonorrhoeal Urethritis is by far the most common cause, and is due to the infection of the urethra by a specific organism, the gonococcus of Neisser (Plate XII, Fig. R). In form it is a diplococcus with flattened surfaces approxi- mating each other ; it stains readily with basic aniline dyes, but differs from other diplococci in being decolorized by Gram's stain. The gonococcus is seen in a stained specimen to be intracellular, penetrating not only the leucocytes but also the epithelial cells found in a smear preparation, and, though the cocci may be found also between the cells, their appearance in the cells is strong evidence of their specific nature. In any case presenting a purulent discharge from the urethra, it is necessary, in order that appropi'iate treatment may be carried out, to ascertain the extent of the infection, not only in the urethra itself, but also in the other organs of DISCHARGE, URETHRAL 207 the genito-urinary apparatus. For the purposes of cUnical investigation, the urethra is divided into anterior and posterior portions, separated by the membranous urethra, the anterior comprising the bulbous and penile urethra, and the posterior the prostatic portion. A urethritis is also, according to its clinical aspect, acute or chronic, the acute form being characterized by a thick, creamy, purulent discharge, with pain, and the chronic by a thin, greyish, muco- purulent discharge. Acute gonorrhoea affects not only the superficial layers of the urethral mucous membrane, but also the subepithelial tissues and the glandular elements, causing a leucocytic infiltration. The tendency of the inflammation is to spread backwards along the canal, so that the prostatic urethra may become infected, even in the acute stage, though most frequently this occurs at a later period ; the prostatic and the ejaculatory ducts may become infected, and the inflammation may spread to the seminal vesicles, epididymes, or testes. In all cases of urethral discharge it is necessary to differentiate between an infection of the anterior and the posterior urethra. In the acute stages of the disease, the infection of the anterior urethra is accom- panied, as a rule, by redness of the external meatus, scalding pain during micturition, and painful erections ; occasionally all pain is absent, especially in patients previously infected with gonorrhoea. If the anterior urethra be irrigated with sterile water or saline solution, the urine passed immediately afterwards will be quite clear ; or without irrigating, if the urine be passed into two glasses, the first portion will be turbid from the admixture with the urethral discharge, wliilst the second portion remains clear. When the posterior urethra becomes infected in the acute stages, the symptoms are much more severe. Micturition is more painful and greatly increased in frequency, both during the day and night, the patient often being obliged to pass urine every half-hour. Even after irrigating the anterior urethra free of discharge, the urine passed will be turbid with pus that has accumulated in the prostatic portion or passed backwards into the bladder, and the terminal urine may be tinged with blood. In these circumstances it may be necessary to eliminate actite prostatitis or prostatic abscess, either of which may compli- cate an acute posterior urethritis. In either condition, micturition may be very painful, or there may be acute retention ; the temperature will be raised, and in cases of abscess there is often a rigor ; upon rectal examination, the prostate is found much swollen, hot to the touch, and extremely tender, whilst with an abscess, a soft fluctuating area may be felt. An acute posterior gonor- rhoea is practically always accompanied by infection of the bladder, and the diagnosis between it and cystitis is practically impossible. Under suitable treatment an acute urethritis may remain confined to the anterior urethra and clear up, but in less favourable cases a slight discharge remains. If this continues for longer than six weeks after the initial onset, it is spoken of as chronic gonorrhoea or gleet. The discharge is small in amount, thin and watery, or may be so slight as only to be present in the morning after a long period of freedom from urination, or as filaments in the urine. There is no pain or increased frequency of micturition, and there is no difference in the subjective symptoms between an anterior and a posterior infection, although in most cases of chronic gonorrhoea both are present. In any case of chronic urethral discharge, examination should be conducted to ascertain not only the seat of infection, but also the nature of the lesion promoting the discharge. Thus, the patient should be directed to hold urine for at least three hours before he presents himself for examination, when the anterior urethra may be thoroughly irrigated by a fairly forcible stream of sterile water, the urinary meatus being alternately occluded and opened during the process, so that the whole length of the anterior urethra is distended by the DISCHARGE, URETHRAL fluid. The washing is then examined for any threads, which, if present, must proceed from the anterior urethra. The patient is then directed to pass urine into two separate glasses, and these are again examined. If there is any Uu'bidity of the urine due to excess of phosphates, this is cleared b}- the addition of acetic acid, when, if any threads or plugs of muco-pus are present in the first specimen, they probably arise from the posterior urethra, whereas an}- pus or increased turbidity of the second, shows that cystitis is present in addition. If there be any threads in the posterior urethra, or if only a small amount of discharge is present, it is ad^i5able first to fill up the bladder with sterile fluid by direct Janet irrigation, after which the prostate is massaged by a finger in the rectum, and the patient is again directed to pass the fluid from the bladder. Plugs of muco-pus vnR be found if chronic prostatitis is present. In any case the threads from either the anterior or posterior urethra should be spread as a film, stained, and examined under a microscope for pus and micro-organisms. If the remaining infection is found to be limited to the anterior urethra, the latter should be examined under direct ^•ision by the endoscope. A few minims of a 3 per cent solution of cocaine are injected into the urethra and, with aseptic precautions, the largest sized endoscope tube that the meatus will admit com- fortablv is passed for about an inch. The canal is then illuminated, and at the same time distended with air by means of the inflating bellows attached to the instrument ; the whole length of the anterior urethra can then be brought into \-iew, and each part examined successively as the endoscope tube is passed gradually on until the membranous portion of the canal is reached. It will be found much better to examine the urethra in this manner than by first passing the instrument to the full extent and examining the canal as it is gradually withdrawn, for any infection of Littre's glands, infiltration of the urethral walls, or granular areas are observed under aero-distention before the instrument has passed over it. Where the whole length has been examined under distention, the air is allowed to escape by opening the window of the instrument, and the canal again examined from behind forward by gradually ■withdra^wdng the tube, normal urethral walls falling together in a characteristic striated manner, which is altered into a shght rigidity by infiltration, whilst at the same time glandular infection or ulceration is again seen. Similarl}-, a definite stricture or a small poh-pus which may keep up a slight urethral discharge can be diagnosed with certainty, and any local treatment for the various lesions appUed. By a careful examination conducted on these lines we are able to determine, not only which part of the urethra is producing the discharge, but also the nature of the lesion, so that appropriate treatment can be carried out. In the majority' of cases in which a gleet remains in spite of treatment with various kinds of injections, it wiU be found that there is an infection of the posterior urethra or prostatic ducts, which no urethral injection except a complete irrigation into the bladder will reach. There is often no abnormality to be detected "on digital examination of the prostate in the rectum ; but after urethral irrigation, the secretion squeezed out from the prostate by massage will usually show pus corpuscles in addition to the refractive globules and epitheUum which are contained in the normal prostatic secretion. In other cases of obstinate chronic urethritis, a distinct infiltrative process will be found in the anterior urethra, a process which results in rigidity of the urethral wall, and in severe cases leads on to stricture. The urethral glands are implicated, and their secretion gives rise to the filaments in the urine. This infiltration is seen readily by urethroscopy, but it may be imperceptible on the passage of a sound. The urethral meatus is the narrowest part of the canal, and a sound which will completely fill the meatus may still pass readily through an DISCHARGE, URETHRAL 209^ infiltrated portion of the urethra, even when its normal calibre is considerably diminished. In spite of all forms of treatment, a slight urethral discharge occasionally remains, and the physician may be asked if any infection remains, or whether a patient may be allowed to marry. A chronic urethral discharge may contain gonococci or may be entirely free from any organisms. Obviously, if any gono- cocci are found, the discharge is still infectious, but there is often difficulty in detecting the organism in these chronic cases, whilst in some they may be found if any slight exacerbation of inflammation occurs. Other cases again, show a chronic urethral discharge which resists all treatment, but which contains a few pus and epithelial cells, though no organisms can be found. That pus cells are present in this small urethral discharge is no detriment to marriage, provided that no gonococci can be found, and in practice, if no cocci are found after irritation of the urethra by irritant injections, instrumentation, or the free use of alcohol, on several successive examinations, marriage may be permitted. A urethral discharge may in rare cases be present in other conditions than that produced by gonorrhcea or septic urethritis, and as difficulty may arise if one- of these cases be met with, it is necessary to mention them. Herpetic Urethritis. — The mucous lining of the urethra is undoubtedly affected' by herpes in the same manner as other mucous membranes, frequently as a tertiary lesion of syphilis. There is irritation of the urethra during mic- turition, and a slight muco-purulent discharge from the meatus. The small vesicles may be seen by the endoscope, and may be associated with herpes of the prepuce. Soft Sores in the Urethra are distinctly uncommon. They occur in the terminal portion of the urethra, and cause painful micturition and a profuse, thin, purulent discharge, which contains no gonococci. There may be other sores on the glans penis, and an ulcerated surface will be seen readily on endoscopic examination. They occur within a few days of infection, and, if extensive, may produce narrowing of the urethra on healing. Syphilis may affect the urethra either as a hard chancre or as a gumma. The Chancre occurs in the anterior end of the urethra, forming a firm induratecT. mass which can be felt readily on external palpation. The meatus is oedematous'. and swollen, so that the introduction of an endoscopic tube is impossible ; there: is a thin, purulent, and often blood-stained discharge from the meatus. A urethral chancre must be diagnosed carefully from peri-urethral infiltration, due to urethritis ; the period of incubation from the time of infection, the- presence of small, hard inguinal glands, the occurrence of secondary lesions- of syphilis, and Wassermann's serum test will point to the diagnosis. Gummata of the urethra give rise to a watery urethral discharge when they break down and cause ulceration. They may ulcerate through the canal and! form fistute, but may usually be recognized on careful examination. Papillomata of the Urethra may occur either in the anterior or posterior portion, as small, pedunculated tumours in the canal, and frequently as a sequel to a chronic gonorrhoea. They may arise, however, in the urethra of a patient who has never had urethritis. They cause a thin, scanty discharge, which does not yield to injections ; they are readily seen through the endoscope. Carcinoma of the urethra is very rare as a primary disease, and in the few cases recorded has been in association with stricture. It forms a tumour in the urethra palpable from the exterior, and causes painful micturition with a blood-stained discharge, and enlargement of the inguinal glands. Suspicion of carcinoma should arise if a hard, irregular tumour be felt in the course of the urethra, without any gonorrhoeal infection, in an elderly patient. D 14 DISCHARGE, URETHRAL Tuberculosis of the Urethra is always secondary to disease elsewhere in the genito- urinary tract, usually of the prostate or seminal vesicles. Foreign Bodies in the Urethra ma^^ cause a purulent urethral discharge if they remain in the canal for any length of time. They may be introduced through the meatus by intent — matches, pins, etc. ; or a piece may be detached from a damaged catheter ; or a small calculus may be passed down from the bladder and become arrested. In the latter case the history is usually clear — sudden stoppage of the stream of urine during micturition, with penile pain ; a calculus mav be felt from the exterior or seen through the endoscope. r, h. Jocelyn Sic-an. DISCHARGE, VAGINAL. — In order to recognize the varieties of pathological vaginal discharges, it is first important to realize what the normal secretions found in the vagina consist of. The secretion normally present must be a mixture of those from the uterine body, cervix, and vaginal wall. That from the uterine body is watery- and small in amount, whilst that from the cer\dx is thick and mucoid, but clear and transparent, like unboiled white of egg. The vaginal secretion is merely a transudation of plasma from the vessels, mixed with desquamated vaginal epithehum, and in virgins looks like unboiled starch mixed with water. Naturally it is very small in amount. The bulk of the secretion found in the vagina comes from the cervix, because there are far more glands there than in any other part of the genital tract. The secretion from Bartholin's gland, which is thin and mucoid, may be copious under sexual excitement, but under normal conditions is absent, and so does not contribute to the secretions in the vagina. The vaginal mixed secretions are acid in reaction, owing, according to Doderlein, to the presence of lactic acid produced by a long bacUlus which is normally found in the vagina. On the other hand, the unmixed uterine secretions are alkaline, distinctions which liave been clearly pointed out by Gow. Normally, the amount of mixed vaginal secretion should do no more than just moisten the vaginal orifice. When the amount is so great as to moisten the \Tilva and consequently stain garments, the secretion is pathological. The composition of an abnormal secretion varies considerablj" according to the source from which most of it comes. The commonest t3^e is the thick white or yellow discharge associated ^rith inflammatory changes in the cervix. It contains a large proportion of mucus, many leucoc3^tes, masses of shed epithelium from the vagina (" squames "), and bacteria of various kinds. This is quite typical, and is produced by endocervicitis and cervical erosions of the various kinds. When, however, there is a corporeal endometritis present as well, the discharge becomes thinned, white, or vellow, on account of the admixture of much watery secretion from the body of the uterus. The yelloAv colour is due to the admixture of red blood corpuscles, and in some cases the fluid may become actually blood stained. Menorrhagia accompanies these discharges, and serves to distinguish a mixed corporeal and cervical endometritis from a simple cervical catarrh. Micro- scopically the films made from the mixed cases show proportionately less mucus, but otherwise the constituents are the same. Vaginitis rarely exists alone, but when it does occur, the discharge is thick and past%- if it is a simple catarrhal condition : past^^ on account of the large admixture of desquamated vaginal squamous epithelium. On the other hand, in granular catarrhal vaginitis, the discharge is much more purulent and copious. owing to the exudation of more fluid from the exposed blood capillaries. This is the kind of discharge associated with traumatism of the vagina, especially from the irritation of badly-fitting pessaries, and actual ulceration as in decubitus DISCHARGE, VAGINAL ulcers on prolapsed portions. Practically no mucus is found in such discharges unless the cervix shares in the inflammatory process. There is nothing characteristic of gonorrhceal discharges to the naked eye or on simple microscopical examination. The detection of the gonococcus alone can decide the question. This is often a matter of great difficulty, because it is only in the few days immediately after infection that the gonoccocus can be found free in the vaginal discharge. In chronic cases, the gonococcus must be looked for in two places, either the interior of the cervix or in the urethra and Skene's tubes, which open by the sides of the meatus urinarius. The best plan is to take some discharge from within the cervix, after carefully wiping away discharges from the os uteri with sterile wool, using a Fergusson's speculum. This discharge should be spread on a glass slide and put by to dry. A second film on another slide should then be made, by squeezing the urethra from behind forwards and mopping up any secretion thus made to appear on the meatus. After drying in the air, the films should be fixed by passing through a flame, and then stained by Gram's method, followed by neutral red as a counter-stain. In films prepared in this way gonococci are stained red, whilst organisms which retain Gram's stain appear deep violet or black. The gonococci are usually found in the cytoplasm of the polymorphonuclear leucocytes (Plate XII). Offensive smelling vaginal discharge is associated with decomposition, and it may be that the discharge itself is decomposing because it cannot escape fast enough from the passage, or that the source of the discharge is a decomposing substance like a sloughing fibroid or necrotic carcinoma of the cervix. In the two latter cases the discharge is copious, watery, and blood-stained, with a horribly foetid smell. When the discharge itself is decomposing, it is usually thicker and purulent, and is commonly retained by pessaries or by redundant folds of vaginal mucous membrane. In old women, a foul discharge may come from the interior of the uterus, a pyometra ; in which case pus can be made to flow from the os uteri by squeezing the uterus or passing a sound. It is due to senile endometritis, the result of infection, and is often associated with cancer of the body of the uterus. Watery blood-stained discharge, not offensive, occurs in cancer of the body of the uterus, in early cancer of the cervix, with mucous polypi, placental polypi, and hydatidiform mole. The differential diagnosis of these conditions cannot be made from the discharge alone, but must rest upon physical examination com- bined with the use of the microscope upon materials removed from the uterus. Vaginal casts may be composed of coagulated surface epithelium, the result of astringent injections or applications, and are easily recognized with the microscope. Membranous flakes may be passed with discharge in cases of membranous vaginitis. They consist of vaginal epithelium entangled in coagulated blood plasma, and present quite a different appearance to casts of coagulated epithelial layers. These membranous masses may be seen lining the whole vagina, and are generally due to special organisms. The Klebs-Loffler bacillus [Plate XII) has been found to be the causal agent in such cases, and in one investigated by the writer, the Bacillus coli communis was the offending organism. T. G. Stevens DIZZINESS.— (See Vertigo.) DOUBLE VISION.— ;Sec Diplopia.) DROP-FOOT. — (See Paraplegia, and Paralysis of One Lower Extremity.) DROPSY.— (See (Edema.) DROP-WRIST. — (See Paralysis of the Upper Extremity.) DULLNESS, DEFICIENT HEPATIC.--(See Liver Dullness, Deficient.) DWARFISM DWARFISM (Microsomia, Xanosomia). — For purposes of diagnosis, dwarfism may be di\'ided into two classes, namely, dwarfism the result of deformity , and dwarfism without deformity. Generally speaking, well-proportioned dwarfs owe their defective stature to a generalised delay or arrest of development, and are therefore in a state of infantilism, whereas deformed dwarfs are stunted in growth only, though the reduction in height may be due rather to the warping or collapse of the bon}- frame-work than to actual curtailment of height. I. — Dwarfism the result of Deformity. As a rule this kind of dwarfism is due mainly or soleh' to shortness of the lower limbs. In bv far the larger number of cases the fault lies in the skeleton, but occasionally it has its source in deficiency of the brain, and still more rarely is brought about by a local defect of development impli- cating the lower extremities. A . Skeletal Dwarfism is occasioned by :— 1. Rickets 2. Achondroplasia 3- Osteogenesis imperfecta 4. Anosteoplasia 3. Osteomalacia. 1. Rickety Dwarfism [Fig. 63) is usuall}^ moderate in degree and is due partly to actual shortening of the bones of the lower limbs and partljr to bending (bow-leg or knock-knee). It may also be the outcome of antero-posterior or of lateral cur\-ature of the spine. The skull looks big and is of the square or hot-cross-bun t^^pe, with bulging forehead. The shape of the nose is not affected. There is often a pigeon breast or a transverse groove round the lower part of the chest (rickety girdle, Harrison's sulcus) and an hour-glass shaped or, at times, beaked (rostrate) pelvis. The muscles are well-developed, and the body is squat and thickset. 2. In Achondroplasia (-Fig. 64) the limbs are shorter than in rickets, and the stature less. The propor- tions are of the dachshund pattern. The shortening of the limbs is chiefly of the proximal segment, and the body, though actually short, is relativeh? long. The legs are often bowed, and there may be bending of the upper limb bones. The joints are usually prominent. The forehead is bulging, the bridge of the nose depressed. There is con- .spicuous lordosis, and the pelvis is small and contracted. The muscles are often disproportionately big, giving the achondroplasic a sturdy appearance and a surprising degree of strength. The fingers are broad, the three middle fingers being of equal length and divergently curved. Fiff. 63. — Extinct rickets. — Age 13. The dwarfism is moderate, and i.s due to bending and .shortening of the thigh and leg bones. There is knock-knee, the tibiae are sabre-shaped, the feet flat. The wrists md ankles are large : the muscles are not afifected. DWARFISM 213 3. Osteogenesis Imperfecta (osteopsathyrosis, fragilitas ossium) {Fig. 65) is characterized by brittleness with softening. There is not much dwarfing, except as the result of the yielding of the bones, and the muscles are usually weak. The disease probably sometimes runs on into osteomalaca. 4. Anosteoplasia (Cautley) or cleido-cranial dysostosis. With general impairment of bone growth, cau.sing nroderate dwarf- ism, there is pronounced defect in the formation of the membrane bones. The skull is rounded and broad, the face small, the den- tition delayed ; the clavicles are rudimentary or absent. The disease is often hereditary. F/«: 64. — Achondroplasia. — Age 15. The trunk is al- most of normal length, and the limbs very short, the proximal being shorter than the distal segments. The epiphyses are enlarged, and the forearms and legs are curved. The nose is deficient at the bridge. In this case there is infantilism as well as dwarfism. 5. In Osteomalacia the dwarfism is due almost solely to the crumpling of the decalcified bones ; but when the disease occurs in childhood there is also some diminution of stature from arrest of bone growth. The muscles are conspicuously weak. /^ig: 65. — Osteogenesis imperfecta. — Age 32. Bending of the tibiae, femora, spine, etc., began at five years and con- tinued for nearlj' ten years before it ceased. There was no epiphysial en- largement. Diagnosis of Skeletal Dwarfism. — Though osteogenesis imperfecta, simple bone brittle- ness, rickets, and achondroplasia can, as a rule, be distinguished readily one from another, cases occur in which one of these diseases seems to blend with another or at any rate to partake of its characters. 214 DWARFISM In distinguisMng rickets from achondroplasia it must be remembered that the most characteristic features of rickety dwarfism are the bending and the post- natal origin, and of achondroplasia the shortness of the limbs (micromelia) and the pre-natal origin. The enlargement of the ends of the bones, which is so distinctive of rickets, disappears as the disease settles down and the bones con- tinue to grow, Avhereas in the hyperplastic form of achondroplasia it remains throughout hfe. Extreme softening must cause us to suspect the existence of osteogenesis imperfecta or of osteomalacia, even if there are rickety enlargements as well, especially if the bending continues to increase after the age of six years. Dwarfism may be due solely to spinal curvature. If a kyphosis it is usually the result of tuberculous disease (caries) of the spine, but is occasionally a local manifestation of rickets, or possibly of osteomalacia. When of rickety origin there is not onh^ k^-phosis of the dorsal region, but a compensatorj^ lordosis of the dorso-lumbar. If it begins in middle or old age it is usuallj^ osteo-arthritic, but as a rare event it may be due to osteomalacia (o. senilis). In the latter event the softening is usuallj^ confined to the spine and pelvis, and may take place with extraordinary rapiditjr, and be followed by gradual hardening and fixation in the deformed position. Scoliosis is usually of mixed origin, the main factor being an inherent laxity of tissue showing itself in weakness of the back muscles and of the spinal liga- ments. This laxity is supplemented by fault}'' positions of standing, sitting, etc., or b\^ the injudicious use of stays. But it is probable that spinal curvature of sufficient severit],^ to produce dwarfism is invariably the result of rickets or, in rare cases, of a mild and local form of osteomalacia. B. Cerebral Dwarfism. — This form of microsomia is most pronounced in micro- cephaly, but hydrocephaly, porencephaly, imbecility, or any degenerative cerebral affection of earlj' progressive development, is often associated with puny growth. The microcephalic dwarf is characterized not only by the relative smallness of his head (circumference never exceeding 17 ins.), but by his sloping forehead, projecting nose, and receding chin, giving him a ferret- or rat-like physiognomy. He is usually quick of movement, and restless, and is either imbecile or idiotic, according to the degree of his microcephaly. C. Dwarfism from Pre-natal Deficiency of the Lower Limbs. — This is of two kinds : phocomelus and ectromelus. In phocomelus the defect is in one or both of the proximal segments, leaving the hands and feet, so that the individual affected resembles a penguin or a seal (phoca) . In ectromelus there is absence of part or whole of the limbs from the feet up. II. — Dwarfism the result of Defective General Development. Infantilism. Well-proportioned dwarfs are not invariably of backward development, for we meet with men of excellent development, who, if not actual dwarfs, are so dwarfish in stature that we have to admit the possibility of the existence of a true dwarfism in which there is no infantilism. Ne^"ertheless, generally speaking, the dwarf of correct proportions is affected with infantilism. To Distinguish Infantilism from simple Dwarfism. — Dwarfism is a defect of growth, whereas infantihsm is a defect of development. In determining whether development is implicated, stature, ossification, and sex development are of great but not decisive importance. Thus infantilism may co-exist with gigantism ; and the ossification in some cases of symptomatic infantilism is not only not delayed, but may be actually premature. It is also premature in progeria. Moreover, a DWARFISM sexually mature child of live or six does not cease to be a child because its ossifi- cation and sexual condition resemble those of an adult. Evidently therefore neither height, nor sex, nor ossification is a cardinal feature of infantilism. Indeed, in some cases of sexual ateleiosis the presence of infantilism is determined by the child-like stature, proportions, and physiognomy alone, the individual being in all other respects a well-developed human being. The Forms of Infantilism. — In- fantilism may be widespread among whole races or nations (racial in- fantilism), or may select certain individuals or families, . and occur epidemically or sporadically as morbid infantilism among people of ordinary development. Morbid infantilism is of two sorts, namely, symptomatic, the result of causes ; and essential, or cryptogenetic. A. Symptomatic Infantilism. This is seldom or never of ex- treme degree, has no uniform type of physiognomy, and, being an acquired condition, is never trans- mitted by heredity. It is best classified according to the nature of the cause by which it is produced. 1. It may be the result of intoxication with the poison of syphilis, wine, or tobacco ; or of rheumatic, scarlet or other fever, or with lead. Herter claims that the intoxication may arise from over-abundance of the normal flora of the intestine (intestinal infant- ilism), r- ' 2. It may be the result of cor- relation, as when it is associated with kyphosis or with splenomegaly, or with hypertrophic cirrhosis of the liver. Perhaps the best ex- ample of this form of infantilism is that which is associated with microcephaly. In some microceph- alic dwarfs there is not only an impairment of growth, constituting dwarfism, but the development of the whole body is staj^ed, apparently because it is the custom for a certain development of the body to go with a certain size of the brain, 'and such customs are liable to be maintained even under abnormal conditions. Dwarfs with diminutive heads may be of just proportions and of fairly good intelli- gence, provided the growth of the body is so retarded that it remains in keep- ing with the growth of the brain. In thymic infantilism there is fatness with anaemia, and liability to syncopal attacks which often end in death. /''ij;. 66. — .Aii.i!i:;i. p'.a^tii; ii I'aii tili-ni. - - Age i6. I here is general delay of de\elopment, but nut to an e.xtreme degree. The phy.siognomy and proportions are of the adult pattern, but se.\ development is more immature. 2l6 DWARFISM 3. In a given case of infantilism it mav be impossible to say how much is due to correlation, how much to intoxication, and how much to mere lack of nutrition. This may be said, e.g. of cardiac, of arterial, and of pancreatic infantilism. Cardiac infantilism exists when there is some dominating incapacity of the cardiac valves. Sometimes there seems to be a deficient development of the whole arterial system, constituting anangioplastic infantilism {Fig. 66). In pancreatic infantilism there are indications of pancreatic in- competence. The stools are fatty, copious or frequent, pale and offensive. Capsules of iodoform enclosed in a glutoid envelope (Sahli's capsules) are only soluble in the pancreatic secretion, and are therefore not dissolved in this form of infantilism (Bramwell). The infantilism is cured by pan- creatic extract. 4. Thyroid infantilism in its most characteristic form — cretin- ism [Fig. 67) — is unmistakable. But cases of infantilism occur in which the physiognomy, stunting of growth, and backward sex development suggest mere thy- roid inadequacy. Some reserve the name of thyroid infantilism for these cases of " myxoedeme fruste,"but the term should only be applied when the intelligence is defective and uniform improve- ment sets in as the result of giving thyroid extract. The thy- roid inadequacy may however not be primary, but a mere in- cident in some other form of infantihsm, e.g., ateleiosis. 5. Mongolism [Fig. 6-8) is dis- tinguished from cretinism or myxoedeme fruste by the pre- dominance of the imbecility as compared with the slightness of other cretinoid symptoms. In realit}' the physiognomy is only cretinoid because it remains of the infantile t^'pe. It is not eneral pseudo-oedema of cretinism, and the The eves remind one of /■ig. 67. — CretiiiiMn.— Age 20. The infantilism is uniform and extreme. The intelligence, proportions, .attitude, manner, correspond with those of a child of" 18 months. The features are puffed and disfigured with the characteristic oedema. ■disfigured by the thick lips and tongue, though sometimes protruding, is not large. the obhqueh'-set eyes of the Chinaman, but it is sometimes difficult to make out the resemblance. The ligaments are lax, and mongols are liable to become knock-kneed and to have " double-jointed " thumbs. There is often some valvular affection of the heart. B. Essential or Cryptogenetic Infantilism. This is distinguished from sj^mptomatic infantilism b}' its pronounced degree, DWARFISM 217 by its seemingly spontaneous appearance, and occasionally by its heredity. There are two forms : ateleiosis and progeria. Fig. 68 Mongolism. — Age 14. The general development is delayed. The physiognomy is un- developed, is without facial hair, and is slightly Mongoloid. The boy is an amiable imbecile. I. Ateleiosis {Fig. 69) is primary, spontaneous infantilism. It may begin at any age of progressive development, and its characters are for the most part those normal to the age of its first appearance. It usually begins in infancy or Fig-. 69.— -A-teleiosis. — Age 12. A boy of twelve with asexual ateleiosis, standing behind a normal boy of six. His height, proportions, contours, and physiognoiny are conspicuously childish. He is inflating his chest, but in reality his trunk development is of the abdominal type. DWARFISM early childhood, and the size, proportions, and physiognomy of this time of life are perpetuated. It is prone to be associated with cryptorchism, or with some corresponding ill-development of the ovaries, causing divergence into two varieties, sexual and asexual. In asexual ateleiosis a\\ the physical features of infantile life are stereotyped ; but in sexual ateleiosis, though the physiognomy and proportions remain infantile or childish, the onset of puberty (often greatly delayed) brings with it some accession of growth and the addition of the primary and secondary sex characters of the adult. Fig. jc — Progeria — Age 15. 'J'he stature .-md pr..pi)rtions ate ijiildish, liut the physiognomy, leanness, and baldness are elderly. The scalp was in reality sparsely covered with grey hair. The ear lobule is absent, ihe nasal cartilages are conspicuous, and the fingers nodose owing to the prominence of the epiphyses. 2. Progeria {Fig. 70) is primary, spontaneous infantilism mingled with prema- ture senility (senilism) . Hence, with shortness of stature and other indications of infantilism, there is baldness, emaciation, arterial sclerosis, and general decrepi- tude. Death from angina pectoris or other senile disease may ensue at 18 or even earlier. Hastings Gilford. DYSARTHRIA. — (See Speech, Abnormalities of.) DYSIDROSIS. — (See Sweating, Abnormalities of.) DYSMENORRHCEA 219 DYSMENORRHCEA — Owes its origin to a variety of causes, which must be carefully differentiated, in order that treatment may be successful. The follow- ing table presents the causes of the three common varieties : — I. Spasmodic. Congenital malformations Deficient uterine muscle Long conical cervix Stenosed external and internal os Neurasthenia 2. Congestive. Endometritis Uterine congestion Retroversion and flexion Uterine fibroids Salpingo-oophoritis Pelvic peritonitis Small cystic ovary Neurasthenia 3. Membranous. The distribution of the cases into these three classes is often quite easy ; in the first place, because spasmodic cases are practically always primary, that is, they commence with the onset of menstruation ; whilst congestive and mem- branous cases are secondary, that is, acquired as a result of some definite lesion. Further, the nature of the pain is often characteristic of the type of case, for in spasmodic cases the pain is intermittent, griping, and " colicky," commencing at the same time as the blood-flow, or only just before it. In the congestive cases, on the other hand, the pain is continuous and aching in character, and begins some hours or days before the flow. In typical cases also this pain is relieved by the flow. In the membranous cases the nature of the pain partakes of the characters of both the former types, being aching and continuous first ; then becoming colicky and spasmodic when the uterus is attempting to expel the characteristic membrane or cast, and being finally relieved when this comes away. Many cases are met with in which the pain partakes of the nature of both the congestive and spasmodic types. This usually means that a woman who originally had spasmodic dysmenorrhoea, acquires some lesion which, in its turn, gives rise also to the congestive type of pain. Having settled that a case belongs to one of the three main types, it is not very difficult to work out the actual causation. This is more difficult in the spas- modic cases than in the congestive, because the latter depend upon well-defined lesions, and the former do not. 1. Spasmodic Cases The causation of this type of case is often obscure ; but a bimanual examination, or a recto-abdominal examination in virgins, will usually reveal a condition of the uterus which can only be described as a congenital malformation. It may be small, but of the adult type ; it often has an exaggerated anterior bend, the " cochleate " uterus of Pozzi ; and, in addition, the vaginal portion of the cervix is often too long, with a conical shape, and a very small pin-hole external os. Into such uteri the sound may pass with difficulty, owing to stenosis and rigidity of the internal os. The underlying true cause of the pain, however, is commonly admitted now to be imperfect develop- ment of the uterine muscle, in itself again a congenital malformation of texture occurring in an organ whose external form also is malformed. The muscle being imperfect, it is also possible that the endometrium is abnormal in these cases, unduly fibrous perhaps, and resistant : a point which our present knowledge does not prove or disprove. One proof, however, of the truth of these views is the effect of pregnancy and labour on such cases. They are nearly always cured, owing to the great muscular development during pregnancy, and the extreme stretching of the lower segment during labour. Neurasthenia also colours and increases the pain in these cases ; but, by itself, will not start a spasmodic any more than a congestive dysmenorrhoea. 2. Congestive Cases It is unnecessary to differentiate the congestive cases as tubal, ovarian, or uterine, because the underlying cause in all is uterine conges- D YSMENO'RRHCEA tion accompanying such lesions as are shown in the table. The differential diagnosis of these lesions is to be made, by a careful consideration of the history^ combined with bimanual examination of the pelvic organs and, if necessary, curettage of the uterus, which also serves to cure the cases of pure endometritis. Cases due to endometritis are to be recognized by the cardinal symptoms of this lesion, namely, menorrhagia, leucorrhoea, often blood-stained, and chronic back- ache. These symptoms accompany slight enlargement of the uterus without any irregularity in shape, such as would occur if fibroids were present. Simple retroversion and flexion can be recognized on bimanual examination ; the fundus will be felt posteriorly, the cervix looking directly down the vagina in a forward direction. Salpingo-oophoritis in its typical chronic form gives rise to irregular, very tender swellings on either side and behind the uterus, sometimes forming definitely retort-shaped swellings, especially if pus is present in the tubes. Fixa- tion of these swellings and of the uterus is a very definite sign of the disease ; whilst the history of one or more attacks of acute illness, with pelvic pain, will assist to make the diagnosis certain. The small cystic ovary may exist without obvious salpingo-oophoritis, and without widespread fixation. The ovary is found to be permanently enlarged and irregular in shape from the projection of ■cysts from its surface. Neurasthenia is included under this heading, because any menstrual pain is made worse by it, and only a very slight lesion need be present for this nerve weakness to accentuate any pain arising from it. 3. Membranous Cases. — The membrane, or cast, is of two types, and is easily recognized and distinguished from other uterine casts, such as those formed by the decidua of pregnancy. The classical cast of membranous dysmenox- Thoea • is hollow, triangular, not more than one-eighth of an inch thick, and possesses three openings. This, however, is not the common form ; for in most cases the cast is solid, and formed by the solid mucosa being rolled upon itself. These casts contain uterine glands in a stroma which is crowded with leucocytes, and contains connective-tissue cells. The solid cast may be nearly half an inch thick, and looks microscopically as if it were composed of endometrium, into which haemorrhage and leucocytic infiltration had occurred. The glands in it are broken up, and often lie on the outside. These casts never contain any compact masses of large cells of the decidual type, but an occasional hyper- trophied connective tissue cell may be found. Decidual casts, on the other hand, are the result of pregnancy, and consist of compact masses of large polygonal cells without any fibrillated connective tissue. They contain glands with hypertrophied epithelial linings, and often show large hsemorrhagic foci. The occasional presence in them of chorionic villi absolutely settles the diagnosis. It must not be forgotten that cases of dysmenorrhoea may be mistaken for those of abdominal pain due to other lesions unconnected with menstruation ; and the differentiation of such cases may be a matter of considerable importance. It is conceivable that dysmenorrhoea may be mistaken for : — Appendicitis Haemorrhage from or into a Graafian Colic, intestinal, renal, or hepatic follicle Perforated gastric ulcer Rupture of an ovarian cyst or pyo- Ruptured tubal gestation salpinx Torsion of the pedicle of an ovarian Dyspepsia with flatulent distention, cyst Obviously, some of these lesions are dangerous to life, and therefore it is essential that they are not overlooked. The danger of doing this is increased if any of these lesions occur at or near the expected time of a menstrual period, and would hardly arise at all if a menstrual period had taken place recently. DYSPAREUNIA or was not expected for some days. It will be noted that all these lesions are accompanied by sudden abdominal pain, which would perhaps lead to a sus- picion of spasmodic dj-smenorrhoea, but hardly of congestive, owing to the character of the pain. T. G. Stevens DYSPAREUNIA, or painful coitus, may depend upon a variety of local lesions which require careful differentiation for their appropriate treatment, or it mav exist when no local lesion can be found at all. It is closely associated with vaginismus, or painful spasm of the levator ani muscle on attempts at coitus, and the same lesions which cause simple dyspareunia may also give rise to vaginismus. It is remarkable that in some women a small local lesion will produce no pain upon attempts at coitus which in another will cause pain accom- panied by violent spasm of the levator ani. In some cases pain arises because there is a difficulty of penetration of the vaginal orifice, whilst in others there is no difficulty, but pain is caused. The lesions which commonly give rise to dyspareunia are the following : congenital absence of the lower part of the vagina, unruptured hymen, inflamed hymeneal orifice, vulvitis. Bartholinitis, leukoplakic vulvitis, kraurosis vulvee, neuritis of the pudic nerve, healed perineal lacerations, urethral caruncle, urethritis, cystitis, prolapsed tender ovaries with retroverted uterus, chronic metritis, salpingo-oophoritis with adhesions, anal fissure, thrombosed and inflamed piles. It will be noted from a perusal of the above that the lesions fall into natural groups, according as the situation of the lesion is at the vulva, the uterus and ovaries, the urinary passages, or the anus and rectum. Consequently it is necessary to carry out a detailed examination of any case of dyspareunia in order to find out whether any of these well-defined lesions are present. The commonest lesion is certainly inflamed hymeneal remains, very often gonorrhoeal in origin and accompanied by redness and swelling of the orifice of the duct of Bartholin's gland. The lesion is self-evident on inspection, and the parts are acutely sensitive to the least touch. Leukoplakia vulvitis is an obvious lesion from the white, sodden appearance of the labia minora, and causes pain on account of the sensitive cracks and fissures which accompany it. Kraurosis vulvce causes actual contraction of the vaginal orifice, and conse- quently penetration is difficult and causes pain. The red projecting growth from the meatus urinarius, caruncle, is self-evident and acutely tender, whilst urethritis is diagnosed by the issue of pus on squeezing the urethra. Cystitis is diagnosed by the presence of pus and mucus in the urine, accom- panied by frequency of micturition, and it causes pain because the bladder is painful in such cases and intolerant of the disturbance caused by coitus. Pudic neuritis is not a well-defined condition, but can be recognized by tender- ness along the pudic nerve just inside the vaginal orifice, where the nerve passes along the inner side of the ischial ramus. In prolapsed tender ovaries and backward displacements there is no pain on penetration and no difficulty, but coitus gives acute pain. The condition is recognized by a bimanual examination, the same remarks applying to salpingo- oophoritis, bearing in mind that there is usually a history of some acute attack of pelvic peritonitis in such cases. In chronic metritis the tubes and ovaries may be normal and the uterus normal in position, but in this condition the uterus itself is tender to the touch, and consequently coitus causes pain. Anal fissure, thrombosed and inflamed piles, can only be recognized by a careful examination of the anus and rectum bj- the finger and speculum. DYSPAREUNIA In the cases which occur without local lesions, the vaginal entrance will be found to be h\-per£esthetic as a rule, and penetration is impossible. Such cases are almost always accompanied by spasmodic vaginismus. The most careful examination fails to demonstrate a lesion in such cases, and they are usuallv termed " neurotic " for the want of a better term. Such cases do not necessarily mean absence of sexual desire ; on the contrary, many such patients are desirous of the consummation of marriage. Enlarging the orifice, or even child-bearing, does not cure a true case of this nature ; it must be in some way a disorder of function of the nerve centres. These cases must be distinguished from those in which the underl\-ing factor is absence of sexual desire and actual dislike of the sexual act. Unhappy and unsuitable marriages conduce to this state of affairs, and the patient is hable to complain of pain when dislike is really what is meant. There is no difficulty in penetration in such cases. 7-. q_ Stevens. DYSPHAGIA is a someAvhat loose term employed on different occasions to denote entirely different s\"mptoms. Literally it means difficultv' in swallowing, but the term itself does not indicate whether the difficulty is mechanical, nervous, or due to pain. There are consequently several entirely different groups of cases, to each of which the term dysphagia has been applied at one time or another. I. Dysphagia due to Mechanical Obstruction to the (Esophagus. — The usual history of progressive mechanical obstruction to the oesophagus is as follows : There is Kttle or no pain, but the patient notices that whereas formerly he could swallow an\-thing with ease, he is beginning to experience difficult],- with the more solid kinds of food, such as meat, dry bread, and vegetables, so that he is obliged to hve mainly upon pulpy foods : milk puddings, gruel, and the hke. Later he can swallow only Uquids. Ultimately the patient finds that even liquids are apt to be regurgitated soon after the}- have been swallowed, and there is often a sense of obstruction at some point between the le\-el of the cricoid cartilage and the lower end of the .gladiolus, which latter corresponds, as regards sensation, with the cardiac end of the oesophagus. When with the above histon.- the patient gives a definite account of ha\-ing previously swallowed some strong irritant or corrosive substance, such as an alkah or a mineral acid, accidentally or with suicidal intent, the diagnosis of fibrous stricture from corrosive injury-, is easy. AMien similar obstruction succeeds the swallowing of a foreign body, such as a tooth-plate {Fig. 71), a large piece of bone, or a coin, the diag- nosis is also easy. Where the s},-mptoms are not directly attributable to anj-- thing of this nature, however, but come on insidiously, the diagnosis generaU}^ lies between primary squamous-celled carcinoma of the oesophagus, spheroidal or columjiar-celled carcinoma of the stomach directly invading the lower end of the oesophagus, and aortic aneurysm stenosing the oesophagus from outside. The actual fact of obstruction has first to be determined, and there is danger in passing a bougie uiiless aortic aneur^-sm can be excluded ; this exclusion is by no means easy, howeA-er, for that variety- of aneurysm which is most hable to stenose the oesophagus is one afiecting the descending thoracic aorta, so that it does not give rise to any tumour, or pulsation, or bruit, and it is placed too far along the aorta to cause inequahty of the pulses, inequahty oi the pupils (from interference with the cer\ical sympathetic), paralysis of a vocal cord (from interference with the left recurrent laryngeal nerve), tracheal tugging, or pain down either arm. The onlv other effects besides oesophageal obstruction likely to be due to aneurysm in this position are : pain in the dorsal region of the spine, possibly radiating along the course of one or more of the mid-dorsal intercostal nerves towards the left, and perhaps obstruction to the lower part of the root of the left lung, causing impairment of note, of air-entry, or of voice DYSPHAGIA 223 sounds, with or without some crackhng rales over the left lower lobe behind. If a bougie is passed, it should be a soft one, and extreme care should be taken ; but the danger may be avoided in towns where ;ir-ray installations exist, for the obstruction may often be demonstrated by making the patient swallow a capsule containing oxychloride of bismuth and watching its course ; while an aneurysm would cast a characteristic shadow in the posterior mediastinum. The older the patient, the more likely is it to be carcinoma of the oesophagus and not aneurysm. The differential diagnosis between primary growth of the oesophagus, and infiltration of the oesophagus by a growth starting at the cardiac end of the stomach, is often one of great difficulty, unless there have been -Sudden death from acute dyspncea and asphyxia : tooth-plate impacted in the larynx. (Fro/u a case of Dt. T . Warner I.acty's, of U'oohvich.) definite gastric symptoms before dysphagia set in. Secondary nodules would naturally be looked for, especially in the lymphatic glands in the lower part of the neck. It is unusual to find secondary deposits elsewhere, but should there be any, they might possibly be in the liver. A history of syphilis and evidence of syphilitic aortic regurgitation, especially in a man between the ages of forty and fifty who had been a hard manual worker and not teetotal, would render aneurysm probable. Dysphagia lusoria is a very rare condition due to compression of the oesophagus by the right subclavian artery where it arises from the aorta beyond the left subclavian and passes to the right side either in front of or behind the 224 DYSPHAGIA oesophagus; the diagnosis in such cases will be almost impossible, though it might be guessed at if there were other congenital deformities, such as club-foot or transposition of the viscera. (Esophageal Pouches are either congenital or acquired ; when acquired, they are said to be of t^vo types, namely, those due to traction from without, and those due to bulging from within ; but the probability is that many of those which are not congenital are caused by a caseous gland in contact with the oesophagus. The contents of the gland having escaped into the latter by a process of ulceration, the pocket thus left in communication with the interior of the oesophagus subsequently became intermittently filled with food, and thus bulged out to produce a larger diverticulum. The symptoms can seldom be interpreted with certainty unless the case is watched for some time. Generally the patient can swallow with perfect ease on some days, but with considerable difficulty on others ; aneurysm, new growth, and traumatic or corrosive obstruction to the oesophagus will be excluded partty by the age, and partly by the results of ;t;-ray examination. The point which suggests the diagnosis of a pouch is that the patient who has been able to swallow perfectlj' well for a few days, and then begins to have difficulty in getting the food down, finds relief presently on the regurgitation, clearly not from the stomach but from some situation higher up, of a larger quantity of food material than had been swallowed immediately before, including perhaps articles which were taken one or more days previously. The reason for these symptoms is that the pouch does not obstruct the oesophagus until it becomes very much distended by the gradual accumulation in it of portions of the food swallowed, relief coming about when the greatly distended sac empties itself back into the cesophagus. 2. Dysphagia due to Nervous Causes without Obstruction. — The two com- monest varieties of dysphagia due to purely nervous causes are probably post-diphtheritic and hysterical. The former is characterized by regurgitation of the food through the nose, due to paralysis of the soft palate ; inspection may demonstrate the flaccid condition of the latter ; there may have been a history of sore throat, of other cases of diphtheria in the patient's neighbour- hood, or Klebs-Loffler bacilh may have been found, or may still be found, in the patient's throat. When regurgitation of the food through the nose develops in a person who is not known to have had diphtheria, the s^miptom will usually arouse grave suspicion that diphtheria of a mild type has occurred but has been overlooked. There may or may not be other signs of peripheral neuritis, or there may be paralysis of the ciliary muscles of the ej^es. Hysteria as a cause for dysphagia is familiar enough under the heading of globus hystericus, the diagnosis of which is not as a rule difficult, especially if the patient be a young woman who has suffered from other functional nervous affections, such, for instance, as hysterical aphonia. Less common varieties of dysphagia of nervous origin are : — Bulbar Paralysis, in which the characteristic and progressive difficultv in the use of the lips, tongue, pharynx, and larynx point at once to the diagnosis, the only difficulty that may arise being perhaps in distinguishing true bulbar paralysis, in which the lesion is in the motor nuclei of the medulla oblongata, from pseudo-bulbar paralysis, where the lesion is due to bilateral cortical softening : in the true form there is atrophy of the tongue, in the pseudo- varietur- the tongue does not atrophy, and chiefly upon this point is the differential diagnosis made. Syphilitic Degeneration of the medullary centres may produce symptoms not unlike those of ordinary bulbar paralysis, but it is generally differentiated by the fact that other cranial motor nerves, particularly those of the eyeball, are probably affected at the same time, and there may also be evidence or a clear history of syphilis, with or without a positive Wassermann's reaction. DYSPHAGIA 225 Lead Poisoning and Alcoholism may also be responsible for degenerative lesions affecting the nerves concerned in the process of swallowing. General Paralysis of the Insane ultimately results in inability to swallow, though the swallowing reflex is amongst the very last to disappear, and the diagnosis has long since been established upon other grounds. Spasmodic Dysphagia due to spasm of the muscular coats of the oe.sophagus and pharynx is probably the cause of globus hystericus, but similar spasticity may prevent swallowing in much more serious diseases, and constitutes a prominent symptom in hydrophobia, in which any effort to swallow liquids pro- duces the symptom in extreme degree. The history of a dog-bite as a source of contagion is the chief point in arriving at the diagnosis. Myasthenia gravis is a very characteristic disease, in which the muscles that are affected are perfectly able to do their work when they first begin to contract, but become fatigued with great rapidity, so that after the first few contractions those which succeed become less and less effectual, until they cease, and the affected muscles will only be able to work again when they have been given a long rest. The neck muscles, and those of the eye, larynx, and mouth, become involved early, and difficulty in swallowing after the first few mouthfuls is sometimes a characteristic feature of the case. The myasthenic electrical reaction (see Reaction of Degeneration) serves to distinguish these cases from those due to bulbar paralysis. Finally, there are very rare cases in which, without any known pathology, the oesophagus becomes enormously hypertrophied and dilated, and the patient cannot swallow, though a bougie passes perfectly well. This so-called idiopathic dilatation and hypertrophy of the oesophagus is fortunately very rare ; it would seem to be due to an erroneous spasmodic contraction of the cardiac orifice, which refuses to relax for the ingress of food into the stomach. It leads to dilatation of the oesophagus behind it, with much hypertrophy, the latter, great though it is, eventually failing to overcome the muscular constriction of the oesophageal sphincter. 3. Dysphagia due to Mechanical Defects of the Mouth or Pharynx, the (Esophagus being Normal. — This group of cases includes patients suffering from such conditions as widely cleft palate, syphilitic stenosis of the pharynx, inability to use the tongue, either because it is acutely swollen from glossitis, bee-sting, or angina Ludovici, or because it is fixed from carcinomatous infiltration, and so forth. There is little need to enter into the differential diagnosis of this variety of dysphagia, for it can generally be determined by direct examination of the buccal cavity. Mumps, quinsy, and post-pharyngeal abscess belong to the same group, the last-named causing more dyspnoea than dysphagia, and being confined to quite early childhood. 4. Dysphagia in which there is no Mechanical Obstruction, but in which the Act of Swallowing causes the Patient so much Pain that he Hesitates to Swallow. — The chief cau.ses of dysphagia which come under this heading are : Inflammatory affections of the mouth or tongue, including the different varieties of stomatitis (p. 88) ; pemphigus or erythema bullosum of the buccal cavity, evidenced by similar eruption upon the skin (see Bullae) ; ulcers of the tongue, whether malignant, gummatous, tuberculous, or due naerely to erosion by a carious tooth or an ill-fitting tooth-plate ; sore throats of various kinds (see Sore Throat) ; pain in the mouth, larynx, or oesophagus after swallowing acute irritants or fluids that are either exceedingly cold or burning hot ; and inflammatory affections of the larynx and its immediate neighbourhood. The nature of the buccal lesions will generally be indicated by inspection. The different varieties of sore throat may be distinguished to some extent by inspection, though bacteriological confirmation is usually advisable. The chief difficulties arise when the cause D 15 226 DYSPHAGIA of the dysphagia is an inflammatory or ulcerative affection of the larynx. Rarities such as variolous, lupoid, leprous, typhoidal, decubital, and traumatic ulcers of the larynx will seldom be diagnosed unless there is obvious collateral evidence, such as the eruption of small-pox upon the skin, residence in leprous countries, prolonged confinement to bed, and so forth, to indicate the nature of the case. The commoner varieties of laryngeal trouble which produce dysphagia are acute laryngitis, tuberculous laryngitis with or without ulcers, carcinomatous ulceration of the larynx, and syphilis. It is essential that laryngoscopic examination should be made, local anaesthesia by the use of the cocaine spray, or by painting the larynx with a solution of cocaine, generally being necessary first. If tubercle bacilli can be found in the sputum, or if there are abnormal signs at the apices of the lungs, the diagnosis of tuberculous laryngitis is pro- bable, and the pallid swelling of the arytaeno-epiglottidean folds, and, still more so, multiple small ulcers of the edge or posterior surface of the epiglottis or of the free edges of the true or false vocal cords, or similar ulcers in other parts of the larynx, bilaterally situated, would indicate the diagnosis with certainty. The chief difficulty arises in the more chronic cases in which, after the larynx has become involved, the lung condition has improved, and tubercle bacilli may not be found in the sputum. Epitheliomatous ulceration of the larynx may be very extensive, and yet for a long time remain confined to one side ; this unilateral distribution of the infiltration is often important evidence in distin- guishing epithelioma from syphilis of the larynx, whilst the latter may also be distinguished by the repair which may ensue even after extensive destruction of the tissues has led to much deformity of the parts. The influence of potassium iodide and mercury upon the lesions may assist the diagnosis, and Wassermann's serum test may be employed. Doubt may remain, however, and sometimes, where it is very important to arrive at a certain diagnosis as soon as possible, a small portion of the affected tissue may be excised and examined microscopically. When tuberculosis, syphihs, and new growth are excluded, and yet laryngitis is present, the probability is that it is due to some infecting organism. Probably the symptoms will have started more or less acutely, even though they persist and become chronic ; laryngeal inspection may show acute hypersemia and injection of the parts with extensive oedema without ulceration, and the nature of the micro-organism concerned — the diphtheria bacillus, streptococcus, pneumo- coccus, etc. — may be determined bacteriologically by preparing cultures from local swabbings. It is possible, of course, for two or more maladies to occur simultaneously, and it is particularly difficult to distinguish syphilitic laryngitis from tuberculous in a syphilitic patient who has undoubted phthisis ; similarly, it may be difficult to distinguish catarrhal laryngitis from tuberculous in phthisical patients, and so on ; indeed, in many instances the diagnosis may be one of opinion only. Measles is very apt to be accompanied by laryngitis, which may often be merely catarrhal, but which not infrequently is due to diphtheria which developed synchronously with the measles. In order to exclude diphtheria, it is always advisable to take swabbings for bacteriological investigation, even where it seems almost obvious that the laryngeal catarrh is merely part of the general coryza of measles. In all these cases dysphagia will be accompanied by hoarseness or other alteration in the voice pointmg to an affection of the larynx. Herbert French. DYSPNOEA, or marked difficulty or distress in breathing, may or may not be associated with orthopnoea : in the milder cases a patient when at rest has no dyspnoea, the difficulty with breathing being brought out only by exertion ; nearly all conditions which may produce dyspnoea, however, are capable in later stages of producing orthopnoea, so that the causes of dyspnoea and of DYSTOCIA 227 orthopnoea are similar in kind though they differ in degree. There is no need, therefore, to repeat what will be found under the heading of Orthopncea, whilst the article on Breath, Shortness of, should also be consulted. Herbert French. DYSTOCIA A term used by Hippocrates, signifying difficult birth or labour. The difficulties of delivery show themselves by prolongation or delay in the completion of the stages into which labour is usually divided. Dif&cult labour is accompanied by progressive symptoms, objective and subjective, which are to be explained by physiological exhaustion, especially in its effect upon the central nervous system of the patient. The results of difficult labour are thus of such importance, affecting, as they do, the life of the mother and child, that anticipation of it, and therefore early and appropriate treatment, are of paramount importance in scientific midwifery. The causes may be best tabulated according as they occur in the first or second stage, the first series delaying the dilatation of the cervix, the second the expulsion of the child. It is not out of place in this connection to add also the causes of difficulties in the separation and expulsion of the placenta, for delivery cannot be said to be complete until the placenta is expelled. Causes of Delay in Completion of the Three Stages OF Labour. 1st Stage. Weak uterine contractions. Rigidity of cervix. Relative, spasmodic, cicatricial, new growths. Pendulous belly, causing anteversion. Early rupture of mem- branes, due to malpresen- tations, morbid adhesions to the lower uterine segment, undue friability. Malpresentations in general. Anything which prevents the head entering the lower uterine segment. Hydramnios. Deficiency of liquor amnii. Twins. 2nd Stage. Weak uterine contractions. Secondary uterine inertia. Absence of accessory muscu- lar effort. Rigidity of vagina and perineum. Loaded rectum. Distended bladder — cysto- cele. Contracted pelvis. Pelvic tumours : Fibro- myoma, ovarian tumours, growths of the pelvic bones, hagmatoma, vari- cose veins, vaginal growths. Malpresentations : Occipito- posterior, breech, face, brow, transverse. Any abnormal enlargement of the chUd : Hydro- cephalus, meningoceles, ascites, tumours, double monsters, very large child. Excessive ossification of the head. Short cord : absolute, rela- tive. Locked twins. yd Stage. Weak uterine contractions. Morbid adhesion of placenta. Uterine spasm. " Hourglass " contraction. Adhesion of membranes. From the above it will be seen that the causes of delay are very numerous and important ; and the successful delivery of the child under many of these condi- tions depends very much on their anticipation, rather than their recognition when delivery is already dangerously obstructed. Consequently, accurate diagnosis at the beginning of labour will often save much trouble to the practi- tioner, and danger to the mother and child. Indeed, some of the dangers of obstructed labour can only be avoided satisfactorily by careful examination of the patient during pregnancy, say at the thirtieth week. This specially appUes 228 DYSTOCIA to the recognition of contracted pelves, of the presence of pelvic tumours, and sometimes of malpresentations, and constitutes an important reason why every patient should be urged to undergo an examination during the later weeks of pregnancy. The routine method of examination of the pregnant woman, whether in labour or not, is the same ; and the deductions to be made from it are identical. The examination is made as follows : first, by abdominal palpation ; secondly, by vaginal examination. Abdominal Palpation — First feel for the foetal head in the pelvis by the " pelvic grip," or Pawlik's grip. In a primipara the head should be well down in the pelvis ; not necessarily so in a multipara. Failing to find the head in the pelvis, palpate for it at the fundus ; failing to find it here, it will be found in one or the other lateral situations. If the head is in the pelvis, and fixed, there can be no pelvic contraction of importance, and tumours of the uterus or ovaries below the brim are quite unlikely. If, however, the head is above the brim and movable in a primipara, pelvic contraction must be suspected, whilst a tumour preventing entrance into the pelvis is a possibility. Pelvic contraction may be verified by pelvimetry, for which see below. Abnormal presentations are recognized by abdominal palpation ; breech and transverse by the actual position of the head ; occipito-posterior by the presence of the " small parts," arms and legs, in front, and the absence of the back of the foetus ; whilst a face cannot be absolutely diagnosed, except in mento-posterior cases, when the groove between the extended occiput and back will be felt in front, whilst the head remains above the brim. Hydramnios may be recognized here if there be fluctuation, and the foetal parts can only be felt by deep dipping of the hands through the fluid. Twins may possibly be recognized by feeling two heads, and hearing two foetal hearts beating with different rhythms. Vaginal Examination, — It is important to remember that very little can be made out with one or two fingers. As a rule, all that can be noted is the condi- tion of the canal, whether narrow or rigid, with a powerfully acting levator ani muscle, and the condition of the os ; note, especially, its consistence, and the integrity of the membranes. It may not even be possible to recognize the pre- sentation, if this has not been made out by abdominal palpation. If contracted pelvis is suspected, the important diameter, namely, the diagonal conjugate, should be measured with the fingers, and the true conjugate estimated by sub- tracting half an inch from this measurement. The only accurate instrument for taking this measurement is Skutsch's pelvimeter ; but its use requires considerable experience, and, in general, the simpler method with the fingers is sufficiently accurate for most purposes. External measurements may be made to supplement the important internal one ; but they are not of the same practical importance. When a difficulty arises in labour, accurate diagnosis is indispens- able, and the whole hand should be inserted into the vagina under anaesthesia. The presenting part may then be grasped, and its absolute character determined. In this way occipito-posterior presentations (the commonest cause of difficult labour) can be diagnosed with certainty, and rectified. Hydrocephalus may be recognized by this manoeuvre ; the hand may be pushed on above the head without danger in most cases, and the neck felt for coils of cord, the body of the child palpated for the presence of tumours or enlargement by ascites. Tumours obstructing delivery are best felt from the vagina ; they are usually wedged between the presenting part and the sacral promontory, part below and part above this prominence. If fluctuating and soft, they are usually ovarian cysts ; if hard and unyielding, they may be fibromyomata of the uterus ; but these also are apt to soften during pregnancy, and to feel like fluid tumours. Tumours of the pelvic bones are usually bony, or cartilaginous ; growths of the EARACHE 229 cervix may be fibroid, but more commonly are friable carcinomata, bleeding freely on examination. Little more than the method of examination can be indicated in a short article on the diagnosis of a case of difficult labour ; but too much stress cannot be laid on the value of abdominal examination and palpation as the most important means of gaining information in any labour. Delay in the Delivery of the Placenta, though not strictly a part of difficult labour, presents difficulties in the completion of delivery, and must not be overlooked. The placenta may be simply retained in utero ; may be adherent to the uterus, totally or partially ; or may be retained in the vagina. In the first case, if there is no haemorrhage, the placenta is likely to lie in the lower uterine segment and vagina, and is not expelled owing to weakness of the acces- sory muscles. If partially adherent, bleeding is certain to occur, whilst total adhesion does not permit of any bleeding. In any case of this kind if, after a sufficient time has elapsed, the placenta cannot be expressed, the hand must be introduced into the uterus in order to diagnose the condition. It must not be forgotten that the placenta may be retained above a spasmodic stricture of some part of the uterus, the so-called hourglass contraction. Hasmorrhage always accompanies this condition if the placenta is partly separated. Finally, the symptoms of exhaustion consequent upon obstructed labour may be mentioned. The first are rise of temperature and increase in frequency of the pulse-rate. These afford very important indications of obstructed labour, and assist us to distinguish simple delay from weak uterine contractions, in which the pulse and temperature remain normal. The later symptoms of obstruction, if not relieved, are local and general. Locally, the vaginal secretions fail, the parts become hot, dry, and swollen. The uterus contracts powerfully, and may go into a tetanic condition, usually known as tonic contraction, in which case the uterus is hard, never relaxing, and is tender to the touch. The exact opposite, of course, occurs in uterine inertia, when the uterus remains flaccid, along with a normal pulse and temperature. Later still, vomiting of a reflex nature may occur, signs of septic infection may appear, and rupture of the uterus may take place, owing to the dangerous thinning of the lower segment when tonic contraction supervenes. This series of symptoms should never occur in properly conducted midwifery ; their possible occurrence should always be anticipated by correct diagnosis early in labour, followed by immediate appro- priate treatment. T. G. Stevens. EARACHE or OTALGIA. — Earache is the term usually applied to the pain experienced in acute inflammation of the middle ear. It is most acute when suppuration ensues. There are, however, a number of other conditions, many of them of great importance, which also give rise to otalgia or pain in the ear. In acute otitis media the pain is usually dull, continuous, and throbbing, with sharp exacerbations in which the pain shoots to the occiput, to the top of the head, or forwards to the temporal region. It is usually worse at night — indeed it may disappear in the day — and it is increased by pressure over the tragus and on opening the mouth. Not infrequently there is some tenderness over the mastoid process. There is always some impairment of hearing. In adults there will probably be a slight rise of temperature, but in children the pain is often very acute, and constitutional symptoms may be very marked. Thus there may be convulsions, vomiting, and delirium, and the temperature may rise to 103° F., or more. Such cases may be mistaken for meningitis, especially in children too young to talk ; but in these little patients attention 230 EARACHE may be directed to the trouble by the extreme tenderness of the affected ear, the least manipulation of which may cause the child to scream. In young children the presence of cerebral symptoms with p^nrexia should always lead to a careful examination of the ears. The presence of optic neuritis favours a diagnosis of extension of the inflammation to the interior of the cranial cavity, but this is not a universal rule, for cases are recorded in which otitis media bv itself has caused optic neuritis. Attacks of earache in childhood are frequently caused by adenoids, and indeed, acute otitis media is practically always caused by an extension of inflammation from the nasopharynx along the Eustachian tubes. When suppuration occurs, the membrane becomes perforated, pus escapes, and the pain usually ceases. When it persists, the perforation is pro- bably too small to allow of satisfactory drainage of the pus. Examination of the tympanic membrane by means of a speculum will show redness, loss of lustre, and probably bulging of the membrane, with blurring of the handle of the malleus, thus enabling a diagnosis to be made. Chronic middle-ear suppuration is usually painless ; but when caries or necrosis occur, pain is often present and may be very acute. This is, however, by no means invariable, and some cases of extensive caries are remarkably free from pain. Pain and tenderness over the hiastoid process are also present in acute mastoid abscess and periostitis. Pain in the ear may also be caused by the following lesions of the external auditory meatus : — Furuncles give rise to very intense pain, often throbbing in nature, followed by a discharge of pus, after which the pain diminishes. Examination shows swelling of the meatus, which is so tender that it may be impossible for the patient to endure the presence of the speculum. A foreign body, especially if an insect finds it way into the meatus, may cause intense pain. Cerumen is usually painless, though sometimes a dull pain may be present. Eczema of the meatus may be the cause of a burning or smarting pain. In all these cases, examination with the speculum will clear up the diagnosis. Sometimes a careful examination of the ear will fail to reveal any lesion. Under these circumstances the possibility of one of the following causes of referred pain must be considered : — ■ A carious molar tooth is a very common cause of pain referred to the ear. Frequently, in epithelioma of the tongue, pain in the ear is a very troublesome symptom. The same may also be the case where there is ulceration of the pharynx or larynx. Acute or subacute tonsillitis often causes acute pain in the ear without any inflammatory lesion of the middle ear. Less frequently, suppuration in the accessory sinuses of the nose has a similar result. Otalgia may sometimes be neuralgic, and it is then usually associated with trigeminal neuralgia. It may also occur in nervous anaemic patients, and some- times must be regarded as a neurosis. It must also be remembered that the glenoid lobe of the parotid gland extends into the non-articular portion of the glenoid fossa, and thus parotitis may cause pain referred to the ear. Similarly otalgia may occur with ost&Q-arthritis or inflammatory trouble in the temporo- mandibular joint. Lastly, it must be remembered that there is a lymphatic gland situated over the mastoid process which drains lymph from the side of the scalp ; when inflamed, this gland may be the cause of pain and tenderness which may lead to a suspicion of suppuration in the mastoid process. Philip Turner. ECCHYMOSIS.— (See Purpura.) ENLARGEMENT OF THE HEART 231 ECTHYMA.— (See Scabs.) ELECTRICAL REACTIONS. — (See Reaction of Degeneration.) EMACIATION. — (See :Mafy an aonic aneurysm ; collatera circulation through the distended superficial veins of ihe neck and thora.\. ring, increases its circumference, and thus renders the aortic valves incompetent, though the cusps may be individually healthy. In addition to the characteristic pulse and the usual signs and symptoms of aortic regurgitation, there may be several indications which point to an aneurysm of the first part of the aorta as the cause of the aortic incompetence : — There may be a distinct bulging of the thoracic wall involving the first and second interchondral spaces close to the right border of the sternum. There may be well-marked pulsation in the second right interchondral space and also in the adjacent spaces, according to the size of the aneurysm, close to the sternum ; when not obvious to the hand this may sometimes be detected by the ear laid flat on the chest. In addition to an increase of the cardiac dullness downwards and to the left. 236 EXLARGEMEXT OF THE HEART there -will be a decided area of dullness in the second right space close to the sternum. There may also be some signs of intrathoracic pressure : — The right carotid pulse may be weaker than the left. The face and neck may be deeply cyanosed if the aneurysm has extended out- wards and has stenosed the superior vena cava, though this is a rare occurrence in this disease {Fig. 72). There may be a loud systolo-diastohc bruit audible in the second right space over the superior vena cava, with maximum intensity an inch or more to the right of the sternum. The superficial veins over the upper part of the right side of the chest in front may be varicose {Fig. 73), and the direction of the blood- current in them may be from above downwards, instead of from below upwards. The right bronchus may be stenosed if the aneurysm pro- jects posteriori}-, and this leads to impairment of percussion note and deficiency in the vesi- cular murmur over the upper lobe of the right lung. The -v-rays might be used to deter- mine the diagnosis {Fig. 74), though the aortic diastolic bruit should serve to distin- guish aneurysm from new growth. J^i'g: 74 — Skiagram of a large saccular :.•.■■.-•/- - i A) of the ascending part of the arch of the aorta : (B transverse arch displaced to the left : (C C) clavicles : (D) dia- phragm : (El apex of left ventricle. — By Dr. Alfred C. Jordan. Causes of Aortic Disease. A diagnosis of aortic disease is incomplete until the actual cause of the lesion ha5 been determined. It may be due to : — I. Lesions of the Valves : — Acute endocarditis Fibrosis after former endocar- ditis Infective endocarditis Sclerosis due to : — Strain (persistent), S}-philis, Alcohol Rupture of a segment Congenital malformation. 2. Dilatation of the Aortic Ring from Aneurysm of the first portion of the Aorta. Lesions of the Valves. Acute Endocarditis occurs most frequentl}- as a comphcation of acute rheu- matism, chorea, or scarlet fever. The indications of acute inflammation of the aortic valves wiU be a systohc murmur in the aortic area, and less commonly an early diastolic (post-systolic) murmur, which first becomes audible in the third left space close to the left border of the sternum. If the bruits are already present when the patient is first seen, it may be difficult to decide whether they are due to existing acute inflammation or to fibrosis after former inflammation. They may be noticed to arise whilst the patient is under treatment in bed for acuti^ rheumatism, and then their acute nature wiU be obvious. In cases in ENLARGEMENT OF THE HEART 237 which the bruits are due to acute aortic endocarditis and not to permanent fibrosis, the pulse will have little of the water-hammer type, the heart will not be much hypertrophied, though it maybe dilated from acute rheumatic toxaemia, and the bruits will be found, as the days go by, either to diminish or increase in intensity, according as the inflammation of the valves resolves or passes on into permanent fibrosis. Fibrosis from Previous Endocarditis. — When aortic disease is due to fibrosis from previous endocarditis, there will generally be a history of attacks of acute rheumatism, chorea, scarlet fever, or tonsillitis. The diastolic bruit which indicates the presence of aortic regurgitation is heard best along the left border of the sternum, the point of maximum intensity being in the third left intercostal space close to the left border of the sternum. There will generally be evidence of organic mitral disease at the same time, and if mitral stenosis be associated with aortic disease, whether there is a history of acute rheumatism or not, the valvular lesions may be considered without doubt to be due to the effects of former endocarditis. The patients are generally children or young adults, though a few survive into middle life. Infective Endocarditis. — In this form of endocarditis, in addition to the signs and sj'mptoms of aortic disease, there may be irregular pyrexia, occasionally rigors and sweating, subcutaneous petechiae and ecchymoses, haematuria and albuminuria from embolism of the kidneys, pain and tenderness in, and enlarge- ment of, the spleen, retinal haemorrhages and signs of embolism in other arteries, such as those of the brain causing coma, which may be followed by hemiplegia, or of the limbs, causing painful local swellings and loss of pulsation in the vessel below the embolus. In some cases a bacteriological examination of the blood shows the presence of such micro-organisms as the Streptococcus pyogenes, Staphylococcus pyogenes aureus. Micrococcus rheimiaticus, Pneumococcus, or others. Sclerosis not due to former Endocarditis : — Strain. — Persistent strain, which is continually increasing the tension of the segments of the aortic valves during the ventricular diastole, is an important factor in the production of aortic disease. Occupations entaiUng long and con- tinued ma.nual labour, and excessive indulgence in athletics are the commonest causes of such a continuous strain on the valve segments, and lead to a gradual and progressive sclerosis and curling of the edges, which narrow the width of cusp and thus lead to incompetence. The tendency is not nearly so great, however, in those who have not had syphilis as in those who have ; so that sclerosis from strain alone must not be diagnosed unless there be neither a history nor evidence of rheumatism, chorea, syphilis, or alcoholism. Syphilis. — A history of syphilis, and any manifestations of this disease in the form of pigmented scars on the legs, body, and face, ulceration of the tongue, patches of leukoplakia, ulceration, scarring, or perforation of the palate, necrosis of the nasal bones, etc., would point to this disease as the cause, and this con- clusion would be strengthened if there were no previous history of rheumatism, scarlet fever, or chorea. In aortic disease from this cause the diastolic murmur is usually best heard along the right border of the sternum in the third or fourth right intercostal space. The patients are nearly all males who have worked hard, and their first symptoms are often brought on by some undue muscular effort which strains the enlarged heart, or even bursts an atheromatous patch in the diseased valve. Uncommon before forty, the lesion is met with often enough between forty and fifty ; in many cases the heart has been passed as normal at forty, whilst at forty-five the aortic regurgitation is extreme. These patients often suffer from very severe attacks of angina pectoris, to which they are much more liable than are rheumatic aortic cases. 238 ENLARGEMENT OF THE HEART Alcohol. — The constant use of alcohol raises arterial tension and may be followed by sclerosis. The general appearance of the patient, the tremor of the tongue and hands, and the history of loss of appetite for breakfast, morning vomiting, and cramps in the calves of the legs at night, would suggest alcohol as the cause in the absence of any evidence of rheumatism or syphilis, but alcoholism without syphilis leads to definite aortic disease less often than it does to a generallv hypertrophied heart which sooner or later exhibits fibroid or fatty degeneration. Rupture of a Segment of the Aortic Valve. — This is a rare occurrence, and usually is brought about by some severe and sudden muscular exertion. The following is a good illustrative case of aortic regurgitation caused b}- rupture of a valve segment. A sailor, who had been examined just previously by the medical officer and found to be sound, was one day pulling on a rope, when suddenly the strain on it was unexpectedly and much increased. He made a tremendous effort to prevent the rope slipping through his hands, and in doing so fainted, and was picked up in an unconscious condition ; on coming round he was very dyspnoeic, and complained of pain in the precordial region. When the doctor examined him again he found a well-marked musical early diastolic murmur in the third and fourth left intercostal spaces close to the sternum, and came to the conclusion that as his heart sounds were normal before the accident, he must have ruptured one of the segments of his aortic valve and thus caused the incompetence. There is always the possibiUty, however, of such a valve having previously been the site of syphilitic atheroma, without bruit, until the extra strain caused a weak spot in the valve to give way suddenly. Congejtital Malformations of the Aortic Valves are extremely rare, and they are to be diagnosed with great caution. Dilatation of the Aortic Ring from Aneurysm of the first portion of the Aorta is nearly always due to syphihtic atheroma of the aortic walls, and in such a case it will be probable that there is syphilitic disease of the aortic valves themselves also. The dilatation of the aorta ("fusiform aneurysm") will be indicated by definite impairment of note in the second right intercostal space near the ster- num ; and the A--rays will confirm it. It will be next to impossible to assess with any degree of accuracy how much of the aortic regurgitation is due to the dila- tation of the ring and how much is due to the concomitant valve changes. 2. Mitral Regurgitation. As a result of mitral regurgitation the left auricle becomes dilated and hyper- trophied, the left ventricle dilated and hypertrophied, and later from backward pressure the right ventricle and auricle may be affected similarh^ The chief symptoms are dyspnoea on exertion, palpitation, congestion of the face and hps, cough, possiblv haemoptysis, oedema of the feet and legs, and distention of the abdomen from ascites and enlargement of the hver. In the earh' stages the pulse may be regular, full, and of low tension. When compensation begins to fail, the pulse becomes rapid, irregular, and intermittent. The cardiac impulse is displaced downwards and outwards. It may be in the fifth intercostal space in the left nipple fine, or outside it, or in the sixth space outside the nipple line. It is usually diffused, and there maybe epigastric pulsation. There may be marked bulging of the precordial area in children. A systolic thrill is rare, but it may be felt at the cardiac impulse. The cardiac dullness is increased outwards and downwards, but also upwards and to the right when the right side is involved. At the impulse there is a systolic murmur, usually of a blowing character, which may either follow or replace the first sound. It is best heard at the ENLARGEMENT OF THE HEART 239 cardiac impulse, but it can generally be traced outwards into the left axilla, can sometimes be heard behind at the inferior angle of the left scapula, and can also be traced inwards towards the left border of the sternum. The pulmonary second sound is accentuated or reduplicated in the second interspace close to the left border of the sternum. When compensation fails, in addition to the above there may be : — A systolic murmur, softer than and different in character from that at the impulse, over the lower part of the sternum and the fourth and fifth left inter- spaces, due to tricuspid regurgitation ; oedema of the feet, legs, and lower part of the body ; abdominal distention from ascites ; enlargement and pulsation of the hver ; signs of hydro thorax ; albuminuria. A diagnosis of mitral regurgitation is incomplete and insufficient by itself, for it is a lesion which may be due to any of a large number of different con- ditions. It is necessary to determine, if possible, the actual cause of the defect. Causes of Mitral Regurgitation. I. Lesions of the Mitral Valve: — Acute endocarditis Fibrosis the result of former endocarditis Infective endocarditis. 2. Dilatation, or Hypertrophy and Dilatation, of the Left Ventricle, without organic changes in the Mitral Valve itself : — Secondary to aortic disease Secondary to increased systemic blood-pressure : — Chronic Bright's disease Arteriosclerosis. 3. Diseases of the JMyocavdium and Pericardium : — Mj^ocarditis Fatty degeneration Fibroid degeneration Pericarditis Adherent pericardium. 4. Acute Dilatation of the Heart from : — Over-exertion ■ Acute nephritis. Acute febrile diseases ' Lesions of the Mitral Valve : — Acute Endocarditis. — Simple acute endocarditis is not a disease per se, but occurs as a comphcation of some other disorder, especially acute rheumatism, chorea, and scarlet fever. It sometimes complicates tonsillitis, which is in many instances a manifestation of rheumatism occurring without any changes in the joints ; and it should also be remembered that in children acute endo- carditis may be the chief, and in fact the only, indication of an attack of rheumatism. There are no characteristic symptonrs which point to acute endocarditis. If in the course of acute rheumatism the patient complains of a little palpitation, precordial pain, and distress, and it is found that the heart action has increased in rapidity without any increase in the joint affection, endocarditis should be suspected. The temperature chart seldom indicates the complication. At first the position of the cardiac impulse and the heart-sounds remain normal, but if watched from day to day, endocarditis having developed, the impulse will be found to have moved outwards, the first sound becomes prolonged and roughened, then doubled, and in a few days it is either followed or replaced by a localized soft blowing systolic murmur. Fibrosis the result of Previous Endocarditis. — If acute endocarditis of the 240 ENLARGEMENT OF THE HEART mitral valves does not resolve, the valve-flaps become sclerosed. The valve gets thickened from fibrotic changes, and in the later stages it may become quite firm and brittle from a deposit of lime salts. The chordse tendinese also may be shortened and thickened. The circumference* of the orifice may be considerably increased in some cases, and although the valve is thickened, it is narrowed if measured from its free edge to its line of attachment to the auriculo-ventricular ring. In the majority of cases, however, the circumference of the orifice is narrowed, so that the valve is not only incompetent but also stenosed. A diagnosis of fibrosis after endocarditis as the cause of mitral incompetence may be made if there is a previous history of acute rheumatism or chorea, and independently of such a history if there is evidence of stenosis as well as regurgi- tation. If actual mitral stenosis can be diagnosed with certainty, it must be due to fibrosis from endocarditis, though there may of course be recent endo- carditis as well. Infective Endocarditis of the mitral valve : if there is a mitral bruit, any sudden or radical change in its character may suggest infective endocarditis, especially if any of the symptoms and signs mentioned on page 237 are present at the same time. Hypertrophy and Dilatation of the Left Ventricle. Secondary to Aortic Disease. — Aortic disease leads to hypertrophy of the left ventricle, which is followed after a time by dilatation of that cavity and mitral regurgitation. Marked pulsation of the superficial arteries, a splashing pulse, capillary pulsation, and the systolic and early diastoUc murmur at the base of the heart, the former best heard in the second right space close to the sternum, and the latter in the third left space close to the left border of the sternum, would indicate the presence of aortic disease. If the patient has suffered from either rheumatism or chorea, the mitral regurgitation might be due to primary endo- carditis of the mitral valve, but if the aortic disease is the result of syphihs, hard work, or aneurysm of the first part of the aorta, then it may be assumed that the mitral regurgitation is the result of secondary dilatation of the left ventricle, and not of primary disease of the mitral valve. Secondary to Increased Systemic Blood-pressure due to Chronic Bright' s Disease. — Associated with the increased blood-pressure of chronic Bright's disease, the left ventricle hypertrophies first of all, and then after a time, when compensation fails, dilates ; mitral regurgitation follows, and may be succeeded by all the signs of backward pressure, such as oedema of the feet and legs, ascites, enlargement of the liver, hydrothorax, heemoptysis from congestion or infarction of the lungs, and so forth. A patient presenting such a group of symptoms may at a first glance be considered to be a case of primary disease of the heart, but a careful investigation will often enable one to determine that the primary changes have occurred in the kidneys. The radial artery may be thickened and tortuous, the tension of the pulse higher than in mitral regurgitation from primary heart disease ; and ophthalmoscopic examination may in many instances reveal the presence of albuminuric retinitis and -retinal haemorrhages ; the urine is variable, for whereas it may formerly have been abundant, of low specific gravity (1008 to 1012), with only a trace of albumin, heart failure may lead to its being diminished in amount, of specific gravity 1020 or more, and albumin may be abundant ; microscopical examination, however, will generally reveal renal tube-casts. Secondary to Increased Systemic Blood-pressure due to Primary Arteriosclerosis. — In this disease there may be signs of enlargement of the heart, mitral regurgi- tation, backward pressure, and a thickening of the arteries, but in contrast to chronic Bright's disease the urine will be of higher specific gravity, and there will be no albuminuric retinitis. It often becomes merely a matter of ENLARGEMENT OF THE HEART 241 opinion, however, whether a given patient is suffering from arteriosclerosis or from granular kidney; post-mortem examination may reveal both, or arteriosclerosis may predominate when granular kidney had been diagnosed, and vice versa. Diseases of the Myocardium and Pericardium. Myocarditis — Inflammation of the myocardium is most frequently associated with either pericarditis or endocarditis, but occasionally it may occur in acute rheumatism as a primary condition. In one form of the disease there is an infiltration of leucocytes between the muscular fibres — interstitial myocarditis ; in another form the actual muscle fibres are involved — parenchy- matous myocarditis ; and there is a third variety which occurs in pyaemia, especially from bone disease, characterized by the formation of abscesses in the myocardium. The weakened condition of the heart muscle leads to dilatation of the ventricles, and thus to enlargement of the heart. When accompanied by pericarditis or endocarditis, the signs of myocarditis are over- shadowed by the symptoms associated with these other conditions. The diagnosis of myocarditis is therefore a difficult matter. If in a case of acute rheumatism there is no evidence of either pericarditis or endocarditis, but there are signs of cardiac failure, a feeble irregular pulse, a good deal of precordial pain and distress, dyspnoea and palpitation, a tendency to sudden collapse, and signs of dilatation of the left ventricle, with a feeble cardiac impulse and a weak first sound, myocarditis may be suspected. Fatty Heart. — The heart may be covered with fat (fatty superposition) ; fat may infiltrate between the muscular fibres (fatty infiltration) ; the muscle fibres may be degenerated, losing their striation, and containing fat granules (fatty degeneration) ; or all these conditions may be associated. Fatty degeneration may occur in patches or be general. When general, the heart becomes enlarged from dilatation as the muscle becomes flabby, has less contractile force, and is more yielding. It is a condition which may be associated with general obesity, severe anemia, wasting diseases such as cancer, phthisis, phosphorus poisoning, and alcoholism. It may be a sequela of severe attacks of tvphoid and other specific fevers. The symptoms and signs of the condition are due to the diminished contractile power of the ventricles which leads to dilatation. The pulse may be small, feeble, and slow — 30 to 40 beats per minute — or it may be frequent and irregular. The cardiac impulse is very feeble or imperceptible. There may be an increased area of cardiac dullness from dilatation, and the first sound may be very faint. The patient is usually feeble and anaemic, and suffers from faintness or severe syncopal attacks which come on suddenly and are characterized by coma, convulsive twitching, and stertorous breathing. (Edema of the legs and venous congestion of the lips and face, which are common in valvular disease, are usually absent. There is dyspnoea on exertion, a feeling of coldness and depression, and a general impairment of the nutrition of the muscles, which are soft, flabby, and diminished in power. In some cases attacks of cardiac " asthma " in the early morning are complained of, and in the later stages of the disease there may be Cheyne-Stokes' breathing. The chief diagnostic signs are the feeble cardiac impulse, the feeble pulse, and the weak first sound, associated with dyspnoea and attacks of syncope, and the absepce of evidence of other causes for the heart svmptoms. Fibroid Heart. — Fibroid degeneration of the myocardium is usually associated with some obstructive lesion of the coronary arteries caused by syphilis. The apex of the left ventricle is the part most frequently affected. It leads to a thinning and weakening of the ventricular wall, and may be followed by aneurysm of the heart and then b}^ rupture. The enlargement of the heart is chiefly due to dilatation of the left ventricle. It is one of the causes of sudden D . 16 242 ENLARGEMENT OF THE HEART death. The most important symptoms are : dyspnoea on slight exertion, palpi- tation, and precordial pain. The physical signs are those of dilatation of the left ventricle. The pulse is feeble and irregular, and maj' be slow. There may be severe attacks of angina pectoris. The diagnosis is more or less a matter of guesswork. Such signs and s}Tnptoms in a patient who has had sj^hiUs but neither acute rheumatism nor chorea, and who has neither aortic disease nor signs of granular kidney or arterio- sclerosis, might be considered indications of this form of cardiac degeneration. Pericarditis — In pericarditis the cardiac impulse is usually displaced, and the area of cardiac dullness increased. These physical signs may be due to enlargement of the heart, or to effusion of serous fluid into the pericardial sac, but whatever the text-books say to the contrary, it is practically impossible to differentiate between these two conditions. Enlargement of the heart due to dilatation is generally the result of the myocardium being affected as well as the pericardium, and the cardiac impulse is diffused and displaced out^vards. If there is an effusion of serous fluid into the pericardial sac, it is said that the impulse is displaced upwards as well as outwards, so that it may be found on a level with, or above and external to, the left nipple, but this is a very unrehablesign. The dullness is increased laterally and upwards, and when carefully mapped out it is said to have a triangular shape, with the base on the diaphragm and a some- what rounded apex pointing towards the left clavicle, and reaching to the second left intercostal space or higher. Percussion, however, is quite unable to distin- guish between a pericardial effusion and a much enlarged heart without effusion. The intercostal spaces are filled out, and may be almost obhterated, so that the ribs feel much less prominent on this part of the chest. On auscultation, in addition to a systohc murmur at the impulse due to mitral incompetence from the accompanjdng dilatation of the left ventricle, a triple " cantering " sound and perhaps a definite rub may be heard in some part of the precordial region, especially near the sternum, independently of respiration, and generally increased in intensity by firm pressure of the stethoscope. The rub is audible whether effusion is present or not. Adherent Pericardium. — Adhesions between the visceral and parietal layers of the pericardium are frequently found post mortem when thej^ had never been suspected during life. Sometimes, however, thej^ are associated with chronic mediastinitis, or what should more correctly be termed mediastinal fibrosis, the outer surface of the pericardial sac becoming adherent to the thoracic wall and to adjacent structures. This condition usually leads to very considerable hvpertroph}' and dilatation of the heart. There may be marked bulging of the precordial area to the left of the sternum. The cardiac impulse ma}- be seen not only in the sixth space outside the left nipple line, but also in the fifth, fourth, and third left spaces, and the pulsation may extend in these spaces from the left border of the sternum to the left nipple hne, or even outside that line. The impulse has a curious wavy character, and it may be noticed that coincident with the impulse in the sixth space there may be a systohc retraction of the spaces above, or of the lower ribs below and outside the cardiac area, best seen when the patient hes over to the other side with his left arm raised above his head. If the heart is adherent to the diaphragm, there may be a S3^stolic retraction of the eleventh and twelfth ribs on the left side behind. Nearly all the cases of adherent pericardium of this type exhibit marked dilata- tion of the superficial veins in the precordial area. Diastohc collapse of the cervical veins is said to occur also. On rolling the patient from side to side it is found in many cases that the cardiac impulse remains nearly in the same position, not altering so much as it does in health under similar circumstances. The hand placed over the heart may feel a diastohc shock or rebound, which is ENLARGEMENT OF THE HEART 243 regarded bj' some as one of the most characteristic signs of the condition. On auscultation there is a s^'stoHc murmur at the apex, which is indicative of mitral regurgitation, and frequently there is also a pre-systolic murmur which is due to a relative stenosis of the mitral orifice. There is also a therapeutic sign which may help in doubtful cases. Mitral regurgitation in young people, if due simply to fibrosis of the valve after endo- carditis, will usually improve under treatment by rest in bed and the administra- tion of appropriate doses of digitahs. Where the mitral regurgitation, however, is associated with adherent pericardium, similar treatment has httle effect, and very slight, if any, improvement follows. Another way of expressing the same fact is that if, in a young person who is presumably rheumatic, the size of the heart and the symptoms are not easily accountable for by the extent of valvular disease suggested by the bruits, the patient probably has adherent pericardium with mediastinal fibrosis. The diagnosis, therefore, is guessed at rather than made. Acute Dilatation of the Heart. From Over-exertion. — Acute dilatation may occur as a result of over-exertion. For example, if a man who has been run down from excessive mental work, and in consequence is in poor condition or bad training from lack of efficient exercise, takes a holiday, and attempts the ascent of a high mountain or engages in some violent form of exercise, his heart is very liable to give way under the strain. The chief indication of such an occurrence will be a feeling of pain, distress, and discomfort in the region of the heart, dyspnoea, and palpitation. The pulse will be rapid, weak, and irregular. The cardiac impulse will be displaced outwards, will be diffuse, weak and undulating in character, and although a maximum point of the impulse may be visible, it cannot be detected clearly by palpation. There will be marked epigastric pulsation, the cardiac dullness will be increased outwards, and the first sound will be feeble, reduphcated, or replaced by a soft blowing systolic murmur. From Acute Specific Fevers. — Similar signs and sjmiptoms occurring in the course of diphtheria, typhoid fever, typhus, scarlet fever, erysipelas, and other fevers, would point to dilatation of the heart in consequence of the toxaemia producing loss of tone in the cardiac muscle from parenchymatous degeneration. 3. Arteriosclerosis and Granular Kidney (see p. 18). 4. Alcoholism. Patients who have been addicted to alcohohsm are liable to develop enlarge- ment of the heart. It is a cause of which the importance is frequently overlooked. The usual signs of hypertrophy and dilatation may be present, with mitral and tricuspid incompetence and signs of backward pressure. The enlargement may be considerable. At a post-mortem examination it is by no means unusual to find the heart weighing as much as from 20 to 30 ounces. The valves are healthy, the aorta is normal, and evidence of arteriosclerosis and granular kidney is absent. Alcoholism may therefore be suspected as the cause of enlargement of the heart where there is no evidence of primary valvular disease, adherent pericardium, arteriosclerosis, or chronic Bright's disease. Other signs and symptoms of alcohohsm may also be present, e.g., loss of appetite, morning sickness, hsematemesis, jaundice, rectal bleeding from haemor- rhoids, furred and tremulous tongue, and so on. 5. Long-continued Over-exertion produces hypertrophy of the ventricles, and for a considerable period may give rise to no sj^mptoms of disease, but after a time, when compensation fails owing to the hypertrophy being insufficient to continue the excessive work. 244 ENLARGEMENT OF THE HEART dilatation is produced, and mitral incompetence and signs of backward pressure become prominent. The subjects of this form of enlargement of the heart are usually either middle-aged men who are robust and healthy in appearance, but have had to follow for many years a laborious occupation entaihng severe manual labour, or else young men of good physique who have indulged in exces- sive athletic exercises, such as rowing, football, boxing, and running, often with insufficient preliminary training. At first, palpitation, dyspnoea, and irregular cardiac action are noticed. Later the ventricles dilate and the mitral valves become incompetent, and all the signs of backward pressure may follow. Enlargement of the heart from tfiis cause is much more Uable to occur where the patient is accustomed to take a considerable amount of alcohol. As a cause of enlargement of the heart it should not be diagnosed until primary valvular disease, granular kidney, and primary arteriosclerosis can be excluded. 6. Exophthalmic Goitre. In this disease, moderate enlargement of the heart, as shown by the displace- ment outwards of the cardiac impulse and the increased area of cardiac dullness, is common, and is probably the result of the long-continued increased rapidity of cardiac action. It is rarely, however, the most prominent sign of the disease. It is distinguished from other forms of enlargement by the presence of tachy- cardia — the pulse-rate in a well-marked case varying between 120 and 160 or being even higher than this — the marked pulsation of the carotids and other superficial arteries, the exophthalmos, the enlargement and pulsation of the thyroid gland, the fine tremor of the extremities, the loss of weight, the excitability, and the pigmentation of the skin of the eyehds. There is very often a loud blowing systolic bruit in the pulmonarj^ area, less often one at the impulse, but frequently one over the thyroid gland. Certain signs associated with the names of von Graefe, Stellwag, and Moebius, are not of the least value in making the diagnosis. 7. Congenital Heart Disease. When there is a patent interventricular septum there may be considerable enlargement of the heart from hypertrophy and dilatation of both ventricles. It is frequently associated with some narrowing of the pulmonary orifice. In addition to the symptoms which are common to most forms of congenital heart disease, viz., cyanosis, clubbing of the fingers and toes, dyspnoea, and polycythaemia, the cardiac impulse will be displaced downwards and outwards, there will be epigastric pulsation, perhaps a prolonged systolic thrill, best felt over the third left intercostal space close to the sternum, an increased area of cardiac dullness in all directions, and a loud systolic murmur at the base of the heart, the maximum point of intensity being the third or fourth left intercostal space, close to the left border of the sternum. It is often very difficult to say whether the lesion is pulmonary stenosis or patent interventricular septum. A well- marked thrill is more constantly associated with the former than with the latter, but the maximum point of intensity of the murmur produced by pulmonary stenosis is in the second left space, close to the left border of the sternum, whereas in patent interventricular septum the murmur is loudest lower down. ENLARGEMENT OF THE RIGHT VENTRICLE. When the enlargement of the heart is due to hypertrophy or dilatation of the right ventricle, the cardiac impulse is displaced outwards more than downwards, there is frequently well-marked epigastric pulsation, and the dullness is increased upwards and to the right rather than to the left. The causes of enlargement of the right ventricle are as follows : — ENLARGEMENT OF THE HEART 245 1 . Diseases of the Left Side of the Heart : — Mitral stenosis All the conditions which cause enlargement of the left ventricle. 2. Diseases of the Lungs : — Fibroid lung Chronic bronchitis and emphysema. 3. Diseases of the Right Side of the Heart : — Congenital pulmonary stenosis Pulmonary incompetence : Due to dilatation of the pulmonary artery Due to infective endocarditis of the pulnionary valve. I. Diseases of the Left Side of the Heart. Mitral Stenosis. — This is by far the commonest and most important cause of enlargement of the right ventricle. The obstruction to the flow of blood from the left auricle into the left ventricle leads to hypertrophy and dilatation of the left auricle, passive congestion of the lungs, red and brown induration of these organs, thickening, dilatation and atheroma of the branches of the pulmonary arteries in the lungs as a result of the increased tension in these vessels. All these changes increase the amount of work to be performed by the right side of the heart, and are responsible for the hypertrophy of the right ventricle, by which means compensation may be maintained for some time. When the right ventricle dilates, compensation fails. In the early stages the pulse shows little variation from the normal, and there may be no obvious synaptoms pointing to the existence of mitral stenosis. In more advanced conditions of the disease the pulse becomes rapid, small, irregular, and intermittent. The cardiac impulse is displaced outwards, and pulsation occurs in the epigastrium and in the third, fourth, and fifth intercostal spaces close to the sternum. On placing the palm of the hand over the region of the cardiac impulse and the adjacent fourth and fifth intercostal spaces, a character- istic thrill may be felt. It usually has a curious rough grating quality. It is diastolic in rhythm, and may be felt to terminate suddenly in a sharp shock which is synchronous with the apex beat. The dullness is increased upwards from the third left rib to the second, or even higher ; it extends well to the right of the sternum, but it does not reach far to the left, though in a few cases it extends to the left nipple line, even when mitral stenosis is the only lesion present. The more the dullness extends to the left, however, the less likely is the diagnosis of mitral stenosis alone to be correct. At or just inside the cardiac impulse, a loud, rough, rumbling, vibrating bruit may be heard, which runs up to, and is continuous with, a loud, accentuated, slapping first sound, which may or may not be followed by a systolic murmur. This characteristic bruit may occupy the whole of the diastole, and may com- mence with a doubling of the second sound. It increases in intensity until it finally ends in the loud first sound. It may, however, be shorter, and commence in the middle or latter part of diastole. It is usually termed a late diastolic or presystolic bruit, as it runs up to and is continuous with the first sound. The other abnormal signs to which mitral stenosis may give rise are described on p. 107 and loS. All the Conditions which cause Enlargement of the Left Ventricle. — When- ever compensation begins to tail in cases of mitral regurgitation from any cause, aortic disease, enlargement of the left ventricle from chronic Bright's disease, arteriosclerosis, alcoholism, or other causes discussed above, and 246 ENLARGEMENT OF THE HEART there is backward pressure through the lungs, hypertrophy of the right ventricle serves to maintain compensation for a time. The increase in the size of the right ventricle would be indicated by the advent of epigastric pulsation and a further increase of the dullness to the right of the sternum, but the diagnosis of its cause would rest upon data already discussed under the heading of mitral regurgitation (see p. 239). 2. Diseases of the Lung. Fibroid Lung gives rise to symptoms and physical signs so characteristic that there is rarely any difficulty in making a diagnosis. The hypertrophy of the right ventricle is of secondary importance, and does not become manifest until late in the disease. On account of the retraction of the lung, the heart is drawn over towards the affected side, and, in consequence of the displaced cardiac impulse and the increased area of pulsation, it may appear to be much larger than it really is. When the right lung is affected, there may be well-marked epigastric pulsation, and the cardiac impulse may be to the right of the sternum in the fifth intercostal space, the maximum point being in some cases as far out as the right nipple line. When the left lung is affected, the heart may be pulled over towards the left, so that the cardiac impulse is situated in the anterior, or even in the mid-axillary line. In consequence of the shrinking of the lung, more of the anterior surface of the heart will lie in contact with the thoracic wall, and there may be therefore an increased area of visible pulsation in the second, third, or fourth intercostal space. In addition to the displacement of the cardiac impulse, there is a diminution in the size and a decrease in the movement of the affected side of the chest, the shoulder is drawn down, the spine curved with the concavity towards the affected side ; there is increased tactile vocal fremitus, impairment of note on percussion, and possibly a cracked- pot sound ; and, should there be dilated bronchial tubes, there are cavernous or amphoric breathing, bronchophony, pectoriloquy, and loud crackling rales. With the exception of compensatory emphysema, there may be no sign of disease in the other lung, a point which helps to distinguish this condition from phthisis. The chief symptoms are chronic cough, dyspnoea, abundant expectoration on rising in the morning, the sputum often being foetid on account of the bronchi- ectasis which is so frequently associated with fibroid lung. The patient may be well nourished and show no signs of loss of flesh. Haemoptysis occv;rs occasion- ally, but no tubercle bacilli will be found in the sputum. There is often extreme clubbing of the fingers. Chronic Bronchitis and Emphysema may so increase the volume of the lungs that they completely cover the anterior surface of the heart ; consequently the cardiac impulse may be invisible, the superficial cardiac dullness diminished or absent, and the heart sounds faint or even inaudible. In these circumstances it is not an easy matter to diagnose with certainty the presence of enlargement of the heart. Should there be dilatation of the right ventricle as well as hyper- trophy, and also tricuspid regurgitation, a systolic murmur may be heard over the lower part of the sternum and in the fourth and fifth left intercostal spaces close to the sternum, and oedema of the legs, ascites, enlargement of the liver, and albuminuria may also be present. If, in addition, there are signs of pulmonary emphysema, viz., the cubical chest, wide epigastric angle, increased tactile vocal fremitus, hyper-resonant percussion note, diminished area of hepatic and cardiac dullness, increased voice sounds, diminished vesicular murmur with prolongation of the expiratory sound, with or without non-consonating rales and rhonchi, and if there are no indications of fibrosis of the heart valves from former endo- carditis, chronic Bright's disease, or primary arteriosclerosis, enlargement of the heart with failure of compensation as a result of chronic bronchitis and emphy- sema may be diagnosed. ENURESIS 247 3. Diseases of the Right Side of the Heart. Pulmonary Stenosis. — This is the commonest form of congenital heart disease. In addition to cyanosis, clubbing of the fingers and toes, polycythaemia, dyspnoea, and signs of hypertrophy of the right ventricle, there is usually a well-marked systolic thrill over the second left intercostal space close to the sternum, and a loud, rough systolic murmur in the same position. The murmur is not trans- mitted to the carotids in the neck as is that of aortic stenosis. Pulmonary Incompetence. — This lesion may be associated with congenital pulmonary stenosis, or may be due to infective endocarditis (especially gono- coccal), but by far the commonest cause is functional incompetence from dilatation of the pulmonary artery and orifice secondary to the high tension produced in the pulmonary circulation by mitral stenosis. It may be difficult to distinguish from aortic regurgitation : the early diastolic bruit of pulmonary incompetence is most audible, however, in the third and fourth left intercostal spaces midway between the left nipple line and the left border of the sternum, whereas in aortic disease the diastolic bruit is usually heard best in the third left space close to the left border of the sternum. The visible pulsation of the superficial arteries, and the collapsing pulse, which are so characteristic of aortic incompetence, are not present in cases of pulmonary incompetence. Herbert French. ENLARGEMENT OF THE KIDNEY.— (See Kidney, Enlargement of.) ENLARGEMENT OF THE LIVER.— (See Liver, Enlargement of.) ENLARGEMENT OF THE LYMPHATIC GLANDS.— (See Lymphatic Gland Enlargement. ) ENLARGEMENT OF THE SPLEEN. — (See Spleen, Enlargement of.) ENLARGEMENT OF THE THYROID GLAND.— (See Thyroid Gland, En- largement of.) ENOPHTHALMOS (or Retraction of the Eyeball). — This may occur : (i) In wasting diseases ; (2) In paralysis of the cervical sympathetic ; (3) In various congenital afl:ections. 1. The enophthalmos in wasting diseases is due to the absorption of the orbital fat, and the diagnosis as regards the eye presents no difficulty. 2. Enophthalmos due to paralysis of the cervical sympathetic is always associated with the other well-defined symptoms of this condition, namely, diminution in the size of the palpebral aperture, consti^iction of the pupil, and absence of sweating and blushing on the paralyzed side. The pupil is constricted owing to the paralysis of the dilator fibres, the pupil therefore not dilating in a feeble light. 3. In certain congenital cases, there is well-marked retraction associated with defective or irregular movements of the affected eyeball. The ocular muscles are, as a rule, inserted much farther back in the sclerotic than is normally the case. The condition appears to be due to the absence or defective insertion of the extrinsic muscles of the eye, and may be recogniied by its existence since birth. Herbert L. Eason. ENURESIS is the term used to denote micturition that is carried out involun- tarily by the reflex stimulation of the detrusor muscle of the bladder. It occurs almost exclusively in children, and although most frequently confined to the night, it may occur in the day. It must be distinguished carefully from incontinence of urine ; the patient has usually full control of micturition during 248 ENURESIS the day, although sometimes the desire to urinate must be satisfied quickly or a little dribbhng ma}'- take place. In this disease, the child completely empties the bladder, often without waking, once or several times during the night. The bladder need not be quite filled for micturition to occur, for it takes place in the early hours of the night. Enuresis is often accompanied, and may be caused, by slight affections, such as phimosis, balanitis, small urinary meatus, vulvitis, constipation, or intestinal worms, the correction of which remedies the trouble, but in other cases there seems nothing to promote the excitabihty of the detrusor muscle. It is cured not infrequently by an operation for the removal of enlarged tonsils and adenoid growths, or after the administration of small doses of thyroid extract. It has been stated that the condition is due to faulty development or deficient innervation of the sphincter muscle, or to spasm of the detrusor ; but it is difficult to reconcile these affections in practice. If the sphincter muscle were paralyzed or deficient, there would be true incontinence of urine present, whereas this is not so, and the children are often of good development and health. It is probable that the infantile condition in which the detrusor muscle holds the mastery over the sphincter persists, and it is a relative disparity between the innervation of the two sets of muscles, so that the con- traction of the detrusor, which normally is held in check by the sphincter, is able to overcome the comparatively weak action of the latter. When enuresis persists throughout childhood, it may disappear at puberty, when the prostate gland enlarges and strengthens the action of the sphincteric apparatus. It is important to exclude both pyelitis and oxaluria before a diagnosis of simple enuresis is made. In either case nocturnal micturition may be the chief symptom ; microscopical examination of the centrifugalized deposit will at once detect the pus cells or the excess of calcium oxalate crystals respectively. R. H. Jocely'n Swan. EOSINOPHILIA denotes a relative increase in the coarsely granular eosino- phile cells of the blood {Plate II, Fig. L) ; it is determined by preparing blood films and making a differential leucocyte count. Normally, the coarsely granular eosinophile cells vary from o to 2 per cent ; the point at which eosinophilia begins is quite arbitrary ; but one may say that although it is unusual, under perfectly healthy conditions, to find more than 2 per cent of these cells in the differential count, they should reach 5 per cent or more before the term eosinophilia is applied to the condition. It is probable that some normal people have upwards of 5 per cent of these cells, but beyond this point they are nearly always pathological. One may divide the causes of eosinophilia under main headings as follows : — - I. — Conditions in which Eosinophilia is slight, inconstant, and of little diagnostic significance : — Post-febrile states, after : — • Scarlet fever Pneumonia Acute articular rheumatism Affections of the bone-marrow : — ■ Splenomedullary leukaemia Sarcoma of bone Rickets Measles Varicella Malaria Osteomyelitis Osteomalacia Addison's disease After certain remedies, particularly camphor In ovarian maladies Gonorrhoea EOSINOPHILIA 249 During the positive stage of tuberculin reaction. Some cases of malignant disease, especially when there are metastases — carcinoma ; lymphosarcoma. 2. Conditions in which Eosinophilia may be marked. [a). Spasmodic Asthma. (b). Certain Skin Diseases, more particularly : — ■ The bullous dermatoses : — Pemphigus Erythema bullosum Dermatitis herpetiformis (Diih- ring's disease) Hydroa Herpes iris, or erythema iris Herpes gestationis. It is much rarer in other cases of skin disease, but is noted occasionally in psoriasis, eczema, and exceptionally in some other affections of the skin, (c). Certain Parasitic Affections, particularly : — Ankylostomum duodenale Bilharzia hsematobia Bothriocephalus latus Taenia solium It is much less constant, and indeed generally absent, in cases of : Taenia mediocanellata Filaria sanguinis hominis Trichina spiralis. Pediculus pubis Pediculus corporis Acarus scabiei. Ascaris lumbricoides Trichocephalus dispar Oxyuris vermicularis Pediculus capitis The list above almost speaks for itself, and little discussion is needed. None of the conditions named is necessarily associated with eosinophilia, but the coarsely granular eosinophile cells often reach a figure between 5 and 15 per cent in the differential count in many of the diseases that come under headings (a), {b), and (c), whilst sometimes during paroxysmal asthma they may reach 25, 50, or even more per cent, and they are often over 20 per cent in the severer forms of parasitic disease. The eosinophilia of leukaemia has often had stress laid upon it in text-books, but as a matter of fact, although the coarsely granular eosinophile cells per cubic millimetre of blood may be considerably above the normal along with all the other corpuscles, yet when reduced to percentages in the differential leucocyte count, the eosinophile corpuscles seldom number more than 2 or 3 per cent of all the white cells present. The value of eosinophilia in discriminating between artificial bleb-formation and a true bullous dermatosis is mentioned in the article upon Bull.^ (?-W-)- The difficulty sometimes present in deciding whether in a given case the lesion is primary emphysema and bronchitis, or primary asthma succeeded by emphysema and bronchitis, is discussed under Polyuria ; and the value of eosino- philia in discriminating between truly asthmatic cases and those which simulate asthma but are really cardiac, renal, or bronchitic, is there referred to. It should be noted that the eosinophilia is not confined to the blood, being present also in the cells in the sputum ; it occurs during the paroxysms of asthma, and rapidly disappears in the intervals. When a patient is suffering from an obscure form of anaemia, and when the blood at the same time exhibits considerable eosinophilia, the latter may some- times be the first suggestion that there is a serious parasitic infection in the case, and careful examination of the faeces or urine for the parasites themselves or for their ova, with the administration of anthelmintic drugs, may then be resorted to for confirmation of the diagnosis (see Parasites, Intestinal). Persons who have been resident in the tropics are more liable to unsuspected infection of this kind than are others. Herbert French. 250 EPIPHORA EPIPHORA, or overflow of the tears, may be due to (i) Increased secretion ; (2) The puncta lachrymalia not being in close apposition to the globe ; (3) Obstruc- tion of the lachrymal canaliculi or duct. 1. The most famihar cause of epiphora due to increased secretion of tears is the act of weeping, in which the flow is due to psychical stimuh. Epiphora may also occur in the lachrymation caused by conjunctivitis, corneal ulcers, and other inflammatory affections of the eye. 2. Tears only find their way down the canaUculi by capillary attraction, the puncta lachrymalia being applied closely to the surface of the globe. In facial paralysis, owing to the failure of the orbicularis palpebrarum muscle, the lids are no longer braced up against the eye, and the lower lid droops away from the globe. The tears coUect in the sulcus thus formed, and run over on to the cheek. The condition is easily diagnosed by the inability to close the eye entirely, either by passive or active movements. In cases of chronic marginal blepharitis , hypertrophy of the hd-edge and the conjunctiva result in a shght eversion or ectropion. The punctum lachrymale of the lower lid is no longer in apposition with the eye, and epiphora foUows, causing continual moisture of the edge of the lids and aggravation of the original condition. Cicatricial ectropion from burns, injury, scleroderma, or lupus of the cheek may also result in epiphora ; and so may severe proptosis (see Exophthalmos), result- ing from tumours or inflammation at the back of the orbit, or from Graves' disease. 3. The lachrymal ducts may be congenitally obstructed. The obstruction is usually unilateral, and is due to a plug or septum of uncanalized epithelium situated in the lower part of the duct. The epiphora is as a rule not evident till the seventh or eighth day, at which period the infant first begins to shed tears, and owing to the suppuration of the tears collected in the lachrymal sac, the malady may be mistaken for a chronic conjunctivitis. The unilateral nature of the affection, and the presence of tears or pus in the sac, are the diagnostic signs, and the obstruction may generally be cured by a single probing of the duct through the dilated but uncut canaliculus. Congenital absence of one or both canaliculi has been recorded. Stenosis of the lachrj^mal duct may also occur as the result of catarrhal congestion of the mucous membrane, or from some organic obstruction, due to cicatrization following abscess in the lachrymal sac or necrosis of the bones forming the walls of the duct. The diagnosis can only be made by syringing through the canaliculi ; in catarrhal obstruction, fluid can usually be forced into the nose, but in organic stricture it is returned through the other canaliculus. In such cases the stenosis can be reHeved by the passage of a probe, after slitting the lower or upper canaliculus. Excision of the lachrymal sac for chronic suppuration is always followed by epiphora, but this condition may often be preferable to the discomfort caused by recurrent lachrymal abscess and the risk of corneal ulcer with hypopyon. Injury to the duct or canaliculus may also cause permanent epiphora. Herbert L. Eason. EPISTAXIS — rhinorrhagia, or bleeding from the nose, is a common occur- rence that may be due to local or general causes, or to a combination of both. In a certain number of cases it occurs spontaneously, and no cause can be indicated. Local Causes. Injury. — Falls, blows, fractures of the base of the skull, foreign bodies in the nose, operations on the nose, violent coughing, sneezing or nose-blowing, nose- picking. Ulceration. — Traumatic, tuberculous, syphilitic, malignant, leprous. New growth. — Adenoid growths, polypi, fibroma, angioma, malignant disease, in the nose or nasopharynx. EPISTAXIS 251 Varicosity of the veins of the nasal mucosa : multiple hereditary telangiectases. Acute infective inflammation. — Severe catarrh, diphtheria, scarlet fever, influenza. General Causes. High arterial blood-pressure, such as obtains in granular kidney and chronic renal disease, arteriosclerosis, gout, cirrhosis of the liver, heart-disease. High venous blood-pressure. — Seen in bronchitis and emphysema, with dilatation of the right heart ; in cerebral congestion, when blood passes from the superior longitudinal sinus by an emissary vein going through the foramen csecum to the nasal mucosa ; in " determination of blood to the head." Altered conditions of the blood. — Hasmophilia, pernicious anaemia, purpura, scurvy, leukaemia, chlorosis, jaundice, and the onset of acute specific fevers, particularly enteric, scarlet fever, and measles. Alterations in atmospheric pressure. — Mountaineering, diving, caisson disease. Epistaxis of Obscure Origin, often attributed to congestion, and occurring : — In childhood ; at puberty, especially in girls ; as the alleged vicarious menstruation ; or as the result of sexual irritation in either sex ; in women at the menopause. The phenomena of epistaxis are familiar. In some cases the blood issues from both nostrils ; in the majority, and particularly when the cause of the bleeding is local, from one only. But it must be remembered that nose-bleeding may occur without the appearance of any blood at the anterior nares. If the patient is lying down,' the effused blood will run down the sides or floor of the nose, passing through the posterior nares and entering the nasopharynx. When this occurs, the patient may cough and spit it up, when haemoptysis will be observed. If, on the other hand, he swallows the blood, he may vomit it later, when hasmatemesis will take place. In the rare instances in which either of these events occurs from epistaxis, careful enquiry should suffice to make the diagnosis clear ; but it should not be forgotten that either haematemesis or haemoptysis may indicate nothing more serious than an attack of nose- bleeding. In every case of epistaxis, the history of the attack should be gone into care- fully. Particular enquiry should be made as to the occurrence of any sort of trauma that might account for it, and also as to the occurrence of previous attacks of nose-bleeding. More important still is a careful examination of the local condition of the nose, with use of a nasal speculum to dilate the nares, and of a mirror and lamp to secure a good illumination. In many cases, the bleeding point can be seen in this way, whether the heemorrhage be arterial or venous ; the so-called " seat of election " of epistaxis being a small and perhaps ulcerated spot on the cartilage of the septum not far from its junction with the ethmoid and vomer. In other instances no such bleeding point can be seen, the blood being the result of general oozing from the mucous membrane. Examination of the urine for albumin should not be overlooked, and the arterial blood-pressure may be measured instrumentally. Recurrent Epistaxis at irregular intervals is likely to be due to some local cause. For example, there may be a small ulcer on the septum nasi, due perhaps to injury in the first instance, that scabs over from time to time but never heals satisfactorily ; a comparatively trifling injury, such as that occasioned by blowing the nose, may suffice to detach the scab, when epistaxis may follow. Malignant disease of or about the nose, and also adenoid vegetations, often give rise to repeated nose-bleeding. Epistaxis has been a prominent symptom in the rare hereditary disease in which numerous friable telangiectases appear about the surfaces of the body and on mucous membranes. Considerable aid in diagnosing the probable cause of an epistaxis is afforded by the age of the patient. In infancy, the cause is likely to be local ; falls are EPISTAXIS not infrequent, foreign bodies are often introduced into the nose, the habit of nose-picking may be formed, or syphihtic disease of the nasal bones may become estabhshed. In childhood, falls and blows on the nose are common, the tempta- tion to insert foreign bodies up the nose still asserts itself, adenoid growths in the nasopharynx are common ; and general causes such as heart-disease, diseases of the blood, or obscure conditions of local congestion, may exist and account for the onset of epistaxis. About the age of puberty nose-bleeding may occur in either sex, and particularly in girls, not only in consequence of the causes enumerated already, but also spontaneously. In the healthy, or apparently healthy, young adult, almost any of the list of local and general causes may account for nose-bleeding ; diagnosis here must rest upon the results of the examination into the local conditions of the nose, and the general state of the organs of the body. In the old, on the other hand, and in middle-aged patients of plethoric habit, high blood-pfessure with or without general arterial disease becomes the most important factor in determining the occurrence of epistaxis. Nose-bleeding in such persons may sometimes be regarded as a natural remed}^ for the plethora from which they suffer, and, indeed, not infrequently does relieve them from such symptoms as a sense of fullness and congestion of the head, tinnitus aurium, or the appearance of flashes of light or muscK vohtantes before the eyes. In other instances, it may serve as a warning, drawing attention to the abnormally high blood-pressure and to the chronic interstitial nephritis or arteriosclerosis that underlies it. Examination of the urine in these cases will often show that the specific gravity is low, and that a trace of albumin is present ; the heart will be enlarged, the first sound at the impulse thudding, prolonged, or even replaced by a soft blowing murmur, whilst the aortic second sound will be very much accentuated. A. J. J ex-Blake. ERUPTIONS, BULLOUS, VESICULAR, Etc.— (See Bull^, Vesicles, Etc.) ERYTHffiMIA. — (See Polycythemia.) ERYTHEMA is a local congestion of the skin, manifesting itself by a superficial redness which disappears on pressure. Though anatomically the rashes of the infectious fevers are erythematous, they have no independent existence as pathological processes, but are the result of the irritation caused by specific poisons in the blood-stream. They will not therefore be considered in this place. Nor shall I deal with the eruptions caused by drugs or by enemata, for, though often erythematous in appearance, they are due either to a toxic action of the chemical substances on the nerve centres, or to direct irritation of the peripheral ends of the nerves supplying the integument. Erythema simplex — characterized by patches of redness on any part of the cutaneous surface, scarlet at first, afterwards pinkish, which gradually fade away, often with slight desquamation — is distinguished from urticaria by the absence of the wheals, and the comparatively persistent nature of the eruption, and from erysipelas by the fact that the reddened area is not raised and is not bounded by a sharply defined edge. The local symptoms, too, are milder, and usually there is no systemic disturbance. If the hj^eraemia is transitory, the red patches coming out suddenly and disappearing in a day or two, the condition is styled erythema fugax. In erythema solare the history of exposure to the sun will supply the diagnosis, and the same may be said of the erjrthema and dermatitis set up by exposure to the AT-rays. Erythema intertrigo, occurring in parts where two opposed surfaces of skin chafe each other, is a simple erythema modified b}' the secretion of the sweat- EXOPHTHALMOS 253 glands. It is readily distinguished from eczema by the absence of weeping. When it occurs in children it may possibly be confused with the erythema of congenital syphilis. In intertrigo, however, hypersemia is usually limited to the napkin region, while in hereditary syphilis it extends down the legs, often to the heels and soles of the feet. In the latter disease, too, concomitant syphilitic signs will be found. Erythema scarlatiniforme begins with shivering and systemic disturbance, quickly followed, if not actually accompanied, by the appearance on the trunk and elsewhere of vivid red efflorescences, which often run together until the whole body is involved. The resemblance to scarlet fever is marked, even to a more or less " strawberry" appearance of the tongue, usually with some reddening of the fauces and soreness of the throat. But desquamation begins quite early in the course of erythema scarlatiniforme — often on the second day, and at the latest on the third or fourth day — while the eruption is still in the florid stage. Other points of difference are that in erythema scarlatiniforme the eruption may persist for several weeks, if not indefinitely, while in scarlet fever it does not last longer than ten days, and that in the former condition the con.stitutional symptoms are less pronounced. If the patient has had previous attacks of erythema scarlatiniforme, the fact may be allowed some weight in the diagnosis ; but the resemblance between the two affections is so close that in all cases isolation should be enjoined until the diagno.sis is clear. From measles, erythema scarlatiniforme differs in that the eruption rarely begins on, and often spares, the face, as well as in the absence of the characteristic symptoms of that affection. From German measles it is distinguished, inter alia, by the absence of glandular swelling. The scaliness in erythema scarlatiniforme is less generally diffused than in pityriasis rubra, and there is repetition of the desquamative process as relapses occur. The diagnosis of erythema pernio can hardly ever be in doubt. That of other forms of erythema is dealt with elsewhere — of erythema multiforme (of which erythema perstans may be regarded as a variety) under Vesicles, of erythema keratodes and erythema nodosum under Nodules, of erythema paratrimma under Finger, Sore, and of infantile erythemas under Napkin-region Eruptions. Malcolm Morris. ERYTHROPSIA. — (See Vision, Defects of.) EXOPHTHALMOS (or Proptosis)— May be bilateral or unilateral. Bilateral Exophthalmos. — The commonest cause of this condition is Graves' disease, in which the exophthalmos is associated with other general symptoms, such as tachycardia, swelling of the thyroid gland, fine tremors, and general nervousness. The eyes are pushed forward to a varying extent (see Facies, Fig. 85, p. 261), in some cases the protrusion being so great that they cannot any longer be entirely covered by the lids. The protrusion causes the upper lid to be unusually raised, and the eyes look wide open, giving the patient an expression of alarm or astonishment (Stellwag's sign, due to spasm of the levator palpebrae superioris). When the eyes are lowered, the upper lids do not descend to the same extent as the cornea, but leave a broad portion of the sclerotic visible above the cornea (von Graefe's sign). Winking takes place less frequently, and convergence of the eyes is sometimes rendered difficult (the sign of Mobius). Bilateral exophthalmos may also be caused by thrombosis of the cavernous sinuses. This condition is usually secondary to some furuncle or carbuncle of the skin of the face in the region of the eye, to orbital cellulitis, or suppuration in the accessory sinuses of the nose. It usually starts on one side, and invariably spreads to both in the later stages of the attack. The eyes are protruded and fixed, the eyelids are red and engorged, and the frontal and ophthalmic veins are 254 EXOPHTHALMOS dilated and full. Movements of the eyes are very limited, and there is much swelling and induration of the orbital tissues. In association with the orbital infiltration there is often some swelling in the region of the mastoid process, owing to the exit in this region of an emissary vein in connecton with the sinuses that communicate with the two cavernous sinuses. This condition is nearly always fatal, as it is followed by a suppurative meningitis. Unilateral Exophthalmos may be due to : — Orbital cellulitis Thrombosis of the cavernous sinus Orbital periostitis Meningocele and encephalocele Gumma New Growth Exostosis Tubercle Arterio-venous aneiirysm Distention of the accessory sinuses of the nose. The diagnosis of orbital cellulitis and thrombosis of the cavernous sinus presents little difficulty, owing to the symptoms of acute inflammation that are present, orbital cellulitis being distin- guished from cavernous sinus thrombosis by the fact that it is usually unilateral and there is no oedema in the mastoid region. Orbital periostitis, especially in more chronic cases, may give rise to varying degrees of proptosis, and in the absence of any obvious thickening of the orbital margins the diagnosis may be obscure. In any periosteal inflammation of long standing, a skiagram will usually show a very definite in- crease of density in the affected bone. Meningoceles and encephaloceles may in some cases be difficult to diagnose from dermoid cysts. The latter are usually placed anteriorly in the orbit, and do not therefore cause any proptosis, though they may displace the eyeball. A meningocele usually presents itself through a gap between the ethmoid and the frontal bones (Fig. 75), and is attached to the bone. An opening may sometimes be found through which the meningocele communicates with the cranial cavity. Meningoceles sometimes pulsate in association with the arterial and respiratory oscillations. They may also be diminished in size by pressure of the fingers, as the fluid can be squeezed into the cranial cavity. In many cases an exploratory puncture is the only means of making a certain diagnosis. A gumma of the orbit can only be diagnosed from the patient's general history, evidence of specific disease elsewhere, a rapid improvement in the condition after the administration of iodide of potassium, and perhaps a positive Wassermann's serum reaction. A growth of the orbit has usually no distinctive feature, and can only be diagnosed by means of an exploratory operation and the removal of a portion Fig. 75. — Meningocele projecting into the face from the anterior part of the base of the skull. (From a. draioing in tlie Gordon Musetan, Guys Hospital.) EYE, ACUTE INFLAMMATION OF 255 for microscopical examination ; but it is to be remembered that tumours of the optic nerve can usually be diagnosed with accuracy by the fact that they always produce some compression of the eyeball in the antero-posterior diameter. Cases of proptosis^ therefore, in which there is increasing hypermetropia on the affected side, may be ascribed to a primary tumour of the optic nerve. Ivory exostoses or osteomata usually arise from the frontal bone and are attached by a broad base, so that their removal presents very great difficulty ; the diagnosis depends on their slow growth and excessiv^e hardness ; a skiagram shows their presence with great certainty. Some cases of tubeyculous disease of the orbit may closely simulate orbital cellulitis or distention of the accessory sinuses of the nose, and the diagnosis can only be made with certainty after excision of a portion of the infiltrated tissue and a microscopical examination of the fragment. An arterial aneurysm is nearly always associated with a pulsating exoph- thalmos, in which there is protrusion of the eye-ball and dilatation of the blood- vessels of the retina, hds, and conjunctiva. There is distinct pulsation of the eyeball, and a loud blowing murmur on examination with the stethoscope. Compression of the carotid on the same side diminishes the pulsation and the sound. The usual cause of arterial aneurysm is the rupture of the carotid into the cavernous sinus as the result of an injury. Rare cases are also seen of inter- mittent exophthalmos, which appears only at intervals or when the head is depressed. These are usually due to varicose veins in the orbit not in com- munication with an artery. The protrusion of the eyeball in dilatation of the accessory sinuses of the nose is, as a rule, less an exophthalmos than a displacement of the eyeball downwards and outwards. In dilatation of the frontal sinus there may be some thickening and fullness of the supra-orbital ridge associated with pain and tenderness over the eyebrow. In dilatation of the ethmoidal cells there is usually a definite swelling to be felt at the inner side of the orbit, which is compressible though not distinctly fluid. Dilatation of the sphenoidal sinus is frequently accompanied by neuritis or atrophy of the optic nerve. In all cases of proptosis due to sinus trouble of any duration, there is evidence in the nose of inflammation of these cavities, the usual symptom being the existence of polypi or of definite swelhngs in the region of the infundibulum. Herbert L. Eason. EXPECTORATION. — (See Sput.\ ; and Hemoptysis.) EXTENSOR PLANTAR REFLEX. — (See Babinski's Sign.) EYE, ACUTE INFLAMMATION OF. — The three most important causes of acute inflammation of the eye are conjunctivitis, iritis, and glaucoma. Pain, photophobia, and lachrymation are common to all three, so that they are liable to be mistaken for one another. Acute Conjunctivitis occurs as a result of the infection of an eye with bacteria of the most various descriptions. In the milder cases it is only the conjunctiva of the lids or the lower lid that is affected ; the surface is more or less vividly reddened by a reticulate injection, smooth, waterv'-looking, and the patient often complains that the lids are gummed together by secretion when he wakes. In the severer infections the conjunctiva of the eyeball is also involved,' it is more highly and more uniformly coloured, the secretion of tears and the deposit of mucous flakes are considerably increased, and small haemorrhages into the loose subconjunctival tissue may be seen ; there is more pain about the eye, and a persistent feehng as if sand or some foreign body were in it. In the worst cases, such as those of gonococcal ophthalmia in new-bom children, the cornea becomes ulcerated, when the pain and photophobia are greatly 256 EYE, ACUTE INFLAMMATION OF increased, and the outlook becomes much more serious — for the crescentic marginal ulcer that now forms on the cornea may lead to the setting up of iritis. • In other instances of conjunctivitis the infiamed membrane is seen to be studded with small raised bodies the size of a pin's head — follicular conjunctivitis. In trachoma, or granular conjunctivitis, small greyish or pink granules appear in the conjunctival fornices. Bilateral conjunctivitis often occurs in epidemics (" pink eye "), sometimes in connection with influenza or German measles. It must be remembered that acute conjunctivitis is often secondary to the intrusion of some foreign body into one or other of the conjunctival sacs, to a corneal ulcer, to keratitis, to infiammatory processes (such as a stye) in other parts of the ocular apparatus, and that all these may be in more urgent need of detection and treatment than the conjunctivitis itself. It must be distinguished from such non-inflammatory or chronic conjunctival conditions as oedema, sub-conjunctival hcemorrhage, Pinguecula, as well as from inflammations of the sclerotic, iris, and ciliary body. The conjunctival oedema of Bright's disease (Bright's " bright eye ") or severe heart disease, in which the bulbar conjunctiva becomes prominent, shiny, and obviously oedematous on close inspection, should hardly be mistaken for inflamraation, even when the vessels are dilated by passive hypersemia, as they often are. Subconjunctival hcBmorrhage or ecchymosis follows the rupture of a small vessel in the bulbar conjunctiva and the escape of blood into its lax tissue, with the result that a vivid or dark-red patch forms over a part or the whole of the white of one or both eyes. It occurs as the result of vascular over-stress, and is common in old people with sclerotic arteries. In the young it may be seen after the severe straining of whooping- cough, vomiting, lifting heavy weights, an epileptic fit ; while in cases of head- injury it is symptomatic of htemorrhage into the orbit from fracture of the base of the skull. Such an ecchymosis is distinguished from conjunctivitis by its uniformly red colour, the absence of a network of dilated vessels in it, and by its sharp limitation from adjoining normal parts of the conjunctiva. Pinguecula is the name given to a chronic yellowish thickening of the scleral conjunctiva where it is most exposed at the inner and outer margins of the cornea. It results from prolonged exposure to weather, wind, and dust, occurs in the second half of life, and even when its vessels are injected it should hardly be mistaken for conjunctivitis. Inflammation of the sclerotic, called scleritis if deep, episcleritis if more superficial, though not common, is found in rheumatic, gouty, or syphilitic adults. It takes the form of small dusky-red or violet inflamed spots in the sclerotic, placed near the corneal margin, and covered by the more or less injected conjunctiva. Periodic and transient attacks of episcleritis have been described by Hutchinson (" hot eye "). The deep and dusky injection of scleritis should suffice to distinguish it from conjunctivitis. The general diagnosis of Iritis, of inflammation of the ciliary body or Cyclitis, and of the common combination of the two, or Iridocyclitis, from conjunctivitis, is indicated in the table opposite. Apart from trauma and from the spread of infection through the cornea, these conditions are due to syphilis in over half the cases, to rheumatic infection in many of the remainder, to diabetes, tuberculosis, or gonorrhoea in others. The pain felt is often extremely severe. It is neuralgic in character, and not confined, as it is in conjunctivitis, to the inflamed eye It radiates into the brow (supra-orbital neuralgia), the side of the nose, the malar region ; and in the syphilitic cases is often worst at night. Inflammation of the ciliary body as well as of the iris is to be diagnosed if deposits of pigmented lymph are seen in the anterior chamber or in the vitreous, if the inflammation is so severe as to bring about oedema of the upper eyelid, if the ciliary region is tender, and if the tension of the eyeball is raised — as it often is in cyclitis. It is of the utmost importance to the patient that an iritis or iridocyclitis should EYE, ACUTE INFLAMMATION OF 257 not be diagnosed as a conjunctivitis, or glaucoma as either ; for complete loss of sight may result from the application of the treatment suitable to iritis in a case of glaucoma, and vice versa. Inflammatory Glaucoma is an acute disease of the later years of life, coming on in bouts often precipitated by indiscretions in diet or regimen, and affecting both eyes. At first the chief complaint is of attacks of obscuration of vision, and the appearance of halos or rainbows round bright lights — the same com- plaint may be made in chronic conjunctivitis. During a mild attack of glaucoma there is a feeling of tension in the eye, and often a dull frontal headache, in addition to the loss of vision. In severe attacks the pain is very violent, radiating from the eyes to the head, the ears, the teeth ; oedema of the lids and of the congested conjunctiva is also common. Examination of the eyes will show the signs tabulated above ; ophthalmoscopically, glaucomatous cupping of the optic disc will be seen so long as the media remain transparent [Plate VIII, Fig. V). Subacute or simple glaucoma may occur in young persons or in adults ; but for its slower course and the absence of severe attacks it resembles inflammatory glaucoma. The importance of discriminating between iritis and glaucoma cannot be over-emphasized ; for the exhibition of atropine or some similar mydriatic is the sine qua non of the treatment of iritis, whilst in glaucoma it is contraindicated. The points which serve to differentiate these three conditions from one another have been summarized in tabular form by Dr. Eason as follows : — CoNJUiNXTlVITIS Iritis Glauco.ma. Conjunctiva Conjunctival vessels bright red and injected ; movable over subjacent sclerotic : injec- tion most marked away from corneo- sclerotic margin ; colour fades on pressure Ciliary vessels in- jected, deep or bluish-red ; most marked at corneo- sclerotic margin : colour does not fade on pressure Both conjunctival and ciliary vessels injected Cornea Clear, sensitive Clear, sensitive Steamy, hazy, in- sensitive Anterior chamber Clear, normal depth Aqueous turbid, anterior chamber slightly shallow Very shallow Iris Normal colour Injected, swollen, adherent to lens, and muddy coloured Injected Pupil Black, active May be filled with lymph, small, fixed Dilated, fixed, greenish Tension Normal Normal Raised A. J. J ex-Blake. 258 FACIES, ABNORMALITIES OF FACIAL PARALYSIS.— (See Paralysis, Facial.) FACIES, ABNORMALITIES OF. — The study of the face in health and disease cannot fail to prove profitable and interesting to all medical men. While it cannot replace careful systematic examination of the body as a whole, it may, in many cases, direct the experienced observer's attention to the most likely and fruitful field in which to find data for his diagnosis. Nothing but observation and experience can teach the student to detect all the features of a face. Photo- graphs and drawings can only illustrate for him the coarse and obvious defects which are present when the face is at rest or when some particular movement is being sustained. The more subtle abnormalities of expression, the play of the emotions, and the response of the features to intelligence, are often too fleeting and too mobile to allow of reproduction on paper, and sometimes so intangible as to defy any effort to describe them. Even if the pen of a skilled artist could succeed in portraying the passive vacant aspect of a chronic alcoholic, it must necessarily fail to depict the traitorous tremor which hovers about the corners I^ig: 76. — Myxcedenia : the character- istic facies, illustrating the broadening of the features and the malar flush, (Com- pare Fig-. 77.) J^ig: 77. — The same patient as J^yg: 76, previous to the development of myxcedenia. (From photographs kindly lent by Dr. Hale White.) of his mouth when he opens it to proclaim his temperance. The shifty eyes of the drug-taker, the fatuous placidity of the patient with advanced insular sclerosis, the anxious look born of abdominal disease, the explosive suddenness with which the victim of double hemiplegia bursts into laughter or tears, are only a few of the many familiar and striking lessons of the face which must be seen in real life if they are to be learned and utilized. On the other hand, there are facies the description and illustration of which may serve to impress their more important features on the minds of those to whom they are not familiar. To these more classical pictures attention must now be drawn. Cretinoid Facies. — Compared with the general stunted growth of the rest of the body, the head is relatively large. The face is broad and remarkable for thick eyelids, broad flat nose, thick lips, and large coarse ears. The mouth is usually open and expressionless, the tongue may be more or less constantly protruded, and the chin is poorly developed (see Dwarfism). The hair is FACIES, ABNORMALITIES OF 259 scanty and brittle, the skin coarse, dry, and often almost yellow in colour. Confirmation of the diagnosis may be sought for in the dwarfed size of the child, the pendulous " frog belly," and the thick .pads of subcutaneous tissue especially frequent above the clavicles. The lack of mental develop- ment, the slow pulse, and subnormal temperature complete the clinical picture. Myxcedematous Fades. — -The dulled intelligence of the patient is betrayed by the apathetic physiognomy {Fig. 76). Fig. 77 shows the same patient previous to the attack. The skin of the myxcedematous face is coarse, dry, and sallow, with occasional cyanotic areas over the cheeks. The puffiness of the eyelids may suggest nephritis, but the subcutaneous tissue is everywhere of firm consistence, and podgy rather than oedematous. The nose is broadened, the ears are thickened, and the lips so much swollen that more than the usual amount of mucous membrane is exposed. The hair is scanty, receding from the forehead, and the eyebrows become poorly marked for the same reason. Similar conditions of hair and skin, together with brittle, striated nails, are found fig: 78. — Congenital syphilis, showing prominent forehead and depressed nasal bridge. Pholi} by Dr. Rendie Short. Fig. 79. — Facies of congenital sj-philis, showing notched teeth and sore angles of the mouth. Photo by Dr. S. A. K. Wilson. elsewhere. Masses of fatty tissue, like those described in cretins, may be found scattered about the neck and trunk. The slow speech, the expressionless face, and the general attitude of the patient may suggest paralysis agitans, but the diagnosis may be made readily by paying attention to the features just mentioned, and by observing the slow pulse and subnormal temperature in myxoedema, and the effects of thjrroid treatment. Congenital Syphilitic Facies. — The victims of congenital syphilis, after ten or twelve years of age, may present a facies which is highly characteristic. An overhanging forehead, perhaps frontal bosses, a depressed nasal bridge {Fig. 78), striated scars radiating from the corners and other parts of the lips (Fig. 79), with a sallow, earthy complexion, are the most prominent features of the luetic facies. Closer observation of the eyes and teeth may detect the opacities of old keratitis and the changes in the upper incisors which are claimed by Hutchinson to be pathognomonic [Fig. 80). These teeth are peg- shaped, irregular, and so deficient in enamel over the anterior and median 26o FACIES, ABNORMALITIES OF parts of their cutting edge that the resulting crescentic notch gives them a striking appearance. When such a facies is noted, the diagnosis may be chnched b}' the discovery of one or more ,,; of the following symptoms and signs : deafness, mental deficiency, physical in- fantihsm, tibial deformities, and chronic arthritis, especially of the knee joints. Myopathic Facies. — Many cases of mj^opathy show no characteristic facies ; others are remarkable chiefly for the loose pout of their hps at rest {Fig. 8i), and the "transverse" character of their smile {rire en travers. Fig. 82). Both features are due to deficient facial musculature, and particularly to weak- ness of the orbicularis oris. The paresis of the orbiculares palpebrarum is only striking when an attempt is made to close the eye, although it may sometimes lead to a prominent and perhaps staring appearance of the eyeballs. In other instances there is a droop of the upper ej^elids rather than anjr tendency to exophthalmos. The inabilit}- on the part of the patient to whistle or to blow ,mmmm ^ Fi^.%a. — Hutchinson ian notched teeth. (From Introduction to Surg^ery, Prof. Rutherfjrd Morison.) /•y^. 81. — Myopathic facies : the loose pout due to weakness of the orbicularis oris. Photo by Dr. S. A. K. Wilson. Fig. 82. — Mj'opathic facies : the transverse smile. Photo by Dr. S. A. K. Wilson. out his cheek quickly demonstrates the weakness of the orbicularis oris, it it is not made obvious by the large amount of labial mucous membrane exposed while the mouth is at rest. Myasthenic Facies. — In patients suffering from m^^asthenia gravis there are t\vo types of facies which can hardly be reproduced by other diseases. The fiist illustrates the exhaustion of the patient {Fig. 83) ; she can hardly keep her eyes open, and her chin tends to drop exhausted on her chest. The second depends for its effect on the characteristic myasthenic smile, a smile which is sometimes more appropriately named a sneer {Fig. 84). This unfortunate and misleading facial expression is the result of deficient action on the part of the zygomatic and risorius muscles, and exemplifies the curious way in which some FACIES, ABNORMALITIES OF 261 muscles are affected and others escape, in this disease, even when they derive their innervation from the same source. The accompanying photograph shows how a shght assymmetry in the muscular affections may be responsible for very different expressions on the two sides of the face. Rcproiitcced fi-oin Blocks kindly lent hv Messrs. Ma.-niillnn <5--- Co. Hg. 83. — Myasthenic facies ; the appearance of fatigue prod need by the droopingof the eyelids and dropping of the jaw is very apparent. ^^^ Fig. 84. — iNIyasthenic facies: this photograph was taken to ilkistrate a " nasal " smile on the left side of the face, and a natural smile on the right. These are best seen by covering up one half of the face at a time. The Facies of Exophthalmic Goitre. — The facial appearance in Graves' diseas'e depends chiefly upon the " stare " {Fig. 85). Surprise or fear is suggested by the prominence of the eyeballs and the retraction of the eyelids. The degree of exophthalmos varies greatly, and it is not present in all cases ; sometimes it occurs on one side and not on the other. Close observation shows that the sclera is visible between the edge of the iris and the eye- lids, and that the usual harmony of move- ment between the eyeball and the eyelid is lacking. Normal winking is frequently much diminished or entirely in abeyance. The surface of the conjunctiva may be abnormally bright and glistening, and the secretion of tears may be excessive. In contrast with the white of the eyeballs, there is often considerable dark pigmenta- tion of the eyelids, which may also be the site of some oedema. The size of the pupils varies, undue dilatation occurring only in exceptional cases. A moist skin and a readiness to flush may often be remarked in the face. The Facies of Paralysis Agitans. — In this disease, a cardinal symptom is muscular rigidity, which affects the skeletal muscles generally as well as those of the face. The ocular muscles, however, escape. It is due to this fact that Fi^. 85. — Exophthalmic goitre. Photo hv Dr. S. A. K. Wilsoh 262 FACIES, ABNORMALITIES OF showing the fixed ii^rliig expreis; :;r. while the face as a whole is expressioiiless, " starch}- " or " masked " [Fig. 86), the eves appear to move -vrith natural or even abnormal rapidity' ; for instance, thev -prill turn in the direction to which the patient desires to look, before the head has assumed a cor- responding position. Frequenth- the face has a staring expression, the e^-eUds being constantly retracted bj- the tonic spasm of the orbiculares palpebranrm. An absence of normal winking has been noted and ascribed to the same cause. In contrast with the slow development of facial ex- pression under the iniiuence of emotion, there is sometimes marked want of control over the fully-developed emotional move- ment, and the patient complains that the exuberance of his laughter or tears is entirely out of proportion to his feeUngs of merriment or sorrow. Tabetic Fades. — In a considerable per- centage of cases of locomotor ataxy the appearance of the face is sufficiently striking, to a close obser^-er, to afford a clue to diagnosis. The small size or the inequahtj'' of the pupils may first attract attention. The shght drooping of the upper eyehds, combined with some wrinkling of the forehead (Fig. 87), due to a compensating effort on the part of the frontahs muscle, gives a sad expression to the face. This drooping of the evehd, vrhich may be termed pseudo-ptosis or hypotonic ptosis, is not due to anv paresis of the levator palpebrse superioris, as mav be shown b}- the raising of the hd when the patient is looking up. It really depends on the fact that this muscle, like most of the muscles of the body, is in a condition of hypotonia. This allows the action of gra%"iir\- to assert its influence, "svith the result that the hd hangs like a half -raised curtain in front of the eyeball. In other respects the face may be normal, but the majorit}.- of tabetics have a sallow complexion and ver\- httle subcutaneous fat, two facts which contribute to their generallv un- healthy aspect. The writer beheves that many \actims of this disease exhibit a deficiency- of the emotional reflex move- ments of the facial muscles. During con- versation, the play of their features in response to the subject of their talk is not so noticeable as that of health}- indi^-iduals. Fades of Acromegaly. — In the course of acromegaly, changes in appearance frequentl}^ take place to such a degree that the patient becomes unrecogniz- able by those of his friends who have onl}- knoA^m him before the onset of his disease. These changes are the result of abnormal gro%^-th on the part of the bony and subcutaneous tissues in many parts of the body, and especially Fig, 87. — Tabetic fades. The photo- graph shows the partial bilateral ptosis and the %4-rinkling of the forehead, which contribute to the expression of sadness. P/u>io by Dr. S. A. K. Wilson. FACIES, ABNORMALITIES OF 263 Acromegaly. part of the face tends to make the head lean to rest upon the sternum. In some cases the lower jaw is not affected, and the face may be described as abnormally square {type carree). Fades of Mongolian Idiocy. — This facies is so characteristic that the diagnosis may often be made at sight (Fig. 89 ; see also Dwarfism). The head is brachycephalic ; the palpebral fissures slant obliquely inwards and downwards towards a broad flat nose, rendered even broader by the presence of epicanthus ; the eyelids show signs of chronic blepharitis ; the ears are large and pitcher- shaped ; the lips are fissured and often left open to allow a coarse tongue to protrude (Figs. 90, 91) ; the forehead is downy, and the hair of the scalp scanty, wiry, and frequently mouse-coloured ; the complexion is florid and mottled. The in the skull and ex- tremities. The char- acteristic facies is brought about by osseous hj'perplasia of the frontal ridges, the mastoid, zj^gomatic, malar, and nasal pro- cesses, while the lower jaw is usually enlarged in all directions. The prominent, arched brows, with retreating and wrinkled fore- head, the massive nose, the long, thick upper lip, and the heavy chin {Fig. 88) form the most con- spicuous features. The lower set of teeth may project some distance in front of the upper, and they are unduly wide apart. The tongue may be so enlarged as to keep the mouth open and to display many fis- sures and indentations as the result of its pressure against the teeth. The increased weight of the lower forward and perhaps ultimately J^i^. Sg. — Achondroplasia. P/ioia by Dr. S. A. K. Wilson 264 FACIES, ABNORMALITIES OF almond-shaped eyes, the presence of epicanthus, the florid complexion, and the absence of fatty masses serve to distinguish ■ the Mongolian from the J^i£: 90. — A Mongolian Idiot in infancy. The photograph shows the oblique palpebral fissures and the large protruding tongue. J^!,g'. 91. — A JNIongolian Idiot, show- ing a large flabby tongue, which is deeply fissured. Photos by Dr. S. A. K. Wilsoti. cretinoid idiot ; in case of doubt the benefit or otherwise of thyroid treatment, may clinch the diagnosis. e. Farquhar Buzzard. F^CES, BLOOD IN. — (See Blood per Anum, and Helena.) F^CES, FAT IN.— (See Fatty Stools.) F^CES, MUCUS IN. — (See Mucus in the Stools.) F.ffiCES PASSED PER URETHRAM.— Fajces or fa;cal fluid are only passed per urethram when the bladder is in fistulous communication with some part of the bowel, or with some fseculent abscess cavity infected with the Bacillus coli communis. Pneum\turia (q.v.) is liable to occur at the same time. The chief causes are as follows : — Cancer of the bladder opening into the rectum or into some loop of bowel which has become adherent to the bladder. Cancer of the rectum , opening into the bladder either directly, or Cancer of the sigmoid colon ' . through the medium of an intervening Cancer of the caecum ) abscess. . Cancer of the uterus opening both into the bladder and into the rectum. Proctitis and periproctitis leading to the formation of an abscess which opens into the bladder. Prostatitis and prostatic abscess opening into the rectum. Retrovesical fistula following injury and local sloughing, particularly after childbirth. Caseous tuberculous disease in the pelvis opening both into the bladder and the rectum. Appendicular abscess opening into the bladder, with or without an opening into the caecum also. The passage of faeces in the urine may be simulated by some cases of very foetid cystitis, when the bladder has been infected by the Bacillus coli comm,unis. FATTY STOOLS 265 If the symptom is due to cancer, it matters little which viscus is the primary site by the time the growth has involved both bladder and bowel. The diagnosis resolves itself, therefore, into one between malignant conditions on the one hand and non-malignant on the other. If malignant disease is not obvious, it will nearly always. be advisable to resort to surgical measures in the hope of curing the primary condition — rectal, appendicular, prostatic, or otherwise. The commonest causes other than malignant, are local sloughing of the parts after labour, and fseculent appendicular abscess opening into the bladder. In any case the diagnosis will be suggested by the history and confirmed by local examination or exploration. Herbert French. FiECES, PUS IN.— (See Pus in the Stools.) FiECES, SAND IN. — (See Sand, Intestinal.) FiECES, WORMS IN.— (See Parasites.) FAINTING ATTACKS.— (See Coma.) FAT IN URINE.— (See Chyluria.) FATTY STOOLS. — All stools contain a little fat ; many contain more than .they should, the fact being discoverable on analysis, although it may not be obvious to the unaided eye : the relative proportions of saponified and of unsaponilied fats may have an important bearing on the diagnosis of pan- creatic lesions [see Cammidge's Pancreatic Reaction). Fatty stools in which the fat is obvious to the naked eye are rare ; when they do occur they indicate one of three things : either that enormous amounts of fat are being ingested — more than can be absorbed by the normal mucosae ; or that the secretions are defective, so that even ordinary amounts of fat remain unab- sorbed ; or that the food is being hurried through the alimentary canal so fast that much fat remains undigested. It is easy to exclude the first of these three possibilities by regulating the diet ; the other two factors generally occur together, and the chief diseases in which fatty stools may be a prominent feature are : — 1. Those associated with severe diarrhoea, especially where the patient may be having an abundance of milk, as in : — Typhoid fever ; Infantile diar- rhoea ; Sprue. 2. Those associated with jaundice, especially where the cause of the latter also prevents the pancreatic secretions from entering the duodenum, such as : — Chronic pancreatitis ; Carcinoma of the duodenum, including the ampulla of Vater. The diagnosis of Group i need not be discussed further here, for it will be indicated by other symptoms than the fatty stools. The different maladies belonging to Group 2, on the other hand, may be directly indicated by the fatty condition of the stools. If, for instance, there is doubt as to whether the patient is suffering from gall-stones obstructing the common bile-duct, or from chronic pancreatitis, the occurrence of pale abundant stools upon the surface of which an iridescent scum of fat is obvious, will be in favour of the latter, for fat can be digested to a far greater extent without bile but with pancreatic juice than it can be without the latter. The symptom affords no means of distinguishing inflammation from new growth, however ; the distinction between these will depend mainly upon the duration of the symptoms — growth of the pancreas kills within a few months of producing fatty stools, whilst chronic pancreatitis may continue for years, or even get quite well. Other points to be on the watch for would be the presence of a tumour, of a dilated gall-bladder, or of 266 FATTY STOOLS secondary deposits. The age of the patient is seldom, much help, for neither disease is common before adult life. The distinction bet%veen carcinoma of the head of the pancreas and carcinoma of the ampulla of Vater and duodenum may be next to impossible without laparotomy or post-mortem examination ; although carcinoma of the head of the pancreas, rare though it is, is much commoner than new growth starting in the duodenum near the bihar\- papilla. Herbert French. FEVER. — (See Pyrexia, and Hyperpyrexia.) FINGER^ SORE. — Digital lesions may be erj-thematous, papular, vesicular, bullous, pustular, squamous, or ulcerative, representing a long hst of cutaneous affections. The erythematoits affections which maj- attack the fingers are er}-thema, lupus er\-thematosus, eczema, urticaria, chilblains and frostbite ; the papular, hchen planus and hchen annularis, pit^-riasis rubra pilaris, angio- keratoma, eczema, and papular s^-phihdes ; the vesicular, scabies, cheiropom- phoK^x (dysidrosis), eczema, dermatitis herpetiformis, chilblains, the irritation set up by the habitual handling of sugar, or (in washersvomen) by immersion in water containing soda, or by contact with such vegetable irritants as rhus, mustard, thapsia, the common orange, eucah-ptus leaves, arnica, etc. ; the bullous, pemphigus, epidermolysis bullosa, dermatitis herpetiformis, scabies, leprosy, and S}'phi1is (chiefly in infants) ; the pustular, scabies, boils, impetigo contagiosa, eczema, and pustular s^.'phihde ; the squamous, psoriasis, eczema, ichthyosis, hchen planus, S}-phihs, acanthosis nigricans, and verruca necrogenica ; the ulceroMve, bedsore, chilblains and frostbite, ;ir-ray ulcer, dissection wounds, lupus ■\Talgaris, leprosy, chancre and s}"pliihtic ulcer, epithehoma, Ra^"naud's disease, diabetic gangrene, trophic ulcer, and scleroderma. The dia,gnosi5 of these various afi:ections will be found under the names of the primar\- lesions — ^papules, vesicles, etc. — and here it is onh- necessary to particularize bedsore, diabetic gangrene, verruca necrogenica and dissection wounds, and chancre. Bedsore on the fingers is caused by friction bet^veen the knuckles and the bedclothes as the patient raises himself to the sitting position. It begins as er\^hema, and its significance can hardly be mistaken, though its presence in such a situation may take the nurse by surprise. Diabetic gangrene most frequently attacks the toes or other part of the foot ; but occasionally' it has been observed in the penis, and I have seen cases in which the fingers have been aft'ected. Post-mortem wart, or post-mortem pustule, the condition sometimes met with, chieflj' on the knuckles and in the interdigital folds, in those who have to handle dead bodies, whether of human beings or of the lower animals, is a form of tuberculosis, caused by infection with hving bacilli from the dead tissue. It is sometimes met with also in coUiers, in whom the site of inoculation is probably an abrasion recei\"ed in the handling of coal. The pustule, beginning as a flat papule, dries up and forms a scab, which, when it faUs oft', leaves a surface that is made irregular by overgrowth of papillae. These grow and become harder, until they form a warti.- mass. The avocation of the patient will suggest the true nature of the lesion. Of dissection wounds, consisting of pustules or small abscesses on the site of a puncture or scratch, or of lymphangitis and ceUuhtis, which may be followed by pyaemia, the history will supply the diagnosis. In chancre of the finger, usually met with in mid- wives, nurses, and medical men, but occasionall}- in others also, a favourite situation of the sore is at the lateral nail-groove, and in many cases the lesion first attracts notice as a persistent fissure. If the sore undergoes induration, and there is enlargement of glands, the diagnosis can no longer be doubtful. Malcolm Morris. FITS,— (See Cox\x-lsions.) FLATULENCE 267 FLATULENCE. — It is important to distinguish between (i) Gastric flatulence, in which wind is eructated ; and (2) Intestinal flatulence, in which it is passed per anuni. 1 . Gastric Flatulence. — Before concluding that excess of gas is being produced in the stomach, it is necessary to exclude the possibility of air-sucking or aiy- swallowing {aerophagia, eructatio nervosa). This condition is by no means un- common, but it is apt to be wrongly diagnosed. It is met with often in women about the menopause ; it is also by no means infrequent in young and other- wise healthy men, although the patient is prone to be " neurotic," or to exhibit signs of neurasthenia or psychasthenia. Eructatio nervosa is recognized by the violence of the belching and the excessive amount of wind expelled. It comes on in attacks both by day and by night, sometimes waking the patient. If a patient can belch " to order," one may conclude with almost perfect certainty that he is suffering from this form of neurosis ; and by watching him during the attack, one can recognize that he is gulping down air. True gastric flatulence is present to a greater or less degree in many — one might almost say in all — forms of gastric disorder. For purposes of diagnosis one must distinguish between the cases in which gas is produced as the result of fermentation in stagnating gastric contents, and those in which no such fermentation is taking place. In the former group the stomach will be dilated, vomiting will almost certainly be present, and examination of the gastric contents will show delay in their trans- mission, and the presence, probably, of sarcinae {Fig. 92) and yeasts. One may then diagnose pyloric obstruction, either simple or mahgnant. /r,;^. g.^sarcina Ve'ntriculi. In these cases the eructations are sometimes offen- (Medium power of the sive, revealing the existence of putrefaction in the microscrope.) stomach contents. Non-fermentative flatulence occurs in almost all forms of functional disorder of the stomach ; but is specially prone to occur in gastric atony. In that case there will be a well-marked splash over the gastric area, even some hours after a meal, but without any evidence of actual dilatation of the organ, although there may be some gastroptosis. (See also Indigestion.) In other forms of gastric disorder flatulence is only a minor symptom, and of little diagnostic value. Flatulence is also not an uncommon symptom in emphysema of the lungs, and in cases of cardiac disease, especially when due to degeneration of the heart muscle. In elderly persons these conditions should always be looked for. In angina, also, flatulence may be a prominent symptom, but in that case the attacks tend to come on after exertion, and are accompanied by the charac- teristic pain of angina. 2. Intestinal Flatulence may be either acute (see Meteorism), or chronic (intestinal flatulence proper). In the latter case, it is often attended by colicky pain, which is relieved by the passage of wind. It is important to note that flatulence is not a feature of ordinary constipation. When markedly present, it is suggestive either of chronic obstruction or of intestinal fermentation. If obstruction be present, coils of intestine undergoing peristaltic contraction are often to be seen, and there is marked constipation, sometimes alternating with diarrhoea. A diagnosis of the exact cause of the obstruction may necessitate the use of the sigmoidoscope, or even of an exploratory operation. In cases of intestinal fermentation, either constipation or diarrhoea may be present. Micro- 26S FLATULEXCE scopic examination of the stools is often of help in elucidating the nature of the fermentative process, undigested muscle fibres (proteid fermentation or putrefaction) or an excess of starch cells (carbohydrate fermentation) being seen. (See also Diarrhoea.) Robert Hutchison. FLUSHING. — The difference between flushing and blushing is that the former only occasionally, the latter invariably, arises from emotion, and that the emotions which find expression in blushing are always, as Darwin points out, the result of excessive self-attention — sh^mess, shame, and modestj-. A flush mav begin instantaneously in all the parts in which it is felt, or, arising in a lower region, it mav ascend to the head, or, beginning in the head, it may descend to some part of the body, or it may pass both upwards and down- wards (Harry Campbell) . The sensation varies in severity-, and may be actually painful. The nerve-storm generally ends in a cold stage, though this may precede the hot stage. The cutaneous s^-mptoms may be accompanied or followed by nausea, vomiting, fainting, a sense of suffocation, numbness, tremors, tinnitus, giddiness, palpitation, paresis. The physical states and conditions from which flushing arises include menstruation and menstrual irregularities, the climacteric, pregnancy, lactation, chlorosis, indigestion, feeble circulation, general debility.-; it may also be an expression of emotion, may be caused by alcohoHc indulgence, or may merge into an epileptic aura. If it becomes chronic, the skin of the face, especially of the flush area — the middle third of the face — ^is permanently" reddened, and the case becomes one of rosacea. Sooner or later the superficial vessels undergo dilatation. Hj^ersecretion and retention of sebaceous matter follow, and inflammation may be set up. The inflammatory.- process, becoming chronic, may give rise, especiallj- if the patient is much exposed to the weather, to h]i"pertrophic thickening of the skin of the nose, with lobulation (rhinoph}-ma) . The condition or habit which is the cause of rosacea will be deduced from the histor\-, especially as regards, tea, alcohol, and dyspepsia, and from examination of the patient. Rosacea is distinguished from aoie vidgaris hy the absence of comedones, the redness of the affected surface, the limitation of the eruption to the face, the telangiectasis, the h}"pertrophy, and by its being an affection of middle life rather than of pubert}'. It differs from lupus erythematosus in the absence of scaliness and of atrophic scarring, in the border — which is not raised and shows no signs of active spreading — and by its fluctuations. Seborrhceic eczema may be met with in the flush area, but it is usually associated with sebor- rhoea capitis, there is no telangiectasis, and the affected surface is oily or scaly. From tertiary syphilides, rosacea is distinguished by its slow course, its sjtnmetry, the dilatation of blood-vessels, and the absence of any tendency to ulceration and scarring, or to atrophy. In s^-philis, further, there will be the stigmata or the historj- of earher lesions. Malcolm Morris. FOOT-DROP. — 'See Paraplegia ; and Paralysis of One Lower Extremity.) FORGETFULNESS.— (See Amxesia.) FORMICATION.— See Pruritus.) FRACTURE, SPONTANEOUS. — Spontaneous fracture signifies fracture of a bone from causes which ordinarily would have been inadequate. Tremendous muscular efforts sometimes lead to the breaking of bones without any external \-iolence, but this variet}- would not be included under the heading of spontaneous fracture if the degree of muscular effort seemed adequate. A man has been known, for instance, to di\-e into shallow water, and in order to bring himself to FRACTURE, SPONTANEOUS 269 the surface quickly and prevent his head from striking the bottom, he has used his neck muscles so strenuously in bending his head back as actually to fracture his vertebrae. This fracture is not spontaneous, but due to excessive muscular exertion. There are three main groups of causes for true spontaneous fracture, namely, excessive brittleness, or innate lack of strength of the bones — fragilitas ossium ; general paralysis of the insane ; and unsuspected lesions of the bones, particularly myeloid sarcoma, chloroma, tuberculous caries, or secondary deposits of carcinoma or sarcoma. Fragilitas ossium. — -When the first fracture occurs in such a patient, there may be doubt as to the diagnosis ; but when repeated breaking of different bones occurs, in each case from apparently trivial causes, the diagnosis becomes clear. The undue fragility may show itself in early life, but more often not until the patient has reached adult stature and weight. Two maladies which differ from fragilitas ossium, and yet which may cause undue bending, or partial or green-stick fracture of bones, are rickets in children, in which disease, for a time at least, there is excess of preparation for bone formation, but difficulty in completing the ossifying process, so that the bones, being unduly soft, not only bend, but also give way as a green stick would, causing the partial or green-stick fracture ; and mollities ossium, a rather rare affection in this country, though reported to be less uncommon in certain parts of the Continent, notably in the Rhine valley, coming on especially after pregnancy, and associated with concentric thinning of the bones from the marrow outwards, so that they eventually consist of a mere shell, which bends with undue ease, and may sometimes break spontaneously. The relationship to pregnancy may suggest the diagnosis, and there is no other disease which produces the same degree of pathological softening and fragility of the bones in adults ; active rickets is practically confined to young children, only a few cases having been recorded during adolescence and none in adult hfe. Spontaneous fractures in general paralysis of the insane occur, like the aural hsematomata of this disease, at a late stage when the patient is bedridden. They may arouse suspicion that the attendants have been unduly rough in their handling of the patient ; but so atrophic do the tissues, and particularly the bones, become, that the latter may fracture from slight and otherwise inadequate causes. The diagnosis will have been made months or more previously, by reason, first, of the mental changes of the patient, particularly ideas of grandeur ; and secondly, by the occurrence of convulsive seizures after there have been changes in the patient's mental condition for a longer or shorter time. The case is generally that of a man who has suffered previously from syphilis, for which treatment was not very prolonged, and whose business has entailed much mental hard work, and possibly worry, in a city. Confirmatory evidence may be obtained, if need be, by finding relatively large numbers of small lymphocytes in the cerebrospinal fluid removed by lumbar puncture, and Wassermann's serum reaction for syphilis may be positive. Before concluding that spontaneous fracture of a bone is due either to neuro- trophic causes, or to fragilitas ossium, it is important to exclude the possibility of primary or secondary new growth in the affected bone, or tuberculous caries. It may be that the patient is already suffering from a bony swelling, such as myeloid sarcoma, before the fracture takes place, or it may be known that there is, or has been, a primary growth elsewhere ; for instance, in the pelvis, breast, or stomach, in which case the spontaneous fracture of a bone would suggest that a second metastasis has occurred at the site of fracture, eroding the bone until it finally broke from a trivial cause. The chief difficulties arise, first, when there are no symptoms of the primary growth itself, for instance, in the 270 FRACTURE, SPONTANEOUS case of a diffuse carcinoma of the stomach of the indiarubber-bottle type ; and secondly, when the patient is really suffering from tuberculous caries whose existence has been entirely unsuspected. As an instance, one might mention the case of a woman fifty years of age, who, seeming to be in perfectly robust health, was standing in her kitchen, when her son unexpectedly entered, causing her to start suddenly, giving her body a twist at the same time. This movement was immediately followed by paralysis of both legs, and it seemed as though the sudden muscular exertion had led either to a haemorrhage or to a fracture-dislocation of the spine ; the cause for the fracture was in itself inadequate, however, and it would not have produced the symptoms had there not been spinal caries which had been slowly eroding the bones for some time previously, until they now gave way as the result of what would otherwise have been a trivial movement. The diagnosis in cases of the kind depends chiefly upon remembering the possibilities, and not omitting a most careful exami- nation of every part of the body. When the .3;-rays are available, they may sometimes be of considerable value in detecting a neoplasm or a tuberculous focus in the affected bone. Herbert French. FREQUENCY OF MICTURITION.— (See Micturition, Abnormalities of.) FULLNESS, SENSE OF.— A sense of fullness may be felt in the abdomen in any condition which leads to abdominal distention. Such distention may be due to the presence of Flatulence {q.v.), of Ascites (q.v.), or of a tumour, or enlargement of any of the abdominal viscera. It is, therefore, by itself, of little diagnostic value. Robert Hutchison FUNGOUS AFFECTIONS OF THE SKIN. — We here include (I) Favus, (II) Ringworm, (III) Eczema marginatum, (IV) Tinea imbricata, (V) Tinea versicolor , and (VI) Erythrasma. I. — Favus. In man this affection is due, in about 99 per cent of cases, to inocula- tion with the A chorion Schonleinii. Four other achorions, of animal origin, have been identified, and it has been proved that the affection can be com- municated from animals to man, but the instances are so rare as to be negligible. Between the achorions on the one hand and the microsporons and trichophytons on the other (see Ringworm, p. 272), there are close morphological resemblances, but the clinical differences are well marked. Favus, while showing a distinct preference for the scalp, may attack any part of the skin {Fig. 93), and even a mucous membrane. The characteristic lesion — a tiny sulphur-yellow disc with a cup-like depression in the centre, resemb- ling both in colour and in shape a honeycomb (hence favus), and in hairy parts pierced by a hair — can hardly be mistaken. An even more unmistakeable diagnostic point is furnished by its peculiar mousy smell. The lesion begins as a collection of whitish material, somewhat resembling a pustule, which grows and presently becomes dry and friable. The cup-like disc can then be detached from the epidermis, leaving a pimply, smooth, greasy surface. As they grow, the discs often run together. In a later stage roughish crusts are formed, separated by pale, bluish-pink scars. The crusts, when broken up, are seen under the microscope to consist of spores, varying much both in size and shape, and of short threads of mycelium, which may penetrate into the mucous layer of the epidermis, and may even reach the derma ; this never occurs in tricho- phytosis. Hairs affected with favus are discoloured and lustreless ; but instead of breaking off as in ringworm, they may fall out. Under the microscope one may FUNGOUS AFFECTIONS OF THE SKIN 271 see in favus-hairs segments of fungus 12-15 jj. in length, dichotomised at an acute angle. If the nails are affected, the ungual cells will be found to be separated by irregular threads of mycelium, or by spores. In the less characteristic cases, the lesions must be closely examined under a good lens for remains of the yellow discs of favus or the broken hairs of ringworm. If, owing to applications to the skin, the crusts are lacking, treat- ■^'£- 93. — Favus : showing the very wide distribution over the body, as well as the scalp. (From Diseases o/ the Skin, Sir Malcolm Morris.) ment should be stopped for a few days, when the whitish points and the discs will usually have reappeared. In prolonged cases, the crusts may be replaced by an irregular, lumpy, dirty-yellowish accumulation, but the odour of favus will still remain. At this stage the disease may resemble psoriasis of the scalp ; but there is a much greater loss of hair, the scales are less pearly, and even when no discs or sulphur-yellow scabs can be seen about the edges, the lustreless hair FUXGOUS AFFECTIOXS OF THE SKIX and the atrophic scarring left by the scahs are sufficiently distinctive of favus. The scarring ma}- suggest lupus erythematosus of the scalp, but in that affection the crusting and the mouse-hke odour are absent, while generally- there are characteristic lesions on the face. From both eczema and seborrhcea favus is differentiated by the fact that its lesions are never diffuse, but always have a" definite margin. In alopecia areata there is no scaling, crusting, or cicatrix. II. — Ringworm. All the forms of ringworm, whether of the scalp, the beard, the hairless skin, the mucous membrane, or the nails, are due to fungi belonging to two different famihes, the microspora and the trichoph^^ta, each of them comprising a number of different species. In the one case the affection is st\-led microsporosis, or tinea with small spores ; in the other, tricJwphytosis, or tinea with large spores. Eleven species of ringworm microsporons have been identified ; of the tricho- phi.'ta, upwards of thirty. In a diagnostic sense, however, only four species of the microspora, and the same number of species of the trichophj^la, are of importance. The four microsporons are M. Andouini, M. felineimi, M. cajiis and M. tardum ; the four trichophytons, T. crateriforme, T. acuminatum, T. sulphureum and T. violaceum. In both famihes some of the species are of animal origin, and it is these which account for nearlv all the inflammatory forms of ringworm, including kerion. Of the microsporons, the ty^e species is M. Audoiiini , which is the cause of some go per cent of the juvenile ringAvorm of London. It is also the cause of much of the juvenile ringworm of Paris, though of much less than was the case a few years ago. M. felineiim- and M. cams, closely allied species, are responsible for an appreciable percentage of human ringworms — the one in England, the other in France. M. tardum, the fourth species mentioned as of clinical sig- nificance, is occasional!}' met ^^-ith in France. Of the four clinicall}- important species of trichoph^.'tons, the one most frequenth" encountered is T. crateriforme. Xext comes T. acuminatum, then T. sulphureum, which, however, is not known in France ; and lastly T. violaceum. The di\-ision of the ringAvorms into a small-spored and a large-spored group may easily lead to confusion in diagnosis. For among both microsporons and trichophytons the spores var\' considerably' in size, according to the species. Those of the microsporons may be as large as 4 fi, while those of the trichoph^'tons may be as small as 3 ^ ; the limits of the one are 2 to 4 ^, and of the other, 3 to 8 fi. Clinically, therefore, microsporosis and trichoph}-tosis are to be differen- tiated from each other not alone by the size of the spores, but also by their shape and arrangement and modes of growth. First, as to shape : In microsporosis the spores are, speaking generally, round or ovoid ; in trichophytosis, they tend to be square with rounded angles, or oblong with sharper angles. StiU more important, for diagnosis, is the arrange- ment of the spores. In microsporosis they are dotted about irregularly, and the mycehum intenvoven ■\%-ith them is curved and branching, and irregularly jointed. In trichophytosis they are arranged in regular chains, and the mycehum is short and regularh- jointed. In microsporosis the fungus forms a greyish sheath around the hair — ^whether of the scalp or of the bod}- — ^^vhich it eats away, fra}-ing the edges, penetrating to the interior of the shaft, and growing downwards towards the root. Presently the hair breaks off, at some distance from the follicular orifice, and the parasitic sheath is disintegrated and may be seen as a patch of ash-coloured scales on the epidermis. In trichophytosis, the parasite attacks the root of the hair first, and grows upward. The hairs are broken off short, and no sheath is to be seen outside the foUicular orifice. By way of quahfication, it should be added that a group of small- FUNGOUS AFFECTIONS OF THE SKIN 273 spored trichophytons form a sheath outside the hair hke that of microsporosis, but the spores observe the chain-formation which is characteristic of tricho- phytosis, and this is never present in microsporosis. These small-spored trichophytons are all pyogenic, and are the cause of many cases of kerion. Trichophytons may be either endothrix or endo-ectothrix. If the parasite penetrates the hair between the cuticle cells and develops entirely within the hair-structure, it belongs to the endothrix class. If it not only develops within the hair, but continues to proliferate in the follicle outside, it must be allocated to the endo-ectothrix, or as Sabouraud rather inaptly styled it, the ectothrix class. The great majority of the cases of scalp trichophytosis, both in London and in Paris, are due to endothrix infections. But the endo-ectotriches are responsible for most of the ringworms of the hairless skin, for nearly all the adult ringworms, and for the majority of specially inflammatory cases. Sabouraud divides the endotriches into (i) true endotriches, and (2) neo- endotriches, the distinguishing feature between them being that in the latter the early [neo) stage of the attack, the stage in which the outside of the hair is assailed, is prolonged. If the parasite is a true endothrix, it is easy to miss the invasion stage, so short is it ; if it is a neo-endothrix, the invasion-stage is so protracted that it is possible to mistake the case for one of trichophytosis due to an endo-ectothrix. The endo-ectotriches are sub-divided into those with large spores (megaspores), and those with small spores (microides). It is the latter which, as mentioned above, may be mistaken for microsporons, unless the chain- formation be looked for. In the case both of the microspora and of the trichophyta, cultures may have to be grown to distinguish between the different species. There are four species of microspora which are of human origin, and these give either a small [petite) or medium [moyenne) culture ; to this group belong M. Audouini and M. tardum. The seven species of animal origin yield a large, enduring (vivace) culture ; in this group occur the two remaining species of clinical importance, M. cams and M. felineum. In the first group pleomorphism is never met with ; in the second, on a suitable medium, a white downy pleomorphism, quite different from the mother culture, is exhibited. Of trichophyton cultures, there are four main types : (i) the crateriform or acuminate ; (2) those with large white growths, either powdery or velvety ; (3) the faviform ; (4) a single species, Epidermophyton inguinale, which is the cause of eczema marginatum. In the first group, to which belong all the four clinically important species, the culture resembles the crater of a volcano, and is white, cream-coloured, or primrose-coloured, or it is like a mountain peak (" acuminate") and is grey or yellowish in colour. The parasites of this cultural group are all endotriches. In the second group the cultures are very large and white, some of them powdery, others velvety. The species which yield cultures of this type are all endo-ectotriches, and are of animal origin. The three species which give cultures like those of the parasites of favus, although the clinical course of the lesions and the appearance of the fungus in the hair leave no doubt that they are trichophytons, are also of animal origin. The Epidermophyton inguinale yields a yellow-orange culture, dry and powdery, but often white and velvety as the result of pleomorphism. Ringworm of the Scalp [Tinea tonsurans). — Both the small-spored and the large-spored ringworm of the scalp begin alike as a small red papule, which develops near the orifice of a hair-follicle. But the size, and yet more the shape and arrangement of the spores, and the way in which the hair is attacked, help to distinguish between them. These points have been touched upon already, but it may be added that in trichophytosis there is a much smaller number of stumps to be seen with the naked eye, and that on the surface D 18 274 FUNGOUS AFFECTIONS OF THE SKIN of the scaly patches, among the remainmg healthy hairs, one may detect those dark points to which the affection owes its name of " blatk-dot ringworm." These dots are pigmented, coiled-up hair-stumps. If the whole scalp is thus affected, the case becomes one of " disseminated ringAvorm." In tricho- phytosis, again, the scales are scantier, or may even be absent, and the outline of the lesions is not so rounded or so well-defined. As a rule it is not difficult to distinguish tinea tonsurans, whatever its form, from other scalp affections, the clinical picture — the broken hairs, the black dots, the slight scaliness, the prominent follicles, the baldness, in varying degrees, of the involved area — being sufficiently distinctive. In favus there is the same dull and brittle condition of the hair, but the patches are not generally circular, while in ringworm the cup-shaped crusts are absent, nor is the skin atrophic. The broken hairs serve to distinguish tinea tonsurans from pityriasis of the scalp and from psoriasis of the hairy skin, since in both these affections the hairs fall out unbroken. In psoriasis, too, there is a greater degree of scaliness, and generally it is not the scalp only that is affected. Nor, in psoriasis, is loss of hair usual, though it sometimes occurs. In the anomalous form of ringworm known as tinea decalvans, or as bald ringworm, in which the hair falls out in places, leaving smooth bare patches, confusion with alopecia areata may be avoided without much difficulty. The billiard-ball smoothness of the patches in the latter condition is not present in ringworm. Another differential feature is the shape of the short hairs found at the edge of the patches : in tinea tonsurans they are bent, whereas in alopecia areata they may be compared to a note of exclamation (!) In the latter condition, too, the hairs that remain are free from fungus. In the infrequent cases of inflammatory ringworm, a condition some- what resembling impetigo or eczema may be set up ; but the broken stumps and the limited area of the affection, together with the history of the case, should prevent confusion with those affections. In these forms of ringworm again, the lesions are sharply defined, and the pustules are invariably situated round the hairs. Seborrhcea can be ruled out by remembering the greasiness of the scales, the diffusion of the condition over the whole scalp, and the absence of patches of baldness. Ringworm of the Beard {Tinea sycosis). — From ordinary sycosis this affection is distinguishable by its more rapid spread, and the greater lumpiness of the affected surface. In sycosis vulgaris, too, the pustules are usually pierced by a hair, and are quite small, and unless there is much more suppuration than is usual, the hairs do not fall out. Tinea sycosis differs from eczematous folliculitis in the absence of the serous discharge that marks the latter affection. In the eczematous condition, again, there is but slight if any loosening of the hairs, so that if they are extracted they bring with them their root-sheaths. The affection is not confined to the hairy parts, as in tinea sycosis, nor do the patches assume the ring-like form. The ring-formation is absent also in seborrhcea, nor is the hair involved as in beard-ringworm. In the circinafe tubercular syphiloderm, the border of the lesion is darker in colour and more infiltrated, and there is either atrophy or pigmentation, or both. Occasionally the severer ca.ses of ringworm of the beard take the form of a single tumour-like formation which may be mistaken for a carbuncle. But the inflammation is almost always less active than in carbuncle, and the swelling and pain are correspondingly less. In any clinically doubtful case, an examination of the hairs imder a microscope will show whether or not the case is one of beard ringworm bj^ revealing the presence or the absence of the trichophytic fungus. Ringworm of the Body Skin {Tinea circinata). — The small, red, slightly raised spot which is the first visible lesion of ringworm of the body, gradually spreads at the edge and becomes scalv. Fading away at the centre, the redness FUNGOUS AFFECTIONS OF THE SKIN 275 leaves a slightly discoloured branny area, which forms the inside of a red ring. The circle slowly enlarges, without any widening of the edge. Usually, though not always, there are several rings, sometimes, though seldom, arranged con- centrically, and those adjoining each other may run together. Frequently, as the edge advances, there is no involution in the centre, the lesions then appearing not as rings but as patches. As a rule, inflammation is present in varying degrees, and the neighbouring lymphatic glands may be slightly enlarged. These symptoms, with the tingling and itching, form an ensemble which can hardly be mistaken for any other affection. In eczema seborrhceicum the scales are greasy, and often there are projections into the glandular openings. In psoriasis the skin is affected in ring-like areas, but all the other characters are different. From the circinate tubercular syphiloderm, ringworm of the body may be distinguished in the same way as ringworm of the beard (see above). As a rule microscopic examination will disclose the ringworm fungus, — usually a trichophvte — without difficulty ; but occasionally the parasitic elements are deep-seated, and must be sought in a section of the affected tissue. Ringworm of the Nails {Onychomycosis) . — Usually, though not invariably, ringworm of the nails appears in association with trichophytosis of the beard or of the body skin. The first visible lesion shows as greyish stains under the borders of the nail and at the root. Inflammation of the matrix follows and the structure of the nail degenerates, becoming thickened, spongy, and more or less brittle, with a dulled surface. When exfoliation occurs, a mass of dis- integrated nail substance is seen, in which the fungus may be found. Similar symptoms to those described may arise in connection with gout and rheumatism and other constitutional disorders — those for instance in which there is impaired nutrition — as well as in such inflammatory affections as eczema and psoriasis. From all such cases, the presence of the parasitic elements will suffice to differentiate onychomycosis. In the onychomycosis of favus, the stains under the borders of the nail are yellower, and the mycelial elements shorter and less regular. III. — Eczema Marginatum. In this form of ringworm of the body, more frequent in tropical climates than in Europe, the parts chiefly attacked are the lower portion of the abdomen, the groins, the buttocks, the fold of the nates, and the axilla — parts, that is, where the skin surfaces are in contact. The hair is never involved. The characteristic feature of the lesions is their broad, bluff margin ; it is scaly, and as a rule papular. Thej^ are often eczematoid, but they can be distinguished from eczema and from eczema seborrhceicum by their gradual spread and broad, elevated margin and by the ring-like formation of the early stage. If any doubt remains, the microscope will clear it up by revealing the parasite, the Epidermo- phyton inguinale. From eczema marginatum, dhobie's itch is very imperfectly differentiated. It is in fact a popular name for all epiphytic skin diseases of warm chmates, but usually it connotes diseases of this group of which the sites are the inguinal regions and the axillae. Castellani distinguishes two fungi as the cause of dhobie's itch, besides Epidermophyton inguinale, namely E. Perneti and E. rubrum ; and Manson holds that, in many cases, the parasites concerned are Microsporon minutissimum and M. furfur. For practical purposes, dhobie's itch may be regarded as another name for eczema marginatum. IV. — Tinea Imbricata. This form of tinea, known also as Tokelau ringworm, was formerly peculiar to certain oceanic tropical climates in the East, but now has a wider area of 2 76 FUNGOUS AFFECTIONS OF THE SKIN distribution. The fungus has not 5?et been classified definitely. Sabouraud holds it to be a trichophyton allied to species of animal origin met with in Europe ; by other authorities it is regarded as a lepidophyton. It has not so far been cultivated. The affection to which it gives rise is characterized by a concentric arrangement of closely-set rings of scaly epidermis. The conditions from which it has to be distinguished are thiea circinata and ichthyosis. From the former it is differentiated by the greater abundance of the fungus elements, the tendency of the process to spread centripetally, the absence of marked inflammation or congestion of the rings, their concentric disposition, and the greater size of the scales. From the latter, by the presence of the fungus, the concentric arrangement of the scales, and the fact that the attached border of each scale is towards the periphery, the free border being towards the centre of the circle, or group of circles, to which the scale belongs. Y. — Tinea Versicolor. This affection, often styled pityriasis versicolor, is caused by the Microsporon furfur, the mycology of which is httle understood. The disease is contagious, but only in a low degree. The lesions, confined to the horny laj^er of . the epidermis, take the form of roundish, scaly patches, with a definite margin, and of a colour varying from fawn to liver — in coloured races, grey or white ; in persons "who have hved in Avarm climates, it may be black. The hair is not assailed, nor are the hands and feet. As a rule the lesions are limited to the trunk, but occasionally they extend to the upper parts of the limbs : they have been mistaken for secondary syphilides, but the colour and distribution, and the large patches in which they are found, should serve to obviate the confusion. In exceptional cases the face may be invaded, and the affection might then be confounded with chloasma. From pityriasis rosea and from eczema seborrhceicum it may be distinguished by the absence of inflammatory reaction, except in persons who perspire freelj' ; in pitj^riasis rosea, too, the upper parts of the limbs are affected equalh^ with the trunk. The lesions of tinea versicolor offer some resemblances to the pigmentary patches sometimes met with in leprosy ; but from these, as from the other cutaneous manifestations mentioned, they may be differentiated almost certainly by the ease with which the scales can be detached b}^ a stroke of the finger-nail, and quite certainly by the fungus elements which may be detected in the scales after these have been treated with potash. The spores are rounded and, like the mycelium, have a double contour with a diameter of 3 to 5 ^ ; they are generally grouped together in masses, suggesting a resemblance to bunches of currants. VI . Er YTHRASMA . There are several points of resemblance between erythrasma, due to the Microsporon minutissinium, and tinea versicolor. In both, it is only the horny stratum of the epidermis that is affected, nor is the hair ever attacked. In both, too, there is but a low degree of contagiousness. The lesions offer some likeness to those of tinea versicolor, but they are reddish-brown in colour, and their usual site is the genito-crural region or the axillae, or both, though occasional!}-, in fat subjects, there may be extension to the abdominal and submammary folds and those of the large joints. In rare cases, erythrasma resembles one type of eczema marginatum, but is distinguished from that affec- tion by its low degree of contagiousness and its slow evolution, and by the absence of inflammation, which also distinguishes it from eczema seborrhceicum and from pityriasis rosea. Any doubt between erj'thrasma and any other affection, including tinea versicolor, may usually be cleared up by examination GAIT, ABNORMALITIES OF 277 of a preparation under a microscope of sufficiently high power. The spores of M. minutissimum, like the threads of mycelium, are extremely minute, having a diameter of about 06 |/. The mycelial threads, of the same diameter, are so abundant and so twined together as to form, here and there, a network over the epidermic cells. Malcolm Morris. GAIT, ABNORMALITIES OF.— As a genuine aid to diagnosis the gait cannot be of much real assistance. There are, however, several diseases and affections which produce manifest, and in some cases peculiar, alterations in gait. In some respects, indeed, the gait is a diagnostic point in identity, though this probably also depends on the total back or front view of the individual, rather than on real peculiarities of gait as such. In analyzing gait for diagnostic purposes, we find that it consists of co-ordinate and painless movements of the muscles of the lower limbs and pelvis — often, indeed, sinking into purely reflex, or at least subconscious, movements — and these are associated, in easy and ordinary walking, with rhythmical movements of arms, body, and head too, in many cases. The directions, therefore, in which it can be disordered are: (i) Inco-ordination ; (2) Local loss of power ; (3) Pam calling attention to the movements. 1. Inco-ordination. — The test for the presence of this is the complaint of the patient that he feels unsteady in walking, especially on turning or walking on uneven ground, or on walking or standing with the eyes shut ; and if co-ordina- tion only be at fault, it will then be found that on testing the legs for simple movements, such as flexion and extension, the power of the muscles is unimpaired. Having discovered inco-ordination, the next question is, to what may this be due ? Tabes dorsalis, ataxic paraplegia (combined lateral and posterior sclerosis) , disseminated sclerosis, and hereditary ataxy (Friedreich's disease), are far and away the commonest causes of this, in the order of mention ; their differential diagnosis depends on many other symptoms and signs, and it is discussed elsewhere. Cerebellar disease causes rather a reeling in the gait than a simple inco-ordination in the individual movements ; and here again, other symptoms will be to the front. Localized paralyses of eye muscles may also cause inco- ordination ; this will probably cause complaints of double vision, and may be diagnosed by the fact that the patient walks better with one eye shut than with both open — in cases of some duration it is quite likely that this simple test will not discover which is the affected eye. 2. Local Loss of Power. — The most peculiar illustration of this defect is the waddling gait of pseudo-hypertrophic paralysis, calculated to get the weight of the body as speedily as possible on the foot as a basis. The diagnosis depends on the peculiar way in which the patient climbs up himself (see Paraplegia). Another condition in which the loss of power is due, not to the muscles them- selves, but to the position of their attachments, is seen in congenital dislocation of the hips ; the gait here, too, is somewhat waddling, the lower part of the back exhibits extreme lordosis, and the belly is thrown forward through attempts to balance on the pelvis, or rather to balance the pelvis on the loose supports at the hips. Other forms of local loss of power betray themselves by a limp or by a dragging of the foot or leg, and (or) peculiar positions of the feet. Infantile paralysis, and old hemi- or mono- or para-plegias are the common causes of this, if it be unassociated with pain, and enquiry must be made as to mode of onset and duration, in completing diagnosis. 3. Pain on Walking. — This is at once obvious, because complained of by the patient ; acute inflammatory troubles of muscles, joints, or tissues will be obvious on examination, and chronic joint troubles, osteo-arthritis, etc., may be 278 GAIT, ABNORMALITIES OF easily discovered, chronic gonorrhoea or pj'orrhoea alveolaris not being for- gotten as possible causes of these. The only thing that may escape observation is hip-joint disease, when pain in the knee may be the complaint. The only other caution we can administer here, is to warn practitioners against any hasty conclusions as to the nature of a disease from the gait ; the high stepping gait of tabes, the shuffling gait of lateral sclerosis, the festinating gait of paralysis agitans, are all easy enough of recognition when a diagnosis is made, but are too frequently absent or atypical to allow much diagnostic superstructure to be built on them alone. Pred J. Smith. GALL-BLADDER ENLARGEMENT. Physical Signs. — The onlj^ physical method of examination which is of any material assistance in determining the existence of an enlargement of the gall- bladder, is palpation ; inspection, percussion, and auscultation are seldom if ever helpful. On careful palpation, however, one may feel an oval, smooth swelling, which maj^ be no larger than a hen's egg, or as big as a swan's, moving downwards close behind the anterior abdominal wall when the patient inspires, descending either from beneath the right costal margin near the tip of the ninth rib, or approaching the under surface of an enlarged and palpable liver in the right nipple line. This smooth oval tumour generallj- extends inwards as well as downwards as it grows bigger, so that it may ultimately cross the middle line below the level of the umbilicus. It may be large enough to be palpable bimanuall)- in a thin patient ; but it seldom fills out the loin in the way that a renal tumour would. It may or may not be tender, according as the cause of the enlargement is associated with inflammation or not ; it feels firm and tense, rather than hard ; on careful percussion it may be found to give a very impaired note, but it is seldom quite dull unless it is verj^ big. Diagnosis from other Swellings. — It has to be distinguished particularly from four groups of conditions which may simulate it : — (i) From carcinoma arising in the bile-ducts or gall-bladder, and replacing the latter with new growth ; (2) From tumours in or attached to the liver in the neighbourhood of the gall- bladder ; Riedel's lobe ; secondary new growth ; or more rarely gumma, abscess, or hydatid cyst ; (3) From movable kidney or hydronephrosis ; (4) From tumours in organs in the neighbourhood, such as carcinoma of the pylorus, carcinoma of the duodenum, carcinoma or sarcoma of the right suprarenal capsule. Carcinoma of the Gall-bladder. — It may be very difficult sometimes to decide whether a given mass is merely an enlarged gall-bladder, or a growth replacing the latter ; in either case there may be a history of gall-stones, Avith bihary colic, pj^rexia, and even jaundice, extending over years, ; for primary new growth of the gall-bladder is nearly always secondary to, and associated with, gall-stones. The rapidity of the enlargement, in the absence of any definite cause, may suggest growth, particularly in a person of the cancer age ; careful palpation may show that the mass is not smooth as most gall-bladder enlargements themselves are, but more or less nodulated or covered with bosses or irregularities, which in themselves suggest new growth ; in some cases there ma}' be secondary deposits in the liver, and sometimes the enlargement of the left supraclavicular gland points to malignant disease Avith metastasis. XotAvithstanding these points, hoAvcA-er, the differential diagnosis may be so difficult that laparotomy' aa'III be resorted to in order to decide it, with a view also to remoA'ing the gall-stones. The Tumours attached to or in the Liver that are most hkely to be mistaken for enlargement of the gall-bladder, or vice versa, are Riedel's lobe, secondary carcinoma or sarcoma of the liver, and much more rarely gumma, abscess, or hydatid cyst. A Riedel's lobe is a tongue-shaped, floating or accessory lobe. GALL-BLADDER ENLARGEMENT 279 sometimes lound attached by a narrow bridge of hepatic or even fibrous tissue to the anterior part of the lower border of the right lobe. It gives rise to no symptoms whatever, but it may be quite impossible to distinguish it by physical examination from an enlarged gall-bladder or from a movable kidney. Owing to the absence of s^-mptoms, there is seldom need for laparotomy ; but sometimes the Riedel's lobe arouses such alarm lest it is some more serious condition, that laparotomy may be resorted to and the diagnosis verified in that way. It is commoner in wonien than in men, possibly as the result of the use of stays. Secondary new growth in the liver, whether carcinoma or sarcoma, nearly always causes ver}' considerable, and sometimes enormous, enlargement and great hard- nessof the organ, not infrequently associated with Jaundice (^.w.). Ascites (q-v.), or both. The diagnosis depends, first, upon the discovery of a primary growth, which in the case of carcinoma is likely to be in the stomach, duodenum, pancreas, colon, or rectum ; or in the case of sarcoma, the eye — some of the very greatest enlargements of the liver being due to secondary deposits of melanotic sarcoma, secondary to a primary ocular growth ; and secondly, on the discovery in the liver of several separate nodules, some of which may be felt to be umbilicated, that is to say, depressed in their central part and raised around the edges. Gumma of the liver is not very frequent nowadays, and when it occurs is very apt to be mistaken for new growth unless there is a very obvious history of syphilis, or the effects of tertiary lesions are visible elsewhere, especially gummatous lesions of the skin or tongue. The diagnosis may be confirmed by obtaining a positive Wassermann's serum reaction, or by the beneficial effects of giving potassium iodide and mercury, though these drugs do not always cause a gumma of the liver to disappear rapidly. In cases that have come to laparotomy, the diagnosis between gumma and new growth is by no means easy, even when the liver is inspected. Abscess of the liver, if it is to simulate an enlargement of the gall-bladder, is likely to be a single large one, which, if it has not arisen in some pre-existent mass, such as a gumma, new growth, or hydatid cyst, is likely to have been acquired in a tropical countrj^, where the patient may have suffered from amoebic dysentery, even if the attack was onh- mild in degree. The diagnosis may not be evident until laparotomy is resorted to, or until the mass is punctured with an exploring needle, when the chocolate-and-milk appearance of the pus obtained may be characteristic. It is often sterile, although scrapings of the abscess wall would show the Amoeba coli {Fig. 12, p. 91). The existence of an abscess would be suggested by the occurrence of considerable leucocytosis, together w-ith a relative increase in the large polymorphonuclear cells. Hydatid cyst of the liver is seldom situated in such a position as to cause difficulty of diagnosis from gall-bladder enlargement, the cyst being more often embedded in the liver substance, or projecting from its upper surface. The diagnosis might be arrived at if the patient were known to have had hydatid cysts elsewhere ; but in most cases it is only when laparotomy has been performed that the correct diagnosis can be made. It might have been suggested by the occurrence of eosinophilia, and also by a specific hydatid serum reaction, though neither of these is likel}^ to be found unless the hydatid cyst has produced toxic symptoms, because latent hj'datid cysts cause no sjmiptoms. The Distinction between an Enlarged Gall-bladder and a Movable Kidney or Hydronephrosis might seem to otter no difficulty ; but clinically the distinction is not always so ea.s\ as might be expected. There is often no jaundice to suggest gall-bladder trouble, nor need there be any obvious urinary changes to suggest kidney, so that the diagnosis has to be made chiefly by palpation. One would lay stress upon the fact that the gall-bladder is more easily felt anteriorly than posteriorly, whilst the reverse is the case with the kidney ; that the kidney is 28o GALL-BLADDER ENLARGEMENT the more freely movable of the two, as a rule ; that it is seldom possible to demarcate the upper pole of an enlarged gall-bladder in the way that a mo\able kidnev can sometimes be made out ; that with a kidney tumour the loin is dull, whilst with gall-bladder enlargement it is resonant ; and that, on rather firm bimanual palpation, the pecuhar sickening sensation that the patient may com- plain of is more characteristic of kidney than it is of gall-bladder. Tumours of other Organs simulating Enlargement of the Gall-bladder have to be distingmshed partly by the fact that new growths of the pylorus, duodenum, or suprarenal capsule, big enough to simulate an enlargement of the gall- bladder, wiU seldom have the smooth oval outhne that the latter nearh* always possesses. There mav, moreover, be distinct S}Tnptoms attributable to the primarv growth, such as dilatation of the stomach, cofTee-ground vomit, and so on, or there mav be extensive secondan,- deposits in the fiver, in the left supra- clavicular gland, or elsewhere, to indicate the diagnosis. It is not easy, how- ever, to exclude enlargement of the gall-bladder ^vithout resorting to laparotomy in some of these cases. The Cause of Enlargement of the Gall-bladder. — Having decided that a given tumour is an enlargement of the gall-bladder, it is necessar\- to determine which of the foUowing causes it is due to : — ^ Empvema of the gall-bladder Chronic pancreatitis Carcinoma of the head of the pancreas T^-phoid fever Cholecystitis from :— (i)- Gall-stones ; (ii.) New gro^vth Obstcucjion_pf--theTomjnoir bile-duct -bp-galPs?one 05iEruction of the cystic duct by gall-stone Simple mucocele. It is particularlv noteworthy that gall-stones lead to enlargement of the gall- bladder far less often than might ha\-e been expected ; if the inflammation they lead to, and which leads to them, does not go on to empyema of the gall- bladder, the latter usuaUy becomes thick-walled, contracted, and embedded in dense adhesions, the latter preventing it from dilating, even when the cystic or common bile-ducts become obstructed by a stone. It is the exception to find a ver\- big gaU-bladder with gaU-stones. Indeed, in a middle-aged patient in whom there has not been any very definite attack of bihary cofic, the occurrence of progressive and considerable enlargement of the gall-bladder, associated with a deepening jaundice and no ascites, should always arouse serious suspicion of there being a lesion of the head of the pancreas which has extended along the pancreatic duct so as to occlude the common bile-duct gradually, the commonest cause of these S3-mptoms being either chronic pan- creatitis or, more serious still, carcinoma of the head of the pancreas. The greater the epigastric pain in such a case, especially if it is paroxysmal, and such as to suggest gaU-stones, the more hkely is the lesion to be chronic pancreatitis rather than new growth, and the suspicion may be confirmed by Cammidge's Paxcreatic Reaction [q.v.). There are, of course, cases in which gall-stones are the cause of the enlargement ; but when this is so, there is nearly always tenderness over the gaU-bladder, and pain when it is firmly palpated, associated with a rise of temperature, possibly with rigors, especiaUj- if the inflammation has spread to the bile-ducts (infective or suppurative cholangitis). Leucocytosis, with a relative increase in the polymorphonuclear cells, would indicate that in addition to gall-stones there is suppurative inflammation — that is to say, empyema of the gall-bladder — requiring surgical treatment. Another important cause for empyema of the gall-bladder is typhoid fever. The diagnosis is not difficult as a rule, for there will be no question of new growth PLATE III. SYMMETRICAL GANGRENE OF THE FINGERS IN RAYNAUD'S DISEASE Rc/>? oduccd by J>a/nission of tJic House Co7}nnittec of St. George's Hospital fioin a %vater-colour drawing; hy Dr. E. A. IVHson. INDEX or- DIAG.MISIS GANGRENE 281 or of gall-stones in most of the cases, and the patient will have been suffering from a prolonged asthenic fever, which will have been diagnosed already by Widal's test. Infection of the gall-bladder by typhqid bacilli is relatively common, and seeing that gall-stones are seldom if ever primary, but rather the result of preceding microbial inflammation in the gall-bladder, it is not surprising that gall-stones are more common in patients who have previously had typhoid fever than in other persons. Apart from gall-stone formation, however, slighter degrees of inflammation of the gall-bladder by Bacillus typhosus are common, and it is thought that the continued infectivity of the excreta in typhoid-carriers is due to the constant discharge of infected bile from the gall-bladder, persisting sometimes for thirty years or more. The gall-bladder is not enlarged in these cases ; but in a certain number of typhoid patients, rapid enlargement of the gall-bladder occurs owing to the bacil- lary infection, and there are instances in which the distention has become so great that the gall-bladder has ruptured spontaneously and produced general peritonitis. Sometimes the inflamma- tory products discharge themselves naturally by the bile-passages ; but it is often necessary to open and drain the gall-bladder, the diagnosis of the nature of the empyema being settled by bacteriological examination of its contents. It is noteworthy that, whereas in uncomplicated cases of typhoid fever Widal's reaction rapidly becomes negative during convalescence, when there are persistent bacillary complications, the serum test may remain positive, or at least partly positive, over much longer periods. When an empyema of the gall-bladder due to typhoid fever remains latent for weeks or longer, the nature of the case may be suggested by the previous history, and by the persistence of the positive serum reaction. Simple mucocele of the gall-bladder is probably the result of former catarrh of the cystic duct, or often of a gall-stone which has disappeared ; nevertheless, in many cases it may be impossible to determine the precise cause ; the gall- bladder may become very greatly distended with perfectly colourless mucoid fluid, free from bile pigment, though sometimes containing crystals of cholesterin {Fig. 94). The fluid is sterile. The cystic duct is generally obstructed as the result of former inflammation. There are usually no symptoms unless the patient may by chance have discovered the tumour for herself. Such a mucocele may be mistaken for a movable kidney, and the diagnosis of the nature of the mass is sometimes obscure until operation is resorted to. Herbert French. GANGRENE. — When any necrotic tissue is, or becomes, infected with putre- factive micro-organisms, the resulting condition is known as gangrene. According to the appearances it presents, gangrene is further described as either dry, moist, or spreading. (See also Gangrene of the Lung.) Causes of Gangrene. Local Traumatic Causes : — Severe bruising or crushing of the tissues, with or without fractures of the bones. ^i]g'. 94. — Cholesterin crystals. 282 GANGRENE The application of extreme heat or cold — burns, hot-water bottles, frost- bite, freezing, ice-bags, etc. The action of strong chemicals — acids, alkalies, phenol, etc. The action of powerful electric currents, or of lightning. Lowered Vitality of the Tissues, either (a) Local, or (fo) General. Local : seen in the immediate neighbourhood of the infected area in such acute infections as — Septic wounds I Syphilis Erysipelas Anthrax Gonorrhoea Diphtheria Scarlet fever. General : occurring after some slight injury as a complication or sequela of- Enteric fever i Cholera Small-pox Chicken-pox Measles Diabetes Infantile marasmus Disturbances of the Innervation of the Tissues, such as occur in Plague Yellow fever Malaria Poisoning by snake- venom. Hemiplegia Myelitis Meningo-myelitis Lesions of the spinal cord and Cauda equina. Raynaud's disease Erythromelalgia Peripheral neuritis Syringomyelia Tabes dorsalis Leprosy Stoppage of the Circulation, due to — Embolism Thrombosis Endarteritis ; senile gangrene Occlusion of vessels, complete or partial, by — Ligature, tight bandages, splints Pressure of new growths Pressure of aneurysms or effused blood The arterial spasm of ergotism, the so-called " epidemic gangrene." Speaking generally, more than one of the causes enumerated above will be at work in the production of gangrene in any particular instance. Thus, in the gangrene following severe injury to one of the extremities, stoppage of the circulation through the affected part is usually observed in addition to the direct injury caused by the mechanical crushing of its tissues. Again, in cancrum oris or noma — the name given to the spreading gangrene of the soft tissues of the mouth and cheek occurring in debilitated children after measles or scarlet fever — great feebleness of the circulation contributes to its production, in addition to the lowered vitality of the necrotic tissues {Fig. ii, p. 88). A diabetic patient with gangrene may owe it partly to the impoverished or altered quality of his blood, partly to the arteriosclerosis that is often associated with diabetes, and partly to peripheral neuritis occurring as a further complication of his disease. In dry gangrene, or mummification, the affected part of the body, usually the distal end of a limb, becomes livid and cold, and gradually blackens as the blood- pigment diffuses out of the blood-corpuscles and enters the tissues, and withers as the fluid in it evaporates. It is a slow process ; putrefaction is little in evidence, and there is no markedly offensive odour about the part, for it is too dry to afford a satisfactory culture-medium for the bacteria of putrefaction that GANGRENE 283 no doubt swarm on its surface and in its tissues. Between this dry gangrenous tissue and the adjoining healthy part of the Hmb, is an inflammatory zone : the line of demarcation (Plate IV). Dry gangrene is common in cases of embolism or other complete obstruction of the arteries, in senile gangrene, and in Raynaud's disease (Plate III) ; the affected part is ultimately converted into a shrunken, black, and mouldy-smelling mass. Moist gangrene, sphacelus, or sloughing, may often be seen after severe crushing of a leg or an arm, when the distal portion of the limb dies and rapidly putrefies. At first hot, red, and painful, the crushed extremity presently becomes mottled, purplish, and cold, as thrombosis occurs in its vessels, and the circulation through it stops. Signs of putrefaction soon appear in the dead tissue, the skin rising into discoloured blebs, which, on rupture, give issue to a highly offensive sanious fluid. A dusky red line of demarcation separates the gangrenous from the adjoining healthy part. " Sloughing " is the name commonly given to the putre- factive separation of smaller parts of the soft tissues from the body ; sloughs are the localized gangrenous patches that result frcm most of the injuries described under the first heading. Spreading gangrene is the form of gangrene due to infections by special virulent bacteria, which cause the death and partial dissolution of the tissues in which they grow and spread. Fatty acids and sulphides are among the chemical com- pounds formed by these micro-organisms, and it is to them that the offensive odour of the debris of tissues is due. The Diagnosis. Traumatic Local Causes and Lowered Vitality of the Tissues. — Gangrene being no more than an infective necrosis of some part of the body, and producing changes obvious to the eye and nose, the fact of its occurrence can rarely be difficult to determine. Consideration of the lists above will show that in every Pig. 95. — Raynaud's disease: stage of local asphyxia. case the gangrene is a direct consequence of some local infection or injury, and occurs in its immediate neighbourhood. The history of exposure to one or another of the forms of severe injury or infection, or of exposure to some injury or infection that would be unimportant if it occurred in a healthy person, but may lead to gangrene in severely debilitated patients, ought to be elicited readily. J 84 GANGRENE Disturbances of the Innervation of the Tissues. — Gangrene due to disturb- ances in the innervation of the tissues is commonly described as a trophoneurosis or trophic change. It may be either chronic or acute in its onset. Gangrene of a Chronic Type. — In Raynaud' s disease gangrene may affect the tips of the fingers or the toes, less often the edges of the ears and the end of the nose or tongue. It is often symmetrical in its distribution, and is preceded by the other two well-known stages of the disease, namely, local syncope, in which the affected extremities become cold, numb, and white ; and local asphyxia (Fig. 95), in which they turn from white to blue-grey or purple. Rarely, Rajmaud's disease is characterized only by recurring attacks of necrosis in the extremities [Fig. 96). It is a chronic affection, and gangrene only occurs in marked cases and in their later stages, although it maj^ be seen at any age. Fi^. 95. — The eflFect of Raynaud's disease after it has produced recurrent necrosis ot the fingers. As a dry gangrene attacking the superficial and terminal parts of some of the digits, it may bear some resemblance to senile gangrene [Plate IV) ; this, however, generallv attacks only one limb, usually a lower limb ; it is more extensive and more progressive than the gangrene of Raynaud's disease ; and it is associated with weU-marked disease of the arterial walls. Gangrene ma}^ be a part of the manifestations of erythromelalgia, a rare and chronic disease of adults who do hard work while exposed to considerable changes of temperature. It is characterized by pain, heat, and flushing of one or more of the extremities, all aggravated when the limb is allowed to hang downwards. The colour varies from rosy red to purple, and the affected parts are hot : hence the condition should not be confused with Raynaud's disease. The gangrene of erj-thromelalgia is confined to the extremities and may be S5rmmetrical ; as a rule it is more narrowly localized and less superficial than the gangrene met with in Raynaud's disease. PL A TE I V. GANGRENE OF THE FOOT a Note the line of demarcation at {n). F7-07II " Introduction to Surgery" by kind permission of Prof. Rutherford Motison. INDEX OF DIAGNOSIS GANGRENE 285 Gangrene is a rare complication of peripheral neuritis clue to alcoholic, arsenical, or other forms of poisoning. It occurs exceptionally, and only in patients exhibiting the vasomotor type of neuritis. These instances closely resemble cases of Raynaud's disease, with which, indeed, some hold them to be identical. The gangrene is symmetrical ; the patient will very probably exhibit some of the other signs and symptoms of peripheral neuritis — disturbances of sensation, tremor, paresis, wasting, trophic changes — and a history of alcoholic excess should be sought from the patient or the patient's friends. Gangrene of the skin and superficial tissues of the hands or feet, and even of the terminal phalanges of the digits, may be met with in syringomyelia ; this disease, if associated with painless whitlows on the fingers, is known as Morvan's disease. This gangrene is to some extent traumatic in origin, and may be symmetrical ; but the diagnosis should not be difficult, for in most cases three prominent symptoms are seen in syringomyelia : {a) Loss of the sensations of pain and of temperature, tactile sense being preserved over the anaesthetic area ; this is the " dissociated anaesthesia " of Charcot, [b) Trophic changes about the extremities, often originating in some neglected or unnoticed injury ; hypertrophy or atrophy of the skin or nails ; trophic changes in the joints, the so-called " Charcot's joints " ; brittleness of the long bones, with a tendency to the occurrence of spontaneous fractures, (c) Progressive muscular atrophy, invading the hands first, later the forearms, arms, and shoulders ; atrophy of the spinal muscles may ensue, giving rise to spinal curvature. Thus the gangrene of syringomyelia is characterized by its painlessness, and by its combination with other well-marked special symptoms ; in addition, it may be mentioned that the hands themselves often present certain deformities, the "Claw-hand " {q.v.) resulting when the muscular atrophy of the hands is marked, the " succulent hand " being exhibited when there are much hyperplasia and redundancy of the soft parts of the hand and fingers. Gangrene of the toes may occur in tabes dorsalis, usually in connection with a perforating ulcer about the ball of the toe. The process is slow and painless, not symmetrical ; and is associated with the other main signs of tabes, especially loss of the knee-jerks, Argyll Robertson pupils, ataxia, and finally diminution, or loss, of control over the sphincters. Gangrene of a similar sort, and similarly started by some ulceration or a neglected injury, is common in leprosy of the " smooth," " nerve," or " an- aesthetic " type. It occurs only in the later stages of this disease, and from its rarity calls for no further consideration here. Gangrene of an acute type, and attributable to trophic changes, occurs in the form of decubitus acutus, or acute bedsore in certain acute disorders or infec- tions of the central nervous system or spinal cord. These are all characterized by the fact that the primary lesion of the nervous system produces both paralysis and anaesthesia, and is also, in all probability, irritative. Within a few days or even hours of the primary lesion, secondary changes are seen in the skin and soft tissues where they are most exposed to pressure. These parts are those about the buttock, sacrum, coccyx, iliac crest, great trochanter, tibia, or heel, according to the position in which the paralyzed patient lies in bed. When the pressure is unduly great or unduly protracted, the skin turns red or purple, and unless most carefully protected may presently undergo extensive and spreading necrosis and gangrene. Hot-water bottles that would expose an ordinary patient to no discomfort or danger whatever, may set up analogous necrosis and gangrene if allowed to remain too long or too closely in contact with the skin of a paralytic patient liable to the formation of bedsores. The chief nervous lesions in which the acute bedsore is seen are the following : hemiplegia, whether due to cerebral embolism, cerebral haemorrhage, or cerebral thrombosis ; acute GANGRENE infections of the spinal membranes or spinal cord, or both, such as meningitis, myelitis, or meningo-myelitis, whatever the origin of the infection may be ; transverse' lesions of the spinal cord or cauda equina, such as are caused by fractures or fracture-dislocations of the spinal column, or by penetrating wounds involving the spinal cord. These bedsores occur only in the anaesthetic areas, and hence tend to escape the notice of the patient, who may also be unconscious or delirious. But it is of the greatest importance that a sharp look-out should be kept upon the skin covering all bony prominences particularly exposed to pressure in these patients, in order that the occurrence of a bedsore may be detected at once, and suitable treatment applied without delay to check its spread. Once well established, the acute bedsore tends to spread in area and in depth, in spite of the most careful treatment, and to bring about the death of the patient by septic absorption, pyaemia, or the exhaustion consequent to prolonged suppuration. Stoppage of the Circulation. — Among the most important and extensive causes of gangrene are those in which the exciting factor is some more or less com- plete vascular obstruction, with consequent stoppage of the circulation, and the death of those tissues whose blood-supply is cut off. In this connection, occlusion of the arteries is more important than that of the veins, the channels for venous return being more extensive and better supplied with anastomotic by-passes than those for arterial supply ; nevertheless, in exceptional cases, moist gangrene of some distal part follows blocking of the veins by thrombosis or by pressure from without, while the arteries are still patent. The importance and amount of the pathological changes following vascular obstruction depend to a large degree on the extent to which collateral or anastomotic channels exist and are able to carry on the circulation through the affected area. If they are ill- developed, and the artery which has been blocked by embolism or thrombosis is an " end-artery " in the sense in which Cohnheim used the term, the conse- quences of the stoppage are likely to be far more serious and extensive than if there are adjacent vessels able to make good some supply of blood for the nourishment of the affected tissues. Embolism of an artery is likely to occur in patients who have valvular disease of the heart, with vegetations on the mitral or aortic valves that may be swept off into the blood-stream ; or else the embolus may be derived from a blood-clot formed in a diverticulum of one of the chambers of the left heart, or in an aneurysm, or upon the surface of a rough atheromatous aorta. Thrombosis, whether arterial or venous, may be suspected in patients in whom no source for an embolus can be detected, but who exhibit widespread arterial degeneration, phlebo- sclerosis, or local disease that may spread to some vessel and set up clotting in its contents. The occurrence of arterial embolism, in the leg for example, is marked by a sudden and very severe pain in the limb at about the level of the blockage. The distal portion of the limb becomes numb, cold, insensitive ; pulsation can no longer be felt in the arteries distal to the obstruction. The gangrene that follows is usually of the dry type. Very similar symptoms may mark the occlusion of an artery in the leg by thrombosis, but the onset is usually much more gradual, and the pain may be terribly protracted and severe, death of the nerves of sensation coming on but slowly. Senile gangrene occurs in patients who are advanced in years and exhibit extensive arterial sclerosis ; in many instances they also give a history of gout, or suffer from diabetes mellitus. It is in reality a form of thrombotic or occlusive gangrene, and due either to the clotting of blood on the diseased and roughened arterial intima, or else to the increasing obstruction of the arterial lumina by a proliferative endarteritis. Senile gangrene is often of insidious onset and confined GANGRENE OF THE LUNG 287 to one lower limb, just as embolic gangrene may be ; but it has a tendency to spread upwards slowly and indefinitely, a tendency that finds a natural explanation in the very extensive character of the arterial degeneration that goes with it. It is not often symmetrical ; if more than one limb is affected, the lesions are successive in their development. Little need be said about the gangrene that follows complete or partial occlusion of the vessels by the other causes enumerated above. The gangrene will be secondary to some primary lesion that will seldom fail to be obvious. The ligature of an artery in the course of a surgical operation — of the femoral artery, for example, in the treatment of popliteal aneurysm — has been known to cause gangrene of the leg in patients whose collateral circulation unfortunately proved to be inadequate. The application of tight bandages round a limb, possibly to check haemorrhage, may cause a similar gangrene if they are left on too long. The pressure of new growths on an artery may be such as to cause its occlusion in exceptional instances, whereas it readily compresses or invades veins and renders them impervious ; in either case gangrene of some distal part may result. The new growth may be primary, or may be a secondary deposit growing perhaps in a lymphatic gland. Thus, a carcinoma in the mammary gland, or an endothelioma of the lung or pleura, may give rise to secondary deposits about the axillary and subclavian vein and artery ; and these may be so extensive as to obstruct the circulation through the arm, and set up moist gangrene in the fingers. Similar gangrene of the fingers may result from the vascular obstruction caused by a large intrathoracic aneurysrn, or by blood that has escaped and clotted round the vessels of the arm. The epidemic gangrene of ergotism is only of historic interest in Great Britain at the present time, although it is said to occur still in Russia. It is seen only in persons who consume quantities of mouldy rye ; the gangrene does not appear to occur in human beings as the result of excessive doses, of the pharmaceutical preparations of ergot. It is stated, however, that minor degrees of ergotism may simulate Raynaud's disease or erythromelalgia. Gangrene due to ergot is dry, chronic in progress, extremely painful, and usually asymmetrical ; it results in much disfigurement from loss of tissue, and has had a high mortality in many of its epidemics. A. J. J ex-Blake. GANGRENE OF THE LUNG.— This occurs whenever a portion of the lung undergoes necrosis, and then, owing to invasion by one or more of many kinds of bacteria, putrefies. It usually occurs in senile, intemperate, or debilitated patients. Most often it affects a circumscribed area of lung-tissue only, but it may be a diffuse process involving a whole lung. It occurs as a rare complication of pneumonia or broncho-pneumonia ; and as a comparatively common compli- cation of aspiration-pneumonia, when it is due to direct infection of the lung by the bacteria contained in food, mucous secretions, or foreign bodies generally (peas, beans, fish-bones, extracted teeth, etc.) that have made their way past the larynx and into the trachea or bronchi. .Gangrene may also result from an extension of the infection in such chronic suppurative affections of the lungs as chronic pulmonary tuberculosis, bronchiectasis, or fcetid bronchitis. In other instances the infecting agent reaches the lungs by the blood-stream ; thus gangrene may follow pulmonary embolism if the emboli contain septic or putrefactive bacteria, secondary, for instance, to lateral sinus thrombosis, the result of middle-ear disease. Finally, pulmonary gangrene may result from penetrating wounds of the lung, or from the spread of infection from the pleura, peritoneum, or pericardium, to the tissue of the lungs. Gangrene of the lung is characterized by great prostration, irregular fever, cough, and in most cases the expectoration of copious fluid and frothy sputum 288 GANGRENE OF THE LUNG of disgusting odour. The sputum settles into three laj^ers on standing, and the lowermost of these will be found to contain fragments of elastic tissue. Severe haemoptysis from gangrenous erosion of a blood-vessel may be noted in chronic cases. In a minority of instances the sputum lacks the indescribable but characteristic fcetor, and this is often est so in the pulmonary gangrene of diabetic patients and of children. The physical signs of gangrene of the lungs are in no wa}^ distinctive ; more or less extensive consolidation or infiltration of the affected part Avill be indicated early in the disease, and later, when the gangrenous tissue has softened and been expectorated, the signs of a cavity ma}' appear. Occurring as a terminal event, shortly before the death of an exhausted and debilitated patient, pulmonary gangrene may not be suspected, and so msLy escape detection. As a rule, however, the diagnosis presents no great difficulty, being suggested by the supervention of copious and highly offensive expectoration in a patient known to be suffering from one or another of the diseases already mentioned. The gangrene may, however, be simultaneous with the development of an aspiration-pneumonia, and this condition may therefore be more fully con- sidered. As already mentioned, aspiration-pneumonia is often set up by the entry of a foreign body into the trachea or into a bronchus'; it may follow stenosis of a bronchus from any cause such as syphilis, the pressure of an aneurj'sm or of a new growth ; it may result from the establishment of a fistula leading from the oesophagus to the trachea or a bronchus, as may happen as a terminal event in malignant disease of the air-passages or oesophagus ; it is seen in patients with spreading infections of the mouth, pharynx, or larynx ; it occurs in the insane, or in persons with extensive laryngeal or bulbar paralj^sis who are constantly exposed to the danger of swallowing food directly into their air-passages ; and it is observed occasion- ally after operations, particularly those on the mouth, pharynx, larynx, or trachea, when infective matter has made its way into the bronchi while the patient was under the influence of a general anaesthetic. In patients with pycsmia, gangrene of the lung due to the establishment of multiple embolic pulmonary abscesses would be suggested if the patient should develop the signs of pulmonary consolidation, cough, and offensive expectoration. Similar symptoms occurring after wounds or contusions of the lungs would make the same diagnosis highly probable. Greater difficulty is experienced, however, in deciding the question whether or no gangrene of the lung has occurred in a patient suffering from bronchiectasis, foetid bronchitis, chronic pulmonary tuberculosis with cavity formation, or putrid empyema discharging through the lung, in whom the expectoration of highly offensive sputum was already present. To some extent the question is then mainh' of academic interest. Elastic fibres and shreds of pulmonary tissue may be, and often are, present in the sputa of all these conditions ; but they are commonest, and present in greatest amount, in pulmonary gangrene. Again, the onset of pulmonary gangrene is often acute, and is accompanied by much prostration, no doubt due to septic absorption ; these facts, coupled with evidence of the appropriate changes in the physical signs of the patient's lungs, should be of assistance in arriving at the diagnosis. Pulmonarjr gangrene, as already stated, may occur so soon before death as to be unsuspected. In a few instances the sputum is not foetid. In other cases, particularly when it occurs in children, the gangrene may lead to no expectoration at all. Under these circumstances the diagnosis is impossible, and the gangrene of the lung may be described as latent. A. J. J ex-Blake. GIDDINESS.— (See Vertigo.) GLYCOSURIA 289 GIRDLE PAIN, or " girdle sensation," which is often a better description of the phenomenon, is a sense of constriction, sometimes of painful constriction, as though a tight band encircled the trunk. The band may be narrow or broad, and may be referred to any level of the thorax or abdomen. Although a common symptom of tabes, it is not pathognomonic of that disease, and may occur with any morbid condition involving symmetrically the posterior spinal roots, such as syphilitic spinal meningitis. Another form of girdle sensation, having a different pathological basis, is often described by patients suffering from spastic paraplegia due to focal disease within or outside the dorsal region of the spinal cord. In such a case the tight feeling is found to correspond with the highest level of spasticity, sometimes to the highest level of sensory loss. Thus a girdle sensation may be a symptom of disseminated sclerosis, of myelitis, or of compression paraplegia. In the last it may help the physician to localize the level of the disease, but it is rarely so reliable for this purpose as the information which can be obtained from a careful investigation of the distribution of motor and sensory paralysis, and of the superficial reflexes (see Paraplegia). e. Farquhar Buzzard. GLANDS, LYMPHATIC, ENLARGEMENT OF.— (See Lymphatic Gland Enlargement.) GLYCOSURIA. — The diagnosis of glycosuria falls naturally into two divisions : — (I) The recognition of glucose in the urine; and (II) The inference as to the disorder with which it is associated. I. — -The Recognition of Glucose in the Urine. The following are the more important chemical tests for the presence of dextrose in the urine : — 1. Trommer's Test. — This and the two succeeding tests, which are modifica- tions of it, depend on the power possessed by glucose of reducing alkaline solu- tions of salts of copper with formation of red oxide of copper. To perform Trommer's test, a small amount of solution of potassium hydrate is poured into a test-tube (say -^-in. depth), and to it are added, first a few drops of solution of copper sulphate, which will produce a precipitate of copper hydrate, and secondly a small quantity of the suspected urine. On boiling the mixture, if glucose be present a red precipitate or suspension of cuprous oxide appears ; while if glucose is absent, black cupric oxide is formed instead. 2. Fehling's Test. — This is Trommer's test modified by the addition of sodio-potassic tartrate, which holds the black oxide of copper in solution. Two solutions are prepared as follows : (i) Dissolve 36'64 grams of copper sulphate crystals in distilled water and make up to 500 c.c. ; (ii) Dissolve 125 grams potassic hydrate and 173 grams sodio-potassic tartrate (Rochelle salt) in distilled water and make up to 500 c.c. These two fluids should be kept in separate stoppered bottles. For use, take equal quantities of each (say \-m. deep in a test-tube), mix and boil. Add to the hot fluid a few drops of boiling urine. If glucose is present a red suspension of cuprous oxide is formed ; if it is absent, the fluid retains its blue colour. 3. Pavy's Test. — This is practically the same as Fehling's, with the exception that a certain amount of ammonia is added, to retain the red oxide of copper in solution. The solution is made thus : Copper sulphate, 4- 16 grams ; sodio-potassic tartrate, 20-4 grams ; strong solution of ammonia, 300 c.c. ; and distilled water to I litre. On boiling this with urine containing glucose it is decolorized. The blue colour returns on contact with the air. This test is seldom used except for quantitative purposes (see below). 290 GLYCOSURIA Sources of Error in the Above Tests. — Error may be caused by the presence in the urine of other bodies besides glucose which have the power of reducing copper salts. The most important of these are Lactose and Pentose. Both of these sugars form " osazone " crv-stals with phenyl- hydrazine, but they do not ferment with yeast. Pentoses give a chern,--red colour when heated with hydro- chloric acid and a little phloroglucin. Thej- also react with the following solutions (Bial's Test) : Orcin, i gram ; lO per cent solution of ferric chloride, 25 drops; and strong hydrochloric acid, 500 c.c. On heatings c.c. of the urine with loc.c. of this solution a greenish-blue colour is produced, and finally a precipitate of this colour is formed. Other substances which may cause error in testing with Fehling's solution are Glycuronic Acid, Uric and Hippuric Acids, Xanthin, Creatinin, and Alkapton. They do not, however, as a rule, produce more than a dull greenish-yellow precipitate, instead of the golden colour given with glucose. They are none of them fermented hy 5'east. Glycuronic acid gives the reactions described as characteristic of pentose. Alkaptonuria is suggested by the dark colour of the urine (see Urine, Abxormal Coloration of). The reduction sometimes seen on testing the urine of patients who have been taking certain drugs, such as morphine, chloroform, chloral, salol, camphor, phenazone, benzoic acid, or carbolic acid, is probably due to glycuronic acid. If the urine to be tested for glucose by means of the copper-reduction method contains anj- large amount of albumin, this should be removed first by boihng and filtration. If the urine be ammoniacal, FehHng's test ma^- be unwittingly converted into Pavy's, and decolorization be produced instead of a red precipi- tate. Strongly alkahne urine should therefore be rendered slightly acid with acetic acid. 4. Bottger's Test. — Put a small quantity of urine (freed if necessary from albumin) into a test-tube, and add an equal quantity of liquor potassae and a couple of grains of bismuth subnitrate (as much as will lie on the point of a small penknife). On boiling, a black precipitate is formed. 5. Nylander's Test. — Make up the following solution : Bismuth subnitrate, 2 grams ; sodio-potassic tartrate, 4 grams ; caustic soda solution (sp.gr. i"i2), to 100 c.c. On boiling 5 c.c. urine containing glucose with 5 or 10 drops of this solution a black precipitate is formed. Glycuronic acid, pentose, and lactose also reduce bismuth. 6. Moore's Test. — Put a small quantity of urine into a test-tube, add an equal amount of liquor potassce, and boil. If sugar is present, a dark-brown colour is produced and gradually deepens to an almost black tint. This test is not of much value, as it requires the presence of a considerable percentage of sugar, and a dark colour may be produced by other substances, such as indican and alkapton. 7. Picric Acid Test. — Pour about 5 c.c. of urine into a test-tube ; add 2 c.c. of saturated solution of picric acid in water and a few drops of liquor potassae, and boil. A dark-brown colour is produced if glucose be present. This test also is of Uttle value, as a dark colour is produced also by lactose, and even by creatinin ; while impure picric acid alone may darken on boiling. S. Plienyl-hydrazine Test.— Fill a test-tube about a quarter full of urine, and add as much phenyl-hydrazine as will lie on the point of the large blade of a penknife, and a rather larger amount of sodic acetate. Boil some water in a beaker, and place the test-tube in this for half an hour. Then remove it, and allow it to cool. If glucose be present, cr\-stals of phenyl-glucosazone will form in the shape of sheaves of bright yellow needles as seen under a low power of the microscope. Other sugars, such as lactose and pentose, as well as glycuronic acid, form cr>-stals with this test. These differ somewhat in shape, phenyl- GLYCOSURIA 291 lactosazone for example being shorter, and rather in the form of bundles than of sheaves. The melting-points of the different compounds also differ. Glycuronic acid usually gives rise to an amorphous precipitate, or scales, not to crystals. The urine to be tested should be free from albumin. 9. Safranin Test. — Place in a test-tube about a -J-inch of urine (free from albumin) ; add equal quantities of liquor potassse and of solution of safranin (i-iooo). A dark-red fluid is produced, which turns yellow or brownish on boiling if glucose be present. This test is seldom used, but appears to be a sure indication of the presence of glucose (Bedford). 10. Fermentation Test. — Boil some urine (200 c.c.) in a beaker, and allow it to cool. Then stir into it a piece of yeast about the size of a small cherry, till it is thoroughly mixed. Alkaline urine should first be rendered acid with a few drops of acetic acid. Fill the graduated limb of a ureometer with the fluid, and let it stand for twenty-four hours in a warm place. If glucose is present, carbon dioxide gas will be formed and will accumulate at the top of the tube. If carefully performed, this test is a certain indication of the presence of glucose. A small amount of fermentation may be produced by bacterial action on other sugars, but by boiling the urine this error is eliminated. Laevulose may also ferment with yeast, but its presence in urine is so exceptional that it may practi- cally be disregarded. A rough indication of the amount of sugar present may be gained by taking the specific gravity of the urine after fermentation, and comparing it with that of a specimen kept under similar conditions but without yeast. It is said that a fall of one point in the specific gravity takes place for every grain of sugar per ounce of urine ; but this mode of quantitation is very inaccurate. Quantitative Measurement of the glucose present may be made by either Fehling's or Pavy's fluid. If Fehlitig's Fluid is used, 10 c.c. of the mixed fluid (i. and ii. ) are placed in a porcelain dish along with about 40 c.c. of distilled water, and heated to boiling over a flame. A burette is filled up to a known mark with the urine, diluted to i in 10 (10 c.c. in 90 c.c. of distilled water), and this is allowed to run slowly, a few drops at a time, into the boiling fluid, which is stirred meanwhile with a glass rod. A precipitate of red oxide of copper forms, and the blue colour is gradually discharged. When this has completely disappeared, the quantity of diluted urine is read off ; and the amount of sugar in this is known to be 0'05 gram. Suppose that, for example, 8 c.c. of urine diluted to i in 10 have been used ; then 8 c.c. of undiluted urine will contain 10 x 0'05 gram glucose, or o'5 gram. Knowing this, the percentage of sugar is easily calculated to be 0"5 X 100-=- 8, or 6-25 per cent. The method of using Pavy's Solution is similar, with the exception that it must be boiled in a closed flask, and the nozzle of the burette connected to this by a piece of tubing which passes through the cork of the flask. The complete reduction of the copper is known by the decolorization of the fluid. Ten c.c. of Pavy's solution are equivalent to 0-005 gram sugar (it is thus only one-tenth the strength of Fehling's). The Polarimeter may also be used for quantitative estimation of glucose ; but as the instrument is not likely to be available in ordinary medical practice, it will not be described here. II. — Diagnostic Importance of Glucose in the Urine. In the great majority of instances, if glycosuria persists for any length of time — e.g., if sugar is found in the urine at frequent examinations during six weeks or two months — the patient is suffering from some form of diabetes mellitus. Two main varieties may be distinguished : — 292 GLYCOSURIA 1. True or Acute Diabetes. — This occurs usually in youngish subjects ; the urine is largely increased in amount, and the condition is accompanied by muscular weakness, wasting, marked thirst, and increased appetite. The face may be flushed, and the tongue often looks large and deep-red in colour. The amount of sugar in the urine is but slightly influenced by diet. As the disease advances, acetone, diacetic acid, and oxybutyric acid make their appearance in the urine. (See Acetonuria.) The knee-jerks are lost. Death finally occurs, usually within two or three years of the occurrence of the first symptoms, in a condition of coma. It may be hastened by the supervention of acute pneumonia, or of a rapidly progressive tuberculosis of the lungs. 2. Chronic Glycosuria. — This occurs in elderly subjects, who are often obese, and may show gouty tendencies. The urine is not markedly increased in amount , and does not contain acetone bodies. The amount of sugar present is consider- ably reduced by strict dieting. There is no wasting, and little alteration of thirst or appetite. Forms of intermediate severity are met with, the rapidity of the progress of the disease diminishing somewhat as age advances. There are a few conditions associated with temporary glycosuria which have to be distinguished from true diabetes. The following are the most important : — 1. Cerebral Injuries, Haemorrhage, and Tumours may be associated with glycosuria. In the case of cerebral tumours the glycosuria may persist till death, and is by some writers described as diabetes due to this affection. It will usually, however, be associated with the cardinal signs of cerebral tumour — headache, vomiting, and optic neuritis. None of these are common in diabetes, though optic neuritis may occur. If a patient is seen for the first time during the coma which is caused by a cerebral haemorrhage or injury, the presence of glycosuria may lead to a mistake in diagnosis. It must be borne in mind that in diabetic coma there are usually acetone bodies present in the urine ; also that cerebral haemorrhage is most often seen in elderly subjects, diabetic coma in younger persons, and that the amount of sugar found in cases of cerebral disease is not as a rule large. 2. In Alcoholic Subjects considerable quantities of sugar may occur in the urine and persist for some weeks, and may yet disappear entirely on careful dieting and complete abstinence from alcoholic liquors. This condition may be due to disturbance of the pancreatic or hepatic functions by the poison, and may really be an early stage of true diabetes, which is amenable to treatment. It is well, therefore, not to make a diagnosis of incurable diabetes in an alcoholic subject until the effects of careful regime have been noted. 3. Pancreatic Disease, acute and chronic, may be accompanied by glycosuria. Pancreatic haemorrhage and acute pancreatitis are signalized by severe pain in the upper part of the abdomen, constipation, vomiting, and collapse — in short, by symptoms suggestive of acute intestinal obstruction. In only a minority of these cases does sugar appear in the urine ; when it does, it is an important aid in diagnosis of the affection present. In chronic pancreatitis — as also in some cases of gall-stones, in which this condition is probably present — glycosuria is encountered ; indeed, the condition may go on to true and fatal diabetes. Wast- ing, pigmentation of the skin, repeated rigors, and the passage of undigested meat-fibres and of an increased quantity of fat (especially neutral or unsplit fats) in the faeces, accompany this form oif pancreatic disease. Jaundice is often a marked symptom. 4. Other conditions in which small quantities of sugar may be found in the urine are Graves' Disease, Starvation, and so-called Alimentary Glycosuria, in which glucose is excreted after meals containing large quantities of this substance HMMA TEMESIS 29 3 or, more rarely, of starchy food. These conditions should not lead to difficulties of diagnosis. It is well to bear in mind that the onset of true diabetes may be signalized by the transitory appearance of glucose in the urine. This symptom may disappear once or twice, with or without special treatment, but may finally return and persist. This occurrence may be observed sometimes in connection with preg- nancy, sugar being found in the urine, or increased thirst and appetite noted along with polyuria, the patient subsequently regaining her health ; then, at a subsequent pregnancy, the symptoms may recur and persist. W. Cecil Bosanquet. GOITRE. — (See Thyroid Gland Enlargement.) GRINDING OF THE TEETH DURING SLEEP is a symptom which troubles the patient little, but may considerably disturb those who sleep with him. In itself it is, however, a symptom of little importance. It is popularly held that grinding of the teeth at night, especially in children, is an indication of the presence of intestinal worms, particularly of the Oxyuris vermicularis ; it would be well, therefore, to have the faeces examined in all cases of the kind, both for parasites and for their ova. The popular belief of the association of intestinal parasites with the teeth-grinding habit is seldom verified clinically, however, and the habit may be very bad and persistent in children, or even adults, who are in perfect health. Very often it is rather a rattUng of the upper teeth against the lower, owing to lateral movements made by the lower jaw as the patient, when half roused, turns over in bed ; actual gritting of the teeth during sleep is far less common. It is possible that in its beginning there was a gumboil or other local irritation which led to jaw-movements that persisted as habitual grinding of the teeth long after the primary cause was gone. Herbert French. GUMS, BLEEDING (See Bleeding Gums.) GUMS, RETRACTION OF.— (See Retraction of Gums.) GUMS, SPONGY.— (See Bleeding Gums.) HiEMATEMESIS. — This term indicates vomiting of blood. It has to be differentiated from haemoptysis, but the distinction is not difficult if the following points are remembered : — • In haematemesis the blood is vomited, and in consequence may be mixed with particles of partly-digested food ; it is usually dark in colour, but if the haemor- rhage is considerable, the blood may be bright red and liquid, or slightly altered in colour, and in clots ; if the haemorrhage has been gradual and the blood has remained for some time in the stomach, it becomes of a dark brownish colour, and has been likened in appearance to coffee grounds, the cause of this alteration being the action of the gastric juice, which converts the oxj^hsmoglobin into hasmatin ; it may be acid in reaction. In haemoptysis the blood is coughed up ; the first indication may be a tickling or gurgling sensation in the throat and a saltish taste in the mouth ; the amount of blood may vary from a few streaks to a pint or more ; it is bright red in colour, and often frothy from admixture with air ; it is usually liquid when expectorated, but it may coagulate in the vessel which receives it ; it is alkaline in reaction ; it may be mixed with sputum which may consist chiefly of mucus or muco-pus ; if the haemoptysis is very profuse, the blood may pour out of the mouth in a stream and rapidly prove fatal ; when haemoptysis has occurred, the sputum may be blood-stained for several days afterwards ; at first it is bright red, but subsequently becomes 294 HMMA TEMESIS darker and assumes a brownish, tinge. For a tabular summary of the points of distinction between hsematemesis and hEemoptysis see Hemoptysis. Having arrived at the conclusion that the patient is suffering from heemat- emesis, the next point is to determine the cause. Bleeding from the mouth and throat Malingering. Causes of Hematemesis A. Swallowed Blood. Epistaxis Haemoptysis B. Diseases of the (Esophagus : — Epithelioma Aortic aneurysm rupturing into the oesophagus Rupture of varicose oesophageal veins Mediastinal growth perforating the oesophagus and aorta Foreign body perforating the oesophagus and aorta. C. Diseases ol the Stomach : — Acute gastritis Chronic gastritis Toxic gastritis Corrosive poisons, such as strong acids or alkalies Gastrointestinal irritants, such as arsenic, phosphorus, anti- mony D. Diseases of the Duodenum : — Ulcer Pancreatico-duodenal fistula E. Portal Obstruction : — Cirrhosis of the liver Pylephlebitis (adhesive) Pressure on the portal veins Chronic heart and lung disease Some cases of enlarged spleen. Acute Febrile Diseases : — • Ulcer Gastrostaxis Haemorrhagic erosions Carcinoma Injuries Atheroma Abdominal aneurysm opening into the stomach. Gall-stone ulcerating denum quite rarely. into the duo- F. Dengue Cholera Acute yellow atrophy. Hodgkin's disease Chlorosis (?) Pernicious ansmia. Malignant variola Malignant scarlet fever Malaria Yellow fever Blood Diseases : — Purpura. Scurvy Haemophilia Leukaemia Miscellaneous : — Chronic Bright's disease Following abdominal operation. It may be said at once that there are only three common causes of profuse haematemesis, namely, gastrostaxis, gastric ulcer, and cirrhosis of the liver. The differential diagnosis between these is by no means always easy. The older the patient and the greater the history of alcoholism, the more likely is the symptom to be due to cirrhosis of the hver ; at this stage of the malady there may be neither jaundice nor ascites, but the liver may be felt enlarged and G. H. HMMA TEMESIS 295 unduly firm, and the spleen may also be palpable. Hasmatemesis in a young, ansemic woman is more likely to be due to gastrostaxis than to ulcer, whereas in older patients, especially in males, gastric or duodenal ulcer is the probable diagnosis if cirrhosis can be excluded. The distinction between gastrostaxis and gastric ulcer often becomes one of opinion only unless operation is resorted to. The longer the preceding history of gastric symptoms, and the more definitely localized the epigastric pains, the more likely does ulcer become. The diagnosis is often arrived at quickly enough, but sometimes a routine discussion of all the possible causes is required : so that we will take each of the above groups in turn. A. Swallowed Blood. Epistaxis. — If there is obvious bleeding from the nose as well as hsematemesis, the probability would be that some of the blood had trickled down the posterior nares into the pharynx, and had been swallowed and subsequently vomited. It should be remembered, however, that the two commonest causes of epistaxis in adults are cirrhosis of the liver and chronic interstitial nephritis, so that the possibility of bleeding having occurred from the stomach as well as from the nose would have to be considered. If a moderate degree of epistaxis has taken place during the night, blood may have been swallowed unconsciously. In some cases in which no blood has come from the anterior nares, examination may reveal blood trickling from the posterior nares, and the epistaxis may become evident if the patient blows his nose. HcBinoptysis. — When blood comes from the air-passages, some of it may flow back into the pharynx and be swallowed, especially if the haemorrhage occurs during sleep. If the patient has a cough, or expectorates blood-stained sputum and presents signs of chronic pulmonary disease, the possibility of swallowed blood must be considered as a cause of the hsematemesis, though difficulties may arise in forming a correct conclusion, for cirrhosis of the liver, for instance, is not infrequently complicated by phthisis, and so on. Bleeding from the Mouth and Throat.- — The gums, tongue, and fauces should be examined carefully, as blood from any of these sources may be swallowed and later vomited. Bleeding from the gums is most likely to occur when they are spongy, as in scurvy or mercurial stomatitis. Malingering. — The possibility of blood having been drunk in secret and afterwards vomited with intent to deceive must be considered in some cases when no cause can be found to account for its occurrence. Should fraud be suspected, it may generally be detected by careful observation. The red corpuscles should be examined microscopically in case the oval corpuscles of a bird may reveal their extraneous source. B. Diseases of the (Esophagus. Epithelioma. — Haemorrhage is rare in the commonest form of epithelioma of the oesophagus which leads to an annular stricture, but it may occur as the result of the ulcerative form of the disease from erosion of small blood-vessels, the amount of blood which is brought up being small. When the ulceration is deeper and more extensive, it may finally lead to perforation of a larger vessel, even the aorta, a condition which causes sudden, profuse, and rapidly fatal haemorrhage. The diagnosis of this cause does not, as a rule, give rise to much difficulty. Dysphagia is the earliest symptom in nearly all the cases, and it is generally progressive unless a good deal of ulceration occurs to re-open the passage. The first difficulty is in swallowing ordinary food, then soft food will not go down, and finally, as the growth closes up, even fluids are regurgitated as soon as an attempt is made to swallow. The food which is thus regurgitated may be tinged with blood. Rapid emaciation is associated with the dysphagia. 296 HMMATEMESIS the abdomen becomes flat and retracted, and in some cases hard and enlarged cervical glands may be felt. Pain may be felt at any attempt to take food, or it may be persistent and severe. One or other recurrent laryngeal nerve is involved in some cases, causing paresis or paralysis of the corresponding vocal cord. There may be some difficulty in differentiating this condition from an aneurysm of the aorta pressing on the oesophagus, and here the value of ;i^-rays in examining the chest is very great. Even without using any bougie, the fact, and the site of oesophageal stenosis can be demonstrated by watching the passage of capsules containing bismuth oxycarbonate, whilst an aortic aneurysm which obstructs the oesophagus is nearly always large enough to present a distinctive pulsatile ;r-ray shadow. Aneurysm of the Thoracic Aorta opening into the (Esophagus . — An aneurysm of the descending thoracic aorta compressing the oesophagus, may finally erode and open into it, with profuse and fatal haematemesis. Such cases may be very difficult to distinguish from epithelioma of the oesophagus, and the danger of passing a bougie is obvious. Hence the great value of the ;ir-rays, as mentioned just now. An aneurysm situated in such a position that it can exert pressure on the oesophagus, is more likely to give rise to subjective symptoms than to physical signs. Syphilis has such an important bearing on its causation that positive evidence of lues, especially if treatment has been insufficient, would be in favour of a diagnosis of aneurysm. Syphilitic stricture of the oesophagus may be disregarded, for there is no authentic case on record. Pain in the back is much more constant and severe in aneurysm than in epithelioma, and it is liable to sharp and paroxysmal exacerbations. The bulge is generally too far along the aorta to cause paralysis of the left vocal cord. Tracheal tugging will be absent, and the pulses and pupils equal. The presence of pulsation and a bruit in the back over the seat of pain, would of course point to an aneurysm, but these are very exceptional signs. The most common effect of aneurysm of the descending thoracic aorta is to obstruct the left main bronchus, and lead to pain in the left side of the thorax behind, with impairment of percussion note, together with crackling rales, and deficient voice sounds, vesicular murmur, and tactile vocal fremitus in the left lower lobe. These pulmonary effects of aneurysm in this part of the aorta should never be forgotten. Rupture of Varicose (Esophageal Veins. — Varicose veins occur in the lower end of the oesophagus as a result of portal obstruction, especially that form which is due to cirrhosis of the liver, and the rupture of such veins is often followed by profuse haematemesis. It is, however, practically impossible to determine whether the blood comes from the lower end of the oesophagus or from the stomach, so that the diagnosis resolves itself into one of cirrhosis of the liver. Mediastinal Growth perforating the (Esophagus and Aorta. — Hsmatemesis from this cause is exceptionally rare, for mediastinal growth is by no means a common disease, and vomiting of blood is an infrequent complication of it. Haemorrhage may occur, however, if the growth compresses and erodes the oesophagus. It is most likely to be mistaken for thoracic aneurysm or epithelioma of the oesophagus. The tendency of new growth to compress and invade the large veins, leading to oedema of the neck and upper extremities, cyanosis, and dilated superficial veins, is characteristic, and serves to distinguish it from aneurysm, in which severe venous obstruction is much rarer. The following case of mediastinal sarcoma perforating the oesophagus and aorta is an example of hsmatemesis from this cause : — Michael H., aged 30, was admitted for dyspnoea and pain in the chest. He had suffered from several attacks of what had been considered to be haemoptysis, similar to that of phthisis, the first occurring seven months before his admission. He was found to have impairment of note, with diminished breath-sounds, over the whole of the left H^MA TEMESIS 297 side of his cliest. About a month after his admission he suddenly brought up a large quantity- of blood, and died. At the post-mortem examination, the stomach and duodenum were full of blood. There was a large sarcomatous mediastinal growth, which had surrounded the lower end of the oesophagus, trachea, and aorta. The wall of the cBSophagus at the level of the bifurcation of the trachea had been destroyed, and the aorta was perforated at the origin of the left subclavian artery, so that a direct com- munication between the oesophagus and the aorta had been established. Foreign Body perforating the (Esophagus and Aorta. — Copious haemorrhage which may cause death may be produced as a result of a foreign body, such as a pin, fish-bone, or tooth-plate, perforating both the oesophagus and some large vessel, or even the aorta. A history of such a foreign body being swallowed, followed by a feeling of discomfort in the oesophagus, would suggest such a condition, which might be confirmed by the use of ;v-rays, bougies, or the oesophagoscope. C. Diseases of the Stomach. Acute Gastritis. — The mucous membrane of the stomach in this disease is congested, and small haemorrhages and erosions may be present. They can be seen clearly with the gastroscope. The haemorrhage which occurs is slight, in the form of streaks of blood mixed with mucus in the vomit, and it hardly merits the appellation haematemesis. Acute gastritis is caused most frequently by errors in diet, irritating or decomposing foods, alcohol, corrosive or irritant poisons, or sepsis from septic teeth, stomatitis, or pyorrhoea alveolaris. The chief symptoms are : a feeling of discomfort and tenderness in the epigastrium, nausea, eructations, vomiting, constipation ; and in children, diarrhoea, headache, a feeling of depression, furred tongue, foul breath, and concentrated urine. Chronic Gastritis. — The mucous membrane of the stomach may be thickened and congested with haemorrhagic erosions scattered over its surface. The vomit usually consists of a good deal of mucus, and occasionally a little blood. It may follow acute gastritis, but most frequently is caused by the continual and excessive ingestion of alcohol, tea, coffee, and irritating and indigestible articles of diet. The main symptoms are : Tenderness in the epigastrium aggravated by the taking of food, nausea, vomiting — especially in the early morning if due to alcohol — flatulence, foul breath, a furred tongue indented by the teeth at the edges, constipation, concentrated urine, and a slight degree of pyrexia. Toxic Gastritis due to Corrosive Poisons. — Strong acids or alkalies destroy the mucous membrane of the stomach as well as injure that of the mouth, throat, and oesophagus. More or less constant vomiting of blood and blood-stained mucus is one of the most prominent symptoms, and it may be associated with intense pain in the mouth, throat, and abdomen, dysphagia, pain and tenderness behind the lower end of the sternum or in the epigastrium, distention of the abdomen, collapse, and a rapid, feeble pulse. The urine may contain blood and albumin and, if the poison is oxalic acid, crystals of oxalate of lime. If corrosive poisoning is suspected, an inspection of the mouth and pharynx will show signs of corrosion, and an examination of the vomit will furnish evidence of the nature of the poison. Arsenic. — The mucous membrane of the stomach is red, inflamed, partly detached, and covered with blood-stained mucus. The chief symptoms are nausea, violent and incessant sickness, burning pain in the epigastrium, diarrhoea, faintness, and depression. The vomit is usually a brownish, turbid fluid, mixed with mucus and streaks of blood. Later, there may be severe diarrhoea, with rice-water stools. Arsenic may be detected in the vomit. Phosphorus, antimony , and other irritant poisons may also cause inflammation of the mucous membrane of the stomach, and lead to slight haematemesis. 298 h.t:ma temesis Gastric Ulcer. — Haematemesis is the most important sj-mptom of gastric ulcer, though it occurs in only about 50 per cent of the cases both in the acute and chronic forms of the disease, in the former being due to the erosion of small vessels, and in the latter to the ulcerative process extending to and opening up larger gastric vessels, and occasionally even the pancreatic or splenic artery. The amount of blood varies within wide limits. If the quantit}^ is small, or if it is graduall}^ poured out into the stomach, it may remain there a sufficient time for the acid gastric juice to act on it and convert the hsemoglobin into hsmatin, a condition which gives to the vomit the characteristic dark-brown coffee-grounds " appearance. In some cases the blood is not vomited but appears in the stools as melaena. If a medium or large vessel is eroded, the bleeding may be very copious, a quart or more of blood being vomited, either liquid and arterial in colour or in large red clots. A profuse haemorrhage causes sudden pallor, a feeling of faintness, restlessness, syncope, and a rapid, feeble pulse. It is rarely fatal unless a large vessel such as the splenic artery has been eroded. Occasionally, haematemesis is the first intimation of the presence of a gastric ulcer, but in the majority of cases there are other symptoms and signs which have preceded it. Clinically it is a disease which was formerly said to occur most frequently in females, especially of the servant class, between the ages of twent}^ and thirty, though not a few cases diagnosed as gastric ulcer are probably examples of gastrostaxis, or bleeding from a spongy, oozing mucosa, without any definite and macroscopic ulceration. An analysis of loi fatal cases showed 59 males and 42 females. Like duodenal ulcer, it seems to be commoner in the North of England than in the South, and in mining and manufacturing rather than in rural districts. In addition to haemat- emesis, the signs most characteristic of gastric ulcer are abdominal pain, nausea, vomiting, and melaena. Pain is felt in the epigastrium just below the ensiform cartilage ; it usually begins a few minutes after the ingestion of food, but in some cases is not experienced until an hour or two afterwards. Pain may also be felt in the back, between the tenth dorsal and first lumbar spines. Its character and intensity are very variable, but it is usually severe. Hyperaesthesia of the skin and tenderness on pressure in the epigastrium may also be present. Vomiting may come on immediately after food is taken, or may be deferred for an hour or two, being preceded usually by a good deal of pain. The vomit has a very acid taste and an abnormally acid reaction. Melaena follows haematemesis ; occasionally it may precede it, and rarely occurs independently. The tongue in the majority of cases is clean, red, nioist, and steady'. Hffimatemesis from this cause is sometimes difficult to differentiate from that due to cirrhosis of the liver or carcinoma of the stomach. There is more or less anaemia ; the points of distinction between gastric ulcer and anaemic vomiting are discussed on page 40. Gastrostaxis (see Anjemia, p. 40). HcBmorrhagic erosions are probabty the earliest stage of gastric ulcer, though they may not develop bej^ond the phase of minute erosions. They may be the actual cause of gastrostaxis, and perhaps the distinctions between gastrostaxis, haemorrhagic erosions, and multiple small gastric ulcers are differences of degree and not of kind. There are certain conditions, however, especially acute malignant fevers, purpura, infective endocarditis, and similar septic states, in which a general tendency to subcutaneous and submucous haemorrhages leads to multiple small gastric erosions, which produce haematemesis, without being directl}- related to ordinary gastric ulcer. Carcinoma. — Haematemesis is a less frequent and important sign of carcinoma of the stomach than of gastric ulcer, for it occurs in but a little over 20 per cent of the cases, and even then is generally slight. Bright-red blood is rarely H.EM A TEMESIS 299 seen in the vomit, for the slow ooze from the ulcerated surface of the growth allows the blood to remain in contact with the gastric juice and develop the so-called " coffee-grounds " appearance. About 60 per cent of the cases occur between the ages of forty and sixty. The chief symptoms and signs of the disease are : pain in the epigastric region, nausea, vomiting, anorexia, loss of weight and strength, pyrexia, anasmia, cachexia, and the presence of an abdom- inal tumour. Pain is one of the earliest symptoms, but it varies considerably in degree and position. It is most frequently referred to the epigastrium, but is not as a rule so severe as in gastric ulcer. ' Vomiting is another early symptom which varies in frequency and character according to the position of the growth. When the pylorus is involved and stenosed, the stomach dilates and a large quantity of frothy, brownish vomit is evacuated every two or three days ; in cases of diffuse carcinoma the capacity of the stomach is diminished, and a small quantity may be vomited two or three times a day ; when the growth is situated at the cardiac orifice, the symptoms resemble those of epithelioma of the oesophagus, and the food immediately after swallowing is regurgitated rather than vomited ; whilst in cases of growth which involve neither of the orifices of the stomach, there may be no vomiting, or if present it may have no special characteristics, the symptoms being mainly those of dyspepsia or gastritis. A chemical analysis of the vomit may show deficiency of hydrochloric acid and the presence of lactic acid ; but the value of this test is limited. The growth may be seen with the aid of the gastro- scope. The loss of weight and strength are usually progressive, and they are amongst the most constant and characteristic signs of the disease. Anaemia of the secondary chlorotic type with a low colour-index may be so prominent a sym- ptom that a primary anaemia may be suspected until a careful blood examination has been made. A very careful investigation of the abdomen must be made, for in about 70 per cent of the cases a tumour may be felt, though it is to be hoped that the gastroscope will lead to the diagnosis of carcinoma ventriculi before this stage is reached, and when surgical cure is still possible. The position and character of the tumour vary according to the part of the stomach which is involved. Pyloric growth may cause the abdomen to be distended as a result of gastric dilatation, and a movable tumour may be felt above the umbilicus, near the middle line and to the right of it. When the cardiac orifice is in- volved, there may be no tumour to be felt and the same applies to the small " indiarubber-bottle " stomach of diffuse carcinoma ventriculi. Tumours of the body of the stomach may be felt in the epigastrium, or below the left costal margin. Injuries. — Haematemesis may follow blows, stabs, or gunshot wounds in the epigastric region, or the passage of instruments or foreign bodies, such as a broken thermometer, into the stomach. The history and the evidence of any such occurrence would make the diagnosis sufficiently obvious. Atheroma in association with arteriosclerosis, or granular kidney and high blood-pressure, may lead to haematemesis in very exceptional cases by causing weakness and rupture of small gastric vessels. Such a diagnosis should be made with extreme caution, even when other symptoms and signs of atheroma are present, for haematemesis as the direct result either of heart disease, lung disease, Bright's disease, or affections of the blood-vessels, is exceedingly rare. Abdominal Aneurysm opening into the Stomach. — Aneurysm of the abdominal aorta is uncommon. The sac may rupture into the stomach, however, and lead to a sudden, profuse, and fatal attack of haematemesis. The chief diagnostic signs are : an abdominal tumour, with distinct expansile pulsation and severe pain, both in the abdomen and in the back, over the site of the bulge in a 300 HmMA TEMESIS patient who has suffered from syphihs and has been accustomed to repeated and violent muscular exertion. D. Diseases of the Duodenum. Duodenal Ulcer. — Hsematemesis is caused in the same manner in this disease as in gastric ulcer, viz., by the erosion of small duodenal blood-vessels or by the ulcerative process spreading to and opening larger and deeper blood-vessels outside. The ulcers are in the first part of the duodenum in a very large proportion of cases. They are about eight times as common in men as in women. Some of the symptoms are similar to those of gastric ulcer, viz., hsematemesis, melaena, abdominal pain and tenderness, anaemia, and vomiting. Hsematemesis, however, is not so frequent as it is in gastric ulcer ; it is generally less marked than is the melsena, and the latter may occur independently of hcematemesis or before it. In the acute form of the disease, there may be a copious intestinal haemorrhage in an apparently healthy person, accompanied by acute pallor and followed by the evacuation of a mixture of black altered blood and bright arterial blood from the rectum. The more the bleeding, the greater the tendency for the blood passed to be still bright red. There may be no pain at all, but more often it is considerable ; it is deep-seated in the' upper part of the abdomen, below the tip of the ninth right rib, more to the right of the middle line than is that of gastric ulcer, and usually its onset is two or three hours after the ingestion of food. One point about this pain that is almost pathognomonic is the way in which, coming on when the patient is beginning to get hungry — " hunger pain " — it is often entirely reheved by taking food. Vomiting is another important symptom which may be very troublesome, though in some cases it is entirely absent. Gall-stones Ulcerating through from the Gall-bladder into the Duodenum. — • Haemorrhage may occur if a large gall-stone ulcerates through from the gall- bladder into the duodenum, and may cause haematemesis and melaena. Previous attacks of pain occasioned by the gall-stone might lead to a diagnosis of gastric or duodenal ulcer ; but if the pain was colicky in character and was associated with tenderness and enlargement of the liver, pain over the gall-bladder, and jaundice, it would point to the presence of a gall-stone. The diagnosis might be confirmed by the discovery of the stone in the faeces, or, in the case of a larger calculus, by the occurrence of acute intestinal obstruction frora its impaction in the small intestine. As a cause of haematemesis, this condition is naturally very rare. E. Portal Obstruction. As a result of obstruction to the fiow of blood through the portal system of veins, passive congestion and haemorrhagic erosion of the mucous membrane of the stomach and varicose gastric and oesophageal veins may be produced. Haematemesis may then arise through oozing of blood from the congested mucous membrane or from an actual escape of blood in the case of haemorrhagic erosion or the rupture of one of the varicose veins. The signs which are common to portal obstruction in addition to haematemesis are : nausea, vomiting, ascites, oedema of the legs, albuminuria, and the presence of dilated and tortuous superficial abdominal veins ; the chief cause is : — Cirrhosis of the Liver. — This disease is one of the commonest and most important causes of profuse haematemesis, and it is often difficult to diagnose from gastric ulcer or carcinoma of the stomach. Haematemesis may be one of the earliest symptoms, and it is frequently profuse and very liable to recur, though it is seldom fatal. There may be a history and the signs and symptoms of chronic alcoholism : morning sickness, loss of appetite, especially for break- fast, epistaxis, melaena, cramps in the legs at night, bottle-nose, dilated stellate HMMATEMESIS 301 venules on the cheeks, ascites, jaundice, dilated and tortuous superficial abdom- inal veins. The liver may be enlarged, its surface being rough and hard, and its edges irregular and beaded. The spleen may be enlarged as a result of the portal obstruction, but in adults rarely attains to such an enormous size as it does in the splenomegalic variety of cirrhosis in children and young adults. In distinguishing this disease from carcinoma of the stomach, it is very important to determine, if possible, the absence of a stomach tumour and of large nodules projecting from the surface of the liver. Adhesive Pylephlebitis. — Non- suppurative thrombosis of the portal vein is a very rare condition, and it is difficult to diagnose. It may, however, give rise to sudden and profuse heematemesis. It is distinguished from other forms of portal obstruction by the relatively sudden onset of ascites, hsematemesis, melasna, and enlargement of the spleen, and by an absence of signs and sym- ptoms of cirrhosis of the liver and other causes of portal obstruction. Pressure on the Portal Vein. — Hcematemesis, when due to this cause, is generally associated with ascites and intense jaundice, since the common bile- duct is liable to be compressed as well as the portal vein on account of their close proximity to each other. (See Jaundice.) Some cases of Enlarged Spleen. — Hsmatemesis is a fairly common symptom in cases of enlarged spleen, even when the enlargement is not associated with cirrhosis of the hver or leukaemia. Osier explains the occurrence as being due to the " intimate relation between the vasa brevia and the splenic circulation." (See Spleen, Enlargement of.) F. Acute Febrile Diseases. Malignant Variola. — Haematemesis occurs in about a third of the cases of hasmorrhagic small-pox. It is associated with cutaneous, subcutaneous, and submucous hemorrhages, hasmaturia, epistaxis, melaena, and bleeding from the gums. The sudden initial rigor, intense backache and headache, severe vomiting, epigastric pain, cutaneous haemorrhages, and the diffuse hypercemic rash with small punctiform haemorrhages which appears first in the groins and lower part of the abdomen, would point to a diagnosis of hasmorrhagic or black small-pox, if such a case occurred during an epidemic of the disease. Malignant Scarlet Fever. — In the hjemorrhagic form of scarlet fever, haemat- emesis may occur ; but haematuria, epistaxis, and cutaneous haemorrhages are more frequent. The sudden and severe onset, the very high temperature, the extremely rapid and feeble pulse, headache, deUrium, and the appearance of the characteristic rash on the second day, would point to scarlet fever. Yellow Fever. — " Black vomit" due to the presence of altered blood is one of the most characteristic features of this disease. Hyperaemia and catarrhal swelhng of the mucous membrane is the only change which is found in the stomach. It is essentially a disease of tropical and sub-tropical countries. The onset is sudden, with a chill, headache, and severe pain in the back and Limbs. The face is flushed, and very soon jaundice appears. After the first day the pulse-rate drops, so that with a temperature of 103° F. or 104° F. the pulse may be only 70 or 80. Albuminuria is another early symptom which may appear on the third day. In addition to the black vomit, there may be cutaneous petechiae and bleeding from the gums. It is often difficult to distinguish from malignant malaria, though, in the early stages in malaria, jaundice, albuminuria and haematuria are extremely rare, whilst an examination of the blood may reveal the presence of malarial parasites. Cholera may be associated with haematemesis sometimes. The sudden onset of acute gastrointestinal symptoms, the rapidly repeated rice-water stools, and the epidemic nature of the maladv, all point to the diagnosis, which may be confirmed by recovering the vibrio from the motions bacteriologically. 302 H^MA TEMESIS Acute Yellow Atrophy of the Liver. — HEematemesis is the commonest form of haemorrhage in this rare disease. Women between twenty and thirty are affected more frequently than men, especially during and just after pregnancy. It sometimes follows fright and mental emotion. The first symptoms are indistinguishable from catarrhal jaundice, viz., malaise, loss of appetite, nausea, vomiting, and jaundice. The vomiting soon becomes intractable, the jaundice increases, and drowsiness, restlessness, and delirium supervene. The vomit is black, and ma}^ resemble treacle, its appearance being due to altered blood. Melgena, epistaxis, and subcutaneous petechise may be noticed. The tongue becomes dry and brown, the liver dullness diminishes, the urine shows characteristic changes in the marked diminution in the amount of urea and the presence of bile pigment, whilst leucin and tyrosin crystals in it are an important diagnostic sign of this disease. G. Blood Diseases. Purpura HcBmorrhagica. — Hsemorrhage from the stomach is rare in this disease. Hsematemesis may occur, however, as a result of blood derived from the mucous membrane of the nose or mouth being swallowed. As purpura is a symptom rather than a disease in the majority of cases, before making a diagnosis of purpura hsemorrhagica or idiopathica, those diseases which lead to symptomatic purpura must be excluded first. In scurvy, the spongy gums, the distribution of the cutaneous haemorrhages around the hair sacs, and the anaemia and debility, which are out of proportion to the loss of blood, are characteristic diagnostic points. The possibility of an acute specific fever may be excluded by the absence of an acute onset of a high temperature. An examination of the blood must also be made, to exclude pernicious anaemia and leukaemia ; and blood cultures may be required. (See Anemia ; and Purpura.) Scurvy. — Haematemesis is uncommon, only occurring in severe and well- marked cases, so that the diagnosis is not difficult. The swollen and spongy gums, anaemia, cutaneous haemorrhages around the hair sacs, and subcutaneous indurations, in a patient who is found to have been living on a diet deficient in quantity and in vegetables, would point to scurvy. HcBmophilia — Out of 334 cases analyzed by Grandidier, there were only fifteen examples of haemorrhage from the stomach. Epistaxis, bleeding from the mouth, and haemorrhage into the joints are the earliest and the coramonest manifestations of the disease. The association of haematemesis with hemor- rhage from other parts, and with haemorrhage into joints in particular, in a patient whose near male relations show a tendency to bleed on the shghtest provocation, would point to haemophilia. There are no pathognomonic blood changes. Leukczmia. — Haemorrhages from and into various parts, especially epistaxis, are common in this disease. Haematemesis may be the actual cause of death. Its association with enormous enlargement of the spleen is by no means pathognomonic of leukaemia, for the two conditions may be present in chronic malaria, splenic anaemia, and splenomegalic cirrhosis. An accurate diagnosis cannot be made until the blood has been examined and a high degree of leucocytosis found (100,000 to 1,000,000 white blood corpuscles per c. mm.), with a large proportion of myelocytes in the case of spleno-medullary leukaemia and a high percentage of lymphocytes (90 per cent) in lymphatic leukaemia. Hodgkin's Disease. — In the late stages of this disease there is a tendency to haemorrhage from and into various parts of the body, e.g., epistaxis, bleeding from the mouth, cerebral haemorrhage, and rarely haematemesis. There should be little difficulty in making a diagnosis, as haematemesis would be a late HMMA TEMESIS 303 symptom, the characteristic features of the disease consisting of enlargement of the glands — especially the cervical group, enlargement of the liver and spleen, with progressive and ultimately severe anaemia of simple chlorotic type, except for the occurrence of occasional myelocytes and basophile corpuscles in blood films. The disease may prove fatal in a few weeks or months, but the patient often survives for several years. Chlorosis. — It is difficult to determine whether hasmatemesis occurring in an anaemic woman under thirty, is due to gastric ulcer or to gastrostaxis (p. 40). That chlorosis has something to do with heematemesis, apart from the formation of macroscopic ulcers, is probable ; it is also probable that chlorosis predisposes to gastric ulcer. The precise nature of the symptom in a chlorotic girl is very difficult to determine therefore, some observers diagnosing gastric ulcer where others prefer to label the condition gastrostaxis. The former withhold solid food longer than the latter, and are perhaps inclined to recommend operation more readily ; these are the main grounds for striving to draw a clear distinction between the two conditions. Young women suffering from chlorosis are usually well nourished. The skin may have a greenish tinge and the sclerotics a distinct bluish appearance. (Edema of the feet, dyspnoea, palpitation, and amenorrhcea are prominent symptoms ; but the diagnosis cannot be made with any certainty imtil the blood has been examined. It is pale and thin ; the red blood-corpuscles are reduced in number, but rarely are under 3,000,000 per c. mm., the average size of the red blood-corpuscles is below normal, the haemoglobin is reduced much more in proportion than are the red blood-corpuscles, so that the colour- index is low, being as a rule about 0-5 or under ; the white blood-corpuscles are not increased, and the differential leucocyte count is almost normal. Seeing that amenorrhcea and hasmatemesis are both liable to occur in anaemic girls, the gastric haemorrhage has sometimes been regarded as vicarious menstruation ; there is little evidence to support this view of its pathology, however, and when the bleedings recur, the attacks do not show any kind of monthly regularity. Pernicious AncBmia. — Hasmatemesis is a very rare symptom in pernicious anaemia ; when it occurs, the difficulty in distinguishing between this disease and carcinoma of the stomach is much increased. A correct diagnosis cannot be made until the blood has been examined. A great diminution in the number of red blood-corpuscles to 1,000,000 or less per c. mm. — the haemoglobin being also reduced, but not in proportion to the red blood-corpuscles, so that the colour index is high — an increase in the average size of the red blood-corpuscles, and the presence of megaloblasts, would point to pernicious anaemia. The urine contains pathological urobihn. Malarial Cachexia. — Anasmia and enlargement of the spleen may follow repeated attacks of malaria, and severe haematemesis may be a prominent symptom. In making the diagnosis, the history of residence abroad, of attacks of ague, and the condition of the blood, must be relied on. A normal or a diminished number of leucocytes, with a relative increase in the large mono- nuclear cells beyond 15 per cent, is strong presumptive evidence of a previous malarial infection. H. Miscellaneous. Chronic Interstitial Nephritis. — Haematemesis occasionally, but very rarely, occurs in this disease. Its association with anasmia, thickened and tortuous superficial arteries, high-tension pulse, hypertrophy of the heart, albuminuric retinitis, polyuria, and urine of low specific gravity containing a variable quantity of albumin and renal tube-casts, would point to chronic interstitial 304 HMMA TEMESIS nephritis as the cause. It is most important that the blood-pressure should be measured instrumentallyj and not guessed at by palpation. Following Abdominal Operations. — Hsematemesis may occur after severe abdominal operations, independently of any injury to the stomach or duodenum. Should death occur, no obvious lesion can be found in the stomach to account for it in the majority of cases. The reason of the occurrence of such an alarming symptom remains a mystery in many cases, but in some infective conditions, such as appendicitis, multiple minute ulcers have been found. Herbert French. H.ff:MATOPORPHYRINURIA.^(See Urine, Abnormal Coloration of.) H.ffiMATURIA. — Blood may appear in the urine as the result of traumatism, of disease in some portion of the urinary tract, or of other organs involving the urinary apparatus, and in a few general diseases of other parts of the body. The blood may be present in large, small, or microscopic amounts, it may continue for days or even weeks together, or may appear suddenly and without apparent cause, and disappear completely for a variable period. Further, it may be present in the urine either as corpuscles or as haemoglobin, and it is necessary to distinguish between the two conditions. In hsemoglobinuria the urine is dark brown from the presence of methaemoglobin, and any deposit is found to consist of brownish debris (see HyEMOGLOBiNURiA). Occasionally the colouring matter of the blood may escape from the corpuscles if the stained urine has been retained for any length of time in the bladder, when crenated or disintegrated corpuscles will be found on microscopic examination of the sediment from a specimen. The following list gives the chief causes of heematuria : — i. h.^maturia from affection of some part of the Urinary Organs. A. Renal Causes. Profuse. Malignant tumours of the kidney : Nephroma Embryoma Carcinoma Sarcoma Innocent tumours — papilloma of pelvis Injuries of the kidney Calculus Tuberculosis B. Ureteric Causes — Calculus in the ureter. C. Vesical Causes. Profuse. Villous tumour Papilloma Villus-covered carcinoma Prostatic adenoma or car- cinoma Slight. Calculus Tuberculosis Renal mobility Hydronephrosis Polycystic disease Traumatism Oxaluria Nephritis, acute and subacute Drugs : turpentine, carbolic acid, cantharides Slight. Epithelioma Tuberculosis Calculus Acute cystitis Bilharzia hsematobia Traumatism D. Urethral Causes Acute urethritis. Impaction of calculus, Traumatism HEMATURIA 305 II. HvEMATURIA FROM DISEASE OF THE NEIGHBOURING VlSCERA INVOLVING THE URINARY ORGANS. Carcinoma of the uterus, vagina, or rectum Acute appendicitis Acute salpingitis Pelvic abscess Dysenteric or tuberculous ulceration of the intestine III. — HEMATURIA IN General Diseases. Renal infarction in endocarditis Arteriosclerosis Leukaemia Purpura and scurvy Haemophilia Acute fevers, malaria, small-pox, and yellow fever In considering the diagnosis of a case presenting haematuria as a symptom, it is seldom that there are not other symptoms present, such as pain, tumour, or increased frequency of micturition, which will point to one or other organ as the source of the bleeding ; but in some cases haematuria may be the only symptom. The following points will often help in the differential diagnosis : — The Colour of the Urine. — If the urine is stained a bright red colour, the haemorrhage is most likely to arise from the bladder or lower urinary tract. Dark-coloured blood in the urine may, however, be due to the retention of blood in the bladder for some time, or from the large amount present in the urine. The Distribution of the Blood in the Urine during Micturition. — If the urine during micturition is only tinged with blood during the final expulsive efforts, or if the terminal urine is stained more deeply than the rest, the source of the haematuria is almost certainly in the bladder. If the first urine passed is blood- stained and the remainder clear, the bleeding is probably from the urethra or prostate, whereas if the urine is evenly stained with blood throughout, it suggests that the source of haemorrhage is in the kidneys, although a vesical lesion which causes more than a slight haemorrhage may also give rise to a deeply blood-stained urine throughout micturition. The Quantity of Blood Present in the Urine. — The passage of a large quantity of blood in the urine, in the absence of traumatism, is always suggestive of some form of growth in the bladder or kidney. Papillomata and villus-covered carcinomata in the bladder may cause sudden profuse haemorrhage without pain or other symptom, whilst equally profuse haemorrhage may arise from a malignant tumour in the kidney which has invaded the renal pelvis. The examination of any clots of blood passed in the urine may occasionally afford useful information in the determination of the seat of haemorrhage. The urine should be poured into a large fiat tray containing water, and the clots floated out, when some may show the triangular or pyramidal shape indicating their formation in the renal pelvis, or others the thin, worm-like form with tapering or decolorized ends from their formation in the ureter. Any clots formed in the bladder are of flat, disc-like character, and are often broken up in their passage through the urethra. The pyramidal or vermicular clots are distinctive of renal haemorrhage, and their passage down the ureter is accompanied by the same acute renal colic that is caused by renal calculus. If the quantity of blood is increased by movement or exercise, suspicion of renal stone or growth will arise. In a recent case, profuse haematuria occurred after three successive railway journeys, when the lesion found at operation was an early carcinoma of one kidney which had recently invaded the renal pelvis. D 20 306 HEMATURIA The Association of other Elements from the Urinary Organs with Blood in the Urine. — Microscopical examinatioo of the deposit obtained by centrifuging a specimen of urine may reveal cellular elements distinctive of the renal pelvis or vesical mucous membrane or epithelial, granular, and blood-casts from the renal tubules [Plate I.), which may help in the diagnosis in a case of haematuria. The presence of a number of urinary crystals in a urine of acid reaction will point to renal calculus. Occasionally, small pieces of growth may be passed in the urine from the delicate villous papilloma or villus-covered carcinoma of the bladder, and more rarely may be found plugs of muco-pus from a caseous tuberculous cavity in the kidney. The association of pus with blood in the urine does not give much assistance in the determination of the seat of the bleeding. Both pus and blood will often be present in either calculus or tuberculosis of the kidney or bladder, and may both be present with vesical growth or with prostatic enlargement. The Amount of Albumin. — If the amount of albumin in the urine is in excess of that which would be due to the amount of blood present, the bleeding is probably renal in origin. The Reaction of the Urine is of very slight assistance in the determination of the source of bleeding in a case of hsematuria. It may be stated in a general sense, that blood in an acid urine is more likely to be derived from the kidney than from the bladder. This, however, is liable to be misleading, for blood may be present in an acid urine in a case of vesical calculus or growth, whereas, on the other hand, there may be blood in alkaline urine in a case of renal calculus as well as in pathological conditions of the bladder. The association of unilateral lumbar pain, situated in the angle between the last rib and the border of the erector spinae muscle, passing forwards above the iliac crest into the groin, with occasional attacks of colic, would suggest a renal lesion, whilst haematuria, accompanied by increased frequency of mic- turition or by penile pain immediately following micturition, would indicate vesical disease. Equally important is it to take into consideration the age of the patient ; thus, in a young adult, continued slight haematuria with increased frequency of micturition are highly suggestive of tuberculous disease of the bladder or kidney, whereas slight haematuria in a more elderly patient suggests vesical carcinoma or calculus. At any age, severe haematuria may be present with a villous tumour of the bladder, or in a patient more advanced in years, with renal growth or prostatic enlargement. Further evidence of the source of the haemorrhage may be obtained upon the physical examination of the patient. This should be carried out systemati- cally, and not only should the urinary organs be examined, but any evidence of disease elsewhere in the body, as in the heart, lungs, blood, liver, or pelvic organs, sought for. Each kidney should be examined bimanually, one hand being placed in the angle made by the last rib and the margin of the erector spinae muscle, and the other in front, immediately below the costal margin ; the patient is then directed to breathe deeply whilst pressure is maintained by the two hands, when an enlarged or unduly mobile kidney may be felt to descend, or may be grasped on deep inspiration. Any pain or undue tenderness on either side should be noted, especially any sharp, pricking pain experienced by the patient if the anterior hand be suddenly depressed, a sign which is said by Jordan Lloyd to be indicative of renal stone. Examination of the bladder by palpation in the suprapubic area may elicit pain in acute inflammatory conditions, or may give evidence of a distended bladder in a case of haematuria from prostatic obstruction ; but much more knowledge may be gained by a thorough rectal examination. For this purpose the patient should assume the knee-elbow position, when the examining finger can explore not HEMATURIA 307 only the prostate, but the vesiculae seminales, the lower end of each ureter, and the bladder base, as well as the lateral pelvic wall. The prostate may show adenomatous enlargement, or may be infiltrated with primary carcinoma — which has recently been shown to be far from uncommon, — when the gland will present marked, firm, rounded nodules, and will often be immovable. Search should be made for any nodules in the prostate or vesicles, or of thickening of the lower end of the ureter, suggestive of tuberculous disease, or of thickening or infiltration in the bladder base, which may often be felt in a case of vesical carcinoma. Examination in the lateral pelvic space may show infiltration of the pelvic lymphatics, or enlargement of the lymphatic glands in a case of carcinoma of the bladder or prostate. Examination of the testes should always be made. A nodule in either epididymis may be evidence of tuberculous disease, which mav have spread to the urinary organs, but care must be taken not to mistake a nodule dating from a gonorrhoeal epididymitis for one due to tuberculous disease. Great assistance may be obtained by the use of the cystoscope {Plates V and VI). Needless to say, the greatest gentleness must be used in carrying out any instrumentation^ to avoid any further haemorrhage, which would obscure a view by the cystoscope, and if any bleeding is present, an attempt should be made to arrest it by irrigation of the bladder with silver nitrate i-iooo, or with adrenalin solution of the same strength. If the bleeding is profuse, it is probablv impossible to obtain a satisfactory view of the interior of the bladder, but with even moderate haemorrhage going on, a rapid distention of the bladder may produce a medium clear enough to obtain a view which will show the seat of haemorrhage. Thus in renal haematuria blood-stained urine may be seen to be emitted from one ureteric orifice {Plate V, Fig. A) and clear urine from the other before the medium is too obscured ; or with vesical haemorrhage a vesical tumour may be seen. Even slight haemorrhage will, however, rapidly render the medium in the bladder too hazy to obtain a satisfactory examina- tion of any minute changes in the vesical wall, such as tuberculous disease. Hence it is better, if possible, to undertake any cystoscopic examination in the interval between attacks of bleeding, when the bladder can be thoroughly examined and any pathological lesion found. If no evidence is obtained in this way, a further examination may be conducted during an attack of bleeding. ft remains to consider the main causes of haematuria. I. H.^MATURIA FROM AFFECTION OF SoME PaRT OF THE URINARY TRACT. A . Renal Causes. The Malignant Tutnours of the Kidney, nephroma, embryoma, carcinoma, and sarcoma, are all associated with profuse haematuria at intervals. The nephro- mata are the most common ; they arise in the adrenal rests found in the cortical portions of the kidney, and are of comparatively slow growth. The embrvomata may occur in small children or in elderly persons, whilst the true carcincmata and sarcomata are much more uncommon. These tumours cause an aching in the loin, and may lead to considerable enlargement of the kidney before any haematuria occurs. In the progressive grow^th of the tumour, the renal pelvis is gradually involved and haematuria is evoked. This is usually severe in t^^e, so that clots may be formed in the calyces of the renal pelvis or in the ureter and cause the typical pain of renal colic in their descent of the latter. The renal tumour usually maintains the shape of the kidney, but in some cases may present a nodular form. Hence profuse haematuria, wath clots of pyramidal or worm-like shape, associated with renal enlargement, is strongly suggestive of renal malignant growths. 3o8 ' HEMATURIA The only common form of innocent tumour in the kidney is that of a papilloma of the renal pelvis. This gives rise to profuse hsematuria and to renal enlarge- ment, which in this instance is due to hydro- or haemato-nephrosis from the obstruction to the ureter by the papillary growth or by blood-clot. Thus the renal tumour may be variable in size. Papillomata of the mucous membrane of the renal pelvis are occasionally accompanied by similar growths in the ureter, and may also show a similar growth at the ureteric orifice upon inspection of the bladder. Injuries to the Kidney may cause haematuria ; the diagnosis is usually obvious. The history of the accident, of a blow or squeeze applied to the lumbar region, associated with haematuria, would point to an injury to the kidney. There may be renal enlargement, but this must be diagnosed from an extravasation of blood in the perinephric tissues from the rupture of the renal cortex. Com- paratively slight injury to the loin may produce haematuria from a small lesion in the renal tissues, whilst in some cases there is no sign or recollection of external violence. In any case of haematuria following traumatism, it is essential to diagnose an injury to the kidney from injury to the urethra or bladder. In urethral injury the tube may be merely contused, or partially or wholl}^ ruptured ; blood may be found at the urethral meatus or may be marked in the first portion of any urine that may be passed, whilst if the urethra be entirely divided, signs of commencing extravasation of urine, with inability to micturate, will appear. DESCRIPTION OF PLATE V. Bladder Appearances seen through the Cystoscope. Fig. A. — Blood-stained urine issuing from the ureter. Fig. B. — Purulent urine issuing from the ureter. Fig. C— Congestion around a ureteric orifice in calculous pyelitis Fig. D. — The retracted ureter common with descending renal tuberculosis. Fig. E. — Tuberculous ulceration around the ureteric orifice in descending renal tuberculosis. Fig-s. D and E are from sketches kindlv supplied by Dr. C. F. Walters, pf Clifton. If the bladder be injured, blood may be present in any urine drawn off ; or in a rupture of the bladder involving the peritoneal coat fluid may be found in the abdominal cavity. The length of time between the last passage of urine and the occurrence of the accident should be ascertained, and a catheter passed ; very gentle irrigation of the bladder with sterile fluid should be carried out in any suspected rupture of the viscus, to see if the amount of fluid run into the bladder is duly returned. At the same time, a thorough examination should be made of the bony pelvis for any sign of fracture, which is frequently the cause of direct injury to the bladder or urethra. In Renal Calculus the bleeding is seldom profuse, is usually associated with a small amount of pus, and frequently is increased after any exertion or by the jolting of a journey. The subject of a renal stone will usually complain of pain in one loin of a constant aching character, which will remain of this character so long as the stone remains embedded in the renal tissues, in which condition slight haematuria is often present. When, however, the calculus pro- jects into or is free in the renal pelvis, the urine also contains a small quantity of pus, and attacks of renal colic come on, characterized by very acute pain in the loin, passing forwards and downwards to the groin, upper part of the thigh, and testicle of the same side, and accompanied by frequent desire to pass urine. The calculus may be passed into the bladder along the ureter, may become impacted in the course of the ureter, or may remain in the renal pelvis, in which case successive attacks of renal colic may occur. The previous passage PL A TE V. BLADDER APPEARANCES SEEN THROUGH THE CYSTOSCOPE Fig. D. Cojiyriglit Fig. E. ]l'. Thornton Shiells, del. l.NDE.V 111- DI,\GNOSIS H.TiMATURTA 309 of a small calculus per urethram, following an attack of renal colic, is an important point in the history of such a patient, but in any case an examination by skiagraphy should be carried out, when a calculus may be proved present in the kidney (Fig. 97). A calculus in the kidney may attain a size too large to become engaged in the upper end of the ureter, when renal colic will be I^ig: 97, — Skiagram of a calculus in a dropped left kidney. (By Dr. Alfred C. Jordan.) absent, or it may cause hydronephrosis, renal abscess, or pyonephrosis, of which symptoms may be present. Renal Tuberculosis, apart from the miliary form of children, is not uncommon as a primary disease of one kidney. The patients affected are usually young adults, who complain of a constant aching in one loin, with occasional attacks of more acute pain resembling renal colic. At the onset of the disease, when the foci are limited to the renal tissues, there is no change in the urine 3IO HEMATURIA beyond the occasional presence of albumin ; but as it advances the foci coalesce and form a softened area which opens into the renal pelvis, when there is a constant discharge of small quantities of pus and blood in the urine. The liberation of tuberculous material into the renal pelvis and ureter causes infection of the mucous lining of these passages, and is marked almost constantly by increased frequency of micturition during both the day and the night, even before any tuberculous infection has occurred in the bladder. These cases are often mistaken for renal calculus, but in any case of persistent slight hasmaturia or pyuria a careful search should be made for tubercle bacilli in the urine. It should be noted also that a skiagram may show a distinct shadow produced by a tuberculous focus in the kidney, but its outline differs from that due to a calculus in its indefinite border. In renal tuberculosis the haematuria is rarely increased by exertion on the part of the patient, as is frequently the case with calculus, and pain in the loin is less mitigated by rest in bed. In Renal Mobility, haematuria is certainly uncommon, but occasionally occurs. In the case of a patient with markedly increased renal mobility, haematuria may follow any exertion, such as hunting or dancing. Renal mobility is so common, however, that the occurrence of haematuria should in any case arouse suspicion of some other lesion of the urinary tract, and a thorough examination both of the bladder (by the cystoscope) and of the kidney, should be made before any attempt at fixation is undertaken. Movable kidney may be entirely painless DESCRIPTION OF PLATE VI. Bladder Appearances seen through the Cystoscope. Fig. F. — Pedunculated carcinoma of the bladder. Fig. G. — Pedunculated bald carcinoma of the bladder. Fig. H. — Uric acid calculus in the bladder. Fig. I. — Appearance at the urethral orifice in bilateral adenomatous enlarge- ment of the prostate. Fig. K. — Bilharzia haematobia. J^ig. G is from a sketch by ])r. }l'alte?-s, and Fig, K is ri:J>roduccd by kina pertnission of Mr. H. A. Wilson. and give rise to no symptoms whatever, or may cause lumbar aching or attacks of acute pain resembling renal colic (Dietl's crises). It frequently causes gastro- intestinal disturbance from the drag upon the duodenum in relation to it, and occasionally also polyuria and increased frequency of micturition. The kidne}^ can be felt to be movable, but care must be taken not to mistake other abdominal swellings for a kidney (see Kidney, Enlargement of). Hydronephrosis occasionally gives rise to haematuria, and the combination of renal tumour and haematuria would suggest a growth in the kidney. The blood from a hydronephrotic kidney, however, is very rarely copious, and the other symptoms of hydronephrosis would distinguish the two, in particular inter- mittency with corresponding changes in the amount of the urine. Polycystic disease of the kidneys is commonly accompanied by haematuria in the later stages of the disease. It occurs in early childhood or in adult life, and is most commonly bilateral, forming an enlargement of each kidney which may reach large dimensions, although on the other hand a tumour may onl}' be felt on one side. In the early stages the diagnosis is difficult ; but later, pain, bilateral tumour, haematuria, and signs of renal inefficiencj' will be present. The renal tumour caused by polycystic disease is smooth and rounded, but differs from hydronephrosis in that fluctuation can seldom be obtained. Bilateral hydro- nephrosis will be diagnosed from polycystic disease by the finding of some lesion obstructing the normal urinary flow, such as stricture of the urethra. PLATE VI. LADDER APPEARANCES SEEN THROUGH THE CYSTOSCOPE Fig. I. Cojiyright Fig. K. W. Thornton Shiclls, del. INDEX OF DIAGNOSIS HEMATURIA 311 prostatic or vesical disease, or carcinoma of the pelvic organs invading the ureters. Oxaluria (q.v.) may give rise to a slight hematuria. The passage of large num- bers of oxalate crystals in the urine occurs in some patients, especially after a diet containing rhubarb, gooseberries, or tomatoes, and is often accompanied by dyspepsia. An examination of the urine on successive days will demonstrate the condition. The aching in one loin and the presence of envelope crystals in the urine, may simulate renal stone, but the absence of a shadow in a skiagram will disprove the latter. Acute Nephritis is accompanied by haematuria, but is usually obvious by the sudden onset of the disease, by the history of some specific fever, or of a chill, and by the subcutaneous oedema. The urine is scanty and of high specific gravity, and contains, in addition to blood discs, hyaline and epithelial tube- casts, many renal epithelial cells, and abundant albumin. There are some cases of acute nephritis in which no oedema occurs, and then the abundance of renal tube-casts in the urine affords the main evidence as to the diagnosis. B. Ureteric Calculus may cause hematuria, either during the descent of the stone or when the latter becomes arrested in the duct without causing complete obstruction to the flow of urine. The diagnosis is usually easy from the history, and the character of the pain, accompanied by the increased desire to micturate ; but in some cases on the right side it may be mistaken for acute appe-ndicitis. The previous history of the passage of a calculus or of renal symptoms of stone will usually be elicited. A skiagram should be obtained. C. Vesical Causes. — The profuse haematuria of a papilloma, villous tumour, or of a villus-covered carcinoma of the bladder, frequently occurs without any other symptom. The haemorrhage may come on suddenly without any exciting cause ; it may last a variable time, and then entirely disappear, or continue as a slight haematuria for some days. With the carcinomatous form there may be some increased frequency of micturition in the absence of bleeding, but in either variety the clotting of blood in the bladder may cause urgent desire to micturate or even retention of urine. A rectal examination may give evidence of infiltration of the base of the bladder or of the pelvic lymphatics in the malignant form, but it is only rarely that an innocent tumour is large enough to be felt by the rectum. In the intervals betw-een ha3morrhages, a cystoscopic examination will demonstrate the presence of a vesical growth [Plate VI, Figs. F and G). It should be noted that the common situation for a vesical tumour is at the base of the bladder, in close proximity to a ureteric orifice ; this latter may be actually obstructed, or dragged upon by the growth in such manner as to cause renal distention or actual hydro- nephrosis, so that a vesical tumour may give rise to renal pain and tumour, and in this way may be readily mistaken for a renal growth. This difficulty will be overcome by a cystoscopic examination of the bladder. Prostatic enlargement of the adenomatous, or more frequently of the carcino- matous variety, maj^ cause haematuria. The age of the patient (54 or more), the increased frequency and difficulty in micturition, the evidence obtained by a rectal examination and by catheterization, suffice to diagnose the disease. The haematuria of prostatic enlargement is often profuse, and may be an early symptom of the disease ; but on careful enquiry it will usually be found that there has been for some months a gradually increasing frequency of micturition. Vesical Epithelioma occurs in elderly patients, and cause? slight but fairly constant haematuria. For haemorrhage to take place from a vesical epithelioma, there must be ulceration of the surface of the growth, and other symptoms will be present, namely, increased frequency of micturition both day and night. 31- HMMATURIA penile pain following the act of micturition, and p^'uria. The blood often occurs as a few drops at the termination of urination, or may be mixed throughout the act. Usually a vesical epithelioma is situated on the base of the bladder, and may be felt as a distinct infiltration per rectum. Vesical Tuberculosis gives rise to exactl}^ the same symptoms as an epithe- Uoma, but it occurs commonly in young adults. Persistent slight haematuria and pyuria in a young patient will always suggest tuberculous disease, and a very careful search should be made in the centrifugalized urine for tubercle bacilli, whilst other evidence of tuberculous disease, especially in the testes, vesiculas seminales, and prostate, should be looked for. Difficulty may arise in the diagnosis between vesical and renal tubercle, for in the latter, persistent haematuria and pyuria, together with increased frequency of micturition, may be present. With renal tubercle will usually be found some renal enlargement and pain, the ureter may be felt to be thickened, and the blood in the urine will not be more apparent at the end than during the rest of micturition, unless the bladder is also affected. Renal tuberculosis is more commonly a primary disease in the urinary organs than vesical, but either may occur in the progress of the disease of the other organ. When a tuberculous nodule, in a vesicle or the prostate ulcerates into the bladder, a sharp attack of haematuria may result. Great assist- ance may be gained in the diagnosis of urinary tuber- culosis b}^ a careful cysto- scopic examination [Plate V, Fig. E). Vesical Calculus also causes slight haematuria, usually as a few drops in the terminal urine of mic- turition. The subject of a calculus in the bladder which is unaccompanied by cystitis will complain of increased frequency of mic- turition during the day or during exercise, but is usually free from micturition during the night. There is pain of a pricking character in the glans penis after micturition, and there may be a history of sudden stoppage of the stream during the act. The patients are usually men, and there may be a history of previous calculi or of the kidney having been found to be unduly movable. The stone may be felt with a sound, or better still, seen by a cystoscope, when small calculi which may be missed with a sound may be diagnosed with certainty [Plate VI, Fig. H). The ;r-rays are also useful in detecting the stone in many cases [Fig. 98). If the calculus has caused cystitis, there will be in addition pyuria and nocturnal micturition. Acute Cystitis is accompanied by haematuria; but the other symptoms, such as vesical tenesmus, suprapubic pain, and pyrexia, together with pyuria and a cause for the condition, will point to the disease. J^ig: 98. — Skiagram of a composite (oxalate and phosphate) vesical calculus. C, calculus ; R, rectum ; S, sj-mphysis pubis. {By Dr. Alfred C. Jordan.) HEMATURIA 313 Bilharzia hcsmatobia causes slight hagmaturia, and gives rise to symptoms very similar to vesical tuberculosis. The discovery of the typical ova in the urine (see Fig. 13, p. 93), together with a history of residence in an affected district, notably Egypt or certain parts of South Africa, will make the diagnosis clear. The cystoscopic appearance in the bladder of small, glistening yellow nodules and small areas of raised granulation tissue, is distinctive of the disease {Plate VI, Fig. K). D. Urethral Causes. Acute Urethritis may cause blood to appear in the urine from the acute con- gestion of the urethral mucous membrane, both in gonorrhoeal and septic infections. The history and the presence of an acute urethral discharge make the diagnosis evident. The Impaction of a Calculus in the urethra causes some bleeding from direct injury to the urethral mucous membrane. There is usually retention of urine, so that true hsematuria may not occur ; but the history of sudden stoppage of the stream of urine during micturition, with acute penile pain, together with the previous history of renal or vesical stone, will usually make the diagnosis clear. It is not uncommon in male children. The calculus may be felt from, the outside in the course of the urethra, often at or near the meatus, or easily seen by an endoscopic examination. II. H.EMATURIA FROM DISEASE OF THE NEIGHBOURING ViSCERA INVOLVING THE Urinary Organs. The direct spread of carcinoma of the pelvic organs may in its progress involve the bladder, and is of not uncommon occurrence in the later stages of carcinoma of the uterus, vagina, rectum, or pelvic colon. The infiltration of the bladder wall before actual ulceration has occurred, is usually indicated by vesical irritability, followed by ulceration and haematuria, together with the passage of urine by the vagina or faecal matter in the urine. Occurring as a late stage of carcinomatous disease, there is usually little difficulty in the diagnosis. Haematuria may occur during an attack of acute appendicitis from the direct spread of the inflammatory process to the vesical wall. In some cases in which the inflamed appendix turns downwards over the pelvic brim, it may become adherent to the bladder, or an abscess may form in immediate relation to the bladder wall. The localized inflammation of the vesical mucous membrane causes haematuria, whilst the sudden appearance of a quantitj^ of pus in the urine has been noticed when an appendicular abscess has ruptured into the bladder. The history of acute pain low down in the right iliac fossa, the pyrexia, and general symptoms of peritoneal inflammation before any urinary symptom was noted, will point to the disease ; a rectal examination may reveal the inflammatory process in the right pelvic region. Acute Salpingitis or Pelvic Abscess may similarly cause haematuria from direct inflammatory extension to the vesical wall, but this is rarer than in appendicitis. Tuberculous and Dysenteric Ulceration of the Intestine have both caused haematuria by the adhesion of the bowel to the fundus of the bladder and the subsequent inflammatory condition of the mucous membrane. In a case of slight haematuria, a cystoscopic examination showed a localized area of intense congestion at the fundus of the bladder without any other vesical lesion, and on opening the abdomen, a coil of small intestine, obviously ulcerated by tubercle, was found adherent to the peritoneal aspect of the bladder. In most cases the symptoms due to the intestinal disease would be apparent. 314 HEMATURIA III. HiEMATURIA IN GENERAL DISEASES. The sudden plugging of a renal vessel by embolism {renal infarction)) is not uncommon in cases of endocarditis, and may be accompanied by hsematuria. The embolism is most commonly seen in infective endocarditis, during the course of which sudden pain is felt in the loin, followed by haematuria. The occurrence of acute endocarditis in the course of acute septic processes, such as acute osteomyelitis, pneumonia, or acute rheumatism, is not uncommon, and will usually be diagnosed before there is any evidence of renal embolism. On the other hand, there are certain cases of chronic heart disease in which the first evidence of infected endocarditis having developed may be the occurrence of sudden haematuria ; and in some such cases there may be difficulty in excluding acute Bright's disease, because around each infarct there is local acute inflamma- tion, and therefore the urine will contain tube-casts as well as blood ; the discs should be examined for optic neuritis, and if there is pyrexia with progressive enlargement of the spleen, infective endocarditis will suggest itself. LeukcBtnia may be accompanied by haematuria ; but the enlargement of the spleen, general symptoms of anaemia, and the total and differential blood counts, will point to a diagnosis. Scurvy and the various forms of Purpura [q.v.) may each be accompanied by haematuria, but the general symptoms of each disease are usually well marked before haematuria occurs. In infantile scurvy, the evidence of subperiosteal haemorrhages should be looked for, whereas in purpura there will be other obvious hagmorrhagic lesions. R. H. Jocelyn Swan. HEMOGLOBINURIA. — Haemoglobinuria differs from haematuria in that the blood-pigment is passed in solution in the urine apart from red corpuscles. In many cases of haemoglobinuria small numbers of red corpuscles, or the ghosts of them, may be found microscopically ; but so far as these red corpuscles go they constitute haematuria in association with the haemoglobinuria ; the essential part of the latter is the passage of the blood pigment dissolved out of the red corpuscles. It gives the same chemical tests as ordinary blood ; spectroscopically it is almost as common to find the bands of methaemoglobin {Fig. 22, p. 95) as those of oxyhaemoglobin {Fig. 17, p. 95) ; by the addition of ammonium sulphide the spectrum is changed to that of reduced haemoglobin {Fig. 18, p. 95), and by the further addition of a few drops of concentrated caustic soda, that of alkaline haematin {Fig. 20, p. 95) is produced. The diagnosis depends upon the discovery of blood pigments in the urine, whilst the microscope shows no red corpuscles, or these are so few in number as to be out of all proportion to the pigment. It is important that the urine should be examined fresh, for otherwise, owing to the disintegration of red cells after they have been passed as such, it is possible to mistake for haemoglobinuria that which is really haematuria. To the naked eye, the urine may be only just tinged with a colour that suggests blood pigment, or it may be absolutely blood red, brown, murky, or even black, as in the tropical blackwater fever. It is seldom clear ; but clouded by mucus, casts, amorphous masses of pigment, and debris. Haemoglobinuria results from any condition which leads to haemoglobinaemia by laking the red corpuscles within the living vessels. It has been produced in animals experimentally by the injection of various haemolytic sera and other substances. It may occur in man as the result of the oral administration of certain chemical substances such as potassium chlorate, pyrogallic acid, naphthol, urotropine, and possibly quinine ; after the inhalation of certain toxic gases, notably carbon monoxide, carbon bisulphide, naphtha vapour, arseniuretted hydrogen ; after the transfusion of certain foreign sera which were formerly HMMOGLOBINURIA 315 employed instead of saline infusions ; after frostbite and extreme exposure to cold ; after severe burns ; after large internal extravasations of blood, especially those within the abdominal cavity ; in a few cases in which pregnancy is associated with toxasmic symptoms ; in some new-born infants, occasionally in an obscure epidemic form ; in association with certain functional disorders of the vasomotor system, especially Raynaud's disease, factitious urticaria and angio-neurotic oedema ; after very long-sustained excessive physical exertions and fatigue ; in association with severe forms of microbial — or presumably microbial — toxaemia, especially malaria and blackwater fever, and to a much less extent in severe syph- ilis, typhoid fever, scarlet fever, acute pyogenic septicaemia, generalized anthrax, yellow fever, and other tropical fevers ; Henoch's purpura ; in certain cases of nephritis ; and in that remarkable affection known as paroxysmal haemoglobinuria. Although the above list may appear formidable, as a matter of fact the differ- ential diagnosis between the different diseases mentioned in it will seldom depend solely upon the presence or absence of haemoglobinuria. The chief importance of the latter, indeed, lies first in the necessity of not mistaking it for haematuria, and secondly in that its occurrence is a sign that considerable haemolysis is taking place and that the prognosis is proportionately less good. It is enough if the fact that it may be a complication of any of the above conditions is borne in mind. The question of whether blackwater fevev is due to the effects of quinine in a patient whose blood is already susceptible to haemolysis on account of malaria, or whether the blackwater is due to a distinct and specific malady, has not yet been settled ; the diagnosis is, however, generally obvious, the geographical circumstances under which the disease develops pointing to its nature. Paroxysmal hcsmoglobinuria is rare ; but in Great Britain it is probably the commonest cause of considerable hemoglobinuria without symptoms of extreme illness. It may affect adolescents or grown-up people, males or females ; it has probably several different ultimate causes ; amongst the latter, however, previous syphilis stands out pre-eminently, and probably heredity is also a factor. Males are affected rather than females. The remarkable feature of the malady is the way in which an attack can be brought on, almost at will, by certain immediate causes, of which the most potent is exposure to cold, others being excessive exercise or mental excitement. Sometimes the exposure has to be considerable before haemoglobinuria results ; on the other hand, it may be impossible for the patient to keep his hands immersed in cold water for any length of time without an attack ensuing. The urine may look like blood, and the output of pigment, together with considerable albuminuria, persists for a day or two as a rule ; the attack may be unaccompanied by other symptoms, but sometimes there is a shivering attack or an actual rigor with rise of temperature, and a general feeling of illness, necessitating rest in bed. Sooner or later, if repeated attacks occur, the patient becomes severely anaemic, with all the symptoms that result from such anaemia. The diagnosis may be very difficult at the time of the first attack, but it is relatively easy when the attacks recur, especially when there is distinct relationship to some definite immediate cause, such as exposure to cold, to undue fatigue, or mental excitement. The main mistake to avoid is a diagnosis ox haematuria, such as a villous tumour of the bladder might cause. The way to obviate this error is to employ both the microscopic and the spectroscopic tests for blood, much pigment and few corpuscles pointing to haemoglobinuria. Herbert French. HEMOPTYSIS. — The term haemoptysis literally means blood-spitting, but clinically it is restricted to the expectoration of blood derived from the lungs, bronchi, or trachea, to the exclusion of the spitting of blood derived from the mouth, nose, or pharynx. Some observers would include blood coming from ulceration of the larynx under the heading of haemoptysis, others would not, so 3i6 HMMOPTYSIS that the meaning of the term is arbitrary. For practical purposes it is simpler to include the larynx as a source for- haemoptysis. The differential diagnosis resolves itself into two main portions, namely, (I) A determination of whether the symptom has really been haemoptysis in the restricted sense, or whether the blood has been derived from the mouth, nose, or pharynx on the one hand, or the stomach on the other ; and (II) If true haemoptj'sis has really occurred, a determination of its exact cause in the parti- cular case. I. — The Distinction between True and Spurious Hemoptysis. True haemoptysis — that is to say, haemorrhage from the lungs, bronchi, trachea, or larynx — can sometimes be distinguished at once from the spitting of blood derived from the nose, mouth, or pharynx. The occurrence of epistaxis bleeding gums, sore throat, ulcerative stomatitis, epithelioma linguae, injury to the mouth, gingivitis from a carious tooth, or from pyorrhoea alveolaris, pharyngitis, septic conditions of the antrum of Highmore, or frontal, ethmoidal, or sphenoidal air-cells, or rarer conditions, such as lupus of the palate or pharynx, sarcoma of the tonsil or of the basisphenoid, may generally be detected by a careful examination of the nose, mouth, gums, and phar\mx ; moreover, the blood in these conditions is usually mixed with saliva, watery, and perhaps non-aerated. It is very important, however, to be decidedly guarded in con- cluding that blood comes from the mouth, nose, or throat, and not from the lungs ; and a careful examination for tubercle bacilli should be carried out in every such case, lest the early stage of phthisis should be missed. The distinction between haemoptysis and haematemesis is often easy enough, but sometimes very difficult. The history may help, or the patient's own sensations may make him certain that he coughed up the blood, and did not vomit it. The following is a summary of the points of distinction : — Hemoptysis. H.ematemesis. 1. The patient coughs the blood up i. The blood is vomited 2. Part of the blood is often frothy 2. The blood is not frothy 3. The blood may occur by itself, but it is 3. The blood may occur by itself, but it is often mixed with sputa, recognizable often mixed with vomit, recognizable microscopically by the presence of food particles 4. The blood is alkaline in reaction 4. The blood may be alkaline if it is abundant, but it is often acid from admixture with gastric juice 5. Tubercle bacilli or elastic fibres may 5. Tubercle bacilli will be absent be detected 6. There may be a previous history of 6. There may be a definite history, with acute rheumatism, or of cough' and or without physical signs, pointing night sweats, indicative of heart or to a gastric lesion or to cirrhosis of lung disease, confirmed by abnormal the liv'er cardiac or pulmonary physical signs 7. Before the blood is coughed up, there 7. Before the blood is brought up there is often a sense of tickling or may be a feeling of sickness, nausea, gurgling in the throat, which is oppression in the epigastrium, always very suggestive of true haemo- faintness, and giddiness ptysis 8. The motions are not altered afterwards 8. The motions are often tarry afterwards unless the blood has been abundant and much of it has been swallowed, when they may be tarry as in haematemesis 9. Blood-stained sputa may be expec- 9. There are usually no sputa torated for several days after a severe attack 10. A history of cough 10. A history of abdominal pains after food. HEMOPTYSIS 317 Notwithstanding all these points of distinction, however, it may be very- difficult to avoid being misled, unless the patient can be kept under observation for a time ; moreover, haematemesis may be caused by haemoptysis, especially when the bleeding takes place in the night, the blood being swallowed as soon as it gets into the pharynx whilst the patient remains asleep and quite unconscious of the occurrence. The frequency with which haemoptysis occurs during the night when the patient is at rest is remarkable ; but in the majority of instances the incidence of bleeding excites coughing, and the patient wakes. Malingering by the production of blood-spitting by gum-sucking is diagnosed upon circumstantial evidence. It has sometimes happened that a patient has produced the blood of fowls with the statement that this has been coughed up — a fallacy that can be detected by examining the red cells under the microscope. II. — Determination of the Cause of the Hemoptysis. Having arrived at the conclusion that a patient has had haemoptysis, the next point^is to ascertain the cause of this very important symptom in the particular case. It may be said at once that by far the commonest causes of haemoptysis are phthisis on the one hand and mitral stenosis upon the other. The heart and lungs need particular examination therefore, and the family and personal history, both as to acute rheumatism or chorea, and as to consumption, may assist. If there are no abnormal physical signs in the thorax, it does not follow that phthisis is absent — even phthisis with cavitation may exist without any definitely abnormal physical signs being detected ; microscopical examination of the sputum, therefore, both for tubercle bacilli and for elastic fibres, should never be omitted, especially after the haemoptysis has ceased ; repeated examinations may be required if the first proves negative. Although these are the commonest, there are a great many other causes, as the following tables indicate : — A. Haemoptysis due to Changes in the Lungs : — Phthisis : [a] Early (6) Later Cirrhosis of lung : pneumono- coniosis : (fl) Knifegrinder's lung [b) Stonemason's lung Cardiac disease, especially mitral stenosis Violent coughing efforts, as in whooping-cough or bronchitis or emphysema Injury : (a) Blows upon the chest wall, without rib fracture [b) Fractured rib (c) Exploratory needling of the chest [d) At the end of paracentesis thoracis. Lobar pneumonia Bronchopneumonia 8. Septic pneumonia, with or with- out abscess 9. Gangrene of the lung 10. Infarction of the lung : {a) Embolic {b) Thrombotic 11. Neoplasm of the lung, whether primary or secondary : (a) Sarcoma (b) Carcinoma 12. Sporotrichosis of the lung : {a) Aspergillosis [b) Actinomycosis (c) Other forms 13. Aortic aneurysm pressing on and opening into the lung 14. Hydatid cyst 15. Primary atheroma of the pulmo- nary arterioles 16. Empyema bursting through the lung 17. Hepatic abscess bursting through the diaphragm into the lung. 3i8 HEMOPTYSIS B. Haemoptysis due to Changes in the Bronchioles, Bronchi, or Trachea 1. Bronchitis : {a) Acute (6) Chronic (c) Plastic 2. Bronchorrhoea 3. Bronchiectasis 4. Aortic aneurysm opening into the trachea or a bronchus 5. Ulceration of the trachea or a bronchus : {a) Tertiary syphilitic (b) Malignant (i) Primary epithelioma of bronchus calcareous bronchial gland. 6. Parasitic infection by the Disto- wia pulmonale westermanni C. Haemoptysis due to Changes in the Larynx : — {d) (ii) Invasion of a bron- chus by a medias- tinal sarcoma, lym- phosarcoma, oesoph- ageal epithelioma, or other neoplasm. Secondary to a foreign body, such as a button, a fruit- stone, a tooth, etc. ; or to a tracheotomy tube Secondary to a caseous or D. Acute laryngitis Tuberculous ulceration Syphilitic ulceration Malignant ulceration : (a) Epitheliomatous (&) Sarcomatous Post-typhoidal ulceration Post-diphtheritic ulceration i Haemoptysis due to Changes in the Blood : 7. Injury to the larynx, by a blow, a throat grip, a cut throat, intubation, or operation 8. Lupus of the larynx 9. Variolous ulceration 10. Leprosy of the larynx 1 1 . Angioma of the larynx 1. Purpura and its various causes [q.v.] 2. Scurvy 3. SplenomeduUary leukaemia 4. Lymphatic leuicaemia 5. Pernicious anaemia E. Doubtful Causes of Haemoptysis :— 1. Granular kidney 2. Arteriosclerosis 3. Vicarious menstruation 6. Hodgkin's disease or lymph- adenoma 7. Malignant types of specific fevers, such as variola or measles 8. Haemophilia 4. Recurrent haemoptysis in arthritic subjects (Andrew Clark) 5. Haemoptysis in apparently sound and healthy young subjects. Copious Haemoptysis has only two causes, namely rupture of an aortic aneurysm into trachea, bronchus, or lung ; and rupture of an aneurysm of a pulmonary arteriole in a phthisical vomica. The former, when once it causes severe haemo- ptysis, nearly always proves immediately fatal ; the latter may also cause rapid death, but sometimes the severe bleeding stops, and recovery may ensue. In either case, however, there is often a stage of slight or premonitory bleeding for days, weeks, or even months before the final and possibly fatal rupture occurs. There are some causes of haemoptysis in the above list about which little need be said. The whole of Group E, for instance, is open to much doubt ; it is true that apparently sound young subjects may have transient haemoptysis, and never develop phthisis ; on the other hand, a certain proportion of such cases do become consumptive later, so that the presumption is that in all of them the haemoptysis really has a tuberculous origin, cure resulting rapidly in some, but not in others. Particular care should be taken in the examination of the sputum and of the chest by the ordinary physical methods, and perhaps by the ;ir-ray3 also, and even although the cause of the haemoptysis may not be precisely determined, the patient would be well advised to live as healthily as possible, HAEMOPTYSIS 319 lest a further stage of phthisis should develop. The same applies to so-called vicarious menstruation ; and in not a few cases in which the hcemoptysis has been attributed to the arthritic diathesis, to arteriosclerosis, or to renal lesions, the lesion may really be an intercurrent infection of the lung by tubercle bacilli even in middle-aged or elderly people. Causes in Group D seldom give rise to extensive spitting of blood from the lungs, though there may be much epistaxis, bleeding from the gums, and so on. The diagnosis between the different conditions in this group will be found else- where. Phthisis is by far the commonest cause of haemoptysis. It may be the very first sign of the disease, it may be the last, or it may occur at any intermediate stage. The amount of blood brought up is very variable. The sputum may be only streaked with blood, or a pint or more may stream from the mouth. In advanced stages of phthisis the diagnosis is not difficult. There is the history of cough, loss of appetite and weight, night sweating, and expectoration ; there are the wasting and flattening of the chest wall, especially above and below the clavicles, often more on one side than the other ; the deficient movement on respiration, the unequal tactile vocal fremitus, the impairment of note, over one upper lobe more than over the other, with the bronchial breathing, consonating rales, bronchophony and pectoriloquy at one apex, with signs of similar but less advanced disease at the other. Detection of pus cells, tubercle bacilli, and perhaps elastic fibres in the sputum, is conclusive. Haemoptysis may, however, be the earliest evidence of phthisis ; the diagnosis is then difficult, for the physical examination may not reveal any abnormal signs. Particular stress may be laid upon greater prominence of one clavicle than of the other, prolongation of the expiration, and the constant presence of one or more apical clicks, or rales, perhaps brought out only on voluntarily coughing. In some cases, the mottled shadows seen with the ;ir-rays may assist the diagnosis {Fig. 27, p. 120), although, taken by themselves, they may be misleading ; tubercle bacilli may be found in the sputa quite early, so that a careful examination even of the most insignificant amount of sputum must always be made before a definite and reliable opinion as to the cause of the haemoptysis can be given. The actual cause of the haemoptysis in phthisis is not constant. In the early stages of the disease it may be the result of a local inflammatory hyperaemia with rupture of the capillaries ; the amount of blood expectorated is then usually small, and it may amount only to streaking of the sputum. A little later, small vessels may themselves become inflamed and softened, or directly invaded by the tuberculous process, consequently rupturing if any extra strain is suddenly put upon them, — for instance, during attacks of coughing. This may lead to a more profuse haemoptysis even quite early in the disease. When the malady is more advanced, the caseation and the breaking down of lung tissue may lead to softening of the external wall of a considerable branch of the pulmonary artery, resulting in an aneurysmal bulge, which, if thrombosis does not occur within it, will sooner or later rupture, and cause a profuse and probably fatal haemorrhage. Cirrhosis of the Lung — Pneumonoconiosis, Miners' Phthisis — is a particular variety of fibrosis due to the inhalation of irritating particles, especially amongst workers at certain occupations. Coal miners seldom get it ; although their lungs become packed with carbon — anthracosis — these particles do not seem to inflame the tissues. Knife-grinders suffer from it — siderosis ; so do workers in certain limestone quarries, rock-drilling gold mines, and diamond mines — silicosis. The chief point in the diagnosis is the history as to occupation ; there is much doubt as to whether these conditions are not really of a chronic tuberculous nature, and tubercle bacilli should be looked for in all these cases. The haemoptysis is far less frequent and less abundant than it is in ordinary cases of phthisis. 320 HEMOPTYSIS Mitral Stenosis is the second commonest cause of haemoptysis. Other forms of heart disease seldom lead to it direct, though mitral regurgitation may do so occasionally, and so may aortic stenosis or regurgitation when they have caused secondary mitral regurgitation. Congenital heart disease, unlike the acquired forms, is so liable to lead to phthisis that any haemoptysis associated with it would arouse suspicions of the latter. Fungating endocarditis may also cause haemoptysis, but as the result rather of the septic state than of the valvular lesion. Mitral stenosis is the chronic valvular heart disease par excellence to produce haemoptysis, and it may do so either when there is complete compensa- tion or when there is evidence of failure. When compensated, the right ventricle pumps blood into the lungs with vigour, and the stenosis of the mitral valve may be so great that there is a great rise of pressure in the pulmonary vessels. This is indicated clinically by the great accentuation or marked reduplication of the second sound in the second left intercostal space close to the sternum. At the impulse, which is often not materially displaced, the first sound will have a slapping character, and it will generally be preceded by a shorter or longer presystolic rumbling bruit. The latter is so short sometimes that it may be overlooked, but there may be a history of chorea or rheumatism to assist the diagnosis, and the accentuated pulmonary second sound will arouse suspicion in other cases, particularly if the precordial impairment of resonance is increased upwards and to the right, but not much to the left. The result of the great rise of blood-pressure in the lungs is, that some of the capillaries rupture from time to time ; the resultant haemoptysis alarms the patient, but it is really no sign of danger ; sometimes patients have this haemoptysis whenever the heart is at its best, losing it again when any failure threatens. Far different is it when blood- spitting occurs in failing cases of mitral stenosis ; it is then generally due to infarction or to pulmonary " apoplexy." The infarction is less often due to embolism from an ante-mortem clot in the right auricular appendix or other part of the right side of the heart than it is to thrombosis, which results as follows : atheromatous degeneration of the pulmonary arterioles is brought about by the greatly increased tension within them ; rupture of small branches of such degenerated pulmonary arterioles gives rise to " apoplexies," and the altera- tion in the tunica intima due to the atheroma, together with the deficient rate of blood-flow, strongly predispose to thrombosis and consequent infarction. An embolic infarct occurs suddenly, and causes acute pain in the corresponding part of the thorax, orthopnoea, increased cyanosis, dyspnoea, and haemoptysis ; a thrombotic infarct arises gradually, and causes haemoptysis without the other symptoms. Violent Coughing efforts, as in whooping cough, or emphysema and bronchitis, may cause such pressure of the fraenum linguae against the teeth as to abrade its surface and lead to the expectoration of blood-streaked salivary sputum — spurious haemoptysis ; it is said that they can also produce true haemoptysis ; this is possible, but before blood-spitting in any given case is attributed merely to violence of coughing, every care should first be taken to exclude both tubercle and heart disease. Injury to the Chest is not an uncommon cause of blood-spitting. There need have been no fracture of a rib — a severe blow on the thorax sometimes suffices. The only difficulty in the diagnosis is to be sure that the injury is the sole cause, and that it has not merely been the final factor in producing haemorrhage from a latent tuberculous focus or an aneurysm. In Lobar Pneumonia the amount of blood expectorated is slight in the majority of cases ; the sputum is thick, viscid, tenacious, and generally there is no more blood than will give it a rusty or russet-brown colour. It may, however, be bright red, and in a few cases copious enough to be in itself alarming. The HEMOPTYSIS 321 difficulty is to distinguish it from phthisis, or from lobar pneumonia superposed upon phthisis. The diagnosis is often obvious enough ; but sometimes, notwith- standing the acute onset, the continued fever, the high ratio of the respiration to the pulse-rate, the viscidity of the sputum, the presence of capsulated diplo- cocci in it, the abnormal physical signs, and the absence of chlorides from the urine, serious doubt remains until the subsequent course of the case has been watched. When the ;tr-rays can be utilized at the bedside, a skiagram may sometimes serve to differentiate batween phthisis {Fig. 27, p. 120) and lobar pneumonia {Fig. 99). Bronchopneumonia is a rare cause of haemoptysis, because it is seen mainly in children at an age when no spitting occurs. In older patients, broncho- pneumonia is generally either influenzal, or else due to the inhalation of septic particles from the mouth after operations under anaesthetics, or in association with such diseases as epithelioma of the tongue, or otitis media with lateral sinus thrombosis. Septic broncho- pneumonia is diagnosed by reason of its being a lung com- plication of some other malady likely to give rise to it. Influ- enzal bronchopneumonia is apt to cause characteristic sticky rales at the bases, with less pyrexia but more asthenia than is the case with lobar pneu- monia ; and the minute Bacilli influenzcB may be found in the sputum in large numbers. If the signs are apical rather than basal, it will be very difficult to be sure that the condition is not tuberculous, except by watching the case, and finding that rapid and complete resolution and re- covery ensue. Gangrene of the Lung, due to whatever cause, is characterized by the extreme stench of the breath and sputa. The only conditions which can produce similar stench are foetid decomposition of the retained sputum in bronchiectatic cavities or old phthisical vomicae, or similar decomposition in the pus of an empyema which has ruptured through the lung, and which is only able to- empty out its contents periodically. Gangrene of the lung can be differentiated from all these by the quantity of pulmonary elastic fibres that may be found in the sputum, the absence of clubbed fingers, and by the history being much shorter than would probably be the case with the others. Infarction of the Lung, embolic and thrombotic, has already been mentioned in connection with heart disease, its most frequent cause. It only remains to add that it may also occur as the result of embolism secondary to thrombosis of systemic veins, infective endocarditis of the pulmonary or tricuspid valves, or from primary thrombosis in some blood diseases, such as leucocythaemia. A large embolus causes sudden death without haemoptysis ; a smaller one may give rise to sudden acute pain in some part of the chest, and a local patch of crepitant rales with a pleuritic rub, and perhaps impairment of percussion note with bronchial breathing. Haemoptysis associated with such physical signs and Fig. 99. — Skiagram of lobar pneumonic consolidation of left lung (A); normal right lung (B); gastric gas bubble (C)'; liver (D). (By Dr. .Alfred C. Jordan?) 322 HAEMOPTYSIS accompanied by evidence of endocarditis or venous thrombosis would suggest infarct as the cause of it. Difhcultj^ arises mainly when there is no obvious phlebitis in the case, when the vein affected is deep-seated in the pelvis, — for instance, after childbirth or some operation. The diagnosis is not so difficult when there have been repeated sudden acute pains in different parts of the chest, each followed bv a little pyrexia and sometimes b}^ haemopt^'sis, due to repeated small emboli. Carcinoma and Sarcoma of the Lung are usualh' secondary. The diagnosis is sometimes obvious, sometimes very obscure indeed. The primary seat of the growth ma}'' be near the lung, for instance in a bronchus, the oesophagus, or breast, or the mediastinal glands ; or it may be distant, in the stomach, or a bone, and so on. The sputum may be merely blood-tinged, or it ma\^ be dark like red-currant jelly ; occasionally the haemorrhage is profuse. A large number of cases of malignant disease in the lung are accompanied bj^ pleuritic effusion, and unless the existence of a primary neoplasm elsewhere is known, growth may not at first be suspected. If aspiration is performed, the fluid is generally found to contain blood ; indeed, the discovery of blood-stained pleural fluid at a first tapping of a case that is not absolutely acute, is always very suggestive of neoplasm. Increasing varicosity of the veins on the chest wall, with reversal of the blood current in them, also points to intrathoracic growth ob- structing the superior vena cava. The neoplasms may also stenose a bronchus, leading to unilateral deficiency of movement and tactile vocal fremitus, impair- ment of note, and deficient or absent breath sounds, with or without faint bronchial breathing and crackling rales ; whilst, accompanying these physical signs, no tubercle bacilli would be found in the sputum, and yet the weakness and emaciation would be progressive. Particles of the new growth have been detected microscopically, either in the sputum or in the pleural effusion, in many of these cases. Sporotrichoses of the Lung are being recognized with increasing frequency. Hitherto they have generally been mistaken for phthisis. They are due to various moulds of the nature of Actinomyces, Aspergillus niger, and others, and the diagnosis .depends upon bacteriological investigations of the sputum by cultural methods. When no tubercle bacilli can be detected on repeated examina- tion in the ordinarj^ wav, the possibility of sporotrichosis should be borne in mind, particularly if the patient's occupation leads to contact with vegetable products such as hay or straw, grain, bird foods, or even cotton, as in the case of seam- stresses and tailors. Aortic Aneurysm far less often opens into the lung itself than it does into a bronchus ; the symptoms are similar in either case, and if the history is long the diagnosis will alreadv have been made on account of some other symptom than hjemoptysis, especiallv pain in the chest or in the back. The ;ir-rays are a valuable means of deciding the diagnosis (Fig. 74, p. 236). Two points are worthy of particular attention, and these are : first, that the rupturing of an aortic aneurj^sm into a bronchus, with copious and rapidly fatal hemoptysis, may be the very first sign that anything is wrong ; and secondh-, that in not a few cases there may have been slight haemoptysis and blood- streaking of the sputum for weeks or months before the fatal rupture ensues ; these preliminary slight attacks of haemoptysis are probably due to erosion of small vessels in the wall of the bronchus, and if the aneurysm is partiall}' obstructing, say, the left upper bronchus, so as to produce impairment of note over the left apex, with a few rales there, and haemoptysis, it is clear that a mistaken diagnosis of phthisis might readily be made. Tubercle bacilli will be persistently absent from the sputum, there will very likely be a previous history of syphiHs, hard manual work, and perhaps drinking ; without the A^-rays to show the pulsating shadow HEMOPTYSIS 323 of the aneurysm, however, the correct diagnosis may be missed, and even when the fatal rupture occurs, the condition may still be erroneously attributed to phthisis, unless a post-mortem examination is made. Hydatid Cysts are much rarer in Europe than in Australia and Xew Zealand ; those of the lung are, as a rule, secondary to hydatid of the liver. They may give rise to neither signs or symptoms ; on the other hand, they maj^ cause haemoptysis, and phthisis may be simulated. The ;i;-rays are very efficient in detecting their spherical shadows (Fig. 100). The blood may exhibit eosino- philia. Primary Atheroma of the Pulmonary Arterioles is so rare as to be undiagnosable. There is no relationship between systemic and pulmonary atheroma, and the commonest cause of the latter is mitral stenosis, as described above. J^i^. loo. — Skiagram of a hydatid cyst of the thorax, occupying the position of the upper lobe of the left lung. Empyema bursting through the Lung may or may not cause haemoptysis ; the main features of the case will generally be an obscure febrile illness subsequent to pneumonia, followed by a sudden eruption of pus from the respiratory^ passages, and a repetition of a similar copious expectoration of pus at intervals ; in many cases there are comparatively few abnormal physical signs, for had the empyema not been hidden away deeply in the thorax, its existence would have been diagnosed earlier, and it would have been relieved by operation before it burst into the lung. A Hepatic Abscess that has burst through the lung is apt to give rise to anchovy- sauce-coloured sputum which is characteristic ; no amoebae may be discovered, and the pus will very likely be sterile ; the diagnosis is generally based upon the history of residence in the tropics, possibh^ of an attack of amoebic dysentery-, 324 HEMOPTYSIS and of hepatic symptoms, pyrexia, and rigors previous to the expectoration of the blood-stained pus. The abscess occurs on the right side more often than on the left, and there may be the typical dome-shaped dullness at the base of the right lung. Haemoptysis due to changes in the Bronchioles, Bronchi, and Trachea, as distinct from changes in the lung, have to some extent been incidentally con- sidered with the latter. Bronchitis should never be diagnosed as the cause for haemoptysis in a particular case until phthisis and mitral stenosis have been thoroughly excluded. Bronchorrhcea is, in most respects, only a variety of bronchitis. Bronchiectasis may be associated with some slight degree of haemoptysis sometimes, or when the bronchiectasis is due to prolonged partial obstruction of a bronchus by a thoracic aneurysm, there may be copious and fatal haemoptysis, as described above. Bronchiectasis seldom occurs apart from fibrosis of the lung ; indeed, fibroid lung is commoner than bronchiectasis ; when fibrosis and bronchiectasis occur together and affect one lung in particular, the diagnosis is relatively easy, for there is deficiency of bulk, movement, and resonance, tactile vocal fremitus, vesicular murmur, and voice sounds over the affected lung ; the heart is materially displaced towards that side ; numerous loud crackling rales, with or without bronchial breathing, bronchophony, and pectoriloquy, will be heard over scattered patches of the affected lung, whilst in the intervening areas there will be little to be heard at all ; the rales will be brought out best when the patient coughs ; the lung on the other side may give relatively normal signs. Clubbing of the fingers may be extreme. The diagnosis of fibroid lung and bronchiectasis itself is not complete, however, until the precise cause of the latter has been ascertained ; sometimes so complete a diagnosis is not possible. The following is a list of the chief causes of the condition : — 1 . Causes in the lung : — Congenital atelectasis Pneumonoconiosis Recurrent attacks of Chronic tuberculosis bronchopneumonia Delayed resolution of lobar pneumonia 2. Causes which act by partially stenosing a bronchus : — [a). Causes within the bronchus : — A foreign body Inspissated bronchitic mucus. (b) . Causes m the wall of the bronchus : — Syphilitic stenosis Primary epithelioma, (c). Invasion of the bronchus from without : — Aortic aneurysm Mediastinal new growth Hodgkin's or lymphadenomatous glands Caseous bronchial glands A hypertrophied left auricle in some cases of mitral stenosis. 3. Causes which have long compressed the lung from the pleural side : — Sporotrichosis Recurrent bronchitis (doubtful). Pleuritic effusion Pleural effusion Thick pneumonic lymph Empyema Pericardial effusion Ascites Subdiaphragmatic abscess Hepatic tumour A large heart | Splenic tumour. HEMOPTYSIS 325 There will be no need to discuss each of these here ; if the different possibilities are kept in mind, a probable diagnosis can be made fairly easily in most cases. The only bronchial causes of haemoptysis that need be dealt with further are syphilitic ulceration and infection by the Distoma pulmonale. Syphilitic Disease of a Bronchus is a tertiary lesion of gummatous nature, and as it heals it causes bronchial stenosis and consequent fibrosis of the lung, with or without bronchiectasis. It will hardly be diagnosed unless there are other very definite means of knowing that the patient has had syphilis, and is still suffering from its tertiary effects ; ar\d even then care must be taken to exclude the possibility of the luetic patient having developed phthisis. The influence of iodide of potassium in such a case does not afford conclusive evidence one way or the other, for even though the syphilitic lesion heals, it leaves behind it the fibrous steno.sis of the bronchus. The Distoma Pulmonale Westermanni is very unlikely to be the cause of haemoptysis in any patient who has not been resident in China, Japan, or Formosa. History of residence in those countries, on the other hand, would suggest the diagnosis, confirmation of which would be afforded by examination of the sputum for the parasites or their ova. The differential diagnosis of Haemoptysis due to changes in the Larynx depends mainly on two things : the history of the case, and the condition seen locally with the laryngoscope. The history and course are the chief factors in diagnosing acute simple laryngitis, post-typhoidal, post-diphtheritic, or variolous ulceration of the larynx, or conditions due to injury of the larynx by a blow, a hand-grip, a cut throat, or intubation or other operation. Leprous ulceration of the larynx seldom, if ever, occurs in any patient who has not lived in leprous lands, and who has not for a long time exhibited subcutaneous and cutaneous evidence of his disease. Of the remaining five conditions given in the list, namely, tuberculous, syphilitic, and malignant ulcerations, lupus, and angioma of the larynx, the last two are very rare indeed, though both may be diagnosable by their laryngoscopic appearance, particularly if there is also lupus of the face on the one hand, or a tendency to cutaneous or buccal blood-oozing nasvi on the other. Between the remaining three conditions there mav be some doubt for a time, but if it can be seen that the ulceration is extensive and yet unilateral, it is probably epitheliomatous ; if tubercle bacilli are present in the sputum, if there are apical lung signs, and if multiple shallow ulcers can be seen along the epiglottis, as well as in the larynx, tuberculous ulceration is probable — it practically never occurs except secondary to pulmonary tubercle, though the latter may be slight and may remain in abeyance, whilst the laryngeal tubercle advances rapidly ; syphilitic laryngitis may be diagnosed by exclusion, but if there is a tendency to healing, with marked deformity, after extensive bilateral destruction of the laryngeal and neighbouring tissues, and if there is decided collateral evidence of tertiary syphilis, including, perhaps, a positive serum reaction, the diagnosis may often be made directly. The chief difficulty arises in cases in which there may be both syphilis and tubercle at the same time. This brings us back once more to the fact that, once it has been decided that true haemoptysis has occurred, the next step is to examine carefully the sputum and the chest for signs of tubercle, and not to diagnose any other condition until both tubercle and mitral stenosis have been excluded. Herbert French. HEMORRHAGE FROM GUMS.— (See Bleeding Gums.) HAEMORRHAGE FROM LUNG.— (See H/emoptysis.) HEMORRHAGE, GASTRIC— (See H^matemesis.) D 21 A 326 HEADACHE HEMORRHAGE, INTESTINAL (See Blood per Anum , and Meljena.) HEMORRHAGE, NASAL.— (See Epistaxis.) HEMORRHAGE, RETINAL.— (See Ophthalmoscopic Appearances.) HEMORRHAGE, SUBCUTANEOUS.— (See Purpura.) HEMORRHAGE, URINARY (See Hematuria.) HEMORRHAGE, UTERINE, and HEMORRHAGE, VAGINAL.— (See Menorrhagia; Metrorrhagia; Metrostaxis.) HEMOTHORAX.— (See Chest, Bloody Effusion in.) HALTING. — (See Gait, Abnormalities of.) HEADACHE is one of the commonest symptoms met with in medical practice, and the various conditions with which it is associated are exceedingly numerous, as the list given below amply demonstrates. Headache may be the first symptom calling attention to the existence of grave organic disease, and the correct diagnosis of the cause of this symptom is obviously of the greatest importance. Too often, unfortunately, treatment of a headache precedes a careful investigation as to its cause, and an increased risk may be thereby incurred bj^ the patient through the delay in recognizing some one of its more serious causes. The explanation of the mode of production of the pain known as headache is not easy, seeing that the brain substance itself is insensible to mechanical stimu- lation. The meninges are supplied with sensory nerves, and abnormal stimuli received therefrom reach the cortex and give rise to the impression of pain. Abnormal states of the intracranial blood-vessels may cause pain, which is more difficult of explanation, as it is uncertain that they have any sensory nerve- supply. It seems probable that the headache produced by increased vascular tension is a pressure effect acting on the brain as a whole, or on its coverings the meninges. The scope of this article does not allow further discussion of this part of the subject. Certain general hnes of diagnosis may be laid down. The closest attention should be paid to the character, situation, and time of occurrence of the pain, and also to accompanying symptoms. The character, whether throbbing, paroxysmal, or affected hy movement or position. Headaches associated with alimentary disturbance, and raised blood- pressure, are often throbbing in character, are reheved by rest in a recumbent position, and are increased on movement. Severe paroxysmal attacks would suggest a neuralgia. The situation. This may be frontal, vertical, occipital, or unilateral, and in cases of organic disease of the cerebrum may be an important indication and an aid in localizing the situation of the lesion. In renal disease, the headache associated with chronic uraemia is usually frontal, but may be occipital. It is vertical in constipation, the " bilious " headache. It may be unilateral in migraine, tumour, abscess, middle-ear disease; or occipital in cerebellar disease. Occipital headache may also be simulated by myalgia in the muscles and tendons of the nape of the neck. Time of occurrence. — Headache associated with organic disease of the brain or its meninges often persists or becomes worse at night, and may wake the patient from his sleep, whereas that due to toxic and functional causes is relieved by rest in a horizontal position. Grave suspicion of the organic nature of the HEADACHE 327 headache should, therefore, attend a case in which pain in the head disturbs the patient's sleep at night. A headache experienced on rising in the morning may be due to a stuffy, ill-ventilated room, or to the slighter degrees of com- bined astigmatism and hypermetropia, or to faulty adjustment of the pillows. Pillows piled too high may cause interference with the cerebral circulation and result in headache. Persistent morning headache may be associated with chronic nephritis, and careful observation should therefore be made of the patient's urine. Evening headaches are most commonly due to mental over- work, or eyestrain^ especially w^here some visual defect exists. For the purposes of classification it is convenient to divide the causes of head- ache into three main groups : — {A) Organic disease (brain, intracranial vessels, meninges, skull, special sense organs) ; iB) Toxic states ; (C) Functional condi- tions. A. Causes due to Organic Disease. These may be classified anatomically as follows : — • 1. Diseases of the brain ;— Concussion Cysts Tumours Hydrocephaly Abscess Disseminated sclerosis Gumma General paralysis of the insane. 2. Diseases of intracranial vessels : — Haemorrhage (rupture) Aneurysm Thrombosis Syphilitic endarteritis Embolism Arteriosclerosis. 3. Diseases of the meninges: — ■ Meningitis, various forms — Syphilis — meningeal type localized or diffuse Tumours. Pachymeningitis 4. Diseases of the skull : — ( Innocent Tumours ' ,t t ^ I Primary I Malignant ^ „ / I ° I Secondary. Tertiary syphilis Suppuration or new growi;h in frontal, antral, or mastoid sinuses Suppuration or tumour in the orbit Dental diseases. 5. Diseases of special sense organs : — • Eye — errors of refraction, iritis, glaucoma, etc. Ear — middle-ear disease. Nose — adenoids, polypi, nasopharyngeal catarrh. Inflammation of one of the accessory air sinuses — frontal, ethmoidal, sphenoidal ; empyema of a frontal sinus. Headache in Organic Cerebral Disease. Time of occurrence. — Organic cerebral disease should be strongly suspected if a history of recurrent nocturnal headache be obtained. Severity. — The pain is often intense, and sometimes paroxysmal in character. Situation. — This may give some clue as to the existence of an organic lesion. In cases of cerebral tumour the pain may be unilateral or frontal, or occipital with a cerebellar lesion. In middle-ear and mastoid disease with unilateral headache and localized tenderness, occipital headache may be one of the earliest symptoms of meningitis. Associated Signs and Symptoms. — One or more of the following signs and 328 HEADACHE symptoms may present themselves at an early period in cases of headache due to organic cerebral disease, and their early recognition is of great importance : — Optic neuritis Irregularity in force and frequency of the pulse The onset of drowsiness Fits. Vomiting — ^that is of the "cerebral type " (see Vomiting) : it usually bears no relation to food, and is not preceded by nausea Inequality of the pupils Squint Tapping the skull over the site of the pain may reveal local tenderness. The onset of any of these signs associated with headache would point to the existence of some organic lesion, such as are enumerated above. As in many of these conditions the diagnosis is unattended with difficulty, it will suffice to direct attention to a few of them. The headache occasionally met with in disseminated sclerosis is sometimes paroxysmal and accompanied by vomiting, and is most frequently situated in the back of the head and neck. The absence of optic neuritis and the presence of the special signs of disseminated sclerosis should lead to a correct diagnosis. Cerebral hemorrhage, thrombosis, and embolism are often followed by headache of varying severity. In cerebral aneurysm a rhythmic beating or pulsation is sometimes felt, and rushing noises are heard, more particularlj^ when the internal carotid is involved. Advanced arteriosclerosis of the cerebral arteries is sometimes attended by very severe headache accompanied by vomiting ; and cases have been described presenting features closely resembling those of cerebral tumour. In arriving at the diagnosis instrumental measurement of the blood-pressure is all-important. In meningitis, especially in the epidemic cerebrospinal and the post-basal varieties, the character of the headache is significant. It is usually very intense, is occipital, and even at an early stage may be attended by stiffness of the neck and retraction of the head. The examination of the cerebrospinal fluid obtained by lumbar puncture is of great importance in determining the presence of meningitis (see Retraction of the Head). Special Sense Organs. — Eye. Headaches due to errors of refraction, glaucoma, iritis, etc., are generally frontal or temporal. A slight error of refraction may cause what appears to be a disproportionately severe headache, particularly in children. This headache is frontal, occurs mostly in the evening or after school hours, and is often attended by a burning, pricking or watering of the eyes. Correction of the defect by suitable glasses settles the diagnosis by curing the headache. B. Toxic Causes. These may be subdivided into two groups, one in which the toxic influence is acquired from without, or is exogenous ; the other in which the disturbing , element or toxin is produced within the body, and is of endogenous origin. 1. Of exogenous origin : — Foul air, as in close, ill-ventilated rooms Poisonous gases, CO.,, CO, chloroform, ether, etc. Drugs, e.g. quinine, iron in some individuals, salicylates, opium. Alcohol Tobacco Lead poisoning. 2. Of endogenous origin : — Uraemia Gout Cholaemia Diabetes Gastro-intestinal disturbances : dyspepsia, constipation Toxasmias : specific fevers, pyrexia in phthisis, suppuration, etc. HEADACHE 329 As regards the toxic causes of headache Httle further need be said as to the diagnosis of the exogenous poisons. Urczmia is classed for purposes of convenience as a condition due to endo- genous bodies, or substances produced within the body. It stands out as one of the most important causes of headache, and special attention must always be given to ensure its recognition. Uremic headaches may be met with in all degrees of severity, from a slight frontal headache felt on rising in the morning to an intense vertical or general cephalalgia. Other ursemic manifestations may be present, such as vomiting, drowsiness, dyspnoea, affections of vision, and retinal changes. The examination of the urine in all cases of headache should never be neglected, as regards its specific gravity, the presence of albumin, blood and casts. C. Functional Causes : — / high, in arteriosclerosis and renal Abnormal blood- pressure -, . low, in anaemia, morbus cordis, I Addison's disease Venous congestion Excessive mental strain Pressure on the head — heavy hats, carrying weights on the head Persistent noises — '' gun headache " Sea-sickness — movement of boat, train Menstruation Hysteria — (" clavus hystericus ") Migraine Epilepsy Eye strain, " academy headache " Sunstroke. High blood-pressure is often a cause of headache, usually of a throbbing character, accompanied by a sense of fullness of the head. The headache tends to come on towards evening and after meals. The vascular condition should be ascertained by means of some suitable apparatus for estimating blood-pressure. Headache associated with low blood-pressure (cerebral anaemia), as in some forms of morbus cordis and anaemia with feeble cardiac action, is relieved by rest in the horizontal position and cardiac tonics such as digitalis and iron. Venous congestion may cause headache. This is also met with in heart disease with failing compensation. It may also account for the headache felt on rising in the morning as the result of sleeping with pillows too high or too low. The "clavus hystericus " is a boring pain felt in the vertex and in hysterical states. Headache in migraine is often unilateral, though quite commonly bilateral, and it is frequently accompanied by vomiting. Transitory visual disturbance usually precedes the headache. In epilepsy headache is of frequent occurrence in the post-epileptic state, and it should be borne in mind tha,t it may also follow the slight manifestations of petit mal. After sunstroke, chronic headache, usually vertical, may persist for months, and the same apphes to many head injuries. It is sometimes difficult to distinguish between headache, which implies pain inside the skull, and neuralgia, which is pain felt in the peripheral course of a 330 HEADACHE nerve trunk (see Pain in the Face). Neuralgia, if of wide distribution, may simulate headache. Careful examination may be necessary to decide whether the supposed headache may not in reality be a neuralgia. The local distri- bution, the often intense and paroxysmal character of the pain, the presence of " tender spots," the existence of some definite exciting cause such as dental caries, should point to the diagnosis of neuralgia. u. Morlcy Fletcher. HEART, ENLARGEMENT OF.— (See Enlargement of the Heart.) HEART IMPULSE, DISPLACED. — The apex beat, which is the lowest and outermost point at which the cardiac impulse can be felt, is situated in the normal adult chest in the fifth left intercostal space, one-half to one inch internal to the mammillary line. It may be impossible to define the position of the apex beat even in health, on account of increased thickness of the chest wall, either due to muscular development or to excess of fat ; or in the female on account of a large mamma. A similar difficulty arises when the cardiac impulse is feeble ; when the heart is overlapped by the left lung, as in pulmonary emphj'sema ; or when pericardial effusion is present. In children, the apex beat is situated further to the left than in adults. Speak- ing generally, it is outside the mammillary line during the first three 3'ears of life, in the mammiUaxy line from the fourth to the tenth j'ears, and it gradually reaches the adult position by the age of fifteen years. In many patients ^rith displacement of the apex beat of the heart, the cause is obvious, as in the case of a cardiac lesion, chronic renal disease and arterial sclerosis, disease of the lungs and pleurae, thoracic tumour, or abdominal enlarge- ment. The conditions which produce displacement of the cardiac impulse can be classified under the following two headings : — A . When the bulk of the Heart is in the Normal Position. 1. Diseases of the heart : (a). Valvular (c). Pericardial. (b). Myocardial 2. Changes in the heart secondary to : (a). Diseases of the lungs, such as emphysema, fibrosis, etc. (6). Arterial sclerosis and chronic renal disease (c). Anaemia and any debilitating conditions which affect chiefly the right ventricle {d). Toxic conditions producing changes in the myocardium, as in specific infectious diseases (e). Muscular exertion. B. When the whole Heart is Displaced. 1. Changes in the lungs : (a). Contraction of one lung or a portion of it (fe). Enlargement of one lung, as in pneumonia, emphj'sema, (c). New growth of lung. 2. Changes in the pleurcB : (a). Pleuris}^ with effusion, empyema, pneumothorax (b). New growth of pleura. 3. Other thoracic tumours — new growth, aneurj-sm. 4. Deformities of the chest wall, as the result of scoliosis. 5. Changes in the abdomen — ascites, t^-mpanites, abdominal tumour, and pregnancy. 6. Transposition of the heart. HEART IMPULSE, DISPLACED 331 To distinguish between these two groups is usually not difficult, for when the bulk of the heart is in the normal position, and the apex beat is displaced beyond the left mammary line, the area of cardiac dullness is found to be increased, not only to the left, but also to the right of the sternum, and in an upward direction. This increase is found in all cases in which there is a general enlargement of the heart, provided that the organ is not overlapped by an emphysematous lung. If both lungs are emphysematous and the cardiac apex is displaced out- wards, although the size of the heart cannot be estimated by percussion, yet the bulk of the heart may confidently be presumed to be in the normal position. The presence of a cardiac lesion, arterial sclero.sis, or chronic renal disease, helps to confirm the view that the abnormal position of the apex beat is due to an increase in the bulk of the heart, and not to a displacement of the organ as a whole. The examination of the pulse gives valuable information ; if it be of high tension and is sustained, or if the pulse is of the " water-hammer " type, it indicates that the displaced apex beat is due to enlargement of the left ven- tricle, and that probably there is no displacement of the heart. The blood- pressure is increased in arterial sclerosis and in renal disease, and must therefore be estimated, for it gives additional evidence that the displaced apex beat is part of a general enlargement of the heart. The examination of the urine must never be omitted, for if there be polyuria, with a small trace of albumin, low specific gravity, and hyaline and granular casts, the presence of chronic inter- stitial nephritis is ascertained, and this will account for the enlargement of the heart, and any displacement of the apex beat downwards and to the left. The presence of a cardiac bruit is of great value in determining that the dis- placed apex is due to morbid changes in the heart ; but the absence of a bruit does not necessarily mean that the displaced apex beat is unassociated with cardiac disease. The enlargement of the left ventricle, due to arterial degenera- tion or chronic interstitial nephritis, may not be accompanied by any bruit, unless dilatation becomes so great that mitral regurgitation supervenes. The characters of any of the cardiac sounds are frequently altered in dilatation and hypertrophy of the left ventricle. Thus, the aortic second sound may be accen- tuated on account of the increased arterial tension, and the second sound over the base of the heart may be reduplicated on account of the aortic and pulmonary valves not closing synchronously. The first sound is frequently louder and more prolonged in hypertrophy of the ventricles, due to an increase in the muscular element of the sound, and the greater force with which the auriculo- ventricular valves are closed. In simple dilatation of the ventricles, the first sound is often slightly accentuated, but is usually sharper and shorter. In the second class of cases, in which the whole heart is displaced, the cause of the displacement is usually easy to ascertain. The chest is frequently asymmetrical, for there will be either bulging of the chest wall on the side from which the heart is displaced, or some shrinking on the side to which it is drawn. When the heart is displaced, examination by percussion may show that resonance is present where normally there is cardiac dullness. Thus, when the right lung is emphysematous and the heart is pushed over to the left in conse- quence, the resonance of the right lung may be found extending to the left of the sternum. A similar absence of cardiac dullness is found on the other side of the chest when the heart is pushed to the right in emphysema of the left lung. It is not always so easy to determine the boundaries of the heart when the dis- placement is due to the presence of a pleural effusion, as there is dullness over the effusion which may be continuous with the cardiac dullness. In such a case, however, the dullness over the base of the lung is not only in front, but is likely to be found behind as well. There are also signs of compression of the lung by the effusion, such as absence of breath- and voice-sounds and the existence of 332 HEART IMPULSE, DISPLACED tubular breathing, and skodaic resonance. .Egophony may be heard at the upper level of the fluid, and when present it is very suggestive of pleuritic effusion. WTien the heart is drawn over to one side by the contraction of the lung, as in fibrosis, there is impaired resonance upon percussion over the fibrosed lung, continuous with the cardiac dullness. The boundaries of the heart may be difficult to define by percussion, but over the fibrosed lung, breath-sounds are present, tubular in character, vocal fremitus and resonance are increased, and crackling rales and other adventitious sounds may be heard. \Vhen the heart is drawn over in this manner by fibrosis of one lung, the resonance over the healthy lung will be found to extend across the middle line, and thus invade the normal position of cardiac dullness. Examination of the chest by means of the AT-rays usually helps to determine the position of the heart ; but large tumours, pleuritic effusions, etc., produce shadows which may be continuous with that of the heart. The pulsations of the heart are generally well seen, especially in children, and indicate its position. The changes in the abdomen, causing displacement of the heart upwards, are not likely to be overlooked, because there must be a considerable amount of abdominal enlargement before the heart can be raised by it ; and therefore, if displacements of the apex-beat are due to ascites, tympanites, abdominal tumours, or pregnane}-, the causes are all of such a marked degree or in such an advanced stage, that they are easily recognizable. ^Vhen the heart is displaced as the result of marked changes in the lungs and pleurae, intrathoracic tumours, or abdominal enlargements, the causes of the displacement are usually found first on account of the symptoms and physical signs they produce ; the alteration in the position of the apex beat is then a confirmatory sign. In the first group, in Avhich the bulk of the heart is in the normal position, the direction in which the apex beat is displaced is of some diagnostic value. It is displaced downwards and to the left in hypertrophy of the heart, especially when it affects chiefl}^ the left ventricle. In mitral regurgitation the apex beat is displaced outwards and to the left, whereas in lesions of the aortic valves the displacement is to the lelt and downwards, so that the apex beat is commonly situated in the sixth intercostal space. In both these conditions the left ventricle is enlarged, but Avith mitral regurgitation the right side of the heart becomes enlarged early in the disease, and the apex is displaced much more outwards than downwards. ^Vhen the right ventricle is alone enlarged, as in pulmonary emphj-sema, the displacement of the apex beat is directly to the left, and not dowuAvards at aU. The varying enlargement of the two ventricles may be fairly gauged by watching the position of the apex. It is raised and displaced slightly to the left by any cause which increases the height of the diaphragm, such as ascites, tympanites, abdominal tumours, and pregnancy. The cardiac impulse is also raised in pericardial effusions. There are, however, a considerable number of cases of displaced apex beat, with the bulk of the heart in the normal position, in which it is difficult to ascertain the cause of the displacement. This is especially so in young adults, in Avhom the apex beat may be found to be displaced slightly outwards without any apparent cause. If the subject be a young and muscular man, who otherwise seems in good health, the condition is probably due to hypertrophj' of the left ventricle as the result of excessive athletic exercise or of some arduous muscular work. The history would confirm this view. If, on the other hand, the patient is not a muscular individual, the displacement may still be due to strain, but some other cause should always be looked for, and in the absence of any obvious cardiac lesion, pericardial adhesions must not be forgotten : these may be very slight, and produce very few symptoms except a slight enlargement of the heart. HEMIANOPSIA 333 In young girls, the apex beat is often situated in the mammary line, and this displacement is associated with chlorosis and other debilitating conditions -which produce dilatation of the conus arteriosus. The apex beat is not only displaced outwards, but is also raised. The diagnosis is confirmed by finding that the cardiac dullness is increased in an upward direction, and by the presence of a functional systolic bruit in the pulmonary area and a bruit de diable in the neck. In elderly people, in whom there is no valvular disease of the heart, the apex may be displaced, not only as the result of hypertrophy of the left ventricle secondary to renal disease and arterial sclerosis, and as the result of enlargement of the right ventricle secondary to pulmonary emphysema ; but also as the result of myocardial degeneration. The last condition may be difficult of diagnosis, but when there is no evidence of valvular disease, emphysema, chronic renal disease, arterial sclerosis, or anything causing displacement of the heart as a whole, it must always be suspected ; for myocardial degeneration occurs more frequently than is generally suspected. When the apex beat is displaced out- wards as the result of myocardial degeneration, certain symptoms frequently accompany it, such as dyspnoea upon exertion, attacks of syncope, palpitation, and oedema of the legs. The pulse is feeble and irregular, and on examination of the heart, the impulse is feeble, a gallop rhythm is frequently present, and a soft systolic bruit audible at the apex. Another form of uniform cardiac hypertrophy that needs special mention is that which results from long-continued drinking of large quantities of fluid, particularly beer — the beer-drinker's heart. J . E. H. Sawyer. HEART SOUNDS, ACCENTUATION OF. — (See Accentuation of Heart Sounds.) HEART SOUNDS, REDUPLICATION OF (See Reduplication of Heart Sounds.) HEARTBURN, or Pyrosis, is an indication of excessive acidity of the gastric contents. This may be due either to excessive secretion of acid (hyperchlorhydria, or hypersecretion) , or to abnormal fermentation of the food leading to the produc- tion of organic acids (lactic, acetic, butyric, etc.). The diagnosis between these different causes must depend upon a consideration of the other signs and symptoms present, and upon the results yielded by a test meal (see Indigestion). It is possible that heartburn may also be produced by the escape of normal gastric contents into the lower end of the oesophagus, as the result of a relaxed condition of the cardiac sphincter. This can only be inferred from the absence of any other cause for the symptom. Robert Hutchison. HEMERALOPIA.— (See Vision, Defects of.) HEMIANESTHESIA.— (See Sensation, some Abnormalities of.) HEMIANOPSIA — or, as it is sometimes called, hemiopia or hemianopia — means inability to see objects in one half of the field of vision. It is generally, but arbitrarily, restricted to cases in which this defect is due to changes else- where than in the retina or disc. It is not a common condition, but it some- times escapes recognition because, whichever half of the visual field has become blind, good vision remains at the central part, and even the patient himself may not ahvaj-s be conscious of his defect until some accident, such as running into objects in broad daylight, draws his attention to it. To map out the blind area with accuracy, an instrument known as the perimeter is required. It is possible to get hemianopsia in one eye only, but this is very rare apart from functional conditions or migraine. 334 HEMIANOPSIA When both eyes are afiected, the bhndness may affect either : (i) Correspond- ing halves of the field of vision — bilateral homonymous hemianopsia — spoken of as right if neither eye can see objects in the patient's right-hand half of the field of vision [Figs. 103 and 104), and as left if in the left half ; or (2) Opposite halves of the field of vision — almost invariably the temporal halves, and referred to as bilateral temporal hemianopsia {Fig. 102). These are the only two varieties that are of clinical importance. They are generally not the only symptoms in the case, but they sometimes serve to localize certain cranial lesions with accuracy. J^/^. loi. — A diagram illustrating the con- nections of the optic nerves and tracts, the 3rd cranial nerves, and the occipital cortex. A, 3rd nerve going to left eye ; B, ditto to right eye ; C, relay of cells in optic thalamus and superior corpus quadrigeminum ; D, left occi- pital cortex, which sees objects in the right half of the field of vision ; E, right occipital cortex, which sees objects in the left half of the field of vision. Fig: 102. — A diagram showing how a tumour of the pituitary body affecting the decussating fibres at the optic chiasma prevents impulses passing from the nasal half of either retina to the corresponding cortex or to the correspond- ing 3rd nucleus. Hence bilateral temporal hemianopsia and absence of pupil reaction to light thrown on the nasal half of either retina. I. Bilateral Homonymous Hemianopsia has a variety of causes, affecting one or other of three main sites, namely : («) one optic tract ; (b) the posterior limb of one internal capsule ; or (c) the optic radiations or one occipital region at or near the cuneus. In any of these sites the pathological lesion may be either vascular — thrombosis, haemorrhage, embolism, or intermittent closure ; or a neoplasm, such as a gumma, a tuberculous nodule, an inflammatory swelling, or a gliomatous, carcinomatous, or sarcomatous nodule. The first step is to locate the site of the lesion ; its nature will then be more easily HEMIANOPSIA 335 determined, because in the internal capsule a hccmorrhage, thrombosis, or em- bolism of the middle cerebral artery is the commonest cause of the symptom ; a neoplasm, or an abscess, is probably its commonest cause in the occipital cortex, though an abscess, or rupture or occlusion of the posterior cerebral artery would also be thought of ; in the optic tract it is as often as not gummatous, or in some other way syphilitic. 2. Bilateyal Temporal Hemianopsia. — There is only one spot at which a single lesion can produce this condition ; this is at the central part of the optic chiasma where the fibres from the nasal half of each eye are decussating. The three com- Fig: 103. — .-V diagram showing how a lesion of the left optic tract causes blindness of the right half of the field of vision of each eye. and also prevents the pupils from reacting in response to a ray of light falling on the blind half of either retina. Fig. I04. — A diagram showing how a lesion of the left optic radiations or of the visual portion of the left occipital cortex causes blindness of the right half of the field of vision of each eye, but does not prevent the pupils from reacting in response to a ray of light falling on the blind half of either retina. monest causes of this rare lesion are : {a) Hypertrophy of the pituitary body, a condition which also leads to acromegaly, so that it is important to test for bilateral temporal hemianopsia in every case of acromegaly, and it will be found in a certain number ; {b) Callus, resulting from a fracture of the base of the skull through the basi-sphenoid bone ; (c) A gumma or other tumour in this region. The differential diagnosis between these three groups will generally be obvious enough when the variety of ha;mianopsia has been established. In order to decide the locality of the lesion it is essential in the first place to determine whether a pencil of light falling upon that part of the retina which 3 3 6 HEM I A NO PS I A cannot see is able to evoke a reflex contraction of the pupil. This requires careful testing in a dark room, with a small pencil of light directed towards different portions of the eye at the observer's will by a suitable mirror or lens. Anatomical considerations make it obvious that if the optic tract is destroyed there is no path by which the light impulses from the non-seeing portions of retina can reach the oculomotor nucleus, so that there will be no reflex movement of the pupil in response to light {Fig. 103). If, on the other hand, the optic tract is intact, the lesion being in the posterior limb of the internal capsule, or in the optic radiations or the cuneus, the same hemianopsia results, but the pupils react to light stimuli falling upon the blind halves of the retinae {Fig 104). If the light reflex is lost the lesion is at once located to the optic tract, pro- vided there is no obvious trouble, such as cataract, or locomotor ataxy, or iritic adhesions, to prevent the reaction. If, on the other hand, the light reflex remains, the lesion must be in one of the three other places mentioned, and in determining this the history may help considerably. If there has been an apoplectic seizure in an elderly person, haemorrhage in the region of the internal capsule is likely, and there will often be both hemiparesis and hemiparsesthesia at the same time. In a younger person suffering from heart disease, a somewhat similar history would point to embolism involving the posterior limb of the internal capsule. If, on the other hand, there has been a slow onset, with increasing headache, vomiting, and giddiness, then a neoplasm or gumma affecting the optic radiations or one occipital pole will not be unlikely. If the patient is unable to see things in the right halves of his fields of vision, the lesion will b=! in his left optic tract, left internal capsule, left optic radiations, or left cuneus, as the case may be, and vice versa. Hemianopsia due to migraine or to intermittent closure of cerebral vessels will be distinguished from that due to the other causes by its presence on some occasions and its absence on others. Irregular or partial forms of hemianopsia result from irregular or partial lesions in the optic tract or other regions mentioned above. The differential diagnosis is then more difficult, though it is made upon the same lines as those described above. From a diagnostic point of view it is fortunate perhaps that hemianopsia, when it occurs at all, is generally definite, and either bilateral temporal or bilateral homonymous. Herbert French. HEMIPLEGIA signifies loss of motor power in the limbs of one side ; the face, especially its lower half, being frequently affected at the same time. In the great majority of cases the face is paretic on the same side as the affected arm and leg, but there is one important exception to this, namely when the lesion is in one side of the pons Varolii, when there is paralysis of the face upon the same side as the lesion, and of the arm and leg upon the opposite side — a condition known as crossed hemiplegia. The lesion in most cases, however, is in or near the internal capsule, less often in the motor cortex, of the opposite side to that which is hemiplegic. There may or may not be hemiansesthesia at the same time, and in rare cases, when the lesion is far back in the internal capsule, there may also be Hkmianopsia (^.u.). When the cause lies in the internal capsule, the paralyzed m^uscles may be either flaccid or spastic, but they do not as a rule exhibit the athetotic and other involuntary movements that cortical lesions may give rise to (see Contractions). When a patient has difficult}- in speech associated with hemiplegia it is important to distinguish dysarthria from aphasia (see Speech, Abnormalities of). Lesions of the internal capsule often produce difficulty in using the tongue, which renders speech mechanically difficult (dysarthria) — a very different thing from the aphasia or difficulty in uttering the correct words when the mechanism for the movements HEMIPLEGIA 337 of the tongue is unaffected. True aphasia associated with hemiplegia suggests a lesion at, or close to Broca's area of the cortex on the left side, and is therefore far less common with left-sided than with right-sided hemiplegia. The fact of hemiplegia is generally not difficult to determine, though in some cases there may be so slight a weakness that doubts arise as to whether there is any hemiplegia at all. The routine examination of such a patient will generally detect a little inequality' in the degree to which the eyes can be closed firmly, a slight difference in the depth of the two naso-labial folds when the patient opens his hps with his teeth clenched, a greater difference than previously between the two hand-grips, as measured by the dynamometer, slightly brisker radial and ulnar wrist-jerks, or tricipital and bicipital elbow-jerks upon the affected side, inequality of the knee-jerks with a tendency to exaggeration upon the paretic side, with corresponding extensor plantar reflex and increased Achillis jerk or even ankle-clonus. All these changes will be pronounced in cases where the hemiplegia is more definite, though if the patient be seen within a short time of the onset of hemiplegia from cerebral heemorrhage, the tendon and other reflexes — which will presently be exaggerated should the patient survive — may for the time being be decreased or even unobtainable upon the affected side. Stress is often laid upon the presence or absence of rigidity in connection with hemiplegia, particularh' according as the rigidity comes on early or late in the case. This helps less, however, in the diagnosis than it does in the prognosis. A few cases of hemiplegia are flaccid throughout, though this is uncommon if the patient survives and the hemiplegia persists ; in cases of hemiplegia due to cerebral haemorrhage early rigidity generally suggests a smaller hasmorrhage than does early flaccidity followed by rigidity ; so variable is this, however, that the point is of less value than has sometimes been supposed. It is difficult to classify the causes of hemiplegia satisfactorily, but the follow- ing is a summary or list of those discussed : — A. — The Commoner Causes of Hemiplegia. 1. Hemiplegia of moderately Rapid Onset. Cerebral haemorrhage Syphilitic endarteritis of a middle cerebral artery Thrombosis of a middle cerebral artery. 2 . Hemiplegia of Sudden Onset. Embolism of the middle cerebral artery, generally due to mitral stenosis, or to fungating endocarditis. 3. Hemiplegia dating from Birth, or from infancy, and resulting from :■ — Injury Congenital malformation Acute encephalitis Sinus thrombosis Meningococcal meningitis. Granted that a patient is suffering definitely from hemiplegia, the exact cause of the symptom has to be determined. One may say at once that the diagnosis is easy in a very large proportion of cases. Hemiplegia of moderately rapid onset in a patient over fifty years of age is almost certainly due to cerebral hcsmorrhage, particularly when it is associated with coma of rapid but not instan- taneous onset, when there is a high blood-pressure and enlargement of the heart, with a ringing aortic second sound, with or without albuminuria or other evidence of granular kidney or arteriosclerosis. If the hemiplegia has been of gradual onset in a young adult, particularly if one limb is very much more affected than the rest of that half of the body, if there had been premonitory symptoms for some hours, or even days, before the paresis became marked, and D 22 338 HEMIPLEGIA if there has been no loss of consciousness, the great probabihty is that the patient is suffering from syphilitic endarteritis of the middle cerebral artery, with or without secondary thrombosis. The diagnosis may be confirmed by a history of syphilis, by the occurrence of cutaneous ulcers or other syphilitic lesions, or by a positive Wassermann's serum reaction. If the patient is young, if the hemiplegia has been of absolutely sudden onset, generally without, but sometimes with, loss of consciousness, the proba- bility of embolism of the middle cerebral artery, secondary to mitral stenosis or to fungating endocarditis, will be considerable, and the diagnosis will generally be confirmed by physical examination of the heart, and by enquiry into the history as regards acute rheumatism, chorea, or other rheumatic affections. In cases of fungating endocarditis there' may have been emboli elsewhere, the spleen will generally be palpable, and there will probably be some pyrexia with progressive anaemia and a tendency to subcutaneous and retinal haemorrhages. If the patient has been hemiplegic from birth or from early infancy, the probability is that there has either been an injury to the opposite side of the brain at birth, or congenital malformation of that side, or acute inflammation of it after birth — the result perhaps of acute encephalitis, sinus thrombosis, or even meningococcal meningitis which has recovered. It is particularly in these infantile cases that hemiathetosis is liable to be associated with the hemiplegia. Although the above are by far the commonest causes of hemiplegia at the different age-periods, it is possible for them to overlap as regards age incidence ; and one occasionally sees fatal cerebral haemorrhage, apparently of the senile type, in persons not much over twenty ; similarly, syphilitic thrombosis of the middle cerebral artery may not occur until after fifty ; fungating endocarditis followed by cerebral embolism may occur at any age, though it is commonest in young persons ; the same applies to cerebrospinal meningitis. The diagnosis will be indicated, if at all, by other symptoms than the hemiplegia. In doubtful cases considerable assistance may be derived from lumbar puncture and analyses of the cerebrospinal fluid : the following are some of the main points in which the latter may differ from the normal under various pathological conditions : — Appearance. — Cerebrospinal fluid is normally quite clear and free from colour, so that in a test-tube it may be difficult to distinguish it from water ; when there are inflammatory changes in the central nervous system, particularly in all the acute forms of meningitis, the fluid becomes opalescent, turbid, purulent, or even fibrinous ; and, instead of being colourless, it may develop a yellow or reddish-brown colour. Specific Gravity. — Its normal specific gravity is low, lying, as a rule, between 1-004 ^•iid 1-007. I't may retain a normal specific gravity even in diseased conditions, for instance in cases of general paralysis of the insane ; but if there are inflammatory changes, such as ineningitis, the specific gravity is liable to be increased. Tension. — Normally the fluid drops out through the lumbar-puncture needle at the rate of 60 drops per minute. If it exudes at a lower rate than this no definite deduction can be drawn, for it may be that the tube is partly occluded ; but if the rate of outflow is higher than one drop per second, it indicates a condi- tion of hyper-tension due to disease such as meningitis, cerebral tumour, haemorrhage, or abscess. Reaction. — Cerebrospinal fluid is always alkaline whether in health or in disease. Cryoscopy.—Th.e normal freezing point of the cerebrospinal fluid is — 0-55° C. ; in disease it may be either above or below this ; generally speaking, the greater HEMIPLEGIA 339 the diminution in the freezing point the more Ukely is acute organic disease to be present in the central nervous system. Sugar. — -The amount of reducing substance in normal cerebrospinal fluid, esti- mated by the reduction of Fehling's solution, is approximately 1-5 parts per 1, 000 ; in diabetes mellitus this is more or less increased ; what the figures are in other conditions has not yet been established fully, but there is some evidence to show that the sugar is materially decreased in dementia prascox. Urea. — Urea in cerebrospinal fluid amounts normally to 1-5 parts per 1,000 ; the disease in which there is any material increase in this is uraemia, and the excess of urea in cerebrospinal fluid in this condition is sometimes an important point in the differential diagnosis in cases of coma. Proteids. — There is little if any coagulable proteid in normal cerebrospinal fluid ; careful analyses have shown that no albumin is present, but that there are traces of globulin ; in diseased conditions, particularly thosv associated with inflammation within the cranium or spinal canal, there are albumin, more globulin than normal, and often some nucleo-proteid. Choline. — Some stress was laid at one time upon the supposed fact that choline platino-chloride crystals were obtainable from the cerebrospinal fluid when acute nervous degeneration was taking place, and not in health, but there is considerable evidence to show that the tests employed were unreliable, so that the general opinion now is that deductions drawn from analyses for choline are entirely erroneous, even when the choline periodide crystals are tested for instead of the platino-chloride. Cytological Examination. — The normal fluid is practically free from cells, although, owing to the impossibility of avoiding slight injury to vessels by the introduction of the lumbar-puncture needle, a few red corpuscles are generally found in the centrifugalized deposit, and a few leucocytes corresponding to the numbers that would be expected in the blood represented by the red cells. It is probable that cerebrospinal fluid obtained quite free from any blood contami- nation would be practically free from leucocytes. Quite otherwise is it in certain diseases — not only in acute lesions, such as meningitis, but also in chronic degenerations, such as general paralysis of the insane. It is important to examine the centrifugalized deposit, not merely for the presence or absence of leucocytes, but also for the different relative proportions of polymorpho- nuclear cells and of lymphocytes. A considerable number of polymorpho- nuclear cells generally indicates bacterial infection of the subarachnoid space by some organism other than the tubercle bacillus, especially streptococci, staphy- lococci, pneumococci, and meningococci. Some degree of polymorphonuclear excess may, however, accompany the characteristic lymphocytosis of a few cases of tuberculous meningitis. Mononuclear proliferation — that is to say lympho- cytosis — indicates, as a rule, a subacute or chronic inflammatory or degenerative condition ; it almost invariably accompanies syphilitic lesions of the central nervous system, particularly general paralysis and tabes dorsalis ; it is also to be expected in tuberculous meningitis, and in sleeping sickness. It is not, how- ever, pathognomonic of any of these, for it has been observed also in entirely- different conditions, such as herpes zoster, acute anterior poliomyelitis, some cases of cerebral tumour, lymphatic leukaemia, chloroma, and even mumps. Although lymphocytosis generally indicates chronic mischief, and polymorpho- nuclear leucocytosis acute infection, in the later stages even of acute microbial infections mononuclear cells may be more numerous in the cerebrospinal fluid than are the polymorphonuclears. Bacteriological Examination. — Normal cerebrospinal fluid is absolutely sterile. In pathological conditions it ma^^ be examined bacteriologically in various ways, including direct staining of films made from the centrifugalized deposit, cultural 340 HEMIPLEGIA methods, and inoculation into animals. The most important organisms that have been found are the pneumococcus, streptococcus, bacillus tuberculosis, meningococcus (Weichselbaum's Diplococcus tntracellularis meningitidis), pneumobacillus, bacillus typhosus, and, probably as a terminal infection only, the staphylococcus and the Bacillus coli communis. The cerebrospinal fluid may be used for testing for Wassermann's reaction for syphilis by complement fixation, though this is better carried out upon blood serum. The Treponema pallidum {SpirochcBta pallida) has been found in the cerebrospinal fluid in at least one case, but it again is more hkely to be detected in the local syphiUtic lesions. The only protozoon at all constantly met with in the cerebrospinal fluid in disease is the Trypanosoma gambiense in cases in which the trypano- somiasis has reached the stage of sleeping sickness. B. — Less Usual Causes of Hemiplegia. General paralysis of the insane Borderland sufficiency of the cerebral circulation in old people (intermittent claudication) Cerebral tumour, with or without hasmorrhage into it Cerebral abscess Stab or bullet wound injuring the spinal cord in the cervical region Hemichorea Meningitis, whether tuberculous, suppurative, posterior-basal, or epidemic cerebrospinal Disseminated sclerosis Caisson disease Hysteria. Amongst the less usual causes of hemiplegia it is perhaps worthy of particular mention that general paralysis of the insane sometimes attracts little or no atten- tion until a seizure of some kind occurs, this seizure not infrequently being epileptiform, and sometimes producing a hemiplegia closely simulating that due to cerebral hsemorrhage. The diagnosis may remain uncertain until the course of the case can be followed, but Wassermann's serum reaction, and the lymphocytosis in the cerebrospinal fluid, may each serve to point to the true nature of the case. Another feature is the very rapid rate of temporary recovery exhibited by some patients ; deeply comatose and hemiplegic when seen upon the day of seizure, nearly all the S3^mptoms may have disappeared by the next morning in a way that would be unusual were they due to a haemorrhage of sufficient size to cause so deep a coma. In quite old people, that is to say those over eighty years of age, incomplete hemiplegia may occur rapidly but transiently over a period of years, in such a way as to suggest during the first attack or two that there has been an actual extravasation of blood within the brain. The rapidity with which the hemi- plegic symptoms may disappear, and the way in which they may recur and yet disappear again each time, render it probable that these patients are not suffering from the effects of recurrent small haemorrhages, but from a condition of partial occlusion of their cerebral vessels by atheroma to such an extent that, whereas the circulation is just sufficient for the needs of the brain at one time, it is just insufficient at other times ; the result being that when the insufficiency of cerebral circulation is most in evidence, weakness of a hemiplegic type ensues, to disappear when rest in bed restores the cerebral circulation to a sufficiency again. Cases of this kind have been spoken of as suffering from intermittent claudication, as though the vessels could alternately dilate and close up spon- taneoush' ; but there is evidence to show that there are no efficient vasomotor HEMIPLEGIA 341 nerves in the cranial vessels, so that the theory of borderland sufficiency of circulation through atheromatous vessels is more probable than that of inter- mittent claudication. Cerebral tumour or cerebral abscess may produce hemiplegia by infiltrating either the cerebral cortex or the pyramidal tract directly, or by these becoming involved in the softening around the tumour or the abscess ; in most cases there will be a history of weeks or months of headache, giddiness, and effortless vomiting, with or without signs of irritation previous to the paralysis ; ophthalmoscopic examination will frequently reveal optic neuritis of the choked disc type (Plate VII, Fig. K), and in the abscess cases there will generally be a predisposing cause, particularly otitis media. It is well known, however, that either a tumour or an abscess within the cranium may be latent for months, and in some such cases symptoms may come on acutely, especially if there has been haemorrhage into a softening tumour. Ordinary cerebral haemorrhage may be simulated in this way, but if well marked optic neuritis is found in both eyes, it is probably not a haemorrhage only. The existence of pyrexia is not by itself evidence of abscess, for haemorrhage near the internal capsule, or in the motor cortex, often leads to some rise of temperature for the time being, wliilst pontine haemorrhage is not infrequently associated with hyperpyrexia, and in not a few cases of intracranial abscess pyrexia is con- spicuously absent. Injury to the Spinal Cord in the Cervical Region is a very rare cause of paralysis of the arm and leg upon the same side ; first, because trauma here is extremely liable to damage more than half the cord ; and, secondly, because the injury must involve the lower part of the cervical enlargement if the arm is to be para- lyzed, and it is, therefore, very liable indeed to interfere with the subsidiary respiratory centres, and thus prove rapidly fatal. Occasionally, however, either a knife stab or a bullet wound on one side of the neck produces hemiplegia with evidence of unilateral paralysis of the diaphragm as observed when the patient's abdominal respiratory movements are watched in a good hght. It has sometimes been asserted that the patient will have aucesthesia, not of the same, but of the opposite side of the body : in practice this is not generally the case, the hemiplegia and the hemianaesthesia being on the same side as the lesion in at least some instances. Children of a rheumatic tendency, who are subject to chorea, sometimes present the movements of the latter upon one side of the body only— hemi chorea ; both before the actual movements appear and after they have ceased there is apt to be considerable, and occasionally extreme, weakness of the affected side ; so much so that some intracranial lesion may be suspected, unless there has been clear evidence of the existence of chorea. Occasionally, weakness of a hemiplegic nature may be the first symptom of meningitis, whether tuberculous, suppurative, posterior basal, or epidemic cerebrospinal ; sometimes, upon post-mortem examination a definite unilateral softening, or a tuberculous nodule affecting the pjrramidal fibres may be found to account for this ; but more often the appearances seen after death fail to explain why there should have been unilateral paretic symptoms. In the earlier stages the diagnosis may be quite obscure, but sooner or later the paresis becomes bilateral, and the course of the disease indicates meningitis beyond doubt, especially if there are convulsions, vomiting, and optic neuritis. Choroidal tubercles may be detected in some cases {Plate VIII, Fig. W), and the cerebrospinal fluid may be examined cytologically and bacteriologically. Disseminated Sclerosis is a very slowly progressive disease, in which during the earlier stages the foci of sclerosis are few and quite irregularly distributed, so that Avhereas in the later stages ataxy, intention tremor, more or less spasticity 342 HEMIPLEGIA with increased knee-jerks, extensor plantar reflexes, ankle-clonus, and staccato speech, are to be expected, these are only present when, in the course of years, numbers of sclerotic foci have accumulated in the spinal cord and brain ; long previous to this there have been irregular symptoms, amongst which may be mentioned hemiplegia ; the diagnosis at this stage is often a matter of opinion only, though if the patient can be watched over a sufficient length of time the nature of the case ultimatelj^ becomes obvious. The symptoms of caisson disease are due to the liberation of definite air bubbles in the nervous system, and what the symptoms will be depends entirely on where these bubbles are ; in most instances they are widely scattered, so that bilateral paralyses are more common than unilateral ; it is possible, however, for caisson disease to produce hemiplegia if a relatively large air bubble becomes hberated in or near the internal capsule. The diagnosis depends upon the history and occupation. Hysteria may be responsible for almost any form of nerve symptom, hemi- plegia being not an uncommon variety. There is no wasting, except that which may be due to disuse ; the knee-jerks may be exaggerated, but the plantar reflexes will remain flexor, and there is no ankle-clonus ; the face, as a rule, is unaffected ; if the patient, hang flat upon her back, is asked to raise her legs from the bed, she will raise the sound leg, but not that which is paretic ; whereas, in a case in which there is incomplete paralysis of one leg due to organic lesions of the upper neurone upon one side, an attempt to raise the leg in this way often leads to the paretic leg being lifted as well as the other. The sex and age of the patient, her previous history, and the presence possibly of other functional nerve symptoms, especially globus hystericus, hysterical aphonia, or the distribution of anaesthesia of the glove or stocking type, woiild indicate the diagnosis. Herbert French. HICCOUGH. — Hiccough is a symptom which far more often than not has no clinical significance, resulting, as it does even in the healthiest people, from excessive laughter, from the stimulation of certain reflex spots, especially about the chin, from tickling, or even coming on spontaneously without any obvious cause at all. Occasionally, however, hiccoughing may be so persistent or may reach so alarming a degree, that it becomes of clinical importance. The patients may be divided into two groups, namely, those in whom there is already severe illness, and those who are not obviously ill. Of the former group there are two main types — the Alcoholic and the Peritonitic. No difficult}^ of diagnosis arises between these two ; the drunken person's hiccough has a character of its own. The patient who has an acute abdominal condition associated with hiccough will have presented grave symptoms long before hiccough sets in, the diagnosis often having been arrived at by urgent laparotomj-. Hiccough in these cases does not serve to distinguish between acute peritonitis due to whatever cause, acute haemorrhagic pancreatitis, acute intestinal obstruction from any cause, or acute post-operative dilatation of the stomach ; its occurrence and persistence, however, indicate a ver}^ grave prognosis. When persistent or recurrent hiccough is a troublesome symptom in a patient who is not obviously ill — so troublesome that something more than a simple hiccough has to be thought of — three main types of malady will suggest them- selves, namely : — 1. Hysteria or neurosis. 2. Mediastinal irritation of vagi or phrenic nerves, e.g., by caseous lymphatic glands. 3. Degenerative changes in the medulla oblongata. HICCOUGH 343 None of these three types is at all common, and their diagnosis during life is often a matter of opinion. Functional Hiccough is a remarkable malady hardly to be mistaken. The patient is generally a girl between 15 and 25 years of age, and she may hiccough persistently throughout her waking hours for weeks, at the rate of two or three times a minute. She will sleep well, and the hiccough stops during sleep. She will eat well, but may hiccough during meals in a most distressing way. She will have exaggerated knee-jerks, brisk flexor plantar reflexes, and she will be amenable to treatment by suggestion. Whether treated or not, the hiccough will cease in time, though it may persist on and off for weeks ; often it will be noticed to have come in the place of some other neurosis, and when it goes it may be replaced by other functional nerve symptoms. Irritation of a Vagus or Phrenic Nerve by something in the mediastinum causes recurrent attacks of intractable hiccough only in rare cases. In a child, the least uncommon cause is tuberculous caseation of bronchial and mediastinal glands ; these seldom obstruct a bronchus or in other mechanical ways afford evidence of their presence ; but they may be associated with periodic attacks of febrile illness in a patient who looks delicate, and who has been in the habit of drinking much milk ; and there may be evidence of chronic enlargement of the glands elsewhere, particularly those in the neck or in the abdomen. In an adult the least uncommon causes are either malignant or lymphadenomatous deposits in the mediastinum, or else fibrous mediastinitis. The former may be indicated by reason of there being symptoms of a primary growth in the oeso- phagus or elsewhere, or by progressive varicosity of the veins of the chest wall, or signs of recent and increasing obstruction to a bronchus ; chronic mediastinitis has generally been preceded by repeated attacks of pleurisy and pericarditis, especially in those subject to acute rheumatism. Hiccough is an exceptional symptom in these cases. Finally, if hiccough is due to degeneration or softening of the medullary centres, it will almost certainly be associated with other symptoms of cerebral or spinal mischief ; in a young adult there might be a suggestive history of syphilis or chronic alcoholism, whilst in an older person there would be thickened and tortuous arteries, a high tension pulse, an enlarged heart, arcus senilis, possibly albuminuria in an abundant urine of low specific gravity — signs of senile degenerative changes. Herbert French. HIPPUS. — (See Pupil, Abnormalities of the.) HUSKINESS.— (See Speech, Abnormalities of.) HYPERESTHESIA.— (See Sensation, Abnormalities of.) HYPERIDROSIS. — ^(See Sweating, Abnormalities of.) HYPERPYREXIA. — The point at which pyrexia becomes hyperpj^rexia is arbitrary ; by some it is fixed at 105° F., by others at 106° F. It may occur occasionally in many different diseases, but it is seldom itself of diagnostic significance. The patient will nearly always have exhibited other symptoms or signs pointing to the diagnosis ; therefore the following list of maladies in which hyperpyrexia may occur needs little discussion : — A . Fevers of microbial, or probably of microbial, origin : — Lobar pneumonia Septicsemia Bronchopneumonia ' Erysipelas Scarlatina ; Typhoid fever Pyemia \ Typhus fever Malignant endocarditis General tuberculosis Tetanus Tuberculous meningitis 344 HYPERPYREXIA Fevers of microbial, or probably of microbial, origin : — -continued. Posterior basal meningitis Epidemic cerebrospinal meningitis Suppurative meningitis Malaria Relapsing fever Cholera Dysentery Yellow fever Rheumatic fever Chorea insaniens Uraemia due to ascending nephritis Pyelitis. B. Lesions of the Central Nervous System : — Cerebral haemorrhage, especially pontine, or into one optic thalamus Fractured skull, with contusion of the brain Cerebral softening Cerebral tumour or abscess, especially tumour of the pons Varolii Fractured spine, especially in the lower cervical or upper dorsal regions Acute mj'elitis after injury. C. Affections that are less easy to classify : — After burns or scalds Heat stroke or sunstroke Infantile convulsions Delirium tremens Uraemia other than that due to septic nephritis Acute yellow atrophy of the liver. D. Hysteria. There are, however, certain small points about hyperpyrexia that may be important in diagnosis. Acute rheumatism is often stated to be a prominent cause of it ; as a matter of fact, hyperpyrexia is excessively rare in acute rheumatism, so that should it occur in a case that has been regarded as rheumatic fever, the diagnosis should be very carefully revised lest it really be septicemia. In children the physical signs alone may leave one in doubt as to whether there is bronchitis only, or broncho-pneumonia, or even general tuberculosis of the lungs ; the occurrence of hyperpyrexia generally indicates that there is more than bronchitis ; if the patient is not particularly livid, bronchopneumonia is more likely than general tuberculosis ; the latter becomes the more probable the more ill the patient is, out of proportion to the physical signs. Occasion- ally h^^perpyrexia occurs in an infant or child after a fit, without any definite cause being assignable either for the convulsion or for the high temperature, and without any serious consequence resulting. In tuberculous meningitis h^^perpyrexia is generally terminal ; in posterior- basal meningitis, on the other hand, it sometimes occurs periodically and transiently, producing acute upward " spikes " upon a temperature curve that is not otherwise very high ; these pyrexial " crises," as they have been called, point to posterior-basal rather than to the more serious tuberculous meningitis. Hyperpyrexia may sometimes serve as the chief point in distinguishing pontine hcBmorrhage or heat-stroke from other forms of coma, such as acute alcoholism or opium poisoning ; in the latter, the temperature is below normal. The circum- stances of the case, such as climatic conditions or occupation, will generally serve to distinguish between heat-stroke and pontine haemorrhage. After an injury to the back — for instance, by a fall in the hunting field — the occurrence of hyperpyrexia sometimes serves to exclude the diagnosis of a mere bruising, and to point to the gravity of the condition — a fractured or dislocated spine near the cervical region, or acute traumatic myelitis or softening of the upper part of the spinal cord. The diagnosis of the other diseases mentioned in the above list is not much assisted by the occurrence of hyperpyrexia. HYPOTHERMIA 345 It only remains to add a word or two about hysteria and high temperatures. There can be no doubt that, in exceptional cases, nearly all of which are of the female sex, the mercury in the clinical thermometer does actually rise to a very high figure without there being any corresponding illness in the patient. Malingerers have sometimes learned a trick, such as rubbing the bulb of the thermometer, to produce enough friction heat to send the mercury up ; but quite apart from malingering, there are females in whom, for some reason that is not yet understood, the mercury really does record temperatures that are not those of the internal tissues. Readings have been taken simultaneously in the mouth, armpits, and rectum, all possibility of malingering being excluded by special precautions ; all the thermometers registered hyperpyrexia. The diagnosis is generally made by the fact that the readings are so high that they must be unreal ; the following have been recorded in various cases : 107°, 108°, 111°, 113°, ii5'8°, 116-4°, 117°. i20-8°, 122°, 127°, 128°, and even 131° F. In most of these patients the symptoms were slight, though sometimes there have been flushings, headache, restlessness, and various functional nerve symptoms, or even delirium and convulsions. Unless it is at once obvious that the patient is not really ill, there must always be difficulty, danger, and anxiety in arriving correctly at the diagnosis of hysterical hyperpyrexia ; the nature of the case may remain in doubt until the course and result have been watched. Herbert French. HYPERTROPHY OF THE HEART. — (See Enlargement of the Heart.) HYPOTHERMIA. — This signifies a condition of subnormal temperature, and generally speaking it is assumed to refer to the temperatures registered by the thermometer in the mouth. Rectal temperatures do not always coincide with those of the mouth, but the clinical significance of variations in rectal temperatures is not yet fully understood. From a diagnostic point of view hypothermia is not often a symptom of great importance, but there are at least two points about it that require special mention. In the first place, coma due to opium poisoning may be closely simulated by coma due to pontine haemorrhage ; in both there are bilateral loss of movement, pinpoint pupils, and few other symptoms ; with opium poisoning, however, the temperature becomes subnormal, whilst with pontine haemorrhage it tends to rise to the level of hyperpyrexia, so that the thermometer may be the means of diagnosing between them. In the second place, patients suffering from chronic valvular heart disease, with symptoms of impending or actual failure of compensation, very commonly suffer from hypothermia. This is a point that is not always sufficiently emphasized ; not a few cases of heart disease having for their normal temperature base-line not 98'4° F., but 97° F., or even 96° F. It follows, that a patient whose normal temperature is 96° F. really has over two degrees of fever when his temperature reaches 98-4° F ; he may develop fungating endocarditis upon the top of his chronic valve lesion, and yet his temperature may not rise materially above 98 '4" F. The fact, therefore, that hypothermia is a common feature in heart cases has great importance, for it indicates the necessity for regarding even slight rises above 98 '4° F. with greater seriousness in them than in other cases. For the rest, hypothermia is not a symptom that helps much in diagnosis, and it will suffice to indicate its chief causes which are as follows : — Chronic debilitating maladies, such as : — Chronic valvular heart disease Addison's disease Diabetes mellitus Myxcedema Cretinism Arteriosclerosis Chronic nephritis^ with or without urasmia. 346 HYPOTHERMIA Coma due to poisons, particularly : — ■ Opium Alcohol Chloral Anaesthetics Carbolic acid Oxalic acid. Increased intracranial pressure in certain cases of : — Cerebral abscess Cerebral tumour Cerebellar abscess Cerebellar tumour Cerebral haemorrhage. These same lesions, especially if they involve either the pontine or the subthalamic regions, or if they affect the corpus striatum, may produce pyrexia or even Hyperpyrexia [q.v.) instead of hypothermia, so that the inconstancy of the latter symptom detracts considerably from its value in differential diagnosis in these cases. Convalescence after certain fevers ; for instance : — Pneumonia | Typhoid fever | Relapsing fever. Shock after severe injury, or after a serious operation. Collapse due to loss of fluid from the tissues from such conditions as : — Severe vomiting, whatever the Peritonitis cause Intestinal obstruction Severe diarrhoea, choleraic or Haemorrhage, otherwise Exposure, especially in the case of a child. In the morning, in cases of intermittent pyrexias of the septic or hectic types. It is important that the temperature should have been taken both night and morning before the low figures for the morning are assumed to indicate continued hypothermia ; indeed, very low readings in the earlier part of the day, in a patient whose malady is not at once obvious, may arouse suspicion of a tuberculous lesion which further investigation may confirm. Herbert French. ICTERUS.— (See Jaundice.) IMPOTENCE. — Strictly speaking, impotence includes any condition, whether in the male or in the female, that prevents the performance of coitus ; by common consent it has come to be restricted to inability on the part of the male. It is not synonymous with sterility ; the latter, in the male, implies absence of the spermatozoa necessary to fecundation ; a man may be sterile without being impotent, or impotent without being sterile ; he may also be both impotent and sterile. There are three main groups of conditions which lead to impotence, namely : — I. — Mechanical defect, such as congenital or acquired malformation of the penis, absence of the penis, carcinoma, elephantiasis, and so on. These need not detain us, for their diagnosis is generally obvious on inspection ; one need only say that even considerable deformities of the genital organs are by no means necessarily associated with impotence. 2. — Entire Absence of Penile Erections : as the result either of some organic disease of the nervous system, or of some general constitutional condition ; one may mention particularly the following : — Locomotor ataxy Ataxic paraplegia General paralysis of the insane Primary spastic paraplegia Disseminated sclerosis Amyotrophic lateral sclerosis Transverse softening of the cord Plumbism Compression of the lower part of the cord INCONTINENCE OF FMCES 347 Dementia Diabetes mellitus Senility Atrophy of the testicles from injury or from severe orchitis, gonor- rhoeal or otherwise Pernicious anaemia Malarial cachexia Syphihtic cachexia Cancerous cachexia Phthisical cachexia Exhaustion from excesses. There is little need to discuss these further here, for, providing they are borne in mind, they will readily be diagnosed as the result of a careful routine examina- tion of the nervous system, urine, lungs, and so on. One need only add that impotence may be an early symptom in ataxic paraplegia, disseminated sclerosis, and phthisis, and that the diagnosis may seem to be neurasthenia only until the case has been watched. 3. — Impotence due to Inability to obtain Erections at the right time. — This is a very common form of the symptom ; the patients are generally told they are suffering from neurasthenia ; and so they are, of a particular sort. This is psychical or nervous impotence : strong erections may be present at inopportune times, there may be emissions during sleep, and yet at the very moment when sexual intercourse is intended the erection is either quite absent or imperfect. Sometimes, owing to extreme irritabihty, emission occurs on so little excitation that it takes place before insertion is complete, the rigidity of the penis relaxing almost at once, so that completion of coitus becomes impossible. Temporary impotence of this kind is not at all uncommon during the first few days or weeks of married life, especially if the wedding has been preceded immediately by particularly hard business strain or mental overwork preparatory to the honeymoon. The diagnosis is arrived at partly by the history, partly by the negative result of careful physical examination of all the systems, especially the nervous and pulmonary ; early phthisis is often accompanied by inabilitj^ to obtain penile erection ; but the final criterion is the effect of time. Where there is no organic cause for the symptom, normal coitus will occur presently if the patient ceases to be over-anxious about it. Herbert French. IMPULSE, DISPLACED CARDIAC— (See Heart Impulse, Displaced.) INCONTINENCE OF F.flECES. — Evacuation of the contents of the rectum without voluntary control or initiation may occur under several distinct con- ditions, the investigation of which may yield results of great diagnostic importance. In healthy persons the reflex relaxation of the sphincter ani which is necessary for defaecation takes place only at the bidding of the will. Some healthy persons are better able to resist an imperative call to stool than others, and it happens occasionally that an individual who is poorly endowed with the power of inhibiting the reflex may suffer from an incontinence of faeces when the stimulus evoked by irritating contents of the bowel is overpoweringly strong. The individual would be conscious of the accident, which would be of rare occurrence, and examination would reveal no abnormality. Children often suffer in this way. Mechanical incontinence of fasces results from injuries or diseases of the rectum or perineum, such as carcinoma, in which the outlet of the bowel is no longer guarded by an efficient sphincter. Local inspection and digital examina- tion of the parts will suffice to discover the cause of such incontinence. In conditions of coma or partial unconsciousness, from whatever cause arising, reflex emptying of the bowel may occur at intervals, particularly if aperients are administered. Digital examination of the rectum in such cases will reveal a normal sphincter which closes on the observer's finger. 348 INCONTINENCE OF FMCES Injuries or diseases of the central nervous system above the sacral region of the cord, if they interfere with impulses passing from the cortex to the lumbo- sacral enlargement, but do not cause serious sensory disturbance in the perineal area, lead to an unstable condition to which the term " precipitancy of defaeca- tion " is applied. In these circumstances, the patient is usually constipated, but the call to stool, when it comes, spontaneously or as the result of aperient medicine, is imperative, and finds the patient powerless to resist or delay the act. The examination of such a person discloses a normal sphincter; but, in all probability, some degree of spastic paraplegia with brisk tendon jerks and extensor plantar responses will be found, and inquiry will elicit the history of precipitate micturition. Moreover, the patient will be conscious of the acts of defaecation and micturition. This association of signs and symptoms is common enough in cases of partial injury to the spinal cord, in cases of old dorsal myelitis, of disseminated sclerosis, of syringomyelia, etc. Somewhat similar " explosive diarrhoea " is also a prominent feature of certain cases of carcinomatous stricture of the sigmoid colon. With more serious disease of the central nervous system above the sacral region, the impulses conveying the need for defsecation do not reach the brain, and the act takes place in a reflex manner without the knowledge of the patient. Under these circumstances, paraplegia with sensory disturbance over the sacral segmental areas will help to localize the site of the lesion. The tone of the sphincter ani may be little below normal or quite unimpaired. Disease or injury leading to destruction of the sacral cord or of the cauda equina is distinguished by the fact that incontinence of faeces is associated with an insensitive relaxed sphincter and with serious motor, sensory, trophic, and reflex disturbances in the lower extremities. When the fseces are small and fluid they escape, more or less continuously, through the gaping anal aperture. On the other hand, they sometimes tend to accumulate in dry masses too large to pass the portal without assistance. The patient is unconscious of the accumulation, unconscious of soiling, and insensitive to the exploring finger. It will be understood from the above statements that for the purpose of dia- gnosis it is necessary, in all cases of fascal incontinence, not only to inquire into the exact features of the incontinence, the presence or absence of a call to stool, the tendency to constipation or precipitancy, the ability to feel the passage of motions, etc., but to supplement the knowledge gained in this way by a local examination, especially of the sphincter ani, and an investigation of the motor, sensory, and reflex conditions in the lower extremities. E. Farquhar Buzzard. INCONTINENCE OF URINE. — (See Micturition, Abnormalities of.) INCO-ORDINATION.— (See Ataxy.) INDICANURIA. — Indican in the urine is mainlj^ due to the formation of indol in the intestine as the result of putrefactive changes in the products of tryptic digestion of proteids. The indol so formed is absorbed from the bowel, and converted in the liver into relatively innocuous potassium indoxyl sulphate, or indican. This is tested for by oxidizing it to indigo, the blue colour of which is characteristic. Almost any oxidizing agent could be utilized for the test, but the difficulty is that even slight excess of the reagent destroys the indigo. A brown ring appearing at the junction of the urine and the acid, when testing for albumin with nitric acid that is slightly fuming, generally indicates a consider- able degree of indicanuria. To be certain of this, Jaffe's bleaching powder test is usually employed. There are several ways of using it. Fresh solution of cal- cium hypochlorite is essential. To about 20 c.c. of urine add 3 c.c. of chloroform and 3 c.c. of hydrochloric acid of medium strength ; the colourless chloroform INDIGESTION 349 sinks to the bottom of the mixture ; a drop of the calcium hypochlorite solution is now added and the test tube deliberately inverted once or twice ; a second drop is added, and so on, the colour of the chloroform being watched the while. If indican is present, it becomes oxidized to indigo, which is dissolved out by the chloroform so that the latter changes from colourless to blue, and the depth of indigo-blue colour in the chloroform affords a rough measure of the amount of indican in the urine. The main precaution to be taken is, not to add the hypochlorite solution too rapidly, for excess of it discharges the colour of the indigo. Indican being an ethereal sulphate, it is present in excess under the same circumstances as an excess of ethereal sulphates. At one time it was thought that much useful clinical information as to the condition of the intestines could be learned from its occurrence. It is true that any circumstances that are likely to increase the putrefactive changes in the proteid in the bowel are also likely to increase the amount of indican in the urine ; marked indicanuria is generally found in cases of chronic constipation, intestinal obstruction, diarrhoea, typhoid fever, dilated stomach, peritonitis, acute enteritis or colitis, appendicitis, membranous, tuberculous or ulcerative colitis, acute and chronic dysentery, cholera, intussusception, and carcinoma coli. It affords no assistance in dia- gnosing between one and another of these various affections, however. Moreover, .it may occur when there is decomposition of albumin elsewhere in the body than in the bowel ; for instance, in gangrene of the lung, gangrenous empyema, putrid bronchitis, bronchiectasis, or advanced pulmonary tuberculosis. Recently, since the rage for treatment by various lactic-acid-producing bacilli has set in, it has been urged that this treatment is most indicated when there are relatively large quantities of ethereal sulphates in the urine ; the degree of indicanuria affords some indication of the amount of ethereal sulphates present, so that, broadly speaking, it is said that the occurrence of indicanuria is a point in favour of treatment by lactic-acid bacilli and their products. The difficulty is that a considerable number of perfectly healthy individuals pass quite large quantities of indican in their urine. There are some who contend that even these healthy persons are really suffering from intestinal putrefactive changes without knowing it ; this is possible, but from the patient's point of view it is tantamount to saying — what is indeed almost true — that indicanuria has no real diagnostic or clinical significance. Herbert French. INDIGESTION — It is important to remember that " indigestion " is a sym- ptom, and not a disease ; and if a patient complains of this, one should enquire more particularly as to the exact nature of the abnormal sensations present, e.g., pain, fullness, flatulence, vomiting, etc. The diagnostic indications furnished by each of these symptoms is considered separately (see Vomiting ; Pain in the Epigastrium; Fullness; Flatulence: etc.), but it may be convenient here to offer some general guidance as to the methods of arriving at a diagnosis in cases in which " indigestion," in one or other of its aspects, is the chief complaint. I. — Simulation of Dyspepsia by other Conditions. At the outset one should never forget that a patient may describe his case as one of indigestion, although he is not really suffering from any primary affection of the stomach at all ; and mistakes can only be avoided by subjecting every such case to a thorough physical examination of all the organs, and not confining it to the abdomen. If the possibility of error is borne in mind, it is not usually difficult to avoid ; and, accordingly, it will be sufficient to enumerate briefly the chief conditions to be thought of. These are : — 350 INDIGESTION 1. The Vomiting of Pregnancy. — The possibility of pregnancy should always be present to the mind when one is consulted by a young woman who complains of vomiting and indigestion, and the other signs and symptoms of pregnancy (amenorrhcea, fullness of the breasts with areolar pigmentation, enlargement of the uterus, etc.) looked for. 2. Cerebral Vomiting. — In children, particularly, vomiting of cerebral origin may be mistaken for dyspepsia. Incipient meningitis and tumour are the commonest causes of such vomiting. The former, in its earliest stage, may be very difficult to diagnose with certainty, but the presence of signs of cerebral irritation (e.g. photophobia, squint, irritability, headache, Kernig's sign, etc.) should make one suspicious ; paralyses, headache, and optic neuritis point to tumour. 3. Uraemia may masquerade as "indigestion," characterized by loss of appetite and vomiting (uraBmic gastritis). The presence of the " ursemic odour " in the breath, of high arterial tension, and of albuminuria and albuminuric retinitis, should be looked for. It must be remarked, however, that albumin may be absent from the urine in undoubted cases of uraemia. 4. Phthisis. — In cases of early phthisis, indigestion may be the chief sj^mptom of which the patient complains, nausea and vomiting being often present. This can be excluded by a careful examination of the chest and of the sputum, which should never be omitted, especially in j^oung subjects. 5. The Gastric Crises of Tabes are apt to be mistaken for dyspepsia. Paroxysmal vomiting of great violence is the usual form they assume, and they may simulate gastric ulcer or other organic affections of the stomach. If the knee-jerks be absent and the pupils immobile to light, the diagnosis is easy, but it must be remembered that gastric crises may occur early in a case of tabes before the usual signs of disease of the cord have manifested themselves. One should enquire in such a case for a history of lightning pains, and for any trouble with the bladder. It is said also that the blood-pressure is raised during a gastric crisis, whereas it is lowered in all other cases of acute vomiting. This may prove of diagnostic value. 6. Nervous or Hysterical Vomiting may also simulate dyspepsia. The diagnosis here must be made largely by the method of exclusion. The patient is usually a woman, and there may be other signs of hysteria present. 7. In Chronic Intestinal Obstruction, the abdominal pains, and the vomiting which often accompany them, maybe described by the patients as "indigestion." In such a case there will be distention of the abdomen, often with visible peris- talsis in the intestine, and a histor}^ of gradually increasing constipation. A tumour may be felt, or examination with the sigmoidoscope maj^ clear up the case. 8. Cholecystitis is very apt to be diagnosed as " indigestion." In the case of middle-aged or elderly women, particularly, who complain of " wind " and " spasms," the possibilitj'- of the presence of gall-stones should always be thought of. (See Pain in the Epigastrium ; and Pain in the Right Hypochondrium.) g. Chronic Appendicitis may manifest itself chiefly by symptoms which point to the stomach rather than to the vermiform appendix as the seat of the disease. The pain in such a case may have the character of a typical " hunger-pain," and be relieved by alkalis (see Pain in the Epigastrium). In children who are brought to one for " indigestion," with vague abdominal pains, the possi- bility of appendicitis should be specially remembered. 10. Angina Pectoris in one of its forms may be accompanied by much flatu- lence, which leads the patient to consult his doctor for "indigestion." The occurrence of the symptoms upon exertion, the characteristic tendency of the pain to spread into the left arm, and the frequent presence of a high blood-pressure, INDIGESTION 351 are all of diagnostic value. Abdominal angina, in which the pain is seated in the large abdominal blood-vessels, may be more difficult to differentiate. Flatu- lence is again a pronounced feature ; but there may also be vomiting, and even haematemesis. Thickening of the peripheral blood-vessels is usually present ; and the therapeutic test is of help, the pain being relieved by vasodilators, and especially by diuretin. 11. Extra-abdominal causes of Pain are often put down by patients to indiges- tion. Examples of these are pleurisy, spinal caries, and abdominal aneurysm. (See Pain in the Epigastrium.) 12. Eructatio Nervosa, due to air- swallowing, is also usually described as indigestion. For the method of diagnosing it, see Flatulence. II. — Functional versus Organic Dyspepsia. Having excluded aU these possible causes of error, one may conclude that one has to deal with a case of either organic or functional disease in the stomach itself. If vomiting, loss of flesh, or severe prin be prominent symptoms, the disease is probably organic ; if these be absent, and the affection has persisted for some time, one has most likely to do with a functional disorder. III. — Differential Diagnosis of Organic Dyspepsias. The chief organic diseases which have to be thought of are : (i) Cancer, (2) Ulcer, (3) Gastritis, (4) Obstructive dilatation. The differential diagnosis of these may now be briefly considered. I. Career. — A malignant growth in the stomach may be situated either at the cardiac orifice, in the body, or at the pylorus. In the first of these situations it will produce difficulty in swallowing (see Dysphagia). If at the pylorus, it will result in dilatation of the stomach (see below). Growths in the body are those which are most difficult to diagnose. (a). A history of "indigestion " beginning abruptly in a patient (oftenest a man) above the age of forty, and which does not speedily yield to simple treat- ment, is very suspicious. On the other hand, it must be remembered that in a considerable number of cases the growth starts in an old ulcer, so that a history pointing to this may also be in favour of carcinoma. (6). Steady loss of weight, and the early appearance of anaemia, point to malignant growth ; but, on the other hand, the absence of these signs, and even a temporary gain in weight under treatment, by no means exclude it. (c). Loss of appetite, and especially a disinclination for meat, are usually early symptoms. Nausea and vomiting supervene later, but are rarely absent altogether. Pain may be present early, and is often more or less constant. {d). A steady diminution in the amount of h3-drochloric acid in the gastric juice, with the presence of lactic acid and of Oppler-Boas baciUi in the gastric contents, is a combination pointing strongly to carcinoma. It is therefore upon a combination of these symptoms and signs that the diagnosis must be based in the early stage (when it is most important to make it). Later, a tumour may be felt below the left costal margin, or in the epigas- trium ; enlarged glands may appear above the left clavicle, although they are exceptional ; and there may be signs of secondary growths in the liver, or at the umbilicus. When ulceration has supervened, traces of blood may be found in the gastric contents, and occult blood in the stools. (See page 197.) In some cases of carcinoma of the body of the stomach, pronounced anaemia is one of the earliest and most striking symptoms. Such cases have to be diagnosed from pernicious anaemia. A blood-count will usually suffice to distinguish them, for in gastric carcinoma the red cells are rarely below 352 INDIGESTION 2,000,000 per cubic mm., -whereas in pernicious anaemia they go much lower than that ; in pernicious ansemia, also, the colour-index is about i or above it, in carcinoma it is less than i. Megaloblasts are found in the film in pernicious anaemia, but not in carcinoma. In spite of all that has been said above, the early diagnosis of carcinoma of the stomach is a matter of great dif&cultj" ; and it may be justifiable to resort to an exploratory operation in a suspicious case which does not clear up after a few weeks' treatment. 2. Ulcer. — The characteristic symptom of ulcer is pain, which comes on after food, and is reheved by vomiting, which is usually though not invariably present. Haematemesis is strongly confirmatory^, but is often absent. The chief sign of ulcer is a localized spot of tenderness on deep pressure. (See also Pain in the Epigastrium ; and Tenderness in the Epigastrium.) 3. Gastritis. — -Chronic " gastric catarrh " is certainly diagnosed oftener than it should be, the majority of cases so described being really examples of functional dyspepsia. The symptoms are loss of appetite, fullness and weight in the epigastrium, depending greatly upon the kind of food taken ; pain is not a feature of gastritis ; nausea is common, and vomiting may occur but is not usually a prominent s^-mptom. There is no characteristic physical sign, and a diagnosis cannot be made with certainty without the use of the stomach tube. This shows : (a) Diminished total acidity, or even complete absence of gastric juice ; (b) Excess of mucus in the contents, or the presence of mucus on washing out the fasting stomach. Having determined the presence of gastritis, one has to settle whether it is primarj' or secondary. Secondary gastritis may occur : (a) AMiere there is disease of the heart, causing back-pressure ; (6) In cirrhosis of the liver ; (c) In chronic renal disease. If aU of these can be excluded, primary gastritis may be diagnosed, and the chief causes of the latter looked for. These are : (a) Defective or carious teeth, and " oral sepsis ; " (&) Abuse of alcohol or tobacco, or the taking of irritating or "indigestible" articles of food. 4. Dilatation. — One has to determine the presence of dilatation, and then to discover its cause. The presence of dilatation is determined : (a) By showing that the stomach is enlarged ; and (b) By proving the occurrence of stagnation of the contents. [a). Enlargement of the stomach may be inferred when, by percussion, the greater curvature is found to reach below the level of the umbilicus, the lesser curvature being in its normal position. In order to facilitate percussion it may be necessary- to inflate the stomach, by making the patient swallow 90 gr. of tartaric acid, followed by 120 gr. of bicarbonate of soda. Examination bv the ;i^-rays after a bismuth meal is of help in obscure cases {Fig. 105). The presence of splashing is not a certain sign of dilatation, unless it be present some hours after a meal. ip). The occurrence of stagnation of contents is proved by giving the patient an evening meal, preferably containing some easily recognizable food, e.g., currants, and washing out next morning. If food residues are present in the washings, stagnation may be inferred. The cause of dilatation may be either [a) Some obstruction at the pjdorus ; or (6) Primary atony of the stomach wall. In distinguishing between these, the historj- ma}' help. Thus the occurrence in the past of symptoms of ulcer points to a cicatricial stenosis of the pjdorus. If visible peristaltic waves are seen, one maj' be sure of the existence of an obstruc- tion. These can sDmetimes be elicited b}' massaging the stomach, or by flicking the surface of the abdomen with a wet towel. The presence of actual stagnation INDIGESTION 3.53 of the contents is also strongly in favour of obstruction, as this rarely, if ever, occurs in cases of atonic dilatation. Copious vomiting also points to obstruction, as it is exceptional to meet with this symptom in atony. Assuming that obstructive dilatation has been diagnosed, one has next to determine its cause. Here one has to distinguish between benign and malignant obsiniciion. The existence of a history, or signs and symptoms of ulcer (see above), point to the former ; the general symptoms of carcinoma, to the latter. A tumour may be felt in either case. Examination of the stomach contents also helps in the differential diagnosis. The presence of abundance of free HCl, with sarcinae and yeasts, points to benign stenosis ; diminution or absence of HCl, with the presence of lactic acid and Oppler-Boas bacilli, to malignancy. One has further to distinguish dilatation from : {a) Gastroptosis ; and (b) Hour-glass stomach. {a). In gastroptosis, percussion (if necessary after inflation) will show that the lesser curvature is displaced downwards, as well as the greater ; but the normal distance between the two curvatures — about four inches — is preserved. In the great majority of cases of gastroptosis the right kidney is more or less freely movable, and this affords confirmatory evidence. The ;i;-rays may also be of help {Fig. 105). {b). Hour-glass stomach may be diagnosed by the following signs: — (i). If the stomach be washed out with a known quantity of fluid, e.g. 30 oz., it will be found that some has been lost, e.g. 6 oz., when the return fluid is measured. Some of the fluid seems to dis- appear, in fact, as if it had flowed through a hole. (ii). If the stomach be washed clean, and the tube passed a few minutes later, several ounces of fermenting liquid may be obtained, which have escaped from the pyloric pouch. (iii) . If the stomach be drained apparently dry, a splash can still be obtained over the pyloric end (" paradoxical dilatation "). (iv). If the stomach resonance be carefully percussed out, and it be then inflated with tartaric acid and soda, as described above, and then again percussed, it will be found that a great increase in resonance has occurred at the cardiac end only. If the abdomen be watched for a little, the pyloric pouch may some- times be seen to fill gradually and become prominent. A loud gushing sound can also be distinguished on listening with the stethoscope over the site of the opening between the two pouches. IV. — Differential Diagnosis of Functional Dyspepsias. Assuming that all the above forms of organic disease can be excluded, one may conclude that the case is one of functional dyspepsia. D 2^ /^7!^. 105. — Skiagram showing Ujl- IjiMUuth shadow of a dropped and dilated stomach, the patient being in the vertical position. C, crest of le(t ilium ; F, finidus of stomach ; p, pylorus ; R, twelfth left rib ; V, vertebral column. — Bj> D?-. A. C. Jordan. 354 INDIGESTION The next task is to determine what particular variety of functional disorder one has to deal with. In attempting to do this, one is met at the outset bj^ the difficulty of classifying functional disorders of the stomach. Three forms of classification may be adopted : (i) Physiological, (2) Clinical, (3) Etiological. 1. Physiological Classification. — In this classification, cases of functional dyspepsia are arranged according to the particular function or functions affected, thus : — (a). Affections of secretion : — (i) Excess = Hypersecretion and hyperchlorhydria. (ii) Defect = Achylia and hypochlorhj^dria. (b). Affections of motility : — (i) Excess = Pyloric spasm, (ii) Defect =^ Atony, or impaired motility, (c). Affections of sensation : — Excess = Hypersesthesia or gastralgia. Any of these may be present alone, or two or more may exist in conjunction The diagnosis of affections of secretion and motility can only be made by the aid of the stomach tube (see p. 355). For the diagnosis of hyperaesthesia (gastralgia) see Pain in the Epigastrium. The above is undoubtedly the most scientific method of making a differential diagnosis in cases of functional dyspepsia, but it has the inconvenience of neces- sitating the use of test meals. 2. Clinical Classification. — Clinically, cases of functional dyspepsia may be classified into certain rough groups according to their symptoms. Thus : — (a) . Hypersthenic dyspepsia, which is probably due to a combination of hyper- secretion and hyperaesthesia. The patient is usually a young man, otherwise healthy ; and the chief symptom is pain during the late period of digestion (see Pain in the Epigastrium). (b). Asthenic dyspepsia. — This is due to impaired motility (atony), with or without some disorder of secretion. The patient may be of either sex, and of any age, and the chief symptoms are Flatulence [q.v.) and Fullness [q-v.). It is often present along with gastroptosis (especially in women) ; and there may be atonic dilatation of the stomach (see above) . (c). Acid dyspepsia. — This is an ill-defined group, in which the chief symptom is a sensation of acidity, or the presence of acid eructations. Some cases are really examples of hyperchlorhydria, with or without the presence of gastritis. In others, the cause is the production of organic acids by fermentation. Dia- gnosis can only be made by aid of the stomach tube. Other clinical forms of dyspepsia are also described, e.g., "senile" dj'spepsia (essentially a hypochylia), " gouty " dyspepsia (the same as the " acid " form), " flatulent " dyspepsia (usually due to defective motility), and others ; but the use of such terms is inaccurate, and should be avoided as far as possible. 3. Etiological Classification, — Instead of attempting to distinguish different forms of functional dyspepsia, one can regard the latter as an aggregation of symptoms of gastric disorder excited by different causes, and classify cases according to the particular exciting cause at work. This method is simple and convenient, and is also useful for purposes of treatment. Adopting it, one may say that functional dyspepsia may be induced by : — {a). Dietetic causes, e.g., unsuitable food, hasty meals, the tbuse of alcohol, tobacco, etc. {b). Physical causes, e.g., imperfect chewing, defective teeth, oral sepsis, over- fatigue, deficient exercise, etc. (c). Mental causes, e.g., over- work, a studious life, etc. IXDIGESTION 355 {d). Emotional causes, e.g., shock, worry, etc. Anv of the above methods is useful, the essential point being that a classifica- tion of some sort should be adopted. Probably a combination of the first and third methods, which take into account both the particular disorder which is present, as well as the cause which has brought it about, will lead to the best treatment. APPENDIX. ^Methods of Ex.a.mining the Stomach. The following is a brief account of some special methods employed in examining the stomach, which are capable of being carried out in ordinary practice : — 1. Determination of size. — This is done by light percussion, or by percussion-ausculta- tion, with or without pre\'ious inflation. The position of the lesser and greater curvatures and of the fundus must be determined. Inflation is performed either : (a) Through a stomach tube connected with a Higginson's s\T:inge : or (b) By making the patient swallow go gr. of tartaric acid dissolved in three ounces of water, followed by 120 gr. of bicarbonate of soda. The two halves of a seidlitz powder may also be employed. A considerable degree of distention can also be brought about if a tumblerful of soda water is drunk, and the patient instructed to retain the gas in the stomach as long as possible. 2. Investigation of the contents. — A test meal, consisting of two slices of dry toast and two cups of tea with a little milk, is given in the morning, and the tube passed an hour later. The tube should have a solid end and one bevelled lateral eye close to it. The sample drawn off should be investigated as regards : — (a). Quantity. — Avery small result containing little fluid indicates diminished secretion (achyUa) ; an abundant and very liquid yield indicates diminished motility. ib). Physical characters. — The presence of large pieces of but slightly altered food indicates defecti\"e secretion and digestion ; a large amount of liquid with a granular deposit shows hypersecretion. A very sour odour reveals the presence of organic acids. \'iscidity of the contents, so that they filter slowly, is characteristic of the presence of mucus in excess. (c). Acidity. (i) Test for free HCl. — Congo-red paper is turned blue, methyl-orange paper red, if free HCl be present. The depth of colour indicates approximately the amount of free acid. (ii) Total Aciditv. — Ten c.c. of the filtered contents are titrated with -- caustic 10 soda solution, two or three drops of phenolphthalein solution being used as an indicator. A pink tinge appears as soon as the acidity has been neutralized. The result is expressed in terms of the amount of caustic soda solution required to neutralize 100 c.c. of the gastric contents: e.g., if 6 c.c. neutralize 10 of the contents, then the acidity is 60. The normal acidity is between 40 and 70. (iii). Organic acids need only be tested for if free HCl is absent. A sour odour of the contents indicates their presence ; acetic acid and butyric acid can be recognized by the odour of vinegar or rancidity respectively ; lactic acid by adding a few drops of the contents to some Ufelmann's reagent (equal parts of 1-20 carbolic and weak liq. ferri perchlor.) in a test tube. A bright yellow colour is produced if the acid be present. (d). Ferments. — Rennin can be tested for by neutralizing some of the contents, and trying whether the addition of a few drops to a Httle milk results in coagulation when kept warm for twenty minutes. There is no convenient test for pepsin, but its absence may usually be inferred if there is no rennin present. (e). Microscopical characters. — Films are made from some of the deposit, and stained with dilute gentian violet. Oppler-Boas bacilli, yeasts, and sarcinse [Fig. q2, p. 267) should be looked for. The first occur specially in cases of carcinoma : the two last in benign stenosis of the pylorus. 3. Determination of motility.- — Impaired motility is shown by the presence of food residues in any quantity (say about 4 ounces) six-and-a-half hours after an ordinary dinner. In order to prove the presence of stagnation, a light meal, preferably containing some easily recognized food (e.g. currants) should be given in the evening, and the stomach washed out next morning. If food be found in the washings, stagnation exists. If there be no food, but if several ounces of greenish acid fluid are obtained, hyper- secretion is present ; flakes of mucus may be found in the washings in gastritis. Robert Hutchison. INEQUALITY OF THE PULSES.— (See Pulses, Unequal.) 356 INSOMNIA INEQUALITY OF THE PUPILS.— (See Pupil, Abnormalities of the.) INSOMNIA means inability to obtain the normal amount of sleep. It includes sleeplessness and broken or restless sleep, and admits of no closer definition because the normal amount of sleep varies so widely with age, habit, and in adults, also with idiosyncrasy. Thus, out of the twenty-four hours, an infant at one month will sleep for twenty-one, at six months for eighteen, at twelve months for fifteen hours. A child four years old needs twelve hours' sleep, the schoolboy of twelve needs ten, the public-school man should have nine. The average hours of sleep in adult life are said to be eight for women, seven for men. But idiosyncrasy may cut down the hours necessary in certain people to no more than three or four, for long periods and without any impair- ment of health or the power to work. Habit may train neglected children or overworked labourers and servants to get on with short hours of rest and interrupted sleep that would speedily make an ordinary person ill. Insomnia is a symptom indicating that something is amiss, not a disease per se. It occurs in a great many acute and chronic disorders, but in the majority of cases it is dependent upon functional disturbances, faulty habits or hygiene, an ill-arranged regimen, and not upon organic disease. It is to be diagnosed whenever lack of sleep causes, or is associated with, loss of health. It should be remembered that most patients habitually underestimate the amount of sleep they get, without any intention to deceive ; and are apt to complain that they have been awake all night, when in point of fact they have had many hours of sleep. The chief causes of insomnia are tabulated below in three main groups, etiologically : — 1. Faulty Habits or Hygiene, such as — Some sudden change in the routine of the day or evening Exposure to undue excitement or bad atmosphere before retiring The use of a noisy, airless, or overheated bedroom The use of too many bedclothes, or too few Going to bed on too full or too empty a stomach Drinking strong tea or coffee too late in the day The over-use of tobacco. 2. Acute Disorders, such as — Pain due to any cause, inflammation, injury, etc. The early stages of fevers Acute insanity, meningitis, delirium tremens, acute nrania, etc. Acute nervous exhaustion Gastro-intestinal disorders, dyspepsia, constipation, etc. 3. Clironic Disorders, such as — Chronic insanity of all sorts, neurasthenia Cerebral syphilis, intracranial tumour Disease of the heart, valvular or myocardial Disease of the lungs, emphysema, bronchitis, asthma, etc. Diseases of the liver or kidneys Arteriosclerosis and high blood-pressure, hyperpiesis Anaemia, primary or secondary Hysteria and malingering. The closer investigation of the causes of insomnia maj^ best be done by taking the age of the patient into consideration. Sleeplessness in an Infant is most often due to indigestion, hunger, or bodily discomfort ; in rare cases it is evidence of nervous instability or ear or brain disease. Enquiry into the methods and hours of feeding the infant will often INSOMNIA 357 show where the fault lies : the food may be improper, the hours of feeding too frequent, the practice of giving the bottle or breast whenever the infant cries may have been followed, or the habit of allowing it a dummy rubber teat to suck at all hours. The artificially fed infant is likely to suffer from indigestion and colic, with screaming, drawing up of the legs, and rigid abdomen ; the breast- fed infant will more often fail to sleep because it is hungry. In many cases the infant fails to sleep because it is in discomfort from a wet napkin or bed, from having too many bed-clothes and being overheated, or from being cold ; the bedroom may be too light or too noisy. In not a few instances it fails to sleep well for want of proper training ; if it finds that it will be fed or rocked in the arms or cradle as often and as long as it sees fit to cry, one can hardly blame it for failing to realize that insomnia is objectionable. When the infant is six months old or more, rickets and the local irritation of teething are common additional causes of insomnia. In a minority of cases the sleeplessness is due to the onset or presence of acute or chronic disease, or to the indeterminate condition described as nervousness or nervous instability, or to definite mental deficiency ; careful examination of the infant and its previous history should suffice to clear up the diagnosis in these cases. As the treatment of sleeplessness in an infant hardly ever demands the use of sedative drugs, but consists mainly in rectifying errors of diet, hygiene, or up-bringing, it is obvious that the medical man must be prepared to go deeply into these domestic rather than medical matters. Sleeplessness in Children is largely due to causes similar to those described above. In a great many cases it is due to indigestion, with which may be associated flatulence, teething, and the presence of worms in the intestine ; tea- drinking is a common cause of chronic dyspepsia, nervous irritability, and disturbed sleep, in children as well as in adults. Many children sleep ill because they are put to bed within an hour or so of a late tea or early supper of too solid a character. In other instances, the child sleeps badly for want of fresh air in the bedroom, waking late on the following morning in a headachy and irritable condition and with little appetite for breakfast. Not a few ill-fed or ansemic school-children sleep badly during term-time because they are over-worked at school, or worried about their lessons or their place in the class without being actually overworked ; in such cases the distraction afforded by games is likely to be more successful in effecting a cure than treatment by rest. It is only in the minority of instances that the insomnia is due to disease, whether acute or chronic, such as adenoids, enlarged tonsils, or organic disease of the various viscera. A few special forms of insomnia seen in childhood caU for brief mention. In early hip-disease it may happen that sleep is disturbed by sudden starting pains ; the child goes off to sleep, only to be awakened almost at once by sudden shooting pains in the affected leg or hip. Sleep is broken by fright in night- terrors (see Nightmares), in which the child wakes up screaming and frightened, but conscious and able to explain, so far as excitement permits, the nature of the fright ; indiscretions in diet, or the presence of adenoids or worms, often explain the occurrence of such night-terrors. In the rarer and more serious form of night-terror, known as Pavor nocturnus, the child awakes, screaming and frightened, but not fully conscious, and unable to recognize those around him. There is no recollection of the fright next day, and in all probability the pavor is akin to epilepsy, occurring only in children with a bad family history of nervous disease. It is plain from what has been said above that the diagnosis of the cause of sleeplessness in a child demands the scrutiny of the daily routine, diet, and sleeping-arrangements, as well as the examination of the child itself. Sedative drugs are practically never required for its treatment, except in the case of severe acute or chronic disease, and even then should be given but rarely. D 23A 358 INSOMNIA Insomnia in Adults, in the majority of cases, is due to faults of habit or hygiene similar to those already mentioned in the case of children ; but it is due to organic disease of one sort or another in not a few instances, and these will be discussed later. The sleepless adult should devote much thought to the economy and arrangement of his bed and bedroom, and the hours he keeps. It is essential that the bed should be comfortable — whether the mattress be hard or soft is a matter of taste ; many people sleep better with a high pillow than with a low, and if a high pillow is not agreeable, the same effect can often be produced by putting blocks two or three inches high beneath the posts at the head of the bed. The bedclothes should be light rather than heavy ; it is essential that they should be warm enough to prevent the occurrence of cold feet, a very common cause of sleeplessness. The bed should not be placed so that the sleeper faces the light. A supply of fresh air throughout the night is essential, and is assured if the room is heated by an open fire : stuffiness and overheating of the atmosphere seem almost inseparable from heating by stoves, hot air, hot water, or steam, and are common causes of sleeplessness. The hj-giene of the bedroom having been attended to, the habits of the sleepless patient should be passed in review. Many well-to-do people sleep ill because they go to bed too soon after a heavy dinner ; a few because they go to bed hungry. Not a few find that they sleep badly if they take a cup of coffee after dinner, or even drink tea in the afternoon ; others sleep Ul if they indulge in brain-work after dinner, or attend exciting public meetings, theatres, concerts, and so forth. It is known that bodily and mental fatigue promote sleep, and some patients with insomnia, solicit sleep and aggravate their condition by pushing fatigue to the point of exhaustion, forgetting that over-fatigue "often produces sleep- lessness. The observance of fairly regular hours for work, food, and sleep is often neglected by busy men, and the neglect often results in disturbance of their sleep. Sudden changes in the mode or routine of daily life, or alterations in the altitude or locality inhabited, may result in acute and persistent insomnia. It is to the investigation of these and similar irregularities, trifling as many of them maj' appear, that one must look in diagnosing the cause of insomnia in healthy or fairly healthy patients ; its treatment will naturally turn mainly on their correction. Healthier habits of life must be advised ; the use of sedatives must be prohibited entirely. In the case of adults suffering from the most various acute disorders, slight or severe, the occurrence of insomnia is a commonplace. It passes off with the amelioration of the disorder, and as the patient is no doubt able to give an account of himself and' his symptoms, the diagnosis should not be a matter of great difficulty. But it is often otherwise with adults suffering from insomnia due to chronic disease ; the sleeplessness may be one of the earliest symptoms of illness, or the other .symptoms that are present may have escaped the patient's notice. For example, persistent inability to sleep is often a prominent and early feature of nervous or mental disease — melancholia, mania, general paralysis, hypochon- driasis, neurasthenia, acute nervous exhaustion, paralysis agitans, and chronic alcoholism may heie be mentioned ; in old age, senile nocturnal mania may occur as a very troublesome form of insomnia. Inability to sleep may be marked in cases of cerebral tumour or cerebral syphilis. Want of sleep throws a great strain on the nervous system generally, and so is a prominent factor in the production of insanity ; the one aggravates the other, and a vicious circle is established. In heart disease, insomnia is frequently a distressing feature ; the patient often has to sleep propped up in bed because of breathlessness whenever the recumbent position is adopted, and when he dees get off to sleep he is often awakened by cardiac palpitation or dyspnoea, Avithin a few minutes. Restless IRRITABILITY 359 nights are passed and sleep is much impaired, even while compensation is main- tained ; when compensation fails and the patient becomes bedridden, the condi- tion is much aggravated. Patients with aortic incompetence and much cardiac hypertrophy may be kept awake by the pulsating shock and noise of their own hearts. Dyspnoea is a common cause of sleeplessness in many diseases of the lungs, just as it is in severe heart disease. Patients with bronchitis, emphysema, spasmodic asthma, extensive pulmonary adhesions or pulmonar^^ tuberculosis, and other kindred diseases, often pass restless nights because they are awakened bv pulmonar\- dyspnoea soon after getting off to sleep. With these patients, as with those suffering from heart disease, the sitting or semi-recumbent position at night is often imperative, the reasons being that diaphragmatic breathing is easiest, and the amplitude of the diaphragmatic movements greatest when the patient sits, less when he lies, and least when he is in the erect position, and that these patients come to depend in the last resort upon their diaphragmatic respiration. Sleeplessness is frequent in cirrhosis of the liver, being accompanied by nocturnal delirium in the acute and the severer cases ; it may also occur in chronic renal disease. It is often a persistent and distressing feature of arterio- sclerosis and high blood-pressure, with hypertrophy of the heart. The mechanism whereby this sleeplessness is produced is obscure ; but from the fact that any treatment that lowers the blood-pressure — massage, hot baths, high-frequency currents of electricity — cures the insomnia, it may be assumed that the high arterial pressure acts directly, preventing the establishment of the degree of cerebral anaemia that is requisite for sleep. But it must be noted that if insomnia results from the supply of too much blood to the brain, it also results from the supply of too little ; hence sleeplessness occurs in grave ancemia, whether primary or secondary. In conclusion, it may be noted that in hysteria, professions of obstinate insomnia may be made that go far beyond the observed facts ; and that the malingerer , claiming not to have slept at all for days or weeks, may urge the sound slumber he enjoys in hospital as an argument for the prolongation of his stay. A. J. J ex-Blake. IRIDOPLEGIA. — (See Pupil, Abnormalities of the.) IRRITABILITY. — It is not very often that irritability can be regarded as a symptom of diagnostic importance. It is a relative condition, varj'ing in its significance with the individual, and more especially with his age. Children, for instance, display irritability much more readily than adults under similar influences, owing to incomplete education of their powers of control, and a like distinction may be drawn between different persons of adult age. In children, therefore, varying degrees of irritability may be recognized under any condition of ill-health, and as a solitary symptom it can hardly be regarded as one of much import. An exception may perhaps be made in favour of the steadily-increasing irritability Avhich is sometimes observed as a prodrome of meningitis, and which may be sufficiently remarkable to instigate a careful look-out for other early signs of that disease, such as vomiting, headache, strabismus, and head- retraction. In regard to adults, the personal disposition is longer established and better recognized, so that definite alterations in temperament, independent of obvious cause, and clearly not of fleeting character, must always receive attention from the medical man to whose notice they are brought. Here again it must be admitted that many chronic ailments, especially those which entail mental or physical suffering, may be associated with increased irritabilit}^ in a number of instances, without exciting special remark. On the 36o IRRITABILITY other hand, there are some constitutional or metabolic disturbances which are noted for the irritability to which they may give rise. Diabetes mellitus and chronic nephritis are common examples of this kind, and the examination of the urine of patients in whom friends have observed, or who may even themselves complain of, irritability, should never be neglected. In such conditions as jaundice. Graves' disease, and acromegaly, other symptoms and signs are more obvious and more conclusive. Irritability often forms part of a neurasthenic syndrome, but in this connection it is as well to remember that the same symptom may be present in the early stages of general paralysis of the insane. A careful investigation of other mental changes, of the condition of the reflexes and pupils, and, if suspicion is aroused, a Wassermann reaction test, should be carried out before coming to a definite diagnosis. It is hardly necessary to add that irritability may be associated with other depressed mental states, such as melancholia and epileptic dementia. Finally, chronic intoxications, and especially chronic alcoholism and plumbism, may be responsible for great irritability, especially in the earlier hours of the day. E. Farquhar Buzzard. IRRITABILITY OF THE BLADDER. — (See Micturition, Abnormalities of.) ITCHING.— (See Pruritus.) JAUNDICE, — This is the term used to indicate the yellow or greenish coloration of the skin, conjunctiva, mucous membranes, and other tissues and fluids of the body, by bile pigment. The following are its chief signs : — The Skin. — The colour varies from a light sulphur yellow to a deep orange, greenish, and, in some cases, dark olive tint. The greenish or dark olive shade is only found in severe cases of long standing, and is due to the conversion of bilirubin into biliverdin and choletelin by oxidation. Intense itching is often produced, especially if the jaundice is the result of obstruction of the bile-ducts ; and this sometimes leads to vigorous scratching and the production of scratch - m.arks, blood-crusts, and sore places. In certain cases, after some time, little yellowish-white or light yellowish- salmon-coloured patches of soft smooth tissue slightly raised above the surface of the surrounding skin may appear on the upper eyelids near the inner canthi. These patches may spread until the eye is entirely surrounded by this altered skin. A similar condition may also occur on the palmar surface of the hands and fingers, or firm rounded nodules varying in size from ;^ in. to \ in. in diameter, more or less raised above the level of the surrounding skin, may develop over the elbows, knees, or in other places. The former condition is termed xanthelasma planum, and the latter xanthelasma tuberosum. The Eyes. — The conjunctivae are yellow. Care must be taken to distinguish deposits of sub-conjunctival fat from actual coloration. Occasionally patients suffer from yellow vision (xanthopsia). The Urine may present almost any shade, from a light saffron-yellow to yellowish-brown, medium brown, dark mahogany brown, greenish-brown, or even almost black. On looking across the upper portion of the urine in a specimen glass a distinct greenish tinge may be detected, and the froth which forms at the top on shaking possesses a distinct yellowish or greenish shade. It stains white blotting-paper and linen a bright yellow. As a general rule, when jaundice is developing, bile pigment can be detected in the urine before the conjunctivae become yellow, and the conjunctivae become jaundiced before the skin. On the other hand, when jaundice is leaving a patient, the bile pigment first disappears from the urine, whilst the skin remains coloured for some time afterwards. There are certain special cases, indeed, JAUNDICE 361 in -which the skin and conjunctivcTc exhibit obvious jaundice, yet there is no bile pigment in the urine. This condition is termed acholuric jaundice. Other Secretions. — The sweat and milk of women who are nursing may be tinged yellow. Pleuritic, pericardial, or peritoneal effusions may be similarly coloured. The tears, saliva, and gastro-intestinal secretions are not affected in this manner, nor are the brain, spinal cord, meninges, or cerebrospinal fluid. The Faeces. — In cases of jaundice due to obstruction of the larger ducts, the iVcces become greyish-white or clay-coloured from lack of stercobilin, and they may contain an excess of fat which by decomposition is likely to give the stools a verj' offensive smell. The bowels are usually constipated. It is frequently stated that the pulse is apt to become much slower than normal, especialh^ in cases of catarrhal jaundice without pyrexia. It is, however, very rare to find these slow-pulse cases clinically ; more often, although physiological experiments show that bile salts tend to slow the heart remarkably, the pulse- rate is accelerated, especially in pyrexial cases. Bruising. — There is a marked tendency'- to capillar^' oozing and haemorrhage in certain cases ; this is important, not only from the point of view of operations, but also because of the ready bruising of the skin which might be mistaken for evidence of violence. Cholaemia. — In cases of severe or long-continued jaundice, cholasmic symptoms ma}' supervene, namely, stupor, delirium, convulsions, coma, and very possibly death. Jaundice must not be mistaken for other conditions which cause yellowness of the skin. There should be but little possibility of this, provided a careful examination is made. Shght jaundice and pernicious anaemia are perhaps the two conditions that may most readily be mistaken for each other ; in the latter, however, the conjunctivae are generally of a pearly whiteness, however y-ellow the skin may be ; and if the urine should be suspiciously dark, its colour will be found to be due to urobilin, detected by its spectroscopic band between the E and F lines {Fig. 23, p. 95), whilst tests for bile pigments would be negative. In very rare cases of pernicious anaemia there may be jaundice also. Acholuric jaundice cases are probably the most difficult to be sure of, and in some of these the diagnosis becomes a matter of opinion. Having decided that a patient is suffering from jaundice, the next step is to decide the cause of the symptom. The following is a list of the chief causes of jaundice : — CAUSES OF JAUNDICE. I. Jaundic3 due to Obstruction of the larger Bile-ducts, especially of the common Bile-duct : — A. Causes within the Duct : — Gall stones j ! Hydatid cysts Inspissated bile j Parasites ': Distomata JAscarides. B. Causes affecting the Wall of the Duct : — Catarrh of the mucous mem- , Carcinoma of the duct brane of the duct Cicatrization following ulcera- Catarrh of the mucous mem- i tion of the duct brane of the duodenum in- \ Congenital obliteration of the volving and obstructing the duct, ampulla of ^'ater ' Catarrh of the pancreas spread- ing to and involving the am- pulla of Vater. (Chronic pan- creatitis) i 362 J A UN DICE C. Causes compressing the Duct from outside or invading it from outside : — Peritoneal adhesions Enlarged portal lymphatic glands : (a) Secondary nialignant {b) Lymphadenomatous (c) Tuberculous {d) Leukaemic Tumours of the liver ,, ,, pancreas ,, ,, duodenum Tumours of the stomach colon right kidney suprarenal capsule ovaries uterus omentum Aneurj^sm of the hepatic artery. II. Jaundice without Obstruction of the larger Bile-ducts : — A. Causes associated with Disease of the Liver : — Carcinoma Cirrhosis Abscess ,^°f, .^ , ( Multiple or pysemic Acute yellow atrophy B. Jaundice in Acute Fevers :^ Malaria Typhus I Typhoid fever Pyaemia Pneumonia i C. Jaundice due to Poisons :— Phosphorus I Arseniuretted hydrogen \ D. Jaundice due to Nervous Causes : — Mental emotion | E. Jaundice due to Unclassified Causes Familial jaundice I Epidemic infective jaundice | Passive congestion from chronic heart failure Syphilis Active congestion. Weil's disease Yellow fever Relapsing fever And some other tropical fevers. Toluylenediamine Snake poison. Concussion. Icterus neonatorum Icterus gravis of children. THE DIAGNOSIS. When diagnosing the cause of jaundice in any given case, it is of the greatest importance to consider, not only the degree of jaundice, but also the age of the patient, the history, and the significance of any other symptoms which may be present. Very intense jaundice and clay-coloured motions indicate some obstruction to the common bile duct, of which the commonest causes are catarrh, gall- stones, chronic pancreatitis, or carcinoma. Jaundice with rigors suggests : (i) Infective or suppurative cholangitis, with or without suppurating gall-bladder from gall-stones or from carcinoma; (2) Infective or suppurative pylephlebitis, especially after appendicitis ; (3) Hepatic abscess (single or pyaemic). Almost all the different causes of jaundice may also cause pyrexia, so that without rigors the existence of pyrexia does not assist greatly in the differential diagnosis. That cirrhosis of the liver and carcinoma of the liver are both very apt to cause evening rises of temperature to as much as 100° F., 101° F., or more, is a fact that is sometimes overlooked. The absence of pyrexia in a jaundice case will serve to exclude such conditions J A UN DICE 363 as abscess, pylephlebitis, cholangitis, acute specific fevers such as typhoid or Weil's disease, and epidemic infective jaundice. Jaundice with enlargement of the liver may occur in any condition of obstruc- tion to the common bile duct, and in congestion of the liver, cirrhosis, carcinoma, syphilis, abscess, phosphorus poisoning. Jaundice, with a very greatly enlarged gall-bladder, especially persistent jaundice in a middle-aged person, suggests carcinoma of the head of the pancreas. Gall-stones seldom cause both jaundice and a large gall-bladder at the same time, perhaps because the infective process that produces the gall-stones also causes peritoneal adhesions about the gall-bladder which tie it down and prevent it from expanding. The diagnosis is very often almost obvious. For instance, jaundice appearing in an infant two or three days after birth, and rapidly disappearing again, is almost physiological (icterus neonatorum). Transient jaundice in an otherwise healthy boy or girl will almost certainly be catarrhal. Jaundice following an acute attack of colic at once suggests a gall-stone. Recurrent attacks, extending over years, are not likely to be due to malignant disease, whereas persistent and deepening jaundice without intense pain in a person over 40 years of age^ who has been wasting and has only been ill a month or two, suggests malignant disease. It often happens that the primary growth, in cases of secondary malignant jaundice, is not at once obvious, and it is important not to omit a rectal examination lest there be a rectal carcinoma that is itself causing no symptoms. A few words may now be said about each of the main causes of jaundice. I. — Obstruction of the Common Bile-duct. A. Within the Duct. Gall-stones may give rise to no symptoms so long as they remain in the gall- bladder. They vary in size from a grain of sand to a hen's egg. If impacted in the cystic duct, distention of the gall-bladder may follow, but there is no jaundice. When impacted in the common duct, intense jaundice is produced, and some enlargement of the liver, but in the majority of cases no distention of the gall-bladder. Before impaction of the calculus takes place as it moves from the gall-bladder along the ducts, intense, agonizing, colicky pain is produced, which is first felt in the epigastrium and right hypochrondrium, extending thence to the back of the lower part of the right chest, to the back of the right shoulder, and it may be so severe that the patient becomes collapsed. Vomiting, pyrexia, and rigors are other symptoms which are frequently associated with these attacks of pain. The latter lasts a varying time according to what happens to the calculus. If expelled into the duodenum the severe pain ceases, and the gall-stone may be found in the faeces. If found, it should be carefully examined, for if its surface is faceted it indicates that other gall-stones are present, and points to the likelihood of further attacks of colic and jaundice occurring. Jaundice dependent on the passage of gall-stones usually comes on about twelve hours after the commencement of the attack of colic, and persists for a varying period according to the length of time the calculus remains in the duct. Occasionally jaundice occurs without any previous colic. Recurring attacks of jaundice in a middle-aged woman, with or without attacks of coUc are almost pathognomic of gall-stones ; only one other disease produces precisely similar symptoms, namely, chronic pancreatitis. In the latter, however, the jaundice is apt to persist longer, and it may never go completely away, lessening between the attacks, to deepen again with each recurrence of the acute pan- creatic pain. It is often very difficult to distinguish gall-stones from chronic 364 J A UNDICE pancreatitis without laparotomy, and yet chronic pancreatitis is curable without any operation. The absence of gall-stones in the faeces, and the presence of a positive pancreatic reaction in the urine (see Cammidge's Pancreatic Reaction), would point to chronic pancreatitis rather than to gall-stones ; the former is distinguished from neoplasm by the greater amount of pain it causes and the longer the case lasts. There are several methods of detecting pancreatic disease, most of which depend upon the non-entry of the pancreatic juice into the intestine. The percentage of fat in the stools when ordinary quantities are given by the mouth is very much greater when the pancreatic juice fails than when the bile alone fails, so that extremely fatty iridescent stools favour a diagnosis of pancreatitis or pancreatic neoplasm. The same indication is afforded when the faeces contain a large number of undigested muscle fibres ; also when keratin-coated capsules are passed undigested, or when such capsules containing methylene blue are given without the urine subsequently turning blue. Other tests concern the tryptic activity of the motions, and so forth, and their value is still sub judice. If a stone remains impacted in the common duct, the jaundice is intense ; but if it soon passes into the duodenum, the jaundice is slighter and transient. Inspissated Bile is always mentioned as a cause of jaundice, but there are no distinguishing signs of this condition, and it would require considerable boldness on the part of the physician to make this the sole diagnosis. Thickening of the bile may occur in acute fevers, poisonings, and so forth, and this is possibly the cause of the jaundice in many of the cases where there is no obstruc tion to the large bile- ducts ; but a diagnosis of " inspissated bile " by itself would clearly be incomplete and inadequate. Parasites. — A hydatid cyst of the liver may happen to be in such a position as to stenose the common bile-duct, or it might open into the gall-bladder, cystic, hepatic, or common bile-ducts. It is, however, an exceptionally rare cause of jaundice, and it could seldom be diagnosed unless by laparotomy. Distoma hepaticum. — The normal habitation of this parasite is the bile- ducts of the sheep ; it is sometimes found occupying a similar position in man, though in England this is of extreme rarity. The chief symptoms are jaundice, ascites, enlargement of the liver, vomiting, pyrexia, diarrhoea, and pain in the right hypochondrium. If circumstances should suggest this infection, the vomit and the stools should be examined for flukes, and the stools for ova, which are constantly present, large, brown, and operculated, measuring O" 1 3 by "08 mm. Ascaris lumbricoides (round worm). — This parasite inhabits the upper part of the small intestine and measures from 15 to 45 cm. in length. It seems to have a special tendency to force itself into small orifices, and it has been recorded as becoming impacted in the common bile-duct, with jaundice as the result. The worms themselves seldom produce symptoms, and unless they are actually found in the duct they could never be diagnosed with certainty as the cause of jaundice. Even if the worms or their ova were found in the patient's faeces it would be a bold thing to diagnose that an ascaris impacted in the bile-duct was the cause of the jaundice. B. Causes affecting the Wall of the Duet. Catarrh of the Mucous Membrane of the Bile-duct (catarrhal jaundice). — This is a common cause of jaundice — in young people the most common of all. It is due to the obstruction caused by the swelling of the mucous membrane, and it is almost impossible to distinguish clinically between cases in which the catarrh is confined to the bile-ducts, and those in which it began in the duodenum and thence extended to the biliary papilla. It is usually preceded by gastro-intestinal disturbances, especially epigastric discomfort and dyspepsia. The jaundice develops almost suddenly in many cases, and it J A UNDICE 365 may become intense, the stools being clay-coloured and the urine dark \vith bile pigment. There may be a slight rise of temperature at first, the pulse may be less accelerated than would be proportionate to the temperature, and in quite rare cases it is absolutely slowed down to 40, or even 30 ; the liver and spleen may be slightly enlarged, the tongue furred and the breath foul ; loss of appetite, nausea, constipation, a feeling of weight and discomfort in the right hypochondriac region, may also be prominent symptoms. In mild cases the jaundice is slight and disappears at the end of one, two, or three weeks ; some- times it lasts as long as eight weeks, or even more. In considering the dia- gnosis, it should be remembered that jaundice in a child or young adult is most likely to be due to catarrh. The slightness of the pain helps to exclude gall- stones and chronic pancreatitis, and malignant disease is rendered improbable if the jaundice presently clears up, and if the patient does not emaciate. Catarrh of the Pancreatic Ducts, extending to the ampulla of \'ater and so to the bile-ducts, has already been discussed under chronic pancreatitis above. It differs from catarrh starting in the duodenum or in the bile-duct by being associated with periodic attacks of colicky epigastric pain resembling gall- stone colic. Cicatrization following Ulceration of the Duct. — Simple fibrous stricture of the bile-ducts is a possible but rare result of ulceration due to gall-stones. If the cystic duct is thus stenosed, distention of the gall-bladder without jaundice follows ; if the hepatic duct, jaundice and enlargement of the liver without distention of the gall-bladder ; and if the common duct, intense jaundice, enlargement of the liver, and possibly, but not necessarily, distention of the gall-bladder. It is practically impossible to diagnose between this condition and impacted gall-stones during life, except by laparotomy. Congenital Obliteration of the Bile-ducts. — Jaundice in infants is almost always transient, icterus neonatorum developing about the third day and passing off in a week or less. If an infant should remain persistently jaundiced, a grave condition is almost certainly present, though only a post-mortem examination, as a rule, can decide whether it is due to congenital syphilis with or without cirrhosis and pervious ducts, to congenital obliteration of the bile-ducts, or to " icterus gravis," the last term being used when the child dies and no obvious cause for the jaundice can be found post mortem. As regards congenital obliteration of the bile-ducts, boys are more frequently affected than girls. Jaundice may be present at birth or appear on the second or third day, or even as late as the fourteenth day. At first it is slight, but soon becomes intense. Constipation, pale motions, bile in the urine, and spontaneous haemorrhages — especially from the umbilicus — are the most prominent symptoms. Death may take place in two or three weeks when haemorrhage occurs, but if there is no tendency to haemorrhage, life may be prolonged for six or seven months. Increasing jaundice, colourless motions, bile-stained urine, and spontaneous haemorrhages would point to some condition more serious than icterus neo- natorum. C. Causes Compressing the Duct from Outside or invading it from Outside. When compression of the common bile-duct is spoken of, the term invasion of it would often be more correct, especially when the so-called compression is due to secondary deposits of malignant disease in the lymphatic glands in the portal fissure. In almost all cases of the kind jaundice is persistent, and it is often progressive, although there may be slight variations in its depth. Enlarged Glands in the Portal Fissure. Secondary Malignant Glands. — The lymphatic glands in the portal fissure are very liable to become enlarged from deposits of secondary growth in cases of abdominal malignant disease. Jaundice with or Avithout ascites is a prominent indication of such a condition, and when 366 ■ JA UN DICE both jaundice and ascites are present in a case of malignant disease of the stomach or intestine, whether the hver is enlarged or not, it is probable that there are enlarged malignant glands in the portal fissure. The difficulty of diagnosis arises in cases in which no primary growth can be found. In a fair number of these it is either in the rectum, colon, or pancreas. Lymphadenomatous Glands. — The portal glands occasionally become enlarged in cases of lymphadenoma (Hodgkin's disease), or lymphosarcoma, with a similar result. The presence of enlarged superficial lymph glands and enlarge- ment of the spleen and liver, together with a simple anaemia without leucocytosis, would suggest this diagnosis. In most cases of lymphadenoma in which jaundice occurs it is a late symptom, arising long after the correct diagnosis has already been made. Tuberculous Glands. — Although the glands in the portal fissure frequently become caseous in cases of tuberculous peritonitis it is decidedly rare to find that their enlargement has been sufficient to compress the bile-duct and cause jaundice. Lymphatic LeukcBniic Glands. — The visceral glands may become enormously enlarged in some cases of lymphatic leukaemia, and in rare instances those in the portal fissure have led to jaundice. The diagnosis is easy, even if the spleen and superficial lymphatic glands are not enlarged, for a blood-count would show that the total number of leucocytes per c.mm. of blood was raised to anything between 50,000 and 2,000,000 per c.mm., whilst the differential leucocyte count would show a very great preponderance of lymphocytes. Tumour of the Liver. — Any disease which causes a local enlargement of the liver, e.g., carcinoma, sarcoma, abscess, gumma, or hydatid, in the immediate neighbourhood of the portal fissure, may compress the common bile-duct and lead to jaundice. On account of the close relationship between the bile-duct and the portal vein, ascites is equally liable to be produced. The association, therefore, of jaundice and ascites with a local enlargement of the liver would point to this last-mentioned condition being the cause of the two former. In many such cases, however, the jaundice is really due to deposits in the portal lymphatic glands ; for if the latter escape there may be very large numbers of malignant deposits in the liver without there being any jaundice at all. Tumours of the Pancreas. — A tumour of the head of the pancreas generally causes jaundice by invading the orifice of the common bile-duct. In some cases, situated far back in the abdomen, a mass can be felt which, on account of its close proximity to the aorta, may present distinct transmitted pulsation. It may prove difficult, without artificially inflating the stomach, to distinguish it from a tumour of the latter or of the liver. A pancreatic tumour is situated behind the stomach, and does not, as a rule, move on respiration, though if attached to the portal fissure it moves with the liver. Glycosuria and fatty stools would be strong evidence in favour of a pancreatic tumour, even if no tumour were palpable. The tests mentioned on page 364 could be employed here too. The gall-bladder is very apt to become greatly distended ; indeed, persistent and increasing jaundice with decided enlargement of the gall-bladder in a person of the cancer age are probably the most characteristic symptoms of carcinoma of the head of the pancreas. Tumours of the Duodenum. — Primary carcinoma of the duodenum is very rare, but when it does occur it usually arises in the immediate neighbourhood of the biliary papilla, and by obstructing the common bile-duct causes persistent jaundice, with progressive emaciation. Tumours of the Stomach. — A carcinomatous tumour of the pyloric end of the stomach may become adherent to the portal fissure and cause jaundice by J A UNDICE 367 compressing the common bile-duct. If, however, the existence of a gastric carcinoma were known in a patient who developed jaundice, the chances would be strongly in favour of the latter being due to obstruction, not by the primary growth, but by secondary deposits in the portal lymph-glands. It should also be borne in mind, however, that even when carcinoma exists, a microbial catarrh of the duodenum may cause transient non-malignant jaundice. Tumours of the Colon. — Carcinoma of the hepatic flexure or transverse colon may become adherent to the liver and cause jaundic-3 by compressing the common bile-duct. It may be difficult to distinguish such a tumour from a local enlarge- ment of the liver ; but constipation, vomiting, tympanitic distention of the intestine, and the passage of blood per rectum would point to a growth in the colon. In most of such cases, however, the obstruction to the bile-ducts is not by the primary growth, but by secondary deposits in the portal glands. The importance of rectal examination has already been insisted on. Tumours of the Right Kidney. — Large tumours of the right kidney, especially malignant growths, may compress the bile-duct and cause jaundice. If the tumour becomes adherent to the liver it is difficult to distinguish it from an enlargement of that organ, as the liver and the enlarged kidney would move together and at the same rate during respiration. If the abdomen is bimanually palpated, however, the loin may be felt to be filled out behind ; and, in front, the edge of the liver may be distinguished lying over the front of the tumour, and it may be possible to distinguish a vertical band of colonic resonance over the otherwise dull mass. Hsematuria, albuminuria, and pyuria would be additional evidence of renal disease. Transitory attacks of slight jaundice are not uncommon in association with movable kidney. This is possibly due to compression of the common bile-duct by the kidney, but it may also result from the associated enteroptosis causing a drag on the duodenum, and a kinking of the common bile-duct. The diagnosis of movable kidney is not difficult, the position and the mobility of the tumour, and the curious sickening sensation experienced by the patient when it is com- pressed, being sufficiently characteristic. Tumours of the Right Suprarenal Capsule. — Malignant growth of the right suprarenal capsule is very rare, but it may give rise to an enormous tumour which is difficult to distinguish from a renal, or even in some cases a hepatic, enlargement. IMalignant disease of one capsule causes no symptoms of Addison's disease if the other remains healthy. Ovarian Tumours. — A large ovarian cyst may extend upwards to the portal fissure, compress the common bile-duct, and cause jaundice, but such a compli- cation is rare ; indeed, when jaundice is associated with ovarian tumour, the suspicion will naturally be that the latter is malignant and that there are second- ary deposits in the glands in the portal fissure obstructing the large bile-ducts. Ascites is very apt to be present at the same time, so that unless the existence of an ovarian tumour is already known, or unless its existence can be determined by abdominal, vaginal, or rectal examination, there may be much difficulty in determining the precise cause of the jaundice, though if cirrhosis of the liver can be excluded, some form of malignant disease will probably be suspected. Tumours of the Uterus. — A large tumour of the uterus may cause jaundice in a similar manner to an ovarian tumour, but even more rarely. Tumours of the Omentum. — A large omental tumour may compress the bile- duct and thus cause jaundice, but it is an exceedingly rare result of such a condition. Whether malignant or tuberculous, it usually lies across the upper part of the abdomen, is superficial, and moves slightly with respiration. If it has become adherent to the liver it may be difficult to distinguish it from a local enlargement of the latter. In any case, the jaundice will probably be diagnosed 368- J A UNDICE as due to deposits — tuberculous or malignant — in the portal glands, rather than to the omental mass itself. Aneurysm of the Hepatic Artery, Cceliac Axis, or Abdominal Aorta. — An aneurysm of the hepatic artery is a decidedly rare condition, but it is by no means unheard of in cases of fungating endocarditis with embolism. Jaundice is intense, on account of the close proximity of the hepatic artery to the common bile-duct. A correct diagnosis would be almost impossible during life, especially in view of the fact that jaundice may occur in fungating endocarditis cases simply from the inspissation of the bile that results from the toxaemia and fever. Aneurysm of the coeliac axis or upper part of the abdominal aorta is also a very rare cause of jaundice. The presence of an abdominal tumour with marked expansile pulsation, a systolic bruit and abdominal pain, are the most important diagnostic signs, especially if they occur in a person who is known to have had syphilis. II. — Jaundice without Obstruction of the larger Bile-ducts. A. Causes associated with Disease of the Liver. Carcinoma of the Liver. — Jaundice occurs in more than 50 per cent of the cases of malignant disease of the liver, whether secondary or primary ; it is seldom, however, that the masses in the liver itself cause the jaundice, but rather the associated deposits in the portal glands. A liver may contain hundreds of nodules of new growth without there being either jaundice or ascites if the portal glands escape. Jaundice brought about in this manner is permanent, and when the common duct is involved is intense. The skin, which at first is a deep orange, becomes greenish, and finally the dark olive-green tint which is almost pathognomonic of jaundice due to malignant disease. Increasing jaundice in a patient over 40 years of age, who has been ill less than six months, who has progressively wasted and become weaker, and whose liver is enormously enlarged, hard, and nodular, points without much doubt to malignant disease, though careful search may be required before the primary source is found. The nodules may even be felt to be umbilicated. Primary carcinoma of the liver should not be diagnosed until a very careful physical examination has failed to furnish evidence of the primary growth in some other organ. Cirrhosis. — In many cases of cirrhosis of the liver the late or multilobular stage of the disease may be reached without there having been any jaundice at all. If it occurs late in the disease, when ascites is already present, the jaundice is usually slight. Ascites is the most constant and characteristic feature at this late stage of cirrhosis, but when slight jaundice and ascites are associated in a patient who gives a definite history of alcoholism, and also has symptoms and shows signs of this condition — nausea, loss of appetite especially for breakfast, morning sickness, attacks of cramp in the legs at night, epistaxis, h^matemesis, melaena, the presence of dilated venules on the cheeks, acne rosacea, tremulous tongue, haemorrhoids, and a hard liver with a well-defined and beaded edge — the diagnosis of cirrhosis of the liver is not diffi- cult. Sometimes, however, jaundice is a marked feature of the case at an early stage, when the organ is still large and the fibrosis unilobular, and at this time ascites is conspicuous by its absence. In most of these cases there is an evening rise of temperature to about foo" F. The liver is considerably enlarged, its surface is smooth, firm perhaps, and tender, and its edge is even and well-defined, reaching to the level of the umbilicus or even below it. The jaundice may pass ofif, and the patient survive many years before the multilobular ascitic stage of his malady is reached ; on the other hand, if the jaundice persists and deepens, the prognosis is grave ; cholaemia sets in, drowsiness and muttering delirium passing on to coma and death. J A UN DICE 369 There is a peculiar form of cirrhosis of the liver (Hanot's) which affects several merabers of the same family, and whose first symptom in each patient is jaundice. The disease appears not to be caused by alcohol, syphilis, or malaria. It is possible for the patient to live many years with more or less jaundice all the time. The liver is enlarged and hard, and the spleen is also moderately increased in size. The diagnosis is arrived at by enquiring into the family history. There is yet another particular variety of cirrhosis of the liver which occurs in children and young people, and is characterized by enormous enlargement of the spleen, slight enlargement of the liver, anaemia without leucocytosis, haematemesis, clubbing of the fingers, jaundice, and stunted growth. It differs from Hanot's cirrhosis in that the liver is smaller and the spleen larger, and from the latter feature of the case it is termed splenomegalic cirrhosis (Taylor). Single or Tropical Abscess. — In cases of single or tropical abscess of the liver, intense jaundice is rare, and it is only likely to occur when the abscess bulges in the region of the portal fissure. The general appearance of a patient who is suffering from hepatic abscess may, however, be mistaken for jaundice, because the complexion is sallow, and the conjunctivae may even have a slightly icteroid tinge. The urine, however, seldom contains bile pigment. It is a disease which mostly affects people who have resided in the tropics, particularly those who have had dysentery. The diagnosis depends on the history of residence abroad, together with more or less severe symptoms, such as a feeling of chilliness, rigors, intermittent pyrexia, profuse sweating, rapid pulse, dull heavy pain in the right hypochondrium and under the right shoulder blade, vomiting, dry furred tongue, severe prostration, and emaciation. The physical signs vary according to the position and the size of the abscess. Inter- mittent pyrexia and an absence of signs of enlargement of the liver may lead to a diagnosis of malaria, but a blood examination should settle this point. In the case of malaria, protozoa may be found in the red blood-corpuscles, and after the initial chill there is a diminution in the number of leucocytes with a relative lymphocytosis, whereas in hepatic abscess there would be a poly- morphonuclear leucocytosis. A large single abscess may cause a fluctuating swelling in the epigastrium if it arises in the left lobe ; may project from the under surface of the liver and simulate an enlarged gall-bladder ; may bulge the ribs in the lower axillary region on the right side if it arises from the right lobe, or push the diaphragm upwards and simulate an empyema. Should the abscess open into the lung the dull reddish pus expectorated would point to its origin in the liver, even though no Amcebce dy sentence be found in the pus. Multiple Abscesses in the Liver. — Multiple abscesses of the liver might theor- etically arise by infection through any one of four different channels, namely, the portal vein, the bile-ducts, the hepatic artery, and the lymphatics. In practice only the first two are important, giving rise to suppurative pylephlebitis on the one hand, and suppurative cholangitis on the other. There are really no sharp lines of demarcation between non-suppurative inflammations of these channels on the one hand and suppurative ones on the other. Thus, there are all intermediate stages between simple catarrh of the ducts and acute suppurative cholangitis ; and there are similar degrees of inflammation in the case of the portal venules. Jaundice is almost constantly a symptom of cholangitis ; and the diagnosis is arrived at when a cause for cholangitis exists, such as gall-stones, carcinoma of the gall-bladder, empyema of the gall-bladder after typhoid fever, and when the patient's liver enlarges and becomes tender, especially if rigors also occur from time to time. Suppurative pylephlebitis is less easily diagnosed, and indeed it is often overlooked as a cause for an obscure febrile illness accom- panied by rigors. About half the patients who have it develop jaundice, and one very important point is that, in over half the cases, the cause of the infection D 24 370 J A UXDICE of the portal vein is a recent mild attack of appendicitis. If, therefore, a patient who has recently had pains or discomfort in the right iliac fossa presenth^ begins to do badly, developing p^-rexia and rigors without apparent cause, and if that patient in the course of a week or so develops a tinge of jaundice and a sUghtly enlarged hver, the grave diagnosis of infective pylephlebitis should suggest itself at once. Acute Yellow Atrophy of the Liver. — Jaundice is one of the earUest symptoms of acute yellow atrophv of the liver, and at first it may appear that the patient is suffering from catarrhal jaundice. At the commencement it may be slight, but it graduaUv increases in intensity- until the onset of nervous s\Tnptoms, when it suddenlv becomes severe and the skin assumes a greenish hue. In the earh- stages bile pigment may be found in the urine, but towards the end, when the skin becomes green, Gmehn's reaction cannot be obtained, or onlj^ a trace of pigment can be detected. The striking resemblance between this disease and that producible hj poisons suggests that in it there is that varietA^ of catarrh of the bile-ducts which Hunter has caUed toxaemic — that is, a catarrh produced by the excretion through the bile of injurious products which cause extensive degenerate changes in the hver cells. This is an exceptionally rare disease. It affects females under 30 years of age much more frequently than males, and in a good many cases has been preceded bv fright, or severe mental emotion. It usually commences in the same manner as an attack of catarrhal jaundice, with nausea, vomiting, loss of appetite, constipation, and pain in the right hypochondrium. At the end of two or three weeks a sudden change occurs, which commences with severe vomiting, headache, restlessness, followed by delirium, convulsions, and coma. The temperature rises to 101° F. or 102° F., and the pulse becomes rapid. The tongue is dr^- and brown. There is a tendency to haemorrhage from various parts, e.g., epistaxis, hgematemesis, melsena, and metrorrhagia. The most important diagnostic signs are the remarkable diminution of urea and uric acid, and the presence of leucin and tj-rosin, in the urine; also the rapid diminution in the extent of the hepatic dullness which takes place after the development of the above-mentioned ner\'ous symptoms. The duration of the disease, in the majority- of cases, is under fourteen days from the time of the sudden change in the type of the jaundice. Passive Congestion (nutmeg liver). — Jaundice occurs in severe cases of passive congestion, especially as the result of long-standing mitral stenosis, or of fibrosis of the lung, with ultimate failure of the right side of the heart. It is usually but an icteric tinge, but when severe its association with C}-anosis gives a curious dusky -green tint to the skin, especially that of the face. CEdema of the legs and ascites are also present as a rule. The liver is considerably enlarged, its edge is sharp and well defined, its surface smooth, firm, tender, and possibly pulsating. Jaundice from this cause should not be difficult to diagnose. If in a chronic heart case there are both pvrexia and jaundice, f ungating endocarditis is probable. Syphilis. — Congenital syphilis may cause jaundice in infants or young children as the result of intralobular fibrosis, but it is possible for the latter to be extensive without there being any jaundice, and even where the latter is present it is usuallv slight. If associated with uniform enlargement of the liver, wasting, and other signs of congenital SA-philis, the diagnosis is not difficult. In an adult it is possible for gummata to cause jaundice by compressing the ducts, but this is distinctly rare. The local enlargement of the liver and pyrexia may lead to a diagnosis of abscess or of secondary- carcinoma. A careful examination must be made for signs of s\-philis ; in some cases it is not until antis\-philitic remedies have been administered and the effect watched, that a J A UN DICE 371 correct diagnosis can be made. If there are any active lesions of the skin or mucous membranes, it may be possible to detect the Spirochcsfa pallida microscopically (see Plate XII, Fig. J) ; or the patient's serum may be examined in the laboratory for Wassermann's reaction. Probably the commonest period at which syphilis may be directly responsible for jaundice is the secondary stage, when it is apt to cause catarrh of many different glandular ducts, including those of the liver. The symptoms will be very like those of simple catarrhal jaundice, together with the roseola, the sore throat, the pyrexia, the albuminuria, and other signs of secondary syphilis. Active Congestion. — Active congestion of the liver is a diagnosis that some observers would not hold with, whilst others are convinced that it is not an uncommon result of many of the acute fevers, such as malaria, and that it may arise from insufficient exercise, especially when associated with alcoholism and over-eating, particularly in Europeans who live in the tropics. The liver is slightly enlarged and tender. The chief symptoms are slight jaundice, pain, and a feeling of fullness, weight, and oppression in the right hypochondrium, which sensations are much increased by pressure ; also pain in the right shoulder, a bitter taste in the mouth, nausea, sickness, a furred tongue with indented edges, constipation, and scanty high-coloured urine. There may be a tempera- ture of 102° F., and then care must be taken to distinguish it from hepatic abscess. An absence of leucocytosis would be in favour of congestion and against suppura- tion. If due to malaria, an examination of stained blood-films should demon- strate the presence of malaria parasites. It is clearly impossible to distinguish clinically between active congestion of the liver and catarrh of the bile-ducts. B. Jaundice in Acute Fevers. Malaria. — Slight jaundice may occur in long-continued tertian and sestivo- autumnal infections, and on account of the associated irregular pyrexia it may lead to a mistaken diagnosis of hepatic abscess. Microscopic examination of stained blood-films, and the discovery of the characteristic parasites in the red blood-corpuscles {Plate XII), are the most conclusive evidence of malaria. Jaundice may also occur as a result of malarial cirrhosis. It should be borne in mind that the parasites rapidly disappear from the blood in cases in which quinine has been administered recently. It is important, therefore, to examine blood-films for the parasites before quinine is given, and if possible at the very commencement of an ague fit, at which time they are at their most typical stage of development. If quinine has already been given, however, there will still be presumptive evidence in favour of malaria if there is no leucocytosis, and if the differential leucocyte count shows a decided increase in the proportion of large hyaline lymphocytes — up to 1 5 per cent or more. Typhus Fever. — Jaundice may occasionally occur in this disease, which, fortunately, is now extremely rare. A few cases have been seen at Guy's Hospital during the last few years, but jaundice was not noticed in any of them. The onset is more sudden, and the prostration occurs earlier and is more marked, than in typhoid fever. A slight leucocytosis may occur in typhus. The rash appears from the third to the fifth day, and consists of a dusky red mottling — the so-called mulberry rash — rose-coloured papules which appear on the abdomen and chest, together with a certain number of petechise — the latter not being found in typhoid cases. The fever tends to terminate by crisis rather than by lysis. Widal's reaction is negative. Typhoid Fever. — Jaundice is a rare symptom in this disease ; it occurred in only three out of Osier's series of 829 cases. It is due to an inflammation of the bile passages by typhoid bacilli. The gall-bladder may become enlarged and tender, and give rise to a typical palpable tumour, though this may also occur in typhoid fever without there being any jaundice at all. It occasionally 372 J A UN DICE arises as a complication in the course of the disease, or it may be a sequela, or again, it may be an early and prominent symptom for which the patient seeks advice. Cases have been recorded of primary typhoid infection of the gall- bladder and bile-ducts without any accompanying ulceration of the intestine. The low pulse ratio, when compared with the temperature, e.g., a pulse of 90 with a temperature of 104° F., the presence of typical rose-red spots on the abdomen, enlargement of the spleen, leucopenia, and a positive Widal's reaction, are the most important signs which would point to a diagnosis of typhoid fever. Pyomia and Septiccemia. — Jaundice is frequently a late symptom of pyaemia, and may or may not be associated with the presence of multiple abscesses in the liver. It is more likely to occur in cases of portal than arterial pyaemia. Rigors, high irregular temperature, rapid pulse, profuse sweating, rapid emacia- tion, and progressive loss of strength, are symptoms which, if developing after parturition, wounds, or operations, would point without much doubt to a diagnosis of pyaemia. In some instances of acute septicaemia due to streptococci, staphylococci, and perhaps other micro-organisms, there has been intense jaundice of the skin and conjunctivae of a peculiar mustard-yellow tint, without the urine giving a positive Gmelin's test. The urine may or may not be discoloured — in some instances it looks merely concentrated, in others it looks almost like porter, and yet it gives no play of colour to the nitric acid test ; the cause of this would seem to be the oxidation of the pigment before it reaches the urine ; in septic cases this occurrence of acholuric jaundice is a very remarkable and, at first sight, confusing factor in the case. Pneumonia. — Jaundice occasionally occurs as a complication of pneumonia. It varies very much in its frequency in different epidemics of the disease. It is noticed soon after the initial rigor, but is rarely intense. It is most probably due to engorgement of the liver and catarrh of the bile-ducts. Its more frequent association with right basal pneumonia is suggestive. The sudden onset with a rigor, the high temperature, the rapid respiration rate, which is above the ordinary temperature and respiration ratio, and the com- paratively slow pulse, e.g., T. 104° F., R. 40, P. 100, the characteristic tenacious, russet-brown sputum, the short catchy cough, the pain in the side, the pleuritic rub, and the signs of consolidation of the lung, the hot dry skin, the deficiency of chlorides in the urine, and the occurrence of herpes facialis, are the accom- panying indications which in the majority of cases would point to a diagnosis of pneumonia. Infections or Epidemic Jaundice — Weil's Disease. — This disease is characterized by a sudden onset, with pyrexia, severe pain in the back and limbs, headache, and giddiness, followed in a day or two by jaundice, enlargement of the liver and spleen, and signs of nephritis. The jaundice becomes intense within twenty- four hours of its onset. The temperature rises to 103° F. to 104° F., and the pulse becomes rapid. Nephritis, next to jaundice, is one of the most constant features of this disease. Males between 1 5 and 30 are most frequently affected, and it appears to have some direct connection with insanitary surroundings. Butchers appear to be particularly susceptible. It is practically unknown in England. Yellow Fever. — This disease in some respects resembles acute yellow atrophy of the liver, but the liver does not atrophy, neither does the spleen enlarge, and crystals of leucin and tyrosin are not found in the urine. It is essentially a disease which prevails in tropical and sub-tropical countries, especially in the West Indies and Central and South America. The incubation period is from three to four days, and the onset is sudden, with rigors, headache, and pain in the back and limbs. The bowels are constipated. Jaundice is an early symptom, and one of the most characteristic, but it varies in intensity, being much more severe in fatal than in mild cases. The temperature rises to 102° F. J A UN DICE 373 or 103° F. ; the pulse is rapid at first, but may fall as the temperature rises, and this is looked on as a very typical sign of the disease. Albuminuria, black vomit, haemorrhage from the gums and beneath the skin, are other important symptoms. A sporadic case occurring in this country would probably be looked upon as acute yellow atrophy of the liver unless a definite history of exposure to infection was obtainable. It may be difficult to distinguish it from dengue and pernicious malaria. From the latter it can be diagnosed if crescents are discovered in the blood [Plate XII, Fig. E.). Relapsing Fever. — Jaundice is a common symptom of this contagious fever, which is prevalent in India, and is liable to arise in other countries in times of famine. Considerable enlargement of the liver and spleen, and a good deal of abdominal pain and tenderness, are present in the majority of cases ; also epistaxis and haematemesis. The most characteristic feature of the disease is the temperature, which rises abruptly to 104° or 105°, and even to 108° F., remains high for five or six days, and then suddenly falls to normal when, after an interval of about a week, it again rises and remains high for three or four days. During the periods of pyrexia the SpirochcBta ohermeieri [Plate XII, Fig. I) may be found on examining blood-films which have been prepared and stained in the same manner as for the detection of malaria parasites. The blood examination serves to distinguish it from malaria. C. Jaundice due to Poisons. Phosphorus. — Jaundice is one of the most characteristic symptoms, but by no means a constant one, of phosphorus poisoning. It is slight at first, appearing on the second or third day in severe, but in mild cases not until the end of the first week, or even later. It is due to concentration and increased viscidity of the bile, leading to obstruction of the smaller ducts. This form of poisoning is rare in this country since the stringent law regulating the manufacture of matches from the non-poisonous form of the drug has been in force. In the cases which do occur, the phosphorus has been taken in the form of match- heads or rat paste with suicidal intent. At first the signs are those of acute irritant poisoning coming on soon after the phosphorus has been swallowed, viz. : nausea, vomiting, severe burning pains in the epigastrium, collapse, extreme thirst, rapid feeble pulse, rapid respiration, and tenderness in the epigastrium and right hypochondriac regions. In many cases that receive treat- ment early, these acute irritant symptoms subside in a day or two, and recovery results. If they do not thus subside, however, after from two to five days the symptoms change, the vomit becomes black or brownish from the presence of blood, jaundice appears and rapidly deepens, the liver enlarges, and headache, drowsiness, delirium, convulsions, and coma supervene, followed shortly by death. If hepatic enlargement cannot be ascertained, it may be difficult to distinguish phosphorus poisoning from acute yellow atrophy of the liver. Haemorrhages, although common, are not as frequent as in acute yellow atrophy. The urine is concentrated and strongly acid ; the total nitrogen is first reduced, as in cases of starvation, to about one-fourth the usual, and then, in spite of the fact that the patient can retain no food, it rises to the usual amount, which shows that there must be a considerable destruction of albuminous tissue taking place. Urea forms the greater part of the total nitrogen, but towards the end the total amount of ammonia is increased. Leucin and tyrosin are not usually found, and the chlorides are diminished. The condition of the urine, therefore, forms a contrast to the changes which are found in cases of acute yellow atrophy. The chief indications of the disease that are found post mortem are jaundice, multiple punctiform haemorrhages, fatty degeneration of the liver, kidneys, and heart, -and enlargement of the spleen. 374 JAUNDICE Arseniiiretted Hydrogen. — This poison causes jaundice in a similar manner to toluylenediamine, through extreme concentration of the bile. According to Hunter, the increase of bile pigment may be to three and a half times- more than its normal amount. The bile acids are diminished. Toluylenediamine. — This drug has been used for experimental purposes, and its action has helped to prove that so-called haematogenous jaundice is really due to obstruction of the smaller ducts through increased viscidity of the bile. When injected into dogs this poison soon produces intense jaundice. It causes destruction of blood, and the haemoglobin thus liberated increases the quantity and viscidity of the bile, so that temporary obstruction of the smaller ducts, followed by jaundice, results. Snake Poison. — Jaundice is a common result of snake-bite, and is produced in a similar manner to the last three forms described, viz. : as a result of con- centration and increased viscidity of the bile leading to obstruction of the smaller bile ducts. The diagnosis depends upon the history. D. Jaundice due to Nervous Causes. Icterus Nervosa — Mental Emotion. — Cases are on record of jaundice following almost immediately after some violent mental emotion, but they are of extreme rarity. Under such circumstances the jaundice has been explained as being the result of a sudden spasm of the bile-ducts. In another class of these cases the jaundice does not appear until twelve or fourteen hours after, and it is then probably due to catarrh of the bile-ducts, associated with some gastric and duodenal catarrh, for it is well enough known that severe mental emotion, grief, or anxiety may give rise to acute dyspepsia. Jaundice may similarly occur after concussion of the brain. Herbert French. JERK, ACHILLIS (See Ankle-clonus.) JERK, KNEE — (See Knee-jerk.) JOINTS, AFFECTIONS OF THE.— ft will be well to place these in two groups : (i) Acute ; (2) Chronic. I. Acute Joint Affections. — Arthritis due to Rheumatic Fever is the most frequent of these. The patient has often had the disease before ; there are manifestations of past rheumatic affection of other parts of the body than joints ; thus the presence of organic mitral disease is of great help in the diagnosis of a doubtful case. A history pointing to past chorea, several attacks of tonsillitis, pericarditis, or rheumatic erythema or nodules will help. The distinguishing features of the arthritis are that it is acute, and affects first and chiefly the larger joints, although in a very severe case even the joints of the hand and fingers may be implicated ; it does not occur in all the affected joints simultaneously, but appears in one, a few hours after in another, and so on. As the arthritis often only lasts a few days in any one joint, in some it may have passed away while others are being affected. The pain is very severe and is greatly increased by any jar of the bed ; it is more fleeting than the arthritis, but like it, flits from joint to joint, hardly ever returning to the same joint in the same attack. The swelling of the joint is usually only slight or moderate ; it is due to synovial effusion, never suppurates, generally subsides in a few days, and usually in a few days, or at most a fortnight, the joint returns completely to its normal condition. Permanent distortion or stiffness of the joints after rheumatic fever occurs, but it is highly exceptional. Often there is a faint red blush over the joint when first affected. The most important diagnostic characteristics of this arthritis are : (i) The fact that it flits from joint to joint. Never diagnose rheumatic fever so long as JOINTS, AFFECTIONS OF THE 375 only one joint is affected. I have known failure to remember this lead to a diagnosis of rheumatic fever in traumatic arthritis, tuberculous arthritis, arthritis due to acute necrosis of a bone near a joint, and acute suppurative arthritis ; in each of the last two, the niistake has cost the patient his life. (2) The arthritis in turn quickly leaves joints ; failure to remember this has often caused septic and various forms of infective arthritis to be called rheumatic arthritis, a mistake which has also cost lives. The drenching sweats, and the relief of the pain by salicylates, are very characteristic of rheumatic fever, but septicasmia causes sweating. The sweating of rheumatic fever is particularly liable to be accompanied by minute glassy vesicles. Finally, the arthritis of rheumatic fever being transient, is not accompanied by muc^ arthritic muscular atrophy. Rheumatic nodules, which are rare, but when present are seen in young boys affected with rheumatic fever and heart disease, are almost dia- gnostic, but very rarely they are met with in osteo-arthritis, and once I have seen them with gonorrhoeal arthritis. Septic Arthritis is constantly being thought to be rheum.atic fever : a bad mistake, especially for the patient. In septic arthritis, it is true, several joints may be affected ; but it may be one only, which it never is in rheumatic fever ; further, in septic arthritis the trouble does not clear up in one joint and then pass to another ; a joint once affected, remains affected till the source of infec- tion is removed ; the soft tissues around are thickened and brawny, quite unlike rheumatic fever, and if the colour is altered — which is not often the case- — it is dusky, and not the bright red of rheumatic fever. Suppuration often occurs : in rheumatic fever, never. Whether or not suppuration takes place, the joint often becomes fixed, which is excessively rare in rheumatic fever. Then, if proper search is made, the source of infection can usually be found ; common places that are overlooked are the sockets of the teeth, and the vagina and uterus, but the source may be anywhere, e.g., septic arthritis maj^ follow dilated bronchial tubes, cystitis, prostatic abscess, a boil on the skin, inflammation of the nasal cavities, and perhaps ulceration of the intestine. Sometimes the most careful seeking fails to find the source, but the search raust not be given up readily. The irregular temperature, usually hectic, the leucocytosis, sweats, and other signs of septicaemia are often a help. Pneumococcal Arthritis. — This is rare in adults, and nearly always exists as a complication of acute pneumonia. It may, however, be found Avithout evidence of pneumococcal disease in any other part of the body. Generally only one joint is affected, usually the knee, less often some other large joint, such as the shoulder or elbow. Often there is a history of recent injury to the part. The patient suddenly feels a pain in the joint ; within a few hours of this the temperature is raised ; the joint swells rapidly, is very painful and exquisitely tender ; yellowish-green pus quickly forms. The diagnosis is obviously easy if the patient has pneumonia, but may be difficult if he has not ; it is important to come to a diagnosis early, for it is a serious disease, and if allowed to go far without incision and drainage the patient may succumb to a general septicaemia. Pneumococcal arthritis is the commonest form of infective arthritis in children under five years old. Rarely it is unassociated with any other pneumococcal lesion, but most commonly it is associated with pneumococcal disease of either the lungs or the middle ear. As in adults, it is confined generally to one large joint. The swelling may be very great, and extend to the soft tissues beyond the joint. The pain is less than in adults, and redness is not common. Its possible presence must be remembered, for as in adults, so in children, it is necessary to drain the joint early. The child has a raised temperature, and looks ill. Typhoid Arthritis. — There are two varieties, both very rare : (i) That which 376 JOINTS, AFFECTIONS OF THE precedes the typhoid fever ; this is a multiple arthritis, not of severe degree, which subsides just before definite symptoms of typhoid show themselves. It is impossible to diagnose it until the appearance of the typhoid fever. (2) This occurs during the t}^hoid fever ; one or many joints may be affected ; the arthritis is of varying severity ; it may subside completely, or require incision and draining. In a few cases, even when there has been no arthritis during or before the attack of typhoid fever, some chronic arthritis may appear later ; most often the joints and ligaments of the spine are affected, and during the convalescence from his fever the patient complains much of pain and stiffness of his spine ; he is then said to have a typhoid spine. In a similar way the hip may become stiff, and very rarely there is chronic osteitis of the head and neck of the femur. Scarlatinal Arthritis. — This affects many joints, is not severe, soon subsides, and is easily diagnosed by the presence of the scarlet fever. It is commonly known as scarlatinal rheumatism, a bad name which quite gratuitously assumes a connection between this arthritis and rheumatic fever, for the existence of which there is no evidence. Arthritis occurs commonly in association with meningococcic meningitis and Malta fever, less commonly with dysentery, rarely in association with influenza, glanders, small-pox, measles, and diphtheria. In all these cases the presence of the principal disease determines the diagnosis. Goitorrhceal Arthritis is often called gonorrhoeal rheumatism, but this phrase should be discarded, for there is no association between gonorrhoea and rheumatic fever. Gonorrhoeal arthritis is frequently overlooked. I have repeatedly demonstrated its presence when the family physician has believed its existence impossible. It is particularly likely to be missed in women. I have met with it in married women of fifty ; it is probable in these cases that they are infected by their husbands. It may follow gonorrhoeal ophthalmia and even ophthalmia neonatorum. The diagnosis may be very easy, as when a patient is seized with an acute arthritis, either of a single joint or of several joints, while he or she is suffering from gonorrhoea. If it is possible to withdraw a little fluid from the cavity of the swollen joint, the discovery of the gonococcus makes the diagnosis certain, but this is usually quite unnecessary, and unless done very carefully may, by introducing micro-organisms from without, greatly increase the damage to the joint. Often a urethral discharge may be found, though sometimes in long-standing cases of gleet it is very slight ; if the gonococcus cannot be found in the discharge, it may be detected in a swab taken from the posterior urethra or vagina. If in women it is thought undesirable to excite suspicion by taking a vaginal swab, the nature of a doubtful arthritis may be determined by the wide variations of the opsonic index to the gonococcus. It is difficult from the clinical character of gonorrhoeal arthritis to tell it certainly from other forms of arthritis. Mistakes happen least often to those who constantly think of the possibility. It is of varying degrees of acuteness ; in the chronic cases of gleet the corresponding arthritis is chronic, but in the acute cases of gonorrhoea it may be so acute that I have more than once known the disease called rheumatic fever. ' Gonorrhoeal arthritis may be limited to one joint, and then most often to a large one, especially the knee ; but it may be multiple, and very many joints, even those of the wrists, hands, and fingers, may be implicated ; there is often much swelling of the soft tissues around, and this is more responsible for the swelling than is the effusion in the joint. G norrhoeal arthritis is usually very painful. The sheaths of tendons are often inflamed and tender, and so are some fasciae, especially the plantar fascia. The patient often complains of pain at the back of the sole of the foot, and in a chronic case he has flat-foot. There is no variety of arthritis in which muscular atrophy JOINTS, AFFECTIONS OF THE 377 is more striking. I have known a severe case of gonorrhceal arthritis of the hand called progressive muscular atrophy. When gonorrhceal arthritis is chronic throughout the whole of its course, and is limited to one joint, the cause of the trouble is often erroneously set down to tubercle. Suppuration is very rare. Some cases are extremely chronic, and may lead to fibrous ankylosis with deformities, but with our modern means of diagnosis and treatment this has become exceptional. Salicylates have no decided effect either upon the joint pains or upon the co-existent pyrexia. All the acute affections hitherto mentioned, except rheuraatic fever, are often included under the phrase " infective arthritis," because they are known to be due to infection by a micro-organism ; but this is a loose term that ought only to be used in a general sense, for a diagnosis of the precise cause of the infection is nearly always possible if care be taken. Sometimes in an infective arthritis there is more than one micro-organism at work to cause it ; thus, in the late stages of gleet, various micro- organisms flourish in the diseased urethra, and the arthritis may be due to a mixed infection in which the gonococcus is not the preponderating micro- organism ; under such conditions pus may form in the joints. Indeed, I have known a mixed infection of gonococci and streptococci from the genitals of a woman, cause in her a very severe acute arthritis with a temperature of 105° F. In exhausting diseases, e.g., typhoid fever, the patient may suffer from a secondary streptococcal infection which may cause arthritis. Acme Secondary Arthritis. — By this is meant arthritis due to spread of disease from the bone in the neighbourhood of the joint. It is limited to one joint ; the most acute and dangerous form is that which follows acute osteomyelitis. More than once I have known this called rheumatic fever because the onset has been DIVOF 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 TIME M E M E M E M E M E M E M E M E M E M E M E M E 3 M E M E ,v E M E M E M E M E M E yfrmaii. - - ~ - - Z 1 - z - - ~ - ~ — ~ - - 1 =^ 1 1 ~i\ 3| % ~r^ EA ^ ^ -~-t 4\ E _ - if = E f 1? 1 \i f \i ? m il=A ^/1 i fl^ r 1- r ip 1 ^ r ^Ir z V- f\^-t- fmm It 1/ W - - - - -if- - '. - - - l- i- - *- !*- V \ f ^- \]i~ ]]/■ 1 ^ E E E E z E - E E E E E - - f E - - r 7 - — — - - - - - - - r - - — - '_ r z 120 114 100 96 88 96 104 116 I08]l08 98 11& 116 100 lOB 100 100 100 100 100 120 120 no 108 116 100 100 101- 116 112 |l04 120 104 104 116 116 104 I00|116 |I04 112 Z"'/^. 106. — Chart showing the pyrexia and' rapid pulse of rheumatoid arthritis. sudden and the temperature raised. It is a most unfortunate mistake, for patients suffering from this form of arthritis are liable to die quickly from general septicaemia, to prevent which the joint ought to be opened and drained at once. The mistake may usually be avoided by remembering that rheumatic fever dres not affect one joint only. The more difficult cases are those in which more than one joint is acutely diseased, as a result of disease of the ends of the bones. To avoid this mistake, disease of the bones themselves must be carefully sought. 378 JOINTS, AFFECTIONS OF THE Fortunately for diagnosis, this disease of several joints is most frequent in infants, and in them severe arthritis due to rheumatic fever is unknown. It is called acute arthritis of infants. Disease of joints may be secondary to an abscess in the bone or to tuberculous disease of the bone. These varieties are diagnosed by discovering the underlying disease of the bones ; ;\r-rays are often of much use. Rheumatoid Arthritis. — The first attack is often acute : therefore the disease is best considered here. The name is bad and has led to confusion ; it owes its origin to the fact that the disease in some respects resembles rheumatic fever ; hence the name implies an arthritis resembling that of rheumatic fever. It would probably lead to worse confusion to invent a new name, so the present had better stand until the micro-organism causing the disease has been discovered. The first attack is ushered in with fever ; the temperature is rarely higher than ioo° or ioi° F. in the evening and 99° or 100° F. in the morning. This fever lasts from three to six weeks, slowly subsiding towards the end {Fig. 106). The T'Vlu-. 107. — Acute rheumatoid arthritis : showing the spindle-shajjed swelling of the joints between the first and second phalanges, and the swelling in connection with the wrist and metacarpo-phalangeal joints. pulse is generally rapid, out of proportion to the fever, the hands and feet sweat profusely, patches of freckle-like pigment are prone to appear on the body. Most of the patients are young women. The pyrexia is less severe and longer lasting than that of rheumatic fever, the pulse is, considering the temperature, faster, the sweating is almost confined to hands and feet, pigment is frequent. Nor are the differences with regard to the arthritis less striking, for in rheumatoid arthritis the characteristic joints to be affected are those between the first and second phalanges, and as it is an affection of the synovial membranes, and also considerably of the soft tissues around the joints, quite eairly in the disease we get a spindle-shaped swelling of these joints {Fig. 107) ; but soon many other joints are affected, and before long almost every joint in the body is implicated, so that we have the simultaneous affection of a great many joints. The temporo-maxillary joint is often involved ; so is the spine. It will be noticed JOINTS, AFFECTIOXS OF THE 379 that in every respect the arthritis is clinically different from that of rheumatic fever. The joints never suppurate, but the epitrochlear gland may be found enlarged. Slowly the attack subsides ; as it does so, passive movements and massage should be undertaken, for if not, the thickening of the tissues around the joints leads to their fixation. That it may be prevented is shown by the fact that the jaw only becomes fixed very rarely, presumably because of its frequent movement. There is never any endocarditis, but the arthritic muscular atrophy is often extreme, indeed, as extreme as in any variety of arthritis. In a few months a second attack comes on, but both the general symptoms and the arthritis are less severe than in the first ; J''ig'. io8. — Severe rheumatoid arthritis : skiagram of the hands, showing ulnar deflection but no bonv intra-articular changes. then a few months later another less severe than the second, and so on until after four, five, or six attacks the disease Avears itself out. In the later stages, if the joints have been allowed to become stiff, the disease is often confused with osteo -arthritis ; but rheumatoid arthritis occurs in younger subjects, and there are no bony outgrowths [Fig. io8), except in a few cases m which chronical!}^ thickened fringes of sjmovial membrane have, by friction during movements of the joints, worn away a little patch of cartilage, exposed and irritated the bone, and led to a slight outgrowth. In such a case the erosion of the cartilage may lead to bony grating, but in even a very chronic and extreme 38o JOINTS, AFFECTIONS OF THE case of rheumatoid arthritis, in which the joints have not been treated, grating and bony outgrowths are quite inconsiderable, and are not a leading feature as in osteo-arthritis. Heberden's nodes [Fig. 109) are not seen in rheumatoid arthritis. The spindle-shaped swelling of the phalangeal joints of this disease is not seen in osteo-arthritis. The joints principally affected are different in the two diseases, as will be seen on reference to osteo-arthritis, and the history is entirely different. Formerly some importance was attached to the trans- parency of the bones to the Ar-rays in the neighbourhood of the affected joints which may be seen in rheumatoid arthritis [Fig. no), but this is now known to be visible in other forms of arthritis. The ;tr-rays are, however, of use as showing the bony outgrowths of osteo-arthritis. In chronic cases of both rheumatoid arthritis and osteo-arthritis ulnar deflections may be seen [Fig. 108). Fig. 109. — Heberden's nodosities situated on terminal phalanges of index and middle fingers. (From Arthriils Deformans, by Llewellyn Jones Llewellyn.) Henoch's Purpura. — This disease is confined to children between infancy and fifteen years old, and early in its course pain and slight swelling of some of the large joints, with a little elevation of temperature, are often present. As in children the pyrexia and arthritis of rheumatic fever are inconspicuous, mistakes have occurred between it and Henoch's purpura, but the pain in the latter is trivial. The attacks of abdominal pain, with perhaps vomiting and diarrhoea, are characteristic, and so is the purpura {Fig. m), together, in many cases, with bleeding from some internal organ : hence hsematuria, haematemesis, or melaena. The purpura should not give rise to any difficulty ; rheumatic purpura is un- known under the age of fifteen. Gout. — This is often said to be present when it is not. The most certain points in the diagnosis of gout are, first, the detection of urate of sodium, usually as white hard masses in connection with a joint [Fig. 112), in a bursa, or as a JOINTS, AFFECTIONS OF THE 381 deposit in the cartilage of the edge of the ear ; here it is frequently not easy to be sure if a white nodule is urate of soda or a projection of cartilage with the skin stretched tightly over it. If it is possible to remove a minute frag- ment with a needle, crystals of urate of sodium may be seen under the micro- scope. Secondly, there may be a history of repeated characteristic attacks. The gouty arthritis that we see now-a-days is generally strongly inherited, but Fig. no. — Rheumatoid arthritis: skiagram showing the transparency of the ends of bones. not often by women, and therefore the family history is of importance ; it rarely shows itself before the age of twenty, but I have seen it in a boy fifteen years old. Most of the sufferers from gout now alive get their attacks quite independently of any errors in diet ; many of them are most abstemious. The diagnosis is not difficult when the patient has one or more attacks of arthritis in the characteristic joint — that of the ball of the great toe, more often 382 JOINTS, AFFECTIONS OF THE III.— Henoch's purpura. the right than the left ; the attack usually begins at night with excruciating pain, which subsides towards the early morning ; the patient, ex- hausted with pain, drops asleep, to wake later and find his joint swollen and tense. There is some fever. Probably during the day his toe does not cause pain unless he walks on it ; but he has another attack the next night, not so severe as that on the first, and on each successive night the attacks are less. He may have another bout at any period of his life, and he may have many bouts, and other joints may become affected subsequently. The real difficulty in the acute cases comes when it is suggested that an acute arthritis with pyrexia, and swelling and red- ness of a joint other than that of the great toe, is caused by gout. I have recently seen the difficulty in one patient in the wrist, in another in the knee. Such cases, if they are not gout, are some bacterial arthritis. If more than one joint is affected with acute arthritis at the same time, the probability is against gout, and the greater the number of joints affected, the less likely is the case to be one of gout. The history and presence of urate of sodium are often conclusive in favour of gout. If pus forms, the case is almost certainly not gout, for gouty joints very rarely suppurate except late in the chronic disease. On the other hand, the implication of tendon sheaths and pain in the back of the soles of the feet are in favour of gout, but it must be remembered that both these occur in gonorrhoeal cases. The presence of a source of infection is of course against gout. The diificulty is made especially great in /'>>. 112. — Chronic gout : deposition of urate cf sodium in and near the joints. JOINTS, AFFECTIONS OF THE 383 these cases by the fact that the general sj'mptoms and arthritis may, although gouty, be continuous rather than paroxj'smal ; but on the whole, continuously increasing severity of general symptoms is against gout. The goutily-inflamed joint looks especially shiny, is exquisitely tender on the surface, and is more painful at night than during the day. Cases of extreme difhculty have been recorded, in which the first joint affected by pyaemia chanced to be that of the great toe. Probably most examples of acute arthritis said to be gouty are so, but mistakes are common about chronic gout. Many patients with chronic arthritis are quite wrongly said to have gout ; usually they have osteo-arthritis. The presence of visible urate of sodium in places already mentioned {Fig. 112), the history of previous acute attacks, the history of gout in ancestors, the age and sex, will all help. The presence of bony outgrowths is strongly against gout, but it is not /^^^. 113. — Chronic gout : skiagram of the hands, showing sodium urate deposits about the ends of many of the phalanges. conclusive, for such may occur in true gout, either more or less all round the joint^ or in the form of little nodules ; but thej^ never attain the considerable size common in osteo-arthritis. If no urate of soda is anywhere visible, the diagnosis may be very difficult ; the reader should consult the principal points mentioned under the heading of osteo-arthritis. Any joints in the body may be affected by gout, but it is very rare in the joints of the trunk, the shoulder, or the hip. The spine, shoulder, and hip are commonly affected in osteo- arthritis. Urate of sodium may be seen in and near the joints as light spots in ;i;-rays prints {Fig. 113). 2. Chronic Affections of Joints. — We will now pass on to consider the diagnosis of varieties of arthritis which are for the most part chronic, but it must be remembered that many of those mentioned as acute become chronic, and their diagnosis has been described. 384 JOINTS, AFFECTIONS OF THE Osteo-arthritis is a chronic disease frequently confused with rheumatoid arthritis, from which it is completely distinct, both clinically, and from the point of view of morbid anatomy. Rheumatoid arthritis (p. 378) is primarily a disease of the synovial membrane and soft tissues of the joints. Osteo- arthritis is primarily a disease of the cartilage and bones leading to the destruction of the cartilage, eburnation of bony surfaces, and the production of much new bone at the edges of the joint ; hence bony outgrowths, grating of the joint, and locking of it so that movement is difficult, are common. Thickening of the synovial membrane occurs, but is less important ; the ligaments become implicated and may soften ; if so, the joint becomes flaU- like ; there may be some thickening of the tissues around the joint and some increase of synovial fluid, and then the joint becomes enlarged.. It is easy to distinguish in most cases between osteo-arthritis and rheumatoid arthritis, by the appearance of the affected joint. In the former we have an irregularly enlarged joint, with palpable bone excrescences and much grating ; often the joint is fixed by these bony excrescences, rarely it is flail-like from destruction of ligaments ; often all the causes just mentioned combine to make it very large. This is altogether different from the spindle-shaped swelling of rheumatoid arthritis (p. 378). Then osteo-arthritis is often confined to one joint, and that a large one, e.g., the knee ; rheumatoid arthritis affects many joints, and is raost characteristically seen in small joints, e.g., those between the first and second phalanges ; but when osteo-arthritis does show itself in small joints, those most often affected are the terminal joints of the phalanges, where the bony excrescences form Heberden's nodes. These are characteristic of osteo-arthritis. Rheumatoid arthritis is far more commonly seen in young women ; osteo-arthritis in women at the menopause. Rheuma- toid arthritis nearly always begins with fever, although often slight ; osteo- arthritis is almost always afebrile. The pulse is often rapid in those who have rheumatoid arthritis ; it is not particularly affected in those who have osteo-arthritis. The spine is more often affected by osteo-arthritis than rheumatoid arthritis, and it is quite common in the dissecting-room to find that a large number of elderly subjects have osteo-arthritis of the spine. Muscular atrophy is far greater with rheumatoid arthritis than with osteo-arthritis. Osteo- arthritis is especially liable to attack the hip — usuallj' only one — and this form of it is commonest in elderly men. It was formerly called morbus coxcb senilis. Great care must be taken to distinguish the pain due to this from that of sciatica. The chief point of distinction is, that in the latter the nerve itself is tender to pressure ; but it must not be forgotten that in very rare cases osteo- arthritic outgrowths from the hip may implicate the sciatic nerve and so cause genuine sciatica. Although osteo-arthritis of the hip usually causes lameness, so many other conditions do this, e.g., sacro-iliac disease, that the symptom is of little value. The knee is the joint most often affected by osteo-arthritis — usually both, but sometimes only one is implicated. This disease of the knee is very common in women of ages between forty-five and fifty-five. Thej' com- plain of pain and stiffness. Often the pain and tenderness, if present, are confined to one spot. There is usually considerable enlargement of the joint, bony irregularities may be felt, and grating and crackling on movement are very common ; these are due to bony out-growths, erosion of cartilage, and thickening of synovial membrane, which also gives a feeling to the observer's hand placed over the joint when it is moved, as though he were feeling the movement of wet sand in a bag. The grating may be heard very loudly through the stethoscope. Other joints often implicated in osteo-arthritis are the shoulder, elbow, ankle, wrist, and temporo-maxillary joint ; but what has been said about the disease in general, and that of the knee in particular, applies to them. The disease may JOINTS, AFFECTIONS OF THE 385 be considerably advanced and yet confined to one joint, or any number may be affected. The points which have been especially mentioned as helping to distinguish osteo-arthritis from rheumatoid arthritis will aid in the distinction of it from other forms of arthritis. Pads {Figs. 114, 115) on the dorsal aspect of the joints between the first and second phalanges are not rare. They vary in size from a split pea to a hazel-nut. The joints are not diseased, but these pads, which are due to a great growth of fibrous tissue under- neath the corium, have been con- fused with osteo-arthritis. They are often associated with Dupuy- tren's contracture [Fig. 44, p. 167). Ulnar deflection (see Fig. 108) is seen in osteo-arthritis, but is also present in so many other affec- tions of the fingers and wrist that by itself it is of no value in diagnosis. Tuberculous Disease of Joints. — This is most common in children of between three and five years, and becomes rarer as age advances. About 40 per cent of the cases are in the spine, 40 per cent in the hip, 10 per cent in the knee, and the other joints which are affected not uncommonly are the ankle, shoulder, elbow, and wrist. The disease is essentially slow, so that the early stages are often overlooked. It is stated that tuberculous arthritis is so insidious in its onset that for one case in which the affection is detected and adequately treated in the first month of its existence, there are twenty in which it is allowed to drift on for three or four months, or even longer, before it is recognized. For some time there may be only slight transient impairment of movement, or an occasional twinge of pain ; gradually impaired movement, showing itself as slight lameness in the lower extremity, becomes evident, but it must not be concluded that necessarily there is no tuberculous disease of a joint because there is no impairment of movement. In the same way, although pain, often worse at night, and causing screaming, is an important sign, yet pain may be absent for a long while, or altogether. In all the joints except the shoulder and the hip — which are so deeply covered by soft parts that unless it is considerable it cannot be detected — swelling is a very important symptom, D 25 -F/^. 114. — Pads on the dorsal aspect of joints : not to be confused with osteo-arthritic changes. ^ (By permission from Quarterly Journal of Medicine, vol. i.) Fig. 1 15. — Skiagram showing that the pads depicted in Fig-. 114 affect the soft parts and not the underlying joints. (By permission from Quarterly Journal of Medicine, vol. i.) 386 JOINTS, AFFECTIONS OF THE for it is almost invariably present, even in the earliest stage. It may be verj' slight. Although, as just mentioned, there may be no defect of movement in the early stages, sooner or later, and often quite early, there is impairment of movement, and this symptom is very common and of great value. Tuberculous arthritis is usually accompanied by wasting of rauscles moving the joint. It must never be forgotten that a tuberculous arthritis is so slow in its development that often it is not ascribed to its correct cause. Also that for a time the symptoms are so slight that no attention may be paid to them. Mistakes are ver}^ serious, and tuberculous arthritis ought always to be present in our minds when examining a diseased joint. It is very rare for more than one, or perhaps two joints to be affected in the same person ; tuberculous disease elsewhere, e.g., phthisis, is not common ; lardaceous disease, formerly so frequent a complication, is now seldom seen; and general symptoms, e.g., p5'Texia, are often absent and rarely extreme ; on the other hand, those affected are often pale. Bon3'' outgrowths are not to be detected ; the joint affected is swollen and feels thick : hence' the phrase " pulpy knee." There is often a history of injury to a joint, which later becomes tuberculous, and then the transition from a traumatic to a tuberculous arthritis is often overlooked. Tuberculous disease of the sacro-Uiac joint is particularly difficult to diagnose. Tuberculosis of the hip is often overlooked, because the pain is referred to the knee, and the slight wasting of the hip muscles is not detected. Acquired Syphilitic Arthritis. — This is most easily recognized by those who constantly bear in mind the possibility of its existence. If the characteristic pains of syphilis, which are usually worse at night, happen to occur near a joint, thejr nia}^ be carelesslj^ ascribed to gout or osteo-arthritis. In the secondary stage of s^'philis, and more particularly earl}^ in it, a sj^hilitic s\Tiovitis of any joint may occur. It is subacute, slow, is attended with stiffness, swelling, and occasionally tenderness, and usuallj^ is confined to one joint. Pain, too, may be present, but commonly neither pain nor tenderness are prominent symptoms. There is some, but not much, enlargement of the joint from distention with synovial fluid ; in a few cases the size of the joint varies considerably in a short time. These cases are often mistaken for tuberculous arthritis, but the error can usually be avoided if the patient is examined carefully and questioned for other evidence of S}'philis ; and in this, and all other forms of arthritis in which there is anj^ possibility of S5''philis, a Wassermann test should be done. Syphilitic arthritis in the tertiary' stage is very rare : there are two varieties of it, both of which produce considerable swelling and disorganization of the joint ; in one there is a deposit of gummatous material in the subsynovial tissue, in the other in the ends of the bone. Both varieties are usually confined to a single joint, neither is painful, and both are liable to recur. Great effusion of synovial fluid is not common, but when the disease is in the subsynovial tissues the joint is enlarged and the thickening of the S3movial membrane can be felt. Congenital Syphilitic Arthritis. — In children and young adults congenital sj^ph- ilis may cause an arthritis which is very like that caused b}'' tubercle. The knees are affected most often, and the disease is often symmetrical. If there is much sj'novial exudation, fluctuation is easily detected ; if there is much gummatous deposit in the subsjmovial tissue, the synovial membrane feels thickened and ir- regular. There is no pain, and verj?- little impairment of movement. The existence of this disease must always be remembered ; the history and examination for other signs of syphilis must be thorough, and a Wassermann reaction must be done. In infants a remarkable result of congenital sj'-philis occurs. Osteochondritis occurs in the sub-epiphyseal plate of cartflage and adjacent bone ; the epiphysis becomes separated from the shaft, so that there is motility and dull grating as if a fracture had occurred. At the same time there is considerable swelling of JOINTS, AFFECTIONS OF THE 387 the soft parts around, from the inflammation having spread to them, so that there is much swelling about the joint, although the joint itself is usually not implicated. Separation of the epiphysis from the shaft makes the limb paralyzed : hence the phrase syphilitic pseudo-paralysis applies to this condition. Suppuration is very rare, and the improvement with mercury is rapid. This condition may be noticed at any period from one month after birth till the age of two or three years, but it is most often seen when the child is two or three months old. It is usually multiple, and there is some tenderness and slight pain. Other signs of congenital syphilis are generally present, but if not, the condition is so characteristic that the child must at once be given mercury. Intermittent Hydrarthrosis. — This rare disease should be diagnosed easily. It is com- monest in women. Cases have been recorded between the ages of eight and fifty, but the patients are most often be- tween twenty and thirty years old. Fluid is rapidly poured out in the joint, so that it is distinctly swollen in a few hours ; the distention attains its maximum in one or two days ; it then recedes, and has disappeared by the fourth or fifth day. The effusion leads to stiffness of the joint, and gener- ally there is some pain, but usually very little tenderness, and the joint is neither red nor hot. The knee is affected most often ; it may be one or both knees ; if not the knee it is almost always a large joint that is the seat of the effusion. It is rare for more than two joints to be affected at once. The remarkable part of the affection is that the effusion is periodic, and often the in- terval of time between the attacks in the same patient is on each occasion exactly the same : thus in one patient the effusion always began on the ninth day from the beginning of the previous effusion ; the interval has been known to be less than this, and it is often more. It may be that for a period the intervals are of a certain length, and then for a period they are of a different but uniform length. In other cases there is no periodicity. In each attack the same joint or joints are affected in the same patient. After three or four years the attacks cease in most cases, but occasionally there are recurrences. Charcot's Disease {Fig. 1 16). — This is the arthritis met with in tabes dorsalis, and if any patient, of such an age that he could be suffering from tabes, has chronic arthritis of a single joint, we ought always to examine him for signs of tabes. y'ijr. no. Charcot's di<;ease of the riglit knee joint in association with tabes dorsalis : showing distention, and also displacement of tibia to the right. JOINTS, AFFECTIONS OF THE Because this is not done many cases are overlooked, for the arthritis may exist even when the patient is unaware that he has any signs of tabes. There is nothing cliaracteristic of tabetic arthritis, and many joints affected with it might, for all the clinical symptoms of the arthritis, or from the appearances after death, be equally well affected by osteo-arthritis ; but the following points will often make one suspicious. The effusion is frequently very great ; some of the biggest joints seen are those the seat of tabetic arthritis ; the ligaments may be much softened, so that the joint becomes fiail-like, but the growth of new bone at the edges of the joint is often quite slight, and there is considerable atrophy of bone ; thus I have seen the floor of the acetabulum as thin as paper, and because it was so thin, the pressure from the neck of the femur had expanded the floor of the acetabulum so far into the pelvis that it formed a large projection into the pelvic cavity. Tabetic arthritis is usually chronic and never acute, but it may be rapid ; thus there may be advanced destruction of the joints in a few weeks ; it is almost always painless ; generally large joints, e.g., knee, hip, are affected ; generally only one joint, but I have seen two. The rarefaction of the bones makes them liable to fracture. When tabetic arthritis occurs in the bones of the hand or foot, the considerable swelling may cause it to be mistaken for tuber- culous disease. In 75 per cent of cases of tabetic arthritis, the joints affected are those of the lower extremity. Arthritis in Syringoinyelia. — In 75 per cent of the patients affected Math this form of arthritis, the joints affected are those of the upper extremity. There is nothing absolutely distinctive of this variety of arthritis ; it resembles closely that due to tabes ; perhaps, on the whole, some of the cases more nearly resemble osteo-arthritis. Owing to the loss of sensation in syringomyelia, wounds are common ; hence the joints may become septic. Mistakes in diagnosis can only be avoided by always having in mind the possibility of the occurrence of syringo- myelia, and examining the patient for it. Happily it is rare, and often the symptoms of syringomyelia are evident before the arthritis shows itself. In about half the cases of syringomyelia there is scoliosis of the spine. Arthritis in H cBmophilia. — In this disease, blood may be poured out into either the synovial membrane or the cavity of the joint. This is probably always the result of a blow, often so slight as to pass unnoticed. It is most common in the knee and ankle. If the bleeding is at all considerable, the joint swells, the rate of swelling depending upon the rate of effusion of blood. The joint is puffy ; there may be fluctuation, pain on movement, and tenderness. The whole trouble often subsides, but sometimes more or less swelling persists for a time, and even if a joint gets well, relapse is likely. In other cases, either the impaired blood-supply resulting from damaged vessels or the friction of the clots, leads to erosion of the cartilage, and permanent disease of the joint results. Forgetfulness of the fact that disease of the joints occurs in haemophilia has led to the serious mistake of incising a joint into which bleeding has occurred. The condition is to be diagnosed by observing the other signs of hcemophilia. Malignant and Hydatid Disease of Joints. — Eoth these are very rare, and in each case the disease almost always begins in the adjacent bone, and therefore properly belongs to diseases of bones. Both are very serious ; hydatid disease of a joint is very liable to lead to suppuration in it. Displacement of Semilunar Cartilages. — The diagnosis properly belongs to surgery. If it causes much synovitis, the cause of the synovitis is very apt to be overlooked. There is often a history of a wrench, or the patient complains that he feels something in the joint slip or catch ; this may cause considerable pain, and there is often tenderness over the internal semilunar cartilage. Some- times similar symptoms are produced by a thickened fringe of synovial membrane JOINTS, AFFECTIONS OF THE 389 becoming nipped. This may occur in osteo-arthritis. The thickened fringe may become detached, and then it forms a loose body. Nervous Mimicry, Neuromimesis, or Hysterical Joints. — In these cases some of the symptoms of arthritis are imitated without there being any actual disease of the joint. It is important to remember that hysteria is a disease and is not mere malingering. The malingerer can voluntarily get rid of his supposed disease if he wishes ; the hysterical girl cannot, as she has not sufficient power of will. There are three main varieties : (i) The joint is kept constantly in an abnormal position, e.g., the knee may be considerably flexed ; (2) The joint cannot be moved, e.g., the hand may hang down from the wrist, as in extensor paralysis, and it cannot be raised ; (3) There may be acute pain in the joint. In all these cases, careful examination will usually show that there are no real symptoms of arthritis : there is no swelling, no heat, no grating, no bony out- growth, the immovably fixed joint can be moved freely under an anaesthetic ; on the other hand, the pain, if present, is far in excess of any pain due to arthritis, I^ig: 117. — Pulmonary osteo-arthropathy : the patient had chronic fibroid phthisis. The bony parts of the fingers were becoming progressively thicker, especially in the right hand. and the tenderness may be so great that the patient will not let the joint be touched. Both pain and tenderness disappear if the patient's attention is diverted, and neither keeps the patient awake nor affects the general health. The pain may radiate far beyond the joint ; very rarely in hysteria there is a trivial swelling, but it is not such as would be produced by distention of the synovial cavity ; it is often more in the neighbourhood of the joint than over it. But nearly always there is no swelling about a hysterical joint. Usually the joint supposed to be diseased is cold ; very rarely it is hot and perhaps a little red ; but this phenomenon, when present, is only a local blush due to the fact that the patient's attention is directed to the joint, and it quickly passes away. The stiffness of a hysterical joint can be made out to be due to contraction of muscles and not to alteration of the joint itself ; occasionally it is variable, and it is often extreme, out of all proportion to any possible joint disease ; and often, too, the attitude of the joint is not that usually seen in arthritis. It has been pointed out repeatedly that muscles which move a joint usually atrophy, often 390 JOINTS, AFFECTIONS OF THE rapidly, when that joint is diseased, quite apart from disuse. In hysterical affections of joints the muscles waste onlv slowlv in proportion to the disuse of the joint. Muscular Paralysis. — Often, e.g., in peripheral neuritis, the muscles which undergo rapid Avasting as a result of disease of the lower motor neuron soon begia to contract, and this leads to considerable alteration in the usual position of joints. Thus, the knee and elbow become strongly flexed, and at first it may be thought that these un- usual positions are the result of disease of the joint, for long-contiaued chronic disease of a joint will lead to unusual per- manent positions from con- tracture of ligaments, from the pull of muscles on a Aveakened joint, and from contracture of muscles wasted from arthritic atrophy ; but a little estimation of the history, the condition of the joints, and the sj-mptoms of nerve disease Avill soon lead to a correct diagnosis. Hypertrophic Pulmonary Osteo - arthropathy. — This rare condition is not really a disease of joints at all, for the change consists in 2JD. enlargement of the ends of the bones, and hence the joints appear large and the patient cannot bend them properly?. Often this is all that is the matter with the joints, but in advanced cases there is some thick- ening of the s\Tiovial mem- brane and some erosion of cartilage. The upper ex- tremit}^ is affected more often than the lower, and the joints usually deformed are the wrist, and the car- pal and interphalangeal joints {Figs. 117 and 118) ; when the condition exists in the lower extremitv the corresponding joints are implicated. In extreme cases, the enlargement extends up the shafts of the affected bones. The condition is easih^ distinguished, for it is almost always accompanied b}' clubbing of the fingers, and almost always (80 per cent of the cases) it is associated with chronic pulmonary disease, especially fibrosis, bronchiectasis, or chronic empyema, and less often with other ,^'i-'- Il3. — Pulmonnry osteo-arthropathy : .showing affec- tion of hands and feet, and the wasting due to chronic phthisis. KIDNEY, ENLARGEMENT OF 391 pulmonary diseases. The remaining 20 per cent of the cases are associated with such diverse conditions that text -books must be consulted ; the most interesting is aneurysm of the subclavian artery. Hypertrophic osteo-arthro- pathy used to be confused with acromegaly, but not only ought the clubbing of the fingers and the associated conditions to prevent such a mistake, but in acromegaly there is considerable enlargement of the hand and characteristic changes in the face (see Fig. 88, p. 263). w. Hale White. KIDNEY, ENLARGEMENT OF.— A renal sweUing may be so slight that it is only found upon clinical examination, may be large enough to attract the patient's attention to it, or may even occupy a large portion of the abdominal cavity. A number of pathological changes in the kidney may give rise to a tumour of that organ, such as hydronephrosis, pyonephrosis, renal tuberculosis or abscess, new growths and various forms of cysts in the kidney ; it is necessary to be able to diagnose any one, not only from another, but also from other tumours simulating a renal swelling. The chief characteristic points of a renal tumour are : — 1. The large intestine is in front of the tumour. When either kidney is merely slightly enlarged, both large and small intestine will be placed in front of it; but when the organ is so enlarged as to reach the anterior abdominal wall the coils of small intestine are pushed aside. The anatomical relation of the large intestine to the kidney, and the absence of a mesentery, do not allow of the same mobility of the colon, which retains its position in front of the kidney. Hence an area of resonance can usually be obtained in front of a renal swelling ; if the colon be empty, it can sometimes be felt in a thin subject and rolled by the fingers on the surface of the tumour. Bowel is never placed in front of a splenic tumour, and only rarely in front of a hepatic tumour. 2. The area of dullness to percussion is continuous from the lateral aspect of the swelling to the mid-line posteriorly — that is, there is no area of resonance between the mass and the vertebral spines, as in a splenic or ovarian tumour. 3. A renal tumour usually retains the shape of the kidney ; it is rounded at its borders and poles, and does not possess any edge or sharp margin, as in splenic or hepatic swellings. 4. A renal tumour in the process of enlargement projects forwards and down- wards. It may fill up the natural hollow of the loin, but very seldom causes any prominence posteriorly. A perinephric abscess, which often simulates a renal swelling, may cause a distinct prominence in the loin. 5. A renal tumour does not descend so freely upon deep inspiration as a splenic or hepatic tumour. A renal tumour may be movable downwards or inwards, or may be fixed in the loin by preceding inflammation. An enlarged kidney can be easily felt bimanually, and if grasped between the two hands can be pushed into the loin. 6. When a renal tumour is large enough to reach the anterior abdominal wall, it commonly comes in contact with the latter at the level of the umbilicus, at the same time bulging out the ilio-costal space. There is usually a line of resonance between the upper margin of the tumour and the hepatic dullness. 7. In renal tumour a varicocele may be developed on the same side as the tumour. 8. With a renal tumour there may be changes in the urine which will point to renal disease : but on the other hand, the urine at any one time may be normal, free from blood or pus, from the fact that the ureter of the diseased side is blocked, or that the disease does not involve the renal pelvis. 9. In exceptional cases, a tumour of the right kidney may extend upwards into the dome of the diaphragm, rotating the liver so that the anterior margin 392 KIDNEY, ENLARGEMENT OF descends below the costal margin, and prevents a satisfactorj- palpation in the renal area. Although, from the above physical characters, it would seem that a renal tumour should present little difficulty in diagnosis, yet it is by no means infrequent to find that a tumour possessing several of these characters may give rise to considerable doubt in the determination of the organ from which it arises. The following points will assist in the diagnosis of renal swellings from other tumours \vith which they are likely to be confused : — 1. Tumours of the gall-bladder are placed immediately below the costal margin, so that no interval exists between the tumour and the lower margin of the liver. They are usually oval in outline, with the long axis in the line between the ninth costal cartilage of the right side and the umbilicus ; are freely movable with the respiratory movements, and movable from side to side about a point at the costal margin. There is dullness on percussion over them, and the}' cannot be felt in the loin or be grasped bimanually. With a tumour of the gall-bladder there may be attacks of colic with or without jaundice. 2. Enlargements of the liver pass downwards from beneath the costal margin, so that there is no line of resonance, or area in which the hand can be depressed between the tumour and the costal margin. Hepatic tumours do not impair the normal resonance in the loin in the same manner as a renal tumour. A tongue-shaped lobe of the liver (Riedel's lobe) may cause difficult],' in diagnosis ; but here the lower margin will not feel rounded as in a renal inimour, nor will it be felt in the loin on bimanual examination. A tumour or cyst in the concave aspect, or of the left lobe of the liver, is especiallj' liable to cause error in diagnosis, whereas, on the other hand, a tumour of the right kidnej^ which pro- jects upwards behind the liver may so rotate the latter that the anterior margin of the liver descends below the costal margin and completely obscures the kidney. In a case of a large carcinoma of the right kidney, the liver was in this waj' so depressed as to render palpation of the kidney impossible. 3. Enlargements of the spleen descend from beneath the left costal margin, and have no bowel in front of them. The edge of a splenic tumomr is usualh^ well-defined and often notched, and there is resonance between the posterior aspect of the tumour and the spinal column. A splenic tumour is more movable than a renal tumour. 4. Perinephric effusions, whether of blood, pus, or urine, may form a tumour in the loin which upon phvsical examination may be mistaken for a renal swelling. A perinephric effusion may arise from some suppurative condition of the kidney, so that the previous history and the examination of the urine will not prove of assistance in differentiation ; or it may be due to conditions entirely distinct from renal disease. An effusion of blood around the kidnej^ is, in nearly all cases, caused by an injury to the loin, and will be accompanied by other signs of injury. A perinephric abscess forms a much more ill-defined tumour than that caused by a renal swelling, is more acute in its general symptoms, such as pain and temperature, and fills up the ilio-costal space. The skin over it may be thickened or oedematous, and fluctuation may be felt to be more superficial than in a renal swelling. 5. Tumours arising from the pelvic organs, from the ovary or uterus, may in some cases simulate renal tumours. An ovarian cyst with a long pedicle occupy- ing the loin, has frequently been mistaken for an enlarged or movable kidney, and any sudden attacks of pain occurring from torsion of the pedicle may be looked upon as due to renal colic. The usual ovarian cyst or uterine fibroid will seldom be confused with a renal swelling, for they are placed in the middle ine of the body, can be felt to come up from the pelvis, and can be readily felt upon bimanual vaginal examination to be attached to the uterus or its KIDNEY, ENLARGEMENT OF 393 appendages. These tumours also give rise to dullness anteriorly, and do not alter the normal resonance in the loin. In cases of malignant ovarian tumours associated with ascites, the lumbar resonance may be lost, but on turning the patient over upon one side, the previously dull note becomes replaced by resonance in the uppermost loin. In the case of an ovarian cy§t with a long pedicle, or of a uterine fibroid of pedunculated, subserous form, the position in the loin may sometimes suggest a renal tumour ; it will be found, however, to occupy a more anterior position in the abdomen than a renal tumour, and to possess a much greater range of movement, but it does not slip back into the loin near the costal margin in the same manner as an enlarged kidney does ; there is resonance posteriorly, and the kidney may be actually palpated as well as the abdominal tumour, whilst a distinct connection with the pelvic organs can sometimes be traced from the tumour when the latter is drawn up. In contradistinction to the above, a very large cystic renal swelling may be mistaken for an ovarian cyst. It may occupy the greater part of the abdomen, and even be felt, per vaginam, to be encroaching upon the pelvis ; but on careful examination in a renal tumour of this form there will be no line of resonance between the mass and the vertebral column posteriorly, the natural hollow of the loin will be filled up, and there is frequently a distinct bulging in the lower thoracic wall, together with an increased length of the ilio-costal space on the affected side. Some assistance may be obtained from the history, when a hydro- nephrosis may have been first noticed as a tumour commencing under the costal margin, and gradually increasing downwards towards the iliac fossa and inwards across the median line, whereas an ovarian tumour may have been noticed to increase upwards from the pelvis. 6. Suprarenal tumours may occasionally be of sufficient size to form an abdominal tumour, presenting a rounded, movable swelling in the hypochon- drium. It is practically impossible to distinguish them from renal tumours, without laparotomy. 7. Faecal accumulations in the colon, caecum, or sigmoid flexure may give rise to a tumour and pain of a colicky nature in the loin. They will be distinguished from renal swellings by the general intestinal symptoms, flatulence, and the changes in form consequent on the administration of large enemata. It must be remembered that a patient with a collection of fasces in the colon may not complain of constipation, but may in fact have a small daily evacuation from the overloaded bowel. 8. Inflammatory thickenings about the appendix will be diagnosed from renal tumours by the situation of the pain and the swelling in the iliac fossa rather than in the loin. In some cases, however, the pain may be referred to the lumbar region, or an appendical inflammatory thickening may spread upwards. The onset of the trouble, the acute symptoms and the febrile disturbance, will usually distinguish these cases from renal lesions. 9. Malignant growths of the large intestine, especially of the ascending or descending colon, may form a tumour in the loin which closely resembles a renal swelling. The mass formed by the growth may be grasped bimanually, is movable in the same directions as a renal tumour, and comes forward under the costal margin. The percussion note over the front of the lump is resonant, and there is usually an aching pain in the loin. If the growth has infiltrated through the wall of the bowel uncovered by peritoneum, the perirenal tissues may be thickened, or albuminuria may be produced by direct invasion of the kidney, when the case will even more resemble a renal lesion. Cancer of the large intestine should be suspected if there is diarrhoea, mucus or blood in the motions, or any symptom of commencing obstruction in the 394 KIDNEY, ENLARGEMENT OF intestine. The tumour may be irregular and nodular, whereas a renal tumour presents rounded margins. The occurrence of a tumour in either side, associated with discomfort or palpable distention of the Ccecum from the accumulation of faeces, would render a growth in the colon the more suspicious. lo. Tumours of the omentum, mesentery, or pancreas, either cystic or malignant, are more median in position, do not project into the loin, and seldom resemble a renal tumour. A kidnej' may be enlarged but j'et not palpable, from the fact that it is either whoUv above the costal margin or obscured by the liver or the thick abdominal walls of the patient. On the other hand, a kidney may be so diseased as to be functionless and shrunken, when it cannot be felt ; but the remaining organ may be enlarged in a compensatory degree and ma}^ be distinctly palpable. One must remember the danger of regarding an enlarged kidney as the diseased organ, when it is in reality the only functionating one. Aching pain may be present on the functional side, as a reno-refiex pain from the disease on the other side. The kidney of normal size and position is not palpable from the abdomen, or on bimanual examination with one hand on the loin ; but, in a thin subject, the lower pole may be felt to descend between the hands, on the patient taking a full inspiration ; if, therefore, a kidney can be felt easily on bimanual examina- tion, it is either unduly mobile or enlarged. It is often difficult to say if a kidney that is movable is also enlarged to a slight degree ; and a kidney which was thought clinically to be enlarged has often been found to be of normal size when exposed ; this is in part due to the thick coverings of the abdominal wall, or to the amount of fatt\^ tissue surrounding the organ. If the kidney is definitelj^ enlarged, it remains to determine the nature of the enlargement ; in this one is guided, not only by the physical characters of the tumour present, but also by other symptoms that are associated with it, more especiall}', perhaps, by the altered characters of the urine. The kidney may be enlarged only slightly, as in tuberculosis, pj'elonephritis, commencing hydro- nephrosis, or carcinoma; or may be enlarged to a considerable degree in poh'cystic disease, hj^dro- or p^'onephrosis, and in some forms of malignant growth. From the phj^sical examination of the enlarged organ it is often possible to say that the swelling is fluid or solid in nature, but it is seldom that a true diagnosis of the lesion can be made from palpation of the kidney alone. In the following diseases in which renal enlargement is usually present, the diagnosis must be arrived at b}^ the consideration of associated symptoms. In renal tuberculosis the disease occurs in a miliary or in a caseous form. Miliary tuberculosis occurs as a part of a general tuberculosis, usually in children, is bilateral and causes no tumour. The caseous variety occurs as a primary disease in one kidney in which one or several foci may be present. These enlarge and soften to form a tuberculous abscess, Avhich invades the medullary tissues, to open eventually and discharge its contents into the renal pelvis. The kidney is enlarged and tender, and there are persistent pyuria and heematuria in small amount. The lining membrane of the ureter is quickly invaded by the tuberculous process, becoming thickened and infiltrated, and at the same time shortened in length. An early symptom of renal tuberculosis is increased fre- quency of micturition, even before the bladder has become infected in the downward progress of the disease. The ureter may be felt to be thickened per rectum or per vaginam, or other tuberculous foci may be found in the prostate, vesiculae seminales or testes in the male. A thorough search should be made for tubercle bacilli in the urine. In pyelonephritis the kidney may be slightly enlarged, together with renal pain, pjmria, and general malaise. Pj^elonephritis is usually bilateral, and due KIDNEY, ENLARGEMENT OF 395 to some infective or obstructive lesion in the lower urinary tract, symptoms of which are usually obvious (see Pyuria). Malignant tumours of the kidney give rise either to an irregular nodular enlargement of the kidney, or to a general, uniform, solid tumour. There is usually aching pain in the loin, with intermittent attacks of profuse hsematuria, the latter occurring as soon as the growth has infiltrated the renal pelvis. The bleeding may be so profuse that clots are formed in the renal calyces, pyramidal in shape, which in their passage down the ureter give rise to typical renal colic. The malignant tumours found in the kidney are of several varieties, and their origin and exact pathological nature have given rise to much discussion in recent years. The true carcinoma and sarcoma exist, but are very rare, forming but a small percentage of the malignant renal tumours. They give rise to renal enlargement and intermittent hsematuria, are usually extremely malignant and are accompanied by early metastases. Much more commonly a malignant tumour of the kidney arises from an " adrenal rest," or the small collection of aberrant suprarenal tissue which is frequently found in the kidney. These tumours commonly arise in the upper pole of the kidney, are of yellow or brown colour, and are usually fairly well defined from the renal tissues. Micro- scopically, their structure is similar to that of the suprarenal gland, and their metastases are of the same nature. These tumours have formerly been classified as angiosarcoma, alveolar sarcoma, endothelioma, or carcinoma, but are now classified under the term hypernephroma. They form a comparatively slowly- growing tumour of the kidney, and give rise to less severe symptoms than the true sarcoma or carcinoma. There is aching in the loin, and enlargement of the kidney may be found on examination, but at first the symptoms are slight. Hcematuria occurs without any apparent exciting cause, and there may be renal colic from the passage of clots down the ureter ; the tumour may be of fair size before any hsematuria is noticed. Another form of malignant tumour that occurs in the kidney is that which is supposed to arise from embryonic tissues, and to which the name of embryoma has been applied. These tumours are formed of striated muscle (rhabdomyoma) or of mixed tissues such as striated and non-striated muscle, cartilage or bone, and epithelial stiuctures in tubular or glandular form. They grow in the renal tissues, expanding the latter to form a spurious capsule. They occur most frequently in children, and hsematuria is comparatively infrequent. Thus, the occurrence of a renal tumour, accompanied by intermittent attacks of hasmaturia, especially if profuse, should always give suspicion of renal growth in an adult. Renal tuberculosis and calculus both may give rise to renal enlargement, but the hasmaturia is seldom profuse ; with calculus, the hsematuria is often brought on or increased by exertion, whereas with growth it may come on at any time, even during rest. At the same time, it should be remembered that both profuse hsematuria and renal enlargement may arise from a vesical tumour which obstructs the normal flow of urine from the ureteric orifice ; in all cases therefore a cystoscopic examination should be made before any operative measure is carried out. The rapid development of a varicocele, especially on the right side, is a point significant of renal growth, it being due to blockage of the renal vein by direct extension of the growth. Hydronephrosis and pyonephrosis form definite enlargements of the kidnej'' which may attain a large size. The tumour is oval or rounded, smooth, and gives a sense of tenseness or elasticity, whilst occasionally distinct fluctuation may be obtained. A hydronephrosis occurs when there is a partial obstiuction to the ureter, or in cases of repeated attacks of complete ureteric obstiuction. Bilateral hydronephrosis may also exist, from the back- pressure due to any obstiuction of the normal passage of urine from the bladder. Hydronephrosis is 396 KIDNEY, ENLARGEMENT OF usually unaccompanied by pain or haematuria ; but the tumour may show marked changes in size, from the varying character of the lesion producing the obstruction ; thus, if the ureter be wholly blocked, the tumour will increase in size and become more tense ; whilst if the obstruction be partially relieved, the tumour will diminish, synchronously with the passage of a larger quantity of urine of low specific gravity. The presence of any obstruction to the normal flow of urine from the kidney predisposes to the onset of infection of the kidney by micro-organisms, so that a hydronephrosis may become converted into a pyo- nephrosis, or the latter may arise from the obstruction to the ureter of a kidney already the seat of pyelitis. The physical examination of a kidney distended with urine or with pus shows practically no difference between them, but with pyonephrosis there are other indications usually present to assist the diagnosis. The examination of the urine will reveal the presence of pus at some time, although, if the ureter is wholly obstructed at the time of examination, pus may be absent if the other kidney and the bladder are normal. If, however, the ureter is blocked only partially, pus will be found in the urine ; in the inter- mittent form, pus may be present in large quantities, coinciding with the decrease in the size of the renal tumour. With pyonephrosis, also, there will be the general evidence of suppuration, namelj^, raised temperature, sweating, pallor, and often diarrhoea. The most frequent causation of pyonephrosis is renal calculus, so that a careful enquiry into the history of the case for symptoms of calculus may give important indications and ;t;-ray examination may be of service {Fig. 97, p. 309) unless the stone has been passed. A serous or hydatid cyst of the kidney may give rise to a tumour in the loin exactly resembling a hydronephrosis, and would usually be diagnosed as such. The discovery of booklets {Fig. 6, p. 57) or hydatid elements in the urine or in the fluid aspirated from a renal cyst will point to the nature of the disease. Polycystic disease of the kidney may occur in children or in adults, and forms a tumour which is commonly bilateral, though that of one side may be larger than the other. In adults, the disease causes practically no trouble, except the presence of the tumour, in the early stages ; but later, symptoms of renal in- efficiency develop. The turaour gives the usual physical signs of a renal enlarge- ment, and may attain a great size on both sides. There may be aching pain in the loins and, occasionally, marked hasmaturia. The urine is of low specific gravity, is increased in amount, and in the absence of blood often contains a small amount of albumin. The disease is usually accompanied by. arterio- sclerosis. The character of the urine and the bilateral renal tumour are usually sufficient data upon which to form a diagnosis ; but with unilateral tumour, as occasionally occurs, the diagnosis is very difficult. A hydronephrotic or pyo- nephrotic kidney may give evidence of fluctuation which will not be obtained with a polycystic kidney. R. h. Jocelyn Swan. KNEE-JERK, ABNORMALITIES OF THE.— Before discussing the abnor- malities of the knee-jerk, it is desirable to say a few words about the methods used for eliciting this valuable physical sign, and what may be considered to be its normal variations. In the first place, it is essential, if mistakes are to be avoided, to test the knee- jerk with a suitable instrument. The fingers, or the edge of a hand or of a book are unsatisfactory, and useless for accurate examination. Several percussors are made for the purpose, the best being a wooden stethoscope with a moderately heavy ear-piece surrounded by a thick indiarubber ring. In the second place, the patient should be either sitting or lying down. If seated in a chair, he may be directed to cross one knee over the other, or, better still, place both feet on the floor as far away from him as is possible so long as the whole sole of each is KNEE-JERK, ABNORMALITIES OF THE 397 in contact with the ground. In either position a tap on the patellar tendon will provoke a contraction of the quadriceps extensor muscle, which will extend the leg on the thigh, and even if it fails to actually move the leg, may be seen or felt. If the patient is in bed, he should lie flat on his back, and be told to allow the observer to move his legs without resistance. The latter then flexes the knee by grasping the thigh above the joint and raising it until an obtuse angle is formed by the popliteal space, the foot resting on the bed. The position of the manipulator's hand will enable him to detect whether the quadriceps and ham- string muscles are sufficiently relaxed for the purpose of carrying out the test. In the case of small children or infants it is advisable to stand at the end of the bed and to grasp the ankle with the left hand. The knee can then be flexed easily by pushing the foot towards the patient, and, at the moment when the limb feels relaxed, a tap on the patellar tendon be given with the instrument in the right hand. If difficulty is found in making the patient relax his limb in any of these positions, his attention should be directed to carrying out some other voluntary movement, such as pulling apart his grasped hands while he looks at the ceiling. This is known as " reinforcement." The Normal Knee-jerk. — It is impossible to define a normal knee-jerk, because the extent of the reaction varies much in individuals and much in the same person at different times. Absence of the knee-jerk indicates an abnormality, and must be regarded as pathological. Inequality of the jerk on the two sides must also be regarded as very strong evidence of some organic morbid condition. Abnormalities. — The knee-jerk may be exaggerated, diminished, or lost. The knee-jerk is exaggerated when the reflex arc which governs the tone of the quadriceps muscle is insufficiently inhibited or controlled by the higher nervous centres. This occurs under two chief conditions, one of which constitutes a functional, the other an organic, loss of control. Functional loss of control occurs whenever the general health or nervous tone of the patient is below par. Exaggeration of the knee-jerk may therefore be met with in almost any constitutional ailment, and is nearly always to be observed when a person is seriously out of health. For instance, a phthisical patient, a case of chronic renal disease, a convalescent from enteric fever, or a neurasthenic may present very brisk jerks, and their presence may only be looked upon as an indication of a general loss of nervous tone. This fact emphasizes the necessity for never being satisfied with an examination of the knee-jerk alone in attempting to diagnose the condition of the nervous system. The exami- nation of the knee-jerk must at least be supplemented by that of certain other reflexes, the most important of which are the abdominal and plantar. If exaggerated knee-jerks are associated with normal abdominal reflexes and with the flexor type of plantar response, and if the knee-jerks are approximately equal on the two sides, it may be assumed with some exceptions that the exaggeration is due to a functional loss of control over the reflex arc. If, on the other hand, the abdominal reflex is absent and the plantar response is of the extensor type, the exaggeration of the knee-jerk is due to some organic change in the cells of the motor area of the brain or in the pyramidal tracts which are made up of the axonal processes of those cells. From what has just been said it is clear that exaggeration of the knee-jerk due to organic disease is always, or nearl}^ always, associated with other reflex changes, and particularly with the extensor type of plantar response. Fre- quently, but not invariably, these two signs are supplemented by the presence of ankle-clonus, by a spastic condition of the lower extremities, and by a loss of voluntary control over the vesical and rectal sphincters. When the pyramidal tract is equally affected on both sides, the jerks will also be exaggerated equally ; but if, as ir hemiplegia, one pyramidal tract is mor KNEE-JERK, ABNORMALITIES OF THE diseased than the other, there is a corresponding difference in the exaggeration of the knee-jerk on the two sides, that of the paralyzed leg being more brisk than that of the sound limb. Inequality of the knee-jerk is also observed in certain cases of general paralysis of the insane for the same reason. A very brisk knee-jerk is sometimes associated with a phenomenon which goes by the name of patellar clonus. With the limb resting relaxed and fully extended on the bed, the patella is sharply pressed towards the foot, with the result that clonic contractions of the quadriceps are provoked and continue as long as the pressure is sustained. Thus a very exaggerated knee-jerk is associated with patellar clonus, just as a very brisk ankle- jerk is associated with ankle-clonus. The presence of well-sustained patellar clonus is generally indicative of organic disease. In order to summarize in a few words the significance of brisk knee-jerks, it may be stated that they only indicate organic disease when they are accompanied by other abnormal reflex phenomena, such as extensor plantar response, ankle or patellar clonus, absence of abdominal reflexes, or imperfect control of the sphincters, or when they are markedly unequal in the two lower extremities. It might be added that the presence of spasticity is of equal importance ; but there are cases with rigid limbs in which it is often difficult to say whether the rigidity is of hysterical or organic origin. The knee-jerk may be diminished as the result of some pathological processes similar to those which abolish the jerk. On the other hand, owing to the natural variations in the activity of the reflex, it is often difficult to be sure that the sluggish character of a knee-jerk is of pathological origin unless there is evidence to show that it had been obtained previously with greater facility. Most infants suffering from acute febrile or debilitating disorders present very diminished knee-jerks; often the latter cannot be obtained at all, at the height of broncho- pneumonia or epidemic diarrhoea for instance, though they return to normal as convalescence progresses. The knee-jerk is lost only in organic disease, and the absence of that reflex, therefore, is evidence of some pathological process. The conditions under which the knee-jerk is lost may be classified in the following manner : — 1. Affections of the quadriceps extensor muscle, as in the myopathies. 2. Affections of the afferent path of the reflex arc, as in cases of tabes in which the lumbar region of the spinal cord is involved. 3. Affections of the anterior horn cells, such as occur when myelitis involves the third and fourth lumbar segments of the cord. 4. Affections of the efferent fibres in the anterior crural nerve innervating the quadriceps muscle, as in some forms of peripheral neuritis. 5. In complete transverse lesions of the spinal cord above the lumbar enlarge- ment. This is usually the result of a dorsal myelitis, or of a fracture-dislocation of the vertebral column with severe injury to the cord. 6. When the intracranial pressure is greatly increased, particularly in cases of intracranial tumour, and more especially when the tumour occupies the posterior fossa of the skull. It should be noted carefully that the absence of the knee-jerk in most cases affords evidence of some lesion of the structures which constitute the reflex arc, on the integrity of which it depends. It is a localizing sign, not necessarily a sign of some particular disease. For instance, it is quite possible for patients suffering from tabes to retain their knee-jerks so long as the morbid process has not involved the lumbar region of the spinal cord, or one knee-jerk may dis- appear before the other. For the same reason the jerk may be present in certain cases of acute poliomyelitis, or one may remain when the other has been lost. LEUCOCYTOSIS 399 It is also desirable to point out that the abolition of the knee-jerk may be the only indication of any affection of the nervous mechanism. For example, the knee-jerk is often lost after an attack of diphtheria, even when there is no evidence of paralysis of the leg muscles or of any sensory loss in the lower extremities. Another instance of the same kind is afforded by many cases of lobar pneumonia, especially in children, in which the pneumo-toxin is sufficiently poisonous to interfere with the sensitive patellar reflex without producing other signs of disturbance of the nervous system. In diabetes mellitus the knee-jerks may be absent without any further signs of peripheral neuritis developing. Attention has been drawn to the occasional absence of knee-jerk in cases of intracranial tumour. The explanation of this is not very clear and need not be discussed here, but reference may be made to the great variability of this pheno- menon from time to time. At one examination the knee-jerk is obtained ; at another, a few hours later, it is lost, perhaps to return on the following day. This ebb and flow of the knee-jerk is highly characteristic of increased intracranial pressure, and is rarely found under other conditions. Two other forms of abnormal knee-jerk deserve brief reference. One of them is what is sometimes called the choreic knee-jerk. In many cases of chorea, when the leg is extended on the thigh as the result of tapping the patellar tendon, it is held in that position for an appreciable length of time before relaxation takes place and the foot falls to its former position. In myasthenia gravis it is sometimes, but only rarely, possible to tire out the knee-jerk. A ready response is obtained at first, but rapid repetition of the test leads to abolition of the reflex excitability, which quickly recovers itself after a short rest. E. Farquhar Buzzard. KRAUROSIS VULVAE.— (See Pruritus.) LEUCOCYTOSIS is a word which has been used to denote two different conditions, namely : first, an absolute increase above the normal of the number of leucocytes per c.mm. of blood, without distinction as to which particular variety of leucocyte is mainly increased ; and secondly, an absolute increase in the total numbers of polymorphonuclear cells per c.mm. of blood. If the word leucocytosis is used in the latter restricted sense, then there is no clinical term to express an absolute increase of all the leucocytes in the blood, whatever their kind, and it seems preferable to use the term leucocj^tosis in the broader sense, as being an absolute increase in the total number of white corpuscles per c.mm. of blood, indicating the kind of leucocytosis by means of a dift'erential leucocyte count. It is in this sense that the term is used here. The point at which an increase in the total number of leucocj'tes per c.mm. of blood can be called leucocytosis is an arbitrary one, for whereas 5,000 per c.mm. is regarded as the average in health, there are considerable variations during the day, either in relation to digestion, exercise or what not, and the same person who at one time of the day may have 5,000 may at another have even as many as 14,000 per c.mm. If the differential leucocyte count remains normal, no total leucocyte count less than 15,000 per c.mm. can be regarded as abnormal, and it is not until the figure reaches 20,000 or more that much stress can be laid upon it. The numbers tend to be higher in children and in pregnant women than in other healthy individuals. From a cUnical point of view there are only two main groups of conditions in which the existence of leucocytosis is really of diagnostic importance, namely : first, in cases of splenomedullary, lymphatic, or mixed leukaemia, the differential diagnosis of which is discussed under An^^mia ; and secondly, in connection with infective processes, particularly those associated with suppuration. 400 LEUCOCYTOSIS There are a large number of maladies in which a moderate degree of leuco- cytosis may occur, but in which the behaviour of the leucocytes themselves is of little diagnostic significance. Thus, whether there is or is not any leucocytosis makes little or no difference in the diagnosis of the following conditions, in all of which the number may be anything from 5,000 to 20,000 per c.mm. : acute rheumatism, scarlet fever, myxoedema, intestinal obstruction, diphtheria, cholera, foetid bronchitis, bronchiectasis, urethritis, acute follicular tonsillitis, whooping-cough, carcinoma, sarcoma, and rabies. In all of these con- ditions, and probably in many others, whereas many cases show no leucocytic change at all, a certain proportion may exhibit leucocytosis. If there was a universal rule, either that there was or was not leucocytosis, the fact might be used in differential diagnosis ; for instance, the occurrence of leucocytosis in scarlet fever might be used as a point in distinguishing it from measles, in which such leucocj'tosis is rare ; but it is just possible that there may be a leucocytosis in a case of measles, and it is more than possible that scarlet fever may present no leucocytosis, so that whereas the general rule is to the contrary, it is not so constant as to be a safe ground upon which to make a differential diagnosis. It can only be said, broadly speaking, that whereas leucocytosis is not uncommon in the conditions already enumerated, it is upon the whole not common in measles, malaria, tj'-phoid fever, typhus fever, influenza, small-pox, mumps, and tuberculosis other than caseous bronchopneumonia, secondary infected phthisical cavities, or tuberculous meningitis. It is stated that certain drugs may produce leucocytosis, though careful experiments with some of them have by no means always confirmed this. Succinic acid, protargol, and essential oils such as turpentine, peppermint, or cinnamon, are examples of those said to produce shght leucocytosis. After severe loss of blood, such as may result from excessive hsematemesis, venesection, post-partum haemorrhage, and the hke, the leucocytes may rise in a compara- tively short time to over 15,000, and perhaps to over 20,000 per c.mm. It is clear, therefore, that when so many conditions may lead to leuco- cytosis, its importance is much diminished as a means of differential diagnosis. One may say, however, that unless there are other chnical indications to the contrary, a definite leucocytosis of 20,000 or more, the figure sometimes reach- ing even 50,000 or 60,000, together with a relative increase in the polymorpho- nuclear cells from their normal 65 per cent to 80, 85, or even 90 per cent of all the leucocytes present in the blood, is considerable evidence of there being suppuration somewhere. It is worthy of notice, that in a suppuration which produces leucocytosis with a relative increase in the polymorphonuclear cells, the pus requires to be confined under pressure, for instance, in an appen- dicular abscess, an abscess of the hver, empyema of the gall-bladder, suppurative pylephlebitis, infective cholangitis, perineal abscess, pyosalpinx, suppurating ovarian cyst, thoracic empyema, abscess of the lung, cerebral abscess, sub- cutaneous or pyaemic abscess, an unopened whitlow, an infected thrombosed vein, or suppurating lymphatic glands. "When an abscess which has hitherto been associated with leucocytosis is opened, the number of leucocytes in the blood quickly falls to normal ; there is little or no leucocytosis in conditions in which pus is not under pressure, for instance in cases of impetigo and other forms of pyodermia, superficial gangrene of the skin, suppuration connected with opened hip-joint disease or psoas abscess, and so forth. It is probably on this account that fungating endocarditis often produces a slight, but hardly ever any considerable, leucocytosis; the same applying to pyelitis, pyonephrosis, and pyelonephritis, in all of which, if there is free drainage through the ureter, leucocytosis is absent, whilst if there are abscesses in the kidney substance the leucocytosis may be considerable. Gangrene of the lung is another instance of LEUCOPENIA 4or the same kind, for there may be extensive gangrene without leucocytosis if there is free expectoration ; whilst if the gangrenous tissue is prevented from escaping, leucocytosis may result. Erysipelas is an exception to the rule that superficial suppuration does not produce leucocytosis, for here considerable increase in the leucocytes is common. Amongst diseases in which, though they are not in the ordinary sense suppurative, leucocytosis is the rule, may be mentioned in particular acute meningitis and pneumonia. Unfortunately, all forms of acute meningitis, whether tuberculous, suppurative, or meningococcal, lead to more or less leuco- cytosis, so that this point cannot be made much use of in the differential diagnosis between them ; but upon the whole the greatest leucocytosis, up to 40,000 or more, is to be expected in the acute cerebrospinal form. The fact that pneu- monia, whether of the lobar or lobular tj^pe, produces leucocytosis with a relative increase in the polymorphonuclear cells, more often than not makes it impossible to rely upon this point in determining whether or not an empyema is developing after the lung inflammation, unless it is known that up to the time of the crisis there was only a moderate leucocytosis, and that after a continuance of the fever, or a recurrence of it after the crisis, there is a greater leucocytosis, with a still further rise in the relative percentage of polymorphonuclear cells. When there has been no pneumonia, and when the physical signs are such as to suggest fluid in the chest, it is to some extent helpful to know that acute pleurisy, with effusion of the type sometimes spoken of as " simple," shows little leucocytosis, whereas empyema nearly always produces a considerable leucocytosis of the polymorphonuclear type. The value of the knowledge that there is leucocytosis, when a given case has been hitherto regarded as one of some disease not associated with leucocytosis, is obvious (see Leucopenia) ; thus, typhoid fever may have been the diagnosis in a case of obscure pyrexia, in which the existence of polymorphonuclear leuco- cytosis indicates that the diagnosis of typhoid fever is wrong, and that there is really deep-seated suppuration, such as an appendicular abscess or a pyosalpinx. Another similar example of the possible value of this in differential diagnosis is in distinguishing malaria, in which there should be no leucocytosis, from hepatic abscess, in which leucocytosis is the rule. Herbert French. LEUCOPENIA denotes the presence of a smaller number of leucocytes per c.mm. of blood than normal. When there are less than 5,000 leucocytes per c.mm. one may call the condition leucopenia. There are a large number of affections in which this occurs, in most of which the fact is of little, if any, diagnostic importance. It may result from simple starvation, either voluntary, due to stenosis of the oesophagus, or from ulcerative colitis. It is the rule in most chronic intoxications, particularly those which result from plumbism or poisoning by mercury, arsenic, ether, alcohol, or morphia. It is to be found in certain of the severe ancsmias, more particularly in cases of pernicious ancemia, aplastic ancemia, and some cases of Hodgkin's disease or lymphadenoma, particularly in the later stages. Acute miliary tuberculosis is often associated with leucopenia, and so also is tuberculous peritonitis in more cases than not. The chief clinical importance of leucopenia is in connection with two diseases in particular, namely typhoid fever and malaria. In the former it may some- times be of great importance to know that there is leucopenia almost from the beginning, for not a few cases have been regarded at first as examples of typhoid when, days before the Widal's reaction could be positive, the existence of leuco- cytosis instead of leucopenia has served to suggest suppuration rather than typhoid, the pus being subsequently discovered in the pelvis in connection, perhaps, with a pyosalpinx, or in an appendicular abscess or the like. The D 26 402 LEUCOPENIA differential leucocyte count may also be of assistance in the same direction, for the leucopenia of typhoid fever is associated with a relative increase of the smaller Ij^mphocytes and diminution of the polymorphonuclear cells, whilst with suppuration the reverse is the case. Leucopenia will not serve to dis- tinguish between typhoid fever on the one hand, and either general tuberculosis, influenza, or malaria upon the other ; but granted that there is a pyrexial illness suggestive of typhoid fever, the occurrence of leucopenia with a relative increase in the small lymphocytes, helps considerably in confirming the diagnosis days before the Widal's reaction would be positive. The leucopenia persists unless perforation or other complications that may lead to pus formation supervene. Malaria is generally associated with a reduction of the total number of leuco- cytes per c.mm. down to perhaps 3000, 2000, or even less. Associated with this leucopenia there is relative increase, not in the small lymphocytes as in typhoid fever, but in the large hyaline lymphocytes ; the association of these two things together, in a patient whose history points to the possibility of malaria, is of considerable assistance in clinching the diagnosis, and it may be of particular value in cases in which quinine has been administered, so that the most con- clusive proof of the nature of the complaint, namely the discovery of the malarial parasites in blood films is not for the moment possible. One difficulty, which is not at all uncommon in the tropics, is to decide between malaria on the one hand and abscess of the liver upon the other. Leucopenia and a relative increase in the large lymphocytes strongly favours malaria, whereas an abscess would cause leucocytosis and a relative increase in the polymorphonuclear cells. LEUCORRHCEA.— (See Discharge, Vaginal.) LIMPING. — (See Gait, Abnormalities of.) LINE£ ALBIC ANTES. — These are sometimes, and with equal propriety, termed lineae atrophicse ; both terms precisely describe them ; the one their appearance and the other their origin. They consist of areas of skin many, times longer than broad — hence the word linea to describe them ; somewhat shiny, bluish-white in colour — hence albicantes ; and they are produced by atrophy of portions of the true corium (sub-epithelial) — hence the term atrophicae. There is no disease that really resembles them, and indeed no other condition of the skin with which they can be confounded when once they have been pointed out. Morphoea and leucodermia {q.v.) are the only possible exceptions, and these only under the rarest circumstances, for the patches of these affections are not linear, do not shine, are not atrophic, and above all. do not show those small cross wrinkles of epidermis at right angles to the axis of a linea so character- istic of lineae albicantes ; these wrinkles can be smoothed away by stretching the skin in a direction parallel to the linea, but they return at once on relaxing the tension. The meaning of these lineae is that the skin has been unduly stretched over some fairly long period of time ; but it must be distinctly understood that they give not the slightest indication as to the cause of the stretching, this caution being necessary, because when these lineae are found on a woman's abdomen or breasts, it is commonly assumed that they constitute evidence of a past pregnancy ; it is perfectly true that this is the commonest origin ; but any other cause of swelling, such as tumour, ascites, and even fat and oedema, etc., will produce them by stretching the skin. They are very frequently seen on the shoulders and thighs of persons of either sex, and in these positions suggest either present or past obesity, but are not conclusive evidence of anything but undue stretching. Fred. J. Smith. LIPS, AFFECTIONS OF THE RED PART OF 403 LIPS, AFFECTIONS OF THE RED PART OF THE— The simplest affection to which the vermihon of the hps is liable is that known as " chapping," a condition frequently due to exposure to keen winds, and sometimes aggravated by the habit of " picking." In some cases the fissuring is sufficiently deep to cause appreciable pain and great disfigurement. The vermilion of the lips may be involved also in a number of cutaneous diseases, among them lupus vulgaris, lupus erythematosus, lichen planus, herpes febrilis and zoster, tinea circinata, urticaria, psoriasis, and some forms of syphilis. The lesions of the epithelium of the lips, as of mucous membranes in general, are seldom characteristic enough to warrant a confident diagnosis ; in none of the affections enumerated in this paragraph is the red of the lips alone aft'ected, and guidance as to the nature of the affection will be found in the more distinctive lesions of the cutaneous surface. Ordinary eczema is sometimes limited to the lips and immediately adjacent parts. Associated with a slightly seborrhoeic condition of the scalp, there is sometimes a persistent and repeated exfoliation of the vermilion of the lips {cheilitis exfoliativa). In a somewhat similar yet not identical case of mine, the lips as a whole were covered with a thick accumulation of scales, which caused them to protrude. When the scales were removed the lips were blue instead of red. The patient complained of some burning pain, but chiefly of a feeling of deadness in the lips. The condition had persisted for eleven years, and appeared to have been set up by a habit of biting the lips and tearing off the skin. The subjects of cheilitis exfoliativa are usually neurotic, and in this case there was some tendency to that condition, but there was no associated seborrhoea. In cheilitis glandularis there may be neither seborrhoea nor neurosis : the chronic inflammation of the lower lip, with swelling of the mucous glands, appears to originate in catarrh of the mouth and pharynx. It is chiefly the vermilion that is affected, but the inflammation spreads to the inside of the lip, and sometimes also to the neighbouring skin, which presents an erythematous aspect. The conditions here described are all rare, and are not likely to be confused with more ordinary affections of the labial epithelium. In syphilis the red of the lips is sometimes the seat of the primary sore (see Fig. 10, p. 86), and in the secondary stage condylomata may occur in this situation. The chancre may be flattish and covered with a false membrane, or it may present itself as a crateriform infiltrated ulcer. In epithelioma the lip-— usually the lower one — is frequently the point of attack, the growth beginning as a slight abrasion, crack, or papule, and running the usual course. (See under Tumours of the Skin.) Fordyce's disease specially attacks the red of the lips and the oral mucous membrane, the lesions consisting of small whitish or yellowish milium-like bodies, which may be discrete or coalescent, profuse or scanty. Inside the mouth the milium-like bodies are whiter than those on the lip, and are also more projecting. If subjective symptoms are present, they take the form of slight burning and itching, with a feeling of stiffness. The signs can hardly be confounded with those of any other affection. When the lesions are very abundant they may simulate a solid patch ; but if the tissues are stretched, the milium-like bodies can be distinguished. Perleche is a contagious affection almost peculiar to children, and due pro- bably to streptococci. It usually starts at both angles of the lips, as a whiten- ing and maceration of the epithelium, which is easily detached ; it extends along the epithelium towards the middle line, involving also the surrounding skin and the mucosa of the inside of the lips. There are usually some hyperaemia and inflammation, and the feeling of heat and discomfort prompts the child constantly to lick its lips — hence perleche. The affection often appears in 404 LIVER DULLNESS, DEFICIENT association with impetigo contagiosa, or impetiginous stomatitis, or vesicular erythema. In some cases it can only be discriminated from the mucous patches of syphilis by the absence of other secondary signs. From herpes it can be diagnosed by its bilaterality and its not beginning as a vesicular eruption. Malcolm Morris. LIPURIA (See Chyluria.) LIVER DULLNESS, DEFICIENT.— The most common cause for diminution of the hepatic dullness is emphysema. The chest is barrel-shaped, the lower ribs are everted, and the diminution of the dullness is at its upper part. The dullness is diminished from above downwards in cases of tight lacing, which forces the liver down, and in cases of hepatoptosis [q.v., p. 406). But in these two instances the hepatic dullness descends lower than is normal, so that the total liver dullness is often natural. The hepatic dullness is diminished very con- siderably and rapidly in acute yellow atrophy : the signs of this disease are so numerous and striking that the diagnosis is not as a rule difficult. It slowly diminishes when the liver shrinks in the terminal stage of cirrhosis. It is often said that in perforative peritonitis the presence of free gas in the peritoneal cavity leads to a diminution of the hepatic dullness. This is undoubtedly true sometimes, but the sign is so often absent, that considering there are other causes of diminution of hepatic dullness, it is unwise to lay much stress on its presence or absence in coming to a diagnosis of perforative peritonitis. Con- siderable gaseous distention of the bowels will also cause diminution of the hepatic dullness. w. Hale White. LIVER, ENLARGEMENTS OF THE.— In adults, the liver is about ^, but at birth it is ttj to yV ^^ ^^^ weight of the whole body ; therefore in infants and young children it is relatively larger than in adults. Unless this is remem- bered, the liver may in such patients be thought enlarged when really it is of normal size. On deep inspiration, in thin people whose abdominal muscles are lax, the lower edge of the normal liver can, in the supine position, be felt by the fingers to descend, if they are thrust up under the ribs outside the right rectus. In the upright position it may descend half an inch lower than this. In the epigastric angle, a small portion of the anterior surface of the left lobe is in contact with the anterior abdominal wall. Often this cannot be felt owing to rigidity of the recti abdominales muscles, but it may be the only part that can be felt unless the ribs are raised as in emphysema. The hepatic dullness to the left of the sternum cannot be distinguished from that due to the heart ; on the right, it begins at the middle of the ensiform process of the sternum, in the nipple line it reaches the upper part of the fifth intercostal space, in the mid-axillary line the seventh, in the line of the angle of the scapula the ninth. In health the edge of the liver is firm and uniform, and the surface feels smooth. In excessively rare instances the whole organ is lobulated. This is probably not, as has been supposed, a developmental abnormality, but represents past disease, possibly intra-uterine. If the liver is transposed, the right lobe is small and the left large. Occasionally either lobe is dwarfed by disease, e.g., alcohol or syphilis. A tongue-like projection of the right lobe may protrude from its lower right-hand part. This projection, known as Riedel's lobe, is often associated with disease of the gall-bladder such as gall-stones, or with tight lacing, and is commoner in women than in men, but as it may be found in quite young children, it must be regarded as sometimes an anatomical abnormality. A Riedel's lobe may give rise to great difficulties of diagnosis ; the connection between it and the liver may be only peritoneum, LIVER, ENLARGEMENTS OF THE 405 it may then easily be mistaken for a floating kidney, especiall}^ as in such a case there may be a band of resonance between it and the Uver ; or such a lobe may be confused with any tumour that may be found on the right side of the abdomen. When palpating the abdomen it is often very difficult to tell the right-hand lower part of the liver from the kidney, even when there is no projection which can be called a Riedel's lobe. Many conditions quite unconnected with the liver cause an apparent alteration in its size. Thus, a general weakness of the tissues may lead to its dropping downwards in the erect posture from laxness of its supports, which are chiefly its ligaments, and to a less extent the abdominal walls. I have known this occur in wasting diseases, the fact that the liver was not enlarged having been evident on post-mortem examination ; indeed, in such a case I have known the dropped liver to be regarded as enlarged from cancer, which was believed to be the cause of the wasting, when in reality the patient was wasted because he had diabetes. Again, if the liver is somewhat enlarged from disease, its extra weight may cause it to drop, and hence it appears larger than it really is. Thus it is not uncommon for a nutmeg liver to appear during life larger than it is ; but that it is not, may be proved by noticing that percussion shows the upper line of hepatic dullness to have descended. Alterations in the chest may lead to depression of the liver, which may there- fore erroneously be thought to be enlarged. Thus, in an extreme case of fibrosis of the lungs with adherent pleura, I have seen the sucking in of the ribs on inspiration lead to depression of the liver down to the umbilicus : and the right lobe may be depressed into the right loin by compression of the chest due to tight lacing, this being often associated with a movable right kidney. Deform- ities of the chest due to rickets or curvature of the spine may lead to great depression of the hver. It may be depressed by large collections of fluid in the right side of the chest, but they must be quite large, for the fluid will more easily compress the lungs and push the heart to the left than depress the diaphragm. It may also be depressed by a right-sided pneumothorax. If in diaphragmatic pleurisy the diaphragm is not working, and is in a more or less constant position of inspiration, the liver is also constantly in this position, and hence seems to be a little depressed. Extreme pericardial eflusion is said to depress the liver, but this must be very rare, for the pressure would have to act through the fibrous part of the pericardium, which is very firm. It is often stated that a subdiaphragmatic abscess will depress the liver considerably ; but this is incorrect, for the numerous adhesions in connection with such an abscess generally prevent depression of the liver. Tight lacing may cause a deep furrow on the liver palpable during life. I have known so deep a furrow caused by a man's belt that the part of the Uver below the furrow felt almost separated from the rest of the organ ; in such a case there may be a false impression of enlargement. The effect of corsets or other artificial pressure is often such as to give an incorrect impression of enlargement, because the organ is pressed down ; most commonly the liver is forced down, flattened, and elongated from above downwards. It thus forms an apron, covering much more of the intestines than is natural, but sometimes some of them may get in front of it. Such a pressure often leads to a transverse depression across the right-hand lower part of the right lobe, so that a more or less detached portion of it lies in the position of a Riedel's lobe. It is quite rare for enlargement of the liver to lead to any upward extension of the hepatic dullness. This is what might be expected, for the mere weight of the enlarged liver will lead to its falling, and the resistance of the intestines and abdominal walls being much less than that of the diaphragm, it will there- fore grow in the direction of least resistance, that is, downwards. Raising of 4o6 LIVER, ENLARGEMENTS OF THE the upper limit of hepatic duUness is best observed when some local disease of the Uver directly imphcates the diaphragm ; thus, a tropical abscess of the liver growing from its upper surface wiU soften the diaphragm and extend upwards ; a hydatid will do the same. So, when there is an extension upwards of the upper hepatic dullness, it is a local extension forming a dome-shaped addition to the hepatic dullness. Very large collections of ascitic fluid or very large abdominal tumours may push the liver up, but this is excessively rare, for such conditions will more readilj^ compress the iatestiaes and bulge the abdominal walls. A subdiaphragmatic abscess, by its extension of dullness up into the chest, mav appear to extend the liver dullness upwards. There are three moderately common tumours in the abdomen which may give a false impression of increase in the size of the liver. The^' are : A stomach affected with malignant disease, especially when the growth infiltrates much of the greater curvature ; malignant disease of or impaction of fcBces in the transverse colon ; and the great omentum thickened and puckered up towards the transverse colon by some form of chronic peritonitis. Any of these tumours may move up and down with respiration, for they are all directlj'- or indirectly attached to the liver ; but the movement is not usually so extensive as that of the liver should be, and a band of resonance maj^ sometimes be detected betAveen the liver and the tumour, or the edge of the liver may be felt above it. Enlarge- ments of the p3dorus, and thickening in connection with a gastric or duodenal ulcer may aU be difficult to distinguish from an enlarged gall-bladder. The hepatic dullness may be altered by gas, and it ma^^ be almost obliterated by the descent of an emphysematous lung ; slight lowering of the upper margin of the hepatic duUness from this cause is quite common. In emphysema, too, the lower ribs stand so far forward that it maj^ be impossible to feel the lower edge of the liver. When, as in perforative peritonitis, there is free gas in the peritoneal cavity, the gas getting in front of the liver may diminish the hepatic dullness, but this sign is so often absent that its absence must not be used as an argument against the existence of perforative peritonitis. On the other hand, partial obliteration of the hepatic dullness may be due to the fact that some of the intestine is between the liver and the anterior abdominal wall. A large collection of ascitic fluid often renders it difi&cult to estimate the size of the liver. Hepatoptosis, and wandering liver, are terms applied to a liver which, being unduly displaceable, leaves its normal position. It is a rare condition, but must be borne in mind, for, if not, a liver which is only displaced may erroneously be thought to be enlarged. Extreme degrees are met with in cases of general viscero- ptosis. It is commoner in women than men, and is most often seen after the age of fort}^ The abdominal walls are usually pendulous, and, as the abdominal muscles are powerful agents for keeping the abdominal viscera in place, this weakness, combined with a laxit}- of the hepatic ligaments, is probably the cause of the hepatoptosis. Tight lacing leads to weakness of the abdominal muscles, as well as pressing the liver down. "When the liver in this condition is examined, it is found to have fallen, and to be flattened, extending often to the umbilicus, with its greatest prominence near its lower part and on the right. It ma}' form a protrusion of the abdominal walls ; it is easily palpable, moves up and down with respiration, and can usuallj' be pushed back into its normal position when the patient lies down ; indeed, when the patient is in the supine position, it sometimes goes back of its own accord, only to fall again when she stands up. It is movable laterally, and can be rotated with the hands about a horizontal axis passing through the attachment of the organ to the inferior vena cava. There is considerable diminution in, or even absence of, the hepatic dullness in the chest ; in an extreme case the hand may be passed up between the liver and the ribs, and at the upper right-hand part of the abdomen there is a LIVER, ENLARGEMENTS OF THE 407 depression between the liver and the ribs. There may be no symptoms, but the patient usually complains of a dragging pain and a heaviness in the hepatic region. These are much worse in the erect posture, so that she may have always to lie down. Often, sudden attacks of pain occur in the right of the abdomen ; these may be due to gall-stones or to a floating kidney (both often present with hepatoptosis), or to kinking of the bile duct, which may lead to jaundice. The patients are usually neurotic, dyspeptic valetudinarians. As the abdon:iinal muscles are weak, the blood stagnates in the abdominal vessels in the erect posture ; hence faintness, palpitation, exhaustion, and dyspnoea on exertion are common, these symptoms passing away when the patient lies down. We shall now consider each of the pathological enlargements of the liver, and indicate the chief points to be utilized in the diagnosis of each. Venous Congestion of the Liver, or Nutmeg Liver. — There must be heart disease, usually of the mitral valve, or perhaps incompetence of it secondary to severe aortic disease, or disease of the valves on the right side, or severe disease of the myocardium, or chronic pulmonary disease, usually bronchitis. The enlargement of the liver is firm and uniform, its edge is hard and uniform, its surface smooth. The enlarged organ may reach to the umbilicus, and as the abdominal muscles are often weak in these cases, especially in women, and the liver is very heavy from the extra amount of blood in it, the organ is often a little dropped. Pain and tenderness over the liver are very common ; they are due in some cases to stretching of the hepatic capsule, in others to local patches of perihepatitis. The skin over the liver may be tender. In severe cases there is often slight jaundice. Dyspeptic symptoms are frequent. Ascites may be present ; if so, it is associated with the oedema due to the heart disease. In a severe degree of nutmeg liver the organ may pulsate. If so, the tricuspid orifice must be incompetent and the right ventricle must be beating strongly ; then a pulse-wave travels back in the inferior vena cava and hepatic veins to reach the liver, and makes the whole organ expand synchronously with each contraction of the right ventricle. Such incompetence of the tricuspid orifice is nearly always secondary to mitral disease. Great care must be taken not to mistake a thrust downwards of the liver by the contraction of a hypertrophied heart, or the thrust forwards by a pulsating aorta, for hepatic pulsation. The distinguishing feature of this is, that when one hand is placed on the front and the other on the back of the abdomen over the enlarged, congested liver, the two hands can be felt to be separated by the expansile pulsation of the liver. This is not the case when the pulsation is transmitted. Naturally, pulsation of the veins of the neck is often seen in cases in which the liver can be felt to pulsate. General Congestion of the Liver. — This is frequently said to be present in those who suffer from dj'spepsia, but if this be so it does not give rise to a demonstrable enlargement. When, however, a European lives for many years in a tropical country, he is liable to suffer from attacks of congestion of the liver, and these, when frequently repeated, lead to an enlargement called tropical liver. The organ is uniformly enlarged, smooth, somewhat hard, and has a uniform edge. Pain and tenderness are not such prominent features as the}^ are in a nutmeg liver. The condition is often associated with indigestion, errors of diet — especially the taking of too much alcohol — and attacks of p^aexia. When these are present the liver becomes tender, painful, and more enlarged, and I have known such a condition mistaken for hepatic abscess. The sufferer complains of a sensation of weight in the hepatic region ; he is constipated, and the urine is full of lithates. In an extreme and chronic case the organ may extend four inches below the ribs ; the patient is depressed, irritable, and of a sallow complexion. The spleen may be enlarged. 4o8 LIVER, ENLARGEMENTS OF THE Suppuration within the Liver. — Multiple pysemic abscesses within the liver, which constitute part of the condition known as portal pyaemia, generally do not cause enlargement of the liver, but this is often present with a large single abscess. There is usually a history of dysentery, for amoebic dysentery is by far the commonest cause of a large single abscess; therefore it usually occurs in the tropics, and is then commonly called a tropical abscess. Very rarely it is secondary to other specific fevers, it may be due to suppuration round a gall-stone, or may spread from some neighbouring suppuration, e.g., a peri- nephritic abscess. Or again, it may be caused by suppuration of a hydatid or by injury. The presence of any of these causes may help the diagnosis ; but sometimes, even when the abscess is due to the dysenteric amoeba, it may be difficult to obtain a history of dysentery ; and indeed the dysenteric ulcers of the intestine may have healed years before the symptoms of hepatic abscess show themselves. Very rarely it appears to follow intestinal ulcera- tion which, as far as we know, is not dysenteric ; this is so in some of the examples of single large abscess in which the patient has never left this country. Indeed, sometimes a single large hepatic abscess is found in the tropics, when the most careful search fails to find any amoebae in the pus of the abscess, or to obtain any history of dysentery, or only a history of bacillary dysentery. Probably the true cause of a single large abscess is not known, and the amoeba is only a contributory, although a powerfully con- tributory, cause. These abscesses are most common in men between the ages of twenty-five and forty-five. They are much commoner in Europeans than natives. Eighty per cent are in the right lobe, usually in its upper part. The colour of the pus depends upon the amount of broken-down hepatic tissue present ; if there is much, it is the colour of anchovy paste ; if there is none, it is yellow, but the anchovy-paste-like pus is of the characteristic colour. Amoebae may be found in it (see Fig. 12, p. 91), or more often in the granulation tissue forming the wall of the abscess. Bacteria may be present, but if the abscess has existed some time the pus is often sterile. The symptoms and physical signs to which attention must be directed are as follow : — General. — The most important is pyrexia ; often this is the initial symptom. At first the rise of temperature is slight and irregular; gradually it becomes hectic, with a wide daily excursion, say from 99° F. in the morning to 103° F. or 104° F. in the evening. Often the patient is thought to have malaria, but an examination of the blood will show that no malarial organisms are present. There are sometimes considerable intermissions during which the temperature is normal for weeks or months, and then there is a week or so of pyrexia. When such a case occurs in this country, mistakes in diagnosis are very likely. I know of a man afflicted with tropical abscess whose attacks of pyrexia were separated by such long intervals of normal temperature that he was thought by many physicians to have recurrent attacks of influenza, and this although it was well known that he had been in the tropics. Rigors are striking and severe, and in cases of doubtful diagnosis are very suggestive of hepatic abscess, but they also make this disease resemble malaria. In mild cases the rigor is reduced to a mere feeling of chilliness. Often there are profuse sweats. The pulse is rapid in proportion to the temperature. Jaundice may be present. In bad cases the patient is excessively ill and weak, anemic, and wasted to a mere skeleton. In this country we see such cases on their arrival from India, the disease having made rapid progress on board ship. On the other hand, if there are long intervals of apyrexia, the patient hardly suffers in his general health; in such cases the abscess usually has thick walls. The blood may show a great increase of polymorphonuclear cells, but this leucocytosis is often absent, especially if the pus is sterile or the abscess has LIVER, ENLARGEMENTS OF THE 409 thick walls. During the fever the patient has a dry tongue, is thirsty, and has anorexia ; the urine is scanty and high-coloured, and may contain albumin. Local. — The abscess is most often at the upper part of the right lobe, it grows upwards between the layers of the coronary ligament, and thus forms an extra- peritoneal subphrenic abscess which softens the diaphragm and pushes it up, giving a dome-shaped area of dullness varying in size from one to several inches across, added to the top of the normal line of the hepatic dullness, and best seen by mapping out the dullness with a blue pencil. It is usually posterior to the mid-axillary line. Sometimes the abscess is in such a place that a rounded swelling may be felt on the liver when the patient draws a deep breath ; it may be palpable without this, or it may be visible. The measure- ment round the lower part of the chest may be longer on the affected side, the intercostal spaces may be obliterated, and, if the abscess be very large, the lower ribs may bulge. Not uncommonly the abscess is of such a size and in such a position that the greatest care is necessary before it can be detected. The whole of the hepatic area should be pressed carefully by one finger, for local tenderness is often a great aid in the diagnosis. If the abscess presents in the abdomen, the rectus muscle over it may be rigid. Pain is very variable ; it may be absent, it may be severe ; often coughing, drawing a deep breath, or shaking the patient, will cause pain. In about one-sixth of the cases there is pain in the right shoulder ; if the abscess is in the left lobe, there may be pain in the left shoulder. If the abscess comes close to the skin, there may be oedema and redness of it, and in excessively rare cases, fluctuation. Often the liver is enlarged generally as well as locally. If the abscess is large, it may be seen with the ;v-rays, for pus casts a very dark shadow. Lastly, I would again remind the reader, that in some of the chronic cases seen in this country, both the local and general signs may be so slight that great skill is necessary to detect the abscess. If the abscess implicates the diaphragm, infection may spread through it and cause bronchitis, pleurisy, empyema, pneumonia, or gangrene of the lung, but this is not nearly so common as with other subphrenic abscesses ; hepatic pus may be coughed up from the lung when the abscess has ruptured into it, may be vomited when it has ruptured into the stomach, or may be passed by the bowel when it has ruptured into the intestine. Cirrhosis of the Liver. — Nearly always the patient has taken more alcohol than he should, but in rare cases cirrhosis of the liver, indistinguishable from alcoholic cirrhosis, occurs in children and others who have not taken alcohol. Here we have to consider only the stage of cirrhosis of the liver in which the organ is enlarged. It has been known to weigh 200 oz., but anything over 100 oz. is exceptional. In the early stages the liver is not altered in shape, and the surface is smooth ; later on, as the fibrous tissue contracts and the fat is absorbed from the cells which have undergone degeneration, the surface becomes finely uneven ; this unevenness increases, the liver becomes hard and more uneven until the irregularities on it are like hobnails, and can be felt with the hand through the abdominal wall. At this stage the edge of the liver is very firm and irregular. As the irregularity increases, the diagnosis from cancer becomes more difficult, but no irregularity from cirrhosis ever exceeds the size of a small cherry, nor is it ever umbilicated, nor does it ever suddenly enlarge ; whereas a cancerous nodule may be umbilicated and may suddenly enlarge from haemorrhage into it. Usually a cirrhotic liver is not painful ; if it be, the pain is due to some local perihepatitis. Other symptoms to be looked for in cirrhosis, and to be borne in mind when making a diagnosis, are that in cirrhosis the spleen is often much enlarged, and the increased fibrous tissue in the liver con- stricting its small portal veins leads to engorgement of the veins of the stomach ; 41 o LIVER, ENLARGEMENTS OF THE and hence haematemesis, which may be accompanied by melsena, is common ; and occasionally we see dilatation of the veins round the umbilicus. There are often symptoms of chronic gastritis and enteritis. Cirrhosis is commoner in men than women in the proportion of three to one ; the patients are usually over thirty ; there is a more frequent association of alcoholic excess in the lower classes than among those who are socially above them. Dyspepsia and morning sickness are common ; there are much impairment of strength, wasting, a sallow look, dilated venules on the cheek, red nose, a furred tongue which is often tremu- lous, and a dry, harsh skin. The pulse becomes weaker, and when the disease is fatal, its end is usually by cardiac failure. In about one-third of the cases that are ill enough to come into the hospital, the temperature is raised a little every evening. Jaundice is present in about one-third of the cases ; it is usually persistent, and rarely if ever becomes as deep as that seen in cancer of the liver. Ascites occurs in 50 per cent of all cases of cirrhosis ; if it is abundant, the enlarged liver can be felt only by dipping, which means pressing the hand down suddenly on the liver, and so, by dispersing the fluid which is over it, coming down on it. Tympanites is not uncommon in severe cases of cirrhosis, and it too may make it difficult to feel the liver. The urine is usually scanty, of high specific gravity, very acid, high-coloured, and full of urates ; it may contain bile. Naturally sufferers from cirrhosis may have delirium tremens, but apart from this, cirrhosis towards the end is often accompanied by nervous symptoms, especially coma, and this may be so in those who have not recently taken alcohol and who are not jaundiced. In severe cases the ankles swell, even when there is no disease of the heart, lungs, or kidneys, or pressure on the vena cava, to account for it. Lastly, it should be remembered that cirrhosis may exist Avithout any symptoms ; in between a third and a half of all cases of cirrhpsis found in the post-mortem room the patient has died of something else, and in many of these cases, although he has been under observation in the wards, no symptoms of cirrhosis have been observed. The difficulties of diagnosis fall into one of two classes : the cause of Ascites {q.v.), and the cause of enlargement of the liver. If we have made out that the liver is undoubtedly enlarged, it is often a matter of great difficulty to tell whether the enlargement is due to cancer or cirrhosis : this will be referred to in speaking of cancer. Sometimes cancer and cirrhosis are present in the same liver, but this is rare. Syphilis of the liver does not cause much difficulty, for it is extremely uncommon at the bedside ; the irregularities of the liver are much larger than the hobnails of cirrhosis ; the patient who has a syphilitic liver is rarely if ever jaundiced, and hardly ever has ascites. The symptoms of a syphilitic liver are entirely local ; syphilitic disease of the liver produces no general symptoms. Obstruction of the common bile-duct leads to a large smooth liver ; when this is due to a gall-stone there is usualh^ deeper jaundice than in cirrhosis, but no ascites ; the stools are quite white, which is very unusual in cirrhosis, and there is commonly a history of gall-stones. There is no real difficulty of diagnosis between the enlargement of malaria and ordinary cirrhosis, for so-called malarial cirrhosis occurs only in those who have drunk to excess, and is then to be ascribed to alcohol. Hanot's Cirrhosis — often called hypertrophic biliary cirrhosis, an extremely bad name — is a very rare disease, of which the distinguishing features are : Most of the sufferers are children ; few reach the age of thirty ; it is commoner in males than females ; it lasts many years ; the liver is firm, enlarged, and smooth ; long-standing jaundice is present ; the spleen is very much enlarged. The patients are usually children of stunted growth, and therefore the liver appears very large, but the spleen is proportionately more enlarged. The liver usually remains smooth throughout, and even when towards the end of a long LIVER, ENLARGEMENTS OF THE 411 case it becomes a little granular, it never proceeds to anything like the irregularity of ordinary cirrhosis. Jaundice is an early symptom and lasts till the end, so it may be present many years; very, very slowly it becomes darker. From time to time the patient has periods during which he feels ill and his temperature is raised. It is strange that in spite of their jaundice, the children afflicted with this disease do not for years appear ill ; such children may be seen running about enjoying life, with a clean tongue and a good appetite. Ascites is rare, and if present means that the end is near. In many cases the fingers have become clubbed, especially in children. The clubbing is exactly like that seen in chronic fibrosis of the lung. As growth is stunted — for example, the average height at 13 years is 4 ft. 9 in., but a patient with this disease was only 4 ft. I in. — the size of the liver and spleen makes the abdomen very prominent. At the later stages there may be htemorrhages. Splenic Anaemia. — This is a disease in which there are progressive enlargement of the spleen, secondary anaemia, leucopenia, a marked tendency to haemorrhage, especially from the stomach, and in many cases, a terminal stage of cirrhosis of the liver, jaundice, and ascites. The disease is often called splenomegalic cirrhosis, and its terminal stage of cirrhosis of the liver is frequently designated Band's disease. When in this terminal stage the liver is enlarged from cirrhosis, it maybe almost impossible to distinguish the condition from ordinary cirrhosis of the liver, unless we know from the medical history of the case that the spleen has been enlarged for some time. Other points that may help are : on the average the spleen is much larger in splenic anaemia than in ordinary cirrhosis, so that an excessively large spleen is somewhat in favour of splenic anaemia ; hjemat- emesis is an early symptom, usually present long before the stage of cirrhosis of the liver. The disease is very slow, but the patient may die before the super- vention of either ascites or jaundice ; he does not often do this in ordinary cirrhosis. Anaemia is present in both conditions, but is probably, on the whole, severer in splenic anaemia. Bronzed Diabetes. — In this disorder, which is very seldom seen, the liver is enlarged, hard, and cirrhotic, exactly like that of an ordinary cirrhosis : the pigmentation of the skin, which is like the discoloration due to arsenic, the absence of jaundice, and the presence of sugar in the urine, sufficiently distin- guish the disease. Syphilis of the Liver. — Syphilis when it affects the liver produces gummata in it, and leads to increased growth of fibrous tissue. Much of this is in the form of hard bands traversing the liver irregularly and leaving large areas of healthy liver substance. It will be easily understood that what with the presence of recent gummata, gummata that have begun to shrink, bands of fibrous tissue that have begun to contract, and pieces of normal liver, a syphilitic liver is very lumpy and irregular in shape. It may be enlarged, and even during life this lumpiness may be felt, but the syphilitic liver does not become so large as a large cirrhotic liver, unless lardaceous disease be present ; it is much more irregular, and indeed usually resembles a cancerous more than a cirrhotic liver, but it seldom produces any clinical symptoms ; if detected during life the discovery is generally accidental ; it occurs at a younger age than cancer ; there are none of the other signs of cancer, but there may be some of syphilis ; ascites and jaundice do not occur as signs of this disease unless an enlarged gland presses on the portal fissure, which is so rarely the case as to be negligible ; and the liver is at most a little enlarged, never huge as in cancer. In children, congenital syphilis may produce in the liver precisely the same effects as the acquired disease does in adults. Lardaceous disease may be due to syphilis ; it will be discussed presently. 412 LIVER, ENLARGEMENTS OF THE Universal Chronic Perihepatitis may make the liver appear large, for in this condition the peritoneal coating of the whole organ is much thickened ; but as the liver itself is of normal size the apparent increase is not great, rarely exceeding an extra finger's breadth below the ribs. Such of the liver as can be felt is smooth ; the edge is uniform and thick. Usually, however, no apparent enlarge- ment can be detected in universal chronic perihepatitis, and often the organ and its thickened capsule weigh the same as a normal liver, from which we may conclude that the liver itself is a little atrophied : in a few cases it appears actually smaller than natural, for the thin anterior edge is folded upwards under the thick peritoneal coat. There are no hepatic symptoms, e.g., jaundice, and the universal perihepatitis is only part of a general chronic peri- tonitis, symptoms of which, e.g., ascites and thickening of other parts of the peritoneum, may be detected on palpation. Secondary Cancer of the Liver. — This is the commonest tumour of the liver. Generally there will be symptoms of the primary malignant disease, which in about 90 per cent of the cases is in the periphery of the portal area, but not infrequently none are present, and the patient does not know that he has anything serious the matter with him until he has symptoms of hepatic carcinoma. In about half the cases of hepatic carcinoma no symptoms of it are present, and it is not known to exist until a post-mortem examination is performed, for the primary disease kills while the hepatic disease is still in its early stages. Seventy-five per cent of all the patients are between 40 and 70 years old, and hepatic carcinoma is all but unknown under the age of twenty. If the disease gives rise to clinical symptoms the liver can usually be made out to be enlarged both by percussion and palpation. There is no other disease in which such a huge liver may be found. I have known a cancerous liver to weigh 19 lb., and I have read of one which weighed 33-J- lb. ; weights of 6 or 7 lb. are quite common. In rare cases, the increase in the weight of the liver may be so great that the patient actually gains a little weight in spite of the general wasting caused by the cancer. The organ may be felt well below the ribs, even far below the umbilicus. Upward increase of the hepatic dullness is rare, and when present, slight. The edge of the enlarged organ can be felt to move up and down with respiration, unless it is fixed by adhesions, which is unusual. Often it is so big that it can be seen to go up and down with each breath. The edge is hard, and, owing to the presence of carcinomatous nodules, often irregular ; those nodules on such parts of the upper and anterior surfaces as come below the ribs can be felt, so that the whole organ feels irregular, knobby, and hard, and sometimes the lumps on it feel umbilicated ; this is absolutely diagnostic of cancer. Occasionally, if much softening has occurred, a faint sensation of fluctuation may be detected, and in a few instances local peritonitis causes a rub. Sometimes the nodules can be appreciated by the hand only when the patient takes a deep breath, for then those under the ribs come far enough down to be felt. Sometimes the cancer grows so fast that the liver obviously increases in size in a week ; very rarely a nodule may enlarge suddenly from haemorrhage into it. Either or both these points are almost proof that the enlargement of the liver is due to carcinoma. It must not be forgotten that not all livers enlarged from malignant disease have palpable nodules, for they may be in such a situation that they cannot be felt, they may be too small to be felt, or the growth may be diffused through the whole liver. About half the patients have pain in the hepatic region, and may have it near the right shoulder and down the right arm. If the liver is very large, there is a sense of dragging and fullness in the right hypochondrium. About half the patients are jaundiced. It is extremely important to remember that by far the most frequent cause of long-standing jaundice is cancer of the liver, which produces a deeper yellow LIVER, ENLARGEMENTS OF THE 413 of the skin than any other disease ; as time goes on, this yellow changes to deep olive-green. The wasting becomes extreme, the skin dry and shrivelled, the patient becomes weaker and weaker, his pulse feebler, his respiration shallow, and finally he dies comatose. The usual symptoms of Jaundice [q.v.) are present. Ascites {q.v.) is rather less frequent than jaundice, and the patient generally dies before tapping is necessary, for ascites is a late symptom. The urine usually contains much bile and lithates. Rapidly growing carcinoma of the liver is often associated with an evening rise of temperature to 99° F. or 101° F. I have known it to be 102° F. every evening for weeks. The chief difficulty of diagnosis is from cirrhosis. The large cirrhotic liver is uniformly large, and the palpable nodules are small ; if they feel bigger than small cherries the case cannot be one of cirrhosis, for hobnails are never bigger than this ; hobnails are never umbilicated, and never increase rapidly in size ; if jaundice is present and the patient has a large cirrhotic liver, the jaundice is never very deep, and remains yellow ; we never see the dark olive-green seen in cancer. The patient with cirrhosis is more likely to die rapidly after the onset of ascites than the sufferer from cancer ; in cirrhosis we do not get clay-coloured motions nor dilatation of the gall-bladder, but we often find a large spleen. Extreme wasting and dryness of the skin are more common in cancer. A moderate leucocytosis is often found in cancer, but not in cirrhosis. The discovery of cancer elsewhere is of course conclusive, and the history is of great help. Syphilis of the liver, has already been described sufficiently to indicate the points of difference. Cases in which, owing to non-malignant obstruction of the bile- duct, usually by a gall-stone, there are enlargement of the liver and jaundice, may give rise to difficulty of diagnosis ; but these patients rarely have the extreme wasted look, with dry shrivelled skin, so frequently seen in cancer ; the hepatic enlargement is uniform and never so great as it may be in cancer ; and the jaundice does not become green ; if it disappears for a time, it means that the gall-stone has shifted ; that the jaundice due to cancer should disappear is almost unknown. Rigors are common in cases of gall-stones. The age, history, and detection of growths elsewhere will be of help. As far as my experience goes, when we are in considerable doubt as to whether a patient has an impacted gall-stone or a malignant growth, exploration, if done, almost always reveals a growth. Hydatid tumours of the liver are seldom confused with cancer, for almost always these are only one or two in number, the liver is smooth and regular, and is not tender; the hydatid tumour causes neither pain, jaundice, ascites, nor general emaciation, and it may give a thrill. There is no ordinary leucocytosis, but the patient may have eosinophilia. Primary Carcinoma of the Liver. — This is very rare ; the liver has the same character as in the secondary form, but there are no symptoms of a primary growth elsewhere. It is almost always a disease of adult life. It is usually more rapid than secondary cancer ; most of the patients are dead within three months from the onset of symptoms, and therefore the jaundice has not time to become dark green. Wasting, and other general signs including slight pyrexia, are present. During life, primary can hardly ever be diagnosed from secondary cancer of the liver, for, in this condition, the primary disease often gives no symptoms, and is not detected till after death. Secondary Sarcoma and Embryomata of tlie Liver. — These do not produce enlargement enough to be detected during life — except perhaps in the case of melanotic sarcoma, — for the primary disease and the numerous secondary deposits elsewhere than in the liver soon kill the patient. Primary Sarcoma of the Liver is very rare, and cannot during life be distinguished from primary carcinoma. 414 LIVER, ENLARGEMENTS OF THE Adenomata of the Liver are also very rare ; they are hardly ever of sufficient size to be detected during life. They are single, and I know of an instance in which a large one was operated on under the impression that it was a hydatid. Lymphadenomata of the Liver. — New formations consisting of lymphoid tissue, generally diffused through the whole liver but sometimes occurring in nodules, may be seen in those dying from Hodgkin's disease or from lymphatic leukaemia. The nodules cannot be detected during life, but in a few cases the diffuse variety makes the liver uniforinly enlarged ; it is smooth, its surface and edge are firm, it is painless, not tender, never of great size, and there is no jaundice. Leuksemic cases will be detected by the blood- count (see Anjemia). Angiomata. — It is not uncommon to find small angiomata in the liver in the post-mortem room, but they cannot be detected during life unless they are large enough to give symptoms which result from their size, and this is very rare. In nearly all the cases in which a large tumour of the liver has been thought to be a carcinoma, and yet the patient has seemed well enough to be suitable for operation, the growth has turned out to be a cavernous angioma, and these tumours have been excised. About fifteen of such cases are on record, and the patient was usually under fifty years of age. Fatty Liver. — This is very common, but the enlargement of a fatty liver is usually not sufficient to be detected during life, sometimes because the patients are so obese that palpation of the liver is difficult. A fatty liver, if increased in size, is uniformly enlarged, has a rounded edge, feels a little softer than natural, with a smooth surface ; there is neither pain nor tenderness. The causes are so numerous that often they hardly help the diagnosis. The largest fatty livers are met with in phosphorus poisoning ; they then may weigh lo or 12 lbs. Severe anaemia, wasting disease, especi- ally tubercle, and alcoholic excess, are perhaps the commonest causes. There is neither jaundice nor other symptom that can be attributed to the disease of the liver. Lardaceous Liver. — The liver is uniformly enlarged ; the increase in size may be considerable ; indeed, next to cancer, lardaceous disease causes the largest livers with which we meet. A lardaceous liver has been known to weigh 14 lbs. It is so smooth that even through the skin it feels smooth; it is firm, and the edge is sharp and hard ; it causes no pain, and is not tender. The diagnosis of this disease is much facilitated by finding lardaceous disease of other organs ; thus the spleen may be enlarged considerably and uniformly, there may be albuminuria from lardaceous disease of the kidneys, or diarrhoea from lardaceous disease of the intestine. Only two causes for lardaceous disease are known, viz., long-continued suppuration, e.g., psoas abscess, and long-standing syphilis, even if this has not caused any suppuration. I have known it occur in a small child as a result of congenital syphilis. In a very few instances no cause for lardaceous disease can be discovered, but this is so exceptional that we should be very cautious of diagnosing lardaceous disease in the absence of syphilis or suppuration. Tuberculosis of the Liver. — It is excessively rare for a tuberculous deposit in the liver to form a mass sufficiently large to be detected clinically : indeed, so rare is it that the diagnosis could not be made before exploration unless it were known that the patient had tuberculous disease at the periphery of the portal vein. Judging by morbid anatomy, a tuberculous tumour of the liver would, if discovered during life, be a solitary tumour of the liver. At an exploratory operation an irregular shaggy abscess cavity would be found, the pus of which would contain tubercle bacilli. LIVER, ENLARGEMENTS OF THE 415 Actinomycosis, or, as it is sometimes called, stveptotrichosis of the liver. This could hardly be diagnosed without laparotomy unless the patient were known to have actinomycosis elsewhere. It is very rare, and has seldom been recognized in the liver until after the patient's death. If detected during life, there would be a local enlargement of the liver. The pus in it would be in an irregular cavity with shaggy walls and trabeculae, and the characteristic little sulphur-coloured granules would be seen in it with the naked eye, and the ray fungus on examination with the microscope [Plate XII, Fig. S). Hydatid Disease of the Liver. — This can hardly be recognized unless the cyst causes a discoverable tumour of the liver. This may be huge. Hydatid cysts of the liver may contain thirty pints or more. If the tumour can be felt, it is rounded, smooth, localized, and regular, and thus is distinguished by its feel from cancerous or syphilitic livers, for in these the tumours are irregular and rough, and often there are one or more in different parts of the liver. A hydatid tumour is neither tender nor painful, and thus differs from an abscess. If the tumour projects from the lower part of the liver, it may resemble a gall-bladder ; if it is more on the surface of the liver, it may be felt there, especially when the patient takes a deep inspiration, for then it descends from under the ribs. A large hydatid cyst of the lower part of the right lobe of the liver causes considerable intra-abdominal enlargement of that lobe ; on the other hand, if, as is frequently the case, it grows upwards between the layers of the coronary ligament, it pushes up the diaphragm, forming a rounded projection which may be percussed out in the chest as an addition to the top of the normal hepatic dullness : in exceptional cases the tumour may be so huge that the dome shape of the dullness is lost, and the case is regarded as one of pleuritic effusion. When the tumour attains considerable size there is impaired vesicular murmur over the right chest, which is bulged so that it measures more than the left. If a hydatid tumour is deep in the liver, the swelling feels hard ; if it comes to the surface, the tumour feels tense — so tense that fluctuation is very rare. The so-called hydatid thrill, being the thrill felt in the finger lying on the tumour when it is struck by a finger of the other hand, is not often felt, though it may be obtained over any tense collection of fluid ; but if it be present it is of considerable diagnostic value, for other tense cysts are very unusual in the liver. Occasionally two or even three hydatid cysts are present in .the same liver ; each then has the characteristics of a single cyst, but the diagnosis of these cases may give much difficulty. It is excessively rare for hydatids to cause pressure symptoms ; jaundice is hardly ever seen ; if present, it is probably caused by rupture of the cyst into the bile-passages. A huge cyst may displace the heart. Eosinophilia [q-v.), even to a considerable degree, is sometimes found. I have seen 10 per cent of eosinophiles, and even 50 per cent have been recorded. A more moderate increase is sometimes seen in cancer. Usually, eosinophilia is absent in hydatid disease ; when present it is a considerable help in diagnosis. It decreases greatly after the cyst is drained. If the hydatid fluid become absorbed the patient may have urticaria. When the blood-serum of a patient with hydatid disease is mixed with some hydatid fluid, a precipitate may be formed after about twenty hours ; this reaction is not constant, but it does not occur when hydatid fluid is mixed with the serum of a patient who has not got hydatid disease. Hydatid fluid does not give an albuminous precipitate when heated, whereas the fluid of an ordinary pleuritic effusion does ; on the other hand, hydatid fluid gives an abundant white precipitate of silver chloride when silver nitrate is added to it. Hooklets (see Fig. 6, p. 57) may often be found in hydatid fluid, especially after it is centrifugalized. Hydatid cysts sometimes suppurate, and then they can hardly be distinguished from other forms of single solitary abscess. 41 6 LYMPHATIC GLAND ENLARGEMENT Alveolar Echinococcus Disease is very rare. No case has been recorded in England. The liver is enlarged, and jaundicej graduallj' deepening during the two or three j^ears the patient lives, is present. P}Texia and gastro-intestinal symptoms are often present, and the patient dies from exhaustion. Other cj^sts of the liver are very rare and very difficult to diagnose. Special text-books dealing with the liver should be consulted about them. W. Hale White. LIVIDITY, EXTREME (See Cyanosis.) LOCK-JAW (See Trismus.) LYMPHATIC GLAND ENLARGEMENT. [A). — Generalized Enlargement. There are certain diseases in which there is a tendency for all or nearly all the IjTnphatic glands in the body to be enlarged — generalized glandular enlargement, as distinct from enlargement of local groups of glands only. The distinction is not an absolute one, however, for in a certain proportion of patients suffering from a malady which usually causes general lymphatic glandular enlargement, the changes may be confined to local groups instead of being as widespread as usual. It may be said, however, that if there is generalized enlargement of the lymphatic glands, the patient is probabl}^ suffering from one or other of the following diseases : — Lymphatic leukemia Hodgkin's disease Lj^mphadenoma Lymphoma Lj-mphosarcoma Secondary syphilis German measles Still's disease Plague. It is of course important to be quite sure that the glands are really enlarged, and not merely palpable with greater ease than usual ; experience alone will decide this question. There are many conditions in which wasting affects the subcutaneous fat and not the lymphatic glands, so that the latter are felt with considerable ease, especially in the groins in very thin persons. General glandular enlargement usually imphes affection of the cervical, axillarj', and inguinal glands at the same time ; those in the popliteal space or above the internal condyle of the humerus, are less often affected ; the various groups within the abdomen can seldom be palpated, unless perhaps in the iliac region or pelvis, whilst enlargement of the mediastinal and bronchial groups can only be surmised when there is evidence of obstruction to one or other bronchus. When a case of generahzed Ij^mphatic glandular enlargement presents itself, it is important to make a blood-count ; the blood-changes will either indicate lymphatic leukcemia (see Anemia), or else, if the characteristic leucocyte counts of the latter are not found, lymphatic leukaemia will be excluded. Xone of the other conditions exhibit pathognomonic blood-changes, although there will very often be a considerable degree of aneemia of the chlorotic type. Hodgkin's disease nearly alwa3-s starts with much swelling of one group of glands before the rest, especially those in the neck ; there is usually a moderate degree of enlargement of the spleen at the same time, and in the course of weeks or months, generalized swelling of the lymphatic glands occurs, especially those in the axillae and within the thorax, the resultant masses sometimes being of considerable size {Fig. 119) though the individual glands remain distinct from one another, do not tend to break down and suppurate, and do not become fixed either to the skin or to the deeper parts, as they would do if they were LYMPHATIC GLAND ENLARGEMENT 417 tuberculous or due to secondary deposits of malignant disease. The blood- changes in Hodgkin's disease are for the most part negative (see An/Emia), though in blood-tilms the occurrence of an occasional basophile corpuscle or myelocyte may help to clinch the diagnosis. Lymphadenoma differs from Hodgkin's disease so little that some authorities use the two names as though they were synonymous ; others reserve the term lymphadenoma for those cases in which splenic enlargement is not apparent, whilst the affection of the lymphatic glands is very profound in one group and little marked elsewhere. Lymphoma is a term that has sometimes been used in the same sense. Where lymphosarcoma ends and Hodgkin's disease, lymphadenoma, or lymphoma begin, it is difficult to say. If there is generalized enlargement of the lymphatic glands without much affection of the spleen, without any Fig-. 119. — Hodgkin's disease. The lymphatic glands in the left side of the neck are very large ; there is considerable overgrowth of the lymphatic gland.s in the right axilla, particularly along the outer border of the pectoralis major muscle ; the glands in the left axilla are also enlarged, but to a less extent ; even the left epitrochlear gland is visibly enlarged. pathognomonic blood-changes, and with a rapidly fatal ending, the condition is spoken of as lymphosarcoma, but it might equally well be termed acute lymphadenoma. Syphilitic glands seldom reach any great size, only swelling, roughly speaking, to two or three times the normal ; the first to be involved are those in the neighbourhood of the chancre, and therefore most often those in the groin, spreading later to all the glands in the body, including those in the occipital region, which are not as a rule affected except by sjrphiUs, pediculosis capitis with sores, and German measles. Syphilitic glands are almond-shaped and firm, painless, or at most slightly tender, and they do not become adherent to the skin or to the deeper parts. They may remain palpable for years after all the signs of secondary syphilis have disappeared. The difficulty in their diagnosis does not arise when chancre or roseola is present ; but later, their nature may not be obvious unless there is a clear history of syphilis or unless Wassermann's serum test is positive. D 27 4i8 LYMPHATIC GLAND ENLARGEMENT Gernian measles causes generalized enlargement of the lymphatic glands very similar to that of secondary syphilis, but the diagnosis is generally obvious from the nature of the skin eruption. The occurrence of enlarged occipital and other glands associated with a measles-like rash serves to distinguish German measles from ordinary measles, and also from scarlet fever and other erythemata. Still's disease attracts attention primarily on account of the affection of the joints, and the enlargement of the lymphatic glands is a symptom of secondary importance. It is an affection of children [Fig. 120) precisely corresponding to acute rheu- matoid arthritis of adults ; no joint in the body is exempt, and it is probable that the Ivmphatic glandular enlargement is secondary to absorption of micro-organ- isms from the infected joints. The patient becomes anaemic, with a tendency to pigmen- tation, and the spleen is en- larged as well as the lymph- atic glands. The disease is unmistakable. Similar lym- phatic glandular enlargement occurs in the acute rheuma- toid arthritis or infective svnovitis or peri-arthritis of older persons, especially in that form which is charac- terized by spindle-shaped swelling of the first inter- phalangeal joints of the hands {Fig. 107, p. 378) ; but, as a rule, the enlargement is confined to those glands which are closest to the affected joints — epitrochlear glands, for instance, in the case of the fingers and hands, and so forth. Plague may be associated with very acute glandular enlargement all over the body ; the diagnosis depends largely on the history, and particularly upon the patient having been exposed to the risk of contracting plague in some infected town or port. The diagnosis may be confirmed bacteriologically. B. — Localized Lymphatic Glandular Enlargement. It has been mentioned already that in all those diseases in which enlargement of the lymphatic glands may be general, it may sometimes be local, or may begin locally before it becomes general, so that in every case in which there is an affection of a local group of lymphatic glands, it is important to remember the possibility of the case being due to one of the diseases already discussed under heading A. The following additional causes, however, have also to be considered, namely : — Fig. 120. — Still's disease : acute rheumatoid arthritis in childhood. The knees are swollen and their ordinary outlines lost ; there is typical spindle-shaped enlargement of the first interphalangeal joints. LYMPHATIC GLAND ENLARGEMENT 419 Septic absorption, from sores, etc., on the skin or mucous membranes from which the lymphatics drain into the particular glands that are involved Tuberculous disease Secondary malignant disease. Whenever there is any doubt, a blood-count should be made in order either to diagnose or exclude lymphatic leukasmia. When this can be excluded, the nature of the local glandular enlargement will generally be suggested by the age of the patient, by the characters of the glands themselves, and by their locality. We will here deal with the subject from the point of view of the particular group of glands involved. Occipital Glands. — These seldom, if ever, become enlarged as the result of leukasmia, Hodgkin's disease, lymphadenoma, German measles, syphilis, or tuberculosis, unless there is obvious enlargement of other glands at the same time. When there is enlargement of the occipital glands and no others, by far the most likely cause is septic absorption from the posterior region of the scalp, particularly from impetigo, seborrhceic dermatitis, or most hkely of all, pediculosis capitis. Nits should always be looked for in the hair with care, and they may sometimes be found even in wealthy ladies in whom the mode of infection may be quite inexplicable. The patients generally have much irritation of the skin at the back of the neck at the same time, and it may be attributed to the rubbing of a collar or the neck of a dress. There is generally considerable anaemia, and the patient looks unwell. Pre-auricular Gland. — ^The most common causes for enlargement of the pre- auricular glands are : Septic infection of the skin of the cheek, eyehd, ear, or temporal region of the scalp, or epithelioma of these regions. The occurrence of enlargement of this gland in association with an ulcer which may be rodent on the one hand, and an epithelioma on the other, does not necessarily indicate the latter, for without there being secondar}- deposits, the gland may become enlarged from absorption of bacteria and their products from the pus of rodent ulcer. In those very rare cases of chancre of an eyelid or other neighbouring part, enlargement of the pre-auricular gland may precede the generalized en- largement of the glands to which syphilis gives rise. The gland may also be the site of melanotic sarcoma in very rare cases, the primary growth being in the eye. Submaxillary Glands. — The commonest cause for enlargement of these is septic absorption from the mouth ; tonsilhtis and inflammation of the fauces are responsible for the great majority of cases in which a firm gland becomes palpable just beneath and behind the angle of the jaw ; generally the enlargement is greater upon one side than upon the other, and it may persist for days or even weeks after the causal inflammation in the tonsil has subsided. The glands are painful in the acute stages, and in a few cases the infection is so severe that the tissues break down, and suppurative adenitis with an abscess results. All kinds of inflammation of the throat may cause this glandular enlargement — ordinary simple tonsillitis, hospital sore throat, rheumatic tonsillitis, quinsy, diphtheria, scarlet fever, acute phlegmonous tonsilhtis. The precise nature of the infecting organism is to be ascertained by taking swabbings from the tonsils or fauces for bacteriological cultivation. Vincent's angina less frequently produces glandular enlargement than do other severe forms of sore throat. Inflammatory changes in glands further forward beneath the jaw are often secondary to caries of a tooth or to some variety of stomatitis, the diagnosis being ascertained by inspection of the mouth. Less acute enlargement, going on to much greater size than is the rule with inflammatory adenitis, may result from secondary deposits of malignant disease in the submaxillary glands when there is squamous-celled carcinoma (epithehoma) . of the tongue, lip, gum, cheek, LYMPHATIC GLAND ENLARGEMENT nose, palate, fauces, tonsil, pharynx, or larynx. The diagnosis in these cases depends upon the presence of an obvious primary epithehoma ; if there is any doubt as to this, a small portion of the ulcerating mass may be excised for microscopical examination. ^Mlen a gummatous ulcer simulates epithehoma, the effect of iodide of potassium and mercury" may point to the former, or Wassermann's serum test ma}^ be positive. A gumma of the tongue is likeh- to be median, an epithelioma not median. Cervical Glands. — Enlargement of the glands in the neck generally maj^ be either unilateral or bilateral. If unilateral, if onty a few glands are involved, and if the histor}" is a short one, the changes are probably inflammatory , particularly if there has been any sore place upon the skin of the neck, upon the buccal mucosa or throat, or if there is any evidence that the patient has been recentty exposed to scarlet fever, or if there is otitis media. Pediculosis capitis is a common cause of enlargement of the cervical glands in the children of the poorer classes. It becomes very difficult, however, to decide when such cervical glandular enlargement is merelj^ inflammatory and when it is due to some more serious lesion, particularly tuberculosis on the one hand and Hodgkin's disease, lymphadenoma, or lymphosarcoma upon the other. The longer the glandular swelhngs persist, the less likely is it that thev are purely inflammatory. The 3?ounger the patient, and the more unsterihzed cow's milk he has been drinking, the more likely are they to be tuberculous. If they are present on both sides of the neck ; if they show a tendency to become adherent to one another and to the skin ; if they are tender notAvithstanding their having been present for some time, they are probably tuberculous, and it is probable that the diagnosis will be settled b}^ surgical measures, the affected glands being excised and examined microscopically. Spontaneous breaking down of the glands, with a discharging fistula, with a red indolent condition of the skin around the fistula, and very slow heahng, are to be forestalled whenever possible ; but if thej' have occurred, then the condition is almost certainly tuberculous in cases in which there is no question of a late stage !)f malignant disease. There may be confirmatory evidence in the shape of tuberculous lesions elsewhere, especially in a joint, the spine, or the peritoneum. It is noteworthy- in this connection, that cases of tuberculosis of the glands are even less hkety than other individuals to develop ordinary phthisis, so that the absence of lung signs is no indication that the glands are not tuberculous. Hodgkin's disease, or Ij-mphadenoma, is sometimes so restricted in its earlier lesions as to affect the cervical lymphatic glands to a great extent, and long before anv other groups are involved ; in such cases, previous to operation and microscopical examination, the nature of the glandular enlargement may be open to great doubt ; and even after an operation there may be differences of opinion, for there are some who hold that the large-celled hyperplasia exhibited microscopicallv bv Hodgkin's-disease glands, is an indication that they are only a chronic variety of tuberculosis. Chnicalh-, the two are distinguished by the fact that tuberculous glands become matted together, while Hodgkin's-disease glands remain separate from one another, and do not soften or break down even when they have become of such great size that had they been tuberculous thej^ almost certainly would have done so ; consequenth^, they do not become adherent to the skin, to one another, or to the deeper parts, and they do not cause a fistulous discharge. Enlargement of the spleen as well as of the lymphatic glands in the neck would indicate Hodgkin's disease rather than tubercle. Secondary carcinoma of the glands in the neck is easy enough to diagnose when a primar}^ growth is ahead}' known to exist ; it is generally either a squamous-celled carcinoma of the buccal cavit}', especially of the tongue, lip, or palate, or else of the pharynx, larynx, or CESophagus. The cases which give rise LYMPHATIC GLAND ENLARGEMENT 421 to the greatest doubt are those in which an oesophageal growth has not caused stenosis, so that the occurrence of secondary deposits in the glands may be the first indication of anything being wrong. The patient's age will generally suffice to make tuberculosis unlikely, for tuberculous glands are far commoner in children than in adults, whilst carcinoma is a disease of the middle and later periods of life ; if there is any doubt to start with, the rapid enlarge- ment of the glands, their extreme hardness, the way they become fixed to the deeper structures and ultimately to the skin, through which they finally ulcerate, will leave little or no doubt as to their character. Sarcomatous glands in the neck are much rarer, the only variety to be met with being that which has already been referred to above as acute lymphadenoma which, on account of its acuteness, is sometimes termed lymphosarcoma. Supraclavicular Glands. — When the glands immediately above the clavicle, especially those on the left side in the region of the attachment of the sterno- mastoid muscle, are enlarged, without affection of any other lymphatic glands in the neck, it is highly suggestive of there being a primary new-growth in the abdomen, with secondary deposits ascending along the course of the thoracic duct, and exhibiting themselves in the glands close to where the thoracic duct enters the junction of the left jugular and left subclavian veins. There are, of course, many cases of abdominal malignant disease in which these glands do not become affected at all ; but the value of the sign when it does occur can scarcely be exaggerated. No one variety of intra-abdominal carcinoma is more liable than another to produce secondary deposits here ; the primary seat may be the stomach, gall-bladder, pancreas, duodenum, colon, rectum, an ovary, or even a testicle or kidney ; in not a few cases, excision and microscopical examination of the left supraclavicular gland has indicated the exact site of the primary growth. The right supraclavicular gland may be enlarged in a similar way, but far less often ; and generally not as the result of intra-abdominal but of intrathoracic new-growth, particularly squamous-celled carcinoma of the oesophagus. When the supraclavicular glands are affected at the same time as the axillary glands, in cases of cancer of the breast, the condition is very important as indicating that the disease has extended beyond the limits within which operative cure is likely to be possible. Axillary Glands. — The three main causes for enlargement of the glands in one axilla without enlargement of the glands elsewhere are : Septic absorption from sore places upon the fingers, arm, breast, shoulder, or upper part of the back ; secondary deposits of carcinoma from the breast ; and Hodgkin's disease or lymphadenoma. Tuberculous axillary glands without obvious affection of those in the neck have been recorded, but they are by no means common. It is important to examine carefully for any possible source of septic absorption, for sometimes it is by no means obvious ; it may be no more than inflammation around a ragnail. Inflammatory glands are generally very painful, and they are associated with more or less pyrexia. Lymphatic leukaemia will be excluded by the absence of pathognomonic blood- changes ; secondary malignant glands should be diagnosed when primary growth is found on careful palpation of the breast ; Hodgkin's disease will only suggest itself if inflammatory absorption, secondary growth, tubercle, and malignant disease, can be excluded ; and it is probable that if the case is watched, if it is one of Hodgkin's disease, other lymphatic glands will presently become enlarged also, particularly those in the neck of the same or opposite side, and those in the other axilla (see Fig. 119, p. 417). Enlargement of the spleen at the same time would be an argument in favour of Hodgkin's disease. Epitrochlear Glands. — The only important cause of enlargement of the epitrochlear gland is microbial absorption from the fingers, hand, or forearm ; 422 LYMPHATIC GLAND ENLARGEMENT the site of primary infection may be in the skin — a whitlow, for example, or a post-mortem wound, or a dissecting-room sore ; or it may be more deep-seated, as in cases of infective synovitis, arthritis, or peri-arthritis. It is important not to mistake for a simple whitlow such a lesion as a digital chancre, which may also cause enlargement of the epitrochlear gland before infection becomes general ; if the history and the local appearance of the chancre do not suggest the diagnosis, its course and the associated secondary symptoms will indicate the nature of the case. Wassermann's serum reaction should be tried. Mediastinal and Bronchial Glands. — These glands can never be palpated, and their enlargement can only be surmised when there are signs of something within the thorax obstructing one or other bronchus, or leading to laryngeal paralysis, or stenosis either of the innominate vein or of the superior or inferior vena cava. The diagnosis will be between aortic aneurysm, chronic mediastinitis, and mediastinal new growth. The A-raj^s may be of considerable value in confirming the diagnosis, and in distinguishing enlarged malignant glands from aneurysm of the aorta. It is noteworthy that infiammator}^ or caseous bronchial or mediastinal glands seldom if ever obstruct a bronchus in the way that malignant glands do, possibly because, before they reach a sufficient size to stenose a bronchus, they have softened, and perhaps discharged their contents into the lumen of the bronchial tube. When, as happens in rare cases, a caseous gland does obstruct a bronchus, it is important to remember that post-mortem evidence shows that it is very much less uncommon for a right bronchial gland to do this than a left. Mesenteric Glands. — It is seldom possible to palpate enlarged mesenteric glands, although the diagnosis that they are swollen may often be made upon circumstantial evidence. Any inflammatory condition of the bowel may lead to their being enlarged, particularly if there is any breach of the mucous membrane, as in cases of ulcerative colitis, dysentery, tuberculosis of the bowel, or typhoid fever. They are greatly involved in most cases of tuberculous peritonitis ; the masses that are felt in the abdomen, however, are hardly ever the glands themselves, but rather extensive inflammatory and caseous foci of which glands may form the nucleus. Malignant new growth, such as primary carcinoma of the stomach or colon, pelvic organs, or testes, may cause extensive secondary deposits in the mesenteric and retroperitoneal lymphatic glands, usually most marked in the immediate neighbourhood of the primary new growth, but ex- tending thence in the direction of the liver until the portal glands are invohed ; however, without opening the abdomen, it is almost impossible to determine whether the masses felt in cases of this kind are really enlarged Ij-mphatic glands. Iliac and Pelvic Glands. — What has been said above in connection with mesenteric glands applies here also ; but it is more often possible to determine by palpation whether or not the pelvic lymphatic glands are affected. In cases of suspected malignant disease, characteristic nodules of secondary deposits in lymphatic glands may be felt sometimes on careful palpation of the ihac fossa or upon making a rectal examination. Inguinal and Femoral Lymphatic Glands. — The commonest cause by far of enlargement of the inguinal lymphatic glands and not of those elsewhere, is septic absorption from microbial foci in the regions whose lymphatic vessels drain into these glands ; sore places should be looked for upon the toes, and between them, upon the feet, legs, thighs, buttiocks, lower part of the back, .scrotum, penis, perineal and vulval regions (see Sores, Perineal, etc.) ; and a urethral discharge, gonorrhoeal or otherwise, should also be sought for. Most of those cases will be associated with constitutional symptoms, especially p\'rexia and loss of appetite, and with local pain and perhaps reddening of the skin o\er the inflamed glands. The latter may break down into abscesses — buboes. MACULES 423 Another, but far less common, cause for localized enlargement of the inguinal glands, is secondary carcinoma — secondary to squamous-celled carcinoma of the scrotum, prepuce, penis, perineal region, anus, clitoris, labium majus, or vagina. In such cases the diagnosis will become obvious when the .primary growth is found, and if doubt exists as to the nature of any such ulcerating sore, the result of microscopical examination of a small portion excised will clinch the diagnosis. Melanotic sarcoma is another rare but very important cause of enlargement of the inguinal lymphatic glands ; sometimes, when the primary growth is hardly larger than a pea, arising in connection with the skin of one of the toes, or perhaps a mole, the inguinal glands may be as big as pigeon's eggs, rapidly growing and comparatively painless. The nature of this enlargement may be quite obscure unless the dark tinge of the growth can be seen through the skin, or there is melanuria, or a careful examination reveals a small primary new growth of the skin, or unless surgical measures are adopted for their removal. Popliteal Glands are seldom felt, and when palpable they are discovered, as a rule rather because there are enlarged lymphatic glands elsewhere, than from any symptoms which attract notice to the popliteal space itself. Almost the only cause for their enlargement is septic absorption either from joints or from the skin of the toes, feet, or legs, comparable to the conditions which produce enlargement of the epitrochlear glands of the arm. Lymphatism or Status Lymphaticus. — Much attention has recently been attracted to the fact that in young persons under puberty who have died as the result of poisoning by anaesthetics, or of what under ordinary circumstances would be regarded as inadequate causes, such as operation for the removal of tonsils, circumcision, and so forth, the internal lymphatic glands and tissues, particularly the tonsils, thymus gland, bronchial glands, mesenteric glands, the Peyer's patches, and the solitary follicles of the intestines, are considerably larger than is usually the case in ordinary post-mortem examinations upon patients of similar ages who have died of other diseases. It is generally stated that the condition referred to is pathological, and it has been described as the status lymphaticus or lymphatism. It is doubtful, however, whether this is not really the normal condition of the lymphatic tissues at this age, for very similar appearances are to be found in the bodies of children killed, not slowly by disease, but suddenly by accidents. In any case, it is almost impossible to diagnose the so-called status lymphaticus during life, for if it is an affection at all, it is one of the internal lymphatic tissues and not of the peripheral and easily palpable lymphatic glands. It is doubtful, however, if it is really a pathological state, though deaths produced by anaesthetics are being accredited to it. Herbert French. MACULES, — The macule is a circumscribed discoloration or decolorization of the skin, without noticeable elevation or depression. Macules may be due : 1. To the passage of blood, or of the colouring matter of the blood, into limited areas of the skin, as in purpura. 2. To hyperaemia, either arterial or venous, as in erythema. 3. To dilatation of the vessels of the skin, or the fopmation of new vessels, as in capillary naevus and telangiectases. 4. To changes in the pigmentation of the skin, whether of the rete or of the corium — on the side of excess as in chloasma, or on that of deficiency as in leuco- dermia ; and such changes may result from the administration of drugs such as arsenic and chloral, or may be an expression of trophoneurosis, as in glossy skin. Macules of the second and third groups are temporarily effaced by pressure ; those of the first and fourth remain unaltered. 424 MACULES Macules may be inflammatory as in the rose spots of enteric fever, or non- inflammatory as in purpura ; congenital as in moles, or acquired as in the exan- themata ; temporary as in drug rashes, or permanent as in leucodermia ; scanty as sometimes in leucodermia, or abundant as in roseola. They may be attended by subjective symptoms {e.g., itching) as in drug rashes ; but generally there are no such accompanying symptoms. Usually round or roundish, they may be oval, or irregular ; they also vary greatly in definition. In colour they may be red, brown, or yellow, in various shades. In size they vary from a mere speck to, say, the area of a man's hand ; if very widely diffused, as in malaria, the pigmentation is usually styled a discoloration. Most frequently a primary lesion, as in lentigo, the macule may also be secondary to burns, blisters, ex- coriations, and eruptions of various kinds, erythematous, vesicular, bullous, papular, pustular, and eczematous. The brown spots which follow traumatic or purpuric ecchymoses, haemorrhagic urticaria, varicose eczema, etc., form a special group of macules in which the pigment is hemosiderin. If a macule takes on a slight degree of elevation it is sometimes styled a maculo-papule. The differential diagnosis of the erythemas, of which the lesions are for the most part too diffuse to be regarded as macules, is set out in the articles on Erythema and Nodules ; that of the purpuras in the article on Purpur.\ ; that of leucodermia, sclerodermia, morphoea, the various forms of chloasma (including hsmo-chromatosis), and the discolo rations due to the use of drugs, in the article on Pigmentation of the Skin. Nor need the most familiar macule, that which occurs in lentigo (freckles), be described here, for the only affection with which it can be confused is xeroderma pigmentosum, the diagnosis from which is given under Tumours of the Skin, where also will be found the differ- ential diagnosis of another macular affection, xanthoma in its various forms. Tinea versicolor has been dealt with under Fungous Affections of the Skin ; pityriasis rosea under Scales ; lichen planus and herpes, in both of which macules appear as secondary lesions, respectively under Papules and Vesicles. Of naevi and of telangiectases the identification is self-evident, and it only remains to speak of the macules of leprosy and syphilis. In leprosy, following the prodromal symptoms and the period of invasion, erythematous spots appear on the face, limbs, or trunk, varying in colour accord- ing to the natural pigmentation of the skin, but usually in white races of a light red. The colour is brightest at the edge ; the centre may become white and atrophic. In size the macules vary from a pin's head to the palm of the hand, or larger ; they are smooth and shining, with a well-defined outline. Some infiltration is usually present. Fresh crops continue to come out at irregular intervals, and each outburst is accompanied by an exacerbation of the con- stitutional symptoms. After a time the macules and the neighbouring areas of apparently normal skin become more or less anaesthetic, owing to pressure of the infiltration on the peripheral nerves. The macular stage of leprosy may possibly be confused with erythema simplex, but the macular areas are usually larger than in erythema, in which also there is little or no constitutional dis- turbance. As soon as anaesthesia arises the diagnosis is settled. This is indeed the crucial test in all cases of doubt as between leprosy and any other affection, for in leprosy it is almost invariably present, if not in the lesions themselves, then in some neighbouring area of the skin. Its commonest sites are towards the centre of the macule, in the pale patches left by macules that have dis- appeared, and in the hands and feet. Another distinctive feature of leprous spots is that they rarely perspire. In syringomyelia the sensory and trophic lesions may suggest leprosy, but the macules will be absent, nor is there enlarge- ment of lymphatic glands or thickening of nerve-trunks. (For the diagnosis of nodular leprosy from lupus vulgaris, see under Nodules.) Whenever MACULES 425 doubt exists, the lepra bacillus should be sought in the lesions or in the nasal discharge. The macular syphilide is one of the most characteristic lesions of secondary syphilis. The eruption {Fig. 121) , erythematous in character and styded s>-philitic roseola, begins as a macular mottUng, resembling measles but rather more dusky, distributed over the chest and abdomen. It is extremely evanescent, often disappearing in a few hours and coming out again as suddenly. The Fig:. 121- — Macular syphilides. mucous membrane of the throat is the seat of a similar eruption, and superficial ulcers may form on the tonsils. Generally about a fortnight from its appear- ance, the rash begins to fade, giving place to a papular or follicular eruption on the trunk, limbs, face, and neck. Hypereemia of the papilte here and there gives rise on the chest and abdomen, and often on the flexor aspects of the limbs, to red patches which may persist for a longer or shorter time as isolated blotches, varying in colour from a delicate rose to a pale violet or dusky-bluish or even brownish-red. Scattered about among these macular syphilides may 426 MACULES often be seen papules (maculo-papular syphilides), which leave stains of varying" depth. From the macular syphilide both tinea versicolor and tinea circinata may be distinguished by the fungous parasites present in the lesions of those affections, and, in the case of tinea versicolor, by the ease "with which the scaly patches can be detached by the finger-nail ; the erythematous drug rashes by their more vivid redness and the presence of itching and burning ; seborrhasa corporis ■ by its more limited distribution ; measles by the crescentic character of the eruption, the coryza, cough, and the different distribution.* A peculiarity of this, syphilide which should always be w"atched for in doubtful cases is that it varies in colour with the temperature ; a cool atmosphere will bring it out in vivid colours, even when almost completely faded. Malcolm Morris. MAIN-EN-GRIFFE.— (See Claw-haxd.) MARASMUS literally means " wasting," and therefore signifies much the same as loss of weight. By common consent, however, when speaking simply of marasmus, one generally has in mind an infant or young child, so that lesions which cause loss of weight in tender years will be considered under the present heading, whilst wasting in older patients is discussed under the heading Weight, Loss of. The bodies of infants and young children consist so largely of water that great variations may occur within a comparatively short time, particularly in association with a disease which causes loss of fluid. The most rapid loss of weight occurs as the result of acute diarrhoea, with or without vomiting ; in the summer zymotic diarrhoea of infants the subcutaneous tissues may be seen to shrivel in twenty-four hours or less, the eyes become sunken, the fontanelle depressed, and the patient loses weight rapidly. There are probabh^ various micro-organisms producing these acute sj^mptoms, of which the best known are the Bacillus enteritidis of Gaertrier and Morgan's bacillus I., but the exact bacteriological diagnosis of the symptoms can only be arrived at by investigation of the stools and perhaps of the patient's serum in special laboratories. Acute vomiting without diarrhoea generally causes loss of weight, but less markedly than does severe diarrhoea ; it sometimes does so to a considerable extent^ nevertheless, particularly in that periodic type of the malady known as cyclical vomiting of infants. Without apparent cause, a child of tender years who is subject to this complaint is seized, without any preceding irregularity in diet and apparently without anj^thing definite to account for the mischief, with most severe and recurrent vomiting, lasting for twenty-four, thirty-six, or fortj-- eight hours, or even longer, nothing whatever being kept down, and the urine at the same time abounding as a rule with diacetic acid and acetone, the evidence of acidosis. Severe though the loss of weight may temporarily be, the symptoms generally subside as rapidly as they come on, and the patient remains in appar- entty normal health until the next period of similar vomiting with acidosis comes on. Besides cjxlical vomiting, severe attacks of vomiting may be caused by errors of diet of various kinds, though it is remarkable how children escape the disorders of injudicious feeding if only virulent organisms are not administered in the food at the same time. Congenital hypertrophic stenosis of the pylorus is nowadays spoken of as though it were itself a disease ; it is associated with pensistent vomiting of all foodstuffs, the sjrmptoms coming on either immediately after birth or within a few days or weeks, and in not a few instances resulting in death from sheer inanition. At the post-mortem examination in such cases there is undoubtedly both more muscle than there should be in the pylorus, and undue tightness of its constriction, but it is very doubtful whether this is really a condition of congenital malformation, and not the result of spasm of the MARASMUS 42^ pylorus produced by injudicious feeding, especially the giving of food before the mother has milk in her breasts ; the pyloric hypertrophy being, not congenital, but the result of the muscular contractions so induced. Simple starvation owing fo inability of the parents to provide food will naturally cause acute wasting, though the nature of the case may not be obvious to the doctor unless the conditions of home life are known. Defective feeding is one of the commonest causes of lack of progress and of actual marasmus amongst the children of the lower classes. The amount of dirt that reaches the child's mouth from its own fingers, from its mother's breasts, and from the utensils in which the food is given, is by itself enough very often to upset the digestion, even if the right food were given in the proper amounts and at the right intervals ; when, in addition to the dirt, the food supply is of the wrong kind and the intervals irregular, it is not at all surprising that the child does not thrive. Rickets is not so much a cause of marasmus as a concomitant effect of the injudicious feeding — many rickety children being, indeed, unduly fat and heavy. Congenital syphilis, on the other hand, is a very potent cause for marasmus. The diagnosis may sometimes be guessed at ; it may sometimes be obvious from the snuffles, skin lesions. Parrot's nodes, condylomata, and so forth ; it may be known of in the parents ; and it may be confirmed by Wassermann's serum test in the child. Many congenital syphilitic children, without developing any of the better known evidences of syphilis, fail from simple inability to thrive, and, although born fine, healthy-looking infants, presently waste and pine, and they may be said rather to cease to live than in the ordinarj^ sense to die of a disease. Tuberculosis is a very important and common cause for loss of weight in infants, though it is generally very difficult indeed to be certain that a tubercu- lous lesion is present. No obvious foci such as tuberculous glands in the neck, kyphosis from spinal caries, ascites or abdominal lumps from tuberculous periton- itis or tabes mesenterica, tuberculous joints such as the hip or knee, tuberculous dactjditis, and so forth, may be present, and yet there may be some deep-seated lesion, of which the commonest by far is caseation of the bronchial glands. Phthisis pulmonalis is almost unknown in infancy and childhood ; in phthisical patients there is practically never caseation of the bronchial glands ; in infants and young children caseous bronchial glands are very common, and they occur almost entirely in those who have drunk any large quantity of milk. The danger in such cases is that the bacilli will not remain localized to the bronchial glands : many a child is quite unsuspected of having such a lesion until some intercurrent malady such as measles causes the mischief to light up and become generalized in the form of general tuberculosis and meningitis, and at the post-mortem examination caseous bronchial glands, obviously of long standing, are found. Many children recover completely, and the nature of the case at the time when there were loss of weight and general ill -health may never be determined. The child outgrows its delicacy. It is always possible, or even probable, when obscure wasting occurs in a child who objectively presents no particular abnormality except ill-health, that the lesion is tuberculous absorption from infected niilk, with accumulation of the bacilli in the bronchial glands. The faeces may be examined for the bacilli after special treatment in the laboratory. It may often help the diagnosis to eliminate milk from the dietary, and, if need be, butter also, and watch the effects of giving the patient such foods as are known to contain no tubercle bacilU. Von Pirquet's skin reaction might also be tried, though its results are h\ no means pathognomonic, especially if the tuberculin used is not prepared exactly as it was in von Pirquet's original method. Herbert French. 428 MEL^NA MELffiNA. — This term is correctly applied to black motions containing altered blood. The colour is due to the action of the digestive juices upon haemoglobin, and the condition is usually associated with some ulcerative lesion of the stomach or duodenum. Melcena may be simulated by the presence of sulphide of iron or of bismuth in the stools of patients taking either of these metals. The slatey-black colour of these sulphides does not very closely resemble the tarry motions of haemorrhage. In case of doubt, the microscope may be used to reveal blood-corpuscles, or the chemical tests for blood may be employed. (See Blood per Anum.) W. Cecil Bosanguet. MEL ANURIA. — (See Urine, Abnormal Coloration of.) MEMBRANE PER VAGINAM.— (See Discharge, Vaginal.) MENORRHAGIA. — By this symptom is meant an excessive amount of the menstrual flow, or an undue prolongation of the time during which it takes place. It is important to remember that in this condition the patient is free from bleeding during the intermenstrual periods, the term Metrorrhagia {q.v.) being reserved for bleeding which occurs between the periods. The careful distinction between these symptoms often serves to distinguish very important conditions, and they should on no account be confounded with one another or considered as the same entity. Pure menorrhagia is an important symptom of many well-defined conditions which do not, as a rule, give rise to irregular bleeding. Both these terms must be carefully limited to patients who menstruate, and must not be used for bleeding after the menopause. The term Metrostaxis (q.v.) is the best for bleeding occurring after menstrual life has passed. Causes of Menorrhagia. I. Generative SySTEM. 2. Circulatory System. 3. Nervous System. Uterine congestion Uncompensated valvular Excessive coitus Endometritis disease of the heart Prevention of conception Retroversion and flexion Cirrhosis of the liver Fibromyoma Emphysema of the lungs A Single Excessive Period Salpingo-oophoritis Fright Sub-involution The Circulation Violent emotion Passive hyperaemia from : Sudden changes of tem- Acute Infectious Diseases Constipation perature Influenza Tight-lacing Cold bath Enteric Sewing machine Dancing Cholera Gymnastics Scarlatina The Blood Itself Bicycling, etc. Variola Deficient coagulabihty Rheumatism Scorbutus Malaria Purpura Diphtheria Haemophilia Measles High Blood-pressure Arteriosclerosis Disturbance of internal secretions Perusal of the above table will make it clear that the causes of pure menor- rhagia can be grouped under the three headings of diseases of the generative organs, circulatory organs, and the nervous system. In attempting to differentiate these causes from one another, the first point to ascertain is whether there is any disease of the generative system, and failing this, to make such systematic examinations as will place the cause under one of the other two headings. MENORRHAGIA 429. I. In considering the Gsnerative System it is clear that some diseases will be easy to discover, others will require some special method of examination. For instance, of all the causes of pure menorrhagia, fibromyoma of the uterus stands out by itself as the only important growth associated with this symptom, and a simple bimanual examination, as a rule, suffices to show that such a tumour exists, the chief characteristics of a fibromyoma of the uterus being these : the uterus itself is enlarged, and in almost every instance the enlargement is asymmetrical, the typical shape of the organ being altered. As there may be more than one tumour in the uterus, its shape may be exceedingly irregular. The consistence of the tumour is hard and unyielding as a rule, but pathological changes in these tumours are common, some of them leading to softening, others to cystic changes which may give a fluid thrill. The tumour and cervix always move together if the organ can be moved at all. The only difficulty in diagnosis, as a rule, lies in distinguishing a fibromyoma of the uterus from an ovarian cyst, and sometimes this is exceedingly difficult, for it is not always possible to say- that a given tumour is actually the enlarged uterus. It must be remembered, however, that the symptom which has led to this difficulty is menorrhagia, and ovarian tumours almost never give rise to it. Ovarian tumours usually cause no disturbance of menstruation at all, unless they are double and completely destroy both ovaries, in which case they cause amenorrhosa. If the tumour cannot be diagnosed by simple examination, there still remains examination by the uterine sound. If no possibility of pregnancy exists — and with pure menor- rhagia pregnancy is impossible — the sound may be passed into the uterus with every precaution against sepsis. In all cases of fibromyoma the sound passes beyond the normal distance, and it may pass as much as six inches, or even more. In cases of subperitoneal fibroids, the uterus may not be much enlarged, but in such cases menorrhagia is not usually present. In ovarian tumours the length of the uterine cavity is not increased unless a condition of endometritis co-exists, which is very uncommon ; and if it did not exist, the amount of elongation of the uterine cavity would be small. In general, however, it is quite unnecessary to use the sound for the diagnosis of a fibromj^oma. Uterine Congestion and Endometritis. — These lesions can only be inferred in cases of pure menorrhagia when the uterus is not enlarged to any appreciable extent, and when, in addition, there are leucorrhoea and backache. These three cardinal symptoms, Pozzi's syndrome, point always to endometritis, whatever other lesion of the generative system may be present. As a rule, the subjects of these are married and have had pregnancies or abortions, but endometritis may occur in a virgin, the result of infection, without any pregnancy having taken place. The presence of endometritis cannot be proved without the removal of the endometrium by the operation of curettage and the microscopical examina- tion of sections of the material so removed. Retroversion and flexion of the uterus and salpingo-oophoritis are very definite and obvious lesions which are associated with menorrhagia, but the actual prime cause is again endometritis and uterine congestion. So also with sub-involution, which necessarily can only follow labour orabortion ; though a relaxed uterine muscle and a dilated uterine cavity are present, endo- metritis and congestion are present, too, and are the real causes of menorrhagia .. Exanthemata. — The various exanthems are liable to cause menorrhagia except in those instances where they give rise to anaemia. It has been shown bacterio- logically that an acute endometritis may be set up by various zymotic diseases, and therefore it is not surprising that in some instances this condition becomes- chronic and causes a lasting menorrhagia. 2. Circulatory System. — Under this heading there can be no doubt that definite causes of menorrhagia exist, but in the absence of well-defined lesions of hearty 430 MENORRHAGIA liver, or lungs it may be a matter of considerable difficulty to make a differential diagnosis. It is obvious that any lesion of the heart, liver, or lungs, which leads to back-pressure through the venous system, may cause hypersemia of the pelvic organs and consequently lead to excessive ruenstrual losses. It does not follow, however, that this will be the case, because the sufferers from these diseases are sometimes anaemic as far as the quality of the blood goes, and consequently may lack the stimulus to menstruate at all. However, it not uncommonly happens that menorrhagia is caused by uncompensated valvular lesions of the heart, cirrhosis of the liver, or emphysema of the lungs. Passive hypevcBmia of the pelvic organs may occur from constipation, tight lacing, or certain occupations such as the working of a treadle sewing-machine : but it must not be forgotten that endometritis may also be present and be the real underlying cause of excessive flow. AncBWiia. — That the quality of the blood itself may be a cause of menorrhagia is undoubted, and particularly if it be deficient in calcium salts, leading to retarda- tion of the coagulation-time. Modern methods of estimating coagulation-time enable us to distinguish these cases with some certainty, and thus point out a line of treatment. Unfortunately there is no simple clinical method. Doubt also has recently been thrown on the view that the calcium salts have any effect on coagulation-time. The well-known signs of scorbutus in its minor degrees, purpura, and haemophilia may draw attention to cases of this class. Menorrhagia in young girls at the time of puberty and commencement of menstruation depends upon excessive ovarian activity, and we must conclude, therefore, a disturbance of the balance between the internal secretions. It is often associated, too, with retardation of the coagulation-time of the blood, especially in the subjects of chilblains, cold hands and feet, " dead fingers," etc. It must not be forgotten that young girls may have a malignant growth of the uterus, such as sarcoma, but this is more likely to cause irregular bleeding as well as menorrhagia. Finally, high blood-pvessure must be reckoned with as a cause of menorrhagia at any period of life, but particularly when nearing the onset of the menopause. Menopause menorrhagia much more often depends upon one of the well-defined lesions of the uterus above described than on high blood-pressure, but cases occur in which the blood-pressure is alone responsible. In connection with this must not be forgotten the arteriosclerosis which is likely to affect the uterine vessels about this period of life, and which may contribute its share to the causation of a menorrhagia. This high blood-pressure, and possibly the arteriosclerosis also, may eventually prove to be connected with the internal secretions of the ductless glands. Though still considerably a matter of theory, normal menstruation consists in part, at least, of the normal balance being preserved between the various internal secretions, the ovarian and thyroid on the one hand being balanced by the suprarenal and pituitary on the other, and any disturbance of this balance may result in amenorrhoea (as in myxoedema) , or in menorrhagia, as sometimes occurs in exophthalmic goitre and at the meno- pause. In the absence, however, of definite lesions of ductless glands, we have not much evidence at present before us which will enable us to say which gland is at fault. It is very fascinating to believe that high blood-pressure may be due to the unbalanced action of the suprarenal and pituitary secretions, and to suggest a remedy in consequence. 3. The Nervous System alone is never likely to be a cause of lasting menor- rhagia, but that a single profuse period may result from some disturbance of the nerve mechanism of menstruation has long been believed. There certainly are cases of the kind in which no other causation can be recognized, and in which the excessive flow is not repeated. The effect of sexual intercourse upon the METEORISM 431 menstrual flow is difficult to determine, but cases do occur in which excessive menstruation has been cured by abstention, and we cannot but believe that excesses in this direction must therefore have been the cause. Such cases occur chiefly in the newly married. The part played by incomplete coitus, coitus interruptus, or prevention of conception by other means, is still difficult to determine, but we have no real evidence to hand which proves that any menstrual disturbances arise on these accounts. In any case, however, we are not justified in assuming that the nervous system is to blame for a menorrhagia until, by careful examination, we have eliminated the other more important causes. T. G- Stevens. MENSTRUATION, ABNORMALITIES OF.— (See Dysmenorrhcea, Amenor- RHCEA, JNIeNGRRHAGIA, METRORRHAGIA.) MERYCISM. — The term merycism is almost equivalent to cud-chewing or rumination ; it is a very rare condition amongst human beings ; even when it does occur it is no evidence of disease. It has to be distinguished from pyrosis and from flatulence ; in typical cases there is no difficulty, for with merycism the act may be voluntary to some extent : actual food returns to the mouth instead of merely acrid fluid, as in the case of pyrosis, and there is none of the belching of flatulence. One curious feature of the condition is that it sometimes develops in several different members of the same family ; this may be a question of imitation, but it is due quite as likely to some congenital peculiarity. The diagnosis depends mainly upon the patient's own account of what he feels taking place inside him, upon the history of a similar condition affecting other members of the family, and upon the absence of objective evidence of gastric, intestinal, intracranial, or renal disease. Herbert French. METEORISM, or tympanites, is the term used to denote enormous distention of the abdomen with gas, the latter generally being within the alimentary canal, though it may be free in the peritoneal cavity. It is seldom a symptom in itself of diagnostic importance, the nature of the case being determined usually on other grounds. It is apt to be very troublesome in cases of general peritonitis, even when operation has been performed ; the diagnosis will depend upon the history, which may suggest a cause for peritonitis, such as gastric or duodenal ulcer, appendicitis, tj'phoid fever ; and upon the persistent vomiting, the dry furred tongue, the motionless rigid abdomen, the rising rapidity of pulse, the facies Hippocratica, the impairment of note in the flanks, the rub over the liver or spleen, and the absence of borborygmi. Intestinal obstruction, whether acute, subacute, or chronic, and whether due to strangulated hernia, peritoneal band, volvulus, new growth, intussusception, or other cause, often leads to extreme meteorism, with visible peristalsis, the passage of neither faeces nor flatus, and persistent vomiting which will become ffeculent if the case is not operated upon. Peritonitis ultimately supervenes ; but previous to this, intestinal obstruction is differentiated from general peritonitis by the absence of rigidity of the abdominal wall, by the presence of borborygmi and visible peristalsis, the absolute constipation in spite of enemata, the slower pulse, and the relatively better condition of the patient. Acute pancreatitis, whether hsemorrhagic or not, may cause acute meteorism. The symptoms are variable, but they nearly always suggest an acute abdominal condition requiring immediate laparotomy, the diagnosis being then suggested directly the areas of fat necrosis are seen in the omental fat. Previous to laparotomy, the symptoms are rather those of acute intestinal obstruction than of general peritonitis ; the usual history of acute pain in the epigastriuni may at first suggest perforated gastric ulcer, but the abdomen remains supple as in obstruction niore often than it becomes rigid as in peritonitis. 432 METEORISM Meteorism in cases of typhoid fever, dysentery, dengue, and other severe illnesses in which the bowel is affected, is chiefly of importance in that it may lead to a suspicion of perforation and general peritonitis. The diagnosis is often very difficult, and there may be grave anxiety and doubt as to whether the abdomen should be opened or not. One important point in typhoid fever is that perforation is generally accompanied by a sudden drop in the temperature and an equally sudden rise in the pulse-rate, whereas meteorism by itself would not cause this. When the vessels in the mesentery are affected by thrombosis or embolism, acute meteorism results, with all the signs of intestinal obstruction, rapidly followed by peritonitis. The nature of the case may be quite obscure until laparatomy is performed, unless the existence of a cause is known, such as fungating endocarditis. Interference with the solar and mesenteric plexuses of nerves has sometimes led to severe meteorism in cases of tabes mesenterica, or infiltrating intra-abdominal J''i£: 122. — Hirschsprung's disease ; or, idiopathic dilatation of colon. Note the distended coils of intestine. (From Professor Rutherford Morison's Introduction to Surgeiy.) new growth. The symptom occurs late, and the diagnosis will generally have been made on other grounds. Affections of the spinal cord may lead to paralysis of the bowel and tympanites. This may result from transverse "myelitis," whether due to primary softening of the cord from syphilitic or other spinal arterial thrombosis, from compression by spinal caries, new growth, aneurysm, or from destruction of the dorsal region of the cord by a stab, a crushing, or a bullet wound. There will generally be Paraplegia {q.v) to indicate the nature of the case. Diabetes mellitus often indicates its impending termination in coma by the onset of abdominal pains, with more or less meteorism. The diagnosis will be known already on account of the glycosuria. Meteorism is also common in the late stages of cirrhosis of the liver. Particular mention may be made of Hirschsprung's disease — idiopathic enormous distention of the sigmoid colon in children and young people {Fig. 12.1). Careful examination indicates that the enormous gaseous METRORRHAGIA 433 distention of the abdomen is not due to general tympanites, but to ballooning of what may seem at first to be stomach, but which is proved not to be this by the absence of immediate effect on the gas-containing cavity when fluid or gas is given by the mouth, by the swelling appearing to arise from the left iliac fossa, and if need be by the x-iay shadows after a bismuth meal. Obstinate constipation, or even symptoms of recurrent intestinal obstruction, are usual in these cases, and the diagnosis is confirmed by the laparotomy that is generally required, in the end, to reheve the patient. Hysteria, or rather functional derangement of the nervous system, can lead to almost any symptom, including meteorism. Two difficulties arise in the diagnosis : namel}', to be sure : (i) That the condition is meteorism at all, and not pregnancy, ascites, ovarian cyst or other tumour — phantom tumours are difficult to diagnose without examination under an anassthetic, and even laparotomy may be undertaken before the absence of a tumour is certainly established ; and (2) That the meteorism has no organic basis — the circumstances may sometimes suggest this at once, but in some cases the exclusion of an organic cause for the tympanites may take much time, careful enquiry into symptoms and physical signs, and considerable anxiet}' meanwhile. Herbert French. METH^MOGLOBINURIA.— (See Hemoglobinuria.) METRORRHAGIA. — Metrorrhagia means the loss of blood from the uterus in the intermenstrual periods, and naturally the term can only be applied to irregular haemorrhages during menstrual life. It is not strictly correct to apply it to haemorrhages connected with pregnancy, for in pregnancy menstruation is in abeyance. It may, however, be used with propriety in those cases remotely connected with pregnancy in which menstruation has been re-established. The term may be used for losses of actual blood, or for blood-stained discharges in which mucus is mixed with the blood. Causes of Metrorrhagia. I. Generative System. 2. Circulatory System. 3. Nervous System. Malignant Growths : High blood-pressure due to : Sexual excess Carcinoma Internal secretions Squamous epithelioma Arteriosclerosis Sarcoma At the menopause Chorion-epithelioma Undue congestion due to : Benign Growths : Internal secretions Submucous fibroid Deficiency of calcium at Fibroid polypus the onset Mucous polypus Blood Changes .- Inflammatory Lesions : Purpura 1 Erosion of cervix Scorbutus ' Endometritis Haemophilia Tuberculosis of the uterus Leucocythaemia The Generative System. — The lesions of the generative organs which give rise to metrorrhagia are well defined as a rule, and in the case of growths of the cervix uteri are often self-evident. Where growths of the body of the uterus are present, differential diagnosis is often a matter of great difficulty, and cannot be made in many instances without a preliminary curettage and microscopical examination of the material removed. In fact, with the exception of obvious mucous polypi, fibroid polypi, and advanced growths of the cervix, all the growths of the uterus require a preliminary histological examination for their D 28 434 METRORRHAGIA exact diagnosis unless the symptoms demand a radical operation. In such cases it is sufficient to diagnose the actual nature of the growth after removal. It is not out of place here to suggest the best way to make histological prepara- tions from curetted material, a matter often of great importance to the patient, because it is often difficult to distinguish between cancer and endometritis unless the very best microscope sections can be obtained. The curetted material must be obtained after dilatation, with a sharp curette, and the larger the frag- ments removed the more easy will the histologist's work be made. Anassthesia, therefore, is always essential except in the case of cervical growths. In doubtful cervical growths a wedge should be cut out, including some normal tissue, if possible. Curetted fragments should be washed free from blood for a minute or two, but should not be left to soak in water. They should then be placed imme- diately in an ef&cient fixing fluid, and the best all-round fluid for this purpose is lo per cent of formalin in -75 per cent saline solution (formalin loc.c, -75 per cent salt solution 90 c.c). Twenty-four hours in this fluid lead to good fixation, after which the tissues can be dehydrated in successive alcohols, cleared in xylol, and finally embedded and infiltrated with paraffin wax. Sections cut from these paraf&n blocks are the best obtainable, far superior to any freezing method or celloidin infiltration. If the stained sections are submitted to a histologist who has experience of uterine growths, there should not be two per cent of doubtful specimens. If, however, the tissues are improperly fixed, thick sections are cut, and badly stained, then the most skilled histologist will be unable to give a definite and reliable diagnosis. Cancer of the body of the uterus, cancer of the cervical canal, early cancer of the cervix, sarcoma of the uterus, chorion-epithelioma, some sloughing fibroids, tubercle, and endometritis can only be distinguished from one another by investi- gations carried out on these lines. The fact that all these lesions produce metror- rhagia, and may give rise to haemorrhage on coitus, walking, straining at stool, and bimanual manipulation of the uterus, makes it imperative that we should have histological confirmation of the nature of the lesion before making an exact diagnosis. The relation of fibromyoma to metrorrhagia as opposed to pure menorrhagia, which is the rule with these tumours, is interesting. Fibroids only produce irregular bleeding when they are submucous and in process of extrusion, when they are infected and sloughing, or when they are actually polypoid. The reason for this is that in these conditions the tumours are always partly strangu- lated by uterine contractions, and therefore in a state of gross venous congestion ; hence they bleed more or less constantly, without provocation. The occurrence of irregular bleeding in a person who is known to have fibroids almost always means one of these conditions, and, commonly, extrusion of the tumour from the uterus. On the other hand, it must not be overlooked that carcinoma may develop in the endometrium with a fibroid also present, or that a fibroid may become sarcomatous, or that a sarcoma may arise de novo in the uterus, and attack a pre-existing fibroid. Rapid enlargement of a uterus, with irregular haemorrhage, is very suspicious of a sarcoma, but as it is not uncommon for several fibroids to be present in the same uterus, it is also common for rapid enlargement to occur as a result of cystic changes in one of them, whilst haemorrhage may take place due to extrusion of another. Pure carcinoma of the body of the uterus rarely produces much enlargement of the organ, and any increase in size is not very rapid. Chorion-epithelioma follows hydatidiform mole in about 50 per cent of the recorded cases, and it always follows pregnancy, never having been seen in the METROSTAXIS 435 uterus in a case where pregnancy could be excluded. It is associated especially with profuse bleeding and the rapid development of a foetid discharge due to decomposition of blood and necrosing tissues in utero. Carcinoma of the body of the uterus rarely produces foul discharges until the condition is very advanced and has become exposed to the air. The differential diagnosis of bleeding due to cancer, erosion, and tubercle of the cervix is often difficult in the early stages. In advanced cancer the friable hardness of the growth distinguishes it at once from the tough leathery hardness present in erosions. In the former^ the growth can be broken down with the finger ; in the latter, the soft velvety erosion can be scraped off the tough leathery and fibrous cervix beneath. Nothing, however, but sections made from wedges removed from the cervix will assist us to distinguish cancer or erosion from tubercle in the early stages. Tubercle of the cervix is usually mistaken for cancer, but the difference is of course clear enough in microscope sections. Mucous polypi and fibroid polypi are common causes of intermenstrual bleeding, and are usually quite definite growths. The mucous polypus is soft, strawberry- red in colour, often pedunculated, and contains cystic spaces filled with glairy mucus. It almost never gives rise to a malignant growth. The fibroid polypus is hard, and shows the glistening whorled appearance so well known in fibro- myomata on section. These growths are liable to infection and sloughing, and are then apt to be mistaken for cancer or sarcoma. The microscope alone will enable the difference to be made out. Endometritis rarely causes severe metrorrhagia, but is often associated with a bloodstained watery discharge. In a doubtful case there is absolutely no way of distinguishing it except with the microscope. The Circulatory System is sometimes responsible for metrorrhagia, just as it is for menorrhagia, and the actual causes are much the same. It is, however, especially at the onset and the decline of menstruation that irregular bleeding is likely to occur from this cause. The same disturbance of the internal secretions which may cause menorrhagia at these periods, sometimes acts in the same way in causing irregular bleeding. It is fairly common to find young girls at the onset of menstruation having menorrhagia and metrorrhagia, and it is often very difficult to be certain of a cause. It depends, however, very largely on two definite factors, namely : (i) Unusual uterine congestion the result of an excess of the biochemical stimulus (internal secretions) of menstruation, and (2) deficient coagulation power possibly due to a want of calcium in the blood. The former cannot be diagnosed by any defined investigation, but the latter is determined by estimating the coagulation-time. Purpura, scorbutus, and hsemophilia are readily diagnosed when they act as causal agents. Leuco- cythasmia is sometimes responsible for irregular uterine bleeding, and is readily diagnosed by making a total and differential leucocyte count. The Nervous System seldom causes metrorrhagia, but there is no doubt that sexual excess, often seen in the first months of married life, is a reflex cause of uterine congestion, and may cause metrorrhagia as well as menorrhagia. T. G. Stevens. METROSTAXIS. — Metrostaxis is the term applied to uterine haemorrhage at any period of life, unconnected with menstruation, or at times when menstrua- tion is in abeyance. It is convenient to keep this form of haemorrhage separate from the other varieties, because in this way all the pregnancy haemorrhages can be carefully differentiated. Metrostaxis may be classified according to whether the uterus is pregnant or not. The bleeding which occasionally occurs from the vagina in new-born infants is usually thought to depend upon uterine congestion subsequent to the cessation of the placental circulation. It 436 METROSTAXIS never depends upon any lesion requiring definite investigation, and is usually trivial. A fatal case, however, was reported by McKerron. Causes of Metrostaxis. NON'-PREGNANT UtERUS. Pregnant Uterus. Uterine bleeding in the new-born Malignant growths Polypi Senile endometritis Senile granular vaginitis Pyoraetra Secondary post-partum haemorrhage Sub-involution Threatened abortion Ante-partum hsemorrhage Extra-uterine gestation Malignant growths of cervix or vagina Erosions Polypi The differentiation of malignant growths, polypi, and senile endometritis can only be established in the same manner as in cases occurring during menstrual life. Senile adhesive vaginitis must not be overlooked as a possible cause. In this condition the vaginal walls at the fornices are liable to become inflamed and form granulation tissue, which may bleed if the surfaces rub together. On examining such cases, too, the surfaces may be partly adherent, and the separa- tion brought about by the finger may cause bleeding. In any doubtful case, the routine dilatation and curettage of the uterus must never be omitted. An unsuspected pyometra, or distention of the uterus with pus, may cause haemorrhage, along with a foul discharge, and although it is almost always accompanied by a malignant growth, may be only the result of infection and granulation-tissue formation. In relation to a recent pregnancy, haemorrhage may result from simple sub- involution, from retained products of conception, and from chorion- epithelioma. The differentiation of these conditions can only be established by exploration of the uterine cavity, with, if necessary, the assistance of the microscope. Such conditions may be termed secondary post-partum haemorrhage in cases occurring within a few days of delivery. Haemorrhage from the pregnant uterus almost always means separation of the embryo from its attachments, or separation of the placenta ; but malignant growths of the cervix, erosions, and polypi may have to be considered. Haemor- rhage from a pregnant uterus is never due to malignant growths of the body of the organ, because pregnancy is practically impossible together with such lesions. There are, however, two great difficulties in connection with pregnancy haemorrhages : these are to differentiate (i) the uterine haemorrhage which occurs along with extra-uterine gestation from that due to threatened abortion ; and (2) to distinguish the bleeding of placenta prcBvia from that due to the separation of a normally situated placenta. In the first case, arising very early in pregnancy, it must be remembered that the haemorrhage occurs when the extra-uterine gestation is separated from its tubal or other attachments and is converted into a tubal mole, when it becomes extruded from the fimbriated extremity of the tube, or when the tube ruptures. Therefore, there may be history of acute abdominal pain, faintness, and possibly collapse from internal haemorrhage. Along with this, the uterus will not be found obviously enlarged, whilst there is some sort of swelling in one or the other posterior quarter of the pelvis. Haemorrhage due to threatened abortion cannot be diagnosed unless the presence of an intra-uterine pregnancy can be established. Therefore, in this MICTURITION, ABNORMALITIES OF 437 case we must look for the definite signs of a normal pregnancy, which in the early months will be : amenorrhoea, morning sickness, breast changes, enlarge- ment of the uterus, Hegar's sign, and Braun's sign. The former consists in the extreme softening of the upper part of the cervix and lower part of the uterine body, combined with the as yet unsoftened vaginal portion and globular tense fundus ; it is found from the sixth to the eighth week. The latter consists in the irregular shape of the uterus from the eighth to the t^velfth week. One side is larger than the other, and an ill-defined groove is found between them. In the second case, occurring generally after the sixth month of pregnancy, it is of the greatest importance to be able to diagnose placenta prcsvia. The only definite sign is the feeling of the placenta through the cervix, when it will admit of this method of investigation. The suggestive signs are those due to the filling up of the lower uterine segment by the placenta. The presenting part remains high up and movable, not engaged in the brim, and there is a sensation of great increase of thickness between the vaginal fornices and the presenting part. In any case of severe hemorrhage, however, the cervix must be dilated so as to admit a finger, as treatment depends upon diagnosis, and no patient with a placenta praevia is safe until she is delivered and bleeding has ceased. T. G- Stevens. MICROPSIA. — (See Vision, Defects of.) MICTURITION, ABNORMALITIES OF. — A person in health micturates about five times during the twenty-four hours, the total amount of urine passed being about 1500 c.c, or 50 ounces. This varies according to the amount of fluid taken and the amount lost by perspiration, and so forth. The act of micturition is controlled by a nervous mechanism, a stimulus from the vesical mucous membrane starting an impulse which causes contraction of the detrusor muscle, and at the same time relaxation of the sphincter at the urethral orifice. The special centres controlling the motor functions of the bladder are in the spinal cord at the level of the third sacral nerve, whilst the brain controls these centres in response to sensory impulses received. The abnormalities of micturition which are met with in practice depend partly upon lesions of some portion of the urinary apparatus, and partly upon some change in the nervous mechanism controlling the act, and will be discussed from these points of view under the following headings : — 1. Increased frequency of micturition 2. Changes in the stream during micturition 3. Difficulty in micturition 4. Retention and incontinence of urine 5. Pain during micturition 6. Micturition through fistulas 7. Disorders of micturition from diseases of the nervous sj'stem 8. Enuresis (q-v.). Increased Frequency of Micturition. — A large number of diseases of the genito-urinary tract are accompanied by increased frequency of micturition, and it is necessary to ascertain if the increased frequency of micturition depends upon an increased amount of urine to be passed. Thus in diabetes or chronic interstitial nephritis, the increased amount of urine will cause an increased frequency of desire to micturate, provided the capacity of the bladder is unaltered. If the total amount of urine remains normal, any increased frequency of micturition will be caused by some lesion of the genito-urinary apparatus, and a due consideration of the other symptoms of a case will often point to a definite diagnosis. It must be remembered, however, that increased frequency does not necessarily imply that the bladder is the seat of the disease, as the 438 MICTURITION, ABNORMALITIES OF symptom is present with any form of renal pyelitis — commonly calculous or tuberculous — or with prostatic enlargement. It is important to ascertain the relationship between micturition during the da}^ and during the night. Normalh-, a health}- person should not wake during the night to pass urine, unless an excess of fluid has been taken ; but if any inflammatory condition is present in the bladder, micturition will be present during the night, as well as increased in frequenc}^ during the day. Any form of cystitis or acute inflammatory conditions of the prostate or neighbouring organs, will cause increased frequency during both the day and night. In patients with chronic nephritis who are passing normal quantities of urine during the day, frequent micturition at night is common, and is due to delayed excretion of fluid from the body bj- the kidneys. In vesical calculus there is increased frequency during the day, but often no urination is necessary during the night. The frequencj" during the day is increased with activity or exercise, or by the jolting movements of travelhng, but is absent during a period of rest. If the presence of a calculus has excited cystitis, increased frequency of micturition will be present during both day and night. In prostatic enlargement, whether simple or carcinomatous, the increased frequency is most marked at night, and is commonly the first symptom of the disease noticed by the patient, generally a man of about sixty years of age. The mucous membrane of the prostatic urethra becomes stretched by the enlarging gland, and often pushed upwards into the bladder by the intravesical enlarge- ment, and the contact of this with urine in the bladder causes the stimulus to micturition. Further, with prostatic enlargement, the bladder is not completely emptied, so that the addition of a relatively small amount of urine from the kidneys soon fills up the incompletely emptied viscus and sets up afresh the desire to micturate. In vesical carcinoma, increased frequencj- of micturition is present during both the day and night, as the infiltration of the vesical wall prevents the bladder from being distended without pain, and it is frequently' associated with cystitis. In renal colic caused by calculus or blood-clot, or in the torsion of a movable kidney, there may be increased desire to micturate, and the sj-mptom may be present in inflammatory diseases in the pelvis, such as salpingitis, pyosalpinx, or a low-placed appendicitis, or in the secondary infiltration of the bladder in carcinoma of the uterus or rectum. Increased frequency of micturition may be produced by mechanical obstruc- tion to the normal vesical distention by a tumour occupjdng the pelvis, and is commonly seen in ovarian cyst, uterine fibroid, or with a retroverted gravid uterus ; these tumours will be found upon vaginal examination. In children, increased frequencj^ of micturition may be due to phimosis, balanitis, a small urinary meatus, worms, penile calculus, oxaluria, coli bacilluria, or to hyperacidity of the urine. Changes in the Stream of Urine. — An abnormahty of the stream of urine may be due to a congenital deficiency of the terminal urethra, as in hypospadias or epispadias, or to some lesion mechanically obstructing the stream. Most commonly this is due to a stricture of the urethra. If the stricture be situated in the penile portion, the stream of urine is of small calibre but of fair force, whilst if the stricture is in the bulbous urethra, the mechanical effect upon the stream of urine passing through the stricture into the urethra of wider calibre beyond the stricture, is that the force is diminished, whilst the actual stream as it leaves the meatus is not thinned. A stricture at or near the urethral meatus forms a thin but forcible stream ; but no rehance can be placed upon the complaint of a " twisted stream." MICTURITION, ABNORMALITIES OF 439 The obstruction to micturition by an enlarged prostate causes the stream of urine to be slowed and forceless, so that it may fall vertically from the meatus instead of in the usual arched manner. This same dribbling of urine will be seen when a urethral stricture becomes much narrowed, or again when the bladder musculature has lost its contractile power, or in disease of the nervous system affecting the motor paths to the bladder. In any case presenting an abnormality in the stream of urine, careful enquiry should be made to ascertain if the stream has become gradually and progressively narrowed, as in stricture, or if the alteration in the force of the stream is accom- panied by increased frequency of urination, as in prostatic hypertrophy in an elderly patient, or by urethral discharge in a case suggestive of acute prostatitis. A stricture may be diagnosed with certainty by a careful endoscopic examina- tion under air-distention, or, failing this, by the obstruction offered to the passage of a catheter or bougie. Prostatic enlargement or inflammation will be suggested by the history of the case, and confirmed by a digital examination of the gland by the rectum ; in the absence of a mechanical obstruction in the urethra, examination should be conducted for any disease of the spinal cord, by testing the knee-jerk and other reflexes. Sudden stoppage of the flow of urine during micturition may be caused by a small, movable vesical calculus, if the latter happens to engage in the internal urethral orifice or becomes impacted in the urethra. The same sudden cessation of the flow is caused occasionally by a tuft of a vesical villous tumour blocking the urethral opening during micturition. Usually the flow will be resumed after a few seconds, unless the calculus has passed into the urethra, when it may be passed naturally or require to be removed by surgical means. If the symptom recurs, a cystoscopic examination of the bladder will readily distinguish between the two conditions. The same sudden cessation of the stream may occur without any intra- vesical lesion as the result of spasmodic contraction of the vesical sphincter. Patients subject to this trouble (so-called stammering bladder) can at times pass urine quite normally, but at others the stream is frequently interrupted, or they may be unable to pass urine at all, especially in the presence of a second person. Difficulty in Micturition. — Frequently associated with some change in the character of the stream of urine, a patient may complain of difficulty in mic- turition, either as a hesitation in commencing the flow or a need to strain to maintain it. This, again, is most common with urethral stricture or prostatic enlargement, or may be due to the impaction of a calculus in the urethra or to the formation of blood-clot in the bladder. A calculus may be passed into the urethra and become arrested in the canal, but not so that it wholly obstructs the passage of urine. It is not uncommon for a calculus to occupy the dilated portion of the urethra behind a stricture, or occasionally a prostatic calculus projects from the gland into the lumen of the posterior urethra. A calculus so placed may increase in size by the further deposition of urinary salts whilst in the urethra, and cause difficulty in micturition ; it may be felt in the canal from the outside, upon rectal examination, or upon passing a soft bougie into the urethra. Even if placed behind a stricture, it may be felt by a fine guide or bougie passed to dilate the stricture. Difficulty in micturition due to the presence of blood-clot in the bladder will usually be indicated by the previous passage of blood-stained urine and by the constant efforts to micturate. Difficulty in micturition in the female may be caused by a pelvic tumour by the drag or direct pressure on the urethra or vesical neck. This may occur with a uterine fibroid or a pregnant retroverted uterus. Occasionally, difficulty 440 MICTURITION, ABNORMALITIES OF is produced by the direct infiltration of the urethra by a carcinoma of the vaginal wall or vulva. Difficulty in micturition is n"ot uncommon in disease of the nervous system, causing paralysis or paresis of the detrusor muscle of the bladder. This may be due to trauma and pressure on the spinal cord by blood-clot, or to myelitis or tabes. It must be remembered that it is not uncommon for the early cord- changes of tabes to affect the urinary organs, and that difficulty in passing urine may be complained of when the urethra and bladder are normal. Atony of the bladder wall without any affection of the nervous mechanism, from recurring over-distention of the bladder, may cause difficulty in micturition. Retention of Urine — by which is implied the gradual accumulation of urine in the bladder, with inability to pass any per urethram — may arise from mechanical causes obstructing the urethra, or from derangement of the nervous system. Retention of urine must be distinguished from anuria, or failure of the kidneys to secrete urine, for in retention the kidneys are still functioning, and the urine is collecting in the distended bladder. Retention of urine occurring suddenly, produces very severe pain and strangury, but in cases of old-standing obstruction the bladder may be enormously distended before pain becomes severe. If the retention remains unrelieved, urine may continually dribble away per urethram, when a condition resembling incontinence of urine is produced ; but it is most important to distinguish the condition from true incontinence of urine due to injury or paralysis of the vesical sphincter muscle. In true incontinence, the bladder remains empty, urine flows away as soon as it passes down into the bladder, and there is no obstruction in the urethra ; whereas, in the condition of involuntary passage of urine from an unrelieved distended bladder — incontinence from overflow, or false incontinence — the bladder may be felt distended in the suprapubic region, and there exists some mechanical obstruction in the urethra, or at the internal urethral orifice. The common causes of retention of urine are urethral stricture and prostatic enlargement. In stricture, it does not necessarily follow that the urethra is entirely occluded by the fibrosis, but rather that some spasm or congestion is present at the stricture, from exposure to cold or indulgence in alcohol, when a small catheter may be passed. In elderly men with prostatic hypertrophy , acute retention may occur early in the disease from a congested condition of the enlarged gland, or in the later stages be due to actual obstruction of the urethra by a localized enlargement from either lateral lobe or the so-called third lobe which acts as a ball- valve to the internal urethral orifice in such a manner that each forced attempt at urination closes the orifice more securely. In these cases of prostatic enlargement, a large coude catheter can usually be passed readily ; but in cases of acute retention, especially in those of old-standing obstruction in which the kidneys are probably affected by the backward pressure, it must always be remembered that if a catheter is passed, the urine must be drawn off very slowly, either by a fine catheter, a few ounces at a time, or by replacing some of the fluid withdrawn by sterile boracic lotion, so that the increased intrarenal tension may be lessened slowly ; otherwise, fatal anuria may be induced. A case of acute retention of urine from stricture of the urethra will generally be that of a comparatively young patient, who will give a history of gradually increasing difficulty in micturition, with narrowing of the stream, and inability to finish the flow completely without some dribbling of urine. Examination of the urethra by an endoscope, or by the passage of olivary-pointed flexible bougies, will reveal the presence of a stricture. In prostatic enlargement the patient is usuallj^ above the age of fifty-five years, has been troubled with increasing frequency in micturition, especially at night, MICTURITION, ABNORMALITIES OF 441 with straining and loss of force in the stream of urine. Per rectum, the prostate may be found to be enlarged both from above downwards and laterally ; it may be smooth, elastic, and movable in the pelvic space in the case of adenomatous enlargement, or nodular, hard, irregular, and fixed in the case of carcinoma, the subjective symptoms of both of which are very similar. In some cases the prostate may not appear to be much enlarged upon rectal examination, though it is causing an intravesical tumour which obstructs urination, or a firm fibrous collar around the internal urethral orifice which gives rise to marked prostatic symptoms. In prostatic cases, a catheter of coude form can usually be passed into the bladder readily. Acute retention of urine may be produced by other causes than the above. A small calculus may be passed into the urethra and totally obstruct the passage of urine. This may occur at any age, and the calculus become arrested at some narrow portion of the canal — usually at the meatus or at the membranous urethra. The urethra may lodge a calculus for some time with comparatively little pain ; but more often the calculus passes into the canal during micturition, causing a sudden pain, with cessation of the flow of urine and the dribbling of a few drops of blood. The calculus may be palpated if it lies in the penile urethra or in the perineum, or will be felt on passing a metal instrument into the urethra. Retention may be caused by the blockage of the internal urethral orifice by the free portion of a pedunculated vesical tumour. On any attempt at micturition the growth is forced into the orifice and obstructs it. These cases are rare, but in one under the care of the writer, a man, owing to his inability to pass any urine, had been condemned to catheter life on the assumption that he had prostatic enlargement. No enlargement could be felt per rectum, but upon cystoscopic examination, a papilloma was found in the bladder, attached by its pedicle just above the urethral orifice and obstructing the flow of urine. Retention of urine may also occur with paralysis of the motor nerves of the detrusor muscle of the bladder, or interference with the spinal centres by compression paraplegia, locomotor ataxia, or myelitis, each being diagnosed on examination of the nervous system ; or as a reflex spasm of the vesical sphincter after operations upon the rectum or neighbouring organs. In other cases, retention of urine is present in association with other sym- ptoms of hysteria ; but care must be taken not to give a diagnosis of hysteria until all other causes of retention are excluded. These cases usually occur in children or in young women. Pain during Micturition. — Pain may be present during or immediately after micturition, and it is important to ascertain not only the period at which pain is present, but also the actual location of the pain. If pain is present in the urethra during micturition, it usually indicates that a stricture or some inflam- matory process is present, the latter being evidenced by a urethral discharge (see Discharge, Urethral). If pain is experienced immediately after micturition, and felt as a tingling or pricking sensation in the glans penis, there is some inflam- matory or irritant process at the trigonal region of the bladder. Formerly this symptom was looked upon as diagnostic of vesical calculus, and though it is almost a constant symptom of the latter, provided the calculus is not trapped in a post-prostatic pouch, it is also present in cystitis, tuberculous or otherwise, in vesical carcinoma which is infiltrating the bladder base, and in acute or subacute prostatic infections. Prostatic infection can be diagnosed by the history of the case, usually following an acute urethritis, and by a rectal examination. Tuber- culous cystitis usually occurs in young adults, and frequently other tuberculous lesions are present in the genito-urinary organs, such as the epididymis, vas deferens, seminal vesicles, or prostate, whilst the urine contains not only blood 442 MICTURITION, ABNORMALITIES OF and pus, but tubercle bacilli. Cystitis from other causes, and vesical growth or calculus, can be ascertained upon cystoscopic examination. Pain ma}' be felt in the perineum during and after micturition in cases of prostatic disease, especially if much straining occurs during micturition, or ma}^ be felt in both the perineum and the anal area in vesical carcinoma. In the female, pain is felt at the urethral orifice and in the vulva after mic- turition in cases of cystitis or vesical carcinoma. It should be noted that in either sex, severe pain may be present at the termi- nation of the urethra after micturition, Avhen a calculus is impacted in the vesical end of a ureter, especially if the latter is partially prolapsed into the bladder. In one such case the patient would hold her urine for hours rather than pass it, owing to the pain that followed micturition. Micturition through Fistulse. — Urine may pass, either whoUy or in part, through a fistulous tract communicating -^dth the urinary organs, such opening being the result of preceding disease or trauma. Occasionally, owing to con- genital malformation of the urethra or bladder, urine passes by an opening in the perineum, pubes, or into the vagina ; but these cannot be regarded as fistulae. Urinarj- fistulae are most common in connection vritii the urethra as the result of peri-urethral abscess, stricture, or from the result of some operation ; and in a case in which a penile fistula is present, it is necessan,- to ascertain if the cahbre of the urethra is in any way narrowed by cicatricial inflammation. A fistula may open in the perineum as the result of inflammation and extravasation behind a fistula, following an operation upon the lower urinarj' organs, or in the female into the vagina from trauma during parturition or some vaginal operation. In cases in which a fistula opens into the vaginal fornix, the urine may leak from the bladder or from the lower end of the ureter, and an accurate diagnosis must be made before any attempt at repair is performed. The opening of the fistula is usually smaU and embedded in an area of cicatricial tissue, so that it is ver\- difficult to pass a probe along the tract. In these cases, evidence of the nature of the fistula may be obtained by filling the bladder with some sterile coloured solution, such as weak meth^-lene blue ; if the opening is in communi- cation -^^-ith the bladder, coloured solution vnil appear in the vagina, but if the urine comes from the ureter, no stain "\^-ill be found. Evidence may also be obtained by means of the cj'stoscope, when a cicatricial area may be found in the bladder surrounding a retracted fistulous opening, or the ureteric orifice of the one side maj^ be found displaced from its normal situation by the scar contraction when the ureter is at fault. In these cases it maj- be impossible to pass a bougie into the ureter more than a ver\^ short distance, the tip being arrested by the scar tissue. A urinary- fistula may be present in the suprapubic area in connection with the bladder, or in the lumbar area communicating with the kidney, as the result of operation measures on these two organs. A fistula has been seen in the ihac fossa as the result of an operation on the ureter, and after the opening of an abscess formed around the ureter from the ulceration caused by a ureteric calculus. Disorders of Micturition from Diseases of the Nervous System. — In most of the foregoing paragraphs it will be noticed that symptoms referable to the urinary organs have been stated to be due in some cases to disease of the nervous system, such as myehtis, tabes dorsahs, or hemiplegia ; in spite of repetition it is advisable to gather these under one heading. The control of the act of mic- turition depends upon the integrity of the nervous system ; for although special centres exist in the lower segments of the spinal area presiding over the motor functions of the bladder, the impulse calhng for action of these centres is supplied by the brain after a stimulus has been convej-ed to the latter by the sensory MUCUS IN THE STOOLS 443 nerve fibres from the bladder. There are two centres in the lower spinal segment, by one of which the detrusor muscle of the bladder is brought into action, and by the other the sphincter muscle surrounding the vesical outlet is maintained in tonic contraction until inhibited by the same stimulus which produces con- traction of the detrusor. The two vesical muscles are thus antagonistic in their action, the detrusor contracting and the sphincter relaxing in answer to the stimulus to micturition. In the diagnosis of all neuroses of the bladder, it is most important to exclude all lesions of the urinary apparatus, and not to overlook the fact that vesical symptoms are often produced by some lesion in the kidney, when the bladder on careful examination appears quite normal. (a). Irritability of the Sensory Nerves of the Bladder. — Some patients experience an urgent and frequent desire to pass urine, often every half-hour, though no objective symptoms of disease can be found, and all inflammatory lesions can be excluded ; there is no pain and no increased frequency of micturition during the night. The cases have received the name of cystalgia, hypercssthesia vesiccB, and irritable bladder, and they must be carefully distinguished from those in which there is some lesion of the urinary organs, the rectum, and of the female pelvic organs. [b). Irritability of the Motor Nerves of the Bladder. — In this conditon there is a spasmodic contraction of the sphincter muscle of the bladder, with resulting retention of urine or great difficulty in micturition. There is no stricture or urethral obstruction present, as is shown by the ease with which a catheter is passed, nor is there any prostatic enlargement. The neurosis is not confined to the male sex, and is seen in hysteria as well as in those nervous affections which affect the spinal centres, such as myelitis, lateral sclerosis, and tabes dorsahs. (c). Paralysis of the Motor Nerves of the Bladder may affect the peripheral nerves or spinal elements, but the results as regards the bladder are the same. If the nerves supplying the detrusor muscle or its spinal centre be paralyzed, retention of urine occurs, and the patient can only expel urine by the force of the abdominal wall. If the sphincter muscle is affected, it becomes relaxed, and urine dribbles away. In many cases only part of the motor tract is affected, so that the power of the bladder is not abolished but diminished, and a portion of the urine is retained in the bladder after micturition. The bladder may be thus affected in compression of the spinal cord by fracture, or haemorrhage into the membranes, in myelitis, Paraplegia (q.v.), and locomotor ataxia. (d). Destruction of the Spinal Centres for Micturition, by injury, softening, or compression, gives rise to incontinence without distention of the bladder. The urine dribbles from the urethra as fast as it enters the bladder. R. H. Jocclyn Swan. MUCUS IN THE STOOLS.— This occurs in such a variety of conditions that it is impossible to give a complete differential diagnosis of them here. Its presence always indicates organic disease, usually of the large bowel, for if it comes from the small bowel it wUl, unless the motions are very fluid, be so incorporated with them that it cannot be seen. It occurs in malignant disease of the colon as a clear glairy raucus, often bloodstained, and it has the same characters in intussusception, for the obstruction in both these cases accounts for the absence of faecal colouring. It is often seen in constipated motions, the hard motion having led to irritation of the large bowel, with consequent excessive secretion of mucus ; if this has lain some time in the bowel it has become coagulated into white shreds, which can be seen attached to the motion and look like parasitic worms. In severe cases a motion may consist almost entirely of these shreds ; there may be little fascal matter ; if it has not lain so long in 444 MUCUS IN THE STOOLS the bowel, it appears like a jelly outside the motion. Sometimes, especially in adult women who are constipated, complete casts of the bowel formed of coagu- lated mucus are passed ; they may be a foot or raore in length {Fig. 123). Often, however, by the time they are passed, they have become broken into fragments which the patient describes as skins, and which look not unlike segments of tape-worm. Patients passing this variety of mucus are said to have mem- branous colitis. In the more acute varieties of inflammation of the bowel, the ■Fi[?. 123. — Tubular mucous cast of large intestine, from a case of muco-membranous colitis. The cast measured 255 inches in length. mucus passed is jellj^-like and semi-fluid, of varying colour according to the amount of faecal staining. In severe cases of enteritis the motions consist of nothing but mucus and blood. It is impossible to attempt to differentiate here between all the numerous varieties of enteritis. w. Hale White • MUCUS IN THE URINE is generally of little chnical significance. Many normal urines, particularly those of women, develop a faint or even a more definite deposit of mucus, which may remain in suspension or may accumulate as a light fioccular deposit at the bottom of the specimen-glass. Such mucus is a normal product of the epithelial cells of the urinary passages. It is not possible by merely looking to say whether it is in excess or not. It may indicate catarrh of the mucous membranes ; but such catarrh will be shown more decisively by the occurrence of epithelial cells or actual pus corpuscles, or bj' a cause for catarrh such as Oxaluria [q.v.) ; diagnosis depending not upon the mucus but upon the other substances present with it. It is important not to mistake elongated strands of mucus for tube-casts ; the error is particularly apt to occur if the cover-glass, on being pressed down on a specimen stained with methjdene blue, shps slightly and draws out the mucus into long narrow strands. When large numbers of these are seen all parallel with one another, they are not likely to be mistaken for casts. Mucus stains readily either with methylene blue or with eosin, but exhibits no structure beyond granular particles, or cells that may have become entangled in its meshes. If a male patient has formerly suffered from gonorrhoea, a residual catarrh of the glands in the prostate often persists long after the cure may have seemed to be complete. Urine from such a case, looked at in a tall glass vessel, often exhibits numerous filaments or "prostatic threads," consisting for the most part of mucus coming in the form of casts from the prostatic tubules. Herbert French. MYDRIASIS. — (See Pupil, Abnormalities of the ) MYOSIS — (See Pupil, Abnormalities of the.) NAILS, AFFECTIONS OF THE. — Various pigmentary and degenerative changes may occur in the nails as the result of occupation, as in dj^ers, washerwomen, jewellers, and others ; or the condition known as pterygium may arise, the fold NAILS, AFFECTIONS OF THE 445 of skin at the proximal end of the nail adhering and growing over the nail, like a " wing." These appendages are liable to attack also in such cutaneous affec- tions as ringworm, favus, eczema, psoriasis, and epidermolysis bullosa. The differences between the onychomycosis due to ringworm and that due to favus are described in the article on Fungous Affections of the Skin. In eczema, usually the first sign of involvement of the nails is pitting, which gives them an appearance somewhat resembling orange-rind. They become discoloured and thinned, transverse and longitudinal splitting follows, and finally exfoliation may occur. In long-standing cases they may be thickened to the extent of deformity. In psoriasis, if the matrix of the nails is attacked, they become furrowed transversely, and dull in colour ; later the nails split and may be shed, but not permanently. In other cases, instead of the matrix being affected, the nails are discolored about the free border, and they become thickened as the discoloration extends downwards to the root. In epidermolysis bullosa there may be repeated bleb-formation at the finger-ends, causing atrophy of the skin and loss of nails. The signs of nail involvement in these three conditions are sufficiently distinctive to obviate confusion between them ; and the lesions else- where will aid the diagnosis. Trophic changes in the nails may also be consequent on acute illness or senile decay, or they may occur without any apparent cause : the longitudinal striae may be exaggerated, transverse furrows may appear, or white spots may develop, and a large part or the whole of the nail may become white (leuconychia). With this condition spoon-nails may be associated ; the nail becomes thin and hollowed, either from side to side or antero-posteriorly. Shedding of the nails may occur not only in distinctively cutaneous affections, but also in diabetes mellitus and syphilis, in locomotor ataxy and other nervous disorders. Either without definite etiology, or in connection with inflammation of the finger-tips, the nail may be separated from its bed without being actually shed. Onychia, or inflammation of the nail, is in some instances due to syphilitic or tuberculous infection ; in the latter case associated scrofulous lesions will often be found in the eyelid and elsewhere. Onychia, however, may also be due to trauma, or may be idiopathic. Whatever the cause, the condition cannot be mistaken. If the process is acute there is great pain, with redness ; suppuration takes place beneath the nail, which becomes thickened and discoloured, and is ultimately shed, leaving an unhealthy sore. If this should fail to heal, the lymphatics may be involved, and the case becomes one of paronychia, or whitlow. This condition is sometimes caused by the pressure of tightly-fitting boots, or by irritation set up by the edge of a badly-cut nail — usually that of the big toe. Onychorrhexis, brittleness of nails, may be either congenital or acquired. It is sometimes present in cheiropompholyx, and in other cases is associated with nervous affections and anomalies of development. In onychauxis, hypertrophy of the nail, there may be overgrowth in one or in all directions, accompanied by distortion or discolora- tion, and sometimes by inflammation. In some cases the free end may grow to a great length, and may become twisted like a ram's horn (onychogryphosis). This curious distortion is often found in connection with congenital ichthyosis. A rarer condition of modified nutrition is that known as egg-shell nail, which is intimately associated with hyperidrosis ; it has been met with in debilitated young women ; the nail tends to grow upwards rather than forwards ; its connection with the distal portion of the bed is enfeebled ; and in typical cases the colour is precisely that of the inner face of the shell of a hen's egg — a delicate combination of white and purple. It has been suggested that, owing to the maceration of the distal portion of the nail-bed due to hyperidrosis, there is interference with the normal cornification of the nail-plate. Whatever the process, the diagnosis is clear. Malcolm Morris. 446 NAPKIN-REGION ERUPTIONS NAPKIN-REGION ERUPTIONS.— Infantile eruptions in this region, when they are a manifestation of congenital syphilis, are usually erytheraatous or papular, but they may also be pustular, bullous, squamous, or polymorphic ; in all cases alike they are symmetrically distributed on the buttocks. Frequently, around the anus and the genital organs the papules are moist and coalescent, and form flatfish condylomata. Similar lesions are also found on the soles, palms, forehead, and around the mouth, and in these regions also the distribution is symmetrical. The eruption is as a rule transitory. The other symptoms of hereditary syphilis are so characteristic that the lesions here described are seldom liable to misinterpretation. The skin eruption is usually preceded by a chronic coryza (" snuffles ") and laryngitis. Often the nails are severely affected coin- cidently with the skin. The colour of the lesions, approximating to the char- acteristic raw-ham tint, the loose, dry, cafe-au-lait skin, the senile aspect of the face, the accompanying cachexia, form, with the symptoms mentioned above, a distinctive clinical picture. A napkin-area eruption which was often mistaken for congenital syphihs until Jacquet showed that it had no specific character, is that which is styled by Adamson the infantile erythema of Jacquet. It is a process which manifests itself in : (i) Simple erythematous, (2) Erythemato-vesicular, (3) Papular, (4) Ulcerating forms. These may develop consecutively or coincidently. The most common forms are the erythematous and the papular. All alike are probably due in part to the irritation set up by moist or soiled napkins, but vasomotor irregularities and gastro-intestinal toxaemia may also be con- cerned in the etiology. The preference sites of all four forms of the eruption are the convex surfaces of the buttocks, of the thighs, and of the scrotum or vulva. In the simple erythemas, of which the usual subjects are quite young infants, the rash may be limited in mild cases to the genitalia, the inner sides of the thighs, and the perineum, while in severer cases it may extend to the lumbar region, the lower abdomen, and the calves and heels. In the erythemato-vesicular form there appear on the convex surfaces towards the centre of the erythematous areas small bright-red erosions which, form- ing groups of from two or three to a dozen or more, may become confluent. The earlier form of the erosion is a vesicle, and this typical lesion may usually be found near the borders of the reddened area. The third or erythemato-papular form of the eruption is met with when the erosions just described have thrown up flattened granulations, which give to the lesions the appearance of flat, reddish papules. In this stage the heels and the lower abdomen may be involved in the erythema. In the fourth form of the eruption, the erosions, failing to granulate, develop into ulcers, with sharply defined borders or coalescing into vermicular lesions. They are confined to the convex surfaces, the folds always escaping. Attention to the appearance and distribution of the lesions, and the course they run, together with the absence of the more familiar signs and symptoms of congenital syphilis, will prevent confusion with that disease, or with the condition which Colcott Fox has styled vacciniform ecthyma of infants. Pemphigus neonatorum consists of an eruption of bullae on the thighs and buttocks in new-born infants. It is not, however, confined to this region, but attacks other parts, including the face, and this is true also of the bullous impetigo of older babies, which Adamson believes to be, like pemphigus neonat- orum, a form of the impetigo contagiosa of Tilbury Fox. The diagnosis of these affections has been given under Bull.'e. The " seborrhoeic eczema of infants " has been styled " seborrhoeic dermatitis of infancy " by Adamson, who was the first to lay stress upon its special incidence NIGHTMARES 447 upon the napkin region, and who does not regard it as a form of eczema. The whole napkin region is occupied by a uniform bright-red rash, for the most part covered with moist or greasy yellowish scales, though in prominent parts the surface may be smooth and polished. The margins of the area are sharply defined. The rash often extends downwards to the thighs and calves, and upwards to the umbilicus, while beyond this area there are smaller patches and many pin-head, red, scaly papules. Other parts that are frequently attacked are the bends of the knees, the flexures of the elbows, the axillae, the side of the neck, the naso-labial fissure, and behind the ear. On the scalp will always be found a red, squamous or crusty eruption. The diagnosis rests upon the distribution and the sharply defined margins, with the patches and crusted papules. It is assisted by the readiness with which the eruption yields to mild local parasiticidal applications. In cases of congenital syphilis which mimic this condition, the presence of the concomitant specific signs, as enumerated above, will prevent confusion between that disease and " seborrhoeic eczema." In adults the same region, known as the bathing-drawers area, is liable to attack in a number of affections. In eczema marginatum (tinea marginata, as I prefer to term it), dhobie's itch, and erythrasma the eruption occurs exclusively, or almost exclusively, in this region ; of these affections the differential diagnosis has been given under Ringworm (p. 272). In pediculosis pubis the pubes may alone be affected, or the parasite may wander to the abdomen, the thorax, the axillae, and may even reach the beard, whiskers, and eyelashes. The diagnosis of this condition can present no difficulty. In scabies the lesions may be very slight on the hands and wrists, and the brunt of the attack may be borne by the penis and scrotum, the lower part of the abdomen, and the thighs. (For the diagnosis see Vesicles.) In psoriasis the eruption is sometimes very severe in the bathing-drawers area, of which the surface is an almost uniform deep red, and is the seat of profuse desquamation, while on the special sites of election — the arms and legs — the lesions may be quite insignificant. (For the diagnosis, see Scales.) In eczema intertrigo and eyythema intertrigo the folds in the area under consideration are only liable to attack in common with folds in other parts. The diagnosis of these affections has been given elsewhere ; but it may here be mentioned that in diabetes, eczema may begin on the penis or the vulva, and may spread thence to other regions. Other conditions which may specially affect this area are : acute traumatic erysipelas, pruritus ani (see Pruritus), small-pox in the prodromal stages, and the various forms of syphilis. In syphilis the commonest site for the moist papule is around the anus and genitalia (see Papules) . Malcolm Morns . NEURITIS, OPTIC — -(See Ophthalmoscopic Appearances, Notes on.) NIGHTMARES may occur at any age, but they are particularly common in children between four and eight, when they may be so bad and persistent as to merit the term night-terrors. The commonest cause for a nightmare in an adult is some indiscretion in diet, the last meal having been taken too late in the evening, or else having contained some injudicious article. The symptom is not otherwise of diagnostic import, though some individuals, particularly those of nervous inheritance, are more liable to nightmare than others, and the tendency is certainly increased by such excitement as the reading of thrilling novels or participating in unusual events. Children are particularly prone to night-terrors during term-time, when they are working at high pressure ; during the holidays the symptom often disappears. Those who are keenest upon their school work are apt to suffer most, and similar evidence of excitability of the nervous system is exhibited particularly by those who have a tendency to acute 448 NIGHTMARES rheumatism in the form of chorea. Night-terrors may occur in these patients without any other cause than over-pressure, particularly if they he upon the back rather than upon one side during sleep ; but the tendency is much increased by errors of diet, such as the eating of unripe fruit and so forth, by the presence of intestinal worms, and by the existence of adenoids, with or without enlarged tonsils, so that when night-terrors are a prominent symptom in the case, particular examination for any of these exciting causes should be made. Herbert French. NODULES. — In ordinary dermatological usage, the term nodule or node is applied to solid elevations larger than a papule and smaller than a tumour. This definition, however, makes no pretence to scientific exactitude, for while some new growths of quite small size are classified as tumours, certain lesions of leprosy and tertiary syphilis, for example, although smaller than a pea, are styled nodules. To formulate a definite canon of size would be an arbitrary and unprofitable proceeding ; and from this article no lesion commonly accepted as a nodule will be excluded because it does not conform to a rule-of- thumb definition. The term " tubercle " is sometimes employed as a synonym for " nodule," but now that it has acquired a special meaning as denoting the characteristic lesion of tuberculosis, its use in the older sense should be discontinued. Nodules differ from papules not only in size but also in their greater tendency to downward growth ; the substantial difference between a nodule and one of the larger papules is that the one is a solid lesion extending upwards, while the other is a solid lesion projecting both upwards and downwards. Nodules maj^ be neoplastic, or hypertrophic and inflammatory. The ordinary colour is a dull or brownish red, but they may be pink, or a dark purple. Generally rounded, they are sometimes flatfish, conical, or of irregular shape. They vary from each other in the course they run, not less than in colour and form. They may be absorbed, as papules so frequently are ; they may degenerate and ulcerate, and be followed by scars, or they may persist indefinitely. Little need be said here of the nodules met with in some malignant diseases, for the differential diagnosis of carcinoma and of sarcoma will be found under Tumours of the Skin. Fibroma, myoma, and cysts are also dealt with under this heading, and glanders in the article on Pustules. The nodules of lupus vulgaris, arising in either the superficial or the deep part of the corium, are soft, brownish-red, and translucent, resembling apple jelly. At first buried in the skin, they presently appear as discrete papules the size of a pin's head, arranged in groups or in irregular circles, dull red at the outset but afterwards pale. Gradually the papules develop into nodules, the intervening skin meanwhile becoming thickened by cellular infiltration, reddened by inflam- matory stasis, and raised into a patch which is covered with fine branny scales. Around the edge of the patch new nodules spring up, and thus a large area of skin may be invaded. The disease usually starts from a single focus, but others may arise and, spreading separately, may involve large areas of cutaneous surface. The patch may undergo slow involution and be followed by scarring ; but much more often ulceration occurs, the sore being covered with a greenish- black crust, around the ragged edges of which will be seen apple-jelly nodules in various stages of development. In parts like the nose there may be necrosis of cartilage, but there is never erosion of bone. The apple-jelly nodule is the chief diagnostic feature of lupus vulgaris. In typical cases the patch described above, with its infiltrated, raised surface, its well-defined edge studded with the nodules, and its covering of fine scales, can hardly admit of misinterpretation. Less typical cases may require to be differ- entiated from lupus erythematosus, rodent ulcer, epithelioma, scrofuloderma and NODULES 449 syphilis. Lupus erythematosus begins as minute red points, not as dull-red papules, and the lesions never develop into apple-jelly nodules, nor do they ever ulcerate or extend to the deeper parts and erode cartilage. They are symmetrical in distribution, as lupus vulgaris scarcely ever is, and the affection seldom appears before puberty, as lupus vulgaris almost invariably does. It is only when the lesions peculiar to lupus vulgaris are masked by cedematous swelling that the two affections can be confused ; but if the skin at the spreading edge be stretched, small amber-coloured nodules can usually be seen. In rodent ulcer there is usually but one lesion, which runs a much more sluggish course than the nodules of lupus vulgaris ; the ulcer has an indurated border and a firm base, and penetrates deeply into the tissues ; and the disease is essentially one of later life (see Ulceration of the Face). Epithelioma, again, is a disease of later life. The hard, everted edge of the growth, the foul base, frequently roughened with warty formations or sprouting with caulifiower- like excrescences, the implication of neighbouring glands (which very occasionally, however, occurs in lupus), and the secondary deposits, form quite a different clinical picture from that of lupus vulgaris. In one form of scrofulodermia nodules develop under the skin, and an ulcer is formed which is bordered by dark bluish, thin, undermined skin that has too little vitality to allow of repair. But there is no infiltration, as in lupus vulgaris, the nodules do not present the apple-jelly aspect, and other evidences of the disease will be found on the neck or elsewhere, in the form of enlarged glands or scars. As, however, the two conditions frequently co-exist, and the treatment is virtually the same, diagnosis between the two is of little practical importance. In the diagnosis from " lupoid " tertiary syphilis, again, the apple- jelly nodule of lupus vulgaris plays the chief part. The syphilitic process, further, is much more rapid, nor is acquired syphilis generally a disease of early life. The nodules and ulcers of late syphihs — neoplasms that grow by infiltration of the surrounding parts and often break down into ulcers which are prone to become serpiginous, and show little or no tendency to spontaneous cure — have in turn to be differ- entiated from other conditions. They may be mistaken for abscess, but if opened they give issue not to pus but to a gummy hquid. If the ulcer into which the gumma breaks down be on the leg, it may resemble callous ulcer, but its obduracy to ordinary treatment and its response to the iodides will reveal its true nature. From syphilitic ulcer rodent ulcer differs in its hard edge, and red, shining, dry floor, as well as in its favourite situations ; from epithelioma, in that a process of new growth has preceded the ulceration ; from scrofulodermia, in the undermined border of the ulcers and the slow rate of the pathological process. In yaws, as in syphilis, the nodule is the most characteristic lesion of the tertiary stage. It arises in the subcutaneous tissue, and generally leads to the formation of superficial ulcers which spread serpiginously, like the ulcers of tertiary syphilis. New nodules frequently appear in the neighbourhood of the older ones, and masses resembling syphilitic gummata may form and break down into ulcers. These late ulcers mostly appear on the lower part of the leg, especially around the ankle, but they are not uncommon about the lips, and indeed may occur in any part of the body. The clavicle, sternum, ulna, tibia, and the metacarpal and metatarsal bones, are often the sites of nodules which may occasion permanent thickening, or break down and cause ulcers. Between yaws and syphilis there are obvious resemblances in the tertiary stage, but there are marked differences in the primary and secondary stages. In yaws the inoculation lesion is not indurated, there is seldom distinct glandular enlarge- ment, the mucous membrane lesions of syphilis are absent, and the niost char- acteristic lesion, which appears in the secondary period, is the framboesial D 29 450 NODULES granulomatous excrescence known as the yaw (see Scabs). In yaws, the exan- them, the alopecia, the iritis, the affection of the permanent teeth, the bone lesions, the polymorphism, the nerve lesions and the gummata of syphilis are wanting. Yaws is never hereditary nor congenital ; yaws and syphilis confer no immunity as against each other, nor does one ever give rise to the other ; and as Manson remarks, yaws may die out in a community while syphilis remains, or it may be universal in a community where syphilis is unknown. The minute histology of the lesions of the two diseases also furnishes important differences. From tuberculosis yaws differs (apart from the tubercle bacillus) in the absence of the characteristic tuberculous architecture with its giant-cells and daughter plasma-cells, more marked disintegration of the fibrous stroma and complete disappearance of the blood-vessels. In leprosy the nodule {Fig. 124) marks one of the three types of that affection, the others being nerve or anaesthetic leprosy, and mixed or complete leprosy. In nodular (or tubercular) leprosy the macules which are always the primary lesion are transformed into nodules by sudden increase of inflammatorj^ infiltration. When fully developed they vary in size from a small shot to a filbert, or larger, are round or oval, but raised considerably above the level of the skin. They may mimic lupous nodules, syphilitic papules, rosacea, erythema nodosum, or sycosis. Sometimes telangiectases may be observed on their surface. They are elastic to the touch, are at first sometimes hyperjesthetic, but later very • frequently become temporarily or permanently anaesthetic. Nodules on the mucous membranes are red or grey, and may resemble syphilitic lesions. Both on skin and on mucous membrane they tend to break down, but in exceptional cases they either undergo cicatricial shrinking or reach the ulceration stage by way of suppuration. The differential diagnosis of leprosy in the macular stage is given under Macules. In the later stages the identification of the disease seldom presents difficulty. The nodules of leprosy may resemble those of lupus vulgaris and the tubercular syphilide, but the lupous and syphilitic eruptions are both of limited extent, and there is no anaesthesia. The syphilide also is serpiginous, or occurs in crescentic groups. In the early stage of nodular leprosy the lesions may strongly resemble those of erythema nodosum, and,, as in that affection, there may be pains about the joints. But if the case be one of erythema nodosum the nodules will disappear within a fortnight, though successive crops may arise for three or four weeks longer. To differentiate erythema nodosum from other conditions than nodular leprosy its clinical features must be briefly described. Preceded and accompanied by pains about the joints, by pyrexia and other symptoms of constitutional dis- turbance, oval nodules, ranging in size from a walnut to a hen's egg, appear on the legs and feet and, less frequently, elsewhere. In colour they are at first bright red, but soon become bluish in the centre and purple at the periphery, exhibiting as they subside the changes of tint presented by a bruise. Erythema nodosum is an affection of adolesence, and girls are attacked by it twice as often as boys. There is never ulceration, and this, with the pains and swellings about the joints, distinguishes it from syphilitic nodules. The same features distinguish it also from an erythema of the legs, the result apparently of excessive standing, to which young girls are sometimes subject, and from the node-like swellings which some- times occur in the legs of women suffering from varicose veins. The absence of ulceration and the presence of joint-pains are points which differentiate erythema nodosum from erythema induratum scrofulosorum (Bazin's disease). Here the nodules, which occur chiefly on the legs, are at first sub- cutaneous, and can only be felt, not seen. They are generally discrete, but may become fused together into a solid, infiltrated mass, and are apt to break down into irregular ulcers. They differ from the nodules of erythema nodosum NODULES 451 not only in the features already noted, but also in colour, being violet instead of bright red, and undergoing successive changes of tint. From gummata they differ in being less painful and inflammatory, and in running a less rapid course, as well as in being more numerous, and in attacking both legs. The only effect of antisyphilitic treatment is to aggravate the condition. The nodules of erythema keratodes differ from those both of erythema nodosum and of erythema induratum scrofulosorum in that they appear only on the back of the finger-joints, while on the palms and soles there is overgrowth of the horny tissue, accompanied by oedema and tenderness. Fig: 124. — A tj'pical case of nodular leprosy in a Norwegian. (From a j>hotograph by Dr. Arinauer Hansen.) The condition which Boeck designated multiple benign sarcoid, or miliary benign lupoid, presents some resemblance to lupus and sarcoma. The nodules, at first rose-coloured, afterwards become livid, then brownish. In size they vary from a millet seed to a large bean. The favourite sites of the eruption, which is always symmetrical, are the face, shoulders, wrists, and the extensor surfaces of the upper limbs ; but exceptionally the scalp, the back, and the lower limbs are attacked. Occasionally the lymphatic glands are enlarged. The nodules never break down, but after a period, it may be of several years, shrink and 452 NODULES disappear, leaving a slight atrophic scar. The affection, which often accom- panies visceral tuberculosis, is distinguishable both from sarcoma and from lupus vulgaris by histological examination, as well as by the course it runs. From the latter affection it is distinguished also by the negative reaction in inoculation experiments. In a final paragraph I ma}^ deal with nodules which belong rather to general medicine than to dermatology. One is the subcutaneous nodule of acute vheu- inatism. It generally presents over the sheaths of tendons and the fascia covering bony prominences, around joints, and on the scalp. The nodules may be as small as a pin's head or as large as a bean. Within Umits they can be made to ghde on the underlying tendon-sheath or fascia. They are sometimes met with in adults whose hearts have not been damaged by the toxsemia, but much more frequently in children with distinct valvular lesions, and according to some authorities they are analogous to, if not identical with, the nodules that have been found post mortem on the borders of the mitral curtain. The coincidence of nodules such as these with rheumatic fever can leave no doubt as to their true nature. Heberden's nodes, the little knobs on the finger-joints which are caused bv osteophytic outgrowths from the bases of the distal phalanges in certain elderly persons are unmistakeable. Multiple subcutaneous cysticerci are a rarit}^ the diagnosis of which may be suggested by the eosinophilia, but can onh^ be clinched by excision and microscopical examination of one of the nodules. Malcolm Morris. NOISES IN THE EARS.— (See Tinnitus.) NUMBNESS OF THE FINGERS.— (See Sensation, Abnormalities of.) NYCTALOPIA — (See Vision, Defects of.) NYSTAGMUS. — Several varieties of associated tremor of the two eyes are comprised in nystagmus. These are : (i) Searching movements ; (2) Pseudo- nystagmus ; and (3) Nystagmus proper. 1. Wide purposeful and slow movements of the ej^es in all directions are usually seen in people who are born blind or have lost the power of fixation as the result of some obstruction of the retina or choroid at the yellow spot. The eyes appear to be seeking for something but never rest on any definite object. 2. Pseudo-nj^stagmus, which is commonly confused with true nystagmus, is the term applied to rapid jerking movements of the eyes when they are carried to the extremit}^ of an excursion in any direction. The eyes, instead of remaining fixed on the object, rapidly recede from their position and return to it at the rate of four or five oscillations a second. This condition is a characteristic symptom in Friedreich' s or hereditary ataxy, and is also met with in 40 or 50 per cent of cases of disseminated sclerosis and in many cases of cerebellar tumour. For the differential diagnosis of these conditions see Paraplegia. 3. Nystagmus proper is the term applied to the condition in which the eyes make rapid regular oscillations about a fixed point, not only at the extremity of an excursion, but when the eyes are otherwise at r-est, and looking directly forward. The oscillations may be in the vertical or the horizontal meridian, or may in some cases exhibit a rotatory form. The condition is usuall}^ bilateral, though it is occasionally met with affecting one eye only, and in some rare cases the character of the nystagmus may differ in the two eves. True nystagmus is caused by : — {a). Conditions causing defective vision in the early months of life. As a result of such affections, the macular region is not differentiated from the sur- rounding portions of the retina as is the usual course in the early months of infant life, and power of fixation is never acquired. Conditions which may OBESITY 453 thus cause nystagmus are ophthalmia of the new-born, congenital cataract, colour blindness, albinism, and certain cases in which there is an unusual distri- bution of the retinal pigment. The diagnosis of these various conditions depends on an accurate examination of the eye. [b). Conditions developing in later life due to constant strain from peculiar occupations, as for example miners' nystagmus, which is due to the continued work in a cramped position with the eyes constantly directed upwards. As a rule it improves on the cessation of the occupation which causes it. (c). Aural irritation, in which it is usually associated with vertigo. {d). Nj^stagmus may also occur in about 12 per cent of all cases of dissemin- ated sclerosis. {e). In certain cases of cerebellar tumours it is a marked symptom, and it may occur : — (/). In various rare conditions, after traumatism or poisoning, and possibly s>Tingomyelia. H. L. Eason. OBESITY implies an excessive accumulation of fatty tissue in the body. It is not necessarily pathological, but even in otherwise healthy persons obesity ultimately incommodes them, and is very liable to lead to cardiac symptoms due to fatty changes in and around the heart. The following are some of the chief causes : — Testicular atrophy or excision Ovarian insufficiency Hypothyroidism Hj^pernephroma Adiposis dolorosa ) or Dercum's Diffuse lipomatosis ) disease. The majority of the above need little discussion. Families in which all the members tend to run to fat are familiar enough ; the individuals maj' weigh Heredity Continued over-eating Continued drinking of malt liquors Too little exercise A pre-glycosuric state Chronic parenchynaatous nephritis J^!^. 125. — A girl, aged 6, suffering from hypernephroma, which proved fatal from secondarj- deposits in the lungs : the photograph shows the premature development of pubic hair, which in this case appeared at the age of eighteen months. anything from i6 to 30 stone, without necessarily being ill. Over-eating, over- drinking, and under-exercising are generally obvious if the patient's mode of living is known. The pre-glycosuric state is particularly important from the point of view of life insurance : when a young man or woman under thirty- five begins to run to fat without apparent cause, it is clear that there is an error in his metabolism ; there may be no glycosuria at this time, but in quite a 454 OBESITY number of these cases the error of metaboUsm develops as time goes on, until presently there is glycosuria, and finally typical diabetes mellitus. Chronic parenchymatous nephritis sometimes gives rise to a large, pale person, who looks, and is, fat and flabby. Part of the apparent fatness may be due to excess of fluid in the tissues, but there need be no obvious oedema with pitting on pressure. There may or may not be a history of previous acute nephritis — some of these cases arise insidiously : the diagnosis is not difficult, however, where renal tube casts and an abundance of albumin are found in the urine, particularly if there is a big heart, a prolonged first sound at the impulse, a ringing aortic second sound, a high blood- pressure, and perhaps albuminuric retinitis. Testicular atrophy or excision as a cause for undue fatness is best exemplified by eunuchs ; similar fat accumulation sometimes occurs in less degree as the result of atrophy after bi- lateral gonococcal orchitis or epididymitis ; it does not follow tuberculous destruction, for the patient then wastes instead. Palpation of the scrotum may indicate the diagnosis. Ovarian insufficiency is probably a potent cause in certain women for undue stoutness, but it is difficult to prove this, because many of the patients suffer from hypothyroidism at the same time : there is a close inter-relation- ship between the thyroid gland and the ovaries. Only a small proportion of those cases in which both ovaries have been excised become obese ; but when the normal ovarian activities are beginning to abate, especially at and immediately after the menopause, it is common for women to become very stout. They develop at the same time peculiar nervous symptoms, and it is remarkable how easily both the latter and the obesity may be relieved by relatively small doses of thyroid extract ; such cases may be termed sufferers from hypothyroidism, even though they may not have the typical signs of complete myxoedema — increasing stoutness, loss of strength, broad features, increasing slowness of the intellect, broadening and thick- ening of the fingers and hands, malar flush, and falling out of hair and eyebrows. The best test of the diagnosis is the effect of ad- ministering carefully graduated doses of thyroid extract. There are certain boys and girls — especially boys — who tend to become enormously fat long before they reach the age of puberty. The papers were full of a typical example of this malady a while ago — the Fat Boy of Peckham. There is reason to suppose that this abnormal development of fat and size is a disease associated with an affection of a suprarenal capsule or kidney — hypernephroma. The latter does not always cause this overgrowth, however, for in another type of patient the tumour leads merely to premature develop- ment of the pubic hair and external genitalia. Figs. 125 and 126 are from a girl, aged seven, who had had thick pubic hair since she was eighteen months old. Fig'. 126 — Thesame case as Fig. 125, after removal of the pubic hair : show- ing the hypertrophy of the external genitalia, without development of the breasts. (EDEMA, ASYMMETRICAL 455 The clitoris was enlarged, but there had been no menstruation. The diagnosis was confirmed post mortem, the congenital suprarenal tumour having produced secondary deposits in the lungs after seven years. Adiposis dolorosa, diffuse lipomatosis, and Dercum's disease all seem to be closeh' related. There are two types — the alcohohc and the congenital syphilitic ; the former is the commoner, and occurs in older patients than does the other. Extreme fatness develops, but not quite universally ; the abdominal wall, especially on either side of the umbihcus, the neck, shoulders, arms, forearms, thighs, and legs may become enormous, but the hands, feet, scalp, ears, nose, and forehead escape. The patient's muscular power, as tested by the dynamometer, is very small, sometimes not a tenth of the normal ; and when any of the fat parts are taken hold of firmly, without any pinching or other procedure that would be unpleasant to an ordinary patient, some of these cases experience acute pain — the name adiposis dolorosa describing the tr\vo main symptoms of the malady. There are often mental symptoms at the same time ; a patient of thirty may periodically imagine she is only eight, and behave and speak as though for the time being she were a child again ; and so on in other cases, the types of mental symptoms being protean. Superficially these cases may simulate myxoedema, but a moment's observation will show that there is no affection of the hands and feet, which are just the parts to be first broadened and thickened by myxoedema, besides which thyroid treatment does not bring about material improvement. Herbert French. OBSTIPATION.— (See Constipation.) OBSTRUCTION, INTESTINAL (See Vomiting.) (EDEMA, ASYMMETRICAL. — By this is meant oedema of one leg or arm which is not due to such a cause as renal insufficiency or cardiac failure, but to obstruction to the venous or lymphatic outflow from the limb. It may be due to any of the following causes : — Congenital. Constriction by amniotic bands Communications between arteries and veins. Acquired. Blockage of veins : 1. From within — non-infective thrombus, varicose veins infective thrombus, e.g., white leg 2. By pressure from without — by glands, tumours, aneurj^sms, etc. Blockage of lymphatics, e.g. in cellulitis, filaria, etc. Artificial, by hgature Angioneurotic oedema. Congenital Causes. — These are so easily identified that no further mention of them need be made. Acquired Causes. — The diagnosis may be obvious : For instance, there may be a well-marked cellulitis, with red streaks extending up the limb showing the course of acutely inflamed lymphatics. It is only rarely that a cellulitis presents any difficulty in recognition ; namely, when the inflammation is not very acute, and when there is no obvious source of infection, such as an abraded toe or a suppurating wound of a finger. Cellulitis may then be confounded with gout ; but the history, the presence of leucocytosis, and the absence of other gouty manifestations will indicate the real complaint. There may be considerable pyrexia in acute gout, so that the temperature chart does not serve to distinguish it from cellulitis. 456 (EDEMA , A S YM METRIC A L Varicose veins are a frequent cause of asj^mmetrical oedema, especiallj^ in the lower limb, and, if there is thrombosis as well, very marked swelling is the result. The thrombus, however, does not always lie in a superficial varicose vein, and if it is in one of the deep veins such as the popliteal, femoral, or iliac, the case may not be so clear. The thrombus in these cases is often due to septic infection, and the common source is sepsis in connection with the uterus following parturi- tion — white leg — or in the course of typhoid fever. When none of these causes is present it is necessary to examine carefully, in order to ascertain whether there is any swelling pressing on and obstructing the veins, such as an aneurysm in the popliteal space or a mass of malig- nant glands ; and not only must the whole limb be examined, but also the rectum, vagina, and lower part of the abdomen, and the neck and upper thorax in the case of the leg and arm respectively. For instance, there may be a tumour springing from some structure in the pelvis causing pressure on the iliac veins ; and swelling of the arm might be caused by an aneur- ysm, subclavian or thoracic, or by a mediastinal new growth. Lymphatic Obstruction. — In the case of oedema due to venous obstruction there will be marked pitting on pressure, but where the lymphatics only are blocked the oedema is much more solid ; this may be an important diagnos- tic point. As has been mentioned, cellu- litis is a fertile cause of h'mphatic obstruction. Elephantiasis. — In England it is not conrmon to find true ele- phantiasis, that is to saj' blockage of lymphatics by the parasite filaria sanguinis hominis, though a pseudo - elephantiasis, due to long-standing hmrphatic obstruc- tion, with resulting roughening, thickening, and fibrotic changes in the skin and underlying tissues, is not uncommon, and maj- result from long continuance of a tumour, or be associated with a badly-united fracture, or follow some operation in which the Ijmiphatics have been removed, e.g. after amputation of the breast and axillar}- contents for carcinoma. Probably the most difficult group of all cases to diagnose is that in which there is a thrombus of one of the deep veins of the leg without any obvious disease, and in this event the diagnosis can only be arrived at by a process of exclusion. Milroy's Disease {Fig. 127) is diagnosed from the family history (see p. 460). Ligature. — It sometimes happens that a patient, generallj' a female, presents Pig. 127. — Milroy's or Meige'.s disease : A case ol unilateral hereditary trophcedema of the leg. The condition had developed spontaneously in a girl who had never been out of England, and who suffered little inconvenience from the affection. She was 21 when the photograph was taken, and had had the swelling for years. (EDEMA, SYMMETRICAL 457 herself with an oedema of a hmb for which no explanation can be offered. It has to be borne in mind that there are some neurotic individuals who will tie a ligature round their limbs in order to simulate disease or to excite sj^mpathy, and who have even gone so far as to suffer amputation. It is often extremely difficult to detect the fraud ; but if the possibility be suspected, the nurse in charge must be instructed to keep watch, and at unexpected times to search the patient, when a handkerchief or a piece of string may be found constricting the limb. The fact that the upper limit of the oedema is sharply defined should awaken suspicion. It may be difficult to differentiate this from angioneurotic cedema, but the latter condition is, as a rule, transitory, and affects different parts of the body, e.g. the tongue, lips, eyelid, hands, etc., at different times {Fig. 128, p. 458) ; the family history, and the fact that the patient has had previous attacks, generally point to the diagnosis at once. George E. Gask. (EDEMA, SYMMETRICAL. — Owing to accidents of posture— such, for instance, as the patient sitting with one leg to the ground and the other supported upon a chair, or lying in bed turned well over to one side, and remaining in this asymmetrical position for a long time — it is possible for oedema which would really be symmetrical to appear asymmetrical. Allowing for this source of fallacy, however, the causes of symmetrical oedema are different from those of asymmetrical oedema (see above). One may subdivide cases into three main groups, namely : — 1. Those in which the cedema is universal. 2. Those cases of cedema in which the swelling involves the face, neck, and arms, but not the legs or the lower half of the trunk. 3. Those in which the oedema affects the legs, or the legs and lower half of the trunk, but not the arms, neck, or face. (Edema of the legs is by far the commonest type, and by far the most important point in the diagnosis is to decide as soon as possible whether this cedema is due to Bright's disease, heart failure, or to some other cause. The broad distinction into these groups is seldom difficult. The urine should be tested at once ; if albumin be present, microscopic examination for renal tube-casts is essential, their presence indicating renal mischief, their absence probably excluding it, unless the renal lesion is very acute, in which case there will be renal epithelial cells even if there are no tube-casts ; if there be no albu- min in the urine, renal inflammation as a primary cause of oedema of the legs is unlikely. It will be easy as a rule to decide whether there is failure of cardiac compen- sation or not ; if there is, the differentiation between the four main groups of causes of heart failure, namely, primary valvular, primary muscular, primary lung affections, and primary arterial or renal conditions, will be made upon the lines indicated upon p. 18. Other causes for oedema of the legs will be suggested by other symptoms in the case or by the history, but they cannot be diagnosed with certainty until both renal inflammation and heart failure have been excluded. It seems worth while, however, to discuss in rather greater detail each of the main groups indicated above. I. Cases in which the (Edema is Universal. — When a patient has a tendency to universal symmetrical oedema, the great probability is that he is suffering from either primary acute nephritis or acute nephritis superposed upon chronic nephritis ; the diagnosis is indicated by the occurrence of albumin with tube- casts. The degree of oedema exhibited in different regions varies partly by reason of the looseness of the subcutaneous tissues in different places, and partly by reason of the effects of gravity. Other things being equal, the 458 (EDEMA , S YMMETRICA L oedema^shows raost in the legs, lumbar region (lumbar cushion), penis, scrotum, labia, eyelids, and face, though careful examination may show that there is some degree of oedema in every tissue from scalp to toes ; it is due to the influence of gravity that when the patient is up and about the oedema is most marked in the legs ; is very marked in the lumbar cushion and the genital organs when the patient sits propped up in bed ; and is most prominent in the eyelids when the patient has been lying horizontally, as during sleep. Other causes lor universal oedema are rare, but it may sometimes be due to a universal condition of angioneurotic cedema {Fig. 128), though this is much more often asymmetrical ; or to overloading of the tissues with fluid, — for instance, as the result of excessive transfusion or infusion, or in patients who have been swilling beer day after day until their bodies have become sodden. Such cases present an appearance highly suggestive of acute nephritis, but the absence of albumin from the urine, the history of excessive drinking over long periods, and the complete recovery when the drinking is stopped, point to the diagnosis. Certain poisons may produce universal oedema, though rarely ; iodide of potassium has been known to do so to a mild degree ; one of the effects of snake-bite also is to produce universal oedema with or without albu- minuria, though as a rule the part originally bitten is very much more swollen than are the other portions of the body. Only in very rare cases does heart failure produce oedema of the hands and arms as well as of the legs, and when it does so the patient usually has been ill some time, the diagnosis has already been made, and the end is not far off. 2. (Edema of the Face, Neck, and Arms, but not of the Legs or Lower Half of the Trunk, is nearly always due to obstruction to the superior vena cava or to the main branches which go to form this, and the commonest causes of this obstruc- tion are thoracic aneurysm, mediastinal new growth, or gumma, chronic mediastinal fibrosis, and thrombosis spreading to the main trunk from, for instance, an axillary vein infected from a whitlow or from other sources of phlebitis. When the swelling comes on acutely, as it may in any of the above conditions, acute Bright's disease may be simulated on account of the extreme puffiness of the eyes ; but further examination will show a remarkable limitation of the oedema to the head and upper limbs, whilst the urine will probably not contain albumin. If the obstruction to the superior vena cava persist, there will be evidence of collateral circulation in the form of varicose veins upon the chest wall (see Veins, Varicose Thoracic). It only remains to add that, instead of being asymmetrical, inflammatory lesions may sometimes produce almost symmetrical oedema of the face or neck. Fi^. 128. —Angioneurotic cedema of the eyelids simulating acute nephritis. (EDEMA, SYMMETRICAL 459 in -which connection one may mention erysipelas, celluliHs, anthrax, angina Ludovici, the differential diagnosis of which is based upon the history, the constitutional symptoms, the local appearances of the inflammation, and the results of bacteriological examination. Similar symmetrical swelling may be produced in the hands or arms either hj angioneurotic oedema (Fig. 128), or by allied vasomotor neuroses, such as Raynaud's disease. Swelling of the eyes and face suggestive of oedema maj'' sometimes be due to bouts of crying, prolonged attacks of coughing, as for instance in whooping-cough, or as the result of catarrh due to a coinnion cold, measles, or to the effect of such remedies as potassium iodide or arsenic. 3. (Edema of the Legs and Lower Part of the Trunk, without any of the Neck or Face, is suggestive of heart failure or of nephritis, and the main points that arise in the differential diagnosis have been discussed above. If both of these main groups of causes can be excluded, however, it is important to remember how often the legs may swell as the result of poverty of the blood in any condition of An.^mia [q.v.]. This is perhaps seen best of all in cases of chlorosis, for patients suffering from the severer tj'pes of anaemia, such as pernicious ancemia, lymphatic or splenomedullary leukcemia, Hodgkin's disease, splenic ancemia, pseudo- leukcsrnia. infantum, are less continuously up and about than are many cases of chlorosis. The same applies to the severe ancBniia which follows loss of blood from haemoptysis, haematemesis, post-partum and other haemorrhages ; or to the less acute anaemias that result from parasitic infections such as Bothrio cephalus latus ox Ankylostomum duodenale, or the effects of certain drugs ; or to cachectic conditions such as result from carcinoma, sarcoma, syphilis, tuberculosis, starvation, malaria and various other tropical infections. The differential dia- gnosis of the various conditions thus enumerated will seldom depend upon the presence of oedema alone, and each of the maladies will be found discussed under the heading of some other symptom. Obstruction to the inferior vena cava may lead to extreme oedema of the legs ; if due to phlebitis, the clotting of the inferior vena cava itself is nearly always preceded by that of the veins of one leg, so that even when the final result is symmetrical, the history' nearly always points to it having begun asjonmetrically. When the inferior vena cava is obstructed by new growth or by the pressure of ascitic fluid, the diagnosis will depend upon the discovery of some abnormal mass, or upon the interpretation of the cause of the Ascites [q.v.). Much difficulty sometimes arises, as in a case mentioned on p. 8. The influence of the vasomotor nerves in controlling the balance of h^mph production and lymph absorption in the legs is sometimes interfered with. One sees a good example of this in the oedema which develops in the lower extremities in convalescent patients when, having been long in the horizontal position from any cause, they first begin to walk about ; it is probable that a perfectly normal person kept at rest in bed for three months, would suffer from oedema of the legs in varying degree for some days or weeks after first beginning to use his limbs, and the tendency is still more marked in those who have been laid up hy gastric or duodenal ulcers, typhoid fever, fractured femur, and so on. The oedema of the legs in convalescents is a common symptom which may at first arouse a suspicion of some kidney lesion, though the absence of albumin, and the way in which the oedema disappears spontaneously in time, especially under the influence of massage, indicate the diagnosis when the histor\' is known of illness confining the patient to a horizontal position for some time previously. Diseased conditions of the vasomotor system may produce even more marked oedema, as seen in elderly people, in some cases of Raynaud's disease ; in angioneurotic oedema ; in association with peripheral neuritis, 460 (EDEMA , S YMMETRICA L especially in the tropical varietjr called heri-ben, an epidemic febrile illness associated with peripheral neuritis, and generally seen in this countrj' only in seaport towns, as the result of an outbreak amongst seamen on board ships in which the diet has consisted largely of not quite fresh rice. There is a peculiar hereditary disease in which oedema of the lower extremities, occurring in many members of a familj^ (Fig. 129), ma}' be a prominent feature; in the early stages this oedema is asymmetrical, affecting one leg before the other^ but sooner or later both legs may become in^-olved, until, if the family and personal history were not known, the oedema of Bright's disease might be suspected. The affection is known as Milroy's disease, Meige's disease, or hereditary trophoedema. The sudden demarcation between the swollen and the non-swollen parts at the level of a joint — ankle, knee, or hip — is a character- istic feature in many of these cases. There is sometimes a historj^ of periodic acute attacks of pjTexia, and of gastric disorder, associated with an increase in the swelling, not altogether unlike those occurring in angioneurotic oedema. The swelling ma}- cease at the ankles in the early stages ; when a subsequent spread occurs, it may reach almost suddenly up to the knees, ceasing there for a variable number of j^ears, until ultimately it spreads to the groins, above which it seldom extends. The diagnosis is easy when the family history is obtainable. Myxoedema is a condition in which the swelling of the legs ma}' simulate actual oedema very closely, and indeed in not a few cases the subcutaneous tissues of the feet and legs do pit to a certain extent, on pressure. When there is actual oedema as well as myxoedema, considerable doubt as to whether there may not be a cardiac or other factor, as well as th}Toid insufficiency, will arise. The urine will generally be found to contain no albumin, however ; the patient is nearly always a woman of middle age, who has recenth' begun to get much stouter, and at the same time less active both mentally and phvsically. The diagnosis of myxoedema will be confirmed if the untoward S}anptoms and the abnormal state of the subcutaneous tissues disappear under the influence of thyroid medication. It is not easy to include all the possible causes of oedema in a classified list, but the following include those which have been discussed above : — I. Universal (Edema. Primary acute nephritis Acute nephritis as an exacerbation of chronic nephritis Angioneurosis Excessive transfusion or infusion J^i^. 129. — Bilateral hereditary trophoedema of the legs in a girl of 21, twelve other members of the family being affected by the complaint also. She had never been out of England. There was no abnormality above Poupart's ligament. Milroy's or ]Meige's disease. (For a full account see Hope and French, Quart. Jour, of Med., vol. i, No. 3, p. 312.) Soddening from beer drinking Iodide of potassium Snake-bite Heart failure. PLA TE VII. OPHTHALMOSCOPIC APPEARANCES Cnpy right IN'DEX OF DIAGNOSIS A. U\ Head, del. OPHTHALMOSCOPIC APPEARANCES 461 2. CEdema of Face, Neck, and Arms, Obstruction to the superior vena cava by: Thoracic aneurysm Mediastinal new growth Mediastinal gumma Mediastinal fibrosis Thrombosis Erysipelas Cellulitis 3. CEdema of the Legs, without any Heart failure secondary to : Valvular disease Myocardial affections Chronic lung affections Renal or arterial affections Chlorosis Pernicious anaemia Lymphatic leukaemia Splenomedullary leukaemia Hodgkin's disease Splenic anaemia Pseudo-leukaemia infantum Anjemia following excessive blood loss Parasitic affections, especially : Bothriocephalus latus Ankylostomum duodenale OLIGOCYTHEMIA. — (See Anemia. OLIGURIA — (See Anuria.) but not of Legs. Anthrax Angina Ludovici Raynaud's disease Angioneurosis Crying Coughing Measles Common cold Ptomaine poisoning, shell-fish variety of the Neck or Face. Cachectic states due to : Carcinoma Sarcoma Syphilis Tuberculosis Starvation Malaria Tropical affections Inferior vena cava obstruction by : Thrombosis New growths Ascites Convalescence Old age Raynaud's disease Angioneurosis Beri-beri Milroy's disease Myx oedema. [oedema) (hereditary troph- Herbert French. OPHTHALMOPLEGIA. — (See Strabismus ; and Pupil, Abnormalities of.) OPHTHALMOSCOPIC APPEARANCES, NOTES OYi.~{Plates VII and VIII.) Fig. a. — A Physiological Cup may vary in size, but usually occupies the centre of the disc. The retinal vessels dip over the edge, which is usually steeper on the nasal side, the temporal slope being more gradual. At the bottom of the cup is seen the lamina cribrosa, which is mottled by the openings through which pass the retinal nerve fibres. A physiological cup is distinguished from that caused by glaucoma [Fig. v) by the fact that it occupies only the centre and not the whole of the disc. Fig. h. — Congenital Crescents are common, and usually situated at the lower part of the disc, in contrast to myopic crescents {Figs. Ji and i), which are seen on the outer side. They are probably due to an uneven distribution of connective tissue in the lamina cribrosa, and are often associated with hypermetropia. Fig. c. — Pigmented Crescent in Disc Margin. — The disc margin is always more or less pigmented, the amount varying from a small crescent to a complete ring. The pigment has no pathological significance. Fig. d. — Coloboma of the Choroid is a congenital deficiency, and it may be recognized by its situation below the disc, the small amount of pigment at the edge of the wliite area, and the presence of healthy retinal vessels on its surface. 462 OPHTHALMOSCOPIC APPEARANCES It mav be associated ^\-itli other congenital abnormalities, such as coloboma of iris, optic disc, or lens. Figs, e, f- — Opaque Nerve Fibres exist normally in the retinae of some mammals, e.g., the rabbit. The condition is due to the persistence of the medullary nerve sheath of the retinal iibres, the sheath being lost usually at the passage of the nerve fibre through the lamina cribrosa. The condition may be recognized by the brilliant white colour of the nerve fibres, the striated appear- ance of the white patch, and the fact that the retinal vessels are more or less embedded among the nerve fibres. Pig_ g_ — Advanced Syphilitic Choroiditis. — In advanced choroiditis the inflam- matorv process has ended in the total destruction of the choroid in patches, which in some places have joined to disclose large bare areas of sclerotic. There are large masses of pigment, usually surrounding the white areas, the pigment being chief!}- derived from the choroid. The retinal pigment is also increased in the great majority- of cases, and vision is rendered extremeh^ defective. Macular choroiditis is degenerative in origin, and does not usually appear till middle hfe. It probablv commences in the form of macular hemorrhages, which lead to destruction and fibrosis of the retina. Figs, h, i. — The Myopic Crescent is usuaUj- found on the outer side of the disc, and mav vary in size and extent from a thin crescent to a large atrophic area surrounding the whole disc (posterior staphyloma). Usually, the size of the crescent varies with the amount of the myopia and increases with age. Figs, k, I. — Recent Optic Neuritis is characterized by the swelling of the disc and the blurring of its outhne by retinal oedema. The retina is greyish and striated in appearance, owing to oedema between the retinal nerve fibres, and the veins are extremely dilated and tortuous. Flame-shaped hemorrhages are also seen on the disc and in the surrounding retina, and numerous small retinal vessels on the disc, usually invisible, become dilated and apparent. In the later stages of the neuritis the hcemorrhages may disappear, and the whole disc become greyer and paler, the condition ultimately terminating in post- neuritic atroph}- {Fig. I). The outUne of the disc is entirely lost, and in severe cases the disc may be so swoUen as to resemble a small mushroom in shape. Radiating lines of white patches may also be seen in the macular region, resembling albuminuric retinitis (Figs, p, q, ?'.)• Figs. Ill, n. — Primary Optic Atrophy {Fig, n) is characterized b}- the pallor of the disc, white or bluish-white, sharply defined lamina cribrosa, well-marked edge, and retinal vessels of normal size. In post-nenritic atrophy {Fig. m) the disc is covered with fibrous tissue, which fills up the phj'siological cup ; the colotur is greyish- white, the retinal vessels are thin and tortuous, and the edge of the disc is irregular. In some cases of old post-neuritic atrophy or fibrosis, following slight optic neuritis, it maj^ be impossible to distinguish the condition from primary atrophy. Fig. o. — Thrombosis of the Central Retinal Vein. — In thrombosis of the centra retinal vein the disc is extremely swoUen and oedematous, the edge being indis- tinct and blurred. All the retinal veins are enormously dilated and tortuous, and the fundus is covered with flame-shaped and petechial haemorrhages. The oedema of the retina from the obstruction of the venous circulation maj^ be so great that the vein mav occasionally be hidden entirely. Figs. JO, Q, r. — Albuminuric Retinitis is characterized by the presence of flame-shaped haemorrhages in the nerve-fibre layer of the retina, and white patches. The white patches are of t%vo kinds. Those seen in the earh* stages of the disease are ill defined and woolly, scattered about the macular region in an irregular manner. These are due to exudate in the nerve-fibre la^-er of the retina. In the later stages, smaller white patches may be seen usually arranged PLA TE VIII. OPHTHALMOSCOPIC APPEARANCES Copyright INDEX OF DIAGNOSIS A. IF. Head, del. OPISTHOTONOS 463 in radiating lines from the macula, which are well defined, and glistening or chalky white. Fig. s.— Embolism of the Central Retinal Artery. — In embolism of the central retinal artery the retina is generally pale grey or white, owing to the anaemia consequent on the obstruction of the artery. The macula itself being adherent to the choroid does not share in the general pallor, and appears as a bright cherry-red spot in conttast. The retinal arteries are extremely small, being only fine white threads in places, and the veins may be nearly empty. The optic disc is white, blurred, and indistinct. Fig. f. — -Detachment of the Retina. — The detached portion of the retina is silvery-grey in colour, and raised above the surrounding fundus. In cases due to serous exudate, the detached part of the retina is transparent, arranged in billowy folds, and may float about on movement of the eye. When the detach- ment is due to growth, the retina is usually smooth and opaque. The retinal vessels are small, very tortuous, and dark in colour. Fig. IV— Glaucomatous Discs. — The excavation of the optic disc maybe distin- guished from the physiological cup by the fact that it affects the whole of the disc, the edge often being surrounded by an atrophic ring. The retinal vessels bend sharply over the edge, and may disappear from view behind the overhanging margin of the disc, reappearing on the bottom of the cup. The lamina cribrosa is well marked, and the disc is white and atrophic. Fig. w. — Tubercles In the Choroid are seen as ill- defined circular masses, usually four or five in number, varj'ing in size from a pin's head to masses nearly the size of the optic disc. They are usually associated with miliary tuberculosis, grow rapidly, but rarely attain any great size owing to the death of the patient. It is stated that they occur most commonly in the neighbourhood of the disc, but this is due to the fact that only the posterior portion of the fundus is visible with the ophthalmoscope. Post mortem fhey are found all over the choroid. Fig. X. — Hypermetrophie Astigmatism. — In hypermetropic astigmatism the disc is often oval in shape and ill defined. The phj^siological cup is absent, the disc is red, and the margin is ill defined. The vessels may be tortuous though not dilated, and unless the error of refraction is observed, the condition may be mistaken for optic neuritis. Herbert L. Easan OPISTHOTONOS. — This is a rare but characteristic condition, in which all the muscles of the neck, back, and legs are rigidly contracted in such a way that the body is over-extended in the form of an arch, supported by the occiput above and by the heels below. This position may be maintained ; but more often it is assumed periodically, with partial or complete relaxations between the tetanic seizures. Its chief cause is tetanus, but it may also be due to strychnine poisoning, spinal meningitis, urcemia, and hysteria. Tetanus. — The history will often point to the correct diagnosis. If there has been a punctured wound recentty, and if stiffness of the neck muscles, and of the lower jaw (trismus or lockjaw), has set in, to be followed within a day or so by generalized rigidity, with severe paroxysmal exacerbations, the opisthotonos is almost certainly due to tetanus. The fixed smile — risus sardonicus — is common to tetanus and to strychnine poisoning. An attempt will be made to obtain the drumstick bacilli [Plate XII, Fig. i) from the suspected wound, very often without success. In some cases there will be no obvious wound or contusion ; but although the source of contagion will then be obscure, the early lockjaw and the course of the disease will point to tetanus beyond doubt. Strychnine poisoning does not give rise to lockjaw, and the paroxysms of opisthotonos are separated by intervals of far more complete relaxation of the 464 OPISTHOTONOS muscles than is the case in tetanus ; moreover, there may be direct evidence of the source of the poisoning, either accidental, suicidal, or homicidal, in the form of a bottle, a hypodermic syringe and needle, a packet of vermin-destroyer, or something of that kind. In some cases the diagnosis can only be arrived at by analysis, either of the gastro-intestinal contents, or of the viscera post mortem. Spinal meningitis seldom causes difficulty in the diagnosis, for it is generally part of acute cerebrospinal meningitis, of which the* general symptoms and pyrexia will have existed some days, if not a week or more, before opisthotonos is likely to occur. Optic neuritis may be found, and in some cases the bacterio- logical and cytological results of lumbar puncture, especially the discovery of the meningococcus, may clinch the diagnosis. Urcemic convulsions are associated with complete coma, whereas in tetanus and in strychnine poisoning consciousness is perfectly retained ; the convulsions are epileptiform rather than tetanic ; there is no persistent lockjaw ; and the urine will nearly always contain albumin and renal tube-casts. Hysteria sometimes takes a form that may for the moment be very difficult indeed to distinguish from tetanus or from strychnine poisoning. Unlike malingering, hysterial contractions that are even violent enough to cause opisthotonos, do not always make the patient perspire, and they do not lead to fatigue in the way that similar voluntary efforts certainly would. The diagnosis of hysteria is generally arrived at by watching the case. Persistent lockjaw may be present, as in tetanus ; but whereas in strychnine poisoning and in tetanus there is a great similarity between one exacerbation and the next, hysterical convulsions are apt to be polymorphous ; the more the writhing and the change of attitude and position, the less likely is the attack to be organic. The mind remains perfectly clear in tetanus and strychnine poisoning, though the outward expression of the mind may be prevented by the muscular paroxysms ; in hysteria, the mental attitude is in one way or another obviously abnormal for the time being. In arriving at a diagnosis, it may be of very great assistance to know full details of the patient's previous medical history, for there may have been similar hysterical outbursts on former occasions. Herbert French. OPTIC ATROPHY. — (See Ophthalmoscopic Appearances, Notes on.) OPTIC NEURITIS — (See Ophthalmoscopic Appearances, Notes on.) ORTHOPNCE A, or the inability to breathe unless propped above the horizontal position, may be due to many causes, which may be grouped as follows : — Failure of the Right Side of the Heart : — Secondary to valvular disease of the left side of the heart : Aortic disease with secondary mitral regurgitation. Mitral stenosis Mitral regurgitation Mitral stenosis and regurgitation Secondary to affections of the heart muscle : Fatty heart [ Adherent pericardium Fibroid heart | Some cases of pericarditis Secondary to high systemic blood-pressure : Arteriosclerosis | Granular kidney. Secondary to lung affections : Emphysema Chronic bronchitis Fibroid lung with or without bronchiectasis Pneumothorax. ORTHOPNCEA 46: Obstruction to the Larynx or Trachea Acute oedema of the laryiix Acute abductor paralysis Post-pharj'ngeal abscess Laryngeal diphtheria Larj^ngismus stridulus Catarrhal laryngitis, especially at the onset of certain cases of measles Acute pneumococcal or strepto- coccal laryngitis Qidema due to potassium iodide Laryngeal crises of locomotor ataxia Foreign body Enlarged thyroid gland Enlarged thymus gland Aortic aneurysm Mediastinal new growth Malignant glands in the neck Lymphadenomatous glands in neck Irruption of a caseous gland into the trachea CEsophageal tumour. Acute Obstruction of the Bronchi and Bronchioles :- Acute bronchitis Acute capillary bronchitis Some cases of acute broncho- Asthma Whooping-cough. New growth Hydrothorax. Neurosis or hysteria Solid or cystic tumours. pneumonia Mediastinal Masses : — • Aneurysm Huge heart Enormous Distention of the Abdomen by- Ascites Tympanites By far the commonest cause of orthopnoea is heart failure of some kind or another, and the differential diagnosis of the variety of heart failure, and whether it is due to valvular disease, to myocardial degeneration, to arteriosclerosis, to granular kidney, or to the effect of difficulties in the pulmonary circulation from bronchitis and emphysema or fibroid lung, has to be decided upon the various grounds that are discussed on p. 18. When orthopnoea is due to obstruction to the larynx or trachea the fact is generally obvious on account of other symptoms such as stridor, up-and-down movements of the larynx itself, sucking in above and below the clavicles and of the lower intercostal spaces, the main difficulty in some of these patients being to decide whether the obstruction is sufficiently near the larynx to be relievable by tracheotomy, or whether it is due to mischief lower down in the trachea, bronchi or bronchioles. The nearer the obstruction is to the larynx the greater will be the spasmodic up-and-down movements of the thyroid cartilage, and the stridor. If the evidence is that the obstruction is in the larynx itself, and if the orthopnoea and difficulty with respiration are extreme, the probability is that tracheotomy will be resorted to as an urgency measure, the precise diagnosis being determined later. The history, or a local examination, would serve to diagnose or exclude acute ,abductor paralysis, post-pharyngeal abscess, foreign body, enlarged thyroid gland, malignant glands in the neck, lymphadenomatous glands in the neck. Enlargement of the thymus gland can seldom be more than conjectured, or diagnosed by a process of exclusion, unless there is definite dullness behind the upper part of the sternum in a child under ten years of age, together perhaps with an x-ra.Y shadow of the gland. Aortic aneurysm or mediastinal new growth obstructing the trachea will generally have given rise to other characteristic symptoms at the same time ; particularly in the case of mediastinal new growth, to obstruction of the innominate veins or the superior vena cava, with varicose distention in the superficial thoracic veins by way of collateral circulation. The ;r-rays may be useful in confirming the diagnosis. D 30 466 ORTHOPNCEA In a great many cases, particularly in children, none of the above will be the least likeh'j and if foreign bodj^ and post-phar\Tigeal abscess have been excluded by digital examination, the first suspicion will be that the patient is suffering from laryngeal diphtheria. This may be confirmed by the presence of a small quantity of membrane on the pharynx, the uvula, or elsewhere, though quite commonly when laryngeal diphtheria is extensive there is no obvious exudate upon any of the visible parts at the back of the mouth. The existence of cases of diphtheria in the same house or in the neighbourhood may point to the diagnosis ; but in every case swabbings should be obtained from as far back in the throat as possible, and examined for Klebs-Loeffler bacilh, both in films and in cultures incubated at bod}' temperature in a bacteriological laboratory. Until laryngeal diphtheria can be excluded bj- the absence of Klebs-Loeffler bacilh — and a single negative result does not necessarih^ exclude the disease — the nature of the case will probably remain in doubt. Acute oedema of the larynx is nearly always due to some microbial infection, and therefore in a sense it includes acute pneumococcal or streptococcal laryngitis, the diagnosis of which depends upon bacteriological cultivations from swabbings from the throat. CEdema may also be due to similar infection of ulcerated places in the throat developing in the course of tuberculous, syphilitic, malignant, lupoid, traumatic, or post-typhoidal laryngeal ulceration. The previous history, the results of previous examination of the lungs, larynx, and sputum will indicate the diagnosis of these various conditions. The laryngeal crises of locomotor ataxia are exceedingly rare ; the}' might be suggested if the patient were known to have no knee-jerks and Argj'll Robertson pupils, but even then there might be doubt as to whether they were really crises and not the result of syphilitic ulceration, or due to the administration of potassium iodide in these cases. Acute oedema of the lar\Tix is sometimes spoken of as one of the complications of acute Bright's disease, but it is very rare in this malady, rarer than acute cedema of the lungs ; it is usually a terminal factor, the diagnosis of nephritis having been made previously on account of general oedema and albuminuria with tube casts. Laryngismus stridulus is a dangerous diagnosis to make, for many cases thought to be this are really examples of diphtheria : if laryngismus stridulus does occur, it is to be expected in rickety children who show a tendency to spasmodic muscular contractions in other parts besides the larynx, such for instance as convulsions from slight causes, or the carpo-pedal contractions of infantile tetany. It is supposed that similar spasmodic contractions of the muscles of the larynx produce paroxysms of larvngeal obstruction with acute dyspnoea, orthopnoea and cyanosis ; but no such cases should be diagnosed as simply neuro -muscular until every precaution has been taken to exclude all other causes of laryngeal obstruction, especiallv diphtheria. Now and then one meets with a case in which an apparently healthv child is suddenly seized with acute dyspnoea, cyanosis, orthopnoea and general respiratory distress, without any signs of laryngeal obstruction, the result of irruption of a caseous bronchial or mediastinal gland into the lower part of the trachea or a main bronchus. The symptoms are preciselj^ such as one would expect if the patient had suddenly inhaled a foreign bodj^ of some size, and if one can be quite sure that no such foreign body has been inhaled the correct diagnosis may sometimes be guessed at. It would be confirmed if, as occasionally happens, a sudden effort of coughing leads to the caseous or cretaceous mass being expectorated. The difficulty of being certain whether, in a given case of severe respiratory distress with evidence of obstruction, the mischief lies in the lar5-nx or in the lungs is sometimes considerable ; in either case there may be marked c^'anosis, orthopnoea, dyspnoea, sucking in above and below the clavicles and of the lower OTORRHCEA 467 intercostal spaces : the most important point is whether the larynx itself remains stationary as when the mischief is in the lungs, or whether it moves up and down with the respiratory movements as it does when the trouble is in the larynx. Very often both the lungs and the larynx are involved, and it maj' then be very difficult to decide which is the more so, and consequently whether tracheotomy is indicated or not. The chief point on which to lay stress, besides the movements of the larynx, is the result of a physical examination of the chest for evidence of acute bronchitis or of bronchopneumonia. True asthma is a spasmodic variety of dyspnoea, the diagnosis of which, and the difficulty of distinguishing between asthma complicated by bronchitis and bronchitis simulating asthma, are discussed elsewhere. Whooping-cough is seldom difficult to diagnose, for even when the patient himself does not exhibit the typical whoop, he will be affected by a severe paroxysmal cough, possibly leading to vomiting, and at the same time relatives or friends may be affected by cough which gives rise to the typical whoop. Mediastinal masses, such as aneurysm, a huge heart, new growth, hydro- thorax with marked displacement of the heart, and enormous distention of the abdomen by ascites, tympanites, or by large tumours, will generally have been diagnosed before they reach the stage of producing orthopnoea. The chief reason why a very large heart or a thoracic aneurysm may produce orthopnoea, even when there are no signs of failure of the cardiac compensation, is that when a patient sits up there is a greater distance between the sternum and the vertebrae than when he hes back. The cause for the orthopnoea is thus mechanical, the patient sitting up to allow a bigger space for the accommodation of the abnormal mass ; hence in some of these cases he may be able to walk about and see to his business without distress during the daytime, and yet be unable to lie down at night. The cause of the orthopnoea associated in this way with a huge heart, is quite different from that in which there is failure of the right side, the former being a mechanical means of giving a big mass more room, whilst the latter is due to the need of maximum assistance from the respiratory blood-pump. Herbert French. OTORRHCEA. — Discharge from the ear is a very common symptom which may result from a great variety of causes, some of which are of a trivial nature, while others are of the most serious import. The skin of the normal external auditory meatus contains numerous ceruminous and sebaceous glands, the secretion of which, known as cerumen or wax, escapes either as small niasses or as a thick oily fluid. It may give rise to trouble by forming a hard solid plug which becomes impacted in the meatus and gives rise to such serious s^^mptoms as deafness, tinnitus, and vertigo. Though not usually included under the heading of " discharge," impacted cerumen may be the cause of a purulent discharge from the ear. When a patient complains of an aural discharge, the colour, amount, and character should be ascertained. Any offensive odour should also be noted. The discharge may be purulent, muco-purulent, or serous, but occasionally it consists of blood, either alone or mixed with one of the above-mentioned varieties. A discharge of blood from the external auditory meatus {otorrhagia) may be the result of an injury. The following lesions may cause this symptom : — Fracture of the base of the skull. "When the line of fracture crosses the middle fossa it traverses the petrous portion of the temporal bone and opens the tympanic cavity, tearing the tympanic membrane. Injury to the external auditory meatus, usually at the junction of the carti- laginous and osseous portions, the result of a blow on the chin, the force being transmitted backwards along the inferior maxilla. 468 OTORRHCEA Rupture of the tympanic membrane, which may occur as the result of the introduction of a foreign body through the external auditory meatus, or after a fall or blow on the head without any injury to the base of the skull. Bleeding from the ear is thus by no means diagnostic of fracture of the middle fossa ; indeed, in the greater number of cases the skull is not injured. Care must always be taken to make sure that the blood has not trickled into the meatus from some small wound of the scalp or of the external ear. If the external auditory meatus has been injured, the source of the haemorrhage may be dis- covered by mopping the blood away with plugs of cotton-wool and examining with a speculum. A tear in the tympanic membrane may be visible if the haemorrhage comes from the tympanum. If the skull is fractured, the haemor- rhage is usually profuse (otorrhagia), while if the membrane alone is injured it is comparatively slight. The hearing should be tested, for if the base of the skull is fractured, injury of the auditory nerve is an occasional complication. A variety of acute inflammation of the middle ear known as acute hcemcvrhagic otitis is characterized by a discharge of blood. This trouble is usually associated with influenza, but may also occur in haemophilic patients. The hcemorrhage is preceded by pain, and the membrane is markedly hypersemic, or may show petechial spots. A haemorrhage or blood-stained purulent discharge occurring in the course of chronic suppurative otitis media will probably be due to the presence of polypi or of masses of granulations. A similar blood-stained discharge may be present in malignant disease of the external or middle ear. Very rarely erosion of the internal carotid artery may lead to a severe fatal haemorrhage from the external auditory meatus. The artery in its course through the carotid canal is separated from the anterior part of the tympanic cavity by only a thin plate of bone, which may be deficient. Owing to chronic suppuration, this portion of bone may be destroyed and the walls of the artery weakened, so that it may suddenly give way, leading to a quickly fatal bleeding from the ear, nose, and mouth. A similar severe or fatal haemorrhage may result from erosion of the lateral sinus from a similar cause. Cerebrospinal fluid may escape from the external auditory meatus after a fracture of the middle fossa, and its presence may be regarded as diagnostic of this injury. The flow is usually copious, and may last for some days. Liquor Cotunnii may escape when the labyrinth is injured. In appearance it resembles cerebrospinal fluid, but the amount is very small. In chronic suppurative otitis media the discharge may be serous in character, and may bear some resem- blance to cerebrospinal fluid, from which it may have to be distinguished in a patient unconscious as the result of a head injury. Apart from examina- tion of the membrane through a speculum, this can be effected by collecting some of the fluid and testing for albumin. The serous septic discharge contains much albumin, while cerebrospinal fluid has only the merest trace. Purulent Discharges. — In by far the greater number of cases the discharge is obviously purulent, muco-purulent, or sero-purulent. Such a discharge may arise from some lesion of the external auditory meatus, from disease of the middle ear, or from suppuration in some adjacent structure, the pus making its way into the external or middle ear and so draining from the external auditory meatus. The following lesions of the external auditory meatus give rise to such a discharge : — Eczema. The discharge in this case may be serous. The trouble may be caused by the irritation of a plug of impacted cerumen, or it may be associated with eczema of the auricle or of some other region of the body. It must be remembered that eczema of the external auditory meatus and of the external ear may be caused by a discharge o^ pus from the middle car, and hence, when OTORRHCEA 469 the external auditor^' meatus is eczematous, every care must be taken to make sure that chronic middle-ear suppuration is not also present. The presence of a foreign body, such as a plug of cotton-wool which has been inserted and forgotten, or of such foreign bodies as children occasionally insert, may produce a dermatitis of the meatus leading to a discharge of pus. This condition is recognized easily' on examination with the speculum. Fiirunciilosis. — This not uncommon trouble gives rise to very acute pain and swelling of the meatus, followed by a discharge of thick pus. A furuncle may usually be seen on otoscopic examination, and the trouble may be diagnosed from the extreme tenderness and swelling of the meatus, and the presence of an opening from which the pus escapes. Secondary Syphilis. — In this disease condylomata may occur in the external meatus. The discharge is usually serous in character, and may have a very foul odour. The diagnosis will depend upon the presence of other secondary troubles or the history of the primary sore. Tertiary syphilitic ulceration may also occur at the orifice of the meatus. Suppurating Sebaceous Cyst. — The cutaneous lining of the external auditory meatus is well supplied with sebaceous glands, which may give rise to cysts, and which mav inflame and suppurate. The signs, symptoms, and appearances closely resemble those of furunculosis. Diphtheritic InfJatnmation. — This is a rare trouble. Diphtheritic membrane is present, associated with much swelling and a muco-purulent discharge. The Ivlebs-Lofilier bacillus (Plate XII, Fig. L) is found in the discharge and the membrane. Epithelioma of the external auditory meatus. In this trouble the meatus may be occluded completely. The appearance is characteristic, and the diagnosis presents no difficulty. It must be remembered, however, that a rodent ulcer occasionally occurs in this situation, and in appearance closely resembles an epithelioma. Caries or necrosis of the bony external auditory meatus will give rise to a profuse purulent discharge, associated with the presence of polj^pi or of masses of granulations. The diagnosis of the above causes of an aural discharge may be easy, but on the other hand it may be a difficult matter to make sure that there is no disease of the middle ear, for there is likely to be so much swelling, and probably tender- ness of the meatus, that it is impossible to get a view of the membrane. It must also be borne in mind that when there is a discharge of pus from the middle ear the lining membrane of the canal is frequently swollen, inflamed, and eczematous. The most frequent cause of a purulent discharge from the ear is suppurative otitis media, either acute or chronic. In the former case, the discharge is preceded by acute pain, usually paroxysmal, with pjTexia and more or less severe con- stitutional symptoms. The discharge usualh^ consists of thick pus, and there is much swelling of the meatus which may prevent a satisfactory view of the membrane. \Mien this can be seen it has a characteristic hyperasmic and swollen appearance, and the perforation through which the pus escapes can be made out. Tuberculous disease of the middle ear is a not uncommon cause of purulent discharge. Deafness and tinnitus are also present, but there is usually no p\Texia, and pain is remarkably absent. Examination shows a swollen condition of the membrane, which is dull red or pink in colour, while a perforation, often in the anterior region, may be made out after cleansing the meatus. In this disease, rapid destruction of the bone may also occur without pain. In chronic suppurative middle-ear disease the character and quantity of the discharge vary enormously. Thus there may be only a slight serous discharge in some cases, while in others there may be a profuse flow of foul pus, 47° OTORRHOEA Frequently the amount and character vary from time to time, and occasionally the flow is intermittent. The presence of other symptoms, such as deafness, tinnitus, pain, and vertigo, must always be inquired for. The membrane must be examined after syringing out and drying the meatus. In practically every case a perforation will be found, though occasionally the pus may make its way along some bony track which opens into the external auditory meatus. The position of the perforation should be ascertained, whether it is in the.membrana propria or in Shrapnell's membrane. In the latter case the suppuration occurs chiefly in the attic, and the ossicles are likely to be carious. Generally speaking, perforations in the anterior portion of the membrana propria are of less serious nature than those in the posterior portion. The presence of polypi or granu- lations must be noted, and if possible the site from which they spring must be determined. In addition to the above causes of an aural discharge, abscesses in adjacent structures may occasionally burst into, and lead to a copious discharge of pus through, the external auditory meatus. An acute mastoid abscess may discharge in this way through a sinus which opens on the posterior aspect of the meatus. In chronic mastoid suppuration, pus may make its way from the mastoid air- cells in a similar manner. Rarely a cerebral abscess in the temporo- sphenoidal lobe may burst into the tympanum and discharge through the external auditory meatus. Occasionally, an abscess in the parotid gland may extend backwards and discharge through the anterior wall of the meatus. A similar result may happen with an abscess which originates in disease of the temporo-mandibular joint. Philip Turner. OXALURIA. — This term is generally used to include any condition under which crystals of calcium oxalate are to be found on microscopical examination of the urine. They occur in two forms, of which by far the most characteristic and common is familiarly described as the " envelope " crystal — really a regular octahedron ; when crystallization has occurred imperfectly, a spheroidal form with a central constriction like that of a "dumb-bell" may occasionally be seen (Fig. 130). Either form is trans- parent, highly refractive, and usually quite colourless. If the precipitate is suflicjpntly abundant to be visible to the naked eye, it is generally pure white ; it often comes down after more or less mucus has already gone to the bottom of the specimen glass, so that a dense white layer is seen lying on the top of a less white flocculent mass ; this appearance has been described as that of the " powdered wig." The crystals are soluble in any mineral acid, but they are insoluble in water or ordinary acetic acid solution. They may be found in any urine, whether acid or alkaline, but are commonest in acid urines. They may be in the urine when it is voided ; more often they form as the urine stands in the specimen glass, and it is important to remember that, if a slide is prepared from the centrifugalized deposit of a urine and allowed to stand for a while before it is examined under the microscope, numbers of very minute calcium oxalate crystals may appear, even when none are to be found in a similar specimen examined at once. -Varieties of crystals of calcium oxalate (high power). OXALURIA 4TL The deposition of calcium oxalate is by no means necessarily pathological ; indeed upwards of 20 milligrams are excreted in the urine daily, even 35 milligrams not being bej-ond the normal limit. So long as the oxalic acid is combined to form soluble salts such as those of sodium or potassium, no envelope crj^stals appear, but it is common for the proportion of oxalic to other acids on the one hand, and of calcium to other bases upon the other, to be such that the insoluble oxalate of lime is formed and precipitated, either in the urinar^r passages or after the specimen has been voided. Circumstances which cause an absolute increase in the amount of oxalic acid excreted will naturally increase the tendency to visible oxaluria. The best-known exogenous sources of oxalic acid are certain vegetable products, of which the following in particular may be mentioned : tea, cocoa, spinach, gooseberries, figs, coffee, chicory, chocolate, peas, beans, beetroot, artichokes, tomatoes, and beer. It is probable, however, that there is also an endogenous source for oxalate of lime, for even a starving person still excretes oxalates in his urine. The source of these is still obscure, but it is held by many that uric acid, creatinin, and possibly other alhed substances, may be a source of oxalate. The fact that uric acid cr\'stals and those of oxalate of lime are to be seen not infrequently^, either together, or alternating with one another on different days, would seem to favour this view, and gouty persons are perhaps more liable than others to oxaluria. Calcium oxalate crystals may be found in the urine at any age, however, from infanc}^ onwards. In great part, oxaluria is physiological and dietetic ; nevertheless there is a decided tendency now-a-days to revert to the older view that when a patient's metaboHsm is such as to cause a constant deposition of calcium oxalate cry'Stals in the urine, it is also apt to lead to a group of symptoms of which nervous dyspepsia, neurasthenia, and even hypochondriasis are the chief. The dis- covery of calcium oxalate crystals in the urine of such patients therefore might be of assistance in determining the nature of the dietetic and other treatment that should be adopted for the cure of the other general symptoms. There are at least three other ways in which the knowledge of the existence of oxaluria may be decidedly important : — 1. Concerns patients who present symptoms that may be due to renal or vesical calculus. Microscopical examination of the centrifugalized urinary^ deposits in such a case may serve to detect not only pus cells and red blood- discs, but also calcium oxalate cr^-stals that, instead of being all separate from one another, as is the rule in a dietetic or neurasthenic case, may be obviously agglomerated into minute calculi ; if there are clinical symptoms of stone, the discovery of microscopic aggregations of crv^stals is highly suggestive of there being a larger calculus present somewhere in the urinary system. 2. If oxalate crystals are deposited in numbers in the urine whilst it is still in the bladder, irritability^ of the latter is apt to follow, with a tendency to undue frequency of micturition ; such oxaluria is not altogether infrequent as the cause for persistent nocturnal enuresis in girls and boys. 3. In some ways this is one of the most important features of oxaluria. The same irritation by oxaluria that may produce the nocturnal enuresis in girls and boys may lead to the urine of adults containing a considerable excess of nucleo-proteid, and, in the male, numbers of spermatozoa. There may be no symptoms whatever, and in that case the only importance of the condition lies in the fact that the nucleo-proteid may be mistaken for albumin ; for if the boiling test is applied to a specimen containing nucleo-proteid in excess, a cloud of phosphates may come down, and then when acetic acid is added to dissolve up this cloud, a residual haze may remain behind because the acetic acid, at the same time that it dissolves the phosphates, precipitates some of 472 PAIN, ABDOMINAL the nucleo-proteid. This source of fallacy may be obviated in either of two ways : the haze of nucleo-proteid will clear up on addition of a drop of nitric acid, whereas a similar haze, due to albumin, will remain ; or, to make quite certain, three test-tubes may be used : into the first, put plain urine without any boiling ; into the second, urine plus acetic acid without boiling ; and into the third, urine plus acetic acid, the mixture being thoroughly boiled. If the haze is due to a nucleo-proteid only, it will be equally marked in the second and third tubes, whereas if there is albumin as well, the haze in tube three will be denser than that in tube two. Just as oxaluria may lead to nocturnal enuresis in adolescents, so in a few adult males it has been regarded as a factor in the causation of excessive nocturnal emissions or spermatorrhoea. Herbert French. PAIN, ABDOMINAL (GENERAL).— Most abdominal pain is local, e.g., that due to a renal or biliary stone. The most serious cause of general abdominal pain is acute general peritonitis. If this be perforative, at first the pain is local at the seat of perforation, and the abdomen is retracted ; but soon, whether the peritonitis is or is not perforative, the abdomen becomes distended from paralysis of the bowel, and the pain becomes general. Increase in the rate of the pulse and immobility of the abdominal wall on breathing are most important signs for diagnosis. Quickly the pulse becomes more rapid and wiry, the patient looks ill, the temperature is raised a little, the bowels are constipated, and there is some nausea, perhaps vomiting. There is often a rapidly progressive leucocytosis. It is often said that the drawing up of the knees on to the abdomen is of importance ; sometimes it is very striking, but in many patients with acute - general peritonitis the legs are not drawn up, and they may be drawn up in other conditions. The early diagnosis of acute general peritonitis is of the utmost importance. It has been estimated that in many cases each hour's delay in opening the abdomen means that the chances of death are increased 5 per cent. Morphia should never be given when it is thought there is even a remote possibility that any illness is acute general peritonitis, for it makes the subsequent diagnosis so difficult. The onset of pneumonia is sometimes announced by an abdominal pain so acute that the patient is thought to have acute general peritonitis. Chronic General Peritonitis. — This usually causes a dull feeling of heaviness rather than a general acute pain. The chief points to be observed in arriving at a diagnosis are the chronicity of the trouble, the presence of fluid in the peritoneal cavity, and the fact that masses of thickened peritoneum can often be felt. The most usual sign is the puckered, thickened omentum, which is to be felt as a tumour lying transversely at the middle of the abdomen ; sometimes other lumps can also be felt. It must not be forgotten that an infiltration of the stomach with new growth will give rise to a tumour lying transversely across the abdomen, and so may a diseased colon. The presence of these peritoneal thickenings often gives the abdomen a dough-like feel. The commonest cause of chronic peritonitis is tubercle. Often there is no discoverable tubercle elsewhere to help as to a diagnosis, but the hectic, irregular temperature maj^ be a guide. As the fluid increases, the umbilicus becomes flattened out (see Ascites), and in tuberculous peritonitis sometimes red. Intestinal Colic. — This is due to many causes which lead to painful contraction of the intestinal muscles. The pain is always paroxysmal and usually recurrent, so that a severe attack consists of frequently recurring paroxysms. There are all degrees, from quite a slight pain to one that causes the patient to shriek and break out into a cold sweat. The temperature is usually normal, but is occasionally slightly raised. The pulse is usually of normal rate unless the PAIN, BEARING-DOWN 473 temperature be raised. The abdomen is generally distended, and in a bad case peristaltic movements of the coils of intestine may be seen. Often the abdominal muscles are reflexly contracted and rigid. The pain maj^ come on without warning, or may be accompanied by nausea, eructations, and borborygmi. It is usually felt at the umbilicus, from which region in a severe case it spreads over the whole abdomen. The patient tosses about in the severity of it, and finally selects a position in which he can bring pressure to bear on the abdominal wall ; in peritonitis this, so far from relieving the abdominal pain, increases it. Intestinal colic is usually brought on by eating some indigestible article of food, so the history will help us ; but it may be due to obstruction. In children, intestinal colic is recognized by their cries, restlessness, and the drawing up of the legs. Acute or subacute Intestinal Obstruction is a common cause of general abdominal pain, and requires most careful diagnosis (see Vomiting). Lead Colic. — This is diagnosed by the symptoms of colic, as given above, bv the history and occupation, and by the presence of other signs of lead poisoning, of which the most characteristic is a blue line on the gums. Gastric Crises may cause general abdominal pain, but they will be recognized by the absence of knee-jerks and other signs of tabes dorsalis. Abdominal Neuralgias. — This phrase is applied to severe abdominal pains unassociated with any organic disease. The greatest caution must be exercised, and a diagnosis of abdominal neuralgia must be looked upon wdth great supsicion, for there is no doubt that such a diagnosis is often wrong, the patient really having organic disease. The pain may be local, e.g., those neuralgias of the kidney which resemble renal calculus, or it may be general. Disease of the spine must be excluded carefully. Often these patients have neuralgia elsewhere. The cases last a long while ; they are commoner in women than men. In a few, opening the abdomen has shown that the small intestine or colon is spasmodically contracted (enterospasm), and indeed, it may be felt through the abdominal wall as a swelling like a thick cord. These patients are often given morphia, but this should not be done. It is not infrequent to find that severe abdominal pain is apparently due to the administration of morphia, for the pain ceases when the drug is withheld. I have seen two such cases recently. General Visceroptosis often causes a general dull, dragging abdominal pain. It can easily be diagnosed by feeling the displaced liver or kidney, by looking at the abdominal outline seen from the side when the patient stands up, and bj' observing the displaced stomach (see Fig. 105, p. 353 ; see also Constipation) or intestines by the ;r-rays after the administration of bismuth. w. Hale White. PAIN, BEARING-DOWN This form of pain is a very frequent symptom in diseases of women, and is an associate of many pelvic conditions. It is impos- sible in many instances to dissociate it from chronic aching pain ; but it is not every chronic pain which has the bearing-down character. It is usually the result of impaction of some pelvic structure, and owes its character more parti- cularly to pressure on the rectum, and sometimes on the bladder. Displacement of pelvic organs, or even simple congestion of them, will sometimes produce it. Its source is not always strictly gynsecological, as it may be the result of actual rectal disease, such as cancer, ulcer, or haemorrhoids. It is thus closely associ- ated with rectal tenesmus. The commonest cause is, perhaps, backward dis- placement of the uterus, and it is most marked in retroversion of the pregnant uterus, especially if impaction of the organ occurs. Impaction of a pelvic tumour may produce it, uterine fibroids, ovarian tumours, and pelvic haematocele being the chief swellings which give rise to it. These, no doubt, produce pain of a different character in addition, due to pressure on nerves ; but the bearing- 474 PAIX, BEARIXG-DOWN down character is more particularly referred to the rectum, hence it is commonh^ believed to have some relation to pressure on the rectum. A pelvic abscess of peritoneal origin is an unusual impacted swelling, which gives rise to very severe bearing-down pain : impacted, because it is bound down by peritoneal adhe- sions, and exercising pressure because of the tension in it. The bearing-down character becomes most marked if the abscess involves the rectal wall, as it so frequenth^ does, causing a flow of mucus and much irritation of the rectum. The differential diagnosis of the causes of this t^-pe of pain can only be made after a complete pelvic examination b}' abdominal palpation, and bimanual examination by the vaginal and by the rectal touch. Further, it may be necessary to examine the bladder by the cystoscope, or the rectum by the finger or sigmoidoscope. The difl'erential diagnosis of the pelvic disorders mentioned is discussed under Swelling, Pelvic. t. G. Stevens. PAIN, GIRDLE.— (See Girdle Pain.) PAIN, INTERSCAPULAR.— Interscapular pain may be due to caries of the dorsal vertehrcs. There will then be stiffness of the back, with perhaps promi- nence of the spines of one or more of the dorsal vertebrae, with tenderness on pressure over them, or on applying a hot sponge down the back (see Tenderness IN THE Spine) . A skiagram may reveal disease of the bones. A tumour of the cord may cause pain between the scapulas ; in that case there will probabh' be indications of pressure on nerve roots, and perhaps on the cord itself — exaggeration of the knee-jerks, bladder sj-mptoms, etc. Aneurysm of the descending aorta, or a mediastinal tumour, may cause severe interscapular pain. In such cases there are often indications of pressure on the oesophagus, or upon a bronchus ; and an examination with the ;ir-rays may make the diagnosis clear. Interscapular pain is often felt in cases of gastric ulcer, or carcinoma of the cardiac end of the stomach, and sometimes also when gall-stones are present. (For differential diagnosis, see Pain in the Epigastrium, and Pain in the Hypochondrium, Right). In such cases there is not uncommonly tenderness in the neighbourhood of one or two of the lower dorsal spines. An accumulation of gas in the fundus of the stomach may also cause a pain between the scapula. (See Indigestion ; and Flatulence.) Robert Hutchison. PAIN IN THE ANKLE.— (See Joints. Affections of.) PAIN IN THE ARM. — (See Pain in the Extremity, Upper.) PAIN IN THE BACK. — From occiput to anus, a pain referred to the spinal axis is a frequent complaint, and the diagnosis of its cause is very often a most troublesome problem. We start with the broad generalization that a pain in any area must be due to irritation, either of the trunk or the terminals of the sensory nerves supplying the spot, or, it may be, of a nerve which is in immediate anastomosis with that to the painful area. Pain referred to any one spot and due to central (cerebral) irritation is so rare as not to require mention here (except that arising from gross cerebral trouble, which will be referred to b}' the patient as headache) ; and applying this principle to the spinal axis, we find that the sensory divisions of the spinal nerves, from the first cervical to the coccj'geal, all divide into branches for {a) the skin, [b] the bones and meninges of the spinal canal, (c) the muscles lying on the vertebral column, and {d)' the viscera contained in the cranium, neck, thorax, abdomen, and pelvis. Consequently, to interpret rightly the meaning of a pain in the back, we must look not only to general conditions PAIN IN THE BACK 475 affecting the blood (fevers of all sorts are often associated with a general backache as a prominent feature), but to the condition of the organs contained in that spinal segment (or the one immediately above or below it) in which the pain is complained of. Another very useful generalization is this. We may draw a distinction between a pain spontaneously complained of in a spot not associated with tenderness on firm pressure, and one in which such tenderness is present. In the latter case, the tender spot is located in all probability as the seat of the trouble ; in the former case it is probable that the pain is one referred by the brain to the spot, but not really arising there — a " referred pain," as it is termed ; and this is the more likely if we find that the skin over the area is very sensitive to light stimulus, but not more sensitive — perhaps even less so — to a stimulus which is rather rougher, a pressure rather firmer than a light touch. Carrying this to its extreme, we have the paradoxical phenomenon of severe pain being complained of in an area the skin over which is absolutely ansesthetic ; this indicates a complete lesion of the trunk of the nerve concerned. Coming now to the practical diagnosis of a pain in the back, we can pretty easily and accurately eliminate those cases owning a pyrexial origin by observing that the patient not only complains of a pain in the back but looks acutely ill ; if he does so, take his temperature, and if this be found to be raised above 100° F., we may be sure that we have to deal with a zymotic disease at its onset, with meningitis, perhaps myelitis or acute rheumatism, or at any rate with a con- dition in which the pain in the back is only an obtrusive but misleading symptom, to which will very soon be added some of the signs distinctive of the disease. Such a history is, however, comparatively uncommon, and we have much more usually to deal with cases in which the patient, except for the pain in the back, is comparatively well, and he is concerned to know what it means. Two or three questions immediately arise in such a case, the answers to which will throw very great light on the nature of the trouble. Obviou.sly, the first thing is to ask him to locate the pain ; the next to enquire how did it arise, i.e., did it come suddenly after a blow ? after some unusual exertion ? after some unintentional movement, say of the head and neck, or a slip off a pavement ? And then again, how long has he had it, and has he ever had a similar pain before ? Again we proceed to ask, is it constant or intermittent ? If the latter, what action on the patient's part will cause it to return, or what position will ease it when it is present ? It is but seldom that we have not by these questions arrived at a provisional diagnosis in our own minds, but we must never omit to make a careful physical examination for points which will corroborate or correct this diagnosis. Inspection may reveal skin conditions, such as a patch of herpes, etc., which may be either the real cause or an outward manifestation of a cord or bone lesion ; swellings or redness may be apparent, or undue prominence of a spinal process ; bruises or purpura may be seen, or a pulsating tumour proving aneurysm ; glands may be visible in the posterior triangle of the neck. It will also reveal any trace of lateral curvature, a frequent source of backache in young people. Palpation may reveal great tenderness on pressure, either of muscles or bone ; it may show fluctuation (remember that this fluctuation must be vertical, not lateral, to be very reliable) ; per contra, it may prove the absence of tender- ness, and may also show hypersesthesia of the skin, suggestive of pain referred from a viscus. A very useful hint is frequently derived from the observation of the results of palpation ; sometimes these can better be seen when a special stimulus such as an electric current or persistent rubbing is applied to the skin ; thus it may be found that over one small area a blush is more easily raised, or is 476 PAIN IN THE BACK more persistent, than elsewhere ; this is strong evidence pointing to visceral disease as the cause of the pain ; it is due to, and proves disorganization ofj the sympathetic nerve distributed to the viscus. This method will also reveal hypersesthesia or anaesthesia if testing be conducted with a light touch and a pin. The next step is to apply tests for disease of the bony walls of the canal ; tap each spinal process in turn with a percussion hammer, and note whether pain is elicited at any spot ; jar the heels alternately with the leg held rigid from the hip ; letting the patient come down on the heels himself is more risky and less satisfactory ; also test for pain on resisted movements of the limbs or trunk. We may then find if pain is aroused by movements of any kind — flexion, extension, and rotation. Lastly, with the patient lying on his back, a careful examination must be made from the front in the ordinary way for evidence of any visceral disease, or of growth of any kind. If the cause of the trouble should still remain obscure, or perhaps in any case for future reference, two or three ;(r-ray photographs of the painful area will be taken. We may now consider the reverse order of procedure, and ask what are the local diseases associated with pain in the back, and what are their distinguishing points. We may enumerate these according to the structures involved, thus : Skin. — Ulcers, herpes, etc. ; obvious on inspection and requiring no further notice here. Muscles. — Abscesses, trauma, acute inflammations ; so-called rheumatism, stiff neck, lumbago, etc. ; simple debility ; overwork. Joints. — Rheumatism ; implication in caries or in rheumatoid arthritis, etc. Bones. — Caries, aneurysm, and other growths eroding, invading, or primary ; trauma. Meninges. — Inflammations and growths. Cord itself. — Tumours ; inilammation ; trauma. Viscera in front. — Aneurysm ; gastric ulcers ; dyspepsia ; uterine trouble or ovarian ; appendix ; rectum ; bladder and vesiculae seminales ; kidneys. It would be impossible within the limits of this article to give a complete differential diagnosis of all the above, but the procedures of investigation which we have already noticed will almost certainly enable us to come to some con- clusion, and it remains here only to indicate a few of the more special points in differential indications, and a few of the commoner mistakes. Lumbago v. Tumours. — If a patient complains of " lumbago " of some standing, it is essential to test the nervous system, the knee-jerks and other leg reflexes, and to contrast them on the two sides ; to look for wasting of muscles, especially on one side, to investigate the power of the muscles in walking and in simpler movements ; to examine the pelvic organs and the abdomen for growths of any kind. Only when all these points yield negative results can we permit our- selves to think that it is simple lumbago. Lumbago is almost always on both sides ; a tumour most frequently gives one-sided symptoms first, though they may gradually spread to the other side later. Rectal examination should never be omitted, and in suitable cases vaginal examination should be made also. Aneurysm in Thorax v. Indigestion, etc. — It cannot be said that this is a common mistake, for aneurysms eroding the thoracic vertebrae are certainly not very common ; but the mistake is a very serious one. The difficulty is that, when an aneurysm behaves in this way, it is extremely hard to recognize it when it arises frona the descending arch ; bruits are usually absent, and it is perhaps only when a pulsating tumour in the back appears, that the diagnosis is made. The severity, the dull, aching character, and the persistence of the pain are the PAIN IN THE CHEST 477 main features that may help to suggest such a serious cause. The patient should be investigated by the A--rays, either by photograph or screen. Occipital Headaches v. Caries of Spine. — Owing to the frequency with which delicate patients, particularly women and young subjects, complain of pain in the neck, it is well to draw special attention to this locality, though diagnosis is fairly easy. The occipital headache due to a tumour is unmistakable by its severity, and the almost invariable association of vomiting and optic neuritis. The dull, constant, wearing pain of caries, worse on any slight jar, and the fixed position in which the patient holds the head, are sufficient to arouse suspicion, and then the ;ir-rays applied to this region will almost certainly clear up the diagnosis. A simple stiff neck is acute in its onset, and generally preceded by a definite history of sitting in a draught. A " crick in the neck," possibly the equivalent for the rupture of a few ligamentous or muscular fibres, can be recognized by its sudden occurrence in the midst of health with no history of previous pain. Debility in Youth, or Lateral Curvature v. Caries. — The shapes of the curves are usually sufficient ; but care must be taken to examine the integrity of the bones by the tests given above, and one must not be satisfied until all the bone tests have been tried and found negative. Local rigidity over the painful area, best tested by making the patient stoop and rise again, whilst the physician feels the spine with the fiat of the hand, is strong evidence, if persistent, of caries. Pelvic Organ Trouble v. Lumbago. — This mistake is of course more frequent in women than in men. The only rule to be laid down is always to think of these organs when a woman complains of " lumbago " or " backache," and to enquire carefully into the history of confinements and menstruation, and to make a thorough examination of the organs. In conclusion, more mistakes are made in the diagnosis of a pam in the back from want of thought and from carelessness in examination, than from any inherent difficulties in the diagnosis, at any rate in so far as the more serious causes are concerned. Fred. J . Smith. PAIN IN THE CHEST. — Chest-pains are very common in all sorts of disorders. Except in the case of highly intelligent persons, or of patients whose fortune it has been to have a large experience of chest-pains due to various causes, no great amount of help in diagnosing the cause of such pains can be obtained by enquiring into their individual characters. More assistance is furnished by investigation of the circumstances in which the pain is chiefly felt, and the conditions that ease or aggravate it. Thus chest-pains due to disease of the heart will be increased by anything that makes the heart beat more rapidly ; those due to lung-disease by anything causing the patient to breathe faster or cough ; those caused by disorders of the stomach will generally be aggravated by or soon after taking food. For clinical purposes, pains in the chest are best classified according to their pathology, and the nature and situation of the disorders to which they are due. For pains in the back wall of the chest, see Pain in the Back. Pains in the chest may be classified as follows : — I. Pains due to Diseases of the Tissues composing the Thoracic Walls ; the pain is in most cases a direct pain : — Inflammation of the skin and sub- j Neuralgia : mastodynia cutaneous tissues Herpes zoster Adiposis dolorosa ; neurofibroma- ' Pressure on nerves tosis Disease of the bones of the chest. Myalgia : pleurodynia : stitch 478 PAIN IN THE CHEST 2. Diseases of the Thoracic or Abdominal Viscera ; the pain is in most cases a referred pain : — • Pleurisy ; diaphragmatic pleurisy ; empyema Pneumothorax Pneumonia Heart disease — Valvular disease, aortitis ; angina pectoris, true and false Pericarditis Aneurysm ; dissecting aneur3'sm Mediastinal new growths Mediastinitis Qisophageal obstruction Diseases of the spinal cord. I. Diseases of the Thoracic Wall. — Pain in the chest due to inflammation of its superficial tissues should not be hard to diagnose. The pain will be confined to the inflamed parts and their immediate neighbourhood, and the other three cardinal signs of inflammation — heat, redness, swelling — will not be absent. In most cases a superficial wound or abrasion will be found ; in others, the inflammation will have spread to the surface from some deep-seated lesion, caries of a rib, for example, or an empyema or hepatic abscess, or a metastatic abscess arising in the course of pyaemia. The diagnosis must be made on general lines in these unusual cases. The inflammatory phenomena of herpes zoster are considered below. The very rare condition known as adiposis dolorosa, or Dercum's disease, is characterized by symmetrical and painful deposits of fat about the body and limbs. It occurs in middle-aged women of full habit. Neurofibromatosis is characterized by the growth of multiple benign false neuromata on the nerves, which give rise to pain ; but they are not tender on pressure, and so contrast with the single false neuromas, which equally give rise to pain over the area of distribution of the nerves on which they are situated. When pain is felt in the intercostal or other muscles about the chest, and can be referred to nothing more definite than " muscular rheumatism," the condition is referred to as one of myalgia or pleurodynia. Tenderness of the affected muscles is the only physical sign present, and it is important that graver mischief, such as pleurisy, should be excluded before the diagnosis of pleurodynia is made. The sudden pain in the side familiar to untrained athletes as stitch comes on after sudden exertion, and is in all probability due to overstrain of the fibres of part of an intercostal muscle. All these muscular pains are relieved by rest or pressure, and aggravated by exertion. Pains in the chest may be due to neuralgia, a term which is theoretically applied to pain felt in a nerve that shows no evidence of active or old disease. Practically, however, neuralgia is the name also given to nerve-pains that follow organic disease both in the nerve itself (herpes, neuritis, etc.) and in other parts of the body (gout, tabes, etc.) In intercostal neuralgia the pain is felt along the course and distribution of one or more of the intercostal nerves. There is marked tenderness on pressure in the affected intercostal space, with three points of maximum tenderness corresponding to the posterior primary, lateral cutaneous, and anterior cutaneous branches of the nerve, given off near the vertebral spines, the mid-axillary region, and the costosternal articulations. The pain is increased by movement or breathing. Unilateral intercostal neuralgia often follows herpes, and must be carefully distinguished from pains that may be felt in organic disease, such as tabes, aneurysm or mediastinal tumour, and vertebral caries, in which the intercostal nerve is directly or indirectly involved. In phrenic or diaphragmatic neuralgia, a rare condition, the pain is felt in the lower part of the thorax along the line of insertion of the dia- phragm, which may be tender on pressure ; coughing and breathing are acutely painful, but there will be no physical signs of disease except the tenderness PAIN IN THE CHEST 479 on pressure. The diagnosis must be made from diaphragmatic pleurisy or peritonitis, acute hepatic or splenic disorders, and spinal caries, on general lines. Mastodynia, mammary neuralgia, or the " irritable breast " of Astley Cooper, occurs in women during pregnancy or lactation, or in connection with pelvic disease. The pain is constant, with paroxysmal exacerbations, and its severity may lead to the fear of cancer. Local changes — redness, swelling, tenderness — will be found about the breast and nipple. Pains in the chest are habitually felt in herpes zoster of the intercostal nerves, sometimes before, always during, and often after the attack : the third, fourth, and fifth intercostals are those most often involved. Groups of vesicles arise over the area of distribution of the affected nerve, filled with serum and implanted on an inflamed base ; they are most marked about the exits of the posterior primary, lateral cutaneous, and anterior cutaneous branches. The axillary glands become enlarged if the herpes is above the seventh dorsal nerve, the inguinal if it is below it. In a week or so the eruption scabs over ; in all but the mild cases, small whitish scars remain as permanent evidence of the attack. The diagnosis is obvious in cases presenting the eruption or its scars, but may be difficult until the herpetic vesicles have appeared. It is especially in older patients that severe neuralgic pains are likely to remain for months or years as a legacy from herpes. Pains in the chest will be felt whenever there is pressure on an intercostal nerve ; in many cases such pressure is bilateral, when the patient will com- plain of girdle-pains. Injury or fracture of the spinal column may involve the posterior nerve-roots or the intercostal nerves, either at once by the pressure of fractured bone or of effused blood, or later by the pressure of callus ; abscesses, aneurysms, or primary or secondary new growths, may press on the nerves and give rise to severe pain in their areas of distribution. In the great majority of cases there will be other physical signs or symptoms to point to the diagnosis ; but where there are none, and the pain is due, perhaps, to a minute carcinoma in the spinal canal, or to a small thoracic aneurysm that strikes backwards and presses on an intercostal nerve, there is no little danger lest the patient be treated for functional disorder or malingering. The pains are very severe, and persist for months in spite of treatment, while the patient is likely to lose health, weight, and strength. It is true that these phenomena may also be observed in functional cases ; but the diagnosis of functional disease or neuralgia should not be made until the most careful physical examination, including the use of the ;v-rays, has excluded organic disease of all sorts. Chest-pains are, of course, common in inflammations or injuries of the bones of the chest — coccal infections, tuberculosis, hydatid disease, etc. — or of the joints connected with these bones. In few such cases will the diagnosis of inflammation present difficulty. 2. Diseases of the Viscera. — Pain in the chest is extremely common in the various diseases of the thoracic viscera, whether inflammatory or otherwise. In acute pleurisy the onset is often insidious, and the pain felt most acutely in the mammary or axillary region, being made worse on breathing deeply or coughing. The pain is stitch-like, lancinating, described as resembling " a knife," " stabbing," " tearing " ; it is relieved by anything that assists in immobilizing the affected side. The intercostal spaces are tender to pressure in pleurisy, just as they are in intercostal myalgia. The diagnosis turns on the discovery of other physical signs of pleurisy, whether with or without effusion, particularly of pleural friction-sounds. In diaphragmatic pleurisy, the pain is felt in two chief sites : one near the costal margin, corresponding to the attachment of the diaphragm ; the other about the crest of the shoulder, corresponding to the cutaneous distribution of the fourth cervical nerve ; this 4So PAIN IN THE CHEST is a referred pain, due to afferent stimuli coming up the phrenic nerve to the spinal centre of the fourth cervical nerve. The pleuritic friction sounds often fail to make themselves heard in diaphragmatic pleurisy. The pain in empyema is much like that of pleurisy ; it should be noted that the appearance of a pleural effusion, whether serous or purulent, often coincides with a diminution in the amount of pain felt, because the two inflamed pleural surfaces become separated b}^ the fluid and cease to be rubbed together by the respiratory and other movements. The pleura itself appears to be insensitive, just as is the greater part of the peritoneum ; no doubt the pain of pleurisy is due to stimula- tion of the sensory nerve-endings in the periosteum, muscles, and other tissues of the intercostal spaces. Chronic pleurisy and old pleural adhesions no doubt give rise to much of the chronic pain in the chest and shoulders and root of the neck that occurs from time to time in patients with pulmonary tuberculosis. In many of these, no doubt, the pain is evidence of spread of the pulmonary infection ; in others, it appears to depend on the amount of coughing, increasing when the cough becomes worse ; in yet others, it would seem to depend vaguely enough upon the weather. Pain and tightness in the chest are common in bronchitis, with or without emphysema ; here the diagnosis will not be difficult if pleurisy can be excluded, and much of the pain is probably due to over- strain of the intercostal muscles. In pneumothorax, about half the cases show an acute onset, with the sense of something tearing or giving way in the chest as the patient coughs, and sudden very severe pain in the side, aggravated by breathing. In addition the patient- exhibits dyspnoea, prostration, cyanosis, and rapid and feeble action of the heart. The onset in more than half the cases is insidious, and the condition subacute or chronic, with comparatively little complaint of pain. The diagnosis, if not made frora the history, should be manifest on consideration of the physical signs. The affected side of the chest moves very little on respiration, and is increased in measurement ; vocal fremitus is absent ; the note on percussion is usually tympanitic, in rare cases dull ; and the voice- and breath-sounds are absent on auscultation. If the pneumothorax is at all extensive, the heart wiU be displaced considerably towards the sound side. Examination with the ,r-ra5^s will show that the diaphragm is immobile on the affected side, and the air-containing pleural cavity extremely translucent ; the lung forms a shrunken mass near the middle line and against the spinal column. After a few days, more or less evidence of pleural effusion at the base of the pleural cavity will usually be found. In pneumonia, chest-pain is extremely common, and is due to pleurisy. If the physical signs characteristic of pneumonia delay their appearance, as is sometimes the case, and if the pleural friction escapes detection, the diagnosis of some relatively harmless condition such as pleurodynia or intercostal neuralgia may incautiously be made. This mistake should never occur ; nor is it hkely to do so if due attention be paid to the patient's temperature, aspect, pulse, and pulse-respiration ratio. Pain in the chest is common in acute pericarditis, and is referred to the precordia generally, or to the lower part of the sternum. In man}' cases no complaint of pain is made ; but in a few instances the pain has been exceedingly severe, resembling that of angina pectoris. The diagnosis will turn on the discovery of other signs or symptoms of pericarditis, particularly of pericardial to-and-fro friction-sounds ; the patient is often pale and anxious-looking, and very short of breath. It should be remembered that the friction-sounds often remain unchanged when a dry pericarditis has been converted into a wet one by the effusion of fluid. Pericardial friction-sound is characteristically a superficial grating, rubbing, or creaking, usually double or to-and-fro ; in rhythm it is often PAIN IN THE CHEST not synchronous with either systole or diastole, beginning in one and being carried on into the other. It can often be altered by pressure with the bell of the stethoscope or by changing the patient's position ; often it varies from day to day ; and it is not conducted well in any direction beyond the precordia, being heard within an area that often does not correspond with the areas of audition of valvular murmurs. These characters should suffice to distinguish pericardial friction-sounds from the murmurs of valvular disease ; but it may be verv difftcult in certain cases to distinguish pericardial from pleuropericardial friction-sounds — that is -to say, friction-sounds generated in pleurisy by the lieart's movements. If there is pleurisy of the thin anterior edge of the left lung that comes between the parietal and pericardial pleurae, the beating of the heart will readily give rise to friction-sounds that have a cardiac and not a respiratory rhythm, but are due to pleurisy and not to pericarditis. Pain in the chest will be felt in either case ; the two may generally be discriminated by the influence of deep inspiration and expiration on the fi^iction-sound. In pericarditis, expiration will strengthen and inspiration will weaken (but not abolish) the friction-sounds. Pleuropericardial friction will in all probability be altered profoundly by respiration, being much increased in one phase (whether inspiration or expiration), much diminished, or lost, in another. Pain in the chest is common in cases of heart disease, taking in general two forms: (i) precordial pain; and (2) Palpitation [q.v.). There is nothing characteristic about the precordial pain felt in heart-disease, except the fact that it is brought on most often by exertion or excitement. Very similar pain may be experienced by patients with sound hearts who are suffering from flatulent dyspepsia ; here the pain is usually felt after meals, bur may be brought on by exertion if the latter is made soon after food has been taken. The diagnosis must be based on the general signs and symptoms exhibited by the cardiac patient. In aortic incompetence, the precordial pain is sometimes exceptionally severe, taking the character of angina pectoris, and radiating down the left arm or through to the back. The sensory nerves of the heart are connected with the spinal cord from the first to the eighth dorsal nerve roots ; the first and also the most painful impressions are usually received at the second dorsal roots, which are described as being most central to the paths of pain from the heart. The painful impressions received from the heart at these root- centres are referred to the corresponding areas of cutaneous nerve distribution. Those from the ventricle ascend from the second to the fifth ; from the auricle, the fifth to the eighth ; from the ascending aorta, the third and fourth cervical, and the first to the third dorsal root-centres. These anatomical connections, made out by Head and others, explain the distribution of the pains in the chest and elsewhere felt in diseases of the heart and aorta. Severe pain in the chest, often of anginal character, is felt in acute or chronic aortitis occurring in young syphilitic or rheumatic patients, with or without valvular disease ; the pain is most marked when the base of the aorta and the coronary orifices are involved. Pains in the chest, together with mental anguish, are the outstanding features of true angina pectoris, and are in most cases brought on by exertion. The pain is in the region of the heart, and suggests that the heart has been caught in a vice, so excruciating is it. A sense of impending dissolution, or of a pause in the operations of nature, has been described as added to the physical torture. Radiations of the pains through to the shoulder, down the left arm's inner side to the little and ring fingers (less often down the right arm), up the neck, into the supra-orbital region, are very common. The patient becomes faint and collapsed, pale, and clammy ; the pulse changes ; flatulence and the passage of abundant pale urine follow the attack, which may last for a few seconds or minutes, or may continue, with varying intensity, for hours. Attacks of true D 31 4S2 PAIN IN THE CHEST angina are always serious, as any one of them may cause death. The diagnosis will rest on the extreme severity of the pain, its association with valvular disease or arteriosclerosis, or both, and the fact that the attacks are almost always brought on by exertion or severe emotion. The true must be distinguished from false angina pectoris, also called pseudo-angina or vasomotor angina pectoris. This commonly has a neurotic, less often a toxic (tobacco, tea, coffee) basis ; it is less severe, and is never fatal. It is far commoner in women than in men ; often comes on when the patient is at rest, or at night ; may occur at any age, and is not associated with cardiac or vascular disease. The attacks of false angina last fo,r an hour or two, and come on spontaneously ; the extremities are chilly in the vasomotor type of the disease. True angina is perhaps ten times commoner in men than in women, and occurs between the ages of forty and sixty as a rule ; false angina is perhaps five times as common in women as in men, and occurs in younger patients. From what has been said above, it is clear that typical cases of the two conditions will be readily distin- guished from one another, but every gradation between the two may be met with, and it may be impossible to refer intermediate cases — for example, patients with severe heart-attacks and valvular or myocardial lesions — with logical precision either to one class or the other. Chronic' or recurrent pain in the chest is a very variable symptom of aortic aneurysm. In some patients, a large aneurysm may erode rib-cartilages and intercostal spaces, and present itself at the surface of the body without having made itself felt. In others, agonizing pain (true angina pectoris) may be occasioned before an aneurysm at the root of the aorta has grown large enough to produce any physical signs at all ; in these the pain is no doubt due to aortitis or mesaortitis for the most part, or to obstruction at the coronary orifices. Speaking generally, the pain of aortic aneurysm may arise in two ways : (i) From changes in the aortic wall, already considered ; and (2) From pressure on neighbouring structures, particularly the walls of the chest. As has been already noted, pressure-erosion of the sternum or costal cartilages may be comparatively painless in fortunate cases. Erosion of the vertebral bodies commonly gives rise to intense and continuous boring pains in the chest that wear the patient out and make life insupportable ; girdle-pain may result from pressure on the intercostal nerves (direct pain), and referred pains up the neck or down the inner side of the arm may also be felt. Pressure on the oesophagus may give rise to dysphagia and pain, the pain being increased by swallowing. Compression of the lung may lead to pulmonary collapse and inflammation, when pain from pleurisy will probably be felt. It appears that no particular complaint of pain follows compression of the trachea, bronchi, phrenic or vagus nerves, or heart. An acute and severe pain, on the other hand, may arise should the aortic aneurysm perforate and allow blood to escape into the adjoining parts. Such perforation may take place into the air-passages, oesophagus, large intrathoracic pulmonary or systemic veins, pericardium, heart, pleura, peritoneum, or spinal canal. The appearance of the appropriate physical signs will suggest the diagnosis of such a perforation. If the effused blood is limited in amount, the patient will appear more or less blanched and collapsed ; if a great quantity escapes, rapid or sudden death may occur. Particular mention may here be made of the pain due to the formation of a dissecting aneurysm. The arteries are acutely sensitive to pain, as may be seen when an artery is ligatured in a conscious patient ; the establishment of a dissecting aneurysm is a terribly painful experience, and is equivalent to an attack of true angina pectoris. If the escape of blood is limited by the walls of the aorta, recovery is likely to occur. The diagnosis of such an incident could onl}' be made on grounds of probability. PA IX IN THE CHEST 483 Pain in the chest is usually an early symptom of mediastinal new growth, and varies in its nature and distribution with the cause and site of its origin. If the growth is in the anterior mediastinum, the pain will be behind the sternum ; if in the posterior mediastinum, pressure on or erosion of the vertebrae will set up the severe continuous boring pain referred to above as occurring in aortic aneurysm ; if one side of the chest is involved, the pain will be felt in the side, and down the arm if the brachial plexus is pressed upon. It is often of a darting and lancinating character, shooting up into the neck and head, or down into the abdomen. It may be constant, intermittent, or paroxysmal ; in some cases it is a discomfort rather than a pain that is felt, the complaint being of fullness or tightness in the chest. Other symptoms of mediastinal tumour are, lirst and foremost, continuous or paroxysmal dyspnoea ; evidences of pressure on the air-passages, oesophagus, or nerves ; cough, expectoration, haemoptysis, alterations in the voice or cough ; disturbances in the action of the heart, and evidences of venous obstruction. Anaemia or even cancerous ca- chexia are not rare. The general diagnosis of mediastinal tumour (including aneurysm) is seldom difficult once pressure-symptoms of any sort have appeared, for these are very rarely caused by other lung-conditions associated with pain in the chest, such as bronchitis, bronchiectasis, or pul- monary tuberculosis. But it may be very difficult to decide between aortic aneurysm and mediastinal new growth in certain cases. Aneurysm is commoner in men than in women, and rare in per- sons who have not had syphilis ; anginal pains and the very severe pain of bone-erosion are commoner in aneurysm than in mediastinal new growth ; anaemia, cachexia, and irregular pyrexia are in favour of new growth ; and so is the discovery of new growth in other parts of the body and of second- arily-infected lymphatic glands. Examination under the ;ir-rays will prove of the greatest help {Fig. 74, p. 236, and Fig. 131), the rays being passed through the patient's thorax in a number of horizontal directions successively ; if ^this be done, the presence of an aneurysm and its connection with the t aorta can almost always be established when one is present, to the exclusion of mediastinal new growth. r 1 In acute mediastinitis and mediastinal abscess — both of them rare disorders and due to syphilitic, tuberculous, or other infection of the mediastinum — pain behind the sternum is commonly the chief complaint, with marked superficial tenderness and a tendency to radiation through into the back or shoulder. Local signs of fullness and inflammation may develop, particularly about the intercostal spaces in front and the episternal notch ; and mediastinal crepitations resem- bling pleural friction have been heard about the sternum. The diagnosis should not be difficult. Fig. 131. — Skiagram ot an aneurysm of the innominate artery (A), with dilated aortic arch (B)- {By Dr. Alfred C. Jo7-dan.) PAIN IN THE CHEST In chronic mediastinitis or mediastino-pericarditis, another rare condition due to inflammation arising in the mediastinum, or spreading to it from the pericardium, and seen in youth or early adult life, chronic pain behind the sternum and a sense of tightness and dragging in the chest may be present. But the main symptoms will be cardio-vascular, valvular disease of the heart and adherent pericardium leading to cardiac troubles, and the mediastinitis causing venous obstruction. Dyspnoea, lividity, anasarca, ascites, and progres- sive distention of the thoracic veins, are the main features upon which the diagnosis of mediastino-pericarditis must be made, new growth being excluded by the duration of the case. Deep-seated pain within the chest and at the bottom of the sternum may be felt in diseases of the oesophagus, being evoked by the act of swallowing. In cicatricial stricture or carcinoma of the tube, pain is less prominent than Dysphagia {q-v.), and progressive emaciation is the rule. In younger and neurotic patients, on the other hand, spasmodic stricture of the oesophagus may give rise to difficulty in swallowing, with much complaint of pain and constriction in the throat and chest. This condition, termed oesophagismus, occurs in hys- terical young persons and in hypochondriacal old ones ; it is improved or cured by the passage of a bougie ; is associated with other evidences of the neurotic temperament ; and must be diagnosed from organic oesophageal stenosis. Pain in the chest is very frequently met with in diseases of the abdominal viscera, particularly of the stomach. " Pains round the heart," often accom- panied by or productive of Palpitation (q.v-), are the common basis upon which patients build when they come complaining of " heart-disease " or " weak heart," while as a matter of fact they are suffering from the less serious condition of gastritis, or flatulent dyspepsia. The pain is felt at the bottom of the sternum and in the epigastrium ; it is often of a dull boring character, and radiates out towards the left breast and through to the back between the blade-bones. It is definitely connected with the taking of food, and relieved by vomiting or the eructation of wind ; and these are the characters by which it must be diagnosed. In other instances, the complaint is of " heart-burn," a burning pain felt over the lower part of the sternum, and probably due to the regurgitation into the oesophagus of the gastric contents during digestion. It is a referred pain felt in the area of distribution of the fifth dorsal nerve, and is often associated with pyrosis or water-brash, the regurgitation of acrid watery gastric contents into the mouth. For the most part, however, pain due to gastric disorders (such as ulcer, new growth) is referred to the upper part of the abdomen rather than the chest. Pains in the chest are not rare in various diseases of the spinal cord. Girdle pains or girdle sensations are common in tabes dorsalis, the patient feeling as if constricted by a hot or painful girdle. They occur early in the disease, and so are often set down vaguely to gout or rheumatism, when a more careful examina- tion would yield early evidences of tabes. In transverse myelitis, or fracture of the dorsal column with injury to the cord, girdle pains round the chest may be felt at the level of the cord lesion, with loss or abolition of sensation below it. A. J. J ex-Blake. PAIN IN THE EAR.— (See Earache.) PAIN IN THE ELBOW. — (See Joints, Affections of.) PAIN IN THE EPIGASTRIUM. A. Sudden, severe epigastric pain may result from the rupture of a gastric or duodenal ulcer, of a gangrenous appendix, or from acute pancreatitis. The pain in such a case is attended by severe shock and signs of collapse, and it may be difficult to say to which of the above causes it is due. The past history of the patient, however, and a careful study of the other signs present, may guide one PAIN IN THE EPIGASTRIUM 485 to a correct conclusion ; but as all the conditions mentioned require immediate surgical treatment, the differential diagnosis is not a matter of great importance. It should be borne in mind, however, when the diagnosis of an abdominal emergency has to be considered, that " if the history, symptoms, and signs do not exactly fit acute intestinal obstruction, or stomach or duodenal perforation, perforating appendix, or acute cholecystitis, and yet have some resemblance to each of them, pancreatitis is the most probable cause " (Morison). B. Chrcnic or recurrent pain in the Epigastrium may be due to a variety of causes : — (i). It should be remembered, in the first place, that epigastric pain may be due to extra-abdominal causes. Amongst these are spinal caries (especially to be thought of in children), pleurisy, and intercostal neuralgia. The first two of these can easil}' be distinguished by the usual signs ; intercostal neuralgia is to be diagnosed by the presence of tender points along the course of the nerve. A dilated right ventricle may also be the cause of severe epigastric pain, which may even simulate the pain of gastric ulcer or gall-stones. In cases of emphy- sema, or heart failure, this should be borne in mind. In such cases the pain is aggravated by exertion. Small epigastric hernicB may cause recurring attacks of severe epigastric pain. They can be detected b}^ careful palpation, usually in the linea alba. Affections of the abdominal muscles, e.g., strain from coughing, or rheumatism (in children), may also cause pain in the epigastrium. (2). Assuming these to be excluded, the cause of the pain may be looked for in the following organs : — (a). Stomach. — The chief causes of gastric pain are carcinoma, ulcer, hyper- chlorhydria, and gastralgia. (See Indigestion.) The pain in carcinoma is usually more or less continuous, although apt to be temporarily aggravated by food. A tumour may be felt. Vomiting is usually present, and the gastric contents show absence of free HCl (in most cases) . In cases of ulcer the pain is more definitely related to the taking of food, and often passes through to the back. Vomiting is usually a feature, with or without h^ematemesis. There is localized deep tenderness on pressure, often over quite a small and well-defined area. The gastric contents usually show the presence of an excess of acid. In cases of hyperchlorhydria the pain is less severe than in either of the above conditions ; it occurs in the late period of digestion, and is relieved temporarily by the taking of food. There is an absence of other signs and symptoms, and of local tenderness ; and a test-meal shows the presence of an excess of acid. Gastralgia should only be diagnosed when all other possible causes of gastric pain have been excluded. The patient is usually a young woman ; the pain may occur even when the stomach is empty, but is aggravated by food, even by liquids. Vomiting is usually absent, and on physical examination there is diffuse deep tenderness over the whole of the gastric area. Epigastric pain may also be felt to a greater or less degree in all conditions of the stomach associated with flatulence, and in that case it is relieved by the bringing up of wind. (See Flatulence.) The gastric crises of tabes may be attended by severe epigastric pain, and as these may occur in the pre-ataxic stage of the disease, before other signs are present, the diagnosis may be in doubt. The characteristic features are the sudden onset of the pain, and the fact that it is usually attended by urgent vomiting. There is no rise of temperature, but during the attack the blood- pressure is raised ; whereas in aU other forms of acute abdominal pain (except lead colic) it is lowered. Absence of the knee-jerk, and the characteristic pupil signs of tabes are not necessarily present. 4S6 PA IX IX THE EPIGASTRIUM Perigastric adhesions are a possible cause of epigastric pain, but are difficult to diagnose with any certainty-. If the pain is much influenced bj' muscular movements, or change of posture, it is in favour of adhesions being the cause ; but except for this, it has no other characteristic features. (b). Liver and Gall-bladder. — Epigastric pain mav be produced by congestion of the liver, either active (hepatitis), or passive, as in mitral disease. It is also produced by such conditions as hepatic abscess and carcinoma (see Liver, EXLARGEMENT OF THE) . Stone in the gall-bladder may sometimes be a cause of epigastric pain, which ma^- even be definitely related to meals, or to the taking of a particular article of food. Pressure over the gall-bladder will often ehcit tenderness ; and if the patient is made to take a deep breath Avhilst the pressure is applied, there will be a painful catch in the breath as the diaphragm descends. In a doubtful case, in which the diagnosis lies between gall-stones and gastric ulcer, the following points are in fa\-our of gall-stones : (i) The occurrence of the pain at rather long intervals, with comparative freedom from s^^mptoms bet^veen ; (ii) Long duration of the attack of pain ; (iii) Continuance of the pain in spite of vomiting ; (iv) The occurrence of shght shivering and rise of temperature with the attacks. (c). Pancreas. — Pancreatic calcuh, chronic pancreatitis, or new growth, may all be the cause of epigastric pain. An accurate diagnosis of these conditions is difficult, and often impossible ; but there may be present other signs of disturbed function of the pancreas, such as fattj- diarrhoea, or a " pancreatic reaction " (p. 115) in the urine. A tumour also may be felt. Glycosuria may be present, but is not invariable. In cases of chronic pancreatitis there is usually a histon,- of gall-stones. (See also Pain in the Hypochondrium, Right.) [d). Abdominal Aorta. — An abdominal aneurysm mav cause pain in the epigas- trium, but the pain is more marked in the back. The patient is usually a young man with a sj-phihtic histor\-, and a pulsating expansile tumour can be felt on deep palpation. The ;!r-rays will confirm the diagnosis. Abdominal angina, which is associated with arterial atheroma and a high blood-pressure, is an occasional cause of severe epigastric pain, which comes on in paroxysms, especially upon exertion. The pain in such a case tends to radiate Uke that of true angina, and is often attended by flatulence, tenesmus, and other abdominal s}.-mptoms. There are usually signs of atheroma in the peripheral vessels ; and the diagnosis mav be confirmed by the yielding of the pain to vascular depressants, and especiall}- to diuretin. (3). Colon. — Spasmodic contraction of the transverse colon (enterospasm) may be a cause of epigastric pain, which may simulate gastric pain by being induced b\- the taking of food. Such pain, however, tends to be relieved by pressure, and by the passage of gas per anum. Obstinate constipation is usually a feature of the case, and there are often mucus and shreds of membrane in the motions (muco-membranous colitis). A similar pain may be due to phtmbism, for the diagnosis of which see Colic. Robert Hutchison. PAIN IN THE EXTREMITY (LOWER).— The causes of pain in the lower limbs are so numerous that much space would be required if any attempt were made to discuss them in full. Fortunately the majority are easily detected when attention is paid to the site, nature, and history of the pain, and the painful spot is examined. An attack of gout in the big toe, an ingrowing toenail, a flat foot, a synovitis of the knee or ankle, phlebitis of a varicose vein, a tumour of one of the long bones, and many other localized pathological processes require only an elementar}- medical knowledge, and the enlightened use of eyes and fingers on the part of the medical man, in order that a correct diagnosis may PAIN IN THE LOWER EXTREMITY 487 be arrived at. On the other hand, there are many conditions of which pain of a more or less diffused type is a prominent sj-mptom, and which require very careful investigation if mistakes are to be avoided and diagnostic traps escaped. The fact that the nerves of the leg spring from the lower part of the spinal cord in the dorso-lumbar part of the vertebral column, and that they have a some- what lengthy course within the lumbo-sacral vertebral canal and the pelvic cavity, where they are comparatively inaccessible, before they reach the limb, explains why the origin of some pains referred to the lower extremity is rendered obscure. ^Moreover, some of the painful conditions met with are connected only indirect!}' with the nervous paths, and are more directly associated with morbid conditions of other structures, such as joints, blood-vessels, etc. The classification of the various painful conditions in the lower extremity which need our attention from the point of view of diagnosis is no easy matter. One may consider first those which are primarily nervous in origin, and use them as a basis for comparison with those due to disease of other tissues. I. Pains of Neuralgic or Neuritic Origin. Sciatica. — This name is comnaonly applied to a condition of the sciatic nerve which may sometimes be described as a neuralgia and sometimes as a neuritis, according to the severity of the attack and the amount of alteration in nervous function to which it gives rise. It is characterized by pain of a neuralgic type referred to a part or the whole of the course of the sciatic nerve and its branches, from the sciatic notch to the sole of the foot. Usually the pain is most severe along the back of the thigh and along the outer side of the leg. Tenderness is found on pressure over the gluteal region, over the sciatic notch, and generally all along the nerve. Exacer- bation of pain is produced by stretching the nerve, for instance by forcibly flexing the thigh on the trunk with the knee fully extended. The pain is intensi- fied by muscular exertion, and is often severe at night, especially when the patient lies on his back. Sciatica is often associated with lumbago, pain and tenderness in the muscles of the lumbar region. In long-standing cases the nutrition of the affected leg suffers and the muscles appear generally smaller than those of the other limb, but localized atrophy picking out individual muscles suggests that there is something more than a simple neuralgia or neuritis at work. Numbness, and even slight cutaneous ansesthesia, may be found on the dorsum of the foot, in the distribution of the musculo-cutaneous branch, in cases of simple sciatic neuritis. The knee-jerk is never affected in sciatica, but the ankle- jerk is often diminished or lost, and may remain absent for a long period after the pain has disappeared. The plantar reflex is of the flexor type. Before making a diagnosis of sciatica or sciatic neuritis in a patient who complains of pain in the course of that nerve, the physician must satisfy himself that there is no gross disease in the hip joint, pelvis, or spinal column which could give rise to the symptoms. The mobility of the hip joint must be investigated carefully, and, if doubt exists with regard to its integrity, the joint should be subjected to skiagraph}'. The pelvis should be examined externally and internally per rectum or per vaginam. The writer has seen a case of sarcoma of the innominate bone mistaken for sciatica, when a glance at the pelvis as a whole was sufficient to demonstrate the swelling on the affected side. In the same way the mistaken diagnosis of sciatica has frequently been made when a rectal or vaginal examination would detect a pelvic inflammatory or malignant mass pressing on the nerve. Even a retroverted uterus may sometimes cause pain in the sciatic distribution. Tuberculous, gummatous, or malignant disease of the lumbo-sacral vertebrcs, tumour, or meningitis involving the lower part of the spinal cord and caiida equina, are also capable of producing pain which resembles that of sciatica. In such cases, inquiry into the action of the sphincters of the bladder 4-88 PAIN IN THE LOWER EXTREMITY and rectum may suggest the position of the lesion, and should always be made in patients complaining of sciatica. Skiagraphy of the lower part of the vertebral column may help to disclose disease of that structure. Lumbar puncture may be necessary for the purpose of diagnosing syphilitic meningitis. In most cases of this kind, however, a careful scrutiny of the lower limb will show that the pain is not limited to the distribution of the sciatic nerve, that the latter is not acutely tender on pressure, that there are atrophy and paresis of certain groups of muscles, some of which are supplied by other branches of the lumbo- sacral plexus, that there are patches of anaesthesia corresponding to root rather than nerve areas, or that the knee-jerk is lost and perhaps the plantar reflex altered in character. It should also be remembered that sciatica is nearly always unilateral, whereas growths or inflammation within the vertebral canal tend to produce signs and symptoms in both legs at a comparatively early stage. The frequency with which sciatica is diagnosed when some much more serious disease is really present, is sufficient excuse for laying emphasis on the above points, and every practitioner would do well to make it his invariable rule, when faced with a case apparently conforming to the picture of sciatica, to inquire into the action of the sphincters, to inspect carefully and palpate the pelvis and spine, to make a rectal examination, and finally to keep a sharp look-out for signs of present or past malignant disease in other parts of the body. In all cases of neuralgic or neuritic pain the urine should be examined for the presence of sugar. Anterior Crural Neuralgia. — Neuralgia in the distribution of the anterior crural nerve is much less common than sciatica, and precautions similar to those just mentioned must be adopted before the diagnosis is made. In this condition, the pain and tenderness involve the front of the thigh as far as the knee, and the knee-jerk is sometimes diminished. In some cases the pain extends along the saphenous branch to the ankle, inner aspect of foot, and big toe. Occasionally it is associated with sciatica. Obturator Neuralgia. — Pain in the distribution of the obturator nerve is rarely of simple neuralgic origin. Disease of the hip joint and obturator hernia are two of the conditions which may give rise to it. Neuralgia parcesthetica is the name given to a variety of pain which is referred to the course of the external cutaneous nerve of the thigh. The relations of this nerve to the psoas muscle and the fascia lata render it liable to stretching or pressure in standing or walking, with the result that the neuralgia is intensified by the maintenance of the erect posture. In certain instances of great obesity, prolonged sitting has been supposed to play a part in producing this type of neuralgic discomfort. There is sometimes a painful pressure-spot just below the anterior iliac spine. A liat-foot is met with not uncommonly in these cases. Metatarsal Neuralgia, or Morton's Affection of the Foot. — This neuralgia is of the paroxysmal type, and is described as dull throbbing pain in the base of the fourth — sometimes of the second — toe, and spreading up the leg. There is tenderness on pressure over the metatarsus. In a certain number of cases the pain is probably related to the wearing of tight or ill-fitting boots, or to the presence of flat-foot. Calcanodynia is another form of pain liable to occur in neuralgic subjects who are doing much walking. The pain is often bilateral, worse in the evening and at night, and tends to spread from the heel to the base of the toes. There are no objective signs of disease. One patient who consulted me for this con- dition returned a year or two later with a typical brachial neuralgia. Multiple Neuritis. — The lower extremities are often the site of multiple neuritis giving rise to great pain, but the diagnosis is rarely difficult owing to the association of atrophic palsy of the muscles, the electrical reaction of degener- ation, dulling of cutaneous sensibility below the knees, and loss of the knee- PAIN IN THE LOWER EXTREMITY 489 and ankle-jerks. Perhaps the most characteristic and constant phenomenon in such cases is the presence of marked tenderness of the muscles on pressure. The nerve trunks are sometimes hypersensitive also, but not so constantly as are the muscles below the knees. The pain in multiple neuritis is often acute, worse at night, and aggravated by movement and the pressure of bed-clothes. Tabes Dovsalis. — The pains of tabes are more often complained of in the legs than in any other part of the body. Unlike the neuralgias, they are usually bilateral and not referred to the distribution of any particular peripheral nerve. The " lightning " pains are so characteristic that they can hardly be compared with painsof any other origin. "Whether trivial and " niggling," or so intenseas to draw sweat and cries from the most heroic of sufferers, they are always short and lightning-like in duration, often rapidly repeated in the paroxysms, irregu- larly periodic in their attacks, and fleeting or hovering in their locahzation. It is a practical point of importance to remember that many patients, when asked if they suffer from pains, emphatically deny it, but readily admit to " rheumatics," and then describe in a graphic manner the lightning pains of tabes. The idea of rheumatics is evolved from the fact that these pains are often provoked by changes in the weather. In addition to lightning pains, sufferers from tabes often complain of dull aching or boring pains, which are more continuous and less intermittent than those just described. It is certain that tabetic pains may precede all other signs and symptoms of the disease, in which case their diagnosis may be difficult. The following points should be investigated carefully when pains answering to the description given above are complained of : (i) A history of syphilis, congenital or acquired. The writer has known a woman, probably the subject of congenital syphilis, to suffer from lightning pains from early childhood up to forty years of age, when she presented other signs of tabes ; (2) The presence or absence of a positive Wassermann serum reaction ; (3) The presence or absence of a Ivmphocytosis in the cerebrospinal fluid ; (4) The reaction of the pupils to light ; (5) The condition of the knee- and ankle-jerks ; (6) The presence of deep and superficial analgesia over the legs ; (7) A history of gastric crises ; and (8) The condition of the sphincter vesicae. Particular attention is drawn to a valuable sign of tabes which is not referred to so commonly as are Argyll Robert- son pupils and absent knee-jerks, i.e., the impaired pain-sensibility in the calf and other muscles when they are squeezed. AcroparcBsthesia. — (Sec p. 493.) 2. Pain in connection with Disturbances of the Circulation. Intermittent Claudication. — This term is applied to a condition the pathology of which is still obscure, but which certainly depends on an insufficient blood-supply to the muscles of the lower extremities when they are called into activity during locomotion. It may lead eventually to gangrene. The malady occurs chiefly in men over forty years of age, and particularly in those who have indulged freely in tobacco, who have contracted syphilis, or who have thrown strain upon their legs over a long period of time. The patient complains of pain in one or both legs, generally in the calf muscles, coming on after walking a certain distance, and disappearing with rest. The pain becomes so intolerable that he is obliged to stand or sit still until it passes off. As time goes on the distance he can walk in comfort becomes progressively shorter. Examination of the affected limbs reveals nothing obvious ; they are well nourished, powerful, and normal in regard to sensation and reflexes. Probably, however, the observer will fail to detect pulsation in the arteries of the foot, and perhaps he may not feel the popliteal artery behind the knee-joint. The femoral artery can usually be felt to pulsate in a normal manner. After the exertion of walking, the foot may 490 PAIN IN THE LOWER EXTREMITY appear unduly pale. ^Yith rest, the returning flush of normal colour spreads gradually over its surface. In several cases of this kind the writer has noticed myokymia of the calf muscles ; that is to say, slow worm-like contractions of individual muscle bundles without any movement of the foot. The condition is not verj^ uncommon, and its diagnosis is not difficult if the characteristic history of pain coming on during the act of walking is borne in mind and leads to the search for the signs referred to above. The importance of its recognition needs no emphasis in view of its tendency to go on to gangrene. Raynaud's Disease. — The pain attendant on the local syncope and local asphyxia which characterize this disease may be severe, but the diagnosis is obvious owing to the onset of symmetrical pallor or cyanosis of the toes preceding the acutely painful stage (see Gangrene). The hands are nearly always affected at the same time. Erythromelalgia. — In this condition, which may affect various parts of the bod}', but which is seen most commonly in the feet, pain raay precede any other phe- nomenon. The pain is more or less continuous, with paroxysmal exacerbations, and it is aggravated by the dependent position of the limb as well as by warm applications. The raising of the foot to, or above, the level of the body, and the application of cold, are attended by alleviation. Local patches of cutaneous flushing follow, or sometimes precede, the pain, and are often found about the ball of the big toe or along one edge of the foot. These patches are generally rose-pink in colour, but may become purplish-red in severe paroxysms. The local temperature is raised, and pulsation of the vessels may be observed. Superficial and deep tenderness is also present, but no changes in the reflexes are noted. In long-standing cases a certain amount of oedema results. Erythromelalgia occurs in persons who are apparently healthy in other respects ; on the other hand, it may be an early symptom of, or be associated with, some disease of the spinal cord, such as disseminated sclerosis, tabes dorsalis, or syringomyelia. The following table is drawn up with a view to summarizing the chief points in the differential diagnosis of intermittent claudication, Raj'naud's disease, and erythromelalgia: — Intermittent Claudication Raynaud's Disease E RYJ'H ROM ELALGI A Age 40 and over All ages 20 to 60 Sex Males more than females Females more than males Males more than females Site -j As a rule symmetrical in calf muscles Sj^mmetrical in toes AsA'mmetrical in feet, rarely bilateral ( Pain -' Onset while walking Worse in cold weather Only with exercise No sensory change During syncopal phase or absent Unaffected by postion May be excited by cold Paroxj'smal Ana?sthesia and anal- gesia during paroxj^sm Precedes vasomotor phe- nomena Aggravated by depen- dent posture Cold beneficial More or less continuous, with exacerbations Superficial and deep ten- derness Vaso- motor J changes No change or slight!}- pale Absence of pulsation in arteries. Feet some- times cold Gangrene occasional Pallor and lividity Ischaemia and local cold Gangrene common Pink to purplish flush Increased pulsation and local heat Gangrene rare Associa- \ 1 tions 1 Arteriosclerosis Tobacco Syphilis General vasomotor dis- turbances Functional and organic disease of the central nervous svstem PAIN IN THE UPPER EXTREMITY 491 3. Referred Pain in Visceral Disease.- — In the lower extremity the referred pain of visceral disease is not so often recognized as that of cardiac disease in the upper extremity. Disease of the rectum, bladder, prostate, or uterus may, however, give rise to pain and cutaneous tenderness, chiefly in the fifth lumbar and sacral areas. Head quotes a patient who suffered from prostatitis and whose complaint was as follows : " My life is a burden, for I cannot stand owing to the pain in the soles of my feet, I cannot walk owing to the pain in my calves, sit on account of the pain ovei the ischial tuberosities and in the perineum, or even lie owing to the pain in my loins and side." A careful examination of the abdominal and pelvic viscera is necessary, therefore, in all cases of pain referred to the legs without obvious local cause. E. Farqiihar Buzzard. PAIN IN THE EXTREMITY (UPPER) Pain in some part or other of the upper extremity is a common complaint, and one for which relief is often sought. In order to relieve the pain it is necessary for the medical man to make a diagnosis of the pathological condition which underlies it. This article makes no pretence to deal with the diagnosis of cases in which there is some obvious source of pain, such as an acute arthritis or a tumour, but is intended to serve as a guide for the diagnosis of cases in which the pain is more obscure in origin. In the first place, it is always essential to inquire into the character of the pain, its exact site, its duration, and, if paroxysmal, its usual time of onset, its relation to movement, rest, etc. In the second place, a careful examination must be made, not only of the offending limb, but of the functions of various organs and of the nervous system in particular. It must be remembered that the arm is innervated by branches of the brachial plexus, and that the latter.. is made up of nerve fibres derived from the fifth cervical to the second dorsal spinal segments through their corresponding roots. Consequently, complete examina- tion may necessitate an investigation ot the spinal functions, and an inquiry into the condition of the cervical vertebral column and the cervical meninges ; it may even be desirable to take a skiagram of the neck or to make a lumbar puncture for the purpose of a correct diagnosis. Attention may be drawn espe- cially to the fact that pain in any situation may be a forerunner, the first symptom of a nervous or spinal lesion which ultimately leads to more serious disorders of function, such as paialysis, loss of sensibility, and alteration of reflexes. The following are various pathological conditions of which pain in the arm is often a prominent symptom : — Brachial Neuralgia. — This, like neuralgia in other parts, is characterized by pain and tenderness in the distribution of one or more nerves. The pain may be referred to the course of all the branches of the brachial plexus, but some- times is limited to that of one or two nerves, such as the ulnar, musculo-spiral, or internal cutaneous. It may occur only in paroxysms, but more commonly there is a constant aching discomfort, with occasional severe exacerbations excited by exertion, cold, or mental worry. The patient is generally glad to rest the limb or to carry it in a sling, in order to avoid the more acute attacks ; on the other hand, the continuous aching drives him to find temporary relief in frequent changes of position. Pressure over the affected nerves is accom- panied by tenderness, especially over the brachial plexus in the posterior triangle of the neck, over the musculospiral as it winds round the humerus, and over the ulnar along its superficial course in the region of the elbow. The tenderness so produced may be associated with pain or tingling referred to the more peripheral course of the nerve. The skin may be hyperaesthetic and show vasomotor changes in the way of flushing or hyperidrosis. In making a diagnosis of brachial neuralgia it is desirable to seek for some cause to which it can be ascribed, such as a rheumatic ox gouty diathesis, orahistor}' 492 PAIN IX THE UPPER EXTREMITY of some preceding toxic condition, such as influenza, malaria, or alcoholism. In some cases no satisfactory explanation beyond unusual worry or work in a neuropathic individual is forthcoming. The urine should be examined for sugar, as neuralgia is sometimes of diabetic origin. The presence of muscular atrophy or anaesthesia removes the case from the category of neuralgia, and the diagnosis of neuritis or of some more gross organic affection, to which reference will be maae, must be substituted. On the other hand, it must not be forgotten that a cervical rib may produce many of the symptoms of brachial neuralgia without any definite muscular atrophy or sensory loss. In contradistinction to some of the conditions about to be described, brachial neuralgia is practically always unilateral. Brachial neuralgia may be diagnosed, therefore, if there is pain and tender- ness in the distribution of the brachial plexus without paralysis or sensory loss, and if no gross lesion can be found to account for the symptoms. So-called muscular rheumatism differs from brachial neuralgia in that the pain is generally less acute and the points of local tenderness are to be found over muscular insertions rather than over the nerve trunks. At the same time it must be admitted that the muscles as well as the nerves are hypersensitive in severe cases of neuralgia. Brachial Neuritis. — When muscular atrophy and sensory loss are found in addition to pain and tenderness, the condition must be regarded as one of neuritis. Unilateral brachial neuritis is very uncommon except as a result of some gross lesion, such as pressure on, or irritation of, the nerve-trunks. Bilateral brachial neuritis is common enough, but is then a part of a multiple peripheral neuritis due to alcohol, arsenic, lead, diabetes, etc., in which the lower extremities also are generally involved. Before making a diagnosis of one-sided brachial neuritis, careful search must be made for evidence of such conditions as cervical rib, tumour in the posterior triangle of the neck, glands in the axilla, aneurysm of the subclavian artery, malignant disease or caries of the cervical vertebrcB, cervical pachymeningitis, spinal tumour, or spinal gliosis. Neuromata or fibroneuromata are generally widely distributed about the peripheral nerves, but cases have been recorded in which they have been limited to the brachial plexus and have given rise to a brachial neuralgia or brachial neuritis. Such tumours may be so small as easily to escape observa- tion unless looked for. Adiposis dolorosa is another rare condition which may give rise to neuralgic pain in the arm, but it is not limited to one limb. Cervical Ribs. — A supernumerary seventh cervical rib, unilateral or bilateral, is a frequent congenital abnormality. In a small proportion of cases it may give rise to symptoms, especially in adults who use their arms and hands con- tinually in the course of their employment. Women suffer more often than men. Pain radiating from the root of the neck to the tips of the fingers, more often than not along the ulnar border of the arm, is usually the first, and may be the only, symptom. The pain is of an aching or dull boring character, and is much influenced by rest and position. For instance, if a woman, who has been suffering much when at work, takes a holiday, and ceases to use her arms for scrubbing, lifting, etc., she may lose the pain altogether until she resumes her occupation. Similarly the pain is worse at night after a day's work, and may be influenced favourably by keeping the arm in certain positions. Lying in bed with the hand behind the head is a favourable attitude in many cases. Very occasionally the pain spreads into the scapular region along the course of the suprascapular nerve. There is rarely any tenderness along the peripheral parts of the nerves, but pressure in the posterior triangle of the neck, just above the inner part of the clavicle, may give rise to pain radiating down the arm. In addition to pain there may be disturbances of motor, sensory, and vasomotor PAIN IN THE UPPER EXTREMITY 493 origin. Atrophic palsy of the intrinsic hand muscles and of the iiexor muscles in the forearm are the common motor disturbances, and may lead to deformities such as Claw-hand {q.v.). Anaesthesia along the ulnar border of the forearm, and perhaps extending on to the inner fingers, is sometimes observed. In one bilateral case the writer has observed intense vasomotor disturbances without definite muscular atrophy or sensory loss. Both hands were the seat of a painful cyanosis involving the fingers, and almost amounting to the condition seen in cases of Raynaud's disease. Sometimes there is a diminution in the radial pulse on the affected side. The diagnosis of cervical rib or ribs must naturally depend on the use of the ,r-rays to reveal their presence, but it must be borne in mind that the pressure on the trunk or trunks of the brachial plexus is usually exerted by a fibrous band passing from the tip of the cervical rib to the first dorsal rib, and that therefore the size of the rib shown by skiagraphy affords no guide as to the importance of its effect. The most rudimentary rib is as important from the point of view of diagnosis as one which is fully developed. AcroparSBsthesia. — This term is applied to a fairly common complaint, usually made by women between thirty-five and fifty-five years of age, who are continually using their hands, and especially by those whose hands are frequently immersed in waters of different temperatures. Charwomen, domestic servants, needlewomen, and washerwomen are particularly liable to suffer. IMany of the victims indulge to a moderate extent in spirit-drinking. They complain of a burning pain, associated with tingling and numbness, in the fingers and palms of their hands. It is chiefly noticed in the latter part of the day after their work is over, and becomes intensified when they are warm in bed. In the early morning their fingers are numb and clumsy, but the discomfort passes off while they are at work, only to return again towards evening. As a rule, there is little to see on examination, but there may be redness or pallor of the affected parts, associated with a subjective feeling of heat and swelling. Sensibility is unimpaired if allowance is made for the cutaneous thickening usually present in persons whose hands are much exposed to moisture and friction. There is no definite palsy or muscular atrophy. Acroparaesthesia as a rule affects both hands, and very occasionally it is accompanied by a similar condition in the feet. Similar paraesthesiae are sometimes complained of by patients suffering from tabes dorsalis, but in those cases the pains are of the lightning character, and never limited to the hands. Other tabetic signs, such as Argyll Robertson pupils, ulnar analgesia, impaired sense of position, and absence of tendon- jerks, serve to make a diagnosis. In the early stages of subacute combined degeneration of the spinal cord, paraesthesiae, sometimes of a markedly painful character, are referred to the hands and feet. The presence of some ataxia or spastic para- plegia, with increased tendon- jerks and extensor plantar reflexes, differentiate this disease from the ordinary acroparaesthesiae. Radicular Pain. — Under this title may be included all pains in the arm which radiate through the peripheral distribution of the posterior spinal roots from the fifth cervical to the second dorsal. These pains extend from the neck towards the periphery of the limb, and are usually of a sharp, lancinating type. In the large majority of cases they are produced by some gross morbid process involving the roots within the spinal canal or in their course through the intervertebral foramina. The morbid processes most commonly responsible are intravertebral tumour, cervical pachymeningitis, cervical caries, and malignant disease of the cervical vertebrce. In all these conditions the radicular pain may precede all other symptoms, with the result that the diagnosis is often difficult and sometimes impossible until further phenomena develop. 494 PAIX IX THE UPPER EXTREMITY The pain is occasionally unilateral, more often bilateral ; it may be accompanied b}' tenderness on pressure over the vertebrae, especially in the case of vertebral caries or malignant disease. ^lovements of the neck will intensify the pain in the latter conditions. The diagnosis must be arrived at by careful attention to the following points : (i) Evidence of deformit\% rigidity or tenderness of the cer^dcal vertebrae, supplemented by an A--ray examination ; (2) The presence of other root S}.Tnptoms, such as localized atrophic palsy, anaesthesia, and loss of tendon-jerks in the arms ; (3) Evidence of pressure on the spinal cord, pro- ducing spastic paralysis of the trunk and lower limbs, together with anaesthesia, loss of abdominal reflexes, increased knee-jerk, ankle-clonus, and extensor plante^r re.^exes ; (4) The occurrence of oculo-pupillar\' phenomena when the eighth cervical and first dorsal roots are involved ; and (5) The condition of the cerebrospinal fluid obtained b}- lumbar puncture. In addition to the gross extrinsic processes affecting the spinal roots, there are other cases in which a spinal root is the site of an intrinsic inflammatory or vascular lesion. Herpes zoster is a common result of such a lesion, and may be found in the peripheral distribution of an}- of the posterior roots which go to form the brachial plexus. The pain which precedes the eruption and the post- herpetic neuralgia are instances of pain in the upper extremity, the latter being sometimes of a persistent character and often associated with marked hyper- esthesia in the corresponding root area. Uniradicular pain, followed b}- atrophy of the muscles supphed by the efferent root fibres and by sensory loss in the region innervated by the afferent fibres, with or without the development of an herpetic rash, also occurs in rare instances as the result of an inflammator}- or vascular lesion of the spinal nerve in the neighbourhood of the posterior root ganglion. Referred Pain In Visceral Disease. — In disease of the heart and aorta, especially with syphilitic disease of the acrtic valves, or with atheroma or aneurysm of the first few inches of the aorta, attacks of pain in the left arm are often com- plained of. The pain is really radicular in distribution, and is referred to the first and second dorsal root areas, or, in other words, to the ulnar border of the arm, and sometimes extends into the httle finger. During the attacks of pain, cutaneous h^-peraesthesia may be present over the same areas. In all cases of paroxysmal pain referred to the left arm, a verjr careful examination of the thoracic viscera is therefore indicated. Occupation Neuroses. — The upper limb is the common site of occupation neuroses (writer's cramp, typist's cramp, and so on), since it has to do with writing, t^-ping, needlework, telegraphy, hair-cutting, etc. These neuroses are mainly characterized by some form of muscular spasm, but pain of a cramp-like character is a frequent accompaniment of the spasm. The diagnosis is eas^', because careful inquin,- will elicit the fact that the pain and spasm are evoked by the employment of the limb in a particular occupation, and that other manipulations involving the use of the same muscles may be carried out with impunity. The acute pain associated with the spasm may be followed by a dull aching for some hours after the occupation has been indulged in. Finally, the term "Psychalgia " may be appUed to pain referred to the arm, as well as to other parts of the body, by patients whose nervous and mental resistance is undermined or exhausted. Neurasthenic pain of this kind is rarely limited to the arm ; in fact, it is more commonly referred to various parts of the head and to particular regions along the course of the vertebral column. E. Farquhar Buzzard. PAIN IN THE EYE is experienced commonh' in all inflammaton^ conditions. It is most se\'ere in glaucoma, where it is often accompanied by severe headache and vomiting. The pain of iritis is often severe and neuralgic in character, and is distributed over the whole trigeminal area. Conversely, pain produced PAIN IN THE FACE 495 by irritation of the other branches of the fifth nerve may be referred to the eye. Hemicrania and pain behind the eyes are common symptoms of eye-strain due to errors of refraction, more particularly those of low degree in persons of high visual acuity. The character of the pain alone is seldom diagnostic, however. Herbert L. Eascn. PAIN IN THE FACE. — The distinction between pain in the face and pain in the head, though to some extent artificial, is sufficiently marked in most instances ; the latter form of pain, with its diagnostic significance, is discussed under Headache. There are certain etiological points, however, at which face-ache and headache overlap; for example, the supra-orbital pain and the headache which may both originate from ocular errors of refraction. Pain in the face, like pain elsewhere, may be due to very obvious causes, such as an inflamed parotid gland, a gumboil, or an acute conjunctivitis, and it is outside the scope of this article to discuss the diagnosis of these conditions. On the other hand, pain in the face is frequently complained of when superficial, and perhaps minute, examination fails to discover an adequate basis. Guidance towards the correct diagnosis of such cases is essential for their proper and successful treatment, and may be obtained by a consideration of the course, signs, and symptoms of different clinical types of facial pain. In pursuing this course I shall follow broadly the classification adopted by Dr. Head, who has made a careful study of these conditions. Major Trigeminal Neuralgia (tic douloureux or epileptiform neuralgia) may justly be regarded as a distinct disease, owing to the general similarity of one case to another. Its pathology is still unknown, but in each case, as Head points out, the pain is attributed in its early stages to some local defect, such as a carious tooth, and many sound, as well as many diseased, teeth are removed in a vain endeavour to arrest this malady. Beginning usually after thirty-five years of age, tic douloureux is characterized by paroxysms of acute pain in the distribution of one or more of the divisions of the trigeminal nerve. The intervals between the paroxysms vary from seconds to months, and may be influenced in their length by many factors, such as the general state of health, mental worry, and exposure to cold. There is a tendency for the intervals to become shorter, and the paroxysms more severe and more extensive in their distribution. The pain is described as beginning in spots beneath the skin, and radiating along the peripheral branches of the nerve. These spots correspond to points where the nerve bundles penetrate the deeper tissues to reach the more superficial structures, and may be recognized as places pressure upon which is particularly liable to start an attack. In severe cases, the lightest touch, a breath of wind, attempts at articulation or mastication, and even the act of defascation may be sufficient to provoke an agonizing spasm in which the violent reflex contraction of the muscles of the corresponding side of the face affords some evidence of the suffering endured. During the paroxysm the patient may endeavour to obtain relief by firm pressure with his hand over the starting- point of the pain. In addition to the muscular spasm, the attack of pain may be accompanied by cutaneous flushing, photophobia, lachrymation, and saliva- tion, as well as by a subjective sensation of swelling in the affected tissues. When the tongue is affected, a metallic taste is sometimes described by the sufferer. Trophic changes in the hair and skin are also observed as a result of repeated attacks. From this brief description it may be inferred that the diagnosis of major neuralgia depends chiefly on the following points : (i) The age of onset ; (2) The absence of relief or only temporary alleviation, afforded by removal of possible exciting causes, such as defective teeth ; (3) The presence of definite starting- points of the pain corresponding to exits of branches of the fifth cranial nerve, 496 PAIN IX THE FACE and the spread of the pain along the corresponding nervous paths ; (4) The paroxysmal character of the pain and its intense severity ; (5) The excitability of the attacks by peripheral stimuli ; and (6) The various reflex, vasomotor, secretory', and trophic phenomena to which the attacks of pain give rise. From a practical standpoint the most important task in diagnosis is to dis- criminate between cases of idiopathic major neuralgia and those which belong to the next group. Trigeminal Neuralgia due to Organic Lesion of the Nerve or its Roots. — This form of neuralgia may simulate tic douloureux in everj^ particular, and its diagnosis can be made only by careful systematic examination of the patient, with the possibility of an organic lesion being the source of pain before the physician's mind. Tumouvs at the base of the brain in the middle fossa, tumours growing from the base of the skull in the neighbourhood of the foramen ovale and foramen rotundum, as well as tumours of the cranial nerves themselves, are amongst the causes of trigeminal neuralgia. Gummatous meningitis and gum- matous periostitis may be mentioned in the same connection. In every case of trigeminal neuralgia, therefore, headache and vomiting should be enquired after, and optic neuritis looked for. Examination of the functions of each cranial nerve must be carried out, and in particular those of the fifth nerve carefully tested. Any impairment of sensibility in the cutaneous territory of this nerve must be regarded as evidence that the case is not one of idiopathic neuralgia, and the same may be said when there is impaired motor power in the muscles of mastication. In several cases of severe trigeminal neuralgia, I have found atrophic palsy of the masseter and temporal muscles on the same side, with slight anaesthesia on the face, and these cases have alwaj^s proved to be instances of growth involving the structures at the base of the skull. In one patient the neoplasm originated in the sphenomaxillary fossa. Trigeminal neuralgia may also occur as the result of intrinsic disease of the Gasserian ganglion, e.g., in cases of herpes zoster. This condition is fairly common in the distribution of the first division of the trigeminus, much less common in that of the second and third divisions. The pain usualh^ precedes the herpetic eruption by some days, and is associated with constitutional malaise and sometimes with pyrexia, two important points in diagnosis. The latter becomes clear with the development of the rash, but even then it is necessary to bear in mind the possibility that the Gasserian ganglion may be affected by gross external disease, such as neoplasm or gumma, or an extension of bony disease. In persons over fifty years of age it is frequently found that pain of a neuralgic character persists after the herpes has disappeared, and maj^ last for months and even years. Careful examination in such cases generally reveals the presence of cutaneous scars corresponding to the site of the previous vesicular eruption Neuralgia Minor. — Under this heading may be classed the varieties of facial pain which are secondary to disease of various local structures, such as the teeth, the eye, the ear, the nose, and the tongue. According to Head, the pain in these conditions can be distinguished by certain features as belonging to one or other of two types. The first is to be regarded as a true neuralgia, that is to say, a pain which is distributed along the course of one or more divisions of the trigeminal nerve, and usually starting in the neighbourhood of the diseased structure. The second type is an example of referred visceral pain, the pain being referred to some spot which may be at a distance from the disease, and which is usually the site of superficial hyperaesthesia or tenderness. The history of a decaying tooth affords an example of how these types of pain may arise. In the early stages of caries the pain is limited to the tooth, which betrays its source. With inflammation and destruction of the pulp, pain is PAIN IN THE FACE 497 referred to a segmental area on the surface of the face varying with the particular tooth implicated. Thus a diseased canine tooth is associated with pain and tenderness in the naso-labial area [Fig. 132, Na.L.). Finally, after the pulp is dead, local suppuration may start a neuralgia which may not only spread along The Segmental Areas of the Head and Xeck, and their Maximal Points [after Head). Inf.L /'■/V. 133 Man. Fig-. 134. Fp. N. Fronto-nasal ; Fr. T. Fronto-temporal ; H, Hyoid ; Inf. L, Inferior laryngeal ; M, Mental ; Man, Mandibular; Max, Maxillary; Mid. O, ^lid-orbital ; Na. L, Naso-labial; Oc, Occipital; P, Parietal; R, Rostral; Su. L, Superior laryngeal ; T, Temporal; V, Vertical. the nerve branch which supphes the tooth socket, but may extend into neigh- bouring branches and into other divisions of the trigeminal nerve. The maximal points in the segmental areas referred to are shown in the accompanying diagrams, and the general relationship between individual teeth and their segmental areas may be described as follows : — D 32 498 PAIN IN THE FACE Upper Jaw. Incisors - . . . . Fronto-nasal | ist molar Canine . . . . Naso-labial I 2nd ,, ist bicuspid . . ,, ,, 3rd ,, 2nd „ Temporal or maxillary | Incisors Canine . . ist bicuspid 2nd Lower Jaw. Mental ist molar 2nd Doubtful 3rd Maxillary Mandibular Hyoid Hyoid or superior laryngeal. The value of this knowledge in relation to diagnosis lies in the fact that pain, with tenderness, referred to any one of these segmental areas, should lead the observer to seek for its cause in disease of the corresponding viscus. The headache, sometimes called neuralgia, which results from errors of refrac- tion, especially astigmatism, is referred to the mid-orbital area, where superficial tenderness may often be discovered on examination. This form of pain comes on in the morning as soon as the eyes are opened, and is intensified by reading or sewing. It disappears under the use of atropine, and wears off of itself if the eyes are not used for near work. Occasionall}^ it takes on a paroxysmal character without any particular relationship to the use of the eyes. In iritis and glaucoma, referred pain may be intense, and it is usually situated in the temporal and maxillary segmental areas as well as in the eyeball itself. The occurrence of referred pain in chronic glaucoma without pain in the e^^eball is a point which may be of great diagnostic importance, as it may draw attention to the unsuspected ocular disease. In ear disease the hyoid area is that to which pain is referred and in which hyperaesthesia of the skin may sometimes be found. In the more severe types of disease, such as suppuration in the middle ear, the pain maj^ also be referred to the vertical and temporal areas. Lesions of the tongue may produce, in addition to local pain in the organ itself, referred pain in three other areas. When the disease affects the anterior portion of the tongue, pain may be referred to the mental area ; when the lateral portion is involved, to the hyoid area ; and when the dorsum is the site of the lesion, to the occipital area. In inflammatory affections of the nose and frontal sinuses, pain is referred to the fronto-nasal and mid-orbital areas on the forehead. The various forms of pain in the head associated with disease of the thoracic and abdominal organs are discussed under Headache, and the same article deals with the aches which accompany general constitutional diseases. In lobes dorsalis pains are sometimes described in the face, and have the same characteristics as those in other parts of the body. They are paroxysmal, sudden, severe, and lightning-like. They are rarely limited to the face. They may be accompanied by a more continuous dull, boring kind of pain. The diagnosis of these cases is easy if a systematic examination of the nervous system is carried out. Argyll Robertson pupils, areas of analgesia, ataxy, and absence of tendon reflexes are among the physical signs which will disclose the correct diagnosis. Pseudo-neuralgias, or psychalgias, which are complained of by hysterical and neurasthenic individuals, are vague in their distribution, not limited to the trigeminal area, and often bilateral. They tend to disappear when attention is drawn in other directions, and are less intense during eating and talking. E. Farqiihar Blizzard. PAIN IN THE FOOT.— (See Paix in the Extremity, Lower.) FAIN IX THE HYPOCHONDRIUM 499 PAIN IN THE FOREARM. — (See Paix in the Extremity, Upper.) PAIN IN THE HAND. — (See Paix ix the Extremity, Upper.) PAIN IN THE HEAD.— (See Headache.) PAIN IN THE HIP. — (See Joints, Affections of the.) PAIN IN THE HYPOCHONDRIUM (LEFT).— Pain ia the left hypochon- drium may proceed from : — 1. The Stomach. — Any painful condition of the stomach may cause pain to be felt below the left costal margin. In particular, a new growth or an ulcer towards the cardiac end may produce it. For the differential diagnosis, see Indigestion, and Pain in the Epigastrium. Flatulent distention of the fundus may also be a cause, which can be diagnosed by the fact that the pain disappears on eructation. 2. The Spleen. — Some enlargements of the spleen are painful (see Spleen, Enlargement of) ; or the pain may be caused by perisplenitis, in which case a friction sound can sometimes be heard on auscultation over it. 3. The Left Kidney. — Stone in the left kidney may cause pain which has the characters described in the section on pain in the right hypochondrium (see below) . A movable left kidney is rarely a cause of pain. A perinephric abscess may cause pain, as it does in the right hypochondrium (see p. 500). 4. The Colon. — A new growth in the splenic flexure of the colon, or obstruction of it lower down, may cause pain in the left hypochondrium. In the former case a tumour can usually be felt on bimanual palpation ; in the latter, signs of chronic obstruction will be present (see Constipation). Apart from growth, a mere accumulation of fcBces in the transverse and descending colon may cause a feeling of pain and weight in the left hypochondrium. The disappearance of the pain after the administration of a few large enemata will establish the diagnosis. 5. Pleurisy, intercostal, Neuralgia and Herpes Zoster may all cause pain in the left hypochondrium. In the first of these, a friction sound will be heard ; in intercostal neuralgia there will be tender points over the course of the intercostal nerve. In the case of herpes, the cause of the pain will be cleared up by the appearance of the eruption, but pain may persist long after this has disappeared. 6. Subdiaphragmatic Abscess. — (See p. 501.) Robert Hutchison. PAIN IN THE HYPOCHONDRIUM (RIGHT).— The differential diagnosis of the cause of pain in the right hypochondrium is often a matter of great difficulty, or even of impossibility, as it may proceed from any of the following organs : (i) Liver and gall-bladder, (2) Duodenum, (3) Head of the pancreas, (4) Right kidney, (5) Appendix vermiformis, (6) Colon, (7) Uterine appendages. Intra- thoracic disease, affections of the chest wall, and subdiaphragmatic abscess may also cause pain in this situation. The diagnosis is rendered still more difficult by the fact that disease may easily be present in more than one of these situations at the same time. I. Liver. — Various forms of enlargement of the liver. are apt to be attended by pain in the right hypochondrium, e.g. hepatitis, passive congestion, hepatic abscess, and carcinoma (see Liver, Enlargement of the). Disease of the gall-bladder must also be thought of, e.g., gall-stones, chole- cystitis, and carcinoma. In these it will usually be found that there is tenderness on pressure over the gall-bladder, with the characteristic catch in the breath when the patient is asked to take a deep inspiration while the fingers of the observer are pressed in over the organ. In acute cholecystitis there will be a rise of temperature. PAIN IN THE HYPOCHONDRIUM The pain of biliary colic may be felt chiefi}^ in the right hypochondrium, but tends to radiate through to the back and up towards the right shoulder. It may be closely simulated both by the kinking of a movable kidney and by renal colic (see below) . It must specially be noted that the absence of jaundice in no way contra- indicates a diagnosis of gall-bladder disease. 2. Duodenum. — A duodenal ulcer may cause deep-seated pain in the right hj^pochondrium, which usually has the character of hunger pain. It raust be remembered, however, that pain due to chronic cholecystitis, or appendicitis, may also have this character, and an exact differentiation of them may not be possible without exploration. Duodenal ulcer is commoner in men^ disease of the gall-bladder in women, whilst appendicitis may occur with almost equal probability in either sex. A history of melaena would determine one in favour of ulcer. 3. Pancreas. — Malignant disease of the pancreas may cause pain in the right hj^pochondrium. In such a case a deep-seated tumour may be felt, and there is often jaundice along with a distended gall-bladder. On the other hand, when gall-stones lead to jaundice, the gall-bladder is not usually distended (see Jaundice). 4. Right Kidney. — A freely movable right kidney may, by ureteral kinking, cause sudden attacks of pain in the right hypochondrium which may exactly simulate gall-stone colic. Indications of intermittent hydronephrosis should be looked for, e.g. the appearance of a renal tumour, and the occasional discharge of large quantities of urine. Stone in the right kidney may cause chronic pain in the right hypochondrium and back. The kidney is often found to be enlarged and tender on bimanual palpation in such a case, but it must be remembered that the urine may furnish no diagnostic indication. The ;i;-raj's, however, may make the diagnosis clear,, although a negative result does not exclude the possibility of stone. The pain of renal colic may be difficult to diagnose during an attack from gall- stone colic, lead colic, or appendicitis, but has a characteristic tendency to pass downwards into the groin. It may be attended by vomiting and fever. During or after the attack there may be blood and gravel in the urine ; but it must be remembered that the urine may be heavily loaded with urates after an attack of biliary colic. Pyelitis may also be the cause. The urine will then furnish diagnostic indica- tions (see Pyuria) ; and the kidney may be felt to be enlarged on bimanual palpation. A perinephric abscess may cause pain in the right hj'pochondrium and lumbar region. A tumour will be felt, and there will be the usual signs of deep-seated suppuration. 5. Appendix. — The pain of chronic appendicitis may be felt chiefly in the right hypochondrium, and, as already remarked, maj' be of the nature of a hunger pain. Tenderness over McBurney's point should be looked for. When an acute attack of appendicitis simulates gall-stones, it may be of help to remember that indicanuria is common in the former, but is usually absent in the latter. 6. Colon. — New growths in the neighbourhood of the hepatic flexure may cause pain in the right hypochondrium ; but in that case a tumour can usually be felt, and signs of chronic interstitial obstruction are present. 7. Uterine Appendages. — Salpingitis, a twisted ovarian pedicle, and a ruptured extra-uterine gestation, may all cause pain in the right side of the abdomen which, ' however, has usually its maximum intensity rather below the hypochondriac region. A careful pelvic examination will usually make the diagnosis clear. PA IX IX THE JAW 5or S. Pleurisy, Intercostal Neuralgia, and Herpes Zoster may be causes of pain in the right hypochondrium. 9. Subdiaphragmatic Abscess. — In this case there will be a history pointing to precedent gastric or duodenal ulcer, appendicitis, or hepatic abscess. The onset of the pain may be sudden or gradual. There will be pyrexia and leuco- cytosis, pointing to deep-seated suppuration. There is usually an abdominal swelling, which does not move with respiration. The note over this may be tympanitic, from the presence of gas in the abscess, and in that event the coin- sound will be obtained on percussion. There are usually indications of pleurisy at the base of the corresponding lung, but the liver is not, as a rule, pushed down. The use of the ,v-rays may help in locating the abscess ; but the exploring needle should not be used except when the patient is on the operating-table, and one is prepared to open the abscess at once if found. Robert Hutchison. PAIN IN THE ILIAC FOSSA (LEFT). — If unaccompanied by sw-elling or any other signs or symptoms of disease, pain in the left iliac fossa may usually be assigned to wind or to an accumulation of faeces. The administration of a purge or enema will quickly settle -the correctness of the decision. Pain associated with Diarrhcea and Discharge of Blood and Pus. — Dysentery and colitis, whether catarrhal or ulcerative, are associated with colicky abdo- minal pain. This is usually general, but if the disease is confined to the sigmoid and rectum, may be referred to the left iliac fossa. The continued diarrhoea, blood-stained mucous stools, and tenesmus indicate the disease, but if further help be required, a sigmoidoscope may be passed and the state of the mucous membrane examined. Carcinoma of the Sigmoid Flexure, if of the contracting variety, ma}' go on even to the causation of complete intestinal obstruction w-ithout forming a palpable lump. Its presence may be suggested by vague but continuous pains in the left iliac fossa, and disorders of defaecation similar to those found in carcinoma of the rectum. (See Rectum, Abnormalities felt per.) It is extremely important that the diagnosis of such a case should be made early, and if there is any doubt, a complete examination should not be delayed. An anaesthetic should be given, a bimanual exploration of the rectum made, the abdomen palpated, and a sigmoidoscope passed. An exploratory laparotomy may even be necessary. I'olvulus and kinking of an o\"erloaded sigmoid must be borne in mind as a possible cause of pain. Further differential diagnosis is discussed under Swelling in the Iliac Fossa (Left). George E. Gask. PAIN IN THE ILIAC FOSSA (RIGHT), if it be unaccompanied by any swelhng or by tenderness, can usualh" be ascribed to wind or to an accumulation of fjeces, though it may indicate a slight degree of tj-phlitis, or the stretching of adhesions following an attack of appendicitis. The differential diagnosis is discussed under the headings — Swelling in the Iliac Fossa (Right), and Tenderness in the Iliac Fossa (Right). George E. Gask. PAIN IN THE JAW (LOWER) — unaccompanied by any sweUing (see Swelling OF the Jaw, Lower) — is generally due to dental caries, i.e., toothache, and it is with this thought in the mind that an examination should first be made. The decayed tooth may be ob\-ious at once, or it maj- be so hidden as to call for the services of a sldlled dentist. Occasionally an unerupted molar may be the cause of the pain, and a skiagram may be needed to complete the diagnosis. Neuralgia. — -Here, pain is the essential feature, and it may be of two kinds. It either follows the course of a nerve such as the inferior dental in the lower PAIN IN THE JAW jaw, or it affects a considerable part of the jaw without special reference to any nerve. It varies greatly in severity, being sometimes slight, at other times so severe as to call for all the fortitude of the patient to bear it. Usually neuralgia of the inferior dental nerve is combined with neuralgia of the other branches of the fifth nerve, and this in conjunction with the spasmodic character of the pain makes the diagnosis easy. Some cases of neuralgia are embarrassing, especially when sources of irritation in decayed teeth are present as well, and it may be that the true condition can only be settled after all the teeth have been extracted. George E. Cask. PAIN IN THE JAW (UPPER).— What has been said above as to pain in the lower jaw being caused by dental caries and neuralgia applies equally to pain in the upper jaw, but there is an important additional cause to be sought for in the latter, and one easily overlooked, namely, inflammatory affections of the antrum of Highmore. Abscess of the Antrum of Highmore. — The presence of pus within the antrum is indicated by local pain, generally dull in character, but sometimes acute. On examination of the jaw, the gums will "often be found tender and swollen, and a carious tooth is frequently the source of the infection. So far, the signs are compatible with those arising from a septic tooth, without implication of the antrum, and further evidence is required ; the most certain is the periodical discharge of pus, which may run from the corresponding nostril when the head is bent forwards, or trickle down the pharynx Avhen the patient is lying on the back. If the normal opening of the antrum into the nose becomes closed, as it may from inflammation, this valuable sign is lost, and though local signs of inflammation and general febrile disturbances are present, it ma}^ be difficult to arrive at a diagnosis, for the condition is simulated by inflammation in the nasal fossae or suppuration in the ethmoidal and frontal sinuses. It must also be remembered that a growth, either innocent or malignant, starting in the antrum and not yet big enough to cause a swelling, may easily be mistaken. Recourse, therefore, should be had to the method of transillumination, and the antra on the two sides compared (see Fig. 62, p. 205). The position of the antrum should be shown by a bright red area, and if instead a shadow is thrown, there is presumably some affection of the antrum. It does not mean necessarily that there is an abscess, for a growth or a thickening of the bone may cast a shadow equally well. In these conditions a skiagram may help. Diagnosis by Puncture. — The only certain method of diagnosis, which is to be used if the others fail, is to tap the antrum with an exploring syringe. This can be done through the nose immediately under the anterior part of the inferior turbinate bone. The fluid withdrawn may be subjected to micro- scopical and bacteriological examination. George E. Gash. PAIN IN THE JOINTS. — (See Joints, Affections of the.) PAIN IN THE KNEE. — (See Joints, Affections of the.) PAIN IN THE LEG. — (See Pain in the Extremity, Lower.) PAIN IN THE LIMBS, GENERAL, — In the great majority of cases pains in the limbs are the result of some general or systemic disease : in but few instances can they result from symmetrically distributed local lesions. For clinical purposes they may be classified by their duration, according as they are acute or chronic. PAIN IN THE LIMBS, GENERAL 503 I, Acute General Pains in the Limbs occur in- Muscular overstrain Myositis — Acute polymyositis Neuromyositis Trichinosis Rheumatic fever Acute rheumatism Acute infections or inflammations, such as — Acute coryza Tonsillitis Febricula or chill Influenza Acute specific fevers Inflammations of the lungs, kidneys, etc. Secondary syphilis Peripheral neuritis Neurasthenia Hysteria Diseases of hot climates — Dengue, Malta fever, etc. Chronic General Pains in the Limbs occur in — Peripheral neuritis Tabes dorsalis Tabes dolorosa Chronic rheumatism Myalgia Chronic wasting diseases, such as — Pulmonary tuberculosis Gastritis Cirrhosis of the liver Bronchitis Emphysema Morbus cordis Severe ansmia Mahgnant disease Nephritis. These general pains may be felt most acutely sometimes in one tissue or part of the limbs, sometimes in another. The muscles, for example, may be the chief seats of pain in a child with rheumatism ; in a rheumatic adult the pains are usually worst in and about the joints ; in a patient with secondary S3'phihs the pain is often deep in the bones, the so-called osteocopic pain. In the majority of instances the general limb-pains are made worse by movement, and this is particularly the case when they are accompanied by inflammatory changes in the joints. But the general pains of chronic rheumatism, or the stift'ness and pains left after muscular overstrain, will often pass off if the movements be persisted in for a little time. As a rule, general pains in the limbs are least felt when the patient is at rest, especially when he is at rest in bed. But in .some cases, rest appears to lead to stifthess and increased discomfort, change of position giving temporary relief ; in others — particularly the muscular pains of rheumatism and the osteocopic pains of specific disease — the pains are at their worst as soon as the patient gets warmed up by lying in bed. I. Acute Pains. — Few people can be unacquainted with the general pains and stiffness due to muscular overstrain, the result of some violent and unusual muscular exertion — walking, running, playing games, etc. — undertaken when the body was out of training. The pains will be accompanied by local tenderness of the affected muscles, and there may be slight fever if, as often happens, the stomach has been loaded with more food than it has been able to deal with in the exhausted state of the general bodily functions. When the history of such an attack has been obtained, the diagnosis should not be difficult. Myositis, or inflammation of the muscles, is a comparatively rare cause of general pain in the limbs. It occurs in several varieties, of which only the generalized forms need be considered. Acute polymyositis, also described as 504 PAIN IX THE LIMBS, GENERAL dermatomyositis and as pseudotrichinosis, is characterized by pain, rigidity, and tenderness in the muscles, oedema of the extremities, and a rash resembUng one or other of the exudative erj-themas. In addition, there are the general symptoms of malaise, anorexia, general debihty, and fever. It must be dis- tinguished from trichinosis, in which the aifected muscles are found to contain Trichinella spiralis, the face and eyes are oedematous, and the blood shows eosinophiha. A second rare form of myositis is the neuromyositis described by Senator, in which the nerves are involved as well as the muscles. In this, sensation is lessened, the reflexes are lost, and vasomotor phenomena are seen in the extremities. The affected limbs are tender on pressure, and painful when movement is attempted. Trichinosis, or infection with Trichinella spiralis, is verj^rare in Great Britain, though common in countries where pork is eaten uncooked. Its symptoms are due to gastro-enteritis, and to invasion of the tissues of the bodj^ particu- larh- the muscles, b}^ 3-oung trichinellse. For the first week or ten days the main S5Tnptoms are gastro-intestinal, and ma}- often suggest the diagnosis of cholera. Then the second stage of trichinosis comes on, with pains and swellings in the muscles, particularly the flexors. The face and trunk are affected as well as the limbs ; the face and e}-es become oedematous ; profuse perspirations are common, and high fever is not rare ; eosinophiha and leucocytosis are usual. Mvositis due to invasion of the voluntary- muscles is the characteristic of this stage of trichinosis ; it lasts for a month or more, subsiding gradually into the third stage, that of convalescence, as the larval trichineUa^ become enc3^sted in the muscles. The diagnosis of trichinosis is hkely to be difficult because of its ^arit3^ In the early stages, acute gastro-enteritis, enteric fever, or even cholera, will be suspected, the main symptoms arising from the irritation of the alimentarj^ canal set up by the parent trichinellae breeding in it. Later, rheumatism will be simulated ; but the pain and swelling are in the muscles, not the joints, and the occurrence of oedema and of changes in the blood should help in the diagnosis. It maj- be added, that adult trichinellae may be found in the stools of a patient with trichinosis, and larval trichinellae in portions of the affected muscles removed intra vitam for microscopical examination : encvsted larvae wiU also be seen in the infected meat that gave rise to the attack, should an}- of it have been preserved. General pains in the hmbs are common in rheumatic fever, occurring mainly in the limbs in which there is acute inflammation of the joints. Similar pains will also be felt in acute rheumatism. In the severer cases of rheumatism the cause of these pains wiU not readily be overlooked : it is in the com- parativeh^ mild cases in children that failure to make the proper diagnosis is likely to occur, when the general pains in the limbs may be set down as " growing pains," and no careful examination be made with the special object of detecting other evidences of the rheumatic infection that may be latent in the patient. There is no doubt that " growing pains " occur in healthy children, quite independenth* of rheumatism ; but the t^vo are together in so many instances, that any complaint of growing pains should lead to a careful investigation of the patient's histor}-, and of the condition of his heart. In this waj- a family history or past personal history of either rheumatism or chorea will often be made out ; and not rarely, examination of the heart will lead to the discovery of valvular disease. The joint-affections of rheumatism are far more prominent in adults than in children ; in children the non-arthritic lesions are the most conspicuous — endocarditis, chorea, inflammations of the fibrous tissues generally and of the skin, sore throats. Aching pains aU over the limbs or bod}-, or both, are quite common at the onset of man}- of the acute infectious disorders, or of acute diseases that mainh- PAIN IX THE LIMBS, GENERAL 505 affect one or another of the organs of the body. Associated with these pains are other general S3'mptoms, in most instances, such as malaise, headache, anorexia, and more or less fever. Thus, a severe acute coryza or tonsillitis may be ushered in by general pains in the limbs ; so may the obscure and elusive acute attack known as a febricula or a chill, in ■which the fever and general symptoms persist for a day or two, but no localizing signs or symptoms can be detected to give evidence as to " where the chill has settled." Such febriculae may really be abortive attacks of pneumonia or rheumatism, instances of undetected sore throat, acute gastro-intestinal upsets, cases of larval enteric, scarlet fever, measles, or what not. If they are associated with much pain or prostration, there is a great tendency to apply the term " influenza " to them indiscrimin- ately, quite apart from considerations of fact — evidence of infection with Pfeiffer's bacillus ; or of probability — the detection of any source whence influenzal infection could have been derived. But, however satisfactory it may be to the patient, the diagnosis of influenza should not be made without further evidence, such as is furnished by the discovery of the micrococcus catarrhalis in the patient's nasal or bronchial secretions, or by the occurrence of the attack as one of many in an influenzal epidemic. Influenza is well known to be a protean disorder. In many instances its main symptom is a severe coryza, with headache, lachrymation, and much prostration. In others the type is respiratory, bronchitis with cough and viscid expectoration taking the place of the coryza, and leading up to a bronchopneumonia or lobar pneumonia that not infrequently results in death. A third variety of influenza is the abdominal and gastro-intestinal ; abdominal pain, vomiting, diarrhoea, and perhaps jaundice, being the main phenomena. But in all of these the pains, depression, and prostration come on very rapidly, and appear severe out of all proportion to the objective signs of the disease, while the fever is usually of short duration. The diagnosis of epidemic cases should not be difficult, but in the sporadic cases may be far from easy, and must be made on the general lines indicated above. It is not necessary to refer in detail to the many other acute infections or inflammatory processes in which general pains occur in the limbs. In measles, scarlet fever, or small-pox, for example, the pains often occur at the outset, but are only subordinate features of the attack ; and the diagnosis will be made on the other symptoms, and confirmed by the appearance of the characteristic rash. Various febrile disorders of the lungs, such as bronchitis, tuberculosis, or pleurisy, may begin with similar pains ; so may gastro-intestinal infections, or acute inflammations of the kidneys. The diagnosis in these instances will be made from the special symptoms developed in each ; the pains in the limbs will rarely be the only or the most prominent complaint. In peripheral neuritis of the symmetrical multiple type, the amount of pain felt is very variable — great in some cases, little in others. The peripheral nerves contain motor, sensory, and vasomotor fibres ; in peripheral neuritis, therefore, motor and vasomotor symptoms are habitually present, as weU as sensory. Alcoholism is the commonest cause of multiple symmetrical peripheral neuritis ; the chief complaints are of numbness and tingling in the extremities, " pins and needles," sensations of " dead fingers," cramps in the legs, and severe gnawing or aching pains in the limbs. Beginning in the hands and feet, they tend to spread to the trunk ; motor weakness comes on, the skin develops hyperaesthesia, the limbs become very tender to pressure. The deep reflexes, originally increased, are now lost ; the sphincters are hardly ever involved in alcoholic neuritis unless the mind is affected. Mental symptoms are common in alcoholism, taking the form of Korsakow's psychosis ; memor}^ for recent events is lost : the patient may forget his name and address, and not know where PAIN IN THE LIMBS, GENERAL he is ; and in the endeavour to make good the lacunse in his recollections, he is likely to lie freely, and quite without any definite wish to deceive. The physical signs of arsenical neuritis are very similar, but the cutaneous and deep hypercesthesise are more marked than in alcoholic neuritis, muscular paresis and wasting come on earlier, and muscular inco-ordination is more marked. In the neuritis due to acute lead poisoning the sensory signs are entirely subordinated to the motor, and pains in the limbs are absent. Peripheral neuritis is a fairly frequent legacy of influenza, and may then be characterized by great severity and persistence ; it may also occur as a complication of other infectious disorders — such as diphtheria, tuberculosis, or sj^philis. The diagnosis of peripheral neuritis will be suggested, speaking generally, if the pains in the limbs are associated with marked sensory changes — anaesthesia, parsesthesia, hyperaesthesia — with tenderness of the skin, muscles, or along the course of the nerves, and with weakness, atrophy, and the reaction of degeneration in the muscles. Hysterical and neurasthenic patients sometimes suffer acutely from pains in the limbs that lack any objective basis on examination, and ma}^ give rise to much trouble in diagnosis until the functional character of the disorder has been securely established. It is of the greatest importance that organic disease of every kind should be excluded, as far as is possible before the diagnosis of hysteria or neurasthenia is given out. The hysterical patient is generally a woman, and is likely to exhibit several of the many phenomena common in hysteria, such as functional aphonia, globus or clavus hystericus, stocking-and- glove anaesthesia, hemiansesthesia, variable paralyses often due to the contraction of antagonistic muscle-groups, hysterical seizures, and the like. The signs and symptoms of hysteria change from time to time, the recovery from any particular affection often being as sudden as its onset. The neurasthenic patient, on the other hand, is oftener a man than a woman, usually overworked, run down in general health, and worried. The symptoms are those of " brain-fatigue " for the most part ; inability to attend to or take interest in either work or pleasure ; the bodily strength is lessened, and subjective sensations of all sorts may be felt in the back or limbs. Headache is a prominent feature in some neurasthenic patients ; dyspepsia or palpitation in others ; imaginary sexual disorder in others. In all the deep reflexes tend to be increased, and the temperature to be subnormal. General pains in the limbs are common in certain diseases of hot countries, of which only two need be considered here. Both occur in Southern Europe, as well as in more tropical regions. Dengue is an epidemic infectious disease, much like influenza in many respects. Its onset is sudden, with headache and pains all over, fever, sore throat, an initial erythematous rash, and rapid pulse. The pains may be in the joints mainly, or diffused throughout the muscles of the limbs, and are made worse by movement. After two or three days the patient feels better, and begins to get about again ; but after an interval of a day or two a slight or severe relapse occurs, with pains as before, fever, and a secondary rash which is roseolar, and begins on the hands and wrists, later spreading in patches over the whole body. The relapse is soon over ; but convalescence may be a slow business, because of persistence of the general pains in the limbs. The diagnosis should be easy in epidemics of dengue ; the sudden onset, extent of the pains in limbs, head, and loins, and the characteristic course of the disease, should suffice to distinguish sporadic cases from other acute disorders such as measles, scarlet fever, rheumatic fever, etc. Malta fever occurs mainly in the Mediterranean and on its shores : it is a chronic fever, characterized by perspirations, constipation, and rheumatic PAIN IN THE LIMBS, GENERAL pains in the limbs ; arthritis, orchitis, and enlargement of the spleen are common. The early sjmiptoms are obscure ; but pains in the limbs and general debility, gastric derangements, headache, bronchitis, and continued fever, are the general characteristics Avhen the disease is established. The diagnosis would turn on the discovery of exposure to infection, the milk of goats that are carriers of the Micrococcus melitensis being the actual vehicle of infection : the patient's serum shows the specific agglutinating reaction. 2. Chronic General Pains in the Limbs will often remain after several of the disorders mentioned under the former heading. Thus, the pains due to peripheral neuritis may become a chronic affection in cases of chronic lead poisoning, after influenza, or in gouty, diabetic, or syphilitic patients. Usually only one or two of the limbs will be affected in these cases ; and the diagnosis will not have to be made from the occurrence of the pains, but will have become evident from the development of other signs of disease, so that it need not be discussed at any length here. In chronic lead-poisoning the chief symptoms may be anaemia, blue-black line on the gums, colic and constipation, wrist-drop, gout, arteriosclerosis and high blood-pressure ; post-influenzal neuritis will date from an attack of influenza or an " influenzal cold " ; gouty patients will give histories of attacks of acute arthritic gout, and are hkely to exhibit tophi about their joints or in the ears, and to exhibit the signs of granular kidney ; diabetic patients will complain of thirst and polyuria, large appetite, wasting, and skin- troubles, and sugar will be present in their urine. In certain uncommon cases of tabes dorsalis the name tabes dolorosa has been given, owing to the severity and extent of the pains that are felt. The patient presents the usual symptoms of tabes ; in addition he has frequently repeated lightning pains in the limbs, so severe as to form the dominating element in his disorder, at any rate from the subjective point of view. The diagnosis will be made from the suddenness and shocking intensity of the pains on the one hand ; and on the other, from the discovery of further signs of tabes — Argyll Robertson pupil, loss of knee-jerk, ataxia, sphincter troubles, areas or zones of anaesthesia. The pains will have a radicular distribution, and the nerve-trunks and muscles will not be tender on pressure. General pains in the limbs are common in chronic rheumatism, occurring particularly in consonance with changes in the weather. In some instances, the muscles are the chief seat of the pain ; in others, the joints or the fibrous tissues round them. In most cases, exercise, massage, or movement tend to diminish these pains, if indeed the patient can be induced to submit himself to the dis- comforts of motion or exertion. Occurring in children, these chronic pains are usually set down as " growing pains " ; but their association with acute rheumatism is so frequent that the patient should always be examined for other evidences of the rheumatic infection (see above). In adults, on the other hand, chronic rheumatism is less often an inheritance from acute rheumatism, and is not so frequently combined with valvular disease of the heart ; but it gives rise to pseudo-ankylosis of the joints, inability to work, and much impairment of the general health. Myalgia, or the so-called " muscular rheumatism," is a common affection of certain groups of muscles, and may in some instances affect the limbs generally. It is due to chill, exposure to cold after sweating, sitting in a draught, and the like. Its commoner forms, such as lumbago, stiff neck, pleurodynia, stiff back, need only be mentioned here ; in the rare cases where the limbs are attacked, the diagnosis of muscular rheumatism will probably be made faute de mieux, although there is nothing to show that the affection is rheumatic, and no proof that it is the muscles (and not their sensory nerves, for example,) that are primarily affected. 5o8 PAIN IN THE LIMBS, GENERAL There remains for consideration the large class of diseases characterized by chronic wasting or cachexia, in which general pains in the limbs are often a prominent feature. There is no doubt that these pains are due to widely different causes in different instances. In some, they may be due to nothing more than exaggerated muscular fatigue or overstrain ; the debilitated patient has but little muscle, and that little is exhausted by exertions that would be trifling for a normal subject, so that the cachectic patient becomes the victim of general pains by the mere fact of being up and about. In other cases, the pains are no doubt connected with peripheral neuritis, set up by the circulation of toxins in the patient's blood, though few or none of the other signs or sym- ptoms of neuritis may be detected on investigation. In others, again, the pains seem to be connected with the occurrence of fever, being lessened or absent when the patient's temperature is normal. In the great majority of cases these pains are lessened by rest, or by any line of treatment that builds the patient up and increases his strength. Either the lungs, the heart, the gastro-intestinal system, or the kidneys may be the organs primarily at fault, and bodily wasting and weakness will be among the main symptoms. In cases where the organic disease is deep-seated and out of reach, there is danger lest the patient who is really seriously ill, should be suspected of nothing more than functional disease and treated for such. Thus, patients with carcinoma of the stomach may be treated for hysterical vomiting or anorexia nervosa ; the victim of a carcinoma or aortic aneurysm invading the spinal canal may receive the treatment usually meted out to the malingerer. It is of great importance, therefore, that the most thorough examination should be made, and deep-seated organic disease of every sort excluded as far as is possible, before the diagnosis of functional disease be made in a cachetic patient. This is all the more necessary because there is no doubt that purely functional disease of long standing may reduce nutrition or bodily strength to a very low ebb. A. J. Jex-BIake. PAIN IN THE NECK.— (See Sore Throat ; and Stiff Neck.) PAIN IN THE PELVIS. — In practice, pelvic pain can usually be classified under four headings, namely : (i) Deep-seated pain ; (2) Superficial pain in the skin ; (3) Spasmodic pain ; (4) Backache or sacralgia. Deep-seated Pain is aching in character, continuous, and may, of course, be acute in onset, or may be chronic in duration. It is, consequently, associated with tension in the pelvic organs, usually the result of overfilled vessels, or, in other words, of congestion. If the result of actual inflammation, i.e., con- gestion due to infection, it is acute, and very severe. It is elicited by pressure, and thereby made worse. In its worst form it is of peritoneal origin ; but it may be due to simple congestion of the uterus, tubes, or ovaries, without infection or evidence of actual inflammation. The presence of adhesions between the pelvic organs is an important factor in the differential diagnosis of this type of pain, making it abundantly clear that there has been a past peritoneal inflam- mation, and that the tension in the organs is the result of the binding and pressure of new fibrous tissue. Thus it may be caused by : — Local peritonitis due to infection, recent or remote, caused by salpingo- oophoritis, infection after labour or abortion, ovarian cyst with torsion of the pedicle, extra-uterine gestation, appendicitis. Simple congestion, caused by retroversion and flexion of the uterus, prolapsed ovaries, sclerosed ovaries, hasmorrhagic corpus luteum cyst, endometritis. Superficial Pain in the Skin — ^This is elicited by pinching or touching the skin with the head or point of a pin. It is essentially a referred pain, and may radiate very widely over the abdominal area, down the groins, over PAIN IN THE PELVIS 509 the crest of the ihum, and down the thighs. The area on the skin in which referred pain is felt in connection with uterine, tubal, or ovarian disease, is that to which the tenth dorsal nerve is distributed, according to Head ; and the area is that which is commonly known as the " ovarian region." It is not, however, ovarian only, and it is not even uterine and tubal only, but may be affected also by lesions of the kidney, ureter, gall-bladder, and some parts of the intestines. Consequently, referred pain in the skin in this so-called ovarian region cannot be taken to indicate disease of the generative organs at all, unless other lesions can be eliminated. The region of the tenth dorsal segment is simply a horizontal band spreading behind from the first to third lumbar spines, and extending round the body with its upper level in front at the umbilicus. All parts of the region are not necessarily afEected equallj-, but there may be points of maximum intensity ; one, notably, is midway between the umbilicus and anterior superior spine. This spot, especially on the left side, has often been taken erroneously to indicate pain due to ovarian inflammation. It is interesting to note that referred pain is commonly more marked on the left side of the body, the explanation of which is not quite clear. Referred pain in this segment may not be due to any local lesion at all, but may be a marked manifestation of hysteria in its graver forms. When extreme hyperaesthesia of this area on the left side is accompanied by anaesthesia of the skin of the legs and feet up to the level of the knees, with brisk knee-jerks and absence of the palate reflex, the diagnosis of hysteria is almost certain. Spasmodic Pain in the pelvis is nearly always due to painful uterine contrac- tions, when it is of genital origin. The exception to this is the pain, which is certainly spasmodic in character, and which occurs in connection with tubal gestation, as a rule, in the week or two preceding tubal abortion or rupture of the tube. In this case it is supposed to be due to contraction of the muscle-coats of the tube, but there is no real evidence that this is a fact. There can be no doubt that, even though a part of the pain is muscular, some of it at least must be due to peritoneal irritation. The only Avay to diagnose between this tubal pain and that due to uterine contractions, will be by a careful consideration of the history of the case, and the finding of a definite tubal swelling by the bimanual method. Even then, the diagnosis is exceedingly difficult and often impossible. Spasmodic pain due to uterine contractions is caused by : The onset of abortion or labour ; deficient development of the uterine muscle in spasmodic dysmenorrhoea ; expulsion of a growth from the uterus such as a fibromyoma ; " after-pains " following labour ; gauze packing of the uterus after operations. The differential diagnosis of these conditions is fortunately easy ; but a much greater difficulty is sometimes met with when spasmodic pain has to be diagnosed on account of causes which may not be of genital origin at all. The possible extraneous causes of spasmodic pain have already been outlined (see Dysmexor- rhcea), and are : Appendicitis, intestinal, renal, or hepatic colic, leaking gastric ulcer, ruptured tubal gestation, twisted ovarian pedicle, haemorrhage into a Graafian follicle, rupture of an ovarian cyst or pyosalpinx, dj'spepsia^ and flatulent distention of the bowels. Backache, or Sacralgia, is a very common symptom in all classes of pelvic disorders ; and may be present at the same time as deep-seated pain and super- ficial skin tenderness. It is, however, especially associated with chronic uterine congestion and endometritis, displacements of the uterus, backward displace- ments, downward displacements (prolapse), and impacted uterine or ovarian tumours. Sometimes the only lesion to be demonstrated is a chronic cervical catarrh or a cervical erosion. It is a very difficult pain to explain in all cases ; but it is usually regarded as one referred to the roots of the actual nerves which supply the uterus, tubes, and ovaries. In cases of impacted tumours it is PAIN IN THE PELVIS possible that the pain is due to actual pressure on the sacral nerves at their exit from the bone, in which case pain will also be felt down the inner side and backs of the thighs. In cases of carcinoma of the cervix, backache is complained of, but is always associated with pain in the " ovarian regions," inguinal region, and also radiating down the legs. It must not be forgotten that this form of backache is not necessarily of genital origin, but may be the result of many other lesions. Thus, it may be the result of some irritating urinary constituent, like excess of urates and phosphates ; also it may accompany a calculus in the ureter or some lesion of the renal pelvis. As a rule, in renal cases, the pain is situated rather higher up. Further, caries of the spine low down, growths of the spine, or of the spinal cord membranes, may give rise to it. Inflammation of the sacro-iliac joint, rectal growths, hsemorrhoids, and ulcers, may be its originating cause. It is clear that a correct diagnosis in any case cannot be made without a complete examination of all these structures, combined with careful urinary analysis. Thos. G. Stevens. PAIN IN THE PENIS — is a symptom which occurs frequentlj' in urinary surgery, not only in association with lesions of the penis or urethra, but also as a referred pain with disease of the prostate, bladder, or kidney. The sym- ptom is one which is common to many diseases, so that in the diagnosis of any case, due consideration must be given to the other symptoms accompanying it, without placing too much reliance on a single symptom which may point strongly to the urethra or bladder. Penile pain may be present either during or immediately after micturition, or may be entirely independent of the act. It may be said generally that if pain is felt only during micturition there is some inflammatory lesion of the urethra or prostate ; whilst if it occurs immediately after the flow of the urine, it suggests some lesion in the urinary bladder. On the other hand, pain may be present quite apart from micturition, due to various diseases of the penis, bladder, ureter, or kidney. The term " pain," too, is a relative quantity, varying with the nervous susceptibility of the patient, for what is pain in one may be merely discomfort in another, so that the patient's account may have to be discounted to a certain extent by the clinician. I. — Pain in the Penis experienced During Micturition. This may be caused by : — - I. Diseases of the Urethra — Acute inflammations The passage of a calculus or the impaction of the latter Stricture of the urethra Injury of the urethra. Diseases of the Prostate- — Acute prostatitis Prostatic abscess Prostatic carcinoma. Diseases of the Bladder — Acute cystitis Vesical calculus Villous papilloma Pedunculated carcinoma. I. Diseases of the Urethra. — By far the most common cause of pain in the penis occurring during micturition is an acute inflammation of the urethra, usually gonorrhoeal, but occasionally of a septic origin. In the earliest stages of an acute urethritis, before any marked urethral discharge is apparent, there is usually a sense of smarting or tingling in the terminal urethra, which becomes more marked as the discharge increases, when it is of a burning or scalding character. The occurrence of this pain during micturition within a few days of PAIX fX THE PENIS 311 sexual connection is frequently the earliest symptom of urethral infection, whilst a purulent discharge from the urethra is usually present when the case comes under observation. The passage of a calculus through the urethra causes a sharp, cutting pain along the urethra, the cause of which is apparent when the calculus is voided. Occasionally it may happen that micturition occurs in these cases in the dark, or that urine is not passed into a vessel, so that the calculus is not actually seen by the patient ; but if there is a history of previous renal descent of a stone or symptoms pointing to vesical calculus, the sharp urethral pain during micturition occurring upon one single occasion is significant of the passage cf a calculus. A stone may, however, pass on to the urethra during micturition and become arrested at some narrowed portion of the canal, usually at the membranous portion or at the distal end, when a sudden, sharp pain is felt in the urethra, and at the same time the flow of urine is partially or completely stopped before the bladder has been emptied, whilst further efforts fail to re-start the stream. In these cases the presence of a stone should be suspected, and the whole length of the urethra examined by passing the finger along its course, when a stone may be actually felt,, or the canal may be illuminated by an endoscope and the calculus seen. Urethral Stricture occasionally causes pain in the urethra during micturition, especially if the calibre is small, and if there is septic infection or ulceration of the urethral mucous membrane behind the stricture. The forced efforts at urination may cause pain in the urethra during micturition, but as a general rule stricture causes but little pain. The gradually increasing difficulty in micturition, the feeble stream, and the dribbling of urine from the meatus after the stream has terminated, are symptoms pointing to stricture of the urethra ; the diagnosis will be confirmed readily by the obstruction offered to the passage of a full-sized bougie, or better, by direct observation of the urethra by means of the endoscope. Injury of the Urethra may cause pain during micturition. The urethra may be injured by a faU on the perineum, by a kick or blow, or by the faulty or careless passage of instruments ; it may also be injured or lacerated in association with a fracture of the pelvis. The urethra may be merely bruised, may be lacerated on one aspect, or may be completely ruptured. If the urethra be injured, there is usually an appearance of blood at the external urinary meatus, together with a contusion in the perineum or along the course of the urethra, if the laceration is caused by direct injury. Any attempt at micturition causes pain in the penis, whilst urine may or may not be expelled from the meatus, depending upon the extent of the injury, or may be extra vasated into the perineal or scrotal tissues. As a rule, no difficulty will be experienced in the diagnosis, but in any suspected case the greatest care should be exercised in passing an instrument into the urethra. 2. Diseases of the Prostate. — Any acute inflammation of the prostate causes pain in the urethra during micturition. Thus acute prostatitis and prostatic abscess both give rise to pain during micturition, in addition to increased frequency and difficulty during the act. Both are usually sequelse of an acute urethritis, and whereas an acute prostatitis is accompanied by a temperature raised to 100° F. or 101° F., a prostatic abscess causes the usual rise and fall in temperature common to septic processes. The diagnosis of the two conditions is readily made on a careful rectal examination, when the acutely inflamed gland presents a much enlarged, smooth-surfaced prominence in the rectum ; whilst if an abscess be present, a softer area in the inflamed gland can usually be detected. Adenomatous enlargement of the prostate gives rise to no penile pain during PA IX IX THE PEXIS micturition ; neither does the prostate containing tuberculous deposits, but pain in the penis is occasionally present during micturition in cases of prostatic carcinoma, owing to the direct infiltration of the urethral mucous membrane. Prostatic carcinoma is by no means uncommon, and whilst in its general s^^nptoms it resembles those of prostatic adenoma, there is a marked difference found on digital examination of the gland per rectum. The carcinomatous gland presents rounded areas of densely infiltrated tissue, in contradistinction to the elastic, uniform feel of the adenomatous variety- ; the whole gland is fixed and immovable, and in advanced stages distinct infiltration of the lateral pel^'ic h-mphatics may be felt extending from the lateral aspects of the affected organ. Care must be taken not to mistake the hard nodules felt in a prostate containing calculi for carcinoma. With calculous disease, the gland is not fixed and is only shghtlv enlarged, whilst on gentle pressure -svith the examining finger the calcuH mav be felt to grate upon each other. During the passage of a catheter through the prostatic urethra, distinct grating may be felt if any calculus has ulcerated the urethral wall. 3. Diseases of the Bladder may cause penile pain during micturition under cer- tain circumstances, although it is much more common to find that pain in vesical disease follows the completion of micturition. In acute cystitis, penile pain is present throughout micturition, due to the intense congestion of the vesical mucous membrane of the trigone and around the internal urethral orifice. The other s}Tnptoms of acute cystitis, namely suprapubic pain, pATrexia, increased frequency of micturition, and the presence of pus and blood in an acid urine, are sufiicient for the diagnosis. Pain during micturition in other vesical lesions is caused whenever there is any sudden obstruction to the normal flow of urine by the implantation of some body against the internal urethral orifice. This may occur with a small calculus or with a pedunculated tumour, whether simple or maUgnant, when during micturition the flow is suddenly arrested, accompanied by a shooting pain in the urethra, whilst after an inter\-al of a few seconds the stream may be re- estabhshed. With vesical calculus, the urine may be normal or may contain pus and blood if the bladder has become infected ; there is penile pain after micturition, and the stone may be felt with a sound. With a simple villous papilloma there is no pain unless part of the fimbriated portion of the tumour engage in the urethral orifice during micturition, but there are usually recurrent attacks of profuse haematuria, whilst in a villous-covered carcinoma there is increased frequency of micturition, with pain following the act, more or less constant haematuria, and usually p^niria. Upon rectal or vaginal examination, the base of the bladder may be felt to be infiltrated, but b}- far the most valuable means of diagnosis between the three conditions is cystoscopy', when a calculus or viUous tumour is readil)" seen, whilst a pedunculated carcinoma appears as a dark red tumour covered with stunted processes. (See Plate VI j. II. — Penile Paix followixg Micturition. This s\-inptom. is common to many lesions of the urinary' bladder, more especially those in which there is any ulceration or infiltration of the basal areas. The particular pain felt by the patient is described as a sharp pricking or tingling sensation at the terminal part of the penis on the cessation of micturition, lasting some minutes and causing a desire to squeeze the glans. It has often been described as t^^-pical of vesical calculus, but this is very* far from being the case, and it rather points to some affection causing changes in the trigonal portion of the bladder. PAIN IN THE PENIS 513 The common causes of pain in the penis following upon micturition are :- Vesical — Calculus Tuberculosis Tumour^ — carcinoma papilloma Acute cystitis Bilharzia. Ureteric — Calculus in lower end Descending ureteritis Descendin9 tuberculosis. Prostatic — Acute inflammation Abscess Calculus. Rectal : — Carcinoma. Anal :■ — • Fissure Inflamed haemorrhoids. I. In Diseases of the Bladder. Calculus. — If a calculus is present in the bladder, unless it is trapped in the pouch behind an enlarged prostate, it causes pain in the glans penis after micturition. A calculus may exist without causing cystitis, although commonly there is some degree of pyuria when the case is first seen. There is increased frequency of micturition during active exercise or during the jolting of travelling, but not during complete rest unless cystitis is marked. The terminal drops of urine during micturition are often tinged with blood, and on some occasions there may have been a sudden stoppage of the stream during micturition. In some cases there is a history of the descent of a stone from the kidney without the subsequent appearance of a calculus in the urine. Patients subject to vesical stone have usually reached the later part of life, and although the symptoms are as a rule sufficiently marked to render the diagnosis easy, some- times they may be so few that vesical calculus is quite unexpected, or the symptoms are so like those caused by other lesions of the bladder, that error is easy. In such a case it is advisable to examine the interior of the bladder with a cystoscope rather than by the usual vesical sound ; with a sound a small calculus, or one contained in a vesical pouch, may be missed, whilst with a cystoscope it is readily seen, its approximate size determined, and any other condition of the bladder accompanying or simulating calculus may be diagnosed with certainty. (See Plates V, VI.) Vesical tuberculosis may be a primary affection, but is more frequently second- ary to tuberculous disease in some other part of the genito-urinary tract. It causes marked penile pain after micturition, together with pyuria and a tinge of blood in the terminal drops of urine ; the frequency of micturition is increased during both day and night, and is uninfluenced by rest, thus differing from the increased frequency of calculous disease. Vesical tuberculosis usually occurs in young adults, but it must be distinguished carefully from other vesical infections, and more particularly from renal tuberculosis, in which symptoms referable to the bladder are commonly present before the bladder is attacked by disease. In a j^oung patient in whom increased frequency of micturition, pyuria, and penile pain are present, a search should be made for any tuberculous focus, especially in the testes, prostate, and seminal vesicles, or for marked thickening of the terminal ureter as felt per rectum, whilst a careful search should be made for the tubercle bacillus in the urine. A cystoscopic examination may be necessarj' to determine the extent of the disease {Plate V, Fig. E), but, speaking generally, the less instrumentation that is carried out in these cases the better. Vesical Tumours. — Carcinoma of the bladder occurs in two forms : the infiltrating epithelioma and the villus-covered carcinoma. Either form most commonly begins in the basal portion of the bladder, the muscular planes of which become infiltrated. For this reason, the contraction of the bladder D 33 514 PAIN IN THE PENIS wall during micturition causes pain which is referred to the terminal portion of the urethra. Both forms occur in elderly patients, and give rise to increased frequency of micturition during both day and night, and to hsematuria. They also often give rise to renal pain when the infiltration has extended to the ureteric orifice in the bladder. The base of the bladder may be found per rectum to be infiltrated, or enlarged glands may be felt in the lateral pelvic space, and a cystoscopic examination will usually clear up the diagnosis {Plate VI, Figs. F, G). Whereas the carcinomatous growths of the bladder give rise to penile pain after micturition from the direct infiltration of the vesical walls, the peduncu- lated villus-covered carcinoma and the simple villous papilloma may give rise to sharp penile pain during micturition, from the blocking of the internal urethral orifice with a process of growth. The occurrence of this, together with attacks of profuse haematuria, are evidence of a pedunculated growth. On cystoscopic examination, the carcinomatous pedunculated tumour is seen to be covered by blunt, stunted processes ; it is often multiple, whereas the innocent villous papilloma is single and presents much more delicate fimbriae. Acute cystitis causes tingling pain in the penis after micturition from the inflammatory infiltration of the trigonal area. The mode of onset, the character of the pain, and other symptoms of cystitis will point to the cause of the pain. Bilhayzia hcsmatobia gives rise to clinical symptoms very similar to that of vesical tuberculosis. The history of residence in an infected district, the micro- scopical examination of the urine for ova (see Fig. 13, p. 93), and the typical cystoscopic appearance of the bladder (see Plate VI, Fig. K) will render the diagnosis apparent. 2. Ureteric lesions not infrequently produce pain in the glans penis after micturition, and may cause considerable difficulty in the diagnosis from vesical disease. When a calculus becomes impacted in the narrowed terniinal or intramural portion of the ureter, symptoms are produced almost exactly similar to those of vesical calculus or tuberculosis, namely, increased frequency of micturition, pain in the glans penis after micturition, and a small amount of pus and blood in the urine. Intimate knowledge of the history of the illness will often be of value in these cases ; the first attack of pain is usually described as being sudden, and felt in the renal angle posteriorly, passing forward above the iliac crest and spine, and finally becoming localized at the situation of the external abdominal ring. The calculus may become impacted in the terminal inch of the ureter, when, in addition to this pain, increased frequency of micturition and penile pain are added. In a recent case under the author's car,e, in which a small oxalate calculus was impacted in the terminal part of one ureter, there were frequent attacks of fairly profuse haematuria, suggesting a villous papilloma, but this is probably infrequent. With ureteric calculus there is usually pain in the kidney of the affected side from the dilatation of the pelvis of the latter, due to the increased renal tension. The diagnosis of these cases is not so difficult if a careful enquiry is made into the history and symptoms, and so long as it is remembared that increased frequency of micturition and penile pain may be caused by ureteric impaction of a calculus. A good skiagraphic examination of the pelvic areas may show the shadow of a stone, whilst the latter may be felt occasionally as a small, painful nodule above the seminal vesicles upon examination per rectum. A cj^stoscopic examination also affords valuable information, not only in excluding vesical lesions, but by giving a distinct indication of ureteric calculus by the marked congestion and dilatation of the blood-vessels in the immediate vicinity of the ureteric orifice. A small bougie passed into the ureter may meet with obstruction PAIN IN THE PENIS 515 in its passage, whilst a wax-tipped bougie may be grooved or indented by the stone. Ureteritis descending from infection of the renal pelvis may give rise to slight penile pain and to increased frequency of micturition. This is most commonly seen in the tuberculous form, but is present in a less marked degree with infection by other organisms, of which the most common are the Bacillus coli communis and the staphylococcus. When the infection has reached the ureter, the symptom may be present before there is any visible infection of the vesical mucous mem- brane, and in this way rather point to a diagnosis of vesical disease. In the non- tuberculous form, the ureter may be felt per rectum to be slightly thickened, but the cvstoscopic appearance of the inflamed ureteric orifice is quite distinctive {Plate V, Fig. C). In descending tuberculosis from the kidney, the ureter may be felt as a firm, infiltrated cord on the bladder base, the penile pain and increased frequency of micturition are more marked, the kidney may be felt enlarged and tender, and tubercle bacilli will be found in the urine. Apart from this, typical changes in the ureteric orifice are seen on cystoscopic examination, the orifice being pulled up or retracted or horse-shoe shape, and usually occupying a position slightly above and outside the situation of the normal orifice, due to the actual shortening of the duct by infiltration of the submucous coats {Plate V, Fig. D). 3. Diseases of the Prostate often cause pain in the penis immediately following micturition. This is most commonly seen in the acute inflammation or abscess in the gland as a sequela of an acute gonorrhoeal or septic urethritis. In either case there is penile pain, sometimes associated with erection, but little difficulty will ■ be experienced in the diagnosis on due consideration of the symptoms and upon rectal examination. Prostatic calculi are not uncommon, and there may be a single calculus or a nest of them in the prostate. They tend to ulcerate into the urethra, so that smaU calculi may be passed in the urinary stream, or some may pass back along the dilated prostatic urethra into the bladder. If a calculus projects from the prostate into the urethra, it causes pain in the penis after micturition. A diagnosis of prostatic calculus is often made by the grating sensation imparted to a catheter in traversing the prostatic urethra, whilst on rectal examination the calculus may be felt as an isolated, hard nodule in the gland, or, if more than one is present, by the crepitation of one upon another on digital pressure in the rectum. 4, 5. Diseases of the Rectum and Anus may occasionally give rise to penile pain following micturition, apart from any infection of the bladder or prostate. Thus, a carcinoma in the anal canal, a rectal fissure, or an inflamed haemorrhoid may occasionally cause pain in the penis, but in each the local symptoms of the trouble wiU be the more marked, and little difficulty will be found in the diagnosis if a local examination is made with care. III. — Pain Apart from Micturition. Under the above divisions the symptom penile pain has been considered in relation to the act of micturition, and it remains to consider some condi- tions giving rise to pain in the penis apart from urination. These include certain local lesions of the penis and urethra, and also the pains referred from disease elsewhere. Although a local lesion may cause little more than discomfort in many patients, in some it is described as pain, the degree of which depends upon the nervous susceptibility of the patient. Thus, penile pain mav be present with acute urethritis, with balanitis in association with phimosis, with paraphimosis, or with the lymphangitis of the organ due to a septic sore or abrasion of the skin or mucous membrane. In some instances herpes of the 5i6 PAIN IN THE PENIS prepuce or penile skin causes distinct pain. Any infiltration of the cavernous tissue of the penis causes pain during erection of the organ ; thus during an attack of acute urethritis, the common symptom known as chordee arises from this cause, whilst in a chronic form, cavernitis may be due to infiltration in association with tertiarj^ syphilis or to gouty diathesis, so that erection of the organ is only partial or confined to the proximal part, and causes pain. Another condition causing the same condition arises from the organization of a hcsniatoma in the cavernous tissues of the penis following upon a local injury', either from external violence or during forcible attempts at coitus. Epithelioma of the penis occasionally gives rise to pain in the organ. Pain maj' be felt in the penis in some cases of renal colic, in which case it is classed as a referred pain. Thus, in the acute colic accompanying the passage of a calculus, blood-clot, or debris of caseous material, aching pain ma}^ be felt in the penis quite apart from the increased desire to pass urine. Penile pain is, however, only a minor detail in the presence of the severe pain in the loin, and is often only lightly alluded to. R. H. Jocelyn Swan. PAIN IN THE PERINEUM. — Pain in the perineum is a symptom which is often mentioned by patients in giving their history? of some affection of the genito-urinary apparatus or of other organs, but usualh^ onl}^ as a dull aching pain, of which little notice is taken, as it is generally of miner consequence in comparison with other more striking symptoms. The complaint of perineal pain per se does not convey much information to the clinician, and it is practically never present as the only symptom in a case. Aching in the perineum is frequently present in diseases of the following organs : — • Prostate — Acute or subacute inflammation Abscess Tuberculosis Calculus Adenomatous enlargement Carcinoma. Seminal Vesicles — Acute inflammation Tuberculosis. Urinary Bladder — Cj^stitis Tuberculosis Calculus Carcinoma. Urethra — Traumatism and rupture Stricture with extravasation or urethral abscess Fistula Calculus impacted in bulbous Testicle — Congenital misplacement in perineum. Anal Area — • Haemorrhoids Fissure Boil Carbuncle Ulcer Carcinoma. Vagina — Acute inflammation Inflammation or abscess of Bartholin's glands Cj^stocele Epithelioma. Cutaneous Diseases — Intertrigo Eczema, gouty and diabetic Condylomata. portion. i From the foregoing list it will be seen that aching in the perineum occuis' with numerous different lesions, but other sj-mptoms are in almost every case more marked. These have already been discussed elsewhere, and to them reference should be made. R. H. Jocelyn Swan. PAIN IN THE SHOULDER.— (See Pain in the Extremity, Upper.) PAIN IN THE TESTICLE 517 PAIN IN THE SPINAL REGION, CERVICAL.— (Sec Pain ix the Back.) PAIN IN THE SPINAL REGION, COCCYGEAL.— (See Pain in the Back.) PAIN IN THE SPINAL REGION, DORSAL.— (See Pain in the Back.) PAIN IN THE SPINAL REGION, LUMBAR. — (See Pain in the Back.) PAIN IN THE SPINAL REGION, SACRAL.— (See Pain in the Back.) PAIN IN THE STERNAL REGION.— (See Pain in the Chest.) PAIN IN THE TESTICLE. — Pain of a varying degree may be present in the testicle in many conditions, and it is well for the consideration of this symptom to discuss it under separate headings into which tlie various causes fall, namely : — {A) Diseases of the body of the testis or epididymis. (B) Affections of the coverings of the testicle. (C) Affections of the spermatic cord. (D) A retained or misplaced testicle. {E) Pain from lesions remote from the testis. A. — Diseases of the Body of the Testis or Epididymis. I. Inflammatory Lesions. — Inflammation may attack the testis proper, or, as is more common, it may begin in the epididymis ; it rarely remains confined to one part of the organ, however, for the process tends to spread rapidly from one part to the other, so that the whole organ is involved and the result termed an " epididymo-orchitis." An inflammatory affection of the testicle may be acute, subacute, or chronic, the latter being the terminal result of the former. An acute epididymo-orchitis arises most commonly by the direct infection of the organ from the urethra via the vas deferens. When any inflammation has reached the prostatic portion of the urethra, the orifices of the vasa deferentia may become infected, and inflammation spreads rapidly along the duct to the epididymis and testis. Whilst formerly the occurrence of an acute inflammatory condition of the testis, following upon some form of urethritis, was looked upon as " metastatic," it has been shown that this view is no longer tenable, and that we must look upon it as a direct spread of infection via the vas deferens. Causes of Acute Epididymo-orchitis : — Causes of urethral origin : — Gonorrhoeal urethritis Septic urethritis Passage of catheters Urethral instrumentation Ulceration behind a stricture Ulceration about an impacted calculus or a prostatic calculus Injections into the posterior urethra. General causes : — Fevers — Parotitis (mumps) , Influenza Enterica 1 Gout and rheumatism. Scarlet fever Traumatism Acute epididymo-orchitis begins as a painful thickening of the epididymis associated with febrile symptoms. Before any actual pain is noticed in the testis, there is often a sense of discomfort and weight over the external abdominal ring and inguinal canal due to the inflammatory piocess extending along the vas deferens. The swelling of the epididymis increases, and with it the tubules 5i8 PAIN IN THE TESTICLE of the testis proper become infected, causing swelling of its body and increase of pain. The whole organ thus becomes enlarged, and it is often exquisitely tender, the touch of the clothes or the most gentle examination causing pain. The swollen gland is often flattened on the outer and posterior aspect from pressure against the adductor muscles of the thigh ; the vas deferens and tissues of the spermatic cord are thickened. By far the most common cause of an acute epididj-mo-orchitis is an acute gonorrhoeal urethritis. During the third week of the disease the prostatic portion of the canal frequently becomes infected, when the orifices of the ejaculatory ducts may share in the inflammation, and infection be conveyed by the vas deferens to the testicle. Similarly, but less frequentl}', infection may arise from a septic posterior urethritis, contracted during connection with a woman the subject of a vaginal leucorrhoea. The gonorrhoeal form of acute epididA^mo-orchitis usually resolves slowty, and shows very little liability to suppurate, whereas the inflammation resulting from a staphylococcal or a streptococcal infection may break down into a testicular abscess. Acute epididymo-orchitis may also arise from septic processes in the urethra following upon the passage of catheters, of instruments for vesical operations, such as lithotrity, from ulceration behind a urethral stricture or about a calcuhis in prostatic urethra, and occasionally after the instillation of strong solutions into the posterior urethra in the treatment of a chronic urethritis. In an}- case the onset of pain and rapid swelling of the testis should always lead to the suspicion of urethral infection, and attention should be directed to the urethra with that in view. Bacteriological examination of any urethral discharge is essential (see Discharge, Urethral). Acute epididymo-orchitis occasionally arises without any preceding urethral, infection, and uncommonly occurs as a complication of acute specific parotitis (mumps), enter ica, scarlet fever, or influenza. The testicle becomes painful, and enlarges rapidly in the same manner as in acute inflammation from urethral infection, and under appropriate treatment gradually resolves. Less frequently testicular inflammation ma}^ occur with gout or acute rheumatism, or after a direct injury to the organ, such as a blow or squeeze. The pain in an acute inflammation is generally of an aching character at first, felt not only in the testis, but at the external abdominal ring, and often as a heavy dragging pain in the loin of the aft'ected side. As the testis enlarges, the local pain becomes more severe, so that the swollen gland is exquisitely tender to pressure or to the touch. After a few days the pain subsides to a large extent, but remains as a dull ache until the swelling becomes greatly reduced, and usually disappears some time before the organ returns to the normal size. In a few cases in which a fibrous scar remains in the epididymis, pain may remain and cause some difficulty in the diagnosis from a commencing tuberculous lesion, but the earlier history of acute inflammation will help in forming an opinion. In other cases the persistence of the pain and swelling may indicate the formation of an abscess in the testicle, when, after decrease at first, the swelling increases, the skin covering it becomes reddened, and a soft area becomes evident to one or other side of the organ. 2. Tuberculosis of the Testicle is comparatively common, occurring as a primary disease or secondary to tuberculous disease of the kidney, bladder, or prostate. It begins as a localized deposit in almost all cases, causing a rounded, firm nodule in the epididymis. It frequently arises in the upper pole of the epididymis, whereas the inflammatory affections secondary to urethral infection begin in the lower pole. This nodule may remain unaltered for many months, or may enlarge, soften, become adherent to the skin and coverings ol the testicle, or actuall}^ ulcerate through them to form a discharging fistula PAIN IN THE TESTICLE 519 in the scrotum. The small commencing nodule in the epididymis is usually painless at hrst and may be found by accident, but later, as it gradually enlarges, it causes an aching pain in the organ. Other nodules may be formed in the epididymis, or the body of the testis may become involved, whilst commonly small shot-like thickenings may be felt in the course of the vas deferens. In the most advanced stages, nodules may be felt upon rectal examina- tion in the seminal vesicles or prostate, or the epididymis of the other side. Tuberculous disease of the testicle usually presents little difficulty in the dia- gnosis. In an early case the occurrence of one or more nodules in the epididymis, which are painful on pressure and which have not resulted from a preceding acute epididymo-orchitis, should always suggest a tuberculous focus, and a careful search should be made for any other tuberculous lesion in the body. Should none be found, the estimation of the opsonic index of the blood to tubercle, or one of the several cHnical tests for tubercle, such as von Pirquet's tuberculin skin reaction, may clear up the diagnosis. In later stages the diagnosis i.<^ less difficult ; the gradual enlargement of the nodules, their craggy or bossy feel, the infection of the vas or other genito-urinary organs with tuberculosis, and above all, the tendency of the focus in the epididymis to soften and to become adherent to the scrotal coverings, are points to be looked for ; whilst if it should have led to the formation of a fistula, tubercle bacilli may be detected in the discharge. 3. Syphilitic disease of the Testis causes very little pain in the organ, but there is often a sense of dragging or heaviness, and for this reason it must be considered. Syphilis may attack the testicle in several different ways, producing : — In Congenital Syphilis Interstitial orchitis Gummatous orchitis. In Acquired Syphilis : — Diffuse interstitial orchitis Gummatous orchitis Epididymitis. The outstanding feature of syphilitic disease of the testicle is that it affects the body of the testis rather than the epididymis, thus differing in a marked degree from tuberculous disease. In the interstitial form there is thickening of the intertubular connective tissue, with an infiltration of spindle cells, which, forming young connective tissue, yield fibrous tissue when untreated. The subsequent contraction of this fibrous tissue may cause atrophy of the testis. The testis may, on section, show small gummata in addition to the diffuse orchitis, or if the inflammation is more localized, gummata may be the main feature, these varying in size from that of a pea to that of a walnut, or larger. The epididymis is but rarely affected, but cases are on record of a nodular swelling in the epididymis during the secondary stage of syphilis, which disappeared rapidly under antisyphilitic treatment. In congenital syphilis, both the interstitial and gummatous forms exist ; they usually occur in childhood or in young adult life, and in many cases the affection is bilateral. Sj^philitic inflammation of the testicle may be accompanied in either the acquired or the congenital form by a vaginal hydrocele. There is a sense of weight in the scrotum rather than pain, and often an aching or dragging feeling in the inguinal or lumbar region. On palpation, the bod}^ of the testis feels enlarged and nodular with the gummatous deposits, but the epididymis can usually be distinguished from the testis and be found to be unaffected. The tissues of the cord remain unthickened. The diagnosis of syphilitic disease of the testis is usually simple. There may or may not be a history of syphilis, but other signs of the disease should be looked for — thus, in the acquired form, any scar of pievious ulceration or periosteal thickening, or in the congenital variety, signs in the teeth, eyes. 520 PAIN IN THE TESTICLE or ears. If any doubt remains, a positive Wassermann reaction of the blood,, or the behaviour of the sweUing when treated with large doses of potassium iodide and mercury, should be noted. Syphilitic disease is distinguished from tubemilous disease of the testis by the fact that the epididymis is usually free from infection; that the cord, prostate, and vesicles remain normal ; and by the comparative absence of pain in the testicle upon pressure being made upon it. Tuberculous deposits tend to soften and to involve the scrotal coverings in spite of treatment. From chronic orchitis it is differentiated by the history of traumatism and by the absence of the history or signs of syphilis. Syphilis also tends to attack both testes. From malignant tumours of the testis it is distinguished by the history of syphilis, the tendency of syphilitic disease to be bilateral, the slow enlargement, and a positive Wassermann reaction. In malignant disease, the increase in the size of the testicle is more rapid, whilst the tumour often shows areas of varying consistence ; the cord is often enlarged in malignant cases. 4. Malignant Tumours of the Testis may give rise to pain in the organ, but as a rule pain is only experienced in the later stages of the disease. Both carcinoma and sarcoma may arise in the testis, but embryoma is more common, exhibiting both epithelial structures and a combination of several forms of connective- tissue type — cartilaginous, myxomatous, etc. Clinically, without microscopical examination, a soft carcinoma and a sarcoma can rarely be differentiated, and as their symptoms and history are so similar, they may for convenience be considered together. A testicle that is the seat of a malignant growth enlarges rapidly, but as pain is at first absent, there may be nothing to arouse the patient's suspicions. As long as the tunica albuginea remains intact, the swelling retains the shape of the testis, but when perforation of the fibrous covering takes place, nodular projections appear and render the surface of the tumour irregular. These projections are softer than the remainder of the growth, and they form a valuable point in the diagnosis. In a rapidly growing sarcoma or carcinoma of the testis, the mass may be so soft as to appear to be a fluid collection in the tunica vaginalis. Generally, however, although a growth may be accompanied by a small amount of fluid in the tunica vaginalis, the more solid mass can be felt through the fluid on careful examination ; this fluid is often bloodstained. The epididymis may become incorporated in the growth, so that it cannot be distinguished, and the tissues of the cord become thickened. The coverings of the testis become stretched over the tumour ; the mass does not become adherent to the scrotal skin until late in the disease. In both carcinoma and sarcoma, the iliac and lumbar glands become enlarged, and may be felt in a thin subject at the brim of the pelvis, and pain due to the pressure of these glands upon nerve structures may become marked. The inguinal glands are usually not enlarged unless the scrotal skin is affected. The diagnosis of malignant disease of the testis may be quite easy in the case of rapidly growing tumours, but in others, especially in the early stages, it may present great difficulty. Between sarcoma and carcinoma it may be clinically impossible to distinguish. In quite early life the tumour is more likely to be a sarcoma ; the cord is thickened earlier in carcinoma, but with rapidly growing tumours it may be quite impossible to say whether it is a sarcoma, carcinoma, or embryoma until a piece is examined under a microscope. Orchitis m.ay be confused with the more slowly-growing forms of sarcoma. In both the swelling may have followed an injury, and in both there may be a syphilitic history. Orchitis is, however, more chronic, it retains more the oval shape of the testis, and does not present the rounded, slightly raised bosses which are commonly present in a sarcomatous testis. In orchitis the ■PAIN IN THE TESTICLE 521 cpididyiDiis is usually distinguished more easily, and the cord is not so thickened as with a growth. Finally, the result of treatment with strapping and with mercury and iodide will often show the disease to be of a non- malignant nature. Chronic torsion of the testicle is not very uncommon amongst habitual horse- riders, and sometimes, if there is no clear history as to the relationship between the swelling and a saddle injury, the nature of the painful tumour may be so uncertain that operation and histological examination are resorted to. Tuberculous disease is usually diagnosed easily from malignant disease by the tendency of tubercle to attack the epididymis, to caseate, suppurate, and to become adherent to the scrotal skin comparatively early. Tuberculosis occasion- ally attacks the body of the testicle first, however, forming an oval, smooth tumour of the organ ; the epididymis and vas deferens may be unaffected for a time, and if no deposit is found in the prostate or vesicles, the differential diagnosis between tubercle and growth may be far from easy. These cases are very rare, so that the difficulty will seldom arise. HcBmatocele. — The diagnosis between a ha3matocele and a malignant tumour of the testis may present considerable difficult^^ In both the swelling may date from an injury, whilst the indistinct fluctuation obtained in the soft areas of a growth, accompanied sometimes by some fluid in the tunica vaginalis, may give the appearance of hsematocele. The latter feels heavy to the hand, but is usually softer in its whole mass and more regular than a growth. Care must be taken not to place too much reliance upon the withdrawal of a few drops of blood from the tumour by means of a trocar and cannula, a result which may happen equally with growth or haematocele. A hsematocele may cease to enlarge, or even diminish in size, whereas, in growth, increase in size is progressive. The cord remains unaffected with h3ematocele and testicular sensation is more likely to be lost in growth. If any doubt exist, it is advisable to make an exploratory incision rather than a puncture, when, if necessary, a radical operation can be proceeded with. Hydrocele. — A hydrocele of very long standing, an irregular, nodular surface, and the absence of translucency due to the thickened tunica vaginalis and the thick contents of the sac, may simulate a new growth, but the long history of the case, and the absence of progressive increase in size of the swelling, will prevent a mistake of this kind. 5. Cysts of the Testis occur most frequently in connection with the epididymis, very rarely with the body of the testis. These cysts are quite different from hydrocele of the tunica vaginalis, and are often spoken of as encysted hydrocele of the epididymis or testis, or as a spermatocele, although all do not contain spermatozoa. They cause a swelling of varying degree in the scrotum, and usually an aching in the testicle, groin, or lumbar region. They may arise as retention cysts of the tubules of the epididj'^mis or from one of the foetal remains which occur about the globus major of the epididymis, namely, the organ of Giraldes, the hydatid of Morgagni, or the vas aberrans of Haller. These cysts are usually placed above and to the outer side of the testis, occasionally behind it. They move with the organ, and can usually be dis- tinguished from the latter by the test of translucency. Their increase in size is very slow, but they may cause aching pain in the testicle by pressure upon, or stretching of, the tissues of the epididymis. They can be distinguished from hydrocele of the tunica vaginalis by the relative position of the swelling to the testicle, and by the fact that the fluid contained in them is colourless or slightly opalescent from the contained spermatozoa, in distinction to the straw-coloured fluid of a vaginal hydrocele. PAIN IN THE TESTICLE B. — Affections of the Coverings of the Testis causing Pain IN THE Organ. The only comnion lesions of the coverings of the testis are hydrocele and hesmatocele ; new growths of the testicular tunics are so rare as to render them surgical curiosities. Hydrocele may occur occasionally as an acute affection accompanying an acute epididymo-orchitis, injury to the scrotum, or in the course of acute specific fevers such as small-pox, rheumatism, or mumps. Recently acute hydrocele has been described in conjunction with acute lesions of other serous membranes — multiple serositis or polyorrhymenitis. The more usual form of hydrocele is the chronic variety, which may be due to some disease of the testicle,. but for which, in the majority of cases, no ascertainable cause can be found. A hydrocele may cause some aching in the testicle, but more frequently it causes a dragging sensation in the loin from the mechanical effect of its weight. It forms a swelling on one side of the scrotum, oval in shape, with smooth uniform surface ; it gives a distinct sense of fluctuation. The swelling is. distinctly limited above from the cord or external abdominal ring, and gives nO' sense of impulse on coughing ; with a good light it can be found in most cases to be translucent, the testicle usually occupying a posterior and low position in the swelling. The diagnosis of hydrocele is usually easy, but occasionally, when in old- standing cases the walls are much thickened, difficulty may be experienced. A hydrocele must be diagnosed from (i) A scrotal hernia, (2) Heematocele, (3) New growth, and (4) An encysted hydrocele of the testis. 1. Scrotal Hernia. — Usually a hernia gives an impulse on coughing, can be reduced into the abdomen with a sudden slip or gurgle, and varies in size with the position of the patient. A hernia comes down frora above and descends into the scrotum. In a large irreducible hernia, some part of it is usually resonant from the contained intestine, the swelling is not limited above, and the testis can be distinguished at the bottom of the scrotum. A hydrocele is distinctly limited above, and the spermatic cord can be distinguished easily ; it gives no impulse, and is translucent. The testis in a hydrocele cannot usually be distinguished in the scrotum as in a hernia. Difficulty may arise between the two conditions when the hydrocele extends along the inguinal canal, and thus gives an impulse on coughing, or if the trans- lucency is lost owing to the thickness of the walls or contents of the sac. A scrotal hernia in an infant may be translucent. 2. HcBmatocele is distinguished from hydrocele by the absence of translucenc3\ the greater weight, and the suddenness of the onset, usually after an injury or puncture. If any doubt exist, an incision may be made into the swelling, permission being obtained to proceed to any form of cure that may be found desirable. 3. New Growths of the Testis. — A hydrocele is of much slower rate of increase in size, of smooth surface and uniform consistence, and is translucent. 4. Encysted Hydrocele of the Testis (see above). Haematocele may occur as the result of tapping a hydrocele, from puncture of a vein in the sac or of the testicle, or by the occurrence of bleeding into a hydrocele. It may occur quite independently of a hydrocele, usually after direct injury. As a rule there is a rapid onset of swelling in the scrotum following the injury, with ecchymosis of the scrotal skin ; the resulting tumour resembles a hydrocele in its clinical symptoms, save that it is not translucent. In other cases the swelling arises more slowly, when a pyriform or oval swelling is present in one side of the scrotum covered by normal skin ; the surface of the swelling is PAIN IN THE TESTICLE 525 smooth, and gives a sense of fluctuation and elasticity. There is no translucency, and, on tapping, dark blood-stained fluid is withdrawn. The diagnosis in the less acute cases often presents a difficulty, especially with regard to malignant disease of the testicle (see above). From hydrocele it is distinguished by the absence of translucency ; from hernia by the same points, except translucency, mentioned above in the diagnosis between hydrocele and hernia. C. — Affections of the Spermatic Cord causing Testicular Pain. An inflammatory affection of the cord secondary to urethral infection is not uncommon, but rarely exists without a similar inflammatory affection of the epididymis. Similarly, tuberculous infection of the cord is practically never present without corresponding infection of the testis or epididymis. New growths of the cord, lipomata, myxolipomata, and sarcomata or hydroceles of the cord, cause no pain in the testis. A varicocele, especially if large, in a pendulous scrotum, is a frequent cause of a dull, aching pain in the testicle. The characteristic feel of the enlarged veins of the cord in the erect position, and the slight impulse on coughing, will readily point to the correct diagnosis. D. — The Retained or ]Misplaced Testis. This, in its various situations, may give rise to pain, and may cause some difficulty in the diagnosis of the condition present. A testis may be arrested in its descent at the external abdominal ring in the inguinal canal, may remain inside the abdomen, or may pass (i) into the perineum after traversing the inguinal canal, (2) to the upper part of the thigh vicl the crural ring, or (3) to the root of the penis in front of the pubes. In the various situations in which an undescended or ectopic testicle is placed^ it may be attacked by the several diseases which affect the normally placed organ, and thus give rise to pain ; but in addition, owing to the effect of constant muscular strains and the comparative immobility of the organ, it is particularly liable to recurrent attacks of traumatic inflammation, especially when the testis is retained in the inguinal canal : in the intra-abdominal position it remains protected from muscular injury, whilst ectopic testicles have a greater range of mobility than has one that is retained in the inguinal canal. The inflammation of an undescended testicle may be so acute as to lead to gangrene of the organ, with or without torsion of the cord. The pain may be first complained of when the testes begin to swell at puberty, at which time an undescended right testicle may produce symptoms easily inistakeable for appendicitis. The diagnosis of undescended testicle rests upon the following points : the fact that one side of the scrotum is empty, the outline and situation of a swelling in the inguinal canal or elsewhere, the testiculai sensation upon pressure, and the recurrent attacks of pain. An undescended testicle may give rise to acute pain from inflammatory lesions or from acute torsion of the organ, and may, if placed in the inguinal canal, give rise to symptoms suggestive of a strangulated hernia. It must be remembered also that a partially descended testicle is often accompanied by an inguinal hernia. It is also stated that the misplaced testis is prone to become the seat of malignant disease. E. — Testicular Pain from Lesions other than in the Testicle. It is necessary to mention this class of case, in which complaint is made of testicular pain, when on clinical examination the testis is found to be normal. After an acute inflammation of the organ, even when no palpable nodule remains. 524 PA IX IX THE UMBILICAL REGION the resulting cicatrization ma}^ cause an aching in the organ, especially after sexual excitement or prolonged desire. Apart from former testicular disease, pain may be felt in the organ if a calculus be present in the pelvis of the kidney or upper ureter, with a marked degree of oxaluria, or from stimulation of the peripheral nerves by carcinoma of the bodies of the lumbar vertebrcB or the pressure of an aneurysm in this situation. R. Jj. Jocelyn Szvan. PAIN IN THE THIGH.— (See Pain ix the Extremity, Lower.) PAIN IN THE THROAT.— (See Sore Throat.) PAIN IN THE UMBILICAL REGION.— Pain associated with External Swelling. — This may be due to the following causes : — Umbilical Hernia. — This is common in youno infants, and also in fat, middle- aged people, particularly women who have borne children. Attention is often first called to the protrusion by the presence of pain. In the early stages, while the hernia is j^et small, it may easily be overlooked, especially if the patient is obese. The sweUing is usually globular in shape, has an impulse on coughing, and may or may not be reducible. In a verj- large proportion of cases the hernia is irreducible, and it nearly always contains omentum. Sebaceous Cyst. — This is found not uncommonly at the umbilicus. It presents itself as a smaU spherical swelling, which might be mistaken for a small irreducible umbilical hernia. There is, however, no direct impulse on coughing, and the swelling is attached to the skin. There is generally but little pain unless the cj-st has become injured or inflamed. Xew Growth. — Occasionally the umbilicus is the seat of a small secondary nodule of growth which has been brought by the vessels in the round ligament from the neighbourhood of the liver. It may furnish a clue in making the diagnosis of an obscure abdominal ailment. Eczema Intertrigo. — Ver\- obese people of uncleanly habits may suffer from this trouble at the umbihcus. Divarication of the Recti Muscles. — A patient lying in the recumbent posi- tion may show no evidence of this condition. Diffuse pain is complained of about the umbilicus, and the divarication is at once made evident if the patient is asked to lift the head. Pain associated with Internal Swelling. Tuberculous peritonitis with, formation of a localized abscess is the commonest cause of pain and a swelhng situated inside the abdomen at the umbihcus. The patient is usually a child, and presents well-marked signs of chronic abdominal disease. Carcinoma of the Pylorus or Carcinoma of the Colon maj' present as an umbilical tumour, especialty if it has become fixed by adhesions, but it can usually be diagnosed without difficult\- on account of the special s%'mptoms arising in each case. Pain without Swelling or other Localizing Symptoms. The causes of umbilical pain are so numerous and varied, that in order to mention all it would be necessar}" to enumerate nearh- all abdominal complaints. This cannot be done here, but an indication wiU be gi\"en of possible causes in patients in whom no trace of abdominal disease can be found, and who still complain of pain at or about the umbilicus. Tabes Dorsalis. — The only complaint of the patient ma}' be of abdominal pain, often referred to the region of the umbilicus. The typical gastric crises may be replaced b}^ a much more difiuse pain, and more than one person has PALPITATION 525 been operated on, and a gastro-enterostomy performed, under a mistaken dia- gnosis. A systematic examination of the knee-jerks, pupil-reflexes, etc., should be made in all cases. Lead Poisoning. — Severe attacks of cramp-like abdominal pains referred tO' the umbilicus may be the chief, or even the only, symptom of plumbism. The patient's occupation may suggest the diagnosis ; a blue line may be found upon the gums ; lead may be discovered in the urine after evaporation of a bulk to dryness. Tumour of the Spinal Column or Cord, Spinal Caries, and Compression Myelitis. — Though a less common source of error, these must be borne in mind. Owing to its situation, a growth in the spine may be very hard to locate ; a skiagram may be of service. Phthisis. — In this disease gastric pains are a common symptom, and the pains may even be referred to the umbilicus. George E. Gask. PAIN IN THE WRIST. — (See Joints, Affections of the.) PAIN, PRECORDIAL.^(See Pain in the Chest.) PAINFUL COITUS.— (See Dyspareunia.) PAINFUL MICTURITION. — (See Micturition, Abnormalities of.) PAINFUL SWALLOWING.— (See Dysphagia.) PALLOR. — (See An.emia.) PALPITATION signifies the sensation experienced by a person who is con- scious of his heart beats. It is not necessarily associated with pain. It may be due to manv different causes, of which the following are the chief : — Aortic stenosis Aortic regurgitation Aortic stenosis and regurgitation. 1. Valvular Heart Disease, especially Mitral stenosis Mitral regurgitation Mitral stenosis and regurgitation 2. Heart affections associated with very High Blood-pressure : — Arteriosclerosis | Granular kidney. 3. Myocardial affections : — Fatty heart 1 Pericarditis Fibroid heart Adherent pericardium Cloudy swelling ' Senile changes with atheroma. 4. Lung affections leading to Failure of the right side of the Heart:— Chronic bronchitis I Fibroid lung Emphysema | Large pleural or pleuritic effusions. 5. The Effect upon the Heart of certain Drugs, etc. :— Tobacco Tea Coffee Alcohol Absinthe Morphia Cocaine Digitalis Thyroid extract. 6. Heredity, Nervousness, and Allied Causes Fright or other emotion Neurasthenia Graves' disease (exophthalmic Hysteria goitre) Locomotor ataxia Paroxysmal tachycardia Epilepsy. Anaemia from whatever cause, but particularly Chlorosis I Pernicious anaemia. 526 PALPITATION 8. Mechanical Interference with the Heart by : — Mediastinal new growth Chronic mediastinal fibrosis Thoracic aneurysm of large size Tympanites Ascites Pregnane}' Ovarian cyst or other large intra- abdominal tumour. 9. Dyspepsia : especially that which is associated with flatulence and with stoutness from lack of exercise. The majority of patients who complain of palpitation jump to the conclusion that they have something the matter with the heart and^ although the above list is a long one, the diagnosis resolves itself in all but a few cases into deciding whether the palpitations are cardiac or gastric in origin. A routine examination of the various systems will very often indicate the correct diagnosis at once. Valvular heart disease will be indicated by the history of rheumatic fever, scarlet fever, chorea, syphilis, or the like, and by the alteration in the size of the heart, together with the various bruits. Mitral stenosis is sometimes more difficult than the others to diagnose on account of the possible absence of a bruit or of enlargement of the left ventricle, but it may be suggested by the patient's malar flush, by the history of acute rheumatism, and by the loud, sharp, slapping character of the first sound at the impulse. Aortic regurgitation is sometimes present without a bruit, but it can generally be detected in these cases by the typical collapsing character of the pulse ; if there is still doubt, and the patient is able to take exercise, it is frequently possible to bring out an aortic regurgitant bruit by asking him to take a few steps briskly. High blood-pressure conditions are best detected by means of a sphygmo- manometer ; the diagnosis will be confirmed by the big heart, the albuminuria with tube casts, and perhaps by retinitis (p. 18). Of the myocardial affections, pericarditis and cloudy swelling are both acute conditions, often associated with fever and with sufficient general illness to confine the patient to bed, so that the palpitations are a minor part of the malady. The diagnosis of fatty or fibroid heart and of adherent pericar- dium are discussed on pp. 241, 242. Palpitations due to heart-muscle affection are sometimes most difficult to distinguish from similar palpitations due to dyspepsia. This applies particularly to fatty changes in the heart. Not a few middle-aged persons suffer from palpitations which, by some observers, will be attributed to gastric trouble, whilst by others both the palpitations and the dyspepsia will be attributed to fatty heart ; nor can the diagnosis be made by watching the effect of slight exercises upon the pulse-beat, for in typical dyspeptic persons without fatty heart, the general condition is usually sufficiently lacking in tone for the pulse-rate to be readily increased by exercise. If material benefit results from the giving of digitalis, from the adoption of Schott's Nauheim treatment or some modification of the latter, the argument will be in favour of some mj^ocardial degeneration; but in many instances of flatulence and palpitation the diagnosis between fatty heart and mere dyspepsia will remain largely a matter of opinion. Lung affections causing strain of the right ventricle, and thus leading to palpitations, are detected as a rule by physical examination, but here again there may be so much difficulty in interpreting the physical signs, that when a stout, middle-aged person, with obvious emphysema, and with wheezing and shortness of breath on exertion, complains of dyspeptic symptoms and also of palpitations, it may be very difficult indeed, except by watching the effect of different lines of treatment, to say whether the actual cause of the palpitations is emphysema with secondary dilatation of the heart, or dyspepsia with reflex palpitations, or the result of fatty changes in the heart muscle of a dyspeptic person of sedentary occupation who is both stout and emphysematous. PALPITATION 527 Tobacco is a very important cause for palpitations in a patient who may seem to be perfectly healthy : the degree to which different individuals can smoke tobacco with impunity varies enormously, and whereas some may smoke from morning to night and develop no untoward symptoms at all, others develop some ill effects from what are relatively quite small quantities. Cigarettes seem to be the greatest offenders in this respect, particularly cheap cigarettes sold in packets of considerable numbers for a penny. In bad cases the heart becomes absolutely irregular ; in all cases of the kind any extra exertion, such as trotting a hundred yards, causes a rise in the pulse-rate out of all proportion to what it should ; the pulse may rise, for instance, from 70 to 150 or 160 per minute as the result of slight exertion which in an ordinary individual would only increase it to gcj or 100. These patients may have palpitations at any time ■of the day or night, but particularly when they first get into bed, when violent thumpings may cause them considerable alarm. Similar thumpings of the heart, closely allied to but hardly identical with palpitations, are complained of by elderly men, particularly those of the gouty habit, probably with atheroma- tous degeneration of their coronary arteries. Another condition in which the heart may produce similar symptoms is epilepsy, in which disease, quite apart from the major attacks, there are innumerable accessory sjonptoms of which cardiac thumpings in bed at night are one. In that particular variet^^ of epileptic convulsions which is associated with a sudden halving of the pulse- rate and coma — sometimes spoken of as Stokes- Adams syndrome — palpitations may also be a prominent symptom. Tea, coffee, alcohol, and absinthe, as causes of cardiac irregularity and consequent palpitations, can be diagnosed best by the history and by the effects of stopping the drugs in question. Morphia and cocaine, if taken over periods sufficiently long to lead to palpitations, will generally be indicated by the presence of multiple prick-marks upon the body or limbs. The palpitations and other cardiac symptoms are worse, not while the drug is being taken, but when it is being intermitted. Digitalis and thyroid extract will be recognized as the cause at once if they are being prescribed b}^ the medical attendant. When palpitations are due to nervousness, fright, or other emotion, they are transient and not difficult to diagnose ; if they keep on recurring from apparently trivial causes in a person who has not hitherto been nervous, it is important to bear in mind the possibility of Graves' disease, for although exophthalmos and enlargement of the thyroid gland are important symptoms of this disease, it is not at all uncommon for them to be absent, especially in the early stages, and for the only sign of the malady to be undue nervousness of the patient with a tendency to tachycardia and palpitations. Any condition in which the nervous system seems to be lacking in force or in control is liable to be" termed neurasthenia nowadays, and if neurasthenia, be defined in this broad sense, then ■one variety of it has palpitations for a chief symptom : the making of a diagnosis of neurasthenia, in such cases, how"ever, is equivalent to saying that the palpitations are of purely nervous origin, so that all one has really done ds to exclude organic changes. The same applies to hysteria, though it should be borne in mind that modern authorities distinguish between hysteria and neiivosis, confining the word hysteria to those cases in which the symptoms are directly controllable by suggestion. Locomotor ataxia may give rise to symptoms referable to almost any of the viscera, and there seems no reason why cardiac crises should not occur as much as laryngeal, gastric or intestinal ; they are, however, rare, and when cardiac symptoms develop in a patient suffering from locomotor ataxia, syphilitic affection of the heart would be a safer diagnosis than would cardiac crises. The relation of epilepsy to palpita- tions has been mentioned above. 528 PALPITATION Ancsmia, when it produces palpitations, is usually obvious from the patient's appearance, and it can be confirmed by blood examination. As a rule, palpitations in anaemic patients are entirely absent while the patient is at rest in bed, occurring mainly when she exerts herself and causes temporary dilatation of the anaemic heart. The palpitations disappear when the anaemia is cured. Palpitations due to mechanical interference with the heart, by masses or fluid or wind displacing it, can generally be relegated to their correct cause as the result of physical examination of the chest and abdomen ; mediastinal new growth, tympanites, ovarian cyst of large size, and the other conditions referred to above, generally make their presence obvious before they are of sufficient size to produce palpitations, and they will have been diagnosed upon other grounds. Herbert French. PAPULES — or pimples — belong to the group of elementary or primary (as distinct from secondary) lesions of the skin. In the diagnosis of derma- toses they hold a most important place, so varied are they, and so numerous the affections in which they occur. They may be defined as solid, circum- scribed elevations of the skin, not larger than a pea. Similar formations exceeding that size are classed as tubercles — not, of course, to be confused with the characteristic lesion of tuberculosis — or as tumours. They do not persist indefinitely, but, unless they are transitional, undergo spontaneous resolution^ as tubercles do not ; nor do they cicatrize — as tubercles do. From Vesicles [q.v.) they are distinguished by their solidity ; if a papule is punctured, nothing but blood exudes. But in many instances papules, especially those of an inflammatory kind, are transitional lesions, passing into (a) vesicles, [b) pustules^ (c) scales, or [d] breaking down into ulcers, (e) undergoing hypertrophy, as warts, or ( / ) atrophying. If the transformation into pustules or vesicles is only partial, the lesions are described as papulo-pustules or papulo-vesicles, and if this is characteristic of the greater number of the lesions, the eruption is said to be papulo-vesicular (or vesiculo-papular) or papulo-pustular. If the lesions, originating as erythematous macules, do not take on the full character of papules, they are said to be maculo-papular or erythemato-papular. In size, papules may vary from a pin's head, as in lichen scrofulosorum, to a pea, as in lichen ruber planus. The most typical shape is that of the papule of lichen planus, flattened and with an irregular base ; but they may be rounded or oval, as in prurigo, or cone-shaped, as in pityriasis rubra pilaris ; or triangular, or umbilicated as in lichen planus. In colour, they may be pink or rose-coloured, as in the inflammatory papules of urticaria papulosa, violet or purplish as in lichen planus, bright red as in eczema, dark or coppery as in syphilis, yellow as in xanthoma, whitish as in milium, almost black, as in infiltrations sometimes met with in sarcoma, or simply skin-coloured, as in prurigo or verruca plana. They may be discrete, as in prurigo, or may occur in patches, as in lichen scrofulosorum ; sometimes they form round a hair follicle, as in eczema folliculorum and pitj^riasis rubra pilaris ; they are also met with in connection ' with the sebaceous glands, the sweat-glands, or the papillae. They may be inflammatory, as in eczema, or non-inflammatory as in severe goose-skin, or when they are the result of retained secretion, as in acne, or of excessive corni- fication round the mouths of hair-follicles. Usually, inflammatory papules give rise to itching ; with the non-inflammatory kind there are seldom marked subjective symptoms. Papules may occur in the epidermis, as in verruca plana, or in the derma, when they may be oedematous, as in urticaria, or infiltrated, as in lichen scrofulo- sorum ; or they may affect both structures, as in lichen planus and the strophulus papule of acute prurigo. The epidermic papule may be recognized by its PAPULES 529 soliditv, its hardness and dryness, and its superficial elevation ; the oedematous dermic papule by its pinkish colour and its momentary yielding to pressure ; the infiltrated dermic papule by its redness, induration, and elasticity ; the epidermo-dermic papule by its union of some of the characters of the other varieties. One of the most famihar examples of the papule is that met with in papular eczema. The small papule which occurs in this affection is usually conical in shape, with a rounded base ; and is bright red in colour. Owing to rupture bv scratching, the papules are covered with a tiny dome of blood-crust. In papular eczema there is usually intense itching. Eczema of this type may resemble lichen ruber planus, but in that affection the papule, as a rule, is flat or umbihcated, with an irregular base, is dark-red or violaceous in colour, and has a ghstening surface ; nor is there ever any discharge or crust-formation. The papules of hchen planus, again, are not transitional, and they leave behind them brownish or black stains, while those of eczema frequently pass into vesicles and seldom produce discoloration. Confusion between the plaques of lichen planus and those of scaly eczema may be ob\iated by attention to the differences in colour and in definition ; in the former affection the plaques are generally dark red or purpUsh, and are sharply defined ; in the latter, they are bright red and are not clearly marked oft' from the surrounding skin. Moreover, under the lens, a minute vesicle can often be seen on the top of each papule in eczema papulatum, which is not the case in lichen planus. Yet another point of distinction between the two conditions is, that in Hchen planus, characteristic discrete papules can usually be found at the margin of the patches. This feature serves, too, to differentiate hchen planus, in its turn, from generalized psoriasis, which is marked also by more scahness and less thickening. Lichen scrofulosorum is a papular dermatosis which chnically bears some resemblance to hchen planus, but it has no right to the designation hchen, and belongs rather to the tuberculides. The papules are seldom larger than a pin's head, are usuall}^ flatfish but occasionally conical, very shghtly resis- tant, sometimes smooth and shiny but more usually covered with a tiny scale which is but shghtly adherent ; occasionally the summit is occupied by a pustule instead of by a scale. The prevaihng colour is red, but it varies from a pale yellow through red to violet. At first the lesions are disposed in groups, forming patches of various sizes. Others are arranged in arcs of circles, which are usually seen about the orifices of the sebaceous glands. The eruption shows a distinct predilection for the trunk — the lower part, and the back of the abdomen ; but it occasionally extends to the beginnings of the limbs and may invade the face. If the affection becomes generalized by the spread and coalescence of the scattered groups of papules, the whole skin is covered with thin scales and is of a dirty reddish-brown hue. Itching is absent, or is so shght as to be negligible as a symptom. The eruption begins insidiously and may last for several months ; and, having disappeared, leaving behind it no trace, it may reappear again and again over a period of several years. In the great majoritv' ^ of cases, the disease is associated with some form of tuberculosis — with phthisis, or necrosis of bone, or scrofuloiis ulceration of the skin ; but much more commonly with enlarged glands, submaxillary, cervical, or axillary. Its usual subjects are children and adolescents ; it is uncommon after the age of twenty. The characters of the papules — their homogeneity, their flattish shape, their arrange- ment in groups, their painlessness, their situation on the trunk — with the absence of itching, and the youth of the patient, are generally sufficient to determine the nature of the affection. In papular eczema, as we have seen, the papules are not limited to the trunk, are bright red, and there is troublesome itching ; D 34 530 PAPULES moreover, in many cases there are vesicular or papulo-vesicular lesions as well as papules. From miliary papular syphilides, lichen scrofulosorum can be distinguished by the absence of any other sign of syphilitic affection, and bv the usualh' restricted distribution of the lesions. In keratosis pilaris, or xerodermia, the papules do not form groups or patches as in lichen scrofulosorum, and usually they appear on the limbs, most frequently the thighs ; they consist of projecting hair-follicles, which convej' to the hand the sensation of a nutmeg-grater. This affection has, in turn, to be distinguished from goose-flesh, in which the elevations, besides being evanescent, are not rough or scaly. Keratosis pilaris is one form of ichthyosis ; another form, sometimes met with in association with xerodermia, but more often alone, is ichthyosis hystrix, in which the lesions consist of small papillar}- papules with horn}- tops, which stud the skin as with minute nail-heads, and sometimes develop into large warty masses. The condition, dating back to infanc}', or at least to early childhood, is easy of identification. The same may be said of the ordinary wart [verruca vulgaris). The small fiat wart [verruca plana juvenilis) may sometimes suggest Uchen planus, but it is smaller than the papule of that affection, it has not the dark colour, it gives rise to no itching, nor is there any tendency for the growths to run together into rough, scaly, infiltrated patches. In pityriasis rubra pilaris, papules form at the orifices of the hair-follicles, usually following in the wake of an eruption of scaly patches, or of a dry eruption covered with eczematous-looking crusts. The papules, when fhey appear, are seen to be small, red, and dry, harsh to the touch, more or less conical in form, and the centre of each is pierced b}^ a single atrophied hair, which is surrounded by a sheath that penetrates into the folhcle. The surface of the integument, thus roughened, has been likened by Besnier to the skin of a newly-plucked fowl. At first the papules are discrete, but later they tend to run together into patches which present the aspect of pale j'ellowish-red areas covered with papery scales, or with small adherent ones resembling mica. They mostly affect the limbs, especially the surfaces where hair is most abundant ; if they encroach upon the trunk the}^ are usually found at the waist and the lower part of the abdomen. Itching is sometimes absent, and when present is always insignificant. When the patches are covered with mica-like scales and are met with in the situations most common to psoriasis — the tips of the elbows, fronts of the knees, and the extensor surfaces of the hmbs — there is some danger of confusion with that disease ; but at the edge of each patch, the characteristic conical papule with its single hair, plugging the mouth of a follicle, is always to be seen. The best place to look for the papule is on the backs of the fingers. In psoriasis, again, the lesions grow by peripheral extension instead of by the accretion of new papules. The fact that the general health is not » affected suffices to mark off pityriasis rubra pilaris from other forms of exfoliative dermatitis, in which also there is rarely any appreciable thickening of the skin, while the colour is redder than in pityriasis and the scahness more marked. From lichen ruber planus, pityriasis rubra pilaris is distinguished by the absence of itching and of impaired nutrition, and by its irresponsiveness to arsenic. In lichen planus, too, the papules are flattened, and often umbihcated. In acne vulgaris, the papule forms the primary lesion. If the obstruction is at the mouth of the sebaceous gland-duct, the plug appears on the surface as a small black point — the comedo ; if it is in the gland itself, the obstructing material is seen as a tinj^ whitish mass in the substance of the skin — the milium. The lesion may not develop beyond this stage, but usualh^ it grows into a reddish papule about the size of a pea, and in many cases the papule passes into a pustule. Acne can usually be recognized by the distribution of the PAPULES 531 lesions — on the face, especially the cheeks, nose, forehead and chin, and less frequently the back of the neck, the back between the shoulders, and the chest — their discrete character, the presence of comedones or of milia, and the patient's age, for the affection is essentiall}^ one of puberty. Usualh', too, the several stages through which the lesions pass are present at the same time — the comedo or milium, the papule, the pustule. Rosacea differs from acne in that it chiefly affects the flush area of the face, is marked bj^ much congestion, and is most common in middle hfe. (See also Pustules.) In erythema multiforme, papules, tubercles, vesicles, bullae, nodules, macules may all be present at the same time. Any one of these lesions may be predomin- ant in a particular case or at a given time ; but the type of eruption most frequently met with is that which consists wholly or predominantly of papules — srythema papiilatum. This, too, is usually the first stage of the eruption in cases which go on to other types. The papules are generally, at the beginning, no larger than a pin's head, bright red in colour, and fiattish, sometimes umbilicated. If closely grouped together they may coalesce and form raised patches as large as a threepenny or a sixpenny piece ; each patch has a sharply defined border, and is surrounded by an areola of congested skin ; the tint in the centre soon deepens to violet, and afterwards to purple. The favourite sites are the dorsal surfaces of the hands and forearms ; sometimes, too, the legs, feet and the face are involved. Papular erythema multiforme is, as a rule, easy of recognition. Urticaria of the papular variety — the strophulus or prurigo simplex aigu of French dermatologists — in which the wheals are no larger than a lentil, and leave papules when they subside, occasionally offers some resemblance to it ; but the two affections differ in that the lesions of erythema papulatum are much more persistent, are not white in the centre, do not give rise to itching, but do leave stains. One of the most marked of these differences is that which concerns itching, for in papular urticaria this symptom, though variable, is frequently most severe. In urticaria, too, it is chiefly the covered portions of the body, and especially the lower lumbar region, that are attacked, and the affection is mostly met with in children. Papules like those of urticaria papulosa are often met with in prurigo, both in prurigo ferox of Hebra, the severe form of the affection, and in prurigo mitis, the mild and ordinary form. The characteristic lesion is an eruption of discrete, firm, very slightly raised papules, more or less hemispherical in shape, with a roundish, sometimes oval contour, and a glistening surface. At first, the papule is of the same colour as the skin, but afterwards it becomes red, yellowish, or brownish, increases in size, and is frequently covered by a blood-crust. In structure, according to Darier, it is a localized acanthosis. Most abundant on the extensor surfaces of the Hmbs, and rarely seen on the flexor aspects, or on the face, the papules occur not infrequently on the chest, the lower part of the abdomen, the sacral region, and the buttocks. The itching is intense, and mixed with the secondary changes produced by scratching, there may be found others not unhke those of eczema. Pustules and sores are common, often accompanied by great enlargement of the axillary and femoral glands. In prurigo ferox, the papules are much larger and more numerous, and in parts the skin feels to the touch hke very coarse brown paper or a nutmeg-grater. The changes secondary to the inflammatory process in prurigo are summed up by French dermatologists in the term lichenisation or lichenification. The skin is thickened and rugose, and owes its pecuhar aspect to an exaggeration of the fine striae of the normal integument, so that it becomes quadrillated into a network of which the meshes are square, lozenge-shaped, or polygonal, with a flat surface which often, as Darier says, presents the aspect of glossy..and brilliant facets, as of a mosaic. Sometimes it is covered with fine scales. The skin is, 532 PAPULES of course, less supple than normal skin, and though in colour it may undergo no change, it is more often gre^dsh or brownish. The condition has to be distinguished from the lichenization met with in other dermatoses. In eczema and psoriasis, the thickened and rugose skin is red, it has no glistening facets, and the margins are clearly defined. In lichen planus the plaques are formed by confluent papules and are surrounded by characteristic papules. Apart from these secondary characters of prurigo, the diagnosis is made by excluding other itching affections, such as scabies and pediculosis, on account of the absence of the lesions characteristic of those conditions, and by the positive characters — the origin of the affection in infancy, and its persistence, the poor general health, the preference the papular eruption shows for the extensor surfaces of the limbs, the freedom of the bends of the joints, and the glandular enlargement, especially in the inguinal region. In syphilis, papules are frequently met with in association with macules, but they may occur independently. They may be divided into two main classes : (i) Miliary papular, and (2) Flat papular syphiloderms. I. Miliary, or follicular, papular syphilides are the result of infiltration around and beneath the pilo-sebaceous follicles ; they are rough to the touch, and feel like small shot ; they vary in size, from a pin-head upward, and may be either acuminate or rounded. The sites of election are the trunk, back, shoulders, and loins, but the limbs may be invaded, and also the face. Very frequently the lesions appear in groups which run into each other ; and they are sometimes disposed in rings. The characteristic colour is that of raw ham, but at first they may be pink or red. Involution proceeds slowly, the stain left behind is long in dying away, and is sometimes succeeded by a shallow depression which may last for years. There is often a slight scale on the surface of the papule, and not seldom a tiny vesico-pustule or pustule may be detected on the summit. Sometimes there is overgrowth of the papillse ; and if the lesion is situated in a moist part, the warty growth is covered with sodden white epithelium, when the lesion is known as a moist papule, or mucous papule. A more marked degree of hypertrophy transforms the moist papule into a mucous tubercle or condyloma, distinguishable from a wart in that the overgrown papillae are welded into a coherent mass by swelling of the intervening tissue, while in the wart they are free. Flat or lenticular papular syphilides vary in size from a pin-head to a bean, and the small or the large lesions may predominate in a given case. They may develop directly out of macular syphilides. In contour they are almost perfectly round, with a flattened top, are but slightly elevated, and in colpur usually brownish-red. The whole body is affected pretty impartially ; there is little tendency to agmination ; sometimes the lesions form a kind of circlet on the brow round the margin of the hair (the corona veneris). In some cases, ring-like patches (the circinate or annular syphiloderm) appear on the chin, around the lips or nostrils, or sometimes on the vulva ; they are made up of small yellowish-red papules, with fine scales ; elsewhere the papules, in the same case, are of the ordinary kind. In other instances, the flat lenticular papules of this group become seborrhoeic ; these are characterized by their obduracy to treatment. When there is marked scale-formation, the papules being covered with a dry, dirty-grey scale, they are styled papulo-squamous. Favourite situations for papulo-squamous syphiloderms are the palms and the soles, where they may be mixed with maculo-papular and papulo-tubercular lesions. Syphilides in these sites are often rounded or irregular in shape, have but slight elevation, are at first brownish-yellow or brownish-red, but presently become of a dirty grey, and on the disappearance of the PA RAL YSIS , FA CIA L 533 scales are seen to have the characteristic colour of raw ham. When the scales are more abundant than usual, they form the syphilides cornees of French dermatologists. The small papular syphilides may in some cases be difficult to distinguish from a widely ditfused lichen ruber planus ; but in this affection the rash is uniform, the papules generally have a linear arrangement, and there is usually severe itching. The papules of syphihs are most hkely to be confused with psoriasis — the squamous papules with the ordinary form of psoriasis, the papules in rings with annular psoriasis. Attention must be paid to the polymorphism of the S}-phihtic eruption, the coppery colour, the enlarged glands, the sore throat or tongue, and the distribution of the lesions, no such partiahty for the elbows and knees being shown as is observed in psoriasis, and the papular s\-philide having a preference for the flexor surfaces of the hmbs, while psoriasis affects rather the extensor aspects. The syphilitic scales, too, are thin and dirty white, while those of psoriasis are heaped up in layers and have a silvery sheen. In psoriasis, the subject will usually have a history of previous attacks to relate ; and often the affection can be traced back to early hfe, whereas in s\'philis a particular lesion is seldom repeated. The palmar and plantar syphiloderms described above, which occur symmetrically as secondary and unilaterally as tertiary lesions, may be confused with the dry chronic eczema of those regions ; but in eczema there are heat and itching, and usually'', in the case of the palms, the fingers also are involved, and at some point or other the process is seen to have a catarrhal character. Palmar syphiHdes may be distinguished from eczema seborrhoeicum by the fact that in the latter there are coincident lesions in the common situations — the scalp and eyebrows, the neighbourhood of the beard, the naso-labial folds, the sternal and inter- scapular regions ; nor do they usually assume the form of crescents or segments. Whenever the diagnosis is doubtful, recourse may be had to Wassermann's serum test. Malcolm Morris. PAR.ffi3THESIA. — (See Sexsation, Abnormalities of.) PARALYSIS, CROSSED.— (See Hemiplegia.) PARALYSIS, FACIAL. — This term is commonly applied to a condition of complete or partial paralysis of the muscles supplied by the 7th cranial nerve. One or both sides of the face may be involved, the unilateral being more common than the bilateral affection. It is in some cases the result of a morbid process hmited to the 7th nerve, when it is known under the name of Bell's palsy ; in other instances it constitutes one of the diagnostic signs of a more com- plex, and perhaps more remote, disease. In complete unilateral facial palsy, whatever its origin, the asymmetry of the face may be so marked that the diagnosis can be made at sight. On the other hand, less severe facial weakness may be overlooked unless the means for its detection are borne in mind and employed. It will be well, therefore, to recall briefly the evidences of facial palsy before proceeding to point out the particular features which characterize its various forms. Even with the face at rest, there are certain appearances on the affected side which attract the attention of the careful observer. The natural lines and \\Tinkles are less marked, and, with the obliteration of the naso-labial fold, the cheek has a somewhat flattened or, in old persons, bagg^' aspect. If the patient is unconscious or asleep, the flabbiness of the tissues may be emphasized by the flapping of the cheek with respiration, especially if breathing is laboured or stertorous. The palpebral fissure is wider than its fellow, and the corner of the mouth may tend to droop. 534 PARALYSIS, FACIAL When the facial muscles are thrown into action by attempts to raise the eyebrows, to close the eyelids, or to expose the teeth {Fig. 136), the difference between the two sides is rendered more obvious, the movements on the paretic half of the face being carried out with less power and more slowly than those of the healthy half. The ability to whistle or to move one nostril may also be impaired, and even with shght degrees of paresis, a person who has previously been able to close the eye of the affected side, the other eye remaining open, is no longer able to perform the feat. The same difficulty is experienced in making movements of the ear, by patients who have formerly possessed that accomplishment. Having estabhshed the presence of some facial weakness, it is necessary, in order to take full advantage of its diagnostic value, to make certain careful observations with a view to determining the site of the lesion which is responsible for the defect. Thus, facial paralysis may be brought about by : (i) A lesion anywhere in the com-se of the pyramidal fibres passing from the lower end of the precentral g}Tus in one cerebral hemisphere to the facial nucleus on the opposite side of the pons Varolii {supranuclear paralysis) ; (2) A lesion involv- ing the facial nucleus itself {nuclear paralysis) ; and (3) A lesion of the 7th nerve between its origin in the nucleus and the point where it divides in order to supply the various facial muscles {peripheral paralysis). I. Supranuclear Paralysis. — Owing to the fact that the fibres of the pyramidal tract concerned with facial movements cross the mid-line of the brain-stem only a very short distance above the 7th nucleus, the facial paralysis is on the side opposite to the lesion. Occasionally these fibres are alone involved ; more often those destined to the correspond- ing arm and leg suffer as well, in which case the facial palsy forms part of a hemiplegia. In this type of paralysis the difference between the two sides is not nearly so marked in the upper as in the lower half of the face. For instance, the patient is able to elevate both eyebrows and to close both eyes, although it will be found, on testing, that he- is not able to resist an attempt on the part of the observer to open the eye of the affected side with the same degree of success as attends his efforts on the healthy side. {Figs. 137, 138, 139.) In the attempt to expose the teeth, the facial asymmetry is more striking, the lip remaining immobile or retracting slowly and feebly on the paretic side. In this way the contrast between the depth of the naso-labial folds on the two sides is clearly emphasized. Notwithstanding the impairment of voluntary movement on one side, the face may present perfect symmetry when it responds automatically to emotional or reflex impulses. In laughing or crying, the lines and wrinkles are equally developed, while protective closure of the eyelids is accomplished as well on one side as the other in response to any threatened violence to the eyes. The preser- vation of these automatic movements depends on the integrity of a facial reflex centre in the mid-brain. When this centre is involved at the same time as the fibres of the pyramidal system, the emotional movements are lost or impaired along with those of voluntary origin. /^/^. 136. — Paralysis of the right side of the face, the patient attempting to show her teeth. Note that the right palpebral fissure is wider than the left. I'/ioia by Di: S. A. K. Wilson. PARALYSIS, FACIAL 535 The corneal reflex can generally be elicited in this form of facial paralysis, provided there is no coexistent diminution of sensibility within the area supplied by the trigeminal nerve of the same side. In sharp contradistinction to what F/^. 137. — Post-paralytic contracture of the left side of the face. At a first glance the appearance suggests that the right side is the seat of paralj-sis. J^ig: 138. — Post-paralytic contracture. The same patient closing her ej-es and showing the over-action of all the facial muscles on the affected side. obtains in the nuclear or peripheral tj^pes of, palsy, the nutrition and electrical excitability of the facial muscles undergo no alteration when the lesion is situated above the nucleus. Bilateral supranuclear paralysis, such as is seen in cases of cerebral diplegia 1 tPI^^^^I^^H^^H^ i I i 4 ■K ^ A n f^^^^k-^*-^ ^1 ^H 1 /^i^. 139. — Post-paralytic contrac- ture. The same patient smiling, with an involuntary wink. P/iotos by Dr. S. A. K. Wilson. Fig: 140. — Bilateral facial palsj-. The photograph shows absence of all lines and sagging of both corners of the mouth. Photo hy Dr. S. A. K. Wilson. and pseudo-bulbar paralysis, is characterized by a general impairment of the natural movements, and tends to the production of a stiff, expressionless physiognomy {Fig. 140). With the consequent defective inhibition of the 536 PARALYSIS, FACIAL reflex centre, emotional movements are often uncontrolled, and with little provocation the patient betrays in his face degrees of mirth or distress which he is very far from feeling. This condition can be distinguished from true bulbar palsy b}^ the preservation of the nutrition and the normal electrical excitability of the muscles, and by the absence of accompanying atrophic paralysis of the tongue, masseters, etc. Reference must be made to the occurrence of cases, the result of mid-brain lesions, in which the emotional movements are lost and the voluntary movements are preserved on one side of the face. Asymmetry is then onlj' noticeable when the patient smiles or cries. Finally, it must not be forgotten that in long-standing cases of infantile hemi- plegia, facial weakness may be associated with spontaneous athetoid movements similar to those observed in the arm and leg. 2. Nuclear Paralysis. — Lesions of the facial nucleus may be slight or severe, and the resulting facial paralj^sis may consequently be partial or complete. As a rule, all the muscles supplied by the nerve are more or less equally affected, and the impairment of movements obtains whether they are voluntary, emotional, or reflex in origin. In cases of complete nuclear palsy, certain additional effects are produced. The inability to close the eye, and the drooping of the lower lid, lead to imperfect protection of the eyeball, and to the overflow of tears on to the cheek (epiphora). Conjunctivitis and blepharitis may result. Paralysis of the lip muscles allows of saliva escaping from the corner of the mouth, and may interfere materially with the articulation of labial consonants. Paralysis of the stapedius muscle disorganizes the control of tympanic tension, so that the patient suffers from excessive sensitiveness to deep tones (hyperacusis) and perhaps from tinnitus. Unlike supranuclear paralysis, the nuclear forna is accompanied by atrophy and alteration in the electric excitability of the facial muscles. In slow de- generative (usually bilateral) processes affecting the facial nucleus, the electrical response shows a quantitative modification ; in acute destructive (usually unilateral) lesions of the nucleus, the facial paralysis is followed rapidly by the reaction of degeneration. Owing to the situation of the facial nucleus in the pons, unilateral nuclear palsy may be associated with paralysis of the external rectus muscle of the same side and paralysis of the opposite arm and leg (" crossed " paralysis). 3. Peripheral Paralysis. — The clinical picture of a peripheral facial paralysis resembles in its most important details that which has aheady been described under the heading of nuclear paralysis. All the muscles supplied by the nerve are affected in more or less equal degree, and the palsy is associated, within a short time of its onset, with atrophy and alterations in electrical excitability of the muscles concerned. The diagnosis between the two types depends chiefly upon the presence of additional symptoms resulting from interference with the function of neighbouring tissues, and this varies again with the exact site of the lesion in the peripheral course of the nerve. A lesion affecting the fibres within the pons is likely to produce, in addition to the facial paralysis, external rectus palsy, together with other symptoms in proportion to the extent of the destructive process. A lesion between the surface of the pons and the internal auditory meatus will probably interfere with the vestibular and cochlear parts of the 8th nerve, and so give rise to vertigo and impairment of hearing. At the level of the geniculate ganglion, the chorda tympani is unhkely to escape, and the taste fibres coming from the anterior two-thirds of the tongue lose their function. At the same time, irritation of the ganglion may provoke an herpetic eruption on the auricle and around the external auditory meatus. PARALYSIS, LARYNGEAL In the upper part of the Fallopian canal a lesion produces complete facial paralysis and loss of taste on the anterior part of the tongue ; in the lower part of the canal the resulting symptoms are the same, with the exception that paralysis of the stapedius, with its consequent hyperacusis, does not occur. The nerve to the stapedius leaves the facial nerve between these two points. Involvement of the chorda tympani may also cause deficiency in the salivary secretion of the submaxillary and sublingual glands of the same side. At the stylomastoid foramen, the effects of a lesion are limited to the facial nerves, the taste fibres being no longer in close apposition to the latter. From the above data, the site of any lesion causing peripheral facial palsy can be determined approximately, and it is only necessary to add that the term Bell's palsy is generally limited to cases in which the exciting cause, probably an acute inflammatory process, operates at some point within or just below the Fallopian canal. From the diagnostic standpoint it is important to remember, that a condition which often results from a long-standing Bell's palsy may produce a facial as3-mmetry capable of erroneous interpretation, unless the observer is familiar with it. This is the so-called post - paralytic contracture, which emphasizes the folds and lines on the affected side in such a way that the opposite side of the face may appear at first sight to be the weaker. It will be noticed, however, that an attempt to close the eye is imperfectly carried out, and that the angle of the mouth is strongly, although involuntarily, retracted at the same time. Similarly, on asking the patient to show his teeth, he can only do so slowly and with effort, while the eye is almost closed on the same side by a powerful associated contraction of the orbicularis palpebrjE. The only complaint of a girl suffering from a sHght degree of this contracture, was to the effect that she was unable to smile without at the same time giving the impression that she was winking. Hysterical facial spasm is another condition which may suggest weakness of the opposite side of the face, but the nature of the defect will be made obvious when the whole face is put into action. Facial hemiatrophy often simulates facial paralysis {Fig. 141) ; it may be differentiated by the fact that not only the muscles, but all the tissues of the Fig^. 141. — Hemiatrophy of the left side cjf the face in an early stage. This condition is sometimes mistaken for facial palsy. face on the affected side, undergo atrophic changes. E. Farqiihar Buzzard. PARALYSIS, LARYNGEAL. — Laryngeal paralysis is to be distinguished from interference with the vocal cords by inflammatory or ulcerative lesions, fixation of the ar\-tenoid joints, and other affections which mechanically prevent free movements of the cords. The distinction can scarcely be made without careful examination of the parts with the laryngoscope. In some cases, especially when bilateral abductor paralysis comes on suddenly, the symptoms may be urgent and extreme ; in others, there may be no definite symptoms at all, particularly if there is but partial paralj'sis of one vocal cord, the other being freely movable and able to cross the middle line so as to meet its fellow for purposes of speech or coughing. In most cases the symptoms which point to the presence of paresis or paralysis of a vocal cord are a definite 538 PARALYSIS, LARYNGEAL change in the character of the patient's voice, as noticed by himself and his friends, and a greater difficulty in coughing effectually when need arises, the act of coughing being sometimes associated with a peculiar sound described by the terms " brassy cough " or " bovine cough." For purposes of differential diagnosis laryngeal paralysis may be divided into three main groups, namely : (i) Functional ; (2) Unilateral organic ; (3) Bilateral organic. 1. Functional Paralysis of the Vocal Cords has for its main symptom aphonia without pain or discomfort, the patient nearly always being a young woman, or a girl over the age of puberty, who complains that she has almost suddenlj^ become quite unable to speak otherwise than in a hoarse whisper. There may or may not have been other functional nerve symptoms, the commonest being perhaps difficulty in swallowing owing to globus hystericus. This form of loss of speech is due to functional adductor paralysis during vocalization; but when the patient is asked to cough she does so with perfect ease, and thus demonstrates that the adductor paralysis is not real, for one cannot cough properly without adducting the vocal cords. If the larynx is examined with the laryngoscope the cords will be seen to move perfectly well both with respiration and when the patient retches, though they may remain in the abductor position if the patient is asked to make any particular voice sound. The condition always gets well, and it may pass off almost instantaneously as the result of local electrical applica- tion or of treatment by suggestion. 2. Unilateral Organic Affection of a Vocal Cord is obvious on laryngoscopic examination ; it may, however, be due to more than one cause. It is nearly always the result of interference with the corresponding recurrent laryngeal nerve, and owing to anatomical differences between the two, the left is more commonly affected than the right. It may be paralyzed by pressure from, or infiltration by, an intra-thoracic aortic aneurysm ; a mediastinal new growth ; secondary deposits in the deep cervical or mediastinal lymphatic glands, for instance in a case of squamous-celled carcinoma of the oesophagus ; lymph- adenoma ; gumma ; or mediastinal fibrosis, particularly, though not very com- monly, in association with syphilis, or with fibrotic phthisis affecting the upper part of the left lung. The differential diagnosis between these various condi- tions will be found discussed elsewhere ; ;v-ray examination of the thorax may be helpful. In the absence of special indications, paralysis of the left vocal cord due to interference with the left recurrent laryngeal nerve in a man of about forty-five years of age is always suggestive of an aneurysm of the distal portion of the arch of the aorta, particularly if the patient has had syphilis, has not been an abstainer, and has undergone strenuous physical exertion. 3. Bilateral Affections of the Vocal Cords are seldom due to thoracic aneurysm, but any of the other diseases mentioned in the preceding paragraph may extend far enough up into the root of the neck on the right side to reach and involve the right recurrent laryngeal nerve as it passes beneath the right subclavian artery, as well as the left recurrent laryngeal nerve as it turns round the arch of the aorta to the left of the left subclavian artery. Careful examination of the chest for evidence of new growth or of syphilitic or tuberculous fibrosis is necessary, therefore, before one is in a position to diagnose the more common cause for bilateral paralysis of the vocal cords, namely degeneration of the nerve cells in the vagus centres in the medulla oblongata. It should also be remembered that some enlargements of the thyroid gland, particularly those of a malignant type, and also secondary deposits in the deep cervical lymphatic glands, or even extensive infiltration of the latter by tuberculous processes, may involve both recurrent laryngeal nerves as they lie on either side in the sulcus between the trachea and oesophagus, and thus cause bilateral paralysis of the vocal cords. When the paralysis is due to central degeneration in the vagal nuclei there is generally PARALYSIS OF ONE LOWER EXTREMITY 539 abductor before combined abductor and adductor paralysis ; in cases in which the affection is symmetrical from the beginning the bilateral adductor spasm may result in acute dyspnoea simulating acute suffocative oedema of the larynx and requiring immediate tracheotomy. More often, fortunately, one vocal cord passes through the stage of abductor paralysis into that of complete paralysis before the other is affected, so that the dangerous condition of simultaneous abductor paralysis of both vocal cords is avoided. The diagnosis depends upon the alteration in, or the loss of, voice, together with the inability to cough effi- ciently, except with the sound which simulates the coughing of a cow (bovine cough) ; upon observation of the bilateral paresis of the cords with the laryngo- scope ; upon the exclusion of gross lesions within the thorax, or in the neck ; and upon the co-existence of other indications of changes in the central nervous system. These in younger people are generally the result of syphilis, often taking the form of strabismus, or of locomotor ataxy, or general paralysis of the insane ; whilst in older people there may be vascular degeneration associated with evidence of cerebral softening with or without albuminuria, glycosuria, thickened arteries, an enlarged heart, and a high blood-pressure. Only in very rare cases is the symptom due to hcemorrhage or neoplasm in the medulla oblongata, for with either of these lesions the patient does not usually survive to show signs of the laryngeal paralysis. Herbert French. PARALYSIS, OCULAR. — (See Strabismus ; and Pupil, Abnormalities of.) PARALYSIS OF BOTH LEGS.— (See Paraplegia.) PARALYSIS OF ONE EXTREMITY (LOWER). — The diagnosis of those morbid conditions in which paralysis of both legs occurs is dealt with under Paraplegia ; the present article only refers to cases in which paralj^sis of one leg is complained of. It is, however, a common experience for the clinician to find signs pointing to a bilateral affection when the patient is only aware of disability affecting one lower extremity. A notable and cominon example of this is afforded by many cases of disseminated sclerosis. The patient complains of weakness in one leg, and the physician finds exaggeration of both knee-jerks as well as extensor plantar responses on both sides, and is led to the conclusion that both pyramidal tracts are affected, although one may be damaged more severely than the other. The various types of crural monoplegia may be divided roughly into two classes, one of which includes those cases without muscular atrophy, and the other those which present greater or less degrees of muscular wasting. Paralysis of One Leg without Muscular Atrophy — The cases in this class may be sub-divided into two groups, the first comprising those in which the pyramidal tract is affected, and the second those in which there is no evidence of pyramidal affection. Spastic paralysis of one leg may result from a lesion of the pyramidal tract in any part of its course, but for anatomical reasons it is more likely that the paralysis will be confined to one side when a lesion affects the opposite cerebral hemisphere above the pons, that is to say, above the level at which the two pyramidal tracts run in close proximity. Spastic paralysis of one leg may, however, result from a lesion at any level, and the diagnosis of the level must be made from a consideration of other symptoms. In all cases the condition of the leg is qualitatively, if not quantitatively, the same. A spastic leg is charac- terized by a certain amount of weakness, a certain amount of rigidity, by an exaggeration of the knee- and ankle- jerks, and by the presence of the extensor type of plantar response. It is useful to remember that the weakness in a spastic leg does not affect all the movements to the same extent. If the movements at the various joints are tested against the observer's resistance, it will generally 540 PARALYSIS OF ONE LOWER EXTREMITY be found that dorsifiexion of the ankle and flexion of the knee are more profoundly affected than other movements. It is for this reason that the patient tends to drag his toes more on the affected side than on the other, and evidence of this is often forthcoming in the fact that he tends to wear away the toes of his boot. The muscles of a spastic leg show no localized wasting, and present no alteration from the normal in their response to electrical stimulation. In the attempt to diagnose the level of the lesion which gives rise to spastic paralysis of one leg, certain considerations are of particular importance. If the lesion is situated immediately above the lumbar enlargement of the cord, the abdominal reflexes can be obtained. If the lesion is situated at the level of the loth dorsal segment, the lower abdominal reflex on that side will be absent, while the epigastric reflex remains intact. A lesion of any of the upper dorsal segments causes abolition of all abdominal reflexes on the corresponding side. A lesion above the cervical enlargement will lead probably to some, even if slight, weakness in the corresponding upper extremity, in which the tendon- jerks will be found exaggerated. In the same way, a lesion of the higher part of the pons or of any level between the pons and the cerebral cortex will produce some asymmetry in the facial movements as well as weakness in the arm and leg. Disseminated sclerosis has been mentioned already as a disease in which spastic paralysis of one leg may result from a lesion situated in the spinal cord. In all probability evidence of other patches of disease will be discovered in such cases if a careful examination is made. Some intention tremor in one or both hands, nystagmus, diplopia, optic atrophy, and sphincter troubles are among the signs which may be forthcoming. Less commonly, a one-sided affection of the spinal cord above the lumbo-sacral enlargement is due either to some intra- medullary disease, such as a patch of myelitis, a gumma, or a new growth. When this occurs there may arise a symptom-complex to which the term Brown- Sequard paralysis is applied. In this condition there is spastic paralysis of the leg on the same side as the lesion, together with loss of sensibility, especially of thermal and painful sensibility, in the opposite leg. The physical signs in Brown- Sequard paralysis are represented in greater detail in the accompanjdng diagram : — Zone of HvperfEsthesia J 1 f Atrophic Paralysis vff U ' Painful and Thermal Loss £.necis (^ j^^gg ^^ ^jj Rgflexes Not Spastic Paralysis ( Loss of sense of passive posi- tion and movement „ ons an ( j^^^^ ^^ tactile discrimination > } Diminished skin reflexes i 3 Increased tendon reflexes i Ankle -clonus Extensor plantar reflex Fi£: 742. — Diagrammatic representation of the results of a one-sided lesion of the spinal cord- Brown-.Sequard Paralysis. No Local Effects (4 to 6 normal segmental areas) No paralysis Loss of sensibility to painful and thermal stimuli Loss of tactile and pressure I uncommon sensibility and localization > Normal skin reflexes Normal tendon reflexes No clonus Flexor plantar reflex PARALYSIS OF ONE LOWER EXTREMITY 541 Hysterical paralysis of one leg usually does not afford much difficulty in dia- gnosis. The affected limb may be either rigid or flaccid ; in either case there is no true muscular atrophy and no alteration in the muscular response to electrical stimulation. The condition of the reflexes provides the most important informa- tion. In the hysterical form of paralysis the knee- and ankle- jerks may be exaggerated, but they are never lost. A true ankle-clonus is never obtained, and the plantar reflex is either absent or of the flexor type. As a general rule the tendon reflexes in the opposite unaffected limb will be found to be equally brisk. In contradistinction to spastic paralysis resulting from a pyramidal lesion, in which it has already been pointed out that dorsiflexion of the ankle and flexion of the knee are the movements most profoundly affected, the move- ments of the leg in a case of hysterical paralysis are found to be more or less equally deficient at all joints and in all directions. Certain attitudes and certain types of gait are almost characteristic of hysterical paralysis of one leg. In one form the whole leg is kept rigidly extended, and the foot strongly inverted, so that the patient walks on the outer plantar edge with a stiff leg. In another form, the leg is flaccid and is dragged behind the opposite limb with the toes scraping the floor. In some cases, examination of the Umb when the patient is at rest in bed reveals little or no paralysis, but in the attempt to stand or walk the limb appears to be quite useless. Hysterical paralj^sis of a leg may of course be associated with similar palsies of the opposite leg, or of the arm on the same side (hysterical paraplegia, hysterical hemiplegia). More otten than not a leg- which is the seat of hysterical paralysis also presents complete insensibihty to all forms of stimulation, and the upper limit of such anaesthesia may correspond with the line of the groin or the level of the umbilicus. In the early stages of paralysis agitans a patient may complain of loss of power in one leg, and the diagnosis of this condition may present considerable difficulty if the characteristic tremor of this disease has not made its appearance. An examination of the limb may show little that is abnormal. Some sHght paresis and some slight stiffness in response to passive movements may be detected, but no alteration in the character of the reflexes will be observed. The diagnosis must depend more upon the general aspect and the attitude and gait of the patient. Some loss of facial expression, the general slowness of his movements, and the tendency to shuffle with the affected leg, are points which may lead the observer to form a correct opinion. Paralysis of One Leg with Muscular Atrophy. — In any case which presents tlie signs of atrophic palsy of one leg, the first essential point for making a diagnosis is to ascertain the exact distribution of the atrophied muscles, and to review this distribution in the light of what we know with regard to the central and peripheral innervation of the muscles of the lower hmb. The reader's memory on this point can be refreshed by reference to the table on p. 542. Single nerve palsies in the lower extremity are not so common as similar affections in the upper extremity, but they may occur, especially as the result of injury. Isolated paralysis of the anterior crural nerve and of the obturator nerve are quite uncommon, and when they do occur are generally the result of compression of the nerve within the abdominal cavity, either by growths or during the act of parturition. In affections of the anterior crural nerve, the movements of flexion of the thigh on the trunk and extension of the leg upon the thigh may both be impaired or lost. Wasting of the anterior thigh muscles, and diminution or loss of the knee-jerk, are other obvious signs of this condition. When the obturator nerve is injured, the patient can flex his hip but cannot adduct the thigh, and so, when sitting, he can raise his knee but cannot throw it across the other leg. He can walk about with no obvious disturbance of gait, but he cannot rotate the thigh either outwards or inwards, with any degree of force. 542 PARALYSIS OF ONE LOWER EXTREMITY Table showing the Muscles to which the various Nerves of the Lumbar and Sacral Plexuses are distributed. Nerve. Muscle. Obturator (L. 2, 3, 4) Anterior crural (L. 2, 3, 4) Sciatic nerve (L. 4, 5, S. I, 2, External popliteal (L. 4, 5, S. I, 2) Internal popliteal (L. 4, 5, S. I, Internal plantar External plantar Nerve of the quadratus femoris (L. 5, S. I) Nerve of the obturator internus (L. 5, S. I, 2) Nerve of the pyriformis Superior gluteal nerve (L. 4, 5, S. I, 2) Inferior gluteal nerve (L. 5, S. I, 2) Adductor longus I Gracilis - Adductor brevis I Obturator externus ■ Adductor magnus riliacus J Pectineus j Sartorius I Quadriceps extensor i Semitendinosus \ Biceps 1^ Semimembranosus /Tibialis anticus Extensor proprius hallucis I Extensor longus digitorum -a.r. (High power.) (From , , t . , ^t-i , r j i French's Medical Laboratojy the aumentary canal. ihe symptoms are lor the Methods.) most part those of progressive anaemia and asthenia, inabilitj^ to continue with work, oedema of the lower extremities, shortness of breath, and the occurrence of boil-hke skin eruptions, described popularl}^ as the " flowers " of the disease. The appearance of the patient may suggest pernicious anaemia, and the blood- count may sometimes seem to confirm this diagnosis at first ; for whereas a great many of the patients have a severe chlorotic tj'pe of anaemia, some have a marked reduction of the red corpuscles and a sHghtly less reduction of the haemoglobin, so that there is a high colour-index such as is characteristic of pernicious anaemia. There is generally no leucoc^'tosis, but the differential leucoc^-te-count maj" suggest the diagnosis at once, for nearly all the patients present a considerable degree of eosinophiha. The administration of anthelmintics such as thj^mol ma}- lead to the evacuation of the mature worms, Avhich may be recognized in the faeces [Fig. 14, p. 94), each being from ^ in. to fin. in length. The o\-a{Figs. 15 and 16, p. 94) are oval, with a clear transparent shell and coiled-up embryo parasite. Melaena is another sj^mptom, which maj^ be prominent in some of these cases. The tW'O intestinal parasitic affections which produce the most serious anaemias and other toxic effects in man are Ankylostomum duodenale and BothriocephaJus latus. Herbert French. PARESIS.— (See Paralysis.) PERISTALSIS, VISIBLE. — The importance of visible peristalsis hes in the fact that it is always pathological except in a few cases in which its unimportant nature is immediately obvious. The two chief conditions which render the normal movements of the bowels visible are divarication of the abdominal recti muscles, and ventral herniation of a laparotomy scar. The latter is obvious at once ; the former is best detected when the recumbent patient, who is generally a multiparous woman with a soft flabby abdomen, tries to raise her head and thorax from the couch without the use of her arms ; the contracting recti come together then, and close over the gap in the middle hne in which, under the stretched and unsupported skin, the bowel movements had been seen. Under almost all other circumstances visible peristalsis is pathological ; it may then be divided into two types — gastric and intestinal. Gastric Peristalsis takes the form of a comparatively large swelling in the upper part of the abdomen, coming and going, generally appearing from under the region of the left ribs, progressing slowly downwards and to the right, where it fades away and disappears ; it corresponds more or less with the greater curva- ture of the stomach. It is often stated that a return wave, passing along the lesser curvature from right to left, can also be made out, but this is exceptional. PHOSPHA T URIA 571 Sometimes, instead of progressing, it comes and goes almost in the same spot, varying in shape but scarcely in position. The exact site of the wave must depend mainly upon the size and position of the stomach. It indicates pyloric or duodenal obstruction, and its presence serves to exclude atonic gastrectasis. There may or may not be other signs of dilated stomach, particularly a widely distributed succussion splash, vomiting of large volumes of fermenting fluid at relatively long interv^als. and a greatly increased bismuth ;t;-ray shadow. Whether the pyloric stenosis is simple or malignant has to be decided upon other grounds. Visible Intestinal Peristalsis is, with the limitations discussed above, one of the surest signs of grave intestinal obstruction. There are almost certain to be abdominal distention, vomiting, and constipation along with it, and the discussion of the differential diagnosis of the different causes of these symptoms will be found elsewhere. The great importance of visible peristalsis is seen in those doubtful or obscure cases in which the patient seems hardly ill enough to be suffering from intestinal obstruction. It may be thought that cohc, the result of some indigestible article of diet, is a more hkely diagnosis, and that a dose of castor oil will cure the malady. Rather than wait for increas- ing severity- of the symptoms to clinch the diagnosis in these cases, it is most important to arrive at a diagnosis of the necessity for laparotomy at the earUest possible moment if life is to be saved. If the small intestine alone is involved, the waves are multiple, and they run more or less transverse!}^ across the abdomen — the ladder-rung type ; when the colon is obstructed, vertical waves, especially in one or both flanks, are the chief form the peristalsis takes. Definite and visible intestinal peristalsis is. so far as any single sign can be relied on, an almost infallible indication of the need for laparotomy in any case in which the other symptoms and the history point to a possibihty of intestinal obstruction. Herbert French. PERSPIRATION, ABNORMALITIES OF,— (See Sweating.) PHOSPHATURIA. — This is a term the precise significance of which is by no means clear ; the meaning it conveys to one observer is not always that which it imphes to another. Some restrict it to conditions in which the total quantity of phosphates in each da^-'s urine is greater than the average maximum. Others use the term when there is a spontaneous deposit of phosphates in the specimen glass. Others would include cases in which, on applying the boiling test for albumin, a cloud of phosphates comes down. So loose is the application of the word phosphaturia that it is generally used whenever an^-thing arises to remind the observer ocularly of the fact that the urine contains any phosphates at all. What is reallj- required is a series of different terms to express the following conditions : — 1. Circumstances under which a greater quantity of phosphates is habitual!}' passed in the urine than is the average maximum in health. 2. The spontaneous deposition of phosphates in a urine that has stood in a specimen glass until cold. 3. The spontaneous deposition of phosphates in the bladder, so that the urine is thick and milk-like even when it is being passed per urethram. 4. The deposition of phosphates as a white cloud when the urine is heated. Absolute Phosphaturia. — The phosphoric acid in the urine is chiefly exo- genous, i.e. derived from phosphates in the food. It is chiefly in inorganic combination as salts of the alkalies and alkaline earths. There is a certain small percentage of urinary- phosphorus derived from the katabolism of nuclein and lecithin, but the amount derived from these in health}- persons is very- slight as compared with that which comes direct from the food, so that the phosphates 572 PHOSPHATURIA almost disappear from the urine during starvation. There are wide variations in the amounts excreted by normal persons ; the average is 3-5 grams per diem, but the healthy linaits are as far apart as i gram and 8 grams. It has been asserted that persons whose business entails great wear and tear of the nervous system excrete more than the average amount of phosphates, and the same has generally been held to be true of sufferers from certain nervous disorders of the hysterical or neurasthenic type, particularly when sexual matters are in question. There is very little evidence, however, to show that there is any real increase in the urinary phosphates in these cases. There is often a very abundant deposit of phosphates on applying the heat test to the urine, and this may give the impression that the total quantity of phosphates present must be above the normal ; but the impression has not been confirmed by exact analysis. There is only one well-defined condition in which there is absolutely and persistently more phosphate in the urine than healthy limits would allow, and that is phosphatic diabetes — a very rare condition of which the main features are thirst, emaciation, aching in the loins and back, and polyuria wdthout sugar but with an absolute excess of phosphates in the urine. Physiology of Phosphatic Deposits. — In nearly every case the deposition of phosphates is a purely physiological process. A molecule of phosphoric acid, H.^PO^, contains three hydrogen atoms. Each of these can be separately replaced by an atom of any monobasic metal, such as sodium. Three types of salts are formed, according as one, two, or three of the hydrogen atoms have been replaced, as in the following examples : — NaHjPO^ - - Sodium dihydric phosphate NaoHP04 - - Sodium monohydric phosphate Na3P04 • - Sodium phosphate These salts may all be present in the same urine, the proportions of each varying with the amount of phosphoric acid present, on the one hand, and the total amount of bases (i.e., sodium, potassium, etc.), and the total quantities of other acids present in the form of chlorides, sulphates, and so forth, on the other. The greater the quantity of chlorides and sulphates, the greater will be the amount of the metallic bases required to form them, and consequently the less will be the amount of bases left to combine with phosphoric acid ; the result must then be a relative excess of NaHoP04. Conversely, the scantier the chlorides and sulphates, and the more abundant the bases, the greater will be the proportion of NaoHPOj^ and Na.^POj^. Now the three sodium salts differ from one another in at least two physical respects — their action upon litmus, and their solubility in water. Sodium dihydrogen phosphate (NaHoPO^) turns blue litmus red — in other words, it is an acid phosphate. The acidity of ordinary urine is mainly to due it. Sodium monohydrogen phosphate (Na^HPO^) is also an acid salt technically speaking, and there are some colour tests which exhibit the acid reaction along with it ; litmus, however, is not one of these, for Na.3HP04 turns red litmus blue. When a given urine contains more Na„HPOj^ than NaHoPO^, the reaction of that urine to litmus is alkaline ; that is to say, it turns red litmus blue and does not turn blue litmus red. Some urines have what is known as an amphoteric reaction — they turn red litmus bluish and blue htmus reddish — a different thing from neutrality of reaction, in which neither red litmus nor blue is turned in colour at all. The cause of the amphoteric reaction of a urine is the even balance in that urine of the Na.^HPO^ on the one hand and of the NaH„P04 on the other. Now the dihydrogen phosphate is much more soluble in water than is the mono- hydrogen phosphate, whilst the tribasic phosphates are as a rule far less soluble still. When it is stated, therefore, that phosphates are more soluble in acids PHOSPHATURIA 573 than they are in alkahes, it must be remembered that it is not a question of a difference of solubiUties of the same salt of phosphoric acid, but of an acid urine containing the bulk of its phosphates in a salt diff event from the one present in an alkaline urine. The very fact of a urine being alkaline means that there is relatively little of the more soluble NaH^.PO^^ present, and relativelv much of the less soluble Xa^HPO^ and Na.POj^. Conversely, the fact that a urine is acid implies that the phosphates are relatively more abundant in the soluble NaHoPO^ form than they are either as Na^HPOji^ or Na.,POj^. As a matter of fact, the three degrees of phosphates of sodium, potassium, and ammonium are all so soluble that they practically never become spontaneouslv precipitated, nor do they take part in forming calculi. It is the phosphates of calcium and magnesium that form precipitates, but what has been said above of sodium phosphate applies equally to calcium and magnesium phosphates. The less acid a urine is, the more will the less soluble varieties of calcium and magnesium phosphate prepon- derate, and it is on this account that phosphates come down in alkaline or neutral rather than in acid urines. Again, it is often stated that phosphates are less soluble in hot urine than thev are in cold, and this is given as the reason for the cloud of precipitated phosphates that so often forms when a urine that is not alreadv very acid is boiled. This, however, does not express the real reason for the cloud ; the heat does not precipitate the same phosphate as the cold urine contained, but leads to the formation of a different, and less soluble, phosphate. The calcium mcno- hydrogen phosphate dissociates into calcium dihydrogen phosphate and normal calcium phosphate ; it is the latter which is so insoluble that it comes down : 4CaHP04 = CaalPOJ, + CalH.PO^jj Medium solubility. Relatively insoluble, and Relativelv the most so coming down as a cloud. soluble of the three. Milky Urine. — The urine of many healthy people, especiallv children, and eaters of large public dinners, is sometimes milk-like when it is passed soon after a full meal. Many a person has become alarmed at the sight, and has feared some grave disorder of the sexual organs or functions, especially either gonorrhoea or spermatorrhoea. The condition is physio- logical. It results from increased quantities of hydrochloric acid being required in the stomach at the time, increased quantities of bases being passed in the urine in conse- quence. The result of this is that the urine tem.porarily contains such an abundance of bases in proportion to acids that the less soluble monohydrogen phosphates exceed the more soluble dihydrogen phosphates, and they may become precipitated even in the urine that is still within the bladder. The commonest salt to come down is cal- cium monohydrogen phosphate, CaHPOj^, which is either amorphous, or else assumes the form famihar as "stellar phosphate." MgHPO^^ may come down with it in the form of amorphous particles, or as needles. Ammonio-magnesium Phosphate. — This, generally known as triple phosphate, ^MgNH^POj^, is comparativeh- insoluble, and when precipitated it nearly always assumes the form of prisms — the familiar " knife-rester " or " coffin-Ud " crystals (Fig. 155). It is clear that these will onlv come down when the Fig'. 155. — Triple phosphate crystals. 5 74 PHOSPHA T URIA urine contains ammonia. The latter naay of course have been produced by ammoniacal decomposition of urea after the urine was passed. If urinary decomposition after passage can be excluded, however, it is usually stated that the presence of ammonio-magnesic phosphate crystals indicates a purulent lesion in the urinary tracts, especially in the bladder. It is quite true that ammoniacal urines from cases of cystitis often abound in crystals of triple phosphate. The diagnosis is given by the pus cells and so forth, however, and not by the triple phosphate crystals. It is important to remember, moreover, that each day's urine normally contains enough ammonia for ammonio-magnesic phosphate crystals to occur in an absolutely healthy urine, even apart from decomposition on standing. This fact detracts very greatly from the value formerly attributed to the detection of triple phosphate crystals in the urine. Indeed, the importance of phosphates in the urine lies almost entirely in the fact that errors of interpretation may arise unless their physiological behaviour is clearly understood. Microscopically they are often amorphous, but the three well-defined forms of crystals shown in Fig. 155 may be recognized microscopically. The chief chemical test is the addition of dilute acetic acid, which causes a precipitate of phosphates to clear up. The main importance of recognizing them correctly is to avoid mistaking them for pus in the case of a spontaneous deposit, for spermatozoa, or gonorrhoea, when the urine comes milky from the urethra, and for albumin in the case of the boiling test for the latter. Herbert French. PHOTOPHOBIA may occur in all inflammatory affections of the conjunctiva, cornea, or iris. It is most extreme in children suffering from corneal affections, such as superficial corneal ulcers or interstitial keratitis. It may also occur in snow blindness, scurvy, or albinism, and in normal persons after staying for long periods in the dark. It has no special diagnostic significance in differentiating between various forms of ocular inflammation. Herbert L. Eason. PIGMENTATION OF THE SKIN. — Anomalies of the natural pigmentation of the skin, on the side either of excess or deficiency, may be due to irritation of the abdominal sympathetic, and particularly the solar plexus, leading to general pigmentation, or to the exudation or extravasation of the colouring matter of the blood, producing local pigmentation. Local pigmentation may be brought about by the action of irritants, may result from a condition of hj^per- semia, or may be a sequela of skin eruptions. The most familiar errors of pigmentation are covered by the term chloasma. This may be either idiopathic or symptomatic. Idiopathic chloasma is usually caused by counter-irritants, such as vesicants, or some other form of external irritation, especially scratching, as in vagabond's disease — phtheiriasis ; but in some cases it is impossible to trace the cause. Symptomatic chloasma is a sequela or an accompaniment of cutaneous eruptions, or is the result of abnormal conditions of the uterus or of other abdominal viscera, or of cachexia. It is most often met with as chloasma uterinum, which may occur not only in connection with pregnancy, but also in association with any form of uterine irritation. The smooth j^ellowish-brown patches are seen most commonly on the forehead, but almost the entire face may be involved, and also the trunk and limbs. Somewhat similar irregularities of pigmentation occur in rheumatoid arthritis, pernicious ancemia, Hodgkin's disease, Graves' disease, abdominal tuberculosis, and other disorders of the abdominal viscera, and in cases in which arsenic has been given over long periods. In Addison's disease there is a general bronzing of the skin, together with pigment deposits in the mucous membranes of the mouth, anus, vulva, and urethra ; PIGMEXTATIOX OF THE SKIN 575 and pigmentarv abnormalities occur also in cachexia associated with malaria, cancer, nodular leprosy, and secondary syphilis — in malaria, a yellowish-brown to black ; in cancer, a sallow tint ; in nodular leprosy, a fawn colour early in the disease, and a general bronzing at a later stage ; in secondary syphilis, an earthy tint affecting the face. In the rare condition known as ochronosis, the skin, cartilages, and sclerotics are blackened, as the result in some cases of alkap- tonuria, in others of the prolonged absorption of carbolic acid. In hemochroma- tosis, another rare condition, apparently due to diseases of the ahmentary tract and liver, the patient may be pigmented from head to foot, the prevailing colour being a deep blue-grey slate tint. The diagnosis of urticaria pigmentosa seu nigricans is generally clear. Pigmentary deposits in the skin form only part of the skin changes characteristic of Kaposi's disease. The pigmentation of bronzed diabetes can scarcely be misinterpreted if, when the urine is examined, glvcosuria be found ; most cases of this form of diabetes have cirrhosis of the liver as well, so that there is a non-teetotal historj-. The diagnosis of the various forms of chloasma is usually easy, though the particular cause of the pigmentation can only be deduced, of course, from the general sj'mptoms. Chloasma can be differentiated from chromidrosis, hj observ- ing that in the latter condition the colour, which is derived from the exuded secretions, readily disappears if washed with ether or chloroform. In tinea versicolor, and some other fungous diseases which resemble chloasma, the patches are not smooth but seal}', and the discoloration can be scraped off". The pigmen- tary syphilide, which may take the form of a diffused brownish hue, brownish spots, or dappled patches, is seldom met with except on the neck. Question may arise between chloasma and leiicodermia (vitiligo) when in the latter condition the white areas have spread over the greater part of the body, and are taken for the normal colour ; but in leucodermia the border of the area is concave, whereas in chloasma it is convex. Moreover, in leucodermia the history is that of the formation of white patches surrounded by a pigmented border, which may spread until large areas, and even the whole surface of the body, are affected. Leucodermia has in its turn to be distinguished from sclerodermia, morphoea, macular leprosy, pigmentary syphihde, and partial albinism. The skin is not stiff" and thickened as it is in sclerodermia. The edges are not streaked with small dilated vessels, making a pink or violet border, as in morphoea, nor is there a.nY interminghng of atropliic striae. The patches are not destitute of sensation as in nerve-leprosy, nor, though it has been styled " white lepros}'," has leuco- dermia any other resemblance to that affection save the colour of the patches. Doubt as between leucodermia and a congenital condition hke partial albinism could only arise by disregarding the historj'. Of albinism itself, whether partial or universal, nothing more need be said here ; for though it is an abnormality of pigmentation, its true character can never be in question. Xor need I speak of jaundice, for that condition forms the subject of a separate article. Discoloration of the skin may be due to the prolonged administration of drugs. Thus picric acid may turn the skin and the conjunctivae 3'ellow, arsenic may cause a pecuhar greyish, brownish or freckle-like pigmentation, nitrate of silver may set up the condition known as argyria, in which the integument and the mucous membrane, particularly in situations exposed to light, take on a bluish-grey or grej^dsh-black colour, especially on the face and the flexor aspects of the hmbs. This condition may closely resemble hsemochromatosis and similar abnormahties, but the history of protracted use of the drug will make the diagnosis clear. Since, however, arsenic mav be derived from some un- suspected source, as was the case in the peripheral neuritis epidemic in and 5 7f> PNE UMA T URIA around Manchester due to beer containing it as an impurity, chemical analysis of the hair should be made, which will serve to prove or disprove a suspicion that the patient has been ingesting arsenic, as the latter becomes stored up in the hair that grows ^\-hilst the arsenic is being taken. Malcolm Morris. PLANTAR REFLEX, EXTENSOR.— (See Babinski's Sign.) PNEUMATURIA — or the passage of gas per urethram, either along with or independently of urine — is a rare symptom, but when it does occur it is a very striking one, particularly in males. It maj^ be due to one or other of t^vo entirely distinct groups of causes, namely : 1 . Communication betw^een the rectum, caecum, vermiform appendix, or other part of the alimentary canal and the bladder, ureter, or renal pelvis ; either directly, or via an intermediate gas-containing abscess cavity. 2. Infection of the bladder or other part of the urinary tract by micro- organisms that produce gas, Avithout there necessarily being any breach of surface of the mucosa. When the cause lies in the first group, the patient is very liable to pass fsecal material at the same time as the gas, and the differential diagnosis between the various possible lesions will be found discussed under F^ces PASSED PER Urethram. It should be added, however, that the passage of gas without faeces per urethram by no means excludes there being a fistulous communication between some part of the alimentary canal and the urinary tract ; the fistula may be tortuous, so that gas gets along it, but not faeces. It may happen, moreover, that a lesion such as appendicitis has led to the formation of a local abscess which, owing to its infection by the Bacillus coli communis, contains gas ; this abscess may open into the bladder and cause the discharge of pus and gas, but no faeces, per urethram. The same applies to other abscesses which, though not arising primarily in connection with the bowel, nevertheless occasionally contain gas from infection by the B. coli communis — a suppurating ovarian dermoid cj^st, for instance, a suppurating hydatid cyst, or a pyosalpinx. Sometimes there may be serious doubts as to whether the gas is finding its way into the urinary passages from some external source, as above, or whether it is being produced in situ. In the absence of any rectal or other pelvic or abdominal evidence of disease outside the bladder, it will be remembered that several different organisms are able to produce gas when they grow in urine ; notably the Bacillus coli communis, and in glycosuric cases, various yeasts, including the common yeast. The urine will be examined for sugar, and if it be present, a catheter specimen will be obtained to see if saccharomyces are present in the bladder-urine ; if so, and if there is no pus or evidence of infection by other micro-organisms, the nature of the pneumaturia will be clear ; as a rule, in these cases the patient voids urine that is bubbly rather than distinct and separate from the gas. If, on the other hand, no sugar is present, a catheter specimen will be cultivated to find out whether the B. coli communis is present, and if so, in what quantity. If it is, and if no sign of any fistulous communication between any part of the bowel, or a gas-containing abscess cavity, and the urinary tracts, can be made out, then there will be a presump- tion that the pneumaturia is due to coli bacilluria, although the latter is far commoner without than with pneumaturia. The urine in these cases may contain very little obvious pus and only a trace of albumin ; it may be acid, and not foul smelling or ammoniacal ; on the other hand, it may sometimes be so foul and faeculent as to cause serious suspicions of a communication betAveen the colon and the bladder, even when there is none. A cystoscopic PNEUMOTHORAX 577 examination will serve to exclude a fistulous opening into the bladder, but it may be much more difficult to exclude a similar communication with the higher parts of the urinary tract, especially the renal pelvis. The latter condition is so rare, however, that it is wiser to diagnose coli bacilluria only unless there is direct evidence of a cause for communication between the bowel and the renal pelvis, such as a carcinoma coli. Herbert French PNEUMOTHORAX, or gas in the pleural cavity, may exist with or without clear fluid, pus, or blood in the lower part of the pleura at the same time. If there is any kind of fluid in the cavity along with the air, the fact is generally made obvious at once, when the patient's thorax is auscultated whilst it is being actively or passively shaken, so as to produce the typical succussion splash, often followed by the ringing sounds made by drops of fluid falhng from the compressed lung into the pool of fluid beneath. The nature of the fluid — hvdro-pneumothorax, pyo-pneumothorax, or hsemo-pneumothorax, as the case may be — can seldom be diagnosed except by obtaining some of it by means of an exploring needle and syringe. Whether the pneumothorax is or is not associated with any of these fluids, the diagnosis is generally easy on account of the deficiency in movement of the affected side of the chest, the displacement of the heart in the opposite direction, and hyper-resonance to percussion, together with remarkable deficiency or complete absence of the vesicular murmur and voice sounds. The coin-tap sound, obtained by placing one silver coin on the chest wall, tapping it with another silver coin, and listening through the stetho- scope for the ringing echo produced when the sign is positive, may serve to confirm the diagnosis, but it is not essential. Partial pneumothorax, in which complete collapse of the lung is prevented by former adhesions, is proportionately more difficult to diagnose, but the same type of physical signs, including the coin-tap sound or bruit d'airain, will generally be found in these cases, though in less degree than when the pneumothorax is complete. The ;i;-rays show an abnormal clearness corresponding to the air in the pleural cavity. It is not sufficient, however, merely to diagnose pneumothorax ; its cause has to be determined from amongst the following : — Phthisis : {a) early, ip) late. Rupture of an emphysematous bleb. Gangrene of the lung with necrosis of the pleura. Empyema ruptured through the lung. Instrumental : e.g. after tapping a pleural effusion. Stabs, or gunshot wounds of the chest wall. Epithelioma of the oesophagus ulcerating into the pleura. Gastric ulcer or carcinoma ventriculi, leaking so as to produce a gas-containing sub-diaphragmatic abscess, which in its turn may perforate the diaphragm and cause a pneumothorax. Infection of the pleural cavity by gas-producing organisms, such as the Bacillus coli communis. The commonest cause by far is phthisis ; and when the occurrence of the pneumothorax does give rise to symptoms, it is generally due to comparatively earl}^ phthisis ; indeed, when a sudden acute attack of pain in one side of the chest, associated with rapid shallow breathing, and cyanosis with or without . haemoptysis develops in a young adult without apparent cause, it is almost certain that the patient has a tuberculous focus at one apex, even though, as frequently happens, there have been no abnormal symptoms previously, such as cough or night sweats, and even though absolutely no abnormal physical signs can be detected at the apex of the other lung. There may be a Httle sputum, and in this tubercle bacilli may be detected. D 37 578 PNEUMOTHORAX When pneumothorax is attributed to rupture of an emphysematous bleb, there must always remain in the physician's mind a serious doubt as to whether it is not really due to a bleb in the immediate neighbourhood of an undiagnosable tuberculous deposit, and the case should be treated as one of potential phthisis. If the tuberculous process in the lung has made considerable advance pneumo- thorax is far less common, because there will almost certainlj^ have been pleurisy with thickening and adhesions sufficient to prevent pneumothorax occurring ; nevertheless, in some such cases pneumothorax does develop, and the diagnosis of its cause is easy both on account of the abnormal physical signs and of the sputum with the tubercle bacilli in it. In a later stage still, the occurrence of pneumothorax may cause very little additional disturbance, on account of the extent of lung already diseased, and although its cause would be obvious enough, the occurrence of the pneumothorax often escapes detection. When the patient has had a pleuritic or pleural effusion tapped, the detection of air free in the pleural cavity upon the next day is by no means an uncommon occurrence ; it does not follow that this air has leaked in through the tapping instrument, for it is quite as commonly derived from the rupture of the super- ficial alveoli which have been re-expanded rather too rapidlj^ in the withdrawal of fluid by the aspirator. The air generally becomes re-absorbed in a few days, and the temporary pneumothorax is of little significance. Similar escape of air into the pleural cavity, as the result of cuts, stabs, fractured ribs, or gun-shot wounds, is remarkably rare ; this rarity depends upon the fact that the two layers of pleura tend to cohere in a way similar to that which makes two thin sheets of Indian paper difficult to separate, so that when an injury from outside penetrates one layer, it nearly alwaj^s perforates both, and air from within the lung escapes into the subcutaneous tissues instead of into the pleural cavity, and produces surgical emphysema instead of pneumo- thorax. It rarely happens that an injury separates a sufficient area of the two layers of pleura one from the other to cause a pneumothorax. All the remaining causes of pneumothorax in the list above are uncommon, and none of them will arise without there having been other sj^mptoms to indicate the nature of the malady. It is possible for an empyema to rupture into a bronchus, and so lead to the sudden expectoration of much foul pus, without any pneumothroax arising, or at least none of any extent, because for such an empyema to rupture into the lung it must have been shut off all round by firm pleural adhesions. Gangrene of the lung, such for instance as that which may follow upon a foreign body becoming impacted in a bronchus ; septic bronchopneumonia due to inhalation of particles from a cancerous tongue or to septic emboli from thrombosis of a lateral sinus and jugular vein in connec- tion with otitis media ; growth of the lung breaking down, or lobar-pneumonia becoming entirely necrotic — these are only the terminal factors of an already serious disease, and pneumothorax due to these causes may even pass without recognition on account of the severity of the symptoms already existing in the case. Gas-containing abscesses beneath the diaphragm, such as may either perforate directly into the pleural cavity or lead to infection of that cavit}' by the Bacillus coli communis or other gas-forming organism, never arise suddenly-, but are preceded by a simple or malignant ulceration of either the stomach, duodenum, or colon, the symptoms of which will generalh' have existed for days, weeks, or months ; so that if the possibility of gas appearing in the pleural cavity in this way is borne in mind, the diagnosis of its origin need not be difficult. The ;ir-rays maj^ serve to show a large gas bubble below the diaphragm as well as gas in the pleural cavity, and that the gas bubble is not intragastric may be demonstrated by filling the stomach with a bismuth meal and finding that the gas bubble does not become blackened. Herbert French POLYCYTH.^MIA 579 POLYCYTHEMIA. — The term polycythemia is used to denote a material increase of the red corpuscles above their normal number per cubic millimetre of blood. In males they should average 5,000,000 per c.mm. ; in females, 4,500,000. Any considerable increase above these figures, for instance up to 6,000,000 per c.mm., or more, constitutes polj^cythaemia. Figures as high even as 14,000,000 are sometimes reached. The following are some of the conditions in which polycythaemia occurs : — ■ 1. Congenital heart disease of the type spoken of as morbus coeruleus — generally due to pulmonary stenosis (see Fig. 50, p. 184). 2. Persons who live in high altitudes. 3. Patients afflicted with chronic shortness of breath, with a tendency to periodic cyanosis, particularly cases of (a) mitral stenosis, {b) fibroid lung with and without bronchiectasis, (c) chronic bronchitis and emphysema, (d) spasmodic asthma, (e) some renal cases. 4. Patients who have recently lost a quantity of fluid from the tissues, the result of such conditions as (a) severe vomiting, e.g., the uncontrollable vomiting of pregnancy ; (b) severe diarrhcea, e.g., the summer diarrhoea of infants, cholera, ptomaine poisoning, arsenic ; (c) inability to obtain fluid to drink, especially if there exists already a disease tending to polyuria, such as diabetes mellitus, diabetes insipidus, or granular kidney. 5. Splenomegalic polycythaemia. As a rule, the diagnosis of the cause of polycythemia in a given case is not difficult. When it is due to congenital heart disease it is nearly always associated with an extreme degree of cyanosis without proportionate dyspnoea, and with clubbing of the fingers, both these dating from birth, or early childhood. The patient is generally young, though some survive into adult life. There is not always a cardiac bruit, and the precise lesion will then be obscure ; often, however, percussion shows increased cardiac dullness to the right of the sternum, and upwards towards the second left rib, indicating increased size of the right auricle and ventricle ; and in most cases there is either a loud rumbling or blattering systolic bruit of pulmonary stenosis, heard loudest in the second left space close to the sternum, but also audible over the greater part of the precordial region, and often over both sides of the chest in front and behind ; or else a very similar universal systolic bruit, differing chiefly in having its maximum intensity either behind the sternum between the two fourth ribs, or else in the fourth left intercostal spaces close to the sternum, indicative of patent septum ventriculorum. These two lesions may both be present in the same patient, and they are the commonest cause in cases of morbus coeruleus that survive infancy. The red corpuscles seldom number less than 6,000,000 per c.mm., and in some cases they have been no fewer than 14,000,000 per c.mm. The percentage of haemoglobin is also greatly increased, but usually to a less degree than are the red cells, so that the colour index falls below i . This applies to nearly all causes of polycythaemia. There is no simultaneous increase in the number of leucocytes per c.mm., and the differential leucocyte count falls within the normal limits. It is noteworthy that cases of persistent ductus arteriosus seldom present either cyanosis, clubbed fingers, or polycythaemia. Residence at high altitudes often causes polycythaemia. The increase is seldom extreme, but the red cells not infrequently reach 6,000,000 or more per c.mm. This rule is not by any means universal, however, though upon the whole the higher the altitude the higher the normal average number of red cells per c.mm., particularly in those who have resided long and continuously in the mountains. The individuals are not ill ; it is merely that their red cells stand at a higher figure normally than do those of dwellers nearer sea level. Quite apart from the presence or absence of anasarca, patients suffering 58o POLYCYTHEMIA from chronic lesions which tend to produce dyspncea are also very apt to have polycythaemia, particularly when the lesion causes marked redness of the lips. This is very well seen in many cases of mitral stenosis when there has been a tendency for some time past for failure of compensation to ensue. There is no similar polycythaemia in aortic cases unless mitral disease is present as well, and the red cells are much less increased in mitral regurgitation than in mitral stenosis. In the latter they often reach 6,000,000 or even 7,000,000 per c.mm., and it would seem to be an attempt on nature's part to try and compensate for the failing circulation by distributing the haemoglobin over a larger corpuscular area. The same explanation probably accounts for the similar polycythaemia due to morbus coeruleus, and to high altitudes, and to certain cases of fibroid lung, bronchiectasis, emphysema, chronic bronchitis, renal disease with chronic dyspnoea, and spasmodic asthma, in which some degree of polycythaemia, though not the rule, is sometimes met with, just as it is in mitral stenosis. The colour index is less than i, for although the haemoglobin is increased, it is less so than are the red cells. The leucocytes remain unaltered. The polycythaemia will seldom if ever be the most prominent symptom in the case, so that the diagnosis will nearly always have been made upon other grounds — the presystolic bruit at the impulse ; the displacement of the heart towards that side where the lung presents an impaired note, with or without crackling rales and bronchial breathing ; and so on. The maintenance of the poly- cythaemia is important, however, and therapeutic measures should be directed to this end, for many cases of mitral stenosis with 5,000,000 red cells per c.mm. are relatively anaemic ; they should have 6,000,000 or more. The effect of cholera, ptomaine poisoning, arsenic, summer diarrhoea of infants, severe thirst that cannot be assuaged, the toxcemia of pregnancy, and so on, in concentrating the blood by withdrawing or withholding fluid from it, and thus producing some degree of polycythaemia, is an acute condition which is to be counteracted by continuous saline infusion or some similar method of restoring fluid to the tissues. The polycythaemia seldom reaches any marked degree except in quite early stages, for instance, in cholera ; later, the red cells in the blood disintegrate more rapidly than they are replaced, and the poly- cythaemia is thereby masked. In measuring the concentration of the blood in these conditions, it is of less value to count the red cells than to measure the specific gravity. This is most readily done by the chloroform and benzene method. The specific gravity of chloroform is high, that of benzene is low, and by mixing the two in different proportions it is possible to obtain fluids of every intermediate specific gravity. A mixture of the two of the normal specific gravity of the blood, viz., 1056, is made, and poured into a specimen glass of sufficient depth to allow a urinometer to float in it. For strict accuracy, certain corrections in the readings of the ordinary urinometer are required, but for emergency use the instrument will serve. The lobule of the patient's ear is pricked, a large drop of blood is allowed to fall into a suitable small cup or other receiver containing some of the chloroform-benzene mixture, and thence transferred to the main bulk of the fluid in the specimen glass. If the blood- drop sinks, more chloroform must be added ; if it floats, more benzene ; ultimately a point is reached at which the blood-drop neither sinks nor floats ; the specific gravity of the chloroform-benzene mixture is then the same as that of the blood. In cases of collapse from loss of fluid, there is a rise in the specific gravity of the blood, even when there is no polycythaemia, — and the greater the rise, the greater the need for infusion. Splenomegalic polycythcemia is a somewhat rare condition that is also termed erythrcemia, or erythrocythcsmia. Its name suggests its main features, which are : Enlargement the spleen, increase in the red cells up to as many as POLYURIA 581 10,000,000 per c.mm., or even more, and duskiness or lividity of the face and of the extremities. The nature of the malady is still obscure, though some regard it as due to disease of the bone-marrow. It affects adults and females rather than children and males, and its course is chronic. It only remains to add, that whereas to be typical the spleen must be enlarged, there are cases, probablv of the same affection, in which, without the spleen becoming palpable, the onlv definite clinical signs are progressive lividity and polycythaemia. Herbert French- POLYDIPSIA. — (See Thirst, Extreme.) POLYURIA. — The term polyuria signifies the passage of more than the average amount of urine per diem. It may be either (I) Transient or (II) Con- tinued. It is important not to mistake frequency of micturition for polyuria, for although the latter almost necessarily causes the former, there are many conditions that lead to frequency of micturition without polyuria — for example, tuberculous ulceration of the bladder, enlargement of the prostate, or urethral stenosis, in all of which urine may be passed frequently, but in small quantities at a time. In case of doubt the total amount of urine passed in each period of twentv-four hours should be measured. The normal limits are very wide, the average being about 50 ounces per diem, more being passed in cold weather than in warm, during rest than after exercise, waking than sleeping, and after drinking than after taking little fluid by the mouth. Under certain conditions the total amount exceeds 200 ounces per diem, or even two gallons. The point at which polvuria begins is arbitrary ; if a patient passes 70 ounces or more per diem it is almost certain to attract attention, and therefore to merit the term polyuria. In degree, the polvuria due to causes in Group I seldom exceeds 100 ounces a dav ; some of the causes in Group II, especially diabetes mellitus and diabetes insipidus, may cause polyuria to the extent of 200 ounces, or even 300, 400, 500, 600, or more, per diem. In arriving at the differential diagnosis of the cause in any given case, one of the first points to note is whether the polyuria is persistent ; or whether, even if recurrent, it is transient. Any of the causes that usually give persistent polvuria may in some individuals produce the symptom intermittently, but upon the whole one may classify the causes of polyuria as follows : — I. — Causes of Transient Polyuria. 1. After drinking abundance of water or other fluid. 2. After drinking fluids containing diuretic principles, such as alcohol (beer, gin, whisky, hock) ; caffeine (tea, cocoa, coffee) ; citrates or tartrates (artificial lemonades). 3. As the result of nervousness, or of nervous attacks, such as : — (a) Medical examination for life assurance (b) Preparation for some physical or mental competition (c) Hysteria, especially during recovery from an acute outburst {d) Neurasthenia {e) After an epileptic attack (/) After migraine {g) After an asthmatic attack [h) After an attack of angina pectoris {i) Periodic polyuria, apparently without cause. 4. Hydronephrosis, with periodic emptj'ing of the renal sac, especially with movable kidney or with renal calculus. 5. The cold stage of a malarial attack. 582 POLYURIA 6. In some cases of convalescence from a febrile illness, such as enterica or pneumonia. 7. As the result of the clearing up of extreme oedema or serous effusions, — for instance, during recovery from acute nephritis ; mitral stenosis, with heart failure ; cirrhosis of the liver, and so on ; especially if the fluid clears up quickly after giving diuretic remedies, such as blue pill, digitalis, calomel, copaiba resin, potassium salts, uva ursi, broom tops, or dwarf elder. When the cause lies in Group I its nature is generally obvious, though it is essential to examine the urine carefully for sugar, albumin, and renal tube-casts, for purposes of exclusion. Nevertheless, the diagnosis may be in doubt until the course of the symptom has been watched for a while. For instance, polyuria may seem to be due to profuse drinking, when really the kidnej's are granular and contracted ; or in a life insurance case, nervousness may seem to be the cause, when there has really been a bout of drinking ; or, again, the drinking may be secondary to the extreme thirst produced by diabetes insipidus. Excessive Drinking. — When due to drinking water, tea, wine, spirits, or artifi- cial lemonades, the polyuria ceases when the drink in question is limited or avoided. Nervousness. — The history and circumstances of the case, together with the absence of signs of gross disease of heart or kidneys, will be the main factors in deciding whether the polj-uria is caused by excitement, nervousness, hysteria, or neurasthenia. Epilepsy. — The character of the convulsive seizures, their recurrence at inter- vals, and the influence of bromides upon them, will serve to diagnose epilepsy, for polyuria in association with the latter nearly always follows immediately after an attack of grand mal. It may, however, be associated with petit mal, or even be the chief phenomenon in some cases of epilepsy. Migraine. — The diagnosis of migraine depends on the history of the case and the absence of optic neuritis and other evidence of gross intracranial disease. Asthma. — Asthma is sometimes easy to diagnose, sometimes very difficult ; it may be mistaken for recurrent bronchitis, cardiac dj^spncea, renal dj'spnoea or urcemic " asthma," mediastinal new growth, thoracic aneurysm, thymic " asthma," laryngeal papilloma or fibroma, foreign body in the air-passages, syphilitic stenosis of a bronchus, goitre, or hysteria. It so frequently develops into emphysema and bronchitis that one is apt to forget that the essential sym- ptom of asthma is dyspnoea, and not cough. To diagnose a difficult case it may be necessary to examine the chest with the .y-ra^^s to exclude aneurysm and new growth ; to examine the larjmx and vocal cords, the heart, the retinae, and the urine ; to exclude renal and cardiac mischief ; and even then, doubt maj' remain unless there is a clear and typical account of the nature of the earlier attacks in a patient who has had recurrences for years, and who is relieved by cocaine sprays to the nose, b}^ ethereal tincture of lobelia, by inhalations of stramonium fumes, or by other anti-asthmatic remedies ; it may sometimes be of assistance to know that Eosixophilia [q.v.) is more likely to be found during an attack of asthma than as the result of any of the other conditions that may simulate it. The polyuria occurs in by no means every case ; when it does so, it generally follows immediately after an attack, and this applies also in cases of angina pectoris, the diagnosis of which is not difficult when the acute attacks of precordial pain radiate upwards and outwards to the left shoulder and down the left arm, and when there is evidence of an aortic lesion, or of atheroma, and arterio- sclerosis with high blood-pressure. Periodic Polyuria, apparently without cause, is a condition which is regarded by some as a clinical entity ; the diagnosis must always be difficult to be sure of POLYURIA 583 however, and the more carefully a cause is looked for, the fewer will be the cases remaining in this category; it will be found that some are due to epilepsy; others to secret drinking ; others to granular kidney ; others to hydronephrosis, and so on. Hydronephrosis, with periodic emptying of the renal sac, is the chief cause of typically periodic polyuria. The diagnosis is arrived at by having the urine carefully measured each day, and by carefully palpating the loins bimanually for evidence of renal enlargement. When a kidney swelling can be detected, and when this increases in size at the same time that less urine is being passed, whilst it materially decreases on the days when the polyuria occurs, the diagnosis of hydronephrosis or pyonephrosis is clear ; and the distinction between the two depends on whether there is or is not pyuria. The commonest causes for hydronephrosis are movable kidney and renal calculus ; and the ;v-rays often serve to distinguish the latter from the former. It should be noted that the bowels should have been well emptied shortly before the ;v-rays are used in examining kidney for stone, for otherwise the dark and light areas due to alternating faeces and gas in the bowel render it impossible to be sure about the shadow cast by a calculus. Fevers. — The polyuria that occurs during the cold stage of a malarial attack is speedily replaced by the opposite condition when the hot stage is reached ; the diagnosis is afforded by the circumstances of the case, such as residence in a malarial district and previous attacks of the malady ; by the discovery of malarial parasites in blood-films ; by the absence of leucocytosis, the relative increase in the large lymphocytes in the differential leucocyte count, and by the beneficial effects of quinine upon the disease. Polyuria during convalescence from other fevers, such as enterica or pneumonia, is not uncommon ; it is a phenomenon that may attract some attention at the time, but it seldom gives rise to difficulty in diagnosis. (Edema and Diuretics. — The considerable polyuria that often results in renal or cardiac cases when oedema is clearing up under treatment is noteworthy, but the diagnosis is not, as a rule, difficult. If the polyuria is due merely to the excretion of accumulated fluid, it will cease when there is no longer any oedema ; whilst if it is due to granular kidney, or other underlying malady, it will continue even after the oedema has gone. II. — Causes of Continued Polyuria. 1. Diabetes mellitus. 2. Red granular contracted kidneys. 3. Arteriosclerosis. 4. Pale granular contracted kidneys. 5. Lardaceous or amyloid kidneys. 6. Cystic kidneys. 7. Diabetes insipidus : [a) Due to no gross nervous lesion {b) Due to tumour or injury of the medulla oblongata. 8. Incorrigible drinking of beer or spirits. 9. Phosphatic diabetes. 10. Azotic diabetes. 11. Some cases of acromegaly. 12. Some cases of m^^xoedema. Diabetes Mellitus. — A very important step in the diagnosis is to examine the urine carefully. If sugar is present, a diagnosis of diabetes mellitus will be made, especially if diacetic acid and acetone are also present, and the specific gravity •584 POLYURIA is between 1035 and 1045. Some authorities distinguish in kind as well as in degree between what they term true diabetes mellitus on the one hand, and ahmentarv glycosuria on the other, though others hold that these differ only in degree ; it is chiefly in severe diabetes of young people that poh'uria is marked, something between 100 and 600 ounces of urine being passed per diem ; in elderly people with glycosuria the polyuria is often slight ; in these cases the specific gravitv need not be above the normal, and diacetic acid and acetone are generally absent. If no sugar is present upon one occasion it may be on another, so that several examinations may be required. Albuminuria. — If sugar is persistently absent^ diabetes mellitus can be excluded, and special attention should be devoted to testing for albumin. If this is present, and the pohoiria cannot at once be attributed to anything so obvious as the clearing up of oedema or the administration of a diuretic, the next thing is to make a very careful microscopical examination of the centrifugahzed deposit for renal tube-casts ; if the latter are absent, and if the patient is a young adult male, who seems to be in good health, whose heart and other organs present no abnormal physical signs, and whose polyuria troubles him chiefl}- at times of excitement, for instance when he is in for an examination, the diagnosis is very likely to be that of " functional " or " physiological " albuminuria, in which case repeated tests will show that the urine is often quite free from albumin, especially the first thing in the morning, and the blood-pressure would not be raised. If, on the other hand, more than an occasional renal tube- cast was found, and the albumin and polyuria Avere persistent, the diagnosis of one or other of the following renal lesions would suggest itself : red granular contracted kidney-, arteriosclerosis, pale granular contracted kidney, lardaceous kidney, or cvstic kidne}-. The differential diagnosis bet^veen these is discussed under Albuminuria (q.v.). Diabetes Insipidus. — If neither albumin nor sugar is found, even on repeated testing, and if the polyuria is extreme and persistent, whilst the specific gravity of the urine is constanth" low (1004 to 1008), a diagnosis of diabetes insipidus will suggest itself, and it will probably be correct. Before this diagnosis is finally made, however, precautions must be taken to determine that the patient's thirst and polyuria are not due to habits of drinking to excess : it may be difficult to decide this in cases in which alcohoUc beverages are consumed ; but when the patient is a water-drinker, and 5'et cannot do with less than 8 or 10 pints a day, the drinking is probably a necessity, and not a habit ; and diabetes insipidus is the probable diagnosis. In cases of doubt, the difficulty can be decided by restricting the intake of fluid and determining the specific gravity of the blood. This should be about 1056, and in a case where poh^uria is due to drinking habits, restriction of fluids will not materially alter it ; in a case of diabetes insipidus with restricted intake of fluids, however, the drain of the latter from the blood still goes on, and the specific gravity rises to 1060, or 1065, unless the patient is allowed fluid by the mouth again. Phosphatic and Azotic Diabetes. — Another point that needs investigation in a case suspected to be diabetes insipidus, is the amount of solids excreted daily in the urine. In ordinary diabetes insipidus the total solids are normal, the only increase being in the water. There are rare cases in which, in addition to polyuria, there is a great increase in the total solids in the urine also — so-called haruria. Rare though these cases are, they have been divided into two types, namely, those in which the inorganic salts are most increased — phosphatic diabetes (p. 572), and those in which the nitrogenous constituents are mainly augmented — azotic diabetes. The diagnosis here depends mainly on quantita- tive estimation of the various urinary substances. There are two groups of diabetes insipidus, according as there is, or is not, a PRIAPISM 585 gross lesion of the central nervous system. If the malady follows on a fractured base of the skull, or if there are vomiting, headache, optic neuritis, or other symptoms of cerebral tumour, there is probably a gross lesion of the base of the brain in or near the medulla oblongata — thrombosis, softening, haemorrhage, small aneurysm, gumma, glioma, or other neoplasm. In other cases, the com- plaint arises after a fright or shock, or even without any apparent cause, and there seems to be no gross lesion to account for it. Acromegaly and Myxoedema. — It only remains to add that symptoms not unlike those of diabetes insipidus have sometimes arisen in cases of acromegaly and in myxoedema. There is probably a nervous factor in both cases, coupled in myxoedema with dryness of the skin, and consequent deficiency in perspiration ; whilst in acromegaly there is the tumour-like enlargement of the pituitary body which may cause polyuria like any other lesion near the medulla oblongata. The diagnosis of acromegaly may be confirmed by the Ar-rays, which will show the great enlargement of the bones of the hands, feet, and head ; whilst in myxoedema, if the general symptoms, the pseudo-oedema of the legs, the acquired dullness of intellect, the increasing weight, and the broadening of the features, the fingers, and the hands, do not at once indicate the nature of the complaint, the beneficial effects of treatment by thyroid extract may serve to clinch the diagnosis. Herbert French. PRECORDIAL PAIN.— (See Pain in the Chest.) PRIAPISM signifies erection of the penis, continual, of troublesome degree, and not. necessarily accompanied by sexual desire. Though generally spoken of in connection with the male sex, a precisely similar affection may occur in the female clitoris. The symptom is not often by itself of diagnostic importance, though it may be due to a considerable number of different causes. Most of the latter need be little more than enumerated, for if they are borne in mind they will nearly always lead to a speedy diagnosis. Two in particular merit special mention, however. The first of these is priapism in elderly men. The marriage of old men with relatively young wives is often spoken of as foolish, and doubtless in most instances this adjective is deserved ; but in the case of some old men who are widow-ers or unmarried, it becomes a matter of physical necessity for the relief of priapism which is most troublesome, and which yet cannot be called pathological. In some such cases there may be enlargement of the prostate, or local inflammation such as gouty urethritis, but in many other cases the priapism seems to occur, without pathological cause, as a sort of final outburst of sexual energy before the onset of senile impotence. The other special condition under which priapism may be exceedingly trouble- some is after injury to the upper dorsal region of the spinal cord. The damage may be so serious as to have produced a fracture dislocation of the spine with paraplegia, in which case the diagnosis will be obvious ; short of this, however, there may have been only a minor degree of injury, with contusion and perhaps multiple small haemorrhages into the substance of the cord, in association with which priapism may in some instances be very pronounced and last for weeks or months before recovery occurs. For the rest, the causes of priapism may be summarized briefly according to age periods, the chief being : — Priapism in infancy : — Phimosis Oxaluria Worms, especially oxyuris vermicularis Balanitis Posthitis Calculus, urethral or vesical Certain conditions of mental deficiency. 586 PRIAPISM Priapism at puberty : — The changes in the genital organs associated with the onset of puberty. Priapism in young adult life : — Sleeping on the back Fracture of the dorsal spine Xon-emptying of the bladder Transverse myelitis of the upper when full Ill-litting trousers Sexual excitement Gonorrhoea Epilepsy After circumcision dorsal region Spinal meningitis Certain aphrodisiac drugs : — Cantharides Turpentine Alcohol, especially port wine in Masturbation some persons, champagne in Convalescence from an acute others disease Tetanus Hydrophobia Leukaemia Strvchnine Cannabis indica Camphor Phosphorus Damiana. Priapism in older men : — The male menopause Local irritation as the result of : — Gouty urethritis j HaBmorrhoids Enlarged prostate | A loaded rectum. Hemorrhage into the middle lobe of the cerebellum Lesions of the pons varolii. Very seldom indeed will priapism be the only symptom in the case ; the diagnosis will be made from the history and from the other symptoms. Herbert French. PROLAPSE OF THE UTERUS.— As a matter of practical fact, the uterus only descends as a result of a much wider displacement of all the movable structures which go to make up the pelvic floor. This is composed of a movable or pubic portion, and a fixed or sacral portion, and it is descent of the pubic portion which produces the actual lesion known as prolapse of the uterus. In other words, the uterus onlj' descends because it is a part of the pubic portion of the pelvic floor. Modern anatomical research has shown that the uterus, bladder, and anterior vaginal wall are normally kept in position chiefly by the connective tissue sheaths which accompany the blood-vessels supplying them, and that it is injur}' and stretching of this connective tissue which allows of descent of the organs named. There is no doubt, however, that injuries to the fixed portion of the pelvic floor, the perineal bod}', and levatores ani muscles and their fasciae, will contribute something to the facihty with w-hich the structures mentioned may descend. In practice, therefore, prolapse of the uterus and descent of the pelvic floor lead to the appearance of a swelling at the vaginal orifice. There are other swellings which come do^^-n the ^•agina and appear at the vulva, and from them, therefore, prolapse of the uterus has to be diagnosed. These swell- ings are : (i) Hypertrophic elongation of the cervix uteri; (2) A tumour protrud- ing from the vagina ; (3) Inversion of the uterus ; (4) Cystocele and rectocele ; (5) Extroversion of the bladder through an i^ijiiry in its floor. I. Hypertrophy of the Cervix. — The hypertrophy may be of the vaginal, the intermediate, or the supravaginal portion. The first is always congenital, and consists of elongation of the portio vaginahs. It may protrude from the vaginal entrance, but the vaginal fornices will be found unaltered at their usual level, and the sound will pass an increased distance proportionate to the length of the PROLAPSE OF THE UTERUS 587 portio. The os uteri forms the apex of the protrusion. The fundus remains at its usual level. In hypertrophy of the intermediate portion, the anterior fornix of the vagina is carried downwards with the cervix, and may be obliter- ated, whilst the posterior fornix remains at its usual level, because the elongated portion lies between the insertion levels of the anterior and posterior vaginal walls. The sound passes an increased distance, and the os uteri forms the apex of the protrusion. The fundus remains at its usual level. In hypertrophy of the supravaginal portion, both fornices are carried down with the cervix, and both may be obliterated. The bladder is displaced downwards, but the rectum does not descend. The fundus uteri will be found on bimanual examination to be at its usual level, whilst in true prolapse, the fundus uteri descends as a whole with the rest of the uterus. It is common for some prolapse of the uterus as a whole to accompany elongation of the cervix, and this can only be appreciated by a careful bimanual examination. 2. A Tumour protruding into or from the vagina is most commonly a fibromyoma of the uterus. It may be either a pedunculated growth from the cervix, or a pedunculated growth protruding through the cervix, in either case hanging free in the vagina. It may grow from the cervix in the connective tissue in front, between the uterus, bladder, and anterior vaginal wall ; or behind, between the uterus, rectum, and posterior vaginal wall. In either case the vaginal wall is stretched over the growth. In such cases the uterus will be felt high up, the growth hanging from or protruding through the cervix in the case of pedunculated growths. In the latter the hard ring of the cervix is felt encircling the pedicle. In the case of sessile interstitial growths, the cervix is high up in front or behind the growth, as the case may be, and if the tumour is a large one, may be out of reach altogether. In any case there is no descent of the uterus, and it may even be higher than usual. The growth may be a fibroid growing from the vaginal wall, a mucous polypus of the cervix, or a malignant groivth. 3. Inversion of the Uterus may be chronic, or may be encountered immediately after labour as an acute condition which could hardly be mistaken for anything else, except perhaps extrusion of a fibroid immediately after delivery. In the latter case the tumour protrudes through the cervix, whilst the whole uterus can be felt above it bimanually, whereas in inversion the uterus turns inside- out, partially or completelj^, a cup-shaped depression is felt above instead of the rounded fundus, and a finger or the sound will only pass a short way by the side of the mass, or not at all if inversion is complete. Both conditions may be accompanied by haemorrhage, but that with inversion may be exceed- ingly severe. Acute inversion is always accompanied by great shock, whilst extrusion of a fibroid is not. Chronic inversion is more likely to be mistaken for prolapse or a polypoid fibromyoma. It is distinguished from prolapse in that the uterus does not necessarily descend as a whole, the cervical ring is felt high up in its usual position, and the sound will only pass a short distance all round the protruding mass, according to the degree to which the uterus is inverted. A cup-shaped depression, instead of the rounded fundus, is felt in the vaginal vault by a hand on the abdominal wall. 4. Cystocele and Rectocele more often accompany prolapse of the uterus, but may occur independently of it. They are essentially bulgings of the anterior or posterior vaginal walls towards or through the vaginal entrance, the bladder or rectum being attached, and following them of necessity. A sound passed into the bladder, or a finger in the rectum, will directly enter the bulging vaginal wall, whilst the uterus will be felt bimanually above in its normal position. 5. Extroversion of the Bladder can occur either through a congenital defect in its wall, or through an injury to its basal portion. For instance, in removing a PRURITUS growth from the vaginal wall, a gap may be left in the bladder through which extroversion may occur. The mucous membrane will be exposed in the vagina, and on it will be seen the two orifices of the ureters, with urine issuing by inter- mittent jets. The uterus in such a case ma}' have its normal position. Thos. G. Stevens. PROPTOSIS. — (See Exophthalmos.) PRURITUS. — Itching may be a substantive affection, associated with no visible lesions of the skin, save those due to scratching, or a subjective symptom of a large number of cutaneous diseases. It is to the former condition that the word " pruritus " should be restricted ; but in this article the subject of itching generally will be dealt with. In both senses of the term, the idiopathic and the symptomatic, hyperaesthesia appears to be the most important pre- disposing cause. The diseases of which itching is a symptom may be either neuroses, such as hysteria, hypochondriasis, and other affections of the nervous centres, or general nutritive disorders affecting the nervous system secondarily, such as arthritism and diabetes mellitus ; or the irritation may be set up by the attacks of parasites, or by definite skin lesions. Itching varies in character : it may be interpreted by the patient as a tingling, or pricking, or as a formication — a feeling as of insects crawling on the skin. It varies also in degree, from a mild sensation which is welcome to the patient from the pleasure he finds in scratching, to an irritation so severe and persistent as to endanger his life from sleeplessness, or his reason from the nervous irritability which it sets up. The affections in which itching is slight are seborrhoea, erythema, pityriasis rubra pilaris, and pemphigus ; it is more severe, in varying degrees, in eczema, prurigo, some cases of psoriasis, dermatitis herpetiformis and dermatitis gestationis, lichen planus, lichenization, and lichen urticatus, in pityriasis rubra, mycosis fungoides, and sometimes in pityriasis rosea, cheiropompholyx and chilblain, prickly heat, tinea marginata, urticaria, scabies, the various kinds of pediculosis, mosquito- and bug-bites, and jellyiish and other stings. Even in the affections in which it is usually severe, it varies much in degree in different cases. Itching seldom has any distinct diagnostic value, but in cases in which the cutaneous lesions may admit of more than one interpretation, its presence or absence may suffice to turn the balance. Pruritus proper is an affection of which the diagnosis is as easy as the etiology is involved. It may be general or local. Of general pruritus there are four varieties — pruritus universalis, pruritus hiemalis, pruritus senilis, and bath pruri- tus. The local varieties affect chiefly the anus, the vulva, and the scrotum, but the nares, the palms of the hands, and the soles of the feet may be the seat of the irritation. One of the most curious forms of pruritus is that which is associated with bathing. According to Stelwagon, who has made it a subject of special study, it most commonly affects the legs from the hips downwards ; but the fore- arms also maj^ be involved, and it may have even wider range. It is an affection of adolescence and adult life, and is more frequent in males than in females. If no lesions of the skin are present save those which can be accounted for, directly or indirectly, by the scratching, the diagnosis of pruritus "imposes itself," Care must, however, be taken to exclude all possible sources of parasitic irritation ; and it must always be remembered that lice and acari sometimes find harbourage in the most unexpected quarters. If the scratches are on the shoulders, or in the genital region, the presence of lice must be suspected ; if on the wrists and between the fingers the burrows of the Acarus scahiei must be sought for. Only when careful investigation fails to reveal any local source of irritation should the case be diagnosed as one of pruritus. Malcolm Morris. PTOSIS 589 PTOSIS is the term applied to drooping of the upper eyelid with inability to raise it to the full extent (Figs. 156 and 157; 158 and 159) ; it must not be Paralysis of the Left Third Nerve. J^',^. 156. — The patient's face at rest ; there is complete ptosis from paralysis of the lett levator palpebrje superioris. Note the scar of the healed gumma on the left cheek near the left an?le of the nose. J-^i£. 157. — The patient is trying to look to his right ; the left eyelid is being held up to show that the left eye is unable to look to the right owing to paralysis of the left in- ternal rectus muscle. Left-sided Nlcle.^r axd Infranuclear 7TH Nerve Paralysis and Complete Ptosis fro.m Paralysis OF the Left 3RD Nerve ; the result of Cerebral Syphilis. J^i]g: 159. — When voluntary effort was made to show the teeth and close the eyes. 590 PTOSIS confused with the inequahty of the palpebral apertures sometimes observed in people accustomed to screw up one eye. It is usually caused by paralysis of the third nerve, in which case it may also be associated with paralysis of other ocular muscles, either external or internal {Fig. 157). Sometimes it is accompanied by paralysis of other motor cranial nerves, the 7th for instance (Figs. 158 and 159), in which case the multiple cranial nerve paralyses immediately suggest a s^rphilitic cause^ which may be verified in many cases by means of Wassermann's serum reaction. In paralysis of the cervical sympathetic, slight ptosis may be associated with diminution in the size of the pupil on the affected side, and retraction of the eyeball or enophthalmos. It may also occur in myasthenia gravis. Ptosis of the lids, associated with much oedema and infiltration of the lids, is also found in all inflarnmatory affections of the conjunctiva, and is a very constant sj^mptom in trachoma. Congenital ptosis is usually bilateral, and associated with smoothness of the npper hds and absence of all the usual cutaneous folds. The levator palpebrae is absent or ill-developed, and efforts to open the eye are made by the occipito- frontahs muscle. Herbert L. Eason. PTYALISM. — Ptyalism is the term generally emploj^ed to denote excessive secretion of saliva. It is not easy, however, to determine in every case whether there is really any excess, or whether the patient is not merely allowing the normal sahva to dribble from the corners of the mouth. It is difficult to draw an absolute distinction, therefore, between dribbling of saliva and ptyalism, though in practice the nature of the case may be obvious enough. One has but to consider the various conditions under which trouble with the rsaliva may arise, to see how in some cases the difficulty is solely one of swallowing the normal secretion, as in bulbar paralysis and in babies ; how in others there is both excess of secretion and difficulty in swallowing it, as in mercurial :Stomatitis ; and how in others, again, there is too much secretion but no difficulty in swallowing it, as in functional or hysterical cases of ptyaiorrhoea. When a case is being investigated, the first step in arriving at the diagnosis ■of the cause is to inquire carefully as to the nature of any medicine or drug that the patient may be taking orally or appljdng externally, especially : — Mercury Pilocarpine Jaborandi Iodide Bromide Phosphorus Arsenic Antimony Aconite Chlorate of potash Cantharides Copper salts. Mercury is the most important of these ; its effects are most serious when the mouth is not kept scrupulously clean, particularly when there is also nephritis, as is not uncommon in severe secondary syphilis. If the salivation is not due to any drug, it may be the result of one of the many iorms of general stomatitis : — Aphthous 1 Tuberculous Dyspeptic Due to sprue Septic Suppurative Ulcerous Mahgnant Vciriolous Diphtheritic Syphihtic scurvy pyorrhoea alveolaris necrosis of the jaw angina Ludovici cancrum oris pernicious anaemia haemophilia. PTYALISM 591 The exact nature of a severe stomatitis in any given case will be diagnosed by making a careful local examination, ocular and digital, assisted by the history and, if need be, bv bacteriological examination of swabbings from the mouth, by Wassermann's serum reaction for syphihs, or by microscopical examination of a fragment of the affected tissues. Tuberculous stomatitis is one of the rarest forms, but when it occurs it is very severe ; it may be primary, but more often it is associated with obvious and rapidly progressive phthisis. If drugs and general stomatitis can be excluded, local examination may still serve to detect a local cause acting by reflex irritation of the fifth nerve, especially : — A jagged carious tooth A rough filling A stump left beneath a tooth-plate A broken or ill-fitting tooth-plate A foreign body, such as a fishbone, impacted in the gum Neuralgia of the fifth nerve A ranula A gumboil A myeloid sarcoma of the jaw An epulis A salivary calculus An eschar left by some recent irritant or corrosive substance, or injury. If careful examination serves to exclude all these, the salivation, apparent rather than real, may be found to result from mechanical difficulties in swallowing, the effect of such lesions as : — Mumps Acute tonsillitis Quinsy Fracture of the jaw Dislocation of the jaw Fixation of the jaw, as by osteo- arthritis of the temporo-maxillary joint Painful affections of the larynx, phar- ynx or oesophagus. In the absence of any obvious structural lesion locally, it may yet be clear that inability to swallow, owing to paralysis of some kind, is the cause of the apparent salivation, for instance in cases of : — Bulbar paralysis Pseudo-bulbar paralysis Bilateral facial paralysis Myasthenia gravis. Hypoglossal nerve paralysis Diphtheritic paralysis Paralysis agitans Hydrophobia. The differential diagnosis of these conditions is discussed elsewhere, and of them all it is only in bulbar and pseudo-bulbar paralysis that the dribbling of much saliva is a prominent symptom. The sequence of events that is sum- marized by the term labio-glosso-pharyngo-laryngeal paralysis is sufficiently characteristic as a rule ; pseudo-bulbar paralysis, being of cortical instead of medullary origin, has not the wasting of the tongue that is prominent in the latter. The salivation that results from gastric or hepatic reflexes is almost piiysio- logical, though sometimes it reaches a pathological degree in certain cases of : — - Dilatation of the stomach I Gastric carcinoma Gastric ulceration Duodenal ulcer Acute dyspepsia Acute gastritis Biliousness Hepatic disorder Pancreatitis. Mere slovenliness and lack of proper cerebral control are responsible for the slobbering and salivation of : — Idiots I Dements Imbeciles and other mental cases. 592 PTYALISM Finally, there is sometimes a very remarkable degree of salivation that can be attributed to nothing but functional disorder — ptyalorrhcea. It can scarcely be called hysterical, because it may occur in men as well as in women, generally in later life rather than at a time when hysteria is commonest. The condition is a sort of salivary neurosis, which may come on suddenly and without obvious cause, or as the result of some worry, shock, or mental emotion. It may possibly be a functional affection of the 5th nerve analogous to the far more distressing tic douloureux. It is sometimes a very prominent symptom amongst the neuroses that are apt to accompany pregnancy. It can only be diagnosed when a careful examination has served to exclude any likelihood of organic disease, when the history is suggestive, and when the excessive salivation ceases after a time almost as suddenly as it began. In many such cases, notwith- standing the diagnosis being " functional," it will be found that there is a high systolic blood-pressure, with other signs of arteriosclerosis, suggesting that there are errors in the circulation which may involve the vasomotor and other brain centres, and thus produce the symptom. Herbert French. PULSATING TUMOURS.— (See Swelling, Pulsatile.) PULSATION, UNDUE ABDOMINAL AORTIC— Excessive pulsation of the abdominal aorta may occur in cases of aortic regurgitation, when all the arteries throughout the body may pulsate with undue violence. Apart from aortic regurgitation, however, it is nearly always an entirely functional disorder of the aorta. It occurs much more frequently in women than in men, the patients generally being unmarried or childless, between 20 and 40 years of age. They complain of pain in the abdomen, especially in the epigastrium ; a feeling of discomfort and distress ; a sensation of pulsation and throbbing over the abdo- minal aorta ; nausea, retching, sickness, and constipation ; they are usually thin, anaemic, extremely nervous, often hysterical, and sometimes decidedly hypochon- driacal. There may be nothing else the matter with them at all, or they may be suffering from some other complaint of which much nervousness is a feature, exophthalmic goitre for example. The condition is not infrequently associated with movable kidney and enteroptosis ; in many patients the symptoms may suggest some organic disease, such as gastric ulcer, appendicitis, or ovaritis, without any of these being present. On palpation of the abdomen the pulsation may be found to be forcible ; but the normal cylindrical outline of the aorta can generally be felt to be quite free from any saccular bulging or fusiform dilatation ; there is no thrill over it ; on applying a stethoscope lightly to the pulsating region, no murmur will be audible ; but firm pressure of the stethoscope, sufficient to compress the aorta slightly, will bring out a systolic bruit. The heart, lungs, and urine are usually normal. The knee-jerks are apt to be much exaggerated, though the plantar reflexes remain flexor, and there is no ankle-clonus. The chief importance of the condition clinically is that it is apt to be mistaken for an aneurysm of the abdominal aorta. Abdominal aneurysm is so extremely rare in women, however, that it should never be diagnosed unless the pulsation can be made out to be definitely expansile, or unless, in addition to pulsation, a definite tumour can be felt attached to the aorta. Herbert French. PULSE, UNDULY RAPID.— (See Tachycardia.) PULSE, UNDULY SLOW.— (See Bradycardia.) PULSES, UNEQUAL. — Inequahty of theTpulses may be a perfectly natural phenomenon ; one frequently finds that the radial arteries of the two sides are not of the same calibre, owing to variable degrees of collateral circulation by PUPIL. ABNORMALITIES OF THE 593 an enlarged comes nervi median! . Inequality of the pulses is a much more important sign when known to have developed in a patient whose pulses were formerly normal. In such a case the cause is probably one of the following : — Thoracic aneurysm Mediastinal new growth Accessory cervical rib Embolism Atheroma. Of these, by far the most common in the present connection is thoracic aneurysm, and even this is distinctly rare, for it is only in a small minority of aneurysm cases that the pulses are unequal. It is true that when very careful simultaneous records are made from the two radial pulses, slight differences in size and definite differences in time can be detected, the one being delayed behind the other ; but in clinical medicine such minute methods of investigation are seldom applicable, and it is only in a very small proportion even of these cases that the diagnosis cannot be arrived at in other ways. Definite inequality of the pulses, or definite delay of one behind the other, as gauged by simultaneous palpation of the two radial pulses, is distinctly uncommon, but when it does occur it is highly suggestive of thoracic aneurysm : if the latter involves the origin of the innominate artery, the right pulse will be smaller than the left ; whereas if the aneurysm affects that part of the arch from which the left subclavian artery is derived, the left radial pulse will be smaller than and delayed behind the right. Similar delay or inequality might be produced by new growth compressing either the innominate artery on the right side or the subclavian artery on either side ; but this is rare. An accessory cervical rib might stenose the subclavian artery, but the condition is generally bilateral, so that it rarely produces inequality of the radial pulses ; its symptoms are more likely to be those of interference with the lower part of the brachial plexus, with consequent pain, paraesthesia or paresis corresponding with the nerves distributed upon the ulnar aspect of the arms and hands. Embolism of one or other radial artery will rather obliterate it altogether than cause it to be less in size than that of the other side. It will almost always be due to fungating endocarditis, of which there will be other evidence in the form of cardiac bruits, pyrexia, progressive anaemia, enlargement of the spleen, haemorrhages, and evidence of multiple emboli. Atheroma of the brachial or subclavian artery on one side might cause the corresponding radial pulse to be less than that on the other ; but this very rarely happens, and in such a case it would be more probable that atheroma of the aorta with an aneurysmal dilatation would be diagnosed than atheroma restricted to the vessels in the upper arm, unless the ;\?-rays exhibited no trace of aneurysmal opacity in the thorax. Herbert French. PUPIL, ABNORMALITIES OF THE. — Abnormalities of the pupil may be classified into : — I. Irregularities in shape ; II. Irregularities in size. I. Irregularities in Shape. — The normal pupil is circular or slightly oval. Its outline may become irregular owing to an adhesion between the iris and the lens, the result of old iritis. These adhesions are most evident when the pupil is dilated. A similar irregularity sometimes occurs with the persistence of a pupillary membrane — a congenital affection. The adhesions due to this cause may be distinguished from inflammatory adhesions by the fact that they arise from the anterior surface of the iris at a slight distance from the pupil, and not from the posterior surface and the extrpme edge. The pupil may also become irregular in shape as the result of injuries, such as rupture of the sphincter, and tearing of the root of the iris from its ciliary D 38 594 PUPIL, ABNORMALITIES OF THE adhesion (iridodialysis) ; of dislocation of the lens ; or of partial adherence to an old perforated corneal ulcer. II. Irregularities in Movement and Size. — Before considering the irregularities in the movements and size of the pupil, it is desirable to remember that its normal size varies during life. In extreme infancy it is small. It becomes larger during j^oung adult and middle life, and ultimately becomes small again in old age. It is also, as a general rule, small in hypermetropic, and large in myopic eyes. There are also four normal pupillary reflexes ; (i) The light reflex ; (ii) The reflex to accommodation ; (iii) The reflex to sensory stimulation ; (iv) Psychic reflexes. The reflexes to light and to accommodation are both constrictive, the constriction in accommodation being more in the nature of an associated muscular action. The sensory and psychic reflexes are both dilatations, the dilatation being caused by either sudden sensory stimuli or some sudden emotion, such as fright or terror. The pathological variations in the pupil are best classified after Uhthoff as follows : — 1. Loss of the Pupillary Light Reflex, either with or without constriction of the pupil, constitutes the Argyll Robertson pupil. The pupil is constricted in nearly all tabetic cases, and the affection is most commonly bilateral. It never occurs in healthy individuals, but has been observed most frequently in loco- motor ataxia, to an extent varying according to different observers from 70 to 90 per cent of all the cases. The condition is usually permanent. It also occurs in general paralysis of the insane. 2. Loss of Convergent Accommodation Reflex and Retention of the Light Reflex. — This condition is extremely rare, but has been observed in syphilis, basal menin- gitis, myelitis, and tumour of the corpora quadrigemina. 3. Loss of the Convergence pupillary reflex may be unilateral or bilaterpj. It occurs, rarely, in locomotor ataxia, and after some cases of diphtheria and alcoholic intoxication. 4. Loss of all Reflex Movements of the Pupil. — In this condition there is paralysis of Ihe sphincter of the pupil and of the ciliary muscle, the extrinsic muscles of the eye being unaffected. The site of the lesion must, doubtless, be nuclear, and it is most frequently unilateral, though occasionally bilateral. Syphilis is the most frequent cause. It may also occur after diphtheria, and injury, or in some intracranial diseases. 5. In the condition in which there is a lesion of the optic tract on one side, between the chiasma and the globe, there will be, as a result, a loss of direct light reflex in that eye, and of the consensual light reflex in the opposite eye (see Hemianopsia). ' 6. Loss of Sensory or Psychic Reflex occurs in lesions of the dilatator pupillary tract, such as paralysis of the cervical sympathetic ; in which condition it is associated with slight ptosis of the upper lid, enophthalmos, and diminished tension of the globe. 7. Abnormal Constriction of a Pupil, with Retention of the Light and Convergent Reflexes, may occur from abnormal stimuli of the sphincter, or paralysis of the dilatator pupillce as the result of acute encephalitis, intracranial abscess or growth, in which the lesion irritates but does not destroy the centre for conver- gence. In all cases of brain disease the constriction is ultimately replaced by dilatation. 8. Abnormal Dilatation of the Pvipil, with Retention of the Light and Convergent Reflexes, is met with in cases of stimulation of the cervical sympathetic. It may also be observed in certain mental states, such as epilepsy, acute mania, or catalepsy. PURPURA 595 9. Inequality in the size of the Pupils is observed frequently, and may have no pathological significance ; but pronounced difference in the size of the pupils is nearlv always symptomatic of some organic lesion. In cases where the abnormal pupil is the smaller, the condition is usually due to hyperaemia of the iris, such as occurs in iritis ; paralysis of the cervical sympathetic ; or the use of a m^^otic drug such as physostigmine. In cases where the abnormal pupil is the larger, the dilatation is usually due to stimulation of the sympathetic, the use of a mydriatic, paralysis of the fibres of the third nerve, or increased ocular tension, such as may occur in glaucoma. In cases of inequality of the pupils one may suspect tabes, general paralysis of the insane, a unilateral lesion of the third nerve or cervical sympathetic, trigeminal neuralgia, carotid or aortic aneurysm, a unilateral intracranial lesion, or glaucoma. 10. Irregularities in the shape of the pupils other than those mentioned above may occur in tabes and various cases of insanity. There is no marked or sharp irregularity, it only being noticed that the pupil is not circular owing to paralysis of certain fibres of the iris. 11. Hippus. — This term is applied to a condition in which, when both eyes are shaded, and then illuminated, the pupils will alternately dilate and contract. It is sometimes associated with nystagmus, and occurs also in disseminated sclerosis, and in some cases of brain tumour. It is observed most frequently when there is a central scotoma in the field of vision, with some injury to the macular or axial fibres of the optic nerve. It is also common in alcoholic subjects. 12. Paradoxical Pupillary Reflex : pupils dilating under the stimulus of light. This condition is extremely rare, and has only been observed in patients affected with grave lesions of the central nervous system, usually locomotor ataxy. 13. Heniianopic Pupillary Reflex : lesions of the brain situated in the optic tract above the corpora quadrigemina may give rise to partial loss of vision, but will not affect the pupil-reflex arc. For example, a lesion in the right occipital cortex may give rise to a left homonymous hemianopsia, but the pupil will react even when a Hght is thrown on the blind side of the retina (see Hemianopsia). In cases, however, where the lesion is situated in the optic tract below the corpora quadrigemina, hemianopsia may also occur, but under these circumstances no pupillary reflex for hght can be obtained on stimulus of the blind side of the retina, the pupil reacting to light when the opposite side of the retina is stimulated. This reaction is termed the hemiopic pupillary reflex, and is of great value in the localization of intracranial lesions. Herbert L. Eason. PURPURA signifies haemorrhage into the skin, and, according to the size of the extravasation of blood, the lesions are spoken of as puncta or spots, vibices or lines, petechiae or small patches, ecchymoses or bruises. The lesions cannot be obliterated by pressure with the finger, which distinguishes the effused blood from mere congestion. The diagnosis of the actual fact of purpura is seldom difficult ; the persistence of the discoloration under pressure difierentiates it from erythematous lesions, and the colour generally serves to distinguish it from pigmentation of the skin other than that due to haemorrhage. In a case of doubt, the course which the lesions follow will serve to distinguish purpura, which changes and disappears, from capillary naevi or from pigmentation of the skin, which persist. It may be more difficult, however, to decide what is the nature of the purpura in any given case ; the following is a list of its better recognized causes : — 596 PURPURA CAUSES OF PURPURA. I. — -Due to Local Injuries : Flea-bites Pediculosis Leech-bite Blows 2. — The Effect of Drugs and Poisons Antipyrin Iodoform Iodide of Potassium Sulphonal Copaiba Belladonna Chloral Chloral hydrate Butyl-chloral hydrate Veronal 3. — In Fevers : Typhus fever Cerebrospinal fever Small-pox Pyaemia Septicaemia Malignant endocarditis General tuberculosis Dysentery Cholera Yellow fever 4. — In association with Jaundice from whatever cause (see Jaundice). 5. — ^Bright's Disease. Sprains Rupture of a muscle Rupture of a vein, especially a vari- cose vein. Mercury Arsenic Quinine Ergot Salicylic acid Potassium chlorate Diphtheritic antitoxin Ptomaine Snake-bite poison. Weil's disease, or bilious typhoid Plague Remittent fever Severe malarial fever Blackwater fever Measles Diphtheria Typhoid fever Scarlet fever. Peripheral neuritis. Pseudo-leukaemia infantum Scurvy Barlow's disease Haemophilia Chloroma. 6. — Chronic Alcoholism : Cirrhosis of the liver 7. — The so-called Blood Diseases': Splenomedullary leukaemia Lymphatic leukaemia i Hodgkin's disease]] Lymphadenoma Sarcomatosis Splenic anaemia 8. — Peliosis Rheumatica. 9. — Henoch's Purpura. 10. — Purpura Simplex . Morbus maculosus of Werlhof Purpura haemorrhagica Purpura fulminans. A number of the above conditions require but little discussion, for if they are but borne in mind, their diagnosis as the cause of purpura in any particular case will generally be easy. Flea-bites are by far the commonest cause of purpura in the out-patient department of a hospital, and they may sometimes be so very numerous as to raise a misleading suspicion that the patient is suffering from some serious disease. PURPURA 597 The relati\-ely small haeniorrhagic foci, and their pre\-alence on the parts covered by the clothes rather than upon the hands, face, or exposed parts of the legs, serve to indicate the diagnosis, even in a severe case. The commonest variety' of pediculosis to produce purpura is P. corporis or vestimentorum ; the circumstances of the case and the distribution of the purpura itself and of the marks of scratching, particularly in the regions where collars and other constrictions in the dress occur, -would indicate the diagnosis. The haemorrhage around a leech-bite is so characteristic that, once seen, it cannot be mistaken for anything else. Blows and sprains, if sufficiently severe, produce purpura even in the healthy, in whom the history gives the diagnosis ; it is important to bear in mind, how- ever, that there are some normal individuals who bruise with such ease that there may be no clear evidence of injury unless careful inquir}^ is made, when some trivial stumble or knock may be recalled to mind by the patient. Such easy bruising may of course occur in any of the blood diseases, but it is not uncommon in certain otherwise health}- women. A case of epilepsy may some- times come under observation for multiple bruises simulating some other kind of purpura, but due to injuries produced during the attacks, which may them- selves be unsuspected if they occur during the night. Spontaneous rupture of a muscle leads to very extensive purpuric extravasation of blood, but the diagnosis is not difficult if the history is clear, and one can often feel the place where the muscle has given way unless it is too deep-seated to palpate, as in the case of the plantaris longus, which is apt to rupture during sudden efforts, such as may be made in playing tennis or the organ. The purpuric discoloration of the skin around varicose veins in the legs, together with its resultant dark-brown pigmentation, is familiar to all. As regards drugs, the list above indicates that there are many which may sometimes produce purpura ; it may be said at once, however, that none do so at all commonly. Nevertheless the possibihty should be borne in mind, and enquiry made as to the remedies the patient may have been taking. Anti- diphtheritic serum and ptomaines merit particular attention. The commonest eruption resulting from anti-diphtheritic serum, or from other forms of antitoxic horse-serum administered h^^-podermically, is urticaria ; purpura is relatively rare ; either form occurs as a rule about nine or ten days after the serum has been given, and is generalh' associated with lassitude, muscular and joint pains, anorexia, and more or less p^rrexia, lasting from a few hours to two or three days. Ptomaine poisoning is often very difficult to recognize with certainty unless it occurs in epidemic form. It is due, however, in most cases to the products of the action of Gaertner's bacillus, and seeing that the blood-serum of patients affected by this bacterium develops agglutinating powers against it similar to Widal's reaction for typhoid fever, this serum test should not be omitted ; if it proves positive the diagnosis is clear ; a negative result, however, does not exclude ptomaine poisoning. In the great majority of acute fevers, the occurrence of purpura is of prognostic rather than of diagnostic value ; in diphtheria, for example, even a single well- defined purpuric spot is a sign of grave omen, but it does not assist at all in the diagnosis of the disease, which has to be recognized upon other grounds. The same applies to measles, scarlet fever, and so on ; indeed, the only two fevers in the above list in which purpura is of essentially diagnostic value are typhus and cerebrospinal fever. The former of these is now very rare in Great Britain, but Avhen it was common and t^'phoid fever began to be differentiated from it, the point upon which greatest stress was laid was that in true tj-phus or gaol fever there is always more or less purpura, whereas in typhoid fever all the red spots fade upon pressure. It happens occasionally, even yet, that typhus fever PURPURA develops in the poorest parts of cities, and this point is most useful in distin- guishing it from typhoid. In the latter, if flea-bites are excluded, purpuric spots are exceedingly rare. Cerebrospinal fever presents many characters that are common to it and to other forms of acute meningitis ; but if with these there is a purpuric eruption, it is at once differentiated from the others, though the absence of purpura does not exclude the disease. So characteristic is the purpura in some cases that the malady has earned the title of spotted fever, which used to occur in widespread epidemics, and still does in smaller ones from time to time. The diagnosis may be clinched by bacteriological examination of the cerebrospinal fluid obtained by lumbar puncture. Small-pox may present cutaneous hemorrhages of three different kinds ; there may be hsemorrhage into the pustules in a late stage, when the diagnosis has already been made and when the prognosis is not thereby made worse ; there may be heemorrhage between the pustules, vesicles, or papules, the diagnosis having already been made, in which case the prognosis is not good ; and there may be a hsemorrhagic eruption either all over the body or in the so-called bathing- drawers region in the prodromal stage of the disease, in which case the patient will almost certainly die before the true small-pox eruption develops, so that if there is not an epidemic at the time, the diagnosis may be exceedingly difficult. Almost any condition in which there are pyogenic micro-organisms circulating in the blood-stream may be associated with extensive purpura, and this applies to pycBmia and septiccBmia in general. The diagnosis will be confirmed best by obtaining cultivations from the blood, though there will very likely have been rigors, pyrexia, and other symptoms pointing to the nature of the case. Malignant endocarditis is only a variety of pyaemia or septicaemia. Seeing that it is very rare to get purpura in association with chronic valvular disease of the heart if both purpura rheumatica and infective endocarditis can be excluded, the occurrence of purpura in a heart case may be one of the main symptoms indicating that fungating endocarditis has supervened. So indefinite is the nomenclature in regard to this disease, that the terms malignant, ulcerative, fungating, infected, and infective endocarditis are used indiscriminately by different observers to denote the same condition. The disease may be further indicated by sudden changes in the bruits, by evidence of embolism, by pro- gressive anaemia, by enlargement of the spleen, by irregular pyrexia, by retinal haemorrhages, or by optic neuritis. General tuberculosis is not a common cause of purpura, and yet in a few instances extensive purpura has been the first, and for the time being the only, symptom of an obscure illness which has ultimately turned out to be general tuberculosis. The patient has generally been a child, and the diagnosis has only been possible when the course of the case has been watched. The same may be said of sarcomatosis in certain cases, though this has been included under a different heading in the above list. Jaundice is well worthy of being borne in mind as a cause of purpura, for although the occurrence of the latter symptom does not assist in differentiating one kind of jaundice from another, one might be misled into diagnosing some- thing more serious than is necessary if one did not bear in mind that any kind of jaundice may produce purpura. Moreover, some of these patients may seem to have been grossly illtreated if one were to judge only by the degree of bruising that may result from ordinary palpation ; the danger of fatal oozing after operation is always to be remembered when surgical measures are thought of in a jaundiced subject. Spontaneous haemorrhage into the skin is less common here than is haemorrhage from what otherwise would be trivial causes. Bright' s disease, particularly the chronic varieties of the complaint, is capable of producing haemorrhage anywhere in the body. Purpura is not a very common PURPURA 599 form of such haemorrhage, but when it does occur it may be extensive. The diagnosis is discussed under Albuminuria {q.v.). Chronic alcoholism, especially if it has already led to either cirrhosis of the liver or to peripheral neuritis, is occasionally a cause of considerable purpura, though the latter is generally confined to the legs, particularly to the parts below the knees. In many instances the diagnosis is easy, even if the history is not given with perfect honesty ; but considerable difficulty sometimes arises in the case of ladies who have contracted the habit of secret drinking, their relatives and friends being entirely unaware of it. Any of the so-called blood diseases may present purpura as a prominent symptom, and in some cases, particularly in lymphatic leukcsmia in children, extensive purpura may be the first symptom that anything is wrong. More often, however, the disease has already given rise to anaemia or to enlargement of the spleen or lymphatic glands, or to some other prominent haemorrhage, and the diagnosis has already been made by the time the purpura supervenes. (See An.emia ; Spleen, Enlargement of the ; and Lymphatic Gland Enlargement.) Broadly speaking, the method of diagnosis should be to have the blood examined in the first instance ; if there is a very great increase in the number of leucocytes per cubic millimetre, the diagnosis is some form of leukaemia ; if there is no such leucocytosis, and if there is enlargement of the lymphatic glands, the diagnosis is lymphadenoma or Hodgkin's disease ; if the spleen is much enlarged but the lymphatic glands are normal, splenic anaemia suggests itself in an adult, or pseudo-leukjemia infantum in a child. Scurvy in an adult is relatively rare, but is sometimes met with in those who have been obliged to live upon a diet containing no fresh vegetables for reasons of poverty ; for instance, a man may try to live for a month or more on plain bread, in which case typical scurvy may develop in him, with the spongy heaping up of the gums both inside and outside the teeth, and with the knotty haemo- rrhagic swellings in the muscles of the calves, as well as purpura. Children who are fed upon patent foods without a sufficiency of fresh cow's milk, or vegetable food, or fresh meat, not infrequently develop a milder form of scurvy, with marked tenderness of the periosteunr of the long bones, pasty pallor, mouth bleeding from spongy gums, and possibly purpura ; this is infantile scurvy or Barlow's disease, which should not be confused, as it is apt to be, with rickets. HcBmophilia is generally indicated at once by the history of persistent oozing from slight cuts and scratches, and also by the fact that other members of the family, especially males, have suffered in a similar way. Chloroma is a very rare disease, in some ways related to sarcomatosis, and in others to lymphatic leukaemia ; it produces swellings in connection with the bones, especially of the head, together with enlargement of the lymphatic, lachrymal and salivary glands ; it develops in early life, proves slowly fatal, and the diagnosis is confirmed by the green colour of the new-formed tissue — " green cancer." The blood changes are negative. Peliosis rheumatica, or purpura rheumatica, or Schonlein' s disease, was formerly regarded as being related to acute rheumatism ; but it is exceedingly rare for a patient affected by it to present unmistakable signs of valvular heart disease, although there may be a local systolic bruit at the impulse. The reason why it is thought to be related to acute rheumatism is, that in addition to the extensive purpura, which comes out in successive crops and may affect any part of the body, though it is commoner upon the lower limbs than elsewhere, there is considerable pain, redness, and swelling of many joints, which may become affected successively ; the temperature rises during an attack to 103° F. or 104° F., the throat generally being sore at the same time. It is not impossible that the purpura is due to the absorption of microbes or their toxins from the 6oo PURPURA acute tonsillitis ; but be this as it may, the diagnosis is not difficult when the purpura, the joint pains, and the pyrexia are present together. The disease is little influenced by sodium salicylate ; it may be associated with more or less erythema as well as purpura ; the malady affects young persons, especially between the ages of ten and thirty ; it is not confined to either sex, but is commoner in males than females. Henoch's purpura is chiefly met with in children (Fig. iii, p. 382), and the same patient may suffer from recurrent attacks, which usually cease at or before puberty. In addition to the haemorrhages beneath the skin, there is generally some tendency to joint pains not unlike those of peliosis rheumatica, but in addition to this the child is seized with more or less severe acute abdominal symptoms, varying from simple vomiting and stomach-ache to severe prostration with agonizing cramp-like attacks of colic, some of which may be followed by the passage of blood and mucus per rectum to such an extent as to simulate acute intussusception ; the abdominal attacks are probably the result of sub- mucous intestinal haemorrhages. There is every degree of the affection, from mUd to very severe, but the association of the purpura with the abdominal attacks in childhood suggests the diagnosis at once, especially if there has been a similar attack previously. The chief error to avoid is mistaking for Henoch's purpura that which is really an acute nephritis ; the urine should be examined periodically for albumin and renal tube-casts, even if there is no oedema, though the occurrence of blood alone would not be sufficient to indicate acute nephritis, seeing that haemorrhage from the kidney may be due to Henoch's purpura itself. It is only when every precaution has been taken to exclude all the above causes of purpura that one can be satisfied with any of the remaining four diagnoses, namely purpura simplex, purpura hcBmorrhagica {morbus maculosus of Werlhof), or purpura fulminans. These differ from each other only in degree ; broadly speaking, purpura simplex signifies haemorrhage into the skin only; purpura haemorrhagica has, in addition, haemorrhages from the mucous mem- branes, particularly of the mouth, nose, and bowel, less commonly of the urinary passages ; whilst purpura fulminans is the term used to denote a condition in which a person may seem perfectly healthy to-day, may be seized with acute purpura and be dead before to-morrow, without developing any other sym- ptoms to indicate the nature of the complaint. These kinds of purpura have sometimes been spoken of as idiopathic, but they must have some under- lying cause, it only it can be found. It is better probably to label them cases of purpura of which the exact cause is not yet known, than to be content with such a term as purpura simplex, and it is probable that if bacteriological examinations were made, a bacterial cause would be discovered, particularly in connection with the tonsils, the gums in states of septic gingivitis or pyorrhoea alveolaris, the uterus, the bowel, or the circulating blood itself. Herbert French. PUS IN THE CHEST.— (See Chest, Pus in.) PUS IN THE STOOLS in sufficient amount to be recognizable by the naked eye, indicates the rupture of an abscess into the intestinal tract. The symptom is a rare one, however, for even when a large appendicular abscess perforates into the caecum, the pus either becomes indistinguishable when mixed with the faeces, or unrecognizable on account of digestion and decomposition. The less the pus is mixed with other intestinal contents, the nearer to the anus has the site of rupture been ; but the diagnosis of the source of the abscess needs to be 'determined upon other grounds, particularly the history, and upon the results of general physical examination, including that of the rectum and vagina. Abscesses which are most apt to cause a discharge of pus with the stools are of PUSTULES 601 the appendicular, cholecystic, perinephric, psoas, pelvic, perigastric, or other local peritoneal types, and pyosalpinx. Microscopical quantities of pus in the stools may be due to any of the causes ahready mentioned ; but they may also be derived, not from lesions outside the intestines, but from affections of the mucous membrane itself : acute or chronic coHtis, with or without ulceration ; dysentery; cholera; dengue; mucous or muco- membranous coUtis ; tuberculous, typhoidal, malignant, or venereal ulceration of the bowel. The pus corpuscles may be recognizable as such under the microscope ; but it is difficult to determine when the leucocytes derived from the intestinal catarrh are merely leucocytes in excess, and Avhen their numbers become sufficient to merit the term actual pus. Examination with the sigmoidoscope is sometimes in\-aluable when the diagnosis has not been indicated clearly by other methods. Herbert French. PUSTULES. — The pustule, one of the primary' cutaneous lesions, is an epider- mic elevation, either unilocular or multilocular, containing a purulent hquid, and differing from a vesicle or a bulla only in the character of its contents. Alwa^-s a product of inflammation, it may originate as a pustule or may develop from a papule, but much more often it is a transformed vesicle ; if the metamor- phosis is imperfect, the lesion is styled a papulo-pustule or a vesico-pustule. Frequently the transformation from a papule or a vesicle is so swift, that the true origin of the lesion may escape notice ; but in such cases it is usual to find papules or vesicles intermingled with the pustules. The pustular cavity maj^ be situated in the epidermis, in the derma, or in a follicle ; a purulent accumu- lation beneath the derma is either an abscess or a gumma. Epidermic pustules may be superficial, as in impetigo, or deep, as in the condition known as ectMnna, which I regard as but a severe form of impetigo. Dermic pustules, e.g., in miharv abscess of new-born children, are seldom met with, while follicular pustules, such as those of sjxosis, are of frequent occurrence, the pyogenic cocci eftecting entrance into the folhcle when this is not the original site of the suppuration. In colour, pustules are usually 3'ellowish or greyish, with a red areola ; but when the contents are mixed with blood, the yellow may be tinged with red or brown. If a pustule is punctured or ruptured, the hquid is seen to be more or less turbid and yellowish ; under the microscope it is found to consist largely of leucoc^-tes and serum as well as cocci. Pustules vary greatly in size : they ma 3" be as small as a pin-point, as in some of the pustules of eczema, or as large as a split pea, as in severe impetigo. The small ones may remain of incon- siderable dimensions, or maj' become large by excentric extension. The prevalent shape is roundish or convex, as in furuncle and acne ; but it may be acu- minate, as is frequent in sycosis and eczema, or flat and irregular, as in impetigo and s\-philis, while in rare instances, as sometimes in scabies, it maj^ be oblong, with a tendency- to the hnear form. In variola and the varioHform syphihde, the pustules may be flattened or concave, either because the fluid ma}- not fully distend the cleft in which it Hes, or from flaccidity of the sac, due to commencing absorption. Pustules mav develop slowly, as sometimes occurs in impetigo and in the pustular syphiloderm ; but as a rule they run a rapid course, and terminate either hy rupture — much more often accidental than spontaneous — or b}- desicca- tion. In either case, a yeUow, brown, or blackish crust, more or less thick and irregular, is formed ; but if the termination is by desiccation, the crust has a less pronounced coloration, and is friable instead of firm. A cutaneous affection in which the pustule plays a leading part is impetigo, in both its principal forms — the impetigo contagiosa of Tilbury Fox, otherwise impetigo vulgaris, and the folhcular impetigo of Bockhart, the one due primarily to the streptococcus and secondarily to the staphylococcus, the other solely to the 6o2 PUSTULES staphylococcus. In impetigo vulgaris, usually following slight febrile disturbance, small erj'-thematous spots appear, on which form vesicles containing a turbid fluid that quickly becomes purulent. When the pustules break, as they soon do, they discharge a fluid that quickly dries up into scabs that are at first yellowish, and afterwards green. Dotted about among the scabs are pustules, which may coalesce so as to form, on rupture, crusts of considerable size. The eruption may be limited to a few discrete lesions, or may extend over large areas of the bodj^. In parts where the pustules are exposed to friction, as on the limbs, they are generally ruptured at an early stage, and a flat irregular scab, surrounded by an areola, forms over them — the condition known as ecthyma. Sometimes the distribution is annular {impetigo circinata or gyrata). In the condition known as impetigo bullosa the lesions are much larger, and are not always transformed into true pustules. With impetiginous eruptions, though not with these alone, cutaneous diphtheria is sometimes associated, especially in children. The most typical form of this affection has the appearance of an impetiginous eczema, associated with conjunctivitis, and occasionally with otorrhoea and rhinitis. No diphtheritic membrane may be present, and if cutaneous diphtheria is suspected, the Klebs-Loffler bacillus should be sought for bacteriologically. The differences between impetigo vulgaris and follicular impetigo are well marked. The latter is pustular from the beginning, and always situated around a hair-follicle. It starts as a round pustule, often pierced by a long or coarse hair, and it may be quite small, or as large as a pea ; the pus collects under the horny layer, which it distends and raises. The eruption, usually multiple, has no sites of election, but appears wherever a breach in the horny layer affords entrance to the pyogenic organism. The pustules are more resistant than those of impetigo contagiosa, and are less quick to break. When they rupture, yellow crusts, smaller and thinner than those of impetigo vulgaris, are formed. The pustules of follicular impetigo can hardly be mistaken for those of any other affection. The other form of impetigo, however, has in rare cases to be diagnosed from pemphigus. In the latter the lesions start, not as small vesicles but as bullae, and the fluid they contain is only sometinaes inoculable. Usually, too, there is marked systemic disturbance. But it is with pustular eczema that impetigo vulgaris is most likely to be confused, especially when the pustules of the latter condition have run together into a patch. In eczema, however, the pustules are smaller, there are severe itching and burning, there is an inflammatory areola around the crusts, which is seldom the case in impetigo vulgaris, and other definitely eczematous lesions will usually be found if care- fully sought for, including infiltration and thickening of the integument. Like follicular impetigo, sycosis vulgaris is a staphylococcic infection. The lesions begin as papules, or as nodules which form round the hairs — usually of the face, and especially of the chin, but sometimes attacking also the eyebrows, eyelashes, and the axillary and pi:bic regions — and presently develop into pustules, each of them pierced by a hair. As the result of suppuration, the hairs are loosened, and if one is pulled out, a drop or two of pus usually exudes. In severe cases, the pustules may be so closely packed together as to form infiltrations, which may assume a f ungating character. The chief diagnostic features of the affection are its inflammatorj^ character, its origin in the hair-folhcles, and its limitation to the hairy parts, usually as I have said, of the face. The differential diagnosis from tinea sycosis has been given under Fungous Affkctions of the Skin. Eczema is not limited to the hairy parts, and if the follicles are involved it is only secondarily, nor, as a rule, is the inflammation so severe as in sycosis vulgaris. Of sycosis vulgaris again, intense itching is not a feature. Sometimes, when the sycosis is widely diffused, the crusts may have to be removed to clear PUSTULES 603 up the diagnosis ; when this is done, the folhcular imphcation will soon be per- ceived. Tertiary syphilitic ulceration is not restricted to the follicles, and behind it there lies a history of earlier specific lesions, as well as of the primary infection, unless this should have escaped notice. If there is ever any doubt as between sycosis vulgaris and acne vulgaris, the presence of the latter on non-hairy parts should of itself suffice to decide the question. The pustules of acne vulgaris can scarcely, indeed, be confounded with those of any other affection, except with the lesions of small-pox (see below) and those of bromide and iodide eruptions. In these drug eruptions, however, comedones are absent, the lesions occur on any part of the body, and are generally a brighter red, while the fluid they contain is rather thinner. Drug eruptions, again, occur at any time of life, whereas acne vulgaris is essentially a disease of puberty. Pustular syphilides may attack any part of the body, and are generally grouped, which is never the case with the pustules of acne. A furuncle is so characteristic that the only lesion from which it can ever require to be differentiated is a carbuncle. The pathological process is the same in both ; but while in furuncle there is but one point of suppuration and opening, in carbun- cle there are several. The only condition from which a carbuncle has in turn to be diagnosed, except a furuncle and malignant pustule (see below), is diffuse celluhtis, in which there is no circumscribed outline. In malignant pustule (anthrax), following itching and burning at the site of inoculation, a livid red papule usually appears, on which a bulla or pustule quickly forms and breaks, drying up into a black gangrenous eschar. This is fringed with tiny vesicles or pustules, and surrounded by a broad areola of sohd oedematous infiltration, the skin over which is tense and violaceous. There are constitutional symptoms, with septic fever. The diagnosis rests mainly upon the presence of a gangrenous patch surrounded by infiltration in a patient whose occupation exposes him to infection with the anthrax bacillus, especiall}' from cattle, hides, or wool. The organism may be detected without difficulty under the microscope. It is only at the outset that the lesion can be mistaken for a carbuncle. The primary lesion of sypliilis can be excluded by its indolence, and by the absence of gangrene and of febrile symptoms. In glanders, the cutaneous lesions begin as red spots, which pass through the papular and vesicular or bullous stage into pustules that give rise to widespread ulceration. The condition, with its severe constitutional disturbance and, except in some chronic cases, the peculiar discharge from the nostrils, is usually easy of recognition ; and in exceptional cases in which the diagnosis is in doubt, recourse should be had to mallein, or the bacillus — B. mallei — may be sought for with the aid of the microscope. In scrofulodermia (tuberculides), usually an affection of childhood and adoles- cence, pustular lesions take the form which has been stj'led by Diihring the large fiat pustular, and the small pustular scrofuloderm. The former begins as one or more superficial indurations which, becoming pustular, extend peripherallj^ and form a fiat, yellowish, crusted pustule of considerable size, surrounded by a violaceous areola. ^Neighbouring pustules may coalesce. When the crust is removed, a granular scrofulous ulcer is seen. The small pustular scrofuloderm is usually a papulo-pustule rather than a fuUy-developed pustule, the pus being frequently limited to the central part of the summit, while the outer part of the lesion remains hard. The crusting is sometimes a slow' process, which may occupy several weeks, and when the crust drops off it leaves indelible scars not unlike those of variola. The only diseases with which scrofuloderma generally can be confused, are lupus and syphiUs. The absence of "apple-jelly " nodules and of infiltration will distinguish it from lupus, though the tAvo conditions raa}' coexist. The syphilitic ulcer is met with in adults, and is usually a much more" 6o4 PUSTULES active process than scrofulodermia, nor has the lesion the undermined border which is characteristic of the latter affection. Concomitant s^'philitic signs will usually be present, just as in scrofulodermia there will generallv be other tuber- cular symptoms. In syphilis, the pustule is a much less frequent lesion than the papule, and is generally found in association with a cachectic state of health. It appears in two different forms, the acuminate and the flat pustular sj-phihde, and in both the lesion may be either small or large. The small acuminate or mihary syphihde, not usually much larger than a pinhead, in most instances begins as a papule, and papules will generally be found intermingled with the pustules. When the crusts into which the pustules dry are detached, there may be some scarring, or the lesions may leave no trace except stains, which presenth' disappear. The diagnosis of these small acuminate pustules seldom presents any difficulty ; but it is not so with the large acuminate pustules, the acneiform syphilides, which may be mistaken not only for acne, but also for variola and iodide eruptions. Appearing on a base which may at first be pink, and afterwards copper, they may be pustular from the beginning, or raa,y start as vesicles or as papules ; they are more or less generahzed, about the size of a pea, disseminated, or grouped irregular^, and while they are predominantly acuminate, some of them may be rounded. Some of the pustules may be dimpled, and occasionally the majority of them display this character. When the crusts fall off, brownish stains are seen, and there may be shght scarring, which, however, is seldom per- manent. The grouping which is characteristic of these pustular syphilides, and the drjdng-up of the pus into scales, are important points in differentiating them from the lesions of acne, which, further, instead of being generalized, seldom affect parts other than the face, the back of the neck, the chest, and the back between the shoulders. The comedones of acne are another distinguishing feature, the eruption is of a more sluggish and chronic character, and there is no cachexia. The diagnosis as betAveen pustular syphihdes and variola is given below. The pustules met with in iodic eruptions are seldom either generalized or profuse. Small flat pustular syphilides (" impetiginous syphihdes ") inaj^ begin as such, or may develop from macules or papules. They are discrete ; but in such regions as the face and scalp maj- run together. The eruption is of a generalized character, with a preference for the genitals, the scalp, and the face. The crusts into which the pustules quickly dxy axe frequently adherent ; beneath them there is superficial ulceration ; occasionally they are surrounded by an areola of the characteristic raw-ham colour. When the eruption is extensive, the patient is often anaemic and cachectic. The affections from which these syphilides have to be differentiated are pustular eczema and impetigo. The ulceration which underhes the crusts in the syphilides is not found in either of those conditions, nor is itching present as in eczema. In impetigo, the pustules most frequenth' affect the face and hands, and are superficial ; and the eruption is mild in charac- ter and of shorter duration. The large flat pustular syphilides (" ecthymatous syphihdes ") differ httle from the small ones except in size, and the only lesions with which the}'' are likely to be confused are those of severe impetigo vulgaris. The diagnosis from that condition must rest upon the slow development, the greater number of the pustules, the coppery areola and base, the accompanying cachexia, and the pigmented scars. But it should be remembered — and this applies not to pustular syphilides only, but to syphiUs generally — that in m.ost cases a sure diagnosis of sj'philis can only be made when all the factors of the case are taken into account : the history, character, course and termination of the lesions, and their reaction to mercury or arsenic and the iodides. The distinctive characters of secondary lesions generally are their symmetry, their coppery colour, the PUSTULES 605 positions in which they occur, their polymorphism, and the absence of itching, together with enlarged glands, sore throat or tongue. In doubtful cases, the whole cutaneous surface should be examined for characteristic marks or lesions. If the diagnosis is still uncertain, the Wassermann test should be applied. Of all diseases of which the pustule is one of the manifestations, small-pox is that which presents the greatest difficulty in diagnosis. The lesion, occasionally preceded by a roseolar rash not unlike that of scarlatina, begins as a mere fleck, of pin-head size, flush with the surface and impalpable. In the course of a few hours it swells up into a pink papule, which can be felt embedded in the skin like a small shot. In a few days, the papule undergoes vacuolation, at the same time getting bigger, and becoming grey and translucent. So the papule passes into the vesicle, which is loculated, so that if it is punctured the contained fluid is not entirely discharged. As a rule, the smaller vesicles are hemispherical, the larger flat-topped, and occasionally the crown is indented. After about twenty- four hours the contents become turbid and the covering dull and whitish, and so the pustular stage is entered upon. While the lesion is undergoing this transition, the grey translucent centre is encircled at the periphery of the crown by a white or yellow ring. By the sixth day from its birth, the lesion has become vellow throughout and the crown dome-shaped, and so the pustule attains maturit}', and if of full size measures about three-eighths of an inch across. Even in unmodified small-pox, however, the lesions often fail to reach those dimensions. As the pustule develops, the erythematous zone, the areola, which encircled the papule and was biggest and brightest in the vesicular stage, begins to wane, and has disappeared by the time the pustule reaches maturit}^. This occurs about the ninth day. As the pustules dry up or burst, scabs are formed, which on separation leave dark stains, scars and " pits," the number and depth of the pits usually being determined by the severity of the disease. In mild attacks the pustules remain discrete, in severe cases they run together (confluent small-pox, Fig. 160, p. 606). In bad cases, hajmorrhage takes place into the skin and the interior of the pustules. The mucous membranes of the air-passages mav be invaded, the extent to which they are involved being determined by their susceptibility^ rather than by the severit}^ of the attack. In modified small- pox the eruption may resemble that of the unmodified disease, as here described, the difference being that the lesions are less abundant and are seldom confluent. It has been usual in the diagnosis of small-pox to lay the chief stress upon the solidity and hardness of the papule, the umbilication of the vesicle, and the loculation of its cavity; but in his masterly monograph (" The Diagnosis of Small-pox ") to which I owe the following description, Ricketts has shown that the distribution of the lesions is of more diagnostic value than their char- acter, as also it is more easily observed. The parts most liable to the eruption are the face and hands, exposed as these are to constant stimulation from wind and weather and other causes ; and of the two, the face, as the more exposed part, is more liable than the hands. Next to the hands in susceptibility come the upper limbs, then the trunk, then the lower limbs ; the order being deter- mined by the amount of friction with the clothes which these parts undergo. As to the trunk, the rash is thicker behind than in front, and thickest on the shoulders, where there is most friction. The incidence is smallest on the great flexures of the body, because these are the most sheltered parts, while the extensor surfaces of the limbs, and especially the elbow, receive a disproportionate share of the rash. The neck, sheltered by the head and the shoulders, fares better than either of those parts ; the back of it suffers more than the front. On the flank, protected as it is by the arm, the rash is less profuse than on the adjoining parts of the chest-wall, either in front or behind. On the foot, the distribution is marked by great inconstancy. Usually the back of the foot 6o6 PUSTULES receives more attention than the sole ; between the toes, and the folds beneath the toes, enjoy comparative immunity; and the parts for which the eruption shows most preference are the instep, especially the tendinous ridges and the o ^ bony eminences, the tendo Achilhs, the balls of the toes, the toe-pads, and the heels. When the malleoh present few lesions, as not seldom happens, it is because a well-fitting boot has been worn, and so these prominences have been protected from friction. The absence of uniformity of distribution in the case PUSTULES 607 of the foot is explained by differences in the conformation of the foot, in the foot-gear which is worn, and in the degree to which the patient is accustomed to wallc. ■ In the hand, the palm, and especially the hollow of it, suffers httle, and the brunt of the attack is borne by the extensor surface ; the rash is thickest on the back of the wrist and hand, and over the heads of the metacarpals. To these usual characters the distribution offers exceptions, some of them difficult of explanation ; but they are neither so numerous nor so considerable as materially to lessen its diagnostic importance. Its significance consists mainly in the eruption being neither localized nor elliptic, but generalized ; in its being symmetrical and graded — graded, too, evenly in homogeneous areas ; and in its preference for surfaces exposed to friction. The diagnosis of small-pox from chicken-pox — the disease with which it is most often confused — and from vaccinia, has been set out under Vesicles. The eruptions of measles and of German measles differ from that of small-pox in that, instead of being papular, they are macular, and that they never pass into a vesicular or a pustular stage. In German measles, further, there is enlargement of the posterior cervical glands, w^hich is never the case in small- pox at ah early stage. In scarlatina, the " strawberry tongue " is a sign which is quite diiferent from the condition of the tongue in small-pox. The rose-red lenticular spots which make up the rash of enteric fever are neither so hard nor so prominent as the papules of smaU-pox, and they appear chiefly' on the trunk, and elect the abdomen and chest rather than the back ; the arms and legs, and especially the face, almost always escape. The purpuric spots some- times seen in enteric may be misinterpreted as the signs of severe small-pox ; but the absence of pronounced systemic disturbance and severe pain, and of an erythematous rash, should obviate the confusion. If the pink, sUghtly elevated macules of simple purpura are mistaken for the eruption of small-pox^ the error is soon corrected by the deeper colour which the macules take on ; nor, even though the macules may become papules, have the lesions the characteristic hardness of variolous papules. Another point of difference between simple purpura and small-pox is, that in the former affection the face and trunk are seldom attacked, the sites of election being the Hmbs. In erythema multiforme, although the rash makes its chief attack upon the limbs, it may be widely diffused and may even invade the face. In such cases, however, the diffusion will usually be less general than that of the variolous eruption, nor is the order of incidence the same. With the involution which the erythematous lesions undergo, the resemblance to small-pox ceases. Even in cases of acute febrile er\'thema, in which the whole cutaneous surface is covered by. a profuse eruption, the distribution is quite different from that of the small-pox eruption. Confusion between small-pox and syphilis is much more hkely to arise when the svphihde is pustular than when it is vesicular or papular. The erroneous diagnosis may be assisted by the fever and aching symptoms which may precede pustular sj-phihdes, and b}' the fact that the lesions may begin as papules. In svphihs, however, the constitutional symptoms are less severe, the eruption runs a more indolent course, and appears in successive crops, whilst the vesicles which form on the summits of the papules have an indurated base. Sometimes, too, the sj-phihtic eruption is indifferent in distribution, and often it comprises various t\'pes of lesions, even when it is not distinctly polymorphic, whereas in small-pox the departure from homogeneity is much more limited. Occasionally, impetigo vulgaris is mistaken for mild modified small-pox [Fig. 161, p. 608), but attention to the points which mark off the former affection from pustular eczema (see above) should prevent the mistake. Further differentiating features as bet^veen impetigo vulgaris and smaU-pox are, that in impetigo there 6o8 PUSTULES is no fever, and that the lesions begin as vesicles or bullae and dry up into flat, yellowish crusts. In those cases of sudden and acute eczema which may mimic small-pox, guidance is to be found in the small size and superficiaht)^ of the eczernatous lesions, and the oedema and infiltration of the underlying skin. In scabies, again, the vesicles are superficial, burrows will generally be found, and the heterogeneity of the secondary lesions will aid the diagnosis. In all these PYREXIA, PROLONGED 609 affections, the distribution is quite different from that of small-pox, the incidence being partial or patchy. Thus, in impetigo, the lesions are frequently confined to the face and extremities, and if the trunk is invaded, it is the front more than the back, the lower part more than the upper. Acute eczema is seldom widely diffused. In scabies, except in children, the face escapes, and the com- monest sites are the hands and fingers, buttocks, and feet. In Ricketts' experience, no affection, except chicken-pox, is so frequently confused with small-pox as acne vulgaris, in spite of its chronic, afebrile char- acter, and the absence of subjective symptoms. If, however, the rash is limited to the upper part of the body and a few characteristic acne lesions such as comedones are found, small-pox may be excluded. I have seen copaiba eruption mistaken for small-pox. The absence of con- stitutional symptoms such as pain in the lumbar region and fever, the mixed character of the lesions, and the history are the chief points in the diagnosis. It is seldom that bromide or iodide eruptions are mistaken for the rash of small-pox. In doubtful cases, attention must be paid to the larger size of the pustules, as compared with those of small-pox, and to the symmetrical or patchy distribution. Malcolm Morris. PYREXIA, PROLONGED. — A pyrexia may, for the purposes of this article, be considered to be prolonged if its duration is more than ten days. In the majority of cases, no doubt, there are signs and symptoms, or facts in the history, which enable the practitioner to make a diagnosis before this time ; but sufficiently often difficulties arise from the absence of the distinctive characters of any one of the diseases commonly accompanied by such pyrexia. In most cases such a prolonged pyrexia is the result of one of the infectious diseases, and it is by a careful consideration of the more probable among these that one may often arrive at a definite opinion. The general infections most likely to give rise to a long-lasting fever are : — Typhus fever Typhoid fever Paratyphoid fever Malta fever Influenza Tuberculosis Malignant endocarditis Septicaemia from deep-seated foci of disease, such as : — Empyema, Cere- bral abscess, Pylephlebitis, or other form of suppuration Malaria Syphilis Bacilluria Bronchopneumonia. A high temperature of very long duration occurs often in connection with diseases of the blood and blood-forming organs, such as : — Addison's anaemia Leukaemia Hodgkin's disease. It also occurs much more often than has been commonly supposed in sarcoma and carcinoma of different organs, and has been observed in cirrhosis of the liver. There are two other forms of pyrexia which should be borne in mind, namely, a prolonged pyrexia occurring in children, often very difficult to explain ; and so- called neurotic pyrexias. Modern research has a tendency to rely upon its own methods alone, and to ignore the older clinical differences. But this involves a separate investigation for each disease as it comes to be considered ; and thus it may happen that one patient may have to undergo, in addition to a thorough bedside examination of all his organs, a lumbar puncture, and the removal of blood for the Widal test, or for the cultivation of organisms; and these may have to be repeated. A full knowledge of the history of the illness, of exposure to infection, and of the clinical changes as far as they are manifested, is desirable in order that the D 39 6io PYREXIA, PROLONGED researches of the bacteriologist may be directed as early as possible into the right path. Typhus. — On the score of prolonged pyrexia little need be said of this fever. The eruption is generally distinctive, and shows itself before the fever has attained any duration ; but it is capable of being confounded with t}'phoid fever, and even with malignant endocarditis. The distinction from typhoid fever is given elsewhere ; and a confusion with mahgnant endocarditis is only possible if the latter should produce a very uniformly distributed petechial eruption over the skin, while the cardiac murmur is of high intensity ; or if a person already the subject of cardiac murmur should contract tj'phus, and have an ill-defined eruption. In either case, if the pj^rexia were prolonged bej^ond the t^velfth or fourteenth day, typhus would be unhkely. Influenza. — -In the majority of cases of influenza, uncomphcated by definite visceral changes such as pneumonia or gastro-enteritis, the fever is of short duration, and does not come within the scope of this article. But it is often as long as a week or ten days, and sometimes three weeks or more. The longer period, accompanied as the fever is by few distinctive signs, is sufficient to lead to a confusion with tj'phoid fever, tuberculosis, or malignant endocarditis, either of which may proceed for two or three weeks, and the last t\vo for mam^ more Aveeks, without distinctive cUnical signs. The constant presence of influenza amongst us, and the great variety in the characters it assumes, make it very difficult to exclude it until positive signs of another complaint have manifested themselves. Equally difficult, however, is it to prove the existence of the disease, since the organism, Pfeiffer's bacillus, is not easilj' found in the blood ; and in the prolonged cases, the rather striking peculiarities of the intense acute attacks, such as severe pain in the head and back of the eyQ, and in the lumbar region, maj^ be absent. The diagnosis can often be made positively'- only via exclusionis, when the bacteriological tests of typhoid fever and tuberculosis have failed, and if there is an entire absence of rose spots, diarrhoea, or enlarged spleen on the one hand, or of pulmonary symptoms on the other. All the more must we bear in mind the possibility that an apparent attack of recovered influenza may only be the pyrexial equivalent of the earliest tuberculous infection, and if at any time in the course of the illness sputum is available, it should certainly be examined for tubercle baciUi. Typhoid Fever. — This should be comparatively easy to diagnose in the present day. A fever commencing with frontal headache, perhaps with diarrhoea, generally compelUng the patient to lie up in bed hj the end of the first week, and showing within the first ten days, rose spots on the abdomen and a shght enlarge- ment of the spleen, while at that time the temperature is ioi° F. or 102° F. in the morning, and 103° F. or more in the evening, and the pulse is relatively slow, namely from 80 to 100 in the minute, should be typhoid fever. The AVidal reaction, that is, the agglutination of typhoid bacilU by the patient's blood serum, becomes positive about the tenth or twelfth day. All these signs ma}^ fail for a time : spots may be absent, the bowels may be persistently constipated, enlargement of the spleen may be difficult to prove, the Widal test may and often does fail. Examinations of the faeces for Eberth's bacillus are not easy ; but cultivation of the bacillus from the blood taken from the patient's vein may yield the bacillus, and this at an earher date than the Widal reaction can be obtained. Apart from such cultivation, the appearance of rose spots from the sixth to the tenth day, with additions to their number every day for five or six days, forms perhaps the most conclusive evidence of tj'phoid fever ; and the diagnosis based on these grounds should not be upset b}'' one or tsvo failures to get a positive reaction with the Widal test. P Y REX I A , PROLONGED 6ii This test may require to be made with two or more strains of Eberth's bacillus, and failing them, paratyphoid bacilli should be used. A positive Widal reaction in a case otherwise unlike typhoid fever must be accepted with caution. If a case is devoid of spots, and gives no Widal reaction, the probability of its being typhoid fever might be asserted from its mode of onset, a characteristic chart of temperature {Fig. 162), with high readings morning and evening in the middle of the second week, and ending in twenty to twenty-five days after wide oscilla- tions, and finally a pulse always under 100. On the other hand, a pulse of more than 100 does not exclude typhoid, as it is common enough in the severe adynamic forms. Typhoid fever may be confounded with many acute diseases ; as a prolonged r.vr''- .0-.' ■-r:n- --.-- ■7- -i.-5!in rv^ ----flr^ ".T^ --i— -.-^ ' , -^■■' - 1 . TiWi,- V.r-- -sssr- r-fvr- "n— BJ.— -y^r- ,™p^^ 107 .^ "'^'i*- yU ; jj.i^ji' -f •H" r . ..[.,1, ! • Ti"' 105 104 103 1- 1 , , > Il hi'! [ 13 ! •1 ■ ■: A a -| 1* 1 ' , 1 1 i m * ^ f ^ ■ii 'k' ,*' / \ *• Liv r° ■'x_ Ji ^■■'f> f. K . 1 ■ ^' 1 ;- V ; V * *'. ' ' l\ '[I. V •^ V A ^"V V r- ^^ V'- ^:i\: 101 100 39 -;:i : : :- 1 1 l'^ :\^. ;(■ 1 1 i 1 1/ "i 1 1 : 1 ■ '■ [■ ■ :;!::- -1-!^ ' ; _4^ ^ - i SB ff 1 ; ... t- "^■ Y'l' \j '\'l 1 1 . : : j 1.' ' -"W- :--l^" :-,;■;■ ■I 1. , i- 1 . -»^ ^ii ;:|:i:: r-v -i|: 4:r .:'■ r. ^Ti- '■.}. --!:-!-■ :T:|:: :j::;^ ::::{:: ;:!::: :::::: -j|- "\--: ■1 .■ I . : .■i-i. V: .1::;-- .t.|: ^■|:^!- J^'ig-. 162. — Temperature chart of a case of typhoid fever. pyrexia it is especially pulmonary tuberculosis, malignant endocarditis, a long- lasting influenza, septicsemic processes, and occasionally tuberculous meningitis which will give difficulty. Paratyphoid Fever. — Of this it need only be said that it presents the features of a benign typhoid fever, in which all the distinctive characters are less marked. Like typhoid, it may be confounded with a mild long influenza, or with early tuberculosis. Its recognition depends ultimately upon the agglutination of paratyphoid bacilli by the patient's blood serum. Malta Fever. — This is one of the most prolonged of the fevers due to one recognized micro-organism ; for in the undulant form of the disease successive exacerbations of pyrexia may carry on the illness into the fifteenth or sixteenth 6l2 PYREXIA, PROLONGED week (Fig. 163). It closely resembles typhoid fever, and is proved to be due to infection with Micrococcus melitensis, conveyed, almost invariabl}^, in goat's milk. In British practice its occurrence is unhkelj^, except in one who has been in the parts of the world where it is rife, — namely, the Mediterranean coast and islands. It differs from typhoid fever in the absence of spots, and of characteristic diarrhoea, but as these often fail in tj^phoid fever, the distinction is not always available. However, the diagnosis can generally be made by the Widal test, since the blood serum will agglutinate the Micrococcus melitensis as earlj- as the fifth dajr of the disease. Tuberculosis. — The onset of general miUary tuberculosis, or of mihary tuber- culosis of the lung, has often for its only symptom a moderate pjTexia, with accompanying phj^sical weakness and anorexia. Such a condition may continue for weeks without any other sign ; the breathing need not be quickened, and there may be an entire absence of abnormal signs in the lungs. The morning temperature is frequently near the normal, while the evening temperature Fig-. 163. — Temperature chart of a case of Malta fever of undulant tj-pe. alone is high : and it does not as a rule increase to a maximum and subsequently fall, so as to form the curve which is characteristic of t^^phoid, but continues nearly at the same level for long periods. In the absence of sputum, the detec- tion of tubercle bacilh is not available. TubercuUn tests may, however, be tried, and will probably give positive results. Of these the most suitable is the cutaneous tubercuhn test of von Pirquet. Tuberculous infection in other locaUties may equally, when not accompanied b}' striking local signs, and only presenting the pyrexia, be taken for typhoid fever : for instance, tuberculous disease of the kidney, or pyelitis, and especially tuberculous meningitis. Head- ache and fever occur both in this and in typhoid, and ma}'- be for a time the only facts in the case ; until in the one case spots or loose motions assert themselves, or, in the other, optic neuritis, convulsions, paralysis, or retracted abdomen point to a cerebral localization. Infective or Malignant Endocarditis. — This may be mentioned next because for days or weeks the only prominent feature may be a continuous pjnrexia with evening rises to 101° F., falling in the morning to 99° or 98-4° F. [Fig. 164). In most cases a cardiac murmur is present, and then one ma^'^, after a certain lapse P Y REX I A , PROLONGED 613 of time, such as fourteen days, and excluding .the possibiUty of typhoid fever, often make a diagnosis with confidence. This is confirmed by the occurrence of enlarged spleen, by rigors, by the appearance of petechial spots and small haemorrhages under the skin, by the cessation of pulse in one or other of the accessible arteries, such as the radial, posterior tibial, or dorsalis pedis, by F/£: 164. — Temperature chart of a case of malignant endocarditis. optic neuritis or retinal haemorrhages, and by anaemia. An attempt should be made to obtain an organism from the blood by cultivation, but it is not always successful. In the early stages the difficulty is not uncommonly increased by the fact that no murmur can be heard, in spite of the fact that Fi^. 165. — Temperature chart of a case of pyaemia, secondary to otitis media and lateral sinus thrombosis. There was a rigor almost daily. endocardial changes are present. The course of some of these cases of infective endocarditis, which may be called chronic, is remarkably prolonged, sometimes for six, eight or twelve months, with little variations in the accompanying conditions. Long before that, of course, typhoid fever and tuberculosis would have been excluded ; and after eight or ten weeks the co-existence of cardiac 6i4 PYREXIA, PROLONGED murmur, with uniform prolonged pyrexia, would make the diagnosis certain. Cases in which the brunt of the disease falls upon the brain may actually have meningitis, as in pneumococcal cases ; or they may be mistaken for meningitis, or for typhoid fever, or, if petechise are present, for typhus. But in such instances the illness is generally a short one, and it would not come into the present category. Septiccsmia. — In any prolonged pyrexia the possibility of a focus of deep- seated suppuration should be considered. In many situations the focus causes pain, which at once directs attention to the origin of the trouble ; but in some cases pain is absent, and foci in some situations are habitually painless. The disorders to be thought of are otitis, abscesses in the throat, a small empyema, cerebral abscess, deep-seated glandular suppuration, suppurative pylephlebitis, appendicitis, and pelvic suppurations in women. If the blood shows a leucocytosis, this will be in favour of a suppurating centre. At any rate, it will exclude typhoid and miliary tuberculosis. Each possible centre of infection must be DAY OF DISEASE /fA ;z*5< '*• 71 R TIME M E M E M E M E M E H E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E 105 6- 104 ■^ 103 ** 8 - O 6- 10 ^..- in 102 1- «- U t_ X 2- Z 101 UJ 8- cc '■- 2 100 e- 9S ■5- - z z Z^ — < z z z z - z z z z z z: = z = z z 3\ z = E = E I E E E E E E z ~ _ — —i i z j \~0 ^ / z = z E E = = E E z E z z i 4 I £[ E I H \i = — ( E i i=, = E E z -3- 'zl f \fB i z z 1 z 1? ? E l -^ i = E z Jr 1 I z z ~ z z p ,- I E M~ 1? ~n E ^ E z E I z z z z - — ^i E z V^ ^ - z z - z t z z z z — — z z z z z - 98 8~ - - - - - - — - - , - - — - - - — - — - - - - - - - - - - - - - - - - - - - - - - ■Fig. 166. — Temperature chart of a case of facial erysipelas following a septic scratch. called to mind, and the locality concerned must be investigated. Suppurative pylephlebitis, in spite of the extent of the lesions and the size of the organ concerned, has frequently been overlooked, and has been mistaken for typhoid fever, pneumonia, peritonitis, or appendicitis. It is relatively rare, but it is a sequel of other suppurative lesions in the abdomen, and should therefore be thought of when appendicitis or other similar affection has been under treatment. Rigors are very inconstant in diseases of this class ; if they occur they compel attention to the possibility of pyogenetic centres [Fig. 165) ; but their absence must not be allowed to influence one in the contrary sense. They are most constant in visceral pyaemia, but this illness is not generally prolonged. Erysipelas, though generally of short duration, sometimes causes pyrexia lasting more than a fortnight (Fig. 166). Syphilis. — Like other infections, this has its fevers, both in the secondary stage, — that is the stage of generalization of the infection — and in the late stages accom- panying gummata and other local processes. The secondary fever is certainly PYREXIA, PROLONGED 615 not present to a marked degree in most cases ; a little feverishness there may- be, but it scarcely requires special mention. Only occasionally there is a really prolonged pyrexia, with decided evening elevations of temperature. The diagnosis is rarely in question, because the fever only accompanies the rash and sore throat ; and the origin in a local infection is generally well known. The same help may be with us in the fever attending gumma-formation ; but if the gumma is deep-seated, or in a viscus such as the liver, even though it should be painful, and recognized by palpation as an abnormal enlargement or thickening, some hesitation may be felt as to the diagnosis, unless it is remembered that such pyrexia may be present. Moreover, a pyrexia of this kind has occurred in connection with the lesions of the inherited disease. Syphilitic pyrexia is frequently of decided character, with evening elevations to 103° F. or more, and morning falls nearly to normal, until stopped, as it may be at once, by the administration of potassium iodide. In both these cases the Wassermann re- action is available to make certain the nature of the infection. Bronchopneumonia. — -This may be mentioned because it has sometimes a duration of many weeks, and during the whole time an oscillating temperature is present. The local signs are, however, sufficient to explain the presence of fever, and the difficulty lies only in the fact that a general pulmonary tuberculosis may resemble almost exactly the more curable bronchopneumonia of pneumo- coccal or streptococcal origin. Malaria. — Important as is this disease, its diagnosis may be dealt with briefly here. The non-malignant quartan and tertian fevers produce isolated pyrexias of short duration which do not come within the scope of this paper. It is only the malignant fevers, which do not arise in this country, and are little likely to be seen in other than regions known to be malarious, which cause prolonged con- tinuous pyrexia. The diagnosis is based upon a consideration of the symptoms, upon the discovery of the parasite, and upon the results of treatment with quinine. The symptoms, chill, fever and sweating, have less value in a continuous pyrexia than in the simple tertian and quartan fevers, and in a quotidian fever the resemblance to septic poisoning is well recognized. An enlarged spleen is present in malaria, but also commonly in typhoid fever. Most reliance is to be placed upon a microscopical examination of blood-films coloured with Romanowsky's or Leishman's stain ; for in cases of pernicious malaria, it is rarely that the organisms [Plate XII, Fig. E) fail to be discovered by this means. Absence of leucocytosis and an increase of the large mononuclears to 15 per cent in a differential count of the leucocytes in the blood, are also in favour of malaria, at least in the first two weeks ; after which the results may be very similar in typhoid fever. The third test is the administration of quinine, which, given in sufficient quantity, will stop malaria ; and on the other hand, if the fever continues in spite of it, malaria is excluded. An adequate dose for this purpose is 3 or 4 gr. every three hours, day and night for two or three days. Bacilluria. — This is usually due to infection of the urinary passages with Bacillus colt communis. The symptoms may be slight or they may be those of cystitis or pyelitis in a marked degree. With these there is a more or less continuous pyrexia. The diagnosis consists in the recognition of the Bacillus coli in the urine by microscopical examination. The urine is acid, with an unpleasant odour, clear when passed, but cloudy and turbid on standing ; and the sediment contains pus cells, bladder epithelium, and perhaps renal cells, and hyaline and granular casts. An amount of albumin, usually not more than O'l per cent, may be present. The bacilli are best detected by centrifuging the urine, staining the deposit with methylene blue, and examining with an oil- immersion lens. The disorder is common in infants, and in adults it is most frequent in women in connection with pregnancy. The symptoms, especially in 6i6 PYREXIA, PROLONGED infants, may be few, or none at all other than the p^Texia, which is variable in degree, generally irregular from day to day, may be accompanied by chills and sweating, and may last several weeks. In some cases, however, there is fre- quency of micturition, pain, perhaps paroxysmal, in the kidney or bladder, and gastro-intestinal s\Tnptoms. Hence in an obscure fever in infants, the urine should be examined carefully. Other organisms sometimes infecting the urine are Bacillus lactis aerogenes, the t5rphoid bacillus, and Bacillus proteiis vulgaris. AncBmia. — -The several forms of pernicious, idiopathic, or Addisonian anaemia are frequently accompanied by a moderate degree of pj-rexia, which mav persist 167. — Characteristic temperature chart of a case ot pernicious anaemia. for man}- weeks [Pig- 167). Such an anaemia might be the manifestation of tuberculosis, of infective endocarditis, or of mahgnant growths ; but an exam- ination of the blood with the discovery of poikilocytosis, of a colour-index above unity, the lemon-yellow tint of the skin in some cases, and the history, will generally determine the diagnosis, though the differentiation of the par- ticular form of anaemia may still remain to be considered (see Ax.emia). Hodgkin's Disease. — In some, but by no means all, cases of this disease, a very remarkable form of pyrexia occurs. It consists of alternating periods of p^Texia and apyrexia, each of eight, ten, or twelve days' duration, lasting in aU for PYREXIA, PROLONGED 617 six, nine, or twelve months. During the pyrexial period the temperature, begin- ning near the normal, becomes day by day higher and higher, till on the fourth or fifth evening it reaches 102° F. or 103° F., its highest point ; it gradually dechnes during the next four or five days to the normal ; and then for three or four days it becomes increasingly subnormal, till a minimum is reached, and from this point there is a gradual return to the normal, when a second pyrexial curve begins (Fig. 168). If the cervical, axillary, or inguinal lymph-glands, apart from or in company with the spleen, are enlarged, and the condition of the blood is normal, or of the simple chlorotic type, the diagnosis of Hodgkin's disease is 31 JULY TO AUCUS7 13 14 AUGUST TO AUGUST 27 2B AUOUS.T. TO fEPTEMBERIO ISEFTEMBER TO SEPTEMBERS* | Fir.STWEEH SECOND W£E« THIRD WEEK rOUBTH WEEK rjrTH WEEK SrXTH WECM SEVENTH WEEK EIGHTH WEEK 1 !0S> 1 loz- 1 '"'" ■ '^ 100- 09' Ntrmrl 98' - 87° \ 1 V fy . \ ^ / f V [ \ \ V ' A ^ ^ V J \ vv .A \ ^ f, f] ^f^ ) 1a t^ ^ l\ A, y /^ \/ V A/ 1 \ / L V ^ 1 F/[^. i68. — Temperature cliart of a case of Hodgkin's disease. safely made. If such a temperature is observed without any enlargement of the spleen or of the external glands, a lymphadenomatous enlargement of the internal glands, bronchial or mediastinal, should be suspected, and endeavours should be made to demonstrate them by palpation, percussion, or ;tr-rays. Leucocytosis should be absent ; but its occurrence in a late stage of the pyrexia would not militate against the diagnosis. Leukcemia. — Pyrexia is a common occurrence in the different forms of leuksemia. As a rule the great size of the spleen in one group of cases leads to an easy diagnosis, and in another group the glands are manifestly enlarged, though Fig. 169. — Temperature chart of a case of sarcoma of the neck and mediastinum. acute cases occur in which these changes do not appear early ; in all these forms an examination of the blood will show the excessive number of leucocytes, of one or other variety, a sufficient explanation of the occurrence of pyrexia. New Growths. — The belief that new growths are not as a rule accompanied by pyrexia is well founded ; but many exceptions have been recorded, both in regard to sarcoma and to carcinoma. A case of sarcoma of the neck and medias- tinum was accompanied for the four months preceding death by a pyrexia resembling in its variations from week to week that which is so characteristic of Hodgkin's disease [Fig. 169), and carcinoma has now frequently been known 6i8 PYREXIA, PROLONGED to be accompanied for weeks or months by fever, especially where there are secondary deposits in the Uver. For obvious reasons the diagnosis is not generally dif&cult ; that is, the tumour is in evidence. A point of importance is that the presence of pyrexia does not help to distinguish between syphilis and cancer. Cirrhosis of the Liver. — The diagnostic relations of pyrexia in cirrhosis of the liver are on the same footing. It occurs in some cases and is apparently due to cirrhosis ; whether because it is an inflammatory process, or because the cirrhosis is due to a toxeemia which may raise the temperature, does not seem to be determined. The fact is of interest when we consider that ascites due to hepatic cirrhosis has often been mistaken for tuberculous peritonitis, and, per- haps less often, tuberculous peritonitis for cirrhosis. The absence of pyrexia might possibly be held to exclude tuberculous peritonitis, but its presence would leave the diagnosis open, since it might be due to either. Neurotic Pyrexia. — This term may be applied to two classes of case : in one the mercury is found at extraordinarily high levels at irregular intervals, often at different levels in different parts of the body, and falling again rapidly to the normal. This may be repeated many days, but hardly constitutes prolonged pyrexia. In the second variety the patient has a genuine pyrexia, lasting two, three, or more weeks, irregular in the elevations which the temperature may reach on successive days, but on the whole resembhng the pyrexia of sepsis. These cases are more often females, and the fever may be associated with symptoms referable to the pelvic organs, or may persist after the entire subsidence of such symptoms, so that skilled obstetric physicians have been unable to find any active local lesion. The neurotic origin of such cases may be open to doubt, but it is supported by the variabiUty of the pyrexia, and by its occasional rapid cessation without adequate explanation, and without any local change. The diagnosis can only be made as a rule via exclusionis, and must always be con- sidered provisional as long as there is any probability of an adequate cause being found. The Unexplained Pyrexia of Children. — This form of pyrexia is in a somewhat similar position to the above. All students of disease in children are familiar with the fact that in patients under nine or ten years of age a mild pyrexia may occur, lasting two, three, or four months, for which no explanation can be found. Since it arises in quite j^oung subjects, a neurotic origin is not so readily suggested nor so hkely, as in the adult female, and yet it is possible that some cases are of this nature. Tuberculosis should be considered carefully, but is often safely and rightljr excluded. Gastro-intestinal disturbance, such as constipation ; the unsuitable nature of the food ; and acute intoxication from the alimentary canal, are other possible explanations of some cases. Since the prognosis is good, it is satisfactory to be able to recognize the clinical condition, even though the causa- tion is obscure ; but the diagnosis can only be established after careful exclusion of t>nphoid fever, tuberculosis, and local inflammatory conditions such as otitis, bacilluria, and other definite lesions or infections. Frederick Taylor. PYREXIA WITHOUT OBVIOUS CAUSE.— It is barely fifty years since the clinical thermometer came into regular use, yet now its report is the most commonly ascertained factor in diagnosis and prognosis, though possibly not the most reliable. A great deal of time and effort has been spent in attempts to ascertain the precise mechanism by which the human body maintains in health an average temperature (practically constant) of 98-4° F., and also in determining the exact factors that lead in disease, and also even in health, to a departure from that temperature. From these studies, associated with, and controlled by, clinical observations, PYREXIA WITHOUT OBVIOUS CAUSE 619 there have been established a number of general principles and facts which must be grasped before we can form a just estimate of the value of the reading of the thermometer in diagnosis. We must briefly state the more important of these without discussion. 1. Sources of the Actual Production of Heat in Health in order of importance : {a) Muscles at work ; {b) Glands at work ; (c) All minor tissues in which kata- bolic changes are proceeding. 2. Provisions for the Escape of Heat. — {a) Temperature changes in the air, especially that expired ; [b) Escape by the skin, radiation and evaporation of sweat ; (c) Escape by urine and fjeces ; [d) Warming of food and anabolic tissue changes. 3. Mechanisms for Regulating the Distribution of Heat generated Locally. — {a) A main centre for regulating the distribution of the blood, situated in the medulla ; {b) Subsidiary centres for the same purpose situated in the cord and (?) elsewhere ; (c) The physical properties of the blood, lymph, and tissue juices as regards heat capacity and their circulatory movements. These three belong to the province of pure experimental physiology ; we have, then, the further observations shared by physiology and clinical medicine : A. That the temperature in perfect health can be considerably raised (at least to 102° F. — Hill) by strenuous physical exertion ; such elevations very rapidly disappear, possibly with small oscillations. 5. That in exhaustion from violent effort or exposure (generally both, as in shipwrecks and similar accidents) the temperature can be, and is, very dangerously depressed, this being possibly the sole cause of death. 6. That in every form of microbic invasion of the body, the temperature may be altered, either by the poisonous products of the microbes, or by the activities of the microbes themselves, or by the effects of either of these activities upon the mechanism for regulating the distribution of heat, probably by all these methods and, perhaps, others. Lastly, as purely clinical observations we have learnt : — 7. That in order that variations in temperature may kill, or indeed of themselves be of very serious import, they need to be very extreme (say 6 or 7 degrees above or below normal) or else very prolonged, the necessary duration varying, of course, with the degree of departure from the normal. 8. That, in the wards of a hospital where the temperatures are taken and charted at regular intervals, it is scarcely possible to find a chart of chronic disease which does not show some oscillations in temperature, the causes of which are obscure or overlooked. From these general propositions we may pass to the practical value of thermo- metric observations in diagnosis. We may again generalize, and say, that standing alone as a primary and isolated observation, the fact of a disturbance in temperature is of little use ; but when this observation is controlled by other factors in diagnosis, and we have made a complete diagnosis of a given disease, we are then in the position of knowing by experience approximatelj^ the course of the temperature for that disease, and we shall get manj^ useful hints frcm the thermometer as to complications or the severity of the attack : a point to which we shall presently refer. Hence, it is useful in our present discussion to divide all patients into two main groups : (i) Those who are well enough to visit their doctor, and (2) Those who are too ill to do so. I. Patients who are well enough to visit their doctor Unless some special complaint or physical sign soon leads to satisfactory diagnosis, let it be an accepted rule to take the temperature ; by doing so we shall have the primary, but possibly merely negative, satisfaction of not having omitted this element in 620 PYREXIA WITHOUT OBVIOUS CAUSE diagnosis, and not infrequently we shall have the very positive satisfaction of having discovered, early, a disease which we might otherwise have overlooked until something or some one else had drawn attention to it, greatly to our discomfiture and loss of credit. The three most typical illustrations of this position are perhaps typhoid, phthisis, and a condition which in our haste we label " Influenza." A headache lasting four or five days, and associated with some degree of pyrexia, is, even standing alone, so suspicious of the first, that the patient must be ordered to bed to be watched. A nasty (Ixy cough, with general ansmia, weakness, tiredness, and malaise, make us very suspicious of the second, espe- ciallv if there is also the slightest alteration in the breath sounds anywhere. The third is the recently developed refuge of the diagnosticaUy destitute ; it leads to much mortification when suppurating gums or tonsils, gonococcal discharges, decomposing urine, or other critical points are discovered later : a position which may be avoided by examining all easily accessible orifices, even in the consulting-room ; and if the mouth, throat, and nose all seem healthy, by labelling the trouble fever of uncertain origin, and ordering the patient to bed. In fact, if on examining the patient in the consulting-room no cause for the pyrexia is apparent, I would lay down as a golden rule — Remove the patient at once from Group (i) and place him in Group (2) for further critical examination of his or her person, blood, and excreta. 2. Patients who request their doctor to visit them. — It must be admitted that in this group also, pjnrexia by itself is not a very strong diagnostic point, for ex hypothesi the other symptoms are of considerable severity and importance, and therefore point pretty strongly in some diagnostic direction. Our residuum from Group (i), with a certain proportion of individuals originally in Group (2) , wiU, however, together make up a by no means negligible number of patients, in whom the cause of pyrexia is obscure to an ordinary examination, and we must lay down rules of procedure. Here it is the first rule to systematically examine every orifice of the body for a possible source of trouble ; gums, ears, nose, throat must be more care- fully inspected, and vagina, rectum, and urethra must now be examined criti- cally ; should all these prove health}'-, the fingers and toes must be overhauled for overlooked sores ; and the bones near joints investigated for a possible osteomyelitis. The Blood. — It is by now almost certain that some clue will have been obtained but should none have appeared (in some cases even with a complete diagnosis), we must now proceed to have the blood examined by the best available scientific methods ; we may by this means prove that the blood itself is at fault, or that it contains some microbes, thus : — 1. Leucocytosis. — Suggests leucocythsemia perhaps, in which disease out- breaks of pyrexia are not uncommon ; or some obscure focus of suppuration ; or perhaps it proves that an obvious focus requires the surgeon's assistance ; or per contra, it provides a slight argument against tj'phoid or tubercle, and in favour of gross parasitic worms. 2. Poikilocytosis. — Suggests a severe anaemia, which, like leucocythaemia, is known to have pyrexial periods. 3. Widal's Test. — This ma}^ clump motile typhoid bacilli, practically proving the presence of typhoid. 4. Cultivation of it may prove to demonstration a microbic invasion, and the name and nature of the invader, and possibly suggest the point of invasion. 5. The microparasites (malarial or other) may actually be recognized in the blood under the microscope. PYREXIA WITHOUT OBVIOUS CAUSE 621 The Urine may be found to be thick or decomposed, and thus give a clue to tubercle of the genito-urinary tract, to calculous trouble, or to B. coli communis invasion. The Faeces may yield information : melaena, fatty stools, gall-stones, or even eggs of parasites may be found, thus clearing up the cause of an obscure pyrexia. Calmette's Reaction may be tried for latent tubercle, but the dropping of tuberculin into an eye is not without its own risks, and in my opinion had better be avoided, especially as by the time tubercle has caused pyrexia it has probably so far advanced as to be discoverable by careful physical examination of the chest. Moreover, the test is alleged to be so delicate as to discover obsolete tubercle, which is not the cause of the pyrexia, and so may lead one astray. When physical examination, clinical methods of investigating secretions and excretions, and bacteriological aids have thus all been exhausted, there will still remain a few rare cases in which the cause of the pyrexia is undiscoverable. These are chiefly abdominal : thus gall-stones and their complications, pyle- phlebitis, ovarian abscess, and deep-seated phlebitis have all presented instances to the writer ; but he knows of no rules by which such cases can be discovered ; time or an autopsy, can alone clear them up. Apart, however, from such obscurities, there still remain some interesting and useful observations to be made on certain clinical thermometric measurements. Pyrexia or Subnormal Temperatures in Children. In children we know that the heat-regulating, like other nervous mechanisms, takes time to develop proper and complete connections with, and control over, subordinate centres of regulation, whether these be foci of production or surfaces of loss ; hence we are not surprised, still less alarmed, at temperatures above normal in children, which in adults may have a very different signifi- cance. It is rather the reverse with those below normal, because we know that the growing child requires very large supplies of heat to carry on the anabolic functions of growth and development. It is scarcely an exaggeration to say that every acute illness (reckoning by time only) or symptom complex in a child is associated with a departure from the normal temperature, and the importance of ascertaining the cause and degree of this departure can hardly be exaggerated from a therapeutical, if not from a diagnostic, point of view. Subnormal Temperature Suppose we find a child in this condition, the imme- diate diagnosis is great exhaustion ; such temperatures are generally found in marasmic children who have been starved, or its equivalent, i.e. badly fed, or exposed ; the indications are hot food, stimulants, and warmth. Subnormal temperatures are also found in summer diarrhoea, or sometimes in conditions associated with intense pain ; also, at an interval after convulsions (not imme- diately), and in many other conditions, the differential diagnosis of which will generally be obvious. Pyrexia, on the other hand, as we have said, owns an infinity of causes, of which we can only glance at a few which may give rise to trouble in diagnosis. 1. Excitement. — In children's wards, visiting day almost invariably causes a plentiful crop of high temperatures, even as much as 103° F., and the private practitioner has to remember this when a loving aunt or an injudicious visitor of any sort has come in contact with his little patient at home. A bad night may easily send the temperature up to any height. 2. Febricula. — This is merely a Latin name for the fact of pyrexia, but before using the term let every system be carefully examined for signs of disease. It may be that there is absolutely nothing else wrong, and cause No. i may be at work alone. The following is a useful and ordinary average clinical rule : for 622 PYREXIA WITHOUT OBVIOUS CAUSE each 1° F. the temperature rises we may expect the pulse to increase in frequency lo beats (or in children 15) per minute, and the respirations 2 to 3 per minute, and if this ratio is maintained it is fairly safe to say that heart and lungs are neither of them specially threatened, and hence, if there be nothing else to attract attention, it is safe to say that the child is certainly feverish, and we must nurse and watch it. I have known a delicate boy of 9 or 10 thus to have a temperature of 1 02 '5° to 1 03 '5 for three or four days at a time for no reason that I could ever detect ; he ate well, slept well, and felt well ; and this aspect of affairs should be remembered. On the other hand, such temporary attacks of pyrexia may be aroused by the presence of some micro-organisms which have hitherto escaped detection, but qua the pyrexia in itself nothing more can be said. Deep-seated tubercle, perhaps, in internal lymphatic glands, may be suspected, but it will often be exceedingly difficult to settle the diagnosis. 3. Convulsions. — These must be remembered as a possible cause of a tempera- ture of even 103° F. if the thermometer be used at once. 4. Specific Zymotic Diseases. — On discovering a child with fever, suspicion will naturally be aroused that one of these troubles is at hand. The only thing to be said here is : Do not attempt to give a diagnosis on the thermometer alone ; the temperature is raised long before a diagnosis is possible. It is well to note that a temperature of 102° F. only, or less, is a point in favour of diphtheria against a tonsillitis of other causation, which frequently has a pyrexia of 104° F. or 105° F. Slight pyrexia, with headache and vomiting, make us suspect tuberculous meningitis, whereas a temperature of 103° F. or 104° F. with similar associations renders pneumonia probable. In Children and Adults. Here we may draw attention to some of those cases in which the fever of known average departs from its usual course. 1. Empyema. — Suggested by the crisis of a pneumonia, followed in a few days by intermittent or remittent fever. 2. Endocarditis. — Suggested in rheumatism by a temperature of 100° F. to 100-5° F. or 101° F. following the initial fall from the administration of salicylates ; though the absence of such pyrexia does not exclude the existence either of endocarditis or of pericarditis. 3. Hyperpyrexia. — Met with in rheumatism, typhoid, and other septic con- ditions ; its onset is easy to detect in the latter conditions ; in the former, restlessness with less complaint of pain may cause suspicion. The diagnosis must be confirmed by a frequency of registration proportionate to the severity of the initial observation ; two-hourly, hourly, or even quarter-hourly observa- tions may be necessary, that treatment may be controlled. In addition to such obvious causes, it must be remembered that in cerebral diseases and injuries of almost any kind, the temperature may rise to most unusual heights ; one over 104° F. almost certainly heralds a fatal event ; the same is sometimes found in uraemia. 4. Attention may be drawn to the fact that malaria is not quite extinct in England, and a regular succession of pyrexial attacks at the same time of day suggests this cause. 5. Sudden Drops in Temperature. — These are met with in many diseases at times, e.g. typhoid, and the patient must be carefully examined for other sugges- tive factors — -blanching, severe abdominal pain, etc., indicative of haemorrhage, perforation, or other complication. Do not forget that the crisis in pneumonia is a great deal more of a crisis for the patient than it is for his microbes, and be ready with the appropriate stimulants. PYURIA 623 6. Pyrexia and Malignant Disease. — When the nature of a swelling in the liver or elsewhere is being critically considered, it is well to bear in mind that the discovery of a temperature hovering about 101° F., or even higher, does not mihtate at all strongly against a malignant growth, for these frequently give rise to pyrexia, and so, too, but more rarely, may cirrhosis of the liver. 7. In the differential diagnosis of cerebral abscess from tumour it must not be overlooked that a subnormal temperature, contrary to the usual rule of suppura- tion, suggests an abscess rather than tumour. 8. It is well to bear in mind that after an operation, a few degrees of pyrexia, even for forty-eight hours, are not a conclusive proof of infection of the wound. 9. When the source of a continued pyrexia is being sought for, the heart must be carefully examined every day, or even more frequently, for infective endocar- ditis is a by no means infrequent result of gonococcal and other microbic inva- sions, which may be most difficult to detect. Fred. J . Smith PYROSIS.— (See Heartburn.) PYURIA. — Pus appears in the urine in all suppurative conditions affecting the urinary tract, and occasionally from the rupture of an extra-urinary abscess into the urinary apparatus. It may be present in large or in microscopic quantities ; when in bulk it forms a thick, greyish, tenacious sediment, which must be distinguished from phosphates and from urates ; urates are of a pinkish colour, and will be cleared by heating the specimen ; phosphates will be dissolved by the addition of acid, whereas pus will remain unaltered by either test. In alkaline urine, the pus cells tend to run together into a dense viscid deposit, leaving the upper layers of the urine slightly turbid. Urine containing pus will always contain at least some albumin and frequently epithelial cells from some part of the urinary tract. If the specimen containing pus be gently shaken with ozonic ether, a slight effervescence will be produced, or if mixed with liquor potassae, a ropy precipitation occurs. Microscopical Characters of Pus cells in Urine. — The pus cell when present in acid urine is multinuclear, rounded, and about twice the size of a red blood-disc. The contents are granular, but the addition of acid clears the cell and makes the nucleus stand out more distinctly. It may be said, as a general rule, that a small amount of pus in an acid lu^ine is derived from some form of pyelitis, whilst a larger amount of pus in alkaline urine is of vesical origin. There are, however, exceptions to this rule, as for instance, when a pocket of pus is discharged from a pyonephrotic kidney, although usually the pus from a kidney does not show the same viscidity as the pus in the urine of a case of chronic cystitis when alkaline fermentation has taken place in the bladder. The following is a classified list of the causes of pyuria : — {A). From Diseases of the Urinary Organs. 1. Renal : Pyelitis Pyonephrosis Pyelonephritis Tuberculosis Renal abscess Calculus. 2. Ureteric : Calculus. 3. Vesical : Cystitis Tuberculosis, acute or chronic Calculus Ulcer — Simple Epitheliomatous Tumour — Sloughing papilloma Villus-covered carcinoma Bilharzia h^matobia. 4. Urethral : Urethritis — Gonorrhoeal, Septic, Gouty Stricture. 624 PYURIA (B). From Diseases outside the Urinary Organs. Leucorrhoea. Balanitis with phimosis. From the extension of inflammatory processes to the bladder, or the rupture into the bladder or urethra of an abscess such as : — Prostatic abscess Appendicular abscess Ihac or pehic abscess Psoas abscess Pyosalpinx Carcinoma of the pelvic organs — uterus or rectum Carcinoma of the c^cum, sigmoid or pelvic colon Ulceration of the small intestine — tuberculous or dj'senteric. It is impossible to determine the lesion producing pus in the lurine simply by the examination of the latter. Due consideration must be given to the history and the other sj-mptoms of any case, and particular care be taken not to lay too much emphasis upon any sjTiiptom which ma}' point to a vesical lesion when in reality the trouble is in the kidne}'. This is perhaps most likeh- to occur in a haematogenous infection of the kidney by micro-organisms, in which increased frequency of micturition is a marked s\Tnptom, whilst the bladder remains quite free from disease. Occasionally, after pus has been present con- tinuously in the lu'ine for some time, it may disappear entirely, the change being accompanied by increase of pain in the side, by an elevation of temperatiure, or enlargement of the kidney in a case of pyonephrosis, when the obstruction to the flow of urine from that side has become temporarily complete. Very little help is derived from the character of epithelial cells accompan^-ing pus in the urine. The shapes of the cells of the renal pelvis, iu"eter, and deeper layers of the bladder are so much alike, that it is usually impossible to differentiate them. Some assistance in the determination of the origin of the pus in the urine may be gained by instrumental examination : By Catheter. — If a catheter be passed and the bladder washed out with clear solution of boracic acid, it will be found that the medium is soon rendered clear if the pyuria is of renal origin, but that it is much more difficult to obtain a perfectl}^ clear medium if the bladder is the seat of the suppurative lesion. If the medium is quickly cleared, but yet, after some ten minutes retention in the bladder is again found to be turbid, the pus is almost certainly descending from the kidney. The Cystoscope. — Much more certain evidence is gained, however, by a careful cystoscopic examination. By this means it can be determined in the great majoritv' of cases if the bladder is infected or if an}' ulceration is present. In a few cases the bladder may be so affected that only a smaU dilatation is allowed, or bleeding is so easily produced that cystoscopy is rendered futile ; in these cases there will be little need for an inspection of the bladder. If the bladder be found to be normal, evidence of a suppurative lesion in the kidney may be obtained from the appearance of the ureteric orifices or by the variations in the character of the urinary efflux from them. Instead of the normal forcible flow of clear urine from each orifice, mixing with the medium in the bladder in a characteristic swirl, urine containing pus in an}- quantity may be seen emitted, appearing in the field as a smaU smoky puff from the orifice (Plate V, Fig. B) ; pieces of muco-pus may be seen to pass from the orifice, or the turbid urine may be seen to leave the orifice in a gentle trickle instead of a jet if the renal-secreting function is impaired or if renal dilatation is present. Apart from the alterations in the urinary efflux from an orifice, the actual appearance of the orifice may show changes which indicate renal disease. Thus, PYURIA 625 in pyelitis, the margins of the orifice are slightly cedematous and congested, and appear to pout into the bladder (Plate V, Fig. C) ; the mucous membrane of the bladder, immediately below and internal to the orifice, is frequently congested or granular from the effect of the altered urinary flow upon it. If the renal pelvis and ureter are dilated, the orifice is usually elongated and patulous, whilst in tubercle or in diseases in which the ureter is thickened, the whole ureteric orifice is drawn upwards and outwards from its normal situation (Plate V, Fig. D), and is seen at the apex of a conical retracted area in the bladder base. A. The following are the chief Diseases of the Urinary Organs in which pyuria may be present : — I. Renal Disease. Diseases of inflammatory origin. Pyelitis and pyelonephritis may arise as an ascending infection from the lower urinary tract, especially when there is some obstruction to the normal passage of urine. Thus, it is common in cases of prostatic enlargement and stricture. When cystitis is present, it is usually bilateral, although one kidney may show much more advanced disease than the other. Any growth or lesion in the bladder which is accompanied by suppurative infection, and which involves the ureteric orifice, such as vesical epithelioma, or the direct involvement of one or both ureters in the spread of uterine cancer, may set up pyelitis in the kidney, the infection ascending either by the ureter or by the peri-ureteric lymphatics. In this group of cases the primary cause of the disease has usually advanced to a sufficiently late stage to be obvious, and the symptoms of suppurative ascending infection of the renal pelvis or renal tissues are usually overshadowed by the symptoms of the disease causing the obstruction. Aching in the loin, rigors or raised temperature, tenderness on deep palpation in the renal area, or actual renal enlargement, are usually indicative of renal infection. The urine is often increased in quantity, of low specific gravity, and the daily excretion of solids is lessened ; the skin is dry and harsh and the tongue glazed. Pyelitis and pyelonephritis may also arise as an infection of the kidney apart from any other disease in the genito-urinary organs. Infection is conveyed to the kidney by the blood-stream (hsematogenous form), and is not uncommon in acute fevers, or with mild forms of suppuration in other parts of the body, or in association with pregnancy. In the less acute forms a pyelitis may result, as in typhoid fever, but in most cases the hsematogenous infection produces first a suppurative process in the renal parenchyma, from which infection spreads to the calyces and pelvis. This form of disease has been shown by recent work to be due most frequently to the colon bacillus in association with affections of the intestinal canal, less frequently to the staphylococcus, streptococcus, pneumococcus, or typhoid bacillus. The renal pyelitis which ensues when a calculus has ulcerated into the renal pelvis is truly a hematogenous infection. Acute haematogenous infection of the renal pelvis without involvement of the renal parenchvma usually begins with slight rigors, tenderness in the loin, and increased frequency of mictm-ition. The urine is faintly turbid and opalescent, does not settle to a pronounced sediment, but remains of a sheeny appearance. It contains numerous bacteria, a little pus, and a little albumin. When the infection first attacks the renal parenchyma as well as the pelvis, the symptoms are much more severe, and the patient may become rapidly ursemic. In the less acute cases, small foci of suppuration occur, which coalesce to form an abscess, with the general symptoms of suppuration. Renal abscess may also result from injury when an eft'usion of blood in the renal tissues becomes infected by pj-ogenic micro-organisms, or by the breaking down of a renal infarct. Pyonephrosis — or dilatation of the pelvis and calyces of the kidney with pus or with pus and urine — is caused when suppuration has occurred in a kidnej^ which is at the same time subjected to some form of obstruction to the normal passage D 4c 626 PYURIA of urine. Pyonephrosis is most commonly caused by renal calculus or tubercu- losis, but is by no means uncommon with a chronic cystitis, complicating urinary obstruction from an enlarged prostate or stricture. Carcinomatous ulceration affecting a ureteric orifice, either primary in the bladder or by direct extension of uterine cancer, is also a comparatively common cause of pyonephrosis. In contradistinction to suppurative pyelonephritis, the symptoms of pyonephrosis are less severe ; at first they are those of the obstructive lesion causing the disease, to which are added the general symptoms of suppuration. Pyone- phrosis causes a renal tumour of variable size, whilst in the same patient distinct intermittence in size may be observed, a decrease being associated with the discharge of a larger amount of pus in the urine. The urine in suppurative disease of the kidney and its pelvis requires careful examination. It may be normal with a localized cortical renal abscess or with closed pyonephrosis ; in all other lesions it contains pus and micro-organisms. If the pus-cells are found in the form of casts of the renal tubules, infection of the renal parenchyma is present, whilst in this latter the albumin in the urine is in excess of that due to the pus present. Polyuria, with a diminution of the total solids of the urine in a daily examination, is commonly present in inflam- matory lesions of the renal tissue. Renal Tuberculosis. — The miliary form of tuberculosis occurs in children as part of a general dissemination of tubercle, and causes no urinary symptoms. The kidney is, however, attacked not infrequently by primary tuberculous infection, when it is unilateral and begins as a deposit in the form of small tuberculous nodules. These enlarge and coalesce to form a larger caseating area, which eventually opens into the renal pelvis by direct ulceration of a calyx to discharge its contents by the urine, when the lining membrane of the renal pelvis and ureter become infected with tubercle and thickened bj^ submucous infiltration. At first, before ulceration into the renal pelvis has occurred, the symptoms of the disease are very slight ; there may be aching pain in the loin and slight albuminuria, but as soon as the renal pelvis is involved, more marked symptoms occur — including persistent pyuria, lumbar aching, increased fre- quency of micturition, and polyuria. The urine is pale, of low specific gravity, and of opalescent turbidity ; by careful examination after centrifuging, the tubercle bacillus is usually found. A small amount of blood is generally present. The increased frequency of micturition occurs before any descending vesical infection has occurred, and this symptom, accompanied by pyuria, has frequentlj' given rise to a diagnosis of vesical disease. The occurrence in a young adult patient of persistent pyuria which is not due to gonorrhoea, injury, or stone, should always be looked upon with grave suspicion, and a careful search made for the tubercle bacillus ; should this not be found by the microscope, inoculation experiments into guinea-pigs should be conducted. A careful examination of the bladder should also be made by the cystoscope, when vesical tuberculosis may be rendered apparent {Plate V, Fig. E), or the characteristic changes in the ureteric orifice may show the presence of renal infection (Plate V, Fig. D) . By digital examination per rectum, the lower end of the ureter may be felt to be thickened and rigid in renal tuberculosis. Renal tuberculosis is often confounded with renal stone, and the colic which is usually associated with stone may be present in tuberculosis if a piece of caseous debris be passed down the ureter. A skiagraphic shadow of a calculus shows well-defined margins [Fig. 97, p. 309), whereas a tuberculous focus in the kidney may give rise to a faint, blurred, indistinct shadow in the renal area. The presence of tubercle bacilli will, however, determine the existence of tuberculosis, whilst tuberculous lesions elsewhere in the body, most frequently in the testes, prostate, or vesicular seminales, may also serve to confirm the diagnosis. PYURIA 627 The symptoms of renal calculus vary with the position of the stone and the changes that have taken place in the kidney in consequence of its presence. It may be situated in the renal parenchyma, and cause no symptoms beyond lumbar aching ; or in the renal pelvis, when, if movable, it may cause acute renal colic, due either to the attempted passage of the stone by the pelvic outlet or to the increased intrarenal pressure from blockage of the ureter. So long as the kidney remains aseptic the urine contains only a trace of blood in microscopic amount ; but if it becomes infected with micro-organisms, pyelitis, pyelonephritis, or pyonephrosis may result, with their attendant symptoms. Thus, pus only occurs in the urine in a case of renal stone when infection of the kidney has occurred. 2. Ureteric Calculus. — A small renal calculus may become impacted during its passage along the ureter, and may cause some difficulty in diagnosis. The usual situations of the obstructed calculus are in the upper few inches of the ureter, at the pelvic brim, or at the vesical end of the tube ; in most cases the previous history of renal colic and symptoms of renal stone will be sufficient to indicate its partial ureteric descent. A calculus may, however, be present in the upper end of the ureter or at the pelvic brim, and give very few symptoms beyond a fixed pain in the course of the ureter ; in the latter situation it has frequently been mistaken for ovarian pain or for chronic appendicitis. If the stone blocks the ureter completely, the kidney of the same side — in the absence of septic infection — becomes functionless and atrophies ; but if the calculus only partially occludes the lumen of the tube, renal distention will occur, with resulting uro- or pyonephrosis. If, however, the calculus becomes impacted in the vesical segment of the ureter, a train of sj^mptoms occurs simulating vesical stone or vesical tuberculosis ; namely, increased frequency of micturition, penile pain following micturition, and often a small amount of blood and pus in the urine, in addition to the aching pain in the loin. A ureteric calculus impacted in this situation may often be felt in the ureter upon a rectal or vaginal examination ; it may be demonstrated by the x-Ta.ys ; whilst the changes seen around the ureteric orifice, and the absence of a vesical lesion on cystoscopic examination, will confirm the diagnosis. 3. Vesical Diseases. — Pyuria may occur in any lesion of the bladder which is associated with inflammatory changes. The fact that urine is retained in the bladder renders the latter much more liable to septic infection, so that cystitis is common with urethral stricture or prostatic obstruction. Any ulceration of the bladder, tuberculous or malignant, is also accompanied bv inflammatory changes, when pus will be present in the urine. Cystitis may be acute or chronic, and the essential factor of either form is the infection of the bladder by some micro-organism ; any agent which produces either congestion of the bladder or retention of urine, acts as a predisposing cause of cystitis. With acute cystitis the mucous membrane of the bladder becomes oedematous and highly congested, and epithelial desquamation and formation of pus rapidly follow. Haemorrhage may occur from the congested mucosa, or small abscesses develop in it and rupture into the bladder, to leave small area,s of ulceration. In severe cases, patches of the mucous membrane may become gangrenous. The symptoms of acute cystitis are usually distinctive ; frequent and painful micturition, elevation of temperature, pain in the perineum and suprapubic area, with the presence of pus and blood in the urine, which is commonly of an acid reaction. Usually, some distinct cause for the onset of acute cystitis is apparent, such as some form of acute lu'ethjritis or of previous instrumentation, and there is little difficulty in the diagnosis. The same symptoms are, however, produced by an acute inflammation of the prostate which, in nearly all cases, is preceded by acute urethritis ; the presence of swelling of the gland, 628 PYURIA and acute pain on rectal palpation, will determine the presence of prostatic inflammation. Chronic cystitis may succeed acute. The sj^mptoms are less marked^ but increased frequency of micturition is always present. The urine is alkaline, contains pus and mucus, and the disease is commonly associated with some form of urinary obstruction, or with retention or incontinence due to some nervous disease, such as locomotor atax}' or transverse myelitis. The possibility of retroversion of a gra\'id uterus should not be overlooked. The association of pyuria and increased frequency' of micturition, which is present in chronic cystitis, must be distinguished carefully from that due to pyelitis or pj-elo- nephritis, for it has been shown that increased frequenc}^ of micturition may be present without any vesical infection. In renal pyeUtis, the urine is usually acid in reaction, pale in colour, and shows a general turbidity, Avith little inchnation towards a deposit at the bottom of a specimen. The urine of chronic cystitis is alkaline, and rapidly deposits a greyish sediment of pus. In pj^elitis and pyelonephritis, the urine contains more albumin than the pus would account for, and on microscopic examination renal or pus casts are frequently found, whereas in cystitis the albumin is less, and vesical cellular elements are present without casts, unless the kidneys are affected also. Further evidence may be obtained by the use of the cystoscope. In c^'Stitis the bladder wall is found to be trabeculated and the mucous membrane thickened ; it has lost the normal iridescent appearance, and the vessels of the mucous membrane are obscured. With pyelitis, the bladder wall is normal, but the ureteric orifice of the affected side shows the thickened or pouting lips and slighth^ raised area of thickened mucous membrane, whilst the urine flowing from the orifice ma}' be seen to be turbid or to contain small particles of muco-pus. Chronic cystitis may be simulated by an infiammation of the posterior urethra. In such a case, there is almost always a history of urethral infection, and the diagnosis can be made by tirethral irrigation. The patient is directed to retain his urine for some three hours, and after irrigating the anterior urethra as far as the compressor muscle with sterile water or boric acid lotion, the urine is passed into two glasses. With posterior urethritis the urine contained in the first specimen will contain shreds of muco-pus, whilst that of the second specimen is clear ; whereas, with cj'stitis, the second specimen will be as turbid as, or even more turbid than, the first. Tuberculous cystitis occurs usuaUj' in young adults. The characteristic symptoms are increased frequency' of micturition during both da)'' and night, p^Tiria, A\ith pricking pain in the glans penis at the end of micturition, and the appearance of a few drops of blood in the last drops of urine. The same symptoms are often present with vesical calculus and with vesical epithelioma, when ulceration has taken place. Vesical calculus is usualU" present in older patients, and during the earlj- part of the illness, before cystitis has set in, the calculus only gives rise to desire to micturate during movement, and to penile pain. When cystitis supervenes, the frequency of micturition will be marked during both day and night. Vesical epithelioma also occurs in older patients, and when ulcerated may cause hagmaturia ; frequently the diagnosis may be made by the palpation per rectum of an indurated area in the bladder base, or of some enlarged glands in the pelvic h-mphatic space. Tuberculous cj-stitis in the early stages, when the disease is characterized b}- the deposition of greA'ish tubercles in the submucous coat of the bladder, may give rise to increased frequency of micturition without other sj'mptoms, but in the progressive advance of the disease the tubercles enlarge, coalesce and ulcerate on the surface, by which time pus and blood will be present in the urine, and tubercle bacilli should PYURIA 629 be found. It -may be taken as a general rule that in any patient of young adult life with increased frequency of micturition and pyuria, a careful search should be made for tubercle bacilli in the urine, and for other tuberculous lesions, especially in the testes, prostate, or vesiculae seminales. Tuberculous cystitis is less often a primary disease than secondary to other lesions in the genito-urinary apparatus — most commonly to tuberculous disease of one kidney, when, after the primary focus has ruptured into the renal pelvis, the lining membranes of the latter, of the ureter and of the bladder become successively affected. The diagnosis between primary renal and primary vesical tuberculosis is very often difficult, for it has been shown that when the renai focus has ulcerated into the pelvis, and descending infection has commenced, the symptoms of the two affections are very similar. Thus, with renal disease, persistent pyuria, increased frequency of micturition, and penile pain at the termination of urination, may be present before the bladder shows any sign of disease ; blood is usually present in small quantity in the urine, but its amount is not so definitely greater in the urine passed at the end of micturition as is the case in vesical disease. In renal tuberculosis there may be tenderness in the loin, the kidney is usually enlarged, and the lower end of the ureter can be felt distinctly thickened upon rectal or vaginal examination. The two conditions can usually be diagnosed by a careful cystoscopic examination. In vesical tuberculosis the deposition of submucous tubercles, together with the shallow ulceration in the bladder mucous membrane, may be seen {Plate V, Fig. E), whilst in renal tuberculosis, changes may be seen in the ureteric orifice of the affected side {Plate V, Fig. D). At first the orifice becomes thickened, oedematous, and slightly patulous ; but later it is rigid and patent, or drawn up by the shortening of the ureter to occupy a position above and outside the normal situation in the trigonal area of the bladder, or drawn up to the apex of a conical retraction of the bladder base. When tuberculous cystitis is secondary to lesions in the testes, prostate, or vesicles, the disease commonly begins in the epididymis of one side, and spreads to the vesicle or prostate, whence a focus may directly ulcerate into the bladder. The patient will first notice increased frequency of micturition and vesical pain, followed by an attack of haematuria when actual ulceration into the bladder base occurs ; the formation of a tuberculous tilcer in the bladder leads to pyuria and the other sj^mptoms mentioned above. This sequence is by no means uncommon ; the history of testicular disease and the evidence obtained by rectal examination will serve to indicate the nature of the condition. Vesical calculus may give rise to pyuria when it is accompanied by cystitis, but may be present a long time before any inflammatory infection occurs. When cystitis is present, the urine shows no features which will distinguish it from that of patients suffering from some other form of cystitis, except that there may be a constant presence of crystals, or' an increased amount of blood after exercise. The constant symptoms of vesical calculus are vesical irritability during the day time, penile pain after micturition, and haematuria, especially after any exercise. If the presence of a calculus is suspected in the bladder, an examination by the ;i;-rays {Fig. 98, p. 312), a sound, or the cystoscope, will reveal it. Rontgen rays will detect even a uric-acid stone ; the cystoscope may detect a stone that is in a diverticulum, partially encysted or Ijdng in the pouch behind an enlarged prostate, where it may easily be overlooked in searching the interior of the bladder with a sound. Ulceration of the urinary bladder, apart from tuberculosis and epithelioma, occurs as a simple ulcer, consecutive to chronic cystitis, or as the result of injury. A single non- tuberculous ulcer, similar to gastric ulcer, has been described as occurring in young adults in the neighbourhood of the ureteric 630 PYURIA orifices, causing haematuria and painful frequent micturition. Later, the surface of the ulcer becomes encrusted with phosphatic material, when the urine contains muco-pus, and often small flakes of phosphatic debris from the surface of the ulcer. This single ulcer is rare, and can only be diagnosed by the use of the cystoscope. Ulceration may also occur in the bladder as a result of severe cystitis, when necrosis has occurred in the mucous membrane. This condition is occasionall}^ present in a case of obstinate cystitis, giving rise to painful and frequent micturition, and may be diagnosed by means of the cystoscope. Both the simple and the consecutive ulcer must be differentiated from tuber- culous ulceration of the bladder ; in the latter, haemorrhage is usually slight, and occurs at the termination of micturition ; tubercle bacilli may be found in the urine, or other deposits of tubercle found in the epididymis, prostate, or seminal vesicles. The cystoscopic appearance of tuberculous disease, and its more generalized distribution in the \-esical wall, will afford the strongest evidence in the diagnosis. Malignant ulceration of the bladder occurs in two distinct forms : [a) The infiltrating epithelioma ; {b) The villus-covered carcinoma. {a). The infiltrating variety occurs as an ulcer, with raised edges and uneven necrotic surface, placed usually at the basal portion of the bladder. It is usually met with in men over fifty years of age, causing increased frequency in micturition, pain at the glans penis following micturition, with blood and pus in the urine. The bladder-wall in the vicinity of the ulcer is denselj' infiltrated, and frequently can be felt on digital examination by the rectum, whilst at the same time the lymphatic glands in the pelvic space may be felt to be enlarged. {b) The villus-covered carcinoma of the bladder is not uncommon, and gives rise to irregular profuse haemorrhages. The tumour is attached to the bladder by a broad pedicle, or may be entirely' sessile and covered by blunted villi, presenting a coarsely mammilated surface. It occm-s in elderly patients, and the tumours are frequently multiple. The surface is often necrotic, giving rise to pyuria. The diagnosis is not difficult, the frequently recurring haemorrhages m the urine, associated with increased frequency of micturition, pain, and pyuria in an elderl}^ patient, being fairly distinctive. IS^ot uncommonly there is unilateral renal aching from the interference, by the position of the growth, with the flow of urine from one ureteric orifice, so that renal disease may be suspected ; but in all cases a careful cystoscopic examination will show the nature of the disease. Difficulty may be experienced in obtaining a satisfac- torily clear medium for a cystoscopic view, but in most cases this can be accomplished by gentle manipulations, or by the use of a styptic such as adrenalin I- 1000, or silver nitrate i-iooo. Difficulty may be found in distinguishing cystoscopically between a benign papilloma and villus-covered pedunculated carcinoma ; but the broad attachment of the latter to the bladder, the stunted villi covering it, and the multiplicity of the tumours, will be signs of malignant disease [Plate VI, Fig. F). In rare instances a benign papilloma may begin to slough on the surface, or may be accompanied by cystitis, when pyuria will be present. A cystoscopic examination will reveal the diagnosis. Microscopical examination of the urinary deposit may show distinctive fragments of new growth. Bilharzia hcsmaiobia may cause pus in the urine in advanced cases. When the small nodules in the submucous tissues (Plate VI, Fig K) of the bladder ulcerate, sm.all fungating masses are found in the bladder. The typical ova in the urine {Fig. 13, p. 93), in addition to pus and blood, will be found on microscopical examination of the urinary sediment. 4. Urethral Causes. — Any condition which sets up a purulent urethritis will cause pyuria. If the urethritis is recent or profuse, the local condition will be PYURIA 631 enough to indicate the diagnosis, but it must be remembered that cystitis may complicate a case of urethritis by direct backward infection. If, in addition to urethral discharge, there is increased desire to urinate, suprapubic pain, or haematuria, acute cystitis is probably present. The anterior urethra should be irrigated well with sterile water or boric acid lotion, and the patient then directed to pass urine into two glasses. If the first portion passed contains pus and the second is clear, infection is present in the posterior urethra and not in the bladder, but if both specimens are turbid with pus, cystitis is present. The onset of acute prostatitis complicating urethritis gives rise to increased desire to micturate, and perineal and suprapubic pain, in addition to pyuria, or may cause retention of urine. Digital examination of the prostate, per rectum, will show the prostate to be acutely inflamed, enlarged, and very painful. A small amount of pus may be present in the urine in cases of chronic urethritis which is not sufficient to cause any visible discharge from the meatus. The anterior urethra should be irrigated well, and the urine again passed into two separate glasses, when, if the first washings from the urethra contain pus, there is infection in the anterior urethra ; if the first specimen of urine contains pus but the second is clear, there is infection in the posterior urethra ; whilst if both contain pus, cystitis is present. In any case of urethral discharge, a bacterio- logical examination should be made for the organism causing the infection, for it is far from uncommon to find that an apparent gonorrhoeal urethritis is in realit}^ due to staphylococcal infection. Pyuria is commonly present in cases of stricture of the urethra, from the co-existing urethritis or cystitis. B. Pyuria caused by Disease outside the Urinary Organs. — Pus may be present in the urine, apart from any disease in the urinary apparatus, either b}- accidental contamination of the urine, or by the direct spread of inflam- matory or carcinomatous processes from neighbouring organs to the urethra, the bladder, or more rarely the ureter. In the male, the accumulation of pus behind a phimosis may account for pyuria, or in the female a leucorrhoeal discharge may contaminate the urine. In the latter case the vulva should be cleansed well with an antiseptic, and a catheter passed to obtain a specimen for examination. The spread of inflammatory processes, or the actual rupture of an abscess into any part of the urinary tract, will cause pyuria, and may create considerable difficulty in diagnosis. If symptoms pointing to urinary trouble, such as markedly increased frequency of micturition or slight hasmaturia, be followed by the sudden appearance of a quantity of pus in the urine, there is strong probability of the rupture of an extra-urinary abscess into the bladder or urethra, provided that the sudden emptying of a renal abscess or a pyonephrosis can be eliminated. Frequently the history of any case will give some indication of the primary trouble, of which the most frequent are prostatic abscess, appendical abscess, pyosalpinx, psoas, iliac, or pelvic abscess. Prostatic abscess is most frequently a sequela of an acute urethritis which has infected the posterior rurethra and caused an acute prostatitis. It may be due to a gonorrhoeal or to a septic venereal infection, or may result from septic instru- mentation in the urethra. An acute prostatitis is very prone to result in the formation of an abscess which may rupture into the urethra, bladder, or rectum, unless appropriate surgical measures be undertaken. The onset of acute pros- tatitis is marked by increasing desire to micturate, pain in the perineum and hypogastric areas, and raised temperature, whilst, per rectum, the prostate is felt to be uniformly enlarged and very tender. If an abscess result, there may be rigors and increased difficult}^ in micturition, even retention of urine, whilst a 632 PYURIA soft area may be felt in the prostate from the rectal aspect. A prostatic abscess may occur more rarely in connection with a prostatic calculus ; it may open into the urethra or bladder, or may be present in advanced genito-urinary tuberculosis, when a prostatic focus may caseate and ulcerate into the trigonal area of the bladder, a condition which is usually accompanied by a sharp attack of hematuria. A tuberculous focus in the prostate is commonly a compara- tively late feature in the disease, and the presence of nodules in the epididymis or seminal vesicles, or the previous knowledge of vesical tuberculosis, will assist very largely in the diagnosis. Pyuria in Inflammation of the Vermiform Appendix. — In the usual position of the appendix the bladder is commonly not affected ; but if the appendix passes downwards across the pelvic brim, it is not uncommon to find that, should it become inflamed, the patient complains of frequent and painful micturition. The appendix may be adherent to the bladder, when the latter will show on cystoscopic examination a localized area of acute congestion on the right lateral wall, and both pus and blood may be present in the urine ; further, a small abscess may be formed in the adhesions betw^een the appendix and the bladder, ulcerating into the latter and giving rise to pyuria. Two such cases have come under the care of the writer, when the association of frequently recurring attacks of pain low down in the right side of the pelvis, with increased frequency of micturition and pyuria, had given rise to the suspicion of ureteral calculus. In each case a cystoscopic examination showed a normal ureter, and a small ulcer in the right lateral wall of the bladder, surrounded by an area of acute cystitis. The diagnosis of these cases is by no means easy ; in the first place the situation of the pain is lower in the pelvis than is usual with appendicitis, whilst the association with urinar^^ symptoms rather points to vesical disease ; but the character of the onset of the trouble, with elevation of temperature and pulse-rate, and right-sided abdominal rigidity, will point to an acute intra-abdominal lesion. In other cases, again, an abscess resulting from appendicular suppuration may track . down into the pelvis and, if unopened, may rupture into the bladder. In these cases, there will be the usual history of acute appendicitis, followed by a tumour in the right iliac fossa or pelvic space, with a continuance of pjTexia, or even rigors, which subside on the appearance of a large quantity of pus in the urine. A pyosalpinx may rupture into the bladder or cause cystitis from the direct spread of the inflammatory process to the bladder. There will usually be a history of leucorrhoea, with constant aching or dragging pains in the lumbo-sacral region, aggravated at intervals with more severe attacks of pain and malaise, The periods may be profuse and associated with more pain than usual, and on vaginal examination a distinct fullness or tumour may be felt in one or both fornices. Psoas or iliac abscess may rupture into the bladder, and a psoas abscess has been known to open into a ureter ; but the swelling in the iliac fossa or inguinal region, together with signs of spinal caries, will point to the condition. Carcinoma of the neighbouring organs in the pelvis frequently attacks the bladder by the direct spread of the growth. This is most common in carcinoma of the uterine cervix and of the rectum, but may result from cancer of the pelvic colon, sigmoid, or caecum. In any case, the spread of the disease to the bladder occurs late in the disease, so that symptoms of the initial trouble are sufficiently manifest to point to the diagnosis. The implication of the bladder is first shown by an increased desire to pass urine, and by pain during the act ; later, when the growth has actually infiltrated the vesical mucous membrane, ulceration into the bladder occurs, with the passage of pus and blood in the urine. If the growth has extended from the uterus or vagina, there may be a leakage of urine REACTION OF DEGENERATION 633 into the latter ; or if from the rectum or colon, some fseces or flatus may be passed per urethram. Tuberculous or dysenteric ulcers of the small intestine have in some instances become adherent to the bladder wall, and caused cystitis by direct spread, or liave even perforated into the bladder. r. h. focelyn Swan. RAINBOW VISION.— (See Vision, Defects of.) RASHES. — (See Erythema ; Pustules ; Vesicles, Etc.) REACTION OF DEGENERATION.— In testing muscles and nerves elec- trically, two different kinds of current are employed, namely : faradic, in which there is a very rapid alternate making and breaking of the current, and the .galvanic, in which the current flows continuously until it is voluntarily interrupted by the operator. The faradic current continuously excites the nerve and muscle all the time it flows ; the galvanic current only excites when it is made and ■when it is broken ; not whilst it is flowing. In the case of the faradic current there is no difference between the poles, each being alternately an anode and a kathode many times a minute ; in the galvanic current, on the other hand, the pole connected to the zinc of the battery is known as the kathode, and it is by this pole that the current leaves the body, whilst the other pole is known as the anode, and by it the current enters the body. When testing muscles •or nerves, it is usual to have one pole in contact with an indifferent part, such as the spine, and the other over the motor point of the muscle or nerve to be tested. Broadly speaking, the best spot for stimulating a nerve is the place •where it is most superficial, and for a muscle, over the site of entry of its motor nerve. It is important to have the skin well wetted, in order to minimize its resistance to electrical conduction ; and the strengths of current required to produce contractions should be measured by a galvanometer, without which the relative excitabilities of the nerves and muscles of the two sides of the body cannot be compared. Under normal conditions, both faradic and galvanic currents produce brisk contractions of a muscle when applied either to it or to its nerve ; and with galvanism it is found that a weaker current will suffice to evoke a contraction on making the circuit when the kathode is on the muscle or nerve than when the anode is similarly employed. This is usually summarized by the formula K.C.C. > A.C.C., which means " the kathodal closure contraction is more easily obtained than is the anodal closure contraction." When the nerve is degenerated, however, there is a change in these electrical reactions, and when there is complete reaction of degeneration — -often written and spoken of as R.D. — stimulation of the nerve itself evokes no muscular contractions whether the faradic or the galvanic current is employed, stimulation of the muscle evokes no contraction when the faradic current is used, whilst with galvanism the muscle can still be made to contract, though its method of response differs from the normal in the following respects : — • 1. It may sometimes be evoked by a strength of current less than the healthy minimum. 2. The twitch of the contraction is slow and sluggish, instead of brisk and quick. 3. It may be evoked at least as readily when the pole upon the muscle is the anode as when it is the kathode ; this is expressed by the formulH; A.C.C. = K.C.C, or A.C.C. > K.C.C, which mean that the anodal closure contraction is obtained from quite as small a current as is the kathodal closure contraction, or even from a smaller current than the minimum required for the kathodal closure contraction. 634 REACTION OF DEGENERATION In this connection, however, two distinct considerations require to be clearly understood. In the first place, if a given nerve were cut across with a knife, there would be no immediate R.D. ; it takes a week or more for the process of nerve degeneration to reach the stage that produces R.D. ; it then depends upon what happens to the nerve how long the R.D. persists ; if regeneration occurs, it takes from t\velve weeks onwards to complete itself, and R.D. will be found all that time ; if the nerve does not regenerate, then R.D. may persist for t«-o or three vears or more, provided that the muscle fibres are kept, by massage and electrical treatment, from becoming mere strands of fibrous tissue. Should the latter change ensue, there will be no more electrical response in the fibrous tissue that used to be muscle than there would be in any other fibrous tissue. In the second place, it happens, as often as not, that when some fibres in a nerve trunk degenerate, others do not. and the same apphes to the corresponding muscle fibres. It foUows that there wiU then be a mixed reaction, the normal fibres giving a normal response, the degenerated fibres giving R.D. ; the greater the proportion of degenerated fibres, the nearer will the reactions obtained approach to complete R.D., and vice versa. The result is spoken of as partial R.D. ; some excitabilitv- both of the nerves and of the muscles to faradism remains, but it is less than normal ; the nerve responds to galvanism, but not so readilv as does the muscle when the latter is stimulated directly ; the response of the muscle wUl be less brisk than normal, and yet K.C.C. may still be more easily obtained than A.C.C. It is by no means eas}' to be sure of the interpreta- tion of a partial R.D., but partial is commoner than complete R.D. The chief use of R.D. is in distinguishing cases of muscular atrophy that are due to organic changes in the lower neurone from other cases of atroph}', especially when the latter is due to general wasting from cachexia, or to arthritis,, or disuse, or a priman,' muscular dystrophy. When R.D. is present there is a lesion in the lower neurone, either in the anterior cornual cells, in the anterior nerve roots, or in the peripheral motor nerve fibres. The differential diagnosis of the various affections of these parts is discussed under Atrophy, Muscular. It remains to add that there are a few maladies in which the electrical reactions are pecuhar, though they do not present R.D. In tetan}', for instance, Erb has shown that A.C.C. is often greater than K.C.C, although in other respects the reactions are normal. In Thomsen's disease there is variabilit}^ in the polar responses, but excitability- to faradism remains. In some cases of Raynaud's disease, and in angio-neurotic oedema and allied vasomotor neuroses, there may be variations from the normal galvanic reactions. In myasthenia gravis [Figs. 83, 84, p. 2G1) it is characteristic that, whereas the affected muscles respond readily to the first few faradic stimuli, the contractions rapidly diminish in size and cease after a few minutes, notwithstanding the continuance of stimulation. After a period of rest this myasthenic reaction is obtainable again, and so on. This t3^e of electrical response corresponds precise!}^ to the rapid fatigue of the voluntan.- muscle movements, and the diagnosis is not difficult, though the disease is rare. Herbert French. RECTUM, ABNORMAUTIES FELT PER. Method of Examination. — The patient should be placed in a good light and on a couch of convenient height. With male subjects the position recommended is the knee-elbow, and with females the right lateral with the knees flexed and the right arm drawn behind the back. The examination should be made with the left hand, lea\ing the right free for manipulations. Most diseases of the rectum are situated within two inches of the anus. It is advisable, therefore, that to begin with, the finger should be inserted as far as the first joint onl}'. RECTUM, ABNORMALITIES FELT PER 635 and the lower inch of the bowel examined thoroughly. The examination must not be concluded until the finger has been passed up as high as possible and the whole of the rectum within reach explored, as well as the coccyx, sacrum, ischio-rectal fossae, and adjoining viscera. The rectal speculum and the sigmoidoscope may also be needed to complete the examination. If any abnormality be felt, the first thing to ascertain is (i) Whether it lies free in the lumen or is attached to the wall of the rectum ; (2) Whether it is some abnormality of an adjoining structure or viscus that can be felt through the rectum. I. — Abnormalities lying Free in the Lumen or Attached to the Wall OF the Rectum. A. Foreign Bodies. — Though faeces can hardly be considered as foreign to the rectum, yet a hard, scybalous mass, enterolith, or hair-ball may amount to an abnormality. True foreign bodies include those that have been introduced through the anus, and those that have been swallowed. Examples of the first class are seldom met with, and then are generally in persons of weak intellect. Thieves sometimes employ the rectum as a hiding-place for stolen goods. The majority of foreign bodies felt per rectum have been swallowed, and consist of fishbones, pins, needles, and splinters of wood. Their importance lies in the fact that they may cause a rectal or ischio-rectal abscess, and in treating such a case their discovery and removal is essential for a complete cure. B. Swellings of the Rectum projecting into the Lumen. 1. Internal Haemorrhoids are rarely palpable to the finger unless chronically inflamed, thrombosed, or gangrenous. If palpable, they will be felt immediately inside the anus, and can easily be hooked out with the finger and made to protrude through the anal orifice for inspection. The existence of piles having been, diagnosed, an effort should be made to see if there is any causative condition, such as a carcinoma in the bowel above. 2. Abscess (submucous) gives rise to a more or less elongated, smooth, elastic swelling in the rectal wall. It is intensely tender, the slightest pressure causing great pain. The mucous membrane may feel hot, and pit on pressure. If the abscess has burst or bursts during examination, the finger on withdrawal will be covered with pus. An abscess that has already emptied itself feels like a small pea or bean in the submucous tissue. 3. Polypus is a term used to designate, without reference to its histological characteristics, any benign tumour that is pedunculated. Almost all innocent tumours in this position, even if sessile at the beginning, become pedunculated owing to the downward pressure of the faeces. The passage of blood and mucus, combined with the absence of piles and carcinoma, should lead one to suspect the presence of a polypus. It may not be easy to feel, because its consistency is much the same as that of the mucous membrane, and further, its peduncle may allow such free movement that it may easily be mistaken for a small mass of faeces. The best way of fixing these growths is to sweep the finger round and round the whole circumference of the rectum up to the highest point attainable. The growth is then arrested by the pedicle, and the finger can be hooked round it, so that the growth is drawn down and, if possible, made to protrude through the anus. If the polypus is large, a rectal speculum may be of service. It is to be remembered that polypi are often multiple. 4. Ulcers, unless malignant or chronically inflamed, can rarely be felt with the finger ; they must be exposed to view with the speculum. They may be tuberculous, gummatous, traumatic, or due to ulcerative colitis or dysentery. 636 RECTUM, ABNORMALITIES FELT PER 5. Carcinoma occurs usually in people over forty. Its commonest site is within the four terminal inches of the bowel. The exploring finger feels a swelling in the wall of the rectum, and unfortunately', because patients do not present themselves early for examination, the swelling will be large. The great characteristic is that it is hard, fixed, irregular, and nodular. The extent of the growth varies, of course, with the stage of the disease : it may involve onl^'- a small part of the circumference of the bowel, or may extend right round so as to occlude the lumen and cause a stricture. The growth is usually disinte- grated on the surface, forming a malignant ulcer ; this surface is friable and bleeds easily. There is nearly alwaj's a belt of normal mucosa between the internal sphincter and the neoplasm. Not only the lateral but the upper limit of the growth is to be ascertained by inserting the finger to its extreme limit, care being taken not to split the mass. Another point to be gauged by a rectal examination, is the degree of infiltration as measured by the fixity of the tumour to the neighbouring struc- tures e.g., sacrum and coccjrx. Following the rectal examination, the abdomen is to be palpated for evidence of infection of the inguinal, pelvic, and lumbar glands, and the existence of secondary deposits in the liver. The clinical symptoms of carcinoma of the rectum are ver}' suggestive. The patient generally complains of diarrhoea, the bowels being open five to twenty times a day, and this may have followed on a period of constipation. Xotwith- standing the apparent diarrhoea, the total amount of faeces passed is very small, and no sense of satisfaction is obtained by the patient after stool. The action of the bowels may be so rapid as to merit the description " explosive diarrhoea." Haemorrhage from the bowel is a common symptom, and in the later stages there is a discharge of mucus. Pain is complained of — a dull aching pain in the rectum and at the bottom of the back, which is not made much worse by the passage of a motion, quite unlike the sharp temporary excruciating pain associated with an anal fissure or ulcer. Emaciation is rapid, and a history of wasting and diarrhoea in a middle-aged patient should always lead to a careful examination of the rectum, and if nothing is to be felt with the finger, a sigmoidoscope should be used. A carcinoma is likely to be overlooked from care- lessness and from not making an examination. ^listakes may, however, arise between carcinoma and an adenomatous polypus or ulceration, either traumatic or tuberculous, around which much long-standing inflammation has caused thickening. The facts that a carcinoma is hard, the surface often excavated, and the edges nodular and everted, are generally sufflcient. If real doubt exists, a piece of the ulcer may be removed for microscopic report. 6. Intussusception. — Occasionally a piece of intussuscepted bowel maj" come down so far as to be felt per rectum. This condition is associated with the passage of blood and mucus, and therefore might be mistaken for a disease of the rectum proper. The fact that intussusception occurs nearly always in children, especially at the age of nine months or thereabouts, and causes intes- tinal obstruction, should make such a mistake easily avoidable. \ C. Stricture due to a carcinoma is dealt with above, but a few remarks re: to be made about fibrous stricture. This may be present at the anal orifice^ at the level of the upper border of the internal sphincter, or three to four inches up the rectum. It may be annular or tubular. The finger meets with a firm cord-like constriction, which perhaps will not allow the entrance of more than its tip ; there will be no bleeding unless the finger is forced through the stenosis and the mucous membrane torn. D. Fistulae, either recto-vaginal or recto-vesical, whether congenital or acquired, maj^ be felt with the finger. The passing of urine or faeces by abnormal passages indicates the complaint. RECTUM, ABNORMALITIES FELT PER 637 E. Malformations of the Rectum. — Some children are born without an anus, or without the lower portion of the rectum, or the finger introduced may be stopped by a membrane separating the upper from the lower portion of the bowel. The diagnosis is obvious. The usual types of abnormalities are shown on the accompanying diagrams, Figs. 170- 173, reproduced from the Medical Annual, iQio : the figures are a summiary by Dr. A. Keith of a series of 54 cases in male, and 52 cases in female, children. Fi£: 170. — Sagittal section of the pelvis of a male child, showing the rectum opening into tlie prostatic part of the urethra. A Bladder ; B rectum ; C recto-vesical pouch ; D uterus masculinus ; E intracloacal anus ; F prostate ; G proctodaeum ; H external and internal sphincters ; I Cowper's gland. /^!^. 171. — Illustrating the degrees of imperfection in the male. The rectum is shaded ; the various degrees make tip a series between the proctodaeum and base of the prostate. F/^. 172.— Sagittal section of the pelvis of a female infant, showing the rectum opening into the navicular fossa of the vulva. A Bladder ; B rectum ; C recto- uterine fold : D symphysis pubis ; E vulva-anus ; F cer- vix ; G proctodaeum (rarely present if the rectum opens into the vulva) ; H urethra ; I clitoris ; K hymen. 7^!£: 173. — Illustrating the common varieties of malformation in the female ; the various degrees make up a series between the proctodaeum and the recto- uterine fold. 638 RECTUM, ABNORMALITIES FELT PER II. — Abnormalities of some Neighbouring Structure or Viscus FELT through THE RECTUM. It does not lie within the scope of this article to give the differential diagnosis of all the morbid conditions that can be felt through the rectum ; it suffices to take the structures within reach of the finger, and indicate the varying conditions in which a diagnosis may be aided by a rectal examination. On the Anterior Wall the structures that can normally be felt are the prostate in the male, and the uterus in the female. Prostate. — Any enlargement is easily felt. An adenoma is the commonest form. This is soft, elastic, and has a groove in the middle line. A carcinoma or sarcoma is hard and fixed, and the outlines are blurred. A prostatic abscess causes a marked painful protrusion into the rectum. The VesiculcB Seminales are not palpable normally. The fact that they can be felt is almost sufficient to declare them diseased. They are most commonly affected in connection with tuberculosis of the testes or from present or past gonococcal vesiculitis. The Bladder is not felt if healthy. If greatly distended it may form a tense resistance in the anterior wall of the rectum. Rarely, a large stone or a malignant growth of the floor may be felt. The Uterus is easily palpable. Any enlargement or retroversion can be recognized ; the pressure of a foetal head may occlude the rectum. The Vagina cannot be felt unless it is occupied by a foreign body such as a pessary, or is the seat of a growth. The Ovaries, if enlarged by cystic disease or by new growth, may come within reach of the finger ; pyosalpinx is often a bilateral affection in which the inflammatory masses can be felt per rectum in Douglas's pouch ; they can be detected more readily by vaginal examination, however, when this route is permissible. Through the posterior wall the only structures that can be recognized are the coccyx and sacrum. The Coccyx may be found bent in and pressing on the rectum. In coccy- dynia any movement of the coccyx may cause great pain. The Sacrum may be the seat of either a growth or an abscess, which will cause a bulging into the posterior wall. ^ On the two lateral surfaces no structures are\normally recognized. The ischio-rectal foss« are common sites for abscesses, ati4 these can be felt as tense swellings pushing in the wall. Rarely an aneury^rn-. of the internal iliac artery or a stone in the lowest portion of the ureter may be felt.^. If anything is felt with the tip of the finger through the uppe^portion of the rectum, it will usually be something distending Douglas's pouchr — This may be blood coming from a ruptured or leaking ectopic gestation, or, more likely, a localized abscess, either parametric or arising from a septic Fallopian tube or the vermiform appendix. In some cases, an abscess in this position may exert such pressure on the rectum as to cause intestinal obstruction. Some surgeons state that they are able to detect the appendix if it is hanging over the brim of the pelvis, but to do this the finger must be long and the senses very acute. Sometimes, when there is doubt as to whether symptoms arising in connec- tion with a more distant organ, e.g., the stomach or the gall-bladder, are due to malignant disease or not, rectal examination affords valuable evidence of malignancy even when there arc no pelvic symptoms at all. When secondary deposits have arisen, they develop not infrequently in the pelvic peritoneum. REGURGITATION OF FOOD THROUGH THE NOSE 6^9 presumably as the result of gravitation of malignant particles into Douglas's pouch. These latent secondary deposits can sometimes be felt very definitely .as a firm band or shelf — the " rectal shelf " — if the observer's index finger is a fairly long one. . George E. Cask. RECTUM, BLOOD PER. — (Sec Blood per Anum ; and :Mel.5xa.) REDUPLICATION OF HEART SOUND. — It very seldom happens that the diagnosis in a particular case is influenced to any marked degree by the presence or absence of reduphcation of either heart sound ; nevertheless, the reduplication is sometimes so definite that it attracts special attention and needs interpretation. It has to be distinguished from other triple sounds, particu- larly from the canter-rhythm that occurs most commonly with acute peri- carditis, and less often with dilatation of the heart from fatty change, especially in pernicious anaemia and other conditions of oligochromeemia ; and from the beginning of a mid-diastolic bruit at the impulse in a case of acute rheumatic endocarditis of the mitral valves. One can lay down no rules as to how these various sounds are to be distinguished ; it can only be done by having heard them in other cases ; sometimes, indeed, opinions differ as to whether the sounds heard in a given patient are due to a bruit or to a reduphcation. Reduphcation of the first sound is rare, and to all intents and purposes it never occurs except at or near the impulse ; it indicates some abnormahty, but does not specify exactly what that abnormahty may be. If there is no bruit, the commonest cause is great hj'pertrophy of the left ventricle from granular kidney or arteriosclerosis, indicated by the big heart, high blood- pressure, urinary and retinal changes. Reduplication of the second sound is common, especially in the pulmonary area (second left intercostal space close to the sternum). It generally indicates great relative increase in the intrapulmonary blood-pressure, so that the pulmonary valves close a fraction sooner than the aortic ; the reduplication may alternate with simple accentuation (see p. i), the commonest cause being mitral disease, especially mitral stenosis. Similar reduplication of the second sound may be heard at the impulse also in these cases, though more often the second sound here is weak or inaudible. The commonest cause for reduphcation of the second sound at the impulse is great relative increase in the systemic blood-pressure — especially in cases of arteriosclerosis or granular kidney. The second sound in the aortic area (second right intercostal space close to the sternum) is generally very loud and at the same time ringing, or even reduph- cated also if the pulmonary second sound is of its ordinary loudness. There are no other really important causes of reduplication of either of the heart sounds. Htibc-yt French. REFLEX, PLANTAR.— (See Babinski's Sign.) REFLEX, PUPILLARY. — (See Pupil, Abnormalities of the.) REGURGITATION OF FOOD THROUGH THE NOSE.— This occurrence may be but a temporary accident, the result of an unsuccessful attempt to stave off a sneeze, a cough, or a burst of laughter when the mouth is full of food or Huid. It may also result from an explosive return of gas from the stomach or oesophagus, particularly after drinking gassy fluid such as soda-water, champagne, ginger-beer, cider, or beer. In such cases the diagnosis is generally obvious. Repeated regurgitation of food through the nose results from two main groups of causes, namely : — 640 REGURGITATION OF FOOD THROUGH THE NOSE A. Structural Imperfections of the Palate : — (a) Congenital : cleft palate (b) Acquired perforation : (i.) traumatic, (ii.) syphilitic, (iii.) malignant, (iv.) tuberculous. B. Paresis or Paralysis of the Soft Palate or of the Pharynx : — {a) Post-diphtheritic (e) The result of pseudo-bulbar [b) Post-operative paralysis (c) Syphilitic ' (/) Cases of undetermined cause. {d) The result of bulbar paralysis Simple inspection of the roof of the mouth is generally sufficient to decide whether the cause belongs to group A or to group B. The median and sym- metrical imperfection of a congenital cleft palate is obvious, and there is the history of the trouble dating from birth. There may be a harelip or other congenital abnormality at the same time. ^Vhen an ulcerative process is still in progress, there may for a time be some doubt as to whether it is syphilitic, malignant, or tuberculous. The history may help, or the healing of the ulcer under the influence of mercury or iodide of potassium may indicate its syphilitic nature. If it is important to arrive at the correct diagnosis as earl}' as possible, a small portion of the pathological tissue may be excised and examined microscopically, or some assistance may be derived from the application of Wassermann's serum test, or by direct examination of scrapings from the ulcer for the Spirochcsta pallida or for tubercle bacilli. Tuberculous ulceration of the palate is very rare', and is generally associated either with lupus or with definite phthisis. A new growth of the palate may be either epithelioma, endothelioma, or sarcoma, the distinction between these depending mainly on the microscope. Diphtheria If there is no structural defect of the palate, the regurgitation of food through the nose being due to paralysis, by far the most likely cause, when this is the chief symptom, is previous diphtheria. The existence of the latter may have been recognized at the time, but quite often the diphtherial attack has been so slight as either to have caused no definite illness at the time, or else to have been regarded as simple sore throat. The palate alone may be paralyzed, giving rise to a nasal alteration in the character of the voice, as well as to the regurgitation ; or there may be paresis of the ciliary muscles and the eyes as well, causing difficulty in reading ; less commonly, there is further evidence of peripheral neuritis affecting the limbs and heart. The trouble may not come on for three or four weeks after the diphtheriai^ attack and therefore it ma}' no longer be possible to detect Klebs-Loffier bacilli"~inswabbings from the tonsils or fauces ; but in every such case it is important to looit^or them, both directly and by means of cultures. Probably not a few cases ascribed to " influenza," or to undetermined causes, are really post-diphtheritic. The paresis recovers in time, sometimes quickly, but often not until three months or more have elapsed. Post-operative Cases. — The history in these cases will point to the diagnosis ; the accident is rare, and as a rule the effects are temporary ; it maj' happen during the removal of tonsils and adenoids. Syphilitic Paralysis of the Palate is not common, and it hardly ever occurs by itself. It is a general rule that luetic affections of cranial nerves are multiple and often asymmetrical ; thus there may be strabismus, or a larjmgeal paresis, in addition to that of the palate ; or there may be a history or other evidence of syphilis. Bulbar or pseudo-bulbar Paralysis When this affects the palate and causes regurgitation of food through the nose, there have generally been other symptoms RETRACTION OF THE HEAD 641 for some time. The malady is slowly progressive, and starts with paresis of the lips and tongue ; swallowing is difficult, not so much because of the regurgitation as because the tongue is unable to thrust the bolus back between the fauces. The constant dribbling of saliva from the angles of the mouth is characteristic of some cases. The title labio-glosso-pharyngo-laryngea paralysis indicates the usual sequence of events. Bulbar paralysis may be associated with progressive muscular atrophy, and it may be distinguished from pseudo-bulbar paralysis by the atrophy of the tongue, which occurs in the former but not in the latter. Bulbar paralysis is due to a lesion in the medulla oblongata, whereas pseudo-bulbar paralysis has very similar symptoms due to bilateral cortical softening. In either case the patients are generally elderly. Undetermined Causes. — As regards such cases, it may be repeated that the majority are doubtless post-diphtheritic, so that it is important to take swabbings from the throat of all such patients, in order to examine culturally for the Klebs-Loffler bacillus. Herbert French- RETENTION OF URINE. — (See Micturition, Abnormalities of.) RETRACTION OF THE ABDOMEN. — (See Rigidity of the Abdomen.) RETRACTION OF THE GUMS is occasionally a symptom which troubles patients very much, but in itself it seldom indicates more than a local affection. In a mild degree it may be due to excessive use of a hard tooth-brush ; in the absence of this cause it suggests that there is a local infective process, especially tartar, caries of the teeth, or pyorrhoea alveolaris. These conditions are dis- cussed under the heading of Bleeding Gums, though very often retraction may be present, even in an extreme degree, without actual bleeding. Herbert French. RETRACTION OF THE HEAD. — Retraction of the head may be a marked symptom in the following conditions : — Acute meningitis (i.) Suppurative ,, ,, (ii.) Tuberculous (basal) „ ,, (iii.) Meningococcal (posterior basal) „ ,, (iv.) Meningococcal (epidemic cerebrospinal) Cerebellar or other subtentorial tumour or abscess Superior longitudinal sinus thrombosis Acute encephalitis Bronchopneumonia with partial asphyxia Laryngeal obstruction, especially diphtheria in children Strychnine poisoning Tetanus Hydrophobia Catalepsy Spasmodic torticollis Paramyoclonus multiplex Hysteria and hystero-epilepsy. In arriving at a diagnosis in any given case, the probabihty is that strychnine poisoning, tetanus, and hydrophobia will either suggest themselves at once on account of other circumstances in the case, or else will not need to be discussed at all. Hysteria can only be diagnosed when all other possibilities have been excluded, and probably not until the case has been anxiously watched for a time ; there may be other functional symptoms in the case ; the patient is generally a young adult, more often female than male. Catalepsy and hystero-epilepsy will be suggested by the mental symptoms, or obvious insanity. D 41 642 RETRACTION OF THE HEAD These things being excluded, the first thought that marked and maintained retraction of the head arouses is that the patient has some serious intracranial lesion, probably meningitis. Before coming to this conclusion, however, it is important not to forget that extreme dyspnoea in children sometimes produces considerable head retraction, so that the physical signs in the lungs and heart should be noted carefully, bronchopneumonia and capillary bronchitis being kept specially in mind, and any signs of laryngeal obstruction looked for, especially stridor and spasmodic up-and-down movements of the thyroid cartilage, with sucking in of the thorax above and below the clavicles, along the attachments of the diaphragm, and in the intercostal spaces. Diphtheria, foreign body in the larynx, and retropharyngeal abscess have all been mistaken for meningitis. If there is no evidence of sufficient throat or lung trouble to account for the symptom, an intracranial lesion is probable ; and by far the most hkety, especially in a child, is acute meningitis, either tuberculous or posterior basal. Symptoms common to all the intracranial affections are headache, vomiting, and giddiness ; P3^rexia, generalized convulsions, coma, incontinence of urine and faeces, retraction of the head, and optic neuritis ; or even local symptoms, especially twitchings, convulsions, or paralysis of individual limbs or parts of hmbs, according as one part of the brain or another is more irritated or softened than the rest. If there is an obvious source of sepsis in connection with the cranium, such as otitis media, mastoid abscess, facial erysipelas, a septic scalp wound, boils, pediculi with sores, suppuration in the orbit, nose, antrum of Highmore, frontal, ethmoidal, or sphenoidal air-cells, or nasopharj-nx, the probabihty is that any acute meningitic symptoms are due to staphylococcal or streptococcal suppurative meningitis ; pneumococcal meningitis may occur without local sepsis, either alone or as part of a general pneumococcal septicaemia ; suppurative meningitis due to the Bacillus diphtherias, the typhoid bacillus, or the Bacillus coli communis maj'- occur, but it is decidedly uncommon and clinically indistinguishable from other forms of suppurative meningitis, in all of which marked pyrexia and a fatal ending in two or three days are the rule. Tuberculous meningitis is much commoner in childhood than it is at any other age ; it is always part of a general tuberculosis, and it is very rare in adult life. At first there may be no pyrexia, though this depends on the caseous glands and tuberculous lesions in the lungs and elsewhere more than upon the meningitis. At first, the diagnosis is apt to be uncertain, but as the days go by the serious nature of the complaint generally becomes obvious ; the effortless vomiting, the irregular pj^rexia, severe headache, optic neuritis, retracted head, possibly choroidal tubercles {Plate VIII, Fig. W) or evidence of tuberculous foci elsewhere, serve to clinch the diagnosis. The chief difficulty, after the stage of retraction has been reached, is to decide between tuberculous meningitis on the one hand and meningococcal {posterior basal) meningitis on the other. The duration of the disease is often of assistance in this respect — suppurative meningitis kills in two or three days, tuberculous meningitis in two or three weeks, whilst posterior basal meningitis ends in recovery in a variable percentage of cases, even after continuing for two or three months. The tendency to head retraction is greatest with the posterior basal, least with the suppurative forms. Optic neuritis barely has time to develop in suppurative meningitis, but it is present more often than not in both basal and posterior basal mening- itis. The way in which the heels touch the occiput in some cases of the latter may by itself decide the diagnosis. Another point in favour of meningococcal meningitis, is the occurrence of periodic spike-like rises of the temperature chart - — pyrexial "crises" lasting twenty-four hours or less, and superposed upon what is otherwise a chart of but moderate type. When doubt remains as to the RETRACTION OF THE HEAD 643 fact of meningitis or as to its nature, microscopical and bacteriological examina- tions of the cerebrospinal fluid obtained by lumbar puncture will often serve to establish the diagnosis. The Cerebrospinal Fluid. — Normal cerebrospinal fluid is clear like water, alkaline in reaction, of specific gravity i -004 to i -007 ; it should drip out at the rate of 60 drops per minute ; it contains no albumin, a trace of globulin, and a substance which reduces Fehling's solution. In cases of acute meningitis it is opalescent, turbid or obviously purulent, yellowish or even brown ; its specific gravity is raised, it comes away at a greater rate than 60 drops per minute, and it contains excess of globulin, together with albumin and nucleo-proteid. Its alkalinity and its reducing power remain as in health. Microscopically, the normal fluid is practically free from cells, whilst in all forms of acute meningitis there are many polymorphonuclear cells, and in tuberculous cases, many lymphocytes also ; bacteriologically, tubercle bacilli are the least easy to find. The Gram- negative meningococci {Diplococci intracellulares meningitidis Weichselbaumii) [Plate XII, Fig. N) are characterized by their occurrence within the leucocytes in pairs, like gonococci, but without the reniform shape of the latter. The organisms of suppurative meningitis may be discovered on direct staining, but more often cultural methods are required. Where posterior basal meningitis ends and epidemic cerebrospinal meningitis begins, it is difficult to say ; they are both meningococcal, and probably they are only different types of the same malady, connected together by sporadic cases in which posterior basal meningitis is associated with more or less severe spinal symptoms. The way in which the least touch or movement causes the patient to cry out with pain sometimes indicates how inflamed the coverings of the posterior nerve-roots are, besides which, the erythematous, vesicular or purpuric skin eruptions that may accompany it often suggest the diagnosis. There is no difficulty during an epidemic ; it is the sporadic case that may be missed. The clinching point in the diagnosis is bacteriological investigation after lumbar puncture, assisted perhaps by the beneficial effects of the specific antimeningococcal serum. Superior longitudinal sinus thrombosis and acute polio-encephalitis are both nearly always diagnosed as acute meningitis in the first instance. It is when a case that has simulated acute and severe meningitis, with coma and apparently impending death, gets rapidly better after a few days and ends in speedy recovery, with or without some impairment of local or general brain functions, in a child or young person, that one changes one's diagnosis of meningitis to polio- encephalitis, though even then it remains one of opinion chiefly. Almost the same applies to superior longitudinal sinus thrombosis ; though, if acute cerebral symptoms in a previously healthy child end in a gradual and but partial recover};-, accompanied by permanent spastic paralysis of the legs, without much affection of the arms, it is very possible that the lesion has been thrombosis of the superior longitudinal sinus, with softening of the leg areas of cortex on either side of it. Cerebellar or other subtentorial tumours or abscesses generally cause a much more gradual onset of symptoms than do any of the other conditions named. Head retraction is not present until the later stages. The diagnosis of tumour will rest on the slow increase in the signs of raised intracranial pressure, with nystagmus, optic neuritis going on to optic atrophy, and a tendency to fall always in one definite direction — forwards or backwards if the tumour is in the vermis, to the right or to the left according as it is in the right or left hemisphere. There is often marked ataxy, with exaggeration of the tendon reflexes, particularly on the same side as the tumour. If nystagmus is well marked, this serves as a point of some value in distinguishing a cerebellar from a cerebral tumour. Abscess is distinguished from tumour chiefly by the existence of some obvious 644 RIGIDITY OF THE ABDOMEN cause for intracranial abscess, especially otitis media on the one hand, bronchi- ectasis upon the other. Cerebellar abscess may give rise to no pjTrexia and no leucocytosis ; but Avhether the temperature is raised or not, the pulse-rate is often absolutely slowed. Herbert French. RIGIDITY OF THE ABDOMEN is a sign not to be regarded hghtly, and one to find the true significance of which may call for the greatest care and skill. The patient should be examined Ijang on the back with the whole of the abdomen and lower thorax exposed. The observer, seated on a level with the patient, should watch the abdomen for a minute or so and see whether it moves or not with respiration, and whether one part moves more than another. It should be remembered that some patients, whether from modesty or timidity, hold their abdomens intenselj^ rigid in a wholly unnecessarj^ waj^ a tendency which may create a false impression. This can be avoided hy engaging them in conversation for a minute or two, hy asking them to take a few deep breaths, or by making them draw their knees up and keep their mouths open, when the normal abdominal walls will general^ relax. There are varying degrees of rigidity. The w-hole abdomen may be rigid, the upper or lower part only, or one side, as in the presence of a locahzed appendicular abscess. Again, one part or one rectus muscle maj^ be put, as it is termed, " on guard," whenever the patient thinks a tender spot is about to be touched. The rigidity over an inflamed gall-bladder is an instance of this. The commonest cause of rigidity is septic infection of the peritoneum, which may follow external wounds, abdominal operations,, childbirth, abortion, endometritis, parametritis, extension of inflammation from or perforation of the appendix, ulcer of the stomach, duodenum, or bowels, perforation of the gall- bladder, suppurating Fallopian tube, or abscess of the Uver, spleen or kidney. It is a safe rule to believe there is peritonitis until the contrary is proved. As in the case of other disease, diagnosis must not be based on one clinical sign, and the patient must be examined for the other signs of peritonitis. The history of the onset is important. In perforative cases, the beginning is marked by intense abdominal pain. This may be general and continuous, or by being referred to the stomach or appendix region give an indication of the seat of the mischief. The position taken up is on the back, sometimes with the knees drawn up to relieve abdominal tension, and the patient generally lies still, for any movement causes increase of pain. In colic, on the contrary, whether intestinal, biliarj-, or renal, the patient rolls about during the spasms. It is painful to use the diaphragm : therefore, respiration is superficial and costal in type. The abdomen gradually becomes distended, tense, and tym- panitic ; the liver dullness which was previously present may disappear, and, in some forms of peritonitis, fluid may accumulate in the abdomen and be detected by the signs of shifting dullness in the flanks. The pulse is small and rapid, loo to 150, and has the tendency to quicken. A friction rub may be heard over the liver or the spleen when the patient breathes. Borborygmi will generally be absent. Vomiting is an earh% prominent, and almost constant feature. The contents of the stomach are ejected first, then bile-stained fluid, and later green or brownish fluid wdth a slight f^cal odour. The vomiting is often of a peculiar " pumping " character. The bowels may be loose at first, and then constipation follows, but is not complete, as in intestinal obstruction. Micturition is frequent ; occasionally there is retention when the pelvic peritoneum is acutel}^ inflamed. WTien the disease is well developed, the appearance of the patient is very characteristic, exhibiting the " Hippo cratic facies." In this, as in other diseases, successful treatment RIGIDITY OF THE ABDOMEN 645 demands early diagnosis, and it is to be hoped that this will be made long before the clinical picture is complete. Leucocytosis as a Diagnostic Sign.— In suppurative peritonitis this is marked early, and is almost invariably present (15,000 to 30,000 per c.mm.). In very severe cases, in which the patient is rapidly poisoned by the quantity and viru- lence of the toxins, and is not reacting, it may be absent. Here, however, the other signs of peritonitis will be well marked. It does not necessarily follow, because the whole abdomen is rigid, that the peritonitis is general. For instance, in cases of perforative appendicitis it has been shown by operation that pus was only to be found around the ccecum, and yet there was general rigidity. Without operating, it is often impossible to tell. The best way of finding out whether there is pus in the abdomen, and the method to be employed at once if there is any doubt, is to open the abdomen and see. Other Conditions associated with Abdominal Rigidity which may be mistaken for peritonitis. Pneumonia or Diaphragmatic Pleurisy. — In the early stages here, before the onset of dullness in the lungs and other physical signs in the chest, the most prominent features may be abdominal pain and rigidity. Laparotomy has often been perforraed on the mistaken diagnosis of peritonitis. If, however, the examination is thorough, signs pointing to implication of the lungs will usually be found. Rapidity of respiration, working of the nares, and blueness of the lips should receive particular attention. Examination of the blood will often reveal a high leucocytosis (30,000 to 40,000) ; in suppurative peritonitis the numbers are rarely so high. Colic. — The suddenness of the onset of pain, its intense character and the abdominal rigidity, may render this condition extremely difficult to differentiate from peritonitis due to perforation of some viscus. Collapse may be marked, and the effect on the pulse is considerable ; vomiting is common also. The tem- perature is slightly raised but rarely exceeds 100° F., and the pulse, though it may be rapid, does not tend to quicken progressively. The pain is spasmodic, not continuous as in peritonitis, and is generally relieved in a few hours. Biliary and renal colic are fairly characteristic, but that due to lead, the crises of tabes dorsalis, or gastro-intestinal disturbances may easily be mistaken. The gums are to be examined for a blue line, the knee-jerks and pupils tested, and a blood- count made. In uncomplicated colic there is no leucocytosis. In cases of extreme difficulty the abdomen may have to be opened. The persistence of borborygmi is in favour of colic rather than of general peritonitis. Intestinal Obstruction. — The vomiting and constipation here present may lead one to think of peritonitis, and indeed the two conditions may be present at the same time, as in the case of an ulcerating carcinoma of the bowel. Usually the rigidity is not well marked, and the constipation, which is not absolute in peritonitis, is here complete. Injuries of the Abdomen. — 1. Contusion of the abdominal wall, with laceration of muscle : Particularly in patients who have been run over across the abdomen, rigidity is a marked feature, and there must always be a doubt at first whether any of the viscera have been torn and are bleeding, or whether the escape of their contents is setting up peritonitis. In the case of mere contusion, if the patient is put to bed and kept warm, collapse will soon disappear, the abdomen will become less rigid, and the pulse-rate will fall. 2. Contusion of the abdominal wall with injury of viscera : The signs here will be more marked, and instead of tending to diminish rapidly will become 646 RIGIDITY OF THE ABDOMEN worse. If there is internal bleeding, the mucous surfaces will be pale, the skin cold and clammy, and the pulse small and frequent. If the contents of a viscus have escaped, the signs of peritonitis will develop rapidly. In all cases of doubt an exploratory laparotomy should not be delayed. Ruptured Tubal Gestation. — This may simulate general peritonitis. The abdominal rigidity here is not well marked, and the signs of bleeding are. A moderate degree of leucocytosis is present (10,000 to 15,000), but the number of red cells is much diminished. If the patient is a woman of the child-bearing age, is known to be a week or more overdue as to monthl}^ period, and has begun to lose blood per vaginam synchronous^ with the onset of acute abdominal pain and pallor, the diagnosis will suggest itself at once. Acute Hcsmorrhagic Pancreatitis is usually diagnosed as intestinal obstruc- tion or acute perforative peritonitis. The attack sets in with intense pain, usually in the upper and left part of the abdomen. Vomiting, constipation, and tjonpanitic distention are present. The condition is so rare, and the signs are so unreliable, that an exploratory laparotomy should be made, and the nature of the case becomes obvious directly the characteristic opaque yellow patches of fat-necrosis are seen in the omentum. Rupture of an Abdominal Aneurysm, Dissecting Aortic Aneurysm,, Embolism of the Superior Mesenteric Artery, may simulate peritonitis, and so also may Acute Thrombosis of the Inferior Vena Cava ; but all these conditions are rare, and they will be very difficult of diagnosis unless the existence of some cause for them, such as aortic aneurysm or fungating endocarditis, is already known. Acute Suppurative Nephritis sometimes gives abdominal rigidity, and is associated with fever and vomiting. There is always marked tenderness in the loin on the affected side, and the urine will contain albumin, pus, blood, casts, and bacteria. Thq milder types of the infection (see Bacteriuria) may be mistaken for acute appendicitis, or for general peritonitis, unless the cen- trifugalized deposit from the urine is examined microscopically for pus. George E. Gask. RIGORS, or CHILLS, are common at the onset of the most various acute febrile disorders, and may occur at regular or irregular intervals in the course of many of the more severe of them. The chief sign of a rigor is shivering, the chief S3^mptom a feeling of cold and general wretchedness. At its beginning, the patient looks chilly, pinched, and blue, and sits or lies huddled up, complaining of the cold ; his arteries are contracted, the pulse is rapid, small, and of raised tension ; the extremities are chilled superficially, but the internal tempera- ture is raised above the normal. Very soon the sensation of cold induces involuntarjr shivering to correct it ; the patient shakes all over, sometimes so violently that the chair or bed is thrown into noisy vibration ; his teeth chatter, and even the muscles of the face twitch involuntarily. This shivering lasts for a few minutes, or even for an hour, gradually dying away as the patient feels himself to be warmed up. Thus the initial stage of the fever passes into the second stage or fastigium, in which the complaint is of sweating, thirst, and undue heat, and the body temperature rises stiU further. In children, general convulsions, Avith partial or complete loss of consciousness, may occur at the onset of an acute infection, under conditions that would give rise to a rigor in adults. In adults, convulsions are not known to take the place of rigors. Cases may arise, however, particularly when only an imperfect histor}'- can be obtained, in which it may be hard to say whether a patient has had a rigor, or an epileptiform, hysterical, or epileptic fit. Should the patient have lost con- sciousness during the shivering, or have fallen down, bitten his tongue, or passed his water during the attack, or should he give a history of similar attacks on previous occasions, the diagnosis of epilepsy would be more than RIGORS, OR CHILLS 647 probable. Epileptiform fits that unskilled observers might confuse with rigors, may occur in uraemic or eclamptic patients ; the history of the case, and the discovery of albumin in the patient's water, together with other evidences of acute or chronic renal disease, should make the diagnosis clear. Fits indistin- guishable from rigors to the untrained eye may occur in hysteria ; in these, however, the shivering patient would be red in the face, or at least would not present the slightly livid and shrunken facial appearance characteristic of a rigor, the temperature would not be raised, and the signs or a history of other hysterical phenomena should be obtainable. For their further consideration it is convenient to classify rigors according as they are single or multiple. I. Single Rigors. — The occurrence of a single rigor at the outset of an acute infectious disorder is extremely common, and may be taken as evidence of the severity of the infection to some extent ; in lobar pneumonia this initial rigor is often particularly long and severe. No exhaustive list of the disorders that may be thus ushered in can be given ; but it may be generally stated that an initial rigor is common in : — Erysipelas Cerebrospinal fever Acute poliomyeUtis Malaria Yellow fever Weil's disease Lobar pneumonia Small-pox Influenza Severe feverish colds Septicaemia Pyaemia Pneumonic tuberculosis Typhus Relapsing fever It is less often seen in : — Scarlet fever Measles Diphtheria Tonsillitis Rheumatic fever Tetanus Miliary tuberculosis And is comparatively rare in : — Enteric fever German measles Mumps Gout Anthrax Hydrophobia The diagnosis of all these different morbid conditions must naturally be made from the history of exposure to infection, and from the subsequent signs and symptoms. It is clear that the occurrence or non-occurrence of an initial rigor will rarely be of much practical assistance in determining the nature of the disorder from which any given patient is suffering. A rigor after catheterization is not rare, whether the kidneys be sound or no, and in some cases is due to septic infection of the urethra or bladder by the instrumentation. In others, however, it ensues when no infection has taken place, and is not followed by any evidences of urinary sepsis ; in these instances the rigor must be referred vaguely to nervous shock, and need not give rise to alarm. After catheterization. Saprsmia Glanders Sick headache Acute gastro-intestinal disorders Nephritis Cholelithiasis Renal calculus. Cholera Plague Dysentery Malta fever Beri-beri. RIGORS, OR CHILLS 2. A Second Rigor coming on in the course of any of these disorders, or a rigor occurring unexpectedly for the first time when the disease is well estab- lished or declining, is often evidence of the spread of the infection, or of the occurrence of some complication. For example, a second rigor occurring in the course of lobar pneumonia may coincide with the appearance of signs indicating the spread of the disease to the second and previously sound lung ; a second rigor happening after the crisis may indicate the establishment of an empyema. In enteric fever a second rigor may be due to such complications as perforation of the intestine, acute peritonitis, pleurisy, pneumonia, middle-ear disease, periostitis, and so forth. But it must be remembered that there is an abnormal type of enteric fever in which rigors occur for no apparent reason, followed by heavy sweats ; and that rigors may be observed in cases with constipation, or during defervescence, or in enteric patients who have been treated with anti-pyretic drugs. 3. Recurring Rigors. — The occurrence of a series of rigors often gives infor- mation of more definite value, for it is seen in but a comparatively limited number of local or general infections, most of which have some characteristic or localizing signs. In themselves, these rigors are no more than evidence of the severity of the infections in which they are seen, and of the extent to which bacterial or other toxins have been absorbed into the blood and have upset the thermotactic centres. The following are the chief disorders characterized by a series of rigors : Malaria — tertian, quartan, sestivo-autumnal or malignant tertian, and mixed types Relapsing fever Acute leuksemia Acute blood-infectiorip, including : — or a py 1 gpgcial forms of which may be known as puer- (~7 ,■ ■ \ \ peral fever, malignant endocarditis, acute infective •^ . ^ . osteomyelitis, suppurative pylephlebitis, etc. oepticsemia \ Acute inflammations, such as : — Pyelitis Cholecystitis Pyelonephritis I Empyema Cystitis \ I Infective sinus thrombosis. Abscess formation : — ■ Hepatic (tropical abscess) Perinephric Appendicular Prostatic Subphrenic Cerebral. Pulmonary tuberculosis ; bronchiectasis. Enteric fever ; influenza. Erysipelas. It is neither possible nor desirable to detail the diagnosis of all these dis- orders ; but it may be pointed out that a very thorough physical examination of any patient presenting multiple rigors should be made ; the condition is always of serious import, and may be due to septic absorption from some deep- seated abscess that produces only the scantiest of physical signs, but calls out urgently for surgical treatment. When no abnormal physical signs can be found, bacterial cultures should be made from the circulating blood, care being taken to draw off a sufficient quantity of blood — 5 to 10 c.cm. — and to repeat the cultivation several times before it is decided that the blood-stream is sterile. In malaria the rigors tend to recur at regular intervals of forty-eight or seventy-two hours in the benign tertian and quartan infections, at shorter RIGORS. OR CHILLS 649 intervals if the infection is mixed. In the eestivo-autumnal form, the rigors and also the course of the fever, are much less regular. In all cases of malaria the parasite can be found in the circulating blood, and the patient, if not in extremis, is cured by quinine : there is no leucocytosis, but a relative increase in large lymphocytes occurs. In relapsing fever the onset is acute, with a rigor or a series of rigors. A fort- night later, when the patient has been convalescing for a week or ten days, relapse and a second rigor or series of rigors occurs. A second relapse may be noted at the end of the third week, and in a very few cases a third relapse. To all intents and purposes relapsing fever has died out of the United Kingdom, but it is met with in Egypt, India, and other countries. It occurs in epidemics, and Ober- meier's spirocheete {Plate XII, Fig. I) can be found in the patient's blood while he is feverish. Multiple rigors occur exceptionally in the course of acute blood-diseases, such as acute leukaemia, pernicious ana;mia, or Hodgkin's disease. Severe and pro- gressive anaemia, wasting, fever, heavy sweats, and ha2morrhage from the mucous membranes, are likely to occur in these cases, with characteristic changes in the microscopical appearances presented by the blood. Multiple rigors are without doubt commonest in the various forms of acute blood-infections, given the presence of bacteria of the proper degree of virulence in the blood-stream. Special forms of these infections have received particular names. Thus puerperal fever occurs after delivery, and is due to bacterial infection of the uterus and its spread thence to the blood ; the patient will probably have a sanious or offensive vaginal discharge as well as the evidences of septicaemia or pyaemia. In malignant endocarditis , attention is mainly directed to the condition of the heart, the presence of valvular murmurs, the detachment of emboli from the inflammatory vegetations on the heart-valves and their lodgement in various peripheral arterioles. In acute infective osteomyelitis the first complaint arises from the acute inflammation occurring in the marrow of one of the bones. Portal pycBmia or suppurative pylephlebitis, is seen in patients with various acute inflammatory intra-abdominal lesions, and is due to the spread of bacterial infection to the portal vein. The commonest precursor is mild appendicitis. The blood in the portal vein clots, the clot is infected with microbes, softens, and breaks up, to be dispersed throughout the liver in the form of infective emboli. Multiple hepatic abscesses result, with pain, swelling, and tenderness in the hepatic region ; jaundice is present in less than half the cases, with more or less coloured stools , vomiting and diarrhoea are frequent, and there is hectic fever. Pycemia is characterized by the formation of abscesses — metastatic abscesses — in any of the tissues or organs of the body, oftenest in the lungs, in consequence of the lodgement there of multiple infected emboli. Before the days of antiseptic or aseptic surgery, pyaemia was the common outcome of serious surgical operations or severe wounds. Nowadays it is comparatively infrequent, and when it does occur is secondary to a severe infected wound, to ulcerations of the mucous surfaces, or to deeply-seated abscesses that are not amenable to surgical treatment. Occasionally it seems to be idiopathic, or due to some infective lesion that escapes discovery. Pyaemia oftenest begins sud- denly ; the main symptoms are hectic fever, rigors, leucocytosis, diarrhoea and vomiting, heavy sweats, prostration, and the formation of secondary abscesses due to the arrest of septic emboli. When the lungs become the seat of multiple abscesses, the breathing becomes rapid, and signs of bronchitis, pleurisy, or pulmonary consolidation appear. Abscesses in the more superficial tissues or joints make their presence known by the local evidences of pain, swelling, redness, and heat ; in the deeper parts or organs, by pain and disturbance of function. The development of secondary subcutaneous abscesses is common in the less 650 RIGORS, OR CHILLS acute cases ; abscess-formation in the heart, and suppurative pericarditis, are prone to occur when the primary lesion is a periostitis or an acute necrosis of bone. Pyaemia may be distinguished from enteric fever onh' with great dif&cultj-, if evidences of abscess-formation or some source of primary infection are not forthcoming, especially as the typhoid state is common in the later stages of both diseases ; the occurrence of multiple rigors is rare in enteric fever, common in pyaemia, and Widal's reaction should be of assistance here. From malaria, pyaemia is distinguished bj^ not reacting to quinine ; malarial parasites will not be found in the circulating blood. Pain and inflammation in the joints after childbirth or a miscarriage may be diagnosed as rheumatism when the condition is really one of pyaemia or puerperal fever. The precise diagnosis between pyaemia and septicaemia is often impossible, and is, indeed, of academic rather than clinical interest. The necessity- for it is in part avoided by the use of the term septicopycsmia, the evidences of which are much the same as those of pyaemia : all three conditions ma}^ arise from identical causes, and bacteria (streptococci, staphylococci, gonococci, pneumo- cocci, B. coli communis, B. typhosus, B. influenzcs, B. pyocyaneus, etc.), may be cultivated from the circulating blood in anjr of them. Multiple rigors are far commoner in pyaemia — where several may occur daily — than thej^ are in septicas- mia. Septiccemia, the disease due to the growth of microbes in the blood without the formation of metastaticabscesses, originates in lesions very similar to those that underlie p^^aemia, or resrirEs~froni infected but apparently trifling cuts or injuries, or even from neglected chronic suppuration about the teeth. Its main symptoms are fever, debilit5^ anaemia ; in severe cases rigors occur, and the patient may fall into the typhoid state. The bacteria causing it can be cultivated from the circulating blood ; septic rashes are often seen in both pyaemia and septicaemia, but they are not seen in enteric fever. It should be noted that, at the best, a deal of looseness attaches to the meaning of the term septicaemia ; for in lobar pneumonia, enteric fever, Malta fever, and many other acute febrile disorders, the specific microbes can habituallj^ be cultivated from the circulating blood. Technically speaking, therefore, these are all instances of septicaemia. Two new terms have recently come into vogue in this connection, namely, bacillcsmia and hactericBmia. Multiple rigors occur in a number of acute inflammatory infections localised in various parts or organs of the body, provided that the inflammation is sufficiently extensive and the infecting micro-organism of a sufficiently virulent type. It is often impossible to say how far such rigors are evidence of the absorption of toxins, and how far they indicate that hving bacteria have gained access to the blood-stream. Situated in the genito-urinary tract, these inflammations are often associated with a history of gonorrhoea, renal calculus, or gout, and produce characteristic pathological changes (haematuria, pyuria, albuminuria) in the urine, or difficulties in mictrurition. If the gall- bladder or bile-ducts are the seat of the inflammation, jaundice and pain in the hepatic region will probably be observed with the fever and rigors, and a history of gall-stone colic may be given ; Charcot's hepatic intermittent fever is due to chronic cholangitis, with intermittent biliary obstruction due to a baU-valve stone often lying in the ampulla of Vater. The occurrence of rigors in a child convalescing from pneumonia, measles, scarlet fever, or pleurisy, ma^^ lead to the discov-er\^ of an unsuspected empyema. Infective sinus thrombosis character- istically occurs in patients with chronic or intermittent otorrhoea, and indicates that the bacterial infection has spread from the ear to one of the cranial venous sinuses. Its symptoms are general — those of septicaemia or pyaemia, often with an initial rigor and vomiting followed by high iexer, more rigors (Fig. 165, p. 613), and sweating — and local. The local symptoms are very severe pain RISUS SARDONICUS 651 about the ear, excruciating headache, and venous congestion of the optic disc, with others that vary with the site of the thrombosis. If the sigmoid sinus is thrombosed, oedema and tenderness over the mastoid appear, and should the clotting spread downwards a thrombus may be felt in the internal jugular vein. Thrombosis of the cavernous sinus is accompanied by squint, exophthalmos, and oedema of the orbits and eyelids. Thrombosis of the superior longitudinal sinus may set up oedema of the scalp near the sagittal suture. The diagnosis must be made from cerebral or cerebellar abscess, in which repeated vomiting is likely to occur, and the localizing signs and symptoms will suggest brain- disease ; and from meningitis, in which rigors are rare. In other patients, some acute inflammatory disorder may result in definite abscess formation, when rigors may develop from toxic or septic absorption ; here again, the virulence of the particular microbe causing the inflammation will be the chief factor in determining whether rigors occur or not. In many cases the rigors will really be due to a secondary and probably terminal septicaemia or pyaemia. Tropical abscess of the liver, usually single, occurs in patients who have been abroad and have had dysentery, whether amoebic or bacterial. The early symptoms of liver abscess are often obscure, malaise, fever, sweating, rigors, and gastro-intestinal disturbances occurring, or a pleural efl:usion secondary to spread of infection through the diaphragm, while nothing particularly suggests implication of the liver. As a rule, complaint of dull pain in the right hypochon- drium, axilla, or shoulder will be made ; if the abscess is at all large, absolute increase in the size of the liver-dullness will be found, particularly in an upward direction and to the right, the liver will be somewhat tender, and the patient will prefer to lie on the right side. Slight jaundice is frequently observed. The diagnosis from infective cholangitis must be made, where jaundice is more marked and often intermittent, and enlargement of the gall-bladder can be made out. The diagnosis of the other forms of abscess mentioned in the list given above must be made on general lines, and will not be further considered here. Multiple rigors may occur from septic absorption in various diseases of the lungs, the most important of which are bronchiectasis, and advanced pulmonary tuberculosis, with secondary pyogenic infection of the bronchi or tuberculous cavities. In either case the sputum will be abundant, and will probably contain fragments of elastic tissue ; it is sure to be offensive in bronchiectasis. High or irregular fever with recurring rigors has been recorded in a few unusual cases of enteric fever and of influenza free from any complication. A. J. J ex-Blake. RINGWORM. — (See Fungous Affections of the Skin.) RISUS SARDONICUS. — The term risus sardonicus is used to denote the fixed unmirthful grin that results from spasm of the muscles of both sides of the face. The angles of the mouth are drawn outwards and the eyelids are raised by tonic contraction of the same muscles that produce the facial expression of smiling, but the spasm is maintained in a way that at once excludes natural smiling. The chief causes of the condition are tetanus, strychnine poisoning, malingering, hysteria, catalepsy. Catalepsy. — The differential diagnosis is not, as a rule, difficult. A cataleptic case is chronic ; the facies is by no means always that of smiling, but if it should be, then the smile is a fixed one ; the chief characteristic of the condition is the maintenance for hours at a stretch of some attitude that would rapidly fatigue an ordinary person ; the history and the associated mental symptoms of melancholia or dementia would point to the diagnosis, and tetanus and strychnine poisoning would be excluded by the absence of tetanic spasms. 652 RISUS SARDONICUS Hysteria sometimes takes a form that may for a while raise doubts as to strychnine having been taken, but, as a rule, the multiformity of the contortions points to the correct diagnosis. The features may be kept fixed for a time, but sooner or later they become twisted into all sorts of shapes, and the tonic and clonic spasms of the bodj' and linibs are not in any way regular, as they are apt to be in str3xhnine poisoning and tetanus. The patient is hkeh' to be a woman, and there may be a history of previous hysteria. During a quiescent interval it may be found possible to stroke or touch the patient without bringing on a convulsion, whereas in str3'chnine poisoning and in tetanus the slightest touch is apt to evoke a violent and generalized spasm, even opisthotonos. Malingering may take the form of imitated convulsions, during which the features may be kept fixed in one position or another, sometimes in that of smiling. The fixed voluntarj' contractions cannot be long maintained, hoAvever. on account of fatigue, so that although there may be some doubt at first, this generally disappears soon. The patient is generally a man who has something to gain by malingering : a night's lodging in a hospital, for instance. Strychnine Poisoning and Tetanus are the two chief causes of t\^ical risus sardonicus. The main point to rely on in distinguishing the two is the history, if it is obtainable^ -the Jjij ection of an overdose of strychnine h^-podermically, or the taking of a rat-paste^ on the one hand, or the occurrence of some small but penetrating wound by a rusty nail or earth-soiled knife or stick during the fortnight preceding the symptoms, on the other. The absence of any known wound, however, does not exclude tetanus. If lock-jaw and stiffness of the neck are prominent features, tetanus is more probable than strychnine poisoning, and vice versa. In strychnine cases, the patient wiU either die quickly, or the symptoms will rapidly subside, whereas in tetanus they may persist unabated for several days. In a few instances the diagnosis may onh' be settled by the discovery of strychnine in the gastric contents, or of tetanus bacilli (Plate XII, Fig. T) in anaerobic cultivations from the infected wound. It onlv remains to add that a few cases of facial sclerodernita may simulate risus sardonicus, though more often there is complete smoothness of the features and lack of expression. There are no spasmodic contractions, the condition comes on gradually, is permanent, and the diagnosis becomes obvious at once when the hard smooth skin is palpated, for one cannot pick it up between one's fingers. Herbert French. ' RUMINATION.— (See Merycism.) RUPIA.— (See Scabs.) SALIVATION, UNDUE.— (See Ptyalism.) SAND, INTESTINAL. — This is seen in the motions, especially when they are fluid, of some sufierers from membranous colitis. It is like the finest sea-sand ; its colour varies owing to varj'ing degrees of imbibition of faecal pigment. Usualh' it is red, looking something like fine uric acid, and it varies from this to a pale dirty ^^ellow. It is seen best showing up against the white of the bed-pan in which it lies. Analysis shows that it consists of from 30 to 70 per cent of organic matter, doubtless all derived from the faeces. The inorganic matter is invariably nearly all calcium phosphate, with traces of calcium oxalate, magnesium, iron, and perhaps silica. The amount of sand passed in a day may be four teaspoonfuls, but usualh' it is much less. Many patients pass it for years, but not always constanth- even then ; it may be passed daily for weeks, and then for weeks none is passed. It is far commoner in those who have membranous colitis than in other patients, but it has been /'LATE IX. Fii A. True Intestinal Sand Fig. B. False Intestinal Sand, consisting of sclerenchynnatous particles of pears. RtpToduad by kind ptrmisiim of Ihi Aulhirr, atUrJthr Royal SocUljr of MeJUinc. SCABS 6.53 seen with malignant disease of the large intestine ; it always indicates some organic disease of the colon. It must be distinguished from false intestinal sand, which looks very like it and may be found in the motions of those who have eaten largely of pears. This is entirely vegetable, and can be distinguished easily from true intestinal sand by microscopical examination [Plate IX). W. Hale White. SCABS. — The scab, or crust, one of the secondary cutaneous lesions, is a more or less irregular, dried-up mass of exudation on the surface of the skin. It may be produced by the desiccation of serum, pus, or blood, or of a mixture of these fluids, and commingling with these substances there may be epithelial debris, or fat, or fungous elements. Scabs form on matured vesicles, bullee and pustules, on ulcerations, erosions, and on every kind of excoriation, pathological or traumatic. If the exudation is thin, as some- times in eczema, they are soft and friable, and soon eliminated ; if it is thick, they may be tougher and raore adherent, and successive layers may be formed, as in the rupial crusts of syphilis. Scabs composed largely of fungous elements are more or less friable, and these, like those resulting from the seborrhoeic process, may partake of the character of scales as well as of scabs. Such formations, however, as for example the " crusts " of favus, are in the nature of scales rather than of scabs, and are noticed elsewhere. (See Scaly Eruptions ; and Fungous Affections of the Skin.) Scabs vary greatly, not only in consistence, thickness, and adhesiveness, but also in colour and in form ; and by attention to these differences the diagnosis of the affections in which they occur may be assisted. Some guidance may also be obtained from the condition of the surface from which the scab has been removed ; it may be dry when the scab has been long adherent, as in some cases of impetigo, excoriated as in eczema, or ulcerated as in rupia. But the chnician will be guided much more by the primary than by any secondary lesion ; and for the decisive diagnostic features of the diseases about to be mentioned, the reader is referred to the articles Macules ; Vesicles ; Bull^ ; Papules ; Nodules ; and Pustules. In irritative herpes the vesicles on the skin shrivel up and form yellowish- brown crusts, which after a few days become detached, as a rule leaving no scar, but only a brownish stain, which slowly fades away. In herpes zoster most of the vesicles which do not abort, reach the same termination ; but others, instead of drying up, may burst and discharge a fluid, which then forms yellowish or brownish crusts. In zoster a scar is sometimes produced. In erythema, multiforme there is often considerable scabbing, as is mentioned under Vesicles. In eczema the lesions may dry up either into scales (see under Scaly Erup- tions) or into crusts. Crustation is usually the third stage in the evolution of the disease, the discharge from the vesicles drying into greyish-yellow scabs of varying thickness, which become detached and are succeeded by others until the "weeping" ceases. When the lips are attacked, they may become so stiffened under layers of crusts superimposed one upon another that the patient can hardly move his lips without fissuring the skin. In the male, the " bathing- drawers " area may be so covered with crusts that the patient cannot walk or sit down without breaking them. In the same region in the female the inflam- mation and crustation may be even more severe, and the scabs may be marked by much foulness. One of the characteristic features of what is called papular eczema is the appearance of a tiny dome of blood-crust on the papules, due to scratching. In seborrhoeic eczema there may either be scaUng, or the sq names may be massed into fatty crusts (see Scaly Eruptions). The scabs in eczema rubrum are extremely thin, like goldbeater's skin ; when they are torn off, a red, wet, raw, tender surface is laid bare. The crusts of scabies may be distinguished 654 SCABS from those of eczema by their being isolated and distributed irregularly, instead of being grouped, and by the multiformitj^ of the lesions with which they are mixed — vesicles, bullae, pustules, hsemorrhagic scabs, etc. In most itching diseases there wiU be found blood-scabs, resulting from the scratching to which the patient is provoked. In cheiropompholyx the bulls into which the httle sago-grain vesicles run, dry up into crusts, the removal of which reveals a surface that is red and exquisitely tender. The appearance and sensitiveness of the underlying skin, together with the hmitation to the hands and feet, and often to the hands alone, will help the diagnosis. The crusts of sycosis vulgaris also have a hmited distribution ; thej' niay be confined to the upper hp, and in any case thej^ do no JL extead^JjeyeBti the hairy parts of the face. They are brown or yellow in colour, thin, and distinctly adherent. In impetigo contagiosa (Tilburj- Fox) the scabs which are formed from the dried- up fluid discharged by the pustules on rupture are ^^ellowish ; in uncleanly persons they are brown, or even black. A characteristic feature is that they have around them no hj^eraemic halo, but look as if they might have been stuck on artificially. In the severe form of the disease stjded ecthjTna, however, the flat irregular scab formed from the ruptured vesicles is surrounded by a more or less pronounced areola. At first loosely attached, the scabs in impetigo contagiosa afterwards become so firmly adherent that their removal requires some force and gives rise to a httle bleeding. In this afiection there is what ma}' be called a secondary scab, formed hy the drjdng-up of the thick, purulent discharge — honey-hke in consistence and appearance — from the surface left raw by the removal of the earUer crusts. The reddish stain that appears when the lesion heals is not permanent. In pemphigus vulgaris the crusts into which the bullae shrink are brownish-j^ellow ; and when they fall ofi spontaneously, the surface beneath is not raw, as in impetigo, but is found to be covered with newly-formed epidermis, at first purple, but afterwards turning brown, and gradually becoming normal in colour. When the area covered by the scabs is extensive, there is an unpleasant sense of tension, and if the}^ are removed prematurely, excoriation may be caused. In the more serious affection known as pemphigus foliaceus, the crusts are 3'eUowish, and as the disease proceeds, large scales are formed. In pemphigus vegetans the foul-smelling secretion from the patches of affected skin forms a thin crust, which can easily be stripped off, when a papillarj' excrescence, partly covered Avith a thin stratum of epidermis, is revealed. The process usually ends in gangrene and death. The excrescences are distinguishable from the condA-lomata of syphilis by always being surrounded by a zone of bullae, while condylomata have an infiltrated border. In nerve leprosy the buUae, which have the same characters as those of pemphigus vulgaris, form, on rupture, a large crust, the removal of which exposes a grey surface consisting of altered rete, the epidermis being cast off by suppuration. In this wa}^ a succession of yellow scabs or crusts may be formed and fall off, leaving at last a granulating surface, which ultimately is converted into a white scar. If the bullee abort, they are followed by a parch- ment-hke scale instead of a crust, and this in turn gives place to a h^^peraesthetic ulcer. The scabs of nerve leprosy have some resemblance to the rupial crusts of secondary SA'phihs, but there is little danger of confusion between the two. The rupial crusts, greenish or blackish, consist of several successive layers, each one smaller than the one immediately below it, so that a pj'ramidal structure is formed, somewhat resembling the shell of a hmpet. This very characteristic crust, which can scarcely be mistaken for that of any other condition, and is distinguishable from the psoriasis rupioides of M'Call Anderson by the base being ulcerated, usuaU\' is formed from pustules, but may follow also on the drying up SCALY ERUPTIONS 655 of bullae. The scabs in secondary yaws form upon the yellow heads of large papules, and beneath them are found reddish raspberry-like granulations which secrete a little pus, and after a time become pale or even white. Healing usually takes place beneath the scabs, which fall off about the end of the second month from the onset of the secondary rash. The raspberry-like granulations, the characteristic lesion of j'aws, will obviate confusion between these crusts and those of any other affection. The crusts of lupus vulgaris are greenish-black, like rupial crusts, but they do not consist of layers superimposed upon each other, and dotted around the ragged edge will be seen the " apple- jelly " nodules which are the " note " of lupus. In small-pox the formation of scabs on the pustules begins in the centre and causes a secondary " umbilication " ; it is generally attended by intense itching. In from three to four weeks from their appearance the crusts fall off, leaving a reddened surface, made uneven by scars or " pits." The true nature of the disease will have been discovered, even in doubtful cases, before the crust stage is reached. (For the differential diagnosis, see under Pustules.) In the diagnosis of ulcers, as in that of small-pox, the crust is of little importance. These are dealt with under Ulceration of the Face and Ulceration of THE Foot. Malcolm Morris. SCALY ERUPTIONS. — The squame, or scale, one of the secondary cutaneous lesions, is a dry, and as a rule laminated, exfoliation of the epidermis. Dis- regarding the slight, imperceptible desquamation which is a purely physiological process, scales may be said to result either from inflammation, as in psoriasis and pityriasis rubra pilaris ; from an abnormal dryness of the skin, as in dry seborrhoea and keratosis pilaris ; or from an earlier acute hyperaemia, as in scarlatina and other erythematous eruptions. The process may consist in an over-multiplication of the epidermic cells or in interference with the normal horny transformation. In colour, scales are ordinarily white or grey, either dull and lustreless, as in seborrhoea, or silvery, as in psoriasis ; but they are sometimes a dirty yellow, as in some dry syphilides, or even reddish-brown, as in oily seborrhoea. They may be large and thin, as in pityriasis rubra, or small and branny, as in tinea versicolor ; even in the same affection (e.g., pityriasis rubra) they may vary greatly in size in different regions. They may consist of a single layer, as in squamous eczema, or of several adherent strata, as in psoriasis. In quantity they may be inconsiderable, as in tinea versicolor, or most profuse, as in psoriasis and pityriasis rubra. Usually they are dry and friable, but if mixed with an oily secretion, as in seborrhoea, or with a serous or seropurulent discharge, as in eczema, they may partake of the nature of both scales and crusts. A brief description of the scales met with in various affections may be given here ; but except in a few diseases of which they form a highly characteristic manifestation, such as seborrhoea, psoriasis, and pityriasis rubra, they have little diagnostic value, and, as I have said elsewhere of scabs, diagnosis must usuallj' rest upon primary rather than upon secondary lesions. Sometimes there is scale-formation in eruptions due to the internal adminis- tration of such drugs as quinine or belladonna, or to the external application of carbolic acid, iodine, etc. ; but it has no significance in diagnosis. In keratosis pilaris (xeroderma) and other forms of ichthyosis, there is always more or less desquamation of the dry and roughened and sometimes warty skin ; but here also it is without diagnostic import. Of the scales of scarlet fever, measles, German measles, and other infectious fevers, again, nothing need be said, for the diagnosis ought to have been settled before they appear. Nor need I speak of the scaliness of tinea tonsurans, tinea versicolor, and other fungous affections. G56 SCALY ERUPTIONS for the differential diagnosis of these diseases has been given under Fungous Diseases. The scales of papular syphilides, again, have been described under Papules, and the diagnosis of the lesions, both primary and secondary, from those of psoriasis will be found in that article. In the unusual instances of urticaria in which desquamation is present, it is so slight as to be negligible. In most forms of erythema, scales occur ; but here again they have little significance for the diagnostician, and it will be sufficient to say that in erythema simplex the desquamation is slight, and that in erythema scarlatiniforme it is more considerable. In lupus erythematosus the central scar-like depression of the primary eruptive lesions may be covered either with thin, papery, greyish »^^r-or with-a-^mly^dherent scab. In parts furnished with sebaceous glands, the skin will usually be covered with small adherent scales of sebum, which at the margin of the patch plug the dilated orifices of the glands, so that numerous comedones are formed. From other forms of erythema, as also from ringworm, lupus erythematosus may be distinguished b}^ the slowness and persistence of the process. The lesion itself, atrophic in the centre, with a well-defined red border, and studded with plugs, can scarcely be mistaken when it appears on its site of election, the face. When, however, it occurs on the hands, it may mimic chilblains so closely that only the lapse of time can make the diagnosis certain, lupus erj^thematosus being much more obdurate to treatment, and not disappearing in the summer. For the diagnosis between lupus erythematosus and psoriasis, see below ; for that between lupus erythematosus and lupus vulgaris, see under Nodules. We now come to affections in which scales play a more important part. In seborrhcea sicca, there is an excess of the solid fatty constituents of the sebum, and the excreted material takes the form of scaly but usually somewhat greasy masses. In seborrhcea oleosa there is an abnormal predominance of the oily part of the sebaceous secretion, which dries into yeUoAvish or reddish-brown cakes of greasy scales, often with a hyperaemic base and a fringe of papules about the edge. In the face, oily seborrhoea is more often met with than the dry form ; but seborrhoea generally, though it may occur on the trunk and limbs, almost invariably begins on the scalp. When not hmited to the scalp, as usually it is, it spreads downwards to the face, round the neck, the chest, the centre of the back, and the limbs. In the hght of this preference for the scalp, and the downward extension when the affection is not confined to that part, a typical case of seborrhoea is unmistakeable. In cases of seborrhoea which resemble psoriasis, guidance may be found in the scales, which in the latter affec- tion are silvery, and harder. The respective starting-points of the eruptions, however, furnish a safer indication, psoriasis almost always appearing first on the elbows and knees and spreading upwards. In typical eczema^ scaling forms the final stage of the pathological process. After the initial erythema comes the exudation, then the crustation (see Scabs), next the dry stage, and lastly the desquamation, the epidermis being shed in scales that become progressively thinner and smaller until only a brownish stain is left to mark the site. All the stages, as need hardly be said, are often present at once in a given case. Scaling is frequently a noticeable feature when there is a predominance of erythematous lesions, as it is also in eczema folliculorum. But it is in seborrhceic eczema that this phenomenon is most prominent, the latent catarrh with which the affection begins being followed by the agglutination of epidermic scales which are thrown off in the form of large lamelte. In some cases the scales may increase in quantity, in others, as is mentioned under Scabs, they may become massed into fatty crusts among the hairs. The differential diagnosis of eczema has been set out in the articles on the primary lesions. The secondary lesions in this affection may indeed SCALY ERUPTIONS 657 be rather a hindrance than a help in determining its true nature, and in doubtful cases the first thing to do is to remove both scales and crusts in order that the underlying lesion may be carefully examined. As between eczema and psoriasis, however, just as between eczema and seborrhoea, the scales afford guidance in the diagnosis. While in psoriasis the lower layers of scales are whitish or silvery and hard, in eczema they are yellowish, dull and friable. In this affection, psoriasis, the scale has distinct diagnostic value. It enters, indeed, into the definition of the disease as an affection of the skin, charac- terized by flat, dry patches of varying extent, covered 'with whitish, silver- grey, or asbestos-like scales. The scaliness may vary from a thin film to a dense, heaped-up mass. If the scales are removed, a smooth, shining hyperjemic surface is seen, studded with spots that show various gradations of colour, from a deep to a bright red, the bright-red points being the tops of inflamed papillae. The eruption appears as papules of pin-head size, at first red, but becoming white as the scales form. Spreading centrifugally, the papules form patches, generally roundish or oval when small, and becoming more irregular as they grow larger. They may remain stationary for a long time, and slowly disappear, or, continuing to spread, may become confluent. While the disease is active the individual patch is encircled by a narrow zone of redness, but when it is not spreading this fades away. Sooner or later involution takes place, and the redness which the lesions leave behind them soon disappears, though in protracted cases a brown stain may persist, and in rare instances there may be superficial atrophy. In distribution, psoriasis is almost invariably symmetrical. Like small-pox, it shows a marked predilec- tion for surfaces that are exposed to friction. Almost alwaj^s it starts on the tips of the elbows and the fronts of the knees. After the extensor aspects of the limbs, its favourite site is the hairy scalp, and then the trunk, especially over the lumbar region. In typical cases the clinical picture — the patches with sharply defined border, covered with hard, shiny scales ; the hypersemic surface beneath, dotted with red points ; the distribution as just described ; the unim- paired health, the natural complexion, the proneness to attack blue-eyed fair- haired persons, and the absence of exudation — scarcely admit of misinterpreta- tion. In all these particulars, except the unimpaired health, psoriasis differs from eczema, as well as in the less intense and less constant itching by which it is attended. On the scalp, while psoriasis usually occurs in patches and ends abruptly at or only just beyond the margin of the hair, seborrhoeic eczema almost invariably extends over the whole surface, and often involves the face and the neck. Almost always, too, psoriasis spreads upwards from its sites of election, seborrhoeic eczema downwards from the head. In very chronic forms of eczema, in which there may be no history of " weeping," the diagnosis from psoriasis may be difficult. In all doubtful instances, gentle scratching on the affected surface will bring out the silvery scales, if the case is one of psoriasis. In the papular stage of lichen planus, that affection may in some cases be mistaken for psoriasis. In lichen planus, however, the eruption shows a preference for the flexor aspects of the wrists and knees ; it consists of shining- smooth papules, while scales are absent ; the ground-tint, so to speak, is bluish red or violet ; and the patches are formed by the aggregation of a number of papules instead of by centrifugal extension. In doubtful cases the whole body must be searched for the typical lesions of either disease. Lupus erythematosus differs from psoriasis in that, in the former condition, the scales are not abundant, the edge of the patch is more elevated, the cheeks are usually attacked, as they are not in psoriasis, and there are the distinctive plugs in the orifices of the sebaceous ducts, as described earlier D 42 65 S SCALY ERUPTIOXS in this article. Scarring, too, may be found in the patch, and there may be atrophjr of the ears. As between psoriasis and papular syphilides, the diagnosis is given under Papules. The heaped-up crusts of the condition which has been styled psoriasis rupioides can be distinguished from the rupial lesions of syphihs by the base being ulcerated in the latter disease ; but s\-philis mimics everything, and cases sometimes occur in which it can onlj^ be distinguished even from so distinctive an affection as psoriasis by attention to the history, and hy the discovery of other lesions, the presence of cachexia, the influence of iodides and mercury, or bv the Wassermann serum test. In pityriasis rubra the whole cutaneous surface is always inflamed and reddened, wdthout infiltration or thickening, but accompanied by profuse des- quamation {Plate X), branm^ on the head, shed in larger flakes from the trunk, and from the hands and feet in huge scales. Pit5Tiasis rubra may occur as an independent disease — an extremeh^ rare ev-ent — or may follow in the wake of ervthema multiforme, eczema, psoriasis, lichen pIanuB7"dermaHtis herpetitormis, and certain drug eruptions. Its most frequent precursor is psoriasis. The con- stant and profuse desquamation, the papery scales and sheets in which the epidermis is shed, are important diagnostic signs ; others are the vivid redness of the eruption, the rapidity with which it is diflused, its universahty, the serious impairment of health — sometimes issuing in death — which it produces, and the frequent absence of itching. From eczema it is distinguished hy the absence of exudation and of crusts ; from psoriasis b}' its rapid spread and universal diffusion ; from pemphigus fohaceus by the absence of loose buUse and of foul- smelling discharge, the less severe general symptoms, and the greater amena- bihtj^ to treatment ; from hchen ruber planus by the absence of papules, as well as by its rapid extension and involvement of the whole area of the body. The essential lesions of pityriasis rosea are patches or circles, very slightly raised and thinly covered with small scales. The eruption usually first shows itself on the abdomen, though it may begin on the chest, the face, or the arms. It spreads less rapidly than pityriasis rubra, but in two or three weeks the trunk, the face, and the hmbs may be covered, and though occasionally it is universal, it seldom extends below the elbow or the knee. The diagnosis is seldom in doubt, the characteristic " herald patch " with which the rash begins, the pale- red tint, the sUght elevation of the patches, the minghng of maculate and circinate lesions, the shght degree of scaHness, and the spontaneous involution, forming a distinctive ensemble. The differences it presents from pityriasis rubra have been indicated. From psoriasis it is differentiated by its less inflammatory character, the more rapid onset, the slight scaliness, its neglect of the situations most vulnerable to psoriasitic attack, and the absence of hypersemic spots on the surface beneath the scales. From seborrhoea corporis, by the dryness of the scales, its much less chronic character, the lesions disappearing spontaneously in a few weeks. From tinea circinata, by the large number and wide distribu- tion of the lesions, and the absence of the fungus which is the cause of cutaneous ringworm. From the maculo-papular sj-phihde, b}- the absence of infiltration, the lighter colour, the fact that the palms of the hands are usually spared, and the lack of concomitant syphihtic signs. Pityriasis rubra pilaris may appear in the form of scaly patches, resembUng psoriasis, on the palms and soles, or as a dry eruption, covered with eczematous- looking crusts ; but the papule which soon appears is a more characteristic lesion, and the diagnosis of the condition from psoriasis and other affections will be found under Papules. Malcolm Morris. SCOTOMATA. — (See Vision, Defects of.) PL A TE X. PITYRIASIS RUBRA ^^^ From " Diseases of the Skin" by kind permission of Sir Alalcolm JlforHs, K.C.V.O. INDEX OF DIAGNOSIS SENSATION, SOME ABNORMALITIES OF 659 SENSATION, SOME ABNORMALITIES OF.— The abnormalities of sensa- tion which we meet with in disease are as numerous as they are important for the purpose of diagnosis. Under Pain in the Face ; Pain in the Upper Extremity; and Pain in the Lower Extremity, the question of subjective I Great occipital, poM. branch { of second cervical Auriclllo. divisions of spinal nerve, of Wrisberg Lateral branches of intercostal Int cutaneous of musculo-spiral neous of musculo-spiral cutaneous Internal < -Iliac branch of ilio-inguinal Second lumbar Radial Ulnar Median Inf. ha:innrrlioi ft ~ .g tl S3 -e . {Pressure and its localization. Deeo J-P^«s«"''« ^'="''- ^' i Movements of muscles, joints and ( tendons, Cheir extent and directioiiT' (Tactile Discrimination.- Epicritic. -{Light touch and its localization. ' {Temperatures {Ss'-M'C.) Tj . .,• {Temperatures (fielow 20° and above is°C.)- Peripheral. (.Nerves) fig. 177. — Diagram illustrating the course of the sensory impulses passing from the peripheral nerves into the spinal cord, (from the author's article in Osier's ^/oilern Medicine, vol. vii.) The chief points of practical importance in clinical work to be deducted from the above considerations are as follows : In the first place, analgesia resulting from a cord lesion always includes deep as well as superficial pain, and so differs from the analgesia produced by a peripheral nerve lesion in which, as we have PLA TE XI. DIAGRAM SHOWING THE RADICULAR SENSORY AREAS OF THE HUMAN BODY. '—0234^ Copyright. By D?-. E. Fa7-quhar Buzzard. This diagram has been compiled by the writer from a study of similar diagrams published by others, and modified in accordance with his own experience. Although the various areas depicted in the diagram are essentially Root Areas, the information they supply can be used clinically for the purpose of localizing both radicular and intramedullary lesions. It must be remembered, however, that the deductions in the one case are different from those in the other. If, for instance, the character of the sensory change in one of these areas is of the peripheral type, a radicular lesion of the corresponding segmental level may be diagnosed ; if, on the other hand, the sensory loss is of the central type in a particular skin area, the spinal lesion must be sought at a level several segments higher than that which corresponds to the sensory area. For practical purposes it is important to remember that the uppermost level of sensory change (not the upper level of total analgesia) should be compared with the nearest corresponding line on this diagram. If employed with an intelligent appreciation of these points the diagram is of much clinical importance, but it should not be exploited blindly as a mechanical calculator. Individual variations alone are sufficient to demand a considerable margin of error. INDEX OF DIAGNOSIS SENSATION. SOME ABNORMALITIES OF 663 seen, superficial analgesia may be associated with deep hyperalgesia. In the second place, a lesion of the spinal cord may abolish the appreciation of thermal stimuli, but, if it does so, the discrimination between all degrees of heat and cold will be lost. This again differs from the effect of some peripheral lesions. In the third place, a lesion of the posterior columns may produce loss of the sense of passive position and movement without any loss of tactile, painful, or thermal stimuli, a combination which does not obtain as the result of a lesion limited to the peripheral nervous system. In all diseases or injuries of the spinal cord, the degree of sensory loss depends, of course, upon the severity of the lesion. On the other hand, the distribution of the sensory loss is of the greatest importance for the diagnosis of the level of the lesion. The distribution must be mapped out care- full}^, and then compared with the accompanying diagram {Plate XI), which shows the sensory areas corresponding to the different spinal segments. In a case of myelitis, for instance, it may be found that sensation is perfect above the level of the umbilicus, and impaired on the trunk and legs below that level {Fig. 179). We shall be justified in concluding that the highest point of the disease corresponds to the gth dorsal segment of the cord. Take another example : fracture dislocation of the vertebrae is common in the cervical region, and may crush the spinal cord at the level of the 7th cervical segment. The resulting sensor}' loss is repre- sented in the accompanjdng chart {Fig. 180). Fig. 178. — Comminuted frac- ture of the sacrum, with injury to the 3rd, 4th, and 5th sacral roots. Complete loss of sensi- bility to touch, superficial pain, heat and cold. /■Vy. 179. — Dorsal myelitis affecting the cord as high as the gth dorsal segment. The shaded parts are insensitive to touch, deep and super- ficial pain, and all degrees of temperature. Fig^. 180. — Fracture-dislocation of the cervical spine. The shaded area represents the loss of sensibility to touch, pain, heat and cold. 664 SENSATION, SOME ABNORMALITIES OF In testing the sensibility of the skin, it is ahvays advisable to work from the anaesthetic area towards the normal, and to note not only complete anaesthesia, but all modifications of sensation. For instance, bordering on the region of complete anaesthesia there ma}- be an area in which the patient is able to appreciate a touch or a pin- prick, but in which he describes the sensation produced as differing from the natural sensation elicited by these stimuli. Such modifications should be taken into account in diagnosing the level of the lesion. As a result of disease or injury of one side oTTEhe--spinal__cord, a symptom- complex called Brown-Seqiiard paralysis is met with. This includes loss of sensibility in parts of the body on the opposite side to that of the lesion, and at a lower level. The sensor}^ loss, is often of a dissociative tj^pe, that is to say, tactile sensibihty is pre- served while painful and thermal sensibility is lost. Fig. i8i illus- trates the sensor}- loss in a case of this kind. Syritigomyelia and hczmatomyelia are other conditions in which dis- sociative anaesthesia is common [Fig. 182). In the former disease thermo- anjesthesia and analgesia are usually found first in the upper extremities and thorax, and they tend to spread all over the body. In rare instances thej- commence in the lower extremities or on the face. Their distribution is nearly always asymmetrical. The borders of the cutaneous loss are not sharp but shaded off, and correspond to the limits of spinal-root areas. On the other hand, charts sometimes show regions of dissociative anaesthesia which correspond lateralh' to one or more root areas, but do not cover their longitudinal extent. For instance, the sensory loss in one hand may be limited above by a line encircling the forearm so as to give it the appearance of a glove distribution. Similarly, on the face a central area, including the nose, mouth, and eyes, may preserve its sensibility intact, while the surrounding regions are completel}^ insensiti^"e to painful and thermal stimuli. Thermo-anaesthesia and analgesia are sometimes, but not always, co-extensive. Tactile loss also occurs, but usually supervenes in the later stages of the disease. Subjective sensations may form the initial evidence of the disease, and may be thermal, painful, or tactile. Lancinating pains and cramps are described. ]\Iore curious are the subjectiAe sensations of drenching sweat in a part which is dry, or of cold in a part which is quite normal in temperature. In tabes dorsalis the disturbances of sensation are numerous and charac- teristic. Lightning and dull boring pains, tingling, numbness, girdle sensations, and \-arious painful crises are among the subjective abnormalities. Impairment or loss of deep and superficial pain sensibility in various parts of the body is one of the earliest and most important phj-sical signs for the purpose of diagnosis. ^ig^- 181. — Brown-Sequard paralysis due to an intra-meduUary one-sided lesion of the lower thoracic cord. The shaded area was insensitive to deep and .superficial pain and to all degrees ot temperature, but sensitive to touch. The sense of passive move- ment and position and tactile discrimination were disturbed in the right foot. There was spastic paralysis of the right leg only. (After Head and 'Jhovipson.) SENSATION, SOME ABNORMALITIES OF 66 = The cutaneous analgesia is generally found on the legs, and often also in the root areas on the arms and thorax corresponding to the C 8 to D 5 segments (see Fig. 183). Deep analgesia is nearly always present in the calf muscles. Superficial nerves such as the ulnar may often be found insensitive to rolling or pinching. Delayed sensibility is another phenomenon very characteristic of some cases of tabes dorsalis. Hyperassthesia may be present, especially in bands around the abdomen, when gastric or intestinal crises form part of the clinical picture. Intolerance of hot or cold water on any part of the skin is described not uncommonly by patients suffering froru severe forms of the disease. Allocheiria, or refer- ence of a sensory stimulus to the opposite side of the body, has also been observed. The sense of position and move- ment is nearly always disturbed in locomotor ataxy, and this results . in varying degrees of inco-ordina- /•'4'. 182. — Syringomyelia. The .shaded parts show the areas of dissociative anaesthesia, i.e., of tliermo-ansesthesia and analgesia. This was associ- ated with atrophic palsy of the upper extremities. tion and in the production of Romberg's sign. Astereognosis, or the inability to gauge approximately the size and shape of objects placed in the patient's hand, is another common sensory defect. In disseminated sclerosis, sensory troubles do not as a rule constitute so prominent a feature as do the motor disabilities, but subjective and objective changes are by no means uncommon. Numbness of one limb lasting a few weeks or months, girdle sensations, and even pains of a neuralgic type, are sometimes complained of. I have known transient hemianaesthesia to be an initial symptom in one case, and astereognosis with loss of sense of position on one side, to be the earliest signs of disease in two or three cases. From the diagnostic standpoint these are important facts, because it is very tempting to assume, erroneously, that such sensory phenomena, occurring alone without any reflex or motor signs of organic disease, are hysterical in origin. Thej' /•'i^. 1S3. — Early tabes dor.salis. The dotted areas represent a cliaracteristic distribution of sensory disturbance. The loss is chiefly to painful stimuli, and the superficial analgesia is almost always associ- ated with deep analgesia. 666 SENSATION, SOME ABNORMALITIES OF are doubtless due to patches of disease in the neighbourhood of the internal capsule. This brings us to the consideration of the Abnormalities of Sensation resulting from disease of the Higher Parts of the Nervous System. Hemiansesthesia is a common result of the various vascular accidents responsible for apoplexy and hemiplegia. It may be present with or without any motor paralysis and with or without hemianopia ; sometimes all three phenomena are associated in the case of severe lesions of the internal capsule and optic radiations. In most cases of apoplexy hemiansesthesia is slight and transient. Tactile and pain sensibility may be impairedj usually more so on the limbs than on the trunk, and more especially in the distal portions of the arm and leg. Even when touches are perceived, they are localized badly by the patient. In lesions of the optic thalamus the opposite side of the body may be the site of a curious sensory disturbance which consists in part of a lowered sensibility to painful stimuli and in part of a great exaggeration of the disagreeable effects produced bj^ such stimuli when they are per- ceived. For instance, the patient may fail to recognize a light pin- prick so well on the affected as on the sound side, but a scratch may produce an intensely painful sensa- tion referred to a, very wide area and not localized to the spot stimulated. In such cases the patient often complains also of paroxysms of severe pain in the affected limbs. The hemiancBSthesia of hysteria is usually far more complete to all forms of stimulation than any hemianaesthesia due to organic dis- ease of the brain. The hysterical patient is found to have lost taste, smell, and sometimes even hearing, on the anaesthetic side. The visual defect, instead of being hemianopic as in the organic cases, is generally a marked contraction of the visual especially in the eye corresponding 184. — Thrombosis of left posterior inferior cerebellar artery. The dotted areas show the regions of dissociative anaesthesia, i.e., loss of sensibility to pain and temperature of all degrees. fields, sometimes amounting to blindness to the other sensory defects. Lesions of the brain-stem may also be responsible for extensive loss of sensation. For instance, thrombosis of the posterior inferior cerebellar artery gives rise to a localized softening on one side of the medulla, which produces thermo- anassthesia and analgesia on the same side of the face, and on the trunk and limbs of the opposite side. This sensory disturbance is sometimes comphcated by homolateral cerebellar ataxy and cranial nerve palsies. So far we have dealt chiefly with the various forms of lowered sensibility, and have given little attention to perversions of sensation, such as are indicated by the terms hypercssthesia and parcssthesia. Hypercssthesia is observed in cases of tabes dorsalis and peripheral nerve lesions as described above, but it is also met with in other conditions of organic as well as functional disease. It is found, for instance, in root areas in cases of SKODA IC RESONANCE 667 vertebral and intra vertebral disease. In spinal caries and in tumours of the spinal meninges, a zone of hyperaesthesia may be detected just above the area of anaesthesia produced by the compression of the cord, or it may precede the appearance of compression signs. The increased sensibility is probably caused by pressure on, or irritation of, the posterior root fibres. A similar phenomenon is a frequent accompaniment and sequel of an attack of herpes zoster. The shape and situation of such hvperaesthetic zones afford a clue to the site of the lesion. Hyperjesthesia as well as parsesthesia are among the earliest signs of stibaciite combined degeneration of the cord, and are referred b}^ the patient to peripheral parts of his four extremities. They may precede by many weeks or months the appearance of ataxic or spastic paraplegia and definite areas of sensory loss. Similar symptoms are also complained of in not a few cases of pernicious anaemia and other severe blood diseases, probably on account of scattered degenerations in the nervous system as the result of the Anaemia (q.v.). Neurasthenic and hysterical states are responsible for hA'perjesthetic areas which have no relation to central or peripheral innervation. In neurasthenia, especially the traumatic variety, the patches are usually found on and around the spine and over the scalp. In hA'sterical conditions similar patches may be detected in the mammary and ovarian regions. HA-peraesthesia in connection with visceral disease has been referred to in other articles, such as those on Pain in the Face; Pain in the Upper Extremity; etc. E. Farqithar Buzzard. SHIVERING FITS.— (See Rigors.) SHORTNESS OF BREATH.— (See Breath, Shortness of.) SKIN ERUPTIONS.— (See Macules; Papules; Etc.) SKODAIC RESONANCE.— WTien there is a basal and unilateral pleuritic effusion of medium degree, it may often be noted that the pitch of the percussion note over the upper part of the thorax in front is higher on that side of the chest on which the effusion is than on the other. It is not a question either of impairment of resonance or of hyper- resonance, but merely of pitch. This higher pitch of the percussion note over the upper lobe, when the lower lobe is compressed by an effusion, is named " Skodaic resonance," after the observer who first drew attention to it. Its importance is mainly twofold : in the first place it does not indicate disease of that part of the lung which affords the sign — for instance, the fact that, in a case of right-sided effusion, the right upper lobe gives a higher-pitched percussion note than does the left cannot be taken as evidence that there is a lesion, perhaps tuberculous, at the right apex ; in the second place, it is erroneous to suppose that this is only obtained in cases of effusion ; its occurrence cannot be taken as proof that dullness at the base is due to fluid there. It is true that pleural effusion gives it not only in most marked degree, but also most commonl^^ ; nevertheless it may also be observed in some cases of basal pneumonia without effusion, or as the result of compression of a lower lobe by such causes as subdiaphragmatic or hepatic abscess, hepatic masses such as carcinoma, gumma or hydatid cyst, great enlargements of the spleen such as occur in splenomeduUarj^ leukaemia, a big heart, a pericardial effusion, or a mediastinal or pulmonary new growth. The cause of Skodaic resonance has never been quite decided, and manv theories have been propounded about it ; clinically, the most serviceable view is that anything that lessens the degree to which the upper lobe is stretched, yet without actually compressing it, may produce a rise in the pitch of its percussion note. Bilateral compression of the bases of the lungs 668 SKODAIC RESONANCE by such lesions as ascites, presumably causes bilateral Skodaic resonance, but this is difficult to determine, because the latter is only recognizable when there is a difference of pitch between the-lwa_sidea_ofthe upper part of the chest in front. Skodaic resonance over an upper lobe when there is some lesion affecting^he lower lobe on the same side, should not be confused with the tympanic note that may sometimes be heard over the other parts of the thorax. Stomach tympany is normally heard external to and below the precordial region over an area known as Traube's space, which is bounded above by the precordial dullness, behind by the splenic dullness, and below by the rib margin. When the stomach is dilated, there may be an abnormal extent of this gastric tympany in the thorax. When the transverse colon is distended with gas, or when it is pushed upwards by something intra-abdominal, it may produce abnormal areas of thoracic tympany, particularly in the lower sternal region or on either side of this. Such conditions can scarcely be mistaken for Skodaic resonance, for the latter concerns the upper part of an upper lobe in front, and is not a definite tympany, but rather a moderate rise in the pitch of the ordinarj^ percussion note, not as a rule obvious till the two sides are contrasted. Herbert French. SLEEPLESSNESS.— (See Insomnia.) SMELL, ABNORMALITIES OF. — Abnormalities of the sense of smell fall into three main categories, namely : — (i) Too great sensitiveness to smells which actually exist ; (2) Deficient sensitiveness to smells which actually exist ; (3) Sub- jective sensations of smells which do not exist. 1. Too great sensitiveness to existing smells is sometimes a nuisance to the individual, but is very seldom a sign of disease. There are very great differences in the powers of perception of different sensations in different persons, and just as some can appreciate very slight differences in sounds more than others, so can some detect smells which are undiscernable by others. This is natural idiosyncrasy. 2. Deficient sensitiveness to actual smells is often but the obverse of the above, and no sign of disease, although it may be a detriment to the individual, especially in certain commercial pursuits in which the varying qualities of products are judged partly by smell. When the power of smell, having been normal, becomes deficient or totally absent, the change may affect one nostril only, or both. The condition may be transient or persistent. The commonest cause of transient anosmia is acute nasal catarrh, whether the result of an ordinary co^ii, or of other affections such as hay fever (coryza e feno), oncoming measles, or the effects of drugs such as iodide of potassium or arsenic. Persistent anosmia may be due to : — (a). Inability to get air freely, or at all, through the nostril, as the result of : — Adenoids ' Hypertrophic rhinitis Polypi Syphilis Dislocation of the nasal Necrosis of bones in the nares septum Occlusion of anterior or posterior Xasal septal spur nares. {h). Alteration in the olfactory mucous membrane, so that it no longer transmits impulses to the endings of the olfactory nerve, although the airway is free : — Atrophic rhinitis Paralysis of the fifth nerve, leading to undue dryness of the mucosa. SNORING 669 (c). Abnormalities of the olfactory nerves. Congenital absence Hydrocephalus Olfactory neuritis, either the result of overstimulation locally by strong noxious vapours, ammonia, or snuff ; or part of a general peripheral neuritis Post-influenzal changes (d). Cranial lesions, especially haemorrhage, thrombosis, emboUsm, softening, injury, or tumour of the uncinate gyrus, which is the centre for smell, (e). General nerve diseases, especially : — General paralysis of the insane Locomotor ataxy. (/). Hysteria. There is httle need to discuss the above table in detail, for each heading speaks for itself. When a case is being investigated, the history is very important ; it is next necessary to examine the nose carefully through a speculum, and to test the air-way through each nostril ; if there is any local lesion, it will generally become obvious at once, and only after local affections have been excluded should conditions in groups c, d, e, and / be discussed. Anosmia will seldom if ever be a prominent symptom, except in connection with local affections of the nose ; when due to any other cause, there will nearly always be some other symptoms which will attract attention more than the anosmia itself. 3. Subjective sensations of smells which do not exist externally may be due to : — (a). Offensive or purulent inflammations of the nose or of the air-cells communicating with it, especially empyema of the antrum of Highmore, or of a frontal sinus. ip). Local thickening of the meninges, tumour of the brain, or inter- ference with the vascular supply, causing irritation of the hippo- campal region, (c). An aura preceding an epileptic seizure. {d). Hysteria. [e). Insanity. In arriving at a diagnosis, it is chiefly important to exclude purulent affec- tions discharging into the nose ; if it is possible to state with certainty that the abnormal sensations have no such organic basis, it is not difficult as a rule to decide between the other causes. It is a curious fact that subjective abnor- malities of smell are apt to be associated with delusional insanity concerning the genital organs, in which the prognosis is not free from acute dangers. Herbert French. SNORING may be a very troublesome symptom in some patients, particularly to those who have to sleep in the same room with them ; but it is often less an indication of disease than merely a bad habit. Most snorers sleep with their mouths open, and breathe partly through the nose and partly through the mouth ; but it is possible for snoring to occur with the mouth completely shut, and nothing the matter with the nasal passages. The tendency is increased, however, by any obstruction of the nasal airway, so that particular examination should be made for such lesions as undue smallness of the nares or a tendency for the soft parts of the nostrils to collapse on inspiration, deflected septiim, hypertrophic rhinitis, polypi, adenoids, acute or chronic nasal catarrh, inflam- mation of the accessory sinuses or of the pharyngeal^ tonsils, or even a fibro- sarcoma or other neoplasm of the nasopharynx. Herbert French. 670 SORE THRO A T SORE THROAT may be due to one or other of many different causes 1. Affections of the Tonsils : — Quinsy. Acute Tonsillitis. {a). With reddening and swelHng only: Acute inflammation due to various micro-organisms, especially to streptococci ; staphjdococci ; pneumococci ; diphtheria bacilU ; Hofmann's bacilli ; Vincent's spirilla and fusiform bacilli ; spirochceta (treponema) pallida ; micrococci catar- rhales ; bacilli influenzae ; tubercle bacilli. The sore throats of scarlet fever, German measles, and measles are probably not due to specific micro-organisms, but to streptococci, or others of the bacteria just enumerated. [b). With redness, swelling, and exudation : Follicular tonsillitis due to streptococci, etc., as above. Diphtheria Vincent's angina Syphilis, (c). With ulceration : Phlegmonous tonsillitis due to streptococci, etc., as above. Syphilis Vincent's angina. Chronic Affections of the Tonsils : — Recurrent inflammation often associated with adenoids, or tonsillar hypertrophy, especially in children Primary or secondary syphilis Vincent's angina Squamous-celled carcinoma Sarcoma Gumma Tubercle. 2. Inflammation of the Soft Palate, Uvula, and Fauces : — Catarrh, occurring either by itself or associated with any of the varieties of tonsillitis enumerated above Gumma Squamous-celled carcinoma Tubercle. 3. Affections of the Pharynx : — Acute catarrhal pharyngitis due to any of the micro-organisms men- tioned under the heading of acute tonsillitis Chronic granular pharyngitis due to smoking in excess ; or to over-use, as in clergyman's, costermonger's, or stockbroker's sore throat Squamous-celled carcinoma of the pharynx Post-pharyngeal abscess Varicella Variola. 4. Laryngeal Conditions, especially :— Acute catarrhal laryngitis due to any of the organisms mentioned above. Tuberculous laryngitis Syphilitic laryngitis Carcinoma laryngis Acute perichondritis of the arytenoid cartilages. 1 SORE THROAT 671 5. Sore Throats the result of the Swallowing or Inhalation of Irritants : — Corrosives, such as alkalies or strong acids Ammonia vapour Hot steam. 6. Mumps. 7. Acute and Subacute Adenitis of the lymphatic glands in the neck. Notwithstanding the length of the above list the differential diagnosis of a sore throat in practice is not difficult as a rule. Enquiry into the history and inspection of the parts locally in a good light will generally serve to give one a very shrewd notion of the nature of the complaint. The chief point in practice is to determine as soon as possible whether the Klebs-Loffler bacilli of diphtheria are present or not, for it has been established that there is no kind of sore throat which can be recognized clinically as non-diphtheritic. It is important that swabbings should be taken from the inflamed parts and examined by a bacterio- logist both directly in films stained by Neisser's method, and by means of cultures. Similar bacteriological investigations will serve to determine which of the organisms mentioned above is responsible for an acute or follicular or ulcerative sore throat other than diphtheritic, it being borne in mind, however, that the organism should be found in fairly pure cultures if it is to be regarded as causative and not merely as a secondary or even casual infection. I. Affections of the Tonsils. Quinsy is practically always an asymmetrical affection, one tonsil being very much more bulged than the other ; the- surface is reddened, generally without follicular suppuration, and the diagnosis is ultimately confirmed by the bursting of the abscess. The presence of Klebs-Loffler bacilli in association with a sore throat may be regarded as conclusive proof that the lesion is diphtheria, even though there may be no typical diphtheritic exudate. Diphtheria having been excluded, the diagnosis of one of the other varieties of acute tonsillitis is rendered possible. The frequency with which acute rheumatism is associated with recurrent tonsil- litis, especially in young people between the ages of five and twenty, should always be borne in mind ; the patient may or may not have suffered from other effects of acute rheumatism, such as joint pains, endocarditis (evidenced by the bruits), pericarditis, pleurisy, erythema nodosum, chorea ; or a history of such rheumatic affections may be obtained in other members of the same family. The tonsillitis is benefited by sodium salicylate, but by no means to the same extent as are the joint pains, so that the effect of treatment is not by itself conclusive evidence of the nature of the complaint. When acute rheumatism gives rise simultaneously to generalized erythema and to tonsillitis, there will be very considerable difficulty in excluding scarlet fever, especially if there has been considerable nausea or actual vomiting ; in some such cases the diagnosis will be one of opinion only ; that which was regarded at first as acute rheumatic tonsillitis and erythema may prove to have been scarlatina after all, should the patient presently develop acute nephritis ; the occurrence of extensive peeling of the skin is not conclusive evidence of scarlatinal erythema and sore throat. If the patient is known to have had scarlet fever formerly, the rheumatic nature of the case is more likely. Follicular tonsillitis is not a final diagnosis, for it may be due to various different micro-organisms, and there is no doubt that the diphtheria bacillus may produce that which to inspection presents multiple foci of pus in the different tonsillar , crypts formerly regarded as characteristic of follicular as distinct from diph- theritic tonsillitis. The only conclusive proof that a comparatively simple follicular tonsillitis is not diphtheritic is bacteriological examination. If clinical 672 SORE THROAT points alone have to be relied on, one would say that the higher the temperature, the greater the constitutional disturbances, and the more sudden the onset, the more likely is it not to be diphtheria. Vincent's angina has been differentiated bacteriologically, cases of this kind having formerly been regarded either as diphtheria or as follicular tonsillitis. The characteristic micro-organisms present are elongated fusiform bacilli sym- biotic Avith spirilla {Plate XII, Fig. M). The disease is, as a rule, more resistant to treatment than are other forms of acute sore throat, so that what has originally been a tonsillitis with exudation presently becomes an ulceration associated with remarkable foetor of the breath, but without that tendency to fatal termination presented by most other varieties of acute ulcerative or phlegmonous sore throat. The disease cannot be recognized without the aid of the bacteriologist. Syphilis may cause acute soreness of the throat in its secondary stages, and unless that possibility is borne in mind, one may diagnose as acute simple or acute follicular tonsillitis that which is really syphilitic. There is more or less pyrexia at the same time, and in most cases there will be tenderness of the scalp and of the bones, together with the well-known roseolous eruption upon the skin and the " snail-track " ulcers upon the pharynx. The diagnosis may be more difficult in women than in men, for in the latter the remains of the chancre may still be obvious. Wassermann's serum test may materially assist in the diagnosis of doubtful cases. Chronic affections of the tonsils in children are nearly always the result of recurrent acute attacks of non-diphtheritic tonsillitis, generally in association with adenoids, both affections arising from the habit of mouth breathing. Inspec- tion of the bulging hypertrophied tonsils, with or without digital examination of the posterior nasal fossse, will indicate the diagnosis. In an older person, simple hypertrophy from a recurrent tonsillitis becomes progressively less common. Chronic tonsillitis in a young adult may be diphtheritic, syphilitic, or due to Vincent's angina, the diagnosis between these being arrived at in the way described above. It may be mentioned that in very rare instances an actual chancre appears upon one tonsil, giving rise, unless secondary symptoms are present, to much difficulty in diagnosis until the case has been watched. Malignant disease of the tonsils, whether squamous-celled carcinoma, or sarcoma, is fortunately not very common ; when it does develop, its comparatively non-acute course and its unilateral distribution Avith progressive ulceration of the central parts and overgrowth of the edges of the neoplasm will point to the diagnosis. A gumma of the tonsil is very rare, and it might at first simulate squamous-celled carcinoma : in case of doubt a small portion of the suspicious mass might be excised, and examined microscopically ; or if operative measures were not to be adopted at once, potassium iodide might be administered, and the lesion would be shown to be gummatous if it were thereby relieved or cured. Tuberculous ulceration of the tonsils is quite uncommon, practically never primary, but secondary to extension from the lungs, and nearly always preceded by both phthisis and tuberculosis of the larynx. The diagnosis will be indicated by the discovery of tubercle bacilli in the sputum, though it should not be forgotten that carcinoma or gumma might affect the tonsils in a person Avho had phthisis. 2. Inflammation of the Soft Palate, Uvula, and Fauces. This may be seen in many cases of common cold ; in association with acute rheumatism ; in persons Avho have recently returned to tOAvn from a holiday in the country ; in patients Avho have been subjected to the influence of motor-car dust stirred up from the roads after the latter have been dry for about three days — a longer period of dryness seems to lead to relative disinfection of the dust, Avhilst rain keeps the dust from rising, so that either continuance of fine SORE THRO A T 673 weather or a return to wet leads to a disappearance of the sore throats ; or in those who are subjected to the influence of relatively concentrated microbes, as in the air of old-fashioned hospital wards, of ill-ventilated much-inhabited rooms, of sewers, and the hke. Often a rim of acute reddening is to be seen all along the edge of the anterior pillars of the fauces, and affecting much of the uvula and of the soft palate, producing, as a rule, but little pj^rexia, though much discomfort in swallowing, and a raspy feeling on the back of the mouth on first waking in the morning. This inflammation of the palate and fauces may or may not be associated with tonsillitis, pharyngitis, or laryngitis ; it is clearly microbial ; and doubtless more than one of the varieties of bacteria mentioned above ma}^ produce the lesion. The diagnosis of the fact of inflammation is obvious on inspection ; that of the nature of the micro-organism requires skilled bacteriological assistance. Gumma, squanious-celled carcinoma, and tuberculous affections of the fauces, soft palate, and uvula are relatively uncommon ; they are differentiated in the same way as has been described in connection with tonsillitis. 3. Affections of the Pharynx. Acute pharyngitis may occur by itself, or in association with acute tonsillitis or acute larj-ngitis, and in either case it may be due to any of the micro-organisms mentioned above. The differential diagnosis of the micro-organisms is carried out in the bacteriological laboratory. The fact of acute pharyngitis is deter- mined hy careful inspection of the structures at the back of the mouth. Chronic pharyngitis is generally the result of excessive smoking, or of the undue use of the voice, in which latter case it may be associated with hoarseness or ready tiring of the voice, as in those who have to declaim loud and long — clergymen, stockbrokers, costermongers, pubhc orators, and others. The history will generally point to the nature of such a case, though it is necessary to examine the sputum and the lungs for evidence of tuberculosis, and also to look for signs of either syphilis or new growth, in order to exclude these possible alternatives. Post-pharyngeal abscess is rather a cause of acute dyspnoea than of soreness of the throat ; it is almost confined to infancy ; after three or four years of age the disease becomes almost unknown. It might be simulated by spinal caries, in which, long before there is soreness of the throat, there is severe pain in the cervical region of the spine, especially on movement. Chicken-pox and small-pox may each produce its characteristic eruption in the mouth, pharynx, and oesophagus, and thus give rise to sore throat ; but the latter symptom will never be present by itself, and the presence of the cutaneous papules, vesicles, or pustules, will indicate the diagnosis, especially if there have been other similar cases in the neighbourhood. 4. Laryngeal Conditions. Acute laryngitis may be due to the same micro-organisms as acute tonsillitis; soreness of the throat is generally less complained of than is huskiness, or weakness or loss of voice. The nature of the inflammation is determined bacteriologically in -most cases. One variety of acute non-diphtheritic laryngitis that merits special mention is that due to pyogenic cocci- — pneumococci, streptococci, staphylococci — which in a few cases, in addition to producing acute superficial inflammation, also lead to rapid and extreme oedema of the larynx, with death from asphyxia unless tracheotomy be speedily performed. These cases have been spoken of as acute suffocative oedema of the larj-nx. Tuberculous, syphilitic, and carcinomatous lesions of the larynx are less acute, though they may have relativel}^ acute exacerbations or may become secondarily infected with pyogenic cocci ; their diagnosis depends partly upon larjTigoscopic inspection — ^tuberculosis and syphilis being bilateral, whilst new growth is 15 43 ' 674 SORE THRO A T generally unilateral ; upon examination of the sputum for tubercle bacilli, and of the lungs for apical physical signs of phthisis ; upon the beneficial influence of potassium iodide and mercury ; upon Wassermann's syphihtic serum test ; upon microscopic examination of small excised portions ; or upon the course of the disease. 5. Sore Throats the Result of the Swallowing or Inhalation of Irritants and Corrosives, are diagnosed as a rule by the history ; enquiry into the circumstances of the case will generally suffice to indicate that some irritant has been taken, or there may be direct evidence of it in the form of eschars on the hps or the buccal mucosa ; there may be vomiting and hsematemesis ; analysis of the gastric contents may indicate the nature of the poison taken ; ammonia may be detected by the smell. 6, 7. Mumps and Acute Adenitis of the Cervical Lymphatic Glands maj^ each produce marked soreness of the throat in addition to d3^sphagia, stiffness, discomfort, and pain. Mumps is not difficult to diagnose unless its possibiht}' is forgotten, in which case it might be mistaken for acute oedema of the neck or other similar lesions. The way in which the sweUing is located in the salivary glands, starting on one side and spreading to both, is often pathognomonic. Cervical adenitis might simulate mumps, but careful palpation will generallj'' enable one to determine that the swelling is not in the salivary but in the lymphatic glands, and it will only remain to decide what has been the source of the infection. This will probably have been from some inflammatory, ulcerative, or malignant focus in connection with the shoulders, neck, head, face, lips, cheeks, gums, teeth, tongue, fauces, uvula, palate, tonsUs, pharynx, or nares ; the differential diagnosis will be based upon inspection and palpation of the parts, together with bacteriologickl examination. It only remains to add that scarlet fever is at the present time so at^^pical that acute cervical adenitis may really be of scarlatinal origin Avithout any scarlatini- form rash having been observed upon the skin. One would naturally look for evidence of desquaniation, sore throat, bald tongue, albuminuria, nephritis, perhaps otitis media ; but there is no doubt that some cases of acute cer\dcal adenitis are really scarlatinal, without there having been any other sign of this disease except pyrexia and sore throat. A few such cases prove rapidly fatal, and they have recently been recorded as examples of acute and fatal sore throat corresponding with one form of the angina maligna of the eighteenth century. Herbert Fretich. SORES, PENILE.— Sores on the penis may be present on the thin mucous covering of the glans or prepuce, or on the cutaneous surface of the body of the penis ; they are more common in the former situation. Ulceration in the neighbourhood of the glans penis may be due to : — 5. Epithelioma 6. Gummatous ulceration 7. Tuberculous ulceration. 1. Balanitis 2. Herpes progenitalis 3. Soft sore 4. Chancre I. Balanitis. — If inflammatory processes have been allowed to continue beneath the prepuce, ulceration and excoriation of the mucous membrane covering the glans penis or lining the prepuce, will occur. The surface of the glans will be seen to be denuded of epithelium, and the process will be accom- panied by a stinking, purulent discharge. Multiple shallow ulcers are formed, rapidly coalescing and causing considerable discomfort. The prepuce often becomes swollen and oedematous, preventing retraction, so that a condition of phimosis occurs. In this condition care must be exercised in the diagnosis of 3, simple balanitis from one accompanying acute gonorrhceal urethritis or an SORES, PENILE G75 underlying syphilitic or soft chancre. With an acute urethritis, there will be a history of infection, pain along the course of the urethra during micturition, and other symptoms, such as chordee ; further, the intracellular gonococcus may be identified in a stained smear of the discharge {Plate XII, Fig. R). If a chancre exist under the swollen phimosed prepuce, there is often a tender spot about the corona or at the frsenum. With a soft sore, consecutive sores may appear about the orifice of the prepuce, whilst the inguinal glands are much more likely to be inflamed or to suppurate than in a simple balanitis. A syphilitic chancre obscured by a phimosis can usually be felt distinctly under the skin, and causes a comparatively small amount of discharge, whilst the inguinal glands become enlarged but do not suppurate. The history of the date of infection, and the subsequent appearance of secondary symptoms, will materially help in the diagnosis. A form of balanitis which is frequently very obstinate to treatment may occur in patients the subject of gout or diabetes mellitus. 2. Herpes Progenitalis. — Herpes may attack the genital organs as part of a herpes zoster in which the cutaneous eruption depends upon some lesion of the central nervous system, or as a local affection, the so-called catarrhal herpes. The disease begins as a patch of erythema on the inner surface of the prepuce or on the glans penis, followed by the appearance of vesicles and pustules ; the latter become rubbed by the clothes, and form small ulcers. Herpes of the genital organs tends to recur, so that a previous history of a similar attack is often forthcoming. If it arise during the vesicular stage, no difficulty will be met with in the diagnosis ; but if suppuration has followed, it must be diagnosed from a venereal sore. Soft chancres are usually deeper, with marked edges ; their base is sloughing, and they are usually accompanied by a bubo, which is exceptional with herpes. A syphilitic chancre is usually single, indurated and raised, and is accompanied by the typical, multiple, discrete, amygdaloid glands in the inguinal region. It should be remembered that syphilis may become inoculated upon a herpetic patch, or that herpes may appear in an area previously inoculated with the syphilitic virus. 3. Soft Sores or Chancroids of the penis occur almost invariably from infection during sexual connection. The incubation period is short, a vesicle occurs in two days, and this rapidly breaks down to form a rounded or oval ulcer with sharply defined edges, and a yellowish sloughing base. The ulcers appear usually on the mucous surface of the glans, fraenum, or corona, and are most often multiple, direct inoculation occurring from an ulcer to the contiguous part. They may cause rapid destruction of tissue, perforating the fragnum or spreading over the surface of the glans. The soft sore must be differentiated from others occurring on the glans, and above all from a syphilitic chancre. At the same time it must be remembered that besides the infection with chancroid, a simultaneous infection with syphilis may have taken place, so that a soft sore may ultimately become indurated and assume the character of a primary syphilitic lesion. The chancroids are multiple, are accompanied by a good deal of thin, purulent discharge, and by a painful swelling of the inguinal glands, usually of one side, which have a marked tendency to suppurate. On the other hand, a syphilitic chancre is single, is raised and indurated, has littl-e discharge, and is accompanied by enlarged, but firm and indolent, glands in both inguinal regions ; the incubation period of a syphilitic chancre is from twenty-one to twenty-five days. The multiple ulcerations caused by herpes are more superficial, and rarely cause a bubo. 4. Chancre — -the initial lesion of syphilis — generally appears on the penis, and is most common in the neighbourhood of the fraenum or coronary sulcus. A 676 SORES, PENILE chancre appears about twentj'-one days after infection, as a reddened patch, which becomes raised above the surface of the mucous membrane, with distinctly- indurated margins. The central part breaks down into an ulcer, discharging a thin, purulent fluid, and at the same time the inguinal glands of both sides become palpable, slightly enlarged, but discrete, and with no tendency to suppurate. The chancre increases but slowly in size, or may occasionally become smaller without any treatment, and after a further lapse of from four to six weeks the typical secondary symptoms make their appearance ; namety, a roseolar rash on the chest, abdomen, face, and thighs, general adenitis, and a mucous patch about the faucial pillars and tonsils. The diagnosis of the primary lesion of syphilis frequently presents no diffi- culties, the indurated character of the sore, the date of its appearance after infection, and the presence of firm, indurated glands in the inguinal region, being distinctive. In other cases the character of the sore is by no means dis- tinctive, and it is necessary to differentiate it from other lesions of the penis. If the sore be syphilitic, the secondary manifestations of the disease will follow, provided that the doubtful ulcer is not treated as a chancre. Thus, in any case in which syphilis is suspected, but not wholly certain, it is advisable to withhold any specific treatment for syphilis until such time as secondary symptoms appear, so that a patient may not be condemned to the lengthy process of treat- ment for syphilis until the diagnosis is absolutely certain. Wassermann's serum reaction may also be tried, and the Spirochceta pallida looked for in scrapings from the affected parts. A chancre may be simulated by an inflamed soft sore, especially if the latter has undergone cauterization. Soft sores are, however, frequently multiple, appear within a few days c f infection, and are accompanied by a painful enlarge- ment of the inguinal lymphatic glands, which are particularly prone to suppurate. It must not be forgotten that a double infection may have occurred, so that a soft sore may show little inclination to heal or, becoming indurated, may present the features of a chancre after about three weeks, and later, the symptoms of constitutional syphilis. Epithelioma of the penis in the early stage may be confused with syphilitic chancre. In epithelioma there is no history of infection ; it occurs only in elderly patients, and there is frequently a greater destruction of tissue than in syphilis. The inguinal glands are not enlarged until the sore has been present for some weeks, and there are no secondary lesions such as the faucial ulceration and cutaneous rash. If any doubt exists, a small piece may be removed from the edge of the ulcer for microscopical examination. Perhaps the greatest difficulty in the diagnosis of a chancre is experienced when the latter is hidden beneath an inflamed and phimosed prepuce. There is a purulent and foul discharge from beneath the prepuce, which may be oedematous and swollen ; the inguinal glands are enlarged from the associated sepsis, either with a simple balanitis or from subpreputial ulceration. If a chancre is present, it can frequently be felt as an indurated area under the prepuce, whilst if it has been present for some time, the secondary lesions of syphilis may be present. If any doubt exists in an elderly patient whether an indurated subprepucial area be an early epithelioma or a syphilitic sore, the prepuce should be split up along the dorsal aspect under anaesthesia, the ulceration inspected, and a small piece submitted to microscopical examination if necessary, without loss of time. 5. Epithelioma (squamous-celled carcinoma) is ths most common form of malignant growth of the penis. It arises most frequently from the inner aspect of the prepuce, or from the mucous membrane of the glans, as a small, raised ulcer, with friable, irregular edges. Epithelioma is rarely present before the SORES. PERINEAL 677 age of forty years, and frequently occurs on the site of previous ulceration or long-standing irritation. An epitheliomatous ulcer increases gradually in size, in spite of various forms of treatment, and with it is frequently associated glandular enlargement in the inguinal area. At first the glands may be enlarged from septic infection, but later from malignant infiltration. An epitheliomatous ulcer raay in some cases be confused with a chancre ; but the friable, irregular edges of the former, the liability to bleed, and the gradual progressive increase in size in spite of treatment in an elderly patient, should give rise to grave suspicion of malignant disease. The microscopical examination of a small piece removed from the edge of the ulcer will give direct evidence ofr epithelioma. 6. Gummatous Ulceration of the penis occasionally occurs, resulting from the disintegration of a small gumma of the glans or prepuce, frequently in the position of an old scar. A gumma commences as a small, elevated nodule, which, if left untreated, softens and discharges its contents, leaving an ulcer bounded by thin edges and with a yellowish, sloughy base. A gummatous ulcer has been mistaken for a primary lesion of syphilis ; but the absence of induration, the history of the onset and of a previous infection with syphilis, would be points against a chancre. A second infection with syphilis is by no means unknown, but it is very rare in comparison Avith a gummatous ulceration. Occasionally the base of a gummatous ulcer proliferates into a papillary tumour and has given rise to a suspicion of carcinoma ; the diagnosis will be confirmed by the behaA-iour of the lesion under potassium iodide, when a tertiary syphilitic affection will rapidly clear up. 7. Tuberculous or Lupoid Ulceration of the penis is rare, and is usually associ- ated with advanced tuberculous infiltration elsewhere. Tuberculous ulcers are usually shallow, with thin overhanging edges, painful and multiple. In rare instances the infection has resulted from the rite of infantile circumcision by the Jewish method. r, jj. Jocelyn Swan. SORES, PERINEAL. — Ulceration may be present in the perineum as the result of : — • 1. Cutaneous inflammations and 3. Prostatic suppuration traumatism I 4. Syphilis 2. Urethral fistulje or suppuration 1 5. Epithelioma. 1. Cutaneous Inflammation and Traumatism. — An ulcer in the perineum may result from direct injury to the area, or from inflammatory infection of the sebaceous or hair follicles of the cutaneous covering. An ulcer from these causes may be placed at the centre or to one side of the perineum, is movable on the deeper parts, and shows no tract into which a probe can be passed, indicating its derivation from other tissues. In women, ulceration of the perineal area may be associated with gonorrhceal or septic vaginal discharge. 2. Urethral Suppurations or Fistulae. — During the progress of an acute urethri- tis, a glandular follicle frequently becomes infected. The suppurative process leading from this in the bulbous urethra may extend towards the perineum and open externally, leaving a small fistula which may or may not discharge urine during the act of micturition. In a similar manner, urinary fistulse may result from the inflammatory processes behind a urethral stricture, and in an old-standing case it is not uncommon to find a urinary calculus in the dilated portion of the urethra behind the stricture. In the first instance, when the urethral suppuration is acute and an abscess bursts in the perineum, the diagnosis will be quite obvious, and the ordinary treatment for an abscess, in addition to that of the acute urethritis, will usually suffice to cure the condition. If, however, the perineal wound discharges urine, it will be found that this 678 SORES, PERINEAL occurs as a rule only during the act of micturition, as there is no interference with the vesical sphincter. In nearly all cases, however, it will be found that there exists a stricture of the urethra, though not necessarily one of sufficient degree to cause any severe interference with micturition. An endoscopic examination will show the presence of a urethral stricture, whilst behind it can be seen frequently the sloughy granulations denoting the position of the internal or urethral opening of the fistula. Occasionally it may be found that urine drains frora a perineal fistula con- tinuously, and not only during the act of micturition. In these cases there is constant soaking of the perineal skin, and frequently excoriation. That urine should leak constantly from the fistula denotes interference with the vesical sphincter, either by dilatation behind a tight urethral stricture, by the presence of a calculus in the prostatic or membranous urethra, or by actual division of the vesical sphincter following some operation, such as perineal prostatectomy or perineal lithotomy. 3. Diseases of the Prostate. — An abscess or tuberculous focus in the prostate may occasionally discharge in the perineum, and remain as a sinus. An abscess in the prostate arises practically always from some infection in the posterior urethra, from venereal causes, or after septic instrumentation. It is accompanied by urethral discharge, or there is a history of a recent infection, whilst per rectum the prostate may be felt to be inflamed or scarred from the shrinkage of the abscess cavity. That a tuberculous cavity in the prostate should open in the perineum implies that there is advanced tuberculous disease, so that little difficulty will be found in arriving at a diagnosis. A tuberculous prostate is very rarely a primary condition, but in most cases is secondary to disease in the testis or bladder, so that an examination of these organs will in nearly all cases give evidence of tuberculous disease and indicate the nature of the perineal fistula. Palpation of the prostate per rectum may reveal the rounded nodular deposit of tubercle in the gland. 4. Syphilis may cause ulceration on the perineum either as a chancre or by mucous tubercles. A chancre on the perineum is rare. It forms a small ulcer with slightly indurated borders, indolent in character, and accompanied by slight enlargement of the inguinal lymphatic glands. A chancre of the skin does not possess the usual features of a genital chancre, and is not usually diagnosed with certainty until the secondary lesions of syphilis become apparent ; but an ulcer with raised, infiltrated edges, which shows no tendency to heal under aseptic precautions, should always give rise to a suspicion of syphilis. The Spirochceta pallida may be looked for, and Wassermann's serum test tried. Condylomata may be present about the perineum in association with active syphilis. They may extend from the anal or vulval orifice, and form oval or rounded, flat-topped, sessile masses, covered by macerated, grejdsh epithelium, or they may be ulcerated on the surface. The accompanying signs of syphilis will indicate the diagnosis. 5. Epitheliomatous Ulceration of the perineum is practically only seen as a direct spread of a growth of the anus or vulval area, when the diagnosis presents no difficulty. An epithelioma may develop in the scar of some former cutaneous affection, in which case an ulceration may exist, showing the usual characteristics of a cutaneous epithelioma, namely, gradual progressive increase in size, raised, friable edges, and tendency to slight haemorrhages. The inguinal glands may be enlarged early from inflammatory absorption, or later by infection with malignant disease. In case of doubt a fragment may be removed for micro- scopical examination. R. H. Jocelyn Swan. SORES, SCROTAL 679 SORES, SCROTAL. — Ulceration of the scrotum occurs in association with : — 1. Xew growth : 3. Testicular disease : Epithelioma j Inflammatory Papilloma ! Tuberculous 2. Fistulae. 1 Syphilitic. ! 4. Suppurating cysts. 5. Syphilis. 1. Epithelioma of the Scrotum is the most common form of ulceration met with in this region. Although commonly known as " chimney-sweep's cancer," scrotal epithelioma is by no means limited to this avocation, but it is certainly more common in men engaged in work in which they are exposed to much irritation from solid particles or from noxious fumes. Hence the disease is most commonly seen amongst chimney-sweeps, employees in gas-works, paraffin and chemical works, and coal-mines. The disease commonly begins as a small subcutaneous nodule, over which the skin is thinned and adherent ; the nodule slowly enlarges, and the thinned covering gives way, to form an ulcer with thickened, irregular edges and with a tendency to bleed on slight injur j^ The ulcerated area extends both radially and into the tissues of the scrotum, later involving the testes. The inguinal lymphatic glands become enlarged soon after active ulceration commences, at first from inflammatory causes, but later from maUgnant infiltration. In other cases a scrotal epithelioma begins in a wart or in a papilloma, which may have been present for some years with only slight increase in growth. These soft papillomata are not unusually the starting - point of malignant change, when they become more vascular^ whilst the surface epithelium becomes thinned and easily excoriated. A small amount of foul discharge is present, often encrusted into a scab, which on removal leaves an ulcer with indurated, everted edges, with the gradual progress of a cutaneous epithelioma. Thus a small ulcer on the scrotum, especially if indurated or readily caused to bleed, must be looked upon with extreme suspicion, and when it does not improve with ordinary antiseptic medication, should be widely removed with- out waiting for glandular enlargement. Epithelioma may occur in the scrotal area as a localized recurrence after removal of a malignant growth of the penis or testicle. The knowledge of the previous condition for which operation has been performed, would cause any recurrent ulceration about the scar to be regarded with extreme suspicion of malignant disease. 2. FistuISB may occur in the scrotum and cause ulceration. They are most common in association with tuberculous or s^'philitic disease of the testes (see below), but occasionally they occur from urethral extravasation, or the burrow- ing from rectal suppuration. An abscess may form and open through the scrotal skin from a peri-urethral abscess accompanying an acute urethritis or formed by septic infection behind a urethral stricture. In either case a small amount of urine may leak through the opening during micturition, whilst the history of urethral discharge, or of difficulty in micturition and other symptoms of stricture, will point to the diagnosis. 3. Testicular Disease. — In some cases extension of disease in the testicle may involve the coverings of the scrotum, and may even perforate them to form a scrotal sore. This sequence occasionally occurs with : (i) A testicular abscess ; (2) Tuberculosis of the testis ; (3) Gumma of the testis. A testicular abscess is somewhat uncommon, but may arise from direct exten- sion from the urethra via the vesiculse seminales and vasa deferentia or bv a 68o SORES, SCROTAL haematogenous infection during the course of a specific fever, such as scarlet fever, parotitis, or enterica. It may also follow chronic torsio testis. With urethral disease, the primar)' trouble may be due to gonorrhoea, or more fre- quently to a septic urethritis from the introduction of infected instruments, and is thus not infrequent in cases of prostatic enlargement in which the patient is passing his own catheter. In cases in which the infective process extends from the urethra, the epididymis is affected first, Avhilst in the metastatic cases the body of the testis usually shows the first sign of enlargement. These acute inflammations of the testis occasionally suppurate, when the scrotal tunics become inflamed and adherent, whilst softening occurs later, and unless surgically relieved, the abscess opens through the skin, leaving an ulcer, and a sinus discharging pus. Tuberculosis of the testicle ma}- occur as a primar}' disease or as a secondary deposit in association with tuberculosis elsewhere in the genito-urinarj- tract. Testicular tubercle almost always begins as a nodule in the epidid}Tnis, but in the later progress of the disease may extend into the testicle proper. If the tuberculous nodule progresses rather than undergoes cure, the scrotal skin becomes adherent, thinned, and finally perforated, lea\-ing a shallow ulcer ■^•ith thin, undermined edges, and discharging thin pus. Occasionally the necrotic tubules of the epididymis fungate through the opening in the scrotum, appearing as a greyish, sloughy projection from the cutaneous opening — the so-caUed " hernia testis." A gumma of the testis causes a swelling in the bod}' of the testis rather than in the epididymis. A gumma which remains unrecognized or un- treated may soften and ulcerate through the scrotal skin in a manner similar to tuberculous disease, leaving a clearly-defined ulcerated area with sharply- cut margins, and a wash-leather-like slough}^ base. The gummatous granu- lation tissue may fungate through the scrotal aperture, forming a yellowish, necrotic mass. The diagnosis of these three conditions may produce some dif&culty in the earlier stages (see Swellixg, Scrotal), but in the advanced stage now under consideration, when an open scrotal sore is present, the diagnosis is easier. The opening of a testicular abscess on the scrotum leaves a smaU sinus discharging pus and accompanied by a general enlargement of the organ. Preceding the rupture of the abscess there is acute pain in the testicle, with rise of temperature, rigors, and general signs of suppuration, which are much diminished as soon as the abscess is allowed to burst. There is often a urethral discharge, which, however, is often much lessened with the onset of the acute epididj'mitis, with distinct thickening of the cord and aching pain in the neighbourhood of the external abdominal ring, or in metastatic cases the abscess occurs during the progress of an acute fever. The general history is one of acute pain commencing in the testicle, with rapid and extremely tender swelling of the organ, followed by abscess-formation. In tuberculosis of the testis the progress is much more gradual. A nodule may have been present in the epididymis for some time, gradually enlarging, but causing very little pain ; in some cases a nodule may have been present for months without any apparent change, and then it maj' enlarge suddenly, involve the scrotal tunics, and discharge its contents. By the time the disease has reached this stage, it is probable that evidence of tuberculous trouble will be found in other organs, particularly the other testis, prostate, seminal vesicle, or bladder. The affected testicle usually presents several nodules in the epididymis, tender on pressure, whilst small nodules may also be felt in the vas deferens. The opening remaining from the discharge of a gummatous orchitis is usually SORES. SCROTAL 68i a rounded ulcer with sharply-cut edges and yellowish base. The whole testis is enlarged, practically painless, and gives a sensation of weight in the organ. The cord is not thickened, and there is no evidence of disease in the other testicle, prostate, or seminal vesicles. There is probably a history of syphihs, and other tertiary s\^hilitic lesions may be present elsewhere, such as gummatous peri- ostitis. Strong evidence of the s\^hilitic nature of the disease is often obtained by the result of treatment with large doses of potassium iodide, alone or in combination with mercury, when a gumma diminishes in size with marked rapiditv. It should be remarked, however, that, as in two cases under the ^vriter's care, testes which are subsequently removed and found to contain large gummata, mav show no improvement before operation, even under large doses of iodides. A Hernial Protrusion of necrotic Testicular Tissue may be present either ^vith tuberculous disease or from a gumma. In tuberculosis the mass is grejdsh and necrotic, discharging thin pus, and there wiU be sufficient evidence of tuberculous disease in the underlining testis and other genital organs. A distinctive feature of the gummatous hernia testis is found in the appearance of the cutaneous opening ; if the fungating mass be pushed aside, the opening in the scrotal skin will be seen to be cleanly cut and to encircle the protruding tissue tightlv. The fungating hernia testis of tubercle or syphilis must also be diagnosed from other conditions producing a raised tumour on the scrotum. An epithelioma of the scrotum has raised borders, but the centre is excavated, and there is rarely anj' enlargement of the testis. A sloughing papilloma of the scrotum mav more nearly reproduce the appearance, but the tumour and the skin are freelv movable on the underlying testis, whilst in hernia testis the mass is easily seen to be connected with the testicle, and the tubular structure of the latter is often apparent on picking up a smaU fragment of the fungating tumour. 4. Cysts of the Scrotum. — As an exceptional occurrence, a sebaceous cyst may develop in the scrotal skin, suppurate, and leave an open sore. The areas remaining present raised borders, and are easily mistaken for an early epitheh- oma. An accurate history of the previous swelHng in the skin is of little assistance in these cases, but the microscopical examination of a piece removed from the margin of the ulcer will readily exclude malignancy. A suppurating cyst in the scrotum is more uncommon than epithelioma. 5. Syphilis of the Scrotum may be present either as a primary chancre or as a mucous tubercle. A primary chancre in this situation is by no means easy to recognize unless other signs of sj'philis are present ; but the presence of a cutaneous sore which does not show much incUnation to heal under non-mercurial antiseptic dressings should always give a suspicion of syphilis. There is often only slight induration of the ulcer compared with that of a penile chancre, but the edge is raised and of a rolled appearance. The inguinal Ij-mphatic glands are enlarged and discrete, and some five to six weeks after the commencement of the ulcer the usual secondan,- s^-mptoms of syphilis become manifest. JMucous tubercles may be present on the scrotum, usually on the femoral aspect. They may extend directly from the anal area. No difi&culty will be met with in the diagnosis, as other signs of s}-phiHs are obvious. R. H. Jocelvn Swan. SPASMODIC CONTRACTIONS.— (See Contractions.) SPASMODIC DYSPNffiA.— (See Dyspncea.) SPASTICITY. — (See Gait, Abnormalities of.) 682 SPEECH, ABNORMALITIES OF SPEECH, ABNORMALITIES OF.— Speech is a highly-specialized function of the human nerv'ous system, by means of which we are able, more easily and more clearly than by any other means, to communicate our thoughts, desires, commands, etc., one to another. Abnormalities of speech are numerous, vary- ing from complete mutism to slight defects in articulation, and dependent on disturbances, functional or organic, in some part of the complex mechanism which is responsible for the production of intelligible language. This article is intended to expose the broad principles by which various abnormalities of speech can be detected and used for the purposes of diagnosis ; it does not embrace a discus.sion of the controversial views which are held con- cerning their exact production. The amount of investigation required for making a diagnosis in cases of speech abnormality must vary Avithin wide limits. The greatest care is called for in the examination of cases of aphasia which result from disturbances in the function of the cerebral speech centres or their dependent paths of communica- tion. On the other hand, the defective articulation of a patient suffering from cleft palate needs only a comparatively superficial examination in order to arrive at a correct diagnosis. It will be convenient to consider the various abnormalities of speech under the following heads : (i) Mental defects ; (2) Aphasia ; (3) Deaf mutism ; (4) Dysarthria ; (5) Functional disorders — stammering, lalling, idioglossia. 1. Mental Defects. — The acquirement of the power of speech may be delayed in children who are mentally defective, and in some forms of idiocy may be suspended altogether. Before making a diagnosis of mental deficiency in a child who appears to be dilatory in talking, it is well to remember that the age at which speech is acquired is very variable, and that the delay may be con- siderable where no mental impairment is present. In such cases the diagnosis m.ust depend on a consideration of other points in the child's development. Inquirj^ should be made as to whether he is clean in his habits, whether he is destructive, whether he pla^^s with toys or with other children in a natural manner, and whether he displays abnormally bad temper or irritability. In some cases the delay in speaking may be due to a defect in hearing which has been unsuspected by the parents. This point is especially apt to arise in respect to children who have begun to talk at the normal age, and who have lost what little they had learned of the art in the sequel of some acute illness. In adults, loss of speech may be due to many forms of mental deficiency of a temporary or permanent nature. A familiar example of temporary loss of speech ma}^ be the result of that degree of alcoholic intoxication to which the term " speechless " is vulgarly applied. Similarly, the intoxication of the higher mental faculties associated with organic poisons, such as those of pneu- monia or tj'phoid fever, may be responsible for temporary loss of speech. Com- plete mutism due to disease of the higher intellectual centres of the brain is common enough in various forms of dementia, and is proved to be no aphasic defect by the sudden and complete restoration of speech which may take place after months or even years of silence. The speechlessness of a melancholic patient or of one who is suffering from paralytic dementia is further differentiated from true aphasia by the fact that the latter is associated with attempts at communication, while the former is not. On the other hand, it must be remembered that general paralysis of the insane is a disease in which temporary aphasia is by no means uncommon, especially in connection with the transient hemiplegia following " congestive " attacks. 2. Aphasia. — A definition of aphasia is difficult to supply in a few words. The term is used to denote that loss of speech which does not depend on mental deficiency, nor upon paralysis of the motor mechanism of articulation. Such a SPEECH, ABNORMALITIES OF negative description requires, however, some modification, because aphasia is frequently associated with some impairment of intelligence resulting from disturbance of internal language. Internal language plays an important part in all intellectual processes, and any lesion of the cerebral centres connected with it must necessarily interfere with the higher mental activities. This is particularly the case in what is called sensory aphasia, that variety which depends upon a lesion of the auditory and visual word centres situated in the cortex near the posterior part of the left Sylvian fissure of the brain. In right-handed persons the chief speech centres are placed in the left cerebral hemisphere {Fig. 185), and it is customary to consider them as being three in number. The posterior part of the first temporal convolution is regarded as the area in which the auditory memories of spoken words are stored and recalled. It plays an important part in the development of speech, because it is largely through the sense of hearing that the child first learns to associate objects with their names and expressions with their meaning. The cortex in the angular gyrus has a similar special function in regard to the storage of visual word memories, a function which bears the same relationship to written language as Cheiro-kinassthetic centre Visual word centre — Left cerebral hemisphere, with speech centres. the auditory word centre has to spoken language. These two portions of the cortex constitute the sensory speech centres. A third important centre is called the motor, or, better, the higher kinsesthetic centre, and this is located in Broca's area, or the posterior part of the third frontal convolution. In this situation are stored the memories of afferent impulses excited by the motor activities employed in speech. Unless this centre is intact, the conversion of internal into external language is imperfect or impossible. In the opinion of some authorities, there is a similar kinaesthetic centre in the posterior part of the left second frontal convolution, which plays a part in connection with written language comparable to the part played by Broca's area in relation to spoken language. With these physiological and anatomical data as a basis, we can proceed to consider the chief varieties of aphasia and the points in their differential diagnosis. Before doing so, it is well to sound a note of warning with regard to the complications which are constantly being met with by the clinician in attempting to analyze cases of aphasia. In the first place, a diagrammatic anatomical definition of the cerebral centres is liable to give a wrong impression. 684 SPEECH, ABNORMALITIES OF These centres are more diffuse in their function than they appear to be on a map of the brain, and they are much more interdependent than their topography would suggest. Communicating nervous tracts bind them together in such a way that a destructive lesion of one must necessarily upset the function of another, and so modify profoundly the clinical picture of any particular case. In the second place, it must not be forgotten that aphasia is, in the majority of instances, the result of a vascular lesion, and that all the centres to which we have referred lie in the area supplied by one artery — the middle cerebral arter5^ Consequently it is only rational to expect that, even when the main brunt of a vascular disturbance falls on one of the special speech centres, the other centres may also suffer more or less, temporarily or permanently, from disturbances of nutrition. In any case of aphasia, therefore, we may have to be satisfied if we can arrive at a conclusion as to the site of the chief defect, without being able to define the exact limits of the loss or impairment of cerebral function. In the third place, due allowance must be made for the recognized fact that the right cerebral hemisphere may gradually acquire some degree of speech activity, especially in cases of aphasia occurring during the earlier years of life, and may tend to replace the loss caused by the defective action of the left hemisphere. Word-deafness is the result of a lesion either of the auditory word centre in the temporal cortex, or of one which isolates that centre from the periphery : that is to say, of a sub-cortical lesion cutting off the centre from auditorj' im.pulses. In either case the patient who is word-deaf is unable to recognize the meaning of spoken language, although he may hear perfectly the sounds by which it is conveyed. In the course of examination it will be found that he fails to understand anything which is said to him, and that he does not obey simple commands so long as they are not accompanied by gestures suggestive of their meaning. If the visual word centre has not been affected at the same time, he will still be able to read and to understand what is written. In fact he will depend upon writing and reading for his means of communication with others. The amount of interference with spontaneous speech will depend upon whether the lesion is cortical or sub-cortical. In the latter case the integrity of the auditory word centre preserves internal speech, and so permits the patient to speak spontaneously with fluency and probably with accuracy, and his power of writing will be equally unimpaired. When the cortical centre is itself destroyed, internal language is thoroughly disorganized, and although a certain amount of spontaneous speech may be uttered, it is certain to be more or less unintelligible. According to the extent of the lesion, it will vary between a speech containing inaccuracies of minor importance, and one which is a jargon incapable of interpretation. Characteristic of this defect is the fact that the patient himself does not appreciate the mistakes he makes. His written language is likely to be more accurate and more intelligible than his spoken language, but it will probably not reach a very high standard. He may copy with accuracy, but is quite unable to write from dictation. Such are the usual chief attributes of word-deafness in its pure form. Clinically, word-deafness is usually accom- panied by word-blindness, to a greater or less extent. Word-blindness, or Alexia, is produced by a lesion of the left angular gyrus, and may or may not be accompanied by defective vision. As in the case of word-deafness, it may result from a cortical or from a sub-cortical lesion, and it is in association with the latter class of case that Hemianopia [q.v.) is most commonly observed. In cortical word-blindness the patient is unable to read, although he sees the letters clearly and may even be able to copy them in the same way as a child copies letters when learning the alphabet. Writing conveys no meaning to his mind, although in the less severe cases the patient may still recognize familiar words, such as his name. There are, in fact, varjdng degrees SPEECH, ABNORMALITIES OF 685 of word-blindness, some of which are difficult to understand and to analyze. The word-blind patient suiters in his spontaneous speech to a greater or less extent according to whether he uses his visual or his auditory memories chiefly in the process of internal language. Should he be a " visual " his spontaneous speech wall suffer much more than if he is an " auditive." The terms " visual " and " auditive " are used to distinguish two classes of persons, the first depend- ing more on their visual m.emories of words, and the second more on their auditory memories of words in the course of reviving them for the purposes of internal thought and speech. Spontaneous writing is likely to be completely lost, but writing from dictation may possibly be carried out with more or less accuracy. In word-blindness due to a sub-cortical lesion, although hemianopia is almost certain to be present, spontaneous speech and spontaneous writing are perfectly preserved, although the power of reading and the power of copying hand-written sentences into printed capitals is entirely in abeyance. ^Vhen word-blindness and word-deafness coexist, the condition is called sensory aphasia, and is one to which some authorities believe that the term aphasia should be limited. It is, however, usual to describe a motor aphasia which may be dependent upon a cortical or sub-cortical lesion. Cortical motor aphasia results from a destructive lesion of Broca's area, the part of the cortex which stores memories of the afferent impulses excited by speech, and in which such memories must be revived if spontaneous speech is to be carried out perfectly. This form of motor aphasia may be present without any paralysis, but it is usually accompanied by some disturbances of internal speech, and perhaps even by some defective understanding of spoken and written language, which, however, never amounts to true sensory aphasia. IMuch more common is the sub-cortical motor aphasia which is due to a lesion cutting off Broca's cortical area from the motor mechanism connected with articulation. In this form of aphasia the intellectual processes and internal language may be perfectly intact, but in the majority of cases the inability to speak is associated with right hemiplegia in right-handed persons, or with left hemiplegia in left-handed indi\"iduals. The imperfect speech of the patient who is partly aphasic from a sub-cortical motor lesion may resemble to some extent that of the patient who is word-deaf ; but the former is conscious of his mistakes and the latter is not. Sub-cortical motor aphasia may perhaps be better described as an articulator}^ rather than a speech defect : as an anarthria rather than an aphasia. All the attributes for speech are preserved, but its emission is impossible. Agraphia results usually from a lesion of the visual word-centre, or perhaps in some cases from a lesion of the posterior part of the left second frontal con- volution. In the former case the power of writing may be lost, although there is no paratysis of the arm or hand. In the latter case the agraphia is usually- associated with right hemiplegia, and in order to test whether the power of communicating thoughts by written language is preserved, the patient must be asked to use the left hand for the purpose. There is some doubt as to whether pure motor agraphia occurs, and some doubt as to the lesion upon which it maj- depend. I have had experience of the clinical occurrence of pure motor agraphia without being able to correlate the phenomenon with its anatomical basis. We have now considered the various forms of aphasia and have indicated their points of distinction. This will serve as a basis for diagnosing the site of the lesion responsible for the speech defect, but the nature of the lesion must be determined from other considerations. Vascular lesions, for instance, are usually acute in their onset, sudden in the case of embolism, less precipitate as a rule in cases of hcBmovrhage or throynbosis. In cerebral tiimoitr or abscess the onset 686 SPEECH, ABNORMALITIES OF of symptoms is m.ore gradual, and local troubles such as that of aphasia are generally accompanied or preceded by the symptoms of increased intracranial pressure in the form of headache, vomiting, and optic neuritis. But aphasia is not always the result of a gross and permanent lesion. Transitory aphasia may be observed in the sequel of epileptiform convulsions, or may be in itself an epileptic equivalent — a form of petit mal in an epileptic subject. Temporary aphasia occurs also in connection with migraine, and I have known it to occur at intervals during a period of thirty or forty years in a woman who was perfectly healthy in every respect, and who showed no other symptoms suggestive of either epilepsy or migraine. 4. Dysarthria, or in its extreme form " anarthria," is the term used to describe defective articulation as opposed to defective speech. Articulation is carried on by certain muscles of the larynx, pharynx, palate, tongue, and lips which are innervated by the bulbar nuclei, and the latter are set into action by voluntary impulses coming from, the motor cortex of both cerebral hemi- spheres via the pyramidal tracts. The articulatory movements, therefore, are bilaterally represented in the brain, and, like other bilaterally represented movements of the body, are not disorganized by unilateral lesions of the pyramidal system. Thus, in cases of hemiplegia without aphasia, there is little or no defect in articulation, and the examination of such a patient shows that both vocal cords, both sides of the palate, and the tongue, retain their power of voluntary movement almost, if not quite, to perfection. Suprabulbar dysarthria is induced, however, in cases of double hemiplegia, when the fibres from both hemispheres to the bulbar nuclei are interfered with by destructive lesions. When a right-sided stroke is followed by a left-sided stroke, or when double hemiplegia results from a lesion in the pons, dysarthria results. In such cases the power of speech may be perfect, but -the ability to articulate naturally and clearly is disturbed. The patient is not aphasic but dysarthric. Articulation is usually slow, spastic, and indistinct, if it is not altogether unintelligible. These cases are differentiated from cases of dysarthria due to lesions of the bulbar nuclei or of the cranial nerves, not only by the presence of other hemiplegic signs in the limbs and trunk, but by the fact that the tongue retains its shape, nutrition, and normal electrical reactions, and the palate its natural reflex. This condition of pseudo-bulbar palsy, as it is sometimes called, is further distinguished by facial starchiness or spasticity, and by the patient's inability to control the expression of his emotions. Dysarthria of similar origin, but generally of less degree, may be observed in cases of general paralysis of the insane, in cerebral diplegia, and in disseminated sclerosis. In the latter disease the terms " staccato " or " scanning " are applied to describe the articulatory defect. Some cases of Friedreich's ataxy exhibit a form of articulation which is slow and jerky, not unlike that of disseminated sclerosis. Probably some degree of inco-ordination enters into the production of this peculiar utterance. In all these diseases the diagnosis of the condition depends upon the presence of other symptoms and physical signs, and can rarely be deduced from the articulation alone. Dysarthria also arises from disease of the bulbar nuclei, or of the nerves arising from the latter which supply the muscles of the larynx, pharynx, tongue, and lips. In true bulbar palsy, which is a disease depending on a slowly pro- gressive degeneration of these motor nuclei, articulatory defects are often among the earliest symptoms. The diagnosis of these cases is based on the fact that the symptoms begin insidiously and progress gradually, that the paresis affects the muscles of both sides more or less symmetrically, and that it is an atrophic form of paralysis. The atrophy is best seen in the tongue muscles, and is usually associated with a certain amount of fibrillation, and with diminution SPEECH, ABNORMALITIES OF 687 of their electrical excitability. The palatal reflex is also impaired, and an examination of the vocal cords shows that they too are the seat of a progressive palsy. The dysarthria is always accompanied, sooner or later, by some degree of dysphagia, and also by some weakness and atrophjr of the muscles of mastication. Atrophic palsy may also be observed in the small muscles of the hands, and there is a tendency to exaggeration of all the tendon reflexes in the limbs. A similar clinical picture maj' develop in cases of gross disease of the bulb, due either to local softening or hemorrhage, or in rarer cases to the gradual growth of a tumour in that region. Such cases can be differentiated from true bulbar palsy, partly by the more acute onset of symptoms in the case of the vascular lesions, and partly by the asymmetrical distribution of the muscular ■atrophy and paresis when a tumour forms the basis of the disease. Gummatous meningitis at the base of the brain may involve the cranial nerves close to their «xit from the bulb, and so produce a dysarthria of a somewhat similar character. When tumours or meningitis are the cause of the dysarthria, symptoms of increased intracranial pressure are likely to be observed. Another form of bulbar palsy is seen in cases of myasthenia gravis. In this •condition there is little or no atrophy of the articulatory muscles, although some thinning of the tongue is sometimes observed. The distinguishing characteristics of this dysarthria are first of all its marked variability, and secondly the effect produced by fatigue. A myasthenic patient may begin a conversation, or may begin to read aloud from a book, without showing much difficulty in his Titterance, but, as he progresses, his articulation becomes more and more defective and more difficult to understand. Usually the palate fails quickly, and a nasal quality is given to the voice. If he is asked to repeat the word " rub " many times, the terminal " b " becomes an " m," and he ends by saying " rum " instead of " rub." Most cases of myasthenia gravis exhibit similar fatigue phenomena in relation to other parts of the musculature (see Fig. 83, p. 261), and in particular show varying degrees of ocular palsy, which, like the dysarthria, is at one time more marked than at another, and which is much influenced by rest and exercise. Some articulatory defect is produced in cases of bilateral peripheral palsy of the palate, which most often results from the effects of the diphtheria poison. The voice is nasal, and the pronunciation of certain consonants becomes impossible. " B " becomes " m," " d " becomes " n," and " k " sounds like " ng." Bilateral facial palsy interferes with that part of articulation which depends ^ipon the labial muscles, and so renders speech indistinct, although not unintelligible. Facial palsy of this kind is met with in some cases of peripheral neuritis and also in some cases of myopathy, especially that form to which the name Landouzy-Dejerine is applied. Unilateral bulbar palsy may exist without much interference with articulation or phonation. There may be considerable palsy of one vocal cord due to a lesion of one recurrent laryngeal nerve, without a recognizable alteration in the character of the voice. A bilateral laryngeal palsy, when complete, leads to aphonia. Similarly, unilateral palsy of the palate or of one-half of the tongue may exist without articulatory defect, especially after the patient has become accustomed to the altered conditions. 5. Functional Disorders of Speech. — In cases of hj^steria, a functional aphonia is by no means uncommon, and in many cases can only be distinguished from aphonia due to organic disease by an examination of the larynx. Hysterical •aphonia may be complete ; in other cases the voice is reduced to a whisper, and yet the patient is able to adduct the cords properly in coughing. This is often SPEECH, ABNORMALITIES OF a recurrent malady^ and the suddenness of its onset, as well as the suddenness with which it is often cured, are peculiar characteristics. Stammering is another type of functional dysarthria and presents a large variety of forms. There is little difficulty in their recognition, because in all cases when once the articulatory flow is established the utterance is perfectly normal. The difficulty generally arises either in commencing a word or' a sentence, or in other cases the trouble is evoked only in connection with the production of certain consonants. Some of the cases depend on an initial spasm of the articulatory muscles, and others upon an inco-ordination between the action of the respiratory muscles and those which have to do with phonation and articulation. The complete absence of any physical signs of disease, and the history of the case, make the diagnosis easy. On the other hand, stammering is occasionally an early symptora of progressive degenerative conditions of the central nervous system, especially of general paralysis of the insane. The term " lalling " is applied to a defective form of articulation chiefly met with in persons who are more or less mentally feeble. It is characterized by what appears to be an imperfect pronunciation of certain consonants. In more severe cases one consonant is consistently replaced by another, such as " r " by " w." These mistakes in pronunciation are common enough in normal children when learning to speak, but the endurance of the defect after the learn- ing age is passed generally indicates some permanent mental deficiency. A temporary perversion of speech is occasionally seen in children before they learn the proper use of language. They may talk glibly and fluently in a language which they appear to understand themselves but which is unintelligible to their neighbours. In this condition, to which the term " idioglossia " is generally given, the prognosis may be regarded as favourable. e. Farquhar Buzzard. SPLEEN, ENLARGEMENT OF THE. The Physical Signs of Enlargement of the Spleen. — If the organ is only shghtly or moderately enlarged, there is no alteration in the size or shape of the abdomen ; if it is considerably or enormously enlarged, the abdomen may be much dis- tended, and at a first glance this distention may appear to be uniform, as though due to ascites. Closer inspection may show that it is by no means uniform, there being distinct bulging of the left side, especially in the left hypochondrium, the left lumbar, and the left half of the umbilical regions. The inner border may be tilted forward in some cases, so that a distinct edge or ridge may be seen pushing the abdominal wall forward, this ridge running downwards and inwards from the left costal margin near the anterior axillary fine towards the umbihcus ; in a few cases a distinct notch can be seen in this edge or ridge. When the patient takes a deep breath, the prominence may be seen to move distinctly downwards, though occasionally the spleen may be so enormously enlarged that its lower end becomes impacted in the pelvis, when no downward movement is possible. Palpation is the best means of detecting splenic enlargement. If the organ is but little enlarged, it may not be felt until the observer, standing upon the left- hand side of the recumbent patient, and supporting the lower left ribs posteriorly with his right hand, steadily but firmly presses the fingers of his left hand under the left costal margin just in front of the anterior axillary line ; when the patient now takes a deep breath, a definite sense of increased resistance may reveal splenic enlargement when the organ is comparatively soft, as in many cases of typhoid fever for example, or a hard mass with a distinct edge may be felt in more obvious cases. When the enlargement is moderate or ccgisiderable, the splenic tumour will be felt coming down from beneath the left ribs close behind the abdominal wall ; and unless there is a very large liver at the same time, or SPLEEN, ENLARGEMENT OF THE some other cause preventing the viscus from following its natural direction as it enlarges, it tends to reach and ultimately cross the middle line at or just below the level of the umbilicus. It is generall}^ smooth and firm, and the character- istic notch or notches can be felt in its anterior border. Except in those rare cases in which the whole spleen is dislocated, it will not be possible to insert a hand between it and the left costal margin, or to define its upper limit by palpa- tion. The lower pole can be felt readily moving decidedly downwards on inspira- tion, unless the enlargement is very great. On bimanual palpation, the loin is flaccid and not filled out as it would be by a renal tumour, and the mass cannot be pushed back into the loin so as to be felt by the posterior hand as readily as it is by the hand on the anterior abdominal wall. Percussion yields a dull note over the mass, the dullness being directly con- tinuous with an increased area of dullness in the thorax extending upwards as high as the seventh rib in the mid-axillary line, the sixth rib in the nipple line, or even higher, and including the ordinary area of splenic impairment of resonance behind. Percussion of the left loin will generally elicit resonance here, indicating that the colon is not displaced as it would have been by a renal tumour ; no intestines can be felt or percussed over the front of the spleen. Auscultation seldom affords much evidence of value in these cases, but some- times when the splenic enlargement is associated with local peritonitis, as in cases of infarction for example, a loud rub may be heard over the mass ; and sometimes, especially if the enlargement is associated with venous engorgement, a well-marked continuous humming bruit may be heard. Distinction between an Enlarged Spleen and other Tumours which may simulate it. An enlarged spleen has to be distinguished from other tumours which may arise in the left hypochondriac region, especially from : — (i) Kidney tumours or perinephric inflammation or abscess ; (2) Suprarenal tumours ; (3) Carcinoma of the splenic flexure of the colon ; (4) Pancreatic tumours, especi- ally cyst or carcinoma ; (5) Malignant growth of the stomach ; (6) Ovarian tumour ; (7) Tuberculous peritonitis ; (8) Fsecal accumulation in the colon. Distinction from a Renal Tumour. — It may be difficult to distinguish an enlarged spleen from a kidney in some cases. Both conditions may cause local prominence or bulging of the left side of the abdomen ; in the case of splenic enlargement the bulging is more forward and inward, whereas in a kidney enlarge- ment, the loin is more likely to be bulged. No distinct edge or notch can be seen or felt in the case of the majority of renal enlargements, a most important point, the significance of which cannot be over-estimated. Either tumour may move downwards when the patient takes a deep breath ; but the spleen, being in closer contact with the under surface of the diaphragm, moves the more markedly of the two. A renal tumour, being more deeply situated in the abdomen, seldom approximates closely to the anterior abdominal wall unless the enlargement is very great, in which case the loin will be filled out and feel very firm and resistant on bimanual examination. A renal tumour generally slopes away as it approaches the ribs, so that it is less difficult to get one's hand between its upper pole and the costal margin than is the case with the undislocated spleen. The colon may be seen or felt over the anterior surface of a renal tumour, which is never the case with splenic enlargement ; and percussion may yield a resonant note in front, or in t3^pical cases a vertical band of colonic resonance down the centre of an otherwise dull mass, the loin posteriorly being dull ; whereas with a splenic tumour the loin is generally resonant, and the anterior aspect of the mass quite dull. The presence of a local bruit or rub would make renal tumour unlikely. The occurrence of Hematuria [q.v.), Pyuria (q.v.), or Albuminuria {q-v.), would suggest renal enlargement, whilst the conditions of the blood might be such as to suggest splenic. D 44 690 SPLEEN, ENLARGEMENT OF THE Notwithstanding all these points, to distinguish between splenic and renal masses is sometimes by no means easy ; and it is only by paying careful attention to the history and to the patient's own sensations, as well as to the physical signs, and to the changes in the blood and urine, that a correct diagnosis can be made. Malignant Disease of the Left Siipravenal Gland may cause a large mass which is sometimes particularly difficult to distinguish, either from a splenic or from a renal enlargement. Owing to the close proximity of the suprarenal capsule to the kidney, and the liability of the latter to become infiltrated hy growth of the former, the physical signs of a suprarenal are practically the same as those of a renal tumour, except that it may be more difficiilt to pass the hand between the mass and the costal margin. Hsematuria and other urinary changes may result from spread of the disease to the kidney ; affection of one suprarenal gland alone does not produce Addison's disease, and it may be impossible to arrive at a correct diagnosis Avithout laparotomy. A peculiar affection of children deserves special mention : at a comparatively early age there may be an abnormal development of the pubic and axillary hair and of the genital organs (see Figs. 125, 126, pp. 453, 454), with premature puberty, associated Avith overgrowth of suprarenal rests in the kidney, the resultant tumour being spoken of as a hypernephroma. Carcinoma of the Splenic Flexure of the colon is usually annular, giving rise to no definite tumour, but rather to symptoms of chronic, followed by acute, intestinal obstruction. Occasionally, however, the growth may be more voluminous, or it may have caused leakage and inflammatory matting from local perforation through or above the growth, with the result that a fairh' large tumour may be felt in and below^ the left hypochondriura. This mass is generally resonant to percussion, has no well-defined edge or notch, and maj^ vary some- what in position from day to A&y : it will usually be associated with intestinal symptoms, especialljr constipation alternating wath diarrhoea, and the passage of mucus, and occasionally blood, per rectum. Sometimes there are obvious secondary deposits in the liver or in the left supraclavicular glands. Pancreatic Tumours are usuallj^ situated more in the median hne of the abdomen than is a spleen, between the ensiform cartilage and the umbihcus ; sometimes, however, a very large cyst, such as may nearly fill the abdominal cavit}', may cause considerable difficulty in the diagnosis. One very important point is that no definite edge and no notch can be felt. The stomach generally lies in front of a pancreatic cyst ; or, if the latter pushes its way forward so as to displace the stomach upwards and the transverse colon downwards, it may be possible to define its relationship to the stomach by inflating the latter with gas. A splenic tumour rarely extends to the right of the middle line unless the enlargement is great, and then it crosses at or below the umbilicus, Avhereas a pancreatic cyst reaches across to the right of the middle line above the navel. Pancreatic new growth has a similar position ; but the outline of the mass, if any can be felt at all, is more nodular ; there will generallj' be jaundice and a palpable gall-bladder, and the urine may yield Cammidge's pancreatic reaction. Malignant Growth of the Stomach may be mistaken for enlargement of the spleen, and even suggest splenomedullarj^ leukaemia; this is especially so w-ith gastric sarcoma, which, though very much rarer than carcinoma, is more likeh' to involve the whole of the stomach and give rise to a very large tumour occupying chiefly the upper part of the left side of the abdomen. The following changes will serve to distinguish a gastric new growth from enlargement of the spleen : the mass is apt to shift its position during the course of an examination or from day to day ; it does not present a well-defined edge with definite notch or notches ; it may extend a considerable distance to the right of the middle line, although SPLEEN, ENLARGEMENT OF THE 691 its lower limit may not be below the level of the umbilicus ; it is Hkely to be resonant in front, though the percussion note over it may be impaired ; there may be anaemia and leucocytosis, but the blood-changes would not be character- istic of any positive blood disease ; the taking of food may cause an increase in the gastric pain ; vomiting will generally be a prominent symptom ; the vomit may contain blood, obvious or occult ; free hydrochloric acid may be deficient or absent ; sarcinse ventriculi may be found {Fig, 92, p. 267) ; and there may be secondary deposits, especially in the liver or in the left supra- clavicular glands. Ovarian Tumours have been mistaken for enlargement of the spleen, and vice versa, the differential diagnosis being particularly difficult in cases in which the spleen has become dislocated, or is so large as to reach down as far as the uterus. The organ has sometimes been found so dislocated as to lie wholly within the pelvis. The differential diagnosis depends in most cases on the following points : an ovarian tumour rarely extends upwards to such an extent that its upper limit comes into actual contact with the left costal margin, so that the hand cannot be placed between it and the ribs ; it does not move much downwards during deep inspiration ; it extends upwards from the pelvis, whence it may be felt definitely to arise, the lower part of the abdomen being more prominent than the upper ; it is usually more globular than a splenic tumour, and has no sharp, well-defined edge with notches in it, even when covered with projecting bosses of simple or malignant new growth ; it usually extends more to the right " of the middle line than an enlarged spleen ; and it is more apt to transmit aortic pulsations ; a vaginal examination may determine that the mass is attached to one or other of the broad ligaments, and that the cervix and the body of the uterus are drawn upwards ; there will probably be no distinctive blood-changes, but very likely amenorrhoea. Tuberculous Peritonitis may cause various abdominal tumours (see Ascites), and sometimes gives rise to a mass occupjdng the left hypochondriac region, the result of matting together of the intestines, thickening of the omentum, or thickening and infiltration of the peritoneum attached to the abdominal wall here. The tumour does not generally extend close up under the ribs so that the hand may be placed between it and the costal margin, and although it may feel somewhat rounded, with a more or less well-defined edge, there is no definite notch to be felt ; sometimes, however, when there are two, three, or more separate masses united together, a notch may be simulated to some extent. The mass itself may be dull, but there is generally resonance between it and the normal splenic dullness. Ascites {q.v.) is often present, and there may be palpable lumps in other parts of the abdomen, or perhaps redness and oedema of the abdominal wall, or a purulent or faecal discharge frona the umbilicus. There may be signs of tuberculosis elsewhere, for instance in joints, or lymphatic glands. Calmette's or von Pirquet's tuberculin reactions may be positive. The patient will generally be young, and have consumed unsterilized cow's milk. Pyrexia may be present or absent, either with tuberculous peritonitis or with splenic affections, so that its occurrence does not assist the diagnosis much, except perhaps, that if the chart exhibits marked evening pyrexia, with a sub- normal temperature in the morning, it is an additional argument in favour of tubercle in a young subject. The reverse type of pyrexia — morning rise and evening fall — has been spoken of as characteristic of tubercle, but it is seldom met with. FcBcal Accumulation in the Splenic Flexure or adjacent parts of the transverse or descending colon may be mistaken for an enlargement of the spleen upon a first examination ; but this source of error is usually removed when the patient is re-examined after an abundant action of the bowels has taken place. The 692 SPLEEX, EXLARGEMEKT OF THE Splenomegalic polycj-thaemia Splenom egalic cirrtiosis Splenic ansemia Pseudo-leuksemia infantum. condition is found most frequenth" in women if the age is not great, or in elderlj' people of either sex. There is generally a history of severe obstipation, and possibly attacks of temporary,- obstruction. The mass is generally irregular, more or less cyhndrical, and in thin persons it ma^- be possible actually to alter its shape bj^ manipiilation with the hand. The best test of the condition, how- ever, is the effect of copious enemata upon the mass. Hcsmatonia due to Leakage from an Abdominal Aneurysm is by no means al'w"a3's easily recognized, and it ma^' be mistaken for an enlargement either of the spleen or of the kidney, unless the aneurysm itself can be felt pulsa- ting ; or unless there is a history of an acute exacerbation of intra-abdominal pain, accompanied b}- blanching due to the amount of blood lost from the leaking aneurysm. Causes of Splenic Enlargement. Ha\'ing concluded that the spleen is enlarged, the next step is to decide the cause of the enlargement. There are various ways in which the different causes may be classified, but from a diagnostic point of view the following is ser%'iceable : — I. Chronic Enlargement of the Spleen, (a). Very great enlargement : Splenomedullan,' leuksEmia L^-mphatic leukaemia ISIixed leukaemia Chronic malaria Kala-azar ^ (fe). Moderate enlargement. — All conditions mentioned in group [a) will at some stage exhibit a spleen that has not yet become enormous ; and besides these, chronic and moderate enlargement of the spleen may be exhibited in cases of : — ■ Pernicious anemia Thrombosis of the portal vein Rickets Pressure on the portal vein by Congenital s\'philis enlarged hTiiphatic glands or Hodgkin's disease by adjacent tumour of the gall- Cirrhosis of the hver bladder, hver, pancreas, stomach, Lardaceous disease etc. II. Acute Enlargement of the Spleen, the enlargement as a rule being slight, (a). Acute infective fevers : Especiall}' — Tj^hoid fever 1 IMalaria Parathyphoid fever Erysipelas Relapsing fever 1 Septicaemia. Less often in — Pneimionia I Tj-phus fever Diphtheria Influenza Scarlet fever General tuberculosis. Small-pox (6) . Embolism, especiallj^ in cases of f ungating endocarditis. "^ '^^'^-e^' {c). Injury. (d). Strangulation b}* twisting of the pedicle. It will be noted that no mention is made of abscess, gumma, carcinoma (whether primarj'- or secondary), sarcoma (primary or secondary), or hydatid cyst of the spleen, for these are all so exceedingly rare that it is \er3- unlikely J^ /^'O--^^'"^-^ SPLEEN, ENLARGEMENT OF THE 693 they will be met with. It will also be noted that no mention is made of backward pressure, whether due to chronic valvular disease of the heart with failing compensation, or to obstruction to the inferior vena cava above the hepatic veins, such as may result from thrombosis or from pressure upon the veins by mediastinal fibrosis or new growth. These conditions are purposely omitted, for it is quite exceptional for ordinary backward j5ressure to produce enlargement of the spleen. So true is this, that in a case of chronic valvular heart-disease with failing compensation, the existence of a definitely palpable spleen is evidence of there being more than rnere mechanical tieart-failure — probably superposed fungating endocarditis The chief exceptions to this occur in chil'dhood, where the spleen becomes more easijy palpable than in adults, so that with heart-failure in a child enlargement' of the spleen is less good evidence of fungating endocarditis than it is in a grown-up person. I. — Chronic Enlargement of the Spleen. («). Chronic and very great Enlargement of the Spleen. — When the spleen is so large as to occupy half the abdomen or more, the diagnosis is generally very easy. The largest of all spleens are those due to splenomedullary leukcBmia. The first step is to make a full examination of the blood, including particularly total and difi:erential leucocj^te counts. If there is an extreme degree of leucocytosis, up to anything between 50,000 and and 1,500,000 per c.mm. for example, the diagnosis is almost certainly leukaemia, and if in the differential leucocyte count there are from 20 per cent to 50 per cent of myelo- cytes, it is of the splenomedullary type, whilst if the small lymphocytes amount to 00 per cent or more, the disease is of the lymphatic form, in which the lymphatic glands are almost certain to be enlarged as well as the spleen ; in some cases of lymphatic leukasmia it may be scarcely enlarged at all, but in others it may be almost if not quite as large as in the splenomedullary type of the disease. For mixed leukaemia, see Anemia. In the absence of any marked leucocytosis, or of characteristic differential leucocyte counts (see also Anaemia), the diagnosis of the nature of a very large spleen will depend in the first place upon whether there has or has not been residence in a malarial region — the fen districts of Great Britain, the tropics, or certain parts of Europe, particularly Italy. The ague-cake spleen of the fens is now very rare ; it is more often found in chronic cases of tropical malaria, when the history may indicate its nature, and if the patient is having febrile attacks, the parasites {Plate XII, Figs. A, B, C, D, E) may be found in the blood. Recent investigations have shown that some, at least, of the enlarged spleens formerly attributed to malaria, are due to other infections. One of these has been clearly differentiated from the rest, namely Kala-azar, which occurs in India, particularly in Assam, in Africa, and in Sicily, and is diagnosed chiefly by the discovery of the Leishman- Donovan bodies in the fluid obtained b}^ splenic puncture {Plate XII, Fig. H) . Splenomegalic polycythcBmia is a rare affection of adults, characterized by more or less cyanosis and s^^mptoms which might suggest a cardiac lesion, together with more or less enlargement of the spleen, and polycythaemia amount- ing perhaps to six, seven, or even ten million red corpuscles per c.mm. The diagnosis is arrived at when polycythaemia and enlargement of the spleen occur in the absence of any definite cause. Splenomegalic cirrhosis is an affection of children and young adults, in whom there are likely to be more or less jaundice, ansemia, lack of development, and ultimately ascites, as well as considerable enlargement of the spleen. There is a tendency for this maladj^ to affect more than one member of a family, and this sometimes gives the clue to the diagnosis. When death ultimately ensues, in addition to the great enlargement of the spleen, these cases exhibit more or 694 SPLEEN, ENLARGEMENT OF THE less fibrosis or cirrhosis of the Uver, and sometimes the hver is indistinguishable from that of ordinary alcoholic cirrhosis. What relationship this malady has to ordinary alcoholic cirrhosis of the liver on the one hand, and to splenic anaemia or Banti's disease upon the other, is not clear ; but owing to the enlargement of the spleen, it is differentiated as splenomegalic cirrhosis. Haemorrhages, par- ticularly haematemesis, are not infrequent in this as in other forms of cirrhosis of the liver. The blood-changes are merely those of a simple chlorotic anaemia. The diagnosis is afforded chiefly by the age of the patient, by the size of the spleen, and by the absence of any positive blood-changes, particularly if more than one member of the family is affected in the same way. The patient often lives for a number of years, and is able to work in spite of the complaint, until ascites supervenes. The fingers may be clubbed. Splenic ancBmia has been discussed under Anemia (q.v.). The spleen is not as a rule very greatly enlarged, though sometimes it may be [Fig. i86). The blood - changes are simply those of progressive and severe anaemia of a chlorotic type ; even though there may really be a disease meriting the distinctive term, " splenic anemia," not a few cases diagnosed as such on account of the co-existence of splenic enlargement with simple anaemia, ultimately turn out to be cirrhosis of the liver. When that which is really cirrhosis of the liver is dia- gnosed in its early stages as splenic anaemia, the condition is termed Banti's disease. Pseiido-leiikcBmia infanium (voN Jaksch's Disease) is, apart from true leukaemia, almost the only cause of verj' great enlargement of the spleen in young children {Fig. 2, p. 42). It is dia- gnosed by the severity of the anaemia, which is of the in- determinate chlorotic type without great leucocytosis, but with all the changes that are to be expected in any severe ansemia (pp. 27, 28) developing in an infant of a year old or less, running a chronic course, but sometimes resulting in complete recovery. (b). Chronic Enlargement of the Spleen, the enlargement being of moderate size. It is clear that conditions which may sometimes produce great enlargement of the spleen must go through a phase in which the spleen is not yet enormous, and at this stage all those diseases that have just been discussed will come into the present group. The remarks already made need not be repeated here, however, for the diagnosis at the stage in which the spleen is yet only moderately big is arrived at in the way already described. A blood-count is essential in order to exclude or diagnose splenomeduUary leukaemia or /''ig: 186. — Splenic anaemia : photograph showing the outline of the spleen. There was .severe chlorotic ana;mia without leucocytosis; the patient died, and at the autopsy there was no cirrhosis of the liver. SPLEEN, ENLARGEMENT OF THE 695 lymphatic leukaemia ; parasites may be discovered to account for malaria or kala-azar ; and so on. The spleen is palpable in a considerable proportion of cases of pernicious ancBmia, but it is seldom greatly enlarged, and the diagnosis is arrived at by finding the blood-changes described under Anemia. In none of the other diseases mentioned in the hst above are the blood-changes themselves patho- gnomonic. The spleen of a small child is very often just palpable without there being any disease at all ; if it is more decidedly enlarged, the first suspicion will be that it is due to rickets or congenital syphilis. The bony changes, quadrate head, beaded ribs, large epiphyses, exaggerated curves of the long bones, particularly of the legs, delay in the closure of the fontanelles, and the pot-belly, will suggest rickets ; it should be added, however, that owing to the eversion of the lower ribs along a line corresponding with the attachment of the diaphragm, and known as Harrison's sulcus, the spleen often becomes unduly palpable in rickety children without being necessarily enlarged. Con- genital syphilis may be suggested by a knowledge of the family history, by the occurrence of snuffles, of specific skin eruptions, and so forth ; but in many cases the diagnosis will be one of surmise only, unless it can be confirmed by the specific serum reaction of Wassermann. Pseudo-leukcDtnia infantum has already been discussed above ; by some observers it has been regarded as in some way associated either with rickets, with congenital syphilis, or both ; but the most recent view seems to be that it is due to some cause other than these, though its nature is not yet known. Hodgkin's Disease, when it is typical, is associated with considerable and progressive Lymphatic Gland Enlargement [q.v.), especially those of the neck, and later those of the axillae and groins, thorax and abdomen, together with moderate but seldom very great enlargement of the spleen ; without any anaemia to begin with, but later with a progressive and ultimately severe anaemia of the chlorotic type, with all the changes mentioned on pp. 27, 28 ; without leuco- cytosis, and with nothing characteristic about the differential leucocyte count, except that an occasional basophile cell or myelocyte may be seen. Hodgkin himself laid particular stress upon the changes in the spleen in this disease, but there can be little doubt that there are cases of a precisely similar nature in which there is much lymphatic glandular enlargement without enlargement of the spleen. An attempt is sometimes made to distinguish this type from that with splenic enlargement, by styling it lymphadenoma ; but where lymphadenoma ends and Hodgkin's disease begins, and vice versa, is by no means settled. It would seem much more likely that there is every degree of acuteness and severity between extremes that are wide apart, those cases which have lymphatic glandular enlargement and a rapidly fatal ending without leucocytosis as their most prominent feature being styled lymphosarcoma ; similar cases with the addition of enlargement of the spleen, but a fairly rapid fatal ending, being termed acute Hodgkin's disease ; others again, with enlargement of the glands without enlarge- ment of the spleen and with rather greater duration, being termed Ijmiph- adenoma ; whilst precisely similar cases with enlargement of both spleen and glands, and a duration of anything between several months and several years, are termed ordinary Hodgkin's disease. One very important point to be realized about this disease is, that the blood-changes in it are not pathogno- monic even when they are severe. Cirrhosis of the Liver, by the time it has ended fatalty, is nearly always associated with a spleen that is bigger than normal as judged by post-mortem weights. Clinically, however, this enlargement can be made out only in a small proportion of the cases, and even in these the enlargement is seldom 696 SPLEEN, ENLARGEMENT OF THE great. When, however, there is doubt as to the diagnosis, and cirrhosis of the hver seems to be a possible cause for other symptoms, such as H^matemesis {q-v.), Ascites (q.v.), Jaundice [q.v.), the presence of chronic but not very great enlargement of the spleen, without affection of the lymphatic glands and without pathognomonic blood-changes, is an additional argument in favour of the diagnosis. Splenic enlargement is a very prominent and relatively early feature in a few cases, on the other hand, as in the splenomegalic cirrhosis of children and young adults ; whilst in some older patients, long before the hepatic changes themselves attract attention, the case may come under observation for anaemia, with or without haemorrhage such as purpura, epistaxis, haemat- emesis, or the passage of blood per rectum ; and a considerable enlargement of the spleen may be found. The blood-changes may be merely chlorotic, and in the absence of other definite signs or symptoms, the diagnosis of Sjjlenic anaemia, that is to say of simple anaemia associated with an enlarged spleen, may be made ; many such cases ultimately turn out to be examples of cirrhosis of the liver — Banti's disease. Lardaceous Disease. — A lardaceous spleen is not always enlarged, but is frequently big enough to be palpable, and the liver is gen@i;ally enlarged at the same time. Lardaceous disease of the spleen is met with in two forms : (i) the ^ DESCRI'PTION OF PLATE XIL A, Malaria, early ring form; B, Malaria, ordinary ring form; C, Malaria, mature tertian ; D, Malaria, tertian, ready to sporulate ; E, Malaria, crescentic ; F, Filaria embryo ; G, Trypanosoma Gambiense ; H, Leishman-Donovan bodies, obtained by splenic puncture ; /, Spirochaeta Obermeieri of relapsing fever ; /, Spirochaeta pallida of syphilis; K, Tubercle bacilli and pus cells; L, Diphtheria bacilli; M, Vincent's angina, Spirilla and Fusiform bacilli; N, Meningococci within a leucocyte; O, Pneumo- cocci and pus cells ; P, Staphylococci and pus cells ; Q, Streptococci and pus cells ; R, Gonococci, in and outside of pus cells; S, Actinomyces; T, Tetanus bacilli. (The ittagnification of V and S is 7!iuck less than is thai of tJie remainder; the relative magnifications are indicated hy the relative sizes of the white corpiiscles.) sago spleen, in which the changes involve the Malpighian bodies mainly ; and (2) the diffuse waxy spleen, in which the blood-vessels, sinuses, and trabeculae are universally affected. It is a condition which results from long-continued suppuration, discharging sinuses from empyema or spinal caries, purulent cavities in phthisis or bronchiectasis, or from tertiary syphilis. If considerable enlargement of the spleen is associated with any of these conditions, it is most probably due to lardaceous disease. There is generally diarrhoea on account of affection of the intestines ; and pohmria and albuminuria owing to renal changes. The patient is weak, frail-looking, and bloodless. Blood-counts exclude leukaemia, and indicate more or less severe anaemia of the chlorotic type. The disease is very much less common than formerly, and for the most part it is diagnosed by reason of there being obvious cause for it, especially prolonged suppuration or tertiary syphilis. Thrombosis of the Portal Vein as a cause for splenic enlargement can seldom be more than guessed at (see Ascites). Pressure on the Portal Vein by enlarged lymphatic glands or by adjacent tumours, will almost certainly be associated with obstruction to the bile-duct at the same time, so that there will be jaundice, and probably also ascites, in addition to any splenic enlargement ; the latter in any case will not be more than slight or moderate. SPLEEN, ENLARGEMENT OF THE 697 II. — Acute Enlargement of the Spleen. Acute Infectious Fevers. Typhoid Fever is the best known febrile disease in which moderate enlargement of the spleen occurs. The organ is usually soft, so that in many cases only an increased .sense of resistance can be determined on palpating close under the left ribs. The enlargement may be so slight that the organ may only be felt when the patient takes a deep breath, so as to push it down from under the ribs ; or it may be so big that its lower border. reaches down to the level of the umbilicus. If, in a case of obscure fever in which a continued pyrexia is associated (especially during the first ten days) with a relatively slow pulse-rate, the spleen is found to be enlarged, the diagnosis of typhoid fever is very likely, especially if there is a history of a gradual onset with a feeling of anorexia and lassitude, accompanied by headache and sometimes with attacks of epistaxis, a gradual rise of temperature which, if it has been observed from the first, is seen to go up about two degrees every night, with a fall of one degree the following morning, until step by step it reaches 103° F. or 104° F., or even higher ; and perhaps no definite abnormal physical signs whatever except as regards the spleen, or a few rhonchi in the chest. The characteristic rash does not appear until the sixth day or later, when it comes out on the abdomen as a rule, sometimes also upon the chest and back, in the form of small, rosy-red, flattened papules which fade on pressure, come out in successive crops, and are seldom present to the extent of more than half-a-dozen or a dozen at a time. Widal's agglutinating serum reaction should ultimately be positive in a dilution of i in 200 in half an hour, but it is generally the second week before this test is positive. Earlier confirmation of the nature of the fever may be obtained by the blood-count, there being no leucocytosis — indeed, sometimes Leucopenia (q.v.) — whilst, unlike many febrile illnesses, typhoid fever produces a relative increase, not in the polymorpho- nuclear cells, but in the small lymphocytes. Such blood-changes are in them- selves almost pathognomonic, and they are obtainable before Widal's reaction is to be expected, though the latter is the ultimate test of the fever. When neither blood-count nor serum-test is possible, the diagnosis may not be cleared up until the third week or later, when sloughs from Peyer's patches can be dis- covered in the stools. The ratio of the pulse-rate and temperature is of very considerable value in the diagnosis, for in the majority of cases the pulse-ratio is very low ; for instance, with a temperature of 104° F., the pulse-rate may be only 85 or 90 per minute, when the physiological ratio for this temperature is 120. Pneumonia in its earlier stages may also produce a low pulse-ratio; but the respiration-ratio is here increased, which is not the case in typhoid fever. The following figures illustrate these points : — T. P. R. Physiological ratio . . . . 104° F. 125 32 Typhoid fever . . . . 104° F. 90 30 Pneumonia . . . . . . 104° F. 100 40 Paratyphoid Fever is closely related to typhoid fever, the clinical symptoms being very similar ; the importance of distinguishing between the two lies chiefly in the carrying out of Widal's agglutinating serum reaction. It some- times happens that in a case which, from a clinical point of view, is almost certainly typhoid fever, the serum will not cause clumping of Eberth's typhoid bacilli ; and so far as the bacteriological test goes, the diagnosis might remain altogether obscure unless the serum were also tested against the Bacillus paratyphosus A and the Bacillus paratyphosus B. In a certain proportion of cases, clumping will be obtained with one or other of these, the diagnosis of paratyphoid fever being based upon bacteriological rather than upon clinical conditions. The spleen is enlarged in paratyphoid fever to about the same extent as in typhoid. 698 SPLEEN, ENLARGEMENT OF THE Relapsing Fever is associated with considerable enlargement of the spleen. The disease is contagious, but nowada}^s rare, developing only under conditions of filth and famine. It is characterized by an acute onset, with chills, pains in the back, and a sudden rise of temperature. The latter remains high, for six or seven days, and then falls by crisis. For about a week the temperature remains normal, and then it rises again as before, several such remissions and relapses succeeding each other and being pathognomonic of the disease. The pulse is rapid, and there is profuse sweating. Enlargement of the spleen is detected early. It is most conclusively distinguished from other diseases by examination of blood-films in which the Spirochcsta obermeieri [Plate XII, Fig. I), will be found. Malaria. — Apart from the chronic enlargement of the spleen due to recurrent attacks of malaria, the spleen becomes enlarged and soft as the result of active hyperaemia during acute attacks. Even when no splenic enlargement can be detected in the intervals, during the paroxysms the viscus can usually be felt projecting below the costal margin, presenting a soft and indefinite lower border. When the patient has more or less chronic enlargement of the spleen as the result of preceding attacks, each acute febrile paroxysm is associated as a rule with an additional swelling which passes off after the attack. For the characters of the fever, see pp. 34, 35. The nature of the malady will be suggested by geographical considerations, or by the influence of quinine ; but the only conclusive proof of its nature is the discovery in stained blood-films of the malaria parasites [Plate XII, Figs. A, B, C, D). There is often marked anaemia, especially in cases of recurrent malaria, the red corpuscles and haemo- globin becoming reduced as in chlorosis ; the leucocytes are also diminished, and the differential leucocyte count shows a relative increase in the large hyaline lymphocytes up to even 15 or 20 per cent. Erysipelas is often associated with a moderate degree of enlargement of the spleen ; but the fever, rigors [Fig. 166, p. 614), and slightly-raised red spreading infection of the skin are sufficiently characteristic to indicate the diagnosis. Septiccemia may be less easj^ to diagnose unless there is some obvious source of sepsis in the first instance, such as infection of the uterus after childbirth, sepsis in connection with the general peritoneal cavity, joints, wounds, and so forth. The chief difficulty arises in those cases in which the source of the sepsis is not obvious, being due to absorption from such lesions as pyorrhoea alveolaris, whitlows, acne, or other conrparatively small superficial affections ; or to deep- seated suppuration, such as a hidden empyema, infective pylephlebitis, infective cholangitis, pyosalpinx, and so forth. In some cases of chronic or subacute septicaemia, enlargement of the spleen may be considerable, and the diagnosis of infective endocarditis will very likely suggest itself. Whether or not the heart valves are affected in these cases, the ultimate diagnosis will depend upon discovery of infective organisms in cultures obtained by venesection. Diphtheria, Pneumonia, Scarlet Fever, and Small-pox seldom give rise to any very prominent splenic enlargement, and the only importance of it is, that in the early stages of the malady, detection of a spleen that is just palpable may temporarily arouse a suspicion that the patient may be suffering from tj^phoid fever. The course of the disease, bacteriological examination by swabbings from the throat, the physical signs in the lungs, and characters of the sputum and the skin rash, will serve to point to the correct diagnosis in each case. Typhus Fever is fortunately very rare now, although there are small out- breaks of it in the poorer parts of large cities from time to time ; the spleen becomes soft and moderately enlarged, but less constantly so than in typhoid fever. The disease sets in more acutely than enteric, with chills, early prostration, and a high temperature which ends by less marked lysis than does SPLEEN, ENLARGEMENT OF THE 699 that of typhoid fever ; and sometimes almost by crisis at the end of the second ■vveek. The rash differs from that of typhoid fever, in that it appears on the fifth day, and consists of petechise and of dark red groups of subcutaneons macules, in addition to rosy- red papules on the surface. Nervous symptoms become very marked, especially at the end of the iirst week, the so-called typhoid state being an expression used to denote, not the condition that occurs in typhoid fever, but that which develops in typhus. There may be severe vomiting, and retention of urine, important s^-mptoms that are rare in t3'phoid fever. There should be no positive Widal's reaction, and no sloughs in the stools. Influenza is a diagnosis which should never be made unless with very good ■cause, for many febrile illnesses in which the real cause escapes recognition receive the label influenza. It is easiest to diagnose correctly in times of severe •epidemic, and then slight enlargement of the spleen may occur in a few cases. This in itself is not important if influenza can be diagnosed with certainty on ■other grounds ; but until the nature of the fever becomes obvious, it is important in that it may suggest tj'phoid when none exists. The sudden onset, the extreme prostration, the high pulse-rate as well as temperature, the initial chill, the profuse sweating which comes on when the patient begins to improve, and the fall of the temperature after an illness lasting from twenty-four hours to three or four days or a week, would all point to influenza. It may, however, be im- possible to distinguish influenza from typhoid fever until the course of the pyrexia has been watched. It is worthy of note that in influenza as well as typhoid, there is no leucocytosis. General Tuberculosis may also simulate typhoid fever in certain cases, and enlargement of the spleen may result from the developnrent of tubercles in it. When cerebral symptoms predominate, the diagnosis is relatively easy ; the headache may be equally severe in both, but with tuberculous meningitis there is more vomiting and more retraction of the head, whilst it is probable that optic neuritis, and perhaps choroidal tubercles, can be detected. Widal's test will remain persistently negative ; there will be no rosy rash, probably no leucocytosis, and no sloughs will be found in the stools. In some cases, however, general tuberculosis produces a clinical picture that may be very difficult to distinguish from typhoid fever. Lumbar puncture may decide the diagnosis. Embolism. — Fungating endocarditis is nearly always associated with palpable ■enlargement of the .spleen, and sometimes the organ attains a considerable size. As stated above, ordinary heart-disease with failure of compensation does not give rise to splenic enlargement that can be recognized clinically, except per- haps in children, notwithstanding the fact that one might have expected the backward pressure to cause the spleen to be big by being dilated with blood. Except in children, enlargement of the spleen in a heart case should always arouse serious suspicion of infective endocarditis. The enlargement may be due to embohsm and infarction, in which case there may have been a history of acute pain low down on the left side of the chest, accompanied by a definite rub due to perisplenitis over the infarct. The splenic enlargement in some cases, how- ever, is due less to actual infarction than to the general toxaemia ; even when there has been an infarct it is not always easy to be sure of it. Fungating endo- carditis sometimes develops without there being any bruit at all ; the diagnosis is then exceedingly difficult unless the patient suffers from multiple emboli — cerebral, renal, intestinal, splenic, peripheral. Sometimes such an embolus may be followed bj' the development of an acute aneurysm — femoral, popliteal, cerebral, and so forth. A cerebral embolism of this kind has sometimes resulted in sudden transient coma and hemiplegia ; the patient has seemed to be re- covering ; then in a day or two has relapsed into coma again, and died, the cause of the relapse and fatal ending being the de\'elopment of an acute cerebral 700 SPLEEN, ENLARGEMENT OF THE aneurysm at the site of the embolus, rupture of this aneurysm, and death from the resultant hssmorrhage. Progressive aneemia of the chlorotic type, without much leucocytosis, is another feature of these cases. The diagnosis must always be difficult when there is no cardiac bruit ; whilst, when there is a bruit, the difficult}' is to determine whether the patient is suffering merely from mechanical heart-failure, or from fungating endocarditis superposed upon the chronic heart lesions (pp. 38, 39). Thrombotic infarction may cause acute splenic enlargement in almost any of the blood diseases, particularly in lymphadenoma and leukaemia. Neither Injury nor Strangulation of the spleen by its becoming twisted upon its own hilum is a very common event, and the latter is nearly always the result of injury. A blow in the splenic region may be such as to cause a rupture in the pulp of the spleen without bursting its capsule, and without obviously injuring the chest wall or the abdomen. The bleeding that occurs within the capsule of the spleen itself causes very great pain in the part and enlarge- ment of the organ ; the diagnosis can seldom be more than guessed at unless laparotomy is performed. Strangulation of the spleen seldom occurs if the organ is in its natural position ; but when there has been previous dislocation, an abdominal injury, or sometimes a sudden spontaneous effort, has led to its becoming twisted on its own hilum, the symptoms being such as to suggest an acute intra-abdominal condition requiring immediate laparotomy, but seldom pointing to the actual diagnosis until the laparotomy has been performed. Herbert French. SPONGY GUMS.— (See Bleeding Gums.) SPUTA vary enormously as to their amount, consistence, colour, and so forth ; but by far the most important point about them in diagnosis is the determination of whether they contain tubercle bacilli or not. There is no particular variety of sputum which can be said to be characteristic of pulmonary tuberculosis to the naked eye, although much stress is generally laid upon the fact that phthisis with cavitation produces a nummular sputum — that is to say, sputum of which the individual portions expectorated tend, not to coalesce but to flatten out as separate round portions, if they are spat on to a flat, dry surface ; if expectorated into antiseptic fluid, they remain as more or less globular, separate masses. As a matter of fact, however, ordinary bronchitis may produce sputum possessing a typical appearance of nummularity, and it is most unwise to rely on the naked-eye appearances of sputum for any diagnosis except that of lobar pneumonia, when it may be typically viscid and rusty. It is in almost all cases essential to make films of the sputum, and to stain these for tubercle bacilli by the Ziehl-Neelsen method with carbol-fuchsin. The carbol-fuchsin solution is made up of i gr. of fuchsin, 10 c.c. of absolute alcohol, and 100 c.c. of 5 per cent solution of carbolic acid in distilled water. The slide is covered by the stain in a suitable receiver, and held over a small Bunsen burner or spirit flame until the fluid steams briskly but does not actually boil. After immersion in this for five minutes at least, and it does not much matter if for longer, the excess of stain is poured off, the film washed in water, the excess of the latter drained off, and the slide immersed in 25 per cent sulphuric acid for about half a minute ; it is then transferred to water again, and recovers more or less of the red tint of the fuchsin ; if too little of this has been discharged, the slide is returned to the sulphuric acid for another period, and so on ; when well decolorized, only the thickest parts of the film retain obvious red ; it is then counterstained by five minutes' immersion in carbol-methylene blue, the excess of this stain being washed off with water, the film dried in the air, and either mounted in Canada balsam or else examined directly through cedar-wood oil ; the tubercle bacilli (Plate XII, Fig. K) show up as bright red rods in a blue field under the oil-immersion lens. SPUTA 701 The presence of acid-fast bacilli in an ordinary sputum film is ver}^ nearly proof positive of tuberculosis of the lung, the only source of fallacy being the possibility of non-pathogenic acid-fast bacilli being derived from the mouth. It is very unlikely that this source of fallacy will persist from day to day, especially if care be taken to make the films from the interior of the sputum pellets. It should be remembered, of course, that the absence of tubercle bacilh, or rather their non-detection, is no proof of the absence of pulmonary phthisis, and if there is doubt, successive sputa should be tested in the same way. It should also be remembered that a lesion which may have been tuberculous originally, may in time lose its tuberculous character, the tubercle bacilli may die out, though the cavities produced by them still persist and become occupied by pyogenic organisms and their products. Many of the symptoms of phthisis itself are not due to tubercle bacilli directly, but rather to secondary infection by streptococci, staphylococci, pneumococci, and so forth ; and the degree of this secondary infection may be gauged from the films at the same time as one looks for tubercle bacilli. It is also important to reahze that a person may expectorate sputum containing tubercle bacilh in abundance every day for months, and yet may have precisely as much lung tissue left by the end of that time as at the beginning ; this is due to the fact that when cavities have been produced they are lined by granulation tissue, and it is possible for the discharge from the surface of these granulations to produce a continuous supply of sputum without the erosion of the lung tissue progressing. One sees a precisely similar state of affairs in cases of some skin ulcers, which may discharge abundantly and yet remain much the same size for months at a time. The best evidence of lung destruction is afforded by the dis- covery of elastic fibres {Fig. 187) in the sputum ; if these are present there must be something which is eroding the lung tissue, and if tubercle bacilli are present at the same time, the two together indicate advancing phthisis. The elastic fibres may be obvious when ordinary sputum is examined fresh after it has been pressed out between cover-slip and slide, but oftener they are more easily detected when a quantity of sputum has been boiled with strong caustic soda to destroy pus cells, mucus, and so forth, leaving the very resistant elastic fibres unaffected. Tubercle bacilli are also very resistant to the effect of strong alkali, and when they are suspected to be present but cannot be found without in some way concentrating them, it is a useful plan to boil the sputum with an equal amount of 5 per cent caustic potash, to dilute the result with water, to centrifugalize it well, and make films from the deposit. There are various other methods of obtaining concentrated bacilli from the sputum, but this is one of the simplest. It should be borne in mind that tubercle bacilli may be found even when the sputum is exceedingly small in amount and apparently insignificant and mucoid. For sputa containing blood, see Hemoptysis. Viscid, rusty Sputum is almost pathognomonic of pneumonia. As a rule the diagnosis of lobar pneumonia is fairly clear owing to the sudden onset of an acute pulmonary complaint associated with fine crepitations confined to one or more lobes, followed by dullness, with bronchial breathing, bronchophonj-, and Fig. 187. — Elastic fibres from sputum. The lower figure is less magnified than the upper, and shows alveolar arrange- ment of the fibres. (From French's Medical Laboratory Methods.) 702 SPUTA pectoriloquy without rales ; these being succeeded by redux crepitations, with a diminution in the bronchophonjr, pectoriloquy, and bronchial breathing until normal voice and breath sounds are restored. The patient's temperature, after maintaining a high level such as 103° F. or 104° F. for from five to ten or more daj's — usually about seven — falls by crisis {Fig. 188). The respiration rate is very rapid — for example, 40 per minute — during the height of the fever, and the skin is flushed, dry, pungent before the crisis, moist from profuse perspiration after it. The diagnosis is much more difficult in some cases, however ; there are not a few patients in whom the consolidation is deep-seated, so that it does not come to the surface at all, and lobar pneumonia has to be diagnosed when there are no abnormal physical signs to be detected in either side of the chest. In such cases the general symptoms may suggest the diagnosis, and the sticky, viscid sputum, the colour of which is generally that of iron rust — but which may be any of the colours that a bruise may have, from bright-red or brown to greenish-brown, greenish, j^ellowish, or even bluish-yellow — confirms it even when the lung signs remain normal. The viscidity of the sputum in these cases J^2^. 1S8. — Temperature chart of an ordinary case of lobar pneumonia, showing a crisis on the seventh day of the illness, and a slight post-critical rise on the following daj'. is of as much importance as the colour. Films of it usually contain numbers of pneumococci (Plate XII, Fig. O) ; in exceptional instances pneumo-bacilli. When lobar pneumonia is due to the influenza bacillus, the sputum has not the viscid, rusty character as a rule, but is more like that of ordinary muco-purulent bronchitis. The presence of large numbers of pneumococci, however, or of any other micro-organism than the tubercle bacillus, is by itself no proof that this is the cause of the lung lesion, for even in the sputum of perfectly normal persons, pneumococci and other bacteria are frequently abundant. It is quite possible for a patient who is dying of general miliary tuberculosis of the lung to have no tubercle bacilli in the sputum, but an abundance of capsulated pneumococci which may readily, when they are discovered, lead to an erroneous diagnosis. Influenza bacilli are exceedingly small ; but it is important that they should be looked for, both directly and by cultural methods, in all cases thought to be influenzal, before this diagnosis is regarded as established : even when influenza bacilli are found, there is still the possibility that they may be an intercurrent infection in some other malady ; but it is so tempting to think of influenza when no other obvious cause for a febrile illness can be discovered, that it should not be diagnosed until influenza bacilli have been shown to be present. SPUTA 703 Abundance of Foul Sputum, especially when expectorated much at a time at comparatively long intervals, is sometimes by itself a striking symptom, and it suggests that the patient is suffering from one or other of the following : — Bronchiectasis Phthisis with cavitation Foetid bronchitis An empyema ruptured into the lung Gangrene of the lung. It is sometimes very easy to distinguish between these ; with fibroid lung and bronchiectasis the patient is likely to have had symptoms periodically for a long while ; there will generally be marked Clubbing of the Fingers [q.v.) ;. the abnormal physical signs are confined to one lung as a rule, and especially to the lower lobe, with displacement of the heart towards that side ; there will be deficiency of movement, resonance, and vesicular murmur in the affected lower lobe, together with either absence of voice sounds and of rales, or scattered foci of crackling rales, especially when the patient coughs, with bronchophony, pectoriloquy, and bronchial breathing. If, on the other hand, the abundant and foul sputum is associated with abnormal physical signs in both lungs, and if the upper lobes are obviously more affected than the lower, if the patient has a strong tuberculous family history, and if tubercle bacilli are either now present in the sputum, or are known to have been present formerly, — the diagnosis of chronic phthisis with extensive cavitation and secondary infection of the cavities with pyogenic organisms is obvious. Foetid bronchitis is always a dangerous diagnosis to make, and the probability is that many cases so diagnosed have been examples either of deep-seated bronchiectasis, of phthisis with cavitation and secondary pyococcic infection,. or of empyema ruptured into the lung. The latter is generally associated with hardly any abnormal physical signs, because if the original empyema had given rise to its ordinary physical signs, it would have been diagnosed and relieved by operation ; an empyema may develop either between the lobes, or between the pericardium and the lung, or between the diaphragm and the lung, in such a way as to leave normal lung tissue all round the surface next the chest wall, so that the usual evidence of pus in the chest is entirely wanting. Even if abnormal physical signs are produced when the pus is kept in an abnormal position in this way, the needle may have to pass through so much tissue before the empyema cavity is entered, that the pus cannot be located : in either of these cases the empyema will, in the course of time, tend to ulcerate its way- through the pleura and lead to the expectoration of large quantities of foul sputum at intervals as the empyema cavity re-fills. The diagnosis depends largely upon the exclusion of other causes of abundant foul expectoration, and perhaps upon the history of a preceding illness predisposing to empyema, for example, lobar pneumonia. Gangrene of the lung may be simulated to some extent by bronchiectasis or by empyema rupturing into the lung ; but generally speaking nothing but gangrene will produce so much stench. Foul though the sputum in bad bronchiectasis may become, it seldom approaches the awful foetor of pulmonary gangrene. The history, moreover, is acute ; there may be some obvious cause for gangrene, particularly lobar pneumonia in a patient debilitated from some other cause, such as diabetes, or inhalation of foul particles after immersion in a dirty river, or as the result of disease of the mouth, throat, or oesophagus,, or septic embolism of the lung from lateral sinus thrombosis, and so forth. If any doubt remains as to whether the lung tissue is being destroyed or not, elastic fibres can be sought for, their presence at once distinguishing between bronchiectasis or deep-seated empyema on the one hand and gangrene on the other. 704 SPUTA When a large quantity of pus is expectorated through the lung in a person who, having been in the tropics and having possibly suffered from dysentery, has since had symptoms pointing to hepatic trouble, the possibility that an amoebic abscess of the liver may have opened its way through the diaphragm into the lung will immediately occur to one, especially if the expectorated pus is tinged the colour of anchovy sauce. It might be thought that the Aniceba coli would be found in it ; but this is not the case, for this protozoon is not present in the pus of a hepatic abscess, but only in the granulations of the abscess wall. The sputum in these cases is not foul as a rule. The other abnormal features that may be exhibited by sputum are relatively uncommon, and are of diagnostic significance only in exceptional cases. The serous, mucoid, muco-purulent, or purulent sputum of the various stages of acute and chronic bronchitis may arouse a doubt as to whether the patient has not a tuberculous focus ; repeated examination will fail to reveal either tubercle bacilli or elastic fibres, but it is to be remembered that a considerable minority of phthisical subjects seem not to expectorate the bacilli. Black sputum is common in those who live in smoky atmospheres, particularly in towns, colliery districts, and manufacturing centres. Other changes in colour may be due to haemoptysis, pneumonia, or hepatic abscess, which are all discussed above ; sometimes infection by the Bacillus pyocyaneus may produce greenish or bluish sputa which may alarm the patient, but which need not have any serious import. Curschmann's spirals (p. 179) and Charcot-Leyden crystals (p. 117) have been discussed elsewhere. Casts of the bronchial tubes are met with in very exceptional cases, and they are of two main types — namely, diphtheritic, and non-diphtheritic. The distinction depends on bacteriological examination ; histologically they consist of ill-defined exudate containing cells irregularly embedded in it. Non- diphtheritic casts are due to plastic or fibrinous bronchitis, a very rare disease of which the sputum is the diagnostic point. Two other rare causes for the expectoration of casts of the bronchi are lobar pneumonia, and the inhalation of blood from some other part of the lung in a case of hsemoptysis, and its subsequent expectoration after it has clotted. Now and again a cretaceous pellet or a small caseous mass may be found in the sputum of a patient who either has pulmonary phthisis, as evidenced by the abnormal apical physical signs, and by the detection of elastic fibres as well as tubercle bacilli in the sputum, or in children as the result of the ulceration of a caseous bronchial gland into the trachea or a main bronchus, and then expectoration of its caseous or cretaceous contents. Another rarity which has occasionally been found in the sputum is a recogniz- able particle of new growth, the detection of which may be of material assistance in diagnosis. Chemical analyses are relied on by some observers in distinguishing tuberculous from non-tuberculous sputum, it being stated that expectoration containing coagulable proteid is more likely to be the result of tuberculous infection than is sputum which does not coagulate with heat. This distinction, however, is not universally accepted, and microscopical examination for tubercle bacilli is certainly a more reliable test in the great majority of cases. The rarer bacteria and moulds that may be detected in the sputum by special bacteriological methods generally require very special investigation, including cultural tests by skilled bacteriologists : one need not, therefore, enter into details here, though it may be well to enumerate certain micro-organisms which may be pathogenic in the lung in comparatively rare instances — B. mallei, STERILITY 705 generally amongst workers in stables or otherwise in connection with horses ; Aspergillus flav.us, A. niger, A. funiigatus, generally amongst those who have to do with the artificial feeding of pigeons and other birds ; Actinomyces or the ray fungus, in those who have had to do with barley in some way or another, or, as has recently been demonstrated, in those who are in the habit of holding cotton in their mouths, such as tailors and seamstresses. Besides these pathogenic micro-organisms, not a few others which are not actually pathogenic are to be recognized in the sputum when it has become secondarily infected in chronic cases. Penicillium glaucum, for instance, or Oidiuni albicans ; yeast and other moulds ; Micrococcus tetragenus ; or Oidium tropicale, a micro- organism similar to but culturally different from Oidium albicans, which has recently been reported to be a cause of lung lesions both in Europeans and natives in Ceylon, the symptoms suggesting phthisis, but the latter being excluded by the persistent absence of tubercle bacilli from the sputum and by the absence of reaction to tuberculin. Whooping-cough is sometimes difficult to distinguish from other colds and from bronchitis, and if the recent statements to the effect that it is due to a minute bacillus prove true, bacteriological examination of the sputum may be of use in diagnosing this condition in doubtful cases. The lung fluke, Paragonimus Westermani, which causes haemoptysis in Corea, Japan, and parts of China, is to be diagnosed by the discovery of its oval, capsulated eggs in the sputum. Herbert French. SQUINT.— (See Strabismus.) STAMMERING. — (See Speech, Abnormalities of.) STERILITY. — The differential diagnosis of the causes of sterihty is often a matter of great difficulty, and although there are many well-defined conditions which give rise to it, we are bound to admit that there are numbers of cases in which no definite cause can be found. Further, we must not overlook the fact that the husband is responsible for a sterile marriage in one-fourth to one-third of the cases. This is a fact shown by many observers, and too often forgotten when investigating cases. Therefore, we must not consider a case to be complete unless the husband and his semen have been investigated. Many a woman has her married hfe made miserable, and is taken from doctor to doctor on account of sterility, when the husband really is to blame. The causes of sterility are shown in the table on the next page. From a study of this table, it is clear that some of the causes of sterility are primary, whilst others are secondary. Thus absence of the uterus or infantile uterus means primary sterility, whilst hyperinvolution, carcinoma of the cervix, etc., may occur in women who have had children, and only secondarily become sterile on account of these lesions. Further, some of these causes are common, or may be remedied ; others, on the other hand, are rare or absolutely incurable. Diagnosis is therefore of great importance, for it is far better to discover and remedy a defect early in married hfe, than to wait until the best years are soured and embittered by the longing for a child. Unfortunately, many patients, from various motives, put off the investigation too long. Congenital Lesions. — Some of the congenital lesions are diagnosed easily, such as closure of the hymen, absence of the vagina, or closure of the cervix, whilst absence of the essential organs often requires an anaesthetic in order that a bimanual examination may be made satisfactorily. The infantile uterus and small adult type are very difficult to differentiate ; but it may be remembered that in the former the body forms only one-third of the total length of the organ, whilst in the latter it forms two-thirds, both t}^es of uterus being small in the D 45 706 STERILITY antero-posterior and lateral dimensions, and only slightly shortened in the vertical. Of all the congenital lesions, the " cochleate " uterus of Pozzi is the commonest cause of sterihty, and is the most hopeful as regards treatment. The uterus is felt to be unusually curved anterior^, has a long conical cervix, and a small external os. In such an extemall}' malfonned uterus as this, it is possible that the internal structure is abnormal ; the endometrium, perhaps, is unduly thin and fibrous, the muscle layers badh' developed. The hypothetical change in the endometrium maj" be the essential cause of sterihtj^ : hence curettage for its complete removal forms an essential part of the treatment. The pecuhar shape and cur^'ature have long been considered a possible cause, preventing the entrance of spermatozoa into the cavit}'. Pseudo-hermaphroditism usually shows itself by shortness of the vagina, elongation of the chtoris, and the presence of glandular masses in the groins, which are almost alwaj'-s testes, proving that the subjects of it are reaU^' undeveloped males. Lesioxs of the Generative Organs. General Conditions. Congenital Lesions — Absence of uterus, tubes, ovaries Closure of hj-men, vagina, cervix Pseudo-hermaphroditism Infantile uterus Small adult tj'pe of uterus '■' Cochleate " uterus Displacements H\-pothetical changes in endometrium. Acquired Lesions — Dyspareunia Vaginismus Salpingo-oophoritis Uterine fibroids Endometritis Cervical catarrh Polypi Carcinoma of cervix Carcinoma of fundus Ovarian tumours Acquired atresia of vagina cervix Genital fistulae H^^erinvolution Frequent astringent douches Deficient ovarian activit)'. In the male. Azoospermia Ohgospermia Necrospermia. Old age Obesity Anaemia Kutritional disturbances Incompatibihty Absence of sexual feeling. Acquired Lesions. — The difierential diagnosis of the acquired lesions can only be made by complete examination of the patient by inspection, bimanual examina- tion, and the use of the microscope to elucidate doubtful growths. Dyspareunia as a cause is dealt with in the article under this head. Hyperinvolution requires just a word to itself, as it is an interesting and easily diagnosed condition. It occurs alwa^'S after a labour, and strictly means a continuance and progressive increase of the normal lactation atrophy of the uterus. The uterus is felt to be very small bimanuallv, and the sound ma\- pass onl^^ ij inches in a marked case. It is always associated with incurable amenorrhoea. Deficient ovarian activity, whereby the Graafian folhcles do not ripen or rupture, is not to be diagnosed bj' any of the ordinary methods we can employ, and it is doubtful whether a microscopic examination of the ovaries themselves Avould STERTOR 707 reveal the true condition. It is supposed to be associated with scanty nnenstrua- tion or amenorrhoea for which no other definite cause can be found. Absence of ovarian activity must be the true cause in the general conditions, which are outwardly shown by obesity, ancemia, and disturbances of nutrition ; and it is a fact that some women have not conceived as long as they remain too fat, whilst loss of weight has in some cases been followed by conception. Incompatibility between husband and wife sexually is an ill-defined condition, which, however, is fully believed to be a cause of sterilitj'. It is almost incapable of proof, for in the case of a sterile widow who remarries and conceives for the first time. we have no proof that the former husband was capable of procreation. Absence of sexual feeling or the sexual orgasm, too, is not always a cause of sterility, for conception has occurred in women who are absolutely devoid of these feehngs. On the other hand, most authors quote the case of a woman who conceived as a result of the only coitus at which an orgasm was experienced. The influence of age on child-bearing must never be forgotten, the liability to conceive falling rapidly every year over thirty. Sterility of the Male. — Finally, the examination of the husband and his seminal fluid should never be omitted unless there is some quite well-defined cause to be found in the wife. Assuming that the penis and testes are present, and that erections render the sexual act possible, the seminal fluid must be examined carefully. The fluid should be collected in a condom by means of a normal coitus, and should be examined within twelve hours. It must be spread on a shde and examined with a high power of the microscope. There may be no spermatozoa present at all, the condition known as azoospermia, in which case the husband is incapable of procreation. There may be but few spermatozoa, and those exhibiting only feeble powers of movement : oligospermia. There maybe plenty of spermatozoa present, but quite devoid of motility : necrospermia. It is unnecessary in this article to enter into the causes of these conditions. They are usually incurable, and consequently further investigation is unnecessary. Thos. G. Stevens . STERTOR is really another word for snoring ; but it is commonly restricted to the heavy, snoring sound accompanying inspiration, produced not in the nose but by vibrations of the soft palate, generally when the patient is in a state of profound unconsciousness. It differs from stridor in that the latter is produced in the larynx. If, as is generally the case, the patient is comatose, the presence or absence of stertor helps little in the diagnosis, which is discussed under the heading Coma. Sometimes, however, without being comatose, the patient may have stertor during sleep, when he is suffering from any of the following : — • Paralysis of the soft palate Post-pharyngeal abscess. Adenoids Hypertrophied tonsils Quinsy The stertor in these cases is closely akin to snoring. The differential diagnosis generally becomes manifest when the interior of the mouth and pharynx are examined. Possibly the condition most likely to be overlooked is post- pharyngeal abscess, but this should not be mistaken for anything else if a digital examination of the back of the mouth is made ; moreover, except when due to tuberculous caries of the cervical vertebrae, it is commonest in infants and quite small children, becoming rarer with each year of life. Herbert French. STIFF NECK. — This occurs in a number of diseases entirely different in character, and its significance may be either grave or trivial. It is rarely that stiffness is the only symptom, but it may be the first thing complained of, or it may be a complication arising in the course of a disease. yoS STIFF NECK It is not right to assume that the trouble is trivial, or vaguely to designate it as " rheumatic," without a thorough investigation. It is necessary first to enquire into the history of the duration of the illness, when it may become obvious that it follows, say, an injury, or has arisen during the course of some disease and is not primary. Next examine the patient with the head and shoulders bared, and see whether there is any swelling or abnormality present, also the extent of possible movement, and whether or not it is the movement that causes pain ; and if possible locate the seat of the pain. Many further investigations may be necessary, e.g., examination of "the throat for tonsillitis, the ear for suppurative otitis media, etc., according to the circumstances of the case. Exposure to Cold or Sleeping in a Cramped Position may give rise to a transient stiff neck, which is associated with no other symptoms. There is generally a distinct history of the patient waking up in the morning with a stiff neck, and the diagnosis is made by exclusion. It is well not to confound these with cases of rheumatoid arthritis. Inflammation of the Lymphatic Glands and the cellular tissues of the neck. Any inflammatory focus in the neck may cause stiffness, whether it be a boil or carbuncle, or an enlarged gland arising from a carious tooth, an inflamed tonsil, pediculosis capitis, or other similar cause. There is no spasm or rigidit}' of the muscles here, the neck can be moved quite well ; but it hurts to do so, and therefore it is held stiffly. The diagnosis is made easy, for the signs of inflammation will be obvious. Torticollis or Wry-neck is due to contraction of the sternomastoid muscle on one side, usually the result of an injury to the muscle caused by pulling on the aftercoming head in breech presentations. The muscle stands out as a tight band in the neck, and its contraction leads to a characteristic deformity. The head is pulled down towards the affected side, and the face and chin are tilted towards the opposite shoulder. The movements of the head are necessarily restricted owing to the shortening of the one muscle, and in long-standing cases this leads to a marked asymmetry of the face. The consequences are not limited to the head and neck, for the spine shares in the general obliquity, and shows marked lateral curvature in old cases. Spasmodic Torticollis is an unusual form due to spasms of the sternomastoid and other muscles of the neck. The spasms are intermittent, coming on suddenly with great pain, the affected muscles relaxing after a variable time. Cervical Caries. — The greatest care must be taken not to confound muscular rigidity with tuberculous disease of the cervical vertebree. In the latter, pain and rigidity are among the earliest signs ; the pain is increased by the least movement, and the child — for it is generally a child that is affected — takes the greatest precaution to avoid any movement, even holding the head between the two hands. The position of the head varies ; it is most often held very stiff and straight, the natural backward curve of the neck being lost. In the late stages there may be an angular or lateral curve. The distaste for move- ment is very well brought out when the patient is asked to look round — the eyes only are moved, or the whole body is rotated. Bearing the possibility of this condition in mind, there is not much difficulty in diagnosis, but in doubtful cases a skiagram should be taken. Infective Arthritis of the Cervical Vertebrce. — Following infective diseases such as scarlet fever, diphtheria and tonsilhtis, especially in children, there may ensue a very chronic form of suppurative arthritis affecting one or several of the cervical vertebrae, and going on sometimes to complete bony ankylosis. Spondylitis Deformans causes fixation of the neck, though the movements of nodding ' yes ' and ' no ' remain ; the nature of the case is at once indicated, however, by the fixation of the other regions of the spinal column also. STRIDOR 709 Injuries to the Neck. — A stiff neck may arise from some slight injury, such as a blow or a sudden twist. This will be clear from the history. Severe injuries involving fracture or dislocation are almost always fatal : if not immediately, then in a few days. A rare injury that may not be fatal is unilateral dislocation of one of the cervical vertebrae. This may result from a fall on to the head. From the start, there is great pain and stiffness in the neck, the head being fixed immovably and turned to the opposite side to that of the displacement. Burns. — A self-evident cause of stiffness is the cicatricial contraction following a burn on the neck. Stiffness and retraction of the head are important indications of meningitis, but they are by no means constant ; when present they are generally accompanied by other well-marked signs of meningitis. Stiffness of the neck is one of the earliest signs of tetanus ; it is rarely the only one, however. The trouble soon spreads to the jaw, causing trismus. The patient looks very ill, and there is almost always some wound which is sufficient to indicate the cause of the illness. Geo. E. Gask. STRABISMUS. — Squints may be classified, according to their direction, into convergent, divergent, or attitudinal ; according to their cause, into paralytic and non-paralytic (concomitant). The diagnosis between paralytic and non-paralytic strabismus is, as a rule, easy. In a paralytic strabismus the convergence or divergence of the two eyes is not constant in amount in all directions, as the farther the eyes are moved over in the direction of the action of the paralyzed muscle the greater will be the deviation from parallelism. In a concomitant squint the eyes always bear the same relative position to each other in whatever direction they are turned. The diagnosis of the cause of a paralytic strabismus, which is associated with Diplopia, is discussed under that heading {q.v.). The causes of concomitant strabismus are usually — Error of refraction ; Failure of binocular vision ; Defective vision in one eye ; or the association of one or more of these conditions. The cause cannot be determined accurately without a careful examination of the ocular refraction under a mydriatic. In general terms it may be stated that convergent squints are, as a rule, due to hypermetropia, and divergent squints to myopia. Herbert L. Eason. STRANGURY. — (See Micturition, Abnormalities of.) STRIDOR is a term used to denote a harsh, vibrating noise produced as the air passes in or out of a partially obstructed larynx or trachea. It may be due to many different causes, which may be classified as follows : — 1. Partial Obstruction Inside the Larynx or Trachea : — Mucus or muco-pus Foreign body Caseous gland rupturing into trachea. 2. Affections of the Wall of the Larynx or Trachea : — Diphtheria Acute oedema due to — Bright's disease Potassium iodide Acute streptococcal laryngitis Acute pneumococcal laryngitis Acute staphylococcal laryngitis yio STRIDOR Secondary infection in cases of tuberculous ulceration ^, ,, „ syphilitic ulceration J, J, „ malignant ulceration J, „ „ traumatic ulceration ,, J, „ post-typhoidal ulceration Stenosis after tracheotomy or cut throat Epithelioma of the vocal cords Fibroma of the vocal cords Epithelioma of the trachea Syphilitic stenosis. 3. Swellings Outside Compressing the Larynx or Trachea :— Enlargement of the thyroid gland Enlargement of the thymus gland Thoracic aneurysm Mediastinal new growth Post-pharyngeal abscess Epithelioma of the oesophagus invading the trachea Malignant glands in the neck Epitheliomatous glands in the neck. 4. Bilateral Abductor Paralysis of the Vocal Cords, generally due to syphilitic degeneration of the vagal-nuclear nerve cells. Distinction is sometimes drawn between inspiratory and expiratory stridor, and stridor which is both inspiratory and expiratory ; but in practice such a distinction is not helpful. The main value of stridor as a symptom is that it indicates stenosis of the main air-passages by one or other of the above causes, except in those rare cases in which it is functional : hysterical stridor ceases during sleep, is nearly always confined to the female sex, as a rule between the ages of fifteen and thirty, and is often associated with other functional nervous symptoms, such as globus hystericus and functional aphonia. Stridor should never be diagnosed as functional, however, until every possible organic cause has been excluded. The differential diagnosis of the causes of obstruction to the main air-passages will be found discussed on page 464. Herbert French. STUPOR.— (See Coma.) STUTTERING. — (See Speech, Abnormalities of.) SUCCUSSION SOUNDS Succussion sounds may be heard when a part that contains any considerable bulk of both fluid and gas is shaken, whilst the ear or the stethoscope is applied over the part. Sometimes the sounds are so loud that they can be heard at a considerable distance from the patient. A very good example of succussion sound is often afforded by the normal stomach after a quantity of fluid has just been swallowed. It is a mistake to suppose that gastric succussion sounds are evidence of abnormality ; they merely prove that the viscus contains fluid and gas at the same time ; the gas may be due to fermentation, but it is often nothing but air that has been swallowed during drinking. The chief value of gastric succussion sounds is that, according to the position in the abdomen at which they can be heard, they afford some clue as to the position, and perhaps as to the size, of the stomach. They should not be heard lower than the umbilicus ; if they are, the stomach is either displaced downwards, or dilated, or both. Another variety of succussion sounds may sometimes be heard in the chest, especially in cases of hydropneumothorax ; when the patient deliberately oscillates his trunk to and fro, and then stops, the fluid and air can be heard SUCCUSSION SOUNDS 711 making noises like those produced when a partly-filled barrel is moved about. Sometimes the fluid splashes up on to the collapsed lung and then drips off again into the pool at the bottom of the pleural cavity, each drop echoing in the cavity and producing a metallic clink like a bruit d'airain or coin sound. Similar succussion sounds may be produced by a pyopneumothorax or a haemopneumothorax, the difference between these being decided, as a rule, by exploratory needling. Succussion sounds other than those due to the stomach, or to gas and fluid in the pleural cavity, are uncommon, but the following is a list of the chief possible causes : — 1. Causes of Succussion Sounds in the Thorax : — {a) Hydropneumothorax {b) Pyopneumothorax (c) Haemopneumothorax (d) Diaphragmatic hernia (e) Subdiaphragmatic abscess communicating with stomach or duodenum, and so containing air and pus ; or else infected with the Bacillus coli commimis, and containing gas and pus (/) Hydropneumopericardium (§■) Pyopneumopericardium {h) A huge phthisical cavity beneath a thin chest wall. 2. Causes of Succussion Sounds in the Abdomen : — {a) The normal stomach (&) Dilatation of the stomach (c) Enormous dilatation of the csecum {d) Enormous dilatation of the sigmoid colon (e) Enormous dilatation of some other part of the colon (/) Pneumoperitoneum, due to : (i) Perforated gastric ulcer ; (ii) Perforated duodenal ulcer ; (iii) Perforated typhoid ulcer of the intestine ; (iv) Perforated tuberculous ulcer of the intestine ; (v) Perforated malignant ulcer of the colon ; (vi) Production of gas by the Bacillus coli communis, either in a local abscess (e.g., appendicular or subdia- phragmatic) or in the general peritoneum (g) Subdiaphragmatic abscess communicating with the interior of stomach {h) Air and urine in the bladder (see Pneumaturia) {i) Infection of an ovarian cyst or other collection of fluid by a gas- producing micro-organism. I. Succussion Sounds in the Chest The diagnosis is not as a rule difficult. It is very rare indeed for a phthisical cavity to give succussion sounds ; but should it do so, the phenomenon would be apical rather than basal, and thus distinguish- able from most cases of hydro- or pyo-pneumothorax. It is possible for the latter to be apical, however, if old adhesions prevent the parietal and visceral layers of pleura from separating in the lower part of the chest, and then, if tubercle bacilli were found in the sputum, it would become a matter of opinion as to whether the sounds were produced in the pleural cavity or in a huge vomica. Hydro- and pyo-pericardium are very rare, and they are at once distinguished by the extraordinary churning sounds made by the heart beating within the mixture of air and fluid. Survival is improbable. The cause is generally either an epithelioma of the oesophagus opening the pericardium from behind, a foreign body, such as a tooth-plate, ulcerating through from the oesophagus, or else the opening of an air-containing subdiaphragmatic abscess through the diaphragm into the pericardium, or infection of the pericardial sac by a gas- producing organism such as the Bacillus coli communis. 712 SUCCUSSION SOUNDS It may be important to know that a subdiaphragmatic abscess containing air, owing to communication with a hole in a gastric or duodenal ulcer, sometimes pushes the diaphragm up so high that the condition may be mistaken for hydro- or pyo-pneumothorax when it is really subdiaphragmatic ; it may be possible to distinguish the two by knowing that the trouble began with gastric ulceration ; on the other hand^ it may be impossible to tell which it is untU an operation is performed and the position of the diaphragm ascertained. When the trouble is subdiaphragmatic, the tendency is to displace the heart upwards rather than towards the opposite side of the chest, whereas the contrary is true of pneumo- thorax. The ;ir-rays may be of use in deciding whether the diaphragm is above or below the gas-containing cavity. Diaphragmatic hernia is very rare ; it may be congenital, or it may be the result of severe injur}^ to the abdomen and chest. In neither case are the patient's prospects of survival good. The exact diagnosis may not be arrived at without operation or post-mortem examination ; if the stomach is herniated into the thorax, however, the effects of eating and drinking upon the physical signs may point to the diagnosis, or the x-Ta.ys may be used to demonstrate the gastric shadow after the administration of large doses of bismuth oxycarbonate by the mouth. In most cases of hydropneumothorax there is little difficulty as to the diagnosis of the condition itself ; it may be less easy to decide what the hydro- pneumothorax is due to. The onset has generally been sudden, with acute pain in the affected side of the chest, cyanosis, and dyspnoea, and by far the commonest cause is phthisis. The sputum should be examined carefully for tubercle bacilli. In some instances an injury may have been the immediate cause, but injury will very seldom produce hydropneumothorax unless there was already a tuberculous or other lesion in the lung at the time of the accident. Hydropneumothorax may result temporarily after paracentesis thoracis. If there has been bleeding at the same time, hcBmopneumothorax may be found. Either a hydro- or a haemo-pneumothorax may become infected with pj^ogenetic organisms and converted into a pyopneumothorax, in which case the patient will be more gravely ill, with pjnrexia, cachexia, and perhaps rigors. The diagnosis will be confirmed by needling the chest. Pyopneumothorax is apt to escape detection, however, because it arises when the patient is too ill to be shaken — in cases of gangrene of the lung for instance, resulting perhaps from lobar pneumonia, obstruction of a bronchus by a foreign body or a new growth, or the breaking down of an infective bronchopneumonia or pulmonary infarct. Generally speaking, indeed, one may say that the existence of well-marked succussion sounds in the pleural cavit^^ of a patient who has sufficient vigour to shake his own body to and fro indicates hydropneumothorax of phthisical origin. 2. Succussion Sounds in the Abdomen The first point in the differentia diagnosis of succussion sounds in the abdomen is to decide whether the sounds are gastric or not. Generally this is obvious ; if there is doubt, the effect of putting more gas or more fluid into the stomach by taking a seidlitz powder in two halves, or by drinking a quantitj^ of water, will usually so change the character and distribution of the sounds if they are gastric, that little doubt wUl remain ; or the ;ir-rays and bismuth method of demarcating the stomach xaz-j be employed. As has been mentioned, the existence of gastric succussion is no proof of gastrectasis ; if, however, the succussion sounds are audible over a larger area than the normal stomach should occup}?^, they afford valuable evidence of gastrectasis, and the next step will be to determine the cause of the latter. Dilatation of the stomach has three main causes, namely, atony, non-malignant pjdoric obstruction, especially by a healed simple ulcer, and mahgnant pjdoric obstruction by primary gastric carcinoma. SUCCUSSION SOUNDS 713 The presence of visible peristaltic waves, or the occurrence of vomiting, will exclude simple atony, which can never be diagnosed with certainty until it is known that there is no pyloric obstruction. The latter will be indicated by the periodicity of the vomiting ; by the abundance of the fluid vomited being greater than the amount taken at the last meal ; by the presence in it of particles of food eaten a day or more previously — ham, for instance, vomited on Tuesday when last partaken of on Sunday ; — by the visible peristaltic waves correspond- ing with the stomach ; and by the presence of sarcinae in the vomit (see Fig. 92, p. 267). There may also be evidence of delay in the absorption of substances that are not dissolved until they reach the pancreatic juice in the duodenum, tested for instance by giving methylene blue in keratin-coated capsules, and observing when the urine first begins to be blue. Keratin is not dissolved by gastric juice, but is by pancreatic ; if there is no evidence of pancreatic disease, delay of more than one to two hours in the first sign of blueness of the urine, after giving the capsules, indicates marked delay in their transit from stomach to duodenum. It is often a matter of extreme difficulty to decide whether pyloric stenosis is simple or malignant, though upon the whole the shorter the history the older the patient, and the more definite the pyloric thickening or lump the more likely is the lesion to be carcinomatous. The latter may occur in quite young subjects, however, even between 20 and 30; and a long history does not exclude carcinoma, since some cases of simple ulcer ultimately become malignant. Even when laparatomy is performed for the relief of the condition, its nature may not be obvious ; sometimes, indeed, post-mortem examination has failed to decide whether the stenosed pylorus was carcinomatous or not, until microscopical examinations have been made. It has been stated that if the gastric juice after a test meal contains a normal amount of HCl, the diagnosis is unlikely to be carcinoma, and vice versa ; but even this general rule has many exceptions. The diagnosis of pyloric stenosis due to other causes than healed ulcer or a carcinoma is seldom possible without a laparotomy ; occasionally such out-of- the-way things as a calcified retroperitoneal cyst adherent to the pylorus and thought to have been a carcinoma pylori may be found. If there are well-marked abdominal succussion sounds that can definitely be shown not to be gastric, there are generally other well-marked signs and sym- ptoms which materially assist the diagnosis. Succussion sounds in the general peritoneal cavity are excessively rare, for even though this cavity should contain both gas and fluid, for instance after perforation of a typhoid ulcer, the coils of bowel prevent the sounds from being readily produced. The list of causes given above indicates the conditions that may be present. It would clearly be next to impossible to diagnose most of them unless the previous state of the patient was accurately known, or unless exploratory laparotomy was resorted to. It is important to remember that the Bacillus coli communis produces gas, so that intra-abdominal abscesses, appendicular and otherwise, are not infrequently resonant. The occurrence, however, of marked non-gastric succussion sounds in the abdomen of a patient who is not acutely ill will generally arouse a suspicion that there is distention with gas and fluid of some part of the large bowel, especially the caecum or the sigmoid colon. This distention will generally be the result either of chronic constipation (see p. 140) or of some cause of intestinal stenosis. In some cases that were formerly described as idiopathic dilatation of the colon, but which are now regarded as chronic volvulus of the sigmoid colon, the result of persistent constipation, the sigmoid dilatation may be so extreme that this part of the intestine bulges up as far as the diaphragm (Hirschsprung's disease, see Fig. 40, p. 148, and Fig. 122, p. 432 ) ; the occurrence of succussion 7l4 SWEATING, ABNORMALITIES OF sounds in such a dilated colon might readily lead to the erroneous diagnosis of gastrectasis ; the pear-shaped outline of the dilated viscus, and the fact that it is known to have come upwards from the pelvis, may indicate the true nature of the case, but sometimes the fact that succussion sounds are colonic and not gastric, can only be determined by giving large doses of bismuth by the mouth and then outlining the stomach by the dark shadow cast by the bismuth under the ;ir-rays. Herbert French. SUPPRESSION OF URINE.— (See Anuria.) SWEATING, ABNORMALITIES OF. — The functional disorders of the sweat-glands, sudamen {miliaria) and hidrocystoma, sue dealt with from the diagnostic point of view in the article on Vesicles. The other abnormalities require but the briefest notice in a work on diagnosis, for it is hardly possible to confuse them with each other or with any other conditions. In hyperidrosis the secretion of sweat is excessive, either over the whole skin or in some particular region, e.g., the palms and soles, and especially covered parts furnished with large sweat-glands, such as the axillae and genital regions. Occasionally hyper- idrosis is limited to the area of distribution of a particular nerve — the fifth, for example. In some cases a peculiar pink tint of the inner side of the palm and the ball of the little finger and thumb has been noticed. In rare instances hyperidrosis in delicate children is associated with granulosis rubra nasi, a condi- tion in which the skin of the nose becomes intensely red, and is dotted over with minute deep-red specks and papules, the papules gradually developing into pustules which soon dry up. The cells around the sweat-ducts are infiltrated, and both ducts and coils, and also the blood-vessels and the lymphatic spaces of the corium, are dilated. This complication is distinguishable from rosacea by the age of the patient and the absence of telangiectases and of change in the sebaceous glands ; from eczema, by the absence of vesiculation and weeping, and its obduracy to local treatment ; from lupus erythematosus, by the absence of scales ; and from lupus vulgaris, by the absence of apple- jelly nodules. The night sweats of phthisis, and those associated with rickets and with infantile scurvy (Barlow's disease), are not, as a rule, difficult to attribute to their cause. In anidrosis the secretion may be merely diminished or totally suppressed, and either the whole skin, or only some particular area, may be affected. The abnormality is rarely idiopathic, but is usually associated with ichthyosis, psoriasis, eczema, sclerodermia, with disordered innervation, belladonna poison- ing, or with malnutrition. Apart from the dryness there is no symptom except a sense of fullness and tension on exposure to heat. Bromidrosis, or foul-smelling sweat, sometimes associated with hyperidrosis, may occur in connection with such general affections as acute rheumatism, uraemia, and scurvy, or following a serious illness like pneumonia, or may be idiopathic. Occasionally generalized, it is much more frequently limited to particular parts, such as the feet, the axillae, and the perineum. The foul smell is due to the growth of the Bacillus fcetidus upon the sweat after exudation. In chromidrosis both sweat and sebum may be coloured, generally some shade of blue, but occasionally red, green, yellow, violet, and even black. The pigment- ation is usually localized, the most frequent situations being the eyelids, cheeks, forehead, and side of the nose ; but occasionally the whole of the face and large parts of the trunk and limbs, and especially the axillae and groins, are affected. The condition is probably a neurosis, but it may be due to the ingestion of copper (green sweat), or of iron (blue sweat), or to the action of cocci or the Bacillus pyocyaneus upon the sweat after secretion. The chief point in diagnosis is the exclusion of imposture. SWELLING, ABDOMINAL 715 Hcematidyosis, or bloody sweat, generally limited to particular parts, the face, hands, feet, navel, etc., may be a form of so-called vicarious menstruation, or an expression of emotional stress in highly-strung persons. Uridrosis, in which urinary constituents are present in the sweat in abnormal quantity, is not an idiopathic affection, but an accompaniment of such grave conditions as cholera and uraemia. It is quite unmistakable ; the sweat has a urinous odour, and white crystals will be seen on the skin. Malcolm Morris. SWELLING, ABDOMINAL. — These may be acute or chronic, general or local, and caused by abdominal accumulations that are mainly either gaseous, fluid, or solid. The position, physical consistency, and duration of abdominal swellings are their three outstanding clinical features, and it is on these that their classifica- tion for purposes of diagnosis should be based. CLASSIFICATION. I. — Swellings in the Abdominal Wall. II. — General Abdominal Swellings : — A. Mainly gaseous — Surgical emphysema | Meteorism [q.v.) B. Mainly fluid — • Ascites {q.v.) | Abnormal distention of hollow Large cystic tumours j viscera C. Mainly solid — Obesity (q.v.) | ..New growths Constipation {q.v.) \ ^if Hydatid disease- Inflammatory deposits ' I III. — Local Abdominal Swellings : — A. Due to general causes — Encysted ascites Tuberculous peritonitis Hydatid disease Subphrenic abscess Phantom tumours Enteroptosis B. The regional Diagnosis of Local Abdominal Swellings. I. — Swellings in the Abdominal Wall. Swellings that are situated in the abdominal wall itself can be recognized by their superficial position ; by the fact that they adhere to the skin, muscles,, or fascia of the abdominal wall ; or by the discovery that they do not follow the movements of the viscera immediately underlying the wall of the abdomen, and therefore must be superficial to them. But it may be impossible to dis- tinguish between a fatty tumour in the deeper part of the wall, for example, and a fatty omental mass that has become adherent to the parietal peritoneum, and so has practically incorporated itself with the abdominal wall. Inflammatory swelling of the wall may occur by infection from without or,, less often, from within. Thus a liver abscess may cause extensive redness and swelling in the right hypochondriac region ; infiltration of the abdominal wall is often met with in operations for appendicular abscess. In acute cases of Hodgkin's disease and lymphosarcoma, tumours suggesting a subacute inflam- matory process may occur in the abdominal wall ; but they are really localized lymphadenomatous or sarcomatous deposits, not due to infection, and are associated with glandular enlargements in other parts of the body and with anaemia. Inflammatory swelling about the umbilicus is not rare in newly-born infants, and is due to the entrance of infection by way of the cord ; in stout 71 6 SWELLIXG, ABDOMINAL uncleanly adults the umbilical fossa may be the seat of intertrigo, which becomes painful, sweUs, and suppurates, in consequence of infection from without. But a far more serious umbiUcal inflammation may occur in patients, usually children, with tuberculous peritonitis ; a tuberculous mass in connection with the round hgament may break down, perforate at the umbihcus, set up a chronic discharge there, and ultimately a faecal umbilical fistula may be established. In rare cases a subdiaphragmatic or perigastric abscess may cause inflammatory thickening of the round ligament and umbilicus. (Edema of the abdominal wall may be either local or general (see GEdema). Tumours of the abdominal wall, excluding those due to inflammation, are rare except in certain situations. Lipomata and fibro-lipomata maj^ occur in an}' part of it, and in the inguinal or femoral rings closely imitate omental hernias. Herni(B are commoner, particularly at the umbihcus and in the groins, and there is httle likehhood that a definite hernial protrusion in any part of the abdominal wall will be overlooked ; but minute hernias into the abdominal wall, such as may occur along the linea alba, especially above the umbilicus, at the femoral or inguinal rings, or along the hneee semilunares, may sufiice to produce complete intestinal obstruction and yet be small enough to demand ver\' careful palpation for their discovery. In malignant disease of the stomach, pylorus, or region of the portal fissure generally, small secondary nodules may appear quite earh^ at the umbilicus or in the round hgament just above it ; and this may occur before the primarj' tumour has given rise to any definite signs or symptoms. II. — General Abdominal Swelling. A. Mainly Gaseous, — In certain cases of extensive surgical emphysema the fascial planes of the abdominal wall are invaded and dissected out by gas, which imparts to them a highl}- characteristic feathery, crepitant, and crackling feeling on palpation. The gas may have entered from wounds in the neck, thorax, or trachea, or it may have been generated by gas-producing microbes in any abscess or focus of inflammation in the trunk or viscera, and have made its way thence into the abdominal wall. Distention of the intestines with gas is an event so common as to be famihar to all ; its diagnosis is discussed under ]\Ieteorism {q.v.). In this condition the whole of the abdomen, or in special cases some part of it only, is distended, and on percussion gives a highly resonant or tympanitic note. It often happens that the outhnes of the gas-distended viscera can be seen on the abdominal wall, particularly when it is looked at in an obhque illumination. The increased size of the inflated intestine is apt to produce displacement of the other viscera ; the dome of the diaphragm is pushed up into the chest, carrying the heart with it and shifting the apex-beat upwards ; the liver is similarly pushed up, and in addition it is often caused to rotate round a transverse axis, its lower anterior edge ascending and its lower posterior edge descending, with the result that the area of liver-dullness in front is much reduced, or even lost altogether. But it is only a little reduced in the mid-axillary line, so long as the gas remains in the intestine ; and if the liver-dullness in the mid-axillary line disappears, the diagnosis of free gas in the peritoneal cavity is to be made. B. Mainly Fluid. — The diagnosis of the various causes producing accumula- tions of fluid in the peritoneal cavity is given under the heading Ascites (q.v.). Whatever its cause, ascites is usually not difficult to diagnose when the amount of fluid present is as much as three pints or more ; smaller quantities produce no very definite phj^sical signs. Ascitic fluid, when free, always tends to gravitate into the most dependent parts of the abdominal cavit}-, causing localized bulging, dullness on percussion, and transmitting a characteristic SWELLING. ABDOMINAL 717 fluid thrill when percussed and palpated at the same time. When present in moderate amount, it occupies the flanks while the patient lies on his back ; the intestines are floated upwards, and produce a tympanitic or resonant area about and above the umbilicus. When present in large amount — three or four gallons — it may make the whole of the abdomen dull on percussion, probably because the mesentery is not long enough to allow the gas-containing intestine to reach the anterior abdominal wall and make it resonant. It may be impossible to diagnose ascites in an adult when less than about three pints are present ; the fluid appears to spread itself about the abdomen and pelvis, and to occupy the interstices between the viscera, without producing any unmistakable signs of its presence. Such small amounts of fluid may be detected if the patient is placed in the knee-elbow position, when the most dependent part of the abdomen will become dull on percussion ; they may also be diagnosed in women by vaginal examination, when the weight and resistance of the fluid can be felt in Douglas's pouch. It is said that they can be diagnosed in males by pressing a finger upwards and outwards in the inguinal canal, and percussing the abdominal wall above it, the patient standing upright, when a fluid thrill will be communicated to the finger. If a moderate amount is present — one or two gallons — and the abdominal wall is markedly oedematous, the diagnosis of ascites may again be impossible, while it may be difficult also if the abdominal wall is very fat. If peritoneal adhesions are present, the ascitic fluid may become encysted or loculated, and be difiicult of diagnosis because it simulates other cystic or semi-solid growths occurring in the abdomen. There are but few abdominal swellings that simulate ascites. Unusually large and mobile cysts of the ovary, mesentery, omentum, peritoneum, or liver do so most often, and in a few cases large soft retroperitoneal lipomata (which may occur even in emaciated patients) have been taken for ascites. The distinguishing characteristic of ascitic fluid is the readiness with which it changes its position in accordance with changes in the patient's posture and in obedience to gravity. Ovarian and other cystic growths in the abdomen hardly ever exhibit such complete mobility, and tend rather to swing over mainly to the one or the other side of the abdomen about some more or less fixed point — the pedicle of the cyst — as the patient turns from one side to the other on the couch. An ovarian cyst should arise out of the pelvis, and it is usually possible to demon- strate its connection with the uterine adnexa. But every gynaecologist must have met with cases of simple ascites operated upon for ovarian or parovarian cyst, and with cases of cyst treated by paracentesis, in the belief that the con- dition was one of ascites. In instances that are fortunately rare, the mistake has been made of regarding some viscus abnormally distended with fluid as ascitic fluid, and of treating it, as such, by paracentesis. This has most often happened to the bladder {Fig. 191, p. 730), which should always be emptied (either naturally or by the catheter) before the abdomen is tapped ; to a greatly dilated stomach full of fluidr [Fig. 190, p. 728) ; to the intestines when distended with fluid faeces in enteritis or chronic obstruction ; to the gall-bladder in cholelithiasis ; to the uterus in pregnancy alone, or in pregnancy combined with hydramnios. The effusion of blood into the peritoneal cavity, or hcBnioperitoneum, occurring after a fall or after the abdomen has been crushed or has received a blow, may cause a slight movable dullness in the flanks exactly like that of ascites ; but the patient will be blanched and anaemic from loss of blood, with rapid small pulse and sighing respiration, and there will be a history of the recent accident. The blood comes from some ruptured viscus, often the liver or spleen, and the diagnosis is not usually difficult. The accumulation of pus in the peritoneal cavity, or pyoperitoneum, is a part of acute peritonitis of local origin, and may also occur in pneumococcic or tuberculous peritonitis ; it is associated with 71 8 SWELLING. ABDOMINAL many other signs and symptoms — ^pain, fever, vomiting, constipation, wasting, and others — that are foreign to ascites. In rare instances the abdomen may become distended vnth bile, choleperitoneum resulting ; usually the bile is infected and sets up acute peritonitis, but if it is sterile the s^-mptoms are slight, jaundice is absent, and the signs point only to ascites. C. Mainly Solid. — In Obesity {q.v.) the abdomen may swell either in con- sequence of the deposit of fat in the abdominal wall itself, or as the result of fatt\- deposits behind the peritoneum generally, in the mesenterj^, in the omentum and appendices epiploicae. In ver\- fat patients it is rarely possible to diagnose the exact nature of an intra-abdominal mass by the usual methods of palpation and percussion, and without having recourse to exploratory? laparo- tom}', because the abdominal waUs are so thick. The frequency with which inconveniently large fatty accumulations occur in the abdomens of such persons must not be forgotten when the diagnosis of some vaguelj'-felt tumour Avithin the abdomen has to be considered. In the severer and more chronic cases of Constipation (q.v.), abdominal distention may result from the accumulation of faeces in the large intestine, particularh' when dilatation of the colon, whether idiopathic or secondary, is present. The scj-bala can usually be felt quite distinctly, perhaps soft and plastic in the region of the ascending colon, usuall}- hard and nodular in the descending sigmoid and colon. Idiopathic dilatation of the colon seems to be congenital, and is associated -with much hypertrophy of the colon [Fig. 122, p. 432) ; it is known as Hirschsprung' s disease. The child, obstinatelj' constipated at all times, has periodical dyspeptic attacks, in which the distended abdomen becomes even larger ; the bowels may not be open for manj? days or even several weeks together, while manj- pounds of scybala accumulate in the colon and sigmoid, which come to occupj* the whole of the front of the abdomen. Forcible colonic peristalsis is usually visible on the surface of the abdomen. Llalnutrition and chronic impairment of health result, and the patients usually die young, with emaciation or s}-mptoms of intestinal obstruction. Yet no obstruction is found to exist post mortem ; possibly there is a congenital abnormal kinking causing intermittent obstruction at the point where the sigmoid joins the rectum. The diagnosis is easy if the dilatation and hypertrophy of the colon are once seen. In older patients a vers" similar dilatation and hypertrophy of the colon may come on as the result of chronic obstruction about the lower end of the large intestine. (See Vomiting.) As much as 47 lb. weight of faeces may accumulate in the intestines of such patients as these. In rare cases of chronic peritonitis, particularlj? when it is tuberculous, semi- sohd inflammatory 7nasses ma.j bring about a general swelling of the abdomen ; the diagnosis is discussed below. General swelhng of the abdomen may occur in malignant disease of the peritoneum, the so-called malignant peritonitis, due in part to the groAvth of numerous secondarj- malignant nodules, in part to a concomitant ascites. The symptoms are often vague at first — loss of weight, strength, appetite, with indefinite abdominal disorders. The abdomen enlarges, and if there is not much ascites the secondary' deposits can be felt obscurely through the abdominal wall. Occasionalh? they can be palpated in the ab- dominal wall itself near the umbilicus, or in the round ligament above it, or the urachus below. As the case progresses, emaciation becomes marked, the skin loses its elasticity and often develops a diffuse brownish pigmentation ; bedsores are not rare. The primar}' growth Taay be in any of the thoracic, abdominal, or pelvic organs, or in the mamma or testis. If any primary growth can be made out, the diagnosis will not be difficult, especialty if glandular enlargements are found in the groins or axillae, if the ascitic fluid is haemorrhagic, and if it is found to contain multinuclear endothelial cells, and cells with atj'pical mitotic SWELLING. ABDOMINAL 719 figures. Tuberculous peritonitis can be excluded by means of the tuberculin test and by the result of injecting several c.c. of the ascitic fluid into guinea-pigs. Hydatid disease of the peritoneum runs a slower course than malignant peri- tonitis, and echinococcal cysts may be found in the ascitic fluid if it is tapped. General abdominal swelling may occur when multiple cysts representing the bladder stage of Tcsnia echinococcus develop all over its surface. As a rule, these are secondary after the rupture (accidental or by paracentesis) of a primary cyst in the liver, and are very numerous. They cause a slowly progressive enlargement of the abdomen, which appears to be filled with a solid or semi-solid mass ; if the individual cysts are large, they can be seen outlined on the ab- dominal surface, and can be felt. They are freely movable, and do not appear to be connected with any of the viscera in particular ; they do not, as a rule, give the hj'datid thrill on percussion. Peritoneal hydatid disease is extremely rare, excepting in countries (Iceland, Australia) where the inhabitants live very closely in company with dogs that are the hosts of Tcenia echinococms. Eosinophilia may bs found, and when the cysts are living and active the patient's blood-serum may give a specific hydatid precipitin reaction, though the absence of both this and eosinophilia does not exclude hydatid disease. III. — Local Abdomixal Swelling. A. Due to General Causes. — It often happens that the causes which produce general swelling of the abdomen fail to do so in particular cases, and give rise only to a local swelling. Thus in encysted ascites, left behind after an acute diffuse peritonitis, or accompanying a chronic peritonitis, an accumulation of fluid bounded by fibrinous or fibrous adhesions between the adjacent viscera may be found in any part of the peritoneal cavity, but most often in the flanks and about the pelvis. If a good history of the case can be obtained, the diagnosis of the nature of such a cyst will at least be suggested ; the phvsical signs will be those of a fixed cystic or semi-solid tumour, and the diagnosis will often be obscure until laparotomy has been performed. Abdominal swellings of the most various size and position may occur in tuberculous peritonitis. Many of them are composed of the infiltrated and roUed-up omentum, others of enlarged and tuberculous mesenteric glands, others of doughy masses of adherent intestine and fibrin. The amount of ascitic fluid varies widely in different cases. When there is much, and the patient is an adult, the diagnosis of cirrhosis of the liver is likely to be made ; when the peritonitis is dry (the so-called obliterative form), the abdominal cavity may be smaller than normal, and occupied by a doughy, rather tender mass that presents areas of resonance alternating with areas that are dull on percussion. The physical signs here will naturally vary from day to day according to the amount and position of flatus in the intestine. The symptoms of tuberculous peritonitis are very variable ; as a rule the patient is thin, ansmic, seriously ill, with a drawn aspect ; abdominal pain and tenderness are usually observed, nausea and constipation with chronic intestinal obstruction are frequent. If there is ulceration of the large intestine, diarrhoea occurs, and blood may be passed in the motions. The discovery of signs of tuberculosis in some other part of the body, or of a family history of tuberculosis if the patient is a child, are strong arguments for regarding a case with signs like those described above as tuberculous. In patients who have swallowed the ova of Tcsnia echinococcus, single or multiple hydatid cysts may occur in any part of the abdominal cavity. Usually they are single, and the large majority of them occur in the liver, because the six-hooked embryo into which the swallowed ovum develops, travels by way of the vascular svstem and starts from the alimentarv canal. Having reached the 720 SWELLING, ABDOMINAL liver, or in rarer cases the spleen, omentum, mesentery, or peritoneum, the embryo or proscolex develops a laminated chitinous envelope and forms what is called a hydatid or echinococcal cyst. The cyst grows slowly, and is spherical except in so far as it is moulded by the pressure of adjacent structures. It contains a clear saline fluid, in which may be found booklets (-Fig'. 6, p. 57), like those on the head of the adult worm or scolex that infests the intestine of the dog, brood-capsules bearing external and internal scolices, and secondary cysts or bladders that are completely detached from the walls of the primary or parent cyst. Until it has become large enough to cause mechanical obstruction and pressure-symptoms, the single hydatid cyst gives rise to little pain or complaint. It then produces a bulging of the overlying abdominal wall ; on palpation it can be felt as a smooth rounded and more or less tense tumour, sometimes elastic. On percussion, the cyst is dull, and if it is of a certain degree of tenseness it may yield the hydatid thrill — just as any other cyst may. Hydatid cysts in the mesentery, omentum, or peritoneum are often multiple, and may be felt as scattered, rounded tumours ; otherwise their physical signs, and the scanty symptoms to which they give rise, are like those of the single hydatid bladder. The diagnosis of hydatid disease is often easy, particularly when it occurs in persons who have lived in Iceland, Australia, or South America, and who present the marked physical signs and the comparative absence of symptoms indicated above. In other cases, exploratory laparotomy may be necessary before the diagnosis can be established ; exploratory puncture of any cystic tumour in the abdomen cannot be advised. Eosinophilia is sometimes observed in hydatid disease, but not always ; hence its absence does not exclude that condition. A specific serum reaction is reported by some observers. In consequence of bacterial infection spreading towards the peritoneum from within or from without, any part of the abdomen may swell from the formation of an abscess. Several forms of abdominal abscess are more or less localized, and these are considered below (see B) ; others present more general- ized abdominal signs and symptoms, and will for that reason be considered here. A subphrenic abscess is any abscess in contact with the under surface of the diaphragm except those situated in the liver or in the spleen. It is intra- peritoneal in more than half the instances ; it contains gas in about half the cases. The simple or non-gaseous abscesses are generally the result of appendi- citis or of suppuration in the liver, and so are usually on the right side of the body ; less often they are secondary to gastric or duodenal ulcer, or to suppura- tion spreading from the pancreas, kidney, Fallopian tubes, spleen, or thorax. They are deep-seated, and tend to produce abdominal swelling, with signs and symptoms that are indefinite. The onset is insidious, often consisting in nothing more than failure to recover from the primary disorder — appendicitis, hepatic abscess — after it has been surgically treated ; the patient remains seriously ill, with fever and quick pulse, leucocytosis, and often a septic aspect. If the abscess is at the back, the signs may point to pleurisy or pleural effusion, with the appropriate pain and friction sounds. If it pushes forwards, the hypo- chondrium and epigastrium may bulge in front and become tender. The dia- gnosis of subphrenic abscess may be very difficult when there is no obvious antecedent to suggest its occurrence, especially if the abscess is behind and below the liver, and is complicated by pleurisy or empyema. If it is above the liver, it may be very difficult to say whether the pus is inside the liver or outside it, or, indeed, both ; enlargement of the liver downwards is in favour of intrahepatic abscess. Examination with the ;ir-rays is often of great assist- ance ; but often it is necessary to give the patient a general anaesthetic and insert a 4-in. exploring needle successively into the intercostal spaces (tenth to sixth) in the scapular and mid-axillary lines (Barnard). It must be thrust SWELLING, ABDOMINAL in deeply. As viewed by the ;ir-rays the diaphragm is depressed by empyema or pleural effusion, elevated by subphrenic abscess, and immobilized by either. The etiology, signs, and symptoms of a subdiaphragmatic abscess that con- tains gas, or subphrenic pyopneumothorax, are different from those of simple subphrenic abscesses. The gas-containing abscess is commoner in females than in males, and is usually due to the perforation of a gastric ulcer, less often to perforation of a duodenal ulcer or to appendicitis ; in rare instances it is secondary to a suppurating hydatid cyst or to an ulcer of the colon. It is usually on the left side. The onset is generally sudden, with the acute abdominal pain and collapse often seen when a gastric ulcer perforates ; but both the ulcer and its perforation may be latent, and nothing more than a history of chronic dyspepsia may be obtainable. The abdomen soon becomes distended ; hectic fever, with rigors, rapid pulse, marked leucocytosis, and shortness of breath, are the symptoms likely to appear. The physical signs, on the whole, resemble those of Pneumothorax [q.v.) ; the diaphragm is pushed up into the thorax, and the gas in the abscess-cavity below it causes the signs of pneumothorax to develop in the upper part of the abdominal cavity and the lower part of the thorax. The picture is complicated by the fact that the inflammatory process habitually spreads through the diaphragm, so that the signs due to pleurisy, with or without effusion, are added. The diagnosis has to be made between this condition and true pneumothorax. The points that serve to distinguish the two are, that in pneumothorax the gas seems to occupy the whole of one side of the thorax, the heart is pushed or pulled over to the sound side, and the physical signs are limited to the thorax ; whereas in subphrenic pyopneumo- thorax the signs occur at the base of one or both lungs but not at the apex, the heart is displaced upwards but not to either side, and the upper part of the abdominal cavity is involved as well as the thorax. Examination with the ;v-rays is of the greatest service, for it shows that the gas-containing cavity is below the diaphragm and not above it ; the readiness with which the level of the fluid in the abscess changes as the patient alters his position can also be noted, and proves that the abscess-cavity contains gas as well as fluid. The abdomen is not infrequently the seat of phantom tumours. These are felt as fixed and more or less rounded smooth swellings, either in or immediately underneath the abdominal wall ; they are dull on percussion, and may be tender on palpation. The}^ are caused by involuntary contractions of the muscles in the area in which they occur ; they persist when the patient's attention is distracted, and also during sleep, but disappear under the influence of a general anaesthetic. Phantom tumours are commoner in women than in men, and in the neurotic or hysterical than in the normal, more stolid adult. They often persist for long periods, but may vanish when the patient believes that they have been cured. A phantom tumour in the region of the liver may be taken as evidence of cholecystitis, hepatic abscess, or gumma ; in the left hj'pochondrium for a gastric carcinoma adherent to the abdominal wall ; in the appendix region for an appendicular abscess ; above the pubes, a phantom tumour ma}^ resemble the gravid uterus, and lead to the diagnosis of pregnancy [pseudocyesis). In enteroptosis (Glenard's disease), or downward displacement of abdominal viscera, any or all of the organs may slip away from their normal position and attachments (Fig. 39, p. 147, and Fig. 41, p. 149). The diagnosis must be made by the discovery that one or more of the viscera is out of place, and is also abnormally mobile. B. The Regional Diagnosis of Local Abdominal Swellings. — For clinical purposes the abdomen may be subdivided into nine areas or regions, by two vertical lines drawn through the middle of Poupart's ligaments, and by two horizontal lines, one of which passes through the lowest points of the tenth D 46 722 SWELLING, ABDOMINAL ribs (the subcostal line), the other being drawn at the level of the highest points of the iliac crests or through the tubercles on the outer edges of the iliac bones about two inches behind the anterior superior iliac spines. These areas are shown in Fig. 189; the structures and viscera, or portions of viscera, they commonly contain, are given in the table below : — The Normal Contents of the Abdominal Regions. I. Right Hjrpochondriac 2. Epigastric 3. Left Hypochondriac Liver Liver Liver Gall-bladder Stomach and pvlorus Stomach Hepatic flexure of colon Transverse colon Splenic flexure of colon Right kidney Omentum Spleen Pancreas Pancreas Duodenum Left kidney Kidnevs Suprarenal capsules Spleen Lymphatic glands 4. Right Lumbar 5. Umbilical 6. Left Lumbar Riedel's lobe of the liver Stomach Descending colon Ascending colon Transverse colon Small intestine Small intestine Omentum Left kidney Right kidney Urachus Small intestine Duodenum Kidneys Lymphatic glands Aorta 7. Right Inguinal 8. Hjrpogastric g. Left Inguinal Caecum Small intestine Sigmoid flexure of colon Appendix Caecum, sigmoid, and ap- Lj^mphatic glands Lymphatic glands pendix Distended bladder Urachus [nexa Enlarged uterus and ad- The abdominal swellings that may be felt in and about these nine regions will now be considered seriatim, excluding the tumours situated in the abdominal wall itself that have been described under heading I. above. I. Right Hypochondriac Region. (a). The superficial part of this area is mostly occupied b}^ the liver and gall- bladder, and the majority of the tumours in it are connected with one or other of them. Swellings in the liver, such as gumma, new growth, abscess, hydatid or other cysts, can be felt as more or less rounded masses interrupting the normally smooth and impalpable surface of the liver ; they move up and down with the liver on respiration, lie in front of or above the colon, and are very rarely fixed by adhesions to the abdominal wall. If multiple, they are in all probabilit}' secondary malignant deposits, when they often have an indented or umbilicated surface. It may be difficult to distinguish, by touch alone, between the hobnail liver of hepatic cirrhosis and the liver nodulated by malignant disease. It may be very difficult to distinguish between an abscess or cyst in SWELLING, ABDOMINAL 723 the liver itself, and an abscess or cyst situated just outside it — a pancreatic cyst pressing the liver forwards, for example, or a subphrenic abscess ; if the tumour is in the liver, general enlargement of that organ is usually present (see Liver, Enlargements of the). To regard the firm and rounded swelling produced by the upper segment of the right rectus abdominis muscle as evidence of tumour, enlargement, or induration of the liver, is a mistake easily and frequently made. (b). Disease of the gall-bladder may make that viscus palpable ; cholecystitis, cholelithiasis, and new growth are the most likely to occur. The gall-bladder may be felt as a rounded tense mass when distended, and may be recognized by the fact that it is separated from the liver by a sulcus ; gall-stones are occasion- ally to be felt within it. (See Gall- bladder Enlargement.) (c). Tumours in connection with the hepatic flexure of the colon, excluding scybala, are rare. Scybala may be recog- nized by their general shape, the fact that they tend to move onwards towards the rectum, and most of all by the ease with which they can be moulded or indented, as they lie in the intestine, by the pressure of the fingers ; such tumours are dispersed by a purgative. In rare instances malig- nant disease or tuberculosis of the colon may produce a palpable tumour here ; and so may the process of intussusception (see 4 (6) below). The diagnosis must rest upon the previous history and the course of the disease. [d). Tumours of the kidney and supra- renal gland rarely present themselves in this region of the abdomen (see 4 [d) below). Fig, 189. — The regions of the abdomen For the significance of the numerals, see the table on opposite page. 2. Epigastric Region. {a). Abnormal lobes in the liver, tumours in either of its lobes or in its falciform or round ligaments, may be felt here (see i {a) above). (b). The normal stomach occupies a large part of this region, and comes to the surface in its left-hand part. In thin people and children the curvatures of the organ when it is full may often be seen dimly outlined in the epigastrium under normal circumstances, the lower curvature habitually, the upper less often, and the gastric succussion-splash can often be elicited here in healthy persons as well as in those with dilatation of the stomach. If an epigastric splash is obtained, it is usually gastric in origin, but may be colonic. In dilata- tion of the stomach due to obstruction at the pylorus (caused in infants by spasm or hypertrophy of the pylorus, in adults by malignant or cicatricial stenosis), waves of peristalsis travelling from left to right may be seen in the epigastrium. Similar waves, but travelling from right to left, occur in the colon of patients with obstruction in the rectum or sigmoid (see below). Tumours of the stomach, usually carcinomatous, rarely sarcomatous, or due to inflammatory deposits round a gastric ulcer, may sometimes be felt here, particularly when the patient takes a deep breath and drives the abdominal viscera down from out the cover 724 SWELLING, ABDOMINAL of the diaphragmatic dome ; this manoeuvre is particularly useful in the case of the pylorus — it must not be forgotten that the normal pylorus can sometimes be felt in an infant, child, or thin adult, as a rounded finger-like mass deep in the right side of the epigastrium. The connection of a gastric tumour with the stomach can often be made out more clearly if that organ is inflated with gas ; or by the method, little used in this country, of gastrodiaphany. (c). The transverse colon goes across the lower part of the epigastrium in some cases, more usually across the upper part of the umbilical area. Its sacculations and peristalsis are often outlined on the abdominal walls of pot-bellied rickety children or of thin adults, particularly when they are flatulent or constipated. In acute or chronic obstruction the peristalsis becomes much more marked, as it does in the rare idiopathic dilatation of the colon (Hirschsprung's disease, (see par. C, p. 718) of 5^oung children. Tumours of the transverse colon are very rare, except the common occurrence of scybala in it — see i (c) ; a few cases of chronic hyperplastic tuberculosis of this part of the colon have been recorded, with great diffuse thickening of its wall and stenosis of its lumen. (d). Swellings in connection with the omentum lie below the colon and in immediate relation with the anterior abdominal wall, in front of the mass of small intestine. In tuberculous peritonitis it often forms an irregular rope or mass composed of inflammatory tissue, cheesy tubercle, or encysted exudate, that may lie in the epigastrium, or extend into any of the regions of the abdomen — when the diagnosis of malignant disease of the intestine or some other viscus may possibly be made. Similar nodular enlargement and deforruity of the omentum is common in chronic peritonitis of any sort ; and it may become the seat of an abscess in cases of perforated gastric ulcer. Cysts of the omentum, single or multiple, are not very rare, and are often inflammatory in origin. Occurring in the epigastrium, tuberculous or inflammatory masses of omentum are readily diagnosed ; they often adhere freely to the anterior abdominal wall as well as to the neighbouring viscera. {e). Swellings derived from the pancreas push forwards from the depths of the abdomiinal cavity towards the epigastric and the upper part of the umbilical areas, and, whilst small, present themselves as deeply-seated vaguely-felt masses on palpation. They have the stomach, or the stomach and colon, in front of them, and are fixed to the posterior abdominal wall ; they are usually made out best by examination under an anaesthetic ; they move little on respiration, and often transmit from the adjacent aorta a non-expansile pulsation. They are separated from the liver and from the spleen by areas of resonance. These swellings may be carcinomatous, in which case wasting, anaemia, and jaundice are likely to be observed, with death in a few months' time ; or due to chronic pancreatitis, when the course of the disease will be slower and there will be more epigastric tenderness and pain, with clayey stools and perhaps intermittent jaundice and glycosuria. In acute pancreatitis the swollen pancreas has only exceptionally been palpated before laparotomy ; the main symptoms are acute epigastric pain, vomiting, constipation, fever, and proneness to collapse, and are such as to tempt the surgeon to immediate laparotomy. Pancreatic cysts, so-called, are often cysts not in the pancreas but in its neighbourhood, and therefore better called peripancreatic cysts. Pancreatic cysts proper are single or multiple retention-cysts, usually the result of chronic pancreatitis ; they form deeply-seated, smooth, rounded tumours, possibly giving a feeling of fluctuation. At first they occupy the lower epigastric or hypochondriac regions ; but if they enlarge much they may fill the whole upper part of the abdomen, or extend down to the pubic symphysis or fianks. The symptoms of chronic pancreatic disease should be present — chronic indigestion, the passage of pale and bulky stools, glycosuria, perhaps jaundice from time to SWELLING, ABDOMINAL 725 time if pancreatic calculus is present. Peripancreatic or retroperitoneal cysts, due to accumulations in the lesser sac of the peritoneum, or to growths originating in residues of the Wolffian body behind the peritoneum, may produce apparently identical cysts ; the evidences of chronic pancreatic disease should be absent in these cases, but the diagnosis may be impossible until laparotomy has been performed. Cammidge's urinary reaction (see p. 115) is said to be of assistance in diagnosing these cases. (/). Swellings in connection with the duodenum are felt in the right side of the epigastric and umbilical areas, and are usually due to primary malignant disease. In many cases they escape palpation because they are so deeply placed, and they usually have to be diagnosed from such conditions as cancer of the stomach, pylorus, pancreas, bile-ducts, and portal fissure generally, not by their physical signs but by the general symptoms and progress of the disease. A growth in the first part of the duodenum produces symptoms like those of cancer of the pylorus — wasting, ansemia, progressive dilatation of the stomach with visible peristalsis, attacks of copious vomiting, and occasional hsematemesis perhaps ; the motions contain bile, but the vomit does not ; jaundice is absent unless secondary growths appear in the portal fissure. Malignant disease of the second part of the duodenum, in or involving the biliary papilla, soon produces obstructive jaundice and distention of the gall-bladder, and often leads to suppurative cholangitis, when ulceration has destroyed the growth and removed the obstruction, whereas a cancer in the head of the pancreas or bile-ducts produces a steady jaundice and is not followed by suppuration in the bile-passages. Cancer in the third part of the duodenum or below the bile papilla produces duodenal stenosis, with dilatation of the duodenum and stomach and frequent vomiting ; but in this case the vomit is habitually bilious and contains the pancreatic ferments. If there is no stenosis, the bilious vomiting will be less, and the case may be indistinguishable from one of cancer of the stomach. In most of these cases the exact diagnosis is more often made post mortem than ante mortem. (§■). Swellings in connection with the kidneys and suprarenal capsules occur in the epigastrium only after they have reached a considerable size. They rise up out of the loin and flanks, and their diagnosis is considered below (see 4 id) ). ^ (h). Enlargement of the spleen may bring its blunt anterior end or its notched upper edge into the epigastric area. The splenic swelling lies always in contact with the anterior wall of the abdomen, with the stomach above and behind it (see 3 {d), and Spleen, Enlargement of the). (i). In every region of the abdomen there is a plentiful supply of lymphatic glands, and any of these may become enlarged and palpable in cases of Hodgkin's disease, chronic peritonitis, tuberculous peritonitis, or malignant disease. The enlarged glands are felt as nodulated chains or masses, usually hard and rounded, but softer and even cystic if their contents caseate or break down into pus ; they may also calcify, when they become hard and stony. The enlarged glands that will be felt in the epigastric area are those connected with the stomach, liver, and mesentery ; the diagnosis must be made on general and anatomical lines (see Lymphatic Gland Enlargement). 3. Left Hypochondriac Region. (a). An abnormally lobulated liver may make a superficial tumour in this area continuous with the main mass of the liver in the epigastric region. In the same way, a tumour in the left lobe of the liver may project superficially into the left hypochondrium. 726 SWELLING, ABDOMINAL (&). Part of the stomach lies in this region normally ; the diagnosis of gastric swellings has been considered above (see 2 (5) ). A gastric tumour may often be differentiated from a tumour of the adjoining spleen by the fact that while the spleen is anchored at its hilum, and so is capable of but little movement, the stomach is highly mobile, changing its position with the position of the patient, and also in accordance with its fullness and distention. (c). The diagnosis of a tumour of the splenic flexure of the colon — scybalous, tuberculous, or malignant — is considered above (see i (c) and 2'(c) ). {d). The normal spleen is not palpable per abdomen. The first degrees of its enlargement are best detected when the patient is lying down and has his abdominal wall relaxed. The observer stands on his left side and palpates the left hj^pochondrium by hooking his fingers over the costal margin about the eighth or ninth costal cartilages ; the fingers are tucked in under the ribs as the patient inspires deeply, their pressure being relaxed as he expires. The lower pole of the moderately enlarged spleen can then be felt as a rounded mass just touching the finger-tips at the end of inspiration. As it progressively enlarges, the spleen passes on towards or a little below the umbilicus, and then towards the right anterior superior spine of the ilium. The diagnosis of the various causes of its enlargement are discussed under Spleen, Enlargement OF THE. It is usually to be recognized by the fact that it comes down from under the left costal margin in direct contact with the anterior abdominal wall, descends on inspiration, has a smooth surface, and a notched upper and inner margin. In exceptional cases, however, the enlarged spleen seems to adopt a more compact and cubical form in place of its usual elongated prismatic shape, and also to lie back in the loin and left lumbar region instead of occupjdng the anterior and upper part of the abdominal cavity. When this is the case, it will simulate a tumour of the left kidney or suprarenal body, and unless the blood and leucocyte count give a definite lead, the diagnosis may be settled only by a laparotomy. Conversely, a spleen-shaped hyper- nephroma or suprarenal tumour, or a calculous and cystic kidney, may easily be mistaken in an anemic patient for an enlarged spleen, unless the possibility of the error be kept in mind (see 6 (a) below). (e). Tumours of the pancreas and retroperitoneal cysts may project into the left hypochondrium (see 2 (e) above). (/). Tumours of the left kidney and suprarenal body rarely appear in the left hypochondrium unless they are very large (see 6 (c) below). They have the stomach or the stomach and colon in front of them, and so are variably resonant on percussion — according to the amount of gas in those viscera, — and are also less distinctly palpable than tumours arising from the spleen, stomach, colon, or omentum, that may be felt in the same situation. 4. Right Lumbar'^Region^ {a). When the liver is abnormally lobulated, either congenitally or as the result of tight lacing, a thin flange of liver-tissue, known as Riedel's lobe, may be met with as a superficial tumour, continuous with the liver above it, in this region. Sometimes it is freely movable, and then may be mistaken for a movable kidney or for a dilated gall-bladder. {b). The ascending colon can usually be palpated and rolled under the fingers as a tube-like structure at the confines of this and the umbilical region ; when empty and contracted it may feel almost rod-like. Its contents are usually fluid, but it may contain semi-solid or solid fscal masses that can be moulded by pressure, in constipated patients. In patients with obstruction lower down, it may be distended — up to 18 in. in circumference — and show sacculation and SWELLING. ABDOMINAL 727 visible peristalsis. It may become much thickened with inflammatory tissue, or even come to lie in an abscess of its own production, in pericolitis, perityphlitis, typhlitis, appendicitis, and hyperplastic tuberculosis of the colon, forming a thickened and tender mass immediately under the abdominal wall ; the patient will be more or less acutely ill, with local pain and tenderness, constipation, often vomiting. In the more chronic of these cases, the diagnosis of malignant disease of the colon will often be suggested. General thickening of the ascending colon, with tenderness and characteristic mucous or blood-streaked stools, is common in muco-membranous colitis, in dysentery, and in ulcerative colitis. The first of these is met with in nervous constipated women ; dysentery, amoebic or bacterial, is caught abroad, and is commoner in men than women ; while ulcerative colitis, whether it be dysenteric or no, is a severe and progressive painful diarrhoea, often associated with vomiting and irregular fever, that commonly leads to emaciation and death from exhaustion or intestinal haemorrhage in a few weeks or months. The ascending colon can be felt as a sausage-shaped tumour in acute, subacute, and chronic ileocsecal and ileocolic intussusception : at first in the right flank, then extending across the abdomen above the umbilicus, and finally down the left flank and into the pelvis. The chief symptoms are spasmodic abdominal pain, vomiting, the passage of blood and mucus by the rectum, and tenesmus ; the palpability and consistency of the elongated tumour vary according to the degree of muscular spasm in it. (c). The small intestine is but rarely the cause of abdominal swelling in this region, excepting when it becomes the seat of enteric intussusception (see {b) above). {d). Tumours in connection with the Hght kidney and suprarenal body usually make their first appearance deep down in this region, having the ascending colon and small intestine in front of them. They can be lifted forwards en masse from behind by a hand placed at the back of the loin. For their diagnosis see Kidney, Enlargement of. The lower pole of the right kidney can be felt in normal persons on deep abdominal palpation ; but when the kidney is abnormally mobile, the whole of it may be felt, and in rare cases it may be found in any of the adjoining abdominal areas. The shape and consistency of the movable kidney are characteristic, and the patient complains of a peculiar sickening sensation when it is grasped bimanually and squeezed ; in the lesser degrees of mobility it disappears readily into its normal position under cover of the diaphragm, and ceases to be palpable until the patient drives it down again by a deep inspiration. As regards its diagnosis, the movable right kidney will hardly be mistaken for anything else in this region ; on the other hand, Riedel's lobe of the liver, the enlarged gall-bladder, faecal accumulations or a cancer of the ascending colon, and omental masses, have all been mistaken for it, although they are all superficial to the kidney, and lie in contact with the anterior abdominal wall. Other wandering tumours, e.g., of the ovary. Fallopian tube, mesentery, hydatid disease, may give rise to the same error if reniform. 5. The Umbilical Region. (a). In recent years examination with the ;if-rays after a bismuth-meal has shown that the stomach is a far more mobile organ under normal circumstances than was previously supposed, and that in health its lower margin often descends even below the level of the umbilicus. But if much of the stomach habitually occupies the umbilical region, it is probable that it is 72 S SWELLING, ABDOMINAL dilated to a pathological degree, either from atony or from pyloric obstruction {Fig. 190). (b). Tumours in connection with the transverse colon have been considered under the headings i (c) and 4 {h) above. (c). Tumours in connection with the omentum are common in this region : those arising from the small intestine are rare. Both are superficial, and their diagnosis has been given above (see 2 (d) ). {d). Abdominal swellings in connection with the urachns, which runs from the umbilicus to the bladder, are considered below (see 8 (c) ). {e). Swellings arising from the duodenum, kidneys, suprarenals, pancreas, and mesentery, may all present themselves in the deeper parts of the umbilical region, nsually as more or less fixed masses arising from or connected with some definite part of the posterior wall of the abdomen. Their diagnosis will depend mainly upon the success with which the origin and connections of the tumour can be made out ; if the patient is fat, or if relaxa- tion of the abdomen cannot be obtained, palpation while a general anaesthetic is given may be desirable. Consideration must also be given to any general sj^mptoms the patient may present — such as may point to renal calculus, hydronephrosis, pancreatitis, for example. (/). The aorta bifurcates half an inch below and just to the left of the umbilicus. In thin, nervous, and excited patients, particularly young women, great pulsation of the aorta can often be felt in the umbilical and lower epigastric areas, and may lead to the wrong diagnosis of abdominal aneurysm. Careful examination will almost always show that this pulsation is no more than a throbbing, an up-and-down movement as the patient lies, and that a lateral expansile pulsation is lacking. Aneurysm of the abdominal aorta is very rare ; it is seen in patients who have had syphilis, and is commoner in men than in women. The aneurysmal sac is distinctly larger than the normal aorta, and presents the diagnostic expansile lateral pulsation, when grasped between the fingers, that is met with in no other condition. These abdominal aneurysms often leak into the retroperitoneal tissues ; and large irregular clots of blood, weighing several pounds and of the most varied extent and distribution, may form gradually in the flanks, pelvis, and back of the abdomen generally, causing the patient great pain and rendering him anaemic and breathless. The abdominal aneurysm also causes pain and stiffness in the back by eroding the bodies of the vertebrae upon which it presses. Fig. 190. — Idiopathic dilatation of the stomach. The organ post mortem almost filled the abdominal ca\ ity. — Introduction to Surgery (Rutherford Morison). SWELLING, ABDOMINAL 729 6. Left Lumbar Region. (a). The enlarged spleen (see 3 (d) above) may intrude into this area ; it forms a firm mass, dull on percussion, and is in contact with the abdominal wall, driving the splenic flexure of the colon inwards or downwards before it. The spleen, when enlarged, comes down into the abdomen in front of all the other structures in the left side, and its abdominal dullness is continuous with its thoracic dullness, which extends back and up into the axilla along the line of the ninth or tenth ribs. Tumours of the stomach, omentum, suprarenal, kidney, or descending colon, may all be in contact with the anterior abdominal wall, and though usually nodular and irregular, may present a smooth and spleen-like surface on palpation. They may be distinguished from the enlarged spleen by the fact that they produce no such typical area of thoracic dullness in continuity with the dullness of abdominal tumour ; while the renal and suprarenal tumours may in addition be shown to occupy the back of the loin, so that they can be tilted forwards by the fingers placed behind just outside the edge of the erector spinas muscles, and so pushed against the other hand, which is placed on the anterior surface of the loin. A suprarenal tumour may be associated with sexual precocity (see Figs. 125, 126, pp. 453, 454). (&). The diagnosis of tumours of the small intestine, kidney, and suprarenal gland in this region has been given sufficiently already (see 4 [d) and 6 (a) ). 7. Right Inguinal Region and Right Iliac Fossa. Abdominal swellings in the right inguinal region are rarely confined to it, and usually extend into the outer part of the hypogastric region, occupying what may be described somewhat indefinitely as the right iliac fossa. {a). New growths, inflammatory thickenings, and abscesses in connection with the ccBCum and appendix may all extend into this region of the abdomen, giving rise to more or less acute and severe abdominal symptoms — pain, fever, vomiting, constipation, with a tumour in the right iliac fossa. The physical signs are very variable, depending on the extent and acuteness of the process, the degree to which the abdominal wall can be relaxed, the exact position of the tumour — an abscess to the inner side of and behind the caecum and appendix may lie too deeply to be felt per abdomen. The rare condition of sarcoma or lymphosarcoma of the caecum may be associated with fever ; the tumour is soft, and the diagnosis of some chronic inflammatory condition will probably be made. A csecal carcinoma is usually a harder mass and of slower growth ; it tends to constrict the bowel, with the result that faecal accumulation occurs behind it, and so the new growth may be overlooked when the hard mass of impacted fsces is discovered. The diagnosis of appendicular abscess has been made in patients with movable right kidney during a Dietl's crisis ; fever is usually absent in the latter ; careful examination will generally show that the tumour in the right iliac fossa is an enlarged and movable kidney, and a history pointing to intermittent hydronephrosis, with polyuria after the acute attacks, should be obtainable. Inflammation of the right ovary or tube, or ovarian neuralgia occurring with the catamenia, may all give rise to symptoms in nervous patients that closely simulate those of appendicitis ; and if scybala are present in the csecum, and are vaguely felt as a tumour through the rigid abdominal wall, the mistaken diagnosis of appendicitis may easily be made ; but as a rule pelvic symptoms and signs will be found, and pain be felt in the pelvic region and the lower part of the back ; the diagnosis will be cleared up by a vaginal or rectal examination — which, indeed, should never be omitted when there is any doubt as to the exact causation of an inflammatory swelling in the iliac fossa — and by the previous history of the case., 73° 5 WELLING, A BDOMIXA L [b). Inflammator}- swellings and abscesses in the right iliac fossa may arise in connection with psoas abscess, abscess originating in the sacro-iliac joint, hip- jomt, or ilium, and from the swelHng or breaking down of lymphatic glands (the external iliac) infected from some perhaps trivial wound in the leg or perineum. The symptoms of bom^ disease about the hip or the pelvic girdle will be present ; the leg will be held more or less stiffly- in some abnormal attitude of flexion and inversion to relieve the pain, and movement of the leg will be painful. Unless local peritonitis is present, there will be none of the special svmptoms that point to appendicular or ceecal disease. 8. Hypogastric Region. {a). In rare instances, tumours arising in the small intestine, and more often the sausage-like swelling of an enteric intussusception, may be felt in the hypo- gastric area (see 4 (fe) ). Tumours extending into it from the iHac fossas are described under head- ings 7 above and 9 below. (&). In infants, the bladder reaches half way to the umbilicus when moderately full, and does not fall below the pubic symphysis when empty. In the adult, the distended bladder is a common hypogastric swelling, particulars^ in females with retroverted gravid uterus or in males of about sixty with enlargement of the prostate ; it may reach up as an ovoid elastic mass arising from the front of the pelvis almost to the umbilicus under conditions that are in no way pathological, as well as when the retention is due to some pathological cause. Such a distended bladder {Fig. 191) has been tapped as ascites, operated upon as ovarian or urachal cyst, and diagnosed as the pregnant uterus : mistakes that are not likel}^ to occur if these possibilities be remembered, and are put out of court by micturition or the use of a catheter before the diagnosis is made. (c). The urachus is a fibrous cord running in front of the peritoneum from the top of the bladder to the umbilicus, in the middle line ; it represents the obliterated distal part of the intra- abdominal portion of the foetal allantois. It sometimes becomes the seat of cyst-formation, more often in women than in men. The urachal cyst is a rounded tumour lying between the umbilicus and pubes, soft or firm according to the tension of its contents ; it may produce hj'po- gastric pain. It must be distinguished from encysted tuberculous peritonitis, from ovarian cystadenoma, and from the distended bladder. {d). Abdominal swellings arising from the uterus, ovaries, tubes, and uterine ligaments may all rise up out of the pelvis and present themselves as swellings in this region, and, as they grow larger, may spread into the whole or any part of the abdomen. While they are comparatively small and manifestly connected with some intrapelvic organ, their origin is not difficult to determine ; their diagnosis is considered under Swelling, Pelvic. But when they have grown J^ig^. 191. — Idiopathic dilatation of the bladder. The physical signs were those of a cj'stic tumour occupying the lower part of the abdomen. — Inirociiiciioji to Surgery (Rutherford IMorison). SWELLING, AXILLARY 731 up into the abdomen, or have acquired a long pedicle, or have become iixed by adhesions to some distant part of the abdominal wall or to some other viscus, perhaps causing it to become inflamed and impairing its functional activity, these pelvic tumours may give rise to signs and symptoms suggesting any disease rather than one that is pelvic, and the true diagnosis may be very difficult to make. The possibilitv of pregnancy in the female should always be remembered. 9. Left Inguinal Region and Left Iliac Fossa (see 7 above). (a). The sigmoid flexure of the colon can be felt normally as a tube-like cord passing from the left lumbar region down into the pelvis, and rolled under the fingers. It very frequently contains hard ovoid scybalous masses. In rare instances it ma^^ be uniformlj^ thickened and tender in consequence of chronic inflammation, tuberculous or otherwise. It is occasionally the seat of cancerous new growth, when the patient will complain of chronic intestinal obstruction, \vith cachexia, tenesmus, and the passage of blood-stained stools, phenomena that may also be met with in hyperplastic or stenotic tuberculosis of the sigmoid. [b). The left iliac fossa may be the seat of abscess or inflammations similar to those described under 7 (5) above. In addition, suppuration around an exaggerated colonic diverticulum, with symptoms not unlike those of appendi- citis on the wrong side, has been known to occur ; such a condition has been spoken of as acute diverticulitis of the colon. A. J. J ex Blake. SWELLING, AXILLARY. — SweUing in the axilla is due in the great majority of cases to enlargement, from one cause or other, of the lymphatic glands ; an abscess, either acute or chronic, is also of frequent occurrence. An}' other form of tumour is distinctly rare. In examining a case, therefore, these two causes should be uppermost in the mind, and indeed, on inspection only, the diagnosis may be obvious, e.g. : — - Acute Abscess may be recognized at once by the well-marked signs of local inflammation and the general febrile disturbances. There is one form of acute abscess that may not be obvious, namely, one situated in the upper part of the axilla and covered by the pectoral muscles. On account of the distance of the abscess from the surface, the local signs of inflammation may not be great, though the general signs are marked. There will be great dis- incUnation to move the arm on account of pain, and there is usually some cause, such as a whitlow on the finger, to account for the trouble. It must be remem- bered, however, that the abscess may be " residual " ; that is to saj^, the original source of infection, such as the whitlow, may have healed completely two, three, or even more weeks before the axillary abscess declares itself. Chronic or Tuberculous Abscess forms a single fluctuating swelling which, if large, may extend upwards under the pectoralis major. Owing to the fact that few, if any, of the local signs of inflammation may be present, difficulty arises in distinguishing this form of abscess from a soft lipoma. The duration and the rapidity of growth of the swelling are a good guide, for though the duration of a chronic abscess may run into months, it does not exist for years as does a lipoma. Enlargement of the Lymphatic Glands. — Next, supposing that examination proves that the swelling is not an abscess, attention should be directed to ascer- tain whether it is glandular, and it is therefore necessary to recall the anatomical position of the glands. The axillary lymphatic glands are ten to twelve in number, and are arranged in three sets. One chain surrounds the axillary vessels and receives the lymphatics from the arm ; a small chain runs along the lower border of the pectoralis major as far as the mammarv gland, receiving the lymphatics from the front of the chest and the breast ; the third chain is 732 SWELLING, AXILLARY placed along the lower margin of the posterior wall to receive lymphatics from the integuments of the back. If the glands are affected in anj- way, all need not necessarily be enlarged, but it would be extremely unusual if onh^ one were picked out, and commonly two or three, or one entire group are found enlarged. Therefore, axillary swellings due to glandular enlargement are almost always multiple, and are situated in that part of the axilla where glands are normally present. This may not be quite accurate when much inflammation has occurred around the glands and they are matted together, as happens with tuberculous infection ; but even then the mass may be felt to be made up of many glands. For the differential diagnosis of glandular swellings, see Lymphatic Gland Enlargement. Primary Tumours of the Axilla are distinctly rare. Lipoma is the most common. It ma}^ attain a large size in this situation, and extend up under the pectoral muscles. It should be diagnosed by its long historj^, slow growth, definite outline, and free mobility. When very soft, the tumour may give the feeling of fluctuation, and so be mistaken for a chronic tuberculous abscess. Cystic Hygroma of the axilla is wexy rare. It is usually congenital. It forms a soft, fluctuating, painless swelling, which sometimes grows rapidly. It may easily be mistaken for a lipoma. Primary Malignant Tumours may arise, but are of extreme rarity. Aneurysm of the Axillary Artery does occur, but is uncommon. It is easily recognized, because it is comparatively superficial and it gives an expansile pulsation, synchronous with the heart's beat ; the veins of the forearm may be distended on account of pressure on the axillary vein, and the radial pulse on the affected side is diminished in size and delaj^ed. There may be a definite history of local injurj^, or in cases of apparenth' spontaneous aneurysm, there maA'- be signs or symptoms of fungating endocarditis. George E. Gask. SWELLING, FEMORAL. — By the femoral region is meant Scarpa's triangle. It is ver}- easy to define on paper what is a femoral swelling, but in a fat patient it may be very difficult. The two great landmarks which, with care, can always be made out, however fat the patient, are the spine of the pubes and the anterior superior spine of the ilium ; a line joining these two points and curving slightly downwards separates the inguinal from the femoral region, and indicates Poupart's ligament. Mistakes are often made, especially in fat people, because a horizontal crease in the thigh which lies below — sometimes as much as two inches below — is mistaken for the ligament. The first point in making the diagnosis is to decide definitely that the swelling is femoral, and then to decide its nature. It may be obvious at once what the swelling is : for instance, a well-marked acute abscess, with redness and oedema of the skin and an undoubted source of infection, such as a sore toe ; or, a rare occurrence, an aneurysm of the femoral arter\-, showing marked expansile pulsation. Supposing, however, the signs are not so clear, the various conditions may be classed broadly under two heads : (i) Swellings that are reducible and give an impulse on coughing ; (2) Swellings that are irreducible and do not give an impulse on coughing. Reducible Swellings with an Impulse are: (a) Femoral hernia — reducible; (6) Saphena varix ; (c) Psoas abscess. All these three conditions give an impulse on coughing ; they all are, or may be, reducible on pressure ; they all may disappear on lying down and reappear on standing. How then is one to distinguish between them ? SWELLING, FEMORAL 733 [a). Femoral Hernia (reducible). — The sex of the patient is no real guide, for though it is more common to find a femoral hernia in a woman than in a man, this is not sufficient to base the diagnosis on. Below the age of puberty it is very rarely found in either sex. A femoral hernia leaves the abdomen through the femoral canal, and turns directly forward, forming a tumour in the upper and inner part of the femoral region. Then, following the line of least resistance, it turns upwards, extending often above Poupart's ligament, thus simulating an inguinal hernia. More rarely, the hernia extends downwards along the femoral vessels. The course of the hernia must be re;niembered in attempting to discover whether the swelling is reducible. If the hernia is large and contains intestine, it will be resonant, and a gurgling noise may be heard on reduction, which distinguishes it at once from all other femoral swellings. If the hernia is reduced and the finger held over the femoral aperture, the hernia will be felt projected quite forcibly against the finger when the patient is asked to cough. If a swelling is complained of, and none is found even on standing and straining, it is suggestive of femoral hernia, with only occasional descent, and the patient should be examined at another time after exercise. (b). Saphena Varix is a localized dilatation of the saphenous vein at the saphenous opening, immediately before it joins the femoral vein. It may easily be confounded with a femoral hernia, for it forms a swelling in the ordinary position of a femoral hernia, it disappears on lying down, reappears on standing, and gives an impulse on coughing. A little care, however, should suffice to distinguish the two. The impulse is quite different — in a saphena varix it is more in the nature of a thrill such as may be felt in a varicocele or in big varicose veins in the leg. If, while the patient is standing, a finger is pressed on the swelling, it collapses, and as the finger is withdrawn the swelling follows, regaining its shape like an air-ball, whereas a hernia comes out with a pop. A saphena varix is almost always associated with varicose veins in the leg, though, owing to the persistence of valves, none may show between the knee and Scarpa's triangle. (c). Psoas Abscess. — The need to differentiate between this and the two con- ditions above mentioned only exists when the abscess has extended from the iliac region, has passed under Poupart's ligament and the femoral vessels, and is pointing in the inner part of Scarpa's triangle. As before, there is an impulse on coughing and the swelling is reducible ; but another swelling is to be found above Poupart's ligament, and fluctuation is to be obtained between the two. Conclusive proof can be found by an examination of the back. This should be made with the patient standing and the whole length of the back and the hips exposed. An undoubted angular kyphotic curve may be seen at once, or, if that is not present, there may be marked rigidity and impaired movement, denoting some disease on the anterior surfaces of the bodies of the vertebrae. Irreducible Swellings without Impulse : (a) Femoral hernia — irreducible ; ib) Lymphatic glands — inflammatory or malignant ; (c) Primary tumours — lipoma, fibroma, sarcoma ; {d) Ectopic testis. (a). Femoral Hernia. — The irreducibility may be accounted for in four ways : (i) Strangulation ; (ii) A piece of omentum adherent to and plugging the neck ; (iii) An empty sac, but a mass of extraperitoneal fat round the sac ; (iv) A hydrocele ot the sac. If strangulation has occurred, there will be the signs of intestinal obstruction, viz., vomiting and constipation. It must be remembered that the swelling may be but a small one, and when the patient is very fat it may be missed. It is usual to find around the sac of a femoral hernia a quantity of extra- peritoneal fat, even in a thin person, and it is quite impossible to say without 734 SWELLING, FEMORAL dissection whether the sweUing is due to a plug of omentum inside the sac or to a collection of fat outside it. A hydrocele may be formed as a result of a long-standing hernia into which there has been no descent of bowel or omentum, and in which the communication with the general peritoneal cavity has become constricted or closed. The sac then may become cystic and filled with fluid. The feeling of fluctuation can now be obtained in the swelhng, though it is often only on dissection that the exact nature of the condition is revealed. It is to be noticed that in all cases of hernia the swelling is single, and that though it may be movable in some directions, it is always tied down by its neck to the aperture of the femoral canal. (b). Enlarged Glands may be: (i) Inflammatory; (ii) Mahgnant — secondary. Inflammatory Glands. — -The glands may be acutely inflamed as the result of an infection from some part of the limb ; all the signs of inflammation and perhaps abscess may be present, and the diagnosis is obvious. Chronically inflamed glands are very different, and it may be exceedingly hard to differentiate them frora a small irreducible femoral hernia. The whole limb is to be examined to see whether there is any possible source of infection, and the whole patient to see whether there is a general enlargement of the glands, as in lymphadenoma. The chief distinguishing feature between the two conditions is that femoral hernia forms only one swelling, whilst it is very rare for only one gland in its group to be picked out by an infecting agent, and not the others. There- fore, if there is more than one swelling the chances are that these are glands. Perchance both conditions are present, a femoral hernia and enlarged glands : a very difficult combination unless the femoral hernia happens to be reducible or gives an impulse on coughing. In such a case an attempt should be made to feel the neck of the sac running up to the femoral canal. Malignant Glands. — To account for these there will be a primary growth in 5ome part of the limb, e.g., a melanotic sarcoma or an epithelioma of the skin or penis, or a sarcoma of bone. (c). Primary New Growths are rare in this situation. They may be lipoma, fibroma, or sarcoma. The innocent tumours are noted for their free mobihty in all directions. A primary sarcoma is diagnosed rather by exclusion and by its malignant characteristics. {d). Ectopic Testis. — One of the places into which a testis may be drawn abnor- mally is Scarpa's triangle, which it reaches by passing over Poupart's ligament. The facts that the swelling has the shape of the testis, though generally smaller than normal, and that the corresponding half of the scrotum is empty, make the diagnosis easy. Mention may be made here of those swellings which are neither truly femoral nor truly inguinal, but betwixt and between, and bulge Poupart's ligament forwards. They are generally deep, and on that account obscure. They may be due to : — 1. Distention of the hip joint, as in tuberculous disease of the hip. 2. Distention of the bursa between the tendon of the ilio-psoas muscle and the capsule of the hip joint. If large, the swelling may be quadrilateral in shape, and owing to its sensitiveness to pressure the leg is kept in the position of greatest ease, i.e., slightly flexed, abducted, and externally rotated. It is often difficult to distinguish from psoas abscess or from distention of the hip joint, with which, indeed, it often communicates. Diagnosis may be aided by puncturing the swelling with an aspirating needle. 3. Osteophytic outgrowths from the acetabulum in osteo-arthritis of the hip joint. 4. A parametric abscess. George E. Cask. SWELLING IN THE LEFT ILIAC FOSSA 735 SWELLING IN THE ILIAC FOSSA (LEFT).— For general method of examina- tion, compare Swelling in the Iliac Fossa (Right). Swellings connected with Structures normally present in the Left Iliac Fossa. The Sigmoid Flexure cannot be felt normally. It becomes palpable as a cylindrical swelling if distended with faeces or thickened, as it may be, in chronic ulcerative colitis and congenital dilatation of the colon. Carcinoma of the Sigmoid. — Next to the rectum, the sigmoid colon is the most common seat of cancer in the bowel. If of the scirrhous or ring type, no lump may be felt, and the condition may not be discovered until intestinal obstruction has supervened. When infiltrating the bowel widely, and especially when the tumour is undergoing colloid degeneration, a swelling forms which is most evident on bimanual examination, after the bowels have been well cleared by cnemata. - If a lump can be felt in the sigmoid flexure of a middle-aged patient, the strong probability is that it is a carcinoma, and whether there are other clinical signs or not, the diagnosis should be made sure by actual inspection of the swelling by means of the sigmoidoscope, or even through an abdominal incision. Enlarged Lymphatic Glands. — The glands forming a chain round the external iliac vessels may be swollen as the result of pyogenic infection, which has spread up through the femoral lymphatics or from secondar}^ deposit of some malignant growth starting either in the leg, the external genitals, or the pelvis. The enlargement is seldom very great ; the source of infection is usually obvious. Aneurysm of the external Iliac Artery is very rare. It is recognized at once by its expansile pulsations. Swellings connected with Structures not normally present in the Left Iliac Fossa. — These may be : Swellings coming down from above, extending upwards from the pelvis, or pushing forward from behind. Swellings coming down from above. — The Spleen, if much enlarged, may reach even as far as the left iUac fossa. It is recognized by its rounded margin, and the notch on the inner edge. (See Spleen, Enlargement of the.) A kidney, if freely movable, may be displaced as far as the pelvis ; on rare occasions it becomes fixed there by inflammation. For swellings extending up from the pelvis and those pushing up from behind, compare article on Swelling in the Iliac Fossa (Right) ; they are the same on each side. Geove E. Gask. SWELLING IN THE ILIAC FOSSA (RIGHT) It is not always easy to say whether there is or is not a definite swelling in the right ihac fossa, for it may be only small and deep, or be masked by abdominal rigidity or fat. In aU cases a careful inspection of the abdomen is first to be made, the patient h-ing on the back with the whole of the abdomen and the lower thorax exposed. Most mistakes result from want of a complete examination, which cannot be made through a tiny gap in the clothes. Before even touching the abdomen, much may be made out by the use of the eyes, and the points to observe are : — 1. The presence or absence of an obvious tumour. 2. WTiether the abdominal muscles move freely. 3. The conformation, etc., of the tumour, should one be present, and whether it moves on respiration. Palpation is then to be employed, and this method ^\ill go a long wav to eluci- date the complaint, for it wiU. at once be recognized whether there is a well- defined swelling, such as a carcinoma of the caecum ; or an indefinite sweUing, such as is common in appendicitis. It must be remembered that distention with wind may cause a considerable swelling, as will also an accumulation of faeces ; but any doubt existing mav 736 SWELLING IN THE RIGHT ILIAC FOSSA readily be cleared up by the administration of an enema. If the swelling persists, the questions that arise are : is it connected with one of the structures normally present in the right iliac fossa, e.g. the ceecum, appendix, or mesentery, or is it springing from the bone ; or, again, is it arising from some organ invading this space ; for instance, one of the pelvic viscera, or some structure displaced down- wards, as the gall-bladder, stomach, or kidney ? A. — Swellings Connected with Structures Normally Present IN THE Right Iliac Fossa. The Appendix. — Appendicitis is so common that it is put first. Most well- marked attacks of appendicitis are associated at some period with a swelling, though in the acutest and gravest forms the latter may be absent. The appendix itself, even if swollen and thickened, can rarely be felt by palpating the abdomen, and the swelling may be due to one of two causes — paralytic distention of the caecum, or the formation of an abscess. The chief indications of appendicitis are : pain, tenderness, and swelling in the right iliac fossa, associated with a furred tongue, vomiting, constipation, an increase of the pulse-rate, and a rise of temperature. Usually there is also diminished muscular movement in the lower part, or it may be over the whole, of the abdomen. Any movement is painful, and in order to relax the tension the patient lies with the right leg drawn up. A rectal examination should be made, for a bulging abscess may be felt by this route. Micturition is frequently abnormal, with a tendency to be either painful or unduly frequent. A leucocyte count is of great service, for in almost every case of acute appendi- citis the number of white cells is increased. Tuberculosis of the Caecum or of the Lymphatic Glands in the neighbourhood of the CfBCum. — This is not nearly so common as appendicitis, but is not so rare as is often imagined, and when it does occur it is frequently mistaken for appendicitis ; it may be only after the abdomen has been opened that the mistake is discovered. The glands become enlarged and painful, and there may be some local peritonitis over them which makes the diagnosis very difficult. Usually there is some other tuberculous focus about the patient, especially in the lungs, which should be examined with particular care, the A^-rays and sputum analyses not being omitted in cases of doubt. If doubt exists recourse may be had to a diagnostic injection of Koch's old tuberculin, and the opsonic index may be taken both before and after abdominal massage. Von Pirquet's test is not very trustworthy. Actinomycosis starting in the cscum and appendix is another inflammatory condition which may cause a swelling and give the signs of a chronic abscess. The diagnosis can only be made with certainty by an incision, and the finding in the pus of the characteristic yellowish granules (occasionally black — the gun- powder variety), and the recognition under the microscope that these granules are formed of a Gram-staining streptothrix {Plate XII, Fig. S). Carcinoma of the Csecum gives rise to a swelling which occasions few symptoms, unless the passage of faeces is affected and intestinal obstruction results. It is important, however, from the point of view of treatment that an early diagnosis be made. The presence of a non-inflammatory swelling of long standing in the right iliac fossa, with a history of wasting, is very suggestive of a carcinoma, and early recourse should be had to the only sure diagnostic method, namely, laparo- tomy. Very rarely is there passage of blood or mucus by the bowel to help one. Intussusception usually occurs in children, especially during the latter half of the first year of life, and its presence is indicated by the signs of intestinal obstruction, namely, vomiting and constipation, and by the passage of blood and mucus by the rectum. The intussuscepted portion may be palpable, and SWELLING, INGUINAL 737 in some cases it lies in the right ihac fossa, though more frequently in the right h^-pochondrium. Chronic intussusception may also cause a swelling which generally baffles diagnosis, and is commonly mistaken for an enlarged kidney. B. — Swellings Connected with Structures not Xormally Present IN THE Right Iliac Fossa. These may be : Swelhngs coming down from above, swellings extending upwards from the pelvis, or swelhngs pushing forward from behind. Swellings coining down from above. The liver, an enlarged or abnormal lobe of the hver — Riedel's lobe — is some- times very deceptive. The facts that there are few symptoms, that the mass moves on respiration and is continuous with the hver, and that there is no inter- vening area of resonance between it and the hver, should assist the diagnosis ; but cases are not infrequently mistaken for enlargement of the gall bladder. A suppurating gall-bladder has been opened in the right ihac fossa under the mis- taken diagnosis of appendix abscess, for there is often no jaundice in these cases. Laparotomy may be the only means of certain diagnosis. Carcinoma of the Stomach — with extreme distention of the stomach. It is a surprising fact that the stomach may be so distended as to enable the pylorus to he in the right ihac fossa. The history' of copious vomiting, the wasting, and the distention of the stomach, make the diagnosis easy. Swellings extending upwards from the Pelvis — and attached to the uterus and its appendages. Usualh' these can be felt dipping into the pelvis ; vaginal and rectal examinations will assist the diagnosis ; and there are sjTnptoms, such as disturbances of menstruation, indicating their nature. Such swellings might be a large fibroid of the titerus, a laterallj^-placed ovarian cyst, pregnancy , or an abscess extending from the broad hgament. It happens not infrequently that there may be difficulty in determining between an inflamed appendix and an enlarged and tender ovary, particularly when the attacks of pain are coincident with the menstrual periods. These generally turn out to be due to the appendix, though both may be implicated, the appenchx having become adherent to the ovarj^ or tube. Pyosalpinx is easily confused with appendix abscess ; the fact that it is associated with vaginal discharge, or is subsequent to parturition, puts one on the right track. Vaginal examination is essential in these cases. Swellings pushing forward from behind. These may be solid, such as sarcoma or chondroma of the pelvic bones. Here the tumour will be immovable apart from the pelvis, and a skiagram makes the condition clear. If the sweUing is fluid it may depend on suppurative osteomyelitis of the ihum ; or on a tuberculous affection of the ihum, either primary, or secondary to hip-joint disease; or on tuberculosis, necrosis or suppuration of the lumbar vertebrcB. If the sweUing cannot be attributed to any of the causes mentioned above, it is to be remembered that a wandering organ, such as a spleen or kidney, may find its way into the right iliac fossa. Geor°e E. Gask. SWELLING, INGUINAL. — A variety of sweUings may appear in the groin, and be verj' difficult to differentiate. The following are some of the most important: — (i) Enlarged glands : {a) inguinal; (b) femoral; (c) ihac. (2) Abscess, acute or chronic. (3) Hernia : {a) inguinal ; {b) femoral ; (c) obturator. (4) Retained testicle. (5) Hydrocele. (6) Tumours of the cord or round ligament. (7) Aneicrysm and other vascular swellings. (S) New growths. (g) Distended psoas bursa and other cysts. I. Enlarged Glands. — There are two chief groups of glands in the groin. The D 47 738 SIVELLIXG, IXGUIXAL most commonly affected are the inguinal, which lie in the subcutaneous tissues about Poupart's ligament, and drain the external genitals, the anus, the umbilicus, the lower parts of the abdomen and back, the buttock and the upper third of the thigh. The femoral glands rest below the saphenous opening and drain the lower limb below the upper third of the thigh. It must be remem- bered, however, that the lymphatic drainage is somewhat erratic, so that a sore toe may sometimes induce enlargement of an inguinal gland onlj-. The iliac glands drain the inguinal and femoral set, and consequently often enlarge secondarilj' to these ; but they also communicate freely with the abdominal lymphatics and maj- become infected from them. Enlarged glands in the groin are nearly always mvdtiple. and usually sub- cutaneous, so that they are easy to recognize as glands ; but a sohtarj- one adherent to the saphenous opening ma}' be almost impossible to distinguish from an irreducible omental femoral hernia or a hydrocele of a hernia sac. The ihac glands just above Poupart's hgament are more difficult to palpate, because thej' lie deep to the abdominal muscles, but their enlargement is generally secondary to disease of the superficial glands, and this often gives the key to the diagnosis of an obscure swelling in this region. Some Causes of Enlargement of the Groin Glands. — (a) Mechanical or chemical irritation ; ih) Septic infection, for instance, from genital sores or from sores on the toes or legs ; (c) Tubercle ; {d) S}.'phihs ; (e) Other specific diseases, such as rubella and bubonic plague ; (/) Lj-mphadenoma ; (g) Lj-mphatic leukaemia ; [h) MaUgnant diseases : secondary' carcinoma ; secondary or primary sarcoma. (a). The glands become shghtly enlarged and tender as a result of the tnecha.nical irritation of a truss, and more frequently the bites of parasites such as the Pediculus pubis. The glands generally remain movable, and they rarely suppurate. (fe). Septic infection may follow insect bites ; but more commonly a septic sore or recent scar can be discovered upon examination of the area drained by the glands. Septic glands either soon subside or cease to be tender after the removal of the source of infection, or they enlarge rapidh^, become adherent, and suppurate within three or four weeks of their first enlargement. (c). This, and the amount of inflammation of the skin over them, distinguishes septic from tuberculous glands which do not suppurate for some months, and then with but little inflammatory reaction. Epitheliomatous glands may suppurate towards the end. {d). The true syphilitic gland, is hard, movable, and onlj- moderately enlarged, and the existence of the indurated chancre usually makes the diagnosis easy. The SpirochcBta pallida maj- be detected, or Wassermann's serum test maj' be positive ; but a negative reaction is not conclusive. It must not be forgotten that, as an apparently soft sore (septic) may later become hard and definitel}* syphihtic, therefore suppuration of a bubo does not disprove syphihtic infection. Instances of mixed infection by sepsis and SA'philis are fairh^ common. (/). In lymphad,enoma the groin glands are rareh' affected alone, and the smooth, soft enlargement of many glands without signs of inflammation, associated with increasing anaemia and intermittent p\Texia, makes the diagnosis fairlj' easy. The spleen ma}' be affected at the same time. {g). Blood examination will give pathognomonic results in cases of h'mphatic leukaemia. (h). Malignant disease of the groin glands is nearly always epithehomatous, and secondary to a primary epithelioma of the skin or mucous membrane in the area drained by the glands. The primary growth, especially at the anus, may be very small, and the patient may be unaware of its existence. The other SWELLING, INGUINAL 739 main points in distinguishing epitheliomatous glands are their exceeding hardness ; their progressive but slow growth ; their early adhesion to the deep fascia and skin ; and the amount of pain which they give rise to without signs of inflammation. Late in the disease they may suppurate or slough, with severe haemorrhage. Sarcoma of the groin glands is rare ; it may be primary or secondary. Usually, these are not the only glands affected. They grow with great rapidity and remain smooth and fairly soft until they attain a great size, when they may fungate through the skin. They are distinguished from lymphadenoma by their very rapid growth and the absence of pallor until late in the disease. Melanotic growths of the skin give rise to rapidly growing smooth glands, whose pigment may be visible through the skin. The primary growth or ulceration in connec- tion with the skin, particularly of a toe, may not show pigmentation, and its serious import may thus be overlooked. 2. Abscess. — [a.) Acute. The only common cause of acute abscess in the gxoin is suppuration of the glands, and a search must always be made for a primary source of infection, especially about the genitals. A hernia may occasionally suppurate, and an appendicular abscess may point just above Poupart's ligament ; but there is then a history of the characteristic symptoms of appendicitis, and the pus when released has the suggestive smell of the products of the Bacillus coli communis. Both tuberculous and epitheliomatous glands may become acutely inflamed and suppurate. {b). Chronic abscess here may be due to caries of the sacro-iliac joint or to hip disease, or it may arise from tuberculosis of the superficial or deep glands. Psoas abscess, due to caries of the spine, is distinguished by fluctuation from the loin to the groin, and often bimanually, above and below Poupart's ligament, external to the femoral vessels. There is also some tenderness and rigidity, and often deformity of the lumbar or lumbo-dorsal spine. Iliac abscess does not extend up into the loin, and is placed further out than psoas abscess. More- over, there may be pain and tenderness over the sacro-iliac joint, and a limping gait. In hip disease, especially in children, the floor of the acetabulum may give way, and an abscess may thus enter the true pelvis, whence it often ascends and becomes palpable above Poupart's ligament. The diagnosis of the cause is easy from the well-marked signs of hip disease. 3. Hernia. — In examining swellings in the groin, hernia must always be considered. Three chief varieties occur here : inguinal, femoral, and very rarely obturator hernia. A hernia gives an impulse on coughing, but so do psoas abscess, psoas bursa, and a saphena varix. All these may also be reducible like a hernia. A psoas abscess presenting below Poupart's ligament has been mistaken for a femoral hernia ; but it is distinguished by its position — external instead of internal to the femoral vessels. Moreover, it is dull on percussion, whereas a hernia is resonant except when it contains omentum alone. Psoas bursa is also placed outside the vessels. A saphena varix has often been mistaken for femoral hernia ; but it can be easily distinguished from the latter because it returns after complete reduction, even though the finger is kept pressed against the femoral canal. It is not always easy to distinguish the three hernias which occur in the groin, but close attention to the following points usually leads to a correct diagnosis. An inguinal hernia is both seen and felt to be above the fold of the groin and above Poupart's ligament ; whereas a femoral hernia is seen and felt to be below the fold of the groin and below Poupart's ligament. It is to be remembered that when a femoral hernia becomes very large and loculated, it generally extends upwards and inwards over Poupart's ligament. Still, the bulk of it remains below the fold of the groin in the upper and inner part of the thigh. An inguinal hernia often extends into the scrotum 740 SWELLING, INGUINAL or labium ; a femoral hernia never does this. The neck of an inguino-scrotal hernia is above and internal to the spine of the pubis, whereas the neck of a femoral hernia is below and external to this bony prominence. Inguinal hernia is most easily reduced by pressure directed upwards, backwards, and outwards, whereas a large femoral hernia is most easily reduced by pressure directed at first backwards and downwards, and then directly upwards. In difficult cases it is a good plan to reduce the hernia, then to get the patient to stand up, while the surgeon makes firm pressure over the internal ring and asks the patient to cough. A femoral hernia may then come down, but not an inguinal. Similarly, pressure can be made on the femoral canal ; this prevents the return of a femoral hernia, so that if it now comes down it is inguinal. In this connection it may be well to remember that femoral hernia is rare in naales, and also in all females under maturity. The prevalent belief that femoral hernia is more common than inguinal in grown-up women is wrong, the latter being more common at all ages and in both sexes. It is excessively difficult to differentiate between an irreducible femoral hernia containing omentum and an enlarged gland at the saphenous opening or in the femoral canal. A hydrocele of a hernial sac gives rise to the same difficulty, and sometimes an exploration becomes necessary on account of the danger of overlooking femoral hernia, and the risk of strangulation. The diagnosis between femoral and obturator hernia is not very difficult ; it is far more common to overlook an obturator hernia altogether. When an external swelling is caused by an obturator hernia, it is placed further inwards, and it is more vague than a femoral hernia. Moreover, there is pain shooting along the inner side of the thigh, and generally the signs and symptoms of strangulation. Further, a tender swelling can be felt at the obturator foramen upon vaginal or rectal examination. The two chief varieties of inguinal hernia, the oblique and the direct, are usually distinguished quite easily. Direct hernia is rare, and is more globular in shape than the indirect or oblique hernia ; the spermatic cord is antero- external to it, and postero-internal to the ordinary oblique hernia. Direct hernia is placed a little further in and higher up than the oblique. It is generally much more easily reduced, but returns again with striking abruptness when the patient coughs. It rarely travels into the scrotum, and it is uncommon before the age of thirty. There is often a history of sudden onset after some violent straining effort. 4. Retained Testicle. — The most important points in the diagnosis of this condition are the absence of the organ from its proper place, and the presence of a swelling about the inguinal canal. Occasionally, the testicle may be mal- descended, or after leaving the external ring may have found its way into the upper and inner part of the thigh, where it simulates a femoral hernia, or into the perineum. The swelling in the groin may give the characteristic testicular sensation, or the condition may be associated with attacks of pain which have been mistaken for appendicitis or intestinal colic. It is practically always accompanied by actual or potential hernia into the tunica vaginalis, which is in direct communication with the abdominal cavity. 5. Hydrocele. — The neck of the sac of either a femoral or an inguinal hernia may become obstructed, and a hydrocele of the sac may then develop. This may become inflamed and give rise to considerable difficulty in diagnosis. Strangulated or irreducible omental hernia may be simulated, and sometimes an exploration is the only way of settling the diagnosis. It is more easily distinguished from strangulated hernia containing bowel, because it is dull on percussion, and the bowels are not obstructed. An encysted hydrocele of the cord occupying the inguinal canal is sometimes difficult to distinguish from inguinal hernia ; but it is not completely reducible, and it dull on percussion. SWELLING, INGUINO-SCROTAL 741 It is not granular like an omental hernia, and it can even be shown, with some difficulty, to be translucent. Like a hernia, it gives an impulse on coughing. 6. Tumours of the Cord or Round Ligament — The only common tumours of these structures are (a) Lipoma and [b) Fibro-myoma of the round ligament. The former is so soft and displaceable that it gives an impulse on coughing, and is often mistaken for an omental hernia, especially in stout patients. The latter is hard and smooth, somewhat simulating the ovary or a thick-walled hydrocele of the canal of Nuck, for either of which it may be mistaken, a certain diagnosis only being possible by exploration. 7. Aneurysm and other Vascular Swellings. — Aneurysm of the external iliac artery may be mistaken for a vascular sarcoma arising from the pelvis. It can generally be recognized by the classical signs of aneurysm, such as expansile pulsation, bruit, weakening and delay of the corresponding femoral pulse, and marked reduction of the size of the swelling as a result of pressure on the common iliac artery. Saphenous varix has been referred to above. 8. New Growths. — Sarcoma of the pelvic bones or of the soft parts in this neighbourhood is hardly altered in size by pressure upon the common iliac artery, nor does it give such a loud bruit or the expansile pulsation, which are characteristic of aneurysm. The ;tr-rays may give evidence which is valuable in distinguishing aneurysm from sarcoma. 9. Distended Psoas Bursa may give rise to pulsation communicated from the external iliac artery. On careful examination it can be distinguished by the absence of the classical signs of aneurysm already mentioned, by its trans- lucency and irreducibility. There may also be signs of osteo-arthritis of the hip joint. R. p. Rowlands SWELLING, INGUINO-SCROTAL.— The most important swellings which occupy both the inguinal and scrotal regions are : — (i) Hernia ; (2) Varicocele ; (3) New growth ; (4) Hydrocele ; (5) Lymphangioma. Hernia is by far the most common, and when it is reducible there is very little difficulty in the diagnosis. It gives the characteristic impulse on coughing, is resonant on percussion, and when it contains bowel it gurgles on reduction. When it contains omentum only, the diagnosis is more difficult. To distinguish it from a varicocele it is only necessary to reduce the swelling and then to place the finger firmly upon the inguinal canal ; a varicocele returns in a few seconds, but a hernia does not. Moreover, an omental hernia has a granular feel which distinguishes it from varicocele. An irreducible omental hernia is distinguished from varicocele by its irreducibility ; but it may be confused with a very rare condition, lymphangioma of the cord. An irreducible hernia may be confused with encysted hydrocele of the cord. When a hernia contains bowel its resonance distinguishes it ; but when it contains omentum there is more difficulty. An encysted hydrocele or a hydrocele of a hernial sac is more even and elastic than an omental hernia, which is usually nodular. More- over, it may be possible to show that a hydrocele is translucent. This help is not available when the cyst is deep or contains blood, which it occasionally does as the result of injury or strangulation of the omentum at the neck of the hernial sac. A strangulated hernia is distinguished from an inflamed hydrocele by the greater severity of the vomiting and other constitutional symptoms, and the completeness of constipation. Moreover, as stated above, a strangulated hernia containing bowel is resonant on percussion. Strangulated omentum may be very difficult to distinguish from an inflamed hydrocele or a hydrocele of a hernial sac, especially as either of these may complicate it. In such cases an exploration is the final appeal. It should not be forgotten that two or more varieties of inguino-scrotal swellings may co-exist. For instance. 742 SWELLING, INGUINO-SCROTAL it is common to overlook a hernia which inay comphcate a varicocele, and this is especially true when the hernia contains only omentum. Again, it is quite common for a hydrocele of the tunica vaginalis or of the lower part of the cord, to complicate an ordinary omental hernia. In such a case, a part of the swelling may be reducible, and, unless the patient is examined in the upright position, the upper part or the hernia may fail to appear during the examination. Again, the bowel may be reducible, while the omentum, being adherent, is not reducible, and may be mistaken for an encysted hj'drocele of the cord. It is very important in all these cases to examine for translucency. Growths of the testicle invading the inguinal region are, as a rule, easily diagnosed, because of the history and the observed course of the disease, and the general condition of the patient at the later stages. Growth of the retained testis may give rise to more difficulty ; it may be confounded at first with hydrocele of the tunica vaginalis, hydrocele of the hernial sac, or omental hernia, unless care be taken to ascertain if both the testicles are present in the scrotum. Torsion of a retained testicle with strangulation of its vessels, has sometimes given rise to inguinal or inguino-scrotal swelling which has closely simulated strangulated hernia ; but although there may be much abdominal pain and local tenderness, vomiting is rarely so severe as in strangulated hernia, and the bowels are not really obstructed. Retained testicle is dull on percussion, and thus is distin- guished from strangulated hernia containing bowel, and can only be confused with strangulation of the omentum. The oblique hernia is the only common one to reach the scrotum. It may be acquired or congenital. In about one-tenth of the congenital hernije the bowel and the testicle are in the same peritoneal sac ; in the great majority of congenital herniae the two sacs are distinct, the testicle lying below the hernia. The same is true of acquired inguinal hernia. It is important to remember that nearly all inguinal herniae descend into congenital or pre-formed sacs, and this is especially true of herniae appearing apparently for the first tirae in young adults. In such cases, on careful enquiry, it may be found that a hernia existed and was apparently cured by a truss, in infancj^ Again, it vaay be learned that the hernia reached the scrotum on its first descent, whereas acquired inguinal hernia very gradually develops as the result of straining in men past middle age. The swelling at first appears only in the inguinal region, and there the swelling increases in size, and extends into the scrotum only after some months or years. Very rarely, a direct hernia may reach the scrotum ; it is distinguished from oblique hernia by the fact that the cord is antero-external to it, instead of postero-internal, as in an oblique hernia. It may be possible in some cases to identify the contents of a hernia. Attention has been drawn above to the method of distinguishing the bowel from the omentum. Sometimes the appendix can be felt distinctly, especialh^ in right-sided hernia. Occasionally the bladder may be identified, as in Astlej^ Cooper's classical case. When the patient has apparently emptied the bladder, the surgeon reduces the hernia, and the patient is immediately able to pass more water. R. p. Rowlands. SWELLING, MAMMARY. — Method of Examination. — The clothes should be removed to the waist, so that a clear view of both breasts, the thorax, axillae, and supraclavicular fossae may be obtained. Both breasts should then be looked at to see whether there is any obvious enlargement or abnormality such as redness of the skin, dilatation of veins, tumour, or ulcer. Next, palpation is to be employed, using the flat of the hand and not the tips of the fingers ; the surgeon should place himself in a convenient position, using the right hand to examine the left breast and the left hand to the right breast. In the same manner the axillary fosscc are to be explored, it being remembered that the SWELLING, MAMMARY 743 lymphatic glands affected in diseases of the breast lie on the surface of the thorax and not round the axillary vessels. (See Swelling, Axillary.) It often facilitates palpation of the breast with the flat hand if the observer stands behind the patient when she is seated in a chair. In cases of suspected cancer the examination must not be concluded without investigation of the supraclavicular fossa; for fullness or enlargement of glands, and of the thorax and liver for signs of secondary growths. Swelling in Pregnancy and Lactation is normal and physiological. Both breasts are equally enlarged, and feel tense and nodular. The superficial veins are usuallj^ prominent, and on gentle squeezing a few drops of milk are discharged from the nipple. True Hypertrophy of one breast is rare. It may be found in nursemaids who have put children to the breast. The enlargement in the majority of so-called cases of hypertrophy is really due to the presence of one or more fibro- adenomata. Acute Mastitis occurs usually during lactation, occasionally during pregnancy, and is most often due to infection with pyogenic organisms which have gained entrance through cracks in the nipple. At the beginning of the illness, there is shivering, followed by fever and a feeling of weight and pain in the breast ; the pain soon becomes very acute. In the early stages the swelling is limited to one part of the breast, which feels more resistant than normal ; the skin is not reddened at first, nor are the lymphatic glands enlarged. Pressure over the swelling may cause extrusion of a drop of pus from the nipple, and this is dis- tinguished from milk by its viscidity and yellow colour. Later, fluctuation may become evident, and, as the inflammation approaches the skin, this becomes red and oedematous, and ultimately the abscess may point and burst through it ; at the same time other foci of suppuration form, until the breast may be nothing but a bag of pus. The presence of fever and the intense tenderness of one portion of the breast are sufficient to distinguish acute mastitis from the physio- logical engorgement. It is not uncommon to find a small alveolar abscess, the size of a hazel-nut, in virgins. Soon after birth and at puberty, a diffuse enlargement may occur in both sexes, and a small quantity of milk may be secreted. If the breasts are handled or squeezed, this congestive condition may pass into true inflammation and suppuration. Clironic Mastitis may attack numerous lobes of the breast, so that the whole organ has a granular feel (chronic lobular mastitis), or the inflammation may be confined to one segment and form an inflammatory swelling of considerable size. The attention of the patient is usually first called to the breast by the presence of vague pains and tenderness. If the lump is picked up with the fingers it is easily palpable, but if pressed back against the chest wall the induration is much less distinct than with carcinoma or fibro-adenoma. The swelling is elastic, and its outline quite diffuse, more so than in the case of carcinoma. The axillary glands may or may not be enlarged ; if they are, they are generally numerous, not so hard as in cancer, and are met with at an earlier period in the disease. The opposite breast is very liable to be diseased in a similar manner. The diagnosis is often very difficult, ordinary carcinoma of the breast being confounded with it. The two tumours resemble each other, in that in both their outlines are badly defined and the axillary glands are enlarged. In cancer, however, the tumour is densely hard, and at an early period adhesions form, so that the skin puckers on attempting to move it over the swelling. A further difficulty arises from the fact that a cyst may form in connection with chronic mastitis. If this is lax, fluctuation may be detected. 744 SWELLING, MAMMARY but it is usually so tense that it feels hard and solid. This again may be mistaken for a carcinoma or a fibro-adenoma. Where there is the least doubt as to the nature of the swelling and any possibility of the presence of a carcinoma, the right course is to have a microscopic section cut at once. Multiple Cystic Disease of the Breast, — This condition may follow on chronic lobular mastitis. One, or sometimes both breasts, become filled with cysts, large and small, some microscopic and others as large as walnuts, so that the organ has a bossy appearance. The whole organ is often very painful, the pain radiating from the breast and shooting down the arm. There are epithelial changes in the lining membrane of the cysts, and some authorities think that these are precursory stages in the formation of a cancer. Cysts, unless in connection with chronic mastitis or fibro-adenomata, are very rare. A simple serous cyst is described, and is due to lymphatic obstruction. Galactocele is a cyst containing milk, and is formed by dilatation of one of the larger lacteals owing to obstruction. These galactoceles occur only during lactation ; they form movable, fluctuating swellings, and on pressure milk can be squeezed out of the nipple. They are rare. Tuberculosis of the Breast is not so uncommon as was previously supposed, and a certain number of cases of chronic mastitis and chronic abscess are really tuberculous. The disease is insidious, starting as a painless irregular swelling, the periphery of which is hard and the centre soft. Later, the skin becomes reddened, and an abscess forms which may burst and leave a sinus. It differs from an acute abscess in that the duration is much longer, there is little or no pain or fever, and the pus, if examined, reveals no cocci. The facts that its history is a long one, that the swelling or the edges of it are hard, and that the axillary glands are enlarged, render this condition liable to be confounded with carcinoma, of the ordinary form, or one in which suppuration has occurred. The various clinical pathological tests for tuberculous disease may be applied, but the best method is to cut into the swelling and remove a portion of the wall for histological examination. Chronic submammary abscess causes a projection forward of the whole breast ; it is due to tuberculosis of the underlying ribs, or in rare instances to post- typhoidal periostitis, which may have remained latent. The diagnosis is made bacteriologically. Innocent Tumours. — Pure -fibromata, lipomata, and enchondromata are of rare occurrence, and merely call for mention here. Fibro-adenoma is the only common innocent tumour, and though there are many pathological varieties, and some contain cysts and some intra-cystic growths, for the purposes of this article all will be classed under this heading. Fibro-adenoma is an encapsulated tumour, generally single, sometimes multiple, varying from the size of a nut to that of an orange. Because it is encapsulated, the surrounding tissues are not infiltrated ; therefore, if superficial, the outline is very clearly defined and the mass is freely movable, both under the skin, over the pectoral muscle, and, most important of all, in the breast substance. The axillary glands are not enlarged. The tumours cause no pain, and are usually discovered accidentally. Generally they occur in women between the ages of twenty and thirty. After attaining a certain size they remain naore or less stationary, unless they are cystic, when they may go on growing as the result of dilatation of the cyst by fluid. The diagnosis is generally quite easy, but if the breast is fat and the tumour deep-seated, it may not always be quite easy to distinguish from an early carcinoma. The consistency of this, however, is hard, while the adenoma is elastic. From chronic mastitis it is distinguished by being less intimately associated with the breast than is the case with the inflammatory nodules, and by its SWELLING, MAMMARY 745 sharper definition. On account of the well-known possibility of error, however, no definite diagnosis or prognosis should be given until the tumour has been removed and a pathological report on its character received. Malignant Tumours are carcinoma and sarcoma. Carcinoma is the most important tumour of the breast. It is essentially a disease of the female, only about one per cent of the cases occurring in males. The great majority are married, and between the ages of thirty-five and sixty. In advanced cases the disease is obvious ; the tumour is large and hard, fixed to and often fungating through the skin ; the axillary glands are enlarged and hard, and the patient is often cachectic. What is wanted is a diagnosis in the early stages, while the patient still looks and feels in perfect health, before secondary deposits are found in the axillary glands, and while successful treatment is still possible. Too much insistence cannot be given to this point ; it is attainable, and should always be attempted. The Early Diagnosis of Carcinoma of the Breast.- — Usually the patient feels no pain, but discovers a lump in the breast accidentally during ablutions ; there- fore its duration must generally be a matter of doubt. Clinically, it is felt as a small tumour which, unless the patient is very fat, can be palpated easily with the flat of the hand. Its chief characteristic is that its outline is not sharply defined, and that it is hard — stony hard. In the very early stage, the tumour is freely movable over the pectoral muscles and under the skin, but it is not so movable in the breast substance as is a fibro-adenoma. Very soon, bands of fibrous tissue that connect the breast with the skin become involved, and by their contraction prevent free movement of the skin over the swelling, and cause dimphng and puckering. If the tumour is situated anyivhere near the centre of the breast, milk-ducts become involved in the growth, and as they contract cause retraction of the nipple. If a nipple which was previously well formed becomes retracted, this is a very important piece of evidence ; it is to be remembered, however, that nipples are often permanently retracted. Many cancerous tumours, even when extensive infiltration has occurred, cause a shrinkage, so that the affected breast may appear smaller than the healthy one, and in the atrophic form the gland may almost disappear. In the ordinary form (scirrhus) it will be rare to find any discharge from the nipple : a blood- stained discharge may be an indication of a duct-carcinoma. (See Discharge FROM THE Nipple.) After the disease has lasted six months the axillary glands are usuallj^ enlarged and hard, the first affected being those running along the lower border of the pectoralis minor. Too much attention must not be given to the absence of palpable glands, because, first, it is hoped that the diagnosis may be made before they are enlarged ; and secondly, if the patient is at all fat, it is exceedingly easy to overlook them. Attention is to be centred on the lump itself. As stated before, this is stony hard, and that fact alone may be sufficient ground on which to base a diagnosis. The two main conditions which have to be distin- guished from an early carcinoma are fibro-adenoma and chronic mastitis. In the former, the swelling is well defined, elastic, and freely movable ; in the latter, a tumour cannot be felt distinctly with the fiat of the hand ; it is soft, and the whole breast is often nodular. The difficulties in diagnosis are great and the sources of error numerous ; none of the swellings may be typical : they may be obscured by the obesity of the patient, and a fluid swelling may be so tense as to simulate a soUd one. This being so, the course to adopt, whenever the slightest doubt arises, is to incise the swelling and submit a portion to microscopical examination. Seeing the vital importance of avoiding mistakes in this connection, and recognizing the extent of human fallacy, there is a growing feeling among surgeons that all 746 SWELLING OF THE FACE tumours oi the breast, whatever the behef as to their character, should be removed, or at least cut into, so that their true histological constitution may be ascertained early and with accuracy. Sarcoma of the breast is rare. It generally occurs in women under the age of thirty. In the early stage it is not easily distinguishable from a iibro-adenoma, particularly one which is enlarging rapidly on account of a cyst or intracystic growth. It is soft, grows rapidly, infiltrates the tissues, and forms a large fungating tumour. It disseminates rapidly, both via the lymphatics and by the blood-stream. George E. Cask. SWELLING OF THE FACE. — In this article are included only swellings of the skin and subcutaneous tissues. Malignant and other diseases of the facial bones, etc., are considered under Swelling of the Jaw, and Swelling on A Bone. Contusions and injuries to the face are so obvious that they need no mention. The remaining swellings will be classified as (i) Non-inflammatory ; and (2) In- flammatory. 1. Non-inflammatory Swellings. Renal and Cardiac CEdema. — If the whole face is puffy and the eyelids are oedematous, the urinary and cardiac systems are to be exarained for disease. For swelling due to obstruction of the superior vena cava by mediastinal fibrosis, aneurysm, or new growth, see QEdema : and Veins^ Varicose Thoracic. Angio-neurotic CEdema is a disease characterized by the occurrence, some- times periodical, of local oedematous swellings, more or less limited in extent and of transient duration. It is not confined to the face, but the eyelid is a common situation {Fig. 128,. p. 458), and also the lips and cheek. It may be simulated closely by iirticaria following the taking of fish or pork. Tumours are not common. They may be fibroma, lipoma, epithelioma, or sebaceous cyst. 2. Inflammatory Swellings. — Often the cause is obvious : for instance, a boil, carbuncle, or suppurating wound ; or the " blubber-lips " that result from chronic lymphangitis. Erysipelas is prone to occur on the face. It is marked by a vivid red oedema- tous swelling, associated with signs of fever. The redness tends to spread, the edges being raised and well defined from the healthy skin. The oedema may be continuous, or it may disappear in one place and re-appear in another. In the very severe cases the fever is high, rigors occur {Fig. 166, p. 614), the cuticle may be raised in blebs, and sloughing may ensue. Alveolar Abscess and Dental Caries are fertile sources of facial swelling. (See Swelling of the Jaw, p. 747.) Parotitis — either the suppurative or epidemic form (mumps) — is easily recognized by the swelling being acute and limited to the region of the parotid gland. Anthrax chiefly affects operatives in wool and horse-hair factories, and workers of raw hides. The disease is characterized by the formation of a vesicle, which bursts, forms a scab, and then becomes surrounded by a ring of vesicles, and around this is an area of oedema. The diagnosis is made by the microscope. A drop of fluid from one of the vesicles contains large, square-ended. Gram- staining bacilli, which have a characteristic growth on culture media. Vaccinia. — An accidental infection about the face may be mistaken for an anthrax pustule. If inquiry into the attendant circumstances is not sufficient to exclude the graver disorder, a bacteriological examination should be made. Primary Syphilitic Sore, if found on the face {Fig. 10, p. 86), is generally situated on the upper lip. It is not so indurated as when on the glans penis. SWELLING OF THE LOWER JAW 747 but the surrounding oedema is more marked, and the neighbouring lymphatic glands are considerabty enlarged. The condition is often missed because it is not expected. An absolute diagnosis can be made by finding the spirochsetas in the serum discharged from the ulcer [Plate XII, Fig. J), and by Wasser- mann's test. Insect Bites — from mosquitos, gnats, bees, etc. — often cause large, lump}^, irritating swellings. The only difficulty in diagnosis is when they become infected with pj-ogenic organisms. The various skin diseases which may be associated with swelling of the face are considered under Pustules ; Vesicles ; Wheals ; Etc. George E. Gask. SWELLING OF THE JAW, LOWER, — Swelling of the lower jaw may sometimes be mistaken for, or masked by, swelling of the cellular tissues in front of it. The real site of the swelling is first to be ascertained by opening the mouth and running the finger along the outer and inner borders of the mandible and comparing the two sides. There are man}' causes for enlargement, and they inay be subdivided under the following headings : — 1. Injury. 2. Inflammatory affections. ( Innocent — -Fibroma, osteoma, and odontoma. ( Malignant — Sarcoma and epithelioma. 4. Acromegaly. 5. Leontiasis ossea. 1. Injury, — A A^wzfltowfl or traumatic ^mosii^is may follow on a blow. If the injury has been sufficient to cause a fracture, the signs are obvious. The abnormal mobility of the fragments, the irregularity of the line of the teeth and arch of the jaw, and the laceration of the gums, are sufficient to indicate the injury. The nearer the line of fracture is to the symphysis,the more marked is the mobility, and diagnosis is only difficult when the fracture is of the ascending ramus and underneath the masseter muscle. A skiagram may then be needed. It must be remembered that a fracture of the mandible is commonly compound, and therefore is often complicated by septic infection. Later, callus will form a tumour which might be mistaken for one of some other kind until the course of the case has been watched. 2. Inflammatory Affections. Alveolar Abscess. — This is a verj^ common swelling, and is known to all as associated with toothache. An ordinary gum-boil forms at the edge of the gum, and is quite superficial. A more troublesome form of abscess is that which develops at the root of a tooth, which, generally carious, may yet appear healthy on the surface. Pus usually points between the gum and the cheek, but it may travel a long way between the bone and the mucous membrane, and point on the cheek, in the submaxillar}' region, or on the chin. As in the case of injury, periostitis extending up under the muscle may be difficult to diagnose, and it is sometimes mistaken for parotitis. In the early stages the only sign is toothache, but as suppuration becomes established, there are also pain, swelling of the gums, a furred tongue, trismus, enlargement of the lymphatic glands, a raised temperature, and other febrile symptoms. The presence of a septic tooth indicates the diagnosis. Necrosis of the Jaw, often preceded by an acute periosteal abscess, may follow injury, alveolar abscess, syphilis, or mercurial or phosphorus poisoning, and in rare cases acute exanthemata or typhoid fever. In many cases it may be impossible to say whether the bone is necrosed or not, for the signs are much the same as in suppuration in connection with alveolar abscess. It can only 748 SWELLIXG OF THE LOWER JAW be diagnosed for certain if a piece of loose bone can be felt with a probe or seen by the aid of a skiagram. Its presence may be inferred by the long continuance and profuseness of the discharge. Syphilitic disease of the lower jaw is rare, and if present will not usually be confined to the jaw. If there is doubt, a Wassermann's reaction will be of ser\-ice. Actinomycosis. — -A long-standing and obstinate suppuration about the lower jaw, with celluUtis of the neck and formation of sinuses in the skin, should lead to the suspicion of the nature of the trouble. In the beginning it gives rise to inflammatory- changes which simulate alveolar abscess, and the similarity is increased bv the presence of carious teeth, through which the fungus is beheved to gain acc^s to the jaw. In the pus, the smaU yellow grantdes are to be sought for, and the Gram-staining mvceUum on microscopical examination [Plate XII Fig. S\. 3. Tumours. — In many cases there will be no difficult^- in deciding whether a swelling is inflammatory- or a new growth. In the early stages, however — and it is never to be forgotten that an early dia,gnosis in the case of mahgnant disease is of extreme importance — there may be grave doubt. Therefore, all possibiht\- of inflammatory mischief should be excluded by a careful, thorough examination of the mouth and teeth for any source of infection, and for this purpose it is frequently ad^-isable to innate the co-operation of a dentist. Innocent tumom^s are osteoma and fibroma (more commonly called a fibrous epulis). Osteoma. — -This is a rare tumour. It is ver\- slow growing, is ven.- well defined, bonv hard, and does not usually attain a \'eTX large size. A not uncommon place to find it is at the angle of the jaw, projecting into the mouth. It may be bilateral. Fibrous Epulis. — This is a common tumour, soft, composed of fibrous tissue, and covered by the mucous membrane of the gum. It arises in connection vdtln. the root of a decayed tooth, and if not treated may attain a suflacient size to cause displacement of the teeth or even distortion of the arch of the jaw. Sarcomata may start in this manner ; therefore all such tumoiurs should be submitted to microscopical examination before a definite diagnosis or prognosis is given. ]SIahgnant tumours are primary, sarcomata, and secondary, epithehomata, ■which start in the gum or on the floor of the mouth and invade the jaw by direct extension. Sarcomata. — The diagnosis of these may be quite easy, or attended by the greatest difficulty. They occur at any age, even in young infants. They may be of rapid growth, associated with constitutional changes which simulate inflammatory.- conditions before a large size has been attained, or they may be of such slow development as to be confounded "«ith innocent growths. The necessitA- of early diagnosis cannot be urged too strongly, for it is on this that successful treatment depends. Seeing that a growth may be mistaken for a swelling due to suppuration, examination should first be directed towards seeing if any of the ordinan,- signs of inflammation are present, and whether there is an ob\-ious source of infection. The histon,- of the duration of the illness may be of great service, and also the nature of the swelling itself. Is it hard or soft, is the bone expanded, are tissues round the bone infiltrated, are the glands enlarged ? Exercising the greatest care, diagnosis may still be difficult, and much ser\-ice is rendered by a skiagram, with the aid of which it may be discovered whether the swelling is reaUy bony, or in the case of periosteal sarcoma if the bone has been eaten into. If the diagnosis can be settled by no other means, the growth should be cut into and a piece removed for microscopical examination, even if the tumour is bony and a chisel and mallet be required. SWELLING OF THE UPPER JAW 749 Epithelioma — better termed squamous-celled carcinoma — is a very insidious and dangerous form of growth, and in its early stages very apt to be overlooked. It may start as a small ulceration of the gum about a decayed tooth, and so be mistaken for a simple ulcer, and it may not be until a large tumour has formed that the condition is recognized, when most valuable time will have been lost from the point of view of treatment. The diagnosis will be made by careful examination, and noting that the ulcerated gum is hard and indurated and does not heal when the decaj^ed tooth is removed. The name " boring epithelioma " has been well applied to this condition. To make the diagnosis sure, a piece from the edge of the ulcer should be removed for histological examination at the earliest moment that suspicion is aroused as to its malignancy. An epithelioma may also spread from the tongue or floor of the mouth and cause a swelling involving the jaw. The diagnosis here is obvious. Tumours of the Teeth, Odontomata. — These are tumours arising from any portion of the dental tissue, either from the tooth germ or from the fully-formed tooth. It is more common to find them in young people, and clinically they are innocent tumours. The method of diagnosis is to examine the teeth and find out if any of them are missing or abnormallj^ arranged. It is easy to distinguish them from a periosteal sarcoma, but confusion may arise between them and a very slow- growing endosteal or myeloid sarcoma. A skiagram will generally reveal the true state of affairs, for any abnormality or misplacement of the teeth is clearly shown. It is well to remember the existence of these tumours, for unnecessarily severe operations have often been performed in ignorance. Two diseases in which the mandible becomes enlarged, but in which the swelling is not confined to the one bone, and is only one of the manifestations of the complaint, remain to be mentioned : — 4. Acromegaly. — The lower jaw is often conspicuously enlarged in this disease, becoming prominent and massive {Fig. 88, p. 263). There is hypertrophy of the whole bone rather than a swelling in it. The other bones of the face are enlarged, the superciliary ridges are exaggerated, and the general effect of the disease is to give the patient the appearance of a dull, coarse-featured person. In addition, the hands and feet become much enlarged ; also, in the late stages of this very chronic illness, headache and muscular debility become prominent symptoms, and owing to swelling of the pituitary body, bilateral temporal hemianopia is to be expected (see Fig. 102, p. 334). 5. Leontiasis Ossea is the name given to a rare disease in which hyperostoses of the facial and cranial bones are the distinguishing features. It is not likely to be confounded with any of the above-mentioned swellings, except perhaps acromegaly, from which it is distinguished by the absence of changes in the hands and feet. George E. Cask. SWELLING OF THE JAW, UPPER.— (See article on Swelling of the Jaw, Lower.) The remarks there made apply equally to swellings in the upper jaw. Special attention, however, is required concerning tumours arising in the antrum of Highmore, for many cause no pain or discomfort until the late stages. Though innocent tumours may start in the antrum, the commonest is sarcoma. Rapid growth, bulging into and invasion of surrounding foss^, pain, and discharge of blood and pus are momentous indications of malignant disease. In the case, though, of slow-growing tumours and in the early stages, differentiation between innocent growths or suppuration is extremely difficult. Trans- illumination (see Pain in the Jaw, Upper) is to be employed {Fig. 62, p. 204), also puncture of the antrum, and if necessary exploration. George E. Gask. SWELLING OF THE LEGS.— (See CEdema.) 750 SWELLING ON A BONE SWELLING ON A BONE, — It is presumed that the swelhng has been ascertained to be of the bone, immovable apart from it, and that it is not merely some tumour lying close to it. The following method of examination should be adopted : — ■ 1. Inquiry into the clinical history, mode of onset, duration. 2. Search for the signs of inflammation. 3. Evidence as to whether the swelling is a localized projection or involves the whole circumference of the bone. 4. Investigation for involvement of other bones or further signs of disease, e.g., tuberculosis, syphilis, rickets, etc. 5. A skiagram should always be taken if possible. 6. If a discharge is present, a bacteriological examination is to be made. The various swellings may be classified under the following headings : — (I.) Injury ; (II.) Infective Diseases ; (III.) General Diseases, not limited to one bone ; (IV.) Tumours ; (V.) Cysts. I. — Injury. • A blow or kick may give rise to a swelling due to extravasation of blood or serous fluid under the periosteum. This disappears rapidly, but may leave a small permanent thickening or node. Such a node is found not infre- quently on the shins of football players. A fracture of bone is followed by the formation of callus, which forms a large swelling if the broken ends do not lie in accurate apposition, or if there is too much movement between them. After four to six weeks the callus begins to be absorbed, and it may disappear entirely ; in most cases a small permanent swelling indicates the site of fracture. A green- stick fracture may not show any swelling at first, and may be overlooked on this account, only being discovered when the formation of callus draws attention to it. II.— Infective Diseases. These give rise to inflammatory changes in bone, the signs of which are more or less obvious, according to the nature and virulence of the infection. These changes have usually been named according to the chief starting-point (periostitis, osteomyelitis, etc.), though they seldom remain confined to one particular part of the bone. In this article the classification will be made according to the nature of the infecting organism, viz., pyogenic (staphylococci and streptococci), tubercle, syphilis, etc. A. With Pyogenic Organisms. I. Acute infection may occur through wounds or injuries, or via the blood- stream. The resulting swelling is due to the formation of pus between the periosteum and the bone ; this may be of the nature of a localized abscess, or the whole of the periosteum may be stripped off and the bone lie bare in a bag of pus. The disease usually occurs in young people, and the intimate attachment of the periosteum at the epiphyseal lines hmits the spread of suppuration ; in long-standing cases the pus may burrow further and even burst into the joint. Suppuration is rarely limited to the surface of the bone, but spreads into the marrow, causing osteomyelitis ; lymphatic absorption and septic embolism are liable to give rise to a general blood-infection and pysemia. The signs of inflammation are abundant : the swelling is acutely painful and tender, the skin over it red and oedematous, and the constitutional signs of fever are marked. If the blood is examined, a high leucocytosis will be found. SWELLING ON A BONE 751 It is important not to mistake erythema nodosum for this affection ; in erythema nodosum the red swellings are generally multiple, bilateral, and confined to the shins ; it is rare for acute osteomyelitis to be bilateral and symmetrical, and confined to the parts between the knees and the ankles. 2. Chronic infection. — Such a condition as detailed above may often become chronic and cause a swelling which may last for months, years, or through life. If the pus formed under the periosteum escapes, either by bursting or through an incision, sinuses form, and the periosteum, in the process of repair, becomes thickened. If during the height of the inflammation, a portion of the bone has died — necrosis — this acts as a foreign body, keeps up inflammation and suppuration, and great thickening of all the constituent parts of the bone results [Fig. 192). Usually the dia- gnosis can be arrived at without difficulty. Occasionally, if the in- flammatory changes have not been great, and the amount of necrosis is small and deeply-seated (central necrosis), a condition resembling a slow-growing sarcoma may result. If a skiagram is taken it will be observed that the chronic inflamma- tor}^ periosteal thickening is added on to or "applied" to the original compact layer of bone, whereas in the case of sarcoma, though there may be thickening and formation of bony or calcareous spicules in the growth, the compact layer is eaten away [Figs. 196^ 198^ 199, pp. 754, 756). However, this may be some- what slender evidence onl which to base the diagnosis between so im- portant a condition as sarcoma and inflammation, and if doubt arises an incision should be made into the tumour, so that a portion may be removed for pathological investi- gation. B. Tuberculous Disease usuallv starts in the cancellous tissue of the small bones of the carpus, tarsus, and phalanges, and at the ends of long bones. The inflammatory changes, which are slight, give rise to caries of the aftected bone ; the external signs of inflammation are little marked, and it is comparatively rare for any swelling of the bone to result, though the soft parts around the bone may be swollen considerably. Tuberculous dactylitis [Fig. 193) furnishes an instance in which the disease forms a periosteal swelling. It is found most often in quite young children, and the bones commonly affected are the metacarpal bones and phalanges of the hand. The affected digit exhibits a fusiform enlargement, slightly tender, which on rest tends to diminish. Tuberculous periostitis mav develop in any -/■V^. 192. — Skiagram from a case of chronic periostitis of the uhia, due to pyogenic infection. Skiagram by Dr. H^cgk W'alskaiti. 752 SWELLING ON A BONE long bone, on the ribs and the humerus most commonly, and it then has to be differentiated from syphilis. Chronic abscess of hone occurs most frequently in the young adult, and nearly always in the articular extremity of a long bone, by preference in the upper end of the tibia. Enlargement of the bone is only found when the abscess approaches the surface and involves the periosteum. The skin then becomes a little red and oedematous, and there is generally a small spot that is exquisitely tender on firm pressure. It is to be noted that when secondary infection with pj^ogenic organisms occurs — a not infrequent event — all the swellings described under " acute infection " may result. A skiagram will generally reveal the true condi- tion ; if not, a diagnostic injection of Koch's old tuberculin may be made, or von Pirquet's skin reaction tested. C. Syphilis in the acquired form may lead to periosteal thickenings in the secondary stage and to gummata in the tertiary. The former give rise to excessively tender swellings on the surface of the tibiae, clavicles, sternum, ribs, or skull. They are generally multiple, two or three often being found on the same bone. The patient complains of pain, par- ticularly when in bed, because the extra warmth causes further dilata- tion of already inflamed vessels. Relief is given almost at once by taking potassium iodide. Sometimes one of these swellings is followed by the formation of compact periosteal bone, giving rise to a node which fades gradually into the surrounding parts, like a hill rising gently from a plain. Gummata may form localized swellings, or may invade the whole substance of the bone, causing osteo- myelitis and general thickening. The condition has to be distinguished from tuberculosis, chronic pj^ogenic infection, and sarcoma ; such recog- nition is arrived at by means of the Wassermann test, and the fact that antisyphilitic remedies cause a marked and rapid improvement. Diagnosis by incision has rarely to be resorted to. In congenital syphilis two forms of bony swelling are common : — {a). Periosteal thickenings of the bones of the vault of the skull, called Parrot's nodes — the hot-cross bun or natiform skull. {b). In new-born infants, epiphysitis and separation of the epiphyses. So painful is a limb thus affected that it is kept motionless, and may be thought to be paralyzed. D. Typhoid Fever. — In the course of this disease a periosteal node or abscess may form. From the fluid a pure culture of typhoid bacilli may be obtained, perhaps for a long time after the fever. The nodes by no means always break down into pus. F/g-.ig-},. — Skiagram from a case of tuberculous dactylitis of the first phalanx of the index fins:er of a child. Skia°:rain hy Dr. Htigh Walshani. SWELLING ON A BONE 753 III. — General Diseases not Limited to One Bone. 1. Rickets. — The ordinary form is well known, and can hardly be confused with any other disease. The typical bony swellings it gives rise to are thickenings, due to irregular growth about the epiphyses of the long bones, particularly the lower ends of the radius and femur, and at the costo-chondral junctions, forming the so-called " rickety rosary." There may also be bossing of the bones forming the vault of the skull. 2. Scurvy-rickets is quite distinct from rickets. It arises generally in infants under twelve months old, who have been fed too exclusively on artificial foods or preserved milk. The disease therefore is more common among the children of the rich than the poor. The child is often brought to the doctor on account of the sudden appearance of an exceedingly painful swelling of a long bone, such as the femur. The swelling may fluctuate, and yield on aspiration blood-stained fluid. Spontaneous fracture is liable to occur. The dia- gnosis is indicated by the fact that the child is anaemic, and has spongy gums and haemor- rhages from the mucous mem- branes. The condition is most likely to be confused with acute suppurative periostitis and traumatic fracture. 3. Osteitis Deformans (see Figs. 47, 48, p. 182) is a senile disease, very chronic, and characterized by thickening, lengthening, and bending of the bones. The whole osseous system may be affected, but attention is first drawn to the disease by bending of the limbs and enlargement of the head. In the rare event of one bone only being affected, it may be confused with syphil- itic osteitis, and only be recognized on the failure of antisyphilitic remedies and by the subsequent involvement of other bones. The patient suffers from neuralgic pains, and in the later stages from dyspnoea. In such cases death sometimes occurs from the development of multiple sarcomata of the bones. 4. Acromegaly {Fig. 88, p. 263) is characterized by enlargements of the hands and feet, and thickening of the membrane and bones of the skull and face ; the superciliary ridges and the lower jaw particularly arc enlarged. There is also periosteal thickening, with enlargement of the ridges of insertion of muscles and ligaments. 5. Leontiasis Ossea. — In this disease there are irregular bony outgrowths from the cranial and facial bones. D 48 I^ig. 104. — SkLiijram or a common variety of cancellous exostosis of the femur. Skiagram hy Dr. Hugh M'alshani. 754 SWELLING ON A BONE 6. Swellings of bones associated with diseases of joints may be found in gout, osteo-arthritis, and pulmonary hypertrophic osteo-arthropathy. (See Joints, Affections of.) IV. — Tumours. These are innocent and malignant. Innocent tumours as a whole are characterized by their long history, slow growth, localized projection, and the absence of all signs of inflammation. Varieties of Innocent Tumours. I. Osteoma or exostosis is the com- monest form {Fig. 194). The usual site is in the neighbourhood of the epiph}^- seal line of a long bone. In this position the tumour becomes pedunculated, is capped with cartilage, and often is sur- mounted by an adventitious bursa containing fluid. Fig'. 195. — Skiagram of an enchondroma of the fifth metacarpal bone. Compare with Pigs. 197, 198, 199. Enchondroma and sar- coma do not appear unUke in skiagrams. Skiagram by Dr. Hugh IValshain. The ungual phalanx of the great toe is another common site for a similar tumour. Multiple exostoses are not uncommon, and they may be hereditary. Diagnosis can be made at once by means of a skia- gram, and with this aid it can be seen that the swelling is composed of cancellous tissue continuous with that of the bone. A spurious oste- oma may arise by ossification of a tendon or by an extension of the ridge into which the tendon is inserted. Ivory exostoses may be found on the flat membrane bones of the skull, in the auditory meatus growing from the petrous bone, and causing displacement of the eye if springing from the orbital plate of the frontal bone or the walls of the frontal sinus. 196. -Skiagram of a periosteal sarcoma of the tibia. Skiagram by Dr. Hugh Walshaiu. SWELLING ON A BONE 755 2. Chondromata may grow from any bone. They are most commonly mul- tiple, affecting the phalanges and metacarpal bones of the hand [Fig. 195). The result is increasing deformity, with pain and ulceration of the skin. 3. Fibromata grow from the iibrous tissue of the periosteum, but are rare except in the form of an epulis of the jaw. (See also Swelling of the Jaw, Lower). 4. Lipomata are extremely rare. They grow from the outer layer of the periosteum. Malignant Tumours. These mav occur either primarily (sarcoma), or secondarily by metastasis or bv invasion (sarcoma and carcinoma). Fig. 197. — Skiagram of an early myeloid sarcoma of the lower end of the radius. This and the two succeeding figures should be compared with Fig;. 195, which shows that enchondroma and sarcoma are not distinguishable by -i--rays alone. Skiagram by Dr. HiigJi Jl'alshaiii. I. Periosteal sarcomata are of so many types, and of such varying degrees of malignancy, that it is a difficult task to lay down any rule as to their characteristics. As a rule, the softer their consistency and the nearer they approach to the embryonic type of the tissue, the more malignant they are ; the nearer they reach the fully-formed tissues and contain cartilage, bone, or fibrous tissue, the slower growing and less malignant they are. A tj-pical case may be represented as a rapidly growing tumour, generally about the end of a long bone [Fig. 196). It is not usually painful, and the signs of local inflamma- 756 SWELLIXG ON A BONE tion and general fever are little marked or absent. The patient is commonlj^ a young adult, who often gives a history of injury to the part, and may lose weight and strength before actual cachexia sets in. The veins over the swelling become prominent, the lymphatic glands enlarged, and metastases b}- the blood- stream occur early. It has to be distinguished from chronic and syphihtic periostitis. If a skiagram is insufficient, a piece of the tumour maj' have to be excised, decalcified, and a microscopic section from it prepared. This form of sarcoma is the worst possible, and seeing that amputation does not cure and often does not prolong life, this extreme resource may be delaj-ed where either gumma or chronic periostitis is still a possible diagnosis. J'ig. igS. — Skiagram giving the antero-posterior view ot a myeloid sarcoma of the lower end of the radius. The growth is at a later stage than that depicted in Fig^. 197. Fig: 199 shows the same growth as Fig 58, but seen from the lateral aspect. Skiagrams by Dr. Hugh Wahhaiii. 2. Endosteal or myeloid sarcomata are 01 much slower growth ; so slow are they that some pathologists are inclined to denote then as benign tumours. They are prone to affect the ends of the long bones, particularly the lower end of the femur, the upper end of the tibia, the upper end of the humerus, the lower end of the radius {Figs. 197, 198, 199), the sternal end of the clavicle, and the upper jaw (malignant epulis). Attention is first called to the part by pain ; then a more or less uniform swelhng appears. This is at first bonj' hard, and only as the shell of bone yields does softening occur, or crackling on pressure. The lymphatic glands are not enlarged, and metastases do not occur. In the early stages, diagnosis has to be made from rheumatism and chronic abscess, and SWELLING, PELVIC 757 later from chronic osteomyelitis and periosteal sarcoma ; it is easily made by the aid of ,r-rays as a rule, but it is most important not to mistake the callus that is produced after fracture for a sarcoma ; this mistake is not always obviated even by the use of the ;i;-rays, unless the latter reveal the line of fracture as well as the callus around it. 3. Carcinoma is always secondary. Squamous-celled carcinoma may spread from an epitheliomatous ulcer of the leg, or to the jaw from the lip or floor of the mouth. It is mostly spheroidal-celled carcinoma which infects bone by metastatic growths, particularly from the breast. A swelling of bone may be found, but this is rarely discovered until attention is called to it by a spontaneous fracture. V. — Cysts. 1. Blood cysts are found in degenerating sarcomata. 2. Hydatid cysts are uncommon in this country. They affect the diaphyses of the long bones, converting the shaft into a thin- walled tube, which undergoes spontaneous fracture. 3. Cj'sts of the jaw, or dentigevoiis cysts, are considered in the article on Sw^ELLiNG OF THE LowER Jaw. George E. Gask. SWELLING, PELVIC. — There are so many swellings which may rise up out of the peh"is into the abdomen, and also which may appear to be pelvic when they are really primarily abdominal, that a list in tabulated form may be of value : — Bladder. — Simple distention of ; New growth. Vagina. — Haematocolpos. Uterus. — Pregnancy : normal or abnormal, or associated with tumours of the uterus or ovary New growths : Fibromyoma. Sarcoma. Carcinoma. HEematometra. Chorion-epithelioma. Ovary. — Cysts. Solid new growths. Fallopian Tubes. — -Hjdrosalpinx Pyosalpinx Salpingo-oophoritis New growths Carcinoma Tubal gestation Progressive extra-uterine gestation. Pelvic Peritoneum. — Encj-sted peritoneaL fluid Hematocele due to extra-uterine gestation Haematocele due to haemorrhage from a corpus luteum Pelvic abscess Ascites Hydatid cysts Retroperitoneal lipoma. Pelvic Cellular Tissue. — Cellulitis. Pelvic hsematoma. Appendix Vermiformis. — Abscess around Appendicitis with pregnancy. Pelvic Bones. — New growths of. Omentum. — New growths of. Cysts of. Phantom Tumours. Pancreatic Cysts. Kidney. — Tumours of. Hydronephrosis. Pyonephrosis. Gall-bladder.^Distention of. Spleen. — Enlargement of. Urachus. — Cyst of. 758 SWELLING, PELVIC It is obvious that many of these lesions are not pelvic at all ; but they are not omitted from the list, because they are liable to be mistaken for pelvic tumours. Thus pancreatic, renal, splenic, and gall-bladder tumours may reach the pelvic brim, but the history ought to show that they have grown down from above, not up from below. Further, renal tumours may be associated with urinary changes, or absence of urinary secretion on the affected side, as detected by the cystoscope. Splenic enlargements may be associated with blood-changes, and gall-bladder distention with icterus. Pancreatic cysts are the least hkely to be mistaken for pelvic swellings, but they have been difficult to distinguish from ovarian tumours with long pedicles. Naturally, the commonest difficulty which arises in the diagnosis of pelvic swellings is to = differentiate between the distended bladder, pregnant uterus, ovarian cyst, and uterine fibromyoma, and the commonest mistakes are made between these swellings. The distended bladder is clearly the easiest to dispose of, because the passage of a catheter will settle the question ; and yet the neglect of this simple procedure has led to more than one abdomen being opened. The history is of value in differentiating the other swelhngs, for amenorrhoea is the rule in pregnancy, menorrhagia in fibromyoma, and no change in menstrua- tion in ovarian tumours. These assumptions are absolutelj^ correct in almost 99 out of every 100 cases, but exceptions do exist. The cardinal point in diagnosis is not to think of the possible fallacies until the common rule has been thoroughly considered. Normal menstruation during pregnancy is almost unknown, but it is believed that menstruation is possible up to the third month of pregnancy. This is physiologically unsound, for menstruation represents the failure of the uterus to receive a fertilized ovum, and should not be even possible if conception does occur. That haemorrhages occur during the early months of pregnancy is true ; but in most cases these haemorrhages represent threatened abortion, and not menstruation. Further, fibroids are associated with haemorrhages. This is absolutely true in the case of interstitial or submucous growths ; but there may be no disturbance of menstruation in subperitoneal fibroids. Ovarian tumours only disturb menstruation when they are double, and destroy all ovarian tissue. As long as a small piece of ovarian tissue remains undestroyed, there is no reason why menstruation should not occur normally. Palpation of these tumours may be fallacious, although there is no difficulty in distinguishing foetal parts when the foetus is big enough. In the early months the pregnant uterus may fluctuate like a cyst ; a softened fibroid may do the same, whilst on the other hand a tense ovarian cyst may feel so hard as to be mistaken for a fibroid. Whilst the presence of the foetal heart is characteristic of pregnancy, its absence cannot be taken as evidence of a fibroid or of an ovarian tumour. It is not always possible to hear the foetal heart even in advanced pregnancy. If the pedicle of a tumour can be felt definitely attached to one uterine cornu, it is strong presumptive evidence of an ovarian tumour. It is useful to pull down the uterus with a tenaculum, at the same time pushing up the tumour so as to make tense the pedicle, which might then be palpated by the vaginal touch. When small tumours are in question, the first point which arises is. Can the tumour be separated from the uterus bimanually ? If so, it can be neither a fibromyoma of the uterus nor a normal uterine pregnancy. This point can only be made out by careful bimanual examination, and undoubt- edly may require considerable skill in some cases. Early pregnancy in a retroverted uterus should not give rise to diagnostic difficul- ties if it be remembered that the soft, boggy fundus is felt through the posterior fornix, that the cervix looks down the vagina or forwards to the symphysis, and that the posterior mass is continuous with the cervix. If the retroverted uterus is associated with vesical distention, the picture is usually clear enough. SWELLING, PELVIC 759 The history of constant dribbUng of urine (distention with overflow), amenor- rhoea, other signs of pregnancy, and the presence of tsvo tumours — one in front, tense and elastic, the other behind, soft and boggy — and finally, the passage of a catheter, will settle the question. The diagnosis of sohd ovarian tumours is not alwavs possible, for the pedicle is often short, and the tumour is then so close to the uterus that the two cannot be separated. They are therefore likely to be mistaken for fibroids of the uterus. They do not often cause menorrhagia, however, and this may be remembered as a cardinal point. Large tumoiivs arising in the pelvis are not often difficult to differentiate from one another, bearing in mind that ovarian tumours, uterine fibroids, pregnancy, and ascites are the common conditions which are met with. In this connection, it cannot be repeated too often, that amenorrhcea stands for pregnancy, and occa- sionallv, for ovarian tumours when double. Menorrhagia goes with uterine fibroids except in the case of subperitoneal tumours. Exceptions to these general statements are uncommon, and mistakes in diagnosis will occur but seldom if the}' are borne in mind. Ascites has to be differentiated from ovarian cysts, and occasionally from hydramnios. In general, ascites gives dullness in the flanks on percussion, with resonance over an area somewhere about the umbilicus, whilst ovarian cysts give dullness all over the front of the abdomen, with resonant areas in the flanks and epigastric angle. When ascites exists along with ovarian tumours, the free fluid may be so large in amount that the tumour cannot be felt ; as a rule, however, it can be touched on dipping through the fluid. Ascites with an ovarian tumour does not necessarily mean malignancy, but it may do so. Fibroma of the ovary, and simple ovarian cyst with a tAvisted pedicle, will always be accompanied by some fluid. When pregnancy is associated with tumours, the diagnosis may be of great difficulty. The difficulty, however, does not lie in the recognition of the pregnancy ; amenorrhcea, breast changes, foetal movements, and the foetal heart will usually make that clear enough ; it lies in deciding the nature, or even the presence, of a tumour along with the pregnant uterus. In the early months, when the presence of two tumours can be demonstrated, the diagnosis is easier, but in the later months, the great size of the abdomen, and the way in which the swelhngs merge into one another, may obscure the picture. The relation to the uterus, whether a part of it, or attached to it by a pedicle ; the feel of the tumour, whether sohd or cystic, soft or hard ; and the previous history ; will always be of assistance in making out the nature of the growth. It must not be forgotten that fibroids are extremely hkely to soften and degenerate during pregnancy, so that they are liable to be mistaken for ovarian cysts. In the case of ovarian tumours, it is often impossible to be sure of the exact nature of the growth, and this has to be decided microscopically after removal. It is, however, important to distinguish malignancy in growths of the ovary, and certain points w-ill stand out in favour of this. Thus, fixation of the growth in the pelvis, obvious ascites, emaciation of the patient, and rapid growth in size of the abdomen, are points in favour of malignancy. In the case of definitely uterine tumours, the diagnosis of malignant growths is not often difficult, but may have to be settled by the microscopic examination of curetted fragments. Fibroids are only hkely to be mistaken for mahgnant growths when they produce constant bleeding as a result of extrusion, infection, and sloughing. Rapid growth of a fibroid is naore hkely to be the result of degenerative changes, such as formation of cysts or necrobiosis, than to the development of a sarcoma or other malignant growth along with it. With small tumours confined to the pelvis, or rising only a little above the brim, diagnosis is often a matter of extreme difficult}^ In practice, how'ever, extra-uterine gestation and its resulting blood-tumours stand out pre-eminently 76o SWELLING. PELVIC as swellings which must be recognized at once, if successful treatment is to be adopted. Before rupture or abortion has occurred, a tubal gestation is essen- tially a small tumour in one postero-lateral corner of the pelvis, attached to the uterus, indefinite in consistence, and perhaps — though not always — associated with amenorrhoea of short duration, and attacks of pain in the pelvis of an acute nature. Definite signs of pregnancy may be entirely wanting. It may be mistaken for a chronic salpingo-oophoritis, a small cystic ovary, a small pedun- culated fibroid, or a small ovarian dermoid. The differential diagnosis may be absolutely impossible ; but attacks of pain unassociated with menstruation are not hkely to occur in any of the latter conditions. The attacks of pain are usually the result of over-distention and stretching of the tube from haemor- rhage into its wall or lumen around the fertilized ovum. When tubal abortion has occurred, or tubal rupture, the .signs of internal bleeding, accompanied by sudden pain and collapse, with hsemorrhage from the i;terus, usually make up a complete and unmistakable picture. Hccmorrhage is more commonly severe and copious in tubal rupture than in tubal abortion. If the patient recovers from the initial bleeding, the clinical picture may be that of a retro-uterine hcsmatocele, or of a peritubal hematocele. In this form, the uterus is pushed forwards and upwards against the symphysis pubis, and the mass of blood-clot can be felt posteriorly bulging the posterior fornix, and also the anterior wall of the rectum. The tumour is usually partly resonant in front, because intestine adheres to it. Tubal abortion is most likely to be mistaken for an ordinary uterine abortion ; but the presence of a mass on one side of the uterus, with a closed cervix, and the absence of uterine contractions or extrusion of any products of conception, should make the case clear. Progressive extra-uterine gestation is a rare occurrence, and is the result of continued growth of an embryo after a partial separation from the tube, as a result of rupture, or extrusion from the fimbriated end (abortion). The continued enlargement of a mass beside the uterus, with amenorrhoea and progressive signs of pregnancy, are the most characteristic points. The diagnosis, however, is difficult, because there is always some effused blood which is likely to obscure the outlines of the uterus, and make it appear to be a part of the pelvic mass. The swellings due to salpingo-oophoritis are usually quite easy to distinguish. They form fixed masses in the pelvis, seldom of an}^ definite shape, but occasion- ally presenting the characteristic retort shape, with its narrow end near the uterus, which the tube assumes when distended with fluid. The history is usually that of an acute illness at some period, with pain in the pelvis, rise of temperature, and peritoneal irritation. It is preceded, as a rule, by uterine discharges and menor- rhagia. This inflammatory disturbance in married women is associated with long periods of sterihty, owing to the sealing up of the tubes. The diagnosis of suppuration with salpingo-oophoritis is often impossible, but is always important, because the treatment may depend on it. Constant rises of temperature of the hectic type, wasting, and daily sweating, are the usual accompaniments of suppuration here as elsewhere. A large pelvic abscess may accompany salpingo-oophoritis, or may occur alone without infection of the tubes, as we see occasionally in puerperal septic infections. When it does occur, it is of course peritoneal ; it fixes the uterus in a central position, bulges into the posterior fornix and rectum, tends to rupture into the rectum, is acute in onset, and accompanied by signs of local peritonitis. It is likely to be confounded with pelvic cellulitis, in which the uterus is fixed in a laterally displaced position. It bulges one lateral fornix, tends to burrow along the round ligament to the groin, is slow and chronic in onset, and is not accom- panied by signs of local peritonitis. It always follows labour, whereas pelvic abscess of peritoneal origin may occur with salpingo-oophoritis quite apart from pregnancy. Pelvic cellulitis never bears any relation to salpingo-oophoritis. SWELLING, POPLITEAL 761 Encyated peritoneal ftuid, hydatid cysts, and retroperitoneal lipoma are generally diagnosed as ovarian cysts, and their true nature is only discovered at opera- tion. There are no definite signs by which these conditions may be diagnosed, and as they all require operative treatment, post-operative diagnosis meets their requirements. Distention of the vagina by menstrual fluid is not likely to be mistaken for anything else, if only on account of the absolute closure of the hymen which gives rise to it. Haematocolpos is practically the only central tumour met with between the rectum and the bladder, reaching from the hymen to the pelvic brim. The uterus can usually be felt like a cork movable upon its upper extremity. Urachal cysts occur in front of the uterus and in close relation to the bladder ; but in spite of this they are usually mistaken for ovarian cysts. It is to be remembered, however, that ovarian cysts only get in front of and above the uterus when they are large. Urachal cysts rarely attain a large size. Appendicitis with pregnancy occasionally occurs, and may be mistaken for such a condition as torsion of an ovarian pedicle. The swelhng due to appendix inflammations is, however, in close relation to the anterior superior spine of the ilium, and apparently adherent to the ihac fossa. The lump is ill defined, and rarel}' fluctuates unless there is a large abscess. The acute onset may be similar to that of torsion of an ovarian pedicle. There is usually a definite fluctuating tumour when an ovarian cyst is present, and some interval betAveen it and the ihac crest can usually be felt. Phantom tumours are due to diaphragmatic contraction, causing the abdominal wall to bulge. They are usually mistaken by patients for pregnancy, but are not accompanied by anv of the signs of pregnancy. Amenorrhoea must be excepted from this, however, because these cases usually occur about the meno- pause. Their true nature can usually be discovered by making the patient breathe normally, relaxing the diaphragm ; but if any doubt exists, the pro- trusion will disappear under an anaesthetic. Growths of the pelvic bones are very rare tumours, usually cartilaginous or sar- comatous. They are only likely to be mistaken for adherent inflammatory masses, due to salpingo-oophoritis. They will be found to be continuous with the bones forming the pelvis, and when growing from the sacrum may have the rectum in front of them ; all other tumours have the rectum behind them. They may, however, bear no relation to the rectum at all if they occur on the right side of the pelvis. In most cases of this nature, the i;terus and adnexa can be palpated bimanually, and shown to be free from disease and unconnected with the mass. When complicated by the presence of a pregnant uterus, their true nature may be very difficult to determine. Bearing in mind that they are absolutely fixed and continuous with the bones of the pelvis, the diagnosis ought not to be uncertain. Thos. G. Stevens. SWELLING, PERINEPHRIC— (See Kidney, Enlargement of.) SWELLING, POPLITEAL, — Popliteal swellings may be divided into : — 1. Fluid Swellings : Bursa I Abscess Baker's cyst | Aneurysm. 2. Solid Swellings not connected with Bone : Enlarged glands | Innocent tumours. ]Malignant tumours | 3. Solid Tumours connected with Bone : Exostosis I Periostitis Sarcoma | Separation of the epiphysis. 762 SWELLING, POPLITEAL I. Fluid Swellings. Bursa, — The bursa underneath the insertion of the semimembranosus muscle into the posterior aspect of the inner tuberosity of the tibia is often enlarged. When the leg is extended it stands out as a tense fluctuating swelling on the inner side of the popliteal space ; on flexion it disappears completely. It may be found enlarged in young athletes and cause no symptoms whatever. On account of its frequent communication with the knee joint, it is often distended when that joint is the seat of osteo-arthritis, and the changes found in the synovial membrane of the knee are found also in the synovial membrane lining the bursa, for the two are continuous. When much fluid is present, fluctuation can be detected between the joint and the bursa. The bursa under either of the two heads of the gastrocnemius muscle may be enlarged, but this is rare. Baker's Cyst occurs in connection with chronic tuberculosis of the knee joint, and is formed by the extension of a clironic abscess which spreads along a plane of fascia. Such an abscess may present itself in the popliteal space. The condition of the knee joint will indicate the disease. Acute Abscess is recognized by the signs of acute inflammation ; the skin is red and oedematous, the pulse and temperature are raised, and the swelling is very painful. The knee is kept flexed in order to avoid pressure. The abscess maj^ be caused b):^ suppurating lymphatic glands or by suppurative periostitis or necrosis of the lower end of the femur. In the former case the abscess will be superficial, and in the latter, deep to the popliteal vessels. Aneurysm of the Popliteal Artery [Plate XIII) gives rise to an expansile pulsating tumour, the pulsation being synchronous with the heart's beat. Pressure on the femoral artery above will cause a diminution in size of the swell- ing and cessation of pulsation. The pulse at the ankle on the affected side may be smaller than that on the opposite, and delayed. If a stethoscope be placed over the swelling a distinct bruit can be heard. The complaint of the patient will probably be of pain, which may be referred down the leg if either pophteal nerve is pressed on, or in the site of the swelling if the bone is eroded. Varicose veins are almost always present on account of pressure on the popliteal vein. Owing to its pulsatile character, an aneurysm is not often mistaken for anything else, but it must be remembered that every swelling that pulsates is not an aneurj'sm. A soft vascular sarcoma growing from the end of the femur ma}^ be pulsatile, and over it a bruit may be heard, but the tumour is not as compressible as an aneurysm, and the effects on the distal pulse are not so marked. A skiagram will usually settle the question at once. Distinction must also be drawn between a tumour that pulsates and a tumour to which pulsation is communicated. For instance, an abscess or a solid swelling lying over the popliteal artery may appear to pulsate, but the movement is heaving in character and not expansile. In the rare event of an aneurysm having become filled with clot, it might be taken for a solid tumour growing either from the soft parts or from the bone. Under this delusion a leg has been amputated for sarcoma. 2. Solid Swellings not connected with Bone. Enlarged Glands. — It is not common to find the popliteal glands enlarged from any cause. It is possible that they may become infected with pj'Ogenic organisms from a sore on the back of the leg. Tumours are rare. They may be innocent, e.g., lipoma; or sarcomatous, starting in the connective tissue of the popliteal space, or attached to one of the muscles. The innocent tumours are of long history and well defined ; the malignant, rapidly growing and infiltrating. PLA TE XIII. POPLITEAL ANEURYSM y Reproduced by Jiermissioii froju a zvato-colour paititing in the Gordon Museian, Guys Hospital. INDEX OF DIAGNOSIS SWELLING, PULSATILE 763 3. Solid Swellings connected with Bone. In all cases of bony tumour a skiagram is of immense service, and should always be obtained if possible. Innocent Tumours. — Cancellous exostoses may be found, generally in children and 3'oung adults, growing from the region of the epiphysial cartilage of the femur {Fig. 194, p. 753). There may be others in other parts of the skeleton, and sometimes several members of the family are affected similarly. The swelling is of slow growth, well defined, and rarely gives any trouble. It is most often found at the inner side of the popliteal space. There is one thing that may be confounded with it, namely, ossification of the insertion of a tendon or muscle. The adductor longus muscle is the one most commonly affected. Malignant Tumours are endosteal and periosteal sarcoma. Central sarcoma in its early stages so closely resembles chronic osteitis and periostitis that it may be impossible to come to a correct conclusion without the aid of a skiagram. With this help the difficulty vanishes, for a myeloid tumour is seen clearl}' as a well-defined tumour causing enlargement of the bone (compare Figs. 197, 198, 199, pp. 75 5> 756). Periosteal sarcoma causes a general enlargement of the whole of the lower end of the femur or upper end of the tibia {Fig. 196, p. 754), not swelling in the popliteal space only. It is mentioned here because of its occasional confusion with periostitis with popliteal necrosis. Periostitis. — Popliteal necrosis with abscess formation may give rise to a big swelling. The signs of inflammation will usually be well marked and accom- panied by constitutional symptoms and leucocytosis. Chronic periostitis, or chronic abscess of the bone, or central necrosis, may be extremely difficult to distinguish from a periosteal sarcoma. A skiagram should be taken, and if necessary an incision is to be made down to the tumour, and a piece removed for histological examination. (See Swelling on a Bone.) Separation of the Epiphysis. — In the somewhat rare accident of separation of the lower epiphysis of the femur, the lower fragment becomes displaced backwards, forms a prominence in the popliteal space, and presses on the vessels, sometimes to a dangerous extent. George E. Gask. SWELLING, PULSATILE. — When a tumour can be felt pulsating, the first point to decide, if possible, is whether the pulsation is expansile or whether it is merely transmitted by a non-expansile tumour which is in direct contact with large pulsating vessels. The distinction is sometimes obvious, especially when the tumour has developed in a place where there are no particularly large blood- vessels to transmit pulsation, for instance in the foot, or in direct connection with a long bone at some spot not immediatelyadjacent to the main artery of the limb. The chief difficulty arises when the mass is either in the root of the neck or in the abdomen and, to a less extent, when it is in the axilla, the inner aspect of the upper arm, in front of the elbow, in the groin, or in the pophteal space. Care- ful palpation is probably the best means of determining whether there is actual expansile pulsation or not ; in the case of the abdomen it is important to make the examination with the patient, not only upon his back, but also in the knee-elbow posture, for sometimes a tumour which is in contact with the aorta in the dorsal position falls away from it and ceases to transmit pulsation in the ventral posture. If it can be decided definitely that the tumour is itself pulsating, most probably it is either an aneurysm of an artery or else a very vascular growth, especially osteosarcoma. The existence of egg-shell crackling with pulsation in a tumour would be highly suggestive of osteosarcoma, though it is conceivable that it might also be felt over an aneurysm that had extensively 764 SWELLING, PULSATILE eroded the adjacent bones. Aneurysm will be the probable diagnosis when the markedly pulsatile swelling occurs directly along the course of a known artery. Absence of pulsation does not, however, exclude aneurysm, for the latter may be either too deeply situated for the pulsation to be felt, or else the sac may be partly or wholly filled by organized or organizing clot. Sometimes there may be doubt as to whether there is really pulsation or not, when digital examination alone is relied upon ; in such cases, direct apphcation of the ear to the part in such a way that the pinna is in uniform contact with the patient's skin, will sometimes bring pulsation to the notice very clearly when its amount, appreciable to the membrana tympani, is too shght for the hand to detect ; this applies particularly to deep-seated intrathoracic aneurysms. It must be remembered, on the other hand, that marked pulsation may suggest aneurysm without any being present, particularly at the root of the neck and in the abdomen ; a normal subclavian artery may sometimes seem to be abnormal, particularly if it is pushed forward or displaced by a mass below or behind it, for instance an accessory cervical rib. Undue pulsation of the abdominal aorta, especially in women, is also to be remembered as a possible source of erroneous diagnosis (see Pulsation, Undue Abdominal Aortic). It should also be remembered that normal arteries cause very violent pulsation in cases of marked aortic regurgitation, and in severe cases of exophthalmic goitre, in which the whole neck, including the enlarged thyroid gland, may be seen to be pulsating vigorously. We need not here discuss in detail the differential diagnosis between one kind of aneurysm and another, though one might mention in particular the so-called cirsoid aneurysm of the scalp [Plate XIV), which is rather a conglomera- tion of many abnormally dilated arteries in the form of an arterial nsevus than a true aneurysm. Its position on the scalp will at once suggest the diagnosis. A pulsatile orbital tumour will generally be due either to an osteosarcoma, or to an arterio-venous aneurysmal communication between the internal carotid artery or its ophthalmic branch, and the cavernous sinus. The presence of a loud bruit would be in favour of the latter. It is important not to mistake for the ordinary pulsatile tumours those which may move sjmchronously with respiration, such for instance as hernia pul- monalis, hernia cerebri, and certain congenital abnormalities of the brain and spinal cord, such as meningomyelocele {Fig. 75, p. 254). It is unhkely that a pulsatile liver will be mistaken for any other kind of pulsatile tumour. The cases in which it occurs are those of chronic failure of cardiac compensation, generally mitral stenosis with oedema of the legs, lividity, orthopnoea, and perhaps ascites, which have generally been present for some time before the nutmeg liver becomes obviously pulsating. Rarely, the cardiac pulsations may be transmitted direct to fluid contained in a pleural cavity, so that the bulging intercostal spaces may pulsate synchronously with the radial artery and simulate some more serious pulsatile tumour. The history and the physical signs, including displacement of the heart towards the opposite side, will generally indicate the correct diagnosis, though there may be some trepidation on the part of the operator who decides to insert the exploring needle into the pulsating swelling. Herbert French. SWELLING, SCROTAL — It is first essential to prove that the swelling is really limited to the scrotal region, and this is best done by grasping the root of the scrotum between the fingers and thumb, and thus ascertaining if the swelling does or does not extend into the inguinal region along the cord. Failure to take this obvious precaution has led to the tapping of a hernia with disastrous results. True scrotal swellings may arise in any of the following tissues : — PLATE XIV. CIRSOID ANEURYSM X Rep7-odticed by perjiiission from a zvaier-coloii7- painting in the Gordon Museum, Guy's Hospital. INDEX OF DIAGNOSIS SWELLING, SCROTAL 765 (i) Skin; (2) The various connective-tissue coverings of the testicle; (3) Tunica vaginahs ; {4) Testicle; (5) Epididymis; (6) The lower end of the spermatic cord ; (7) The urethra ; (8) The bones of the pubic arch. 1. The nature of swellings affecting the Skin is usually obvious. The only common ones are : Boils, soft sores and chancre, sebaceous cysts, warts and epithelioma. The latter soon ulcerates, commonly occurs in sweeps, and the groin glands soon become enlarged. 2. Swellings of the various Connective-tissue Coverings are very rare, but occasionallv a fibrosarcoma may occur. These swellings are movable upon the testicle. The symmetrical enlargement called elephantiasis scroti, due to the Filavia sanguinis hominis, is limited to the tropics. 3. The Tunica Vaginalis may become distended with fluid, thus forming the ordinary vaginal hydrocele. Except in late cases, this is translucent, and is thus distinguished from a hsematocele of the same cavity. It should not be forgotten that a hydrocele with thick walls may fail to give translucency. When proved to be translucent, it has to be distinguished from encysted hydrocele of the epididymis and encysted hydrocele of the cord. Vaginal hydrocele occupies the lower part of the scrotum and envelops the testicle, which cannot be felt as a separate object. Encysted hydrocele of the epididymis is placed behind and above the testicle, from which it is distinct, although attached at the upper and posterior part. Moreover, this variety of hydrocele never attains a large size, rarely getting larger than a tangerine orange. It is not tightly distended, but is usually flabby, and it contains a characteristic milky fluid in which chole- sterin crystals {Fig. 94, p. 281) are present. Encysted hydrocele of the cord is placed above the testicle, which can be felt as a separate object. It rarely attains a large size, and is often elliptical in shape, extending upwards along the cord. All the hydroceles fluctuate. To test for this it is necessary to fix the swelling against some hard object. Bleeding may occur into any of them as a result of injury or constitutional disease. It is almost impossible to distinguish between an opaque hydrocele and a haematocele without tapping the swelling. In syphilitic disease, with irregular adhesion between the parietal and the visceral walls, a loculated hydrocele may occur. 4. Swellings of the Body of the Testicle may be inflammatory or neoplastic. Acute inflammatory swellings rarely attain a large size, and they are usually associated with enlargement of the epididymis, and occur as a part of acute epididymo-orchitis due to urethritis of some kind, or to mumps or as a post- typhoidal phenomenon. Chronic inflammatory swelHngs give rise to more difficulty. They are usually either tuberculous or syphilitic, or else due to chronic torsion. In the former disease, swelling of the epididjrmis is practically always primary and more advanced ; but in infants the body of the testis becomes involved at a very early stage. The enlarged epididymis can be felt enveloping the posterior border, and the upper and lower poles of the testicle. There is often a little hydrocele which may obscure the shape of the testicle. If there is adhesion, with perhaps an abscess or a sinus at the posterior and lower part of the scrotum, it is characteristic of suppurative disease of the epididymis, usually of a tuberculous nature. Moreover, in tuberculous disease, the vas is thickened, usually in a nodular manner. It is important to examine aU the palpable part of the vas, for sometimes the nodules are hmited to the inguinal region. Von Pirquet's tuberculin reaction is a valuable aid if its limitations are remembered. In striking contrast Avith this, syphilitic enlargement of the testicle leaves the epididymis unaffected, and is limited to the testicle, which enlarges unevenly, often affecting the tunica albuginea and the tunica vaginalis in a nodular manner. The syphilitic testicle rarely attains three times the natural size. It is curiouslj' devoid of pain. The testicular sensation is often 766 SWELLING, SCROTAL lost, and there is little or no thickening of the cord. Its anterior surface is ■uneven and Tn.a.y become adherent to the coverings, which may later ulcerate, and ultimately give rise to a hernia testis on the front of the swelling. This contrasts with the postero-infero-lateral position of tuberculous sinus or hernia testis. Chronic torsion of the testis is generally the result of a blow, or of an injury in the saddle ; the symptoms may be obscure until the testicle begins to swell. Operation is generally resorted to with the idea that the condition is tuberculous or malignant, and even then the diagnosis may be in doubt until microscopical examination of the organ has been made. It is often very difficult to distinguish syphilitic enlargement of the testicle from that due to growth ; but a course of large doses of antisj^philitic remedies and the Wassermann reaction may settle the matter. Malignant new growth nearly always grows steadily, and being entirely within the tunica albuginea it maintains the shape and smooth surface of the testicle until it reaches a size much larger than that of a syphilitic testicle. Moreover, it causes much more pain, and usually some thickening of the cord^ with later enlargement of the glands in the loin. In some cases the diagnosis betw-een sj^philitic testicle, growth^ and haematocele may be so difficult and so irrgently necessary as to demand an exploration. Malignant grow^ths of the testicle can be divided into four varieties. : [a] Carcinoma ; (b) Sarcoma ; (c) Embrj^oma ; (d) Endothelioma. Carcinoma is far more common than sarcoma, although the contrary has been beheved for many years, owing to the fact that many carcinomatous growths with small alveoli have been ^v^ongly labelled sarcoma. The average age of patients with carcinoma testis is 43, and of those with sarcoma testis, 34. The average duration of carcinoma before operation is 1+ years ; of sarcoma, II months. Sarcoma advances much more rapidly and kills earlier than carcinoma. The former disseminates through the veins, whereas the latter travels along the lymphatics and infects the lumbar glands. Embryoma is, according to Nicholson, " the commonest new growth of the testicle, but it is often overlooked." It can be shown to contain structures derived from all the three blastodermic layers of the embryo. The average age at the time of operation is 29, the average known duration before operation is 5^- years. " Although not necessarily malignant, it ma^^ produce metastases composed of all the tissues of the primary growth, or one tissue may become actively malignant, in which case the deposits will be formed of that tissue alone." It may spread along the lymphatics or disseminate through the veins. 5. The Epididymis may become enlarged as the result of {a) Inflammation ; {h) New growth ; (c) Cystic degeneration. a. Inflammatory swellings are characterized by being elongated in a vertical direction ; by their relation to the testicle, which they overlap at its posterior border, and its upper and lower poles ; and lastlj^, by being flattened from side to side, so that the antero-posterior diameter is greatly increased. Inflam- matory swellings may be : — (i) Gonorrhoeal ; (ii) Septic, secondary to some other form of urethritis ; (iii) Tuberculous. i. The gonorrhoeal varietv is distinguished by its acuteness, great tenderness, the surrounding oedema, and the bacteriological examination of the urethral discharge. Its onset is usually between the second and tenth week. Occasionally a subacute form develops later, at any time during the course of gleet. This is very difficult to distinguish from the tuberculous variety. Most cases of tuberculous epididy- mitis end in suppuration, but the gonorrhoeal variety very rarely breaks down. ii. The inflammation of the epididymis following other varieties of urethritis (such as ulceration near a stricture or due to impacted calculus, instrumenta- tion, or prostatectomy), is often sufficiently indicated by the history if care be SWELLING, SCROTAL 767 taken to go into this thoroughly. The sweUing following prostatectomy is apt to suppurate. Some of these can be mistaken very easily for tuberculous disease. iii. Tuberculous epididymitis, as a rule, is far more insidious and painless in its onset than other forms of epididymitis ; but it should not be forgotten that early subacute or even acute attacks of inflammation may accompany this disease, and that these are often the means of drawing the patient's attention for the first time to a disease which has been going on insidiously for some months. It has frequently been said that tuberculous nodules are limited to the globus major, and that those left after gonorrhoeal urethritis are confined to the globus minor. It is more true to say that the latter are limited to the globus minor, whereas tuberculous disease may attack any part of the epididymis. Wherever the tuberculous disease starts, the inflammatory pro- ducts soon spread through the thin fibrous capsule of the epididymis, and then gravitate towards the postero-infero-lateral corner of the scrotum, where adhesion occurs, followed later by an abscess and a sinus. In the diagnosis of tuberculous from other forms of epididymitis, the general state of health, and especially the presence or absence of other tuberculous lesions^ are of great importance. Nodular thickening of the vas deferens and of the vesiculae seminales and prostate are also valuable signs when the disease is well advanced. It should be remembered that the disease travels upwards along the vas, so that in its early and hopeful stages the upper part of the vas and vesiculae seminales are not enlarged. b. Primary new growth of the epididymis is excessively rare, so that it need not give rise to much concern in diagnosis ; it will generally be regarded as tubercle until after operation and microscopical examination of part of the tissue excised. ^^^^-^ c. Cystic disease of the epididymis may occur in the form of : (i) Solitary cysts (vide supra) ; (ii) Multiple cysts. The latter condition rarely occurs except in men past middle age, and is analogous to cystic degeneration of the breast. The condition is almost painless and harmless. These swellings are translucent. 6. Swellings of the Lower End of the Cord. — The most important swelling of the lower part of the spermatic cord is varicocele. It is apt to be mistaken for omental hernia, but the mistake should never be made, because of the characteristic feel of the varicocele, and the reappearance of the swelling after it has been completely reduced and the finger is firmly pressed on the external abdominal ring. 7. Urethral Conditions. — Occasionally a peri-urethral abscess may form a swelling in the scrotum. Tenderness, oedema, and fluctuation, together with the history and evidence of urethral disease, serve to make the diagnosis clear. Primary epithelioma of the, urethra is distinguished by the great pain and urethral obstruction that it engenders. 8. Diseases of the Pubic Bones. — Inflammatory products may travel into the scrotum from disease of the bones of the pubic arch, especially from the neighbourhood of the symphysis pubis. Acute necrosis of these bones is sufficiently indicated by the grave constitutional symptoms which always accompany it. Caries gives rise to more difficulty. The writer has known a case of tuberculous caries of the lower part of the symphysis pubis in which the inflammatory products gravitated backwards and to the left, so as to form a large firm swelling in the left half of the scrotum, where it gave rise to much difficulty in diagnosis, and was thought to be either a sarcoma arising from the fibrous covering of the crus penis, or possibly a gummatous mass in the same situation. Sufficient attention was not paid to the fact that the man had chronic phthisis. R. p. Rowlands 768 SWELLING, VULVAL SWELLING, VULVAL. — The differential diagnosis of vulval tumours must necessarily include not only true swellings of the vulva, but also swellings which appear at the vulva as a result of the displacement of other structures, such as occur in prolapse and cystocele, and in addition lesions hke kraurosis vulvee, which are not strictly swellings at all. The lesions of the vulva may be tabulated under various headings, as set forth in the following scheme : — Inflammatory Lesions. — Simple vulvitis Gonorrhoeal vulvitis Soft chancre Papillomata Syphilis : Hunterian chancre Condyloma Tertiarj? lesions Cystic Swellings. — Hydrocele of the canal of Nuck Sebaceous cysts Blood Cysts. — Varicocele Rupture of a varicose vein New Growths. — Caruncle Fibroma Lipoma Angeioma Neuroma Fibromyoma of round liga- ment Hernise. — Inguinal Posterior labial Displacement. — Prolapse of urethral mucous membrane Prolapse of uterus Unclassified. — Simple anasarca. Tuberculosis Furunculosis Leukoplakic vulvitis Kraurosis vulvse Pseudo-elephantiasis Esthiomene. Mucous cysts Implantation cysts Dermoid cysts. Traumatic haematoma. Endothelioma Squamous-celled carcinoma (epithelioma) Columnar-celled carcinoma Sarcomata of various kinds. Perineal. Cystocele Inversion of the uterus Fibromyoma of the vaginal wall. Certain of these lesions stand out pre-eminently as presenting difficulties in diagnosis. The general principles by which solid tumours are distinguished from cystic, inflammatory swellings from new growths, or new growths from herniae, need not be insisted upon here. Perhaps the commonest difficulty which arises in practice is the diagnosis of gonorrhoeal vulvitis from simple vulvitis, and also between the gonorrhceal soft chancre and the syphilitic condyloma, the latter differentiation being of much more practical importance than the former as far as the patient is concerned. In the acute stage of a gonorrhoeal vulvitis there is a chance of recognizing the gonococcus in the dis- charge, if films made from it are suitably stained. Practically, all acute forms of vulvitis appear alike cUnically, so that the recognition of the gonococcus becomes a matter of importance. The way to recognize the gonococcus is to make films of the discharge on a shde, dry, fix by passing them through a flame ; then stain by Gram's method, and counterstain by neutral red. The SWELLING, VULVAL 769 gonococcus is not stained by Gram's method, but is coloured red by the counter-stain. The gonococci are seen in pairs inside leucocytes of the poly- morphonuclear t^'pe {Plate XII, Fig. R). In chronic gonorrhoeal infections with vulval swelhng, as a rule the organism cannot be found in the general vulval discharge, but might be found in the urethra or in the cervix. A gonorrhoeal infection may be suspected if the patient gives a history of an acute onset, accompanied by scalding on micturition, and when there is redness of the orifices of Bartholin's glands, and much redness and swelling of the carunculae m\Ttiformes. Papillomata or warts of the vulva may occur also in chronic gonorrhoeal infections, and there is no evidence of a reliable nature to show that they occur in any other kind of infection. The soft chancre of gonorrhoea may be mistaken for the condyloma of secondary syphilis, but as a rule this difficulty should not occur. The soft chancre is a typical punched-out ulcer with a somewhat red base and clean edges, discharg- ing pus. The condyloma, on the other hand, is a raised, fiat-topped excrescence, with sodden, epithelium-covered surface. Soft chancres are not very numerous, as a rule, and are generally limited to the vulva. Condylomata are numerous, and may occur all over the labia, around the anus, and even on the skin of the thighs and gluteal region. Condylomata are from the start, or will be very soon after their origin, accompanied by a sore throat and a t^'pical papular skin rash. In other words, condylomata are always accompanied by typical secondary' syphilitic lesions. Soft chancres clear up with antiseptics ; condylomata persist for long periods, but clear up in two or three weeks as a rule under mercurial treatment. It must not be forgotten that soft sores and condylomata may occur together in the same patient, in wfiich case the diagnosis may be still more difficult. Another practical differentiation which gives rise to anxiety is that between the Hunterian chancre or primary syphilitic sore, and squamous epithelioma of the vulva. This is a question which is of vital importance to the patient, if valuable time is not to be lost in the treatment of a malignant epithelioma. The two lesions look much alike at first ; they form raised hard indurated masses in the skin, which may ulcerate quickly as a result of necrosis of the superficial portions. Both give rise to a thin watery discharge, and to enlarged glands in the inguinal region which do not suppurate at first, but may do so later in the case of an epithelioma. It must not be forgotten that a primary chancre is very seldom seen in women, whilst squamous epithelioma is relatively common. Of course the chancre will be followed in due course by secondary lesions, but it is not safe to wait for these to appear in a doubtful case. The only reasonable way to deal with such a case is to excise the doubtful swelling at once and submit it to microscope examination by an expert. A squamous epithelioma is easily detected in this manner in quite early stages, and does not in the least resemble a syphilitic lesion microscopically. The Spirochcsta pallida may be recognized in scrapings of a hard chancre fixed and stained by Giemsa's or Levaditi's methods [Plate XII, Fig. J). In sections, too, the spirochaete may be demon- strated, but it must be remembered that for this purpose the excised growth must be fixed in 5 per cent formahn solution. Wassermann's serum test may assist the diagnosis. Tertiary syphilitic lesions are by no means common on the vulva. When they do occur, they give rise to spreading ulceration, with great destruction of tissue, and scarring in the older healed portions. Here, the only hkely lesions to be mistaken are some forms of epithehoma, and tubercle. Obviously, in such conditions the only rehable method of diagnosis is to be found in excision of parts of the lesion and microscopic examination of sections made from them. The disease known as esthiomene is probably a tertiary svphilitic affection. D 49 770 SWELLING, VULVAL Pseudo-elephantiasis of the vulva is usually a syphilitic affection of the labia minora, giving rise to great enlargement, with a rough and thickened appearance of the skin. It could only be mistaken for real elephantiasis due to lymphatic obstruction by the Filaria sanguinis hominis [Plate XII, Fig.. F), a disease which is practically never seen in this country. Unilateral oedema of a labium minus is a fairly common condition, and is usually associated with an infected wound or with a primary syphilitic chancre. Bilateral oedema is almost always associated with general anasarca, the result of renal disease, cardiac disease, or pressure upon pelvic veins. It is not likely to be mistaken for any other disease. Leukoplakic vulvitis and kraurosis vulvce have certainly been confounded with one another clinically, and also in the published descriptions of the lesions. In the former, the labia majora and minora and the prepuce of the clitoris are affected, whilst the vestibule always escapes. In the latter, the lesion affects the vestibule, the orifice of the vagina, and the labia minora. There is much greater contraction of the vaginal orifice in kraurosis. Leukoplakia often precedes a squamous epithelioma ; kraurosis is said not to do so. Leukoplakia occurs at all ages, whilst kraurosis is a disease of post-menstrual life. Leukoplakic vulvitis appears as a white sodden hardening of the skin, with flattening and shrinkage of the labia. Kraurosis at first looks red and swollen, but later takes a yellowish tinge. Leukoplakia causes intense itching ; kraurosis gives rise to great pain and tenderness, with a very severe form of dyspareunia. Apart from a cyst developing in Bartholin's gland or duct, cystic swellings of the vulva are not common. A Bartholinian cyst is recognized by its position on one side of the vaginal entrance, distending the posterior part of the conjoined labia, and also within the hymeneal ring. As a rule, the orifice of the gland can be seen on the inner side of the cyst. The contents of this form of cyst may be glairy mucoid fluid, or may be purulent if the infecting agent is virulent. In practice, a Bartholin cyst is not likely to be mistaken for anything else ; but it is wise to remember that the posterior labial hernia occurs in the same situation, and that new growths of the vulva may occur there as elsewhere. Bartholin cysts are always the result of infection, and as a rule a history of vulval inflamma- tion can be obtained. Varicocele of the vulva occurs practically only in connection with pregnancy, and is unmistakable. It has the same " bag of worms " feel as a varicocele in a man, and as the veins are close to the skin, a bluish colour is always to be noted. It is attended by much aching pain, especially on standing. The veins are degenerate, and liable to rupture as a result of labour or traumatism. Hcsmatoma of the vulva is recognized as a blue or violet-coloured swelling covered by tense shiny skin, and often spreading up into the pelvis by the side of the vagina. The history alone will often decide the nature of the swelling, but the appearance is quite typical as a rule. Hsematoma of the vulva may occur apart from pregnancy, and then is always traumatic. Urethral caruncle and prolapse of the urethral mucous membrane may be mistaken for one another. The former, however, is always a pedunculated or sessile new formation, invariably springing from the posterior wall of the urethral orifice. It bleeds readily, is often, but not always, exquisitely painful, and is usually the result of infection. Prolapse, on the other hand, appears as a raised projection with rounded margins, and with the urethral canal in the centre as a dimple. The prolapsed portion may not necessarily include the whole ring of the mucous membrane. It may give rise to pain, and being always more or less strangulated, it is prone to bleed, much in the same way as a caruncle. It occurs as a result of some straining effort, or may accompany pelvic floor pro- lapse ; it is not the result of infection. TACHYCARDIA 771 The differential diagnosis of the new growths of the vulva presents no points of difference from their diagnosis in other parts of the body. The only common benign tumour is the pedunculated fibroma, or molluscum fibrosum, whilst squamous carcinoma {epithelioma) is the only malignant growth which occurs at all frequenth'. If the general characters of a hernia are borne in mind, there should be no risk of overlooking or mistaking any of the varieties which occur in the vulva. The resonance on percussion if the hernia contains bow^el^ the reducibility of the contents, and the protrusion through a pre-existing opening, will usually suffice to distinguish herniae from other swelhngs. An obstructed or strangulated hernia is not so easy to recognize, but the accompanying acute symptoms and the previous history, usually suffice to make the case clear. Hydrocele of the canal of Nuck, an uncommon condition, maj^ be mistaken for an inguinal hernia ; but as a rule it is irreducible, definitely fluctuating and circumscribed, and has no obvious neck running into the inguinal canal. When the canal of Xuck has a patent peritoneal communication, the swelling disappears as the patient hes down, but it is not reducible in the characteristic manner of a hernia. Such a condition is very rare. The displacements included in the list above are all dealt with under the heading of Prolapse of the Uterus. Thos. G. Stevens. SYNCOPE.— (See Coma.) TACHE CEREBRALE. — rac/?e cerebrate is the term used to denote that condition in which, after the finger has been drawn with moderate firmness across the patient's skin, the fine along which it has passed becomes of a bright red colour from dilatation of the superficial arterioles and capillaries, as a result of the mechanical stimulation ; the phenomenon develops within thirty seconds or a minute of the finger stroke, and the red mark remains evident for two or three minutes, or more. If letters or figures are marked out onthe skin in this way, they appear as though they had been written in red, so that the condition has also been termed dermatographia. It was at one time thought to be a characteristic symptom of tuberculous meningitis, but not only is it sometimes absent in cases of the latter, but it is also present in a very large number of other different conditions, and sometimes in perfectly healthy people. All forms of meningitis may give rise to it, so that it is not even a means of distinguishing one t^-pe from another. It is seen in an extreme degree in cases of urticaria, particularly the factitious variety in which numerous wheals may develop as the result of hardly more than ordinary touching of the skin. A similar condition has sometimes been observed in the later stages of severe febrile illnesses in general. Herbert Frendi. TACHYCARDIA, or abnormal rapidity of the heart's action might, strictly speaking, be held to include every condition under which the pulse-rate is faster than the normal ; but by common consent it is restricted for clinical purposes to cases in which there is no pyrexia. Nearly all fevers produce undue rapidity of the heart's action, though some, such as typhoid fever, tuberculous meningitis, cerebral abscess, yellow fever, and influenza do so to a much less extent than others. The rapid heart-action of fevers, however, does not generally come into one's mind when one uses the term tachycardia ; indeed the latter is chiefly employed for conditions in which it is rapid without there being anj-thing which at first sight would seem to be a sufficient cause. Probably the best example of this condition is to be found in cases of pronounced Graves' disease or exophthalmic goitre. TACHYCARDIA The following is a list including this and some other causes of tachycardia : — Graves' disease or exophthalmic goitre Parox^'smal tachycardia Nervousness and excitement Exertion, especially when the patient is out of training or ansemic Tobacco heart JNIitral stenosis Pneumogastric irritation bj^ : — Caseous glands Thoracic aneurysm Mediastinal fibrosis Thoracic new growth Pneumogastric " neuritis " after : — Diphtheria, influenza^ and other microbial infections Drugs : Digitahs ! Belladonna. Alcohol The four classical s^miptoms of Graves' disease are : A staring appearance of the eyes, generally spoken of as exophthalmos, though there need be no actual protrusion of the eye-balls ; moderate and almost sj^mmetrical enlargement of the thyroid gland ; a pulse-rate between 120 and 180 per minute — usuallj'' about 140 when the attack is moderately severe ; and extreme nervousness, vdth. fine tremor of the outstretched fingers. When all these symptoms are present at the same time, there can be no doubt as to the diagnosis, but very often some of them are absent, and it is possible for tachj^cardia to be the only s^^nptorQ of the disease ; indeed, in a patient, particularlj- a woman between tAvent\- and ioxty 3'ears of age, a persistent pulse-rate of over 120 would arouse serious suspicion that the case was really one of Graves' disease, even if the other three classical signs were absent. Paroxysmal tachycardia should be distinguished at once from Graves' disease in which tachycardia alone has developed, by the fact that the tachycardia is not persistent, but occurs in paroxysms ; the patient is more often a woraan than a man, and may have long periods of perfect health ; almost suddenlj^, the result sometimes of a fright or shock, sometimes without apparent cause at all, there AviU be a sense of something the matter in the precordial region, amounting as a rule to little more than a flutteriag or palpitation, together with a feeling of faintness and lack of strength, and perhaps of numbness or of pins-and-needles in the extremities, and when examined the patient may present no other abnormalit\" than a pulse-rate of perhaps 160 or even 200 to the minute. The attack may last a few minutes, or an hour or Irwo, rarely for days or weeks ; it will cease as suddenlj^ as it began, and a similar attack is almost certain to recur after a longer or shorter interval — the main symptom of the complaint being summarized by the title " paroxj^smal tachj^cardia." The very rapid heart action that maj^ be produced hy nervousness, or excitement, or by some ordinary exertion such as coming rather rapidly upstairs when one is out of training, or when the patient is suffering from some degree of ancemia, or during convalescence after an illness, or after the over-use of tobacco, is a familiar phenomenon ; the tachycardia rapidly disappears when the patient rests, and the diagnosis is not as a rule difficult. If ordinary resting for a while does not cause the rate of the heart-beat to return nearly or quite to normal, there ma}' be doubt as to the diagnosis, unless the patient can be re-examined on another occasion ; if there is persistent tachj'cardia a suspicion of incipient Graves' disease will be aroused. Mitral stenosis is of all the valvular lesions of the heart the most liable to lead to rapidity of the heart's action ; but it seldom happens that the pulse-beat TACHYCARDIA 773 is fast until there has been other evidence of failure of the cardiac compensation. The diagnosis will generally be obvious from the history of acute rheumatism or chorea, the typical facies and malar flush, and the cardiac bruits. It is exceedingly difficult to be certain of a diagnosis of irritation of a pneumo- gastric nerve within the thorax unless the existence of mediastinal new growth, aneurysm or fibrosis is already known on account of the abnormal physical signs, the visible tumour, or the varicose distention of the superficial thoracic veins ; it an intrathoracic abnormality is known to exist, and tachycardia becomes a prominent feature of the case, it will probably be due either to mechanical interference with the heart's action or to similar interference with one or other vagus nerve. Caseous glands, irritating the pneumogastric nerve, are still more difficult to be sure of ; but occasionally one ventures upon this diagnosis when a child, who has been fed on untested or unsterilized cow's milk, develops obscure ill-health associated with persistent tachycardia. Such diagnosis would be still further suggested if there were at the same time enlarged glands in both sides of the neck, if there were pyrexia without any obvious explanation of it, or if there were any evidence of obstruction to the right bronchus, for the right bronchial gland is enlarged far more often than is the left. Diphtheria, influenza, and possibly other microbial infections, are occasionally followed by very marked and persistent tachycardia during convalescence, or even for weeks, months, or years afterwards. After diphtheria, the condition is generally fatal. Influenza is always a dangerous diagnosis because it is so difficult to establish, but in certain cases in which the original diagnosis has been influenza., tachycardia to the extent of 200 heart-beats per minute may be present for months without the patient suffering from any severe cardiac symptoms, and the condition ultimately terminates in recovery with a return of the heart-beat to the normal rate. Precisely what is the nature of these cases it is impossible to say, but it has been thought by some that the symptom is due to inflammatory changes in the pneumogastric nerve, produced by what- ever one means by the toxins of the disease. Whether this be so or not, the fact that persistent tachycardia may arise out of febrile illnesses should be borne in mind. There are certain drugs which cause the heart's beat to be very rapid, the best known perhaps being digitalis, belladonna, thyroid extract, and alcohol. Certain patients suffering from cardiac symptoms seem unable to bear digitalis, the heart being driven into the condition spoken of as delirium cordis ; the diagnosis is not difficult when the drug that is being given is known. When alcohol is the cause of the tachycardia, the fact is generally obvious. Belladonna in small doses slows the heart, but there are great variations in the degree to which different patients tolerate this remedy, even pharmacoeopial doses sometimes producing toxic symptoms of which tachycardia is one. Widely dilated pupils and dryness of the tongue will help to point to the diagnosis in cases in which the belladonna is taken otherwise than medicinally. Tachycardia is the chief symptom by which one recognizes that a patient for whom thyroid extract has been prescribed is receiving too large a dose. Herbert French. TALIPES.— (See Club-Foot.) TASTE, ABNORMALITIES OF — Abnormalities of taste may be grouped under three main headings, namely : (i) Impairment or loss of ordinary taste sensations ; (2) Perverted taste sensations ; (3) Sensations of a foul taste in the mouth. The following are the conditions that may produce each of these : — 774 TASTE, ABNORMALITIES OF Impairment or Loss of Taste {Ageustia) : (a). Due to nerve lesions : Paresis or paralysis of the lingual branch of the fifth nerve Paralysis of the facial nerve, including the chorda tympani Glosso-pharyngeal nerve paralysis Bulbar paralysis Cerebral tumour, especially of the uncinate gyrus Hysteria. [b) . Due to affections either of the mouth or nose : A common cold i Other varieties of nasal obstruc- Hay fever (coryza e feno) Atrophic rhinitis Hypertrophic rhinitis Nasal polypus Adenoids tion Bromism lodism Mercurial and other varieties of stomatitis (p. 88). {c). Febrile conditions, especially when associated with coating of the tongue. [d). After destruction of the nerve endings in the tongue by corrosives taken accidentally or with suicidal intent. Perverted Taste Sensations [Parageustia) : Pregnancy Hysteria I Foul Taste in the Mouth [Cacogeustia) (a). Local conditions of mouth or nose : Caries of the teeth Retention of food particles between healthy teeth Furred tongue from any cause Excessive smoking Mouth breathing at night Gumboil Septic stumps under tooth- plate [b) . Severe fevers associated with dryness of the mouth and coating of the tongue especially in : — Pneumonia Typhoid fever | (c). Septic lung conditions, especially- Epileptic aura Insanity. Epithelioma of the tongue or mouth Stomatitis from any cause (p. 88) Septic infection of the antrum of Highmore, or one of the other sinuses communicating with the nose. Peritonitis Septicaemia, etc. Phthisis, with secondary in- fection of cavities Bronchiectasis Bronchiolectasis Foetid bronchitis Empyema ruptured into the lung {d). Certain drugs or poisons, especiall}'- Mercury Copper Arsenic Lead Iodides Paraldehyde Gangrene of the lung Liver abscess ruptured into the lung Subdiaphragmatic abscess rup- tured into the lung. Asafoetida Creosote Guaiacol Valerian Cod-liver oil Castor oil. TENDERNESS IN THE CHEST 775 From a diagnostic point of view, impairment of taste sensations is of little consequence except when it occurs in people who are otherwise apparently well. When it is the chief symptom in the case, however, it may be of con- siderable importance. When there is simple impairment of taste, and it can be determined that this is unilateral, the symptom is almost certainly due to a lesion involving either some portion of the third branch of the fifth nerve, the chorda tympani, or the glosso-pharjmgeal nerve. It is not often difficult to distinguish between these three, for if the chorda tympani is involved it is almost certain that the facial nerve will also be affected upon the same side, and this will be evidenced by paresis or paralysis of the face of the infranuclear type (p. 536) ; there may be excessive watery secretions from the submaxillary gland upon the same side ; the commonest condition to cause these symptoms is disease of the middle ear extending to the Fallopian canal. If it is found that sensations of taste are impaired only in the posterior third of the tongue upon one side, the lesion probably affects the glosso-pharyngeal nerve, and it is very possible that there may be paresis of the same side of the palate or partial paralysis of the pharjmx at the same time. WTien the Hngual branch of the fifth is involved, the impairment of sensation is in the anterior two-thirds of the tongue on the same side. The lesion may be a tumour or an injury affecting the lingual nerve in the mouth ; or it may be part of a more general affection of the fifth nerve of that side, with corresponding interference with cutaneous sensibiUty of more or less of the skin of the face, according to the extent to which the different branches of the fifth nerve are involved ; if the motor root is affected, the fact can be ascertained by feeUng the masseter and temporal muscles, which, when the patient clenches his teeth, do not harden so much on the affected as on the sound side. WTien sensation on both sides of the tongue is affected, it is possible that the lesions described above may be bilateral ; but it is much more likely that the defect is then not primarily nervous, unless it is due to bulbar paralysis, the progressive labio-giosso-pharyngo-laryngeal weakness of which is pathognomonic. When the cause of impaired sensation is in the nose, as in the case of coryza, rhinitis, polypi, or adenoids, it will be found that sonie substances can be tasted easily and others not at all ; this depends upon the fact that taste consists of two parts, flavour and savour ; savour depends upon sensation transmitted by the olfactory nerves — the so-called taste of roast beef for instance ; savours will be defective when the nose is the cause of abnormal taste-sensations ; while flavours such as the taste of sugar, gentian, or salt, which are transmitted by the gustatory nerves of the tongue, will still be fuUy preserved. The differential diagnosis of the other conditions enumerated in the above list need not be detailed, for the conclusion come to will depend upon the result of careful inquiry into the history, investigation of the abnormal physical signs, and the other symptoms in the case. One would only emphazise the possibility of caries, or decomposing food existing between teeth that superficially look quite sound, and the fact that septic infection of the accessory sinuses of the nose may be long overlooked, though in each case abnormal taste sensations ma\- be prominent. Herbert French. TENDERNESS IN THE CHEST implies that pain is felt when some part of the chest wall is touched or pressed. Such tenderness is quite a common symptom, and mav occur in a great variety of diseases. In some instances the pain felt is a direct pain, due to stimulation of sensory nerves actually in the diseased area. In others — perhaps the majority — the pain is a referred pain (the " somatic pain " of Ross), felt in the skin and subcutaneous tissues that are tender, but due to a visceral lesion remote from the tender area. 776 TENDERNESS IN THE CHEST Causes of Tenderness in the Chest. These may best be considered and classified in accordance with the situation of the lesion to which it is due. I. Lesions of the Chest Wall : the pain is for the most part direct : — Inflammations of the skin and underlying tissue Intercostal myositis Myalgia Pleurodynia Affections of the ribs and sternum Blood diseases Intercostal neuritis Injury of the intercostal nerves Intercostal neuralgia Hysteria Herpes zoster Pleurisy Mediastinal disease Pericarditis. Abdominal Viscera : the pain is usually a referred Stomach and cesophagus Liver. 2. Lesions of Thoracic and pain ; felt in lesions of the — Lungs Heart and aorta Diapliragm I. Lesions of the Chest Wall. — Tenderness in the chest is probably the chief complaint in superficial inflammatory lesions of the chest wall, such as bruises, burns, cuts, and superficial infections of all sorts, the diagnosis of which will probably leap to the eye, and need not be discussed further. Pain will be the chief coraplaint in intercostal myositis, often vaguely called rheumatic, that occurs after chill or strain of the intercostal muscles ; but the affected muscles will also be tender on pressure, the tenderness being in the deeper structures, not in the superficial tissues. The condition is also known as intercostal myalgia or pleurodynia ; it has to be distinguished from pleurisy by the absence of friction-sounds on auscultation ; and from disease of, or pressure on, the intercostal nerves. No doubt the tenderness is due to irritation of the sensory fibres in the intercostal muscles. Similar, but more transient, pain and tenderness may be met with in the stitch to which the untrained athlete is prone ; here the tenderness is very possibly due to trauma of fibres of an intercostal muscle. Tenderness in the chest may result from disease or injury of the ribs or sternum, when it will be localized to the injured spot ; fracture, inflammation, or new growth may be the immediate cause. If fracture is present, a history of a fall or injury should be obtainable ; and crepitus between the fragments on move- ment, or deformity, should be made out. Sternal or costal ostitis, or periostitis, may follow injury ; or occur in the course of such diseases as enteric fever, tuberculosis, pyaemia or septicopj^semia ; the local signs of inflammation (pain, redness, heat, swelling) and the general condition of the patient, should make the diagnosis fairly simple. Tenderness in the chest due to new growth in the ribs or sternum — such as hydatid, sarcoma, secondary deposits from carcinoma of the thyroid gland, prostate, or ovary — is a rarity that need only be men- tioned. Tenderness of the ribs and sternum, as well as of the long bones of the limbs, is not uncommon in certain blood diseases, in which hyperplasia of the red marrow, or excessive accumulation of white cells in it, may occur : such as pernicious anaemia or leukaemia. The diagnosis here must be made on the results of examination of the blood. In all these instances the tenderness is deep, and due to irritation of the sensory nerves of the periosteum or bone ; the pain felt on pressure is a direct pain. Tenderness at certain points of, or all along, the course of an intercostal nerze is common in various affections of these structures. The particularly tender TENDERNESS IN THE CHEST 777 spots are three in number, and correspond to the points at which the posterior primary, the lateral cutaneous, and the anterior cutaneous branches are given off, near the spinal column, the mid-axillary line, and the sternal margin, respect- ively. Such tenderness may be marked in intercostal neuritis, which is rare ; in intercostal neuralgia, which is often diagnosed when some more serious intra- thoracic disorder is really present, such as pneumonia or pleurisy ; and in cases of pressure on an intercostal nerve, such as may be set up by abscess about the spinal column, aneurysm of the descending aorta, or new growth invading the spinal canal. Whenever a patient complains of severe or obstinate pain and tenderness in the side, careful and repeated physical examinations should be made while the possibility that some such deep-seated disease may be present is kept in view, before the diagnosis of intercostal neuralgia, or of functional nervous disease (hysteria), is made. In exceptional cases of hysteria, zones of tenderness in the chest, possibly, too, Charcot's spasmogenic zones, may be found. Pain and tenderness along an intercostal nerve are common in herpes zoster, and may be present before, during, and after the appearance of the characteristic rash. The tenderness often has the three spots of maximum development men- tioned above ; it is particularly in the second half of life that herpes may be followed by a long period of pain and tenderness along the course of the affected nerve. Until the rash has appeared, or in the comparatively infrequent cases when the rash leaves no scarring behind it, the diagnosis of herpes may be difficult ; the rash, once seen, can hardly be mistaken. Tenderness of the chest is a common complaint in pleurisy, and is no doubt due to inflammation of the sensitive nerve-endings in the adjacent periosteum and the tissues of the intercostal spaces ; the pleura itself would appear to be devoid of nerves of sensation. The physical signs of pleurisy should suffice to make the diagnosis a simple matter if a careful physical examination be made. The tenderness is deep as a rule, and not exhibited by the skin and loose sub- cutaneous tissues. The sternum may be tender in the rare cases of mediastinal inflammation or tumour that are met with from time to time ; tenderness and direct pain may similarly be caused by the pressure of aneurysms on the internal surface of the chest-wall. The diagnosis in these cases must be made on the results of the physical examination of the patients, and will not be detailed here. Tenderness with pain over the precordia is fairly common in pericarditis, but it will hardly be the patient's chief complaint, and should not give rise to trouble in diagnosis. It may be so extreme as to preclude percussion or a satis- factory physical examination. Similar pain and tenderness have also been found at the epigastrium and the upper costal angles in these cases ; due, perhaps, to involvement of the diaphragm in the inflammatory process. 2. Lesions of the Underlying Viscera. — Tenderness in the chest is very frequently a symptom of disease in the underlying viscera, thoracic or abdominal, when the pains to which it gives rise are in most cases referred pains. The tenderness is therefore, as a rule superficial, confined to the skin and subjacent areolar and fatty tissues ; if these can be drawn aside, pressure can be made on the deeper tissues that normally underlie the tender area without provoking pain. Properly speaking, " tenderness in the chest " can only refer to tactile hypersesthesia, or the eliciting of pain on pressure, whether light or heavy. Such tactile hypersesthesia, or the production of unpleasant sensations or pain by the very lightest touch, is common in neuralgia and in neuroses, or in cases of referred pain. But a similar hyperaesthesia for cold, or less often for heat, sometimes occurs in the chest — in tabetic patients, for example ; this may perhaps be regarded as a special form of " tenderness." In the same way hyper- 778 TENDERNESS IN THE CHEST aesthesia for pain, or hyperalgesia, in which a normally painless stimulus or impression becomes transformed into an acutely painful sensation, is to be regarded as a form of " tenderness " in the chest. Further, perversions of sensation sometimes occur in organic nervous diseases, such as sjrringomyelia or tabes. Thus, tenderness may be elicited by the continuous application of a pressure that is painless if applied only for a short time (summation of painful stimuli) ; or the pain may be first felt some little time after the application of the stimulus to the tender area (retarded sensation). Chest tenderness is not rare in cases of acute or chronic disease of the lungs, particularly tuberculosis ; in these, it is hard to be sure that one is not deahng with referred pains due to old or recent pleurisy or pleural adhesions. The tenderness may be either superficial or deep ; sometimes it is so marked as to be elicited even by the pressure of the clothes. It is generally felt most about the region of the apices of the lungs, the curve of the shoulder, or the scapula. It is often a very chronic trouble, vanishing during periods of general improvement, returning again when the patient's health is low or the pulmonary lesion is' progressing. Similar tenderness is often met with in acute bronchitis, or with chronic bronchitis and emphysema ; the diagnosis must be made on general lines. It must be remembered that identical areas of referred chest- tenderness may be observed in disorders of such various organs as the heart, lungs, liver, and stomach ; and that a patient may be long treated for " rheumatism " of the shoulder, for example, when he is realh^ suffering from one or more of such widely different disorders as tuberculosis, gall-stones, gastritis, or coronary sclerosis. Direct tenderness about the precordia is sometimes seen in heaj't disease ; as a rule, however, the tenderness is due to hyperaesthesia of referred origin. It is most marked in angina pectoris, and often persists after the anginal pains have passed off. Both the pain and the tenderness are felt within the area of distribution of the first to the eighth dorsal nerve roots ; the roots usually receiving the first and most intense impressions are the second dorsal. The left ventricle, the commonest primarjr seat of pain, is in relation with the second to the fifth dorsal nerve-roots ; the auricle with the fifth to the eighth ; the ascending aorta with the third and foiurth cervical and the first to the third dorsal. It is commonly stated that the pain and tenderness in morbus cordis are of two sorts, direct and referred ; but Mackenzie argues with some force that they are in reality always referred — a viscero-sensor}^ reflex. The nerve- connections stated above explain the extensive radiation and wide distribu- tion that may be exhibited by the tenderness and pain in the superficial tissues that may form such prominent symptoms of heart disease ; for the chest, neck, and arm may all be affected. The tenderness of angina pectoris commonly occupies the same areas as the pain, takes the form of a soreness, smarting, or of hyperalgesia to touch, and may last for days after the pain is over. In some cases, touching or stimulating the hyper-algesic area on the chest, arm, or neck, may refiexly induce an anginal attack — even the pressure of a stethoscope applied for auscultation may suffice — which is a strong argument for regarding the tenderness as a viscero-sensory reflex or a referred tenderness. Such anginal attacks and tenderness are commonest in coronary sclerosis, aortic aneurysm, aortic reflux, and acute aortitis ; they may also be seen in any form of heart-disease in which hypertrophy and dilatation have taken place, and the heart has to do more work than it can manage. In well-marked cases, the cardiac origin of areas of tenderness in the chest should not be difficult to diagnose, owing to their association with severe anginal pains on the one hand, and with the fact that the pain is brought on by exertions or emotions that increase the work of the heart. Identical areas of tenderness may TENDERNESS IN THE EPIGASTRIUM 779 be found in pleurisy or chronic pulmonax}' tuberculosis ; but here the pain will be connected with respiration or coughing in an unmistakable manner, and there will be the history and signs of pulmonary rather than of cardiac disease. Identical areas of chest tenderness may be found in diseases of the stomach, in the areas of distribution of at any rate the fourth and fifth dorsal nerves ; the diagnosis here will turn on the history of gastro-intestinal disorder, and on the radiation of the pain and the discovery of tenderness in the epigastrium. Tenderness in the chest may be seen in injuries or inflammations of the diaphragm, the lower costo-chondral margin being affected. The diaphragm is innervated bv the phrenic nerves mainly, and so is connected with the third, fourth, and fifth cervical nerve-roots ; accordingly, referred diaphragmatic pain and tenderness ma}- also be felt in the top of the shoulder, an area innervated by the fourth cervical nerve. In most cases, these areas of tenderness w^ill be due to diaphragmatic pleurisy. Diseases of the stomach, particularly gastric ulcer and flatulent dyspepsia, mav give rise to pain and tenderness in the chest that may be verj^ hard to distinguish from those due to cardiac disease. As a rule, the history of gastric disturbances should be of great assistance in coming to a correct diagnosis ; although it must be remembered that flatulence and temporary gastric upsets are not infrequenth^ seen in true angina pectoris. Further, the pain and tenderness due to diseases of the stomach are mainly abdominal, are in the epigastric and left hypochondriac regions, and in the lower half of the back of the chest ; whereas in cardiac disorders they are characteristically situated higher up in the chest and back. It is possible that disease or painful stimulation (as bj^ hot drinks) of the oesophagus may produce an area of referred tenderness in the chest, over the lower third of the sternum and in the middle line, in correspondence with the pain that is felt here in these conditions. Tenderness in the right side of the chest near the costal margin is not rare in diseases of the liver and gall-bladder, corresponding to the cutaneous distribution of the seventh, eighth, and ninth dorsal nerves ; for the most part, however, the pain and tenderness are in the epigastrium and the right h}-pochondrium. In addition, the right phrenic nerve (third to fifth cervical) sends twigs to the liver and gall-bladder, so that tenderness and pain may also be felt in the right shoulder, just as they may be in disorders of the diaphragm. It is particularly in cases of gall-stone or biliary colic that these areas of tenderness are likely to be found. In patients with hepatic abscess, the spread of inflammation to the chest wall may give rise to direct pain and tenderness in the chest, with the development of characteristic local and general s\Tnptoms and signs ; the dia- gnosis here will have to be made from such things as axillary abscess, empyema making its wav through the chest-wall, or abscess arising in the chest-waU. A. J. J ex-Blake. TENDERNESS IN THE EPIGASTRIUM.— In thin and nervous subjects, particularly women, tenderness may be elicited on deep pressure in the epigas- trium over the coeliac plexus. In the absence of other sjTnptoms this is of no significance. The upper bellies of the recti may be tender after strain, e.g. from hard exercise, vomiting, coughing, or retching. The fact that the tenderness is in the abdominal wall maj- be proved by pinching it up laterally when the muscles are relaxed. Epigastric tenderness may also be due to dHatation of the right ventricle, to pleurisj-, or to any of the painful conditions of the liver, stomach, or pancreas, the differential diagnosis of which is considered under the heading of Paix ix the Epigastrium. Robert Hutchison. TENDERNESS IN THE HYPOCHONDRIUM (LEFT),— (See Paix ix the Hypochoxdrium, Left.) 78o TEXDERXESS IX THE ILIAC FOSSA TENDERNESS IN THE HYPOCHONDRIUM (RIGHT).— (See Pain in the HvpocHOXDRirM, Right.) TENDERNESS IN THE ILIAC FOSSA (LEFT).— There is no particular condition to be recorded in which tenderness in the left iliac fossa is unaccom- panied by either pain or swelling. (See Pain in the Iliac Fossa, Left ; and S%^'ELLiNG IN the Iliac Fossa, Left.) Georgc E. Gask. TENDERNESS IN THE ILIAC FOSSA (RIGHT). (See also Swelling in the Ill^c Fossa, Right.) If a patient complains only of tenderness in the right iUac fossa, if there are no other guiding s^-mptoms and no sweUing, and if the case is not acute, it maj- be supposed that there is some slight inflammation of the ccecwm or vermiform appendix, or irritation of the mucous membrane of the csecum by the accumu- lation of faeces. It is not uncommon, in ver^^ acute abdominal conditions ob^■iously requiring immediate laparotomy, to find that tenderness in the right ihac fossa, without swelhng, is associated with signs of acute general peritonitis. There are three chief causes for this : — 1. Acute perforative or gangrenous appendicitis. 2. Perforated gastric or duodenal ulcer. 3. A ruptured tubal gestation. The commonest of the three is appendicitis. Acute Appendicitis. — The fact that the pain and tenderness started and are most marked in the right ihac fossa points to the diagnosis. There may have been a previous attack in which the s^miptoms were more definitely locahsed. Perforated Gastric or Duodenal Ulcer. — Usuall}^ the tenderness will be in the hj^ogastrium, but there are cases in which confusion arises because the tender- ness is most marked in the right ihac fossa, and because there is no previous historj' of indigestion, haematemesis, melaena, or vomiting. In anj^ case where grave s^-mptoms are prominent, an exploratory laparotomj^ is not to be delayed, and it is onh' a question of whether the abdomen is to be opened over the appendix region or over the stomach. Ruptured Tubal Gestation. — It is highlj- desirable that a diagnosis of this com- plaint should be made early. There will generally be the signs of internal haemorrhage — pallor, fall of temperature, rise of pulse-rate, and the presence of free fluid in the abdomen ; the patient is usually a week or more overdue as to a menstrual period, and the acute symptoms come on sjmchronoush^ with a loss of blood per vaginam that may be mistaken for the onset of the ordinary menses. George E. Gask. TENDERNESS IN JOINTS.— (See Joints, Affections of.) TENDERNESS IN THE LIMBS.— (See Pain in the Limbs, General ; and Sensation, Some Abnormalities of.) TENDERNESS IN THE SCALP occurs in two main varieties :— I. Direct Tenderness, due to injurv or disease, such as — Bruising or infected wounds Inflammation or suppuration complicating pediculosis, ringworm, favus, eczema, pruritus, acne, etc. Herpes and dermatitis herpetiformis, er\-sipelas Lupus er\-thematosus, von Recklinghausen's disease Sclerodermia, Brocq's " pseudopelade " Diseases of the skull — ^rickets, syphilis, tumour. TENDERNESS IN THE SCALP 7S1 2. Referred Tenderness, either due to disease elsewhere, or functional : — Meningitis, increased intracranial pressure, intracranial tumour, concussion of the brain, otitis media. Neuralgia, major and minor, whether primary or due to disease of the eves, ears, teeth, or viscera. Neurasthenia and hysteria. Fig. 200 exhibits the cutaneous nerve-supply of the scalp and face, indicating the areas in which tenderness and pain are to be expected when disease or disorder of the various nerves is present. I. If tenderness in the scalp is due to bruising or wounds, it should not be difficult of diagnosis when the history has been obtained. A similar tender- ness is naturally to be expected when- ever inflammation or suppuration occurs as a complication or later stage of any of the numerous skin diseases to which the scalp is liable, such as pediculosis, ringworm — a suppurating ringworm is known as kerion — seborrhceic dermatitis, favus ; the itching of eczema or pruritus may be so severe as to lead to scratch- ing which breaks the skin, with the result that impetigo or pus-infection ensues. In young men and women acne may spread back to the scalp from the forehead, face, or neck ; acne decalvans is a mild staphylococcal infection of the hair-follicles that slowly creeps across the scalp, and leaves it bald by destroying the hair -follicles. Furunculosis of the scalp, and inflammation of a sebaceous cyst, need only be mentioned in this connection. In herpes ophthalmicus, or herpes zoster of the area supplied by the ophthalmic or first branch of the trigeminal or fifth cranial nerve, extreme tenderness over the affected area may be noted while the eruption lasts ; and after it has dis- appeared, tenderness and itching may be left behind for many months or years. Dermatitis herpetiformis is a somewhat similar grouped vesicular or bullous eruption, with ringed and other er^-thematous lesions, but characterized by a much more extensive distribution than herpes zoster ; when it involves the scalp much tenderness may ensue, although the chief complaint will be of itching, and the course of the disorder is long and uncertain. Erysipelas is common in the scalp, and should be diagnosed readily. Lupus erythematosus of the scalp may cause tenderness while progressing actively, when it may resemble even a severe persistent er\-sipelas ; as a rule it is a very chronic, slowly progressive disorder, commoner in females than in males, starting between the ages of twent^'-five and forty-five. It produces smooth and depressed areas of complete and permanent baldness, reddened by abundant injected venules. In von Recklinghausen' s disease, subcutaneous neurofibromas are found all over the body, in association with freckling and pigmentation ; occurring on the scalp, these tumours will make it tender, whereas the tumours of fibroma molluscum {Fig. 201), a disorder at first sight resembling von Recklinghausen's disease, are not sensitive to pressure. Sclerodermia of the scalp may occasion much tenderness, particularly in its early stages ; it is a chronic diffuse infil- tration of the skin that ends in atrophy, and by many is supposed to include fig'. 200. — The cutaneous nerve-supply of the scalp. G A, Great auricular nerve ; G O- SO, and Th. O, Great, small, and third occipital nerves ; V i, V 2. V 3, Ophthalmic, superior maxillary, and inferior maxillary divisions of the trigeminal (or fifth cranial) nerve. 782 TEXDERXESS IX THE SCALP the " pseudo pelade " of Brocq, an atrophic indurative affection of the scalp giving rise to depressed areas of absolute and permanent baldness that adhere to the underlying skull, and connected by Brocq with alopecia areata. Tenderness of the scalp is common in rickets, and is the main cause of the head-rolling and restlessness of the recumbent ricketv' chUd. It is due to hvperaemia and disordered growth of the cranial bones ; and can often be diagnosed at sight by the thinness of the hair or positive baldness of the occipital region to which the head-rolling leads. A similar tenderness of the cranial bones is seen in congenital syphilis, and is caused by the rarefying (craniotabes) or hyperplastic (hot-cross-bun skull) osteitis present. In adults with neglected syphilis the skull may be tender from secondaiy syphilitic periostitis or tertiary gumma ; besides the tenderness, pain is present, and is characteristically worse at night. Tumour of the cranial bones may give rise to tenderness of the over- lying scalp or periosteum ; in adults such tumours are usually secondary to malignant disease of the breast, thyroid gland, testis, or prostate. In children they are often secondary to sarcoma of the suprarenal gland, and may be the first clinical evidence that anvthing is amiss. 201. — MoUuscum fibrosiim in a comparatively early stage. F7-m>i photog7-aph lent hy Dr. A. Rcitdlc Short. 2. Tenderness in the scalp may be due to organic disease that is not in direct connection with it. In meningitis, whether syphilitic, tuberculous, or due to pus-producing microbes, local or general tenderness of the scalp maj- be a marked feature ; and the same is true in cases with increased intracranial pressure due to any cause whatever. The chief complaint, however, will be of headache {q-v.). In intracranial tumour the scalp and periosteum are sometimes tender to pressure in the neighbourhood of the growth ; the associated signs, such as vomiting on change of position, slow pulse, optic neuritis, and local paresis or paralysis, should aid the diagnosis. Tenderness of the scalp in the occipital region and below it has often been noted after concussion of the brain, whether mild in degree or severe, and apart from neurasthenia ; the pain and tenderness may each be both superficial and deep. Tenderness of the scalp is often marked in neuralgia, a vague term applied to any severe pain that follows, or seems to follow, the distribution of a nerve. In trigeminal neuralgia, neuralgia major, or tic douloureux, the pain and tenderness often spread back to the vertex and parietal eminence, in correspondence with TENDERNESS IN THE SCALP 783 the cutaneous distribution of the first or oplithahiaic branch of the fifth nerve. Pressure over the tender area will often bring on a paroxysm of pain ; yet while the pain is raging, the patient often gains some relief by firm pressure over the painful part. When the paroxysm is recently past, pressure does not have any obvious effect in some cases. Identical neuralgic pain and tenderness may be met with in the rare cases where a tumour presses on the trigeminal nerve or its roots, as may happen in patients with meningeal new grow-ths ; the diagnosis here is important, because operative removal of the Gasserian ganglion would be useless in such a case. Definite loss of sensation occurs if the nerve is involved in a tumour, whereas in tic douloureux there is no anaesthesia ; in addition, the other signs of intracranial tumour should be looked for. In another group come the cases of neuralgia minor, in which pain and tender- ness in the scalp form a visceral reflex, and are due to disease in the eyes, teeth, ear, and thoracic or abdominal viscera. A referred visceral pain usually brings with it superficial tenderness, and both the pain and the tenderness, according to Head, are found over " segmental " areas, or areas that do not correspond with the distribution of the peripheral nerves, but follow a central distribution The Segmental Are.\s of the Scalp {after Head). MD.'^; -j V-Fr.n Fig. 2C2. — The segmental areas. Fig. 203. — The maxima of the segmental areas shown in Fig. 202. Fi\ n, Fronto-nasal ; Mo, Mid-orbital; Oc. Occipital; P, Parietal; T, Temporal; V, Vertical. {Figs. 202, 203). In other patients, however, the same lesions produce areas of pain, and less often of tenderness also, that do follow distributions correspond- ing with those of the peripheral nerves ; and these are described as cases of neuralgia minor proper. To give examples of reflex neuralgia, disease of the upper bicuspids may cause pain and tenderness in the temporal region ; disorders of the eye, particularly astigmatism and hypermetropia, iritis, and glaucoma, may cause headache and tenderness spreading from the forehead to the vertex and to the temporal area ; suppuration in the middle ear may make the whole side of the head tender. Certain areas on the head are segmentally united with other areas on the body ; the temporal area of the scalp is connected thus with the seventh dorsal segment, and so diseases of the heart, lungs, or stomach may all bring about temporal pain and tenderness, associated with the segmental area of cutaneous tenderness about the level of the epigastrium that directly represents the seventh pair of dorsal nerves. It is probable that a number of patients with undetected disease of the teeth, eyes, ears, or viscera, are treated for " neuralgia " for long periods, when a more careful examination of their historv' and investigation of their physical condition would lead at once 784 TENDERNESS IN THE SCALP to the proper diagnosis. In a certain number of cases pain and tenderness in the scalp are due to general diseases such as diabetes meUitus, malaria, and rheumatism ; a fact that leaves room for much looseness in diagnosis. In both neurasthenia and hysteria complaints of pains and tenderness are common, and the scalp may be affected just as any other part of the body may. The neurasthenic often has occipital tenderness, with pain referred to the hair ; brief mental effort niay bring on pain and tenderness in the sinciput or vertex. The hysterical patient may be prostrated by headache, with extreme tenderness of the scalp. It is not necessary to say that the greatest care to exclude organic disease of every sort should be taken before the diagnosis of neurasthenia or hysteria is made in a patient complaining of tenderness in the scalp. It is noticeable that any conditions tending to build up the strength and improve the nutrition of neuralgic, neurasthenic, or hysterical patients, are likely to lessen the pains and areas of tenderness of which they so often complain. Conversely, these persons are always much worse when their health is low, and particularly when they are ansemic. a. J. J ex-Blake. TENDERNESS IN THE SPINE occurs in conditions of two different sorts. In the first it is due to local disease of the skin or subcutaneous tissues, fasciae, muscles, bones, or nerve-tissue in the immediate neighbourhood of the spine ; and the pain felt when the tender spot is touched is a direct pain. In the second there is no local disease, and the pain felt on stimulation of the tender area is a referred pain, due in most cases to organic disease of one or other of the viscera, in a few to some obscure nervous disorder. The tenderness varies widely in degree. In the severest cases, whether direct or referred, the pain may be such that the patient cannot endure even the light pressure of the clothes ordinarily worn, and is in agony the moment a finger is laid upon the tender place. I. When due to Local Disease, the tenderness is usually associated with rigidity of the spine in the tender section, a protective reflex designed to give rest to the diseased part. This is particularly well marked when it is bone — the vertebral column — that is diseased. A similar but less complete and more extensive rigidity will be noted when the local disorder is in the muscles or fasciee of the back. Should the local disease or injury be so extensive as to involve or compress the spinal cord, special symptoms (girdle-pain, paresis, anaesthesia, etc.) will be added. The chief morbid states in which such tenderness of the spine occurs are summarized in the following table : — Diseases of the skin and subcu- (Trauma, infected wounds, abscess- taneous tissue j formation, etc. Diseases of the muscles, fascia, or nerves Gout, rheumatism, trauma, herpes, etc. , Tuberculosis and other infections Caries sicca, spondylitis deformans, " typhoid spine " Diseases affecting the vertebrcs -! Erosion by aortic aneurysm I Invasion by malignant disease Trauma, with or without injury to the cord. Traumatic neurasthenia, with \ local lesions that are not de- '- " Railway spine." monstrable i To consider these lesions in detail : Obviously the skin and subcutaneous tissues may be tender over the spine after falls or blows on the back, infected wounds, in acne and furunculosis, in abscess-formation, whether the infection TENDERNESS IN THE SPINE 785 is derived from without, or from within as in pyaemia ; a psoas abscess has been known to point and discharge on the back over the vertebral column. Tenderness in the spine due to affections of the fascicB and muscles may be experienced by any ill-trained person who over-uses or strains his spinal muscles ; it is also common in gouty patients ; and frequently it is associated in the rheumatic with attacks of lumbago. Deep-seated inflammations in this region are not rare, and are seen usually in connection with spinal caries ; less often the inflammation may be due to pyaemia, empyema perforating spontaneously, trichiniasis and other very rare forms of myositis, when they chance to attack the spinal region. In a few instances, no doubt, disease of the spinal nerves, particularly when their posterior primary divisions are affected, gives rise to tenderness in the spine as well as along the course of the nerves themselves ; this may occur when pressure on the nerves or their roots exists, and in cases of herpes zoster or neuritis. Most of the causes of spinal tenderness enumerated above are comparativeh' rare ; and their diagnosis should not be difficult if a careful examination of the patient be made, and his other signs and symptoms of disease be noted. The cases in which the tenderness is due to disease of the vertebrae are far more important than the above, and probably commoner also, as well as far more serious from the point of view both of prognosis and treatment. Excluding spinal trauma, which usually declares itself obviously and is considered below, the three disorders to which the vertebrae are liable in this connection are tuberculosis, invasion by malignant disease, and erosion by an aneurysm. In other rarer instances they may be affected with similar symptoms and results by actinomycosis, pyaemic abscess, the spread of infection from adjoining parts (retropharyngeal, mediastinal, subdiaphragmatic, perinephric, or pelvic abscesses), hydatid disease, spondylitis deformans, and vertebral arthritis due to the gonococcus and other microbes. When caused by vertebral tuberculosis, the spinal tenderness is local, and is generally accompanied by more or less angular deformity of the spinal column, collapse of the diseased and softened anterior part of the vertebral body, causing abnormal projection of its dorsal spine at the same time. If it is the posterior part of the affected vertebra that collapses, the spinous process will sink inwards ; it must be remembered, how- ever, that congenital defect or deficiency of a spinous process is not very rare, and may be mistaken for the result of injury or disease. Whether deformity accompanies spinal caries or no, rigidity of the diseased part of the spinal column is sure to be present. It is maintained by involuntary contraction of the appropriate muscles, and becomes conspicuous when the patient is encouraged to bend his back in any direction, or to rotate the body on the pelvis. In addition, pain will be felt in the back when the patient's vertex, shoulders, sacrum, or legs are jarred ; his gait, too, and method of holding himself and turning, designed to relieve the diseased part of the spinal column from shock or strain, will be characteristic. In children who are not well looked after, this spinal tenderness and deformity may be unnoticed and the diagnosis of spinal caries not established until a psoas abscess has formed and has declared itself by pain in the leg, or lameness. The importance here of early diagnosis cannot be overstated ; spinal tuberculosis is commonest in children, but may occur at any age. It often happens that rickety children are suspected of " spinal disease " by their parents ; they present marked spinal curvature, due to flabbiness of the muscles, and, like all their bones, their spines may be tender on pressure. But there is no localized spinal tenderness in rickets, there is no angular deformity, the spinal curvature vanishes when the child is suspended by the head or arms, no pain is caused by jarring or rotating the spinal column, and there is no rigidity of the back. And the other ordinary D 50 786 TENDERNESS IN THE SPINE evidences of rickets will be present, so that the diagnosis should not be difficult. In adults, however, and particularly during the second half of life, it may often be difficult to determine whether a persistent tenderness over some part of the spine, associated with persistent pain and rigidity, is due to tuberculosis, aneurysm, or malignant disease affecting the vertebral column. The occurrence of angular curvature, due to softening and collapse of the vertebral body, would, argue in favour of tuberculosis, being comparatively rare in aneurysm or malignant disease ; evidence of tuberculous mischief in the patient's joints, lungs, or larynx, a history of cough or blood-spitting, or a marked family history of tuberculosis, would all point in the same direction. Aortic aneurysm, eroding the vertebral column and causing pain and tenderness by pressing on the nerves in its vicinity, would be suggested if the patient were a middle-aged man giving a history of syphilitic infection, and exhibiting more or less arterial degenera- tion. Examination under the ,r-rays and testing for the presence or absence of Wassermann's reaction might be of great assistance here ; deep abdominal palpation, under an anaesthetic if necessary, might reveal the expansUe pulsation of an aortic aneurysm. Secondary deposits of malignant disease, invading or enconipassing a vertebra, may occasion marked spinal tenderness and pain in the back of the severest description ; in rare cases, the malignant growth may be primary. The vertebrae are the bones most often invaded by secondary malignant growths ; the primary growths most frequently responsible for secondary deposits in the bones are carcinoma of the thyroid, testis, prostate, and mamma, primary sarcoma of bone, and melanotic sarcoma. Here again the diagnosis may be very difficult, in the earlier stages of the disorder particularly, because the primary growth may be small and deep-seated, and may have given rise to no signs or symptoms leading to its discovery, so that the presence of secondary deposits is not suspected. In the later stages, the growth often burgeons into the spinal canal, and causes symptoms of paraplegia by compressing the spinal cord. When this occurs the diagnosis is easier, for the site of the compression may be indicated by a girdle-pain and a zone ot hyperaesthesia ; while anaesthesia, with paresis or paraplegia, is found below it, the sphincters are affected, the knee-jerks are increased, and ankle-clonus and Babinski's extensor plantar reflex can be elicited. But, as has been pointed out already, it may be impossible to find any definite physical signs in a patient complaining of very severe and intractable pain and tenderness in some part of his spinal column ; and raost physicians of experience must have met with sad cases where such patients have been treated as malingerers, the honesty of their complaints failing to win recognition until a pathological basis for them has been established at an autopsy. Little more need be said about most of the other local diseases that may make the affected region of the spine both tender and painful. Caries sicca is the name given to an obscure rarefying osteitis of chronic course, non-suppurative, that raay attack the vertebra". The signs and symptoms of vertebral actino- mycosis resemble those of tuberculosis. In chronic pycemia a vertebral abscess may arise, and in patients with abscesses in the spinal region — such as pelvic, perinephric, subdiaphragmatic , mediastinal^ or retropharyngeal — a spread of infection to the vertebrae may conceivably occur, giving rise to tenderness in the affected part of the spine ; hydatid disease of the spinal canal or vertebral column may do the same in persons exposed to echinococcus infection. But in all these instances the tenderness in the spine wUl be but a minor symptom of a serious and more or less acute disorder, with other features that are more characteristic. Tenderness in the spine is often marked in spondylitis deformans, the name given to practically any chronic non-suppurative form of vertebral arthritis. It is no doubt an infectious process, and occurs after gonorrhoea. TENDERNESS IN THE SPINE 787 influenza, enteric fever (the " typhoid spine "), tonsillitis, and other bacterial dis- orders. It is characterized by stiif^ness in some portion of the vertebral column, with irregular deposits of new bone in the adjoining ligaments, particularly the anterior common ligament, well seen by the use of A^-rays. The chief sign is stiffness in the back, and in a few of the cases osteo-arthritis of some joints of the limbs occurs as well ; in instances where the hip or shoulder are thus involved the disease has been named " spondylose vhizomelique " by Marie. Men are affected four or jive times as often as women, and the disease usually begins between the ages of twenty and fifty. Its diagnosis may be difficult, because the chief complaint may be of pain in the hips, legs, abdomen, or thorax, or of " sciatica " or " lumbago," so that disease of the vertebral column may be neither suspected nor looked for. In most patients, the affected region of the spine is tender ; much spasm of the dorsal muscles is found in the more acute cases, while in those of long-standing, atrophy from disuse will be found. The typhoid spine is a rare sequela of enteric fever, usually occurring early in convalescence. The patient complains of tenderness and the most acute pain in the lower part of the vertebral column, after an initial stage of backache. Fever is present at first in half the cases, and no doubt the condition is commonly due to vertebral periostitis set up by the Bacillus typhosus. The symptoms last for manj^ months as a rule, and deformity of the spine is left in half the patients ; but suppuration of the affected vertebrse seems to be unknown. Men are more often affected than women, and the diagnosis should not be a matter of great difficulty. In milder cases no physical signs of vertebral disease appear, and so the affection has been described as hysterical, the spine as an irritable spine ; in yet other instances, the spinal cord appears to be involved, as if the periostitis affected the spinal canal, loss of control over the sphincters being observed, with paresis of the legs, and changes — usually increase — in the reflexes. Tenderness in the spine due to trauma may be the expression of either organic or functional disease resulting therefrom, and the precise diagnosis may be extremely difficult. The trauma is usually a raUway or other accident of locomotion (" railway spine "), a fall, a sudden shock or concussion ; in another group of cases it is either a single sudden muscular over-strain, due to over- exertion or the effort to avoid an accident, or the more chronic over- strain to which rowing men, football players, and the like are exposed. A gross injury may produce fracture of a vertebra, with or without displacement of the fragments such as can be demonstrated by use of the x-xdt,YS ; subperiosteal or subdural hemorrhage, haemorrhage into the spinal canal, haemorrhage into or bruising of the cord, all of which will give rise to localizing cord-symptoms (girdle-pain at the level of the lesion, varying degrees of paresis and anaesthesia below it) when the lesion is marked. At the other end of the scale are found the sufferers from traumatic neurasthenia, who have been exposed to identical injury or over-strain, but present no definite signs of disease in the spine or cord, although quite incapacitated for months or years, by weakness and severe pains in the injured region. These patients often have increased knee-jerks and even ankle- clonus ; but definite evidences of organic disease are wanting, the sphincters are unaffected, Babinski's extensor plantar reflex is not obtained, muscular wasting is not found, unless from disuse, and the various pains and tendernesses of which complaint is made have a neurasthenic or even a hysterical distribution and character. Traumatic neurasthenia may follow after surgical operations or comparatively slight injuries to the head, back, or testicle, in addition to the severer traumas and strains already mentioned ; and it must be noted that a delay of one or more weeks, an incubation-period, may intervene between the receipt of the injury and the development of the neurasthenic pains. It would be unfair to take such a delay as evidence of a hysterical factor in the case, or of malingering. 788 TEXDERNESS IK THE SPINE ist Dorsal Spina It is clear from the foregoing paragraph, that traumatic neurasthenia includes cases in which it is not possible to say for certain whether a local organic lesion of the spine exists or not. Such instances form a natural transition to those in which there is : — 2. Tenderness in the Spine due to Functional Disorders, or to Disease in Other Parts of the Body. — In very few of these is there an}- deformit}^ of the spinal column ; it is flexile and not rigid ; and pain is rarely produced when it is carefully bent, twisted, or jarred, so long as direct stimulation of the tender part is avoided. As a rule, the tenderness is superficial rather than deep, and it is often associated with other areas of tenderness in the side or front of the body. In h5'steria, complaint of pain and tenderness in the spine and back is not rare — ^the " hA'sterical spine." The tenderness over the vertebrae is often accompanied by tenderness on either side of it ; in extent it may change from time to time, invohT.ng a single vertebra or even most of the vertebral column. In neurasthenia the spine may be tender from top to bottom, and more or less rigidity is often found also. When the tenderness is local- ized to a small part of the back, it may easily be taken as evidence of local organic disease ; but the presence of other neurasthenic s\Tnptoms — ^headache, irritability, fatig- ability after brief exertion — and the absence of signs of definite local disease or in- volvement of the cord, should help in the diagnosis. To dis- tinguish clearly between neur- asthenia and hysteria is often difi&cult, and particularly so in the milder cases of traunaatic neurasthenia, because the}- ma}^ develop hysterical features such as areas of anaesthesia, a craving for sjnnpathy, a tendency to exaggerate the symptoms, and so forth. The harmful efiects of mental worry on neurasthenia, of the uncertainty attaching to an impending law-suit in which, perhaps, damages for injury are being claimed, are well known. Tenderness in the spine is ver}^ commonly a reflex from disease in one or other of the thoracic, abdominal, or pelvic viscera. The tenderness is characteristically superficial in these cases, and acute pain may result from light pressure on the area involved ; and if the tender tissues can be pulled aside sufficiently, it will be found that pressure on the spine itself causes no pain Avhatever. The different viscera produce this tenderness with some regularity in different and definite spinal areas, and the fact, worked out by Head, Mackenzie, and others, is of ser\dce in diagnosing the site of the actual lesion from which the patient is suffering. A scheme of the areas is given in the diagram {Fig. 204). ■pyg. 204. — Areas of referred spinal pain and tenderness {after I\Iackenzie). A, In diseases of the heart ; B, In dise.-ises of the stomach ; C, In diseases of the liver ; D, In diseases of the rectum and uterus. THIRST, EXTREME 789 The organs and diseases most often giving rise to this referred tenderness and pain in the spine are as follows : The aorta, in aortitis, arteriosclerosis, and aneurysm ; the heart, in coronary sclerosis particularly, myocarditis, myocardial fibrosis, acute dilatation and failing compensation ; the stomach, in gastric ulcer, malignant disease, gastritis ; the liver, in cholelithiasis, cholangitis, new growth, and the venous congestion of tricuspid reflux ; the intestine and rectum, in acute inflammatory disorders and in constipation ; the uterus, in labour, menstruation, and inflammatory affections. It would appear that the lungs, whether inflamed or wounded, do not give rise to a referred tenderness ; on the other hand, the whole or any part of the thoracic spine may become tender in disorders of the pleura, such as pleurisy, pleural adhesions, or new growth. To illustrate the frequency with which pain and tenderness of the spine occur, may be quoted the axiom of many hospital out-patient departments, that there is no woman in London who has not got a pain at the bottom of her back — a libel on the sex, one may hope. The importance of distinguishing between the cases in which the physical signs of organic disease in the vertebral column or cord are absent, and those detailed in Class i above, need not be emphasized further. The referred pains and tendernesses disappear or are relieved with the cure or relief of the cardiac, gastric, or other disorder to which they are due. The diagnosis of the cause of tenderness over the fourth dorsal vertebra, for example, which may be due to disease of the heart, pleura, or stomach, must be made on general lines, and by consideration of the o!;her signs and symptoms exhibited by the patient. A. J . J ex-Blake. TETANIC CONTRACTIONS.— (See Contractions.) THERMO-AN^STHESIA.— (See Sensation, Some Abnormalities of.) THIRST, EXTREME. — Cases of extreme thirst may be subdivided into two main groups ; namely, those with and those without polyuria. To the former belong such conditions as diabetes mellitus, diabetes insipidus, hysteria, and so on, which are discussed under Polyuria. To the other group belong such conditions as are for the most part so obvious as to require no more than simple enumeration under main headings, as follows : — 1. Prolonged abstention from drinking, purposeful, or the result of necessity. 2. Fevers and febrile states. 3. Excessive loss of fluid : (a) From the skin by profuse perspirations, natural or pathological ; [b] From the stomach, from repeated vomiting ; (c) From the bowel, from excessive diarrhoea; {d) Into serous membranes, as in acute peritonitis. 4. After severe haemorrhage : [a) External, e.g., post-partum ; [b) Internal, e.g., from duodenal ulcer. 5. Gastrectasis due to pyloric stenosis, owing to the fact that the stomach absorbs little fluid as compared with the intestines. 6. Poisoning by such drugs as dry up the secretions of the mouth, notably belladonna and its allies, or astringents such as alum, gallic acid, tannic acid, or perchloride of iron. 7. The exhibition of excess of various salts, particularly sodium chloride, either as such, or incorporated in various food-stuffs. It is clear that in some cases more than one factor at a time may be causing extreme thirst. Herbert French. THRILLS, PRECORDIAL — In order to arrive at a diagnosis of the cause of any thrill which is felt over the prsecordia, two facts must first be ascertained, namely (i) The situation of the thrill; and (2) Its rhythm. Having discovered a thrill over the mitral area, that is, in the region of the apex beat, and found 790 THRILLS, PRECORDIAL that it is presystolic in rhythm, it is obvious that it is due to mitral stenosis. The valvular lesion will be confirmed by the presence of a presystolic bruit, as it is rare to find the thrill without a bruit being associated with it. On the other hand, if the thrill be systolic in time, and mitral regurgitation be present, the thrill is due to this valvular lesion. A systolic thrill at the cardiac apex may also be caused by pericardial friction fremitus, or pleuritic fremitus. A pericardial friction fremitus can be distinguished from an endocardial thrill b}- being more rubbing in character, usually occurring both during systole and diastole, while an endocardial thrill is a more purring vibration, and it only occurs during systole in this situation. The pericardial friction is confirmed by auscultation. Pleuritic fremitus in this region may be distinguished from an endocardial thrill and pericardial friction fremitus by asking the patient to hold his breath, when the fremitus will disappear. These distinguishing features between endocardial thrill, pericardial friction fremitus, and pleuritic fremitus, apply to any area in which thrills are detected. A pericardial friction fremitus may be present over the whole or any part of the prsecordia, but the most common situation is near the base of the heart. A systolic thrill in the second right intercostal space close to the sternum may be due to aortic stenosis, thickening of the aortic valve, atheroma, and dilatation or aneurysm of the ascending portion of the thoracic aorta, and the diagnosis of the cause of the thrill can only be made by the other physical signs which indicate the morbid condition present. Thus, if there be dullness in the second right intercostal space, over which the thrill is felt, there is dilatation or aneurysm of the arch of the aorta. There is no dullness in this situation when the thrill is due to aortic obstruction or to atheroma of the aorta. Kot only may dullness on percussion accompany the thrill, but there may be pulsation, and even a pulsating tumour, in this region, showing that there is an aneurysm of the aorta. Other signs of an aneurysm may be present, and an x-rs-y examina- tion is helpful in confirming the diagnosis. A diastolic thrill may also be felt in the second right intercostal space close to the sternum, but it is rare ; when present, it is due to aortic regurgitation, and is accompanied by the characteristic diastolic bruit. Sometimes the thrill, like the bruit, is most marked in the third left space close to the sternum. It must also be remembered that pericardial friction fremitus may be felt in the aortic area, and can be distinguished by the diagnostic signs which have aheady been considered. In the pulmonary area, viz., in the second left intercostal space close to the sternum, systolic thrills also occur, and are due to congenital affections of the heart, especially pulmonary stenosis, and patency of the ductus arteriosus. An extensive thrill felt over the base of the heart in young children is nearly always due to a congenital malformation of the heart, and can be distinguished by the other signs of congenital heart disease which are usuall}' present, especially cj-anosis and clubbing of the fingers. When thrills in this area are due to con- genital malformation, the apex beat is generally near its normal position. The cardiac dullness usually extends to the right of the sternum as the result of the enlargement of the right ventricle, and there is commonly a loud universal systolic bruit, having its point of maximum intensity over the base of the heart. The following signs of congenital malformation of the heart, other than patent ductus arteriosus, are also to be expected : cyanosis, either continuously present or occurring at intervals, dyspnoea, especially upon exertion, clubbing of the fingers and toes, and polycythsemia. With patent ductus arteriosus there may be no symptoms accompanying the abnormal physical signs. Thrills due to congenital malformations of the heart may occur almost anywhere over the praecordia ; the}- are systolic and sometimes diastolic in time, often felt over a THYROID GLAND, ENLARGEMENT OF THE 791 large area, and of very marked intensity. Wlien present, they are always accompanied by ample evidence of congenital disease. It must be remembered that a thrill may occur in the second left intercostal space close to the sternum, and be associated with a functional pulmonary bruit. In such a case, the functional origin of the thrill may be distinguished by the general condition of the patient, who will be suffering from anaemia or some debilitating condition. The signs of congenital heart disease, just mentioned, will be absent, so that the diagnosis of the cause of the thrill is usually quite easy. Presystolic and systolic thrills sometimes, but very rarely, occur to the right of the sternum in the tricuspid area, due to stenosis and incompetence of this valve. /. E. H. Sawyer. THYROID GLAND, ENLARGEMENT OF THE.— An enlarged thyroid gland gives rise to a swelling in the mid-line of the neck, internal to the sterno- mastoid muscles and the carotid vessels, which, if the swelling is large enough, are pushed outwards. The gland is intimately connected with the larynx ; hence the most important sign of a thyroid tumour is that it rises and falls with the larynx and trachea during deglutition. In the great majority of cases the presence of this sign alone is sufficient to make a correct diagnosis. There are two sources of fallacy : (i) A swelling not thyroid in origin but lying in front of it, such as a sub-hyoid bursa or sebaceous cyst, and also a suppurative or syphilitic perichondritis of the thyroid cartilage, may present the above sign ; (2) A thyroid swelling, if fixed, as it may be by inflammation or malignant growth, may not present it. In the vast majority of cases, however, a swelling in the position of the thyroid gland which moves on deglutition indicates an ■ enlargement of that gland. Varieties of Enlargement and their Differential Diagnosis. — During menstruation and pregnancy the thyroid is said to become enlarged, but this is rarely sufficient to cause symptoms ; if the gland happens to be the seat of pre-existing disease the increase of swelling may be sufficient to induce respiratory difficulty. Parenchymatous Goitre, or a general hypertrophy of the whole gland, is the commonest form of enlargement. All parts of the gland are affected more or less equally ; the tumour being bilateral, the normal shape is preserved. The swelling is freely movable, painless, and soft in consistency. It is rarely congenital, and more often appears about puberty. Its rate of growth is usually very slow, and it may attain an enormous size without causing any other symptoms. Cystic Goitre is a loose term used to cover any form of enlargement of the thyroid which is chiefly caused by the presence of one or more cysts. If the cyst is large and lax, fluctuation may be made out. The cysts, however, are often small and tense, and cannot be distinguished from solid adenomata'. Cysts are rarely present without some enlargement of the rest of the gland. Adenomatous Goitre. — The common cause of unilateral enlargement is the presence of an adenoma, a definite encapsuled tumour which may contain cysts and grow to a large size. A haemorrhage into one of these cysts may cause a very rapid enlargement, and so give rise to a suspicion of malignancy. Adeno- mata may be single or multiple ; when present in both lobes, the enlargement may be difficult to distinguish from the parenchymatous form. Malignant Disease is seldom met with. It occurs with equal frequency in both sexes, and is rarely seen before the age of forty. In the early stages, while still confined within the capsule of the gland, it may be difficult to differentiate from the other forms of goitre. It should be recognized by its rapid growth, its hardness, and irregular and bossy outline. When the neoplasm has penetrated 792 THYROID GLAXD. ENLARGEMENT OF THE the capsule and invaded surrounding structures, the diagnosis is made with more ease. The tumour may become iixed, no longer moving on deglutition ; often one or other vocal cord is paralyzed, a condition rarely seen with innocent goitre ; and involvement and ulceration of the trachea is common. The lym- phatic glands maj" be enlarged, but as those first implicated are placed deeply, def\-ing detection, not much help is gained from this source. Exophthalmic Goitre (Graves' disease, von Basedow's disease) is far more common in women than in men {Fig. 85, p. 261), and rarely occurs before puberty or after middle life. The most prominent features of the disease are : (I) Exophthalmos; (2) Tach^xardia with palpitation ; (3) Enlargement of the thjTToid gland, often pulsatile ; (4) Tremulousness of the hands and general nervous excitability^ ; (5) Breathlessness on exertion. The vision is normal, but when the eyebaU is moved downwards the upper hd does not follow as in health (von Graefe's sign). The palpebral aperture is wider than in health, owing to retraction of the upper and lower lids (Stellwag's or Dalrymple's sign). Pigmentation of the skin maj^ be intense and simulate Addison's disease, but the mucous membrane of the mouth is not affected as in the latter maladv. A well-marked case is quite characteristic, but there are others extremely hard to separate from simple parench\Tiiatous enlargement, for with this, especially in young girls, ancemia is often associated, and with it the symptoms of tachycardia, palpitation, and breathlessness. It often becomes a matter of opinion whether a given case should be styled simple parenchymatous goitre or incipient Graves' disease. The above are the commonest forms of enlargement. Others much rarer are : Enlargement due to pyogenic infection, either acute or chronic. In pyaemia it is not uncommon to find the thyroid the seat of multiple abscesses. Tuberculous and gummatous disease m.a.\ also cause enlargement, and a slight degree of goitre has been noted in typhoid jever, acute rheumatism, malaria, variola, cholera, and secondary syphilis. Hydatid cysts of the th^Toid gland have been noted on a few occasions. It ha^dng been ascertained that the swelling in the neck is definitely th^-roid in origin and its nature defined, it remains to see whether there are any pressure signs on the surrounding structures. Pressure on the Trachea. — Dyspnoea is hy far the most important of all the sj'mptoms that maj- be produced by enlargement of the thjToid gland. It may be the onh- thing complained of b}- a patient not even aware of the presence of a goitre. The size apparently is not so important as the shape and situation, for one reaching to the waist may cause no obstruction, and one the size of a cherrj-, if situated between the sternum and trachea, may givx rise to the most intense dyspnoea. If the goitre is unilateral, the trachea is pushed over towards the opposite side and flattened ; if bilateral, as in the parenchymatous form, it is compressed laterally. The dyspnoea maj^ be constant and distressing, or only noticeable on exercise or on h'ing down. Most such patients like to lie high in bed, propped up on piUows. An idea as to the amount of pressure on the trachea may sometimes be gained by a question on this point. Pressure on Nerves. — Unless malignant, a goitre rareh^ causes much pressure on nerves. Those that ma}' be involved are : (a) The recurrent laryngeal, resulting in paralysis of a vocal cord ; (b) The sympathetic, shown by contraction of the pupil on the affected side and ptosis ; (c) The vagus ; [d) Rarely the nerves of the brachial and cervical plexuses. If any of these nerves are involved, suspicion must arise as to the malignancy of the tumour. Pressure on the (Esophagus.- — Being placed behind the trachea, the oesophagus generally escapes pressure b}- a goitre, though this is to be remembered as a rare cause of dysphagia. TINNITUS 793 Pressure on Veins is common, particularly on the internal, external, and anterior jugulars. The pressure is rarely more than sufficient to make them stand out prominently. George E. Gask. TINEA, VARIETIES OF. — (See Fungous Affections of the Skin.) TINNITUS is a symptom which occurs in a large proportion oi cases of disease of the ear, and occasionally when there is no obvious lesion of the auditory mechanism. The sounds complained of are usually subjective, but they may occasionally have an objective origin. Tinnitus may be continuous or intermittent. Its intensity and character vary greatly in different patients ; to some it is an intolerable annoyance, and occasionally has even been the cause of suicide. The character of the sound should always be ascertained, as this may give some clue to the cause. Thus a pulsatile or rhythmical sound may be produced by the flow of blood through the internal carotid artery, which in its course through the carotid canal is separated from the tympanum only by a thin plate of bone, which may be deficient. A creaking noise may be produced by cerumen, or a foreign body, in the external auditory meatus. A bubbling noise may be due to the presence of exudation in the middle ear, the result of catarrhal inflammation. A cracking or clicking sound may be caused by spasmodic contraction of the dilatator tubas and salpingopharyngeus muscles which are attached to the Eustachian tube. When the character of the sound is described as humming, hissing, roaring, whistling, or musical, its origin is subjective, and is due to some irritation of the auditory nerve, rarely cerebral or in its course, but usually at its terminations in the lab\Tinth. A distinction must be made between tinnitus and hallucinations of hearing, the latter usually taking the form of hearing voices, and indicating mental trouble, usually of a serious nature. Tinnitus, however caused, is usually influenced markedly by the general health and environment of the patient. Thus, sometimes the noises are less marked when the patient is in the open air, when his attention is occupied by other matters, or when the sense of hearing is occupied by listening to objective noises. Similarly, the trouble may only be present at night, but may appear in the day-time if the patient closes the external auditory meatus with his finger. Generally speaking, tinnitus becomes less marked and more bearable when the general health of the patient is good, and increases when the sufferer is out of health or overworked, either mentally or physically. Working in close, stuffy rooms, or in proximity to noisy machinery, over-indulgence in alcohol, and excessive smoking, have a bad effect ; in women the trouble may be increased during pregnancy, men- struation, or the menopause. Though tinnitus is very common in diseases of the ear, yet serious lesions of the middle ear, internal ear, or auditory nerve, may be present without this symptom. There is no constant relation between tinnitus and deafness. The former may be present with perfect hearing, but when long continued the hearing nearly always becomes impaired. The sounds, too, may persist when the patient has become totally deaf. Tinnitus may occur in the following diseases of the ear : — 1. The presence of cerumen, aural polypi, or a foreign body in the external auditory meatus. Removal of the offending body will in this case probably lead to the cessation of the tinnitus. 2. In any inflammatory disease, acute or chronic, suppurative or nonsuppu- rative, of the middle ear. In catarrhal inflammation of the middle ear, the noise frequently has the character of bursting bubbles, and is due to movements of the viscid exudation in the ear itself. In otosclerosis, tinnitus is a very 794 TINNITUS prominent and usually early symptom. It may occur before any alteration in hearing is present. 3. In diseases of the internal ear, tinnitus is especially liable to occur in a severe and intractable form. Thus, it is especially likely to be present in Meniere's disease, syphilitic disease of the internal ear, and in those lesions of the internal ear which may arise in the course of typhoid and other specific fevers. Extension of suppuration to the labyrinth from the middle ear is also an important cause ; and it may be present, usually associated with deafness, after a fracture of the base of the skull. Tinnitus has been recorded as occurring in a cerebral tumouv involving the roots of the auditory nerve, but this is a very unusual condition. " Noises in the ears " may be present in a considerable number of general diseases, either with or without a lesion of the ear. Thus, it is frequently present in ancsmia, and in diseases such as leukcBmia or pernicious ancemia, in which anaemia is a prominent symptom. Some cardiac lesion, especially aortic regurgitation, may be found in the pulsatile variety of tinnitus, treatment of which may lead to the disappearance of this symptom. Gout, chronic nephritis, and arteriosclerosis with high blood- pressure, may also be responsible for tinnitus, and it may occur during attacks of migraine. Sometimes it has apparently a reflex origin, being associated with neiu"algia or digestive disturbances. Malaria may also be a cause, though here the trouble is likely to be the result of large doses of quinine. Other drugs likely to cause the trouble are salicylates and antipyrine. It must be remembered that tinnitus may be an exceedingly severe symptom, and that patients not infrequently present themselves for treatment on this account rather than for any coexistent deafness. Philip Turner. TREMOR occurs when the normally continuous contractions of a muscle at work, or the normally uniform tone of a muscle at rest, are replaced by a succession of separately perceptible muscular twitches. In these circumstances, a movement which is normally uniform becomes tremulous ; a position that can be steadilj' maintained under normal conditions is now kept unsteadily or shakil}-. The normal muscular contraction is due to the discharge of a rhythmic series of nervous impulses from the motor neurons that govern the muscle. It is estimated that, in health, from five to fifty such nervous impulses leave the motor nerve-cells and reach the contracting muscle-fibres every second, the actual number per second varying in different motor neurons, and also in the same neuron according to its temporary condition of nutrition or fatigue. It is when the number of nervous impulses received per second by the contracting muscle-fibres becomes low, that steady and apparently uniform muscular con- tractions are likely to be replaced by tremors. Tremors are of very various periods, amplitudes, and general characters in different cases. Their physiology and pathology are not at present fully under- stood, so that it is not yet possible to classify them etiologicalh'. From a clinical point of view they may be classified roughly in accordance with their more obvious physical characteristics — their fineness, periodicity^, regularit}^, and the circumstances that favour or inhibit their production. But it must be understood that an unbroken series of graduated tremors can be traced in various diseases, passing by imperceptible degrees from the rapid and minute oscillations observed in paral3'sis agitans to the extremely coarse and irregular movements composing the intention-tremor of disseminated sclerosis. A similar variety of regular tremors may be observed sometimes in a normal person, as the tempera- ture of his body falls from exposure to cold, or during the occurrence of a rigor. Hence a rigid clinical classification of tremors is impossible. TREMOR 795 Mercury- Lead Classification. Fine Tremor. Exposure to cold, nervousness,! Chronic intoxications, e.g., by — emotion Muscular fatigue or weakness Convalescence Congenital and familial tremor Senile tremor Paralysis agitans General paralysis of the insane Graves' disease Occupation neurosis Unilateral Fine Tremor. Cerebral tumour Chronic hemiplegia Hysteria Chorea. Coarse Tremor. Exaggerated degrees j Familial and hereditarj' , Chronic hemiplegia, of fine tremors ' ataxias i Chronic intoxications, e.g Alcohol Cocaine Tobacco Absinthe Morphia High pyrexia Hysteria Neurasthenia Railway spine Ursemia. Congenital cerebral diplegia Some cerebral or cerebellar lesions. Intention Tremor. Disseminated sclerosis Hysteria Fine Tremor. — This consists of regular oscillations of small, amplitude due to alternating contractions in antagonistic muscles or groups of muscles, repeated from three to nine times per second. It is usually most marked in the extremities, but ma}' also — as in old age and in paralysis agitans — affect the head and neck. It may occur only when some movement is attempted ; or it may continue also when the patient is at rest. Fine tremors cease almost invariably during sleep ; emotion habitually increases them. They are not purposive movements ; and should be distinguished from the fibrillar contractions (see Contractions) of individual muscle-fibres or muscle-bundles, seen in some degenerations of muscular tissue. Fine tremors occurring in consequence of cold, nervousness, excessive emotion, convalescence, and muscular fatigue or weakness, are matters of the commonest daily observation. They are most noticeable in the upper extremities, although in Homer's time the lower limbs would seem to have been most seriously affected. They tend to pass off as the patient's condition of mind or body improves, and should occasion little trouble in diagnosis, if the fact of their existence and frequent occurrence be kept in mind. Congenital and familial fine tremors occur mostly in children or young adults, mainly in the hands and arms, face, or tongue. The oscillations are often absent while the patient is at rest, but make their appearance whenever movement is attempted, and are increased by nervousness or emotion. They can often be suppressed for a time by a strong effort of the will, and in many instances they disappear as the child grows up, or the adult grows older. They cause practically no inconvenience, and are not accompanied by any other abnormalities in the neuro-muscular apparatus. Their diagnosis should be made plain by the patient's past personal and family histories. Senile tremor and paralysis agitans may well be considered together. Senile tremor comes on with old age in the form of fine regular or irregular oscillations affecting the arms and the head. Both sides of the body are involved, the head is involved early, and the tremor ceases during repose and in sleep. The muscles of the affected parts are neither rigid nor weak. These senile tremors must be carefully distinguished from the tremors of paralysis agitans, or Parkinson's disease, a progressive and far more serious disorder. In paralysis agitans, the 796 TREMOR tremors are of several varieties. A fine oscillatory to-and-fro tremor, with from three to six excursions per second, affects the extremities and head in some cases. In others, the tremor is coarser, rh\"thmical, slower, and to some extent purposive ; in tj-pical instances it produces the alternating movements in the thumb and index finger described as " bread-crumbhng " or " cigarette-rolling." These may be combined with more irregular movements of flexion and extension at the wrist, pronation and supination of the forearm. The progressive development of these tremors and movements is often characteristic ; beginning in one hand, the fine tremor may spread to the other after some months or ^-ears, and ultimatelv the lower limbs, the head and neck, the lips and tongue, and even the muscles of the trunk, may become involved. As a rule, the movements continue when the patient is sitting, or Ijing at rest ; in severe cases they may persist, even during sleep. In most instances they can be lessened by an effort of the will, and diminish also on passive or voluntary- movement. If, on the other hand, they increase on voluntary movement, a tolerable imitation of an intention tremor may result. They are augmented by emotion or excitement. In cases of some duration a weU-marked coarse shaking of the arms may be a noticeable feature ; w^hUe contractions alternating in the flexor and extensor muscles of the legs may cause the feet to chatter when they are placed on the floor ; the thighs are commonly held in adduction. Paralvsis agitans is characterized by other signs that facihtate its diagnosis, and the chief of these are : — (a) Muscular rigidity, causing a fixed, expressionless facial aspect (see Facies), a monotonous voice, a bent and rigid carriage, and a shuffiing, hesitating gait, with festination, propulsion, and retropulsion. Festination impUes that the patient in walking from one point to another, starts with slowness and difiicultv', but he accelerates as he goes along, much as if he were running after his own centre of gravity, and at the end he may even faU down fonvards unless there is some object at hand for him to catch hold of. Propulsion, retropulsion, and the rarely observed lateropulsion, are terms meaning that when the patient is standing at rest and is sent off with a vigorous push to walk forwards, backwards, or sideways, the same acceleration and procHvit}- to faU down at the end — forwards, back- wards, or sideways — are observed. (b) Muscular weakness of the tremulous or rigid parts. (c) ParcesthesicB, such as aching pains about the Umbs or bod}-, flushes of heat or cold. The sphincters and mental faculties are not affected in paralysis agitans, while the deep reflexes are usually normal, but may be increased. It must not be forgotten that cases of Parkinson's disease occur, in which tremor is absent ; the presence of the other signs mentioned above, however, should suffice for its recognition. Bilateral cortical degeneration, with its slowlv increasing rigidity,- and muscular Aveakness, and its set facial expression, may resemble paralysis agitans ; but it is accompanied by progressive mental failure, increase of the deep reflexes, sphincter troubles, and the other evidences of cortical degeneration. The tremor of certain tvpes of general paralysis of the insane is a fine, irregular oscillation, often with a twitching character. It first appears in the hands and arms, and mav spread till it is conspicuous in the tongue, lips, and face, when it is associated with the characteristic changes — slowness and blurring — in the speech. For the most part this tremor occurs on exertion ; it varies in extent, and may almost disappear during periods of general improvement. In the later stages of the disease a coarse universal tremor sets in, combined, perhaps, with grinding of the teeth. In these patients the moral and intellectual changes, tottering gait, alterations in the tendon- and pupil-reflexes, and other phenomena of general paralysis, will probably not escape attention. In Graves' disease a fine, regular, and rapid tremor, about eight to the second, TREMOR 797 on exertion, is one of the cardinal signs. It affects the arms and hands most, less often the legs ; and it is increased by movement or by excitement. In addition, attacks of trembling that affect the whole body may occur. It is only in aggravated cases, however, that these tremors are so severe as to interfere with the customary employments of the hands. The tremors of Graves' disease are likely to be of comparatively sudden onset, and the patient will generally exhibit many of the other prominent signs or symptoms of hyperthyroidism, such as thyroid enlargement, exophthalmos and the other ocular phenomena, tachycardia, attacks of palpitation, wasting, sweating, or mental changes, so that the diagnosis ought not to be difficult. Fine tremors are frequently observed in many of the chronic intoxications, particularly those due to alcohol, absinthe, lead, mercury, nicotine, carbon disulphide, morphine, cocaine, and many other organic compounds that may be taken in excess in rare cases, whether intentionally or by accident. Alcoholic tremor is fine, regular, and rapid ; it is well shown in the outspread fingers of the extended hand and in the feet. In many cases it can be felt by the observer's hand more readily than it can be perceived by his eye ; or it may be rendered more conspicuous by laying a sheet of paper on the backs of the outspread pronated fingers and hand. It is absent during rest, and is increased by move- ment, excitement, or fatigue. It may also affect the tongue, lips, and facial muscles, taking the form of a rapid and rather irregular twitching, increased on exertion. This tremor is an early sign of alcoholism, and is often more marked in the morning hours, when it is due, perhaps, to fatigue and want of alcoholic stimulation ; it can be controlled to some extent by the will. Asso- ciated with it is a certain general nervousness and jumpiness ; in addition, the patient will no doubt exhibit some of the other signs of chronic alcoholism — venous stigmata or acne rosacea on the nose and face, restlessness, insomnia, gastric disturbances — particularly the morning vomiting of mucus on an empty stomach — paraesthesia and weakness of the extremities, mental and moral deterioration, and so forth. If the main facts of the case can be made out, tremors due to alcoholism should not be hard to diagnose. A history of chronic alcoholism should always be enquired after most carefully, both from the patient, who may deny it in toto, and from the patient's friends, who may hasten to admit more than the facts warrant. This is of importance, because mere nervousness at the prospect or realization of an interview with a medical man, will often bring on a fine but temporary tremor, indistinguishable, for the time being, from the lasting fine tremor of the heavy drinker. If such a tremulous, but teetotal, patient has indigestion and acne rosacea, and repudiates any veiled suggestion of alcoholism with apparently unnecessary warmth, there is some danger lest these evidences should be taken as confirming the apparently natural, but erroneous, diagnosis of alcoholism. The tremor of mercurial poisoning, a very rare complaint nowadays, is at first fine, but later becomes coarse and even choreiform. It begins in the face, hands, and arms, and may spread to all parts of the body. At first, it is brought out only by excitement, or on attempted movement. Later, it may persist even during sleep, and speech may be interfered with from involvement of the muscles of the tongue, pharynx, and larynx. Other prominent symptoms of mercurialism that should not be absent are profuse salivation, stomatitis, anaemia, and cerebral symptoms of various kinds. Mercurial tremors may have to be diagnosed from those of paralysis agitans or disseminated sclerosis. In lead poisoning a fine tremor of the affected limb is sometimes met with in cases marked by paralysis. The oscillations may also be seen in the tongue and lips, particularly in the rarer instances of chronic plumbism that exhibit cerebral symptoms and simulate general paralysis of the insane. 798 TREMOR The diagnosis of these unusual cases would be difficult unless a suspicion of lead-poisoning were aroused, either by a history of exposure to the intoxication, or by the occurrence of other and well-known signs and symptoms of piumbism ; especially anaemia, blue-black line on the gums, colic, constipation, and dropped wrist. In hysteria the clinical picture of any or every disorder of movement or sensation may be more or less closely reproduced ; and tremors of every variety m.ay be met with in hysterical patients. The diagnosis may be extremely difficult until hysteria is suspected, when it may be confirmed by the discovery of signs and symptoms that, singly or together, are pathognomonic. Such would be the occurrence of hysterical fits ; of hemiansesthesia, or of anaesthetic or paraesthetic areas, varying from day to day, and not corresponding with the known distribution of the peripheral nerves ; of flaccid or spastic paralyses, that change from time to time with great suddenness, and perhaps vanish when the patient believes herself to be no longer under observation ; of emotional out- bursts and psychical changes. Certain symptoms are so characteristic that they have been labelled as hysterical : such as the hysterical aphonia due to bilateral adductor paralysis ; the globus hystericus, or sensation of choking due to the rising of a ball into the throat ; the clavus hystericus, a peculiar vertical headache that feels as if it were due to a nail driven into the top of the head. The diagnosis of hysteria should never be made lightly ; but only after a careful consideration of the history, signs, and symptoms, and when all evidences of organic disease have been looked for and found wanting. Unless a careful examination be made, the tremor of intracranial tumour, for example, or of disseminated sclerosis, may be wrongly diagnosed as hysterical. Unilateral Fine Tremor is but rarely seen. It may be a hysterical manifestation, functional, and significant of no underlying lesion of the central nervous system ; the diagnosis of hysterical tremor has been considered immediately above. Unilateral tremor may occur in tumour of the frontal region of the brain ; if present, it occurs in both arm and leg, and only on the same side of the body as the tumour. The patients will often exhibit mental changes, such as inattention, incoherence, loss of memory, alterations in character ; sometimes, too, irritative phenomena occur. Unilateral fine tremor may develop on either the same or the opposite side of the body in tumour of the mid-brain and sub-thalamic region. The general sym- ptoms of cerebral tumour will be present, and in addition certain localizing signs may make their appearance. The chief of these would be paralysis of the third nerve, loss of sensibility over the area supplied by the fifth nerve, eccentric position of the pupil, defective reaction of the pupil to light, and weakness of the upward movements of the eyeballs. It may be added that fine tremors occasionally occur in the paretic limbs after hemiplegia. The history of the case and the presence of other signs characteristic of hemiplegia should make the diagnosis here a comparatively straightforward matter. Fine tremor may be seen in chorea, and may, of course, be unilateral in such cases. Coarse Tremor. — Coarse tremors may be developed as temporary exaggera- tions or later developments of the fine tremors occurring in several of the morbid states already considered. Thus, when the body is thoroughly chilled or fatigued, or when a patient is in a rigor, the initial fine tremor will often pass on into a very coarse tremor, as the amplitude of the involuntary muscular contractions increases, their rhythm remaining much the same. The fine tremor of paralysis agitans or general paralysis may similarly grow into a coarse tremor ; coarse tremors are not infrequently seen in hysteria. The diagnosis in all these cases must be made on the lines already indicated. TREMOR 799 Coarse tremor is met with sometimes in the various forms of familial and hereditary ataxia. Thus in Friedreich's disease, in addition to the intention tremor considered below, irregular involuntary motions, described as coarse tremors in some cases, as choreiform in others, take place in the arms while the patient is at rest. Irregular nodding or tremulous movements of the head and trunk, also occur in advanced cases ; the muscles of articulation and of the face may exhibit irregular purposeless contractions or quiverings when conversation is attempted. In spmo-cerebellar ataxia, irregular choreiform movements, or constant tremors, large and small, may be seen in the head, trunk, and limbs, whenever the attempt is made to hold them steady, but unsupported. Similar disturbances have been recorded in cerebellar ataxia and in the olivo-ponio- cerebellar atrophy of Dejerine and Thomas. In all these conditions the ataxia is the prominent symptom, the coarse tremor being no more than an occasional epiphenomenon ; the diagnosis between them must be sought in special manuals, and also under the heading Ataxy {q.v.). The coarse tremor of the affected limbs seen in patients with chronic or spastic hemiplegia or diplegia, and in some other cerebral disorders, is a variant of the athetoid or choreiform movements that are characteristic of those conditions. They are considered under the heading Convulsions {Paramyoclonus multiplex) . As has been mentioned already, it is practically impossible — were it, indeed, desirable — to draw any hard-and-fast line between the grosser fine tremors and the finer coarse tremors. In the same way, coarse tremors merge insensibly into the lesser degrees of athetotic and choreiform convulsions. Intention Tremor — known also as action or volitional tremor — has been defined as tremor produced, or, if not produced at least exaggerated, by voluntary movements. These tremors affect the upper extremities, and sometimes the head and trunk also ; the limb is quiet when not in actual use, but as soon as voluntary move- ment is attempted irregular and involuntary to-and-fro motions begin in it, and are superadded to the intended movement. These to-and-fro motions become more marked, and sometimes more rapid the more nearly achievement of the desired movement is reached. The greater the amount of precision demanded by the voluntary action, the greater becomes the amplitude of these involuntary excursions. Wishing to drink, the patient may lift the cup from the table steadily enough ; but as the cup approaches his lip, the involuntary movements appear and rapidly increase till its contents are jerked wildly in all directions as it reaches his mouth. The tremor may spread from the muscles that are being put into action, and cause extensive jerky movements of the head and trunk. The pathogeny of intention tremor is obscure. Very possibly it is due to destruction of the short intersegmental nerve-fibres in the substance of the spinal cord. The destruction of these fibres would render impossible the accurate mutual adjustment of the contractions of antagonistic muscle-groups F70. 205. — Movements in intention tremor. -Movements in ataxy. The dotted lines show the direction of the movement attempted. 8oo TREMOR that is essential lor the smooth performance of even the simplest willed movements. Intention tremor is one of the most characteristic features of disseminated sclerosis. The arms are most often and most markedly affected ; but careful observation wiU often show that none of the voluntary muscles escape in\'oh-e- ment. The head may oscillate whenever the patient is holding it up ; the trunk may exhibit jerky movements whenever he sits or stands ; and the legs whenever he stands or walks, after the disease has made some progress. Disseminated sclerosis has been carefully studied of late years, and has sho^^■n itself to be a protean disorder. Typical examples, however, may be recognized by the occurrence of intention tremor [Fig. 205), muscular rigidits^ n^-stagmus, pallor of the optic discs, and staccato or scanning speech. The deep reflexes are increased ; the gait is spastic or ataxic ; Babinski's sign is present ; subjective sensorv signs are far commoner than objective : and control over the sphincters mav sometimes be impaired fairly early in the disease. In manj^ instances, however, some, or even many, of these characteristics are absent ; the diagnosis of disseminated sclerosis may then be far from easy, especiall}' in its early stages. In hysteria, for example, intention tremor ma}' occur in just the same wa}' as a fine or a coarse tremor may ; and other points of correspondence between hysteria and disseminated sclerosis may often be found in the age and sex of the patient, in the remittent course pursued by either of the disorders, in the frequent occurrence and partial recovery of various parah'ses and of amblyopia with contraction of the visual fields, and in exaggeration of the deep reflexes. But distinct differences between the two are, fortunateh', not wanting. In hysteria, the objective senson,- signs are weU marked, the optic discs are not affected, nystagmus is absent, Babinski's sign probabh* never occurs, and control over the sphincters is not lost. Attention to these points should suffice to clear up the diagnosis between hysteria and disseminated sclerosis ; but in the earhest stages of the latter it ma\' be necessary to keep the patient under observation for some little time before a definite opinion can be pronounced. Intention tremor has also been described as an exceptional feature in patients suffering from neurasthenia. An intention tremor is not very rare in the familial and hereditary ataxias, among which may be mentioned Friedreich's disease and cerebellar ataxy ; but the disturbance of movement in these disorders is characteristically an Ataxy [q.v.). It is necessary to refer briefl}- to certain intracranial conditions in which intention tremor occasionally or exceptionalh- occurs. The congenital or acquired- cerebral diplegia of backward or mentally defective children, occasionally appear- ing as a familial disease, and characterized by bilateral spastic paralysis affecting the limbs, or limbs and body, is sometimes associated with intention tremor. It is athetosis [vide supra) that is characteristic of these cases ; but disordered movements of all sorts occur in them. In addition, the sphincters are commonlv affected, the deep reflexes are increased, optic atrophy or inequaUty of the pupils are frequently found ; and if the patient is able to get about, a spastic or " scissor " cross-legged gait is to be seen. A congenital cerebral diplegia in which the spastic weakness is most marked in the legs, is described as a case of Little's disease. The intention tremor occurring in birth palsy or in infantile hemiplegia has, unfortunately enough, been described under the name chorea spastica. Intention tremor has also been recorded in a few instances of lesion of the superior cerebellar peduncle, corpora quadrigemina, or optic thalamus, particularly when the tegmentum, red nucleus, and rubro-spinal tract are involved. It may be noted in patients with so-called extra-cerebellar tumours growing in connection TRISMUS 80 1 with the eighth nerve, and occupying the posterior fossa of the skull between the pons and cerebellum. It is seen in a certain proportion of the cases of cere- bellar atrophy, whether the degeneration is primary parenchymatous, progressive and due to interstitial and vascular lesions, or acute and following some acute specific fever. Intention tremor is also present in some patients with olivo- ponto-cevebellar atrophy. The diagnosis of these rare instances will naturally depend upon the development of other general and localizing signs of intra- cranial disease. A. J. J ex-Blake. TRISMUS. — Trismus, or lockjaw, signifies a maintained closure of the jaws by tonic muscular spasm, so that the mouth cannot be opened. It is best seen in cases of tetanus. The term does not include mechanical inability to open the jaws owing to such affections as mumps, alveolar abscess with surrounding inflammatory oedema, angina ludovici, quinsy or severe tonsillitis, an odontoma, epithelioma of the mouth, myositis ossificans, and so forth ; but there are at least two mechanical conditions that may not at first sight be obvious, but which may lock the jaws together and simulate true trismus — impaction of a wisdom tooth, and arthritic changes in the temporo-maxillary joint. These will be diagnosed as the result of a careful local examination of the teeth and of the joint respectively, and in the latter case there maybe osteo-arthritic changes in other joints also. Circumstantial evidence will generally serve to distinguish trismus due to hysteria or to facial neuralgia ; and if there is any doubt as to the nature of the case at first, this will disappear if the patient can be watched for a while. If there are convulsive seizures in a hysterical patient with trismus, they can generally be distinguished from those due to tetanus or to strychnine poisoning by their polymorphous character, and by the fact that touching the patient, and other similar stimulation, does not bring them on so certainly as would be the case with strychnine or tetanus. The rigidity of the face muscles that may be found in certain cases of tuberculous or posterior basal or cerebrospinal meningitis never occurs by itself, and it is a minor symptom amongst others that generally point to the correct diagnosis. The same applies to epilepsy and to uramia. Malingering may sometimes take the form of lockjaw-, and it ma}^ be a little while before the fraud can be detected ; sleep is sure to come in time, and as the result of fatigue the malingerer's muscles relax completely. Catalepsy may include trismus amongst its varieties of maintained muscular contractions ; the general mental symptoms will assist the diagnosis, and as a rule there are no convulsive seizures. Trichinosis is very rare nowadays, but if infected pork is eaten raw, or insufficiently cooked, the larv^ of the parasites find their way to many different muscles, and they show some predilection for those of the tongue, mouth, and jaws. The resultant irritation, pain, and stiffness cause trismus, whose nature may be difficult to determine unless the history points to pork as the origin. The patient is very ill in the earlier stages, with high fever, and the condition is often fatal. There may be an epidemic of the malady. The blood exhibits marked eosinophilia. The final criterion of the diagnosis is the discovery of the typical parasites coiled up in their little oval cysts amongst the affected muscle fibres. Hydrophobia and tetany seldom exhibit trismus as a prominent symptom. The former, though it is, almost unknown in Great Britain now, would suggest itself if anj^ convulsive illness developed after a definite bite by a dog, wolf, or other similar animal, particularly if the spasmodic muscular difficulty was markedly increased by efforts at swallowing. The symptoms may not develop D 51 8o2 TRISMUS for weeks or months after the bite, so that the patient may fall ill when he has come home, after being bitten abroad. Tetany, also rare, is at once dis- tinguished by its typical carpo-pedal contractions {Fig. i, p. 3), and by the fact that, though it may be severe for a time, it does not kill. It is apt to follow pregnane}', or operations on the thyroid gland, or to be associated with gastrectasis. A mild form occurs in rickety children. Strychnine poisoning gives rise to generalized twitchings and convulsions long before trismus, the lateness of the development of the latter serving to distinguish it from tetanus. There may be evidence of strj^chnine having been taken or administered, either by the mouth or hj'podermically ; the symptoms develop very acutely, and are apt to be rapidly fatal. Tetanus is the cause par excellence of trismus ; and the diagnosis is often obvious enough if there is a clear historj^ of an illness developing steadily in an otherwise healthy person or new-born infant, starting with stiffness of the neck muscles, spreading to those of the face and jaw, and thence to the rest of the trunk and limbs, with a tendency to extremely painful exacerbations on the slightest stimulation, even by a stroke with a feather or the banging of a door ; risus sardonicus ; opisthotonos ; no complete relaxation of the stiffening muscles unless chloroform is given ; a duration of da^'S rather than hours, and a termina- tion in death more often than in recovery, especially if all these things follow a few days, or a week or more, after a small penetrating wound with a rusty nail, or a piece of stick or other similar body that may have been contaminated with tetanus bacilli from the soil (see Plate XII, Fig. T). It may even be possible to demonstrate the drum-stick bacilli in films prepared from the deeper parts of the wound. The chief difficulty arises when there is no clear history, or when the wound has been so small that it has healed or cannot be found. Even then, most cases are so typical that they can be diagnosed as tetanus without much difficult}'. Unnecessary anxiety arises chiefly in cases of impacted wisdom teeth, and of hysteria, where tetanus maj^ at first be suspected, though the subsequent course of the malady soon serves to exclude this. Herbert French. TUMOURS.— (See Swellings.) TUMOURS OF THE SKIN.— The malignant tumours which affect the skin include carcinoma, epitheUoma, Paget's disease, sarcoma, mycosis fungoides, and xeroderma pigmentosum. As a rule, cancer en cuirasse and nodular (lenticular) cancer are secondary to cancer of the breast or other parts, and their diagnosis is self-evident. In 7nslanotic carcinoma the tumours differ greatly in size, and also in colour, varying from a slate tint to bluish-black ; they appear more frequently on the genitalia and the extremities than elsewhere. The only condition from which melanotic cancer requires to be distinguished is pigmented sarcoma, and for this histological examination is necessary. Paget's disease, occurring chiefly in women after the age of forty, begins as a reddening of a patch of skin, usually on or around the nipple, followed by branny desquamation. Infiltration soon produces a bright-red, granular, indurated surface, with a sticky, yellowish discharge, which by forming crusts ma}^ obscure the nature of the lesions, save at the border, which continues to be characteristic — sharply defined, indurated, and sometimes distinctly raised. After a period, which is usually about two years, but may be much longer, deep-seated parts may become affected, this extension of the disease showing itself on the breast by retraction and induration of the nipple and the formation of a tumour in the substance of the eland. In the earlv stage Paget's disease TUMOURS OF THE SKIN 803 has to be distinguished from chronic eczema, which it closely resembles. Its difl'erentiating features are the bright-red, granular surface exposed after removal of the crusts, the induration at the well-defined edge, the intractability, the age of the patient, and (later) the retraction of the nipple. The diagnosis may be made certain by microscopic examination of scrapings in iodized serum or liquor potassae, when the bright, oval, nucleated bodies styled psorosperms will be seen, some still contained within the host-cells, others surroimded by distinct capsules. Epithelioma begins usually as a single growth, superficial, deep-seated, or papillary, but all the forms alike are marked by peripheral extension, infiltration and destruction of neighbouring parts, central ulceration, and (except in rodent ulcer, for which see Ulceration of Face) a tendency to the formation of secondary growths in lymphatic glands, in viscera and elsewhere. Epithelio- mata have a predilection for the natural orifices, for such moist parts as the glans penis, for exposed regions, and parts exposed to friction and trivial injuries. A wart, a mole, an ulcer, lupus vulgaris lesions, or an A^-ray cicatrix, may be the starting-point. If the tumour begins in the skin, it appears first as a papule ; if in a gland, as a nodule. In the former, the more frequent case, the papule becomes firmer and extends laterally ; infiltration is evidenced by the hard, raised, pearly border. Ulceration occurs in the centre of the growth while extension is proceeding in the depths and at the sides. If the necrotic process involves the vascular tissue, there is more or less haemorrhage. If the lateral extension predominates, the discoid type of epithelioma, as in sweep's cancer of the scrotum, is the result ; the surface is raised, with a steep border, and is bright-red, with a firm, granular surface. If the granulations are of large size, the growth is of the papillary type. The chief diagnostic features of epithelioma are : the origin as, usually, a single growth, the site, the starting-point, the slight discharge, the characteristic border, the secondary growths in glands and elsewhere. From a wart or a mole, epithelioma can be distinguished conclusively only by microscopical examination or by long- continued observation, and should signs of ulceration or crustation appear in such growths, epithelioma should be suspected. The so-called tubercular ulcerating sj^philides are, as a rule, multiple, and not rounded, but rather segmental. (For the diagnosis of epithelioma from lupus vulgaris, see under Nodules.) Sarcoma of the skin is most frequently secondary to growths commencing in the lymphatic glands or the deeper structures. Sarcomata vary considerably in colour, from reddish to brown or bluish-black, and also in consistence ; those of the spindle-celled type are fairly firm, the small-celled ones soft, with all intervening grades of density. They may appear in any part of the body, but are often found on moles, warts and ulcers. The diagnosis usually depends upon histological examination, and it must suffice to say that a tumour which arises in previously healthy skin, or in a mole or wart, or at the site of an injury, which is soft and reddish from the vascularity that is a marked feature of this kind of tumour, or bluish from pigment, and which, after a period of slow growth rapidly enlarges, projects above the surface, and readily ulcerates and bleeds, is probably a sarcoma. In the early stage of mycosis fungoides the lesions are dull red or livid patches, sometimes slightly tinged with yellow, varying in size from the area of a finger-nail to that of the palm of the hand, with border sometimes well marked, sometimes fading off, most frequently raised or thickened, but occasionally flat. At first the patches are smooth and dry, afterwards they become scaly, and later still they may be moist or covered with crusts. Presently the surface becomes infiltrated, and tumours as small as a pea or as large as an apple, firm and 8o4. TUMOURS OF THE SKIN lobulatedj broader at the free than at the attached end, and somewhat resem- bUng tomatoes, project above the level of the skin (" fungoides "). As a rule, progressive thickening occurs, leading on to fungation. The l3Tnphatic glands may be enlarged throughout the bod3^ In the premycotic or eczematous stage — which is sometimes absent — the diagnosis may hesitate between mycosis fungoides and an eczematous or urticario-eczematous condition, and in some cases it may be impossible at this stage to distinguish definitely bet\veen the two. But in mj^cosis fungoides the lesions will make httle response to therapeutic measures, the red of the patches may be slightly tinged with yellow, and they are naore persistent than those of eczema. The only malignant condition which mycosis fungoides in the mycotic stage at all resembles is sarcoma, but there is seldom an^' difficulty in distinguishing between the two. The initial lesions of xerodermia pigmentosum (Kaposi's disease) are small spots resembling freckles, but rather darker, which appear chiefly on the face, neck, arms and legs, and generally begin within the first t%vo years of Hfe. Usually they disappear in winter and return in summer ; but after a time they become permanent, and often quite black. At first the condition suggests nothing but excessive freckling, but presently amid the " freckles " appear white, glazed, atrophic spots, telangiectases, and superficial ulcers discharging pus which dries into j'^ellow crusts. After some years, small, wartj-looking growths develop on the " freckles." Tumours now form and ulcerate, producing fungous masses, and the process extends both widely and deeply, and destroys every tissue it encounters, not excepting bone. It is only in the earliest stage that there can be anj^ difficult}^ in recognizing this very distinctive disease. In that stage it may be mistaken, as is suggested above, for simple lentigo, from which there may be nothing but the more extensive distribution to distinguish it. With the appearance of the later lesions lentigo will be dismissed from con- sideration, and it should be not less easy to rule out sclerodermia. The benign tumours of which the diagnosis may be, in very different degrees, open to doubt, are sebaceous and dermoid cysts, fibroma moUuscum, von Recklinghausen's disease, neurofibromata, myoma cutis, m^-xoma, the xanthomas, rhinoscleroma, moUuscum contagiosum, colloid milium, benign adenoides cysticum, and keratosis follicularis. Sebaceous cysts, most frequently seen on the scalp, the face, and the back, rounded, often somewhat flattened on the top, and sometimes as large as an orange, are distinguished from fatty tumours by the absence of lobulation and the fact that the sebaceous contents can be squeezed out w^hen there is an opening. Dermoid cysts may resemble fibromata, but if they are incised a sebaceous- looking material escapes. Fibroma moUuscum, a pear-shaped or rounded fibrous tumour, usually covered by smooth skin and pedunculated, varying in size from a pin's head to an orange, and nearly always multiple {Fig. 201 p. 782), differs from a sebaceous cyst by its solid structure, and from a fatty tumour by its usual pedunculation and the absence of lobulation. Von Reckling- hausen's disease, of which the lesions consist of nodular tumours, on and around which there is coffee-coloured pigmentation, is differentiated from ordinary fibroma in that the tumours are composed of fibrous and nervous, and not simply of fibrous, tissue. There is also a perceptible thickening of the nerves of the arms. N euro- fibromata, which have their origin in the tendon-sheaths or the sheaths of the nerve fibres, and range in size from a pin's head to very large dimensions, are sometimes mistaken for rheumatic nodules, but instead of specially affecting the region of the elbows and the scalp, they occur on the trunk and extremities generallj^, nor is there (except from coincidence) a history of rheumatism. TUMOURS OF THE SKIN 805 Superficial myoma cutis occurs in the form of nodular tumours on the arms, back, chest, and cheek ; the deeper kind, originating in the subcutaneous muscular structures, occurs as a solitary tumour, commonly on the breasts and genitals. The former growths are soft and elastic, and, like the latter, are often painful. The distinctive clinical feature of mj^oma cutis generally is that it contracts under the influence of cold. This, with the pain, the absence of any tendency to ulceration, and the aspect and slow course of the growth or growths, should enable the affection to be identified. Myxoma, when it arises in the skin — most frequently in the loose skin of the scrotum and labia — usually forms rounded, pedunculated, translucent tumours which tend to enlarge slowl3\ They have to be distinguished from molluscum contagiosiim. This begins by the formation of small growths that have been likened to tiny mother-of-pearl shirt-buttons. They are usually flattened at the top, where as a rule there is a depression in which can be seen a small aperture leading into the interior of the tumour. Through this orifice a whitish material, or sometimes a milky fluid, can be squeezed out. When they are very small the tumours resemble the vesicles of varicella, but a microscopic examination of the contents will obviate the confusion. A small molluscum body on the genitals may resemble a hard chancre, but similar growths will be found elsewhere. Xanthoma planum, often associated with jaundice and migraine, and characterized by the formation of yellow or yellowish- white plaques (rarely nodules), usually in the upper eyelid and sometimes affecting also the lower lid, is easy of recognition, the appearance of the yellow patches embedded in the corium, and almost imperceptible to the touch, being absolutely distinctive. Xanthoma multiplex, however, is not identified quite so easily. Here the lesions are nearly always nodular, and often observe a linear grouping, and the colour varies, a blackish or reddish pigment being mixed sometimes wdth the yellow. Usually the nodules occur in connection with hepatic disease. The condition has been confounded with urticaria pigmentosa, but there is no itching, there are no wheals, and it is impossible to produce factitious lesions. The tumours may be indistinguishable from multiple dermoids of the skin until microscopic examination is made. Xanthoma diabeticorum differs from other forms of xanthoma, inter alia, in the presence of a raised red area around the yellow spots. This feature has led, in the early stages of the affection, to confusion with acne, but if the lesions are punctured they will prove to be solid. In the same stage the lesions may simulate those of lichen planus, but the resemblance soon disappears. Rhinoscleroma begins, usually before the age of forty, in and around the nostrils as nodules in the cutis, and in the deeper layers of the mucous membrane. These coalesce to form a hard, smooth, ghstening growth which spreads inwards from the lip and downwards to the pharynx from the posterior nares. The growth does not break down spontaneously, but is generally slowly progressive. It is not likely to be mistaken for anything but epithelioma, which is prone to ulcerate, generally has infiltrated edges, seldom attacks the upper lip, and usually begins later in life. In rhinophyma, pustules are often present, the growth is soft, and there is vascular dilatation. In colloid milium, small, yellow, cyst-like formations containing a gelatinous substance appear in the skin, chiefly on the upper part of the face. They may become depressed in the centre and be slowly absorbed, or may inflame and dry up. The only condition from which colloid milium needs to be distinguished is epithelioma adenoides cysticum, in which the tumours, shining and translucent, contain one or more white, brightly refracting, milium-like bodies. The face is the part most frequently attacked, but the growths may appear on almost 8o6 TUMOURS OF THE SKIN any part of the bod)^ They are not yellow, like the growths in colloid milium, nor are they soft. Keratosis follicularis begins as small brown or yellow crusts, hard and dry, which, when detached from the underlying tissue, are found to present on their under surface a softish prolongation which dips into a follicle. At first discrete, the lesions may become confluent, and there is thickening of the affected parts until nodular masses are formed, from which oozes an offensive discharge. The affection is slowly progressive. At the outset the condition may be mistaken for keratosis pilaris, but it is not confined to the situations affected by that disease. The prolongation into a follicle gives it some resemblance to molluscum contagiosum, but it has a less limited distribution, nor have the growths the pearl}^ appearance of the molluscum bodies, while the aperture in the individual lesions is larger. Malcolm Morris. TYMPANITES.— (See Meteorism.) ULCERATION OF THE CORNEA. — The course of all corneal ulcers conforms to a general type, though the chnical varieties may vary. The process begins with an infiltration in the substance of the cornea, either central or peripheral ; the result of this infiltration is a local loss of transparency, though in early stages the surface of the cornea may still retain its polish. The infiltration proceeds to suppuration, which is followed by a loss of substance, the corneal surface being dull and irregular, and, in the centre of the ulcer, depressed below the sur- rounding level. The base of the ulcer is grey or yellowish, and the surrounding portion of the cornea may be opaque with more or less grey infiltration. The suppuration is followed, in cases which have a favourable termination, by vascularization, superficial vessels from the surrounding conjunctiva encroach- ing on the cornea and invading the suppurating area. The vascularization is followed by cicatrization, the surface of the cornea again becoming pohshed but flattened and opaque. The opacities resulting from corneal ulcers are localized, well defined and opaque, in contrast to the diffuse indefinite haze which follows such non-suppurative forms of inflammation as interstitial keratitis. Corneal ulcers may not heal, but occasionally lead to perforation of the cornea, prolapse and adhesion of the iris, anterior polar cataract, or panophthalmitis. Iritis, iridocyclitis, and pus in the anterior chamber (hypopyon) may also be associated conditions. The usual subjective symptoms are pain, photophobia, and lachry- mation. The presence of corneal ulcers is demonstrated most satisfactorily by the instillation of a drop or two of fiuorescin, which stains necrotic corneal epithehum or exposed corneal substance, green. The brightly-stained ulcer shows up in marked contrast to the surrounding clear cornea. Corneal ulcers may occur in the following clinical varieties : — Catarrhal, or simple infective ulcers. These usually occur as minute grey infiltrated spots in the centre or periphery of the cornea. They heal very rapidly as a rule. They may follow injury to the corneal epithelium by foreign bodies, or may be associated with acute conjunctivitis or rhinitis. Phlyctenular ulcers are associated with phlyctenular conjunctivitis, the ulcer forming after the epithelium on the top of a phlyctenule has been rubbed off. They are usuall}^ marginal, but may occasionally make their way on to the cornea, a leash of conjunctival blood-vessels trailing after them. Similar ulcers may be associated with acne rosacea. Hypopyon ulcer, or ulcus serpens. This is a shallow ulcer affecting chiefly the superficial layers of the cornea, in or about its centre. The middle layers of the cornea are comparatively unaffected, but at the posterior surface the infiltration again becomes dense, with much fibre and debris, associated with ULCERATION OF THE CORNEA 807 the formation of more or less pus in the anterior chamber. The ulcers often perforate ; they are usually due to infection with the pneumococcus. The pus in the anterior chamber is always sterile, unless there is perforation of Descemet's membrane. These ulcers do not react to ordinary methods of treat- ment as a rule, but require cauterization, either by pure carbolic acid or the galvano-cautery. The hypopyon then disappears rapidly. Mooren's ulcer, or rodent ulcer of the cornea, is a chronic serpiginous ulcer, usually affecting the eyes of elderly people. It begins at the margin of the cornea and spreads slowly over the whole surface, the advancing edge being much undermined. The ulcer is always shallow, and perforation never occurs ; the ulcer may heal in places, but this is seldom permanent, and the ulceration usually spreads over the whole surface of the cornea, whatever method of treatment nfiay be employed to arrest its progress, though recently radium has been used with some success. No specific organism has yet been discovered. A dendritic ulcer is characterized by its peculiar shape — a long central stem with small linear ramiiications. It is not really an ulcer, but an infiltration under the corneal epithelium, which in the later stages may become necrotic and break down. It is best treated by rubbing off the affected corneal epithelium with a pointed stick dipped in absolute alcohol. Corneal ulcers may occur in association with pannus in trachoma, their usual site being at the margin of the vascular area. Occasionally they penetrate more deeply into the corneal substance. Corneal ulcers frequently follow gonorrhceal and diphtheritic conjunctivitis. They spread rapidly, and often lead to perforation of the cornea and panophthal- mitis. The diagnosis depends on bacteriological methods and the discovery of the causative micro-organisms. Keratomalacia, a disease of childhood, is associated with night blindness and xerosis or dryness of the conjunctiva. Characteristic foamy white patches are seen on both sides of the cornea. The cornea becomes dull, grey, and cloudy, and ultimately disintegrates from purulent infiltration, associated with very slight signs of ocular inflammation. The ocular condition is associated with marasmus and malnutrition. The prognosis, both as to eye and vision, is bad. Keratitis e lagophthalmo is associated with paralysis of the seventh nerve. Owing to the failure of the orbicularis palpebrarum, the eye cannot be closed, and does not remain closed during sleep. The lower part of the cornea is exposed, becomes dry, and the corneal epithelium dies, with consequent ulceration of the cornea. The condition can be cured by diminishing the palpebral aperture by sewing the eyelids partially or completely together. Similar exposure of the cornea and consequent ulceration is seen occasionally in cases of Exophthalmos (q-v.), for instance in severe Graves' disease. Keratitis neuroparalytica. In paralysis of the fifth nerve, or as a result of excision of the Gasserian ganglion, the cornea becomes dull and cloud}^ and necroses in the centre, only the periphery remaining clear. A hypopyon forms, and in some cases the whole eye is destroyed, though occasionally the keratitis may lead only to a permanent opacity. The condition is due to arrest of lachrymal secretion and absence of corneal sensation, which is followed by abolition of the winking reflex. Foreign bodies lodge on the cornea and are not removed. The prognosis is bad, and is little affected by treatment. Corneal ulcers may be associated with herpes jrontalis, vesicles forming on the cornea simultaneously with the vesicles on the skin, especially along the course of the supraorbital nerve. The ulceration is often severe and may lead to perforation and destruction of the eye, and is in any case followed by con- siderable corneal opacity. The cornea is usually insensitive, and the intraocular tension may be raised. 8o8 ULCERATION OF THE FACE Tuberculous ulceration is not common fortunately, but it should be borne in mind as a possibility in chronic or resistant cases. The diagnosis depends on the history, the presence of tuberculous glands or other similar lesions, positive reaction to the various tuberculin tests, and, most conclusively of all, upon the detection of tubercle bacilli in the discharge from the ulcer itself. Herbert L. Eason. ULCERATION OF THE FACE,— The ulcers most often met with on the face are lupous, scrofulous, syphilitic, or malignant. In lupus vulgaris, the ulceration is extremely chronic. The lesion begins as a papule, develops into a nodule, and. after a while, in the majority of cases, the lupous tissue breaks down and forms a granular sore covered with greenish-black crusts ; but around the ragged edge will still be seen the characteristic " apple- jelly " nodules in different stages of development. The ulceration may extend through the whole thickness of the skin and may become the seat of warty vegetations. In the nose, where the integument is thin, it may cause necrosis of cartilage. The course the pathological process runs, from the papule onwards, as here described, and the frequent presence of the different lesions simultaneously, shed sufficient light on the character of the ulceration. I need only say further that the ulcer of lupus, however deeply it may extend, never erodes bone. This alone is sufficient to differentiate lupus from the ulcers of syphilis and cancer. It nearly always begins before the age of twenty. In the ulcers of scrofula, though they have no absolutely distinctive characters, it will often be noticed that the edge is undermined and the surrounding skin blue and of low vitality. Their occurrence in children of strumous aspect, or in elderly persons who bear the stigmata of scrofulous lesions dating from childhood, and their tendency to become chronic owing to the feeble resistance offered by the tissues to morbid processes, leave no room for doubt as to their true nature. It is in the late secondary and the tertiary stages of syphilis that cutaneous lesions on the face, as elsewhere, are prone to ulceration, instead of to the resolution to which typical secondary syphilides tend. The whole structure of the skin, or mucous membrane, is frequently involved, the ulceration is deep, and frequently the ulcers, while healing in the centre, extend at the margins, and so assume the characteristic circinate or serpiginous form. The appearance of the ulcers, with the history, and the marks of earlier syphilitic lesions, will supply all the guidance the diagnostician needs ; Wassermann's serum test and the effects of mercury and iodide of potassium may serve to clinch the diagnosis. As a rule rodent ulcer occurs in persons of more than middle age, and its favourite points of attack are the outer edge of the orbit and the side of the nose. It begins as a small, circumscribed nodule, dull brownish- red in colour, flat, depressed in the centre, and firm to the touch. After, it may be, years, the cuticle covering it is broken, and an ulcer with depressed granular centre and infiltrated border is formed. Very slowly this extends, both in circum- ference and in depth, infiltrating and destroying the subjacent tissues, including bone. Usually the destruction of the underlying parts is more marked in the centre, so that the ulcer becomes crateriform. Its invariable features — the inconsiderable suffering it inflicts, the singular slowness of its progress, its depressed centre, and the firm, raised, rolled edge, its failure to affect neighbouring glands, and its incurability except by extirpation or by physiotherapy — are so characteristic as to leave little scope for diagnosis. Epitheliomatous in structure, it differs from epithelioma in that the latter growth has a very hard and everted edge, and a foul base roughened with granulation, is often attended by severe pain, is much more rapid in its course, and infects the glands in its vicinity. (See also Tumours of the Skin.) It differs from lupus vulgaris in its mode ULCERATION OF THE FOOT 809 of onset, in the absence of the " apple-jelly " nodules, and in not being a disease that stai'ts in childhood. It may be diagnosed from tertiary syphilitic ulcers by the characters described above, and also by its usually solitary character and its resistance to treatment. Malcolm Morris. ULCERATION OF THE FOOT.— The ulcer which attacks the foot specially, though not exclusively, for the hand may be affected in the same way, is that known as perforating ulcer {Fig. 207). The exciting cause is pressure upon or injury to a foot in which there is interference with the nerve supply, either from peripheral lesion, as in peripheral neuritis, or from damage to the nerve-trunk, as in leprosy, syphilis, or diabetes mellitus, or to the nerve-centre, as in locomotor ataxy and general paralysis. The commonest situation of the ulcer is at the point of greatest pressure — the ball of the great toe, or the under aspect of the metatarso- phalangeal joint of the big or little toe. The ulcer, which is more of a sinus than a true ulcer, and [ is usually painless, may be simple or multiple, and both feet may be affected. It often begins by sup- puration under a corn. When the horny covering is cast off, a track is seen which extends downwards until the bone is exposed. The process is usually very slow, and if the pressure from walking is con- tinued the thickened epidermis forms a kind of corn-shield around the opening. The more essential symptoms of the neurotic disorder of which perforating ulcer is but an incidental manifestation, will disclose the true nature of the lesion. The only malady with which it can be confused is a suppurating corn. From this it is distinguished by the absence or small degree of pain, and by its irresponsiveness to the simple sur- gical treatment to which a suppura- ting corn readily yields. Mycetoma is a fungous disease that is known alternatively as Madura foot, because, endemic in Madura and other parts of India, it usually affects the foot or the leg, though sometimes the hand, and in rare cases the shoulders or the scrotum. The affection appears in several forms, according as they are due to different species of discomyces and aspergillus. The lesions may be black (" melanoid ") or pink (" ochroid "). The disease begins with slight swelling and redness or local induration, and as it progresses the foot swells and the swelling surface becomes dotted with small nodules, each containing the opening of a sinus which discharges a viscid, syrupy, slightljr purulent, sometimes blood- streaked fluid, in which are suspended rounded granules, greyish or yellowish in colour. In other cases the granules are black, at first resembling gunpowder, Pig'. 207. — Perforating; ulcer of foot ; from a case of tabes dorsalis. 8io ULCERATION OF THE FOOT though later they may form black or dark brown masses. As the foot enlarges, the leg, from disuse, atrophies. The only condition from which mycetoma needs to be discriminated is actinomycosis. This affection usually begins in the bone or other deep structures of the jaw, face, or neck, may thence spread to the surface, and may involve the viscera. In the discharge the ray fungus may be found in the form of tiny, friable, yellowish or greyish bodies, though microscopical methods and the discovery of the characteristic ray fungi {Plate XII, Fig. S) will generally be required before the nature of the case can be confirmed. Malcolm Morris. ULCERATION OF THE LEG may be classified under three headings : — (i) Non-infective Ulcers. — These include those that are not due to any specific infection, but which are caused by various factors which interfere with the vitality of the part by injury, lack of circulation, or innervation of the tissue. (2) Infective Ulcers resulting from the direct action of a definite specific infection, e.g., tuberculosis or syphilis. (3) Ulcerating Tumours. — These are malignant tumours, which have originated in or invaded the skin. I. Non-infective Ulcers. — Varieties and Causes. Varicose Ulcer. — The presence of varicosity in the veins of the leg diminishes the free return of blood, and so leads to congestion and interference with nutrition, and thus to ulceration. In the majority of cases the ulcer is situated on the inner side of the leg about three inches above the ankle. It may be small, or may encircle the limb. For some distance round the ulcer the skin suffers from the effects of passive congestion. It becomes indurated and of a purplish- brown colour, and numerous small varicose veins may be seen in it. Any slight injury may cause an abrasion of this weakened skin, and thus another ulcer be formed. On a patient the subject of a varicose ulcer, the scars of previous ulcers are frequently found. The presence of varicose veins associated with an ulcer will usually lead to the conclusion that the latter is dependent on the former, and that view will probably be correct, but it may not be the whole truth, for syphilitic and varicose ulcerations may be present at the same time. Before the introduction of Wassermann's test for syphilis, it was common practice to give antisyphilitic remedies in order to clear up the diagnosis, and this may still be done when the serum test cannot be carried out. Lymphatic Obstruction also leads to loss of nutrition, and ulceration may result. The best instance is seen in elephantiasis due to Filaria sanguinis hominis. In this country elephantiasis is rare. Other instances that may be cited are swellings of the leg following a badly united fracture ; the cicatricial contractions of extensive burns ; phlegmasia alba dolens, or white leg, during pregnancy or after labour. A theroma of the A rteries leads to a feeble or imperfect circulation of the blood, and so to loss of nutrition. Ulcerative conditions of the lower part of the leg are therefore common in such cases, and even gangrene may result. Old Age. — Owing to a weaker condition of the tissues, ulcers are much more frequent in old people than in the young. Cold. — A similar condition is brought about by exposure to cold, especially in persons whose nutrition is imperfect, whether from bad or insufficient food. The first effect of cold is to produce a chilblain ; this if rubbed or irritated may degenerate into an ulcer. Trauma. — In a normal individual, any lesion of the skin of the leg, such as that caused by a kick, a scratch, or a cut, will heal quickly, and no ulcer result. Circumstances may arise which interfere with the healing process. Perhaps the most frequent cause which leads to the formation of an ulcer is infection with pyogenic organisms, and the prevention of the discharge from the wound. ULCERATION OF THE LEG 8ii Fig^. 208. — Gummatous ulcer. Cleanly punched out. Slongh on base. Fig. log. — Tuberculous ulcer. Undermined edges with perforations and tags. Occasionally there is also accidental contamination of the wound with some specific organism, such as that of diphtheria or phagedaena. An important cause of want of healing of an ulcer is interference with its contraction. If contraction is impossible, as when a sore is situated over and adherent to a bone, healing may come to a standstill. Deficient Innervation leads to loss of nutrition. Examples are seen in infantile palsy ; rubbing of the boot or pressure of an instrument is prone to be followed by an obstinate ulcer. In cases of hemiplegia, even when the patient is lying on a w^ater-bed, ulceration in the form of bed-sores will occur much more rapidly on the paralyzed side than on the other. Perforating ulcer of the foot is a well-known sequel of tabes dorsalis. Diabetes mellitus is an instance of a constitutional condition leading to the formation of an ulcer. All the preced- ing were local causes. Ulceration and Gangrene [q.v.) are prone to occur, no doubt because the resistance of a dia- betic individual to micro-organisms is lowered, also because the arteries are often atheromatous, and possibly be- cause the innervation of the whole body is interfered with. 2. Infective Ulcers. — It is possible for the legs to be attacked by any form of acute infective ulcer, such as anthrax or glanders, but such an event is rare. The chief ulcers that belong to this group are chronic, and due to syphilis or tuberculosis. Syphilitic Ulcers are the result of gummata which have formed in the subcutaneous tissues. These ulcerated gummata are almost always circular, and present a punched-out appearance {Fig. 208) ; they are generally multiple and tend to run into one another, so that the ulcer has a serpiginous outline. They tend to heal at one side, while they progress at another. On the leg, especially about the front of the tibia, circular scars of old ulcers can usually be found. The scars are thin and supple, and if in the lower part of the leg, usually pigmented. Gummata are often found with varicose veins or ulcers, and it seems probable that the low state of nutrition of the tissues caused by the obstruction of venous return is favourable to their formation. Diagnosis can in most cases be made on the distribution and shape of the ulcer, especially if they are on the outer aspect of the lower third of the leg, and on the presence of other signs of syphilis. In cases of doubt, a Wassermann's reaction is of service. Tuberculous Ulcer usually follows the formation and bursting of a tuberculous abscess, starting either in the subcutaneous tissue or in a bone, and the history may help materially in diagnosis. The ulcer is very chronic, and is characterized by undermining of the skin for a considerable distance from the edge [Fig. 209). -'TJ: F/o — Diagram of epitheliomatous ulcer. Growth in excess of destruction. A, Normal skin ; B, Heaped-up edges ; C, Ulcerated portion. Fig. 211. — Diagram of rodent ulcer. A, Normal skin; £, Smooth, wire-like edges; C, Shallow cavity. Frovi Introduction to Surgery, by Prof. Rutherford Morison. 8i2 ULCERATION OF THE LEG The surface is pale, and the granulations very small, with here and there small areas of caseation. Pritnan,' tuberculosis of the skin, or lupus, is not often found on the leg, though it may occur there as in any other part of the skin. A useful guiding rule is that lupus never starts later than the age of twenty and lasts for years, whereas a gumma starts at a later period and tends to heal spontaneoush'. In lupus the chief characteristic is the presence of minute, semi-transparent nodules at the margin of the ulcer and in the skin around, resembling apple jelly. If further methods of diagnosis are required, a diagnostic injection of Koch's old tuberculin may be used, or von Pirquet's skin test applied. 3. Ulcerating Tumours. Epithelioma mav develop in a simple varicose ulcer that has existed for many years. The change may be ver\" slow, or rapid. The ulcer spreads, the edges become heaped-up, everted, and indurated [Fig. 210). The glands become enlarged and, if the disease is allowed to progress, the bone is attacked. If any doubt arises as to a change in the character of an ulcer, a piece from the edge should be removed for pathological investigation. Rodent Ulcer (Fig. 211) usually attacks the face, though it may be found on any part of the body. It has to be distinguished from lupus and gumma. Sarcoma, starting in the deeper tissues, may fungate through the skin, which has given way before the pressure of the tumour. George E. Gask. ULCERATION OF THE THROAT.— (See Sore Throat.) ULCERATION OF THE TONGUE. — To enable a good view to be obtained of the affected part, the patient should be seated in a strong light and the protruded tongue gently wiped with a piece of soft linen to remove moisture. The presence of an ulcer being ascertained, its nature may be considered under the following heads : — Carcinomatous Syphilitic Dental 4. Tuberculous 5. D^'speptic 6. Ulcer in connection Avith stomatitis. I. Carcinomatous Ulcer. — ^This is much commoner in men than in women, probably owing to the fact that chronic glossitis due to smoking and sj^philis is more common in the male sex. It is practically unknown before the age of thirty, and rarely starts before forty-five. The ill and wearied expression of the patient may awaken suspicion before the tongue is seen, for the pain and trouble caused by an epithelioma ha^'e a very rapid and marked effect. The tongue in a ncrmal indiA-idual can be protruded from one to one and a half inches beyond the teeth ; if the protrusion is limited, or if it is not protruded straight, it can generally be inferred (except in cases of paralysis) that there is some tumour binding it down, and a very careful search should be made for an ulcer, which may be patent at once, or if on the under surface might escape a superficial glance. Xext, the position of the ulcer is to be studied, and its relation to any sharp and carious tooth. Usually an epithelioma is on the side of the tongue, but there is no rule ; it may be anywhere on the anterior two- thirds, on the under surface, or on the floor of the mouth. As regards the ulcer itself, the tA'pical appearance, when fairly developed, may be described as irregular, deep, foul, sloughy, with raised nodular everted edges, and a surrounding area of induration, the result of infiltration. The lymphatic glands are enlarged and hard, and they may be fixed. The sub- maxillar}' set is generally the first afi'ected, but it is of interest to note that the disease sometimes misses these and infects the carotid and even the supra- clavicular glands. Examination, therefore, should not be concluded before ULCERATION OF THE TONGUE 813 the whole of the neck has been looked at. The diagnosis should have been made, however, before the disease had developed thus far ; in its earliest stages an epithelioma may be represented by a superficial ulcer, a sixteenth of an inch in diameter, by a crack or a small lump, without any enlargement of the glands. In all these conditions, however, the ulcer is hard, and, moreover, is very resistant. to any form of treatment. Any ulcer of the tongue occurring in a middle-aged man, and lasting for more than tv/o or three weeks, should awaken suspicion. Diagnosis from Syphilitic Ulcer. — This may be a very real difficulty, owing to the fact that the two conditions may exist side by side, and that the syphilitic leucoplakia or leucomic wart may be, as is believed by many clinicians, the actual precursor of a cancer. A positive Wassermann's reaction, therefore, would not be proof that an epithelioma is not present. If a well-formed gumma is present, antisyphilitic remedies soon make a great change in its appearance, and a diagnosis may be made in this way, but not more than ten or fourteen days should be allowed to pass in uncertainty. There are many cases in which the cleverest surgeon is in doubt, and seeing the rapid course this disease runs, and the vital importance of securing an early diagnosis, it is urged here with the greatest possible insistence that the only certain method, and the one to be employed early, is that of taking out a piece of the ulcer, or, if small, the whole ulcer, and submitting it to histological examination. Diagnosis from Dental Ulcer. — The ulcer in this case is caused by a bad tooth, and therefore is in a position on the tongue corresponding to the latter. Further, the ulcer is soft to the touch, and heals rapidly when the offending tooth is stopped or extracted. There is seldom difficulty in differentiation except when the ulcer is of very long standing. 2. Syphilitic Ulcer. — This may be primary, secondary, or tertiary. Primary Syphilis or Chancre is certainly rare on the tongue and, owing partly to its rarit}-- and partly to the fact that it is unexpected, it is frequently missed. It is more common in men than in women, but it may occur even in children. It starts as a small pimple, which ulcerates and becomes indurated, though the induration is not so marked as when it is situate on the glans penis. General enlargement of the lymphatic glands is an early and marked feature, and this is an important help to diagnosis. Pathological aids to diagnosis are Wassermann's reaction, and the examination for spirochaetae {Plate XII, Fig. J) in serum from the sore. Furthermore, the sore heals rapidly under the influence of mercury, and the appearance of secondary symptoms will certainly settle the question. Secondary Syphilis manifests itself by the formation of mucous patches and superficial ulcers. The latter are almost always multiple, and situated along the edges and tip of the tongue, and with them are also found similar sores on the mucous membrane of the cheek, lips, palate, and tonsil, and at the edges of the mouth. The ulcers are small, round, painful, with sharply cut edges and a greyish floor. All the constitutional signs and other secondary symptoms will be present, so that there should be no difficulty in forming a correct diagnosis. Tertiary Syphilis or Gummatous Ulcerations. — These are divided into superficial and deep. Superficial gummata begin as small round-celled infiltrations in the mucous and submucous tissue. The ulcers are usually shallow, often irregular and associated with chronic glossitis, fissures, and leucoplakia. They are extremely important, for, as stated above, such a condition is very often followed by an epithelioma. They are also very resistant to antisyphilitic remedies, which only adds to the difficulty of diagnosis. The ulcers themselves are not at first indurated, but if surrounded by interstitial fibrosis may appear 8i4 ULCERATION OF THE TONGUE hard. Therefore a histological examination is eminently desirable if there is the least doubt. A deep gumma starts as a hard swelling in the substance of the tongue ; later it softens, breaks down, and shows itself, generally in the middle line, as a deep cavity with irregular, soft, undermined walls, and a wash-leather-like slough at its base. It is not painful, and does not increase in size. The important thing is to distinguish it from epithelioma and tuberculous disease. Unlike epithelioma, it is not hard, and its historj^ is short. Furthermore, it yields very rapidlv, under the influence of potassium iodide or salvarsan. 3. Dental Uleer is a traumatic ulcer due to repeated small injuries received from the sharp edge of a decayed tooth. It is therefore situated in such a position, generally on the side of the tongue, that it is opposite the tooth. The ulcer is single, small, superficial, and not indurated unless it is of long standing. It is therefore not easily mistaken for any other kind of ulcer, or if doubt arises it is allayed by stopping or extracting the tooth, when the ulcer quickly heals. There is a form of dental ulcer which is found on the frsenum of the tongue in children suffering from whooping-cough ; during the violent expiratory spasms peculiar to the illness, the under surface of the tongue may suffer from rubbing over the lower incisor teeth. DESCRIPTION OF PLATE XV. Fig. A. — Old leukoplakia of many years' duration. Quite recent development of epithelioma, in the form of a very slightly raised smooth red plaque, feeling about as thick as a sixpence. Between it and the middle line is a tiny nodule resembling a pimple. Fig. B. — Area of thin leukoplakia on the right border of the tongue, with a small epithelioma, which had developed in the site of a bite received several months previously. Fig. C. — Leukoplakia of many years' duration, with the very earliest condition of epithelioma to the left of the middle line in the form of a very small area of leukoplakia (a), slightly more raised and a little firmer than the rest. The diagnosis depended as much on the slight hardening as on the appearance. 4. Tuberculous Uleer of the Tongue is rare ; but it occurs at that period of life during which tuberculous disease of the lung is common, that is to say, between the ages of fifteen and thirty-five. It is due to infection with tubercle bacilli brought up into the mouth, and if a patient is found to be suffering from tuber- culous disease of the lungs or larynx and also from an ulceration of the tongue, there is a strong probability that the latter is of the same nature as the former. The ulcer itself may be situated on the tip or side of the tongue ; it has an irregular outline, and the base is nodular, sloughy, or caseous. It has often been mistaken for epithelioma or gumma. The fact that it is not hard, and that phthisis is present, should put one on one's guard. As against gumma, a Wassermann's reaction would be negative. A von Pirquet's test or a dia- gnostic injection of Koch's old tuberculin might be employed, but a more reliable method is the removal and microscopical examination of a piece of the ulcer, when the histological appearances of tubercle will be seen. The tubercle bacillus (Plate XII, Fig. K) is not always found. 5. Dyspeptic Ulcer, as the name implies, is connected with disorders of digestion. The ulceration is often multiple, each ulcer being round, small, often covered with a greyish slough, and with a bright ring of inflammation round it. They PLATE XV. CANCER OF THE TONGUE: VERY EARLY CONDITIONS (From drawings kindly lent by H. T. liuiLi.N, F. R.C.S.) Fig. A. Piz. B. Reproduced by permission fro)ii '''J7ie Medical Annual." INDEX OK DIAGNOSIS URATE DEPOSIT IN THE URINE 815 are placed on the dorsum of the tongue near the tip. The mouth, too, is very foul, and the cervical glands may be enlarged. 5. Ulcers in connection with Stomatitis (Ulcerative Stomatitis). — Septic infec- tion of the mouth due to a variety of causes, such as irritation from decayed teeth, alkalies, acids, or mercury, may be accompanied by the formation of small vesicles which, on bursting, give rise to superficial ulcers. They are not limited to the tongue, but appear on the mucous membrane of the cheeks and gums as well. Aphthous stomatitis commonly occurs in conjunction with the febrile diseases of childhood. It is characterized by the formation of whitish spots on the buccal mucous membrane, and by the shedding of epithelium small superficial ulcers may be formed. The ulcers of the tongue are here, so to speak, accidental, occurring in the course of a general inflammation of the mouth, and will hardly be confounded with any other form of ulcer. George E. Gask. UNCONSCIOUSNESS.— (See Coma.) UNEQUAL PULSES.— (See Pulses, Unequal.) UNEQUAL PUPILS. — (See Pupil, Abnormalities of the.) URATE DEPOSIT IN THE URINE.— A precipitate of urates is often recognizable at once by its pink colour, which is due to their carrying down with them the uroerythrin pigment of the urine. Urates themselves are white, however, and if, as is sometimes the case, there is no uroerythrin present for them to carry down, they form a white precipitate which may be mistaken for mucus, phosphates, or pus. They may be distinguished at once, however, by warming the urine back to body temperature ; they re-dissolve long before boiling point is reached. They are also soluble in liquor potassae, unlike phosphates. Microscopically they are nearly always amorphous, though in rare cases they assume the form of small spheres with irregular projecting spicules — the so-called " thorn-apple " or " hedgehog " crystals. Their only significance from a clinical point of view is that they indicate a concentrated urine. It does not follow that a urine is not concentrated if no precipitate of urates occurs, but the fact that the urates re-dissolve on warming serves to show that, although there may be enough water to keep them in solution at body temperature, the urine becomes supersaturated with them as it cools, and precipitates them out. The reason for the urinary concentration has to be learned from collateral evidence. It may be that there has been much sweating, and in hot weather a precipitation of pink urates is a very common physiological condition which is apt to alarm some patients when they first notice it. On the other hand, the concentration may be due to pathological conditions, of which the commonest are fevers, chronic valvular disease with heart failure, and maladies which lead to loss of fluid by vomiting, sweating, or diarrhoea. The urates themselves afford hardly any clue to the cause of the concentration, and their appearance is just the same whether their deposition is due to physiological or pathological changes. The most marked examples of uratic deposits are to be seen perhaps in cases of acute rheumatic fever, lobar pneumonia, and chronic heart disease with failing compensation. It is a general rule, moreover, that when the kidneys are themselves affected there is decidedly less tendency for uratic deposits to form than when the primary disease is in the heart or lungs ; thus when one may be in doubt as to whether a given case of chronic heart failure is due to primary renal disease or heart disease, the occurrence of an abundant urate deposit 8i6 URIC ACID DEPOSIT IN THE URINE affords some evidence in favour of the latter and against the former. It is no absolute rule, however, and almost any concentrated urine may precipitate urates. Students are a little apt to confuse the significance of urates with that of uric acid, though the two are entirely independent from a clinical standpoint. Herbert French. URETHRA, DISCHARGE FROM.— (See Discharge, Urethral.) URIC ACID DEPOSIT IN THE URINE.— The most typical form taken by a precipitate of uric acid in a urine is that known as the cayenne-pepper deposit. It is made up of numbers of unmistakable, though seldom voluminous, characteristic light- brown prismatic crystals [Fig. 212), arranged, either as separate " whetstones," or in overlapping bundles, or " rosettes " ; occasionally, crystallization is imperfect, and they appear as " dumb-bells." Intrinsically, they are colourless ; but they differ from all other urinary deposits in that they carry down with them the ordinary yellowish-brown urochrome pigment of the urine. For clinical purposes the best test for them is the microscope. Besides the cayenne-pepper deposit, uric acid crystals may be present in con- siderable numbers in the midst of other precipitates, such as mucus, or oxalate Fig. 212. — Uric acid crystals of various types. of lime ; in which case they may not be discernible without the use of the microscope ; or, again, they may become aggregated together into small pellets or calculi, which the patient may be conscious of as " gravel " on micturition. A deposit of uric acid is generally found in a decidedly acid urine of high specific gravity ; but it may occur in urines of almost any reaction or specific gravity. A great deal more importance has been attached to this uric acid than it deserves, on account of its relationship with gout. A cayenne-pepper deposit by no means indicates gout ; indeed, it may be perfectly physiological, occurring abundantly sometimes in healthy young persons, particularly boys. It does not even follow from its occurrence that there is excess of uric acid, either in the urine or in the tissues ; for the precipitation depends nearly as much upon the relative proportions of phosphates, chlorides, and inorganic sulphates to uric acid, and upon the absolute and relative amounts of sodium, potassium, and other bases in the urine, as upon the absolute amount of uric acid. The greater the tendency of the bases to form phosphates, by mass action or otherwise (see Phosphaturia), the less the tendency for the soluble quadri- urates, and the greater the liability for less soluble biurates, to be produced, the URIC ACID DEPOSIT IN THE URINE 817 relatively insoluble uric acid being liberated from the latter and deposited in crystalline form. Considerable care has to be exercised, therefore, before any useful clinical deductions can be drawn from the fact that a urine contains a deposit of uric acid. It is true that a persistent tendency to it is often associated with gout ; but the latter should be diagnosed from the collateral evidence rather than upon the uric-acid crystals in the urine. Many gouty subjects precipitate no uric acid in their urine at all. Naturall}', there will be a greater tendency to such deposition when the total amount of uric acid present is greater than normal. Uric acid in the urine is derived from t^vo sources — exogenous and endogenous. The exogenous sources are such foodstuffs as are rich in nucleo- proteid, and in the so-called xanthin bases, or purin, or alloxuric bodies, xanthin, guanin, hypoxanthin, adenin, heteroxanthin, paraxanthin, episarkin, epiguanin , methylxanthin, and carnin, which are mainly derived from nuclein. Analyses of the various foodstuffs as to purin bases need not be given here, for it is easy to remember that, broadly speaking, these substances are contained in largest quantities in the richest food. A considerable proportion of the xanthin bases are excreted as uric acid, and it is common knowledge that rich foods tend to increase uric acid in the urine. Endogenous uric acid, on the other hand, is derived from the patient's own tissue metabolism. Birds excrete nearly all their nitrogenous waste as uric acid ; man excretes his mainly as urea, and only to a minor extent as uric acid. Sometimes, however, too much of his nitrogenous metabolism stops short at the stage of uric acid, instead of the latter being nearly all converted into urea ; he then excretes an abnormal total quantity of uric acid, with the result that it may be precipitated in crystalline form. One repeats, that this does not necessarily constitute gout, however ; it occurs in certain healthy subjects, in leukcemia, in pernicious anaemia, during the course of certain fevers, and in some cases of chronic heart disease. Perhaps one of the best ways of avoiding too narrow a conception in regard to this uric acid is to remember that in some respects the human body is a fire ; fires may burn their coal well or badly ; if well, the residue is but a little ash ; if badly, the residue is not ash, but clinker ; uric acid is the clinker of the human body, and manj? different things that make human nitrogenous metabolism incomplete, may cause a deposition of this clinker in the urine. Gout is one such thing ; but excessive eating, deficiency of exercise, biliousness, and various chronic imperfections of the circulation, or digestion, may do so ; and the same may occur in apparently healthy subjects, who have never had any untoward symptoms at all. Oxalate of lime (see Oxaluria) is very possibly derived in part from similar imperfect combustion of carbohydrates or fats, and it is noteworthy how often crystals of uric acid and of oxalate of lime occur, either together, or alternating with one another. Still further, error of metabolism may produce glycosuria in association with uric-acid crystals, so-called gouty glycosuria. Besides being evidence of overloading, or of imperfect combustion in a general sense, the occurrence of a uric acid deposit may be of particular clinical impor- tance in certain cases ; first, of frequency of micturition ; secondly, of urethritis ; and, thirdly, of renal calculus. Necessity to micturate frequently, only small quantities of urine being passed at a time, is a symptom that in young people suggests cystitis, possibly tuberculous ; enlargement of the prostate in men over sixty ; or some uterine or other pelvic malady in women. It is important to remember, however, that undue acidity of the urine, with a tendency to deposit crystals of uric acid, or oxalate of lime, may produce the same symptom in considerable degree. It is sometimes spoken of as irritability of the bladder ; the highly acid urine irritates the vesical mucosa, and it may produce actual D 52 URINE, ABNORMAL COLORATION OF cystitis. The same irritation may inflame the urethral mucosa, and produce a " gouty " urethritis ; and, perhaps, epididymo-orchitis, which may be mis- taken for one of gonococcal origin, unless pus films can be shown to contain no gonococci. If the patient has suffered from renal colic, hasmaturia, or vesical pain, sugges- tive of calculus in the kidney, ureter, or bladder, the discovery of abundant uric-acid crystals in the urine affords confirmation of the diagnosis of a uric-acid stone, particularly if they are obviously aggregated together into tiny calculi ; there are generally red corpuscles, excess of leucocytes, and tailed epithelial cells from the renal pelvis, or pyriform cells from the deeper layers of the bladder mucosa, at the same time. The danger of diagnosing glycosuria in the absence of sugar, when uric acid is abundant in a urine, needs special mention. Uric acid has considerable power of reducing Fehling's solution. It seldom gives the copious brick-red or orange-yellow precipitate that is characteristic of abundance of sugar, but it may give just enough reduction or change of colour to make it doubtful whether sugar is present or not. More than a few proposers for life insurance have suffered unfairly on this account ; no such partial reduction should be regarded as due to sugar, until the presence of glucose has been confirmed by other means, particularly the phenylhydrazine and the fermentation tests. Herbert French. URINE, ABNORMAL COLORATION OF. — This may be due to : (i) The presence in abnormally large quantities of certain urinary pigments, such as uroerythrin and hsematoporphyrin ; (2) The presence of pigments formed in the organism, but which are not normally excreted in the urine, such as haemoglobin and the pigments of the bile ; (3) The presence of pigmentary substances derived from drugs or foods, or administered directly by the mouth. Urines of unusual tints may be classified conveniently according to the colours which they exhibit, as follows : (I.) Yellow and orange urines ; (II.) Pink and red urines ; (III.) Brown and black urines, including such as are of normal tint when passed, but darken on exposure to air ; (IV.) Green and blue urines. I. Yellow and Orange -coloured Urines. — The normal yellow tint is wholly due to urochrome, for other urinary pigments are present in traces so minute that their presence has no obvious effect. However much it be diluted, normal urine remains yellow as long as any tint is visible. In some cases of diabetes insipidus the urine is almost colourless, and the abundant urine of diabetes mellitus usually exhibits a greenish-yellow tint which has not yet been explained . Urobilin, when present in large amount, imparts a rich orange-yellow colour ; and when seen in very thin layers, as near the apex of a conical glass, urines rich in urobilin have a pinkish tint, due to selective absorption in the middle of the spectrum. Such urines, when examined with the spectroscope, show a dark absorption band near the solar F line (-Fig'. 23, p. 95). Urobilimiria — the excretion of excess of urobilin — may result from widely different causes, and as a consequence, its clinical significance is not so clear as might be expected. The symptom is met with in connexion with haemolytic diseases, such as pernicious ancemia, in diseases of the liver, such as cirrhosis, and in cases in which excessive bacterial action is going on in the intestine. The bulk, if not the whole, of the urobilin of urine is derived from the intestine, where it is formed by the action of the bacteria present upon bilirubin. It is present in abundance in normal faeces, and in traces in normal urine. Uroerythrin — the highly unstable pigment to which the colour of pink urate sediments is due — when abundantly present in solution in the urine imparts to it a rich orange-red colour, which may even be mistaken for that due to blood. The colour is changed to a pale greenish-yellow by addition of an alkali. Hepatic URINE, ABNORMAL COLORATION OF 819 derangements of almost all kinds, including the most trifling functional dis- turbances, may lead to the appearance of uroerythrin in the urine ; but the most intensely pink urate sediments are seen in cases in which the liver is the seat of pronounced morbid changes, such as cirrhosis, or the passive congestion due to cardiac disease. Choluria. — Urine which contains bilirubin has a rich orange colour with a greenish tint at the edge of the meniscus. The foam formed by shaking it has a yellow colour, whereas that of bile-free urine, even when deeply pigmented, is colourless. The colour of the urine may be much modified by the presence of biliverdin, in addition to bilirubin, and may approach to black or dark green. The presence of bile pigment may be demonstrated by Gmelin's test. This is best carried out by allowing the urine to flow gently on to the surface of some- nitric acid in a test tube ; on gently shaking, the familiar play of colours is seen at the junction of the Uquids, and the urinary layer often retains the green tint of biliverdin for a considerable time. Again, a green ring is observed when tincture of iodine is allowed to flow on to the surface of the urine in a test tube. When the quantity of bile pigment present is very small, the above tests may fail to reveal its presence, and Huppert's test may then be resorted to. A precipitate is formed by the addition, to a much larger volume of urine, of a solution of barium chloride and baryta water, or of calcium chloride and lime- water. The precipitate, which carries down any bile-pigment which may be present, is filtered off and washed into a test-tube with alcohol. Dilute sulphuric acid is then added, and the test-tube is heated in a beaker of boiling water. If bile pigment be present, the acidulated alcohol acquires a rich green tint, due to biliverdin. Choluria is merely a symptom of jaundice, but the appearance of bile pigment in the urine may precede any yellow coloration of the conjunctivse or skin, or, as in cases of acholuric family jaundice, the skin may be tinted although the urine is free from bile pigment. In the very rare cases in which a fistula exists between the biliary and urinary tracts, choluria of pronounced degree has been observed, apart from any jaundice. Certain drugs impart to urine a tint which, although yellow, is abnormal. This is seen when santonin is administered, or chrysophanic acid, which is a con- stituent of rhubarb and senna. In either case, the urine turns pink on addition of an alkali, but the pink colour is far more brilliant after santonin than after chrysophanic acid has been taken. II. Pink and Red Urines. — The conditions which lead to the excretion of a pink or red urine may be classified as follows : (i) Hematuria, in cases in which the blood pigment appears in the urine mainly as oxyhaemoglobin ; (2) Hsemo- globinuria — usually in cases which do not belong to the paroxj^smal class ; (3) Hsematoporphyrinuria ; (4) Administration of rosaniline as a drug ; (5) Eating of sweetmeats coloured with eosin ; (6) Presence of chrysophanic acid in an alkaline urine. I and 2. Hcsmaturia and hcBtnoglobinuria. — -For the significance of these symptoms, and the detection of blood pigment in urine, the special articles dealing with them may be referred to. 3. HcBmato porphyrinuria is a symptom of considerable interest. The name is applied to a condition in which urine is passed which has a pink, port-wine, or nearly black colour, and which contains considerable quantities of the hcemo- globin derivative, haematoporphyrin. In the darker specimens the colour is mainly due to other little-known pigments which accompany the hcemato- porphyrin. For the recognition of the condition spectroscopic examination is necessary. It is most liable to be mistaken for hsemogiobinuria, but when the 820 URINE, ABNORMAL COLORATION OF urine contains no albumin the distinction is not difficult ; when albumin is present in a pink urine, the diagnosis is more difficult, because the spectrum of haematoporphyrin in the combination in which it usually occurs in such cases resembles that of oxyhaemoglobin somewhat closely. However, the addition of hydrochloric acid changes the spectrum to that of acid haematoporphyrin instead of to that of acid haematin {Fig. 21, p. 95). If a mixture of 10 per cent calcium chloride solution and lime-water be added to the urine, the precipitate formed carries down all the abnormal pigments, and the filtrate is yellow. From the precipitate the haematoporphyrin may be extracted with acidified alcohol, and its highly characteristic spectra may be observed and identified. The trace of haematoporphyrin present in normal urine escapes detection by such means, but the increased quantities present in a variety of morbid conditions may be revealed by faint bands, even in cases which do not fall into the class under consideration, and in which the urine shows no obvious anomaly of pigmentation. In the great majority of cases, haematoporphyrinuria results from prolonged administration of sulphonal in medicinal doses, and forms one of a group of toxic symptoms of much gravity, which often usher in a fatal ending. These sym- ptoms may only develop after the drug has been taken for months or even years, and even some days after its administration has been stopped. Their develop- ment calls for the free administration of sodium bicarbonate. It is a remark- able fact that such toxic effects of sulphonal are seldom seen except in women, and the few male cases on record have mostly been of a mild kind. Much more rarely, haematoporphyrinuria, with deep red urine, is met with in cases in which it cannot be ascribed to any drug. Several patients have been sufferers from hydvoa cBStivale, others frora tuberculosis, and others from maladies so different from each other that no definite diagnostic significance can yet be assigned to the symptom. In such cases the haematoporphyrinuria does not appear to have the grave import which it has in sulphonal cases, nor is there manifested any special liability of the female sex. 4, 5, and 6. Coloration by constituents of foods and drugs. — Rosaniline, which was at one time employed in the treatment of albuminuria, imparts a pink colour to the urine which, provided that it be known that the drug is being taken, offers no diagnostic difficulty. Aniline dyes have also, ere now, been deliberately added to the urine for the purpose of simulating haematuria. Eosin has been extensively employed for the coloration of pink sweetmeats and lozenges, and the urine of those who eat such sweetmeats in considerable quantities acquires a rich pink colour, and shows a brilliant green fluorescence. The nature of such pigmentation can hardly be mistaken by any one who is aware of the fact that eosin is so employed. Drugs which contain chrysophanic acid are so frequently used as aperients that this compound may rank as a common constituent of urine ; and if, from any cause, the urine be alkaline, it acquires a pink or red colour, which may easily be misinterpreted. However, the history of the taking of rhubarb or senna, and the fact that the addition of an acid changes the colour of the urine to a bright yellow, renders the diagnosis easy. The pink colour which alkalies impart to the urine of patients taking santonin is so fugitive that it does not call for consideration here. III. Brown and Black Urines The urine may be brown or black in the following conditions : (i) Jaundice ; (2) Haematuria ; (3) Haemoglobinuria ; (4) Haematoporphyrinuria ; (5) Indicanuria ; (6) Melanuria ; (7) Alkaptonuria ; (8) Carboluria ; and after the administration of certain other drugs, such as salol, salicylates, resorcin, gallic acid, and uva ursi. In some of the above conditions the urine has such coloration when passed ; URINE. ABNORMAL COLORATION OF 821 but in others, such as melanuria and alkaptonuria, the urine is usually of normal tint when freshly passed, and only darkens on standing in contact with the air. I . Brown and black jaundiced urine is chiefly met with in cases of long-standing icterus, in which the skin has acquired a dull greenish tint, and the urine contains biliverdin as well as bilirubin. 2 and 3. In some of the early recorded cases of black urine, the colour was certainly due to blood pigment, and the smoky colour of many urines which contain blood pigment in the form of methaemoglobin is familiar to all. In paroxysmal hcsmoglobinuria also, the urine is not unfrequently almost black. The ordinary tests for haemoglobin, together with microscopic and spectro- scopic examination, serve to reveal the nature of such cases {Figs. 17 et seq., P- 95)- 4. That the urine of hcematoporphyrinuria may approach to actual blackness, owing to the abundant presence of purple pigments which have no characteristic spectra, has already been mentioned in the account of that symptom above, 5. Indicanuria. — Urines which contain much indican may show no abnormality of tint ; but occasionally, and especially in extreme cases, there are present in the urine, in association with the colourless indoxyl sulphate, other and higher oxidation products of indol, which impart to it a brown colour, intensified or developed on exposure to air. This variety of brown or black urine is less well recognized than it should be, and it is probable that the condition has not infrequently been mistaken for melanuria. Such urine is not blackened, as that of melanuria is, by the addition of ferric chloride, nor by nitric acid in the cold, but does blacken when heated with nitric acid. The ordinary tests for indican reveal its presence in large amount. Thus, if a specimen of the urine be heated with an equal volume of hydrochloric acid, and a drop of a dilute solution of bleaching powder, or a drop of nitric acid, it becomes black. If, after cooling, the dark-coloured liquid be shaken with chloroform, the latter takes up indigo-blue and red and acquires a deep purple colour ; but the supernatant liquid remains black. If the chloroform extract be separated and evaporated to dryness, the indigo red may be dissolved out of the residue with alcohol, whereas the indigo blue, which is insoluble in alcohol, may be taken up afterwards with chloroform. Indicanuria signifies abnormal amount of protein decomposition in the alimentary canal, brought about by intestinal bacteria ; but it is stated that it may also have its origin in collections of putrid pus, such as putrid empyemata. In such a case, which was recently under the writer's care, the abundant indican disappeared from the urine when a dose of calomel was given, and was probably of intestinal origin. 6. Melanuria. — This is a symptom which is met with in some cases of melanotic sarcoma. The urine, when freshly passed, contains a colourless chromogen, melanogen, and usually has a normal tint. On exposure to air, it quickly darkens, owing to oxidation of the melanogen to melanin, becomes brown, and eventually quite black. When nitric acid is added to such a urine, it causes prompt blacken- ing, even in the cold, and immediate blackening also follows the addition of a solution of ferric chloride. This is the most valuable and characteristic of the tests for melanuria. Bromine water produces a yellow or brown precipitate which quickly blackens. As a rule, melanuric urines, when treated with liquor potassas and sodium nitroprusside, yield a deep Prussian blue on acidification with acetic acid, but this reaction is not due to the melanogen as such, is yielded by some other urines, and cannot be taken as diagnostic of melanuria. It is frequently stated that melanuria may be met with apart from melanotic growths, in cases of wasting and other diseases. There is little doubt that some 822 URINE, ABNORMAL COLORATION OF of the cases quoted in support of this contention, and which were recorded before the more distinctive tests for the condition were known, were, in reality, examples of indicanuria, such as have been described above, and the writer has never met with true melanuria save in cases of melanotic sarcoma. Even in such cases it is not seen so long as the tumour is confined to its primary seat, but only when it has invaded the viscera, and especially the liver. Indeed, the quantity of melanogen excreted is apparently dependent upon the extent to which the liver has been invaded, and the amount of pigmentation in the growths of which it is the seat. Hence it usually happens that the diagnosis of the case has already been established before the peculiar pigmentation of the urine is developed. 7. Alkaptonuria is the outward sign of a very rare anomaly of metabolism which is almost always congenital, and persists through life without any serious detriment to the health of its subjects. The peculiar properties of the urine are due to the excretion in it of an aromatic acid, homogentisic or hydroquinone- acetic acid, a product of katabolism of tyrosin and phenylalanin. It is, in all probability, a product of normal metabolism, which in normal individuals under- goes complete destruction. Alkapton urine seldom exhibits any abnormality of tint when passed ; but quickly darkens on exposure to air, undergoing changes through brown to black, which resemble in the closest manner those seen in melanuria urines. However, the two conditions are readily distinguished by means of simple tests. When a dilute solution of ferric chloride is added to alkapton urine, a deep blue colour appears for a moment, and reappears after each subsequent addition of the reagent, until oxidation of the homogentisic acid is completed. Unless the reagent be very dilute, oxidation occurs too rapidly, and the blue colour is missed. The addition of an alkali causes very rapid darkening, with absorption of oxygen, and heat increases the rate of blackening. As homogentisic acid is a powerful reducing agent, alkapton urines give some of the reactions of glycosuria. Fehling's solution is freely reduced with the aid of heat, but the blackening effect of the alkaline reagent gives a peculiar appear- ance to the reaction. No black precipitate is obtained with Nylander's reagent, but the alkali therein causes conspicuous darkening. The safranin reaction is not obtained, and alkapton urine is optically inactive. An ammoniacal solution of silver nitrate is rapidly reduced, even in the cold, a reaction which is made use of for the quantitative estimation of homogentisic acid. It is because alkaptonuria is so rare, rather than because its recognition presents any special difficulty, that its properties are not widely known and not infrequently fail of recognition. Ochronosis, i.e., a blackening of the cartilages, and deep pigmentation of regions of the skin, a bluish-black coloration of the ears, and pigment spots on the conjunctivae, is sometimes the outcome of alkaptonuria ; but there is a group of cases in which similar pigmentation results from the application of carbolic acid to chronic ulcers, over long periods of years. There is also some reason to believe that the lesions of joints which sometimes accompany ochronosis may also be results of alkaptonuria. 8. Carboluria. — A darkening of the urine, increased by exposure to air, is frequently seen after the administration of certain drugs which contain phenol, in carbolic acid poisoning, and as the result of outward application of carbolic acid. A carbolic-acid compress applied to the head of a child for the destruction of pediculi quickly induces carboluria, and the taking of salol is another common cause. The urine has a smoky tint, or in cases of carbolic acid poisoning may be actually black. In the slighter cases it is best described as brown with a greenish tinge, and the meniscus, when seen from the side, appears black. URINE. ABNORMAL COLORATION OF 823 There is no direct chemical test for carboluria, and the diagnosis is usually based upon the knowledge that phenol, or some derivative or compound thereof, has been administered or applied. After boiling the urine for some time with Fehling's solution, a slight reduction is observed ; but this is in no way comparable with that seen with alkapton urine. Indirect evidence is obtained by the addition of a solution of barium chloride, which in cases of carboluria produces a very slight precipitate or none at all. If, however, the urine be first boiled with hydrochloric acid, a precipitate is obtained such as is yielded by normal urines. This is due to the fact that, in the presence of abundant phenol and oxidation derivatives thereof, the sulphates of the urine are for the most part, or even wholly, combined as aromatic sulphates, which yield no precipitate with barium salts, whereas, when the aromatic sulphates are broken up by hydrochloric acid a precipitate of barium sulphate is thrown down. The diagnosis of the other varieties of brown or black urine which have their origin in the administration of drugs, is based upon the fact that salicylates, or other drugs capable of producing such pigmentation, have been taken. IV. Green and Blue Urines — In some cases of jaundicej the bile pigment excreted is so largely in the form of biliverdin that the urine has a dark green colour : but with this exception, practically all green urines met with in practice owe their colour to the taking of methylene blue, either as a drug or in sweetmeats. \Yhen the dose is small, the tint may be a rich green ; but after larger doses, the urine is frankly blue. It is not always easy to account for the origin of such coloration of urine, for the patient may be quite unaware that he has taken methylene blue in any form, although examination of his urine may leave no doubt that he has done so. Sweetmeats are sometimes coloured with this pigment, as they are with eosin, and it is sometimes used to correct the colour of white sweetmeats. Again, a pill of methylene blue has before now found its way, either by accident or design, into a supply of pills of another kind. Absence of a known cause does not, therefore, by any means exclude this kind of pigmentation ; and experience shows that unless it can be shown, by careful examination, that the colour of the urine is not due to methylene blue, it is needless to search for any other causation. Although the green urine which follows the taking of methylene blue may appear perfectly hmpid, the blue pigment is not held in solution but in suspension, and is, to a large extent, removed even by a single filtration. The green colour of the filtrate is greatly reduced, and the filter paper shows a blue stain. The pigment upon the filter yields a blue solution in chloroform, and if the chloroform solution, or the blue extract obtained by shaking the urine with chloroform, be shaken with liquor potassae in a test tube the chloroform is decolorized, and the supernatant alkaline liquid acquires a pink tint. The original urine, or the chloroform extract, show's an absorption band in the red of the spectrum which may be mistaken for that of indigo blue. There is no reason to think that indigo blue ever produces a green or blue coloration of urine similar to that due to methylene blue. By the spontaneous breaking down of indoxyl glycuronic acid, usually in alkaline urines, indigo blue may be set free, and may form a dark blue sediment, or may impart a blue colour to the phosphatic film upon the surface ; and when, in the earlier years of the last century, indigo blue was somewhat frequently employed as a drug in the treatment of epilepsy, a dark purple colour of the urine of patients so treated was observed, but under no circumstances are indigo pigments spontaneously formed in quantities sufficient to bring about such a result. A. E. Garrod. URINE, ACETONE IN.— (See Acetonuria.) URINE, ALBUMIN IN.— (See Albuminuria.) 824 VEINS. VARICOSE ABDOMINAL URINE, ALBUMOSE IN.— (See Albumosuria.) URINE, BACTERIA IN.— (See Bacteriuria.) URINE, BENCE-JONES' BODY IN.— (See Albumosuria.) URINE, BILE PIGMENT IN. — (See Urine, Abnormal Coloration of.) URINE, BLACK. — (See Urine, Abnormal Coloration of.) URINE, BLOOD IN.— (See Hematuria ) URINE, CASTS IN. — (See Albuminuria.) URINE, CYSTINE IN.— (See Cystinuria.) URINE, DIACETIC ACID IN.— (See Acetonuria.) URINE, DIAZO-REACTION IN.— (See Diazo-Reaction.) URINE, EXCESS OF.— (See Polyuria.) URINE, F^CES IN. — (See F^ces Passed per Urethram.) URINE, FAT IN.— (See Chyluria.) ■ URINE, GAS IN.— (See Pneumaturia.) URINE, GLUCOSE IN.— (See Glycosuria.) URINE, HEMOGLOBIN IN.— (See H^emoglobinuria.) URINE, INCONTINENCE OF. — (See Micturition, Abnormalities of.) URINE, INDICAN IN.— (See Indicanuria.) URINE, MUCUS IN.— (See Mucus in the Urine.) URINE, OXALATE DEPOSIT IN.— (See Oxaluria.) URINE, OXYBUTYRIC ACID IN.— (See Acetonuria.) URINE, PHOSPHATES IN.— (See Phosphaturia.) URINE, PUS IN.— (See Pyuria.) URINE, RETENTION OF. — (See Micturition, Abnormalities of.) URINE, SUGAR IN.— (See Glycosuria.) URINE, SUPPRESSION OF.— (See Anuria ) URINE, URATE DEPOSIT IN.— (See Urate Deposit in the Urine.) URINE, URIC ACID DEPOSIT IN.— (See Uric Acid Deposit in the Urine.) UTERUS, PROLAPSE OF. — (See Prolapse of the Uterus.) VAGINAL DISCHARGE.— (See Discharge, Vaginal.) VARICOSE ABDOMINAL VEINS.— (See Veins, Varicose Abdominal.) VARICOSE THORACIC VEINS.— (See Veins, Varicose Thoracic.) ^VEINS, VARICOSE ABDOMINAL.— The point at which distention of veins becomes varicosity is arbitrary ; most conditions that produce undoubted vari- cosity of the veins of the abdominal wall in some cases, merely dilate them in others. When this dilatation is considerable (Plate XVI), it nearly always has much diagnostic significance, particularly if the direction of blood-flow is reversed. Veins, however, may seem to be dilated when they are but unduly visible owing to wasting of the subcutaneous fat ; or they may, in very rare cases, be simply varicose, like veins in the leg, owing to idiosyncrasy or hereditary predisposition. In neither of these cases, however, is the blood-current in them reversed. To test the direction of blood-fiow, part of a vein should be chosen where there are no side branches, and the blood should be expressed from it by means of two PLATE XVI. VARICOSE ABDOMINAL VEINS A case of obstruction lo the inferior vena cava by malignant disease. INDEX C1F DIAGNOSIS VEIXS, VARICOSE ABDOMINAL 825 fingers pressed down on the vein close together, and then drawn asunder, whilst pressure over the vein is maintained by each ; when a length of the distended vein has been emptied in this way, one of the two fingers is taken off, and the time taken by the vein in re-filling is noted ; the procedure is repeated, the other finger being taken oft' this time ; it will generally be obvious whether the vein fills from below upwards or from above downwards. Normally, the blood flows from above downwards in the veins of the lower two-thirds of the abdominal wall ; when the blood-flow is from below upwards, there is almost certainly an obstruction to the inferior vena cava, the blood, which is unable to return by it, finding a collateral circulation via the azygos veins or the superior vena cava. Obstruction to the inferior vena cava is due to one or other of three main groups of conditions, namel}' : — ■ 1. Great general increase in the intra-abdominal tension, owing to such condi- tions as : ascites ; ovarian cyst ; great splenic or hepatic enlargement. 2. Thrombosis without external obstruction. 3. Obstruction by compression from without, yet without there being obvious increase in the intra-abdominal tension ; such local obstruction to the inferior vena cava results mainly from carcinoma or sarcoma, adjacent to the vena cava, especially secondary growths in the retroperitoneal glands. When the obstruction of the inferior vena cava is due, not to the vein itself being thrombosed or invaded by new growth, but to the general intra-abdominal pressure becoming so great that the vein is, so to speak, flattened out, the vari- cosity of the veins upon the abdominal wall is but a late symptom, and the diagnosis will be made from the cause of the great abdominal distention, generally the result of Ascites [q.v.), or a big tumour. If there is marked varicosity of the superficial veins earl}^ in a case of ascites, the probability is that both are due to malignant disease. When the inferior vena cava is obstructed by " simple " thrombosis, the probability is that the clotting will not have started there, but will have extended to it from branches either in the legs or in the pelvis. QJdema of the legs will be a prominent symptom ; and if a clear history is obtainable, it may generally be ascertained that one leg became oedematous and painful before the other ; when this is so, it is always very suggestive of thrombosis starting in the saphenous or femoral veins (see (Edema, Asymmetrical) ; the other leg becom- ing affected later when the clot has spread up through the iliac veins of the one side to the inferior vena, and thence down the iliac veins of the other side. The higher the thrombus extends, the higher up the back will the oedema spread ; and when the renal veins have been reached, albuminuria, with tube casts, and even hasmaturia, will be marked features of the case. Ascites may also be present. Distention or varicosity of the veins of the abdominal wall will be of assistance in distinguishing such a case from one of acute or subacute nephritis, besides which, there will be no oedema of the eyelids or face. If there is no very tense distention of the abdomen ; if the way the case began does not suggest thrombosis in one leg, or in the pelvis, extending upwards ; and if, nevertheless, there is marked varicosity of the veins of the lower part of the abdominal wall, with the blood-flow in them reversed, so as to be from below upwards, the history being a relativel}- short one, — the probability is that the inferior vena cava is being obstructed b}' something that is in immediate contact with it. There will very likely be symmetrical oedema of the legs, and possibly albuminuria and hsematuria. It is surprising how seldom an aortic aneurysm, or other non-malignant mass, obstructs a large vein sufficiently to produce this collateral varicosity ; hence, the presumption is that such varicosity indicates malignant disease. It is worthy of note that carcinoma o^f the kidney is prone to extend into the renal veins, and thus into the inferior vena cava by a process 826 VEINS, VARICOSE THORACIC of direct extension — sometimes the malignant clot reaches as far as the right auricle, and produces a pedunculated polypus in the latter. In such cases there has generally been hsematuria or other renal symptom before evidence of inferior vena-caval obstruction arose, whereby cases of growth in the kidney invading the inferior vena cava may be distinguished from cases of secondary growth in the retroperitoneal glands, which if they produced hsematuria at all, would do so by first obstructing the inferior vena cava, and thence involving the renal veins. In such cases there are often other synaptoms pointing to primary growth in some organ whose lymphatics drain into the retroperitoneal glands ; the testes and ovaries should not be overlooked in this respect. It is often said that cirrhosis of the liver leads to varicosity of the veins around the umbilicus — the so-called caput meduscs. It is a very rare condition indeed, the great majority of cases of cirrhosis of the liver causing no distention of the superficial abdominal veins until such time as the general intra-abdominal tension has been greatly increased by the tenseness of the ascites which occurs late. Not even the telangiectases that occur so commonly in men past middle age around the lower part of the chest, in a line with the attachments of the diaphragm, indicate cirrhosis ; they are quite as common in cases of emphysema without cirrhosis. In short, varicosity of the superficial abdominal veins generally indicates either thrombosis of the inferior vena cava, secondary to direct spread of throm- bosis up to it from veins in the pelvis or in the leg, or else stenosis of the vena cava by secondary malignant disease. Herbert French. VEINS, VARICOSE THORACIC— Much of what has been said above about varicose abdominal veins applies also to those of the thorax. The veins on the chest wall may merely be unduly visible ; but if they are really distended, there is probably obstruction to one or other innominate vein or else to the superior vena cava ; and the suspicion that this is so becomes a certainty if the blood current in the distended veins can be shown to be from above downwards instead of from below upwards. If the distention is bilateral, and associated with oedema of both arms, and both sides of the neck, face and head, it is the vena cava that is obstructed ; if the distention is unilateral, with oedema of the corresponding arm, but little if any of the neck or face, the obstructed vessel is probably one innominate vein. The superficial varicosity may be only slight {Fig. 73, p. 235), but sometimes it is extreme. In arriving at a diagnosis of the cause of the venous obstruction, malignant disease within the thorax will be uppermost in one's mind — especially mediastinal sarcoma, starting in the thymus or in the lymphatic glands. It is onl}- when the history and course are too long for primary or secondary malignant neoplasm, that other causes of venous obstruction will be regarded as more likely, such as thrombosis extending to an innominate vein or to the superior vena cava from a whitlow, boil, or other inflammatorj^ affection of the hand, arm, axilla, head, face, neck, shoulder, or front of chest ; or chrome fibrous mediastinitis, sometimes tuber- culous or gummatous but often rheumatic in origin, and resulting from repeated attacks of pericarditis and pleurisy, with matting together, not only of the pleurae to the diaphragm and pericardium, but also of all the structures in the superior, posterior, and anterior mediastina to one another ; or, far less commonly, to aneurysm of the thoracic aorta, or a non-malignant mediastinal tumour, such as a hydatid cyst, a dermoid cyst, or a large congenital fibroma, which may have been quiescent within the chest for many years before starting to enlarge and obstruct structures in its neighbourhood ; the latter conditions, except aneurysm, are rarities, and although an aortic aneurysm does sometimes obstruct the superior vena cava sufficiently to cause distention or varicosity of the veins VERTIGO 827 upon the chest wall, such varicosity is so much more marked in a case of intra- thoracic malignant disease that one may say that when the diagnosis lies between neoplasm and aneurysm the presence of marked distention of the veins of the chest wall indicates the former rather than the latter, though the converse of this is not true. Herbert French. VERTIGO, popularly known as dizziness or giddiness, depends upon a dis- turbance of the sense of equilibrium. In slight cases the trouble is perceptible to the suiferer either as the apparent movement of motionless objects (objective vertigo), or his own body may appear to be moving in relation to surrounding fixed structures (subjective vertigo). In more severe cases it may lead to reeling or staggering, and unless the patient can grasp some fixed support he may fall to the ground. The equilibrium of the body is maintained by the co-ordinated action of various groups of muscles, and the nervous mechanism for this co-ordination is situated in the cerebellum. Afferent impulses are brought to the cerebellar centres from the muscles, skin, joints, eyes, and the semicircular canals. The cerebellum is also connected with the motor centres of the cerebral hemisphere, and thus the requisite contraction of the necessary muscles is ensured. Dis- turbances of equilibrium may therefore be the result of a lesion in the cere- bellum itself or in one of the afferent tracts. True vertigo depends mainly upon interference with the afferent impulses from the semicircular canals or from the eyes. The importance of the visual impulses in the maintenance of equilibrium is shown by the frequent occurrence of nys- tagmus during attacks of vertigo, even when this is due to a labyrinthine lesion. Occasionally vertigo may be the result of altered cutaneous impulses such as are present in some cases of anaesthesia of the soles of the feet. Some people experience a slight feeling of giddiness on stepping on to some soft material such as turf or india-rubber pavement after walking on a hard road. Unusual cutaneous impulses are the probable explanation. Interference with the afferent impulses from the muscles themselves, such as occurs in locomotor ataxy, will lead to reeling and staggering rather than to true vertigo. The ocular impressions correct the false sensations from the muscles, and hence loss of equilibrium is more likely to occur in the dark, or when these impressions are cut off by covering the patient's eyes. Vertigo is sometimes divided into " general " vertigo and " special " vertigo. In the latter, objects appear to move, or the patient tends to fall in a definite direction. Special vertigo points to a lesion of a particular semicircular canal. Thus, if there is a lesion of the external semicircular canal, objects appear to move in a horizontal plane, and the patient tends to fall towards the affected side. When the superior canal is the source of the trouble, objects rotate in a vertical plane, and the patient will fall in a forward direction. Temporary vertigo, even of a very severe nature, may be produced readily in a healthy individual by prolonged movements of rotation or of swinging. In this case the cause of the giddiness is probably unequal pressure in the endolj^mph in the different semicircular canals. The dizziness with which niany people are affected when near the edge of a high cliff is most likely ocular in origin, and depends upon the sudden cessation of visual impulses from near objects. Some persons are exceedingly susceptible to alterations in these impressions, and travelling by train or the movement of a boat may be sufficient to cause a considerable degree of dizziness. Vertigo may also be of toxic origin. Alcohol and tobacco are familiar examples, but the dizziness associated with ptomaine poisoning, and in some cases of gastric disturbance, is also probably of this nature. 828 VERTIGO Vertigo is not infrequentlj' of cerebral origin, either with or without some gross lesion. Thus it occurs in migraine, and is also a frequent aura of an epileptic fit. ' Attacks of vertigo occurring in elderly people with atheromatous arteries or suffering form chronic nephritis or arteriosclerosis must always be regarded as of serious import, since an attack of giddiness may be the precursor of cere- bral haemorrhage or thrombosis. Severe vertigo may be one of the syntiptoms of a cerebral tumour. It is more likely to be present when the growth is in the cerebellum, especially if the middle lobe is involved. A tumour involving the auditory nerve in its intracranial course will also give rise to this symptom. A cerebral or cerebellar abscess may also cause vertigo, but in this case there may also be suppuration in the middle ear, and the giddiness may be of labyrinthine origin. Vertigo naay be of ocular origin. It is especially likely to occur when there is some lesion of the nerves or muscles leading to diplopia. Laryngeal vertigo is a very rare condition, where spasm of the glottis is accom- panied by severe giddiness which causes the patient to fall down, and he may lose consciousness for a few seconds. Complete recovery ensues in a short time, but the attacks are likely to recur. This trouble may be of an epileptic nature. Vertigo is, however, most commonly of aural origin, and is a frequent symptom of diseases of the ear, especially of the internal ear or labyrinth. In its most intense form it is one of the symptoms of " Meniere's disease." Its onset is then sudden, and so severe that the patient falls to the ground and even loses consciousness. Associated with the giddiness are severe tinnitus, and unilateral or bilateral deafness, while nausea, vomiting, and pallor of the face are frequently present. The vertigo passes off after a few hours or days, but impairment of hearing and tinnitus persist. The attacks tend to recur. Meniere's disease is probably caused by a sudden increase in pressure in the endolymph, and, in some cases at any rate, appears to be due to haemorrhage into the semicircular canals. True Meniere's disease is very rare ; but the occurrence of the symptoms, viz., vertigo, deafness, and tinnitus, in a less acute and sudden form, is by no means uncommon. They may be present without any obvious lesion of the middle or external ear, though sometimes there is some abnormality in one of these portions of the auditory apparatus. Syphilitic disease of the internal ear may produce symptoms closely resembling those of Meniere's disease, in that giddiness, tinnitus, and labyrinthine deafness are associated, the onset being quite sudden. Vertigo is, however, occasionally absent. The trouble is usually unilateral, and may occur in the secondary or tertiary stages. The diagnosis will depend on the history of syphilis or other evidences of the disease. Similar symptoms may occur in congenital syphilis, usually between the ages of ten and fifteen years, though occasionally much later. Eustachian-tube obstruction is usually present also, but treatment of this fails to improve the hearing, and other characteristic troubles, especially- interstitial keratitis, may be found. Aural vertigo may also be associated with some lesion of the external or middle ear. Thus in the former case there may be a foreign body, or even a plug of impacted cerumen, as the exciting cause. Vertigo is not infrequently present in chronic middle-ear suppuration. This may be due to labyrinthine inflammation or irritation, but a definite labyrinthine lesion is not necessarily present. In many cases the giddiness is caused by pressure on the stapes or the fenestra rotunda. Some patients with a perfora- tion of the tympanic membrane become giddy whenever the ear is syringed. Occasionally the use of unduly hot or cold lotions produces this trouble. It is usually the result of pressure on the stapes, though occasionally the vertigo may have the special character associated with a lesion of the external semi- circular canal {vide supra). When this is the case there is probably some erosion VESICLES 829 of the bony external canal. Similar giddiness may occur from a like cause on syringing the ear after a radical mastoid operation. Vertigo may occur in otosclerosis, though it is not common in this disease, and is always of less importance than the Deafness {q.v.) and Tinnitus (q.v.). When a patient complains of vertigo, the ears should always be examined carefully. The hearing should be tested, and if the cause of the trouble is in the labyrinth, the deafness will have the characters of nerve deafness (see Deafness). The onset of the trouble must be investigated carefully, and any associated symptoms ascertained. The eyes and ocular muscles must be examined, and if nystagmus is present the character of the movements should be observed. A general examination of the patient should also be made for some general constitutional cause such as gout, albuminuria, or arteriosclerosis. Philip Turner. VESICLES. — One of the primary lesions, the vesicle may be defined as a circumscribed epidermal elevation varying in size from a pin's head to a small pea, and containing serous fluid, which may become sero-purulent or be mixed with blood. Serous elevations larger than a small pea are classified as BuLL.^ iq-v-)- To bullae, therefore, vesicles bear the same relation that papules bear to tubercles (see Papules) . The}' differ from bullae, however, not only in size, but in their mode of formation. They are always the result of an inflam- matory process, whereas in the case of bullae there is a veritable cleavage of the epidermis. Vesicles, again, often contain a number of chambers, at any rate in the beginning, whereas bullae are from the outset unilocular. They may originate as vesicles, or may develop from papules. Vesiculation may be either paren- chymatous or interstitial (Darier). In the one case, as in varicella, the plasma accumulates within the Malpighian cells, and the unicellular vesicles which are thus formed run into each other. In the other case, as in eczema, the plasma accumulates between the Malpighian cells. In shape, vesicles are usually rounded, conical, or acuminate ; but they may tend to the oblong form, as in scabies, or they may be both oblong and irregular, as in dermatitis herpetiformis. The larger ones are occasionally umbilicated, as in variola, and instead of being tense, as is usual with vesicles, may be flaccid, as in herpes and dermatitis herpetiformis. At first, the liquid they contain consists almost invariably of pure plasma, and is quite clear, or with the faintest tinge of j-ellow ; but exceptionally the fluid is from the beginning mixed with blood. After a time the clear fluid becomes turbid. In some conditions, as in varicella and miliaria, they remain discrete and few in number ; but usually, as in herpes, eczema, and dermatitis herpetiformis, there is a plentiful crop of them, forming groups or closely-set clusters. As a rule, they are of short duration : either thev rupture and crust over, as in eczema, or they dr}^ up and a crust is formed, as is usual in herpes ; or they enlarge into blebs, as frequently occurs in dermatitis herpetiformis ; or they are transformed into pustules, as in variola. On mucous membranes and the lips, and in folds of the skin, they break more quickly than in other situations, and leave excoriations. Since, as already stated, vesicles are the result of a more or less inflammatory process, they usually give rise to much burning and itching, though in some conditions, as in hidrocystoma, these symptoms are absent. The most distinctivel}'- vesicular aft'ections are herpes simplex and herpes zoster. In simple herpes the face and the genital organs are affected chiefly. The characteristic lesion is a cluster of transparent vesicles varying in number from two or three to twenty or more, seated on an erythematous patch, and surrounded by a narrow red zone. First, a slightly red spot appears on the skin ; effusion quickly takes place under the epidermis, and vesicles are formed ; these become 830 VESICLES opaque — sometimes purulent, — shrivel up, and form yellowish-brown crusts, which after a few days become detached, usually leaving no scar, but a brownish stain that slowly fades and disappears. These four stages in the evolution of the lesion are styled by Brocq the congestive, vesicating, desiccating, and macular stages. On mucous membranes the lesion runs a rather different course. Here the vesicles are quickly reduced to a whitish pulp, which presents the appearance of a false membrane. When this becomes detached, it reveals a number of roundish excoriations, either scattered about irregularly or running into each other and forming largish ulcers. The favourite situations of the vesicles in herpes genitahs are, in raen, the prepuce, especially its inner surface, the meatus, the sulcus, and the glans ; in women, the labia and the cervix. In men, the vesicles are usually discrete, and the patient complains only of the itching and burning ; but if they are neglected, or irritated by the application of caustics, there may be severe and extensive ulceration, with swelling of the inguinal glands. In women, the vesicles tend to become confluent, and the perineum, the inside of the thighs, and the mons veneris may be invaded. There may be a great deal of swelling, excoriation, and discharge, with intense itching and burning, and, as in men, there may be enlargement of the neighbouring glands. In the crusted stage, facial herpes may resemble impetigo, but the rapid course it runs, its limited distribution, the facts that it is not auto-inoculable, and that in impetigo the lips are seldom attacked, should suffice to obviate the confusion. The points which distinguish herpes facialis from vesicular eczema are touched upon below. The vesicles of genital herpes are too characteristic to be mistaken if they are seen before their real significance is obscured by ulceration. If, however, the ulceration is considerable, and especially if there is much suppuration, the herpes may be mistaken for chancroids. Generally, however, soft sores are multiple, have a fouler base, excavate more deeply, and the healing process is much slower. Soft sores, further, are flattened at the base, secrete very little liquid, and are auto-inoculable. In some cases there may be doubt as between herpes genitalis and true chancre, especially as, according to Fournier, a chancre not infrequentl}'- develops in the midst of a premonitory eruption of herpes. The points of differentiation are the absence, in herpes, of induration, the less considerable and more transitory gland-enlargement, the multiplicity, irregular form, and small size of the ulcers, and the intense burning and itching. In herpes zoster (zona, shingles), clusters of vesicles seated on an erythematous base, appear in the region of skin distribution of one or more of the posterior spinal nerve roots, preceded or accompanied by neuralgic pain and tenderness in the part. The erythematous patches, more or less oval, with the long axis parallel to the underlying nerve, come out in crops, the number of lesions varying from two or three to twenty or thirty. Soon the surface of the patches is studded with papules, which are quickly transformed into vesicles, from ten to twenty on each patch, sometimes discrete, sometimes running into each other to form bullre. An important diagnostic feature of the eruption is, that in the great majority of cases it is unilateral, and appears much more frequently on the right side than on the left. In rare cases, however, it forms a complete girdle round the body. The usual limitation to one side of the body, the distribution in one or more nervous territories, and the preceding or accompanying neuralgia, usually suffice to distinguish herpes zoster from erythema multiforme and from dermatitis herpetiformis. Another important point in diagnosis is the history, for zoster is not a recurring disease. These various characters serve to distinguish it also from herpes simplex and herpes genitalis. The neuralgic pain may be mistaken at first for pleurisy, but the course the affection runs VESICLES 831 soon clears up the confusion. I should add that in herpes zoster the conjunctiva and the eyeball are frequently attacked, and sometimes the mouth, especially the tongue. In rare cases, as Head has reported, the lesions on the tongue are not associated with an eruption on the Ups or the palate. Although the vesicular stage is not, as some authorities consider, a necessary phase in the evolution of eczema, the vesicle is undoubtedly the most constant of all the primary lesions met with in that condition. Usually, following sensations of itching and burning, an erythematous blush appears, which is soon studded with numerous tiny vesicles. These grow larger and often coalesce, but they soon rupture or are broken by scratching, and a clear fluid exudes, the " weeping " continuing as later vesicles break. In mild cases, the inflammation gradually subsides, and as the discharge ceases, scales or crusts are formed ; but much more frequently, fresh crops of vesicles start up around the edge of the earher patches, while new centres are formed in other parts, until nearly the whole cutaneous surface may be involved. In some cases papules are the predominant feature, in others erythematous lesions ; in yet others pustules, and in extensive cases, the several kinds of lesions may be all present simul- taneously. From herpes in general, eczema is distinguished by the characteristic exuda- tion, by the crowds of tiny vesicles, which coalesce without forming distinct groups, by the slower evolution of the disease, and by the fact that as a rule there is some inflammatory thickening. From herpes zoster it is differentiated by the pecuhar distribution of the vesicles in that affection (see above) . Doubt can seldom arise as between eczema and dermatitis herpetiformis. It is true that the earhest and perhaps the most characteristic lesion of the latter disease is a vesicular eruption, appearing on an erythematous base ; but the disposition of the vesicles in herpetiform groups should prevent confusion between the two conditions. The vesicles soon dry up and form scabs, but, later, they tend to coalesce into bullae, which scarcely ever burst spontaneously but, as their contents thicken, slowly shrink, and finally, if left to themselves, shrivel up to a thick brown scab. The " weeping " of eczema is therefore absent in dermatitis herpetiformis, of which, further, multiformity is a more pronounced feature — erythematous, vesicular, pustular, papular, and urticarial elements being mingled together in all stages of evolution. The vesicles of impetigo contagiosa are distinguishable from those of eczema by the larger size and discrete character of the former, and by their tendency to dry and form yellowish crusts without breaking, or as soon as they have broken. Even when the lesions run together and large crusts are formed, there will be discrete vesicles and papules which will point to the true nature of the affection. Miliaria rubra may sometimes resemble the vesicular stage of eczema, but here again the lesions, though numerous, remain discrete : they do not run together to form patches, they do not rupture, and there is no " weeping." Miharia of all forms is a very transitory affection, and instead of the intense itching of eczema, the patient describes his sensations as those rather of pricking and tingUng. In the form of miliaria which is known as hidrocystoma, or dysidrosis of the face, small vesicles hke those of miharia appear on the face, but they are so grouped as to form patches, which show no tendency to spon- taneous involution. Scabies is another affection in which the vesicles, hke those of impetigo and of miharia, are discrete. Sometimes the lesions, usually consisting of papules and pustules as well as of vesicles, take on an eczematous character, but they are not locahzed as are those of eczema, and instead of being small, acuminated, or circular, they tend to be hnear. In uncleanly persons, the burrows between the 832 VESICLES fingers and elsewhere which mark off scabies from all other affections, can hardly be overlooked. When they cannot be found, either because they have not yet been formed or because they have been laid open by scratching, the diagnosis of scabies must rest upon the irregularit}^ of the lesions — vesicles, bullae, and pustules being mingled Avith the marks of the finger-nails and the results of secondary inoculations — and upon the distribution, the parts most affected being those where the skin is least thick, namely, the webs between the fingers and toes, the front of the wrist, inside the umbilicus, on the lower abdomen, the genitaha, the nipples in women, and the axillary folds. The face nearly always escapes, except in infants in arms. Another vesicular condition in which the hands are specially attacked is cheiropompholyx , in which numerous minute vesicles deeply imbedded in the skin, and showing through the epidermis like boiled sago-grains, are sj^mmetrically distributed on the extremities — always on the hands, and frequently also on the feet. The general features of the affection — the limitation of the vesicles to the extremities and their proneness to unite and form buUas which dry up, the tendency to recovery followed by repeated recurrence, and the constant association of the eruption with the summer season — are sufficientlj^ distinctive, and the diagnosis is seldom in doubt. In some slight cases there is a general resemblance to certain subacute and limited cases of eczema in which the lesions may present the sago-grain aspect ; ^ but instead of rupturing and " weeping," the vesicles in cheiropompholyx tend to run together into bullae, which shrink and crust over. This formation of bullae by coalescence of vesicles differentiates the condition also from pemphigus. In erythema multiforme the vesicle can seldom be difficult of interpretation, even in erythema iris, or as it is also styled, erythema vesiculosum. In one form of this affection a small red spot appears, upon which is formed a vesicle that is quickly surrounded by a zone of redness. When the central vesicle dries up it leaves a small scab, and a ring of secondary vesicles soon appears on the red zone. On the separation of the central scab, the skin beneath is seen to have a blue, congested appearance. The whole process may be repeated time after time until the concentric rings of vesicles and reddened skin suggest comparison with a target. In the form of erythema iris, which sometimes is infelicitously called herpes iris, a large central bulla is encircled by vesicles of considerable size. Outside the first ring of vesicles another circle may develop, and outside the second, sometimes a third. The symptoms of so-called vesicular erythema multiforme are so characteristic that the affection can hardly be mistaken for anything else. Lichen planus is so characteristically a papular affection that the absence of vesicles is one of the points which distinguish it from eczema. In some cases, however — very rarely in adults, and rather less infrequently in children — vesicles appear, but never so as to confuse the diagnosis. In lichen urticatus a vesicle appears on the summit of the small wheal, and the condition may offer some resemblance to eczema ; but the individual lesions do not tend to run together nor to spread centrifugally, as in eczema, and the itching is usually more intense. The vesicular form of secondary syphilis is so rare, that by some authorities its existence is not recognized, and Stelwagon, who has never met with a case, justly points to the possibility of its being due, at any rate occasionallj^, to drug idiosyncrasy. The vesicles are reported as occurring in several forms : they may be minute, eczematoid, disseminated and grouped, or larger, irregularly scattered, or disposed in herpetiform groups ; and cases have been reported which simulate herpes zoster. The vesicles in syphilis are usually associated with papules, and they have a papular base, the disappearance of which leaves VESICLES S33 a long-persisting dark stain. The papular base and the slow evolution are important diagnostic points ; and usually other signs of syphilis will be present. In lymphangioma circumscriptum, even more than in vesicular syphilis, the significance of the vesicles can hardly be missed. In circumscribed areas of the skin there is an eruption of clusters of small, deep-seated, thick-walled vesicles, straw-coloured, sometimes marked with red striae, and filled with a clear alkaline fluid which contains a few lymph corpuscles. The affection, which consists in the over-growth and dilatation of lymph-vessels and the form- ation of new ones, is probably congenital, though not generally noticed until early childhood. Varicella — to come to the eruptive fevers — is an essentially vesicular affec- tion : only occasionally do the vesicles develop into pustules. They are usually preceded by reddish spots of shght elevation, and the commonest situations -Small-po.x : showing distribution of the eruption. F>-o!ii a photograph by Dr. D. S. Davies. are the face, chest, shoulders, back, and scalp, but they may also be found on the mucous membrane of the palate, mouth, or lips. As a rule the rash comes out within twenty-four hours. Often there is but trifling systemic disturbance. In the infrequent cases in which the varicellar eruption laecomes pustular, it may possibly be confused with a pustular syphilide ; but in the syphilide the lesions are pustular from the outset, or develop out of papules, and although the lesions of varicella start as papules, these are almost invariably small and evanescent. The absence of itching in syphilis is another point of difference. In exceptional cases of strophulus (see under P.a.pules) the vesicle on the summit may develop until it becomes visible macroscopically, and it may then be confused with varicella ; but the cases are so rare as to be negligible. It is with small-pox that chicken-pox is most often confused. In small-pox, the vesicles are usually multilocular ; in chicken-pox they are usually unilocular. ^ ' 53 834 VESICLES In small-pox they are frequently umbilicated ; in chicken-pox they are never umbilicated, and seldom even dimpled. The differences between the two exanthems in respect of the rash and the lesions generally, as summarized by Ricketts in " The Diagnosis of Small-pox/' are these : In variola, the rash is most abundant on the face and limbs, and least abundant on the abdomen and chest {Fig. 213) ; in varicella, the abdomen and chest are covered as thickly as the face, if not more thickly. In variola, the rash is much more abundant on the back than on the abdomen ; in varicella, the abdomen and the back receive equal attention. In variola, the rash is more abundant on the shoulders than across the loins, and on the chest than on the abdomen ; in varicella, the distribution as between these parts is indifferent. In variola, the rash favours the limbs and is distributed centrifugally ; in varicella it tends to avoid the limbs, and when it invades them is centripetal. In variola the rash, unlike that in vari- cella, favours prominences and surfaces exposed to irritation, and tends to avoid protected surfaces and depressions. As to the lesions generally, in variola they are deep-seated and have an infiltrated base ; are generally circular in outline and homogeneous in character ; whereas in varicella they are superficial and liave no infiltrated base, are frequently irregular in outline, or else oval or elon- gated, and are not, as a rule, homogeneous. Vaccinal eruptions may consist (i) of tiny vesicles or small superficial papules, or of a combination of those elements ; or (2) of a small papule with a vesicular or pustular head. In the second case the eruption may simulate modified small-pox, but almost always the vaccinal lesions are more superficial than those of the mildest cases of small-pox, and show a preference for the trunk. In eruptions due to the use of bromides, iodides, and other drugs, the vesicle is but one of the elements, and the nature of the affection is usually indicated with sufficient distinctness by the history of the case, the remission that occurs when the drug is v.'ithheld, and the recurrence that takes place when its administra- tion is resumed. Vesicles that follow the bites or stings of gnats, mosquitoes, etc., are always easily recognizable from the history, and from the central punctum to be seen in the lesions ; nor can there be any doubt as to the significance of those due to such accidental causes as frostbite and pressure from splints. Malcolm Morris. VISION, DEFECTS OF. — This subject may be considered in the following order : — (A) Normal vision, (B) Amblyopia, (C) Partial blindness, (D) Complete blindness, (E) Colour blindness, (F) Abnormal sensations of size, (G) Day- and Nigh I- b lin dness. A. — Normal Vision. I. Visual Acuity. — The act of vision comprises the perception of form, colour, and brightness ; and, in vision with two eyes, the perception of space and distance. These faculties are possessed by all parts of the retina, though in varying degrees, and they are of varying importance. It is necessary to distinguish between peripheral and central vision ; or, in other words, between merely seeing a thing and looking at it. An object is seen by any portion of the retina that has visual perception; but an object is only looked at when its image falls upon a particular portion of the retina, the yellow spot, which is situated at the posterior pole of the globe on the outer side of the optic disc. The act of so directing the eye that the image of a given object shall fall upon the yellow spot, is termed " fixation." The vision obtained by the fixation of the eye is termed " central vision," and owing to the anatomical structure of the retina at the yellow spot, the vision here is the most acute of which the eye is capable, though its area is very limited. In the normal eye, central vision is capable of distinguishing two points or parallel lines, which are separated by a space which subtends an VISIOX, DEFECTS OF 835 angle of i' — approximately the diameter of a sixpenny-piece at 200 feet — and it is on this basis that ordinary test-types are constructed. Central vision, however, though acute, is very limited in extent, and it is estiniated that the field of acute vision is only about the size of the thumb-nail held at arm's length, all vision outside this area being comparatively blurred and indistinct. This limitation of the field of acute central vision is barely appreciated under ordinary circumstances, owing to the rapidity with which the retina receives consecutive visual impressions, and the constant niovements of the eyes. Compared with the visual acuity of the central portion of the field of vision, peripheral vision is relativelv poor, though it is of extreme value in a different way. To appreciate the importance of peripheral vision it is only necessary to try to walk about looking through a roll of paper or music ; though central vision is unimpaired, and the smallest object can be seen distinctly, locomotion is almost impossible, owing to the inability to see where one is going or to ascertain one's position in relation to surrounding objects, the peripheral portion of the field of vision being responsible for the automatic appreciation of these conditions. On the other hand, a person from some cause deprived of central vision, can see to get about quite well, and has useful vision for many purposes, though he is unable to read or write, recognize people when looking directly at them, or do any work in which fine vision is required. 2. Colour Vision. — A person with normal colour vision can recognize six or seven distinct colours in the solar spectrum, and is able to appreciate many hundreds or thousands of varieties of colour caused by mixtures of them, and the colour perception of th-e normal person is most acute in the central portion of the field ; but the field of vision for colours has by no means the same boundaries as the field of vision for white. The fields of vision ior all colours are smaller than that for white, and the fields for red, green, and blue vary in extent among themselves. The field for blue is the largest, for red is next in point of size, and the field of vision for green is the smallest of all, being roughly only about half to a third the diameter of the field for white. 3. Brightness Perception. — The central and peripheral portions of the field of vision vary very much in their perception of brightness. In ordinary illumina- tion the central portion of the field is the most efficient, but in a very weak illumination the peripheral portion has a higher efficiency than the central part : in other words, there is in very dim lights a relative central scotoma or loss of vision. This fact has long been known to astronomers, who have found that in counting stars of low magnitudes, vision is much better if the particular constellation or group of stars is not looked at directly, the Pleiades being a Avell-known example ; more of these stars can be counted when the vision is directed to a point a little above or below them or to one side, whereas direct vision is comparatively dim and confused ; and the same holds good of vision ior any object in a dim light. Walking along a country road on a dark night, it will be found that a foot-path or track can be seen more easily if the gaze is ■directed forwards and not at the ground itself. These facts concerning vision may be correlated with the actual anatomical structure of the retina itself. It is found that in the region of the yellow spot — the area of the retina endowed "with acute vision — the cones are very numerous, with few rods ; towards the periphery of the retina the cones become fewer and the rods more numerous. It is now generally held that the function of the cones is to work in light of considerable brilliance, that they are capable of extremely acute vision for small objects, and are also concerned in the perception of colour. The rods, on the other hand, have no perception of colour ; their perception of form is poor compared with that of the cones ; but in very weak lights their visual S36 VISIOX, DEFECTS OF acuit^• is greater than that of the cones. In support of this theory may be mentioned the fact that the retinse of nocturnal animals are more fullv pro- \-ided Avith rods than cones. B. — Amblyopia. Amblyopia is the term applied to defective vision in which there is little or no e\-idence of any ocular condition which might account for the visual defect. It is not, therefore, employed where there is any obvious intra-ocular or intracranial lesion. The commoner forins of amblyopia are (i) Amblyopia ex anopsia ; (2) Urgemic ; (3) With nystagmus ; (4) Alcohol, tobacco, lead, quinine, organic forms of arsenic such as atoxyl ; (5) Migraine ; (6) Cortical or crossed amblyopia ; (7) \Yith hysteria. 1. Amblyopia ex Anopsia, is usually associated with a squinting e^-e, which may or may not have been put straight by operation. It is still open to dis- cussion whether the amblyopia in such conditions is due to the loss of use by reason of the squint, or whether the squint is due to the \-isual defect ; but the fact remains, that in many squinting eyes the \-isual acuity is very much below normal, though objectively the eye exhibits no abnormal s\Tnptoms. 2. Uraemie Amblyopia or Amaurosis, may be recognized by its association with renal disease, whether complicated by pregnancy or not. It is charac- terized by its comparatively sudden onset, \-ision failing either partiallj' or completely ^^dthin a few hours. The failure of %dsion may be accompanied by well-marked retinitis in both eyes ; but in many cases this is absent and the discs appear quite normal. The failure of ^'ision lasts for from thirt^'-six to fortv'-eight hours, and then slowly disappears, the whole attack lasting, as a rule, under a week. In the majority of cases, unless there is some definite injury to the optic nerve or retina as the result of retinitis, the \asion recovers entirely. In some cases of uraemia the blindness is complete. 3. Amblyopia with Nystagmus is usually associated with evidence of visual affections in very early life. At birth, fixation is not developed, and the higher visual acuit\' is only acquired after the first few months of infant life. Any affection of the e^-es, therefore, that obscures the \-ision during the earlier weeks or months of hfe, prevents the due development of central vision and leads to a permanent amblyopia, as a rule associated with nystagmus. Such affections are ophthalmia neonatorum, which leaves more or less corneal opacity ; perfora- tion of the cornea -n-ith anterior polar cataract as the result of this ophthalmia ; congenital defects, such as a persistent hyaloid arterv or macular coloboma ; and any retinitis or choroiditis affecting the region of the 3-ellow spot. 4. The Amblyopia due to Lead, Alcohol, Tobacco, Quinine, or Atoxyl, is usually described as a toxic amblyopia, and the SAinptoms are somewhat similar in all the varieties. In tobacco amblyopia there is a central loss of vision for colours, green only in the earlier stages, subsequently green and red, and in extreme cases even a central scotoma for white ; total blindness is practically unknown. The patient also states that he sees better in a duU than in a bright light, and that he is incapable of reading or ^\Titing, or distinguishing silver from gold coins. The ocular signs are usually ver}^ slight, being limited to some redness and blurring of the optic disc in early cases, or pallor of the outer side of the disc in later stages. Alcoholic amblyopia resembles in most of its symptoms the amblyopia due to tobacco, though vision for red is usually lost before vision for green. Amblyopia due to lead, quinine or atoxyl is rare, but it is also usually characterized by a central scotoma associated with some slight optic neuritis or atroph}'. 5. The Amblyopia of Migraine is usually transitory, and may occur either in the form of a central scotoma, hemianopia, or monocular blindness. It is more VISION. DEFECTS OF 837 rarely seen in the form of a quadrant hemianopia or a ring scotoma. In all cases the diagnosis is comparatively easy, as the amblyopia seldom lasts more than a few minutes, and is followed later by the characteristic headache and sickness of migraine. 6. Amblyopia has also been described as due to disease of the Visual Cortex, and rare cases have been described of a Crossed Amblyopia, or defect of vision in one eye due to disease of the visual cortex of the other. The loss of vision is, however, usually associated with some slight defect of vision in the opposite eye, and hemianopia is much more commonly the symptom of disease of the visual cortex. 7. Hysterical Amblyopia may, like other hysterical affections, take various forms, such as loss of visual acuity, a loss of colour vision, or diminution in the visual field. The characteristic form of the visual field in hysteria is either a spiral contraction or an extreme concentric limitation. The symptoms, however, vary very much at different examinations, a point of much importance in diagnosis. In certain cases there may be a functional loss of vision in one or both eyes, which can be recognized as hysterical by the employment of Snellen's coloured types or some other device for deceiving the patient. C. — Partial Blindness. This may be (i) Definite, or (2) Indefinite. I. Definite: (a) Hemianopia; (b) Central scotoma ; (c) Peripheral constriction. {a). Hemianopia (see Hemianopsia). (b). Central Scotoma. — A scotoma is a local defect in the visual field, and, from its position, may be either central or peripheral ; it may also be negative or positive. A negative scotoma is one where the defect of vision exists, but where the patient notices nothing abnormal. The best example of a negative scotoma is the blind spot in the field of vision caused by the entrance of the optic nerve. This area is blind, but the individual is not conscious of any visual defect. Scotomata of this character exist where there is some injury of the visual layers of the retina itself, or of the optic nerve or tract. A positive scotoma is one in which the visual defect is noticed as a black or coloured spot or cloud which obscures the vision in some part of the visual field. Such positive scotomata are due to lesions of the retina, such as haemorrhages or patches of pigment which do not destroy the visual layers. Vision still remains ; but it is obscured by some unusual opacity in the retina itself or in the adjacent portion of the vitreous. Scotomata frequently exist in the peripheral portion of the field of vision without being noticed, as they are of little importance in direct vision, and are not discovered unless carefully looked for. A central scotoma, on the other hand, is noticed at once, however minute, because it affects direct vision and produces a considerable defect in the visual acuity. A central scotoma may be either relative or absolute, and may exist for colours only or for objects. Central loss of vision for colours, more particularly red and green, is associated with tobacco and alcohol poisoning. The colours cannot be recognized in small objects when directly looked at, though a red or green object in the peripheral portion of the field of vision will be recognized as such. This scotoma is associated with greater or less diminution of the general visual acuity, and vision in such cases is generally better in a dull than in a bright light. Absolute central scotomata are met with in disseminated sclerosis, in certain forms of hereditary optic atrophy, and may persist after the acute affection of the optic nerve known as retrobulbar neuritis, or in rare cases after severe attacks of migraine. In nearly 25 per cent of all cases of disseminated sclerosis a central scotoma exists, and the diagnosis in such a case will be confirmed by VISION, DEFECTS OF its association with the general symptoms of the disease and with other ocular symptoms, such as optic atrophy, paralysis of accommodation, paralysis of the extrinsic ocular movements, or nystagmus. There is usually some pallor of the optic disc, though this is no indication as to the amount of visual defect. The diagnosis of a hereditary optic atrophy depends to a great extent upon the history of a similar affection among family relations and its usual period of incidence, namely, early adult life. It is associated with either neuritis or atrophy of the optic disc. Retrobulbar neuritis usually occurs in young adults, commonly attacks one eye only, and is sudden in its onset, vision failing from normal to no perception of light in a few hours. In the great majority of cases vision commences to return after the lapse of a day or two, and is ultimately restored in a fortnight or three weeks. If any defect remains it is usualh' central, and is due to some injury to those axial fibres of the optic nerve which supply the macular region. Central scotomata after migraine are rare, but may be ascribed to that cause when there is a definite history of sudden loss of sight associated with the characteristic hemicrania and vomiting. It is to be noted that central scotomata are not always easy to map out on a chart, owing to the patient's loss of power of fixation ; a careful use of the perimeter by an experienced observer is necessar^^ A small central scotoma may cause considerable failure of vision, even though it is too small to chart on the ordinary perimeter. Scotomata may also be paracentral, in the immediate neighbour- hood of the fixation point but not actually upon it, or ma}' take an annular or ring form. (c). Peripheral constriction. — Peripheral constriction of the visual field occurs commonly in affections such as acute or chronic glaucoma, optic atrophy, dissemi- nate choroido-retinitis, retinitis pigmentosa, and various functional conditions. The constriction of the visual field in glaucoma is usually most marked on the nasal side, and can be recognized from its association with the acute sj^mptoms of glaucoma, the circumcorneal injection, steamy insensitive cornea, dilated fixed pupil, hazy vitreous, and general symptoms such as trigeminal neuralgia, head- ache, and sickness. In chronic glaucoma it will also be associated with atrophy and cupping of the optic disc {Plate VIII, Fig. V) . Central vision may remain quite good, even though the field of vision is extremely limited. The field of vision is, as a rule, most limited in retinitis pigmentosa, where the failure of sight will be found to be associated with night-blindness and characteristic ophthalmo- scopic appearances, a small, ill-defined, Avaxy-looking disc, slender vessels, and diffuse superficial pigmentation of the periphery, the retina in patches resembling Haversian bone corpuscles. This condition often occurs in two or more members of the same family, and ma}' exist where the parents have been first cousins. A limitation of the field similar to that of retinitis pigmentosa is often met with in cases of disseminate choroido-retinitis {Plate VII, Fig. G) and consequent optic atrophy ; but may be distinguished from it bj^ abundant evidence in the eye of deeper changes in the retina and choroid. Constriction of the field of vision ma}' also occur in certain functional states, but may, as a rule, be recognized by its variable character and the absence of all evidence of organic ocular or general nervous disease. 2. Indefinite. — A defective visual acuity may exist with no evidence of any ocular or nervous disease (see Amblyopia, p. 836). Defective vision may also be due to errors of refraction, to opacities of the cornea, aqueous, lens, or vitreous, to affections of the choroid and retina, and to lesions of the optic nerve. Opacities of the cornea can easily be recognized on illumination of the eye with a strong light concentrated by a lens, and intra-ocular causes of defective vision can be discovered by ophthalmoscopic examination. Detailed differ- ential diagnosis of all the ocular causes of diminished vision requires a special knowledge of ophthalmology. VISION, DEFECTS OF 839 D. — Complete Blindness. Total loss of vision, blindness, or amaurosis, may be (i) Bilateral, (2) Uni- lateral. 1. Bilateral Blindness. — Total blindness in both eyes may be congenital or acquired. Congenital blindness may be due either to absence of the eyes them- selves, congenital anophthalmos, or to congenital defects in the development of the eyes themselves. Nearly 90 per cent of all cases of total blindness in the United Kingdom are due to the ophthalmia of the new-born. Such cases can be recognized by the history of profuse inflammation or discharge shortly after birth, by the diffuse opacity on the surface of the cornea, associated, in some cases, with thinning and protrusion of the anterior part of the eye, and more or less nystagmus. Total blindness may also be caused by bilateral inflammatory affections of the eyes, such as iritis with blockage of the pupils and consequent glaucoma, or ultimate shrinking of the eyes, bilateral primary glaucoma, optic atrophy, or lesions of the optic chiasma. It is seldom due to lesions of the optic tracts, as this would only be caused by a bilateral lesion totally destroying the optic tract on both sides. Total blindness of a transient nature may also occur in renal disease, and is termed urcemic amaurosis. This condition is recognized by its association with the symptoms of renal disease, whether in pregnancy or not, and by its sudden onset and short duration, the whole attack as a rule lasting not more than four or five days. In the majority of cases there is some evidence of renal retinitis, though in others the eyes are normal. The pupils usually react to light, though occasionally the light reflex is absent. Another form of transient blindness occasionally met with, is apparently due to spasm of the retinal arteries. In these cases the loss of vision may last only a few hours, and during its continuance it will be found that the retinal arteries are of a very slender calibre. It is to be noted that no cataract ever causes total blindness. Provided that the rest of the eye is normal, a patient with the densest cataract can always perceive light, and also has the power of projection, or the recognition of the direction from which the ray of light is coming. 2. Unilateral Blindness. — It is evident that unilateral blindness must be due to some lesion in the eye itself, or between the eye and the optic chiasma. Lesions of the optic tract above the chiasma do not cause monocular blindness, but Hemianopsia {q.v.). Monocular blindness may be either sudden or gradual. Gradual blindness may be due to any of the inflammatory affections of the eye mentioned above, or to such progressive diseases as optic atrophy or glaucoma. Sudden blindness in one eye may be due to one of the following causes :■ — Detachment of the retina [Plate VIII, Fig. T) Embolism of the central artery [Plate VIII , Fig. S) Thrombosis of the central vein [Plate VIII, Fig. 0) Vitreous haemorrhage Acute glaucoma [Plate VIII, Fig. V) Injury to the optic nerve due to an accident or fracture of the base of the skull Compression of the optic nerve from haemorrhage or dilatation of the nasal sinuses Retrobulbar neuritis Migraine. The diagnosis of the majority of these causes is simple, owing to the characteristic ocular or ophthalmoscopic appearances. The only cases which present any obscurity are those in which there is sudden loss of vision without 840 VISION, DEFECTS OF any visible ocular changes. These cases are usually due to retrobulbar neuritis, an acute affection of the optic nerve of obscure origin, characterized by sudden loss of sight, with some pain and tenderness on movement of the eye. The loss of vision as a rule lasts for not more than twenty-four or thirty-six hours, and coincidently with the return of vision, more or less definite neuritis appears at the optic disc [Plate VII, Fig. K). In the majority of cases vision entirely returns, but if there is a permanent defect, it usually takes the form of a central scotoma. Blindness due to compression of the optic nerve by dilatation of the accessory nasal sinuses can only be recognized after a thorough examination of the nasal passages ; sinus disease of any duration is always accompanied by certain well- defined appearances in the nose itself. Monocular blindness may also occur in migraine, but in these cases it is of extremely short duration, seldom more than ten minutes or a quarter of an hour, and is followed by the characteristic headache and sickness. E. — Colour Blindness. Defects in colour vision may be either congenital or acquired. In congenital colour blindness there is inability to recognize in the spectrum the six or seven definitely distinct colours which may be apparent to a normal eye. The commoner cases of colour blindness are those who can only see three colours in varying shades of black and white, or people who can only distinguish two colours, the spectrum being made up of yellow and blue, the one gradually passing into the other. Red, orange, yellow, and green are seen as one colour, blue and violet as the other. Scarlet and grass- green appear very similar to these persons. Cases of congenital colour blindness can be recognized by examination with coloured wools, as in Holmgren's test, or with much more precision and certainty in a dark room by means of a lantern with properly coloured glasses. Acquired loss of colour vision may also occur in tobacco blindness or in optic atrophy. Colour Defects. Rainbow Vision. — Objects, especially lights, may be seen surrounded by a ring containing the colours of the spectrum. The causes of this are, as a rule, either conjunctivitis — in which there is a thin film of mucus on the surface of the conjunctiva — or glaucoma. The diagnosis in the two cases should present no difficulty, because the rainbow vision of glaucoma will be associated with the other important symptoms of this disease, viz., steaminess or lack of brilliancy in the cornea, a shallow anterior chamber, dilatation of the pupil, and some limitation of the field of vision, especially on the nasal side. Erythropsia, or red vision, occurs after prolonged exposure to white or violet light in conditions such as electric or snow blindness. It is accompanied by much inflammation and redness of the eyes, conjunctival discharge, and intolerance of light. It may also occur in slight vitreous or retinal haemorrhages, though in severe vitreous haemorrhages vision is entirely abolished. Erythropsia, and in some cases blue vision, may occur aftei cataract extraction, and appears to be due to some fatigue of the retina. Xanthopsia, or y»llow vision, may occur in jaundice or in poisoning by santonin, amyl nitrite, cannabis indica, or picric acid. G. — Abnormal Sensations of Size. Objects may appear rapidly to increase or diminish in size in the preliminary stages of an attack of epilepsy ; and this variation in size of objects is a fairly common symptom in the slight delirium of infantile febrile disorders. Micropsia, VOMITING 841 or abnormal diminution in the size of objects, also occurs to many normal people during the act of reading. The book appears suddenl}' to recede to a great distance, and it and the type appear extremely minute, though absolutely clear. No satisfactory cause has yet been adduced for this phenomenon. It may be relieved bv a momentary rest, and is of no pathological significance. A similar condition may be produced by the use of certain drugs, particularly cannabis indica and its products. G. D.\Y-BLINDNESS AND NiGHT-BLINDNESS. Day-blindness, or hemeralopia, is caused most commonly by tobacco poisonings it being probable that this condition is due to a direct poisoning of the retinal cones, which are endowed with the faculty of effective vision in lights of high brilliancy. In snow-blindness, also, vision improves directly the light begins to fail, and defective vision in bright light is a common symptom of albinism. Except in the case of albinos, the retina may show no abnormal signs. Night-blindness, or nyctalopia, occurs most frequently in retinitis pigmentosa, in which on ophthalmoscopic examination, the characteristic appearance of a small ill-defined optic disc, thin thready arteries and veins, and the characteristic spider-like pigment cells may be seen at the peripherj^ of the fundus. It also occurs in cases of disseminate choroido-retinitis, and in scurvy. Patients suffering from high myopia may also suffer from defective vision in dim lights. Herbert L. Eason. VISION, DOUBLE.— (See Diplopia.) VOICE, ABNORMALITIES OF THE. — (See Speech, Abnormalities of.) VOMITING. — Strictly speaking, the term vomiting implies the return and expulsion from the mouth of part or the whole of the stomach contents. There are several conditions in which vomiting ma}- be simulated closely, although the vomited matter has never reached the stomach. It will be con- venient to deal with these before discussing the causes and differential diagnosis of true vomiting or gastric regurgitation. In certain diseases of the oesophagus, food may be swallowed and, after a varying interval of time, brought up again. These conditions are : Malignant disease Fibrous stricture Spasm Pressure from without, as by aneurysm, new growth, etc. " Idiopathic " dilatation Diverticula — " pressure " pouches. If the obstruction be of long standing, and near the lower end of the oesophagus, the interval between taking food and its regurgitation may be prolonged consider- ably, especially in cases in which the lumen has undergone much dilatation. This may occur with fibrous stricture, slow-growing carcinoma, or the very rare cases known as " idiopathic " dilatation of the oesophagus. A " pressure " pouch produced by a hernia-like protrusion of the mucous membrane through the muscular coats of the upper part of the oesophagus, becomes filled gradually and, in addition to dysphagia caused by the pressure it exerts on the oesophagus below, may simulate vomiting when its contents are voided. The dift'erential diagnosis of these oesophageal causes of vomiting, or rather regurgitation, is usually easy. The returned matter is practically unaltered, and is undigested. . It may be diluted freely with mucus. Blood may be present, and even portions of growth in cases of carcinoma. In oesophageal pouches. 842 VOMITIXG food may be retained for long periods and returned unchanged. The most important point to recognize is, that in such oesophageal conditions the returned matter is alkaline or neutral in reaction. The diagnosis is confirmed by examination -with a bougie, or by the .r-rays after administration of bismuth emulsion. Further, certain individuals ma}" acquire the power of voluntarily causing a regurgitation of portions of the stomach contents into the mouth, which ma}- be ejected or again swallowed, sometimes after further mastication. There is no accompan3"ing nausea. This condition, known as " rumination " or " Mery- ciSM " (i].v.), must be distinguished from vomiting. ^lention must also be made of conditions in which the mechanism of degluti- tion is deranged, and in which swallowing is interfered with to such an extent that the food or drink is returned. This may occur in cases of bulbar paralysis, myasthenia gravis, etc. Again, in diphtheritic paralysis the return of fluids through the nose, owing to the paralysis of the soft palate, may be mistaken for vomiting. A similar mistake has been made in cases the writer has met with of bronchiectasis in which, during the act of coughing, large quantities of pus have gushed up, not only from the mouth but also throiigh the nose. The regurgitation of milk in healthy breast- or bottle-fed infants after a heart}- meal is met with frequenth", and is often wrongly regarded as vomiting. It is due to simple overfilling, or sometimes to too rapid feeding ; air that has been swallowed is belched up, and drives out some of the milk with it. A brief account of the mechanism of vomiting will facihtate a classification of its causes. The parts concerned are the muscular coats of the stomach; the sphincter at the cardiac orifice ; the diaphragm, and the abdominal muscles ; the vomiting centre situated in the medulla ; the efferent ner^e fibres in the vagus supplying the musculature of the stomach ; the phrenics to the diaphragm ; and the spinal nerves supplying the abdominal muscles. In the act of vomiting, the waUs of the stomach contract, the diaphragm is pushed violenth- downwards in fuU inspirator}- position, while powerful contrac- tions of the abdominal muscles take place. At the same time the cardiac sphincter is relaxed, and the gastric contents are expelled, chief!}- as the result of the pressure thus exerted on the stomach by the diaphragm and the abdominal muscles, aided to some extent by reversed peristalsis. The pyloric sphincter is usually closed, but it may become relaxed, in which case bile and intestinal contents may enter the stomach and be found in the vomit. The vomiting centre may be excited to action by stimuli reaching it from the stomach itself, by afferent fibres in the vagus, or from other parts by many different afl'erent channels. The centre ma}- also be thrown into action by toxic substances acting on it directly. In retching, forcible contraction of the stomach wall, and of the diaphragm and abdominal muscles takes place as in vomiting, but there is no relaxation of the sphincter. In the condition known as ivaterbrash or pyrosis, in which a quantity of clear fluid is brought up into the mouth, usually on rising in the morning, the complete act of vomiting does not occur ; relaxation of the cardiac sphincter takes place without obvious attendant muscular contraction of the stomach or of its auxiliaries, the diaphragm and the abdominal muscles. It is obvious from the above that the causes of vomiting must fall into two great groups : (I) Those acting directly on the vomiting centre, such as certain poisons, e.g., apomorphine ; (II) Those acting refiexly on the centre. The second group is a ven,- large one, as it includes practically aU the pathological states of the stomach, many visceral diseases, disturbances of special senses, etc., as will be seen later. VOMITING 843 I. — Central Causes. Certain drugs — Apomorphine Tobacco Antesthetics Uraemia Diabetes Acute yellow atrophy of the liver Addison's disease Onset of acute infections, especially in children Pregnancy Recurrent, periodic or cyclical vomit- ing in children. There may be some doubt as to whether Addison's disease, pregnancy, and recurrent vomiting should be included in this group, as their pathology is not fully known. The vomiting of pregnancy may be partly reflex ; but there is strong evidence that a toxic element exists, and is probably the chief exciting cause. The differential diagnosis of these conditions presents little difficulty. The examination of the urine will give evidence of the existence of renal disease in ursemic vomiting, and the onset of drowsiness and coma in a diabetic patient may be attended by vomiting. Persistent vomiting occurring in a case of jaundice of apparently the common catarrhal variety should arouse suspicion of its proving acute yellow atrophy. The size of the liver should be determined carefully, and any diminution noted ; the urine should be examined for leucin and tyrosin. Vomiting associated with asthenia, characteristic pigmentation of skin and buccal mucosa, and a persistent low blood-pressure would be diagnostic of Addison's disease. The form of vomiting met with in young children, termed " periodic," or " cyclical," is very severe, and is accompanied by great wasting. The S3^mptoms pass off after a few days, but tend to recur at intervals of months. The urine during the attacks often contains acetone and diacetic acid, and the condition may be regarded as an autointoxication, probably an acidosis (see Acetonuria). The vomiting so frequently met with as one of the earliest symptoms in specific fevers, especially in children, is chiefly due to the direct action of the specific toxin on the cerebral centre, though reflex action may also have a share in it. The diagnosis does not usually present difficulty; the acute onset, vomiting, general malaise, headache, pyrexia, sore throat, rash, etc., speedily give the clue to the cause of the vomiting. In older patients, scarlet fever is the commonest specific fever to begin with nausea and vomiting. We must next consider the chief characteristics of the vomiting due to reflex II. — Reflex Vomiting. Gastric Causes. Irritating articles of food (hard, indigestible substances) Emetics, such as zinc sulphate, mustard, etc. Poisons : Corrosives, irritants Gastritis : {a) Acute : (i) Simple, (ii) Phlegmonous (6) Chronic Dilatation and " hour-glass " con- traction Pyloric obstruction : Malignant disease Fibrous stricture " Hypertrophic stenosis " in infants Pressure on pylorus from without Venous congestion, as in morbus cordis, portal obstruction, cirrhosis of liver Ulcer Malignant disease. 844 VOMITING 2. intestinal, Peritoneal, and General Visceral Causes. Intestinal obstruction Appendicitis Intestinal worms Following administration of enemata Henoch's purpura Peritonitis Biliary colic Renal colic — movable kidney (" Dietl's crises ") Acute pancreatitis Certain conditions of the female genital organs : Pregnancy Retroversion of the uterus Ovarian disease Extra-uterine gestation Affections of the Central Nervous System. Special Senses : — Offensive smells, tastes, repulsive sights. Brain : — Concussion Cerebral tumour or abscess Meningitis Hydrocephaly Cerebral haemorrhage Thrombosis of cerebral sinuses Spinal Cord : — ■ Tabes dorsalis, gastric crises. Phthisis — vomiting may be of central origin or due to irritation of the bronchi or fauces Irritation of the fauces or bronchi by direct stimulation, or by severe coughing : Pertussis Bronzhiectasis Fibroid lung Shock — blows on the epigastrium, injury of a testicle, a kick upon the internal semilunar cartilage of the knee, etc. Middle-ear disease ; Meniere's disease Migraine Epilepsy Sea-sickness Functional or hysterical vomiting. Certain general lines may be laid down of great importance in the accurate diagnosis of the cause of vomiting. Attention should be paid to its relation to food, if any, and at what interval after a meal it occurs ; whether preceded or not by pain ; whether attended or not by nausea. The absence of nausea is a point of great significance ; this is usually present in vomiting due to abnormal states of the alimentary tract and visceral organs, but is often absent in diseases of the brain. The vomited matter should be inspected carefully, and its quantity and general character noted. Alcohol, and certain poisons such as carbolic acid and prussic acid, may be recognized by their smell, or a faecal odour may be dis- tinguished. Blood may be present, either dark or bright red, or dark brown, resembling coffee-grounds. Slight streaks of blood are common with severe vomiting, and are usually due to rupture of small vessels in the oesophagus or pharynx. In whooping-cough, blood is often mixed with mucus from the respiratory passages, and the contents of the stomach are ejected during the paroxysms. The condition of the food remains should be noted carefully ; the presence of substances, such as currants or seeds, taken it may be many hours or some days previously, would point to motor insufficiency of the stomach, either with or without pyloric obstruction ; shreds of meat returned unaltered some hours after a meal indicate deficient protein digestion. The reaction should be ascertained : in corrosive poisoning this may be strongly acid or alkaline according to the toxic agent. It need hardly be said that in VOMITING 845 any case of suspected poisoning the vomit should be kept for analysis. Micro- scopical examination may show sarcinse [Fig. 92, p. 267), yeast cells, the Oppler- Boas bacillus, or cell elements from a malignant growth. Intestinal contents may be mixed with the vomit. Bile is often present in severe or protracted vomiting, and is readily recognized by its colour and the usual tests. Relaxation of the pyloric orifice in such cases allows of the return of the duodenal contents into the stomach. F cecal matter, when present, is recognized by the characteristic odour and the brownish coloration it imparts to the vomit ; it usually occurs as the result of intestinal obstruction. Gastro-colic fistula may give rise to faecal vomiting. I. Gastric Causes. — Most corrosive and irritant poisons cause vomiting immedi- ately after swallowing, accompanied by intense burning pain in the epigastrium. The vomit contains food, blood, mucus, and may have the characteristic odour of the poison. With some irritant poisons, e.g., arsenic, or phosphorus, the vomiting may come on later and resemble that of an acute gastritis. The diagnosis will depend largely on the chemical analysis of the vomit, and the associated signs and symptoms. In acute gastritis there is repeated vomiting, usually very severe, and attended by nausea and abdominal pain. Vomiting occurs shortly after taking food, and causes some relief of pain. The vomited matter consists at first of food ingested, later, of mucus and bile. There are often accompanying diarrhoea and febrile disturbances, especially in children. In the phlegmonous form the constitutional symptoms are exceedingly grave ; pus is rarely found in the vomit, bile is often present. In chronic gastritis the vomiting is associated with nausea and epigastric pain. There is usually much flatulence. The vomited matter consists of partially digested food, mucus, and a considerable quantity of sour-smelling fluid. Hydro- chloric acid is usually reduced greatly in amount, or may be absent. When dilatation of the stomach is present, the quantity of fluid ejected is often very large ; portions of food taken many hours previously may be returned. Fer- mentation takes place in the stagnant gastric contents, so that the vomit, when collected in a glass vessel, often shows an uppermost layer of brown froth, a middle greenish-grey layer of fluid containing streaks of mucus, and below this a semi-solid deposit containing food remains, sarcinse {Fig. 92, p. 267), yeast cells, and bacteria ; chemical tests show the presence of lactic acid and a diminution or absence of free or active hydrochloric acid. " Hour-glass " contraction, due to transverse constriction of the stomach by fibrous tissue, may be a cause of vomiting which resembles in most respects that associated with dilatation. The vomiting due to pyloric obstruction in adults presents no characteristics other than those associated with the dilatation of the stomach which usually results from it. The absence of free hydrochloric acid in the vomit would favour the diagnosis of carcinoma, the presence of free hydrochloric acid that of fibrous stricture ; the presence of the Oppler-Boas bacillus is regarded by many as dia- gnostic of carcinoma. Persistent vomiting in young infants, especially if breast- fed, attended with wasting and constipation, should always arouse suspicions of the existence of " hypertrophic stenosis of the pylorus." The vomiting in these cases is very forcible, the milk being pumped up violently, often very shortly after a feed, and with little alteration. Visible gastric peristalsis and the presence of a small tumour in the epigastrium would complete the diagnosis. Vomiting due to gastric ulcer (non-malignant) is very common. Pain occurs soon after taking food, and is relieved by vomiting, which usually occurs within an hour. The vomit consists of food, more or less digested, according to the 846 VOMITING time which has elapsed after a meal. It almost always contains at least the normal quantity of free hydrochloric acid, and blood may be present in varying quantity. With malignant disease — carcinoma of the stomach — though the general character of the vomit may be very similar to that in simple ulcer, there is usually' a great diminution or complete absence of free hydrochloric acid, and lactic acid and the Oppler-Boas bacillus are often present. Sarcinse may be present also when there is accompanying dilatation. Occasionally portions of the growth may be found in the vomited matter. In both simple and malignant ulcer, blood may be detected in the vomit microscopically or spectroscopically (see Blood per Anum) when it is not recognizable by the naked eye. 2. Intestinal, Peritoneal, and General Visceral Causes. — In intestinal obstruction vomiting sets in after an interval, the length of which may depend on the situation of the blocking. The vomiting is severe and persistent ; the contents of the stomach are returned first, and later, mucus, bile, and intestinal contents. Faecal vomiting should be recognized at once by its odour ; obvious pieces of fsecal matter are rarely distinguishable, but the vomit may have a brownish colour. The vomiting is more severe the higher the obstruction is in the intestinal canal. Vomiting is commonly present in appendicitis, but in slight cases does not persist after the onset. In the severe forms of the disease the vomiting may be a prominent symptom, and resemble that met with in intestinal obstruction ; it is sometimes f^cal in character. Intestinal worms are a cause of vomiting in children, probably owing to the reflex irritation they set up. Occasionally a round-worm is found in the vomit. Enemata in certain individuals cause vomiting, and rare cases have been described in which the fluid injected per rectum has been returned by the mouth. Vomiting is a common symptom in the condition known as Henoch's purpura, and may be due to either gastric or intestinal stimulation. The vomit may contain blood due to haemorrhages from the mucous membrane of the stomach. It is usually accompanied by abdominal pain, sometimes of an acute and agoniz- ing character closely simulating that occurring with intestinal obstruction, these symptoms being due to haemorrhage into the intestinal wall or the mesentery, which occasionally simulate or even give rise to intussusception. Recurrent attacks of vomiting and abdominal pain associated with a purpuric eruption in a boy or girl would point to the existence of this not uncommon disease. In acute peritonitis, vomiting is an early symptom, and causes great pain ; rarely the vomit may have a fascal odour. The history, together with the rigidity and immobility of the abdominal wall, generally indicate the need for early laparotomy. In biliary and renal colic, the vomiting accompanying the attacks of agonizing pain presents no special features. The pain in the thorax and upper part of the abdomen, and the onset of jaundice, distinguish biliary colic from that due to renal calculus, in which the pain is in the loin or lower abdomen, shooting down towards the groin and testicle. Jaundice is absent if the stone is in the cystic duct. Acute pancreatitis may simulate intestinal obstruction closely, in that it is attended by nausea and vomiting, constipation, and severe abdominal pain. The vomit is not faecal in character ; there is usually localized tenderness over the region of the pancreas. The diagnosis is seldom made, however, until laparotomy is performed on account of the urgency of the symptoms, when typical fat necrosis will be found in the omentum. The other visceral causes of vomiting call for no special notice. WEIGHT, LOSS OF 847 3. Affections of the Central Nervous System. — It has been pointed out that in most of the preceding conditions nausea accompanies vomiting, and this brings us to a most important distinction, namely, that in intracranial disease a special type of vomiting is met with, generally known as " cerebral vomiting." In this, nausea is absent, vomiting occurs suddenly and often without warning, and bears no relation to the ingestion of food. The whole or part of the stomach contents are returned. Vomiting of this type, especially if accompanied by headache or ocular changes, should arouse grave suspicion of the existence of organic cerebral disease, such as tumour, abscess, meningitis, or sinus thrombosis. " Cerebral vomiting " may also occur in hydrocephaly due to increased intracranial pressure. Cerebral hcsmorrhage may be attended by vomiting, more often when the cerebellum is the part affected than when other parts of the brain are involved. In Meniere's disease vomiting may follow the attack of vertigo. Nausea and vomiting frequently accompany the severe headache associated with attacks of migraine. Functional or hysterical vomiting is not attended by nausea or pain ; portions of a meal are brought up, usually fluids ; and although the vomiting may be a frequent occurrence, the general state of nutrition often remains good. Other hysterical manifestations are generally present in these patients. Cases have been recorded in which the vomit contained faecal matter. The gastric crises in tabes are attacks of vomiting accompanied by severe epigastric pain. The attacks usually last for several days, and tend to recur at intervals of weeks. Nausea may be absent. During the intervals digestion may be carried on normally. The diagnosis depends on the presence of the characteristic Argyll Robertson pupil and the loss of the knee-jerk. The influence of anaemia upon vomiting, and the manner in which gastric ulcer may be simulated thereby, has been discussed in the article on Anemia. H. Morley Fletcher. WALKING, PECULIARITY IN.— (See Gait, Abnormalities of.) WEIGHT, LOSS OF. — Loss of weight sooner or later accompanies all cases of cancer, phthisis, starvation from lack of food or from inability to swallow, and similar conditions ; but in most such cases there are other definite symptoms pointing to the diagnosis. The present article is concerned chiefly with those cases in which, without any other very definite symptoms, the patient has recently been losing weight. In the case of children, the commonest causes are malnutrition from injudicious feeding, the eating of sweets between meals, gastro-intestinal infections, and latent tuberculosis (see Marasmus). If the patient is an adult and the loss of weight has been considerable, the first suspicion will almost certainly be that there is either phthisis pulmonalis, deep-seated or latent carcinoma or sarcoma, or tuberculosis other than pulmonary. All the systems, including the rectum, and, if need be, the vagina, will need careful routine examination. Any sputum that may be obtainable should be examined for tubercle bacilli ; the physical signs at the apices of the lungs should be watched with extreme care, particularly if there is any difference in the amount of subcutaneous fat on the two sides in this region ; the ;ir-rays may be of value in detecting mottling [Fig. 27, p. 120) at one or other apex when the mischief is too far from the surface to give abnormal physical signs to percussion or aus- cultation. Von Pirquet's skin reaction, or, if it is thought advisable, Calmette's ophthalmic reaction to tuberculin may be tested. Von Pirquet's is nowadays preferred to Calmette's reaction on account of the occasional ill-effects of the latter upon the eye. Those who believe that the opsonic index to tubercle bacilli is of diagnostic significance would have it estimated before and after WEIGHT, LOSS OF inoculations with small or moderate doses of tuberculin ; the family history might be of assistance in indicating the likelihood of a lung lesion, whilst the personal history as to the drinking of much unsterilized milk would indicate the possibility of infection by so-called surgical tuberculosis in the lymphatic glands, abdomen, a joint, or the spinal column. Notwithstanding the most careful investigations, however, doubt as to the cause of the loss of weight in not a few cases remains until, in the course of time, the patient either recovers the lost ground and gets quite well, or else develops other signs or symptoms of growth, tuberculosis, or other definite disease. Young persons may lose weight as the result of change of surroundings, for instance from active out-door school life to work in a city office. Care and anxiety ; the undertaking of serious responsibilities ; sorrow ; love ; too strenuous a life of pleasure ; irregularity of meals ; too long hours of work ; these are amongst the everyday causes of what at the time may appear to be serious loss of weight. Any affection of the alimentary tract sufficient in degree to interfere with the proper digestion and absorption of food may produce loss of weight, especially if there is cause for sapraemia at the same time ; one may mention in this connec- tion loss of appetite from too much smoking, excessive drinking, monotony of food or of existence, carious teeth, ill-fitting tooth plates, pyorrhoea alveolaris, dyspepsia, flatulence, the abuse of purgatives, and the constipation which results therefrom ; gastric or duodenal ulcer ; inflammatory or ulcerative affec- tions of the bowel of the nature of colitis in its many forms. The wasting is seldom severe in any of these ; but especially, for instance, in cases in which gastric symptoms are prominent, it may be very difficult, for the time being, to tell whether the mischief should be labelled merely dyspepsia, or actual carcinoma ventriculi. Analyses of the gastric juice were at one time thought to be valuable in deciding between simple and malignant affections of the stomach, but this is by no means always the case. If, under observation and treatment, the patient succeeds in gaining weight, or even ceases from losing more over a period of some weeks, the argument is against carcinoma ; but if doubt remains, and it is desired, if possible, to adopt surgical measures before any carcinoma has passed the stage of radical curability, it will often be wise not to postpone laparotomy too long as a means of settling the diagnosis. It is too late if one waits until there is a tumour. Any malady which produces sleeplessness or pain, or both, may lead to serious loss of weight, and thus to difficulty in the diagnosis. A thoracic aneurysm, for instance, may erode the vertebrae and produce severe intrathoracic pain, which in turn produces insomnia, and may thus cause so much loss of weight that neoplasm may be suspected. Chronic microbial infections may not in themselves be obvious, and yet they may produce loss of weight by interfering with the general nutrition ; one sees this in many persons who have returned from the tropics after infection there by dysentery, yellow fever, malaria, dengue, and so forth. At home, chronic infections of joints, of the skin, the alimentary tract, the uterus, and genital organs may produce loss of weight in a similar wa^^ One would mention here in particular a malady that has only been recognized of recent years, though it is now known to be common, namely coli ba,cilluria (see Bacteriuria), the diagnosis of which is only possible on bacteriological examination of the urine, though it may be suggested by the discov^ery in the latter of a trace of albumin and, on microscopical examination, of variable numbers of pus corpuscles. Liver affections exert a prominent influence upon general nutrition, and the loss of weight exhibited by some sufferers from cirrhosis of the liver is familiar, though in the early stages the patient may be fat, and towards the end loss of WEIGHT, LOSS OF 849 weight may be masked by a false increase due to ascites. Pernicious anagmia is only diagnosable with certainty by means of blood examination (see Anemia), though it may be suggested by the lemon-yellow colour of the patient ; but one marked feature of the malad}' is, that although the patient does not at first decrease much in bulk, the tissues, from conversion into or replacement bj^ fat, become of less specific gravity than normal, so that the patient diminishes materially in weight. The effect of alcohol upon body weight is variable, some persons becoming exceedingly stout, others not changing much, and others becoming extremely thin. Broadly speaking, it is spirit drinkers who decrease in weight, and in some cases serious doubts may arise as to whether the loss in such a patient is due to the alcoholic habits only, or whether there is not some new growth or tuberculous affection as well, ^^'llen alcoholism leads to peripheral neuritis there is rapid and extreme loss of weight as the result of the muscular atrophy, and the sanre appUes to other conditions of multiple peripheral neuritis (see Atrophy, Muscular). Certain drugs have the power, especially in certain individuals, of reducing weight materially, even though the diet remain the same ; the best known of these is thyroid extract, whilst a long way second comes fticus vesiciilosiis. It will seldom happen that either of these is being taken accidentally, so that the diagnosis of loss of weight due to them is generally obvious. Old age is very apt to be associated with loss of weight ; it is very difficult sometimes to be sure whether the loss of Aveight that may be complained of in a patient of sixty or seventy years of age is merely senile, or whether it is due to underh-ing gro-wth. Diabetes, especially diabetes melhtus in young subjects, may have loss of weight for its earhest and most prominent symptom ; but the diagnosis is sufficiently easy when the urine has been examined. Addison's disease is another affection in which, besides the progressive asthenia, loss of weight, though by no means essential, is sometimes a marked feature. There may or may not have been sjmcopal or gastric attacks ; the diagnosis depends almost entirely upon the discovery of abnormal pigment deposits in the form of patches or spots, not onty upon the skin of the neck, hmbs, and trunk, but also beneath the mucous membranes, particularly of the mouth, where they are generally best seen inside the hps, or within the cheeks. The blood-pressure is sometimes very low in these cases, and if, on actual measure- ment, it is found to be 70 or 80 mm. Hg, this fact tends to confirm the diagnosis. Just as the administration of thyroid extract diminishes weight, so may loss of weight be a prominent feature in cases of Graves' disease — exophthalmic goitre ; sometimes, indeed, it may be the first symptom to attract attention, especially in those cases in which there is no exophthalmos. Tachycardia, nervousness, fine tremor of the outstretched fingers, and sjTnmetrical but not extreme enlargement of the thjToid gland, would confirm the diagnosis. Anorexia nervosa is a disease in which wasting from disincKnation to eat any kind of food except in the smallest quantities is the most prominent sjnnptom ; the patient is nearly always a girl, or young woman, betAveen the ages of fifteen and twenty-five ; there may or may not be other e\ddence of functional nerve disorders. A patient who has been perfectly robust until pubertj'- or shortly afterwards begins to lose all appetite, and the body wastes, until from being eight or nine stone the weight declines even to so little as four or three and a half stone, though the height may be 5 ft. 4 in. or more. One sometimes sees girls of 5 ft. 10 in. or more weighing less than five stone as the result, not of any organic disease, but of the simple functional absence of appetite o 54 850 WHEALS — anorexia nervosa. In arriving at the diagnosis it is important to exclude - the possibiht}- of some deep-seated tuberculous lesion^ especiall}' phthisis pulmo- nahs or tuberculous peritonitis (tabes mesenterica). One of the best means of excluding these is the thermometer, for in anorexia ner\'osa there should be httle if anj'- p\Texia. Yery careful examination of all the systems, including von Pirquet's and perhaps Calmette's tubercuhn reactions, will lead to negative findings, and the diagnosis ■\viU be confirmed b}^ the rapid increase in weight that will accrue when measures for the treatment of the functional disease by the Weir-iMitcheU method are adopted. Herbert French. WHEALS.— The characteristic lesion of urticaria ma}'- be defined as a flattish, evanescent elevation of the skin, the result of an oedema of the derma. It may be regarded also as a special variety- of the papule or the nodule. It is related to er^-thema, and is the expression of angioneurotic excitation, internal or external, which causes a dilatation of the vessels that permits an exudation of plasma. Reaction follows in the form of a spasmodic contraction of the capil- laries. The fluid is not therefore immediately taken up by the vessels, but as soon as the}' return to their normal condition, the wheal disappears, as a rule \vithout leaving any tiace. In colour, wheals are usually pale in the centre, with a red peripher\- ; but they may be uniformly rose-red, or naay have a whitish peripherj- ; or, as the result of hemorrhage into them, they ma}' be purphsh. In size they vary from a pin-head upwards. The smaller ones may take the form of conical or acuminate papules, frequently surmounted by a tiny vesicle. As a rule, they are flat or ver}' sUghtly raised ; but the larger ones, when not the result of coalescence, are hemispherical. They may also be linear in shape, and several inches in length, and by running together, may form roughh' circular plaques. They usually appear suddenly, and last only a few hours, but may be succeeded by others. They are always accompanied by itching or burning, which may be intense. It is not necessary, in a work on diagnosis, to give a detailed description of the different forms of urticaria ; the only other affection in which wheals appear is urticaria papulosa (stiophulus), the differential diagnosis of which has been given under Papules. The sudden onset, the presence of the wheals, the usually fugitive character of the eruption, the irregular distribution, and the severe itching, make up a chnical picture which is generally unmistakable. In bullous tirticaria, however, in which the wheal is crowned or is replaced by a bleb, the afiection may be confused with pemphigus or with the erythematous stage of dermatitis herpetiformis ; btit its true nature is indicated by the history of the case, the course of the eruption, and the almost invariable presence at some points of t}-pical lesions. In cases in which the constitutional symptoms are pronounced, the rash may be mistaken at first for that of scarlet fever, or even for erj'sipelas ; but the course of the lesions will quickly correct the error. ^Mlen wheals are due to such local and accidental causes as the bites of insects, or contact with the stinging-nettle, the diagnosis is furnished b}' the history, and in insect bites bj^ the central punctum. Malcolm i\I orris. WIND. — (See Flatulence ; and INIeteorism.) WORMS, INTESTINAL.— (See Parasites, Intestinal.) WRIST-DROP. — (See Paralysis of the Extremity, Upper.) XANTHELOPSIA.— (See Vision, Defects of.) YELLOW VISION.— (See Vision, Defects of.) GENERAL INDEX Entries in hcnvij capitals {e.g. ACETONURIA) denote niain articles in the text. Small heavy type {e.g. Abscess) is employed partly to indicate [/roups of entries, and partly as an assistance to the eye ivhen rjlancinrj down the columns to locate a reference rapidly. PAGE ABDOMEX, anatomical areas (Fig. 189) . . . . 721 - bulfint; in visceroptosis (Fig. 4ir 1-18 - distention of 473 (see Swelling, Abdominal) in acute hsemorrhagic pancreatitis . . . . 646 peritonitis ..131,472,644 - - in ascites . . . . . . 50 - - atonic constipation . . 143 - - carcinoma . . . . 152 i - - causes of enormous . . 465 in cirrhosis of liver . . 134 - - cystic disease of kidneys. . 15 - - witli gas (see ileteorism) - - Hirsclisprung's disease 148, 151, 713 - - from hydatid disease . . 719 iu intestinal colic . . 473 obstruction 134, 152, 571 - - from meteorism. . . . 716 orthopnoea in . . . . 465 ui pseudo-leutaemia infan- tum 42 - - from splenic enlargement 688 in tuberculous peritonitis 152 typhoid fever . . . . 90 volvulus . . . . 152 - eczema marginatum on . . 275 - fullness of, in colic . . 134 - immobility in peritonitis . . 472 - Jacquet's erythema of . . 446 - lesions of, causing pleuritic efiasion . . . . 123 - lichen scrofulosorum of . . 529 - lineae albicantes on . . 402 - lympliatic drainage of . . 738 - muscles, paralysis of . . 181 - new growth in, intestinal obstruction from . . 431 meteorism in . . . . 432 secondary nodule at umbilicus . . . . 524 glands along thoracic duct . . . . 421 in neck . . . . 421 - pediculosis of . . . . 447 - pendulous in cretinism . . 259 - - hepatoptosis from . . 406 -- pit.vriasis rosea of . . . . 658 - prominent in rickets . . 695 - - in Hanot's cirrhosis . . 411 - prurigo ferox of . . . . 531 - retraction of, at onset of perforative peritonitis . . 472 in tixberculous meningitis 612 - rigid (see Rigidity of Abdo- men) - rub over liver or spleen in ""^ peritonitis . . . . 431 - scabies of . . . . 447, 832 - seborrhceic dermatitis of . . 447 - swellings in, in chronic peri- tonitis . . . . . . 472 - syphilitic roseola on . . 675 - tenderness in (see Tenderness, General Abdominal) PAGE , Abdominal aortic pulsation, j undue (see Pulsation, i undue Abdominal Aortic) i - aneurysm (see Aneurysm, Abdominal) | - angina (see Angina, Abdo- minal) - conditions, hiccough in . . 342 - crises of locomotor ataxy . . 562 - cysts, diagnosis from ascites 53 - disease, chloasma in . . 574 facies in . . . . 133, 258 - neuralgia - . . . . . 4 1 3 - pain (see Pain, Abdominal) - reflexes (see Reflexes, Abdo- minal) - swelUng (see Swelling, Ab- dominal) - tumours, great abdominal distention from . . . . 467 due to aneurysm . . 299 benign in pyloric obstruc- tion . . . . . . 353 from carcinoma of colon 367 causing acute intestinal obstruction . . . . 152 asymmetrical oedema.. 456 ' portal obstruction, i ascites with. . . . 59 in chronic intussusception 148 colic . . . . . . 134 constipation from pres- sure of . . . . 148 from gastric carcinoma 299 inferior vena cava ob- struction by . . . . 459 in intussusception 152, 196 large, ortliopnoea from 467 linese albicantes in . . 402 - - in malignant pyloric ob- struction . . . . 353 multiple causes . . . . 55 in tuberculous peritonitis 56 - - paraplegia due to . . 561 pressure by, causing albu- minuria . . . . 17 dyschezia . . . . 150 jaundice . . . . 362 paralysis of anterior crural nerve . . 541 pseudo-elephantiasis from 456 - - from twisted ovarian cyst 153 - wall, fibro-Upomata of . . 716 Hodgkin's disease affecting 715 infiltration by appendicular abscess . . . . . . 715 IjTnphosarcoma afiecting 715 oedema of, with redness, in tuberculous peritonitis 691 swellings in distinction from intra-abdominal swellings . . . . 715 thickenings of, in peri- tonitis . . . . . . 56 tuberculous infiltration of 56 tumours of . . . . 716 Abductor hallucis, nerve supply of . . . . 542 PAGE Abductor minimi digiti, nerve supply of . . 542, 550 - paralysis simulating acute asphyxia . . . . . . 185 - poUicis, effects of paralysis of 127 nerve supply of . . 550 Abductors and external rota- tors of hip, spinal nerve roots supplying . . Abortion in lead poisoning . . - infective peritonitis after . . - spasmodic pelvic pain in . . - tendency to, in plumbism. . - threatened, simulating ecto- pic gestation - uterine hjemorrhage from 758, 436 - tubal, absence of products of conception in uterine discharge in of uterine contrac- tions in cervix uteri closed in . . collapse due to . . diagnosis from uterine abortion - - pelvic liaBmatocele from ruptured, acute abdo- minal pain from coma from . . 137, 140 general peritonitis simu- lated by hsemorrhage per vagi- nam with . . 646 leucocytosis with resembling dysmenor- rhcea . . signs of internal bleed- ing from . . 646 spasmodic pelvic pain in 509 sudden pelvic pain due to 760 Abscess in adhesions between bladder and appendix . . - albumosuria in . . - anaemia in . . - diagnosis of gumma from - leucocytosis with . . - alveolar, toothache with . . - - bleeding gums from 86 development at root of a carious tooth . . diagnosis from actinomy- cosis of lower jaw necrosis of jaw enlarged lymph glands from furred tongue with necrosis of jaw from - - pointing between gum and cheek . . on the cheek . . on the chin in submaxillary region pyrexia with swelling of face from — of gums in of the lower jaw from trismus froTn - of antrum of Highmore 643 77 644 509 436 700 760 760 760 760 760 646 646 760 646 220 60 632 20 39 449 400 747 J S7 747 748 747 747 747 747 747 747 747 747 747 746 747 747 747, 801 502 852 ABSCESS, APPENDICULAR— ABSCESS, HEPATIC Abscess, contd. - appendicular, abdominal ri- gidity from . . . . 645 - - due to actinomyces . . 736 - - acute peritonitis from . . 55 - - albumosuria -with . . 20 ansemia with . . . . 39 B. coli communis in 711, 713 felt per rectum . . 638, 736 - - fever and rigors from . . 632 - - gas in . . . . 711, 713 infiltration of abdominal wall by . . . . 715 pelvic swelling due to . . 757 -- - leucocytosis in . . . . 400 pus in stools from . . 601 - - rectum obstructed by . . 638 - - resonance over . . . . 713 - - rigors from . . . . 648 rupture into bladder 313, 624 631, 632 simulated by movable kidney . . by phantom tumours . . swelling in right lumbar region from urethral passage of faeces from - axillary, due to whitlow . . pain on moving arm with pyrexia with simulating hepatic abscess 779 lipoma . . . . 731, 732 tuberculous . . . . 731 - of bone, age incidence of 750,j752 - - bursting into joint . . 750 denuding whole bone . . 750 diagnosis from endosteal sarcoma periosteal sarcoma . . - - high leucocytosis in limitation by epiphyses . . localized swelling from . . - - necrosis of bone in occurrence in the end of long bone osteomyelitis from pain and tenderness over popliteal . . pyaemia from pyrexia in - - secondary arthritis from infection in septic embolism from . . sinus formation from red and (Edematous in skin over . . tender spot in . . tubercuUn in diagnosis of tuberculous - - tyiJhoidal - - upper end of tibia the commonest site of - - V. Pirquet's reaction in . . - - s-rays in diagnosis of - breast (see Abscess, Mammary) - cerebellar, from bronchiec- tasis . . . . . . 644 headache in . . 565, 651 head retraction from 641, 643 hypothermia in . . . . 346 - - knee-jerks increased in. . 565 optic neuritis in . . . . 565 - - from otitis media 565, 644 - - paraplegia from . . . . 565 pyrexia in . . . . 565 - - pyrexia absent with . . 644 simulating cerebellar tu mour superior longitudinal sinus thrombosis . . 651 - - slow pulse with . . . . 644 sometimes no leucocytosis with 644 729 721 727 264 731 731 731 756 763 750 750 750 751 752 750 750 762 750 750 378 752 750 751 750 752 752 752 752 752 752 752 752 Abscess, cerebellar, contd. vertigo due to . . . . 828 vomiting in . . 565, 651 - cerebral, aphasia in 685, 686 bradycardia from . . 98 from bronchiectasis 98, 547 coma from . . 136, 137 convulsions from . . 172 from frontal sinus disease 547 with fungating endocar- ditis 547 giddiness in . . . . 341 headachefrom326, 327,686, 847 hemianopsia from . . 335 hemiplegia from 82, 138, 340, 341 hyperpyrexia in. . . . 344 hjrpertension of cerebro- spinal fluid in . . . . 338 hypothermia in . . 346, 547 increased intracranial pressure in . . . . 686 leucocytosis in . . . . 400 due to mastoid disease . . 547 - - occasional latency of . . 341 optic neuritis in, 341, 547, 565 , 686 otitis media causing 340, 341 547 609 594 341 648 614 173 623 470 326 828 643 paralysis from prolonged pyrexia in pupil changes with pyrexia in recurring rigors in septicaemia from signs of . . simulating superior longi- tudinal sinus tlirombosis 651 slow pulse-rate in 547, 771 slow respiration in . . 547 temperature in diagnosis from cerebral tumour temporosphenoidal, dis- charge through ear unilateral headache in . . vertigo due to vomiting in 341,547,651,086,844, 847 - of chest wall . . 194 due to abscess of liver 478 caries of rib . . . . 478 pyaemic . . . . . . 478 simulated by empyema 193, 478 - cholecystic (see Gall-bladder, Empyema of) - femoral, femoral swelling due to . . . . . . 732 - gas-containing, from bacillus coli - - in subphrenic abscess 501, 578, 712, 720, 721 - in heart, from periostitis . . 650 - hepatic, ama3ba coli in wall 279, 704 amcebic, absence of amoebae in pus of . . . . 704 dysentery with . . 279 anaemia in . . . . 39 " anchovy sauce " sputum from .. 176, 323, 704 bursting through hang 323, 409, 704 " chocolate and milk " appearance of pus in. . 279 - - compression of lung by. . 667 from active congestion of liver .. 371, 407 enlarged gall-bladder 278, 279 hydatid disease . . 415 dome-shaped dullness at right base of lung in . . 324 empyema from . . . . 120 enlargement of liver from 408, 651 578 Abscess, hepatic, contd. exercise, insuflBcient, in etiology of exploration in . . following dysentery 323, 651, fullness, sense of, from . . gumma, growtli, or cyst preceding - haemoptysis from 317, history of residence in tropics in infection through hepatic artery causing - - jaundice in 362, 366, 371 with enlarged liver in - large single - age incidence of from extension from neighbouring sup- puration . . injury to liver non-dysenteric intes- tinal ulceration . . race incidence of specific fevers a very rare cause of from suppuration ro\ind a gall-stone of a hydatid leucocytosis with 279, 369, 400, malaise from - multiple . . .. 369, absence of enlarged liver in jaundice with . . patlis of infection in. . suppurative cholangitis causing pylephlebitis causing nausea in pain in axilla from chest from epigastrium in . . hypochondrium from 499 shoulder from pleurisy from with effusion from peritonitis from . . pointing in chest-wall . . - - polymorplionuclear leu- cocytosis in . . fi-om pylephlebitis pyrexia from 324, 362, redness and sweUing of hypochondrium from . . relative leucocyte count in diagnosis from malaria residence in tropics in etiology of . . 371, rigors from 324, 362, 648, - - rupture through dia- phragm, abundant spu- tum in. . into intestine . . lung, foul taste from . . sputum not usually foul in - - - stomacli simulated by phantom tumour by subphrenic abscess - - simulating axillary abscess empyema . . 119, large gall-bladder situation of skodaic resonance due to sterile pus in . . subphrenic abscess from sweating from . . swelling of chest wall from tenderness from . . in chest from . . 704 371 279 324 704 369 651 363 369 408 408 408 408 408 408 408 402 651 372 408 372 369 369 369 371 651 779 486 ,651 651 123 651 644 478 369 649 651 715 402 407 651 704 409 774 704 409 721 723 779 779 278 722 667 323 501 651 194 651 779 ABSCESS, HEPATIC— ABSCESS, PROSTATIC 853 Abscess, hepcUic, contd. - - tropical 3G9 absence o£ bile in urine in 369 albuminui'ia in . . 409 amceba dysentcrioa in 369, 408 in lining wall of liver 408 pus from . . . . 408 aufemia in . . . . 408 " anchovy-paste " pus in .'. .. . . 408 bacteria in pus from. . 408 - - - bronchitis secondary to 409 bulging of ribs in . . 409 chest measurement increased on affected side in . . . . 409 common site of . . 408 - - - diagnosis from malaria 369, 408 - - - difficulty of diagnosis in chronic cases . . 409 - - - dome-shaped area of dullness above liver in 409 emaciation in . . . . 369 - - - empyema secondary to 409 extension upwards be- tween layers of coron- ary ligament . . 400 - - - fluctuating swelling in epigastrium in . . 369 fluctuation excessively rare in . . . . 409 gangrene of lung secon- dary to . . . . 409 histpry of dysentery in 369 - - - ictoroid tinge of con- junctivae in. . . . 369 jaundice in . . . . 408 not common . . 369 liver enlarged in 408, 409 leueocytosis absent in 408 mistaken lor recurrent attacks of influenza 408 obliteration of inter- costal spaces in . . 409 occasional good health in spite of . . . . 408 leueocytosis in 369, 408 - — yellow colour of pus m 408 oedema and redness over 409 pain in right hypo- chondrium in . . 369 on jarring patient in 409 in left shoulder in . . 409 right shoulder in 369, 409 palpability . . . . 409 pleurisy secondary to 409 pneumonia secondary to 409 profuse sweats in 369, 408 pulse rapid in . . 369, 408 pus sterile in long- standing . . . . 408 pyrexia in . . 369, 408 rigiditj' of rectus over 409 rigors in . . 369, 408 rupture into lung . . 369 simulating empyema . . 369 enlarged gall-bladder 369 severe prostration in. . 369 tenderness in hepatic area in . . . . 409 thirst, anorexia in febrile stage of . . . . 409 tongue dry, furred in 369,409 urine scanty and high- coloured in . . . . 409 variability of pain in. . 409 vomiting in . . . . 369 wasting in . . . . 408 .r-rays in diagnosis of. . 409 Abscess, hepatic, contd. upward enlargement of liver in. . . . . . 406 value of leucocyte count in diagnosis of malaria from 401 vomiting in . . . . 371 - - wasting with . . . . 69 - iliac, diagnosis from psoas abscess . . . . . . 739 limping gait in . . . . 739 - - pyuria from . . 624, 632 - - rupture into bladder 631, 632 spinal caries with . . 632 swelling in iliac fossa in 632 - inguinal, causes of . . 739 - ischiorectal, felt per rectum 638 from foreign body . . 655 - of kidney (see Abscess, Eenal) - lachrymal, epiphora from. . 250 - of lung, embolic . . . . 649 foul breath in . . . . 99 leueocytosis in . . . . 400 pleurisy with . . . . 649 rapid breathing from . . 649 signs of bronchitis with 649 simulating empyema . . 119 stinking sputum in . . 176 - mammary 744 purulent discharge from nipple in . . . . 202 tachycardia in . . . . 98 tuberculous, absence of cocci in pus in . . 744 fever in. . . . . . 744 diagnosis from carci- noma . . . . 744 enlarged axillary gland in 744 long duration of . . 744 microscopic section of wall in diagnosis of 744 paui slight in . . . . 744 - mastoid, discharge through auditory meatus . . 470 from otitis media . . 98 pain in the ear from . . 230 tachycardia in . . . . 98 - mediastinal (see Mediastinitis, AcuteJ - miliary in new-born . . 601 of the spine . . . . 785 - myocardial . . . . . . 241 - omental, from perforative gastric ulcer . . . . 724 - orbital, producing diplopia 200 - ovarian, pyrexia due to . . 621 - parametric, felt per rectum 634 femoral swelling from . . 738 - pelvic, acute onset of . . 760 bearing-down pain in . . 474 bulging into posterior fornix 76 into rectum . . . . 760 diagnosis from cellulitis 760 fixation of uterus by . . 760 hfematuria from 305, 313 in hip disease . . . . 739 intraperitoneal . . . . 760 mucus per rectum in . . 474 pelvic swelling due to 757, 760 from puerperal septic infections . . . . 760 pus in stools from . . 601 pyuria from . . 624, 632 rupture into bladder 624, 631, 632 into rectum . . . . 760 - - due to salpingo-oophoritis 760 septicoemia from . . 614 signs of local peritonitis in 760 tenderness in the back from . . . . 785, 786 - pericolitic, swelling in right lumbar region from . . 727 Abscess, pelvic, contd. - perigastric, inflammation round umbilicus with . . 716 pus in the stools from . . 601 - perinephric . . . . 499 abscess of liver from ex- tension from . . . . 408 acute general sj'mptoms in 392 - - diagnosis from renal tu- mour . . . . . . 391 fluctuation in . . . . 392 oedema of skin over . . 392 pain in . . . . . . 392 the left hypochon- drium in . . . . 499 lumbar region in . . 500 right hypochondrium in 500 prominence in loin in 391, 392 pus in the stools from rupture of . . . . 601 recurring rigors in . . 648 renal tumour in . . . . 500 - - temperature in . . . . 392 tenclerness in the back from . . . . 785, 786 thickening of skin over. . 392 - periosteal (see Abscess of Bone) - peru-ectal, acute peritonitis from . . . . . . 55 - perl-urethral, oedema and fluctuation in . . . . 767 scrotal swelling due to . . 767 tenderness in . . . . 767 urinary flstula from . . 442 - popliteal : communicated pulsation in 762 flexion of knee in . . 762 from necrosis of femur . . Y62 painful swelling due to 761, 762 raising of pulse and tem- perature in . . . . 732 suppurating lymph glands 762 from tuberculous knee . . 762 - post-pharyngeal, age-inci- dence of . . . . 673, 707 digital diagnosis of . . 707 - - dysphagia from . . . . 225 obstruction to larynx by 710 orthopnoea from . . 465 stertor from . . . . 707 stridor from . . . . 710 - prostatic 510 acute peritonitis from . . 55 difficulty of micturition in 511, 631 - - felt per rectum 632, 638, 678 frequency of micturition in 511 gonorrhceal . . . . 631 hsematuria due to . . 632 from instrumentation 631, 678 - - pain in penis 510, 511, 513, 515 perineum in . . . . 516 painful erections with . . 515 perineal sinus from . . 678 ft-om posterior urethi'itis 678 prostate felt per rectum to be inflamed in . . 678 from prostatic calculus . . 632 pyrexia with . . 207, 511 pyuria from rupture of 624, 632 recent urethral infection in 678 retention of urine in 207, 631 - - rigors from 207, 631, 648 - - rupture into bladder 631, 632 rectum . . 631, 632 urethra . . 631, 632 septic arthritis from . . .375 sequela of gonorrhoea . . 515 septic urethritis . . 515 soft area in enlarged in- flamed gland on rectal examination in . . 511 fluctuating area with. . 207 tuberculous . . . . 632 854 ABSCESS, PROSTATIC— ACHOLURIC JA UN DICE Abscess, prostatic, conid. Abscess, splenic, conld. Abscess, subphrenic, contd. urethral passage of faeces peritonitis from . . 644 simtilating empyema 119 from 264 - subcutaneous 400 hepatic abscess 723 from urethritis . . 631 678 in pyaemia 649 hydropnenmothorax . . 712 Teaereal infection 631 - subdiaphragmatic (see Ab- pneumothorax 721 - psoas, anaemia in 39 scess, Subphrenic^ skodaic resonance due to 667 causing swelling in Uiac - submammary, from tubercu- from splenic lesions 720 fossa 733 losis of ribs 744 succussion sounds in 711 diagnosis from femoral post-typhoidal periostitis from suppuration in liver 720 hernia . . 739 of ribs . . 744 swelling of chest wall from 194 iliac abscess . . 739 - submaxillary . . 419, 744 tenderness in back from 7S6 dullness on prarcussion over 739 - sub-periosteal (see Abscess of of epigastrium from . . 720 extending under Pon- Bone) hypochondrium from . . 720 part's ligament 733 - subphrenic : in the spine from 785 in Scarpa's triangle . . 733 abdominal swelling from 715 tympanitic note over . . 501 femoral spelling due to . . 733 not moving with res- ar-rays in diasnosina fluctuation in . . 733, 739 piration in 501 501, 578, 712, 721 impulse on coughing in aficecting umbilicns 716 - testicular 732, 733, 7.? 9 air in 712 acute pain in testicle from 680 kyphosis with 733 apparent upward exten- aiiection of epididymis lardaceous disease from . . 414 sion of Uver dullness in 406 first in urethral cases 080 pointing over vertebra . . 785 from appendicitis 119, 720, 721 diaPTirBis frnin onmrna 680 position external to femo- E. coli causing gas in 711 tuberculosis of t^estis . . 680 ral vessels 739 bulging of epigastrium from 720 due to epididymo-orchitis 518 pus in the stools from hypochondrium from. . 720 gonorrhoeal 680 rupture of 601 from carcinoma of colon 578 haematogenous . . 680 pyuria from rupture into of duodenum . . 578 from instrumentation . . 680 bladder . . 624, 632 of stomach 578 metastatic 680 reducibility 739 causing pleurisy . . 122 in mumps 680 rigidity of spine in 733, 739 coin-sound on percussion pyrexia and rigois in 680 rupture into bladder 631, 632 over 501 in scarlet fever . . 680 ureter . . 633 commoner on left side . . 721 scrotal sinus from 680 simulated by distended communicating with duo- sores from . . 679 680 ilio-psoas bursa, 734 denal or gastric ulcer 712 swellin<^ of testis in 518 femoral hernia 733 with duodenum 711 from torsio testis 680 saphena varLx. . 733 with stomach . . 711 in typhoid fever . . 680 in spinal caries 564, 632, compressing lung 324,667, 721 from urethritis . . 518, 679 739, 785 constitutional disturbances 720 — thyroid, in pyaemia 792 swelling of chest wall from 194 diaphragm pushed up by 721 - urethral, pain in perinerun in 516 iliac fossa 632 displacing heart upwarcfc Absinthe, coma due to 137 inguinal region 632, 739 712, 721 - palpitation due to.. 525, 527 right Uiac fossa from. . 730 due to duodenal ulcer 528, 720 - tremor from . . 795, 797 tenderness of spine in 739, 785 721 Academy headache . . 329 - - tuberculous 564 empyema from . . 120 Acanthosis nigricans, sore - rectal, characters of, as felt complicating . . 720 fingers from 266 per rectum 635 exploring needle only to - relation to prurigo f erox . . 531 foreign body causing 635 be used immediately Acarus, pruritus caused by . . 588 rectal tenderness from . . 635 before operation in . . 501 Accentuated heart soimds (see - renal, from infarct. . 625 from FaUopian tube lesions 720 Heart Sounds. Accentuated^ infective peritonitis from 644 fibroid lung and bronchi- Accessorius, nerve supply of. . 543 injury to kidney 625 ecta.«is from 324 Accessory rib (see Pdb, Cervical, - - leucocytosB with 400 foul taste from . . 774 - sinus dilatation, unilateral palpable tumour due to 391 gas-containing501,578, 720 ,721 exophthalmos in 254, 255 polyturia in 626 from gastric ulcer 119, 721, 578. inflammarioTi, polvpi with 255 pyelonephritis . . 625 720 suppuration, cavernous pyuria in.. .. 623, 625 general account of 501, 720 sinus thrombosis due to 253 from renal calculus 309 history of appendicitis in 501 earache from . . 230 tuberculous 394 duodenal ulcer in 501 Accommodation, paralysis of. urine normal in localized gastric ulcer in 501 after diphtheria . . 77 cortical 626 due to hydatid cyst 721 in disseminated sclerosis 838 - retropharyngeal 673 iTiiTnnhiliTincr diaphraxJin 721 ACCOUCHEUR'S HAND {Fig. 1) 3 cyanosis from . . 185 from intestinal obstruction 721 in tetany . . 17S diagnosis of 465 from kidney lesions 720 Acetabulum,' osteo-arthritic . . 784 by digital examination 466 laparotomy in diagnosis of 501 Acetic acid in gastric juice . . 333 in spinal caries 673 leucocytosis with 501, 720 721 test for albuminuria 5 extreme dyspnoea from . . 642 liver not pushed down in 501 phosphaturia . . 20S 574 laryngeal obstruction from 642 onset of pain in 501 ACETONURIA, CAUSES OF.. 4 orthopnoea in 465 opening into pericardium 711 - in cyclical vomiting of retraction of head from 642 pain in left hypochon- infanr.s . . . . 426, 813 - - simulating meningitis . . 642 drium in 499 - iQ diabetes . . . . 292 583 sore throat from 670 right hypochondrium in 501 Achillis-jerk (see Ankle-jerk) tenderness in the back from pancreatic lesions. . 720 - in locomotor ataxy . . 562 from 786 physical signs of. . 720, 721 Aching in loin from vesical the spine in . . 785 pleurisy above . . 122 501 carcinoma (and see Pain - scrotal 767 secondary to . . 720 721 in Loin) 620 fistula from 679 pneumothorax from ..577 578 carcinoma coli . . 393 from peri-urethral abscess pyrexia with 501, 720 721 hypernephroma . . .S95 679 , 767 rapid pulse with . . 720 721 kidney tumour . . 307 395 due to stricture . . 679 rigors with . . 648 ,721 polycystic kidneys 396 tuberculous epididymis . . 767 rupture into lung 774 pyelitis . . 625 due to urethritis . . 679 septic aspect with 720 renal calculus 627 - spinal, tenderness in back sex incidence of . . 721 tuberculosis . . 626 from 786 shifting of level of fluid in 721 - in testis in tuberculous disease 519 - splenic, exceedingly rare . . C92 shortnes of breath with "721 Acholiuic jaundice . . 361 372 A CHONDROPLA SI A —A DOLESCENCE 85: Achondroplasia, bowed legs in 212 - bridge of nose depressed in 212 - bulging forliead in . . . . 212 - distinguished from rickets . . 214 - dwarfism due to (Fiff. 64) 212 - enlargement of bones in . . 214 - lordosis in . . . . . . 212 - prominent joints in . . 212 - shape of lingers in . . . . 212 - sliort lower limbs character- istic in . . . . 212, 214 - small contracted pelvis in. . 212 - strong muscular power in. . 212 Achorion schonleinii in favus 270 Achylia with diarrhoea . . 196 - in functional dyspepsia . . 354 Acid dyspepsia Csee Dyspepsia) - faeces in pancreatitis . . 117 Acidity of urine, effect of phos- phates in . . . . 572 in general bacterial affec- tions . . . . 83 Acidosis . . . . . . 4 - in cyclical vomiting of chil- dren . . . . 420, 843 Acids, strong, gangrene from 282 - cesophageal stenosis from . . 222 - reduced total, in gastritis . . 352 - sore throat from . . . . 671 - of stomach contents, test for 355 - stomatitis from . . . . 815 Acne rosacea in alcoholism 59, 368, 797 association of phlyctenular ulceration of cornea with 806 causes of . . . . . . 268 in cirrhosis of liver . . 368 diagnosis from A. vulgaris 268, 531 granulosis rubra nasi . . 714 lupus erythematosus . . 268 seborrhceic eczema . . 268 tertiary syphilides . . 268 -■ - leprous nodules simulating 450 permanent flushing in . . 268 skin changes in . . . . 26S - vulgaris, absence of cachexia with 604 - - age-incidence of . . 531, 603 - - in bromidism . . . . 112 chronic nature of eruption 604 - - comedones in . . 604, 609 convex shape of pustule in 601 diagnosis from acne rosacea . . 268, 531 from large acuminate syphilide . . . . 604 drug eruptions . . 603 pustular syphilides . . 603 small-pox . . 603, 609 sycosis vulgaris . . 603 - - distribution of 531, 604, 609 in iodism . . . . . . 112 the lesions of . . . . 530 papules of . . 528, 530 pustules in . . . . 603 septicaemia from. . . . 698 simulated by xanthoma diabeticorum . . . . 805 tendernessof scalp from 780,781 spine from . . . . 784 Aconite, ptyalism due to . . 590 Acromegaly (Fig. 88) . . . . 753 - abnormal growth of sub- cutaneous tissue in . . 262 - amenorrhoea in . . . . 23 - bony changes of . . . . 263 - bull^ tongue in . . . . 263 - changes in face in (Fig. 88) 262, 263, 391, 749 - diagnosis from leontiasis ossea 749 - - osteo-arthropathy . . 391 - enlarged bones of liands, feet, and head m 262, 391, 585, 749, 753 Acromegaly, conld. - enlarged fingers in . . . . 128 lower jaw in . .263, 749, 753 pituitary body in 335, 585, 749 ridges of insertion of mus- cles and ligaments in . . 753 superciliary ridges in 749, 753 - headaclie in.. .. .. 749 hemianopia in (Fig. 102) 335, 749 - irritability in . . . . 300 - muscular debility in . . 749 - periosteal thickening in . . 753 - polyuria in . . 583, 585 - teeth in 263 - .r-rays in diagnosis of . . 585 Acroparaesthesia : - age and sex incidence of . . 493 - in alcoholism . . . . 493 - becoming worse in bed . . 493 - definition of . . .. .. 493 - of hands and feet . . . . 493 - occupation incidence of . . 493 - in paroxysmal tachycardia 772 Actinomyces (Plate XII, Fig. S, p. 696) 810 - characters of pus due to . . 786 - Gram-staining . . . . 736 - microscopical recognition of 736 - relation to barley . . . . 705 cotton . . . . . . 705 Actinomycosis bleeding gums from . . . . 86, 88 - of cfecum and appendix . . 736 - distinction from mycetoma 810 - hsemoptysis from . . . . 705 - of jaw . . . . 87, 748, 810 with carious teeth . . 748 cellulitis of neck in . . 748 - - diagnosis from abscess . . 748 - - sinuses from . . . . 748 - liver, rarity of . . . . 415 local enlargement from . . 415 ray fungus in pus in (PtoeA'//,.S'i(7..S',p.696) 415 " sulphur granules " in 415, 748 trabeculate abscess from 415 - of lung 322 haemoptysis in . . 317, 705 - mycelium in pus in. . 415, 748 - simulating spinal caries . . 786 - sites of election in . . . . 810 - in tailors and seamstresses 705 " Acute abdomen " in acute pancreatitis . . . . 431 Acute nephritis (see Bright's Disease Acute ; and Nephritis) - poliomyelitis (see Poliomyelitis, Acute) - rheumatism (see Eheumatism) - yellow atrophy of Uver (see Liver, Acute Yellow Atrophy of) Adamson, re Jacquet's ery- thema . . . . . . 446 - re pemphigus neonatorum 446 - re seborrhceic dermatitis of infants . . . . . . 446 Addison's ansemia (see Pernicious Anaemia) - disease, amenorrhoea in . . 23 arsenical poisoning simu- lating . . . . . . 38 - - asthenia in 38, 843, 849 - - bronzing of skin in . . 574 cancer of one capsule not causing. . . . . . 307 coma in . . . . . . 136 eosinophilia in . . 38, 248 gastric attacks in . . 849 headache in . . . . 329 hypothermia in . . . . 345 loss of weight in . . 849 low blood-pressure in 96, 329, 843, 894 Addison's disease, conld. not produced by uni- lateral suprarenal disease 690 periodic acute diarriioea in 196 pigmentation of skin and buccal mucosa in 843, 849 simulated by exophthal- mic goitre . . . . 792 - - syncope in . . 38, 849 vomiting in . . 38, 843 Adductor brevis, nerve supply 542 - femoris, spinal nerve root supplying . . . . . . 543 - longus, nerve supply of . . 542 tendon, ossification of . . 763 - magnus, nerve supply of . . 542 - obliquus hallucis, nerve supply of . . . . . . 542 poUicis, nerve supply of . . 550 paralysis of . . . . 127 - transversus halluois, nerve supply of . . . . . . 542 poUicis, nerve supply of 550 Adem'n bases, uric acid from. . 817 Adenitis, acute cervical (see I-ymphatic Glands, Cervical) Adenoids, anosmia from . . 668 - a cause of deafness. . . . 190 - cure of enuresis by removal of 248 - with enlarged tonsils . . 670 - epistaxis due to 250, 251, 252 - headache from . . . . 327 - insomnia from . . . . 357 - loss of taste due to 774, 775 - mouth-breathing causing . . 072 - night terrors due to 357, 448 - obstruction to nose by . . 668 - otitis media from . . . . 230 - removal of, palate paralysis after 640 - rhinitis from . . . . 204 - snoring due to . . . . 669 stertor from . . . . 707 Adenoma of liver (see Liver, Adenoma of) - of prostate (see Prostate, Adenoma of) Adherent pericardium (see Peri- cardium, Adherent) Adhesions, appendicular, pain in right iliac fossa from. . 501 - intestinal, in peritonitis . . 5G - perigastric, influence of movement on pains due to 486 - peritoneal, causing consti- pation . . . . . . 147 from gall-stones . . . . 280 - from hernia . . . . 152 - - intestinal obstruction from 151, 152 - jaundice from . . . . 361 loculation of ascites by . . 717 - pleural, pain and tenderness in the back from . . 789 pneumothorax rendered partial by . . . . 577 - in shoulder joint simulating circumflex nerve paraly.sis 552 Adiposis dolorosa, age and sex incidence of . . . . 478 alcoholism causing . . 455 congenital syphilis causing 455 extreme fatness in 453, 454, 455 - - hyperaesthesia in . . 455 neuralgic pam in arm in 492 pain in the chest from . . 477 parts affected in . . . . 455 - - symmetrical painful de- posits of fat in . . 478 thyroid treatment of no effect in . . . . 455 Adolescence, albuminuria of 19 - erythema nodosum in . . 450 - rounded spine of . . . . 183 ADRENAL RESTS— ALBUMINURIA Adrenal rests 395 Age incidence of disease, contd. Age incidence of disease, contd. causing nephroma 307 Henoch's purpura tuberculides 603 in pathogenesis of maUg- 90, 380, 600, 846 tuberculous arthritis 385 nant renal tumours . . 395 hereditary optic atrophy 838 cystitis. . . . 312, 628 in iiidney, hypernephroma of high blood-pressure . . 96 dactyhtis 751 from 690 Hirschsprung's disease 152 718 meningitis 642 AdrenaUn in cystoscopy 630 Huntington's chorea 156 peritonitis . . 56, 691 - irrigation of bladder with . . 307 hysteria . . 710 ulcer of tongue 814 ^gophony in pleural effusion ichthyosis 530 umbilical hernia 524 193, 332 — — insomnia . . . . 356, 359 undue aortic pulsation . . 592 Aerophagia 267 intermittent hydrarthrosis 387 urticaria . . 531 Africa, bUharzia in . . 313 intussusception . . 636, 736 valvular heart disease . . 507 " After-pains " of labour 509 iodide and bromide erup- vesical calculus . . 513, 628 Agar-agar in constipation . . 143 tions 603 von Jaksch's disease . . 694 Age incidence of disease : jaundice . . . .362, 363 365 xerodermia pigmentosum 804 of acne . . 268, 531, 603 joint pains of acute rheu- - in diagnosis of systolic bruits 103 acne rosacea 268 matism . . 507 - influence on heart sounds . . 1 acquired spastic paralysis 155 keratomalacia 807 on child-bearing. . 707 acroparesthesia . . 493 kraurosis vulvae. . 770 on size of pupU . . 594 acute intestinal obstruc- leukoplakia of vulva . . 770 Ageustia (see Taste, Loss of) . . 774 tion 151 hchen scrofulosorum 529 Agglutination reaction (sea mastitis 743 Little's disease . . 154 Serum Reaction ; and yellow atrophy 302 lupas erythema to.~us 449, 781 TTidal's Test) adiposis dolorosa 478 vulgaris 449, 808, 812 Agrapllia, definition of 685 aneurysm. . . . 223, 786 lymphangioma circum- - hemiplegia with 685 angina pectoris . . 482 scriptum 833 - lesions producing . . 685 anorexia nervosa 849 macular choroiditis 462 Ague ("see Malaria) . . 34, 371 aortic aneurysm 538 mediastinitis 484 " Ague-cake " spleen. . 693 lesions, various 107 mitral disease . . 103 110 Air-swallowing 267 ateleiosis . . 217 myocardial affections 61 103 - borborygmi due to. . 97 bacilluria 615 myxoedema 460 Alar chest in phthisis . . 191 baldness . . 84 new growths of testis . . 766 Albinism, diagnosis from leuco- bath pruritus 588 normal Cheyne-Stokes dermia 575 bladder tuberculosis 312, 628 breathing 124 - hemeralopia in 841 bromide eruption 603 odontomata 749 - nystagmus in 453 bronchopneumonia 321 osteitis deformans 753 - photophobia in 574 carcinoma of bladder 311, 514, osteo-arthritl? 214 Albumin in serous discharge 630 osteogenesis imperfecta. . 214 in chronic otitis media . . 468 bowel . . . . 91, 146 150 osteomalacia 214 ALBUMINURIA 5 breast . . 745 oxaluria . . 471 - from abdominal aneurysm 8 pancreas 266 Paget's disease . . 802 - accidental . . 19 penis 676 pain in herpes . . 496 - with albumosuria . . 20 stomach . .299, 351 ,713 pancreatitis . . 153 266 - from arteriosclerosis 1,8 thyroid gland . . 791 parenchymatous goitre. . 791 - withbacUluria 83, 84, 576, 615 ,848 tongue . . 812 peliosis "rheumatica 380 600 - boiling test for, nucleoproteid urethra . . 209 periosteal sarcoma 756 fallacy of . . . .471 472 cerebral embolism 173 Pinguecula 256 phosphate faUacy of . . 574 hsemorrhage . . 138, 173 polyuria of diabetes 584 - from burns and scalds 16 cervical caries 708 popUteal exostosis 763 - in cerebral haemorrhage chancre of the tongue . . 813 post-pharyngeal abscess 98, 138, 337, 503 chloroma 599 673, 707 - cerebrospinal fluid in menin- chorea 156 priapism 585 gitis 643 chronic abscess of bone . . 752 progressive muscular atro- - chronic alcoholism. . 16 cirrhosLs . . 410 phy 165 bronchitis and emphy- coh bacilluria 82 prostatic enlargement . . 440 sema . . 246 congen. syphiUtic deafness 190 prurigo ferox 532 laryngeal paralysis 539 coughs, various . . 176 psoriasis . . 533 peritonitis 56 cystic disease of kidneys 310 pyometra. . 211 pyuria 623 epididymis 767 rectal carcinoma 636 - with chyluria 126 dermatitis herpetiformis 114 polypi and papillomata 93 - in cirrhosis of the liver 16 diabetes . . 292 renal tuberculosis 309 - contracted granular kidney 14 diverticulitis 152 retrobulbar neuritis 838 - after convulsions . . 169, 172 embryoma of kidney . . 307 rheumatic nodules 452 - from corrosive poisoning . . 297 endocarditis 237 purpura . . 380 ,600 - cystic kidneys . . . . 8 , 390 epistaxis . . 251 tonsUhtls 671 - in cystitis 628 erythema nodosum 450 rhinoscleroma 805 - diabetes mellitus . . 16 exophthalmic goitre 772, 792 rickets 214 - diphtheritic 13 faecal tumours . . 692 rodent ulcer 449 - disproportionate to the femoral and inguinal sarcoma of breast 746 amount of pus in, in pye- hernia . . . . 733, 740 , 742 jaw 748 litis and pyelonephritis. . 628 fibro-adenoma of breast 744 testis 520 - in eclampsia 647 filariasis . . 126 scrofula . . 808 - from enlarged prostate 8, 16 fragilitas ossium 269 scurvy -rickets 753 - with epistaxis 251 Friedreich's ataxy 70, 131 164 spinal caries 785 - in exophthalmic goitre 16 functional aphonia 538 splenomegalic cirrhosis. . 639 - febrile 17 gaU-stones 135 polycythcemia 581 - and Fehling's test . . 290 gastralgia . . 485 spondylitis deformans . . 787 - in fungating endocarditis . . 237 gastric ulcer 298 Stokes-Adams' disease . . 172 - gonorrhoea . . 16 glaucoma . . 257 subperiosteal abscess . . 750 - gout 16 gout 381 sjTjhDis of aortic valve. . 237 - haematuria . . 306 Hanot's cirrhosis 369 410 syphilitic epiphysitis . . 752 - ^ith heart failure . . 61 heart failure . . 61, 62 pseudo-paralysis 387 - high blood-pressure .252 526 hsematuria 306 testicular atrophy 78 - from invasion of kidney by hemiplegia . . 337 338 trigeminal neuralgia 495 malignant growth of colon 393 A LB UMIN URIA—A MENORRHCEA . 857 Albuminuria, contd. - lardaceous disease 39, 197, 414, 696 - lead poisoning . . 16, 38, 77 - lympliadenoma . . . . 17 - meduUaiy softening . . 343 - mercurialism . . . . 16 - mitral regurgitation . . 239 - morphinism . . . . 16 - from movable kidney . . 8 - in mumps . . . . . . 16 - myocardial affections . . 18 - nephritis (Bright 's Disease) 1, 13, 63, 303, 331, 454, 466 - after noctiu'nal emission . . 19 - witli ffidema . . . . 457 - from ovarian cyst . . . . 8 - pelvic tumours - physiolofiical effect of calcium on polyuria in - with pleural effusion - pneumonic . . - polym'ia with, causes of - in portal obstruction - pregnancy . . - prolonged, cachexia from - in pyelitis . . - pyelonephritis - rareness in chlorosis - from renal calculus embolism . . - - enlargement and with pus . . without pus . . tuberculosis tumoiu- . . - repeated pregnancies - retinitis in (see Eetinitis) - with tube-casts - scarlatinal . . - in secondary syphilis - shortness of breath with - slight with coli bacUluria - in snake-bit - from stricture of the urethra 8, 16 - suppui'ative nephritis . . 646 - syphilitic . . . . 13, 86 - in thrombosis of inferior vena cava . . . . 61, 825 - treatment by rosanilin . . 820 - with tropical abscess of liver 409 - without tube-casts. . .. 16 - with uremia 329, 350, 464, 647 - froni uterine fibromyomata 8 prolapse . . . . . . 8 - in vasomotor neuroses . . 16 - vertigo with . . . . 829 - in yellow fever . . 301, 373 Albuminuric retinitis (see Retinitis) Albumoses, a source of fallacy in test for albumin . . 6 ALBUMOSURIA with albu- minuria . . . . . . 20 - Bence- Jones' . . .. ..21 - in Bright's disease . . . . 12, 20 - haematogeuous . . . . 20 - in malignant disease of bones . . . . . . 21 - pyogenic . . . . . . 20 - tests for . . . . 20, 21 Alcoholism - acne rosacea from . . 268, 797 - acroparaesthesia from . . 493 - active congestion of liver from . . . . 371, 407 - acute, Babinski's sign in . . 82 subnormal temperatmre in 344 - adiposis dolorosa from . . 455 - albuminuria in . . . . 16 - amenorrhoea from . . . . 23 - anorexia in . . 238, 243 - aortic aneurysm in 538, 564 disease fi-om 236, 237, 238 - arteriosclerosis from . . 238 19 19 .. 584 121, 122 13 584 300 8 115 625 626 41 :, 16 237 689 15 8 8, 16, 310, 626 16, 367 16 8 674 371 101 576 458 Alcoholism, could. - ataxy from . . - brachial neuralgia in - in bronzed diabetes - central scotoma from 836, - cirrhosis of liver from 59, 300, 368, 409, - colic from . . - colom* blindness from 836, - coma due to . .137, 344, - convulsions in . . 169, - cramps in . . . . 78, 179, - delirium from - Dercum's disease from - diarrhoea in - diminished appetite in - disturbed pancreatic and hepatic functions in - dwarfing of one lobe of liver in - dyspepsia from - d.ysphagia from - enlarged heart in 232, 238, 243, - effect on blood-pressure - fatty heart from . . 238, - - liver from . . - fibroid heart due to - Hushing in . . - furred tremulous tongue in 136, - and gangrene of the lung . . - gastritis in . . . . 297, - general symptom-s of 300, - hsematemesis in . . 243, - liEemorrhoidal bleeding in . . - headache in - hiccough in . . - hippus in . . - hypothermia from 344, - infantile convulsions due to - infantilism from - insomnia in - irritability in - jaundice in . . - Korsakow's syndrome in . - leucopenia in - lipomatosis from . . - and Little's disease - loss of appetite in 238, weight due to 848, - medullary degeneration in225, - moral deterioration from . . - morning vomiting in 238, 243, 297, - myocardial changes from . - nerve deafness from - obesity due to - optic disc changes from - pachymeningitis from - pains in the limbs in - palpitation in . . 525, - pancreatitis due to ..116, - parsesthesia from . . - passive vacant aspect in - peripheral neuritis from 60, 165, 285, 492, 505, - pharyngitis in - polyuria from . . 581, 583, - priapism caused by - in prognosis in pneumonia - pupil reflex in - purpura in . . . . 596, - restlessness and insomnia in - signs of . . . . 59, - simulated by disseminated sclerosis . . - - by nervousness . . - simulating new growth tuberculosis - speech lost in - tachycardia from . . - talipes due to - temporary glycosuria in - tinnitus increased by - tremor in 136, 238, 258, 795, - urethral stricture from . . 136 837 346 172 238 195 455 197 49 292 404 354 225 245 238 241 414 238 268 243 287 352 368 295 243 328 342 595 346 170 215 358 360 243 25 401 455 154 243 849 343 797 797 238 191 849 836 563 78 527 153 797 599 136 584 586 194 594 599 797 797 565 797 849 849 682 773 131 292 793 797 440 Alcoholism, contd. - venous stigmata from - vertigo from - weakness of the limits from Alexia (Word Blindness) Algidity in malaria . . Alimentary albumosuria - glycosuria, distinguished from diabetes mellitus . . Alkali added to santonin, pink urine from Alkalies, cachexia from - in diabetic coma - gangrene from - CESophageal stenosis from . . - sore throat from - stomatitis from Alkaline faeces in gall-stone obstruction - urine with bacteriuria effect of phosphates in . . Alkaptonuria, alkali test for 290, - black urine from . . 820, - due to congenital errors of metabolism - dark colom- of urine in - dar-kening of urine on expo- sure . . . . 821, - ferric chloride test for - general account of . . - homogentisic acid in - hydroquinon^-acetic acid in - liquor potassae test for 290, - ochronosis with . . 575, - optical inactivity in - reactions with Kylander's reagent - reduction of Fehling's solu- tion in . . . . 2 - relation to tyrosin and phenylalanin katabolism - no safranin reaction in - silver nitrate test for - simulated by melanuria . . ALLOCHEIRIA - fimctional . . - m tabes dorsalis Alloxuric bases, uric acid de- rived from ALOPECIA (and see Baldness) - areata - - diagnosis from favus - - - ringworm of scalp tinea decalvans " exclamation - mark " hairs m relation to pseudopelade of Brocq - cicatrisata . . - from head injury . . - in syphilis . . Altitudes, polycythsemia at high Alum, extreme thirst due to . . Alveolar abscess (see Abscess) - echinococcus disease (see also Hydatid Disease) . . - sarcoma of kidney . . Amaurosis from hcemorrhage - pregnancy . . - urfemic . . . . 836, Amblyopia, causes of . . - in disseminated sclerosis . . - hj'Steria AIVIENORRH(EA,blood altera- tions and . . - causes of - in chlorosis . . 41, - continued, in ectopic gestation - with deficient ovarian activity - double ovarian tumour 429, 691, - hy]Derinvolution of uterus. . - ia myxoedema - pregnancy . . 350, 437, 758, 797 827 797 684 35 20 584 819 115 137 282 222 671 815 117 83 572 822 822 822 290 822 822 822 822 822 822 822 822 822 90, 822 822 822 822 822 21 22 665 817 84 84 272 274 274 244 782 85 80 450 579 789 416 395 140 839 839 836 800 800 24 22 303 760 707 759 706 430 759 AMERICA, YELLOW FEVER IN— ANESTHETICS America, yellow fever in 372 Aruemia, corvtd. Ancemia, coritd. Ajnido-oxrbutjric acid in urine 4 — catising amenorrhoea 23 - sterility due to . . 706 Ammonia" anosmia from 669 - in cerebral embolism 138 - in StOl's disease . . 4, 8 - co-efficient in urine in - chlorotic, ascites in 64 - suggesting empyema in broncho- phosphorus poisoning . . 373 in tape-worm infection 568, 570 pneumonia of children . . 39 - corrza from. . 203 - in chronic lead poisoning . . 507 - from syphilis . . 459 604 - olfactory neuritis from 669 - colour index in 20 - tachycardia from . . 772 - poisoning by 674 — cord changes from. . 667 - with thymic infantOism . . 215 - sore throat from . . 671 - delirium from 195 - due to toxins 36 - varying amounts of, in urine 574 - diazo-reaction in . . 198 - tropical 115 Ammonio-maprnesium phos- - dilatation of lieart in 528 - in tropical abscess of hver 408 pihate ia urine (Fig. 155) 573 - displaced cardiac impulse in 330 - tuberculosis . . . . 459 616 Ammonium sulphide, reduction - earache from 230 - tuberculous peritonitis 719 of oxyhsemoglobin by . . 314 - enlarsed spleen with, in kala- - -with undue aortic pulsation 592 test in carbon monoxide azar (Plate XII, Fig. H, - uterine haemorrhage 36 42S poisoning 138 p. 696) 34 - vomiting due to . . 847 for lead 77 - eosinophilia with . . 249 simuiatinsr eastric uleer . . 847 AMNESIA 25 - fatty heart in . . 62, 241 AN>ESTHESIA (andsee Sensa- - from toxsemia 20 liver in . . 414 tion, Abnormalities of) Amniotic bands, oedema of - functional bruits in 104, 106 791 - of arm in Erb's palsy 552 arm or leg from . . 455 thrill with 791 - bedsore secondary to 285 Amoeba coli (Fig. 12) 91 - in funo-ating endocarditis - below lesion in fractures of in dysentery 196 9, lO; 76, .593, .598, 613, 616 700 spine (Fig. 180) . . 484 663 - dysenteriae in liver abscess - from ga-stric ulcer . . 298 - in brachial neuritis 492 369, 408 - haematemesis 459 palsy 552 - histolytica (Fig. 12) 91 - hiemoglobinuria 315 - Brown-Sequard paralysis 540 664 Ampulla of Vater. ball- valve - with lipemoperitoneum 717 - from Cauda equina lesions . . 74 obstruction by stone in . . 650 - headache in . . 329 - cervical rib . . . . 493 554 carcinoma of 366 - in HodgMn's disease - in circumflex nerve paralysis 552 fatty stools from cancer of 265 303, 4.59, 617, 649, 695 715 - combined scleroses of the jatmdice from catarrh of 361 - hypochlorhydria with, in cord . . . . 164, 667 Amphoteric reaction of urines 572 "gastric carcinoma 37, 351 - with compression paraplegia Amputation, neurosis leading to -157 - hysterical symptonxs from . . 784 494 786 Amyl nitrite poisoniag, xan- - idiopathic (see Pernicious - definition of 660 thopsia in 840 Anaemia) . . 616 - in diagnosis of cause of ataxy 66 Amyloid disease (see Lardaceous - insomnia in. . . . 356, 359 - dissociative in syringomyelia Disease) - in lardaceous disease 696 75, 112, 128, 285, 554, 563 664 Amyotrophic lateral sclerosis - leukamia . . . . 459 649 in haematomyelia 664 absence of anaesthesia iu 5G5 - liver ctrrliosis 696 from lesion of optic thala- ankle-clonus in 565 - low blood-pressure in 329 mus 666 BabmsM s sign in 82 565 - in lymphadenoma . . 738 medullary softening 666 bladder spasm in 443 - lymphatic leuksemia 599 - from dorsal myelitis (Fig. 179) 663 condition of reflexes in 554 - lymphosarcoma . . 366 715 - of feet, vertigo with 827 contractures in 162, 164 - malaria . . . . 459 698 - functional paraplegia 567 cord changes of 554 - malignant disease of stomach 691 - glove and stocking, in iibriUary contractions in 158 growths . . . . 459 616 hysteria 157, 342, 506 impotence in . . 346 — in mediastinal growth 483 in peripheral neuritis increased knee-jerks in 565 — menorrhagia from . . 430 (Fig. 175) 660 muscular paralysis from 73 - in mercury poisoning 37 797 - hysterical 69, 157, 342, 506, 509, normal sensations in . . 554 - miners', occult hasmorrhage in 94 548, 549, 567, 666 798 I-iaralysis of arm in . . 554 - multiple serositis in 124 paral3'sis of one arm in . . 549 - - - l-iaraplegia from 561, 565 - with negative blood picture 36 of one leg in . . 541 primary 565 - nerve deafness in . . 191 - in inflammation of posterior pupils "normal in 554 - neuralgia from 134 spinal root ganglia 494 reflexes in 565 - noises in the ears from 794 - from inJTiry to cervical roots simulated by myelitis 74 - cedema of legs from 459 461 (Fig. 178) 663 - - - simulating sjTrngomyelia 73 - at onset of phthisis 620 to 3rd, 4th, and 5th sacral slow onset and course of 565 - ovarian 707 roots (Fig. 178) 663 spastic rigidity with . . 163 - pains in limbs from 503 - in Klumpke's palsy 553 spasticity of leg in 159 - palpitation in . . 525, 528 - of leg in paraplegia from taUpes in 131 - from parasites spinal caries 558 wastingof hand muscles 94, 249, 459, 568 570 - in leprosy . . 75, 450, 575 in . . 565 - with parenchymatous goitre 792 - - diagnostic importance of 424 AN>EMIA 26 - from pediculosis capitis . . 419 - musculospiral paralysis 552 - abnormal leucocytes in . . 28 - pernicious (see Pernicious - neuromyosits 504 - in ankylostomiasis 94, 459 570 ^.nsemia) - pain mth . . 475 - aortic disease 233 - in jilumbism 77, 136, 144, 798 - from peripheral neuritis - aplastic (see Aplastic Anae- - pioUdlocjrtosis in . . 620 66, 551, 562, 661 mia; - with positive blood pictures 30 - in paralysis from cervical rib 554 - ascites with . . 54, 62 , 64 - from post-partumhEemorrhage 459 - pernicious anaemia 667 - Babinski's sign in . . 82 - pseudo-leukaemia infantum - sciatic nerve paralysis 542 - ia Banti's disease . . 694, 696 459, 694 - sciatica 487 - from bleeding gums 85 - from pyorrhoea alveolaris 87 - due to spinal hagmorrhage 787 - blood changes in severe . . 27 - pyrexia in . . 32 - from transverse cord lesions 164 various kinds of 26 et set]. - pyrexial periods in 620 - in transverse myelitis 484 - in bothriocephalus infection - in renal disease 172 - trigeminal neuralgia 496 459, 568, 569, 570 - from sarcoma 459 - ulnar paralysis 128 - Bright's disease 13, 14, 90, 126 ,303 — scurvy-rickets 753 Anaesthetics, "acetonuria after 4 - cachexia . .114, 115 4.59 - in septicaemia 650 - coma due to . . 137 346 - canter-rhythm of heart in . . 639 - shortness of breath in 100 - deaths from lymphatism - capillary sensation in severe 106 - splenic (see Splenic -AnaRmia) under . . " . . 423 - from carcinoma of colon . . 147 - in splenomegalic cirrhosis - delirium from 195 duodenum 725 369, 693, 694 - in determining cause of pancTeas . . 724 - from starvation 459 dystocia . . 228 ANESTHETICS— ANEURYSM, THORACIC AORTIC 859 Ancesthclics, cnntd. Aneiin/.im. mnld. Aneurysm, thoracic aortic, conld. - in diagnosis of abdominal - cirsoid (I'hiie XIV) 764 diagnosis from prominent aneurysm . . 786 - external iliac, bruit over . . 741 subclavian artery . . 764 congenital abnormality of decreased by compress- dissecting, anginal pain genital organs . . 705 ing common iliac . . 741 on formation of 482 hysterical joint . . 389 delayed femoral pulse in 741 dullne.ss over . . 790^ spasm . . 133 diagnosis from psoas dysphagia from 222, 483 pancreatic swellings 724 bursa 741 ear in detecting pulsa- phantom tumour 53, 721 sarcoma of pelvis . . 741 tion in 764 - disappearance of phantom expansile pulsation in 741 embolism from 286 tumour under 761 iliac swelling due to . . 735 from embolism 367 - general, Babinski's sign in 82 inguinal swelling due to 741 erosion of rib cartilages by 482 - hypothermia from . . 346 x-rays in diagnosis of. . 741 - sternum by . . 194, 182 - vomiting from 843 - femoral, femoral swelling - - - - vertebrae by Anal fissure (see Anus, Fissure of) due to 732 476, 482, 784, 848 - fistula (see Anus, Fistula of) - - gangrene from . . 282 287 fusiform 238 - prolapse, haem.orrhage in . . 93 of lung in 288 gangrene of fingers from 287 - sphincter (see Sphincter Ani) - of heart from syphilis 241 girdle pain in . . 482 - ulcer 636 systolic bruit in . . 102 hsematemesis from 294, 29G Analgesia from cord lesions . . 662 - hepatic, ascites with 59 haemoptysis from - from cervical rib . . 128 from emboUsm 59, 367, 368 176, 317, 318, 322 - definition of superficial and - - jaundice with 59, 362 368 hard work in etiologv deep 660 - innominate, T-rays in diag- of . . . . 300 538 - from lesion of the medulla 666 nosis of (Fig. 131) 483 heart displaced by ssa - peripheral nerve lesions 662 - internal iliac, felt per rectum 638 impaired resonance from 322 - in syringomyelia (Fig. 182) 665 - popliteal (Plate XIII) 762 insomnia due to 848 - tabes dorsalis (Fig. 183) bruit over 762 loss of w-eight from 479 848 498, 507, 562, 662, 664 665 compression of femoral mistaken for asthma . . 582 Anangioplasia (Fig. 66) 215, 216 artery in diagnosing . . 762 hysteria 777 Anarthria 685 delayed tibial pulse from 762 intercostal neuralgia Anasarca (see Ascites, Oidema) diagnosis from sarcoma. . 762 478, 777 " Ancliovy-sauce " pus in expansile pulsation ui . . 762 mode of production of tropical abscess of liver. . 408 gangrene from . . 287 pain m 482 sputum . . . . 176, 323 oedema of leg from 456 muscle atrophy in arm Anconeus, nerve supply of . . 550 pain in leg from. . 762 from . . 74 Aneurysm, abdominal aortic swelling due to . . 761 neoplasm simulated by - - - absence of pulsation in 764 varicose veins from 762 1S5, 848 albuminuria from 8 x-rays in diagnosis of . . 762 oedema from . . anaesthetic in diagnosis of 786 - pulmonary, in phthisis 318, 319 of face, neck, and arms blanching due to 692 rarity of tuberculous focus in 786 from 456, 458, 461 diagnosis from undue - subclavian, causing oedema orthopnoea from 465, 467 aortic pulsation 592, 728 764 of arm 456 pain in abdomen from 646 erosion of vertebrae by 728 osteo-arthropathy in 891 back from 222, 296, 322, expansile pulsation with simulating brachial neuritis 492 474, 475, 476, 482 789^ 299, 486 786 - thoracic aortic : chest due to 478, 482 848 hasmatemesis from 294, 299 absence of bruits over 476 intercostal due to 478 47» haematoma due to 692 pain with 482 in left arm from 494 Jaundice from. . 368 age incidence of 223, 538 786 - - - - from pleurisy over . . 482 leakage from . . G92 728 alcohol m etiology 538 palpitation from 526 pain in abdomen from angina pectoris due to paralysis of vocal cord 299, 368 692 482 778 from . . 538 back from 299, 486 728 aortic regurgitation from paraplegia from 561 epigastrium from 486 646 107, 235 238 preponderance in men 483 rarity of . . 592, 728 apical rales from 322 pressure signs with 235 rupture into stomach 299 blood per anum from . . 90 pulsatile tumour from sex incidence of 728 bronchiectasis . . 324 235, 476, 564, 763 790- simulating peritonitis. . 646 carotid pulses unequal pulsation in back from - - - - indigestion . . 351 with 236 296, 475 S3T3hilitic history in 486, 728 chest-wall bulged by 193 ,235 pulses unequal with . . .593. systolic bruit over 368 clubbed fingers from . . 128 pupils unequal in 595 .r-rays in diagnosis of collapse from rupture of 482 - - - rarity apart from syphilis 483 (and see A'-rays) . . 486 of lung due to 482 rupture into air-passages 482 - arterio-venous of orbit 255 764 coma from . . 137, 140 bronchus . . 318, 322 exophthalmos due to 254,255 compression of bronchi heart . . 482 loud murmur with 255 by . . 236, 322, 324 482 lung 318 pulsation of eye with . . 255 cord by 561 oesophagus . . 482 - artery, internal, erosion from heart by 482 one of the great veins 482 chronic tympanic suppiu:- lung by . . 222 296 - pericardium . . 482 ation 468 oesophagus by peritoneum . . 482 - axillary, due to embolism . . 732 474, 482 841 plevu-a 482 due to injury 732 phrenic nerve by . . 482 spinal canal . . 482 unequal radial pulses from 732 superior vena cava by trachea 318 - carotid, unequal pupils in . . 595 234, 236, 461, 746, 825 ,826 severe pain in chest pulsation in exophthalmic of trachea by 465, 482 , 710 from rupture of 482 goitre . . 244 of vagus nerve by 482 , 772 sex incidence of 538 786 - cerebral, acute 699 confusion with phthisis 322 signs of descending . . 222 convulsions from 172 cough due to . . 175 ,176 simulated by spinal caries 786 - - diabetes insipidus in 585 danger with bougie . . 222 sites of rupture of iia due to embolism . . 699 diagnosis from carci- slight ha?moptysis of grave headache from . . 327, 328 noma of oesophagus 296 import in 322 sensations in head from . . 328 dyspepsia . . 476 stridor from . . 7ia - of coeliac axis artery 368 enlarged bronchial sudden death from . . 107 abdominal pain from . . 368 glands 422 syphilis in etiology of jaimdice m 368 mediastinal growth 296,483 223, 296, 300, 322, 538 , 78& 86o ANEURYSM, THORACIC AORTIC— ANUS Aneurysm, tJioracic aortic, conld Angioneurotic oedema, corttd. Anorexia nervosa, contd. systolic bniit over 'l05 relation to ililroy's disease 460 "Weir-ilitchell treatment tachycardia from 773, 773 self-induced oedema simu- in diagnosis of 850 tenderness of the spine lating 457 Anosmia, various causes of 668 669 in .. .. 78i 789 Angiokeratoma affecting fingers 266 Ajiosteoplasia, dwarfism due to 212 tbrOl due to . . 790 Angiosarcoma of kidney 395 Ante-partum haemorrhage . . 436 thrombosis in . . 280 Angular curvature (see Ky- Anterior chamber in glaucoma 840 transverse myelitis from 5G4 phosis : Lordosis) in differentiating conjuncti- Taricose chest veins - gyrus, visual word centre in vitis, iritis, and glaucoma 257 from . . . . 236, 826 (Fig. 185) 683 Anterior crural nerve, paralysis 'Wa'ssermann reaction in 786 - word bUndness from lesion of 684 of 541 .T-rays in diagnosis of Anidrosis, causes of . . 714 muscles supplied by . . 542 (Fi^. 74), 223, 296, 322,422, 465, Aniline dye workers, bullae in 110 spinal roots supplying 542 474, 476, 5S2, 593, 7S6, 790 - methsBmoglobinaemia from 187 — neuralgia, with sciatica . . 488 Angina, abdominal, benefit of Anicle, fractures near, causing diminished knee-jerk in 488 diuretin in . . 351, 486 talipes . . 132 distribution of pain in 488 vasodilators in. . 351 - haemophiUc arthritis of 388 - pohomyelitis (see PohomyelitisJ - - diasrnosis from indigeston 351 - osteo-arthritis of . . 384 - thoracic nerve, muscles sup- flatulence in . . 351, 486 - synovitis of . . 486 phed by 550 - - hfematemesis in . . 351 - tuberculous disease of 385 spinal roots derived from 550 induced by exertion 486 - ulceration in vaws . . 449 - tibial nerve, distribution of 659 paroxysmal epigastric pain ANKLE CLONUS 44 Anteversion (see Uterus) in 486 - in amyotrophic lateral sclero- Anthelmintics in diagnosis . . 249 tenesmus in 486 sis 73, 565 Anthraoosis 319 thick peripheral vessels in 351 - birth palsies 558 Anthrax, bacteriology in diag- vomiting in 351 — Brown-Sequard paralysis . . 540 nosing . . . .459, 603 746 — ludovici, bacteriology of . . 459 - disseminated sclerosis 342 - constitutional symptoms in 603 dysphagia due to 225 - with exaggerated knee-jerks 397 - diagnosis of 603 oedema of face, neck, and - in hemiplegia 337 from carbuncle . . 603 arms from . . 459, 461 - method of obtaining 44 chancre . . 603 ptyaUsm due to . . 590 - in neurasthenia 787 - gangrene from 282 stomatitis with . . 590 - paraplegia from spinal caries 558 - hsemoglobinuria from 315 trismus simulated by . . 801 - positional, in normal person 160 - itching and burning in 603 - maligna 674 - in primary lateral sclerosis 567 - malignant pustule of 603 , 746 - pectoris, from acute aortitis 778 - spastic paralysis 547 - occupation incidence of 603, 746 age and ses incidence of 482 paraplegia 494 - oedema of face, neck, and - - aortic aneurysm . . 482 778 - syringomyelia 554 arms from . . 459, 461 disease " 233, 237, 582 778 - Tooth's peroneal atrophy. . 560 round lesion in . . 746 atheroma and arterio- - transverse myelitis 14 - rigors in 647 sclerosis with . . 482 582 Anl(!e-jerlmaturia in . . . . 304 - invaded by carcinoma, faeces or flatus per uretliram . . 632 of rectum . . . . 313 urine per vaginam . . 632 of uterus . . . . 313 vagina . . . . . . 313 - irritability of . . . . 817 in oxaluria . . . . 471 - involved in intestinal ulcera- tion 313 - normal Umits of . . . . 730 - papilloma (see Papilloma of Bladder) - pain (see Pain in Bladder) - paralysis of motor nerves . . 443 - simple ulcer of (see Ulcera- tion of Bladder) - sounding for calculus . . 629 - stammering . . . . 439 Bladder, contd. - suocussion splash in . . 711 - tapped in mistake for ascites . . . . . . 717 - trouble (and see Micturition, Abnormalities of) in cere- bellar tumour . . . . 565 disseminated sclerosis . . 565 locomotor ataxy. . . . 562 transverse myelitis . . 74 - tuberculosis (see Cystitis, Tuberculous) - tumours (and see Carcinoma of Bladiler ; and Papill- oma) description of . . 513 pain in penis during mic- turition due to . . 512 renal enlargement and profuse hiematuria from 395 pedunculated, retention of urine from . . . . 441 sudden stoppage of urine by .. .. 439, 512 - ulceration of (see Ulceration of Bladder) - yeasts in, pneumaturia from 570 Blanching, haemorrhages caus- ing severe . . . . 139 Bleaching-powder test for indican 349,821 Bleb (see Bullae) Bleeding from ear in otitis .. 468 diagnosis of cause of . . 408 from erosion of internal carotid artery . . 468 of lateral sinus . . 468 - - fractured base 138, 467, 468 injury . . . . 467, 468 malignant disease . . 468 testing of hearing in . . 468 BLEEDING GUIVIS .. 85,293 in alveolar abscess 86, 87 asthenia . . . . 85, 87 dermatitis herpetiformis 80, 88 dyspepsia . . 85, 87 erytliema bullosum 80, 88 gangrenous stomatitis 80, 88 liEemophilia . . . . 85 Hodgkin's disease . . 302 infantile scurvy . . . . 115 phagedsena oris . . 86, 88 pyorrhoea alveolaris 80, 87 tartar . . . . 86, 87 variola maligna . . . . 301 - - yellow fever . . 301,. 373 - nose (see Epistaxis) - occult(seeHiemorrhage, occult) - from slight causes in heemo- philia . . . . . . 599 - uterine (see Menorrhagia ; Metror'rhagia ; and Metro- staxis) - vulval from urethral prolapse 770 from urethral caruncle . . 770 Blepharitis, ectropion from.. 250 - epiphora in . . . . 250 - in Mongolian idiocy . . 263 - from nuclear facial paralysis 536 Blindness (see Vision, Defects of; Night-blindness; and AVord-blindness) - with liysterical hemianaes- the.sia . . . . . . 666 - monocular, in migraine . . 836 - nystagmus with . . . . 452 - optic nerve, in idiocy . . 557 - strabismus due to . . . . 709 - sudden, various causes of.. 839 - total, causes of . . 839, 840 - transient in ursemia . . 839 - word, with word deafness 684 Blinking tic 159 Blistering by malingerers, . . Ill Blisters (see BuUie) 868 BLOOD PER ANNUM— BONES, NECROSIS OF BLOOD PER ANUM.. 89 Blood examination, contd. Mood-pressure, low, contd. in acute yeUow atrophy m pernicious anaemia . . 616 anaemia . . 329 of liver . . 302 370 relapsing fever (Plate XII) 698 asthenia . . 96 adhesive pylephlebitis . . 301 splenomeduUary leukae- heart disease 329 anaemia with . . 36, 90 mia 693 - normal in functional albu- due to gastric ulcer . . 40 - in fseces in carcinoma of colon minuria . . 584 in ankylostomiasis 570 147, 393 - in renal and arterial sclerosis 14 carcinoma of bowel 125 150 - loss of (see Haemorrhage) - tabes dorsalis 350 colon 91, 145, 147, 367, - occult ("see Haemorrhage, Bloody effusion in chest (see 393, 690, 731 736 Occult) Chest, Bloody Effusion in) rectum . . . . 150, 636 - parasites in . . 33 Blotches, in secondary syphilis 425 stomach 351 Blood per rectum (see Blood Blows causing deafness 191 cirrhosis of liver per Anum) - purpura from . . 596, 597 300, 368, 409 696 - specific gravity increased in Blubber lips . . 746 with colic 134 coUapse . . 580 Blue line on gums in lead poison- coUtis . . . . 197 501 of, in diabetes insipidus 584 ing 38, 77, 136, 139, 144, 153, colour due to action of method of measuring 580 507, 551, 645 798 digestive juices on - spirochaeta obermeieri in . . 373 - piU, polyuria after. . 582 hsemoglobiQ 428 - in sputum of phthisis (and - vision from cataract 840 - - from duodenal ulcer 300, 500 see Haemoptysis) 176 Blushing, definition of 268 dysentery . . 91 , 501 727 - in the stools (see Blood per - absence of, in cervical sym- in enteritis 444 Anum) pathetic paral5'sis 247 from gall-stones . . 300 BLOOD-PRESSURE, ABNOR- Bockhart, follicular impetigo of 601 - - gastric ulcer 298 MAL 95 Boeck, re multiple benign fromhfemorrhoids in alco- - high, abdominal angina with 486 sarcoid 4.=)1 holism . . 243 accentuated heart sounds Boiler-makers, deafness in . . 191 Henoch's purpura 380 600 with . . . . 1, 3, 252 Boiling test for albuminuria 5 intussusception albuminuria with 19, 526 Boils (and see Pustules) 148, 152, 196, 636, 727 736 alcohol causing . . 238 - in ankylostomiasis . . 570 invagination of rectum . . 150 amenorrhoea with 24 - enlarged gland secondary to 708 mesenteric embolism 153 angina pectoris vs-ith 350 582 - septic arthritis from 375 mucomembranous colitis 727 arteriosclerosis with 64, - stifii neck from 708 polypus . . 635 186, 239, 240, 251, 329, - swelling of scrotum fi'om . . 765 purpura haemorrhagica . . 600 331, 433, 464, 582, 639 Bone in embryonia of kidne}- 395 tuberculous peritonitis . . 719 asphyxia . . 64 - enlargement of ends of, sigmoid colon . . 731 cerebral hsemorrhage with in hypertrophic osteo- ulcerative colitis . . 727 96, 98, 138, 173, 337, 563 arthropathy 390 variola maligna . . 301 Cheyne- Stokes respiration - tumours, albumosuria in . . 21 - in carbon monoxide poisoning 138 with 125 Bones, abscess of (see Abscess - casts, renal . . 7 in chronic lead poisoning 507 of Bone) - changes common to all cirrhosis of the Uver 251 - in achondroplasia . . 214 severe anfemias . . 27 enlarged heart with 526 - acromegaly . . . . 262 585 - Charcot-Leyden crystals in epistaxis from .. 251, 252 - acute osteo-myelitis 751 117, 118 errors of digital estimation of 95 - atrophy of, in general - coagulation-time of 430 in gastric crisis of tabes. . 485 paralysis of the insane. . 269 - deficient coagulability of, gout 251 in tabetic arthritis 388 menorrhagia from 428, 430 granular kidney - carcinoma of 757 - destruction in toluylene- 122, 186, 251, 464 629 - caries of (see Caries of Bone) diamine poisoning 374 headache in . . 326 329 - in congenital syphilis (Fin. - discharge from nipple, causes 205; in heart disease . . 251 78) 259 Blood-clot in bladder, difficulty failure from . . 18, 64 186 - cranial and facial, in leon- in starting micturition sounds in estimation of 96 tiasis ossea 753 with 439 influence of rest in bed on 96 hyperostoses of, m leon- - in ureter, colic from 305, 395 insomnia in . . 356, 359 tiasis ossea . . 749 - urine . . . . 136, 305 laryngeal paralysis with 539 - enlarged locally (see Swelling Blood-crescents {Plale XII, p. lead colic 485 on a Bone) 696; 373 massage, hot baths, high- - fracture of (see Fracture) Blood-culture in diagnosis of frequency currents in 359 - gumma of (see Gumma of cause of obscure pyrexia medullary softening with 343 Bone) 609 620 menorrhagia from 430 - hyperplasia of, in acromegaly 263 fungating endocarditis 613 methods of lowering . . 359 in hypertrophic osteo- septicaemia . . 598, 698 metrorrhagia from 433 arthropathy . . 390 septic conditions 648 mitral regurgitation from rickets . . . . 179 214 various organisms re- 239, 240 - injury of, swelling due to . . 750 coverable ftom 650 stenosis 64 - innocent tumours of 752 - diseases 26 et seq. in nephritis 14 48, - invaded by epithelioma . . 814 cachexia in 114 56, 90, 102, 240, 303, 454 - malignant disoa^ie of 388 causing pleurisy with acute nephritis . . 12 albumosuria in 21 effusion 122 chronic nephritis 64, 96, 122, - necrosis of 751 peripheral neuritis in . . 75 172,186,239,251,331,464 629 abscess in heart from . . 650 tenderness in the chest noises in the ears with . . 794 ansemia with 39 from 776 ptyalorrhoea with 592 - - anosmia from 668 - distribution of, medullary reduplicated heart sound diagnosis from sarcoma 751 763 centre for regulation of 619 with 639 - - earache from 230 - examination in ankylosto- renal tube casts with . . 526 foul breath due to 99 miasis 570 retinitis with 526 lichen scrofulosorum with 529 carcinoma of stomach . . 351 sphygmomanometer in obstruction to nose by . . 668 - - generalized lymphatic gland diagnosis of . . 526 pericarditis from 650 enlargement . . 416, 419 in uraemia 350 from phosphorus. . 87 Hodgkin's disease 617 - low with acute abdominal popliteal abscess due to. . 762 instruments for . . 27 pains except lead colic ptyalism due to . . 590 in lymphatic leukaemia . . 739 and tabetic crisis 485 stomatitis due to 590 - - malaria {Plate XII, p. 696) Addison's disease from syphilis 237 371, 615, 693, 698 38, 329, 843, 849 talipes'from 132 BONES— BRIGHT'S DISEASE 869 Bones, cmul. - node on . . . . . . 750 - in osteitis deformans . . 753 - osteogenesis imperfecta . . 213 - osteomalacia . . 213, 214 - pain in, in sypliilis (and see I'aiu in Bone^ . . . . 503 - in rickety dwarfism . . 21-t - sarcoma (see Sarcoma of BoneJ - sinus in connection with . . 751 - spontaneous fracture of, in scurvy-rickets . . . . 753 in new sjrowtli of 269, 757 tuberculous disease of 2()9 - subperiosteal extravasation on, node after . . . . 750 - syrinaromyelia . . . . 2S5 - swelling on (see Swelling on a Bone) - syphilis of, diagnosis from tuberculous periostitis . . 752 - tenderness of, in scurvy and rickets . . . . -i-l, 115 in secondary sypliilis . . 672 - thickening of, from clironic osteomyelitis . . . . 751 clironic periostitis (Fiff. 192) 751 due to gumma . . . . 752 in osteitis deformans . . 753 a-ravs in diagnosis of (Fios. 196, 198, 199) . . 751 - transparency to a;-rays in rheumatoid arthritis (Fig. 110) 380 - tuberculous disease of . . 751 diagnosis from gumma 752 sites of commencement 751 - unaffected by lupus vulgaris SOS Bone-marrow affections, Bence- Jones' albumosm-ia in . . 21 eosinophUia in . . . . 2i8 - splenomegalic polycythsemia a disease of . . . . 581 Bony out-growtlis in osteo- arthritis and gout 383, 384 Boots, buUie due to . . . . 110 - relation to ilorton's disease 438 - tight, causing metatarsal neuralsia . . . . . . 488 talipes . . . . . . 132 whitlow.. .. .. 445 BORBORYGMI 96 - absent with general peri- tonitis 97,431, 644, 645 - in intestinal colic . . 473, 645 obstruction . . 153, 431 Boring epithelioma of jaw . . 749 Bossing of skull in rickets . . 753 " Bossy " nodules in tubercu- losis of testis . . . . 519 BotlniocephaUts infection, albuminuria in . . . . 17 anemia in 33, 37, 459, 568 - - cachexia in . . . . 115 eosinophilia in . . . . 249 oedema of legs in 459, 461 - (see also Tape-worm) (Fig.lol) 568 B6ttLrer"s test for glycosuria 290 Bottle-nose in cirrhosis of liver 300 Bougie in diagnosis of calculus in urethra . . . . 439 - danger of passing in dys- phagia . . . . . . 222 cesophageal pouch . . 842 urethral stricture . . 439 - olive-pointed flexible, in urethral stricture . . 440 Bovine cough in laryngeal paralysis . . . . 53S, 539 - heart 233 Bowed legs in achondroplasia 212 from rickets . . . . 212 Bowel, casts of, in membranous colitis . . . . . . 444 Boxing, enlarged heart from 244 Boj's, excessive fatness of, in hypernephroma . . . . 454 Brachial artery, unequal pulses from atlieroma of . . 593 - nerves, table of muscles innervated by 550, 556 - neuralgia (see Neuralgia, Brachial) - neuritis (see Neuritis, Brachial) - palsy (and see Paralysis of Extremity, Upper) . . 545 - plexus disease, diagnosis from progressive muscu- lar atrophy . . . . 73 interference with by thjrroid gland tumoiu". . .. 792 lesions, muscular atrophy in 74 palsy (see also Erb's, Du- chenne's, and Klumpke's Palsies) . . . . 552 paralysis of arm from injuries to . . . . 552 from presstire of cer- vical rib on . . . . 539 table of innervation of muscles by . . . . 550 Brachialis anticus muscle, nerve supply of . . 550, 556 Brachvceplialy in Mongolian idiocv 263 BRADYCARDIA ..97,98 - in aortic stenosis . . . . 235 - cerebellar abscess . . . . 644 - fattT heart 241 - jauncUce . . . . 98, 361, 365 - Stokes-Adams' disease .. 172 Brain, coma due to compres- sion of . . . . . . 137 - concussion (see Concussion of Brain) - cystic, congenital . . . . 558 - fatigue in neturasthenia . . 506 - injury, testis atrophy after 79 Clieyne-Stokes' respira- tion after . . . . 125 coma after . . . . 136 diagnostic importance of aura in localizing . . 80 - not coloured in jaundice . . 361 - syphilis of (see Syphilis, Cerebral) - tuberctilous nodule in . . 341 - tumom: (see Cerebrum, Tumour of) Bramwell's test of pancreatic infantilism . . . . 216 Brassy cough in laryngeal paralysis . . . . 538, 539 Braim's sign in pregnancy . . 437 Brazil, ankylostomiasis in . . 570 Bread-crumbling movements in paralysis agitans . . 796 Breast, abscess of, (see Abscess, Mammary) - atrophy of, carcinomatous 745 - carcinoma of (see Carcinoma of Breast) - cliauges in, in lactation . . 743 the new-born . . . . 743 in pregnancy . . . . 743 of puberty . . . . 743 - cyst of (see Cysts of Breast) - cystic disease of . . . . 744 - enchondroma of . . 744, 754 - fibro-adenoma of, absence of enlarged axillary glands in 744 age incidence of . . . . 744 characters of 743, 744, 745 cystic change in. . . . 744 from carcinoma 744, 745 chronic mastitis . . 744 cyst . . . . . . 744 early sarcoma . . . . 746 Brea.1l, fibro-adenoma of, contd. free mobility of . . . . 744 the only conmion innocent tumour of breast . . 744 rarity of . . . . . . 744 - fullness and pigmentation of, in pregnancy . . . . 350 - hydatid cyst of . . . . 202 - hypersestllesic patclies in, in hysteria . . . . . . 667 - linea; albicantes on . . 402 - lipoma of, rarity of . . 744 - male, milk in . . . . 202 - mode of examination of . . 742 - multiple cystic disease of. . 744 - myoma cutis of . . . . 805 - pain in (see Pain in the Breast) - redness of, in mastitis . . 743 in tuberculosis . . . . 744 swelling and tenderness in mastodynia . . . . 479 - sarcoma of (see Sarcoma of Breast) - sinus of, tuberculous . . 744 Breast swellings, general dis- cussion of 742, 743, 744, 745 - tuberculosis of . . . ■ 744 - unilateral hypertrophy of, from fibro-adenoma . . 743 from putting children to the breast . . 743 - veins of, dilated in pregnancy and lactation . . . . 743 Breath, characteristic catch in gall-bladder affections 499 BREATH, FOULNESS OF .. 98 with bronchiectasis . . 579 catarrhal jaundice . . 365 gangrene of lung . . 321 - - gastritis . . . . ... 297 pyorrhoea alveolaris . . 87 stomatitis . . . . 88 Vincent's angina . . 672 BREATH, SHORTNESS OF (and see Dyspnoea, Ortho- pnoea, etc.) . . . . 100 in ankylostomiasis . . 570 bronchitis and emphy- sema . . . . . . 579 cachexia . . . . . . 115 fibroid limg . . . . 579 goitre . . . . . . 792 Graves' disease . . . . 792 mitral regurgitation .. 103 stenosis . . . . 579 pericarditis . . . . 480 polycythsemia in 100, 579 renal disease 13, 14, 579 spasmodic asthma . . 579 subplirenic abscess . . 721 - smell of, in alcoholic coma 138 in ursemia . . . . 350 - sounds (see Vesicular JFurmur) Breathing, Cheyne-Stokes (see Cheyne-Stokes Respiration) - difficulty in (see Dyspnoea, etc.) - laboured, in convulsions . . 169 - paiioful, with gall-stones . . 486 in intercostal nemralgia 478 phrenic neiualgia . . 478 with pleurisy . . . . 479 pneumothorax . . . . ■ 480 - rapid shallow, in pneumo- thorax . . . . . . 577 - stertorous, in convulsions. . 169 - tubular- (see Bronchial breathing) Breathlessness (see Breath, Shortness of) Bright eye in Bright's disease 256 Brlght's disease, albuminuria in 11, 12, 466 870 BRIGHT' S DISEASE— BRONCHITIS Bright s disease, could. Brigfit's disease, acute, conid. Bronchial hrealhing, contd. albumosuria in . . 12 after scarlet fever 671 lobar pneumonia 186, 701 amenorrhcea in . . 23 simulated by angioneu- in lung compression 332 ansemia in 90 rotic cedema (Fig. 128) 458 phthisis . . 319 anasarca -n-ith . . 4S , 54 by excessive drinking 458 pleuritic effusion 193 aortic regnrgitation in . . 107 after infusion 458 - glands (see Lymphatic Glands ascites in. . 63 transfusion . . 458 Bronchial) backward pressure in . . 48 by vena cava throm- Bronchiectasis, albumimu-ia in 18 bacteriiiria in 83 bosis 825 - albumosuria in 20 bulls in . . 110 sudden onset in 311 - anfemia in . . 39 Chevne-Stokes respiration symptoms of . . 48 - aneurysm causing . . 324 ui . . . . 124, 412 universal cedema in . . 460 - causes of 324 chlorides in 12 urinary changes In . . 311 - cerebellar abscess from 644 conjunctival oedema of. . 256 chronic (and see Granular - cerebral abscess from 98, 547 contracted granular kidney Kidneys) - Charcot-Leyden crystals in 118 in 14 albuminuria in 13, 16, 454 - clubbed fingers in 99, 129, 703 conTulsions in . . 160 albuminuric retinitis in - cyanosis from 186 diminution of total solids 303, 454 - (flagnosis from gangrene of in urine in 626 anaemia in 303 lung .. .. 321, 703 distinguished from infarc- big heart in . . 454 epithelioma of bronchus 324 tion of kidney 314 cardiac hypertrophy with - with fibroid lung, diagnosis of 324 physiological albumi- 303, 331 - foul breath in 99 nuria . . 19 chylous ascites in 58 taste in . . 774 epistaxis in . . 90, 251 convulsions in . . 160 - gangrene of lung in 287 general oedema in 466 cramps in 179 - haemoptysis In . . 318, 324 haematemesis rare in 299 eosinophilia in diagnos- - heart failure from . . 61, 186 haematuria in . . 304, 316 ing asthma from . . 249 - indicanuria in 349 hiemoglobinuria in 315 epistaxis in 295 - inspissated mucus . . 324 hsemorrhage in . . 90, 598 general pains in limbs in 503 - lardaceous disease in 10, 696 heart faUure from 63, 461 haematemesis in 294, 303 — leucocytosis in 400 hypertrophy of heart in 90 245 high blood-pressure in - from mediastinal new growthl21 infantile conrulsions in. . 170 90, 102, 239, 240, 303 454 - monoplegia due to. . 547 mercury iniurious in 590 hypothermia in 345 - multiple rigors from 651 mitral regurgitation from irritability in . . 360 - no elastic fibres in sputum in 703 239, 240 micturition frequent in 437 - orthopncea in 464 morning headache in 327 noises in the ear in . . 794 - osteo-arthropathy in 390 multiple serositis in 124 of old people . . 14 - part affected by . . 703 nerve deafness in 191 parenchymatous, obesity - periodical return of symp- nucleoproteid in. . 12 in . . . . 453, 454 toms m . . 703 obesity in . . 453, 454 anaemia due to 30 cyanosis from 579 oedema in 12 -' polyuria in 48, 102, 303, - physical signs of . . 193, 703 of legs in . . 459, 461 331, 437 583 - poiycythaemia in . . 579, 580 pericarditis in . . 122 prolonged first sound - rigors in . . . . 648, 651 phosphates in . . 12 at impulse in 454 - septic arthritis from 375 polyuria in 90 renal tube-casts in 454 - shortness of breath with . . 579 puffiness and oedema of retinal changes in - simulating gangrene of lung 288 face in . . 746 102, 103 240 - sputum in .. ..99,176, 321, purpura in . . 596, 598 ringing aortic second 651, 703, 842 renal tube-casts in 12 sound in 454 - vomiting from . . 842, 844 in scarlet fever . . 674 systolic bruit over mitra: Bronchiolitis, Curschmann's simulated by MOroy's area in . . 102, 103 spirals in . . 179 disease 460 thick radial artery in . . 240 Bronchitis, albumininia in .. 18 mysoedema 43 tortuous arteries in . . 303 - ascites in 61 oedema of convalescence 459 trace of albumin in . . 331 - asthma developing into 1S6, 582 stridor in. . 709 urinary changes in 240 331 mistaken for 582 syphilitic . . 86 vertigo due to . . 828 - blood streaks in sputum of 176 tube-casts in urine in . . 466 of young people 13 - capillary 465 uraemia with 48 subacute, anaemia in . . 39 extreme dyspnoea from . . 642 urea in . . 12 cachexia in . . 115 cyanosis from 185 urine changes in 12, 16 et seq. chyluria in 126 retraction of the head from 642 varieties of ascites with . . 54 chylous ascites with . . 126 sticky sputum in 175 pleural effusion in 122 Brightness perception, normal 835 - Charcot-Leyden crystals in 118 various forms of . . 8 Brittleness of bones . . 213, 285 - chronic, clubbed fingers in 128 weakness in 90 - of naiLs, onychorrhexis 445 albuminuria in . . 246 acute, anuria in . . 48 Broca's area, aphasia from ascites in . . 246 bacteriuria in . . 82 lesion of . . . . 337, 683 enlarged liver in .... 246 cyanosis in 185 situation of 683 right ventricle in 245, 240 diagnosis from Henoch's motor speech centre in 683 - - fraenum linguae abraded in 320 purpura 600 Brocq, re pseudo-pelade heart failure in 61,186,464 ,525 mitral regurgitation in 239 85, 780, 782 oedema of legs m 246 occasional absence of - re vesicles of herpes 83 pains in limbs in. . 503, 505 oedema in . . 311 Bromide eruption, characters of 603 palpitation in 525 cedema in . . 311, 457 diagnosis from smaU-pox 609 poiycythaemia in 579, 580 of face and of labia in 458 Bromides, coma due to 137 systolic murmm- in 246 larynx in . . 185, 709 - loss of taste due to . . 774 tricuspid regurgitation in 246 legs m . . 458 461 - ptyalism due to 590 - complicating asthma 467 lungs in 466 - vesicles from 834 - cough from.. .. 175, 176 penis in 458 Bromidrosis, account of 714 - cyanosis in severe . . 186 scalp in 458 Bromine test for melanuria . . 821 - distinction from asthma . . 180 scrotum in . . 458 Bronchial breathing with bron- - and emphysema (see Emphysema) peritonitis with 55 chiectasis 193, 324, 703 - epistaxis in . . 251 polyuria in; recovery fibroid lung 232 - fibrinous or plastic . . 704 from . . 582, 583 growth of lung . . 322 - libroid lung and bronchiec- scant3' urine in 311 infarction of lung 321 tasis from 324 BRONCHITIS, FCETID— BURNS 871 Bronchitis, conld. - foBtid 99 703 - - abundant foul sputum in 703 foul breatli iii 99 taste in 770 frequently a mistaken diagnosis 703 - - indicanuria in 319 leucocytosis in 404 simulating gangrene of lung . . 287, 288 - hsemoptysis in 317, 318, 320 32 1 - in influenza. . 505 - insomnia in sVe, 359 - in Malta fever 507 - orthopnoeain 186, 404, 405 - pain in the chest in 480 - periodic cyanosis from 579 - physical signs due to 192 176 186 615 - plastic, casts in sputum in 704 - secondary to abscess of liver 409 abscess of the lungs . . 649 - shortness of breath from 101, 579 - simulated by pertussis . . 705 - simulating asthma. . 249, 467 - sputum in . . 176, 700, 704 - tenderness in the chest fi'om 778 - in typhoid fever .. .. 697 - venoas congestion of liver in 407 Bronchophony in bronchiectasis 703 - in fibroid lung . . . . 246 - with fibroid lung and bron- chiectasis . . . . 324 - in lobar pineumonia 186, 701 phthisis . . . . . . 319 Bronchopneumonia, albumin- m-ia in . . . . . . 17 - apical, diagnosis from phthisis 321 - caseous, lividity ia . . 185 - chief incidence in children 321 - cough from. . - cyanosis from - diagnosis from general pulmonary tuberculosis . - diminished knee-jerks in 398,557 - empyema uith . . 39, 119, 186 - extreme dyspnoea from . . 642 - fibroid lung and bronchiec- tasis from . . . . 324 - gangrene of lung in 287, 712 - haemoptysis in . . 317, 321 - hyperpyrexia in . . . . 343 - influenzal . . . . 321, 505 asthenia in . . . . 321 relatively low fever in . . sticky rales at bases in . . - and laryngeal obstruction - after mouth operations - orthopncea in - ■^■\t\\ otitis media . . - pleurisy with - pneumococcal - prolonged pyrexia in C09 - retraction of the head in . . - septic, diagnosis of gangrene of lung from . . from lateral sinus throm- bosis . . . . 321 pneumothorax from 5 from tongue carcinoma 321,578 - shortness of breath in . . 101 - streptococcal . . . . 615 Bronchorrhcea, haemoptysis in 318, 324 - identity with bronchitis . . 324 Bronchus, anem-ysm of aorta rupturing into 140, 318, 322, 482 - carcinoma of (see Carcinoma of Bronchus) - empyema rupturing into, causing pneumothorax 578 - foreign body in . . . . 466 fibroid lung and bron- chiectasis from . . 324 78, 71£ Bronchus, conld. - irruption of caseous gland into 466 - parasitic infection of 318, 325 - pressure of mediastinal growth on . . . . 483 - stenosis of by aneurysm 236, 296, 322, 324, 474, 482 bronchiectasis from . . 324 carcinoma.. .. .. 324 fibroid lung from . . 324 foreign body . . . . 324 gangrene of lung from 288, 712 Hodgkin's disease . . 321 inspissated mucus . . 324 list of causes of . . . . 324 mediastinal new growth 324,343 with mitral stenosis . . 324 new growth 118, 185, 322 - - orthopnoea from . . . . 465 pyopneumothorax from 712 - - in syphilis . . 288, 582 sypliilitio disease, diagnosed from phtliisis . . . . 325 tuberculous bronchial glands . . 324, 422, 773 - ulceration of, hfemoptysis in 325, 328 Bronzed diabetes (see Diabetes, Bronzed) Broom tops, polyuria from . . 582 Brown-S6quard paralysis . . 68 character of . . . . 540 crossed anaesthesia in (Fig. 181) . . . . 664 diagram of physical signs of, (Fig. 142) . . . . 540 Brows, prominence in acro- megaly . . . . . . 263 Bruising of skin in jaundice 361, 598 multiple in epilepsy, simu- lating purpura . . 597 in some normal people . . 597 Bruit in aneurysm of coeliacaxis 368 - d'airain with pneumo- thorax .. .. 193, 577 simulated by drips in thorax . . . . 711 - de diahle . . . . 41, 105, 106 associated with congenital systolic bruit 10-1, 105, 106 in clilorosis . . . . 333 - over enlarged spleen . . 689 - exophthalmic goitre . . 244 - Flint's, in dilatation of left ventricle . . 108, 109, 234 - functional 41, 102, 104, 105, 106 systohc pulmonary, in chlorosis . . . . . . 333 - in fungating endocarditis 9. 10, 38, 240, 598, 649 - hsemic, in chlorosis . . 41 - with high blood-pressure . . 252 - mid-diastolio . . . . 107 - in mitral stenosis 107, 245, 320, 580 - myocardial degeneration . . 333 - over eye with orbital aneurysm . . . . 255 - with patent ductus arteriosus 184 septum ventriculorum 184, 579 - presystolic 107, 320, 580 in tricuspid stenosis . . 110 - pulmonary incompetence . . 247 stenosis . . . .129, 184, 247 systolic, in chlorosis . . 105 - rumbling systolic, in con- genital pulmonary stenosis 579 - sometimes absent in con- genital heart disease . . 579 - of stenosed superior vena cava 236 - sudden changes in, in funga- ting endocarditis . . 38 Bruit, conld. - of tricuspid regm-gitation . . - in undue abdominal aortic pulsation BRUITS, CARDIAC .. 101, witli acute cardiac dilata- tion endocarditis 76, 102, 103, 239, 613, in adherent pericardium with albuminuria aortic disease 138,233,234,235,230,237, aortic and mitral distin- guished . . in arterio-sclerosis 102, cerebral embolism 138, chronic bronchitis and emphysema nephritis . . 14, 102, chlorosis . . . . 41, congenital heart disease 129, 184, 244, 247, in mitral regm-gitation 102, with pleural effusion rumbling or blattering, in congenital pulmonary stenosis - diastolic - systolic Bryant, re spinal cord centres Buboes (and see Lymphatic G-lands, Inguinal) 675, Buccal nerve, distribution of Bug-bites, pruritus from Bulb (see Medulla Oblongata) Bulbar paralysis (see Paralysis, Bulbar) Bulging of chest (see Chest, Bulging of) Bulimia BULL/E, - affecting mucous membranes - in anthrax . . - artificially produced, value of eosinophiUa in detecting - caused by malingerers - in cheiropompholyx 654, - congenital syphilis . . - crusts in - dermatitis herpetiformis 781, - eosinoplulia with . . 114, - in epidermolysis bullosa 110, 113, 266, - erysipelas . . - erythema multiforme - extreme oedema 110, - gangrene and Raynaud's disease . . 110, 112, - glanders - herpes n-is . . - impetigo . . . . 602, - leprosy - pemphigus . . . . 602, neonatorum - relation of vesicles to - in scabies . . . . 654, - urticaria Bullet wound of cord . . Burning sensation in antlirax drug rashes eczema eyes from error of refraction herpes genitalis . . of lips in Pordyce's disease in pustular eczema urticaria . . with vesicular eruptions Burns, contracture after - ectropion and epiphora from - hsemoglobinuria after - hyperpyrexia after - and scalds, albuminuria in - scarring after 239 592 013 671 243 18 240 234 103 563 246 103 333 579 238 121 579 106 101 566 738 659 49 110 249 111 832 446 829 831 249 445 746 531 112 283 603 832 608 654 654 446 829 832 835 650 603 426 831 328 830 403 602 850 829 168 250 315 344 16 709 BURNS— CALCULUS, URETHRAL Burns, conld. Caisson disease, bilateral par- Calculus, renal, conld. - talipes equinus following . . 132 alysis in . . 342 pleuritic effusion from . . 123 - iilcerarion of the leg from. . 810 Cheyne-Stokesrespirationinl25 polyuria due to hydrone- EurrowB in skin in scabies 608 831 deafness in 191 phrosis from . . 581, 583 Bursa over exostosis . . 754 epistaxis in 251 pricking pain on bimanual - lijoid, simulating enlarged hemiplegia in . . 340, 342 examination in 306 " thyroid gland 791 shortness of breatii in . . 101 pyehtts from . . 438 625 - ileo-psoas, femoral swelling Calcanodynia . . 488 pyonephrosis from from . . 734 Calcification of anterior com- 309, 396, 626, 627 simulated by bijj-joint mon ligament in spondyU- pyrexia due to . . 621 disease . . 734 tL3 deformans 787 pyuria from simulating psoas abscess 734 Calcium chloride and physio- 16, 46, 308, 312, 623, 626, 627 - psoas (see Psoas Bursa) logical albuminuria 19 renal abscess from 309, 499 500 - sodium urate in, in gout . . 380 - deficiency at the menopause 433 rigors ■s\-ith . . 647, 650 - spinal, in porters . . 183 metrorrhagia from 433 sex incidence of . . 312 But<;hers' boys, scoliosis in . . 181 - hypochlorite test for indican 349 simulating enlarged spleen 729 Butchers, epidemic jaundice in 372 - oxalate 816 sMa^aphy in (Fig. 97) - Weil's disease in . . 372 crystals in pancreatitis . . 116 309, 500, 583 Buttocks affected by eczema in intestinal sand 6.52 tenderness of kidney in 500 marginatum 275 sources of in body 817 ultimate fate of.. 308 - bedsore over 285 and uric acid, relation- without urinary signs . . 500 - condyloma of 769 ships between 816 817 varif rion in symptoms - eruptions on 446 in urine (and see Oxaluria) 470 ■nith position in kidney 627 - Jacquet's erythema of 446 — phosphates, acid and alka- - salivary, ptyalism due to. . 591 - lymphatic drainage of 738 line reactions of 573 - ureteral 627 - pemphigus neonatorum of 446 in intestinal sand 652 anuria from . . 45 , i6 - prurigo ferox on 531 - salts in diagnosis of tetany 179 coUc in . . . . 135, C27 - scabies affecting . . 609 effects on coagulation diagnosis from appendi- Butyl chloral hydrate poison- time of blood 430 citis . . . . 311, 632 ing, Cheyne-Stokes res- Calculus, biliary, colic in . . 135 vesical calculus or piration in 125 rigors in . . 647 tuberculosis 627 purptira from . . 596 - impacted, blood per urethram villous papilloma 514 Butyric acid in gastric juice. . 333 in . . 441 felt per rectum . . 627, 638 Buzzing in the ears Csee - infantile convulsions arising vaginam 627 Tinnitus) from 170 frequent micturition with - pancreatic, colic, etc., due to 135 311, 627 PACHEXIA «J - acetonuria in . . 114 epigastric pain with 486 h8ematm:iafrom304,311,514,627 4 symptoms of 725 history of renal calculus - albuminuria in 17 - penile (see Calculus, Uretliral) in diagnosis of 627 - ansemia with 37 - prostatic, absence of fixation — impacted 47, 51^, 515, 627 - aquosa, perverted appetite in 115 of prostate on rectal ex- cystoscopic appearances 514 - atrophy of muscles in 634 amination in 512 examination of ureter by - bleeding gums in . . 85 diagnosis from prostatic wax-tipped bougies in - from carcinoma carcinoma 512 cases of . . ... 514 57, 459, 575, 731 745 effects of 512 hydronephrosis from - congenital syphilis 44G grating felt on passing 135, 395, 627 - constipation with . . 143 catheter in . . 512 515 micturition frequent in 514 - functional . . 508 of calculi felt per palpation per rectum . . 514 bruits in . . 106 rectum in . . 512 515 renal pain from dila- - impotence from 347 pain in penis after mic- tation of pelvis in . . 514 - from leprosy 575 turition in . . 513 515 symptoms like those of - malaria . . . . 489, 575 perineum in . . 516 vesical calculus or - mediastinal growth 483 prostatic abscess due to 632 tuberculosis 514 - neuritis in . . 508 ulceration into urethra . . 515 usual sites of . . 627 - cedema of legs in . . 459 ,461 - renal, aching in loin in 308 pain in course of ureter - pains in limbs from fever in 508 agglomeration of crystals from 627 - pigmentation of skin in . . 575 in urine in 471 after micturition in 442 627 in uterine lesions 114 albnminiiriq -m'th 16 in penis from - with pyopneumothorax . . 712 anuria from . . 46 442, 513, 514 627 - sarcoma . . . . 459, 75C blood in urine in 627 tssticle from . . 524 - from starvation 459 causing anuria . . 45, 46 pyuria from 514, 623, 627 - in stomach disease of negroes 115 pleuritic effusion 12.0 sacralgia from . . 510 - syphilis 459, 575, b04 658 Cheyne-Stokes breathing in 124 2--ray diagnosis of 311, 514 627 - tropical diseases . . 459 coUc due to ..308, 627 846 - urethral 510 - tuberculosis . . 459 ,731 crystals in urine in 306 818 acute pain in penis from 313 Cacogeustia 774 cystin causing 187 behind urethral stricture 677 Cscum actinomycosis of 736 diagnosis from growth . . 395 bougie in diagnosing 439 - carcinoma of (see Carcinoma from oxaluria 311 - — common sites of . . 511 of Caecum) renal tuberculosis 310 626 discharge due to 206 - dilatation of, succussion enlargement of kidney in 500 frequent micturition from 438 sounds in 711 frequent micturition in 308 438 hematuria in . . 304, 313 — faecal accimiulations in 393 lia>maturia in 16, 46, 304, 308 impacted . . 211, 439 - fistula of, causing pneimia- after movement 305 395 piain in the penis during ttiria 576 hydronephrosis from micturition in. . 510 - lesions of, causing surgical 309, 581 583 perineum in . . 516 emphysema 231 impaction in ureter 627 at tip of female urethra - normal situation of 722 lumbar aching from 627 from 442 - sarcoma of (see Sarcoma of pain from 46 palpation of stone in 313, 511 Caecumj nephritis from . . 8 passage of 511 - tuberculosis of 736 pain in the left hypochon- priapism from . . 585 simulating appendicitis 736 drium in 499 retention from 313 441 swelling in right iliac right hypochondrium sudden urethral pain from 511 fossa from 7.36 and back in 500 stoppage of micturition Caffeine, diuretic effect of .. 581 testicle in 524 in .. .. 313 511 CALCULUS. URETHRAL— CARCINOMA OF BREAST 873 Calculus, vrelliral, conkl. Cancrum oris (Fig. ll) 88, 282 Carcinuma, contil. from urotlirai fistula 678 bleeding gums in 81 , 88 - starting in lupus vulgaris. . 803 urethritis due to 766 |ityalism due to . . 590 a mole 803 visible by means o£ Cannabis indica, micropsia from 8H a wart 803 urethroscope 511 liiiisdiiiiig, -xautliopsia in 840 from an x-ray scar 803 - vesical.. .. 304, 312 511 liri:i|iisai caused by 586 - with thoracic duct obstruc- - - absf'uce of cystitis in Canter rhythm in cardiac dila- tion, chyluria in. . 126 earliest stages . . 513 tation 6:!9 - wasting with 69 frequency of micturition diagnosis from redui)lica- - of antrum of Highmore .. 205 iluriui,' complete rest 513 tion of heart sound 639 - anus 423 age incideuco of . . 513 628 in fatty heart 639 eiUarged inguinal glands behind prostate . . 629 jipricarditis . . 242, 639 from . . . . 423, 739 concealment in a diverti- Cantharides causing bullixj . . 110 pain in perineum from . . 516 culum . . 629 - hicmaturia caused by 304 jienis from 515 crystals in urine in 629 - priapism caused by 580 - of bile-ducts . . 36, 725 cystitis from . . 513, 629 - ptyalism due to 596 diagnosis from enlarged cystoscopy in (Plates V, - used by malingerers 111 gall-bladder . . 278 VI, p. 308) 312, 439, Capillary oozing in jaundice. . 361 infective cholangitis from 362 442, 512, 513 629 - pulsation in aortic disease jaundice in 361 diajinosis from tubercu- 106, 233 - of bladder 513 lous cystitis . . 628 Capsicum used by malingerers 112 age incidence of ureteral calculus im- Caput medusEB in cirrhosis 51, 826 311, 514, 628, 630 pacted 627 Carbol-fuchsin stain . . 700 - - anuria in . . . . 45 , 47 effect of exercise on mic- Carbolic acid, coma due to 137 346 cystitis due to . . 627 turition with . . 438 diazo-reaction in . . 198 cystoscopy in diagnosis of fallacies in sounding the ferric chloride reaction in (Plate VI., Figs. F, G, bladder in 629 urine from 196 p. 130) 439,442,512,514,630 felt per rectum . . 638 in gastric contents 844 diagnosis from tubercu- frequency of mictm-ition in hsematuria from . . 304 lous cystitis 628 3i2, 438, 513, 628, 629 in hypopyon ulcer 807 enlarged glands from during exercise or hypothermia from 346 307, 514, 628, 630 jolting 513 ochronosis from . . 575, 822 pelvic lymph glands felt hfematuria in reducing body in urine on rectal examination 304, 312, 512, 513, 629 due to . . 290 628, 630 - - iiistory of renal colic in 513 scaly eruption due to . . 655 faeces passed per urethram 633 pain after micturition in used by malingerers 112 felt per rectum . . 628 441, 511, 512, 513 Carboluria, general account of 822 fragments in urine 306 in the bladder from . . 818 Carbon bisulphide, htemoglo- frequency of micturition penis from . . 441 628 binuria from 314 in 311, 438, 512, 514, 630 perineum in . . 516 peripheral neuritis from 77 hfematuria in 47, 304, 305, priapism from 585 - dio.xide, headaches from . . 328 311, 512, 514, 628 630 pyrexia due to . . 621 - naonoxide, coma due to 137 hydronephrosis in 311 pyuria with 512,513,623,626,629 headache from . . 328 infiltration of base of skiagraphy in (i^i(/. 98) 312 629 liajmoglobinuria from . . 314 bladder in 311,512,513 630 stoppage of stream during poisoning, cherry colour in 138 micturition frequent from mictm-ition by Carbonate of calcium in boiling 311, 438, 630 312, 439, 512, 513 test for albumin . . 5 pain after micturition 47 441 the sound in diagnosis of Carboxyhsemoglobin, spectral in penis from 312, 441, 312, 512, 629 absorption band of 95 442, 512, 513, 514 630 m-mary changes due to . . 512 - test for 138 in perineum, anus, and Calf muscles, paralysis of . . 543 Carbuncle, diagnosis from vulva in . . 442 516 talipes from fibrosis and antlirax . . 603 pelvic swelling due to . . 757 contracture of 132 cellulitis . . 603 pyelitis, from 625 Callus, diagnosis from sarcoma 757 furuncle . . . . _ 603 pyonephrosis from 626 - involvement of nerves in . . 75 ringworm of beard 274 - - pyuriiin 47, 311, 512, 623 630 - swelling on a bone due to . . 750 - enlarged gland secondary to 708 rectal examination in 307, 311, - a--rays in diagnosis of 757 - of face, cavernous sinus 312, 512, 514, 628, 630, 638 Calmette's reaction .. 38 thrombosis due to 253 renal growth simulating 311 in diagnosing latent tuber- - on neck, stiff neck from 708 pain from 311, 514, 630 culosis . . . . 621, 847 - several suppuration points in 603 sudden, profuse, painless negative in anorexia Carcinoma, albumosuria in . . 20 hremorrhage in 305 nervosa 850 - anaemia in . . . . 27, 37 459 ulceration of 629 risks and fallacies of . . 621 - cachexia from 114, 459, 461, 575 ureter obstructed by . . 311 - - in tuberculous peritom'tis 691 - causing portal obstruction, urethra obstructed by . . 514 Calomel, cure of indicanuria by 821 ascites with 59 urethral passage of faeces in 264 - polyuria after 582 - diazo-reaction in . . 198 vaginal detection of 512 Calves, Jacquet's erythema of 446 earache from 230 varieties . . . . 306 630 - seborrha?ic dermatitis of . . 447 - enlarged liver from.. 55 villus-covered . . 513, 630 CAMIVIIDGE'S PANCREATIC - eosinophilia in some cases of 249 - of breast 421 REACTION.. 115, 117 - fatty heart in 241 absence of anfemia with . . 37 in affections of pancreas 486 - felt in epigastrium . . 723 - - accidental discovery in first in carcinoma of liver 60, 690 - kyphosis JErom 182 instance in most cases 745 of pancreas . . 59 , 60 - leucocytosis in 400 atre incidence of . . 745 pancreatic cysts 725 - loss of" weight from. . 817 atrophic . . 745 pancreatitis 135, 280, ."64 - oedema of legs in . . 459, 461 axillary glands in 421 745 Campbell, Harr^', re flusliing 268 - prolonged pyrexia due to . . 609 bloody discharge from Camphor, eosinophilia from . . 248 - pyrexia from 617 nipple in 202 - priapism caused by 586 - sallow pigmentation of skin cachexia in advanced . . 745 - reducing body in m-ine due to 290 in cachexia of 575 diagnosis from cyst of Canaliculi, lachrymal, conge- - secondary, spontaneous frac- breast . . 744 nital absence of . . 250 ture from 269 fibro-adenoma. . 744, 745 obstructed, epiphora from 250 - simulated hj chancre of vulva 769 mastitis . . 743, 745 Canal of Xuck, hydrocele of (see rhinoscleroma 805 tuberculous abscess . . 744 Hydrocele of Canal of Nuck) tuberculous ulcer 814 early fixation of , . 743, 745 874 CARCINOMA OF BREAST— CARCINOMA OF KIDNEY Carcinoma nf breast, contd. Carcinoma of colon, conld. Carcinoma of diiodenam, cotitd. en cuirasse 802 diagnosis from renal tu- bile-duct obstruction from 366 fixation of tumour in . . 745 mour . . 303 copious vomiting from . . 725 flat hand in palpating . . 745 of spastic constipation diagnosis from carcinoma fungating througti skin . . 745 from . . 145 of pancreas . . 266, 725 gangrene of liand from . . 287 diarrhoea in 146, 196, 393 distended gall-bladder - - glands in axilla with 742 disorders of defaecatiop in 501 from 725 importance of early dia- dyschezia from . . ; . 150 enlarged supraclavicular gnosis in 745 enemata in diagnosis of. 735 gland in 421 indefinite outline in 745 enlarged mesenteric and fatty stools in . . 256 invading lung 322 retroperitoneal glands in 422 gastrectasis from 725 large hard tumour in . . 745 examination under anaes- hffimatemesis from 725 malignant peritonitis from 718 thetic in suspicious jaundice from 362, 366 725 mammary swelling due to 745 cases . . 501 loss of weight from 725 in married women 745 explosive diarrhcea in . . 348 secondary in liver 279 mobility of tumour in very faBcal distention of csecum simulating bile-duct car- early stages 745 in 394 cinoma 725 pseudo-elephantiasis fol- great abdominal disten- enlarged gall-bladder. . 280 lowing operation for . . 456 tion from 152 gastric carcinoma 725 puckering the skin over 743 ,745 hepatic flexure afliected bv portal fissure carcinoma 725 retraction of nipple in . . 745 500. 723 subphrenic abscess from. . 578 secondary deposits in bones intestinal distention from 367 suppurative cholangitis 182, 269,564, 757,782 786 obstruction from 92, 151, from 725 liver . . 743 152, 393, 500, 501, 645, 731 735 swelling in epigastric and thorax 743 jaundice in . . 362 366 umbilical areas from. . 725 sex incidence of . . 745 laparotomy in diagnosis of visible gastric peristalsis stony hardness of 743 ,745 501, 735 from 725 suppuration with 744 loss of weight from 147 - of externa! auditory meatus 469 supraclavicular glands 421 743 mobility of 393 similarity to rodent swelling not sharply definec 745 movement with respiration 406 ulcer 469 - of bronchus .. 322, 324 mucus in stools in 150, 152, - Of face, affection of lym- - - fibroid lung and bronchi- 393, 443, 690 736 phatic glands from ' . . 808 ectasis from . . 324 pain with 153 — - diagnosis from lupus vul- - of bundle of His .. 98 in left iliac fossa in 501 garis 449 - of caecum, blood per anum hypochondrium from 499 ,500 syphilitic ulcer 449 in 736 umbilical region in . . 524 pain from 808 constipation from 729 perinephric infiltration in 393 - Of fauces . . 420, 670, 673 fewness of symptoms with 736 peritonitis from . . 645 enlarged submaxillary lym- intestinal obstruction from 736 pneumoperitoneum due to 711 phatic glands in 420 involvement of bladder by 632 pus in stools from 601 - Of eyelids 419 laparotomy in diagnosis of 736 pyuria from . . 624, 632 - of fingers 266 loss of weight from 736 rectal examination in . . 501 - of gall-bladder 421 pain in the right iliac fossa resonance between liver biliary colic in . . 279 from 729 and tumour . . 406 catch in breath on deep pyrexia from 729 over tumour in 393 inspiration during pres- swellmg in right iliac sand with 653 sure over gall-bladder in 409 fossa from 736 secondary in liver 279 cholangitis in 369 tumour of right iliac fossa 152 sense of rectal fullness in 150 diagnosis from enlarge- urethral passage of faeces sigmoid affected by 731 735 ment of gall-bladder . . 279 from 264 sigmoidoscope in detecting enlarged supraclavicular vomiting and constipa- 147, 501, 735 glands in .. 279, 421 tion from 729 simulated by diverticulitis gall-stones in . . 278, 279 - of Cauda equina, muscular 141, 152 jaundice in 279 atrophy in 74 local inflammatory lesions727 nodular outline in 270 - of cervix uteri Csee Carci- omental tumour of pain in the right hypo- noma of Uterus) chronic peritonitis . . 472 chondrium in. . 499 - Of cheek, enlarged glands in 419 spastic constipation . . 145 pyrexia in 279 - " chimney-sweep's " 607 tuberculous peritonitis 724 rapid enlargement in . . 279 - of clitoris, enlargement of simulating enlarged liver 406 rectal shelf in 638 inguinal glands in 423 spleen 729 secondary deposits in left - of colon, abdominal swelUng movable kidney 727 supraclavicular gland 278 with . . 91, 367, 499, 524 tuberculous infiltration 146 in liver 278 absence of palpable lump spastic constipation with 145 tenderness over gall-blad- in many cases 501 splenic flexure affected bv der in . . 499 tumour with . . 152 499, 690 - of gum 419 - - aching pain in loin in . . 393 strictiire due to (Fiff. 38) 146 bleeding gums in 86, 88 adhesion to liver in 367 subcostal position of . . 393 - of jaw, connection with age incidence of 146, 150 subphrenic abscess from 578 decayed tooth . . 749 albuminuria from invasion sweUing in umbilical microscopic examination of kidney by . . 393 region in 524 in diagnosis of 749 anfemia from 147 tenesmus due to 731 origin as an ulcer on gum 749 ascites with . . 59, 366 transverse colon affected - of kidney .. .. 395, 421 bile-duct obstruction from 367 by 406 aching pain in loin in . . 395 bladder invaded by 624, G32 tumour with 91, 146, 147, Clieyne-Stokes respira- blood per anum in 91, 147, 394, 499 tion in . . 124 150, 152, 367, 393, 731 vesico-colic fistula from. . 146 diagnosis fromrenalcalculus395 cachexia due to , . 731 visible peristalsis with 91, 147 tuberculo=5is 395 colic from . . 91, 147 vomiting with . . 153, 367 early metastases in 395 colloid degeneration in . . 735 weakness and wasting with 91 enlarged supraclavicular common sites of . . 147 - en cuirasse, secondary to glands in 421 communication with renal breast cancer 802 extreme malignancy of . . 395 pelvis . . 577 - Of duodenum 421 liaematuria in ..304, 307, 395 - - constipation with 91, 367 anaemia from 725 increased haematuria after and diarrhoea in 146 ascites with 59 movement in . . 305 CARCINOMA OF KIDNEY— CARCINOMA OF RECTUM 875 826 825 395 395 826 395 395 674 673 226 325 674 466 670 710 226 Carcinoma of kidney, could. inferior vena cava obstruc- tion from liability to spread into renal veins and inferior vena cava - - nodular enlargement of kidney in origin from adrenal rests polypus of heart due to. . rarity of . . renal colic in enlari^eraent in 391, 394, 395 symptoms of . . . . 307 - of large intestine Csee Carci- noma of Colon) - of labium majus .. .. 423 - of larynx 420 cyanosis from . . . . 185 diagnosis from syphilitic laryngitis tuberciilous laryngitis dysphagia from . . " ulceration unilateral in. . haemoptysis in . . 318, 325 microscopic examination in diagnosis of oedema of larynx in sore throat from stridor from - - ulceration of, described. unilateraloccurrenceof 325, 673 - of leg 812 - of lip . . . . 403, 419 - of liver . . . . 41, 58, 603 absence of symptoms in 50 per cent of cases .. 412 age incidence of . . . . 412 ascites in . . 55, 60, 279, 413 albumosuria in . . . . 20 angioma simulating . . 414 from carcinoma of breast 743 colon gall-bladder oesophagus rectum . . stomach . . 351, 691 common sites of primary growth . . commonest liver tumour compression of lung by . . death in coma in. . diagnosis from cirrhosis 409, 410, 413, gumma hydatid disease 413, impacted gall-stone . . syphilis of liver 411, enlargement of the liver often great and rapid in extreme wasting in frequent absence of sym- ptoms of primary disease 412 impalpability of nodules 412 general account of . . 368 gradual exhaustion in . . 413 great enlargement of liver in 279 green jaundice character- istic of . . 368, hard irregular edge of liver nodules on liver in hardness of liver in jaundice in 60, 279, 362, 366, 368, 412, 413 leucocytosis in . . . . 413 liver enlarged in 338, 363, 368 movement with respiration 412 - - nocturnal rise of tempera- ture in 362 occasional semi-fluctuant feeling from softening in 412 pain in the epigastrium in 486 hepatic region in about half the cases . . 412 690 278 223 636 279 412 667 413 370 415 413 413 412 413 413 412 412 279 Carcinoma of liver, conld. right hypochondrium in 499 shoulder in . . . . 412 primary, extreme rarity of 413 difficulty of diagnosis from secondary . . 413 growth in portal area in 90 per cent . . 412 rapid course of . . 413 symptoms similar to those of secondary 413 progressive wasting and weakness in . . . . 368 pyrexia in 362, 618, 623 rub from peritonitis over 412 sense of dragging in right hypochondrium . . 412 simulating large gall- bladder . . . . 278 skin dry and shrivelled in 413 skodaic resonance due to 667 sudden enlargement from haemorrhage into 409, 412 umbilication of nodules in 279, 3G8, 409, 412 urinary changes in . . 413 - Of lung, hasmoptysis from . 227 secondary . . . . 313 - mammrc (see Carcinoma of Breast) - melanotic . . . . . . 802 - of nose . . . . 204, 420 epistaxis from . . . . 250 - of OBSOphagus afEecttng lung 322 diagnosis from aortic aneurysm . . . . 296 dysphagia from 222, 484 enlarged cervical glands in 223, 296 the first sign in . . 421 erosion of aorta by . . 295 gangrene of lung in . . 288 iiEematemesis in.. 294, 295 haemoptysis from . . 318 invasion of bronchus by 318 laryngeal paralysis in 296, 538 obstruction to trachea by 710 opening into pericardium 711 pain in . . . . . . 296 paralysis of vocal cord from 538 pneumothorax from . . 577 progressive dysphagia in 295 emaciation in. . . . 484 rapid wasting in. . . . 295 right supraclavicular gland enlarged in . . . . 421 - - secondary in liver . . 223 simulated by gastric car- cinoma.. .. .. 299 stridor from . . . . 710 a;-rays in diagnosis of, . . 296 - of ovary,, enlarged supra- clavicular glands in . . 421 peritonitis with . . . . 57 secondary deposits in ribs 776 simulating sciatica . . 74 - of palate . . . . 420, 640 - palpable in inguinal region 731 - of pancreas 421 absence of cholangitis with 725 stercobilm in fisces with 116 behaviour of faecal fat in 116 Cammidge's reaction with 59, 60, 116, 690 diagnosis from duodenal carcinoma . . 266, 725 pancreatitis . . . . 265 epigastric pain with . . 486 tumour from . .366, 500, 724 fatty stools with 59, 364, 365 gall-bladder enlargement with 59, 265, 280, 363, 366, 500, 690 Carcinoma of pancreas, contd. glycosuria with . . 59, 360 inflation of stomach in diagnosis . . 39, 366 jaundice due to 280, 362, 363, 366, 500, 690, 724, 725 occult blood in faeces in . . 117 pain in right hypochon- drium in . . . . 500 in left hypochondrium 726 pancreatitis secondary to 116 peritonitis with . . . . 57 portal glands affected in 366 position and characters of 366 secondary in liver 60, 279 supraclavicular glands en- larged in . . . . 421 transmitted pulsation in 59 wasting, anaemia and jaundice with . . 724 - of penis .. 423, 677, 803 age incidence of.. 676, 677 deposits in femoral glands 734 description of . . . . 676 diagnosis from chancre 676, 677 gumma . . . . 677 inguinal glands enlarged hi 423, 676, 677 liability to bleed . . 677 microscopic diagnosis of 676, 677 obscured by phimosis, slitting up of prepuce in diagnosi'i of . . 670 occurrence on site of previous ulceration . . 677 pain due to . . . . 516 -t - site of origin of . . . . 676 sore due to . . . . 674 - Of perineum 423, 677, 678 development from scar. . 678 direct extension from anal or vulval growth 678 inguinal glands enlarged from . . . . 423, 678 haemorhage from . . 678 microscopic diagnosis of 678 ulcerated . . . . . . 678 - of peritoneum, ascites in . . 57 colloid . . . . . . 57 - Of pharynx, enlarged sub- maxillary lymphatic glands in . . . . . . 420 enlargement of cervical glands in . . . . 420 sore throat in . . . . 670 - of pleura, bloody effusion in 118 - of prepuce 423 - of prostate 307 characters of 441, 512 enlarged pelvic glands in 307 haematuria in . . 304, 311 infiltration of urethral • mucous membrane in 512 micturition frequent with 458 nodulation and fixity of 307 pain in penis during mic- turition in . . 511, 512 - - - perineum in . , . . 516 primary . . . . . . 307 rectal examination in diag- nosis of . . 512, 638 relative frequency of . . 512 secondary deposits in cranial bones from . . 783 ribs . . . . . . 776 vertebrae . . . . 786 similar in many ways to adenoma . . . . 512 - of rectum .. . . 44, 473 absence of satisfaction after stool in . . . . 636 age incidence of . . . . 636 bearing-down pain in . . 473 876 CARCINOMA OF RECTUM— CARCINOMA OF THYROID GLAND Carcinoma of rectum, contd. Carcinoma, contd. Carcinoma of stomach, contd. bladder infiltrated by - Of splenic flexure (and see movement with respiration 406 313, 624, 632 Carcinoma of Colon) multiple serositis in 123 cachexia from . . 93 absence of definite tumour - - nausea, vomiting, and characters of 636 in many cases of 690 pain in . . 351 constipation due to 147, 636 alternating constipation early symptoms in 299 diagnosis from polypus and diarrhoea in 690 obstructing oesophagus 223 C35, 636 blood and mucus per portal vein 692 diarrhoea in 636 rectum in . . 690 occult blood in vomit in 846 dyscliezia from . . 150 diagnosis of enlarged origin from simple ulcer 351,713 enlarged supraclavicular spben from. . 690 Oppler-Boas bacilli in glands in 421 intestinal obstruction stomach in explosive diarrhosa in . . 636 from . . 690 351, 353, 355, 845 846 fsecal urethral discharge in local perforation of . . 690 pain aggravated by food in 264, 313 633 growth usually annular 690 485 691 haematuria in . . 305, 313 resonance of tumour in 690 in epigastrium in 484 485 hiemorrhage in . . 92 636 secondary deposits in an early symptom in 299 incontinence of fsces in. . 374 left supraclavicular left hypochondrium in 499 infection of inguinal, pel- glands in 690 and tenderness in the vic, or lumbar glands in 636 in liver in 690 back from . . 789 with internal piles 636 tumour in left hypo- umbilical region in . . 524 jaundice first symptom m. 363 chondrium in 690 palpable in left hypo- malignant portal glands in 366 - Of stomach, abdominal chondrium 726 microscope in diagnosis of 636 tumour from peritonitis with . . 57 micturition frequent in . . 438 299. 351, 485, 713, 723 physical signs of 690 — - mucus in the stools in . . 636 acetonuria in 4 pneumothorax from 577, 578 pain in penis after mic- age incidence of 299, 713 ptyalism in 591 turition in 513 aneemia in 27, 37, 351, 691 pyloric obstruction from 712 rectum and bottom of anorexia in . . 299, 351 pyrexia with 299 back in 636 nervosa confused with 588 rectal shelf in 638 peritonitis with . . 57 appetite in diminished . . 50 i-etroperitoneal glands pyuria from . . 624, 663 ascites with . . 59 366 enlarged in 422 rapid emaciation in 636 band of resonance between saromae in vomit in (Fig. rectal examination in . . 636 liver and tumour 406 92, p. 267) .. 691 846 sciatica simulated by . . 74 bile-duct obstruction secondary cervical gland secondary deposits in liver from 366 from 223 from . . . . 60, 279, 636 blood count in . . 352 deposits at umbilicus simulating acute Bright's in vomit in 691 from 351, 526, 716 718 disease . . 9 cachexia in 299 growths in bone in . . 269 situation of 636 cardiac end, mterscapular ia liver 279, 351, 691 stricture of rectum from 636 pain in. . 474 lung . . 322 symptoms of 93 tenderness of lower simulated by duodenal talipes from . . 131, 132 dorsal spines in . . 474 carcinoma 725 ulceration of rectum due to 635 chemical analysis in 299 dyspepsia 299 vesical irritability in 313 " coffee-grounds " vomit in 299 enlarged spleen 690 villous, hfemorrhage in . . 93 copious vomiting in 737 epithelioma of oesopha- - Of ribs 776 diagnosis from cirrhosis gus 299 - of scrotum . . . . 423, 679 of liver 301 gastritis 299 absence of testicular en- enlarged gall-bladder . . 280 phantom tumour 721 largement with 681 spleen 690, 726 729 simulating enlarged liver 406 characters of ulcer 679, 681 gastric ulcer . . 846 omental tumour of in coal miners . . 679 from dyspepsia 848 chronic peritonitis . . 472 commencement as small pernicious anaemia . . 351 subphrenic abscess from nodule or wart 679 spleno-meduUary leuk- 577, 578 diagnosis from hernia testis 681 femia 691 swelling in right iliac enlarged glands in groui in diffuse type . . 270, 299 fossa due to . . 737 423, 679, 765 dilatation of stomach in umbilical region in . . 524 extension to testicles 679 299, 351, 712 846 vomiting in gas-workers 679 distaste for meat in 50 351, 485, 691, 737, 843 occupation incidence of 679,765 dysphagia from . . 222 351 nature and time of . . 299 simulated by suppurating epigastric tumour from 723 wasting in . . 299, 737 sebaceous cyst 681 gastroscojie in . . 299 - Of suprarenal, ascites with 59 - - in sweeps 803 glands above left clavicle diagnosis from enlarged - of sigmoid colon (and see in . . 351, 421 691 gall-bladder' . . 280 Carcinoma of Colon) blood great pain due to 767 - Of testis . . . . 421, 520 per anum in 731 hfematemesis in 294, 298, 351 age incidence of . . 766 cachexia from . . 731 HCl absejit from vomit in 485 commoner than sarcoma 766 intpstinal obstruction diminished in dissemination via lym- from.. 501, 731 735 351, 485, 691, 845, 846 phatics . . 766 involvement of bladder 632 hysterical vomiting con- duration of 766 sigmoidoscopy in 501 fused with 508 lumbar glands infected in 766 diagnosis of . . 735 " mdigestion " in 351 malignant peritonitis urethral passage of jaundice from . . 362 366 from 718 fpeces from . . 264 lactic acid in gastric mesenteric and retroperi- - of the sl 47 empyema of antrum of paraplegia due to arising from fibromyoma 434 Higlimore from 204, 205 131, 181, 557, 561 bladder infiltrated by enlarged glands from 419, 708 Pott's curvature in 564 313, 624, 632 submaxillary lymphatic psoas abscess from 632, 739 785 diagnosis from sloughing glands from . . 419 reflexes in 558 fibroid . . 759 fibrous epulis in associa- relative frequency of . . 385 dystocia from 229 tion with 748 rigidity over painful area foul discharge in 211, 435 foul taste due to . . 99, 774 in 477 frequent micturition with 438 headache irom . . 327 of the spine from 474, 785 friable hardness of 435 loss of weight due to 848 sacralgia in 510 hsematuria in . . 305, 313 mercurialism from 86 signs of tuberculosis in . . 564 histological diagnosis . . 434 neuralgia from . . 330, 497 simulated by aneurysm 786 metrorrhagia from 433 435 trigeminal from 495 indigestion 351 metrostaxis from 436 pain in the lower jaw in malignant disease of micturition frequent from 438 501, 502 vertebrrp 786 pain in inguinal regions in 510 tooth in 496 plirenic neuralgia 479 ovarian regions in 510 the upper jaw from . . 502 rickets . . 785 radiating down legs in 510 ptyalism due to . . 591 simulating torticollis 167 pelvic swelling due to . . 757 referred pain in . . 496 spontaneous fracture in 270 pressure on rectum of, segmental areas in stooping gait in . . 181 causing dyschezia 150 face in 497 sudden, paraplegia in . . 270 pyelitis from 625 relation to carcinoma of swelling in right iliac fossa pyonephrosis from 626 jaw 749 due to . . 737 pyuria from . . 624, 632 retracted gums from 641 over spine from 194, 474 sacralgia in 510 stiff neck from . . 708 tenderness in spine in sciatica simulated by . . 74 stomatitis from . . 815 181, 474, 784, 785 simulating prolapse 587 - - swelling of the face from 746 transverse myelitis from 564 S/S CARIES OF SPIXE— CEREBRAL VOMITIXG. Caries of spine, contd. tuberculous, relative fre- quency of . . . . 3S5 j--rays m diagnosis of ISl, 47i - spontaueous fracture froni 269 - swelling of the face from . . 746 - of temporal bone, earache from . . . . . . 230 Caruia bases, uric acid from . . SI 7 Carotid aneurysm (see Aneu- rysm, Carotid) - artery, internal, erosion from chronic tympanic suppur- ation 4GS - pulsation in exophthalmic goitre . . . . . . 244 - pulses, unequal, with aortic aneurysm.. .. .. 236 Carpal joints, hypertrophic osteo-arthropathy in . . 390 Carpo-pedal spasm (see Spasm, Carpo-pedal) Carriers, typhoid, infected bile in 281 Cartilags, blackening in ochron- osis . . . . 575, 822 - itt embryoma of kidney . . 393 - erosion of (see Erosion of Cartilage) CarunculiB myrtiformes, red and swollen in gonorrhoea 769 Caruncle, lu-ethral, dy^par- eunia from . . . . 221 - vulval swelling due to . . 768 Castellani, re dhobie's itch . . 275 Castor oil, taste in mouth from 774 Castration, obesity after, 453, 454 Casts, intestinal, simulating tapeworm (Tig. 123) 444, 568 - renal, in acute nephritis 12, 311 albuminuria with . . 8 without . . 15, 16 in arteriosclerosis . . 15 bacilluria . . . . . . 615 and ceUs, test for in oedema 457 with chyluria . . . . 126 hfemoglobinuria . . , . 314 high blood-pressure con- ditions . . . . . . 526 importance in diagnosis of cause of albuminuria . . 61 with infarction of kidney 314 in kidney lesions causing hEematiuia . . . . 306 lardaceous . . . . 10 mitral regurgitation due to Bright's disease . . 240 nephritis" . . . . 466, 646 chronic 303 of old people . . 14 parenchymatous . . 454 with pleitritic eflfnsion . . 122 in polyuria with albu- minuria . . . . 584 pyelitis and pyelonephritis 628 uraemia . . . . 329, 464 in urine from inferior vena cava tlirombosis . . 825 simuJated by mucus . . 444 varieties of (Plate I) . . 7 - in sputum . . . . . . 704 - vaginal . . . . 211, 220 Catalepsy 140 - dementia with . . . . 651 - melancholia nith . . . . 651 - pupils in . . . . . . 594 - retraction of the head in . . 641 - risus sardonicus in. . . . 651 - trismus in . . . . . . 801 Cataract, anterior polar from corneal ulceration . . 806 from ophthalmia neo- natorum . . . . 836 - blindness never total from 839 - congenital, nystagmus in. . 453 Cataract, contd. - extraction, blue vision from 840 erythropsia from . . . . 840 - monocular diplopia in . . 198 Catarrti of bile-ducts (see Bile- ductiij - buccal and pharyngeal, cheilitis glandularis from 403 - duodenal, jaundice from . . 361 pancreatitis secondary to 116 - gastric (see Gastritis) - nasal, epistaxis in . . . . 251 epiphora in . . . . 250 - of pancreas (see Pancreatitis) - small bowel, chronic diar- rhoea from . . . . 197 - swelling of eyes and face caused by . . . . 459 Catarrhal jaundice (see Jaim^- dice. Catarrhal) - laryngitis . . . . . . 465 Catastrophe, abdominal, causes 472 Catching cold, UabiUty to in rickets . ^ . . . . 171 Catheter broken ofE in urethra 210 - coude, in prostatic enlarge- ment . . . . 440, 441 - in diagnosing cause of pyuria 624 distended bladder ' . . 730 neuroses of bladder . . 443 urethral stricture . . 439 - retained . . . . . . 206 Catheterization, acute epidi- dymo- orchitis after 517, 518 - anuria from . . . . 49 - in distention, care needed in 440 - rieors after . . . . . . 647 Cattle, anthrax from . . . . 603 Cauda equina, affections of, diagnosis from sciatica . . 487 incontinence of fieces from 348 taUpes in . . . . . . 131 tumour on, mode of onset of symptoms . . . . 563 muscular atrophy in . . 74 paraplegia from . . 561 Caustic soda test for elastic iibres 701 Cauterization in hypopyon ulcer 807 Cautley's anosteoplasia . . 213 Cavernitis, gouty . . . . 516 - due to hsematoma . . . . 516 - pain in the penis in . . . . 5] 6 - syphilitic . . . . . . 516 Cavernous sinus, carotid aneur- ysm communicating with 764 thrombosis (see Throm- bosis of Cavernous Sinus) Cayenne pepper deposit in the urine . . . . . . 816 'Cellist's cramp . . . . 177 Cellulitis, acutely inflamed lymphatics in . . . . 455 - asymmetrical oedema from 455 - bacteriology in diagnosis . . 459 - of calf muscles, tahpes from 132 - diagnosis from carbuncle . . 603 - gout simulating . . . . 455 - local infection causing . . 455 - lymphatic obstruction from 456 - of neck from actinomycosis 748 - oedema of face, neck, and arms from . . 459, 461 - orbital, cavernous sinus thrombosis due to 253, 254 - of pelvis (see Pelvis Cellulitis of) Central necrosis of bone (see Bones, !N"ecrosis of) - retinal artery, emboUsm of, ophthalmoscopic appear- ance of (Plate VHP) . . 463 vein, thrombosis of, oph- thalmoscopic appear- ance of (Plate VIII) 462, 839 Cephalalgia (see Headache) Cerebellar artery thrombosis, ataxy in . . . . . . 68 - articulation . . . . 69 - ataxia of children, acute . . 68, 69 intention tremor in . . 800 - hfemorrhage, vomiting with 847 - lesions, ataxy in . . . . 68 deviation of eyes in . . 69 nystagmus with . . . . 69 occipital headache in . . 326 reeling gait in . . 69, 277 tremor in . . . . 795 vertigo with . . 69, 827 - peduncle, superior, intention tremor from lesion of . . 800 Cerebellum, abscess of (see Abscess, Cerebellar) - tumour of, ataxy from 68, 643 Babinski's sign in . . 82 bladder and rectal troubles 565 exaggeration of tendon reflexes from . . . . 643 gait in . . . . 565, 643 headache with . . 565, 651 head retraction from 641, 643 hypothermia in . . . . 346 knee-jerks increased in. . 565 nystagmus with 453, 643 optic atrophy and neuritis from . . . . . . 643 paraplegia from . . . . 562 pseudo-nystagmus in . . 452 rectal trouble in. . . . 565 vertigo due to . . . . 828 vomiting with . . 565, 651 Cerebral abscess (see Abscess, Cerebral) - anaemia, arteriosclerosis pre- venting . . . . . . 359 - aneurysm (see Aneurysm, Cerebral) - congestion, epistaxis in . . 251 - cysts, headache in. . . . 327 -diplegia .. ..154,535,686 - diseases, hyperpyrexia in. . 622 vomiting in . . 328 - embolism (see Embolism, Cerebral) - gumma, headache in . . 327 - haemorrhage (see Hsemor- rhage, Cerebral) - hemisphere, left, with speech centres, diagram of (Fig. 185) . . . . 683 - inflammation, spastic par- alysis of upper extremity from . . . . . . 547 - injuries, ataxy in.. .. 68 grave significance of hyperpyrexia in . . 622 glycosuria after . . . . 292 hemiplegia from.. 337, 338 hiccough in . . . . 343 - monoplegia, talipes in . . 131 - softening, laryugeai paralysis with . . . . . . 539 bilateral, apoplexy with hemiplegia from . . 563 sensory disorders in . . 563 or haemorrhage, para- plegia from . . . . 562 hyperpyrexia in. . . . 34^1 increase of deep reflexes with .796 paralvsis agitans simu- lated by . . . . 796 prosressive mental failure with 796 sphincter trouble with . . 796 - syphilis (see Syphilis, Cerebral) - thrombosis (see Thrombosis, Cerebral) - vomiting (see Vomiting, Cerebral) CEREBRITIS—CHEIROPOMPHOL YX 879 CerebritLs, convulsions in 172 Cerebrum, tumour of, conld. Chancre, conld Cerebrospinal fluid 338 increased intracranial - characters of . . 675, 676 in acute meningitis 563 643 pressure in 686 - common site 675 albumin in, in intracranial insomnia in . . 356, 358 - development from soft sore inflammatory conditions 339 loss of knee-jtrk in 398 676, 738 in intrn^ipinal inflam- taste due to . . 774 - diagnosis from anthrax 603 matory conditions . . 339 lymphocytosis in cerebro- - digital . . . . 266, 422 bacteriological examina- spinal fluid in . . 339 - enlargement of neighbouring tion of.. .. 339 340 nerve-deafness from 190 glands 417, 419, 675,676,678,747 in cerebrospinal fever 598 occasional latency of . . 341 - of eyelid 419 not coloured in jaundice 361 optic neuritis in 98, 292, 341, - on face, less indurated than cytological examination 350, 477, 547, 565, 686, 782 on penis . . 746 of 330 paralyses in markedsurrounding oedema 747 from ear . . 468 340, 341, 350, 547, 782 -incubation period.. 675, 676 in encephalitis, and supe- pyre.xia in 341 - of lip (Fiff. 10) 86, 403, 746 rior longitudinal throm- signs of . . . . 173, 547 - obscured by phimosis, dia- bosis of meningitis . . 55S simulated by arterioscler- gnosis of . . . . 675, 676 general j)aralysis of insane osis 328 - oedema of labium minus 139, 269 simulating hysteria 798 from 770 lymphocytosis in 339 slow pulse in 782 - penile sore due to . . 674 globulin, albumin, and small pupil with retention - on perineum 678 nucleo-proteid in 643 of reflexes in . . 594 - scrotum . . . . 681, 765 - - hypertension of, in menin- subjective smell sensations - simulated by moUuscum gitis .. 338, 339, 643 from 669 contaglosum 805 lymphocytes in (see Lym- temporary glycosuria from 292 epithelioma of vulva . . 769 phocytes; tender scalp in . . 781, 782 penis . . . . 676, 677 meningococci in. . 340, 643 tinnitus from 794 gumma . . 677 - - normal and abnormal tremor in 795 herpes genitalis . . 830 characters of . . 338, 643 trigeminal neuralgia in . . 496 soft sore . . 675, 676 from nose . . 138, 203 of uncinate gyrus, anos- - spirochaeta pallida in {Plate palsy of leg from syphilitij mia from 669 XII, Fig. J, p. 696) meningitis 544 unilateral convulsions in 170 675, 678, 747 769 polymorphonuclear cells exophthalmos due to - of tongue, discussion of . . 813 in acute meningitis . . 643 tubercles 254, 255 - tonsil 672 pyrocatechin in . . 203 vertigo from . . 341, 828 - urethra 209 reducing substances in 203 643 vomiting in, 292, 336, 341, 477, - vulval swelling from 768 sugar, urea, proteids. 686, 782, 844 847 - waiting for secondaries in choline in 339 unilateral headache in . . 326 doubtful cases of 675 trace of globulin in normal 643 Cerumen 467 - AVassermann's reaction in trypanosomes in, in - creaking noises in ear from 793 diagnosis of 422,675,678 747 sleeping sickness 34 - deafness from . . 188, 190 Chancroids (see Soft Sores; . . 675 tubercle bacilli in 643 - earache from 230 - simulated by herpes genitalis 8.30 turbid in meningitis 338 Cervical adenitis (see Lym- Chapping of lips 403 yellow in meningitis 338 phatic Glands, Cervical) Charcoal, coloration of stools by 89 - meningitis (see ileningitis, - caries (see Caries of Spine, - test in constipation 140 Cerebrospinal) Cervical) Charcot, dissociative anaesthesia Cerebrum, abscess of (see - glands, enlarged (see Lym- of 285 Abscess, Cerebral) phatic Glands, Cervical) - re hepatic intermittent fever 6-50 - contracture from lesions of - plexus, interference with by — re spasmogenic zones 777 cortex 162 thyroid gland tumour . . 792 Charcot's amyotrophic lateral - paraplegia from congenital - rib (see Rib, Cervical) sclerosis, fibrillary con- defect of cortex . . 558 - sympatlietic, interference tractions In . . 158, 159 - tumour of, anosmia from . . 669 ^\ith by aneurysm 222 - joiQt (Fig. 110) . . 387 aphasia in . . G85 686 paralysis (see Paralysis of in locomotor ataxy 562 aura in 80 Cervical Sympathetic) syringomyelia 285, 563 bradycardia from 98 Cervico-brachial plexus and painless character of 388 Cheyne-Stokes respiration its branches (Fig. 145) . . 553 CHARCOT-LEYDEN CRYS- from 125 Cervix uteri, carcinoma of (see TALS (Fig. 26) 117, 118 coma in . . . . 136, 137 Carcinoma of Uterus) In asthma 179 convulsions in .. 1G9, 172 closure of, sterility due to 706 Charwomen, acroparaesthesia in 493 not common in 173 congenital elongation of 586 Cheeks, actinomycosis of 87 diabetes insipidus from. . 585- erosion of, metrorrhagia - affection of by acne ^Tilgaris 531 iliagnosis from abscess . . 623 from . . . . 433, 435 - coloured sweat of . . 714 satiumine encephalo- metrostaxis from 436 - dilated venules in alcoholism 368 pathy 139 sacralgia from. . .509 in cirrhosis of liver . . 410 - - " ebb and flow " of knee- gonococci in . . 211, 769 - epithelioma of 419 jerk in . . 399 herpes of . . 830 - flapping of, in facial paralysis 533 epileptic aura from 80 inflammation of . . 210 - myoma cutis of 805 frontal, alteration in long conical, causing dys- — new growths of 204 character due to 798 menorrhosa 219 - paralysis of one, with coma 137 inattention due to 798 normal secretion of 210 - swelling of, due to mercury 86 incoherence due to 798 polypus of, simulating - syphilitic ulcer of Inside of 813 loss of memory due to 798 prolapse of uterus 587 Cheilitis exfoliativa . . 403 unilateral tremor due to 798 simulating' prolapse while - glandularli . . 403 haemianopsia from 81, 335 fundus is in normal posi- Cheiropompholyx 266 hsemorrhage into 341 tion 587 - brlttleness of nails In 445 headache in 292, 327, 350, rigidity of, dystocia from 227 - buUse In .. 110, 111, 654, 832 477, 686, 847 Ceylon, oidium troplcale in . . 705 - crusts in . . . . 654, 832 hemiplegia from 138, 340 341 Champagne, explosive eructa- - distinction from eczema . . 832 hippus in 595 tion of gas from. . 639 pemphigus 832 hyperpyrexia in.. 344 - priapism caused by 586 - pruritus in . . 588 hypertension of cerebro- Chancre, appearance of secon- - relations to summer season 832 " spinal fluid in 338 daries 4 to 6 weeks after 676 - tender hands and feet from 654 hypothermia in . . 346 - balanitis with 676 - vesicles In . . . . 654, 832 88o CHEMICAL WORKERS, BULLM IN— CHLOROSIS Chemical workers, bullae in . . 110 Chilblains 253 CHILLS 64G Chest, acne affecting 531 604 - affecting fingers 266 - acute general pains in the - asymmetrical, from lung - association with menorrhagia Umbs in . . 503 affection . . 331 at puberty 430 - athetosis after 154 morement of in fibroid lung 324 - from cold 810 - in baciUuria 616 followed by scoliosis 180 - lupus erythematosus simulat- — influenza 699 vertebral column in 192 ing 656 - malaria 615 CHEST. BLOODY EFFUSION IN 118 - pruritus in . . 588 - myalgia due to 507 from new growtL in . . 322 Child, dystocia due to large . . 227 - pains in the limbs in 505 - bulging of, by aneurysm . . 235 Child-bearing, influence of - in relapsing fever . . 698 from big heart . . 232 age on 707 - tremor from 798 causes . . . . 193 ,194 Child-birth, constipation after 148 - in typhus fever 698 hydatid cyst of lirer 415 - infarction of lung after 322 Chimney-sweep's cancer 679 precordial, in adherent - infective peritonitis after.. 644 Chin, acne vulgaris of 531 pericardium . . 242 - thrombosis after 456 - circinate syphiloderm of . . 532 in aortic disease 233 Children (and see Infancy), - in cretinism . . 258 heart disease of chil- absence of redness of joint - effects of blow on ear on . . 467 dren . . . . 102 232 in pneumococcal arthritis in 375 - heavy acromegalic . . 263 mitral regurgitation . . 238 - adherent pericardium in . . 62 - rece(Ung in microcephaly . . 214 by cystic renal tumour. . 393 - appendicitis causing vague - reflex hiccough from 342 - cubical, in emphysema 186, 246 abdominal pains in 350 - sycosis vulgaris of . . 602 - deficient morement of, in - athetosis in . . 154 Chiii-drop in myasthenia (Fig. bronchiectasis 703 - Babin.ski"s sign in . . 82 83) .. .. .. 260 in pneumothorax 480, 577 - bacteriuria in . . 81 , 84 China, distoma pulmonale in 325 - deformities of, depression - causes of frequent micturi- - fUariasis in . . 33 of hver in . . 405 tion in 438 - paragonimus "Westermani in 705 shortness of breath in . . 101 insomnia in 357 Chloasma, macular .. 423 - enlargement of affected .side paraplegia in . . 556, 557 - pigmentation of the skin in 424 in pneumothorax 480 - Cheyne-Stokes' respiration - uterinum . . . . 114, 574 - general changes in the form of 191 normal in . . 124 - varieties and causes of 574 - injuries, haemoptysis ia 317, 320 - chorea as rheumatic mani- Chloral hydrate, coma due to - myoma cutis of 805 festation in 504 137 346 - Tiain in (see Pain in Chest) - cirrhosis of liver in. . 369 purpura from 596 - pityriasis rosea of . . 658 - colicky pains of 134 - pigmentation of skin from 423 - pruriso ferox of 531 - coma at onset of fevers in. . 646 - Cheyne-Stokes' respiration chest: PUS IN 119 - convulsions of, due to drugs 169 from 125 - syphilitic roseola on 675 with congenital heart diseasel69 - hypothermia from . . 346 - seborrhrpri 650 from laryngismus stridulus 466 - reducing body in urine from 290 CHEST. SEROUS EFFUSION otitis media 229 Chlorate of potash, methaemo- IN 120 rickets . . 169, 170, 466 globinasmia from 187 - smaU whitish scars on, after — cycUcal vomiting of 843 ptyalism due to . . 690 herpes zoster 479 - delirium from otitis media in 229 Chlorides in acute Bright's - tenderness in (see Tenderness - diacetic acid and acetone in disease 12 in Chest; urine of . . 843 - diminished in urine in pneu- - unilateral enlargement of, - enure-iis in . . 247 monia . . 186, 321 ,372 from empyema . . 192 - epistaxis in . . 251, 252 - in phosphorus poisoning . . 373 shrinldng ^^ith fibroid lung - excessive fatness of, from Chloroform, coma due to . . 137 193, 282, 246 hypernephroma . . 454 - headache from 328 after pleuritic effusion 193 - extensor plantar reflex in . . 557 - poisoning, delayed 4 from pneumothorax . . 193 - hyperpyrexia in 344 tetany in 178 - Taricose veins (see Veins, - incidence of heart failure in 62 - reducing body in urine due to 290 Taricose, Thoracic) - intussusception in, acute Chloroform-benzene method - wail, abscess of (see Abscess diarrhoea from . . 196 of measuring sp. gr. of of Chest WaU) - jaundice of . . 362 blood 580 retraction of from various - knee - jerks decreased in Chloroma .. .. 36 ,599 causes . . 194 general illness in . . 398 - anaemia in . . 44 tumour of 193 - leucocytes in 399 - enlarged lachrymal and wounds of, pneumothorax - loss of speech in (see also saUvary glands in 599 after . . . . 577, 578 Speech, AbnormaUties of) 682 - green colour of new-formed CHEYNE-STOKES' RESPIR- - lymphocytes in 29 tissue in . . 599 ATION (Fig. 28) 124, 125 128 - night terrors in 447 - lymphatic gland enlarge- in fatty heart . . 241 - otitis media in 229 ment in . . 599 tuberculous meningitis . . 174 - paraplegia from Friedreich's - lymphocytosis in cerebro- Chicken-pox, affecting chest 833 ataxy in . . 559 spinal fluid in 339 pharynx . . 670 due to idiocy . . 556 557 - negative blood changes in . . 599 - date of rash in S33 from muscular dvstrophies - occurrence in early life 599 - diagnosis from smaU-pox . . 834 560, 561 — purpura in . . . . 596, 599 - distribution of rash in S34 - perforation of acetabulum - relation to sarcoma 599 - eosinophilia after . . 248 in hip disease in . . 739 - slowly fatal covnse of 599 - gangrene in. . 282 - peripheral neuritis in, from - spontaneous fracture from 269 - occurrence of eruption on diphtheria 559 - swellings on bones in 599 mucous membranes 673 - pneumococcal arthritis in . . 375 Chlorosis 36 - papules in . . 833 - position of heart impulse in 330 - amenorrhcBa in . . 23, 41, 303 - parts affected by . . 833 - prolonged pyrexia from toxic - blood changes in . . 41 303 - simulating molluscum conta- absorrition (alimentary) in 618 - bruit de diable in neck in . . 333 giosum 805 in, often unexplainable 609 - cachexia in . . 115 pustular syphilide 833 - pulmonary systoUc bruit in - cardiac bruits in 41, 105, 303 333 strophulus 833 normal 105 - colour index in 26 - sore throat in . . 670, 673 - rarity of mitral stenosis in 62 - constipation in . . 41, 143 - systemic disturbance slight in 833 - .scurvy in . . 85 - displaced cardiac impulse . . 333 - vesicles and pustules in . . 833 - tabes in 489 - dyspncea in 303 - vesicular fluid within ilal- - tuberculous joints in 385 - epistaxis in . . 251 pighian cells in . . 829 - "Werdnig-Hoffmann muscu- - flusliing in . . 268 Chicory, oxaluria from 471 lar atrophy in 158 - greenish hue of sMn in 303 CHLOROSIS— CIRRHOSIS OF LIVER CIdorosis, contd. - hsematemesis in . . 294, 303 - cedeina of feet and legs in 41, 303, 459, 461 - palpitation in . . 303, 525 - predisposition to gastric ulcer in 303 - rest treatment in . . . . 41 - symptoms and etiology of. . 41 Chocolate, oxaluria from .. 471 Cholaemia in cirrliosis of liver 368 - delirium, convulsions, coma in 361 - headache in . . . . 328 - stupor in . . . . . . 361 Cholangitis, albumosuria in . . 20 - from carcinoma . . 369, 725 - enlarged gall-bladder from 651 liver ill 369 - from gall-stones . . 280, 369 - jaundice from 3G2, 369, 650, 651 - leucooytosis in . . . . 400 - multiple abscesses of liver from 369 - pain in tlie liver region from 650 the back from . . . . 789 - pleuritic effusion from . . 123 - pvrexia \\'ith . . . . 650 - rigors with . . 362, 369, 650 - septicaemia from . . . . C98 - tenderness of liver in . . 369 in the back from. . . 789 - urobUinuria in . . . . 116 Cholecystitis catch in the breath during deep inspir- ation in pressure over gall- bladder in . . . . 499 - clironic, hunger pain in 500 - diagnosis of indigestion from 350 - gall-bladder enlarged in 280, 723 - from gall-stones . . . . 280 - jaundice nith . . . . 650 - from new growtlis . . . . 280 - pain in the liver region from 650 - - right hypochondrium in 499 - pyrexia with . . 499, 650 - rigors with . . . . 648, 650 - simulated by phantom tumours . . . . . . 721 - tendeme&s over gall-bladder 499 Cholelithiasis (see Calculus, Biliary) Choleperitoneum, rarity of . . 718 Cholera, acute gastro-intestinal symptoms in . . . . 301 - albuminuria in . . . . 17 - anuria in . . . . . . 49 - Cheyne-Stokes respiration in 125 - coma in . . . . . . 136 - cramps after . . . . 179 - cyanosis in . . . . 184, 187 - diagnosis from tricliinosis . . 504 - gangrene in . . . . 282 - hsematemesis in . . 294, 301 - hyperpyrexia in . . . . 344 - indicanuria in . . . . 349 - inspissation of the blood in 187 - leucocytosis in . . . . 400 - maligna . . . . . . 184 - menorrhagia in . . . . 428 - polycythsemia in . . 579, 580 - purpura in . . . . . . 596 - pas in the stools in . . 601 - rice-water stools in . . 301 - rigors in . . . . . . 647 - severe diarrhcea in. . . . 579 - swelling of thyroid gland in 792 - uridrosis in . . . . . . 715 - vibrio in motions in . . 301 - wasting with . . . . 69 Cholesterin crystals in hydro- cele of epididymis (Fig. 94^ 765 in gall-bladder . . . . 281 Choletelin 360 Choline in cerebrospinal fluid 339 Choluria, general account of. . 819 Chondroma, commonly multiple 737, 755 - deformity due to . . - pain due to . . - of pelvis fixity of . . a;-rays in diagnosing - plialanges and metacarpals affected by (Fig. 195) . . - ulceration of skin over Chorda tympani, paralysis of loss of taste due to 774 CHORDEE 755 755 761 737 737 755 755 536 775 .. 125 - in acute urethritis ' 516, 675 Chorea, aortic disease after 233, 237 - arsenical neuritis in . . 77 - chronic degenerative 156, 157 - contractions of . . . . 159 - electrica, causing convul- .sions 169 Henoch's . . . . 157 clonic convulsions of. . 161 - endocarditis with 103, 236, 239 - habit spasm simulating . . 156 - hand-grip in .. ..548 - hemiplegia in . . . . 341 | - history of, in cerebral em- bolism 338 in mitral stenosis . . 320 - hysterical . . . . . . 157 - insaniens, hyperpyrexia in 344 - interference with speech in 156 - jerky respiration in . . 156 - knee-jerkin.. .. .. 399 - major, epidemic manifesta- tions of . . . . . . 157 - mitral disease after . . 240 stenosis witli . . . . 773 - night terrors in cliildren with 448 - in pregnancy . . . . 156 - relationsliip of acute rheuma- tism to . . 121, 156, 504, 671 - simulating cerebral lesion . . 341 - spastica . . . . . . 800 paralysis of arm in . . 548 - tongue movements in . . 548 - tremor in . . . . 795, 798 - valvular disease of heart from 233, 237, 240, 320, 526, 773 Choreiform contractions . . 155 in Friedreich's ataxy . . 560 infantile paralysis 155, 156 Little's disease . . . . 154 post and pre-hemiplegic 157 Chorion-epithelioma of uterus, metrorrhagia from 433, 434 histology in diagnosing 434, 436 from hydatidiform mole 434 metrostaxis from . . 436 pelvic swelling due to . . 757 relation to pregnancy . . 434 Chorionic vUli in uterine casts 220 Choroid, coloboma of, ophthal- moscopic appearance of (Flnlr VIT) .. .. 461 - tubercles of (Plate VIII, Fig. Tr,p.463) 341,463,563,699 with Cheyne-Stokes' res- piration . . . . 125 Choroiditis, syphUitic, ophthal- moscopic appearance of (Plate VII) .. . . 462 - amblyopia with nystagmus from 836 - macular, age incidence of . . 462 preceded by haemorrhages 462 Choroido-retinitis, constriction of field of vision in . . 838 - nyctalopia from . . . . 841 - ophthalmoscopic appear- ances (Plate VII, Fig. G) 838 - optic atrophy in . . . . 838 Chromidrosis due to the action of cocci . . . . . . 714 bacillus pyocyaneus . . 714 - blue, red, green, yellow, violet or black sweat with . . 714 - due to copper . . . . 714 - diagnosis of chloasma from 575 - due to iron . . . . . . 714 - nerve factor in . . . . 714 Chrysarobin, bullae from . . 110 - poisoning, diazo-reaction in 198 Chrysophanic acid, abnormal coloured urine from 819, 820 819 819 820 178 126 58 33 in rhubarb serma . . urine, test for . . Chvostek's sign in tetany Chylous ascites (see Ascites) CHYLURIA - with ascites - from filariasls Cider, explosive eructation of gas from . . . . . . 639 Cigarette-roller's cramp . . 177 Cigarette-rolling movements in paralysis agitans . . 796 Ciliary body, inflammation of (see Cyclitis) - muscle paresis after diphtlieria 224, G40 Cinnamon oU, leucocytosis from 400 Circumcision, death from . . 423 - by Jewish method, tubercu- lous infection in . . - priapism after Circumflex nerve, muscles supplied by paralysis of skin distribution of spinal roots derived from Cirrhosis of liver abdominal distention in absence of clay-coloured motions in of dilatation of gall- bladder in . . umbilication of irregu- larities in . . absorption of fat in acne rosacea in age incidence of. . albuminuria in . . albumosuria in . . alcoholism causing 300, 368, 599, 809 amenorrhoea in . . . . 23 anaemia in . . 40, 696 ascites in, 40, 51, 55, 59, 60, 301, 368, 410, 696, 82G diagnosis from tubercu- lous peritonitis . . 618 in Banti's disease 694, 696 bottle-nose in . . in bronzed diabetes caput medusae in cause of pyrexia in cholferaia in clubbed fingers in coma in . . congenital syphilis and contraction of fibrous tissue in . . . . 409 cramps in legs at nieht In 59, 300, 368 delirium in 359, 368, 410 diagnosis from carcinoma 409, 410, 413 of stomach. . . . 301 from enlarged liver due to obstruction of common duct . . 410 splenic anemia 42, 64, 411, 694, 696 syphilis of liver 410, 411 677 586 5-50 552 659 550 409 134 409 409 409 .. 409 59, 368 .. 410 16 .. 20 300 411, 575 51, 826 618 368 129, 369 368 410 1 .. 365 852 CIRRHOSIS OF LIVER— COAL MINERS' EPITHELIOMA 'irrkosis of liver, contd. - diazo-reaction iii . . 198 - diarrhoea in . . . . 197 - dilated venules on cheeks in . . . . 300, 410 - diminished appetite in . . 4.9 - distended abdominal veins in 59, 300, 409, 410, 826 - drowsiness in . . . . 368 - dry, harsh skin in . . 410 - dyspepsia in . . . . 410 - enlai'gement of liver from 301, 369, 409 spleen in 301, 369, 409 - enteritis in . . . . 409 - epistaxisin 251, 295,300,368,696 - firm irregular edge in 368, 409 - frequent total absence of symptoms in . . . . 410 - furred and tremulous tongue in ..59, 368, 410 - gastritis in . . 352, 409 - general account of . . 300 - pains in the limbs in . . 503 - i;enerallv painless . . 409 - Hanot's 410 absence of symptoms in 411 age incidence of . . 410 ascites rare and of evil omen in chronic course of clubbing of fingers in. . diagnosis from spleno- megalic cirrhosis enlargement of liver in familial character of. . firm, smooth liver in . . - - hsemorrhages in - - Jaundice in liver firm and smooth in 410 - - long-standing jaundice in 410 periods of illness with pyrexia in . . prominence of abdomen 411 410 411 369 410 369 410 411 369 411 - sex incidence of . . 410 - smoothness of liver in 410 - splenic enlargement in 410 - stunting of growth in children with . . 410 iiEematemesis due to, 40, 60, 294, 296, 300, 302, 410, 696 ha^maturia in . . . . 368 liEemorrhages in ..368, 694 heemorrhoids iu . . . . 368 hobnail irregularities m 409 hypertrophic biliary (see Cirrhosis o£ Liver, Hanot's) icteric conjunctiva in . . 59 impairment of strength in 410 infantilism from . . 215 insomnia in . . . . 359 jaundice in, 40, 60, 301, 362, 363, 368, 410, 696 liver changes in . . . . 59 loss of appetite in 59, 300 - weight from . . . . 848 in malaria . . 371, 410 melsena in 300, 368, 409, 696 menorrhagia in . . . . 428 meteorism in . . . . 432 morning sickness in 300,368,410 muscular atrophy in . . 76 nervous symptoms in . . 410 oedema of ankles in . . 410 oesophageal varix in . . 296 pain from perihepatitis in 409 pancreatitis from . . 116 passive hyperaemia of uterus from . . . . 430 perihepatitis in . . . . 409 peripheral neuritis in . . 76 phthisis complicating . . 295 pigmentation in.. 40, 59 Cirrhosis of liver, contd. polyuria in prolonged pyrexia due to purpura in 596, 599, pjrrexia due to, 40 362, 368, 410, 609, rapid death after onset of ascites in rare in melancholies red nose in roughness and hardness of liver iu 301, 368, sallow complexion in sex incidence of . . simulating malignant disease simulation by tuberculous peritonitis slow diminishing of liver dullness in late stages smoothness in early stages splenic enlargement in 59, 60, 302, 692, 695, - splenomegaiic age incidence of auEEmia in 369, 693, ascites in clubbed fingers in 369, diagnosis from Hanot's cirrhosis early age incidence of enlargement of liver in familial character of . . ha;matemesis in 369, hremorrhagca in jaundice in . . 369, lack of development in long course of . . relation to Banti's disease splenic ausemia 411, spleen enlarged 692, 093, stunted growth in telangiectases in . . in terminal stage of splenic aneemia tremulous tongue in 368, tympanites in urinary changes in urobiUnuria in . . lu^oerytlirin in urine in varicose abdominal veins vomiting in 300,368, 410, wasting in ..69, 410, weight of liver in - of lung, clubbed fingers in. . fibroid lung and bronchi- ectasis fron^ . . haemoptysis in . . 317, occupations tending to . . tubercle bacilli in sputum - of pancreas, Cammidge's reaction in fat globules in faeces in . . Cirsoid aneurysm (Plate XI V) Citrates, transient polyuria . . Clark, Andrew, re haemoptysis in arthritic subjects Claudication, intermittent, age incidence of . . arterial pulsation in legs absent in cerebral atheroma diagnosis from orythro- melslgia and Raynaud's disease .'. excessive smoking in gangrene in hemiplegia from. . local temporary insufficient blood supply in - - nayokymia in pain in legs after walking relief by rest pallor of foot iu . . 582 609 696 68, 623 413 409 410 409 410 410 404 409 696 369 693 694 693 694 369 369 369 693 694 694 693 693 694 694 694 696 369 59 411 410 410 410 818 819 826 843 848 409 129 324 319 319 319 116 117 764 581 Clavicle, affection in yaws . . 449 - myeloid sarcoma of . . 756 - prominence of one in phthisis 319 - rudimentary . . . . 213 - swelling on, syphilitic . . 752 Clavus hystericus 166, 329, 506, 798 CLAW-FOOT (i^j>. 29) 126-127 - paralysis of internal popliteal nerve causing . . . . 543 CLAW-HAND (Fig. 30) .. 127 - from cervical rib . . . . 493 - chronic poliomyelitis . . 165 - neuropathic muscular atrophy . . . . . . 159 - progressive muscular atrophy 73, 127, 165 - syringomyelia . . 285, 554 - in transverse myelitis . . 74 Cleft palate, dysphagia due to 225 harelip associated with.. 640 regurgitation of food through the nose in 202, 640 Cleido-cranial dysostosis, dwarf- ism with 213 Clergymen, chronic pharyn- gitis in .. .. 670, 673 Climacteric, flushing at the . . 268 Climbing-up-himself posture of pseudo-hypertrophic paralysis . . . . 560 Clitoris, elongation of in pseudo- hermaphroditism . . 706 - epithelioma of, enlargement of inguinal glands in . . 423 - hypertrophied in hyperneph- roma . . . . . . 455 - leukoplakia of . . . . 770 - priapism of.. .. .. 585 Clonic contractions in Bright's disease . . . . . . 160 myoclonus and paramyo- clonus multiplex . . 161 pregnancy . . . . 160 torticollis . . . . 161 - convulsions in Jacksonian epilepsy . . . . . . 161 - spasms, mild, in cases of major epilepsy . . . . 160 Clonus, account of . . . . 160 - ankle (see Ankle-clonus) - influence of parathyroid glands on . . . . 161 - patellar (see Patellar Clonus) Clots in urine . . . . . . 305 CLUBBED FINGERS (Fig. 31) 18, 128, 129 accompanying cyanosis 184 in bronchiectasis 99, 324, 703 cirrhosis . . . . . . 369 congenital heart disease 129, 579, 790 empyema . . . . 99 - - flbroid lung 193, 246, 324 Hanot's cirrhosis . . 411 hypertrophic osteoartliro- pathy 390 with patent interventri- cular septum . . . . 129 pulmonary stenosis 104, 129 seldom present in persis- tent ductus arteriosus 579 splenomegaiic ciri-hosis 369, 691 and toes in congenital heart disease . . . . 244, 247 CLUB-FOOT (see Talipes) Coaclimen, Dupuytren's con- tracture in . . . . 167 Coagulation time of blood, effect of calcium salts on 430 - of urine, spontaneous . . 126 Coal gas poisoning, coma in . . 138 - miners, antlu-acosis in . . 319 epithehoma of scrotum in 679 COCA INE—COLI TIS, M UCO-MEMBRA NO US Cocaine, palpitation from 525, 527 CoH-bacillnria, contd. Colic, conld. - in diagnosis o£ asthma . . 582 rigidity of the abdomen in 646 - laparotomy may be required - spray in laryngoscopy 22(; trace of albumin with 576 848 in diagnosis of . . 645 - tremor from . . 795, 797 COLIC 133 - pancreatic 365 Cocainism, palpitations worse - abdominal pain over colon in 136 signs and associated when Jrug is not being referred to as . . 133 symptoms of . . 135 taken 527 rigidity with 645 - in plumbism 38 77, - mnlti|ile prick marks on body 527 - - wall in . . 133, 134, 645 144, 473, 500, 507, 798 Cocci in pustules 601 - absence of leucocytosis in. . 645 - pulse in . . . . 472, 645 Cocoa, oxaUiria fi-om 471 - in alcoholism 136 - pyrexia in . . 645 - polj'uria from 581 - appendicular 135 - renal 47 Coccydynia, movements of - in arsenical poisoning 75 causes and associateiJ coccyx painful in 638 - atonic constipation 143 symptoms of . . 135 Coccyx, bedsore over 285 - biliary . . . . 135, 509 ciiaracteristic tendency to - fracture of, felt per rectum G38 absence of jaundice with 846 pass down into groin . . 500 - rectal examination of 635 in acute pancreatitis 153 constipation in . . 153 Cod-liver oil, taste in mouth areas of tenderness in . . 779 diagnosis from appen- from 774 constipation in . . 153 dicitis . . 500 Celiac axis, aneurysm of Csee with gall-bladder tumours 392 lead colic 500 Aneurysm of Oceliac Axis^ from gall-stones 152, 278 363 distribution of pain in . . 308 Coffee-drinking, pseudo-angina jaundice with . . 153, 846 due to passage of blood from 482 pain in the chest with . . 846 clots down ureter 305, 395 - gastritis from 297 in the right hypochon- - - gravel in urine in 500 - insonniia from . . 35G, 358 drium in 500 liasmaturia with - oxaluria from 471 upper part of abdomen 153, 306, 395 500 - palpitation from 525, 527 with . . 846 - - hypernephroma . . 395 - transient polyuria from 581 patient rolling about in 644 in kidney tumours 307 Coffee-ground vomit in gastric radiation of pain to back malignant kidney tumour 395 carcinoma 299 and right shoulder in 500 micturition frequency of ulcer 298 shivering in 135 in .. .. 438 516 (and see Hsematemesis) 293 simulation by renal colic 500 mode of production in Coffin-lid crystals of triple urates after 500 renal calculus. . 627 phosphate (Fig. 155) 573 vomiting with . . 846 from movable kidney . . 310 Cohnheim, re end-arteries . . 286 - from carcinoma of bowel 91 147 pain in the groin from . . 846 Coin, oesophagus obstructed by 222 - in colitis 501 loin from 846 - sound on percussion over - collapse from 645 penis in 516 subphrenic abscess 501 - diagnosis of cause of 136 right hypochondrium in 500 in pneumothorax 577 organic disease from 133 testicle from . . 846 Coitus, causes of iisemorrhage in 434 from peritonitis . . 644 patient rolling about in. . 644 - excessive, menorrhagia from 428 - in dysentery 501 pyrexia in 500 - fracture of penis during . . 125 - facies of 133 in renal calculus 308 627 - painful (see Dyspareunia) . . 221 - intense abdominal pain in 645 tuberculosis 309 626 Colcott Pox, re vacciniform - intestinal 472 simulating biliary colic. . 500 ecthyma of infants 446 abdominal distention in . . 473 simulation by abdominal Cold bath, amenorrhcea due to 23 in children, drawing up neuralgia 473 menorrhagia from 428 of legs in 473 biliary colic . . 500 - chilblains from 810 cold sweating in . . 472 twisting of pedicle of - common (and see Coryza ; contraction in 1.34 ovarian cyst 392 and J3ischarge, Nasal) all degrees of pain in 472 spasmodic pelvic pain in 509 - - acute nasal catarrh in . . 668 diagnosis from pain due to - - vomiting with 500, 844 846 anosmia in 668 retained testis 740 - in spastic constipation 144 inflammation of soft palate, from fnecal accumulations 393 - sudden onset of 645 uvula, and fauces in . . 672 due to flatulence 267 - use of term by patients . . 133 loss of taste due to 774 in Henoch's purpura 90, 600 Colic-like pains in dysmenor- micrococcus catarrhalis - - infantile . . 357 rhoea 219 causing . . 203 in clironic intussusception 148 Colitis, abdominal tenderness in 134 cedema about face, neck, due to indigestible food 136 ,473 - acute, diarrhoea in . . 196 and arms from 459, 461 nausea, eructations and symptoms of 196 simulated by measles . . 203 borborygmi in 473 tenesmus in 196 - excessive, coma from 137, 139 in organic stricture of - blood and mucus in stools - exposure to, haemoglobinuria intestine 146 from . . . . 197 501 arisi ng from 315 palpable contracted bowel - catarrhal, constipation as- still neck from . . 708 witii 134 sociated with 144 - extreme, gangrene from . . 282 persistence of borborygmi - characteristics of faeces in . . 134 - febrile, spoken of as influ- with 645 - clnronic, anaemia in 39 enzal 203 - - due to purgatives 144 - colicky pains in abdomen in 501 rigors in . . 647 intestinal obstruction 473, 571 - diarrhcEa in. . .. 134 501 - and heat, effect on mictu- pain spreading from - indicanuria in 349 rition of . . 581 umbilicus in . . 473 - loss of weight due to 848 - influence on myom.a cutis. . 805 paroxysmal recurrent pain - membranous, indicanuria in 349 - muscular twitchings from. . 157 in 472 mucus casts in (Fit/. 123) 444 - nephritis from 13 patient rolling about in 644 - muco-membranous, blood - sense of, in syringomyelia . . 664 pulse in . . 472 per rectum in . . 727 - sheets at bedtime causing relief of pain by pressure 473 castsofbowelin(Fi(7. 123) 444 cough 175 restlessness in . . 473 constipation in (Fig. 37) - stage of malaria 35 rigidity of abdomen in . . 473 145, 727 - tremor from . . 794 795 shrieking from . . 472 enterospasm in . . 486 - ulceration of the leg from . . 810 simulating cramps 177 mucous colic and 133 Coli-bacilluria 16 dysmenorrhoea 220 mucus in the stools from 727 etiology and symptoms 8 2, 83 perforative peritonitis 045 sex incidence of . . 727 little obvious pus with . . 576 spasmodic pelvic pain in 509 simulated by plumbism 486 loss of weight in 848 temperature in . . 472 simulating tape-worm . . 567 pus corpuscles in the urine visible peristalsis m 473 tenderness in right lum- from 848 vomiting in 645 bar region from 727 884 COLITIS, MUCOUS— COMPRESSION OF LUNG Colitis, contd. Colon, continued. COMA 136 - mucous, characteristics of - carcinoma of (see Carcinoma - absent in Jacksonian epilepsy 161 faeces in 134 of Colon) - in acute diabetes . . 292 intestinal sand in 652 - congenital idiopathic dila- encephalitis 643 - mucus in stools witli 144 tation of (see Hirsch- yellow atrophy of liver . . 370 - pain in left iliac fossa in . . 501 sprung's Disease) - from alcohol poisoning 346 right iliac fossa in 134 ,135 - dilated, gastrectasis simu- diBSculties in diagnosing 138 and tenderness in the lated by . . 714 - anaesthetics . . T. 346 back from 789 in acute obstruction of . . 152 - anuria . . . . 4r , 48 - pus in the stools in 601 - diverticula of (see Diverti- - with apoplexy 173 - sigmoidoscope in 91, 92, 19G 501 cula of Colon) - Eabinski's sign in . . 82 - simple, of infants, blood per - faecal accumulations in (see - from carbolic acid . . 346 anum and other symp- F»cal A-CCumulation) - carcinoma of liver . . 413 toms in . . 92 - greedy, as cause of consti- - in cerebral conditions, diag- - tenesmus in 501 pation 143 nosis from diabetic coma 292 - tetany in . . 3 - inflammatory attacks of. haemorrhage . . 337, 140 - ulcerative, abdominal pain constipation due to 727 - from chloral poisoning 346 and tenderness in 92 local pain and tender- - in cholaemia 361 albumosuria in . . 20 ness due to . . 727 - cirrhosis of liver . . 368, 410 blood per anum in 91, 92 727 vomiting due to 727 - diabetic . . _ . . 4, 293 death from 727 - kink of, causing constipation 147 preceded by vo'miting . . 843 enlarged mesenteric glands - malignant disease of (see - from embolism . . 237, 699 in 422 Carcinoma of Colon) - encephalitis 558 indicanuria in . . 349 - normal, situation of 722 - in epilepsy . . . . 160, 646 leucopeiiia in 401 - obstruction, character of - excess of urea in cerebro- mucus in the stools from 727 visible peristalsis in 571 spinal fluid in uraemio . . 339 painful diarrhcea with . . 727 - pemphigus, etc., of 114 - in fatty heart 241 palpable sigmoid flexure in 735 - post-dysenteric ataxy and - from fractured spine 286 pneumothorax from 578 paresis of, diagram of . . 144 - in general paralysis of the pyrexia with . . 92, 727 - pressure on, causing dyschezia 150 insane 340 subphrenic abscess from 578 - resonance in tumour of - hysterical trance . . 137, 140 tenderness in the right kidney 367 - incontinence of fseces in . . 347 lumbar region from . . 727 - scybala'in transverse 724 - in malaria . . 35 tenesmus in 91 - sigmoid, cachexia from - ilenifere's disease . . 828 ulceration of rectum in . . 635 tuberculosis of . . 731 - meningitis . . 642 vomiting in 727 - - carcinoma of (see Carci - at onset of acute fevers . . 646 wasting from . . 69, 727 noma of Colon) - in opium poisoning 345, 346 Collapse from abdominal in congenital dilatation of - from oxalic acid 346 injury 645 colon.. 735 - in phosphorus poisoning . . 373 - acute intestinal obstruction 153 dilatation of, succussion - from pontine haemorrhage pancreatitis . . 292, 724 sounds in 711 344 ,345 - angina pectoris 481 ffecal accumulations in . . 393 - post-epileptic 171 - anuria with . . . . 45 , 49 normal situation of 722 - stertor in 707 - in arsenical poisoning 92 pain in left Uiac fossa - in Stokes- Adams' disease 97 627 - colic . . 133, 135, 645 from kinking of 501 - superior longitudinal sinus - corrosive poisoning 297 palpable in left inguinal thrombosis 643 - gall-stone colic 363 region . . 731 - in tuberculous meningitis . . 174 - gangrenous appendicitis . . 484 normally 731 - urcemic . . 48, 172, 339, 464 - hypothermia in 346 sigmoid flexure in con- - after urinary operations . . 49 - in intestinal obstruction . . 346 genital dilatation of 735 Combined degeneration of the - intussusception 92 in iflcerative colitis . . 735 cord, subacute . . 493 - from loss of fluid. . 580 - spasm of, constipation due to 145 - sclerosis of the cord, anfes- - in pancreatic haemorrhage 292 - spasmodic contraction of thesia from 667 - from perforated duodenal transverse (see Entero- ataxia from 667 ulcer 484 spasm) effects of 164 gastric ulcer 484, 721 - stricture of, due to cicatriza- hyperaesthesia from . . 667 - in peritonitis 346 tion 146 causing paraplegia . . 561 - phosphorus poisoning 373 - transverse, normal situation of 724 (and see Paraplegia, Ataxic) - from rupture of aortic rarity of tumours in 724 spastic paraplegia from 667 aneurysm. . 482 - tuberculosis of, cause of Comedones in acne 530, 604, 609 extra-uterine gestation 436 ,760 swelling ia right lumbar Competitions, physical and - after severe diarrhcEa .346 region 727 mental, transient poly- - - hsemorrhage 346 stricture from . . 146 uria caused by prepara- vomiting . . 346 tumour from . . 723, 724 tion for . . 581 - and shock in acute intestinal - tumour of (see Carcinoma Complexion, florid and mot- obstruction 153 of Colon) tled, in Mongolian idiocy - sudden, in myocarditis . . 241 - ulceration of (see Colitis, 263, 264 Colliers, verruca necrogenica in 266 "Ulcerative; - sallow in cirrhosis of liver. . 410 Colloid carcinoma of peri- Colourblindness 840 congenital syphilis 259 toneum . . 57 due to alcohol 837 general congestion of liver 407 - - of colon . . 735 congenital 840 myxcedema 259 - milium, account of 805 nystagmus in 453 tabes 262 Coloboma of the choroid. from optic atrophy 840 tropical abscess of liver . . 369 ophthalmoscopic appear- tobacco S36, 837, 840 Compositor's cramp . . 177 ance of (Plate VII) 461 - index of blood, varieties of 26 Compressed-air illness (see Cais- - iris . . 462 ankylostomiasis . . 570 son Disease) - lens . . 462 aplastic anaemia.. 42, 64 Compression of brain, coma - macular, nystagmus with 836 in carcinoma of stomach 352 due to 137 - of the optic disc 462 chlorosis 41 - of cord, causes of . . 561 Colon, affection by bullous congenital heart disease 579 partial, simulating prim- eruptions. . 88 leukaemia 32 ary lateral sclerosis . . 565 - ascending, palpable 726 pernicious anjemia 64, 302 616 transverse myelitis from 564 - atony of 149 polycythaemia . . 580 - of lung (see Lung, Compres- - bacillus (ses Bacillus Ooli) - vision, normal ciaracters of 835 sion of) CONCEPTION— CONTORTIONISTS 885 Conception, prevention of, Congenital, contd. Constipation, contd. effect on menstruation . . 431 - ptosis 590 - in anorexia nervosa 50 menorrhagia from 428 - spastic paraplegia, talipes in 131 - appendicitis . . 729, 736 Concussion of the brain, B;i- paralyses of infants 156 - atonic . . . . 143 149 binski's sign in . . 82 - syphilis Csee Syphilis, Con- - in carcinoma of colon coma due to 137 genital) 91, 367, 690 729 headache in 327 - syphilitic arthritis, simulated of rectum 636 jaundice from . . 362 374 by tuberculous joints . . 386 - catarrhal jaundice . . 365 pain in the head from . . 782 - talipes 130 - chlorosis 41 - - tenderness of scalp in 781 782 - tremor 795 - chronic, with vesico-colic vomiting from . . 844 Congestion of face and lips in fistula 146 Condyloma, characters of 769 mitral regurgitation 238 - with colic . . 134 - in congenital syphilis 427, 446 - liver, active (see Liver, Ac- - due to colon inflammation 727 - developing from papular tive Congestion) - congenital, from narrow- syphilide . . 532 venous ("see Liver, Con- ness of anal canal 150 - distinction from pemphigus gestion of Venous) obliteration of bile-ducts 365 vegetans . . 654 - lungs, passive, in mitral - in congestion of liver 371 407 wart 532 stenosis . . 245 - due to deficient motor - distribution of 769 - of uterus (see Uterus, Con- activity of intestines 143 - of external auditory meatus 469 gestion of) - definition of 140 - mercury in diagnosis of . . 769 Congestive attacks in general - in diseases of female genital - pain in perineum from 516 paralysis of the insane . . 682 organs 144 - perineal sores from 678 - dysmenorrhoea described . . 219 - enteric fever 648 - on scrotum . . (;81 Congo red paper in detecting - enterospasm 486 - secondary syphiUtie 769 free HCl 355 - enuresis with 248 - and soft sores, occurrence Conjunctiva, appearance of, in - due to excessive force re- together . . 769 differentiating conjuncti- quired 145 - of vulva 768 vitis, iritis, and elaucoma 257 - foul breath with 99 Cone-hand 3 - blackening of, from ochro- - fragmentary 142 Cones, poisoning by tobacco. . 841 nosis 822 - in gastrits . . 297 - and rods, distribution in - discoloured by drugs 575 - gradually increasing 350 retina 835 - foamy white patches on, - habitual, diagram showing Congenital abnormality, with from keratomalacia 807 bismuth test in . . 141 cervical ribs 492 - gUstening in Graves' disease 261 - headache in . . - 326 ,328 - absence of spinous process 785 - herpes zoster of 831 - in Henoch's purpura 90 of vasinn . . 705 - icteric, in cirrhosis . . 59 - with Hirschsprung's disease - alkaptonuria 822 - icteroid tinge in tropical 433, 713 718 - anophthalmos 839 abscess of liver . . 369 - in hypertrophic stenosis of - cerebral diplegia, tremor in - CBdema of, in glaucoma 257 the pylorus 845 154, 795 - white, in pernicious anaemia 361 - indicanuria in 349 - colour blindness 840 - xerosis of . . 807 - insomnia in 356 - constipation 143 — yellow in jamidice 360 - intestinal, bismuth test in - crescents, ophthalmoscopic Conjunctivitis associated with 141, 142 appearances of (Plate I'll) 461 corneal ulceration 806 delayed passage of faeces in 141 - cystic hygroma of axilla . . 732 - (and see Eye, Acute Inflam- diagnosis of cause of 142 - diaphraamatic hernia 711, 712 mation of) from dyschezia 141 - dilatation of the colon 718 735 - blinking tic following 159 - with intestinal fermentation 267 - diplegia (see Diplegia, Con- - in cutaneous diphtheria 602 - due to intestinal hypoplasia 143 genital) - differentiation of congenital obstruction 26v, 431, 571, - exophthalmos 247 duct obstruction .from . . 250 644, 645, 733 846 - extroversion of bladder . . 587 from iritis and glaucoma 257 - jaundice 361 - eye defects, various 836 - with electric blindness 840 - lead poisoning - heart disease (see Heart - epidemic bilateral . . 256 38, 77, 136, 507 798 Disease, Congenital) - epiphora in . . 2.50 - Malta fever . . 506 - h3rpertrophy of the cervix - follictdar 256 - mesenteric embolism or uteri 586 - haemorrhages in 255 tlirombosis 90 - hypertrophic stenosis of the - haloes and rainbow appear- - with muco-membranous pylorus 426 ances in . . 257 colitis 727 - hvpopln.sia of intestine 143 - inflammations causing 256 - mucus in stools in . . 443 - idiopathic dilatation of - lachrymation from. . 255 - in organic nervous diseases 149 fcolon see Hirschsprung's - of new-born 255 - pain and tenderness in the Disease) - from nuclear facial paralysis 536 back from 789 - intestinal obstruction 151 - pain in the eye from 255 - in pancreatic apoplexy 90 - lachrymal obstruction 2-50 face from . . 495 - passive hypersemia of uterus - lesions of genital organs, list of 705 - photophobia in . . 255, 574 from .. .. 428. 430 - lymphangioma circumscrip- - ptosis of lids in 590 - with peritonitis 644, 718, 719 tum 833 - rainbow vision from 257 840 - due to purgatives . . 848 - malformations of heart fsee - with snow blindness 840 - pyloric 01 oesophageal ob- Heart Disease, Congenital) Connective tissue in fa?.ces in struction . . 144 causing intestinal obstruc- defective gastric digestion 117 - pyrexia from 618 tion 151 pancreatic disease 117 - in rickets 171 of genital organs, dysme- Consciousness, loss of (see Coma) - spastic 144 norrhcea from 219 CONSTIPATION 140 - tenderness in the right iliac hemiplegia in .. 337, 338 - abdominal distention from fossa from 7S0 paraplegia from . . 557 713, 715, 718 - in tuberculous peritonitis . . 719 of rectum, etc. (Figs. - absolute in strangulated - undue abdominal aortic pul- 170-173J 637 hernia 741 sation 592- - narrowness of anal canal 150 - acute 151 - visible peristalsis with 724 - nystagmus . . 453 S3Tnptomatic 153 - and vomiting from intussus- - obliteration of bile-duct . . 361 - in acute pancreatitis 646, 724 846 ception . . 736 - oedema 455 yeUow atrophy . . 370 - a;-ray Ulustration of 141, 142 - onychoeryphosis . . 445 - alternating with diarrhoea - in yellow fever 372 - persistence of pupillary in carcinoma of colon . . 690 Consumption of the bowels . . 56 membrane 593 - anaemia in . . 36 Contortionists, lordosis in 183 886 CONTRA CTED PEL VIS— CO UGH Contracted pelvis, paraplegia Convulsions, contd. Coronary arteries, angina pec- of infant dae to . . 558 - pyrexia due to ..169,34^1 622 toris due to . . 778 CONTRACTIONS, ATHETOTIC, - in rickety children. . 466 atheroma of, violent etc. (and see Athetosis^. . 153 — simulated by malingerers.. 652 thumpings of heart ^\ith 527 - in brachial monoplegia 546 - in sinus thrombosis 139 558 mistaken for rheumatism - carpo-pedal, in tetany 802 - Stokes- Adams' disease 97 of the shoulder 778 - choreiform (see Choreiform - strychnine poisoning 802 pain and tenderness in Contractions) - subnormal temperature after 621 the back from 789 - clonic spasmodic . . IGO, 161 - tetanus 802 Stokes- Adams' syndrome - definition of 153 - unilateral, discussion of 173 from . . 97 - distinguished from contrac- - uraemic 14, 45, 48, 464 647 Corpora quadrigemina, inten- tures 1G3 opisthotonos in . . 464 tion tremor from lesion of 800 - fibrillar (see Fibrillar Con- - after iui.nary operations . . 49 tumour of, loss of converg- tractions) - in yellow atrophy . . 370 ent accommodation - hysterical, simulating tetanus 464 Convulsive tic, chorea simulating 156 with retention of light - involuntary . . 153 - twit€hing in syncope of fatty reflex in 594 - spasmodic .. .. 159 162 heart 241 Corpus cavemosum, inflam- in epilepsy 160 Copaiba, effect on urine 6 mation of 125 a minor sign in various — eruption 609 - luteum, haemorrhage from, nervous disorders 159 diagnosis from smaU-pox 609 pelvic haematocele from 757 of sphincter vesicns 443 - purpura from 596 hEemorrhagic cyst of. in tetanus 162 - resin, polyuria after 582 pelvic pain from 508 - tetanic 161 Copper, foul taste in mouth - striatum, hyperpyrexia from interrupted 160 from 774 lesions of . . 340 resemble cramp . . 163 - green sweat due to . . 714 Corpuscles, red, increase of CONTRACTURES 162 - salts, ptyalism due to 590 (see Polvcvthaemia) - in acute poliomyelitis 555 Coppery areola of syphiUdes. . 604 nucleated (P/a?e//, Fig. F) 28 - chronic arthritis 390 Cor bovinum . . 233 variation in shapes and - differentiation of contrac- Coraco-brachialis muscle, spi- sizes of (Plate IF) 28 tions from 153 nal nerve root supplying 556 - white (see Leucocytes) - facial (Figs. 136-0) 534, 537 - nerve supply of 550 Corrigan's pulse 106 - of hand 3 Cord, combined sclerosis of Corrosive poisoning, oesopha- - with hysterical chorea 157 (see Combined Sclerosis of geal stenosis from 222 - in monoplegia 547 Cord) h»matemesis in 294, 297 - peripheral neiuritis 390 - compression of (see Com- loss of taste from 774 - talipes from. . .. 132 133 pression of Cord) sore tlu-oat from 671, 674 - Volkmann's 132 - lesions at various levels. symptoms of .. 297, 845 from injury to forearm . . 552 effects of 540 vomiting from . . 813 Convalescence, anaemia in . . 36 - spermatic (see Spermatic - sublimate test for bile in - brisk knee-jerks in. . 397 Cord) stools 197 - hypothermia in 346 - transverse lesions of con- Coryza, acute, pains in the - irritable cough of . . 175 tractures in . . 162, 164 limbs in (and see Discharge, - oedema of legs in . . 459, 461 - umbilical (see Umbilical Tsasai ; and Cold, Common) - polyuria during . . 582 583 Cord) 503, 505 - priapism in 586 Corea, paragonimus 'Wester- - in arsenical poisoning 75 - shortn&ss of breath in 101 mani in . . 705 - congenital sypMlis . . 446 - tachycardia during 773 Corn, perforatiag ulcer origin- - e feno, or hay fever, loss of - tremor in . . 795 ating from 809 smell in . . . . 668, 774 CONVULSIONS 168 - suppurating, distinction - impairment of tast« from. . 775 - in acute encephalitis 139 547 from perforating ulcer . . 809 - in influenza 505 - children corresponding to pain in the foot from 809 - from iodides 87 rigors in adults . . 646 Cornea, appearance of, in dif- - in measles . . 426 - cholaemia 361 ferentiation of conjuncti- - various causes of . . 203 - chronic nephritis . . 14 vitis, iritis, and glaucoma 257 Costermongers, chronic pharvn;? - - clonic, in focal epilepsy . . 161 - herpes of 807 itis in . . . . 670 673 - definition of . . 168 267 - insensitiveness of, from para- Cotton, relation to actinomyces - effect of oxygen in 172 lysis of fifth nerve 807 8/, 70.^ - epileptic 160 - opacities of, in congenital - sporotrichosis from 322 with coma from haemor- syphilis . . 259 - wool in ears, otorrhoea from 469 rhage . . 140 from interstitial keratitis 806 eczema from 469 in eclampsia 647 in keratomalacia 807 Coude catheter . . 440 441 in general paralysis of from ophthalmia neona- COUGH 174 the insane 340 torum . . . . 836 839 - in asthma not the essential in lead neuritis . . 38, 77, 139 paralysis of fifth nerve . . 807 symptom 582 not often unilateral 174 from ulceration . . 806 - Charcot-Leyden crystals in 118 saturnine encephalopathy - perforation of, in diphtheria - due to chronic pleurisy . . 480 38, 139 infection . . 807 - drv, due to growths 175 in the Stokes - Adams gonococcal infection 807 - early in phthisis . . 101 620 syndrome . . 97, 527 from ophthalmia neona- — epistaxis from 250 in ura>mia 464 torum . . 8.S6 - in fibroid lung 240 - in general paralysis of the by ulceration 806 - haemoptysis from violent . . 317 insane . . . . 139 269 - rodent ulcer of (see Jlooren's - incessant, in phthisis 194 - from hydrophobia . . 80.' Ulcer) - in influenza . . 505 - in hys'teria (see Hysteria, - steamy in glaucoma 840 - interference with, by laryn- Con\Talsions in) inserLsitive in glaucoma. . 838 geal paralysis . . 538 539 - infantile, hyperpyrexia in . . 344 - tuberculous ulceration of . . 808 - in mediastinal growth 483 - .Tacksonian epilepsy 161 - ulceration of (see Ulceration - micrococcus catarrhalis in, - local (see Contractions) . . 168 of Cornea) in influenza 505 - in meningitis 139, 341, 612 642 Corneal affections, photopho- - mitral regurgitation 238 - non-obstructive anuria . . 46 bia in 574 - morning, in bronchLil catarrh 176 - organic cerebral disease . . 328 - reflex in facial paralysis . . 535 - oedema of face, neck and - otitis media in children 229 Cornet player's cramp 177 arms from . . 459 4C1 - phosphorus poisoning 373 Cornwall, ankylostomiasis in 570 - onset of pneumothorax - poliomyelitis . . 128 555 Corona veneris 532 during 480 COUGH— CYSTIC DISEASE 887 C'oni/li, i-ontd. - pain in the chest due to . . - painful, in phrenic neuralgia - paroxysmal, in whooping cough - in phthisis 101, 17U, 185, 194, 319,577, - pneumonia .. ..175,170, - relation to gastric branches of vagus . . - severe epigastric pain from - tenderness in the epigas- trium from - vomiting from . . 4(!7, Coughing in diagnosis of in- guinal swellings . . Cousins, marriage of, retinitis pigmentosa from Cracked nipples, mastitis from Cracked-pot sound in fibroid lung CRACKLING, EGG-SHELL .. - over myeloid sarcoma CRAMPS - abdominal (see Colic) - in alcoholism 59, 7«, 238, 300, - differentiation of contrac- tions from from contractures peripheral neuritis 78, - dull, aching pain after cessation of spasm in . . - painful spasm in . . - professional, ill-health a cause of . . - - from local injury - in syringomyelia . . - tjrpist's (see Occupation Neuroses) - writer's, (see Occupation Neuroses) Cranial nerve paralyses, mus- cular atrophy in . . ptosis in sypuihiic, multiple asym- metrical Craniotabes in congenital syphilis . . - crepitus with - egg-shell crackling in Cranium (see Skull) Creatinine - darkening with picric acid - oxalates derived from - in urine, reduction by Cremaster muscle, spinal nerve root supplying . . Crenated red corpuscles (Plate II, Fig. m Creosote, foul taste from Crepitations in pneumonia 186, 701, - mediastinal, in acute medi- astinitis . . CREPITUS - in endosteal sarcoma - fractured rib - subcutaneous (see Emphy- sema, Surgical) Crescents, congenital myopic pigmented, oplithalmos- copio appearances of (Plalc VII) . . 461, Cretinism, amenorrhoca in . . - delayed walking from - facies of - fatty pads on shoulders in - hair and skin in - hypothermia in . . 259, - illustrated (Fir/. 07) - lack of mental develop- ment in . . - paraplegia due to . . 556, - pendulous belly in 462 23 557 258 259 259 345 210 259 557 259 no. 134, 654, 829, 270, 448, Cretinimn, could. - relative largeness of head in - slow pulse in - stunted growth in . . - thyroid extract in Crick in the neck Crises, gastric . . jjeriodicity of in tabes dorsalis 134, 350 489, 502, 664, 665, 844, diagnosis from indigestion - intestinal - laryngeal - in lobar pneumonia - pyrexial in meningococcal meningitis - in typhus fever Crossed hemiplegia . . - paralysis (and see Hemiplegia) - pyramidal tracts, Babinski's sign in lesions of Cross-legged gait in Little's disease Croton oil causing bullae used by malingerers Crural lesions causing ataxy . . - monoplegia (see Paralysis of one extremity (lower) ) - nerve (anterior), isolated paralysis of (see Anterior Crural Nerve) Crus penis (see Penis) Crusts (and see Scabs) - in atrophic rhinitis . . - cheiropompholyx - eczema . . 602, - favus - herpes - impetigo . . 113, - keratosis foUicularis - lupus vulgaris - mycosis fungoides . . - Paget's disease . . «02, - pemphigus vulgaris - pustular eczema - from pustules - in scrofulodermia . . - syphilides . . - from vesicles - in xerodermia pigmentosum Crutch, musculospiral paralysis from Crying, oedema of face, neck, and arms from. . . 459, Cryoscopy of cerebrospinal fluid Cryptomenorrhoea Cryptorchism in infantilism. . CRYSTALS, Charcot-Leyden, illustrated in asthma - in acid urine in renal calciilu= . . - cholesterin, in gall-bladder (J''i{/. 94) in spermatocele . . - choline platino-chloride . . - cystin, illustrated . . - dumbbell, in oxaluria of uric acid - of fats and fatty acids in stools - fatty acid in pancreatitis - " hedgehog," of urates . . - leucin . . . . 302, - osazone . . . . 115, - oxalic acid (Fig. 130) - rosettes, of uric acid - " thorn-apple,"' of urates . . - triple phosphate (Fig. 155) - tyrosin . . . . 302, - of uric acid (Fig. 212 ; and see Uric Acid Crystals). . Cud-chewing (see llerycism) 258 259 258 557 477 847 847 473, 847 350 134 460 186 642 371 336 536 82 164 154 110 112 Cup, glaucomatous (Flale VIII p. 463) . . . . 257 - physiological, ophthalmo- scopic appearance of (I'late VII) Curettage in diagnosis of cause of dysraenorrhcEa metrorrhagia . . metrostaxis - in endometritis - relief of dysmenorrhoea . . - sterility CURSCHMANN'S SPIRALS, significance oi (Fig. 46) . . iu spasmodic asthma . . CURVATURE, SPINAL (sec also Ky|ihi)sLs; Lordosis; Scoliosis ; and Spinal Cur- vature) Cutaneous reaction (von Pir- quet's) for tuberculosis. . - sensibility, loss of, mistaken for paralysis Cut throat, hoemoptysis from stenosis of trachea after stridor in . . CYANOSIS, EXTREME - blodd ;ilrr-i-;itions causing cIuI.IhmI lingers in - borborygmi with . . - in chronic mediastinitis . . - congenital . . - in congenital heart disease 129, 244, 579 - during convulsions - of face and neck with aortic aneurysm (Fig. 72) - hands in some cases of cervical ribs - in laryngismus stridulus . . - local, symmetrical, of the extremities, in Raynaud's disease - from malignant ulceration of larynx - mediastinal growth.. - in mitral stenosis . . - myxoedema - passive congestion of liver - periodic, from bronchitis and emphysema from fibroid lung and bronchiectasis in mitral stenosis from renal disease - pneumonia . . - from pneumothorax 480, 577, 712 - polycythsemia with 187, 579 - from pulmonary embolism 320 - - stenosis . . . . 104, 247 - during rigors . . . . 647 - in splenomegalic polycy- themia .. 187,581,693 - in Stokes- Adams' disease.. 97 - from sudden irruption of caseous bronchial glands into bronchus in sulphhfemoglobinaemia . . 401 401 220 433 436 429 220 706 179 118 180 612 .^.45 318 710 710 184 184 128, 184 97 .. 484 .. 184 790 109 234 493 406 490 185 296 764 259 370 579 579 579 579 645 466 187 - syphilitic ulceration of larynx 185 Cyclical albuminuria . . . . 19 - vomiting of children 426, 843 Cyclitis, causes of . . . . 256 - conjunctivitis distinguished from . . . . . . 256 - severe pain in the eye from 250 Cyrtometric tracings of various forms of chest, illustrated 192 Oystalgia, frequent micturi- tion in 443 Cystic degeneration of fibro- myomata . . . . 434 - disease of breast (see Breast, Cystic Disease of) epididymis (see Epididymis) CYSTIC DISEASE— CYSTS, VULVAL Cystic disease, contd. Cystilis, contd. Cystoscopy, appearances, contd. -'- of kidneys S 396 - simulating passage of fseces in ureteral tuberculosis age incidence of 310 per urethram 264 (Plate r. Fig. D, p. 308) 625 albuminuria in 15 - suprapubic pain in vesical tumoure (Plate VI, anuria in . . 45, 48 306, 312, 512, 627 631 Figs. F, G, p. 310; . . 311 bilateral tumours in . . 310 - in tabes 628 in pneumaturia . . 576 bulging of lower thoracic - transverse myelitis 628 - bladder infected from tuber- wall by 393 - triple phosphate crystals in culous bowel 313 Cheyne-Stokes respira- urine in . . 574 - in calculous anuria 47 tion in 124 - tuberculous, general account - carcinoma of bladder (Plate continued polyuria in 583 of . . . . 513, 628 629 VI, Figs. F. G, p. 310) diagnosis from bydro- age incidence of . . 513 442, 512, 514, 630 nephrosis . . " 310 396 associated with tuber- - detecting vesical fistula . . 442 haematuria in 304, 310 culosis of vesicute cause of bearing-down pain 474 iliocostal space length- seminales 312, 513 629 pyuria (Plate V, p. 308) 624 ened in 393 ureteral tuberculosis . . 513 cystitis . . 442, 624, 628 occupation of whole cystoscopic appearances papilloma of bladder abdomen by 393 in (Plate F, Fiq. E, 441, 514, 630 pain in 310 p. 308) 312. 513, 626, 629 pelvic tumour . . 758 palpability on vaginal diagnosis from renal pveUtis (Plate V, Fig. C. examination 393 tuberculosis 312, 513 629 p. 308).. .. 625, 628 renal enlargement from 310 ureteral calculus im- single simple ulcer of similarity to ovarian cyst 393 pacted near bladder 627 bladder 630 symptoms of . . 48 vesical calculus 628 vesical calculus (Plates V, - duct stenosis, distention of - - examination for tubercu- VI, pp. 308. 310) 312, 439, gall-bladder without jaun- lous focus elsewhere m 513 442, 512, 513, 629 dice in . . . . " . . 365 frequency of micturition villous tumour of bladder calculus in, colic without in . . 306, 312, 513 581 512, 514 jaundice from 846 uninfluenced by rest - in differential diagnosis of - ovary, congestive dysmenor- in . . 513 ulceration of bladder 630 rhoea from 220 haematuria from - haematuria (Plates V, VI. Cysticerci, eosinophUia with 452 304, 312, 441, 628 629 pp. 308, 310) 9 307 Cystin crystals (Fig. 51) 187 lesions In testes, prostate. - silver nitrate as an aid to . . 630 - formula of . . 187 or vesicles with 629 - in suspected growth of CYSTINURIA 187 other genito-urinary tuber- kidney 395 Cystitis, abscesses in mucosa in 617 culosis in . .' 312 513 renal tuberculosis (Plate V, - albuminuria in ascending pain after micturition in 441 p. 308).. .. 626, 629 nephritis from . . 16 permeum in . . 516 - vesical tuberculosis (Plate - bacteriuria in 83 in penis . . 441, 513 V, Fig. E, p. 308) - from calculus 312, 513, 629 persistent slight pyuria in 312 312. 513. 626. 629 - congestion of bladder a primary, diagnosis from Cysts, abdominal swelling from 715 predisposing cause of . . 627 primary renal tubercu- - of Bartholin's gland 770 - cystoscope in diagnosing 442 628 losis 629 - breast, blood-stained dis- - diagnosis from posterior prostatic tuberculosis charge from nipple in . . 745 urethritis . . 628 with .. .. 513, 678 with chronic mastitis 202, 743 prostatitis 627 pyuria due to 441, 513, 623 628 diagnosis from carcinoma 744 pyelitis or pyelo- rarely a primary affection 513 fibro-adenoma 744 nephritis 628 slight hsematuria at end mastitis . . 202 744 urethritis 207, 628, 631 of micturition in 513 with fibro-adenoma 744 - due to dysenteric or tubercu- tubercle bacUli in mrine in fluctuation rarel.v felt in 743 lous intestinal ulceration 633 312, 513 , milk retention in lacta- - dyspareunia from . . 221 tuberculous testis with 513 518 tion (see Galactocele). . 744 - frequent micturition in 221, 438, vesiculse semmales with 513 possibly precancerous . . 744 512, 627, 628, 817 ulceration of bladder with simple serous 744 - haematuria in 304, 312, 441, 627, 629, 630 - causing albuminuria 17 512, 627, 628, 629, 631 - from urethral strictiu-e 627 - of corpus luteum . . 508 - due to instrumentation . . 627 - urethritis . . . . 62 7, 63] - dentigerous . . 757 - from malignant ulceration - urinary changes in . . 628 - derived from Wolffian body 725 of the bladder . . 627 incontinence with 628 - dermoid (see Dermoid Cyst) obstruction with 628 - diagnosis of ascites from . . 52 - mucus in urine from 221 - urine acid in . . 512, 627 - of epididymis (see Epididy- - from non-gonococcal ureth- alkaline in 628 mis, C.vstic Disease of) ritis 206 - vesical tenesmus in 312 - hydatid (see Hydatid Cysts) - pain after micturition in 441 627 Cystocele simulating prolapse - of kidney, serous . . 396 in bladder irom . . 629 of uterus . . 587 - lesser peritoneal sac 725 penis from . . 441, 511, - dystocia due to 227 - liver simulating ascites 717 512, 513, 514 - pain in perineum in 516 - mesentery, simulating ascites 717 perineum in . . 516, 627 - vulval swelling due to 768 - in mucous uterine polypi . . 435 vulva on micturition in . . 442 Cystoscopy, adrenalin as an - omental 724 - from papilloma of bladder 630 aid to 630 - ovarian (see Ovary. Cysts ofj - prostatic obstruction 627 - appearances in adhesion of - of pancreas (see Pancreas, - much pus in alkaline urine appendix to bladder in Cysts of) in 623 appendicitis 632 - pneumaturia cattsed by . . 576 - pyelitis from 625 in bilharzia hfematobia - retroperitoneal, laparotomy crystals in urine in 629 irifection (Plate VI, in diagnosis of . . 725 - pvonephrosis from . . 626 Fig. K, p. 310) 313, 514 630 palpable in left hypo- - pyrexia in 312, 512, 620, 627 628 in descendins ureteritis chondrum 726 - pyuria due to .. 221, 312, (Plate y, Figs. C, I), pyloric obstruction from 713 512, 623, 627 p. 308) 515 - in sarcoma . . 757 - recurring rigors in . . 648 dilatation of ureter 625 - sebaceous of scrotum 681, 765 - with retention of urine 627 628 impacted ureteral calculus - of testis (see Testis, Cyst of) - in retroversion of gravid 514, 627 - thyroid gland 791 uterus 628 in thickening of ureter - lurachal (see Urachal Cvst) - septic artliritis from 375 (Plate V, Fig. D, p. 308) 625 - vulval . . . . " 768, 770 CYTOLOGY OF ASCITIC FLUIDS— DHOBIE'S ITCH 889 Cytology of ascitic fluids . . 57 - cerebrospinal fluid.. .. 339 - in general paralysis of the insane . . . . . . 209 - spinal meningitis . . . . 464 - urine in acute nephritis . . 12 DACHSHUND type of dwarf 212 Uactylitis, tuberculous (Fig.ldZ) 751 Diacetic acid in cyclical vomit- ing of children . . . . 843 Dalrymple's sign in exoph- thalmic goitre . . . . 792 Damiana, priapism caused by 586 Damp, nephritis from . . 13 Dancers, cramp in . . . . 177 Dancing, hsematuria after, due to movable kidney . . 310 - menorrhagia from . . . . 428 Darier, re priurigo ferox . . 531 - re vesicles . . . . . . 829 Day-blindness or hemeralopia 841 Dead fingers, association with jncnoiThagia at puberty 430 in li'-ripheral neuritis . . 505 DEAFNESS (and see Word- deafness; . . . . . . 187 - apoplectic . . . . . . 190 - in congenital syphilis . . 260 - from fracture of base of skull 468, 794 - with livsterical hemianses- thesia 666 - in Meniere's disease . . 828 - otitis media . . 469, 470 - otosclerosis . . . . . . 829 - and tinnitus associated . . 79.') - due to wax in ears .. .. 467 Death from inadequate causes in lymphatism . . . . 423 - sudden, from pulmonary embolism . . 185, 321 - - from ruptured aneurysm 140, 482 Debility in acute polymyo- sitis . . . .' ' . . 564 - cirrhosis of liver . . . . 410 - cough due to . . 175 - exaggeration of knee-jerks in any condition of serious 397 - general, in acute polymyositis 504 flushing in . . . . 268 - in Malta fever . . . . 507 - muscular, in late stages of acromegaly . . . . 749 - neurasthenia from . . . . 506 - pain in the back in . . 476 - in pcurvy 85, 115, 302, 753 - septicaemia . . . . 650 Decerebrate rigidity of Sher- ruigton . . . . . . 163 Decidual casts,distinction from m?mbranous dysmenorrhoea 220 Decubitus acutus (see Bedsore, Acute) Defaecation, disorders of, in cancer of sigmoid flexure 501 - disregard of, a cause of con- stipation . . . . . . 149 - frequency of, in colitis of infants . . . . . . 92 dysentery . . . . . . 90 - frequent desire for, from polyin . . . . . . 93 - hfemorrhage on, from uterine srrowths . . . . . . 434 - induced by finger . . . . 149 soap ' 149 - inerticient (and see Constipa- tion : and Dyschezia) . . 148 - insufliciency of . . ... 140 - mechanism of . . . . 148 - obstacles to eflicient . . 150 - painful, in fissure of anus . . 636 .. 848 .. 432 503, 500 worse on movement la . . 506 - pus in the stools in . . 601 - rapid pulse in . . . . 506 - relapse after two or three days' improvement in . . 506 - roseolar rash, beginning on hands and wrists, in the relapse of . . . . 506 - slow convalescence in . . 500 - sore throat in . . . . 506 - sudden on.set of . . . . 506 Dental caries Csee Caries, Dental) Dentiserous cysts . . . . 757 Dentition causing infantile convulsions Depression due to arsenic - with fatty heart - in gastritis . . - general congestion of liver - influenza - irritability in Dercum's disease (see Adiposis Dolorosa) Dermatitis exfoliativa, affect- tion of general health in distinction from pity- riasis rubra pilaris - gestationis, pruritus in . . 588 - herpetiformis affecting fingers 266 bleeding gums in 86, 88 - - buUffi in 110, 113, 781, 829, 831 iJefacalicm, contd. Dengue, conld. - peremptory desire for, as - loss of weight in epileptic aura . . . . 80 - met€orism in - precipitate . . . . 348 - pains in - reflex, primary weakness of 149 - time after meals of . . . . 140 - unfavourable posture in, a cause of constipation . . 149 - weakness of voluntary mus- cles of ,148 Deformities in acute polio- myelitis . . . . . . 555 - dwarfism due to . . . . 212 - with paraplegia in Fried- reich's ataxy . . . . 559 - in svringomvelia . . . . 563 DEFORIVIITYOFTHE CHEST (see also Chest, Deformities of) 191 Degeneration of muscles, fibril- lar contractions in . . 157 - reaction of (see Eeaction of Degeneration) Deglutition difficult, in bulbar paralysis . . . . . . 159 - effects on muscles of, in hydrophobia . . . . 162 Dejerine, re olivo-ponto-cere- bellar atrophy . . . . 799 DELIRIUM .. " ..194 - abnormal sense of size in 840 - in acute yellow atrophy 302, 370 - cholEEmia . . . . . . 361 - cordis, due to digitalis . . 773 - from fractured spine . . 286 - in fungating endocarditis . . 103 - hysteria . . . . . . 345 - muttering, in cirrhosis of liver 368 - nocturnal, in cirrhosis of liver 359 - in non-obstructive anuria. . 46 - otitis media in children . . 229 - phosphorus poisoning . . 373 - prognostic significance of.. 194 - in scarlatina . . . . 301 - typhoid fever . . . . 90 - tremens 195 with cirrhosis of liver . . 410 hyperpyrexia in . . . . 344 insomnia in . . . . 356 spasmodic contractions in 159 Delivery, dilEcult (see Dystocia) Deltoid muscle, spinal nerve root supplying . . . . 556 - nerve supply of . . . . 550 - pseudo-hypertrophy of . . 560 - wasting in phthisis . . 72 Delusions in anorexia nervosa 50 - concerning genital organs, subjective smell sensa- tions associated with . . 669 Demarcation-line in dry gan- grene .. (Plate IV} 283 Dementia, amnesia in . . 25 - catalepsy associated with . . 651 - in cerebral syphilis. . .. 173 - epileptic, irritabiUty in . . 360 - impotence in . . . . 347 - mutism in . . . . . . C82 - precox, decrease of reducing body in cerebrospinal fluid 339 - ptyalism in.. .. .. 591 - in saturnine encephalopathy 139 Dendritic synovitis, crepitus in 179 Dengue, acute general paias in the limbs in . . . . 503 - diagnosis from measles . . 506 rheumatic fever . . 506 scarlet fever . . . . 506 yellow fever . . . . 373 - erythematous rash at onset of 506 - fever in . . . . . . 506 - hajmatemesis in . . . . 294 - headache at onset of . . 506 | - long persistence of pains in j limbs in 506 I 170 297 241 297 407 505 3C0 530 530 distinction from eczema 831 herpes zoster . . . . 830 eosinophilia in . . . . 249 erythema in . . . . 831 long course of . . . . 781 pityriasis rubra after . . 658 pruritus in pustules in relation to herpes gesta- tionis . . scabs in . . . . simulated by urticaria bullosa tenderness of scalp in 78C - - vesicles in . .781, 829, 831 wheals in. . . . . . 831 - of pregnancy, bullre in Dermatographia Dermatomyositis (see Poly- myositis, Acute) Dermoid cysts, diagnosis of meningocele and encepha- locele from displacement of eyeball by 254 mediastinal, varicose tho- racic veins from ovarian . . simulating fibroma xanthoma multiplex. . of vulva . . Desquamation in cheiropom- pholyx - in erythema scarlatiniforme - scarlatinal . . 13, 671, 674 Destructiveness in idiocy . . 682 Detachment of retina, oph- thalmoscopic appearance of (Plate VIH) .. Determination of blood to the head, eplstaxis in Deutero-albumose Dhobie's itch in bathing- dra^v- ers area . . and eczema marginatum epidermophyton inguinale pemeti in rubrum in microsporon furfur in . . 275 - mlnutissimum in . . 275 8.31 111 831 850 781 111 771 254 826 760 804 805 111 253 463 251 20 447 275 275 275 890 DIA BETES— DIPHTHERIA Diabetes - azotic, polyuria in 583, - bronzed absence of jaundice in . . liver cirrhosis with 411, pigmentation of . . 411, sugar in urine in. . - insipidus, acromegaly and myxoedema simulating colourless urine in extreme thirst with in lesions of central nervous system 584, polyuria in 579, 581, 582, 583, 584, specific gravity of blood in urine in total solids in urine in . . various causes of - mellitus, abdominal pain heralding onset of coma 292 584 411 411 575 575 411 585 818 585 789 584 584 584 585 acetonuria in . . 4, 292, acute appetite excessive in 49, coma in . . 13(5, 137, deep-red colour of tongue flushed face in influence of diet in muscular weakness in oxybutyric acid in urine phthisis in pneumonia in . . prognosis in . . - short course of age incidence of albuminuria in . . amenorrhoea in . . apparent enlargement of liver in . . arteriosclerosis associated with atheroma in brachial neuralgia in . . constipation in . . delirium in diacetic acid in urine in 292. distinguished from ali- mentary glycosuria . . dry stools in eczema starting in penis or vulva in gangrene in of finger in leg in . . . . 286, lung in . . penis in glycosuria in . . 291. greenish urine in lieadache in hypothermia in . . . . '• impotence in increased frequency of micturition in increase of the reducing body in cerebrospinal fluid in. . iritis and cyclitis in irritability in loss of knee-jerks in 75, 292 weight in 69, 292, 507 meteorism in neuritis due to 69,75, 165, 282,492 of external popliteal nerve in obesity preceding optic neuritis in. . pain and tenderness in the scalp from - - pancreatitis a cause of . . perforating ulcer of foot from - - polycytliEcmia in 432 583 292 292 292 292 292 292 292 292 292 292 292 292 292 16 23 405 282 811 492 145 195 584 141 447 282 266 811 703 266 507 818 328 345 347 437 339 256 360 399 849 432 507 543 453 292 784 117 Diabetes mellitus, contd. polyuria with. . 292, 437, 507, 579, 583, 584,789 pruritus in . . . . 588 shedding of nails in . . 445 shortness of breath in. . 100 skin troubles in . . . . 507 specific gravity of urine in 584 thirst excessive with 292, 507, 789 true 292 ulceration of leg in . . 811 urine per diem in . . 581 vomiting in . . . . 843 xanthoma in . . . . 805 - phospliatic . . . . 572, 584 absence of glycosuria in polyuria of . . . . 572 achuig in loins and back in 572 continued polyuria in 583, 584 polyuria without sugar in 572 tliirst and emaciation m 572 Diacetic acid, tests for . . 196 in urine . . . . . . 4 in acute cyclical vomit- ing of infants . . 426 diabetes meUitus 292, 583 DIACETURIA ..196 Diaphragm, abscess of, caus- ing pneumothorax 577, 578 - afEected by abscess of liver 409 - immobilization by empyema 721 by pleuritic effusion . . 721 subphrenic abscess . . 721 - nerve supply of . . 779, 842 - pushed up in abscess of liver 409 by subphrenic abscess . . 721 - spinal nerve root supplying 556 - tenderness in the chest from affections of . . 776, 779. - unilateral paralysis of . . 341 Diaphragmatic neuralgia (see Neuralgia, .Phrenic) - pleurisy (see .Pleurisy) DIARRHOEA 196 - aiC£.tonar.iaL^froni . . . . 4 - in acute gastritis . . . . 845 - acute, from new growths in bowel 196 - alternating with consti- pation in carcinoma of colon 690 - due to arsenic 75, 87, 297, 579 - from carcinoma of colon 146, 393, 690 of rectum . . . . 636 - carpopedal spasm in . . '3 - in cholera . . . . 301, 579 - chronic, due to catarrli of small bowel . . . . 197 - in chronic intestinal obstruc- tion 267 - - colitis . . . . 134, 727 - collapse after severe . . 346 - from distoma hepaticum . . 364 - explosive . . . . 348, 636 - extreme thirst from . . 789 - fatty, in pancreas affections 486 - fermenta.tive, starch in stools 197 - in gastritis of children . . 297 - gastrogenic . . . . 196, 197 muscle fibres in stools in 197 - general peritonitis . . 644 - hardening of fspces after . . 150 - in Henoch's purpura . . 380 - hypothermia after . . 346, 621 - indicanuria in . . . . 349 - of infants, blood with . . 92 bacillus enteritidis of Gaertner in . . . . 426 depression of fontanelle in 426 diminished knee- jerks in 398, 557 fatty stools in . . . . 265 Diarrhoea of infants, contd. marasmus from . . 426 Morgan's bacillus I., in. . 426 rapid loss of weight in . . 426 sunken eyes in . . . . 426 in summer . . . . 579 tetany from . . . . 178 - in influenza. . . . . . 505 - with intestinal fermentation 267 - from lardaceous disease 10, 39, 414, 696 - loss of fluid from tissues due to . . . . . . 579 - polycythsemia in 579, 580 - in ptomaine poisoning . . 579 - pyaemia . . . . . . 649 - pyonephrosis . . . . 396 - rickets . . . . . . 171 - in suppurative pylephlebitis 649 - from tuberculous peritonitis 719 - typhoid fever . . 90, 610 - urate deposit after. . . . 815 - wasting with . . 69, 420 Diastolic bruits . . . . 106 - collapse of veins of neck in adherent pericardium . . 104 - shock, in adherent pericar- dium .. .. 104, 242 DIAZO-REACTiON .. ..197 Diet, in causation of beri-beri 460 rickets . . . . . . 171 - - scurvy . . . . 302, 599 scurvy-rickets . . . . 753 - in diagnosing gastric ulcer 40 nature of constipation 142, 143 scurvy . . . . . . 44 - effect in gout . . . . 381 - errors in, causing congestion of liver . . . . . . 407 in children, prolonged pyrexia from . . . . 618 causing diarrhoea . . 196 dyspepsia. . . . . . 354 insomnia . . . . . . 357 nightmares 357, 447, 448 severe vomiting in infants 426 tetany . . . . . . 178 - glaucoma affected by . . 257 Dietl's crises with movable kidney .. 310, 729, 844 vomiting with . . . . 844 Differential leucocyte count (see Leucocyte Count) Digestion, time "occupied by. . 140 Digital chancre (see Chancre, Digital) Digitaiis, bradycardia from . . 98 - delirium cordis from . . 773 - in diagnosis of mitral stenosis 61 - increased muscle tone due to 161, 163 - palpitation from . . 525, 527 - polyuria after . . . . 582 - relief of headache by . . 329 - tachycardia from . . 772, 773 Dilatation of aorta, systolic bruits in 105 - of aortic rins, diastolic bruit 106 - of cervix in diagnosis of pregnancy haemorrhage 437 effect on neurotic dys- pareunia . . . . 222 - of heart (see Heart, Dilata- tion of) - of pulmonary arteries in mitral stenosis . . . . 245 - of stomach (see Stomach, Dilated) Dilatator tubfe, clicking noises in the ear from spasm of 793 Dimpling of skin an early sign of breast cancer . . 745 Diphtheria, acute dilatation of lieart from . . . . 243 DIPHTHERIA— DISSEMIN A TED SCLEROSIS JUplillieria, cunld. - acute tonsillitis from . . C70 - albuminuria in . . 13, 17 - alteration of voice after . . 77 - arthritis in . . . . 37G, 708 - ataxy from.. .. .. OG - bacilli (see Bacillus Diphtheriae) - bronchial casts in . . . . 704 - Cheyne-Stokes' respiration in 12.') - chronic tonsillitis from . . G72 - cornea ulceration from . . 807 - cough from.. .. .. 176 - cutaneous, conjunctivitis with G02 frequent absence of diph- theritic membrane in 602 impetiginous eruption with 602 otorrhcea and rhinitis with 602 simulating eczema . . 602 - cyanosis from . . . . 185 - diazo-reaction in . . . . 198 - distinction from Vincent's angina . . . . . . 672 - dysphagia from . . . . 224 - of ear, otorrhcea from . . 469 - enlargement of submaxillary lymphatic glands in . . 419 - in follicular toiasillitis . . 671 - foul breath in . . . . 99 - gangrene in . . . . . . 282 - laryngeal 226, 465, 642, 670, 673 examinationof swabbingsin 466 extreme dyspnoea from 642, 709 frequent absence of mem- brane on fauces in . . 466 Klebs-Loffler bacilli in tlu-oat-swabbings in . . 466 membrane on fauces in. . 466 mistaken for meningitis 642 one negative throat- swabbing not final in. . 466 orthopncBa in . . . . 465 retraction of the head in G41, 642 - knee-jerks lost after . . 399 - and measles, associated . . 226 - menorrhagia in . . . . 428 - muscular atrophy in . . 76 - nasal, epistaxis in . . . . 251 voice after . . . . 181 - panophthalmitis from . . 807 - paralysis possible 3 or 4 weeks after . . . . 640 of limbs after . . 77, 640 palate after 77, 181, 559, 640, 687, 842 - paresis of ciliai-y muscles in 77, 640 - - of ocular muscles in . . 640 - peripheral neuritis from 13, 66, 76, 77, 165, 180, 181, 50G, 559, 591, 640, G87, 773, 842 - pharyngitis from . . . . 670 - phrenic paralysis after . . 77 - pt> alism from . . 590, 591 - pupil reflex lost in . . . . 594 - purpura in . . . . 596, 597 - in purulent rhinitis . . 203 - pyrexia in . . . . . . G22 gravity of . . . . 597 - regurgitation of food through nose after 77, 181, 559, 640, 842 - rigors in . . . . . . 647 - scoliosis from . . 180, 181 - simulated by membranous rhinitis . . . . . . 204 - sore throat from . . 670, 671 - spinal arthritis in . . . . 708 - splenic enlargement in 698, 692 - stiff neck in . . . . 708 - stomatitis in . . . . 590 - stridor in . . . . . . 709 - tachycardia after 77, 772, 773 - talipes due to . . . . 131 - ulcer of leg from . . . . 811 318 211 773 400 164 686 535 799 556 154 800 800 154 800 800 800 154 800 800 198 lliplitheria, cimkl. - ulceration of larynx after . . - vaginal - vagus neuritis after - variable moderate leueo- cy tosis in . . Diplegia, causing contractm-es - cerebral dysarthria in facial paralysis in - choreiform tremor in - congenital 154, 7U5, 800 - - athetosis in . . . . 154 causes of . . choreiform movements in deep reflexes increased in gait in . . . . 154, hereditary causes of optic atrophy in 154, pupils unequal in scissor gait in speech defective in sphincters affected in . . tremor in 154, 795, DIPLOPIA - crossed, illustrated 199, 200 - homonymous, illustrated 199, 200 - monocular, from double aperture of pupil 198, 199 - from ocular paralyses 277, 709 - vertigo due to . . . . 828 Diplococci intracellulares men- ingitidis Weichselbaumii (see Meningococci) Dipping in diagnosis of ascites 51 - - of pyloric obstruction . . Dirt-eating disease . . 50 DISC, OPHTHALMOSCOPIC APPEARANCES OF (Flaics VII, nil ; see also Optic Disc) 461, 462 Discharge from Ear (and see Otorrhcea) muco-purulent, in aural diphtheria DISCHARGE, NASAL (and see . Cold, Common; and Coryza) 20: on bending head in antral suppuration . . in glanders gonococcal leprosy bacilli in - - due to periodical dis- charge of pus from antrum.. recurrent fibroma of basi- sphenoid sarcoma of antrum DISCHARGE, FROM NIPPLE DISCHARGE, URETHRAL .. bacteriological examina- tion in all cases of with chordee fsecal, commoner causes simulated by cystitis. . gonococci in . . 79, 37G in female . . 211, 769 from, gout . . . . 206 inguinal glands enlarged from method of examination of patient in . . prostatic abscess in associ- ation with purulent, in acute ure- thritis . . pus cells no bar to marriage 209 DISCHARGE, VAGINAL .. 210 absence of gonococci in, in gonorrhcea . . . . 769 blood-stained watery, in endometritis . . . . 435 cachexia with . . . . 114 from carcinoma . . . . 435 410 134 115 463 467 469 502 603 203 425 502 204 749 201 20G 631 125 265 264 422 207 678 511 iJischan/e, vaginal, coiitU. - - endometritis epididymo-orchitis by in fection from . . from herpes membranous flakes in . . perineal sores from from pyometra with pyosalpinx pyuria due to . . - - sanious or offensive in puerperal fever septic arthritis from simulating pyuria ureteritis from . . urinous, in carcinoma of vagina and uterus from uterine congestion Discoloration of skin (and see Pigmentation ; and Jaun- dice) Discomyces in mycetoma Dislocation (congenital) of hip (see Hip) - of jaw, ptyalism from diffi- culty in swallowing in . . - lens, monocular diplopia in - spinal, priapism from Dislocation-fracture of cervical spine, ansesthesia from . . Disorientation ■Disparateness DISPLACEMENT OF CARDIAC 22a 518 . . 83f> . . 211 .. 677 . . 436. 632, 737 624, 631 in .. 649 .. 375 .. 631 .. 206 313 42 & 574 sog' 591 19S 585 199 330 586 888 38» 388 388 388 388 388 MPULSE (and see Heart) - pelvic, causing prolapse of uterus - Of semilunar cartilage diagnosis from loose body in joint nipping of synovial fringes tenderness in joint in " slip " or " catch " in joint in sudden pain in joint in synovitis in - of uterus (see Uterus, Dis- placement of) - of viscera in Glenard's disease (Figs. 39 and 41, pp. 147 and 149) 721 Disseminated sclerosis, absence of abdominal reflex in . . 547 constitutional symptoms 547 accommodation paresis in 838 allocheiria in . . . . 22 - - amblyopia in ankle-clonus in . . - - apoplectiform attacks in astereognosis in . . - - ataxy in . . 67, 341, 565, SOO Babinski's sign in 82, 800 central scotoma in . . 837 changes near internal capsule in . . . . 666 coma in . . . . . . 136 erytliromelalgia in . . 490 exaggerated deep reflexes 80O knee-jerks in . . 539, 565 extensor plantar reflex in 342, 539, 547 fatuously placid expression 258 gait in girdle sensation in headache in and vomiting in hemianfesthesia in hemiplegia in 340, hippus in . . impotence in inco-ordination in intention tremor in 341, 794, 795, 80O 800 342 174 665 277, 800 289, 665 327, 328 547 .. 66» 342 595 347 277 141, 346, 892 DISSEMINATED SCLEROSIS— DUODENUM, ULCER OF Lisseminated sclerosis, contd. Diving, epistaxis from 251 Diihring's disease, bullae in . . 114 knee-jerk increased in . . 342 - fracture of spine from 269 eosinophilia in . . 249 monoplegia in 539, 540, 547 Dizziness (see Vertigo) 827 - re tuberculides 603 muscular rigidity in 800 Doderlein's theory of acidity Dullness behind sternum in neuralgic pains in 665 of vaginal secretions 210 thymus gland enlargement 465 numbness in 665 Dog-bite, hydrophobia from - cardiac (see Heart Dullness) nystagmus in 453, 547, 162, 225 801 - in the chest from lobar 800, 838 Dogs, taenia echinococcus in 719 pneumonia . . 645 701 optic atrophy in 547, 565 838 Domestic servants, acropar- - deficient hepatic (see Liver neuritis uncommon in 565 aesthesia in 493 Dullness, Deficient) paUor of optic discs in 800 ,838 Dorsalis penis of pudic, skin - dome-shaped at base of right parsesthesia in . . 565 distribution of . . 650 lung 324 paralysis of one leg in . . 539 Double consciousness 26 - over effusion 192 paraplegia from 561, 565 Doublejointedness in Mongol- - with fibroid lung . . 193 paroxysmal occipital head- ism 216 - in flanks in general peri- ache in 328 Double vision (see Diplopia) tonitis 644 precipitate defaecation in 348 Douclies, sterility due to 706 - of intellect in myxcedema . . 585 protean character of 800 Doughy feel to abdomen in - in the second right space pseudo-nystagmus in . . 452 chronic peritonitis 472 due to aneurvsm 790 scotoma in . . 565 837 Douglas' pouch, swellings in, Dumb-beU crystals (FUj. 130) sensory changes in 665, 800 recognition on rectal 470 816 signs of . . 174 examination 638 Dum-dum fever (see Kala-azar) simulating functional para Draught, stiff neck due to . . 477 Duodeno-pancreatic fistula 294 300 plegia . . 567 Drawing up of legs in intestinal Duodenum, carcinoma of (see hysteria 565, 665, 798 colic in children. . 473 Carcinoma of Duodenum) mercurial tremor 797 Dreams, terrifying 447 - catarrh of, jaundice from. . 361 primary lateral sclerosis 565 Dribbling of saliva (see Ptyalism) pancreatitis secondary to 116 professional cramp . . 177 Drinking, polyuria from 581 ,583 - congenital malformation . . 151 spasticity in . . 341 800 - excessive, oedema from 458, 460 - normal situation of 722 sphiricter trouble in simulation of acute - obstruction, absence of 547, 565. 806 nephritis 458 distention in 152 " staccato " or " scanning' - secret, difllculty of diagnosing 599 visible gastric peristalsis speech in 342, 686 800 Drooping of eyelid (see Ptosis) in .. .. 570, 571 suprabulbar dysarthria in 686 Dropped foot in paralysis of - reflex constipation in diseases unilateral convulsions in 170 ext. popliteal nerve 543 of 144 variation of symptoms (see Paraplegia and - surgical emphysema from. . 231 suggesting neurosis . . 565 Paralysis) - swellings of, in epigastrium 725 vomiting in 328 - wrist in lead poisoning 551 - ulcer of, acute pallor in . . 300 Distention of abdomen (see Dropsy (see CBdema and Ascites) - - albumosuria in . . 20 Abdomen, Distention of) Drowsiness in. cirrhosis of liver 368 anajmia in . . 37 , 40 - bladder (see Bladder, Dis- - organic cerebral disease . . 328 blood per anum in 89 tention of) - phosphorus poisoning 373 coma from bleeding 137, 140 - gall-bladder (see Gall-bladder - uraemia . . . . 45, 329 communicating with sub- Distended) Drugs, anaemia due to 37 phrenic abscess 712 Distoma hepaticum, ascites - antipyretic, rigors from 648 diagnosis from gastric ulcer 300 from 364 - aphrodisiac 586 - - epigastric pain from 295 enlargement of liver from 364 - black urine after . . 820 erosion of vessels in 300 flukes and ova in vomit 364 - brown urine after . . 820 ex-treme thirst due to . . 789 jaundice from . . 361, 364 - coloiu-ation of skin due to 424 ,575 haematemesisin89,294, 300 ,780 pain in right hypochon- — of urine due to " hunger pain " of 300, 500 drium from 364 818,819,820 823 hyperacidity of gastric in sheep . . 364 - convulsions due to. . 169 170 juice in 89 vomiting, fever, and diar- - deafness from 191 indigestion with . . 780 rhoea in 364 - delirium due to 195 kinking of bowel from . . 147 - pulmonale Westermanni, - diazo-reaction from 198 loss of weight due to 848 geographical distribution 325 - dryness of mouth from 789 melEena in haemoptysis from 318, 325 - eosinophilia after . . 248 37,117,300,428, 500 780 and ova in sputum 325 - foul breath caused by 98 cedema of legs after 459 Disuse atrophy in hysterical taste in mouth from 774 pain in . . 89 joint 390 - green urine after . . 823 the right hypochon- - of muscles a cause of con- - ieucocytosis due to. . 400 drium in 500 tracture . . . . 163, 165 - loss of smell from . . 668 perforated, peritonitis from Diuretics, polyuria from 581, 582 - cedema of legs caused by 459 55, 431, 644, 780 Diuretin in abdominal angina - pityriasis rubra after 658 pneumoperitoneum due 351, 486 - ptyalism from 590 to 711 Divarication of the recti. - purpura due to various 596 severe shock and collapse 484 evident on raising the - raslies simulating syphilides 426 sudden severe epigastric head from the bed 524 itching and burning in . . 426 pain in 484 pain in umbilical region - skin eruptions from tenderness in the hypo- in . . . . . . 524 424, 426, 603, 655, 658 834 gastriimi from 780 test f or . . 148 - that slow the heart 98 in the right iliac unnoticed in the recum- - tachycardia due to 772 fossa from 780 bent position . . 524 - tinnitus from 794 pleurisy from 123 visible peristalsis with . . 570 - tremor due to . . 795, 797 pneumothorax from Diverticula of colon causing Drug-taker, shifty eyes of . . 258 abscess due to 578 acute intestinal obstruction 151 Drummer's cramp 177 ptyalism in 591 in old people 146 Dryness of the mouth (see severe hfemorrhage from 789 - - simulating carcinoma . . 152 :Mouth, Dryness of ; and sex incidence of . . 89 500 Diverticulitis, acute, age inci- Tongue) subphrenic abscess from dence of . . 152 - of skin in myxcedema 585 501, 578, 720, 721 resembling appendicitis . . 731 Duchenne's palsy, injury at; surgical emphysema from 231 - simulating carcinoma 146 152 birth causing 552 thickening round, dia- - swelling in iliac fossa from 731 Ductus arteriosus (see Patent gnosis from enlarged - vcsico-colic fistula from . . 146 Ductus Arteriosus) gall-bladder . . 406 DUODENUM, ULCER OF— DYSTROPHIES, MUSCULAR 893 J)iiodcrmm, ulcer of, contd, uroljilinuria with vomiting in . . 89, 300, ' - visible gastric peristalsis in stenosis of Dupuytren's contracture (see also Contractures} illustrated - fracture causing talipes Duskiness of face and extremi- ties in spleuomegalic poly- cytlutmia Dust, cough due to . . - inllammation of soft palate, uvula and fauces from . . DWARFISM Dj'ers, nail-staining in Dynamometer . . Dysarthria from bilateral bulbar palsy cerebral diplegia facial palsy peripheral palsy of palate - definition of - in disseminated sclerosis . . - electrical reactions in tongue in . . - functional . . - from gummatous meningitis at base of brain . . - hasmorrhage into bulb - in hemiplegia . . 336, - myasthenia gravis . . - palate reflex of - in pseudo-bulbar palsy - from softening in bulb - suprabulbar . . in general paralysis of the insane . . - tongue atrophy in . . - tumour of bulb Dyschezia, bismuth test in . . - constipation from . . - diagnosis of causes of 148, ' - from fibrous stricture of rectum - invagination of rectum . . - pressure of gravid uterus. . on rectum and colon - .r-ray illustration of Dysentery, albuminuria in . . - albumosuria in - amceba in 91, 196, 408, 651, ' - arthritis in . . - atony of bowel after - bacterial . . . . 91, - blood per rectum in 90, 501, - colic in - coma in - cyanosis in . . - cystitis from . . 31S - diarrhcea in . . 196, - enlarged mesenteric glands in . . - hajmaturia in - hyperpyrexia in - indicanuria in - inspfesation of the blood in - involvement of bladder in - liver abscess after 279, 323, 408, 651, - loss of weight in . . 69 - meteorism in - mucus in the stools from . . - pain in the left iliac fossa in - peritonitis from - purpura in . . - pus in the stools . . 501, - rigors in - serum reaction in . . - sex incidence of - Shiga's bacillus in . . - sigmoidoscopy in . . - stricture of colon after Dysentery, could. lie - tenderness in the right lum- 780 bar region from . . 727 - tenesmus in 91, 196, 501 571 - ulceration of rectum in 635 Dysidrosis affecting lingers . . 266 385 - bulla) in 111 167 - relation to miliaria and 132 hidrocystoma - (see Sweating, Abnormal- ities of) 831 581 DYSMENGRRHCEA .. 219 175 - due to appendicitis - conditions it may be mis- 737 072 taken for 220 212 - membranous, described, 219, 220 444 - primary, described 219 337 - with pyosalpinx . . 632 - secondary, described 219 686 - spasmodic . . . . 219, 509 686 Dysostosis, cleido-cranial 213 687 DYSPAREUNIA 22J 687 - from lu-;uin),sis 770 680 - sterility due to 700 686 Dyspepsia (and see Indigestion) 349 - acute, emotional causes in 374 687 ptyalism in 591 688 - asthenic, in atonic dilata- tion of stomach . . 354 687 - bleeding gums m . . 85 , 87 687 - in catarrhal jaundice 304 687 - children, tea-drinking caus- 687 ing 357 686 - chronic with pancreatic cyst 724 686 - in cirrhosis of liver 410 687 - cough due to 175 686 - diagnosis from aortic aneur- ysm 476 686 fatty heart 526 687 - diminution of appetite in. . 49 687 - flatulent, pain in chest and 142 palpitation in 484 141 - foul breath in 99 149 - functional achylia and hyper- chlorhydria in 354 150 - headache in 328 150 - hyperstlienic 354 150 - insomnia in . . 356 150 - lack of muscular tone in . . 520 142 - loss of weight due to 848 17 - nervous, and oxaluria 471 20 - in neurasthenia 506 704 - organic, differential diagnosis 376 of 351 144 - oxaluria with . . . . 311 471 051 - pain in back in 476 727 chest from . . 481 779 501 - palpitation in 526 136 difficult to diagnose from 187 myocardial disease . . 526 , 633 - from pyorrhoea alveolaris. . 87 ,501 - simulated by dysmenorrhoea 220 gastric carcinoma 299 848 422 leaking gastric ulcer 721 305 - simulating heart disease 526 ,779 344 - spasmodic pelvic pain in . . 509 349 - tenderness in the chest from 779 187 - tinnitus with 794 313 - ulceration of tongue in 812 , 814 - in venous congestion of livei 407 ,704 DYSPHAGIA 222 ,848 - from acute cervical adenitis 674 432 - aortic aneurysm . . 482 841 727 - bilateral facial paralysis . . 591 501 - bulbar palsy 591, 641, 687 , 842 55 - carcinoma of oesophagus 596 295, 484 , 841 ,601 - cicatricial sti-icture of cbso- 647 phagus . . 222, 484 , 841 196 - diphtheritic paralysis 591 727 - fixation of jaw 591 196 - fracture or dislocation of 501 jaw 591 146 - m "functional aphonia 538 591 Dysphagia, contd. - hydrophobia - from hypoglossal paralysis - idiopathic dilatation oesophagus - loss of weight from - lusoria described . . - mumps - myasthenia gravis - nervous causes - oesophageal pouches - oesophagismus - osteo-arthritis - paralysis agitans . . - pemphigus of mouth - pseudo-bulbar paralysis - ptyalism from, in jaw lesions 591 in oesophageal affections 591 - quinsy . . . . . . - sore throat . . - spasm of oesophagus - stenosis of oesophagus of pharynx from syphilis - stomatitis . . ve 591 of 841 847 223 591 674 591, 842 224 84 484 591 591 591 591 073 841 222 86, 88 792 591 226 233 582 46ft 303 484 - thyroid gland tumour - tonsillitis DYSPNEA - in aortic disease - from bilateral laryngeal paralysis . . 537, 539 - broncho-pneumonia . . 642 - capillary bronchitis . . 642 - cardiac and renal, asthma mistaken for - caseous bronchial gland ir- rupting into bronchus . . - in chlorosis - chronic mediastinitis - congenital heart disease, 244, 790 - embolism of the lung 185, 320 - enlarged heart froni over- exertion . . thyroid gland - the essential symptom of asthma - in fatty heart - fibroid heart lung - foreign body in larynx . . - hepatoptosis - hydropneumothorax - insomnia from in laryngeal diphtheria 244 793 582, 241 241 246 642 407 712 359 642 - paralysis . . . . . . 53S) laryngismus stridulus . . 406 - from mediastinal growth . . 483 - mitral regurgitation . . 238 - in myocardial degeneration 333 - myocarditis . . . . 241 - non-obstructive anuria . . 46 - osteitis deformans. . . . 763 - paroxysmal, Charcot-Leyden crystals in . . . . 118 in mediastinal growth . . 483 - pneumothorax . . 185, 480 - polycythnemia frequently associated with . . . . 580 - due to pulmonary stenosis 247 - retraction of the head in . . 642 - retropharyngeal abscess 225, 042 - ruptured heart valve . . 238 - spasmodic from asthma . . 467 urfemic . . . . 45, 329 DYSTOCIA 227 - caused by delay in delivery of placenta . . . . 229 - in etiology of talipes . . 131 - symptoms of exhaustion in 229 Dystrophies, muscular, diagnosis of peripheral neuritis from 561 electrical reactions in . . 561 family history in . . 560 infantile and juvenile types 500 894 DYSTROPHIES, MUSCULAR— ELECTRICAL REACTIONS l)jstrophies, muscular, contd. lordosis in . . . . 183 paralysis of arm in . . 555 paraplegia from . . . . 557 plantar reflex in. . . . 82 pseudo-liypertropliic . . 560 sensations normal in . . 561 talipes from . . . . 132 — primary muscular (see Myo- pathy) EAE, acute pain and sweiHns in fiTTunculosis of . . 409 — aXEections, tenderness of the scalp in . . . . . . 781 infantile convulsions from 1 70 neuralgia from . . . . 781 — - nystagmus from . . . . 453 referred pain from . . 498 Tertigo due to . . . . 828 — atrophy of, in lupus ery- thematosus . . . . G58 — bleeding from (see Bleedinsj from Ear) — bluish-black colour of, from ochronosis . . . . 822 — cerebrospinal fluid from, in fractured skuU . . . . 138 — coarseness in cretinism . . 258 — description of the . . . . 187 — diphtheria of . . . . 469 — discharge from (see Otorrhcea) — eczema of, a cause of cough 174 due to wax in . . . . 468 — enlargement in Mongolian idiocy . . . . . . 263 — epithelioma of (and see Car- cinoma) . . ... 419, 468 — examination of, in bleeding from the ear . . . . 468 in cases of otorrhcEa . . 470 obscure pyrexia . . 018 — foreign body in (see Foreign Bodies) — gangrene of, in Eaynaud's disease . . . . . . 284 — glands of . . . . . . 467 — granulations in . . . . 469 — herpetic eruption on, in peripheral facial paralysis 536 — hyperostosis of, in leontiasis ossea . . . . . . 749 — injury of, from blow on chin 467 — ivory exostosis of . . . . 754 — nerve supply of . . . . 481 — noises in (see Tinnitus) — pain in, from glaucoma . . 257 — I'olypi of, discbarge from . . 468 from caries . . . . 469 — sodium urate in, in gout 381, 507 — swollen and iaflamed in otitis media . . . . . . 469 — syringing of, vertigo due to 828 — tenderness of, in otitis media 230 — thickening in myxoedema . . 259 — tophi in, in gout . . . . 507 simulation by projection of cartilage . . . . 381 — use of in detecting slight XJulsation . . . . 235 — wax in, a cause of cough . . 174 EARACHE 229 Earth eating . . . . . . 11 5 — tetanus from infection from 652 Eating, excessive, effect on uric acid . . . . . . 817 Ebumation of bone in osteo- arthritis . . . . . . 384 Ecchondroses, ankylosis of joints from . . . . 167 Ecchymosis (see Purpura) Echinococcus disease, alveolar 416 — booklets in ascitic fluid (Fi(i. 6j (and see Hydatid; 57, 58 Eclampsia - albuminuria in - epileptiform convulsions in - in pregnancy - simulating a rigor . . Ecthyma, definition of - in impetigo contagiosa - relation to impetigo 601, - scabs in - vacciniform, of infants Ectopic gestation (see Gesta- tion, Ectopic) - testis (see Testis, Ectopic) Ectothrix in ringworm Ectromelus Ectropion, epiphora from Eczema, acuminate pustules in - affecting fingers naUs . . . . 275, - anidrosis with - baldness from - burning sensation in - catarrhal character of - character of papule of 528, - crusts in . . . . 829, 172 647 647 160 647 602 654 602 653 446 - diabetic, pain in perineum from starting in penis or vulva - diagnosis from cheiropom- pliolyx . . dermatitis herpetiformis eczema marginatum erythema intertrigo erythrasma favus follicular impetigo granulosis rubra nasi herpes impetigo contagiosa lichen planus . . ruber planus . . scrofulosorum . . miliaria rubra mycosis fungoides Paget's disease . . papular syphiloderms . . jiityriasis rubra . . prurigo ferox . . 531 psoriasis . . ringworm of body scalp scabies small flat pustular syjili- ilide smallpox . . sycosis vulgaris . . tinea versicolor . . - of the ear, cough from 174, earache from otorrhcea from . . - eosinophilia in - erythema in - fissure of the lips from - f olliculorum . . - gouty . . . . . . - impetiginous, simulated by cutaneous diphtheria . . - impetigo in. . - intertrigo, distribution of. . at umbUicus in fat dirty people . . - itching in . . 529, 533, 588, 657, 781, - of lips . . . . 403, - marginatum in bathing- drawers area and dhobie's itch diagnosis from eczema . . eczema seborrhoeicum erythrasma epidermophyton inguinale in '. . . . 273, general account of non-involvement of hair in 273 214 250 601 266 ,445 714 84 602 533 533 831 516 447 832 831 275 253 276 272 602 714 831 831 832 529 529 831 804 803 533 658 ,532 657 275 274 831 604 608 602 276 175 230 468 249 831 653 528 516 602 781 447 524 602, 831 653 447 275 275 275 276 275 275 275 Eczema marginatum, contd. parasitology of . . . . 275 - oedema and infiltration of skin in 608 - papular, intense itching in . . 529 - papules in .. ..275,529,831 - pityriasis rubra after . . 658 - pustular, general account of 602 - pustules in . . 602, 831 - scabs in . . . . . . 653 - scales in 275, 655, 656, 657, 831 - sebOrrhCBicum of infants 275,276 napkin-region incidence of 446 - tenderness of the scalp from 780, 781 529, 714,829,831 253, 653, 714, 831 (see Liver, 118 387 387 388 121 361 177 763 445 313 649 197 518 - vesicles in . . - weeping in . . Edge of liver Edge of) Effusion, bloody, in chest . . - in joint in intermittent hydrarthrosis periodic, in intermittent hydrarthrosis . . in tabetic arthritis - into pericardium (see Peri- cardium) - perinephric (see Perinephric Effusion) - pleuritic (see Pleuritic Effusion) - serous, in cliest (see Chest, Serous Effusion in) - tuberculous pleuritic, inocu- lation of guinea-pig in . . - yellow, pleural, pericardial, peritoneal, in jaundice . . EGG-SHELL CRACKLING .. in osteosarcoma - nail with hyperidrosis Egypt, bilharzia in . . 93 - relapsing fever in . . Ehrlich's diazo-reaction Ejaculatory ducts, infection in gonorrhoea Elastic fibres, method of demonstrating . . . . 99 in sputum 185, 288, 316, 317, 319, 321, 651, 701, 703 Elbows, osteo-arthritis of . . 384 - predilection of psoriasis for 530, 656, 657 - rheumatic nodules of . . 804 - seborrhceic dermatitis of . . 447 - tuberculous disease of . . 385 Elbow-joint disease, arm atrophy in Elder, dwarf, polyuria after . . Electric blindness - currents, gangrene from . . Electrical reactions (and see Keaction of Degeneration) in acute poliomyelitis 70, 555, amyotrophic lateral sclerosis 554 atrophic palsy of arm . . 549 bulbar paralysis . . . . 687 facial paralysis . . 535, 536 Friedreich's ataxy . . 71 hysterical paralysis . . 541 of muscles and nerves, normal. . in muscular atrophy myasthenic myopathies neuropathic muscular atrophy paralysis from cervical rib 554 peculiarities, apart from H. D 634 peripheral neuritis 66, 75 progressive muscular atrophy . . . . 73 spastic monoplegia . . 540 582 840 559 633 69 225 70 633 ELECTRICAL REACTIONS—EMPYEMA 895 lilectrical reactions, contd. Embolism of the lung, contd. Emph;/sema, contd. supranuclear facial paralys s mitral stenosis 320 - enlarged right ventricle in 534, 536 multiple abscesses from 649 245, 246 syringomyelia . . 551 otitis media 578 - epistaxis in. . 251 tetany 634 sources of 186 - eversion of lower ribs in . . 404 - - Tliomsen's disease 634 sudden death in . . 321 - flatulence in 267 I'Uectricity in functional par- - mesenteric . . . • 432, 646 - general pains in the limbs in 503 alysis of vocal cords 538 anal haunorrhage from . . 90 - hasmoptysis in . . 317, 320 - in dia'»nosiasc pains referred constipation with 153 - heart failure from from viscera 475 intestinal obstruction from 432 61, 186, 464, 525 I'lloctrotlierapy in insomnia melaena and hiematemesis 153 - inelasticity of skin with . . 186 with high, blood-pressure 359 mcteorism with . . 432 - insomnia in . . . . 356, 359 Elephantiasis .. -. 33, 456 - T simulating peritonitis . . 646 - liver dullness lost from . . 406 - cliylous ascites in . . 58 - monoplegia from . . 546 - local bulging of chest-wall - chyluria with 126 - multiple, in fungating endo- from 193 - from filaria sanguinis hominis carditis . . . . 9, 10, 699 - orthopncna in . . 186, 464 765, 810 - numbness of limb from . . 286 - pain in the chest in 480 scrotal enlargement in . . 765 - pain from . . 286 epigastrium from 485 - scroti, occurrence in the - paraplegia from 563 - palpitation in . . 525, 526 tropics 765 - predisposing causes of 286 - periodic cyanosis from 579 - testicular atrophy in 78 - progressive ana?mia with . . 138 - physical signs of 101, 186, 192 Eleventh nerve (see Spinal - pyrexia with X38 - pneumothorax from 577, 578 Accessory) - of radial artery, inequality - polycytha;mia in . . 579, 580 Emaciation (and see Marasmus, of pulses in 593 - shortness of breath in and Weight, Loss of) - renal, albuminuria in 8, 9, 237 101, 526, 579 - in alcoholic neuritis 78 htematuria from . . 237 - subcutaneous (see Emphy- - anorexia nervosa 50 - rheumatic history in 138 sema, Surgical) - cachexia alkalina 115 - of spinal cord 565 EMPHYSEMA, SURGICAL .. 231 - cancerous peritonitis 57 - splenic enlargement with abdominal distention from 716 - carcinoma of rectum 636 138, 699 692 swelling from . . 715 - in malignant growth of ovary 759 - suddenness of symptoms in 286 crepitus with . . 179, 716 - iihosphatio diabetes 572 - after thrombosis of Uiac vein egg-shell crackling in . . 177 - i)hthisis 194 186 456 due to gas-producing - progeria 218 - uncinate gyrus, anosmia from 669 microbes . . 231 716 - pyfemia 372 Embryoma of kidney, histology 395 from injury to chest . . 578 - Still's disease 40 haematuria in 304, 307, 395 wounds produeincr 716 - stricture of oesophagus . . 484 occurrence in children . . 395 - tenderness in the chest from 778 - tropical abscess of liver . . 369 symptoms of 307 - thoracic telangiectases in 826 Embolism, absence of pulsa- - of fiver 413 - uterine, hyperaemia from . . 430 tion in limb after 286 - testis (see Testis, Embryoma of) menorrhagia in . . 428 - albuminuria due to. . 237 Emetics, vomiting from 843 - wheezing in . . 526 - aneurysm from . . 367 699 Emissions, nocturnal, with Emprosthotonus in tetanus . . 162 - of central retinal artery, impotence 347 Empyema, without abnormal sudden blindness from . . 839 Emotion, acute yeUow atrophy physical signs 99, 323, 703 ophthalmoscopic ap- of liver preceded by . . 370 - in abnormal situations 703 pearance of (Plate YIll, - angina pectoris from 482, 778 - albuminuria in 17 Fig. S) 463 - convulsions from . . 170 - album.osuria in 20 - cerebral .. 82,128,137,138, 155, - diarrhoea from 197 - anaemia in . . 39 173, 237, 285, 327, 328, 337, - disproportionate exuberance - with bronchopneumonia . . 186 338, 516, 685, 699 in paralysis agitans 262 - bulging of chest-wall with 192 ,193 acquired paralysis of in double hemiplegia 258 - clubbed fingers in.. 99, 128 childliood due to 155 dyspepsia from . . 355, 374 - compression of lung from . . 324 apliasia from 685 - expression of, diminished in - diagnosed by needling chest 186 athetosis after . . 155 tabes 262 from gangrene of lung Cheyne - Stokes respira- - in hysteria . . . . 173, 798 288, 321, 703 tion from 125 - jaundice from . . 362, 374 - diapliragm immobilized by 721 coma from ..137,138 237 - loss of control of expression - difficulties in locating 119 headache in . . 327, 328 of, in pseudo-bulbar palsy 686 - displaced cardiac impulse in 330 - - hemaniopsia from 335 - menorrhagia from . . 428 - fibroid lung and bronchiec- hemiplegia from . . 338 - motor tics increased by . . 160 tasis from 324 loss of consciousness in. . 338 - movements of, uncontrolled - foetid sputum in . . 321, 703 rheumatic history in 338 in facial paralysis 536 - foul breath in 99 sudden transient coma - myoclonus increased by . . 160 - hsemoptysis in . . 317, 323 and hemiplegia from.. 099 - palpitation from . . 525, 527 - indicanuria due to.. 349, 821 - in f ungating endocarditis (see - ptyalorrhoea caused by . . 592 - lardaceous disease from 10, 696 Fungating Endocarditis) - tremor from 795 - latent . . . . 119, 650 - gangrene from . . 282 286 Emphysema, albuminuria in 18 - leucocytosis in . . 400, 401 - liLvmaturia due to . . 237 - ascites in . . 61 - after measles 050 - haemorrhages with . . 138 - asthma developing into scarlet fever 650 - from heart lesions . . 138 155 180, 186, 582 - mistaken for abscess of - heminlegia from - barrel-shaped chest in 191, 404 chest-wall 193 82,138,237,285 337 - and bronchitis (and see - osteo-arthropathy in 390 - of hepatic artery . . 59, 367 Bronchitis) 246 - pain in the chest in 478, 480 - of the lung, acute cyanosis - cardiac dullness in . . 331 - periostitis in 776 from 185 - clubbed fingers in . . 128 - physical signs of . . 119, 192 from appendi"itis 123 - compensatory, in fibroid - after pleurisy 6.50 caasing pleuritic effusion 123 lung 246 - pneumococcal 122 dyspnoea in 185 - constipation in 149 - after pneumonia . . 323, 650 gangrene of lung from . . 287 - cyanosis in . . . . 186, 479 slight value of leucocyte hsemoptysLs in . . 186, 317 - dilatation of heart in 246, 485 526 count in diagnosis of. . 401 intrathoracic pain in . . 185 - diminished liver dullness in 404 - pointing on chest- wall in 193 478 from lateral sinus throm- - displaced cardiac impulse in - post-critical intermittent bosis 578 232, 330, 331 fever in pneumonia due to 622 lividity in 185 - dyspeptic symptoms in . . 526 - retraction of chest-wall after 194 BMP YEMA —EOS IN Empyema, contd. - rigors with . . . . Ci8, 650 - rupture into bronchus . . 578 causing pneumothorax. . 577 - - into lung.. ..99, 323, 703 diagnosis of . . . . 703 previous history of pneumonia in . . 703 no elastic fibres in sputum in 703 foul taste from . . . . 774 sputum in ..99, 321, 703 - scoliosis from . . . . 180 - secondary to abscess of liver 409 to otitis media . . . . 123 - septicaemia from . . 614, 698 prolonged pyrexia in . . 609 - shrinkage of chest after . . 193 - simulating hepatic abscess 779 - simulation by tropical liver abscess . . . . . . 369 - suggested by ansemia. in bronchopneumonia of chil- dren 39 - subdiaphragmatic inflam- mation causing . . . . 122 - from subplirenic abscess . . 720 - tenderness of the spine in. . 785 - undiscovered, difficulty of exploration with needle in 703 - varieties of cause and posi- tion of 119 - 2;-rays in diagnosis of . . 721 - of antrum of Highmore (see An brum of Highmore) - of frontal sinus (see Frontal Sinus) - of gall-bladder (see Gall- bladder, Empyema of) Encephalitis, acquired paraly- sis of childhood due to . . 155 - acute constitutional symp- toms in . . . . . . 547 hemiplegia from. . 337, 338 optic nem-itis in . . 139 pupils in . . . . . . 594 retraction of the head in 641 simulating meningitis 558, 643 symptoms of . . . . 139 vomiting in . . . . 139 - ataxy from . . . . . . 69 - athetosis after . . . . 155 - coma due to 136, 55S, 643 - convulsions in 139, 547, 558 - diagnosis of sup. longitu- dinal sinus tlirombosis from 558 - general head symptoms in 558 - headache in . . 139, 547 - infantile diplegia due to . . 556 - monoplegia from . . . . 547 - paraplegia due to . . . . 556 - pyrexia in . . . . 547, 558 - vomitmg in.. .. 547, 558 Encephalocele, diagnosis from dermoid cyst . . . . 254 - unilateral exophthalmos from 254 Encephalopathy, saturnine (see Saturnine Encephalopathy) ■ ■ 744 Enchondroma of breast - simulating sarcoma (Fig. 195) Encysted hydrocele (see 113^- drocele) Endarteritis, gangrene from. . - preceding paraplegia, his- tory of sjrphilis in - syphilitic . . 327, 337, 563 cerebral, headache in . . 372 cutaneous ulcers in . . 338 hemiplegia from 337, 338 premonitory symptoms 337 without loss of con- sciousness m . . 338 AVassermann's serum re- action in . . . . 338 754 282 563 Endocarditis, acute, changes followmg . . . . . . 240 - in acute rheumatism 103, 121, 504, 671 - aortic disease due to 106, 236. 237 - bruits in 102, 103, 105, llOi 671 - cerebral embolism from . . 173 - changes in heart sounds with 239 - in chorea . . . . 103, 156 - common causes of . . . . 236 - diastolic bruits in . . . . 106 - embolism from . . 173, 286 - in erysipelas . . . . 103 - fungating (see Fungating Endocarditis) - hfem.aturia from . . . . 305 - impulse displaced with . . 239 - not indicated by tempera- ture chart 103, 239, 622 - infarct of lung from . . 322 - infected or infective (see Fungating Endocarditis) - malignant (see Fungating Endocarditis) - mid-diastolio bruit of . . 110 mitral murmur in . . 639 - mitral regurgitation from.. 239 stenosis from . . . . 240 - monoplegia due to . . . . 547 - palpitation from . . . . .239 - in pneumonia . . . . 103 - precordial pain from . . 239 - in puerperal fever . . . . 103 - pulmonary regurgitation from 107 - pulse-rate in . . . . 239 - pvrexia absent with 103, 622 " due to 622 - in septicEemia . . . . 103 - systolic aortic bruit in . . 105 bruit over mitral area in acute .. 102, 103 - ulcerative (see Fungating Endocarditis) Endolymph, rise in pressure of, causing deafness . . 190 Endometritis, acute, in zymotic diseases . . . . . . 429 - blood-stained watery dis- charge from . . . . 435 - cachexia in.. .. .. 114 - chronic, ansemia in . . 39 backache from . . . . 220 - diagnosis from uterhie scrap- ings .. .. .. 429 - dysmenorrhoea from 219, 220 - enlargement of uterus from 220 - infective peritonitis from.. 644 - leucorrhoea from . . . . 220 - menorrhagia from 210, 220, 428 - metrorrhagia from 433, 435 - pelvic pain from . . . . 508 - Pozzi's syndrome in . . 429 - sacralgia in . . . . . . 509 - senile, metrostaxis from . . 436 foul vaginal discharge from 211 - sterility due to . . . . 706 - vaginal discharge due to . . 210 - in virgins . . . . . . 429 Endometrium abnormal m dysmenorrhcEa . . . . 219 Endoscope 208 - in diagnosing impacted cal- culus m uretlira . . . . 511 urethral stricture 439, 440, 511 - examination in cases of stricture . . . . . . 678 in cases of urethral fistula 678 - herpes of uretlu-a seen with 209 - and soft sores in urethra . . 209 - and urethral affections . . 208 calculus . . . . . . 210 papillomata . . . . 209 205 395 287 204 640 766 768 273 736 Endothelioma of antrum of Highmore, purulent rhin- itis from . . - kidney - lung . . - nose - palate - testis - vulva Endothrix in ringworm Endotriches, Sahouraud's classification of . . Enemata in diagnosis of car- cinoma of sigmoid colon of cause of swelling in right iliac fossa fffical tumours 393,499,501,691 intestinal obstruction . . 151 nature of constipation . . 142 - relief of pain by, in faecal accumulations . . . . 499 - vomiting caused by 844, 846 Enlargement of a bone (see Bones) - of gall-bladder (see Gall- bladder Enlarged) - heart (see Heart, Enlarged) - joints (see Arthritis) - kidney (see Kidney, En- larged) - lacrymal gland (see Eacry- mal Gland, Enlarged) - liver (see Liver, Enlarged) - lymphatic glands (see Lym- phatic Glands) - prostate (see Prostate En- larged) - salivary glands (see Salivary Glands, Enlarged) - spleen (see Spleen, Enlarged) - testis (see Testis, Enlarged) - thjToid (see Thyroid Gland, Enlarged) - tonsils (see Tonsils, Enlarged) - uterus (see Uterus, Enlarged) ENOPHTHALMOS .. - in paralysis of cervical sympathetic . . 590 Entassement ui sphial cord lesions causmg paralysis Enteric fever (see Typhoid Fever J Enteritis, in cirrhosis of liver 409 - indicanuria in . . . . 349 - mucus and blood in stools in 444 - simulating ascites . . . . 717 Entero-colitis of infants, blood per anum in . . . . 92 Enterogenous cyanosis . . 187 Enterolith in the rectum . . 635 Enteroptosis, abdominal swell- ing from . . - illustrated . . - jaundice in . . - undue abdominal aortic pulsation associated with Enterospasm in abdominal neuralgias - constipation from . . - distinction from tumour or intussusception . . - induced by takmg food - mucus and membrane motions in - obstinate constipation in . . - pain in the epigastrium in relieved by passage of flatus . . pressure ENURESIS - in children, nocturnal Envelope crystals in urine (see Oxaluria) Eosin, fluorescence due to - pink urine from . . 819 - staining of mucus by 247 594 543 inl 715 721 367 592 473 144 134 486 486 486 486 486 486 247 471 820 820 444 EOSINOPHILIA—EPISTERNAL FULLNESS 897 EOSINOPHILIA (J'laia 11, Jil> id ill III II il IK , iij nid. Einlejjuy, conld. Fici. L, p. 28j . . 248 - tuberculous, yeneral account of 767 - palpitation in . . 525, 527 - in Addison's disease 38 scrotal sifius from 767 - partial 171 - ankylostomiasis 570 suiipuration in most cases of 766 - pavor noctumus in connec- - associated witli parasites 33, 249 (see also Testis, Tubercu- tion with. . 357 - in astlima .. 118, 179, 180, 582 lous disease of) - peculiar sense of size in . . 840 - bloody effusion due to new - varieties of . . 766 - perverted taste in . . 774 KTowths of pleura 118 - vertical elongation of scrotal - polyuria in . . .. 581, 583 bullous dermatoses 114 swellings due to. . 766 - priapism in . . 586 - exceptional in round-worm Epididymo - orchitis, acute. - pupils dilated with retention infection . . 569 acute hydrocele accom- of reflexes in 594 - in fjlaria-sis . . 126 panying . . 522 - relaxation of sphincters in 160 - with hydatid cyst of liver causes of . . . . 517, 518 - simulated by heart block . . 97 58, 279, 413, 415, 719, 720 general account of 517 rigors 646 of luns . . 323 - gouty 818 - smell aura preceding 669 - with multiple subcutaneous Epigastric angle, widening of - spasm of the glottis as an cysticerci . . 452 by ascites 50 aura in . . 828 - in post-febrile states 248 by emphysema 246 - subconjunctival hemorrhage - tape-worm infection 568 - herniae (see Hernia, Epiga.stric) in 256 - trichinosis . . . . 504, 801 - reflex in spastic paralysis of - tetanic contractions in 161 Eosinophile cells in normal one leg . . 540 - treatment by indigo blue . . 82.? blood .. .. 28, 248 - sensation in epileptic aura . . 80 - trismus simulated by 801 - myelocytes (Plate 11) 29 Epigastrium, bulging of, from - unilateral convulsions in . . 170 Epicanthus in Mongolian subphrenic abscess 720 uncommon in . . 174 idiocy .. .. 263, 264 tropical abscess of liver. . 369 - vertigo in . . 828 Epidemic gangrene . . 282, 287 - definition of 722 - vomiting in 844 - jaundice (see Jaundice, Epi- - injury to, vomiting from . . 844 - warning spasms of . . 160 demic) - organs normally contained in 722 Epileptiform convulsions (see - relapsing fever 649 - pain in (see Pain in Epi- Convulsions, Epileptic) - trichinosis 801 gastrium) - neuralgia (see Trigeminal Epidermolvsis bullosa, - pulsation in, in acute dilata- Neuralgia, Major) 495 ]]0, 113, 2G6, 445 tion of heart 243 EPIPHORA 250 Epidermophyton inguinale 273 275 congenital heart disease 244 - in acute conjunctivitis 2.55 - Perneti 275 with enlarged right ven- - from cicatrization in lachry- - riibrum 275 tricle . . 232, 245, 246 mal duct . . 250 Epididymis, cystic disease of, in fibroid lung 246 - Graves' disease 261 age incidence of . . 767 in mitral regurgitation . . 238 - in inflammation of eye . . 2.50 painless and harmless stenosis 245 - injury of lachrymal duct . . 2-50 nature of . . 767 - tenderness in (see Tender- - in nuclear facial paralysis 536 solitary 767 ness in Epigastrium) Epiphyses, enlargement of, in translucency of cysts in 767 - tuberculous masses in 724 rickets 695 - encysted liydrocele of 521, 765 - tumour in, in carcinoma of - injury or inflammation of - enlargement of, causes of.. 766 stomach . . 351 tibial, causing talipes . . 1.32 - fibrous scar in, from former due to scybala . . 724 - separation of, in congenital epididymo-orcliitis 518 - various tumours felt in syphilis . . 752 - gonococcal infection of 207 767 723, 724 725 popliteal swelling due to - inflammatory lesions of (and - visible gastric peristalsis in 723 761 763 see Epididymo-orchitis) 517 Epiglottis, tuberculosis of . . 325 in syphilitic pseudo-paraly - new growth of 767 Epiguanin bases, uric acid sis 386 - nodules in, gonorrhceal 307 767 derived from 817 Epiphysitis in congenital sy- in secondary syphilis . . 519 Epilepsy, aphasia after 686 philis 752 tuberculous 307, 518, - amnesia in . . 25 Episarkin bases, uric acid 630, 680, 767 - athetosis in 154 derived from 817 with tuberculous testis . . 680 - aura in (see Aura) Episcleritis, causes of 256 - pain in, from fibrous scar. - automatism in 25 - distinction from conjuncti- diagnosis from tubercu- - Babinski's sign in . . 82 vitis 256 losis 518 - biting of tongue in. . 646 Epispadias, changes in stream - thickened and painful in - cardiac thumpings at night in 527 of urine in 438 epididymo-orchitis 517 - in children . . 170 EPISTAXIS 250 - tuberculosis of the 307, 519, — clonic spasms in 160 - in acute yellow atrophy of 680, 767 - coma in . . 82, 136, 160 646 liver . . . . 302 370 association with prostate 767 - convulsions in 160 - alcoholism . . 368 tuberculosis of spermatic - deafness from 191 - anaemia after 36 cord 523 - dementia from 360 - in Bright's disease 90 new growth simulating. . 767 - ef4uivalents of 686 - and cerebral embolism 138 with tuberculous bladder 441 - the fit described 169 - chronic nephritis . . 295 tuberculosis of vesiculse - fiushing as an aura in 268 - cirrhosis of liver 295, 300 696 seminales secondary to - headache in 329 - hsematemesis from swal- G29, 767 - imitated in hysteria 160 lowed blood in . . 294 Epididymitis, atrophy of testis - immobile pupil in . . 160 — hiEmophilia .302 from 454 - in infantile paralysis 155 - Henoch's purpura . . 90 - gonorrhceal, bacteriology in - an infrequent cause of - Hodgkin's disease . . 302 diagnosis of . . 454 766 mfantile convulsions 171 - leukamia . . . . 31 302 - involving spermatic cord . . 523 - involuntary micturition in 640 - multiple hereditary telangi- - from non-gonococcal ure- - irritability in 360 ectasis . . --0\ 251 thritis .. .. 206 766 - Jacksonian (see Jacksonian - purpura haBm.orrhagic*' . . 600 diagnosis of 766 Epilepsy) - recurrent 2.51 from tuberculous epi- - mild clonic spasms as - in relapsing fever . . 373 didymitis 767 " warnings " in . . 160 - scarlatina maligna . . 301 - relation of swelling to testis 766 - mimicked by malingerers. . 160 - typhoid fever . . 90, 697 - side-to-side flattening of - minor (see Petit mal) - variola maligna 301 swelling . . 766 - multiple bruising simulating - vicarious menstruation 251 - in syphilis . . 519 purpura due to . . 597 Epistemal fullness in acute - testicular atrophy in 79 - myoclonus in 160 mediastinitis 484 57 EPITHELIAL RENAL CASTS— EUROPE Epithelial renal tube-casts . . 7 Epithelioma adenoides cysti- cum . . . . " . . 805 - (see Carcinoma") - causing perineal sores . . GTS - histology in diagnosis of (and see Histology in Diagnosis) 420, 7G9, 803, 812 Epithelium in hsematuria of acute nephritis . . . . 311 Epitroehlear gland enlarged (see Lymphatic Gland^ Epulis, bleeding gums due to 86, 88 - fibrous . . . . . . 748 association with decayed tooth 748 displacement of teeth by 748 distortion of jaw by . . 748 microscopic examination in diagnosis of . . 748 origin of sarcoma as . . 748 softness of swelling due to 748 - malignant . . . . . . 756 Equilibrium, neuro-muscular mechanism of mainten- ance of . . . . . . 827 Erb's muscular dystrophy . . 70 fibrillary contractions rare in . . . . 158 - palsy, extent and causes of 552 - sign in tetany . . . . 178 Erections, Penile, absence of (see Impotence) Painful (see Chordee) in acute prostatitis or prostatic abscess . . 515 - - - age incidence of . . 585 in cavernitis . . . . 516 gonorrhoja .. .. 207 persistent (Priapism). . 585 Ergotism, gangrene from (see Gangrene, Epidemic) - purpura from . . . . 596 - simulating Raynaud's dis- ease or erythromelalgia . . 287 - tetany following . . . . 178 Erosion of cartilages in hyper- trophic osteo-arthropathy -iGO - - in joints in hemophilic artliritis .. 380, 388 lupus vulgaris . . 448, 808 - - in osteo-arthritis . . 384 - cervix (see Cervix, Erosion of) Eructatio nervosa . . . . 267 - - diagnosis from indiges- tion . . . . . . 351 Eructations in gastritis . . 297 relief of pain by . . 484 - in intestinal colic" . . . . 473 Eruptions, bullous, vesicular, etc. (see Bullae, Vesicles, etc.) Erysipelas, acute dilatation of heart from . . . . 243 - albuminuria in . . . . 17 - bacteriology in diagnosis . . 459 - baldness from . . . . 84 - in bathing-drawers area . . 447 - bullas in . . 110, 113, 746 - diazo-reaction in . . . . 198 - differentiation of erythema simplex from .. ... 252 - endocarditis in . . . . 103 - gangrene in . . . . 282 - hyperpyrexia in . . . . 343 - leucocytosis in . . . . 401 - oedema of face and arms from . . . . . . 4C1 or neck in . . . . 459 skin m . . . . . . 746 - prolonged pvrexia in (Fig. 166) ." 614 - pyrexia in .. ..611,698,746 - rash of . . . . 698, 746 Erysipelas, cmitd. - rigors in (Fig. 166) 614, 647, 648, 698, 746 - sharply defined border of. . 252 - simulated by lupus ery- thematosus . . . . 781 urticaria . . . . . . 850 - sloughhig in . . . . 746 - splenic enlargement in 692, 698 - streptococci m . . . . 113 - tendency to spread in . . 746 - tenderness of scalp from 780, 781 ERYTHEMA 252 - in acute rheumatism .. 6(1 - bullosum, bleeding gums in 86, 88 of the buccal cavity, dys- phagia in . . . . 225 - - buUa3 in . . . . 110, 113 eosinophilia in . . . . 249 - in cerebrospinal meningitis 643 - congenital syphilis . . . . 446 - at onset of dengue . . . . 506 - dermatitis herpetiformis . . 831 - eczema . . . . . . 831 - of fingers 266 - fugax . . . . . . 252 - gestationis, bullfe in . . Ill - with herpes zoster . . . . 830 - at onset of impetigo vulgaris 602 - indm-atum scrofulosorum . (see Bazin's Disease) - from inflammation . . 478 - intertrigo . . . . . . 252 area of distribution of . . 447 - from iodides or bromides. . 112 - iris, buUse hi . . 110, 113 eosinophilia in . . . . 249 relation to pemphigus . . 113 rings of vesicles in . . 832 - keratodes, nodules of . . 451 cedema and tenderness of palms and soles in. . 451 - of the legs, from excessive standing . . . . . . 450 - macular . . . . . . 423 - multiforme, diagnosis from small-pox . . . . 607 herpes zoster . . . . 830 distribution of . . . . 531 mainly on limbs . . 607 papular and other lesions of 531 pitjTiasis rubra after . . 658 scabs from . . . . 653 - simulation by prurigo . . 531 strophulus . . . . 531 urticaria . . . . 531 - slightness of itching in . . 531 - vesicles m . . . . 832 - in napkin region . . . . 446 - nodosum, absence of ulcers ia . . . . . . 450 - in acute rheumatism 121, 671 - - afEection of legs and feet in 450 - bilateral . . . . . . 751 - - colours of . . . . 450 - - diagnosis from acute osteomyelitis . . . . 751 nodular leprosy . . 450 syphilis . . . . 450 • - multiple red sweUings on shins in . . . . 751 ■ - pain and sweUing of joints 450 ■ - pyrexia m . . . . 450 ■ - simulated by varicose veins . . . . . . 450 ■ papulatum, staining of skin after . . . . . . 531 ■ in peliosis rheumatica . . GOO • pruritus in . . . . . . 588 ■ rheumatic, albuminuria with 18 ■ scabs in 832 • scales in . . . . 655, 656 scarlatiniforme . . 253 - desquamation after . . 656 Enjthema, scarladnijorme, contd. differentiation from Ger- man measles . . . . 253 measles . . . . 258 pitja-iasis rubra . . 253 strawberry tongue in . . 253 - simplex . . . . . . 252 diagnosis from macular stage of leprosy . . 424 - solare . . . . . . 252 - vesicular, perleche with . . 404 - vpsirnlosum, vesicles in . . 832 Erythemato-papular lesions, description of . . . . 528 Erythrtemia (see Splenomegalic Polycythasmia) Erythrasma m bathing-draw- ers area . . . . . . 447 - description of . . . . 276 - diagnosis from eczema marginatum . . . . 276 eczema seborrhoeiciun . . 276 pityriasis rosea . . . . 276 tinea vesicolor . . . . 276 - low contagiousness of . . 276 - microsporon minutissimum in 276, 277 - reddish-brown lesions of . . 276 Erythroblasts . . . . 28 Erythrocythaemia (see Spleno- megalic Polycythsemia) Erythromelalgia . . . . 490 - diagnosis from intermittent claudication . . . . 490 Raynaud's disease 284, 490 - in disseminated sclerosis . . 490 - an early sign of organic nervous disease . . . . 490 - elevation and cold relieve pain in . . . . . . 490 - flushing of extremities in 284, 490 - gangrene in.. .. 282, 284 - in some healthy persons . . 490 - heat and pulsation in 284, 490 - local patches of rose-pink to purplish flushing in . . 49i 1 - cedema in . . . . . . 490 - pain aggravated by depend- ent position and by warmth . . . . . . 490 - simulated by ergotism . . 287 - in tabes dorsalis . . . . 490 - tenderness of foot in . . 490 Erythropsia (and see Vision, defects of) - from cataract extraction . . 840 - in electric blindness . . 840 - with retinal hsemorrhage . . 840 - in snow blindness . . . . 840 Eschar, black, gangrenous, in anthrax . . . . . . 603 - from injury to mouth, ptyalism due to . . . . 591 - on lips or mouth in irritant or corrosive poisoning . . 674 Essential albuminuria . . 19 Esthiomfene, syphilitic natm'e of 769 - vulval swelling due to . . 768 Ether, headache from . . 328 - poisoning, leucopenia in . . 401 Ethereal sulphates in urine, indicanuria indicating . . 349 Ethmoidal air cells, infection of, meningitis from . . 642 - dilatation, exophthalmos in 255 - sinusitis, diagnosis from abscess of antrum . . 502 headache in . . . . 327 nasal discharge from 204, 206 Eucalyptus leaves, sore fingers from . . . . . . 266 Eunuchs, obesity in 453, 454 Europe, Malta fever in . . 506 - Southern, dengue in .. . 506 EUSTACHIAN TUBE— EYE, ATROPHY OF 899 Eustachian tube, deafness Exophthalmic tjoilrc, conld. Exostosis, contd. from catarrh of the 190 glistening conjunctiva in 261 - usual situation near epi- infection of ears through 230 glycosuria in 292 physeal line of long bone obstruction from syphilis irritability in 360 (Fig. 194) . . 754 ,763 190, 828 loss of weight in 244, 797 849 - a'-rays in diagnosis (Fig. 194) 754 Exantliemata, monorrhagia in 429 marked pulsation in neck Expectoration Csee Sputa, and Excitability in exophthalmic in 764 Haemoptysis) soitre 244 menorrhagia in . . 430 Expiration sound prolonged - effect on alcoholic tremor . . 797 mental changes in 797 at apex in phthisis 319 choreic movements 156 Mobius's sign in. . 253 in emphysema 192 mercurial tremor 797 ocular symptoms of 253 Exposure, hypothermia in 346 619 tremor in Graves' disease 797 oedema of eyelids in 261 - Pinguecula due to . . 256 - after epileptic convulsions 169 palpitation in 525, 527, 792 ,797 Expression (see Facies) - producing diarrhoea 197 pigmentation of eyelids in - lack of in paralysis agitans 548 - religious, pandemic chorea 244, 261 Extensor brevis digitorum. caused by 157 of skin in 792 nerve supply of . . 542 - tachycardia from . . 772 proptosis in . . 253 ,261 pollicis, nerve supply of 550 - transient polyuria due to . . 582 pulse-rate in 772 - carpi radialis brevior, nerve Exclamation-mark hairs in pupillary changes in 261 supply of . . 550 alopecia areata . . 274 relation to parenchyma- longior, nerve supply of 550 Exercise, decreased passage of tous goitre 792 ulnaris, nerve supply of 550 urine after 581 sex incidence of 772 ,792 - communis digitorum, spinal - deficient, effect on uric shortness of breath in . . 100 nerve-root supplying . . 543 acid 817 signs of . . 244 nerve supply of 550 in etiology of dyspepsia 354 simulation of Addison's - indicis, nerve supply of . . 550 - effect in increasing haema- disease by 792 - longus digitorum, nerve tm-ia in vesical calculus 629 skin changes in . . 261 792 supply of . . 542 micturition in vesical spasmodic contractions in 159 hallucis, hypertrophy of 164 ■ calculus 438 staring eyes in . . 772 nerve supply of 542 on rheumatic pains 507 Stellwag's sign in 253, 792 spinal nerve - root - hsemoglobinuriafi-om 315 sweating in 797 supplying . . 543 - in health, shortness of breath systolic bruit in 244 pollicis, nerve supply . . 550 in . . 100 tachycardia in 244, 253, - minimi digiti, nerve supply 550 - want of, causing obesity . . 453 771, 772, 792, 797 849 - ossis metacarpi pollicis. Exertion, effect on muscle pains 478 thyroid eland enlargement m escape in lead palsy 77 pulse-rate in myocardial 244, 253,' 527, 772, 792,797 ,849 nerve supply of 550 affections 526 occasionally absent 527 - plantar reflex (see Babin- in raising temperature of tremor in 244, 253, ski's Sign) 81 body in health 619 772, 792, 795, 797 849 Extensors of wrist, spinal on sciatic pain . . 487 ulceration of the cornea in 807 nerve-root supplying 556 symptoms of cervical rib 554 undue abdominal aortic External auditory meatus, - in etiology of aneurysm . . 538 pulsation in . . 592 caries of . . 469 - hernia produced by 740 von Graefe's sign in 253 cerebrospinal fluid from 468 - increase of alcoholic tremor EXOPHTHALMOS .. 253 condylomata of 469 by 797 - some causes of 200 diphtheria of . . 469 - influence upon pain due to - epiphora from 250 eczema of 468 heart failure 485 - in exophthalmic goitre epithelioma of . . 469 in intermittent claudi- 527, 627, 772, 792 797' foreign body forgotten in 469 cation 489 - intermittent, in arterial in, ruptured tym- on tremor 796 aneurysm 255 panum from . . 468 in Graves' disease 792 ,797 - in myopathy 260 furunculosis of 469 - palpitations due to 528 - from thrombosis of cavern- herpes in facial paralysis 536 - relation to angina abdomi- ous sinus 651 injury of 467 nalis 486 - ulceration of the cornea in 807 otorrhcea from 469 pectoris . .481, 482 778 - unilateral . . . . 254, 754 polypi of 469 - tachycardia from . . 772 Exostosis, ankylosis of joints rodent ulcer of (see Exhaustion 619 from 167 Rodent ulcer) - on exertion in hepatoptosis 07 - bursa covering 754 suppurating sebaceous - in obstructed labour, sym- - composition of 754 cyst of 469 ptoms of .... 229 - heredity in . . 754 syphilitic ulceration of 469 - subnormal temperature in 619,621 - ivory, in the auditory meatus 754 - cutaneous nerve, skin distri- Exopllilialmic goitre, age inci- of bones of the skull . . 754 bution of . . 659 dence of . . . . 772 792 displacement of eye by. . 754 neuralgia of . . 488 albuminuiia in . . 16 - multiple 754 - iliac artery (see Aneurysm - - amenorrhoca in . . 23 - pedunculated tumour m . . 754 of External IliacJ breathlessness in 792 - popliteal 763 - plantar nerve, muscles sup- cachexia in 115 age incidence of 763 plied by . . 542 chloasma in 574 association with exostoses spinal roots derived Dalrymple's sign in 792 elsewhere 763 from . . 542 - - defective winking power in 261 common situation 763 - popliteal nerve, muscles diagnosis of 772 diagnosis from ossifica- supplied by 542 distinction from paroxys- tion of a tendon or skin distribution of . . 659 mal tachycardia 772 muscle . . 763 spinal roots derived enlarged heart in 232 244 presence of exostoses in from . . 542 epiphora in 250 other members of family 763 - rectus muscle paralysis with excitability in . . 244 slow growth of . . 763 peripheral facial paralysis 536 exophthalmos in tumour well-defined in 761, 763 Extra-uterine gestation (see 527, 627, 772, 792, 797 without symptoms 763 Gestation, Ectopic) occasionally absent in 527 - spurious 754 Extravasation of urine (see extreme nervousness in - tumour capped with cartilage 754 Urine, Extravasation of) 253, 772, 792, 849 - ungual phalanx of great Extroversion of bladder 587 eyelids retracted in 792 toe a conmion site for . . 754 EYE, ACUTE INFLAIVIIVIA- facies of (Fig. 85) 261 - unilateral exophthalmos TION OF 255 flushing hi 261 due to . . . . 254, 255 - atrophy of, from iritis 839 goo EYE, BURNING— FJECES, BLACK Eye, contd. - burning, pricking, or water- ing of from error of refraction - conjugate deviation of, in liemiplegia in cerebellar lesions - dilatation of blood-vessels of, in arterial aneurysm - diseases, headache from epiphora in - - neviralgia from . . photophobia in . . tenderness of scalp vertigo due to . . - displacement of, cause of. . bj"- dermoid cyst . . ivory exostosis . . - epiphora in inflammation of - herpes zoster of - inability to close, from facial paralysis . . in hemiplegia - light flashes before, relieved by epistaxis - limited movement in cavern- ous sinus thrombosis - melanotic sarcoma of - murmur from aneurysm . . - nmscles of, abnormalities in congenital exophthalmos in mvasthenia gravis (Fig. 83", p. 261) . . 225, myopatliy - cedema of, in trichinosis . . EYE. OPHTHALMOSCOPIC APPEARANCES OF (Plales VIl, nil) EYE, PAIN IN - paresis of muscles of, in diphtheria . . . . 77, - protrusion of (see Exoph- thalmos) - puffiness of, in Bright's disease and oedema simu- lating - pulsation from aneurysm . . - retraction of (see Enophthal- mos) - sarcoma of . . . . 279, - shifty, of drug-takers - signs of jaundice in - staring (see Exophthalmos) - sunken in zymotic diar- rhoea of infants . . - tension of, in conjunctivitis, iritis, and glaucoma in paralysis of cervical sympathetic . . - tremor of (see Nystagmus) - tuberculosis of Eyebrows, seborrhceic eczema of - falling out of, in myxoedema - sycosis vulgaris of . . Eyelashes, pediculosis of - sycosis vulgaris of . . Eyelids, affected, in nuclear facial paralysis . . - chancre of . . - coloured sweat of . . - drooping of (see Ptosis) - epithelioma of - aversion of, in clironic marginal blepharitis - oedema of (see Q'idema of Eyelids) - pigmentation in exophthal- mic goitre . . 2-14, - puffiness in myxoedema . . - quivering of in hysteria and malingering - red and engorged in cavern- ous sinus tlirombosis . . - retraction in Graves' disease 254 419 255 260 504 461 494 640 160 Eyelids, contd. - retraction in paralysis agitans 262 - stitching of, in perforation of corneal ulcer . . . . 807 - thickening in cretinism . . 258 - tuberculosis of . . . . 445 - xanthelasma of, in jaundice 360 - xanthoma planum of . . 805 Eyestrain, headache in 327, 329, 498 - migraine from . . . . 495 - pain behind eyes in 495, 498 - supra-orbital pain from . . 495 FACE, acne afEecting 531, 604 - actinomycosis of . . . . 810 - acute swelling of, by gas . . 231 - alcoholic tremor of . . 797 - anesthesia of, in syringo- myelia . . . . . . 664 - asymmetry of, in myasthenia 261 with spastic paralysis . . 540 - athetotic contractions of . . 154 - atrophy of . . . . . . 75 - bloody sweat of . . . . 715 - colloid milium of . . . . 805 - coloured sweat of . . . . 714 - congestion of, iii mitral regurgitation . . . . 238 - dusky or livid in spleno- megalic polycythoemia . . ■ 581 - enlargement of all the bones of, in acromegaly . . 749 - epithelioma adenoides cysti- cum of . . . . . . 805 - erythema papulatum of . . 531 - flushing in diabetes . . 292 - healed gvaama.ot(Figs. 156, 157) 589 - hemiatrophy of (Fig. 141, p. 537) .. .. 167,537 - herpes simplex of . . . . 829 - hyperostoses of bones of, in leontiasis ossea . . . . 749 - lichen scrofulosorum of . . 529 - lupus erythematosus of . . 656 vulgaris of . . . . 808 - meningocele of (Fig. 75) . . 254 - mercurial tremor of . . 797 - motor tics afEecting . . 160 - movements in chorea . . 156 - multiple benign sarcoid of 451 - muscular twitch ings of, in petit mal. . . . . . 160 - cedema of (see Qildema of Pace) FACE, PAIN IN .. ..495 in antral empyema . . 205 - papular syphilides of . . 532 - pemphigus neonatorum of 446 - pigmented in xerodermia . . 804 - pityriasis rosea of . . . . 658 - preference of impetigo for 604 small-pox for . . . . 605 - pustular syphilides of . . 604 - rarity of scabies on 609, 832 - roseolar rash on, in syphilis 675 - scrofulous ulceration of . . 808 - sebaceous cyst of . . . . 804 - seborrhoea of . . 656, 657 - seborrhceic dermatitis of infancv affecting . . 447 - segmental areas of (Figs. 132-13.5) .. '.. 407 - spasm of, in hysteria . . 537 major trigeminal neuralgia 495 tetanus ^ 162 FACE, SWELLING OF (see Swelling of Face) - sm-gical emphysema of . . 231 - sycosis vulgaris of . . . . 602 - tremor of . . . . 795, 797 in general naralysis of the insane .'. " . . 172," 796 - twitching of, during rigors 646 262 258 749 159 C51 59 259, 446 216, 258 253, 261 796 652 214 Face, contd. - type carr^e in acromegaly 263 - ulceration of (see Ulceration) - unusual breadth in cretinism 258 - varicella affecting . . . . 833 Facial changes in 7th nerve paralysis . . . . 533 - neuralgia, varieties of (see Neuralgia) - paralysis (see Paralysis, Facial) - tic, chorea simulatinsj . . 156 FACIES, ABNORMALITIES OF - of acromegaly (Fig. 88) - bulbar paralysis - in catalepsy - cirrhosis - congenital syphilis (Figs. 79) - cretin (Fig. 67) - of exophthalmic goitre - expressionless in paralysis agitans . . . . 259 from sclerodermia - ferret-like, in microcephaly - Hippocratica in peritonitis 133,431 - hysterical, contortion of . . 652 - in lardaceous disease . . 39 - mitral stenosis . . 61, 773 - Mongolian idiocv (Figs. 89, 90, 91,p. 263) '216, 217, 263, 264 - mvasthenia gravis (Figs. 83, 84) . . . . ". . 260 - myopathy (Figs. 81, 82) . . 260 - myxcEdema (Figs. 76, 77, p. 259) 43, 259, 454, 585 - paralysis agitans (Fig. 86) 259, 261, 541, 796 - pericarditis . . . . . . 480 - pernicious ansemia . . . . 76 - rat-like, in microcephaly . . 214 - simple colic - starchy, in pseudo-bulbar paralysis - in tabes (Fig. 87) . . Facio-scapulo-humeral myo- pathy, fibrillary contrac- tions rare in Fsecal accumulation in caecum m malignant growth of colon colicky pain in loin from - in colon . . . . 393 age incidence of characters of mass in . . constipation with 145, 692 diagnosis from renal tumour . . . . 393 splenic tumour . . 691 movement of tumour with respiration . . 406 pain in left hypoehon- drium from . . . . 499 simulating enlargement of liver . . . . 406 enemata in diagnosis of 393,499, 501, 691 flatulence with . . . . 393 obstruction due to 145, 692 occurrence in spite of daily action of bowels pain in iliac fossae from tumour in loin from - fistula of umbilicus in tuberculous peritonitis 51, 57 - odour in vomit (see "\^omiting, Fseculent) Faeces, acid, in pancreatitis . . - alkaline, in gall-stone obstruction - ankylostomum ova in - ascaris lumbricoides and ova in - black 133 686 158 394 393 692 692 692 393 501 393 117 117 94 364 89 FMCES, BLOOD IN— FEET, TREMOR OF go I Faeces, could. Pieces, could. Fatigue, contd. - blood in (see Blood per Anum, - test for bile in 197 - pains in limbs due to 508 and Melaena) - tubercle bacilli in . . 427 - spasmodic contractions from 159 - characteristics in case o£ - typhoid bacilli in . . 610 - tremor from 795, 797, 798 " ^eedy colon " 143 - worms in (see Worms, Intes- Fatness, excessive (and see colic 134 tinal) Obesity) 453 colitis 134 Faeculent vomiting (see Vomit- due to hypernephroma 454 infantile colitis . . 92 ing, faecal) - with thymic infantilism . . 215 - - pancreatic cyst . . 724 Painting, associated with flush- Fatty acid crystals in faeces in in pancreatitis 116, 117, ing (and see Corna) 268 pancreatitis . . 117, 135 135, 364, 724 Faintness in angina pectoris 481 formed during putrefac- - Charcot-Leyden crystals in - due to arsenic 297 tion 283 117, 118 - on change of position due to - casts, renal . . 7 - clay -coloured from chronic aortic disease 233 - heart (see Heart, Fatty) pancreatitis 724 - in fatty heart 241 - infiltration, cardiac 62, 241 in obstruction of common - hepatoptosis 407 - liver (see Liver, Fatty) bile-duct 362 - paroxysmal tachycardia . . 772 FATTY STOOLS 2G5 - coloration in jaundice 361, 365 - preceding hoematemesis . . 316 in pancreatic disease 59, 135, - - consenital obliteration of - from rupture of extra- 197, 292, 364, 366 bile-ducts 365 uterine gestation 436 infantilism 216 rectal lismorrhase 89 Fallopian canal , effects of lesion - superposition of heart 62, 241 suppurative pylephlebitis 649 of facial nerve in 537 Fauces, carcinoma of 420, 670 673 - condition of fat in, in pan- - tubes, absence of, sterility - gumma of . . . . 670, 673 creatic lesions 116 due to 706 - inflammation of 673 - delayed passage of, in affection of, simulating - mucous patcli on, in secon- intestinal constipation.. 141 movable kidney 727 dary syphilis 675 - distoma eggs in 364 inflammation of, sub- - reddeniag of, in scarlet fever - discharge per urethram phrenic abscess from. . 720 and erythema scarlatini- In rectal carcinoma 313 633 new growtli of, pelvic forme 253 - dry and liard in diabetes . . 141 swelling due to 757 - simple ulceration of 670 - eggs of parasites in tumour of, swelling in - spastic, in pseudo-bulbar 04, 364, 569, 621 hypogastrium from . . 730 palsy 086 - enormous accumulations of 718 Falls a cause of deafness 191 - tuberculosis of . . 670, 073 - examination in tropical Familial cliaracter of acute FavUS, alfecting nails 271, 275 445 dysentery 91 rheumatism 121 671 - baldness froin 84 - fat "in (see Fatty Stools) angioneurotic cedema . . 457 - body and scalp {Fig. 93) . . 271 - gall-stones in iSo, 300, 363 621 congenital diplegia 800 - crusts in . . . . 270, 653 - with gas passed per urethram 576 Friedreich's ataxy 559, 560 - description of lesions of . . 270 - hard and bulky, dyschezia - - gout . . . . 381, 383 - diagnosis from alopecia . . 272 due to 150 iisemophilia 599 eczema and seborrhoea . . 272 - heat loss in. . 619 Hanot's cirrhosis 369 lupus erythematosus . . 272 - incontinence of (see Incon- hereditary optic atrophy 838 psoriasis of the scalp 271 tinence) - - jaundice . . 362 ringworm of scalp 274 - insufficiency of quantity of 140 Milroy's disease . . 456 - distribution of 270 - microscopical characters in merycism 431 - loss of lustre of hair in 270 pancreatitis 117 myopathy 555, 559, 560 - " mousey " smell in 270, 271 272 examination in detecting pavor nocturnus 357 - mycelium in 270 cause of flatulence 268 phthisis 848 - scarring in . . . . 270, 272 FAECES, MUCUS IN 443 primary muscular dys- - spores in 270 - - from anal fistula 92 trophies 555, 559, 560 - sulphur yellow discs in 270 - - in arsenical poisoning . . 92 pseudo-hypertrophic mus- - tenderness of scalp from 780 781 biUiarziasis 93 cular paralysis 560 _ - transmission from animals 270 in carcinoma of bowel retinitis pigmentosa 838 ' Febricula in children 621 1.50, 152, 393, 636, 690, 736 splenomegalic cirrhosis.. 693 - diagnosis from influenza . . 505 - - from colitis 134, 144, 197 727 Tooth's peroneal atrophy - pains in the limbs in 503, 505 dysentery . . . . 90, 727 132, 559, 560 - prostration with . . 505 in enterospasm . . 486 Famine and filth in causation - real nature of 505 Henoch's piurpura 600 of relapsmg fever 373, 698 Febrile albuminuria . . 17 from intussusception Faradism in reaction of degen- - albumosuria 20 14S, 152, 196, 636, 727, 736 eration 633 Feet, anaesthesia of, vertigo invagination of rectum.. 150 Fascia, gonococcal inflammation from 827 from pelvic abscess 474 of 376 - in acromegaly 585, 749 -753 oxyuris vermicularis 93 - palmar, Dupuytren's con- - athetotic contractions of . . 154 in rickets . . 171 tracture of 167 - bloody sweat of 715 simple colitis of infants. . 92 - rheumatic nodules in 452 - broad in myxoedema 454,455 ,585 spastic constipation 145 Fascicular muscular twitchings 157 - bromidrosis of 714 in stomach, estimation of Fastigium during rigors 646 - buUte of, in congenital excess of 355 Fat, emulsifled, in urine (and syphilis . . 111 ulcerative colitis 92, 727 see Chyluria) 126 - cheiropompholyx: of 654, 832 - occult blood in, in carcinoma - in fsces in pancreatitis 116 - cold and blue, ia paralytic of colon . . 145 - jaundice 361 talipes . . . . 130, 131 FAECES, PASSED PER URE- - necrosis in acute hemor- - erytliema nodosum affecting 450 THRAM, commoner causes 264 rhagic pancreatitis - - keratodes of 451 in carcinoma of rectum 153, 431, 646, 846 papulatum of 531 or colon . . 313 633 Fatigability in neurasthenia 788 - in erythromelalgia . . 490 simulation by cystitis 264 - in disseminated sclerosis . . 174 - cedema of (see ffidema) - pu^ in (see Pus in Stools) - myasthenia gravis (Fi/;. 83, - pruritus of . . 588 - reactions of . . 117 197 p. 261) 687 - scabies affecting 609 - ribbon-like, in rectal cancer 93 Fatigue, cause of convulsions 169 - sweating of, in rheumatoid - sand in 652 - in etiology of dyspepsia . . 354 arthritis . . 378 - shreds and casts in 134 - alcoholic tremor increased by 797 - swelling of, in angioneurotic - simulating enlarged liver . . 406 - hsemoglobinuria in 315 cedema 459 - tape- worm ova in . . 569 - in malingerers 464 - tremor of from alcohol 797 - tarry 89 - muscular twitchings from 157 - (and see Soles of Feet) 902 FEH LING'S SOLUTION— FIBROMYOMA Feh ling's solution in estima- tion of sugar . . . . 291 reduction in alkaptonuria 822 carboluria . . . . 823 by homogentisic acid . . 822 uric acid . . . . 818 - test for sugar, albuminuria and 290 sources of error . . . . 290 Femoral abscess . . . . 732 - aneurysm (see Aneurysm, Femoral) - hernia (see Hernia, Femoral) - region, definition of . . 732 ectopic testis in . . . . 733 fibroma of . . 733, 734 lipoma of.. .. 733, 734 sarcoma of . . 733. 734 swelling of, due to osteo- artliritis of hip joint . . 734 due to parametric ab- scess 734 (see Swelling, Femoral) - vein, thrombosis in (see Thrombosis) Femur, endosteal sarcoma of, diagnosis from chronic osteitis 763 periostitis . . 763 popliteal swelling due to 763 - exotosis of (Fig. 194) . . 763 - injuries of, causing sciatic nerve paralysis !^ . . . 542 - myeloid sarcoma of . . 756 - necrosis of lower end of, popliteal abscess due to 762 - osteitis of, after typhoid fever 376 - sarcoma of, bruit over . . 762 diagnosis of . . . . 762 - separation of lower epiphysis of 763 Fenestra rotunda, pressure on, vertigo due to . . 828 Fermentation, borborygmi from 97 - gastric, sarcinn? and yeasts in 267 - heartburn from . . . . 333 - in pyloric obstruction . . 134 - starch cells in faeces in 197, 268 - test in glycosuria 290, 291, 818 for glucose, possible fallacies . . . . . . 291 as quantitative test for glucose . . . . 291 Ferments in pancreatic cyst fluid 53 - in stomach contents, test for 355 Ferret-like facies of micro- cephaly . . . . . . 214 Ferric chloride reaction for alkapton . . . . . . 822 after carbolic acid, etc. 196 diaceturia . . . . 196 melanuria . . . . 821 no reaction with indican 821 Festination in paralysis agitans 796 Fever (see Pyrexia and Hyper- pyrexia) Fevers, acute, anuria in 45, 48 dilatation of heart from. . 243 endometritis in . . . . 429 infectious, bacteriuria in 83 epistaxis in . . . . 251 infantile convulsions in 170 nerve deafness after . . 190 transverse myelitis due to 565 - albuminuria in . . . . 17 - amenorrhcea due to . . 23 - baldness after . . . . 84 - bleeding gums in 85, 87 - Cheyne-Stokes respiration in 125 - club-foot arising from . . 133 - coma in . . . . . . 136 at onset of . . . . 646 - congestion of liver in . . 371 Fevers, conld. - constipation in . . 143, - convulsions of children in . . - cramps after - delirium in . . - diazo-reaction in . . - eosinophilia after . . - encephalitis after . . - enlarged spleen in.. - epistaxis in. . - extreme thirst in . . - fatty heart following - hsematuria in - hsemoptysis in - hoemorrhagic erosions in . . - headache in - hyperfESthesia acustica in - insomnia in - inspissation of bile in - loss of taste in - matutinal hypothermia in - metastatic orchitis in - mitral regurgitation in 239 - necrosis of jaw in. . - polyuria in . . - prolonged pyrexia from . . - purpura in various - pyelitis in . . - pyrexia in children with- out obvious cause, due to onset of - rapid pulse in - shortness of breath in - specific, acute general pains in the limbs in . . tetany following . . - tache c6r6brale in . . - thrombosis of spinal artery from - tinnitus in . . - Tooth's peroneal atrophy developing after - transverse myelitis due to 564, - urate deposit in - uric acid in . . - vomiting at onset of Fibrillar contractions.. in amyotrophic lateral sclerosis atrophic palsy of arm. . . chronic poliomyelitis in lesions of central nervous system progressive muscular atrophy rare in primary myopathy of tongue in bulbar para- lysis AVerdnig-Hoffmann pro- gressive muscular atrophy of infants Fibro-adenoma of breast (see Breast, Fibro-adenoma of) Fibroid heart (see Heart, Fibroid) - lung (see Lung, Fibrosis of) - tumours, cachexia in - of uterus (see Fibromyoma of Uterus) - of vaginal wall Fibroma of breast - of femoral region . . 733, - larynx mistaken for asthma - mediastinal, varicose thora- cic veins from - moUuscum, distinction from lipoma sebaceous cyst von Recklinghausen's disease (Fig. 201) . . - nasal . . ' . . epistaxis due to. . - recurrent, of basi-sphenoid 153 169 179 195 198 248 155 692 251 789 241 .305 318 298 328 190 356 364 774 346 680 243 747 583 609 596 625 622 771 100 503 178 771 564 794 560 565 815 817 843 157 554 549 165 165 158 587 744 734 582 820 804 804 781 204 250 204 428 758 429 429 473 429 759 434 434 760 429 758 758 587 759 439 1.50 219 227 759 Fibroma, conld. - simulated by dermoid cyst 804 - of vulva . . . . 768, 771 Fibromyoma of round ligament (see Round Ligament) - of uterus absence of hasmorrhage in sub-peritoneal. . menorrhagia in asymmetrical enlargement of uterus in . . bearing-down pain from connection with uterus determined by bimanual examination . . 392, constant bleeding due to sloughing of . . conversion into carcinoma sarcoma cystic degeneration of 429, 434, 759 diagnosis from ectopic gestation ovarian cyst . . tumour pregnant uterus of prolapse from solid ovarian tumour difficult micturition from dyschezia from . . dysmenorrhosa from . . dystocia due to . . extrusion of . . 434 after labour, inversion of uterus mistaken for 587 fluctuation in softening of 758 fluid thrill m, from cystic degeneration . . . . 4.29 frequency of micturition in 438 hardness of tumour in . . 429 histological diagnosis . . 434 infection of extruded . . 759 irregular outline of tumour 429 length of uterine cavity increased in . . . . 429 median position of . . 392 menorrhagia in 428, 758, 759 metrorrhagia from 433, 435 necrobiosis in nephritis from . . obstructing labour obvious pelvic origin of . . often multiple . . passage of uterine sound in 429 pelvic swelling due to 757, 758 rapid growth of tumour indicative of degenera- tion of relation to metrorrhagia of round ligament 741, sarcomatous degeneration of . . . . 434, — - simulated by inversion of uterns . . simulating sciatica sarcoma sloughing of diagnosis from malig- nant disease foul vaginal discharge due to softening from degener- ative changes . . in pregnancy . . spasmodic pelvic pain from expulsion of sterility due to . . strangulation of.. subperitoneal, absence of elongation of uterine cavity in — swelling in iliac fossa from 737 — tumour and cervix move tosether in . . . . 429 759 392 434 759 434 768 759 587 74 4S4 759 759 211 429 759 509 706 434 429 FIBROMYOMA OF VAGINA— FLUTE-PLAYER' S CRAMP 903 Fibromyoma, could FINGERS, SORE 26G Flatulence, conld. - of vagina 768 - test for movements of, in - atonic constipation 143 ii'ibro-lipomata of abdominal hysterical and cerebral - borborygmi with . . 97 waU 716 paralysis . . 548 - with chronic gastritis 845 Fibro-sarcoma, nasal 204 - tremor of, in Graves' disease - diagnosis from morycism . . 431 - of naso-pharynx, snoring due 244, 253, 772, 849 - in dyspepsia. . 354 to 669 - tingling and numbness in. - from faecal accumulation . . 393 Fibrosis of mediastinum (see in acroparoestliesia 493 - foul breath with 90 Mediastinum, Fibrosis of) - tuberculous disease of skin of 266 - in functional stomach dis- Fibrous tissue inflammation, in - ulnar flexion of (Fig. 108) orders 267 rheumatism in cliildren 504 379, 380 - with gall-stones 350 Fidgetiness, excessive 156 Firemen, enlarged left ventricle - in gastric atony . . 267 Figs, oxaluria from . . 471 in . . 232 dilatation 267 Fifth nerve affected in bulbar First lumbrical, nerve supply fermentation in . . ._, 267 paralysis . . 159 of 542 offensive eructations in.. 267 anaesthesia of, from tumour - sound abnormal in hyper- - interscapular pain from . . 474 of mid-brain . . 708 trophy of ventricles 331 - intestinal 267 herpes of . . 781 Pish, fried, colic due to 136 colicky pains in . . 267 lesions, ptyalorrhoea from - urticaria from 746 spasmodic pelvic pain in 509 591, 592 Fishbone in oesophagus, haema- - loss of weight due to 848 motor paresis of . . 496 temesis from 297 - may simiTlate dysmenorrhoea 220 - - pain in, from iritis 495 - in the rectum 635 - pain in the chest from 484 770 paralysis, anosmia from . . 688 Fissure, anal (see Anus, Fissure epigastrium in . . 485 causing impaired taste 775 of) left hypochondrium from 499 undue dryness of nose - palpebral (see Palpebral Uiac fossa from 501 from. . 668 Fissure) precordial, from 481 Fiii, filariasis in 33 Fistula, anal, bleeding in 92 - palpitation in 484 Filaria sanguinis hominis, - causing pneumaturia 576 - simulating heart disease . . 779 cedema from 455 - gastro-colic, faecal vomiting in 845 - tenderness in the chest from 779 elephantiasis due to - genital, sterility due to . . 706 - visible peristalsis with 724 IL'6, 456, 765, 810 - lumbar, from kidney after Flatus, passage of, in acute - - - - of vulva due to 770 operation 442 pancreatitis 153 embrvo (Plate XII, micturition tlirough 442 intestinal obstruction .-. 151 Fig. F) . . 696, 770 - recto-uretliral, illustrated per urethram in carcinoma lymphatic oljstruotion (Fig. 170) 637 of rectum or colon 633 from . . 810 - recto - vaginal, illustrated Flea-bites, purpura from 596 597 ulceration of the leg in 810 (Fig. 172) 637 Flexor brevis digitorum, nerve Filariasis, blood changes in . . 33 - recto-vesical from growth 264 ,633 supply of 542 - chylous ascites in . . 58 - reno-colic, from carcinoma 577 haUucis, nerve supply of 542 - chyluria in . . 126 - scrotal, general account of 679 minimi digiti, nerve supply - eosinophilia in . . 126, 249 from tuberculosis testis 518 679 of .. .. 542, 550 Filth and famine in causation - suprapubic, after operation 442 pollicis, nerve supply of. . 550 of relapsing fever 698 - umbilihcal ftecal, in tuber- - carpi radiaiis, nerve supply 550 Fingers affected by acute culous peritonitis 691 716 ulnaris, nerve supply of 550 rheumatism 374 - - with tuberculous cervical paralysis of 128 - athetotic contractions of . . 154 glands 420 spinal nerve root supply- - bedsore on . . 266 - urethral, acute 677 ing 556 - broad, in myxoedema 454, 585 chronic 678 - longus digitorum, nerve - burning pain in, in acro- endoscopic examination in 678 supply of 542 parfesthesia 493 from gummata . . 209 hallucis, nerve supply of 542 - burrows of scabies on 832 perineal excoriation in . . 678 poUicis, nerve supply of 550 - chancre of . . 266 pain in. . 516 - profundus digitorum (inner - clubbed fand see Clubbed sore from 677 half) nerve supply of 550 Fmgers) 128, 390, 411, 703 due to stricture . . 677 - sublimis digitorum, nerve - dissection wounds of 266 - urinary, after childbirth . . 442 supply of 550 - eczema of . . 533 from peri-urethral abscess 442 - of wrist and long flexors of - enlarged in acromegaly . . 128 traumatic 442 fingers, spinal nerve root - - pulmonary osteo-arthro- urethral stricture 442 supplying 556 pathy . . 128 - uro-biliary, choluria without Flmt's bruit 108, 109, 234 - epidermolysis bullosa affecting 266 jaundice in 819 Fluid in abdomen in bladder - examination of, in obscure - vesical, cystoscope in detect- injury (and see Ascites) 308 pyrexia . . 620 ing 442 - deficiency in tissues, poly- - flexed in brachial monoplegia 546 - vesico-colic, due to carcinoma 146 cythaemia due to 579, 580 - fusiform enlargement in due to diverticulitis 146 - with gas in pleural cavity . . 577 tuberculous dactylitis . . 751 - vesico-intestinal,fLeces passed - rapid loss of, as cause of rheumatoid arthritis 378 per urethram in. . 264 marasmus 426 - gangrene of, duetocarcinoma - vesico- vaginal, in carcinoma Fluorescence in urine due to of breast . . 287 of uterus . . 632 eosin 820 diabetes . . 266 methylene blue in tracing 442 Fluorescin, in detection of intrathoracic aneurysm . . 287 Fits (see Convulsions) corneal ulceration 806 in Raynaud's disease . . 284 Flaccidity in birth palsies . . 558 Flush, malar, of myxoedema 43 - - syringom.yelia 285 - in hysterical paralysis 541 FLUSHING 268 - sonoooccal arthritis of 376 Flail-like joint in osteo-arthritis 384 - associated symptoms 268 - Heberden's nodes in 384, 452 tabetic arthritis . . 388 - chronic 268 - pads on dorsal aspect of Flanks, shifting dullness in . . 393 - in erythromelalgia . . 284, 490 first interphalangeal joints Flat chest in phthisis 191 - extremities . . 284 (Fig. 114, lln)\. 385 Flat-foot from gonorrhoea . . 376 - Graves' disease 261 - pityriasis rubra pilaris - metatarsal neuralgia in 488 - hysteria 345 papules on 530 - in neuralgia parcPSthetica . . 488 - local, in brachial neuralgia 491 - pniritus of, due to scabies 588 - pain in tlie foot from 486 of skin, from visceral - scabies affecting 588, 609, 832 FLATULENCE 267 disease . . 475 - septic infection, epitrochlear - in abdominal angina 351, 486 - in paralysis agitans 796 gland enlarged in 422 - angina pectoris 350, 481, 779 - trigeminal neuralgia 495 - shape of, in achondroplasia 212 - asthenic dyspepsia 354 Flute-player's cramp . . 177 904 FOAMING AT MOUTH— FRIEDLANDER'S BACILLUS Foaming at mouth during con- Forearm, conld. Fracture, fair, contd. vulsions . . 168 - ulnar anaesthesia in, due to arch of jaw irregular in. . 747 in epilepsy 171 cervical rib 493 commonly compound . . 747 malingerers 17.', Forehead, affection by acne . . 531 septic . . 747 Focal epilepsy. . 161 - bulging in achondroplasia 212 diagnosis difficult in frac- Foetid bronchitis (see Bron- - coloured sweat of . . 714 tures of ascending ramus 747 chitis, foetid) - congenital syphilitic condy- ptyalism from . . 591 - sputum ("see Sputum) lomata of 446 :r-rays in diagnosis of . . 747 Foetor of breath 98 - downy appearance in Mon- - leg, badly united, ulceration Foetus, position in utero 228 golian idiocy 263 from 810 Fog causing coryza . . 203 - new growths of 204 compound, talipes from. . 132 Follicular conjunctivitis 256 - retreating in acromegaly . . 263 - pelvis, bladder and urethra - impetigo (see Impetigo, - slope of in microcephaly . . 214 changes in 308 Follicular) - writtkled, in acromegaly . . 263 injury of uretlira from . . 511 - papular syphilides . . 532 in tabes . . 262 sciatic nerve paralysis from 542 - tonsillitis (see Tonsillitis, Foreign bodies in air-passages. - rib, empyema from 120 Follicular) cough due to . . 175 haemoptysis from 317, 320 Folliculitis decalvans . . 84 dysphagia from 222 pneumothorax from 578 - eczematous, diagnosis from fibroid lung and bronchi- surgical emphysema from 231 ringworm of beard 271 ectasis from . . 324 tenderness in chest from 776 Fontanelle, delayed closure in gangrene of lung from - Skull, base of. auditory nerve rickets . . . . 171 , 695 287, 578, 712 damaged in 468 - depressed in zymotic diar- haemoptysis from 318 bleeding from ears or rhoea of infants . . 426 mistaken for asthma . . 582 nose in . . 138 467 Food, absence of fresh, cause of pyopneumothorax from 712 subconjunctival he- scurvy 85 stridor from . . 709 morrhage from 256 - dyspepsia from 354 symptoms of . . 466 tympanum damaged . . 467 - indigestible, colic from 136 in ear, creaking noises from. 793 cerebrospinal fluid from - irritating, a cause of infantUe deafness from. . 190 ear in . . 138 468 convulsions 170 otorrhcea from forgotten 469 nose after . . 138 203 vomiting from . . 843 pain from 230 coma in . . 137 - particles between teeth, vertigo due to 828 deafness from . . 191 794 decomposing, foul taste in eye, conjunctivitis due to 256 diabetes insipidus from 585 due to 774 — impacted in gum, ptyalism epistaxis from . . 250 - phosphoric acid in urine due to . . 591 hemianopsia from 335 derived from 571 - - in larynx . • . . 465 642 hemiplegia from. . 138 - poisoning, tetany from 178 causing cyanosis 185 hyperpyrexia from 344 - regurgitation through the cough from 176 sudden blindness from. . 839 nose, causes of . . 202 extreme dyspnoea from 642 sub-conjunctival haemor- - relation of pain to, in gastric laryngeal obstruction hage from 256 and duodenal ulcer 89 from C42 tinnitus from 794 vomiting to, under various retraction of the head - spine, acute bedsore from. . 286 conditioas 844 from 642 anaesthesia from (i^i?. 180, Foot, anfesthesia of (see Anaes- simulating meningitis 642 p. 663).. .. 484 663 thesia of Foot) in nose, epistaxis from 250 252 coma and delirium from 286 - deformity of (see Club-foot) nasal discharge from. . 204 from diving 269 - intrinsic muscles of, spinal - - in oesophagus, detection girdle pains from 484 nerve roots supplying . . 543 by .r-rays 297 hyperpyrexia in 344 - numbness of (see Numbness hfematemesis from micturition difficult after 443 of Foot) 294, 297 299 priapism from 585 - pallor after walking, in inter- opening into pericardium 711 transverse myelitis from 564 mittent claudication 489 — in urethra 210 cervical, fatal results of 709 - pain m (see Pain in Foot) urethral discharge from 206 immobility of neck in 709 - perforatmg ulcer of (Fig. Forgetfulness (see Amnesia) stiff neck from 709 207, p. 809) ..285,562 809 Formalin method of fixation dorsal, priapism in 585 in locomotor ataxy . . 562 for spirochfctes . . 769 FRACTURE, SPONTANEOUS 268 tabes . . 285 histological tissues 434 due to carcinoma 757 - spinal nerve roots supplying Formication 588 - - hydatid cyst 757 intrinsic muscles of ' . . 543 Formosa, distoma pulmonale in 325 in mollifies ossium 269 - tenderness in erythromelalgia 490 Foul air, headache from 328 from new growth 757 - tuberculous, simulated by - breath (see Breatli, Foul) in scurvy-rickets. . 753 tabetic arthritis. . 388 Fournier re chancre and herpes 830 syringomyelia 285 - ulcers of (see Ulceration) Fracture, badly-united, pseudo- from tuberculous caries 269 Football, cramp during 177 elephantiasis from 456 Fraenum linguee, abraded in - enlarged heart from 244 - bullae with . . 110 emphysema and bronchitis 320 - spinal symptoms due to . . 787 - contractures following 165 pertussis . . 320 ,814 Foot-drop in alcoholism 131 - crepitus a sign of . . 179 — penis, perforation by soft - after diphtheria 131 - green-stick . . 269 sore 675 - in plumbism 131 - in infants, simulation by Fragilitas ossium, distinction - (see Paraplegia ; and Paralysis syphilitic pseudo-para- from moUities ossium . . 269 of one Lower E.Ytremity) lysis 886 dwarfism from . . 213 - Tooth's peroneal atrophy 560 - muscular atrophy after 71 ', 75 late onset of 269 Foramen ovale, patent 184 - simulated by scurvy-rickets 753 rickets 269 - rotundum, trigeminal neu- syphilitic pseudo-paralysis 386 spontaneous fracture in 269 ralgia from tumours near 496 - swelling on a bone due to Framboesia 449 Forceps delivery in etiology of callus about a . . 750 Freckles in rheumatoid arthritis 378 talipes 131 - with tabetic arthritis 388 - von Recklinghausen's disease 781 - infantile diplegia due to . . 556 - talipes after 132 - xerodermia pigmentosum paraplegia due to 556 - femur, oedema of leg after 459 simulatins 804 Fordyce's disease of lips 403 sciatic nerveparalysis from 542 Frequency of micturition (see Forearm, atrophic palsy of - humerus, musculospiial para- JXicturition, Abnormalities of) from cervical rib 493 lysis after. . 549 Friction, bullae from . . 110, 112 - injury of. isphaamic paralysis - jaw, abnormal mobility of Fried fish, colic due to 136 of liand from 552 fragments in 747 Friedliinder's bacillus (see Bacillus) FRIEDREICH'S ATAXIA— GAIT 905 Friedreich's ataxia .. 686, affection o£ speech in . . Babinski's si^n in cause of death in - - choreiform movements in contracture, etc., in 162, diagnosis of atrophy from duration of electrical reactions in familial character of - - gait in hallux eroctus in 71, 131, inco-ordination in 67, insidious onset of intention tremors in 560, - - knee-jerk absent in 71, 131, monotonous speech in . . nystagmus in 71, 131, optic atrophy in 71, paraplegia in . . 71, 567, pseudo-nvstagmus in - - reflexes in 71, 82, 131, scoliosis in . . 181, sensation normal in slow, jerky articulation in slurring-speech in spastic rigidity with talipes from 71, 131, tremor w-ith . . 795, - sign in adherent pericardium Friflht causing infantile con- vulsions . . - diabetes insipidus from - nienorrhagia from . . - palpitation from . . 525, - in paroxysmal tachycardia Frog-belly in cretinism Frontal bosses m congenital syphilis (Fig. 28, p. 124) - headache in disease of eyes - lobe.agraphia from lesion of - region, ivory exostosis of . . tumours of, unilateral tremor due to . . - ridges, increased size in acromegaly - sinus dilatation, exophthal- mos in disease, cerebral abscess due to . . diagnosis from abscess of antrum . . headache in . . - - - meningitis from spastic brachial mono- plegia due to - - empyema of, causes and symptoms headache from subjective smell sensa- tions from . . nasal discharge from referred pain in fronto- nasal and mid-orbital areas in Frostbite, bulla; from - fingers affected by . . - gangrene from - haemoglobinuria in - vesicles from Fruit, raw, colic due to - unripe, diarrhcea from Fucus vesiculosus, reduction of weight by Fullness of abdomen, in colic - in asthenic dyspepsia - of the head, epistaxis reliev- ing sense of, from arterio- sclerosis - and oppression in rieht hypochondrium, sense of, in congestion of liver . . - in rectum, sense of, in cancer 800 709 82 560 560 164 70 560 71 559 277 559 131 559 800 559 560 560 560 559 452 559 559 559 686 131 163 559 799 104 170 585 428 527 772 259 669 204 FULLNESS, SENSE OF .. 270 in dyspepsia . . . . 354 - - gastritis 352 Functional albuminuria (see Alliuniinuria) - bruits 102, 104, 105, 106 - paralysis (see Aphonia : and Paralysis) Fungating' endocarditis, absence of bruit in .. 013,699 absence of clinical signs for many weeks . . 610 leucocytosis in 39, 400, 700 acute aneurysm in . . 699 peritonitis from . . 432 simulated by embol- ism in . . . . 646 rheumatism causing.. 314 albuminuria in . . 9, 237 - - anemia in 9,10,27,38,76,593, 598, 613, 616, 700 aneurysm of hepatic artery in .. .. 59, 368 axillary artery due to 732 aortic disease due to . . 237 bacteria in blood in 237, 613 - - bruits in 38, 76, 102, 103, 106, 240, 593, 598, 612, 649 changing in 38, 76, 240, 598 cerebral abscess due to.. 547 hfemorrhage from . . 700 cessation of pulsation in the accessible arteries in 613 Cheyne-Stokes respiration in 125 chronic . . . . . . 76, 613 jaundice with cyanosis in 370 coma in . . . . . . 237 continuous pyrexia in . . 612 delirium in . . . . 103 diagnosis from chronic heart lesion 38, 39, 700 influenza . . . . 610 meningitis . . . . 614 tuberculosis . . . . 613 typhoid fever. . 611, 613 typhus fever . . 610, 614 dyspnoea in . . . . 9 - - embolism in 10, 39, 59, 76, 90, 103, 138, 186, 237, 314, 338, 368, 432, 563, 565, 593, 598, 613, 646, 649, 692, 699 cerebral . . . . 338 of cord due to. . . . 565 hepatic artery in . . 59 mesenteric vessels in 432, 646 of spleen in . . 692, 699 superior mesenteric 90, 646 gastric erosions in . . 298 lia^maturia in . . 237, 314 haemoptysis in . . . . 320 haemorrhage in 9, 10, 38, 76, 593 anal, in . . . . 90 hyperpyrexia in.. .. 343 infarction in . . . . 76 of kidney in . . . . 237 lung in . . . . 321 inspissation of bile in . . 368 irregular pyrexia in . . 598 - - jaundice in . . 368, 370 with pyrexia in . . 370 long course of chronic . . 613 meningitis in . . . . 614 mitral regurgitation from 239, 240 multiple emboli In . . 699 muscular atrophy in . . 76 nephritis in . . 9, 10 neuro-retinitis in 9, 10 oedema in . . . . 9 optic neuritis in 38, 76, .314, 598, 613 osteomyelitis causing . . 314 peripheral neuritis in . . 76 Fungaling endocaTdilis, contd pneumococcal . . 314, 614 prolonged pyrexia in . . 609 pulmonary embolism from 186 incompetence with . . 24 7 valve 245 purpura in 237, 338, 596, 598, 610, 613 - - pyrexia in 9,10,38,76,103,138, 237, 314, 343, 368, 593, 598 without pyrexia. . . . 345 retinal haemorrhages in, 9, 10, 237, 338, 598, 613 - - rigors in 103, 237, 613, 648, 649 rupture of valve from . . 106 in septicaemia . . . . 698 spsistic brachial mono- plegia due to.. .. 547 spleen enlarged in 10,38,76,314, 338, 598, 613, 692, 693, 699 subcutaneous hfemorrhage in 76 sudden pain in loin in . . 314 sweating in . . 103, 237 symptoms pointing to cerebral embolism from 138 transverse myelitis due to 565 typical temperature chart in (Fig. 164) . . . . 013 various signs and sym- ptoms of . . . . 237 vesetations on valves in 649 FUNGOUS AFFECTIONS OF THE SKIN .. 270 Furnacemen, enlarged heart in 232 Furred tongue (see Tongue) Furuncle, diagnosis from car- buncle . . . . . . 603 - earache from . . . . 230 - of face, cavernous sinus thrombosis due to . . 253 - point of suppuration in . . 603 - shape of pustule in . . 001 Furunculosis of external audi- tory meatus, otorrhcea from 469 - from iodides or bromides . . 112 - tenderness of the spine from 784 - of viilva . . . . . . 768 Fusiform bacilli (see Bacillus, Fusiform) GAERTNEB'S linfillus (see Bacillus, (riicrtii.T's) GAIT, ABNORMALITIES OF 277 - in ataxy . . . . . . 66 - cerebellar . . . . . . 69 - in cerebellar tumour 565, 643 - clumsy, in Little's disease 154 - cross-legged in Little's disease 154 in cerebral diplegia . . 800 - in disseminated sclerosis . . 800 - hesitant, in paralysis agitans 548 - high steppage . . . . 66 - in hysterical paralysis . . 541 - limping, in iliac abscess . . 739 - in paralysis agitans . . 541 of external popliteal nerve 543 sciatic nerve . . . . 542 - peripheral neuritis . . . . 66 - scissor -legged in Little's disease . . . . . . 154 - shuffling in paralysis agitans 796 - in spastic paralysis of one leg 540 - spinal caries . . . . 785 - staggering cerebellar . . 565 in disseminated sclerosis 565 tabes dorsalis . . . . 827 - stooping in spinal caries . . 181 - tabetic . . . . . . 67 - tottering in general paraly- sis of the insane . . . . 796 - waddling in congenital dis- location of hip . . . . 183 of pseudo-hypertrophic paralysis . . . . 561 9o6 GALACTOCLE— GANGRENE OF LUNG Galactocele 744 Gall-bladder, conld. Gall-bladder, conld. Gall-bladder, carcinoma of (see - suppurating, absence of - in pancreatic ducts 135 Carcinoma of Gall-bladder; jaundice in many cases of 737 - peritoneal adhesions from. . 280 - cholesterin crystals in 281 albumosuria in . . 20 - preceding carcinoma 278 - constipation in diseases of 144 diagnosis from appendix - pyrexia due to 280, 363, 486, 621 - dilated, with carcinoma of abscess 737 - recurrent jaundice with . . 363 pancreas . . 265 - tenderness in the right side of - Riedel's lobe with . . 404 - disease, absence of jaundice chest from (and see Ten- - rigors with 280, 362, 363, 486 not incompatible with.. 500 derness over Gall-bladder) - sex incidence of . . 151 pain in the epigastrium 371, 779 - simulated by movable kidney 500 from 779 - tumours of, absence of cardiac dilatation 485 right hypochondrium interval between liver - sizes of 36a from.. 779 and 392 - stercobilin changes in faaces shoulder from 779 colic associated with . . 392 with 116 referred pain in area of diagnosis from renal tu- - tenderness over gall-bladder in 499 lOtli dorsal nerve in . . 509 mours . . 392 of liver from 300 sex incidence of . . 500 duUness to percussion over 392 over lower dorsal spine in 474 tenderness in the epi- jaundice with 392 - typhoid fever before 280, 281 gastrium from 779 limited mobility of 392 - ulceration into duodenum 300 the right liypochon- mobility with inspiration 392 diagnosis from gastric drium from 779 obstruction of portal vein ulcer 300 shoulder from 779 by 692 - urobilinuria with . . 116 - empyema of, cholangitis in 369 oval outline of . . 392 - vomiting with 486 - - clue to gall-stones 280 pelvic swelling due to - wind and spasms as sym- leuoocytosis in . . 281, 400 downward growth of . . 758 ptoms of . . 350 pus in the stools from Gall-stones, absence of enlarged - without symptoms 363 rupture of 601 gall-bladder with 363 Gallic acid, dark urine from 820 typhoidal. . 369 - account of symptoms of . . 363 drjrness of mouth from 789 Widal's reaction in 281 - acute intestinal obstruction extreme thirst due to . . 789 GALL-BLADDER, ENLARGE- due to . . 151, 152 300 Gallop rhythm in myocardial MENT OF 278 - areas of tenderness from . . 779 degeneration 333 in carcinoma of pancreas - ball-valve obstruction of Galton's whistle 189 59, 368, 500 ampulla of Vater with . . 650 Galvanic current in reaction causes of 280 - in bile-ducts 135 of degeneration . . 633 from cholangitis . . 651 - catch in the breath during Galvano-cautery in hypopyon 807 cholecystitis 723 deep inspiration on pres- GANGRENE 281 in chronic pancreatitis . . 135 sure over . . 486, 499 - albumosuria in 20 from cicatrized ducts . . 365 - Charcot's hepatic inter- - blebs in 283 diagnosis from carcinoma mittent fever from 650 - bullffi in . . . . 110, 112 of duodenum . . 280 - cholangitis from 280, 362, 369 650 - in diabetes mellitus (see liver abscess . . 279, 369 - cholecystitis from . . 280, 650 Diabetes Mellitus) pylorus 280 - colic due to 135, 152, 650 - dry 282 suprarenal . . 280 description 363 - epidemic . . . . 282, 287 gamma of liver 279 - collapse from 363 - in erythromelalgia . . 284 hydatid cyst of liver . . 279 - contraction of gall-bladder in 280 - of face (see Cancrum Oris) hydronephrosis 279 - diagnosis from appendicitis 500 - fatty acids and sulphides in 283 movable kidney 279, 727 chronic pancreatitis 265, 363 - of fingers from aneurysm . . 287 new growth in liver . . 279 gastric ulcer 486 from carcinoma of breast 287 pyloric enlargement . . 406 - distribution of pain from. . 135 - hand from endothelioma of Riedel's lobe . . 278, 737 - empyema of gall-bladder in 280 lung 287 thickening round duo- - enlarged gall-bladder from 723 - hospital, emphysema in . . 231 denal ulcer 406 rare with 135 - in intermittent claudication 489 gastric ulcer 406 - etiology of . . 135 - of leg from atheroma 810 in duodenal carcinoma . . 725 - in ffeces . . 64, 135, 363 - no leucocytosis with 400 exceptional with gall- - glycosuria in 292 - local, in anthrax . . 603 stones . . 135 - haBmatemesis in . . 294, 300 GANGRENE OF LUNG 287 from gall-stones. . 363 - hepatoptosis with . . 407 absence of clubbed fingers new growth 723 - impaction in common duct. in 321 pelvic swelling due to . . 757 large liver and intense expectoration in 288 pliysical signs . . 278 jaundice in . . 362, 363 foetor in 288 - - simulating ascites 717 in cystic duct, large gall- abundant foul sputum in 703 in stenosis of bile-ducts bladder and no jaun- acute history in . . 703 365 410 dice in. . 363 onset in . . 288 tumour of pancreas 366 diagnosis from carcinoma from broncho-pneumonia typhoid fever 281, 371 372 of liver 413 578, 703 , 712 - infection causing pleuritic - incidence in stout persons. . 151 causes of . . 287, 288 578 effusion . . 123 - jaundice with 300, 361, 363 cough in . . 287 - inflamed, local rigidity of - leading to pancreatitis 116 in diabetes 703 rectus abdominis with . . 644 - liver abscess from . . 408 empyema ruptured into - mucocele, absence of sym- enlarged with . . 300 363 lung 703 ptoms in 281 - long duration of attack of diagnosis from aspiration obstruction of cystic duct in 281 pain in . . 486 pneumonia 288 sterility of fluid in 281 - mistaken for rheumatism bronchiectasis. . 321 , 703 - normal situation of 722 of the shoulder . . 778 emoyema . . 321 , 703 - pain and tenderness over, - mucocele after 281 phthisis 321 from gall-stones. . 280 486 - obstruction by, alkaline elastic fibres in sputum in - palpable in cases of new fasces in . . 117 288, 321 703 growth of pancreas C90 - pains over gall-bladder from excessively foul stench in 703 - perforation of, infective 300 486 fcetor of sputum in peritonitis from. . 644 in hypochondrium in . . 499 176, 287, 288, 321 - spontaneous rupture 281 and tenderness from . . 280 from foreign body in - stone in, epigastric pain in 48G in the back from 474 789 bronchus 578 relation of pain to food - painful breathing with 486 foul breath in . .99, 321 , 703 in some cases of 486 - palpable 723 taste from 774 GANGRENE OF LUNG— GASTRITIS 907 Uatigrene - and streptococci associated 377 - ulcenitinn nf the cornea from 807 - in unllii-iil ilisrharge 79, 206, 675 - uretliiilis (lur to .. 83, 675 - in vaginal discharges . . 211 - vertebral arthritis due to . . 785 - in vulvitis . . . . . . 768 Gonorrhoea, acute, acute gouorrhoeal arthritis in.. 376 method of investigating 206, - - prostatitis and prostatic abscess from . . uretliritis in - albuminuria in ascending nepliritis from . . - balanitis in . . - chordee in . . - chronic defined filaments found in urine in joint lesions from - dyspareunia frona . . - enlarged inguinal glands from 422 - epididymo-orchitis 518, 766 - eosinophilia in . . . . 248 - flat-foot from . . . . 376 - gangrene in.. .. .. 282 - infection of ejaculatory ducts 518 prostatic urethra in third week in - iritis and cyclitis in - mode of examining dis- charge for gonococcus . . - nature of vaginal discharge - nodules in globus minor in - orchitis from - pain in tlae penis durmg micturition in . . sole of foot from - papilloma uretlnrae from . . vulva? from - perineal sores from - persistent pyuria in - priapism from - prostatic abscess from threads after 207 5ir> 511 10 674 125 207 207 27S 221 518 250 768 211 767 79 511 370 209^ 769 677 620 580 631 444 purulent uretliral discharge in 511 - pyrexia in . . . . . . 620 - pyuria due to . . 623, 031 - redness of Bartholin's gland ducts in . . . . . . 769 and swelling of carunculte my rti formes . . . . 769 - residual prostatic catarrh of 444 - rigors from . . . . . . 650 - scalding on micturition in 769 - simulated by gouty urethritis 818 - soft cliancre of . . . . 769 - spondylitis deformans after 786 - testicular abscess from . . 680 atrophy after . . . . 79 - thread-worm infection mis- taken for 569 - time of onset of urethral symptoms . . . . 511 - urethral 518 epididymo-orchitis in . . 517 gonococcus in smear of the discharge in (Plate XII, Fig. R, p. 696) . . 675 pyuria due to . . 623, 031 staphylococcus simulat- ing' 031 - vesiculitis in . . . . 638 - vulvitis in . . . . 768, 769 GonorrhcEal artliritis (see Ar- thritis) 910 GONORRHCEAL BARTHOLINITIS— GUMMA Gonorrhceal Bartholinitis 221 Gowers' varieties of hemiplegic Guaiacum test for blood 89 - epididymitis (see Epididj- rigidity . . . . 163, 164 iodides and the . . 112 mitis. Gonorrhoea^ Graafian foUicle, haemorrhage Guanin bases, uric acid from 817 - rheumatism (see Arthritis, into, spasmodic pelvic Guinea-pig, inoculation of, in Gonorrhceal) pain from 509 diagnosing tuberculosis Gooseberries, oxaluria from 311 471 Gracilis, nerve supply of 542 57, 121, 026, 719 Goose-stin, severe 528, 530 Grain, sporotrichosis from . . 322 Gum-boil 747 Gout 380 Grandeur, ideas of, in general - foul taste from 774 - acut« attack of . . 382, 383 paralysis of insane 139, 269 - grinding of teeth due to . . 293 arthritis in .. 3S3 507 Grandidier, re haemophilia . . 302 - pain in the face from 495 in other joints than the toe 382 Grand mal (see Epilepsy) - ptyalism due to 591 - age incidence of . . 381 Granular casts, renal. . 7 Gumma of bone 386 - albuminuria in 16 - kidneys (and see Bright's diagnosis from chronic - bony out-growths in 383 disease) . . 13 pyogenic infection 752 - brachial neuralgia in 491 accentuation of heart sarcoma 752 - carernitis from 516 sounds in . . 1, 2 639 tuberculoas disease . . 752 - cellulitis simulating 455 albuminuria in . . 14, 18 general thickening of bone - chronic (Figs. 112, 113) . . 383 and cerebral haemorrhage 138 in 752 - condition of nails in 275 Cheyne-Stokes respiration localized swelling due to - confusion witli syphilitic with .. .. 124, 125 386, 752 pains 386 cyanosis from . . 186 osteomyelitis due to 752 179 enlarged left ventricle in 23f ,639 - of bundle of His . . 98 - diagnosis from infective epistaxis in 251 - Cauda equina, simulating arthriris . . 382 in gout . . 507 peripheral neuritis 74, 563 - distribution amongst joints in 383 haemoptysis in . . 318 - cerebral, diabetes insipidus in 585 - Dupuytren's contracture in 167 heart failure in . . 464 headache, vomiting and - dyspepsia in 354 high blood-pressnre in giddiness from 336 - eifect of diet in 381 18, 64, 96, 186, 251, 464 639 - of cranium, tenderness of - epididymo-orchitis from 517, 818 orthopncsa in . . 464 scalp from 782 - epistaxis in . . 251 pale, albuminuria in con- - diagnosis from abscess 449 - no essential relationship to tracted . . 17 Bazin's disease . . 451 uric acid precipitates 816 817 or red 63 epithelioma 420 - granular kidney in 507 palpitation in . . 525 lupus 449 — glycosuria in . . 292, 817 pleuritic effusion in 122 - enlarged liver from 615 - headache in 328 in plumbism . . 38, 144 - of face, healed (Figs. 156-7) 589 - heredity in . . . . 381, 383 polycythaemia in 579 — fauces, palate, or uvnla . . 678 - high blood-pressure from . . 251 polyuria from 528, 579, - of joints (see Arthritis, — importance of history in 381 383 582, 583, 584 Tertiary Syphilitic) - intercostal neuralgia in . . 478 reduplicated heart sound - of liver . . . . 411, 615 - iuTolTement of tendon in 639 action of mercury and sheaths in 382 signs of . . 122 iodide in 279 - in lead poisoning . . 77 due to ureteral obstruction 11 ascites with 60 - monarticular character of 382 Granulosis rubra nasi 714 causing pleuritic effusion 123 - neiiralgia in 491 Grating in osteo-arthritis . . 384 new growi:h 279 - orchitis from 79 Gravel, uric acid 816 secondary carcinoma. . 370 - oxaluria in . . 471 - in urine in renal colic 500 local enlargement of liver - pain in the big toe from. Graves' disease (see Exoph- in ... 370 381, 382, 486 thalmic Goitre) pyrexia in . . 370, 615 - peripheral neuritis in 75, 507 Gravid utenis (see Pregnancy) simulated by phantom - plumbism causing . . 38, 507 Great auricular nerve, skin tumours " . . 721 — priapism in 585, 586 distribution of . . 659 simulating enlarged gall- - piyrexia in . . . . 382, 455 - occipital nerve, skin distri- bladder. . .. 278 279 - rarity of suppuration in . . 382 bution of . . 659 situation of 722 - recurrence of attacks of 381 382 Great- toe joint, favourite site therapeutic test for 279, 370 - rigors in . . . . 647, 650 for gout . . 381 Wassermann's reaction in - scleritis and episcleritis in 256 Greedy colon, constipation 279, 371 - senile gangrene and 286 due to 143 - mediastinal (see Mediastinum - sex incidence of . . 381 Green cancer (see Ohloroma) Gumma of) - shiny skin over joint in . . 383 Green-stick fracture . . 750 - meninges 687 - simulated by tabes 484 in rickets 769 - paralysis of vocal cord from 538 - simulating "gonorrhceal ar- Grimacing, mild choreiform - pelvic, simulating sciatica 74 thritis 383 movements causing 156 - of penis 677 pyaemia . . 383 GRINDING OF TEETH DUR- - pyrexia with 615 - sodium urate crystals in ING SLEEP 293 - of skin 279 ioint, bursa, or ear in in general paralysis of the - spinal cord, spastic para- '(Figs. 112, 113) . . 380 insane . . 796 lysis of one leg from . . 540 in tophi in 380 Groin, affected by eczema mar- aUocheiria from . . 22 - soles of feet in 3»2 ginatum . . " 275 - spleen, exceedingly rare . . 692 — swelling of bones in 754 - coloured sweat of . . 714 - spontaneous healing of . . 812 - tenderness in the spine in 784 785 - glands (see Lymphatic Glands ^ - of testis (see Testis, Gumma of) - twticular atrophy after . . 79 Inguinal) - therapeutic test in diagnosing - tinnitus with 794 - hernia in . . 716 254, 279, 420, 672, 677, 752 - tophi about joints or in - oedema of in ilihoy's disease 460 - thyroid gland 792 ears in .. .. 380, 507 - pain in, from renal calculus 308 - tongue . . 270, 420, 814 - - in (Figs. 112, 113) 381, 383 - sweUing in (see Swelling, simulated by tuberculous - urethritis in 206, 585, 586, 818 Inguinal) ulcer 814 - vertigo due to 829 due to lipoma of spermatic - tonsU simulating carcinoma 672 - violent thumpinss of heart cord 741 sore throat Irom. . 670 4 in elderly people liable to 527 Growing-pains 18 - ulcerating, description of 811 813 - z-rays in (Fig. 113) 383 - in children, relation to acute - unilateral exophthalmos Gow on reaction of vaginal rheumatism . . 504, 507 due to 254 secretion . . 210 Guaiacol, foul breath from . . 98 - uretliral . . 209 Gowere' distal myopathy, fibril- taste from 774 - \\'assennann's reaction in lary contractions rare in 15S - poisonhig, diazo-reaction in 198 420, 752 G UMS— HEMOGLOBIN URIA 911 Gums, uc-tinomycosis of . . 87 - Wcciliu!,' (see Bleeding EMOPTYSIS 315 96, 98, 138, 337 - occult (and see Occult Blood) 94 - after abdominal operation 123 in Hodgkin's disease 302 in pancreatitis . . 117 - admixture of sputum in 293 316 hyperpyrexia from 98, 344 - oedema of legs due to 459, 461 - alkalinity of blood in 293, 316 hypertension of cerebro- - into optic thalamus, hyper - amount of blood in 293 spinal fluid in . . 338 pyrexia from 344 - anaemia after 36 hypothermia in . . 346 - pancreatic, collapse in 292 - bright colour of blood in . . 293 Jacksonian epilepsy from 161 constipation in . . 292 - bronchial casts after 704 optic neuritis in 98 glycosuria in 292 - casts in sputum after 704 - - prodromal symptoms of 173 severe abdominal pain in 292 - causes of .. ..317,318 319 ringing aortic second simulating acute intestinal - coma from . . . . 137, 140 sound in 337 obstruction 292 - diagnosis from hfematemesis from rupture of an acute vomiting in 293 293, 316 aneurysm 700 - in phosphorus poisoning . 373 between true and spurious 316 simulated by saturnine - pontine 138 - elastic fibres in sputum 316, 317 encephalopathy 139 absence of unilateral para - - in embolism of the lung . . 186 tumour 341 lysis in . . 138 - caused by epistaxis 251 a first symptom of chronic bilateral loss of move - fatal from aneurysm of aorta 322 nephritis 15 ment in 345 - in fibroid lung .246 temporary glycosuria in 292 coma in . . . . 344, 345 - frequency of occurrence in tendon reflexes after 337 hyperpyrexia ui . . 13S , 341, night 317 thick neck in those pre- 344, 345 - frothiness of blood in 293, 316 disposed to . . 191 pin-point pupils with 138, 345 - in gangrene of lung 288 unilateral convulsions in 170 simulating opium poison - due to growths 176 epilepsy mistaken for. . 174 ing 345 - haematemesis from swallowed from uterine prolapse . . 10 - postpartum 27 blood in . . 294, 295 317 vomiting from . . 844, 847 coma due to 137 - in healthy subjects 318 - into cord from bullet wound 563 from hourglass uterus . 229 - from infarction of lung 186 , 240 - from ears or nose in fractured leucocytosis after 400 - malingering of 317 skull 138 secondary 436 - in mediastmal growth 483 - functional bruits after 106 severe anremia after 459 - mitral regurgitation 238, 240 - in fungating endocarditis - producing diplopia 200 - in parasitic infection of 9, 10, 38, 593 - rectal (see Blood per Anum ) bronchus . . . . 318 ,325 - gastric (see Haematemesis) - in retina . . . . 59 8, 613 - phthisis 185 - into Graafian follicle resem- in albuminuric retiniti 3 462 - from pneumothorax 577 bling dysmenorrhoea 220 chronic Bright's disease . 240 - profuse, due to aneurysm. . 176 - from gums (see ^Bleeding erythropsia with 840 new growth . . 176 322 Gums) in fungating endocarditi phthisis 176 - in Hanot's cirrhosis 411 38, 76, 237, 338, 59 8, 013 - rapidly fatal 293 - hard fteces after 150 macular, precedmgchoroi i- - severe anemia after 459 - internal from ruptured tubal itis . . . . . 462 - spurious, causes of . . 316 gestation 780 scotoma from . . . 837 - from stonemason's lung . . 317 signs of . . 646 - round optic nerve, sudder I - the only symptom of throm- - intermenstrual (see Metror- blindness from . . 839 botic infarct of lung 320 rhagia) - in scurvy . . 44, 85 - tickling in throat in 316 - intestinal (see Blood per - into semicircular canals - tubercle bacilli in 316 317 Anum, and Melaena) M6nifere's disease due t( ) 828 - a:-rays in 318 coma from . . 137, 140 - severe, collapse from 346. HAEMORRHAGE, SEVERE— HEAD'S AREAS 913 licemorrliage, severe, conld Hair, contd. Hand, contd. coniii due to 137,139 140 - brittleness in cretinism . . 259 - professional cramp of 177 ellects of . . 298 - broken in ringworm of scalp 274 - pruritus of . . 588 extreme thirst from 78a - changes in myxoedema 43 - Kavnaud's disease affecting fall of temperature from 780 - distribution of ringworm 459, 490 hypothermia after 346 spores on . . 273 - redness or pallor in acropar- leucocytosis after 400 - falling out, in myxoedema 454 aesthesia . . 493 cedema of legs after 461 - follicles, affection in papular - scabies of . . . . 447, 609 pallor from 780 syphilis . . 532 - sensation of heat and swell- rapid pulse from G46 780 pityriasis rubra pilaris 530 ing in, in acroparasthesia 193 - shortness of breath due to 100 xerodermia 530 - sweating of, in rheumatoid - spinal, amesthesia due to . . 787 - loosening of, in sycosis arthritis . . 378 girdle pain due to 787 -iTilgaris . . 602 - tremor of . . 795 history of injury in 563 - loss of (see Baldnes.s) from alcohol 136, 238, 797 paralysis of upper extre- lustre due to favus 270 general paralysis of the mity from 555 - mode of affection in ring- nisane . . 796 paraplegia due to 561 787 worm 272 in exophthalmic goitre 792 797 priapism from 585 - " mousey " colour in Mongo- - wasting of, in amyotrophic sensory disorders in 563 lian idiocy 263 lateral sclerosis . . 73, 554 - in splenic ansmia . . 411 - scantiness in cretinism . . 259 bulbar palsy 087 - splenomegalic cirrhosis 094 Mongolian idiocy 263 from cervical rib 493 - spontaneous, in congenital and receding in myxoedema 259 in peroneal atrophy 128 obliteration of bile-ducts 365 - shape in alopecia areata progressive muscular atrophy - subconjunctival, in acute 84, 85, 274 73, 127 conjunctivitis 255 - stumps in rmgworm of scalp 273 syruigomyelia 285 distinguished from con- - suppuration round, in sycosis ulnar paralysis . . 127 junctivitis 256 vulgaris . . 602 Hanot's cirrhosis (see Curhosis in fractured skull 138 - thinness at back from head of Liver, Hanot's) - subcutaneous (see Purpura) rolling 171 Harelip with cleft palate . . 640 in fungating endocarditis 76 - trophic changes in major Harrison's sulcus 170, 191, 212 695 - subdural, convulsions in . . 172 trigeminal neuralgia 495 Hat-makers, mercury poison- - subperiosteal in scurvy 44, 8a ,314 Hair-ball, palpation per rectum 635 ing in . . . . Zi , '■7 - into thyroid cyst simulating Hair-cutter's cramp . . 494 neuritis in 77 malignant disease 791 Hair-wash, lead poisoning from 77 Hav fever, acute nasal catarrh - uncinate gyrus, anosmia from 669 Haldane-Gowers' hsemoglo- " m 203, 668 - itrinary (see Ha?maturia) binometer 27 loss of smell in . . 668 - Uterine (see Menorrhagia, Haller, vas aberrans of, cyst taste due to . . 774 Metrorrhagia, ^Metrostaxis ; arising from 521 - sporotrichosis from 322 L'terus, Haemorrhage from) Hallucinations of hearing in Head, choreiform movements intermenstrual (see iletror- mental cases 793 of, in spinocerebellar ataxy 799 rhagia) Hallux erectus in Friedreich's - enlarged in acromegaly . . " 585 - vaginal (see Menorrhagia, ataxy . . 71, 131, 559 cretinism . . 258 Metrorrhagia, :iIetrostaxis) Haloes, appearance of in glau- hydrocephalus . . 557 in extrusion of uterine fibroid587 coma and conjunctivitis 257 osteitis deformans 183 inversion of uterus 578 Halting (see Gait) rickets 170 new-born infants 435, 436 Hamstrings, atrophy of 560 - fixed in cervical caries . . 477 with ruptured tubal gesta- - elongation in contortionists 183 - forward droop in acromegaly 263 tion 646 - spinal nerve-roots supplying 543 - fullness of, epistaxis relieving 2.52 - various, in leukcemia 31 - treadler's cramp of 177 - injuries, alopecia from 80 - into vitreous, blindness from 840 HAND, ACCOUCHEUR'S .. 3 cerebrospinal fluid from erythropsia from 840 - affected by acute rhetunat- nose after 203 sudden blindness from . . 839 ism 374 chronic headache after . . 329 Hsemorrhagic erosions 298 erythema papulatum . . 531 coma due to 137 - small-pox 605 - angioneurotic cedema of 457 459 effects of . . 137 KaemorrhoidSjin alcoholism . . 243 - athetosis of (Fuj. 42) 154 hemiplegia from 138 - bleeding 92 - atrophic palsy of, in amyo- Jacksonian epilepsy after 174 - bearing-down pain from . . 473 trophic lateral sclerosis 131 .159 - quadrate, in rickets 695 - in cirrhosis . . 368 - bloody sweat of '715 - retraction of (see Retraction - diagnosis from rectal polypus 635 - bullse of in congenital sy- of Head) - dyspareunia from . . 221 philis 111 - tremor of . . . . 795, 796 - excessive blood loss from. . 100 in syringomyelia 112 in disseminated sclerosis 800 - increased by pylephlebitis 59 - cheiropompholyx of 654 832 I'riedreich's ataxy 799 - inflamed, pain in the penis - chondromata of 755 paralysis agitans 796 after micturition in 513, 515 - deformity in spastic hemi- - segmental areas of (Ficfs. - internal, carcinoma of rectum plegia 164 132-135) 497 with 635 syringomyeUa 534 Head, H., re alterations in difficulty of palpation tetany 178 sensibility 660 unless inflamed or - enlarged in acromegaly - re Brown-Sequard paralysis 664 thrombosed 635 391, 585, 749, 753 - re distribution of sensation - pam in perineum in 516 - gangrene of 287 changes from lesions in the - priapism in elderly men from 586 - gonococcal artliritis of 376 cord 662 - and prolapse, association . . 93 - lupus erythematosus of . . 656 - re nerves of heart and aorta 481 - retention of urine after - mercurial tremor of 797 - re pain in the face . . 495 operation for 49 - muscular atrophy of (see - re referred pain from pros- - sacralgia from 510 Atrophy, Muscular, of Hand) tatitis 491 - spasm of sphincter ani from 150 - in myxoedema 454, 455, 585 - re segmental areas of scalp - thrombosis or gangrene of. . 635 - oedema of in heart faihn-e 458 (Figs. 202, 203) 783 Hemosiderin in macules 424 and tenderness of, in - re spinal areas of referred H/EMOTHORAX 118 erythema keratodes . . 451 pain 788 Hair, analysis for arsenic - pain in, due to chondromata 755 - re trigeminal neuralgia 495 poisoning. . 38, 78, 87, 576 - paralysis of, m Tooth's Head's areas of referred pain - axiUary and pubic, early peroneal atrophy 71 128 in pelvic disease 509 development with hyper- - preference of impetigo for 604 - segmental areas for referred nephroma 690 small-pox for 605 pain 498 58 914 HE A DA CHE— HE A R T, EN LA RGED HEADACHE 326 Hearing, defects of, delay in Heart disease, conld. - in acute encephalitis 139 acquiring speech due to 682 dry cough due to 175 meningitis . . 139, 563 - impaired in otitis media . . 229 eosinophilia in diagnosing poliomyelitis 128 with facial paralysis . . 536 asthma from . . 249 yellow atrophy . . 370 - tests for 188 epistaxis ui 251 - aortic disease 233 Heart, abscess of (see Abscess flatulence in 267 - arsenical poisoning 76 of Heart) gastritis in 352 - from astigmatism . . 498, 783 - affection common in Mon- general pains in limbs in 503 - in cerebellar abscess or tumour565 golism 216 haematemesis in.. 294, 299 - cerebral abscess 341, 547, 686 847 by post-diphtheritic peri- hEematuria in . . 314 syphilis . . 173 pheral neuritis . . 640 headache in 329 - - tumour 173, 292, 336, 341, - alcoholic, ascites with 62 heart failure from 461 350, 477, 547, 686 847 - block 97 history of chorea in 526 - from concussion 782 - bruits (see Bruits, Cardiac) scarlet fever ui 526 - and cryptomenorrhcea 22 - cloudy swelling of, palpita- syphilis in 526 - with cystic kidneys 48 tion in . . . . 525, 526 hyperaemia of uterus from 430 - digestive 326 - compression in aortic aneur- hypothermia in . . 345 - in encephalitis 547 ysm 482 increase of uroerythrin in - epidemic jaundice . . 372 - dilatation of, acute, epigastric urine in 819 - after epileptic convulsions 169 in pulsation 243 infantile paralysis from 155 - in errors of refraction 498 general account of . . 243 infantilism 216 - frontal in diseases of eyes. . 328 from specific fevers . . 243 insidious onset of fun- - - at onset of typhoid fever 610 canter rhythm in 639 gating endocarditis in 314 - in fronto-nasal and mid- in chronic bronchitis and insomnia in . . 356, 358 orbital areas, in frontal emphysema 246 menorrhagia in . . 428 sinusitis . . 498 fibroid degeneration 241 mesenteric thrombosis in 153 nasal inflammation . . 498 Flint's murmvu in 108 (jedema of legs from 461 - in gastritis . . 297 of left auricle from mitral orthopnoea in . . 359 - general tuberculosis 699 stenosis 245 pain in the chest in 478 - glaucoma . . 257, 494, 783 838 mitral regurgitation from temporal region from 783 - hysteria . . . . 345, 784 239, 240, 243 and tenderness in back - due to hypermetropia 783 in myocarditis . . 241 from (Fig. 204) 788, 789 - increased intracranial pres- pernicious anaemia 639 palpitation in . . 481 sure 686 right ventricle, pain in pancreatitis from 116 - in influenza . . 505, 601 epigastrium in 485 polyuria in clearing up - iritis . . 783 sharp short first sound in 331 of effusion in . . 582 - with lardaceous disease . . 48 simulation of gaU-stones precordial pain in 481 - in late stages of acromegaly 749 by 485 puSiness and oedema of - lesions of central nervous gastric ulcer by 485 f ac« in 746 system 585 systolic bruit in 102, 106 referred pain in arm in . . 494 - Malta fever 507 - disease, albuminuria in.. 18 rheumatic history in 121 620 - meningitis 350, 359, 622, 642 847 amenorrhcea in . . 23 shortness of breath hi . . 100 - in mid-orbital region in errors anaemia in 38 splenic enlargement m. of refraction 498 anal haemorrhage from suggesting fungating - migraine .. ..837, 840 847 mesenteric embolism in 90 endocarditis . . 699 - mode of production of 326 ascites in . . 61 subcutaneous nodules in 452 - neurasthenia 494, 506, 702 788 blood-pressure high from 251 tenderness in chest from 776 - occipital, in affections of low in . . 329 epigastrium from 779, 783 tongue 498 brachial monoplegia in . . 546 precordial region from 778 cerebellar disease 326 cerebral embolism in . . 138 temporal region from 783 cerebral tumour . . 477 in children, splenic en- uric acid in 817 - - diagnosis from cervical caries47 7 largement in . . 693 vomiting in 843 meningitis 327 — congenital, aortic 238 - duUness diminished m simulated by myalgia . . 326 bruits m 102, 104, emphysema 246 - at onset of dengue . . 506 129, 244, 579 790 with hypertrophied heart 331 - paroxysmal, due to eyestrain 498 cardiac dullness in 790 increased in acute dilata- - phosphorus poisoning 373 clubbing of fingers in tion of heart . . 2i3 - plumbism . . . . 38, 77, 173 129, 244, 529, 579 790 aortic disease . . 233 - in puetmionia 622 colour index in 579 enlarged heart 231 232 - preceding apoplexy 173 convulsions due to 169, 170 congenital heart disease - with XJuerperaJ eclampsia.. 172 cyanosis in 129, 184, 244 579 - pyelonephritis 48 244, 579, 790 fatty heart 241 - referred pain in severe ear dyspnoea in . . 244 790 mitral regurgitation . . 238 disease 498 enlarged left ventricle in 232 stenosis 245 - relief by digitalis . . 329 enlargement from 244 pericarditis 242 iron 329 epigastric pulsation in 244 HEART, ENLARGED - with renal tuberculosis 48 haemoptysis in 320 1, 13, 102, 231 232 - in scarlatina 301 hability to phthisis in 320 — absence or presence of - segmental areas of . . 498 polycythaemia in 244, 579 ,790 murmurs in 331 - with sinus thrombosis 139 , 651 ,847 precordial thrill in . . 244 in adherent pericardium 63 - temporal, from car disease 498 pulmonary regurgitation 107 - - alcoholism in 238, 343 333 - from tic doulom/eux 782 stenosis, enlarged right angina pectoris due to . . 778 - toxic caiises of 328 ventricle in 245 in aortic disease. . - in tuberculous meningitis. . 612 rumbling systolic 103, 105, 107, 359 - typhoid fever90, 610, 620,697 ,699 bruit in . . " 579 apoplexy . . 173 - unilateral causes of 320 site of apex beat in . . 790 apparent health . . 332 172 thrill due to. . 790 arteriosclerosis . . 639 - in variola . . 301 without bruit . . 129, 184 beer drinkers' 333 - various character of 326 cyanosis 129 - - Bright's disease 63, 90 - vertical, from ear disease . . 498 conjunctival oedema of. . 256 cardiac impulse displaced in hysteria 798 convulsions in . . 169 172 down and to left in . . 332 - in yellow fever 301 cyanosis from 186 cerebral haemorrhage 138 337 Head-retraction (see Ketrac*^ion) diagnosis of 526 chronic nephritis Head-rolling in rickets 171 78?. displaced impulse 330, 331 332 48, 122, 126, 172, 303, 331 ,639 HEART, ENLARGED— HEMIANESTHESIA 915 Jlcaii, fnliinjed, mnld. cJa'onir |)iireiicliymatoas ncpliritis . . . . '15-1 coiuiircysiou of liiiig by 3^4, GG7 diai^nosis from displace- ment of . . . . 331 epistaxis ia . . . . 252 in exoplithalmio goitre. . 244 heart sounds in . . . . 331 high blood-pressure con- ditions 202, 331, 359, 52G incompetence in . . . . 247 insomnia in . . . . 35'J laryngeal jjariilysis witli 539 due to long-continued over-exertion . . 243, 244 medullary degeneration wlth343 in mitral regurgitation.. 102 from mitral stenosis . . 245 in morbus ca>ruleus . . 579 ortUopncea due to 405, 467 - - with patent interven- tricular septum . . 244 prolonged first sound in 331 - right ventricle, cardiac impulse placed to left in causes of . . 244, 245 diseases of lungs causing in pulmonary incom- petence - - skodaic resonance due to 332 40 swelling of chest wall from 194 332 162 18 . 243 61, 62 64, 96 97 14, 63 . 110 485 362 525 457 461 55 without symptoms - failure, acute, in tetanus . albuminuria in . . from alcoholism . . ascites in . . blood-pressure high in borborygmi in - - from Bright's disease bullae in . . causes of, classified 54, 61, 464 Cheyne-Stokes respiration in 125 congestion of liver in . . 370 cyanosis in . . 184, 186 enlarged liver from 55, 61 mfluence of exertion on pains of - - jaundice in lung conditions causinj main groups of causes . types of nutmeg liver with oedema of limbs in 61, 457, 458 459, 461 orthopncea from.. 464, 465 _- - pain in epigastrium from 485 polyuria in clearing up of effusion in . . . . 582 - - pulsation of liver due to 764 splenic enlargement rare in 693, 699 universal oedema from 458, 460 urate deposit in . . . . 815 - fatty, abuminuria in . . 18 alcohol causing . . 238, 241 ancemia in . . . . 241 ascites in . . . . . . 62 canter rhythm in . . 639 cardiac asthma in . . 241 causes of . . . . 62, 241 causing mitral regurgita- tion . . . . 239, 241 Cheyne-Stokes breathing in . . . . 125, 241 - - degeneration of . . . . 464 from phosphorus . . 87 diagnosis from dyspepsia 526 dyspncea in . . . . 241 faintness and coma in . . 241 - - feeble cardiac impulse in 241 general account of . . 241 Heart, fatly, contd. heart failure in . . . . 404 in obesity . . 103, 241 ortliopneea in . . . . 404 palpitation in . . 025, 520 in pernicious anaiiiiia . . 639 shortness of breatli witli 101 after specific fevers . . 241 systolic apical bruit witli 102 wasting diseases causing 211 - fibroid, albinuinuria in . . 18 due to alcoliol . . . . 238 ascites in . . . . . . 02 Cheyne-Stokes' respira- tion in . . . . 120 ilcLTi'iicraf ion of . . . . 464 - - .lyspiuiM ill .. .. t'4l - - li(':irt fiiiliire in . . . . 404 mitral regurgitation in 239, 241 palpitation in 241, 525, 526 precordial pain in . . 241 shortness of breath with 101 sudden death from . . 242 after syphilis 02, 241, 242 systolic apical bruit with 102 - Hypertrophy of (see Heart, Enlarged) HEART IMPULSE, DIS- PLACED 330 in acute dilatation of heart . . . . 243 endocarditis. . . . 239 adherent pericardium 242 alterations in reson- ance in . . . . 331 aortic disease . . 233, 332 regurgitation . . 107 in ascites . . . . 51 asymmetry of chest in 331 in athletes . . . . 332 bronchiectasis . . 703 chlorosis . . . . 333 congenital heart disease 244 diagnosis from enlarged 331 enlargement of right ventricle 231, 232, 332 exophthalmic goitre . . 244 by fibroid lung 129, 193, 232, 240, 324 with Flint's murmur.. 109 fluid in chest . . . . 193 huge hydatid cyst of liver . . . . 415 hydrothorax . . . . 467 in hypertrophy of heart 332 meteorism . . . . 716 mitral regurgitation 238, 332 stenosis . . 245, 580 valve disease . . 102 orthopncea from . . 467 pericarditis . . . . 242 by pleural efliusion 232, 764 pneumothorax 193, 232, 480, 577, 721 subphrenic abscess 712, 721 x-vays m diagnosis of . . 332 feeble in fatty heart . . 241 normal position of 231, 330 - - position in hypertrophy of heart 332 - - raised in pericardial effu- sion 333 - - senile myocardial degener- ation . . . . . . 333 - irregular in enlarged heart from over-exertion . . 244 mitral stenosis . . . . 61 in organic cerebral disease 328 tobacco poisoning . . 527 - malformation (see Heart, Disease Congenital) - malignant polypus of . . 826 - nerves corresponding to the 481, 778 Heart, contd. - new growtlis of . . . . 98 - patent septum ventriculorum 579 - senile, palpitation from 525, 527 - slow action of (see Brady- cardia) - sounds, abnormal (see Bruits, cardiac, and Heart Sounds, Accentuation of, and Re- duplifatioii) .. .. 101 HEART SOUNDS, ACCENTU- ATION OF 1 in albuminuria .. 14 arteriosclerosis . . 039 cerebral hajmorrliage 139, 337 chronic nephritis 14, 122, 454, 039 parenchymatous ne- phritis . . . . 454 emphysema . . . . 192 with high blood-pres- sure . . 90, 252 loud sharp slapping 1st sound at apex in mitral stenosis . . 520 in mitral stenosis 108, 320 regurgitation . . 239 (see Reduplication of Heart Sounds) relation to reduplication 039 - - - second sound in hyper- trophy of the left ventricle . . . . 331 altered in cerebral haemor- rhage 138 enlargement of heart . . 331 estimation of blood-pres- sure . . . . . . 90 reduplicated . . . . 2 - strain, albuminuria due to 18 - symptoms of arteriosclerosis and sclerosis of kidney . . 14 in chorea . . . . 548 - thumpings of, with coronary atheroma . . . . 527 in elderly gouty men . . 527 - - from excessive smoking. . 527 at night in epilepsy . . 527 - transposition of . . . . 330 - weakness suggested by cough on exertion . . . . 176 HEARTBURN 333,484 - definition of . . . . 842 - diagnosis from merycism . . 431 - in dyspepsia . . . . 354 - regurgitation of acrid fluid into mouth in . . 431, 484 Heat, distribution of, influence of blood, lymph, and tissue juices on . . . . 619 of nerve centres on . . 619 - extreme, gangrene from. . . 282 - and flushing in the extremi- ties in erythromelalgia . . 284 - from inflammation . . 478 - loss, modes of . . . . 019 - production, modes of . . 619 - stroke, coma from 137, 139 hyperpyrexia in . . . . 344 Heberden's nodes (Fir/. 109) 380, 384, 452 Hebra, prurigo ferox of . . 531 Hedgehog crystals of urates. . 815 Heel, bedsore over . . . . 285 - conical . . . . . . 130 - Jacquet's erythema of . . 446 Hegar's sign in pregnancy . . 437 Heller's test for albumosuria 6, 20 Hemeralopia, albinism causing 841 - in snow-blindness . . . . 841 - tobacco poisoning . . . . 841 Hemianaesthesia from apoplexy 666 - from cervical cord injurj'. . 341 - disseminated sclerosis . . 665 9i6 HEM I A NmSTHESIA —HERNIA , ING UINA L 666 666 336 798 157 66G 595 333 335 749 335 81 336, 666 .. 336 .. 595 .. 836 595 HemiancEsthcsia, contd. - dissociative from tlirombosis of left posterior inferior cerebral artery (Fig. 184) - with hemianopsia . . 336 - hemiplegia . . - iiysteria 69, 166, 506, 666 - witli hysterical chorea - loss of taste, smell, hearing, and sight, with . . Ilemianopic pupillary reflex. . HEMIANOPSIA - bilateral homonymous, illus- trated (Figs. 103, 104) . . temporal, in acromegaly (Fig. 102, p. 334) from tumour near optic chiasma - in cerebral tumour - with hemianresthesia - hemiplegia . . - light reflex in - migraine - with normal light reflex in optic fibre lesions above corpora quadrigemina . . - from occipital cortex lesions 595, 837 - optic tract lesion . . . . 595 - perimeter in demarcating. . 333 - pupil tests for site of lesion in 336 - quadrant variety in migraine 837 - with word blindness . . 684 Hemiataxia . . . . 68, 69 Hemiathetosis . . . . 338 Hemiatrophy of face with torti- collis . . . . . . 167 simulating facial paralysis (Fig. 141) . . . . 537 - - or trunli: . . . . . . 72 Hemichorea . . . . 156, 341 - paralysis of arm m . . . . 548 - simulating hemiplegia 340, 341 Hemicrania from ej^e-strain . . 495 - in migraine . . Ilemiopia ("see Hemianopsia) HEMIPLEGIA - abnormal gait in . . - from abscess - acute bedsore in . . - agraphia with - altered reflexes in . . - ankle-clonus in - aphasia in . . - articulation in - ataxy in - atlietosis from - Babinski's sign in . . - bedsores in . . - from bilateral cerebral soft- ening - causas of - from cerebral embolism 285, 699 syphilis . . . . . . 173 thrombosis . . . . 285 - chorea simulating . . 340, 341 - choreiform movements before and after. . . . . . 157 tremor in.. .. .. 799 - with coma . . . . . . 137 - without coma in thrombosis 138 - condition of muscles in . . 336 - conjugate deviation of eyes in 137 - contractures witii . . 162, 163 - crossed . . . . . . 336 - double, dysarthria in 336, 687 without aphasia in . . 687 emotionalism in.. .. 258 - facial paralysis with 533, 536 - with fungating endocarditis 237 - gangrene in . . . . 282 - hemianfEsthesia with 336, 666 - hemianopsia with . . . . 336 - hysterical . . . . . . 69 838 336 278 138 285 .. 137 44 336, 685 .. 687 68 .. 155 .. 82 .. 811 563 82 Hemiplegia, contd. - inequality of knee-jerks in 397 - infantUe . . . . . . 155 ataxy in . . . . . . 68 athetosis in . . . . 68 hemi-athetosis in . . 338 talipes in. . . . . . 131 - from porencephalus . . 164 - puffing out of one cheek in 137 - rigidity with . . . . 164 - site of lesion in . . . . 336 - spastic, characters of hand, arm, and leg in . . . . 164 in general paralysis of the insane . . . . . . 682 - tremor in . . . . 795, 798 - ulceration of the leg in . . 811 - unequal pupils in . . . . 137 Hemitrophy of face on trunk 72 Henoch's chorea electrica .. 157 convulsions in. . 161, 169 - purpura (i^«>. 111).. 90, 380, 382, 600 acute abdominal symp- toms in 380, 600, 846 age incidence of (Fig,llV) 380, 600, 846 arthritic symptoms in 90, 380 blood per anum in 90, 600 - - colic in . . . . 90, 380,- 600 constipation in . . . . 90 diagnosis of . . . . 600 from acute nephritis . . 600 rheumatism . . . . 380 rheumatic purpura. . 380 diarrhcea in . . . . 380 epistaxis in . . . . 90 heematemesis in 380, 846 - - hifimaturia in^ 90, 380, 600 lisemoglobinuria in . . 315 lia;niorrhage from kidney in 600 intestine in . . 600, 846 joint pains in . . . . 600 melfena in . . . . 380 mesenteric haemorrhage in 846 purpura in . . 596, 600 pyrexia in . . . . 380 recurrence of attacks of 600 severe prostration in . . 600 simulating intestinal obstruction . . 90, 846 intussusception 90, 600, 846 stomach-ache in.. .. 600 urine in . . . . . . 600 - - vomiting in 90, 380, 600, 844, 846 Hepatic abscess (see Abscess, Hepatic) - artery, aneurysm of (see Aneurysm, Hepatic) - colic (see Colic, Biliary) - reflex ptyalism from . . 591 - tumour (see Liver Enlarged) Hepatitis, pain in the right hjrpochondrium in . . 499 Hepatogenous albumosuria . . 20 Kepatoptosis, blood-stagnation in abdominal vessels on standing in . . . . 407 - dragging pain in . . . . 407 - dyspnoea on exertion in . . 407 - faintness in . . . . . . 407 - floating kidney with . . 407 - gallstones with . . . . 407 - heaviness of liver region in 407 - influence of posture on . . 406 - kiiiliing of bile-duct in . . 407 - occurrence usually in neurotic dyspeptic valetudinarians 407 - palpitation in . . . . 407 - physical signs of 404, 406, 407 - rarity of 406 - sudden attacks of pain in riglit of abdomen in . . 407 Hepatoptosis, contd. - from venous congestion . . 407 - w'ithout symptoms. . . . 407 Hereditary ataxia (see Fried- reich's Ataxy) - chorea . . . . . . 156 - optic atrophy . . . . 837 - trophoedema (see ilibroy's disease) Heredity and anosteoplasia . . 213 - baldness due to . . . . 84 - and bradycardia . . . . 97 - cystinuria . . . . . . 187 - exostoses . . . . . . 754 - Friedreich's ataxy . . . . 164 - gout 381 - haemophilia . . . . . . 86 - Milroy's disease . . . . 460 - myopathies . . . . . . 70 - obesity . . . . . . 453 - paroxysmal hsemoglobiniu-ia 315 Hernia, bands and adhesions from . . . . . . 152 - bladder in . . . . . . 742 passage of more water after reduction of hernia in cases with . . . . 742 - cerebri, movement with re- spiration . . . . . . 764 - congenital, first descent in adult life . . . . . . 742 - epigastric, pain in the epi- gastrium in . . . . 485 - in the groin . . . . 716 - gurgling on reduction . . 741 - hydrocele of sac of . . . . 740 - identification of contents of 742 - importance of examination both in upright and re- cumbent position . . 742 - impulse on coughing in 739, 741 - internal, obstruction due to 133 - labial, simulating Bartholin cyst . . . . 768, 770 - of the lung . . . . 194, 764 - palpation of appendix in 742 - perineal . . . . . . 768 - reducibflity of . . . . 739 - resonant on percussion un- less omentum only in 739, 741 - retention of urine after operation for . . . . 49 - diaphragmatic, congenital 712 rarity of 712 succussion sounds in thorax with . . . . 711 - femoral, age incidence of 733, 740 causes of irreducibility of 733 diagnosis from femoral gland .. ..734,738,740 from hydrocele of a hernial sac . . . . 740 inguinal hernia . . 739 mal-descended testis . . 740 obturator hernia . . 740 psoas abscess . . . . 739 saphena varix. . . . 739 disappearance on lying down 732 femoral swelling due to. . 733 general account of . . 733 gurgling on reduction of 733 impulse on coughing in . . 732 position and relationship 739, 740 reducible on pressure 732, 740 resonance of . . . . 733 sex incidence of . . 733, 740 simulated by lipoma . . 716 psoas abscess . . . . 733 saphena varix. . . . 733 strangulation of . . . . 733 - inguinal, age incidence of 740, 742 HERNIA INGUINAL— HIP. INJURY OF 917 Hernia, inguinal, co7ild. Hi.rnin, siroii'jidalnl, mnlil. Hrrfics, zoxtrr, could. bowel and testicle in same resonant . . 741 distribution of . . 830 or different sacs 742 severe vomiting in 741 enlarged lymph glands in 479 commoner than femoral at shock and collapse in . . 153 erythema and vesicles all ages and in both sexes 740 - testis, characters of 681 with 830 descent almost always diagnosis from epitheli- of eyes, mouth and tongue 831 into a congenital sac. . 742 oma of scrotum 681 flaccid vesicles in 829 - - diagnosis of adherent slougliing papilloma . . 681 from Gasserian ganglion omentum from encysted due to syiDhUis 680, 681, 766 disease 496 livdrocple . . 741, 742 tuberculous . . 681, 766 herpes genitalis and 675 between direct and - umbilical 716 hypersesthesia from 667 indirect 740 age mcidence of . . 524 of painful area in post- from encysted hydrocele diagnosis from sebaceous herpetic pain 494 of the cord . . 740 cyst of umbilicus 524 influence of age on pains femoral hernia 739 frequently irreducible . . 524 due to . . 479, 496 lymphangioma of cord 741 globular "shape of 524 intercostal neuralgia after 478 extension into labium . . 739 impulse on coughing 524 involvement of lips in . . 403 scrotum 739 pain in . . 524 lymphocytosis in cerebro- frequent association with pressure by omentum in 524 spinal fluid in. . 339 undescended testis . . 523 sex incidence of . . 524 macules in 424 gradual development of 742 Herniae along linea alba 716 malaise and pyrexia with 496 history of hernia in infancy 742 - quite small, intestinal ob- neuralgic pain with 830 hydrocele of the sac of an, struction from . . 716 origin as vesicular eruption 404 diagnosis from new - vulval 771 pain in arm in . . 494 growtli of retained testis 742 Herpes, on the ear . . 536 back from . . 475, 476 mode of reduction 740 - facial paralysis witli 536 chest from . . 477, 777 position and relationship - febrilis, involving lips 403 left hypochondrium in 499 739 740 - frontalis, corneal ulceration right hypochondrium in 501 relation to straining 740 742 from 807 papules in 830 simulated by lipoma 716 insensitiveness of cornea in 807 persistence of pain after strangulated, diagnosis itching in . . 781 disappearance of erup- from inflamed hydrocele 741 opacity of cornea from . . 807 tion 499 suppuration of . . 739 raised ocular tension in . . 807 rarely bilateral . . 830 testicular atrophy from 78 tenderness of the scalp in 781 not recurrent 830 varicocele with . . 742 vesicles in 807 scabs from 653 vulval swelling due to . . 768 - genitalis, bubo rare with . . 675 scars after . . 479 653 direct, ease of reduction diagnosis of 675 simulating pleurisy 830 and suddenness of soft sores from suppu- tenderness with . . 830 return in 740 rating stage of 675 in chest from 776 777 globular shape of 740 distmction from herpes of scalp from . . 780 rarity of 740 zoster . . 830 spine in. . . . 784 785 relation of spermatic enlarged inguinal glands trigeminal neuralgia in . . 496 cord to . . 740, 742 from 830 ulceration from . . s.-so scrotum rarely reached irritation during micturi- vesicles, on an inflamed 740, 742 tion in . . 209 base in.. .. 479 829 - Obturator, diagnosis from itching and burning in . . 830 most marked at exits femoral hernia . . 740 occurrence in herpes zoster 675 of branches of inter- neuralgia from . . 488 parts affected by 830 costal nerves 479 pain shooting along inner penile sores in . . 515 674 Herpetic eruption on auricle side of thigh in 740 of prepuce 209 inperipheral facial paralysis 536 rectal or vaginal examhia- recurrent nature of 675 - urethritis described 209 tion in detecting 740 simulation of chancre by 830 Herpetiform eruptions in ar- - - strangulation of . . 740 chancroids by 830 senical poisoning 76 swelling vague in 740 simultaneous occurrence Herter, views of intestinal - omental, diagnosis from hy- of syphilis and 675 infantilism 215 drocele of hernial sac . . 741 vaginal discharge from . . 830 Heteroxanthin bases, uric lipoma of cord or round vesicles, pustules, and acid derived from 817 ligament 741 ulcers in 675 HICCOUGH 342 new growth of retained - gestationis, bullaj in 110 HI Hides, anthrax from . . 603 746 testis 742 eosinophilia in . . 249 Hidrocystoma . . .. 714, 829 granular feel in . . 741 - iris, bulliB in 832 - relation to mUiaria 831 strangulated, diagnosis eosinophilia in . . 249 High altitudes, polycythsemia from torsion of testis 742 relation to pemphigus . . 113 caused by residence at . . 579 - scrotal, absence of limita- - labialis in lobar pneumonia High-stepping gait in paralysis tion above in 522 186 372 of external popliteal nerve 543 diagnosis from haematocele 523 - simplex, distinction from HUl, re pyrexia in health 619 hydrocele 522 herpes zoster 830 Hip, congenital dislocation, varicocele 767 face and genital organs signs and symptoms of . . 183 impulse on coughing in . . 522 affected by 829 lordosis in . . 183, 277 nearly always oblique vesicles in 829 skiagraphy for 183 inguinal 742 - simulating unpetigo 830 waddling gait in 277 reducible with gurgle . . 522 - urethral 209 - disease in caries of spine . . 564 resonance in 522 - zoster, affection of 3rd, 4th, chronic inguinal abscess testis distinguishable in 522 and 5 til intercostals most from 739 translucency in infants . . 522 often in . . 479 insomnia from night variations in size with from central nervous lesion 675 starting in 357 position of patient . . 522 crusts in . . 829 lordosis with 183 - Strangulated, absolute con- diagnosis from dermatitis pelvic abscess in 739 stipation in 151, 431, 741 herpetiformis . . 830 perforation of acetabulum diagnosis from inflamed eczema . . 831 in 739 hydrocele of the sac . . 740 erythema multiforme 830 wasting of thigh with . . 183 undescended testis . . 523 herpes simplex and - hysterical . . 166 difficulty of detecting . . 733 herpes genitalis 830 - injury of, causing sciatic possibly obturator 740 perUche 404 nerve paralysis . . 542 9i8 HIP—HYDA TID DISEA SE Hip, conld. Histology in diagnosis, conld. Hydatid cysts, conld. - osteo-arthritis of . . 383, 384 for torsi testis . . 521 of bone . . 757 with spondylitis aeformans 787 trichinosis 504 spontaneous fracture in 757 - rarity of gout in 383 tubercle of uterus 435 causing discharge at the - stiff after typhoid ferer . . 376 tuberculosis 255, 435, 744, 814 nipple . . 202 - tuberculous 564 ulcer of tongue . . 814 diagnosis of ascites from 53 femoral swelling from . . 734 uric acid crystals 816 from ovarian cyst 761 lardaceous disease from . . 10 xanthoma multiplex 805 eosinophilia with - - obturator neuralgia and 488 Hoarseness from pharyngitis 673 58, 323, 415, 719, 720 pain refr-rred to knee in 278 - and dysphagia in laryngitis 226 felt per rectum . . 58 relative frequency of . . 385 Hob-nail liver, with ascites . . 60 geographical distribution secondary afEection of Hock, polyuria from. . 581 323, 719, 720 Uium in 737 Hockey, cramp during 177 of kidney. . 396 simulated by ilio-psoas Hodgen's splint, extension simulating hydronephrosis 396 bursa . . 734 apparatus, talipes from. . 132 — of liver 58 swelling in right iliac fossa Hodgkin's disease (see Lym- abscess from . . 408, 410 from 730 phadenoma) ascites in 60 wasting, muscular in 72, 386 Hoftmann's baciUi, acute ton- breath sounds on right Hippocratic facies . . 431,' 644 sillitis, laryngitis, and side impaired from. . 415 - succussion . . 193 pharyngitis from 670 bulgingrightside of chest 415 Hippuric acid in urine, reduc- Hofmeister's test for albumo- causing pleural efEusion 123 tion by . . 290 suria 20 compression of lung by 607 Hippus, association with cen- Hollow-back (see Lordosis') confusion with pleuritic tral scotoma 595 Holmgren's test for colour effusion 415 nystagmus 595 blindness . . 840 diagnosis from abscess 415 - in cerebral tumour 595 Homogentisic acid in alkap- adenoma of liver . . 414 - chronic alcoholism . . 595 tonuria 822 carcinoma . . 413, 415 - definition of 595 quantitative estimation. . 822 syphilitic liver 415 - in disseminated sclerosis . . 595 Fehling's solution reduced dome-shaped upward Hirschsprung's disease U7, 432 718 by "822 extension of liver abdominal distention in Hooklets, hydatid 45, 57, 58 415 dullness in . . 415 148, 151, 152, 713 in nrine . . 396 eosinophilia in 279, 413 ballooning of colon in . . 433 Hook-worm (see also Ankylo- extension upwards of 406 415 bismuth in diagnosis of. . 433 stomiasis) (Figs. 14, 16, general account of 719, 720 constipation 147, 151, _433 713 p. 94) 570 giving rise to hydatid of diagnosis of 433 Horse-hair, anthrax from . . 746 lung . . 323 illustrated (Fig. 122) . . 432 Horse-riding, torsio testis great enlargement of intestinal obstruction in from . . . . 521, 7C6 liver in . . 415, 416 151, 433 Horses, actinomycosis in heart displaced by 415, 416 tympanites in . . 148, 152 workers amongst 705 jaundice in 364, 366 415 risible peristalsis with 148 724 Hospital gangrene, surgical latency of 27!) .r-rays in diagnosis of . . 433 emphysema in . . 231 occasionally multiple 415 His' bundle, lesions of 07 - sore throats.. .. 419 073 pressure symptoms in 415 Histology in diagnosis of affec- Hot-cross-bun skull in con- previous hydatid history 279 tions of breast 744, 745, 746 genital syphilis . . 752, 782 rareness of fluctuation in 415 larynx . . . . 226, 674 in ricksts 212 senim reaction in 279 orbit 255 Hot eye, Hutchinson's 256 simulating enlarged tonsil . . 672 - stage of malaria 35 gaU-bladder 278,279 415 uterus 434, 435, 706 759 - water-bottles, bedsores from 285 situation of . . 722 carcinoma of jaw 749 - weather, urate deposit with 815 skodaic resonance above 007 uterus . . 435 Hour-glass contraction of supptuating . . 415 cause of perforate palate 640 uterus, dystocia due to . . 227 tenseness of . . 415 cysticerci 452 placenta retained in . . 229 thrill in.. .. 413, 415 epithelioma 420, 769, 803 812 - stomach (see Stomach Hour- urticaria from. . 415 of penis . . ()76, 677 glass — of lung 323 perineum 678 Humerus, fracture of (see absence of symptoms in 323 epulis 748 Fracture) liEcmoptysis in 317 323 erosion of uterus 435 - myeloid sarcoma of 750 secondary to hydatid faeces in jiancreatitis 117 - tuberculous periostitis of . . 752 of liver 323 gastric ulcer and car- Hump-back (see Kyphosis) mediastinal 826 cinoma. . 713 Hunger, infantile insomnia from 356 varicose thoracic veins growths . . 421 Hunger-pain in appendicitis 350 ,500 from.. 826 of testis 520 - in elironic cholecystitis 500 pelvic . . . . 757 ,761 hsemoglobinuria 821 - duodenal ulcer . . 40 500 in peritoneum . . 58 melanotic carcinoma or Hunt?r, re toxaemic catarrh ribs affected by . . 776 sarcoma 802 of bile-ducts 370 simulating movable kidney 727 in metrorrhagia . . 433 Hunting, ha?maturia after. phthisis 323 molluscum contagiosum 805 due to movable kidney. . 310 spherical a--raT shadows - - multiple benign sarcoid 452 Huntington's cliorea, descrip- in (Fig. 100) . . 323 nature of ovarian tumour 759 tion of . . 156 of spleen . . 092 new growth of epididymis 767 Huppert's test for bile pigment 819 subphrenic abscess from 721 Paget's disease . . " . . 803 Huskiness (see Speech, Abnor- of thyroid gland 792 polyuria with albumin- malities of) with tumour of liver . . 58 uria 58^ Hutchinson's liot eye 250 Varicose thoracic veins from 826 ptyalism . . 591 - teeth described (Figs. 79, - disease, death from exhaus- rectal carcinoma 636 80) 259 tion in 410 sarcoma . . 803 Hyaline corpuscles . . 28 description of 720 bone . . . . 75G 703 - renal tube-casts 7 extreme rarity of 416 jaw 748 Hyaloid artery persistent, gastro-intestinal symp- sebaceous cyst . . 681 amblyopia witli nystagmub 830 toms in 416 spinal growtlis . . 564 Hydatid cysts, abdominal tu- of joints . . 388 stomach contents 355 mours from 720 liable to suppurate . . 388 sjphilis and cancer 672, 709 ,813 in bile-ducts, jaundice kyphosis from . . 182 for tapeworm ova 569 from 301 lajjarotomy in diagnosis of 720 HYDATID DISEASE— HYPERALGESIA 919 415 , 58 415 57 434 211 26 228 759 228 387 114 820 249 111 Hydatid disease, conld. physical signs of 415, pyrexia in relation to taeniae chino- coccus . . - - serum reaction in 58, 279, 415, 719, site of development of . . peritoneum, account of of vertebras ..181,785, - fluid, characters of . . in ascitic fluid (Fiq. 6) 57 - - hooklets . . 45, 57, 58, illustration of Hydatidiform mole, chorion- epithelioma following . . vaginal discharge from . . Ilydraemia Hydramnios, diagnosis of from ascites . . .1 - dystocia due to . . 227, Hydrarthrosis, intermittent. . Ilydroa - sestivale, hjematoporphjTin- uria in - eosinophilia in - Ljfstationis, biiUce in Hydrocele, translucency in not always apparent. . .. 765 - acute, "accompanymg acute epididymo-orchtis . . 522 in mumps . . . . 522 polyorrhymenitis . . 522 rheumatism . . . . 522 from scrotal injuries . . 522 in small-pox . . . . 522 - bleeding mto . . . . 765 - bloodstained fluid in, in malignant disease of testis 520 - of canal of Nuck, diagnosis from fibromyoma of round ligament . . . . . . 741 disappearance on lying down . . . . 771 simulating hernia . . 771 vulval swelling from . . 768 - cholesterin crystals in fluid of (Fig. 94, p. 281) . . 765 - chronic, aching in testicle in 522 dragging sensation in loin m 522 - of the cord . . . ■ 740, 741 diagnosis from inguinal hernia . . . . 740, 741 vaginal hydrocele . . 765 extension upwards along cord . . . . . . 765 impulse on coughing in. . 741 not reducible . . . . 740 size and shape . . . . 765 translucency in . . . . 741 - development in sac of hernia 740 - diagnosis from cyst of testis 521 encvsted hydrocele of cord 765 ^" testis . . . . 522 growth of testis 520, 521, 522, 742 hfematocele 522, 523, 765 scrotal hernia . . . . 522 - of femoral hernial sac 733, 734 - flabby consistency of . . 765 - fluctuation in . . 522, 765 - formation of hoematocele after tapping . . . . 522 - frequent association with hernia . . . . . . 742 - gi-eat thickening of tunica vaginalis in some cases of 521 - of a hernial sac . . . . 740 diagnosis from femoral hernia . . . . . . 740 - inflamed, diagnosis from strangulated hernia . . 741 - loculated . . . . . . 765 521, 522, 522, Hydrocele, conld. - milky fluid in - plivsical signs of . . - relation of testis to - with syphilitic orchitis - scrotal swelling due to - size of - straw-coloured fluid in - testicle enveloped by atrophy from - translucency in - vaginal - with tuberculous testis Hydrocephalus, anosmia from - antenatal recognition of . . - Cheyne-Stokes respiration in - convulsions in . . 170, - crepitus with - dwarfism witli - dystocia due to - egg-shell crackling in - headache in - infantile diplegia due to . . - meningitis with - paraplegia duo to . . 556, - vomiting from . . 844, Hydrochloric acid in gastric juice, absence of 37, - - deficiency in carcinoma of stomach ..353,845, in benign pyloric obstruction gastric contents . . in chronic gastritis. . gastrectasis . . test for Hydronephrosis, absence of htematuria in pain in . . - bilateral, from obstruction to outflow of urine from bladder in pelvic carcinoma prostatic disease urethral stricture causing in vesical disease - conversion into pyonephrosis - diagnosis of ascites from . . from cystic disease of the kidney . . enlarged gall-bladder - direction of growth from above downwards and inwards ... - fluctuation in - hsematuria in . . 304, - intermittency in . . - due to movable kidney 500, 581, 583, papilloma of kidney renal calculus . .309, 581, uterine carcinoma - pelvic swelling due to - periodic polyuria in 500, 581, - renal enlargement from 391, 394, 396, 500, - round smooth outlme of . . - sense of tenseness and elasticity m - simulation by cyst of kidney - in ureteral obstruction 135, 395, - variations in quantity of urine passed in . . in size of . . - from vesical growth Hydrophobia, convulsions in 169. - diagnosis of tetanus from . . - due to dog or wolf bite 162, - dysphagia in . . 225, - long latency of - mental symptoms in - priapism in . . - ptyalism in . . 765 522 765 519 765 765 521 765 78 765 765 765 669 228 125 172 179 214 227 177 327 556 557 557 847 845 Hydrophobia, conld. - retraction of the head in . . 641 - rigors in " . . . . . . 647 - spasms in . . . . . . 162 - trismus rare in . . 162, 801 Hydropneumopericardium, churning sounds in . . 711 Hydro-pneumothorax •• 577 - acute cyanosis from . . 712 dyspnoea from . . . . 712 pain in the chest from . . 712 - from injury . . . . 712 - needling of chest in diagnosing 711 - from paracentesis thoracis 712 - due to phthisis . . . . 712 - simulated by subphrenic abscess . . . . . . 712 - succussion sounds in . . 710 - sudden onset of . . . . 712 - tubercle bacilli in sputum in 712 Hydrops amnii, diagnosis of ascites from . . . . 52 physical signs of . . . . 52 Hydroquinone-acetic acid in alkaptonuria . . . . 822 Hydrosalpinx, pelvic swelluig due to . . . . . . 757 Hydrothorax in mitral regurgi- tation . . . . 239, 240 - orthopncsa from . . 465, 467 Hygroma, cystic, in axilla . . 733 Hymen, closure of, sterUity due to . . . . 705, 706 - imperforate, with amenor- rhoja . . . . 22, 23 hsematocolpos from . . 761 - unruptured, dyspareunia from 221 Hyoid area, referred pain in, in affections of lateral part of tongue . . . . 498 with hypersesthesia in ear disease . . 498 Hyoscyamus, delirium from 195 Hyperacidity of gastric juice with ulcer . . . . 89 - of urine, frequency of micturi- tion from . . . . 438 Hyperacusis from nuclear facial paralysis . . 536 paralysis of stapedius . . 537 - in fevers, etc. . . . . 190 - migraine . . . . . . 190 HypersBsthesia in adiposis dolorosa . . . . . . 455 - of arms, from visceral disease 494 - band type in tabes dorsalis 665 - in brachial neuralgia . . 491 - from combined scleroses of the cord . . . . . . 667 - compression of cord . . 786 - in Dercum's disease . . 455 - herpes zoster . . 494, 667 - hyoid region from ear disease 498 - hysteria . . . . . . 509 - leprosy nodules . . . . 450 - from lesion of the optic thalamus 666 - in lipomatosis, diffuse . . 455 - peripheral neuritis 505, 506, 666 - pernicious anaemia.. .. 667 - predisposing to pruritus . . 588 - referred pains . . . . 475 - spinal caries . . . . 667 - from spinal tumour . . 667 - in tabes dorsalis . . 665, 666 - vesicae, frequent micturition in 443 Hypenesthesic spots in neur- asthenia and hysteria . . 667 Hyperalgesia during regenera- tion of peripheral nerve 661 - of muscles in peripheral neuritis . . . . 660, 661 - thoracic . . . . . . 778 920 HYPERCHLORHYDRIA— HYSTERIA Hyperchlorhydria, absence of local tenderness in . . 485 - in fonctional djapepsia . . 354 - heartburn with . . . . 333 - increased appetite in . . 49 - pain in the epigastrium in. . 485 relieved by taking food 485 Hyperidrosis ("see Sweating, Abnormalities of) Hjiperlactation, anaemia from 40 H ypermetropia, congenital crescents associated with 461 - convergent squint due to . . 709 - headache from . . 327, 783 - increasing in tumour of optic nerve . . . . . . 255 - small size of pupil in . . 594 - tenderness of forehead from 783 temporal region from . . 783 vertex from . . . . 783 Hypermetropic astigmatism, ophthalmoscopic appear- ance of (Plate YIIl) . . 463 Hypemmesia . . . . . . 25 Hypernephroma, aching in loin 395 - causing premature develop- ment of external genitalia (Figs. 125-6) . . 454, 690 - demarcation from renal tissue 395 - enlargement of the kidney in 395 - haematuria in . . . . 395 - microscopically similar to adrenal tissue . . . . 395 - obesity in . . . . . . 453 - origin' from adrenal rests 395, 690 upper pole of kidney . . 395 - premature puberty with . . 690 - renal colic in . . . . 395 - secondary deposits in lungs 455 - simulating enlarged spleen 726 - slow growth of . . . . 395 - yellow colour of . . . . 395 nyperpiesis (see Blood- prtesure, hish) HYPERPYREXIA .. 343 - in acute rheumatism 194, 622 - cerebral diseases 98, 138, 345, 346, 622 haemorrhage injtiries - heat-stroke . . - hysterical - from lesions of corpus striatum . . . . . . 346 of subthalamic region . . 346 - pontine haemorrhage 138, 345 - - lesions . . . . . . 346 - septic conditions . . . . 622 - typhoid fever . . . . 622 - uramia . . . . . . 622 Hyper-resonance to percussion in pnetimothorax . . 577 Hypersecretion in functional dyspepsia . . . . 354 - stomach-tube test for . . 355 Hypertrophic pulmonary osteo- arthropathy (see Osteo- arthropathy) - pvloric stenosis, congenital 426, 845 - rhinitis (see Ehinitis, Hyper- trophic) Hypertrophy of cervix uteri simulating prolapse of uterus . . . . . . 586 - extensor longus haUucLs . . 164 - of heart (see Heart, Enlarged) - oesophagus, idiopathic . . 225 - prostate (see Prostate, Enlarged) Hypnotics, delirium due to . . 195 Hypochlorhydria in gastric carcinoma . . 37, 351 - in functional dyspepsia . . 354 - gastritis . . . . . . 352 98 622 139 618 Hypochondriasis, constipation in 144 - insomnia in . . . . 358 - oesophagismus type . . 484 - in oxaluria . . . . . . 471 - pruritus in . . . . . . 588 - with undue abdominal aortic pulsation . . . . 592 Hypochondrium, definition of 723 - enlarsed spleen felt in . . 726 HYPOCHONDRIUM, LEFT, PAIN IN (see Pain in Hyp ochondrium) bulging of, by enlarged Spleen . . . . . . 688 liver palpable in. . . . . 726 retroperitoneal cyst in . . 726 swelling in, due to tubercu- lous peritonitis . . 691 subphrenic abscess . . 720 suprarenal tumour . . 393 tumour in, due to carci- noma of splenic flesnre 690 of pancreas . . . . 726 pancreatic cysts . . 724 various tumours felt in. . 725 HYPOCHONDRIUM, RIGHT, PAIN IN (see Pain in Hypochondrium) discomfort in, in catarrhal jaundice . . . . ' 365 organs normally contained in 722 redness and swelling: of due to hepatic abscess - tendemes in (see Tender- ness in Hypochondrium) various tumours felt in . . Hyp ocythaemia HjTJOgastric region, definition organs normally con- tataed in Hypogastrium, bladder form- ing swellirig in (Fig. 191) - Fallopian tube tumour in. . - intussusception felt in - ovarian tumour in . . - pain in (see Pain in Hypo- srastrium) - uterine tumour in . . - various tumours felt in 730, 731 Hypoglossal nerve, bulbar paralysis affecting paralysis, ptyaltm in . . H5Tiomnesia . . Hypopyon, cauterization in. . - galvano-cauteiy in - from paralysis of fifth nerve - pnetmiococcus in . . - pure carbolic acid in - from, ulceration of the cornea 800 Hypospadias, changes stream of urine in Hvpothenar muscles, atrophv of 73 HYPOTHERMIA .- 345,621 715 722 26 722 730 730 730 730 730 159 591 807 807 807 807 438 - in alcoholism , . . . 344 - children, from exhaustion . . 621 in marasmus . . . . 621 - cerebral abscess . . 547, 623 - conditions associated with much pain . . . . 621 - after convulsions . . 621 - in cretinism . . . . 259 - heart disease . . . . 345 - from internal haemorrhage 780 - with lardaceous disease . . 48 - in myxoedema . . . . 259 - neurasthenia . . . . 506 - opium poisoning 138, 34-1 - pyelonephritis . . . . 48 - renal tuberculosis . . . . 48 - starvation . . . . . . 621 - summer diarrhcea . . . . 621 - tuberculous peritonitis . . 57 - uraemia . . . . . . 45 156, 506, 137, field of 666, 837, 163, 165, IGO, 1G9, Hypothyroidism, in ateleiosis - nervous symptoms with . . - obesity in . . . . 453, - tetany from Hypotonia of muscles in tabes Hypoxanthin bases, uric acid derived from Hysteria : - abdominal aortic pulsation in - absence of fatigue in - acute pains in limbs in . . - age incidence of . . - amblyopia with . . 800, - amnesia from - anaesthesia in (see Anaesthesia Hysterical) - anorexia in . . - anuria in . . . . 45 - aortic aneurysm mistaken for - aphonia in (see Aphonia) - ataxy in - Babinski's sign absent 82; - bilateral adductor paralysis in . . - blindness in . . - borborygmi in - brisk knee-jerk in - hullfe in - change of signs and sym- ptoms in - choreic movements in - clavus hystericus in - clonic spasms in . . - club-foot in . . - coma in - constipation in - constriction of vision in . . - contractures in - convulsions in 345, 464, impaired consciousness in polymorphous character of simulating tetanus sphiacter unrelaxed in . . - cough due to - danger of diagnosing - deafness in . . . . 191, - delirium in - diagnosis from disseminated sclerosis . . 665, 798, by effect of suggestion from malingering neurosis . . strychnine poisoning tetanus . . - distention in - dysphagia due to . . - emotional outbursts in - exaggeration of deep flexes in 166, 342, - excessive appetite in thirst with - facial spasm - faecal vomiting in . . - fits described - flexor plantar reflex in - flushing in . . - globus hystericus in 342, 506, 710, - " alove " anaesthesia in 342 - headache in 329, 345, 784 - hemianassthesia in 69, 506, 666, - hemiplegia in 69, 340, - hiccough in. . - hyperaesthesia in . . 509, - hyperpyrexia in . . 344, - impaired consciousness in. . - increase of symptoms from anaemia in - insomnia in . . - intention tremor in 162, re- 343, 342, 216 454 451 178 262 817 592 464 503 710 836 26 50 , 49 69 800 798 666 97 509 111 506 157 798 652 132 140 150 838 166 173, 801 160 464 464 160 175 798 666 345 800 150 389 527 801 801 465 224 800 49 789 537 847 173 343 345 798 506 798 798 342 342 667 345 160 784 356 800 HYSTERIA— INCO-ORDINA TION 921 Hysteria, conld. - joint symptoms in 166, 389 diagnosis o£ . . . . 389 disappearance under anes- thesia 389 disproportionate pain iu 389 muscular atrophy in . . 390 sleep unaffected bj^ the pain and tenderness of 389 stiffness often extreme . . 389 - leg-raising test of . . . . 342 - lock-jaw in. . . . . . 464 - loss of smell in . . 666, 669 taste in . . . . 666, 774 - mediastinal new growth mistaken for . . . . 777 - meteorism in . . . . 433 - mistaken for asthma . . 582 - mj^oclonus in . . . . 160 - and neurasthenia, difficulty of distinguishing . . 788 - nystagmus absent in . . 800 - opistliotonos in 162, 463, 464 - optic discs not affected in. . 800 - pains in the limbs in . . 506 in ovarian region in . . 509 and tenderness in back in 788 scalp from . . . . 784 - palate reflex in . . . . 509 - palpitation in . . 525. 527 - paralysis agitans mistaken for 54S - paralysis in.. 157, 163, 389, 506, 798, 800 absence of associated movements in . . 549 muscular wasting in . . 541 antesthesia in . . . . 549 of arm in . . . . . . 548 general atrophy in . . 548 characteristic attitudes of 166 with chorea . . . . 157 electrical reactions in . . 541 flaccidity in . . . . 541 gait in . . . . . . 541 with hysterical chorea . . 157 joint 389 of one leg due to . . . . 541 typical attitude . . 541 reflexes in . . . . 541 - - rigidity in 398, 541, 548 of arm in . . . . 548 of Imibs in . . . . 39S simulating pregnancy . . 166 - paraplegia in ..69, 562, 567 - perverted taste in.. .. 774 - phantom tumours in 433, 721 - phosphorus excretion in . . 572 - pneumonia mistaken for . . 777 - pleurisy mistaken for . . 777 - polyuria with 581, 582, 789 - professions of insomnia in 359 - pruritus in . . . . . . 588 - pseudo-neuralgia in . . 498 - ptyalorrhoea from . . . . 590 - pupiUary reaction in . . 160 - pyrexia from . . . . 618 - quivering of eyelids in . . 160 - retention of urine in . . 441 - retraction of the head in . . 641 - rigidity of limbs in . . 398 - rigor-like attacks in 646, 647 - risus sardonicus in. . 651, 652 - scoliosis in . . . . . . 180 - screaming in . . . . 160 - " seizures "in . . . . 506 - sex incidence of 506, 641, 710 - simulating cerebral tumour 798 epilepsy . . . . . . 160 strychnine poisoning 464, 652 tuberculous hip or knee 166 - spasm of bladder in . . 443 - spasmodic contractions in 159, 106, 537 - sphincters not paralyzed in 800 Hysleria, conld. - spinal caries mistaken for 777 - spine symptoms in . . 788 - " stocking " anaesthesia in 506 - stridor from . . . . 710 - subjective smell sensations in 669 - sudden recovery from . . 506 - suggestion treatment in 150, 343, 577 - some symptoms of . . . . 157 - tenderness in the chest from 776, 777 of the scalp from . . 781 - tests for motor types of 548, 567 - tetanic spasnis in 162, 464, 802 - tetany simulated in . . 178 - trance in . . . . 137, 140 - tremor in . . . . 795, 798 - trismus in . . . . 162, 801 - typhoid spine simulating . . 787 - variable paralyses in . . 506 - vomiting m.. .. 844, 847 simulating indigestion . . 350 - writer's cramp simulated in 178 Hystero-epilepsy . . . . 161 - retraction of the head in . . 641 ICELAIND, hvdatid disease in . . .'. . . 719, 720 Ichthyosis, age incidence of . . 530 - anidrosis with . . . . 714 - diagnosis from tinea imbri- cata . . . . . . 276 - hystrix, papules of . . 530 - onychogryphosis in . . 445 - scales in . . . . . . 655 - sore fingers from . . . . 266 Icterus (see Jaundice) Ideas of grandeur in general paralysis . . 139, 172, 269 Idiocy, absence of speech due to 682 - convulsions of children in. . 169 - delayed walking from . . 557 - destructiveness in . . . . 682 - dirty habits in . . . . 682 - irritability in . . . . 682 - kyphosis with . . . . 182 - and microcephaly . . . . 214 - Mongolian, facies of . . 263 - paraplegia in . . 556, 557 - ptyaiism in . . . . 591 Idioglossia, description of . . 688 Idiopathic dilatation of the colon (see Hirschsprung's Disease) cesophagus . . . . 225 - muscular atrophy and hyper- trophy, fibrillary con- tractions in . . . . 158 Ileum, congenital malforma- tion . . . . . . 151 Iliac abscess (see Abscess, IliacJ - crest, bedsore over . . 285 - fossa, swelling in (see Swell- ing in Iliac Fossa;) pain in (see Pain in tlie Iliac Fossae) - glands, enlarged (see Lymph- atic Glands, Hiac) - vein, thrombosis in 186, 456 Iliacas, nerve supply of . . 542 Ilio-costal space, bulged out by renal tumour . . 391, 393 perinephric abscess . . 392 Ilio-bypogastrio nerve, skin distribution of . . 659 nio-inguinal nerve, skin distri- bution of . . . . . . 659 Ilio-psoas muscle, spinal nerve- root supplying . . . . 543 Ilium, disease of, swelling in iliac fossa from . . 730, 737 - osteomyelitis of . . . . 737 - tuberculous disease of . . 737 Illusions iu chronic alcoholism 172 Imbecility, amenorrlicca in . . 23 - dwarfism with . . . . 214 - prominent in Mongolism . . 216 - ptyaiism in. . . . . . 591 Impacted wisdom tooth, dia- gnosis of tetanus from.. 162 Im.pending death, delirium in 195 Imperforate hymen, vagina, or cervi.x. . . . . . 23 ImpetiflO, bulte in 110, 113, 446, 602, 608 - crusts in . . . . 602, 831 - cutaneous diphtheria with 602 - diagnosis from mild modi- fied smallpox (Fir/. 161). . 607 pustular syphilide . . 604 ringworm . . . . . . 274 - distinction from eczema.. 831 - enlarged occipital glands in 419 - flat and irregular pustules in 601 - no leucocytosLs with . . 400 - lips rarely affected by . . 830 - papules in . . . . . . 831 - perleche with . . . . 404 - preference for face and hands .. .. 604.609 - pustules in . . 601, 602, 654 - pyrexia slight in . . 602, 608 - relation to pemphigus neonatorum . . . . 446 - scabs in . . . . 653, 654 - simulated by herpes facialis 83(i - small erythematous spots in 602 - sore fingers from . . . . 26f; - streptococcal infection in . . 601 - tenderness of the scalp from 781 - vesicles in . . . . 608, 831 - bullosa, description of 113, 602 - circinata 6O2 - follicular, diagnosis from pemphigus . . . . 602 pustular eczema . . 602 distribution of eruption in 602 pustules pierced by hairs 602 staphylococcal infection in 601 yellow crusts in . . . . 602 - gyfata 6O2 - herpetiformis . • ■ • 113 Implantation cyst of vulva . . 768 IMPOTENCE 346 - in cachexia . . . . - . 347 - distinction from sterility . . 346 - senile, priapism preceding 585 Impulse on coughing in rare cases in hydrocele - displaced cardiac (see Heart) Incompatibility, sterility due to 706, INCONTINENCE OF F/ECES in meningitis primary lateral sclerosis . . - Of urine (and see Micturition, Abnormalities of) chronic cystitis from from destruction of spinal centres . . diagnosis of distention from 440 differentiation of enuresis from distinguished from enuresis dribbling per uretlnram in from enlarged prostate false in meningitis from retroverted gravid uterus . . vesical sphincter lesions Inco-ordination (and see Atax-y; and Contractions) - causing abnormal gait . . 277 - ataxic paraplegia . . . . 277 - cerebellar disease . . . . 277 - chronic alcoholism . . 172 522 707 347 642 567 437 628 443 247 257 440 440 642 438 440 922 IXCO-ORDIXA TIOX—INFL UENZA Inco-ordination, could. Infancy, coiUd. Inferior vena cava, contd. - combined sclerosis . . 277 - insomnia in. . 356 obstruction of, varicose - disseminated sclerosis 277 - jaundice in . . 365 veins in 61 - distineruished from paralysis 545 - metrostaxis in 435 thrombosis (see Throm- - in Friedreich's ataxy 131 277 - mUk in breasts in . . 202 bosis of Inferior Vena - peripheral neuritis. . 506 - muscular dystrophy in 158 561 Cava) - Tabes dorsalis 277 — nystagmus in 452 Inflammation, cardinal sym- - t«st for presence of 277 - obscure fever in, possibly due ptoms of . . 478 India, ankylostomiasis in 570 to baciUuria . . " . . 616 Inflation, in diagnosing car- - mTcetoma in 809 - osteochondritis in congenital cinoma of pancreas 59 - relapsing fever in . . 373, 649 Syphilis in 386 hour-glass stomach 353 India-rubber bottle stomach - paraplegia of, from spina pancreatic cyst . . 690 123, 270, 299 bifida 556 timiour . . 366 - neuritis in workers in 77 - priapism in, causes of 585 size of stomach . . 355 724 INDICANURIA 348 - regurgitation of mUk in . . 842 Influenza, abdominal pain in 505 - abnormal protein decompo- — scurvy of (see Scurvy, Infantile) - acute general pains in the sition indicated by 97 821 - seborrhoeic dermatitis of . . 446 limbs in 503 - in acute appendicitis 500 - spastic paralyses of 154 ha?morrhagic otitis in . . 468 - black urine from . . 820, 821 - splenic ansemia in . . 42 - albuminuria in 17 - bleaching powder test for . . 821 - summer diarrhcEa of, poly- - ariosn^ ia in . . 069 - brown urine from . . 820, 821 cythemia in . . 579, 580 - arthritis in . . 376 - ciu-e by calomel 821 Infantile paralysis (see Paralysis, - bacillus (see Bacillus Influ- - darkening of urine on es- Infantile) enzae) posure to air, from 821 Infantilism 212 - brachial neuralgia in 493 with liquor potassae due tc 290 - causes of . . 215 - bronchitis in 505 - general account of . . 821 - in congenital syphilis 260 - broncho-penumonia in 321, 505 - intestinal origin of . . 821 - cryptogenetic 210 - conditions mistaken for . . 620 - and lactic acid therapy . . 349 - cryptorchism in 218 - conjunctivitis in . . 256 - nitric acid t-est for . . " 3i8 821 - and dwarfism distinguished 214 - coryza, severe, in . . 505 - normal colour of urine with 821 - essential "216 - cough in . . . . 175, .505 - in pancreatitis 116 - and gigantism together 214 - danger of diagnosing 76, 699 773 - due to pus collections 821 - illustrated (Fig. 66) 215 - depression in 505 - from putrid empyema 821 - intestinal 215 - diagnosis of . . . . 505, 610 - simulating melanuria 821 822 — ossification premature in . . 214 from febricula . . 505 - tririal significance of 349 - with premature senility in fungating endocarditis.. 610 Indies, ^Vest, vellow fever in 372 progeria . . 218 paratyphoid fever 611 INDIGESTION 349 - thyroid type described (Fig. tuberculosis 610 - in children, insomnia from 357 67) 216 typhoid fever 610, 611, 699 - chronic, anaemia in 36 Infarction (and see Embolism) - diarrhoea in. . 505 - flushing in . . 2G8 - from fungating endocarditis - epididymo-orchitis from 517 518 - in general congestion of liver 407 39, 76, 138, 237 321 - epistaxis in . . 251 - pancreatic lesions causing 117 - of kidney, albuminuria in. . 9 - extreme prostration in 505, 699 - in pyloric obstruction 144 diagnosis from acute - gastro-en'teritis in . . 610 — rosacea from 268 Bright's disease 314 - headache in. . . . 505, 610 Indigo-blue, blue urine after 823 in fungating endocarditis 237 - jaundice in. . 505 - treatment of epilepsy by . . 823 haematuria in . . 305, 314 - lachrymation in 505 Indoor life, aniemia due to . . 36 renal abscess from 625 - leucocytosis uncommon in400 ,699 Indoxyl-glycuronic acid, blue casts in urine in 314 - menorrhagia in 428 tint of urine due to 823 - of lung, embolic, sudden pain - micrococcus catarrhalis in 505 Induration of lungs in mitral in chest in 321 - muscular atrophy in 76 stenosis . . ~ . . 245 in fungating endocarditis 321 - needfor bacterial diagnosis of 203 Inequality of the Pulses (see gangrene of lung from . . 712 caution in diagnosis of . . 699 Pulses, Inequality of/ haemoptysis from 240, 317 321 - nerve deafness after 190 - pupils (see Pupil, Abnormal- in leukaemia 321 - orchitis from 79 ities of) mitral regurgitation . . 240 - pain at the back of the eyes in 610 Inertia, uterine, dystocia from 227 stenosis 320 in the lumbar region in 610 symptoms of 229 after operations . . 322 severe in . . 505 Infancy (and see Children), physical signs of . . 321 - pancreatitis from . . 116 athetosis in 154 pleuritic effusion in 123 - peripheral neuritis after 165 506 - buLke in 111 puerperal . . 322 - Pfeilfer's bacillus in 505, 610 in impetigo in . . 446 pyopneumothorax from 712 - pink-eye in . . 256 - choreiform movements in 156 ,157 in venous thrombosis . . 321 - pneumonia in 505, 610, 702 - colic in 136 - in spleen 699 - prolonged, absence of the - colitis of 92 - thrombotic . . 700 characteristic svmptoms in 610 - constipation in 149 Infectious jaundice (see Jaun- - pyrexia m 505, 609, 610, 651 699 - contractures in 1G5 dice, Epidemic) - " the recently developed - convulsions in, causes of . . 169 Infective arthritis (see Arthritis refuge of the diagnostic- discassion of 170 Infective) ally destitute " . . . . _ 620 not often unilateral 174 - endocarditis (see Eungating - pulse-rate relatively slow in _ 771 porencephalus in 170 172 Endocarditis) - respiratory type 505 - diarrhoea of (see Diarrhoea - synovitis (see Synovitis, In- - rigors m 647, 648, 651, 099 of Infants) fective) - significance of delirium in. . 194 and vomiting, acetonuria in 4 Inferior dental nerve, neuralgia - splenic enlargement in 692, 099 - epistaxis in . . 251 of ■: . 502 - spondylitis deformans after 787 - eruptions in napkin region in 446 - gluteal nerve, skin dLstribu- - sputum in pneumonic 505, 702 - erythema of Jacquet in, dia- tion of 659 - sudden onset in 099 tmosis of congenital sy- spinal roots derived from 542 - sweating in 699 philis from 446 - vena cava, obstruction of - tachycardia after . . 772, 773 - fibrillary contractions in . . 158 54, 461 825 - talipes from 131 - hemiplegia of 338 albuminuria from . .17, 61 - testicular atrophy after . . 79 ataxy in . . 68 ascites in 60 - thrombosis after . . 131 talipes in 131 hfcmaturia in . . 61 - transverse myelitis due to 565 - hypertrophic stenosis of cedema of back from 825 - tropical abscess of liver pylorus in, vomiting from 843 legs from . . 450 4G1 mistaken for 408 INFLUENZA— INTERNAL POPLITEAL NERVE 923 Influenza, could. - vagal neuritis after . . 773 - Tomiting in . . . . 505 Infra-orbital nerve, distribution 659 Infraspinatus, atrophy from supra - clavicular nerve paralysis . . . . 552 - nerve supply of . . . . 550 - pseudo-hypertrophy of . . 560 - wasting in phthisis . . 7"2 Infratrochlear nerve, skin r^istribution of . . . . C59 Infundibuluni, swellings at, in sinusitis . . . . . . 255 Infusion, oedema after 458, 400 - need for indicated by specific gravity of blood.. .. 580 Inguinal canal examuiation in diagnosis of ascites . . 717 - glands (see Lymphatic Glands) - liernia (see Hernia, Inguinal) - region, organs normally con- tained in . . . . 722 various tumours felt in 729, 731 INGUINAL SWELLING ■■ 737 due to acute abscess . . 739 aneurysm of external iliac artery . . . . . . 741 chronic abscess from hip disease . . . . 739 from sacro-iliao disease 739 distended psoas bursa . . 741 femoral hernia . . . . 739 hernia . . . . . . 739 - - hydrocele . . . . 740 iiigumal hernia . . . . 739 lipoma of spermatic cord 741 obturator hernia . . 739 pelvic abscess . . . . 760 psoas abscess . . 632, 739 retained testis 523, 740 sarcoma of pelvis . . 741 tumours of the cord . . 741 round ligaments . . 741 - - ureteric calculus . . 135 IN6UIN0-SCR0TAL SWELL- ING 741 due to gro^-th in testis . . 742 hernia (see Hernia) torsion of retained testis 742 Injuries, abdominal, causing coUapse . . . . . . 645 chyluria . . . . 126 chylous ascites . . 58 peritonitis . . . . 646 - causing amenorrhcea . . 23 amnesia . . . . . . 25 aneurysm of axillary artery 732 anuria . . . . 45, 49 bleeding from ear . . 467 gums . . . . . . 86 bony swelling . . . . 750 extroversion of bladder. . 587 paralysis of arm.. . . . 552 paraplegia . . . . 558 ulceration of larynx . . 710 - cerebral (see Cerebral Injuries) - to cervical cord, rapidly fatal 341 region, various effects of 552, - chest, empyema from pneumothorax from 577, surgical emphysema from 231, - chordee due to - compression of cord from . . - corneal ulceration from - diaphragmatic hernia from - of ear, laceration of tympanic membrane visible on ex- amination - ectropion and epiphora from Injuries, could. - epistaxis from . . 250, - of external auditory meatus from blow on chin bleeding from ear in - of eye irregular pupil due to . . - forearm, ischoemio paraly- sis of hand from . . Volkmann's contracture from (Fig. 43, p. 166) - gangrene from . . 281 , - ha?matemesis from - hoematuria from - hnffmoperitoneum from - htemorrhage into cord from - to head (see Head Injuries) - hemiplegia from - history of, in pneumococcal artluritis . . - hydropneumothorax from - hyperpyrexia after - incontinence of urine from - to internal popliteal nerve, claw-foot from . . - kidney, diagnosis from urethral or vesical injury hematuria in . . 304, renal abscess from enlargement in - lachrymal duct or canal- iculus, epiphora after . . - larynx, haemoptysis from . . - loin, perinephric haematoma from - loss of pupil reflexes from - neck, stiff neck from - necrosis of nasal bones from - nerve deafness from - nerves, contracture from 163, - neurasthenia resulting from - nystagmus following - onycliia due to - of 'optic nerve, hippus from sudden blindness from. . - orchitis from - pain in the back from - paralysis of serratus magnus from - penile hsematoma from . . - periostitis from - professional cramp from . . - to sacral cord, claw-foot from - sarcoma after . . 756, - slight, as cause of haemophilic arthritis . . - spinal symptoms after Brown-Si^quard paralysis from (Fig. 181) difficult micturition from h^matorrhachis from . . paraplegia from. . priapism after talipes after . . 131, - swelling of face from - tender scalp from 780, spine from - testicular atrophy due to 79 - tetanus due to - of tibia, talipes from - tortion of testis from - transverse myelitis due to - ulceration of lar3'nx from. . leg from . . - to uncinate gyrus, anosmia from - of vagina causing discharge - vomiting after Innominate aneurysm (see Aneurysm, Innominate) Innominate veins, obstruction by mediastinal growth. . of, oedema of arm fi-om 251 467 467 594 594 552 552 283 299 304 717 563 338 375 712 344 440 127 308 308 625 308 250 318 392 594 709 204 191 165 787 453 445 595 839 79 475 551 516 776 177 127 803 388 787 664 440 132 561 585 132 747 781 784 , 80 709 132 766 564 226 810 669 210 844 465 826 Innominate vein.i, conld stenosis by bronchial glands 422 thrombosis, causes of . . 826 varicose tlioracic veins from Insane, general paralysis of (see General Paralysis of the Insane) Insanity, amenorrhea in - athetosis in . . - from chorea of pregnancy . . - chronic alcoholism.. - constipation in - gangrene of lung in - and Huntington's chorea . . - insomnia in . . - and Little's disease - perverted appetite in taste in . . - pupils in - retraction of head in - subjective smell sensations 820 23 154 15C. 172 144 288 156 356 154 50 774 595 041 Insect bites on face . . - - wheals from INSOMNIA - due to aortic aneurysm - cerebral syphilis - chronic alcoholism - insanity from - methods of mitigating - due to plumbism . . pruritus 155 55S 206 156 669 747 850 356 848 173 797 358 358 38 588 Inspissation of blood in cholera 187 cyanosis from . . . . 187 in dysentery . . . . 187 yellow fever . . . . 187 Instrumental delivery, birth palsies due to paraplegia due to Instrumentation, urethritis from Insular sclerosis (see Dissemi- nated Sclerosis) Insurance (see Life Assurance) Intention tremors, diEEerentia- tion of choreiform move- ments from in disseminated sclerosisl74,341 Friedreich's ataxy . . 560 general account of . . 799 in Little's disease .. 154 illustrated (Fig. 205) .. 799 Intercostal nerve paui (see Pain, Intercostal) relation of herpes zoster to 830 skin distribution of . . 659 - neuralgia (see Neuralgia, Intercostal) - spaces, fullness in medias- tinitis 483 sucking in of . . 186, 642 - tenderness (see Neuralgia, / Intercostal) Intercosto-humeral nerve, skin distribution of . . . . 659 Intermittent albuminuria . . 19 - claudication (see Claudication) - closm-e of cerebral vessels, hemianopsia from . . 33G - hydrarthrosis, general account of 387 Internal capsular lesion causing hemianfesthesia . . . . 666> hemianopsia 334, 666 hemiplegia . . 330, 666 - capsule, changes in dis- seminated sclerosis . . 660 - cutaneous nerve, skin dis- tribution of - jugular vein thrombosis . . - popliteal nerve, muscles supplied by roots derived from . . 659 651 542 542 924 INTERNAL SAPHENOUS NERVE— IODOFORM Internal saphenous nerve, skin Intestinal obstruction, contd. Intoxication, contd. distribution of . . 659 simulated by ascites 717 - clironic, leucopenia in 401 - secretions, efEect on menstrua- Henoch's purpura 90, 846 Intracranial growth (see Cere- tion 430 mesenteric thrombosis brum, Tumour of) on arteriosclerosis 430 or embolism 90 Intrathoracic new growth (see Interossei, atrophy of 73 pancreatitis 90, 292, 046 846 Mediastinum, New Growth n) - and lumbricales, spinal nerve peritonitis 645 Intubation of larynx, haemo- root supplying . . 550 stiffening of intestine in. . 152 ptysis from 318 - norve supply of . . 542, 550 strangulated hernia causing Intussusception, abdominal Interphalanseal joints, hyper- 716,- 733 tumour with 92, 134, 148, 152, trophic osteo-artliropathy temporary, due to faecal 196, 723, 727, 730, 736 in . . 390 accumulation 692 - asre incidence of . . 636 736 Interscapular pain (see Pain, thrombosis or embolism - blood and mucus per rectum Interscapular) of mesenteric vessals . . 432 in 148, 196, 443, 036, 727, 736 Interstitial keratitis, photo- tuberculous peritonitis . . 719 - colic due to 148 phobia in 574 colon causing . . 731 - constipation in . . 148, 736 - nephritis ("see Bright's visible peristalsis in 151, 152, - diagnosis from enterospasm 134 Disease, Chronic ; and 267, 350, 431, 571, 723, 724 - diarrhoea from 196 also Granular Elidney) vomiting in 133, 153, 350, 431, - felt per rectum . . 148, 036 Intertrigo, erythema fi-om . . 252 571, 844, 845 846 - indicanuria m 349 - pain in perineum from 516 and constipation witli - intestinal obstruction from - of umbihcus 716 431, 045, 733 151, 152, 431, 636, 730 Inter vpntricular septum, pat- - parasites (see Parasites, In- - rectal examination in 148, 196 ,636 ent .. .. 129, 244 testinal) - sausage-shaped tumour of 152 intestinal colic (see Colic, - putrefaction (see Putrefac- - sigmoidoscope in . . 190 Intestinal) tion) - simulated by Henoch's pur- - constipation (see Constipa- Intestine, acute diverticulitis of 731 pura .. ..90, 600, 840 tion) - atony of, illustrated 144 appendicitis 135 - crises in tabes dorsalis 134, 665 - borborygmi in (see Borbor- - spasmodic abdominal pain ygmi) from 727 liver dullness in . . 404 - carcinoma of (see Carcinoma - symptoms and signs of 92 - fermentation, flatulence in 267 of Colon) - tenesmus from 727 microscope m diagnosis of 268 - diseases of, referred pain in - tumour with . . 92, 152 tetany in . . 3 area of 10th dorsal nerve in 509 in hypochondrium from 723 - fistula causing pneumaturia 576 - dysenteric ulceration of, cys- hypogastrium 730 - neuralgia 134 titis in 033 right lumbar region from 727 - obstruction, abdommal dis- extension to bladder 024 633 - visible peristalsis in 148 tention in 134, 350, 571 infective peritonitis from 644 - vomiting from . . 727, 736 absolute constipation in 431 tenderness in 134 Inversion of uterus . . 587, 768 acetonuria in 4 tuberculous, cystitis in 633 Iodide of potassium, anosmia acute 151 - enlarged mesenteric glands from 668 bile in vomit in. . 846 in tuberculous enteritis. . 422 - bleeding gums from 85 borborygmi in . . 153, 431 - hypoplasia of 143 - buite .. .. no. 112 from carcinoma of colon 92, - indicanuria in tuberculous - coryza from ..87, 203, 668 393, 500, 501, 645, 690, 731 735 colitis 349 - in diagnosis of gumma 681 causes and symptoms of - lardaceous disease of 414 syphilis 226, 254, 279, 325, 151, 431 - large, diagram of normal . . 143 449,520,521,604,640, 058, chronic, diarrhcsa in 267 - matting of, abdominal 672, 674, 677, 681, 808 814 flatulence in . . 267 tumour due to . . 691 - eruption, absence of come- or recurrent . . ■ 147, 148 - musculature of, weak 143 dones in . . 603 colic in 473 - neuro-muscular defects of age incidence of . . 603 collapse in 346 142, 143, 144 bright red colour of 003 conditions of incomplete - pain in spastic constipation 144 diagnosis from acne 603 constipation in 151 - paralysis of, in acute general acuminate syphilide . . 604 constipation in 145, 350, 431, peritonitis 472 small-pox 609 571, 644, 645, 733, 846 from spmal cord lesions 432 distribution of . . 603 from cystic l?:idneys 15 - perforation of tuberculous 711 pustules in . . 112, 603 diagnosis from colic 571 typhoid ulceration of . . 711 - foul taste in mouth from . . 774 peritonitis 431 - peristalsisof (see Borborygmi' 97 - influence on syphilitic pyrexia 615 "feeculent vomiting in 431 845 - rupture of aneurysm into 140 - laryngeal symptoms from foul breath in 98 - small, visible peristalsis in 571 185, 465, 709 gall-stones causing 300 - stricture of, constipation - loss of taste due to 774 general abdominal pain due to . . . . ... 146 - and mercury, aggravation of in . . . . 350, 473 - tuberculous, blood per anum Bazin's disease by 451 hiccough in 342 due to 731 in diagnosis of gumma . . 279 — hypothermia in . . 346 cachexia due to . . 731 effect of, on gumma 677 indicanuria in 349 infiltration causing stricture 140 - ptyalism due to 590 from intussusception 636 736 obstruction due to 731 - purpura from 596 laparotomy in diagnosis tenesmus due to . . 731 - relieving pain in secondary of 267 iilceration of 719 syphilis . . 725 leucocytosis in . . 400 causing pneumo-peri- - simulatmg laryngeal crises 460 meteorism in 431 toncum 711 - swelling of eyes and face from 459 from minute herniae 716 extension to bladder - testicular atrophy due to. . 79 nausea in 846 313, 024, 633 - universal oedema from 458, 400 pain in . . 153 pus in stools from 601 - vesicles in . . 834 peritonitis from . . 431 - typhoid ulceration of, pus Iodine used by malingerers as from pressure of appendix in the stools in . . 001 vesicant ". . 112 abscess on rectum 038 - ulceration of (see Ulceration) - scaly eruption due to 655 recurrent, in children, in - venereal ulceration of, pus - test for bile pigment 819 H irschsprung's disease 433 in the stools in . . 601 Iodized serum, psorosperms rigidity of abdomen not - worms in (see \Vorms, demonstrated by 803 marked with . . 431, 645 Intestinal) Iodoform capsule test of severe abdominal pain in 846 Intoxication, Babinski's sign pancreatic disease 216 sigmoidoscope in 267 350 during alcoholic . . 82 - purpura due to 596 IRIDOCYCLITIS— JOINTS, AFFECTIONS OF 925 Iridocyclitis, causes of . . 25G - from corneal ulceration . . 800 - cedema of eyelid from . . 'JoCi - severe pain in the eye from 25G Iridodialysis, irregularity of pnpil from . . . . 501 Iridopiegia (see Pupil, Abnor- malities of) Iris, adhesions of, diatrnosis between inflammatory and ronireuital origin of . . 503 - appearance of, in con- junctivitis, iritis, and glaucoma . . . . 257 - coloboma of . . . . 402 - photophobia in diseases of 57-1 - prolapse of, from corneal ulceration . . . . 800 - tremulous in lens dislocation 108 Iritis, atropine treatment .. 257 - atrophy of eye from . . 830 - blindness total from . . 830 - blockage of pupils from . . 830 - causes of . . . . . . 250 - constriction of pupil in . . 505 - diagnosed from conjunctivitis 256, 257 glaucoma . . . . 256, 257 - glaucoma from . . . . 830 - headache in 327, 328, 783 - irregular pupil from . . 503 - laclirymation from . . 255 - from ophthalmia neonatorum 250 - pain in eye in 255, 256, 404, 408 temporal and maxillary segmental areas in . . 498 photophobia from 255, 574 trigeminal area in . . 404 - in syphilis . . . . . . 450 - tenderness of the temporal region from . . . . 783 - - vertex from . . . . 783 Iron, black stools from . . 428 - blue sweat due to . . . . 714 - coloration of stools by . . 80 - in diagnosis of cldorosis . . 41 - headache from taking . . 328 - m intestinal sand . . . . 052 - percliloride of, dryness of the mouth due to . . . . 780 - relief of headache by . . 320 Irresponsibility of patient after epileptic convulsions 100 IRRITABILITY .. 359 - of the bladder . . 443, 817 - in chorea . . . . . . 150 - general congestion of liver 407 - in idiocy . . . . . . 082 - leukaemia . . . . . . 31 - meningitis . . . . . . 350 - neurasthenia . . . . 788 - pruritus causing . . . . 588 - in rickety children . . .. 170 Irritable breast of Astley Cooper 479 - spins, tyjahoid spine called 787 Irritant, local, causing cliloasraa 574 coryza . . . . . . 203 - poison, analysis of gastric contents for . . . . 074 eschars on lips or mouth from 674 haematemesis from . . 674 symptoms produced by. . 845 vomiting from . . 674, 843 skin pigmentation from 574 Ischsemia of calf, talipes from 132 - paralysis of the liand from 552 Ischio-rectal abscess (see Ab- scess, Ischio-rectal) - fossas, rectal examination of 035 ITCHING (and see Pruritus) 588 - absence in syphilides . . 604 - in dermatitis herpetiformis 786 - drug rashes . . 424, 421 llclmig, contd. - eczema 533, 057, 781, 831 - herpes genitalis . . . . 830 ophtiiaimicus .. .. 781 - intense^ in iK'/.ema . . . . 831 papular eczema .. .. 520 prurigo ferox . . . . 531 - - stropliulus . . . . 850 - - urticaria . . . . . . 531 - from leukoplakia . . . . 770 - of lips in Fordyce's disease 403 - pustular eczema . . . . 602 - ringworm . . . . . . 275 - scabies . . . . . . 054 - at site of inoculation in antlirax 603 - slight with psoriasis . . 057 - in small-pox . . . . 055 - urticaria pigmentosa . . 805 - with vesicular eruptions . . 829 Ivory exostosis (see Exostosis, Ivory) JABORANDI, ptyalism from 500 Jacl49 - relapsing fever . . . . 373 - simple, of infants . . 302, 303 - slow licart-action in 98, 30.5. - in splenic amcmia . . . . 411 - spleuomegalic cirrhosis . . 093 - stenosis of bile-ducts 305, 410 - tuberculous portal glands 50 - tumours of gall-bladder .. 392 - urine colour In 300, 820, 821 - urolilhiuiria and .. .. 116 - xanthoma planum with . . 805 - xantliopsia in . . . . 840 Jaw, actinomycosis of (see Actinomycosis) - carcinoma of (see Carcinoma of Jaw; - clenched during convulsions 109 - fibroma of . . .. .. "48 - fixed, ptyalism from . . 591 - fracture of (see Fracture o£ Jaw) - hypertrophy of, in acro- megaly (Fir/. 88) 203, 749, 75.3. - lesions of, causing ptyalism 591 - motor tics affecting . . 1 OO - muscles, trichinosis of . . 801 - myeloid sarcoma of . . 756 - necrosis of, in acute exan- themata . . . . . . 747 periosteal abscess . . 747 from alveolar abscess . . 747 detection of sequestrum in diagnosis of . . 748 following injury.. .. 747 from mercurial poisoning 747 phosphorus poisoning 87, 747 ptyalism due to . . . . 590 stomatitis due to . . 590 from syphilis . . 747, 748 in typhoid fever. . . . 747 a'-rays in diagnosis of . . 748 - new growths of . . . . 204 - osteoma of, site and charac- ters . . . . . . 74 8 - sarcoma of (see Sarcoma of .Jaw) - stifrness of, In tetanus .. 102 - lower, pain In • • 501 swelling of (see Swr-lllng of Jaw) - upper, pain in . . . . 502 swelling of (sec Swelling of Jaw) Jejunum, obstmction to, ab- sence of distention in . . 1 52 Jelly-fish stings, pruritus from 588 Jenner's .stain . . .. .. 27 Jerk, achillis (see Ankle-jerk) - knee (see Knee-jerk) Jewellers, nail-staining in . . 444 JOINTS, AFFECTIONS OF (and see Artliritis and Osteo- arthritis) . . . . . . 374 contractures from .. 107 local muscular atrophy in 72 mistaken for paralysis , . 545 in peliosis rheumatica . . 599 926 JOINTS, AFFECTIONS OF— KIDNEY, TUBERCULOSIS OF Joints, affections of, conld. Kidney, contd. Kidney, contd. simulating occupation - atrophy of, due to complete - hypernephroma from supra- neuroses 178 ureteral obstruction 627 renal rests in 690 - chief site of pain in some - bimanual examination of - liypertrophy, compensating cases of chronic rheu- 306, S94, 689 for atrophy of the other 394 matism . . 507 - calculus in (see Calculus) - infarction of (see Infarction - gummata of (see Arthritis, - carcinoma of (see Carcinoma of Kidney) Syphilitic) of KidneyJ - inflammations of, general - hasmorrhage into, in haemo- - changes in old people 14 pains in the limbs in 503, 505 pliilia 302 - colon carcinoma communi- subphrenic abscess from 720 - malignant disease of 3S8 cating with 577 - injury to (see Injuries to Kidney) - mechanism of recognition - cystic disease of (see Cystic - lardaceous (see Lardaceous of movements of 661 Disease) Disease) - obscure pyrexia due of 620 - disease, brachial monoplegia in 546 - lesions causing pleuritic - pains in, in acute rheumatism 121 compensatory hypertropliy effusion 123 dengue 506 of other kidney 394 Cheyne-Stokes respiration 124 Henoch's purpura 600 high blood-pressure from - movable (see Movable Kidney) - - (and see Pain in Joints) (and see Bright's Disease ) 96 - new growths of (see Carci- - prominent in achondro- insomnia in 356 noma of Kidney ; Sarcoma, plasia 212 pain in the back in 476 etc.) - pseudo-ankylosis of, in referred pam in area of - normal situation of 722 chronic rheumatism 507 10th dorsal nerve in . . 509 - of old people, interstitial - rheumatic nodules round . . d52 reno-reflex pain on the fibrosis in. . 14 Jordan Lloyd, on renal pain sound side in . . 394 - pain in penis from disease witli calculus 306 - displacement in general of 510 Judgment defects in general visceroptosis . . 407 473 - papilloma of (see Papilloma paralysis . . 172 - effect of fevers on. . 17 of Kidney) Jugular vein, obstruction by - embolism of . . . . 8, 9, 237 - polycystic disease of 310, 391 558 thyroid gland tumour . . 793 - embryoma of 395 - rhabdomyoma of . . 395 thrombosis (see Thrombosis) - endothelioma of 395 - right, normally palpable . . 7-27 Juvenile muscular dystrophy 561 KIDNEY, ENLARGEMENT OF - Rose- Bradford 14 fibrillary contractions in 158 (and see Kidney, Tumour - sarcoma of (see Sarcoma of of).. .. 310,391, 500 Kidney) KAHLER'S DISEASE 21 aching in lorn in. . 307 - serous cyst of, simulating Kala-azar . . . . 34 693 albuminuria in . . 367 hydronephrosis . . 396 - enlarged spleen with anemia band of colon resonance in 367 - stone in (see Calculus, Renal) in {Plate XII, Fig. H, causing excessive fatness - tenderness in (see Tenderness p. 696) 34 in children 454 over Kidney) - geographical distribution of 693 confusion with movable - tuberculosis of 309, 394, 612 — Leishman-Donovan bodies kidney 394 abscess in 394 in (Plate XII, Fig. H) 693 696 from cystic disease 310, 396 ,558 absence of symptoms in - spleen enlarged in . . 692, 693 filling of loin by . . 729 miliary form . . 626 - splenic puncture in 693 hfcmaturia in 304, 307. 367 aching in loin in . . 309 626 Kaposi's disease . . 575, 804 in hydronephrosis 500 583 age of patient in . . 309 Kathode, meaning of . . 633 from hypernephroma . . 395 albuminuria with 8, 16, 310 Keith on rectal malformation 637 iinjury 308 slight in 626 Keratin-coated capsules in jaundice from . . 362, 367 anuria in. . . . 4c , 48 testing for pancreatic liver mistaken for 405 caseous form, abscess in 394 disease 364 from new growth origin as primary focus of methylene blue in dia- 307, 391, 394 395 in one kidney 394 626 gnosing pyloric obstruc- obscured in various ways 394 causing pleurisy. . 123 tion 713 palpable in epigastrium.. 725 Cheyne-Stokes respira- Keratitis in congenital syphilis lumbar region.. 727 tion in. . 124 259, 828 from papilloma . . 308 colic in . . . . 135, 309 — conjunctivitis due to 256 pelvic swelling due to . . 757 cystitis secondary to . . 629 - corneal opacity from 806 possibly the only function- cystoscopy in (Plate V, - e lagophthalmo 807 ing one 394 Fig. D, p. 308) 626, 629 - neiu-oparalytica 807 in pyelitis . . 500, 625 diagnosis from growth . . 395 - photophobia in 574 due to pvonephrosis renal calculus . . 310, 626 Keratomalacia, age incidence 807 266, 583 624 typhoid fever . . 612 — associated with marasmus 807 pyramidal clots in urine vesical tuberculosis - corneal opacity in . . 807 in 307 312, 516, 629 - foamy white patches on pyuria in. . 367 frequent micturition in 306, conjunctiva in . . 807 in renal calculus . . 500 310, 312, 394, 438, 626, 629 - night blindness in . . 807 colic in . . 307 hD?maturia in . . 16, 304 309 - prognosis in 807 tuberculosis . .312, 315 629 394, 626, 629 - xerosis of conjunctiva in . . 807 sickening sensation from increase in severity of Keratosis follicularis ■ ■ 806 pressure on 280 symptoms with infec- simulated by keratosis simulated by enlarged tion of pelvis in 626 pilaris . . 806 spleen . . . . 726 729 infection of ureter in . . 310 mollusoum contagiosum 806 tumour of right suprarenal inoculation of guinea-pigs - pilaris, papules of . . 580 capsule simulating 367 in diagnosing . . 626 relationship to ichthyosis 530 from vesical tumour 395 kidney enlarged in 394, 515 629 scales in . . 655 worm-like clots in urine in 307 miliary form of . . 394, 626 simulated by keratosis - evidence of bleeding from . . 305 muco-pus in urine with 306 follicularis 806 - felt in left iliac fossa 735 pain in penis at end of Kerion, tender scalp from . . 781 - floating 407 micturition in. . 629 Kernig's sign in meningitis . . 350 confusion with Riedel's plugs of muco-pus in urine 306 Kidney abscess (see Abscess, lobe of liver . . 405 polyuria in 626 Eenalj - granular (see Granular primary . . . . . . - 309 - affection from back-pressure Kidneys) pyelitis from 438 from distended bladder. . 440 - hydatid cyst of 396 pyonephrosis due to 626 - alveolar sarcoma of 395 simulating hydroneph- pyuria in - angiosarcoma 395 rosis 396 16, 310, 394, 623, 626, 629 KIDNEY, TUBERCULOSIS OF— LABYRINTH 927 Kiditfii, titbfirculosis of, contd. Kink of tho nolon causing con- Knee-jerk, exaggeralrd, conld. renal pain in . . 312, 626 stipation . . 147 spastic paralysis of upper tiimour in 391 Klebs-Lotller bacillus (see extremity 547 skiairraphy in 310 Bacillus Diphtheria.') paraplegia . . 494, 558 tenderness in 694 Klumpke's paralysis . . 553, 555 syringomyelia 554 of Icidney in 394, .')15 Knee, Baker's cyst of 762 transverse myelitis 74 in loin in 629 - bursa in neighbourhood of 761 - method of eliciting iu children thickened ureter in 31--', 394, - commonest site of inter- 390, 397 626, 629 mittent hydrarthrosis . . 387 - in paralysis from intra- and felt per rectum in 620 629 - congenital syphilitic 260, 386 extra-medullary lesions 546 vatcinam in 629 - flexion, impaired in paralysis - ready disappearance in - - tubercle bacilli in urine in of anterior crural nerve . . 541 children who are ill 557 39t, 026 lost in sciatic paralj'sis. . 542 - " reinforcement " in the tuberculosis of prostate in popliteal abscess 702 eliciting of 397 with .. .. 394, 626 - gout in 382 - in Tooth's peroneal atrophy 500 testis in . . 394, 518 - ha.'mopl)ilic arthritis of 388 - unequal with coma . . 137 vesiculae seminales in 394 626 - hysterical 166 in general paralysis of the tuberculous cystitis due to 629 - injury- to, vomiting from . . 844 insane .'. ' . . 398 urinary changes in 626 - ETonococcal arthritis of 376 hemiplegia . . 337, 397 - - urine normal in early sta'-'es 310 - lichen planus affecting 057 strong evidence of organic very slight symptoms in - locking of, from displaced nervous change 397 earliest stages of 626 cartilage . . .388 Knee-joint, locking of, from .c-rays in diagnosis of . . 626 - osteo-artliritis of . . 384 displaced cartilage 388 - tumour of (and see Kidney, semi-membranosus bursa Knife-grinders, cirrhosis of Enlargement of). . 307 frequently disteudad in 762 lung in 319 albuminuria with 9, 16, 689 - pain in, in hip-joint disease 278 - lung, hremoptysis from 317 ascites in. . 59 from sj-novitis . . 486 Knife-rester crystals of triple - - bimanual examination of 391 - i>ityriasis rubra pilaris of. . 530 phosphate (Fig. 155) 573 bulging of loin due to . . 689 - pneumococcal artlu-itis of . . 375 Knock-knee in Mongolism . . 216 cystic 15 - psoriasis of . . . . 650, 657 - from rickets 212 cystoscopy before opera- - seborrhccic dermatitis of . . 447 Kocher, re eervico-brachial tion in 395 - tuberculous, Baker's cyst in plexus 553 - - diagnosis from bladder connection with. . 762 - re lumbo-sacral plexus 543 tumour 311 relative frequency of 385 Koplik's spots in measles . . 203 fsecal accumulations . . 393 with spinal caries 564 Korsakow's psychosis 25, 505 hematoma due to thigh atrophy with 72 Krallenhand ("see Claw-hand) leaking aneurysm . . 692 Knee-elbow position in diagnos- Krallen der Zehen Csee Claw- hepatic tumour 391, 392 ins abdominal aneurvsm 763 foot) 120 gall-bladder tumours.. 392 KNEE-JERK. ABNORMALI- Kraurosis vulva, age incidence of770 growth of colon 393 TIES OF 390 confusion with leukoplakia mesentery tumours . . 394 - absent in Friedreicli's ataxv vulvitis 770 omental tumour 394 131, 559 dyspareunia from 221 ovarian cyst . . 392 in anterior crural nerve pain and tenderness from 770 tumour 391 paralysis 541 vulval swellmg from 768 pancreatic tumour . . 394 some cases of myelitis . . 74 Kyphosis, causes of . . 181 pelvic tumours 392 393 - - diabetes . . 75 - combined with lordosis 183 perinephric abscess 391, 392 Friedreich's ataxy 71 - dwarfism due to 214 splenic tumours 391,392 689 peripheral neuritis 488, 562 - from hydatid disease of ver- suprarenal tumour . . 690 - - tabes ..134, 285, 350, 4G6, tebrre 181 thickening round appen- 473, 562, 847 - infantilism with 215 dix 393 dolorosa 507 - in Little's disease . . 164 uterine tumour 392 - in acute poliomvelitis 559 - from osteo-arthritis 214 fixation in loin by pre- - comparison with other re- - osteomalacia 214 ceding inflammation 391 flexes needed 397 - with psoas abscess. . 733 hfematuria in 9, 16, 305 689 - diminution of 398 - from rickets 214 due to hydronephrosis . . 391 in anterior crural neuralgia 488 - and scoliosis associated 181, 183 increased hsematuria after - disappearance in broncho- - from spinal caries . . 214 movement in . . 305 pneumonia 557 - in spondylitis deformans . . 183 laparotomy in diagnosis in simpl? diarrho'a 557 from suprarenal tu- - exaggerated in undue abdo- LABIA, condyloma of 709 mours . . 393 minal aortic pulsation . . 592 - herpes of 830 in movable kidney 500 amj'otrophic lateral sclero- - majora, epithelioma of . . 423 due to new growth of sis .... 73 565 - - leukoplakia of . . 770 kidney . . 391 birth palsies 558 pain in, from renal cal- pelvic swelling due to causes of . . 397, 398 culus 135 downward growth of 758 cerebellar abscess or - minora, kraurosis of 770 in perinephric abscess . . .500 tumour 565 leukoplalcia of . . 221 770 physical signs of 391 ,689 compression paraplegia 786 - myxoma of . . 805 due to pyoneplu-osis 391 in ciisseminated sclerosis - a?dem.a of in acute nephritis 458 pyuria in . . 16 689 342, 539 565 Labour, " after-pains "of . . 509 due to renal abscess 391 functional paraplegia . . 567 - ditKcult (see Dystocia) 227 right, bile-duct obstruc- hysteria . . 44, 342, 509, - dysmenorrhopa cured by . . 219 tion from 367 541, 567 592 - eclampsia with and after . . 172 in right lumbar region. . 727 hysterical paralysis of one - inversion of uterus after . . 587 simulation by tumour of leg 541 - paralysis of anterior crural liver 392 due to lesion ot upper nerve during 541 - - sudden, painless, profuse motor neurone 397 - prolonged, birth palsies due to 155 hsemorrhage in 305 neurasthenia 787 - pysemia after 372 due to tuberculosis of neurosis . . 44 - tenderness in the back froTn 789 kidney 391 primary lateral sclerosis . . 567 - urinary fistula after 442 urinary changes in 391 pyramidal tract lesion . . 546 Labyrinth, escape of liquor varicocele in 391 relation of ankle-clonus to 44 Cotunnii from ear in in- sudden appearance sug- spastic paralysis of one juries of . . 468 gestive of . . . . 395 leg 539 - various aft'octions of 190 928 LABYRINTHINE DEAFNESS— LARYNX Labyrinthine deafnesB, liow Lajjarolomy in diagnosing, conta Laryngismus stridulus, acute indicated 189 hydatid cyst of liver 279, 364 dyspnoea in 466 liaceration of leg;, talipes from 132 disease " 720 carpopedal spasm with . . 466 Lachrymal abscess, epiphora intestinal obstruction . . 267 convulsions with . . d66 from 250 - - mesenteric embolism . . 432 cyanosis in . . 185, 466 - duct, epiphora after exci- mucocele . . 281 mistaken for diphtheria 466 sion of 250 retroperitoneal cysts 725 orthopnosa in . . 465, 466 - obstruction causing epipliora 250 Kiedel's lobe 279 paroxysmal laryngeal ob- syringing in diagnosis of 2.^0 splenic haemorrhage 700 struction in 466 - t'lnnds, enlargement in strangulated spleen 700 in rickety children 170 466 chloroma 599 subphrenic abscess 501 Laryngitis, acute, association in lymphatic leukfeniia 31 suprarenal tumour 690 with acute pharyngitis . . 673 - nerve, skin distribution of 659 tuberculous crecum 736 blood streaks in sputum - secretion, arrest of in liver 414 of 176 paralysis of fifth Berve . . 807 - distinguishing kidney, supra- due to diphtheria 67,^ Lachrymation from conjuncti- renal, and splenic enlarge- dysphagia from . . 225 226 vitis 255 ment 726 oedematous, from staphy- - corneal ulceration . . .S06 renal and suprarenal tu- lococcus 70!) - date of first 250 mours . . 303 rapid oedema of larynx in - in influenza . . 505 - haimatemesis after . . 294, 304 673 709 - iritis . . 255 - infective peritonitis from 644 sore throat in 673 - major trigeminal neuralgia 495 - scar, peristalsis visible in suffocative, bacteriology 185 - running at nose from 203 ventral herniation of . . 570 rapid cyanosis from . . 185 Lacrosse, cramp during 177 - urgent, in acute abdominal tracheotomy in . . 673 Lactation, acute mastitis in.. 743 conditions . . 485, 846 - bacteriological diagnosis of - amenorrhcpa due to 23 - visible intestinal peristalsis natureof 185,226, 465, 670 673 - anaimia due to prolonged . . 40 an indication for 571 - in congenital syphilis 44G - breast cliar.ges in . . 713 Lardaceous casts, renal 10 - diagnosis of laryngeal par- - discharge of milk from - disease, absence of ascer- alysis from 537 nipple during . . 201, 743 tainable cause extremely - dry cough in 175 - flushing in . . 268 rare 414 - haemoptysis in . . 318, 325 - mastodynia in 479 - - affection of intestines in 696 - hoarseness in . . 226 673 - prolonged, followed by tetany 178 albuminuria in. 8, 10, 197, - laryngeal obstruction from 465 Lactic acid in gastric contents 414, 696 - laryngoscopic inspection in 673 299, 333, 351, 353, 845, 846 anfemia in . . 39 696 - in measles . . 226 in gastrectasis. . 845 anuria in. . . . 4r , 48 - pneumococcal . . 465 466 gastric carcinoma blood-count in diagnosis - causing rough cough 175 351, 353, 846 from leukpemia 696 - streptococcal 465 - therapy in indicanuria 349 in bronchiectasis 696 - stridor due to 709 - in vaginal secretions 210 causes of . . • 39 - syphilitic 86 Lactose, darkening vrith picric from congenital syphilis 414 - - bilateral . . . . 325 673 acid 290 diarrhoea in 197, 414, 696 diagnosis of 325 - distinction from glucose . . 290 from empyema . . 696 from carcinoma 67."} - osazone crystals from 290 facies in . . 39 tuberculous . . 226 673 - reduction of bismuth by . . 290 liver, enlarged, in 414, 696 dysphagia from . . 226 - in urine, tests for . . 290 firm in . . 414 effect of mercury and Laennec, metallic tinkling of 193 from long-standing sup- iodide in diagnosis of. . 674 Laevulose in m-ine 291 puration . . 414 696 extensive bilateral tissue Lalling, defmition of . . 688 syphilis 414 destruction in. . 325 - persistence of, indicative of low specific gravity urine healing with deformity in 325 mental deficiency 6S8 in 197 hemoptysis from 318 325 Lamina cribrosa 461, 462, 463 patient weak, frail-look- oedema of larynx in 466 Landouzy - Dejerine's facio- ing, and bloodless in . . 696 sore throat from 670 scapulo - humeral myo-. from phthisis 696 subacute nature of 673 pathy, characters of 561 polyuria in 58?., 584, 696 Wassermann's reaction in fibrillary contractions renal changes in 696 325, 674 rare in 158 sago spleen in 696 - tuberculous, apical lung muscular atrophy in . . 70 severe chlorotic ancrmia in 696 signs in . . 325 Landry's paralysis, acute onset 562 in spinal caries . . 696 association with phthisis 674 parapelgia from.. 5G2, 507 spleen enlarged in 1 97, 414, bilateral occurrence of . . 673 plantar reflexes in 81 692 696 how diagnosed . . 226 Language, written, unafiected symptoms of 39 diagnosis from carcinoma 673 by word deafness 684 - - in tertiary syphilis 411 696 syphilitic laryngitis . . 673 Tjanngo-like hair 84 tube-casts in 10 dysphagia from . . 226 Laparotomy, after abdominal now uncommon in tuber- hfemoptysis from 318 325 injury 646 culous joint disease . . 366 multiple shallow ulcers on - In diagnosing acute abdom- of liver, characters of . . 10 epiglottis in . . 325 inal conditions 90, 342 780 of spleen . . . .10, 414, 696 cedema of larynx in 466 hfemorrhagic pancreatitis 646 Large intestine, carcinoma of primary lung disease in 32c ,674 pancreatitis . . 724 846 (see Colon, Carcinoma of) sore throat from 670 - - carciaoma of cxcum 736 - white kidney (and see Bright's stridor from 710 colon 501 Disease) . . 13 subacute nature of 673 gall-bladder 278 Laryngeal afl'ections, ptyalism tubercle bacilli in sputum sigmoid colon . . 735 from difficulty in swal- in .. .. 325 674 chronic pancreatitis 364 lowing in . . 591 tuberculolis of tonsil with 672 - - cicatrized bile-ducts 365 - branches of vagus, effect Iiaryngoscope in diagnosis of colic 645 on cough . . 174 cause of ha?moptysis 325 encysted ascites 73 9 - crises of tabes 465, 466, 562 - essential in diagnosing - - gall-stones . . 364 365 - diphtheria (see Diphtheria, laryngeal ulceration 226 gastric carcinoma 352, 713 ,848 Laryngeal) - inspection by in laryngitis 673 general peritonitis 645 713 - obstruction (see Larynx, - in laryngeal paralysis 537 539 gumma of liver . . 279 Obstruction of) Larynx, affected early in my- hepatic abscess . . 279 LARYNGEAL PARALYSIS asthenia gravis . . 225 growth 279 (see Paralysis, Laryngeal) - affections of, vertigo due to 828 LARYNX— LEUCOCYTE COUXT 929 Larynx, conld. Lateral sclerosis, cotild. Let/, conld. - angioma of, haemoptysis from - - primary 565 - siiasticity of (see Paraplegia) 318, 325 ankle-clonus in 567 - tremor of, in disseminated - carcinoma of (see Carcinoma bladder and rectal sclerosis . . 800 of Larj'nx) troubles iu . . 567 in Graves' disease 797 - cyanosis in syphilitic ulcera- conditions simulating 565 - ulceration (see Ulceration of tion of 185 contractures in 162, 164 Leg) - decubital ulceration of 226 extensor plantar reflex in 567 - AVerdnig-Hoffmann paralysis - deficiency of deep tenderness incontinence of fePces in 567 of . . 1.58 in locomotor ataxy 562 knee-ierks increased in 567 Le^al's test for acetonuria . . 4 - epithelioma of (see Carcinoma loss of abdominal re- Leishman-Donovan bodies in of Larynx) flexes in (Fig. 146) 567 kala-azar (Plate XII, Fig. H - fibroma of, stridor from . . 710 paraplegia from 561, 565 p. 696) . . . . 34, '693 - foreign body in (see Foreign retention of urine in . . 567 Leishman's stain 29, 33, 34 Body in Larynx) shuffling gait ua 278 Lemon-yellow colour of skin - gangrene of lung after opera- spastic paresis of 567 in pernicious anaemia 610, 849 tion on 288 sjrphilitic origin of 567 Lemonade, artificial, transient - injury, h.Tmoptysis in 318, 325 - sinus, erosion from chronic polyuria caused by 581 cedema of larynx from . . 466 tympanic suppuration . . 468 Lens, coloboma of 462 - irritable, couc;h with 175 thrombosis (see Tlirombosis) - dislocation of, irregularity of suggested by cough on - spinal curvature (see Scoliosis) pupil from 594 getting into bed 176 Lateropulsion in paralysis monocular diplopia in . . 198 - leprosy ulceration of 226 agitans 796 signs of . . 198 hfpmoptysis in . . 318 Latissimus dorsi, atrophy of 560 Lentigo (see Freckles) - lupus of 226 nerve supply of . . 550 Leontiasis ossea . . 749 753 cyanosis from . . 185 spinal nerve roots supplying 556 Lepidophs^ton in tinea imbri- haemoptysis in .. 318, 325 Laughter, explosive bursts of, cata 276 oedema of larynx in 466 in double hemiplegia . . 258 Leprosy, anaesthesia in 75, 4.50 575 - up-and-down movement in - hiccough from 342 diagnostic importance of 424 diagnosis of site of respira- - in paralysis agitans 262 due to pressure of infiltra- tory distress 467 Lavage of stomach, diagnostic tion on peripheral nerves 424 in laryngeal obstnic- 352, 353, 354 355 - bullaj in 6.54 tion 185, 186, 465 642 indications for in cases of - cachexia from 575 - new growths of, mistaken coma . . 137 - diagnosis of erythema nodo- for asthma 582 Law-suit, influence on neur- sum from 450 - obstruction of, broncho- asthenia . . 788 from erythema simplex . . 424 pneumonia associated with 186 Lead miners, ankylostomiasis leucodermia 575 causes of . . . .185, 465 709 in . . 570 syphilis . . . . 75 450 in children 185 - poisoning (see Plumbism) syringomyelia . . 75 424 from crises of tabes 465 Lecithin, deriv.-ition of urinary tinea versicolor . . 276 cyanosis from . . 184 phosphorus from 571 - erythema on face, limbs. diagnosLs of 465 Leech-bite, purpura from 596 597 and trunk in 424 from diphtheria.. 642, 709 Leg, atrophic palsy of one. - exacerbation of symptoms extreme dyspnosa from . . 642 from acute poliomyelitis 128,544 with each crop of macules 424 from foreign body 465, 642 - in Ba/in's disease . . 4.51 - gangrene in . . 282 285 - - head retracted in 641 642 - analgesia, in tabes dorsahs C65 - hyperaesthesia of nodules in 450 orthopnoea in 465 - athetosis of . . . . 154 536 - of larynx 226 paroxysmal, in laryn- - causes of oedema of one . . 455 hsmoptysis in 318, 325 gismus stridulus 466 - compound fracture of. - lepra bacillus in lesions of. . 425 from pneumococcal laryn- talipes from 132 in nasal discharge in . . 425 gitis . . . . 465 466 - drawing up of right in - lupus simulating . . 450 - - retropharyngeal abscess 64l ,710 appendicitis 736 - lymph, glands enlarged in . . 424 simulating meningitis : . 642 infants . . . . 136, 357 - macular . . . . 424, 450 from streptococcal laryn- in intussusception . . 92 absence of sweating in . . 424 gitis 465 - erythem.a of, from excessive - mucous membrane affected in 4-50 stridor in 185, 465, 642 standing . . 450 - nerve trunks thickened in_. . 424 sucking in above and induratum of 450 - neuritis in (Fig. 144, p. 551) belov," clavicles in 465, 642 nodosum affecting 450 75 551 intercostal spaces 465 642 papulatum. of 531 - nodules of (Fig. 124, p. 450) up-and-down movements - hysterical paralysis of 541 75, 450 of larynx in . . 465, 624 - lupus vulgaris of . . 812 - pain in joints in 450 - oedema of (see QEdema of - method of mejisuring length of 180 - perforating ulcer of foot Larynx^ - multiple benign sarcoid of 451 from 809 - pain in, causing dysphagia 225 - muscles, atrophy of, in - rosacea simulating 450 - paresis of, due to syphilis . . 640 mycetoma 810 - scabs in 654 - post-diphtheritic ulceration, sciatica . . 487 - scarring in . . . . 450, 654 hfemophysis in 318, 325 innervation of (Fig. 143) 541 - skin pigmentation in 575 - progressive weakness of, in - niggling pain in, from tabes - sore fingers from . . 266 bulbar paralysis . . 224 dorsalis . . 489 — sycosis simulating. . 450 - sarcoma of, hremoptysis in - cedema of (see Oedema of Legs) - telangiectases simulating. . 450 318, 325 - in osteitis deformans 383 - three types of 450 - stridor from obstruction of 709 - peroneal atrophy . . 128 - ulceration in . . 450, 654 - syphilitic (see Laryngitis, - predilection of psori^'.sis for 447 of larynx in 185 Syiahilitic) - sensation impaired in trans- nose, epistaxis in 250 potassium iodide in dia- verse mvelitis 564 Leucin, absent from urine in gnosing . . 226, 674 LEG, PARALYSIS OF ONE phosphorus poisoning . . 373 - tuberculous (see Laryngitis, (and see Paral.vsis) 539 - and tvrosin in urine in acute Tuberculous) - intermittent claudication in 489 yellow atrophy 302, 370, 843 - tvphoid ulceration of 226, 318, - paresis of, in diabetes 75 Leucocyte count, differential 28 325, 466 - pruritus of . . 588 in bullous dermatoses 114 - ulcers of (see ricersof Larynx ; - in pseudo-hypertrophic para- malaria 402, 583, 615 Lateral sclerosis, amyotrophic lysis 560 splenomedullary leukae- (see Amyotrophic Lateral - pseudo-oedema of, in myx- mia . . 693 Sclerosis,) oedema 585 typhoid . . 402, 615 59 930 LEUCOCYTES— LIGHTNING PAINS Leucocytes, abnormal varieties of 29 Leukaemia, contd. Levator ani muscles, contd. - in blood, variations with - epistaxis in . . 251 302 function in defaecation 148 digestion and time of day 399 - hasmaturia in . . 305 314 injuries of, causing pro- - excess of, in urine in bacteri- - haemoptysis in 318 lapse of uterus 586 uria . . . . 83, 84 - hfemorrhage from mucous painful spasm of 221 - normal varieties (Plate IT) 28 membranes in . . 649 - palpebrce, congenital absence Leucocythfemia (see Leukaemia) - heavy sweats in 649 or ill-development of . . 590 Leucooytic renal tube casts. . 7 - hyperplasia of marrow in 776 paralysis of, causing ptosis 589 LEUCOCYTOSIS 399 - irritability in 31 spasm of, in exophthalmic - absence of in malaria 371 583 - jaundice in . . 362 goitre . . 253 - in acute general peritonitis 472 - infarction of lung in 321 Leyden's myopathy, fibrillary cellulitis . . 455 - leucocytosis in 64, 302, contractions rare in 158 r- after severe loss of blood . . 400 399, 599, 617, 620, 693 Lice, pruritus caused by 588 - definition of 399 - lymphatic, albumosuria in 20 Lichen annularis affecting - with empyema of gall-bladder 280 anaemia in 599 fingers 266 - with hepatic abscess 279, 369 ,408 ascites 58 - planus affecting fingers . '. 266 - in Hodgkhi's disease 617 blood changes in 31, 366 flexor surfaces 657 - in leukfemia 64, 302, 366, examination in 739 character of papule of 528 533 599, 620, 693 changes in liver in 414 diagnosis of pityriasis - new growth of stomach . . 691 enlarged axillary glands 421 rubra pilaris from 530 - with parasitic worms 620 portal glands in 58 from eczema . . 832 - in pneumonia . . 39, 645 haemorrhagic 599 psoriasis 657 - pregnancy . . 399 liigh colour index in 32 syphilides 533 - pyaemia 649 jaundice in 366 verruca plana . . 530 - with ruptured tubal gesta- leucocytosis in . . 399, 693 intense itching in 832 tion 646 lymphatic gland enlarge- involvement of lips in . . 403 - significance of, in pyrexia ment in 58, 59, 76, 416, macules in 424 without obvious cause . . 620 419, 421, 599, 617, 693 papules in . . 657 832 - in septic arthritis . . 375 lymphocytosis in cerebro- pityriasis rubra after 658 - slight in fungating endo- spinal fluid in . . 339 predilection for flexor carditis . . 39 lymphocytes in . . 302 693 surfaces 657 - in subperiosteal abscess . . 750 myelocytes in 32 pruritus in 588 - subphrenic abscess, 501, 720 721 pleuritic efEusion in 122 simulated by xanthoma - due to suppuration . . 614, 620 purpura in . . 596, 599 diabeticorum . . 805 - in suppurative peritonitis. . 645 - - relation of chloroma to . . 44 umbilication of papules in 530 - trichinosis . . .504 spleen scarcely enlarged vesicles in 832 - typhus fever 371 in some cases . . 693 wheals in . . 832 Leucodermia, diagnosis of enlarged in 59, 599, 692 693 - ruber planus, character of chloasma from . . 57-'^ - metrorrhagia due to 433, 435 papules in 528, 529, 533 658 lineae albicantes fromi 402 - mixed . . . . 32, 693 diagnosis from papu- from scbrodermia, mor- - myelocytes in . . 3: , 32 lar eczema . . 529 phoea, macular leprosy, - nerve deafness in . . 191 syphilides. . 533 syphilides, and partial - noises in the ears from 794 staining of skin after 529 albinism 575 - oedema of legs from 459, 461 - scrofulosoriim, absence of - macular 423, - pericarditis in 122 itching in 529 - pigmentation of the skin in 424 - peripheral neuritis in 76 character of papule of 528 ,529 Leuconycliia . . 445 - pleuritic efEusion in 122 distinction from miliary LEUCOPENIA 401 - priapism in . . 586 papular syphilides 530 - in malaria . . 303, 369, 698 - punctate basophilia in 30 papular eczema 529 - pernicious anemia . . 30 - pyrexia in 32, 609, 617, 620 649 xerodermia 530 - splenic ansemia 411 - rigors in . . . . 648, 649 long duration of 529 - typhoid fever 90, 372, 697 - serous inflammations in 32, 122 pustules in 529 Leucoplakia, age incidence of 770 - shortness of breath in 100 relation to sebaceous - oiiithelioma arising from - skodaic resonance due to . . 667 glands . . 529 (Plate XV, p. 814) 770, 813 814 - splenomedullary, absence of scales in . . 529 - syphilis causing . . 257, 813 glandular enlargement in 64 tendency to recurrence of 529 - o£ vulva . . . . 768, 770 albumosuria in . . 17 , 20 - urticatus, pruritus in 588 - - a cause of dyspareunia . . 221 ascites in 64 Lichenization, pruritus in . . 588 intense itching from 770 blood changes in 31, 76, 693 - of skin in prurigo . . 531 Leucorrhcea (see Discharge, diagnosis from new growth Lientery 197 Vaginal) of stomach 691 Life assurance, accentuation Leukaemia, acute, without differential leucocyte count 693 of lieart sound and 3 enlarged spleen or gland 617 eosinophilia in . . 248, 249 albuminuria in relation to 19 - albuminuria in . . 10 , 17 leucocytosis in 64, 693 importance of not mis- - albumosuria m 21 - - myelocytes in 29, 64, 302, 693 taking reduction by - amenorrhoea in 23 pleuritic effusion in 122 uric acid for glycosuria 818 - aiuemia severe in 459, 599, 649 purpura in 596 polyuria caused by exam- - ascites in . . . . 64, 122 spleen enlarged in ination for . . 581, 582 - basophile corpuscles in 3'. , 32 64, 617, 692, 693 Lifting weights, orchitis from 79 - bleeding gums in . . 85 - tenderness in ribs in 776 Ligature of arteries, gangrene - blood per anum in . . 90 of the sternum in 776 from . . . . 282, 287 - blood-count in diagnosis - thrombotic infarcts in 10 - oedema of limb caused by. . 457 from lardaceous disease 696 of spleen in 700 Lightning, gangrene from . . 282 - cachexia in . . 114 - uric acid in . . 817 - pains in childhood.. 489 - Charcot-Leyden crystals in 118 - von Jaksch's disease simu- in face in tabes dorsalis . . 498 - compression of the lung in 667 lating 42 - - in tabes . . 350, 489, 498, - duration of . . 31 - wasting in . . 649 507, 562, 664 - enlarged portal glands In .. 362 - .T-rays in, effect of . . 31 all degrees of severity in 489 lachrymal glands in 31 Levaditi's method,use for spiro- bilateral character of 489 - - liver in . . . . 76, 414 chaeta pallida 769 fleeting nature of 489 lymphatic glands in 31, 362 Levator anguli scapulae, nerve frequently the first .salivary glands in 31 supply of . . 550 symptom 489 spleen in 31, 59, 64, 76, 302, - ani muscles, constipation due induced by changes 314, 599, 617, 667, 692, 693 to weakness of . . 149 in the weather 489 LIGHTNING PAINS— LIVER, CONGESTION OF 031 Lirjldning pains in tabes, contd. irregular periodicity in 489 points to be investi- gated in diagnosis of 489 Limbs, choreiform movements oi in spinocerebellar ataxy 799 - inequality of lower, scoliosis due to 180 - motor tics affecting . . 160 - muscular twitchings of, in. petit mal 160 - pain in (see Pain in Limbs; - papular syphilides of . . 532 - pityriasis rosea of . . . . 858 - post-diphtheritic paralysis of 640 - prurigo ferox of . . . . 531 - seborrhoea of . . . . 656 - tremor of, in paralysis agitans 796 Limping gait in iliac abscess. . 739 - (see Gait, Abnormalities of) Linea alba, hernioe along 485, 716 LINE/E ALBICANTES .. 402 on abdomen . . . . 402 breasts 402 caused by ascites . . 50 diagnosis from leucodermia 402 morphoea . . . . 402 on shoulders . . . . 402 thigh 402 - atrophicae . . . . . . 402 Lingual nerve paralysis, loss of taste due to . . . . 774 Lipoma of abdominal wall 716 - of axilla . . . . . . 732 - breast . . . . . . 744 - distinction from fibroma moUusoum . . . . 804 sebaceous cyst . . . . 804 - of face . . . . . . 746 - in femoral region . . 733, 734 - periosteal . . . . . . 755 - popliteal . . . . . . 762 - retroperitoneal, diagnosis from ovarian cysts . . 761 occurrence even in emaci- ated persons . . . . 717 pelvic swelling due to 757, 761 simulating ascites .. 717 - of round ligament . . . . 741 - simulating axillary abscess 731 - spermatic cord . . . . 741 - vulva . . . . . . 768 Lipomatosis, diffuse, alcohol- ism causing . . . . 455 congenital syphilis causing 455 no effect of thyroid treat- ment in . . . . 455 - - hyperaesthesia in . . 455 obesity of . . 453, 455 - parts affected in . . . . 455 LIPS. AFFECTIONS OF RED PART OF ..403 - in acromegaly . . . . 263 - alcohoUc tremor of . . 797 - angioneurotic cedema of . . 457 - ataxy of . . . . . . 69 - biting, cheilitis exfoliativa from inveterate . . . . 403 - burning and itcliing in Fordyce's disease . . 403 - capillary pulsation in . . 233 - chancre of (Fig. 10) 86, 4C3 - ■' chapping "of . . . . 403 - circinate syphiloderms of . . 532 - congestion of, in mitral regurgitation . . . . 238 - constant licking in perleche 403 - in cretinism. . . . . . 258 - eczema of . . . . . . 403 - epithelioma of 204, 403, 419, 420 origin as abrasion, crack or pimple . . . . 403 - eschars on, in irritant or corrosive poisoning . . 674 Lips, conld. - exfoliation of vermilion of 403 - fissure of, from eczema . . 653 in ilongolian idiocy . . 263 - milium-Uko bodies on in Fordyce's disease . . 403 - paresis of, in bulbar paralysis 641 - perleche of . . . . . . 403 - i^rogi-essive weakness of in bulbar paralysis.. .. 224 - pouting in myopathy (Fig. 82) . ." . . . . 260 - rarely affected in impetigo 830 - rhinoscleroma of . . . . 805 - scars radiating from, in congenital S3'philis - stiffness in Fordyce's disease - swelling of, due to mercury in myxoedema . . stomatitis - sypliilitic ulcer on.. - tremors of in general jiaraly- sis of the insane . . lead poisoning . . paralysis agitans - ulceration in yaws . . - unaffected in herpes zoster - skin diseases involving - white and macerated in perleche . . Lipuria (see Chyluria) Liquor amnii, deficiency caus- ing dystocia - Cotunnii from ear, escape in labyrinthine injuries.. similarity to cerebro- spinal fluid - epispasticus used by malin- gerers - potassae, psorosperms demon- strated by test for pus sugar urates . . Lithates (see Urates) Little's disease athetosis m choreiform movements in clumsy gait in . . contracture in . . defective speech in diagnosis of acquired palsies from . . 154, 155 hereditary causes of . . 154 mental deficiency in . . 154 optic atrophy in. . . . 154 spastic paralysis in . . 154 tremor in . . . . 154 Littre's glands, infection of . . 208 Liver, ss of the body weight in adults 404 - jL to Jj of the body weight in children . . . . 404 - abnormal lobes of, palpable in epigastrium . . . . 723 - abscess of (see Abscess, Hepatic) - actinomycosis of . . . . 415 - active congestion of, etiology and symptoms of 371, 407 - acute yellow atrophy of . . 302 - absence of bile from urine in late stage of 370 age incidence . . 302 albumosuria in . . 20 anorexia in. . . . 370 bile in urine in 302, 370 bleeding gums in . . 85 coma in . . . . 370 constipation in . . 370 convulsions in . . 370 delirium in . . 302, 370 diagnosis from phos- phorus poisoning 373 yellow fever 372, 373 259 403 86 259 88 813 796 797 796 449 831 403 403 227 468 4C8 111 803 623 290 815 800 154 154 154 164 154 Liver, acute yellow atrophy, contd. diminution of liver dullness in 302, 370, 404 urea and uric acid in urine in dry brown tongue in 302 epistaxis in. . 302 following fright h»matemesis in 294, 302^ hyperpyrexia in jaundice in 302, 362, 370 leucin and tyrosin m urme in 302, 370, 843 metaena in . . 302, 370 metrorrhagia in nausea in . . 302 nervous symptoms in onset like catarrhal jaundice . . 302, 370 pain in right hypo- ohondrium in pregnancy associated with pulse in pyrexia in . . rapid course of restlessness and head- ache in . . sex incidence of 302 toxaemic biliary catarrii in lurinary changes in 302, 370 vomiting m 302, 370, 843 - adenoma of, lias been con- fused with hydatid rarity of . . undiagnosable during life - amoebic abscess of (see Ab- scess, Hepatic) - angioma, resembling carci- noma fifteen recorded cases of removal relationship to abdominal wall undiagnosable during life - carcinoma of (see Carcinoma of Liver) - characters in chronic peri- hepatitis . . - cirrhosis (see Cirrhosis of Liver) - confusion, in palpation of kidney, -with right lower part of normal . . - congestion of, general lithates in urine in sense of weight in hepatic region in . . . . 407 jaundice in . . . . 362 with large liver in 363, 407 pain in the epigastrium in 486 - venous in aortic disease ascites with . . in bronchitis . . cardiac oedema in in chronic pulmonary disease dusky-green tint of skin dyspepsia in . . edge in . . 370, enlargement to level of umbilicus in firm uniform enlarge- ment in . . 370, hepatic pain and tender- ness in hepatoptosis in icteric tinge of skin in in mitral disease 407, myocardial disease . . 370 370 370 370 544 370 370 370 370 302 370 370 370 370 370 370 414 414 414 414 414 404 414 412 405 371 407 407 407 407 407 407 407 370 407 407 407 407 407 407 370 764 407 93^ LIVER, CONGESTION OF— LIVER, SPLENOMEGALIC Liver, cotigeslion of venous, contd. pain in the right hypo- chondrium in . . 499 perihepatitis in . . 407 pulsation of liver in . . 407 skin tenderness over liver in . . . . 407 slight jaundice in . . 407 smooth surface of liver in . . . . 370, 407 in tricuspid incompe- tence . . . . 407 - cyst of, simulated by pan- creatic cyst . . . . 723 - diiEculty in estimating size in conditions with much ascites . . . . . . 406 - diseases, ascites in.. 53, 59 causing jaundice 3G2, 368 haemoclu-omatosis in . . 575 increase of uroarythrin in urine in . . . . 819 insomnia in . . . . 356 pain in epigastrium from 779 right hypochondrium from . . . . 779 side of chest from . . 779 shoulder from . . 779 and tenderness in back from (Fig. 204) 788, 789 pleuritic effusion from . . 123 ptyalism in . . . . 591 urobilinuria in . . . . 818 xanthoma multiplex with 805 - displaced by fluid in chest 193, 405 chest conditions simu- lating enlargement. . 405 - - downward by abscess . . 720 in general visceroptosis . . 473 due to spinal curvature. . 405 rickety chest deformities 405 right lobe of from tight lacing . . . . . . 405 right-sided pneumothorax 405 upward by meteorism . . 716 - deep furrow from tight lacing or belt . . . . 405 - dropped . . . . 148, 473 LIVER DULLNESS, DEFI- CIENT 404 acute yeUow atrophy 302, "370, 404 in emphysema 246, 406 from gas in peritoneal cavity . . . . 406 from presence of intes- tine in front of liver 404, 406 in hepatoptosis . . . . 406 meteorism . . . . 716 general peritonitis . . 644 diminution in tight lacing 404 dome-shaped extension upwards in tropical abscess . . . . 409 hydatid cyst . . 415 extent of . . . . . . 404 - dwarfing of one or other lobe in alcoholism . . . . 404 syphilis . . . . 404 - edge of, in chronic universal perihepatitis . . . . 412 cirrhosis . . . . . . 409 fatty degeneration . . 414 firm and uniform in health 404 lardaceous disease . . 414 lymphadenoma . . . . 414 rounded in fatty liver . . 414 secondary carcinoma . . 412 venous congestion . . 407 - embryomata of, impossibi- lity of diagnosis durincr life 413 - engorgement in pneumonia 372 300, 370, 3V9, rectal LIVER, ENLARGED 869,404, from abscess active congestion and ascites, causes of 55, in bronzed diabetes from carcinoma . .60, 363, in catarrhal jaundice cirrhosis 60, 301, 363, cholangitis chronic bronchitis and emphysema heart failure . . compression of lung by . . congenital syphilis congestion . . 363, diagnosis of cancer of colon from from renal tumour 391, in distoma hepaticum in- fection . . epidemic jaundice extreme depression simu- lating . . fibroid lung and bron- chiectasis from free downward movement with inspiration of with gall-stones . . gumma hsematemesis with in Hanot's cirrhosis hepatic abscess . . Hodgkin's disease in hydatid disease importance of examination in with jaundice, causes of 363 lardaceous disease 10, 39, in leuksemia . . lymphosarcoma and lym- phadenoma in mitral regurgitation 238, normal resonance in loin unimpaired by obstructed common bile- duct obstruction to inferior vena cava by . . of portal vein by phosphorus poisoning 363, pseudo-leuksemia pylephlebitis in relapsing fever from secondary carcinoma sharp edge in simulated by omental tumour tuberculous peritonitis - - simulating renal tumour in splenomegalic cirrhosis suppurative pylephlebitis swelling of chest wall from from syphilis . . 55, tricuspid regm:gitation . . tropical abscess . . tumour of right supra- renal capsule simulating varicose abdominal veins from - fatty absence of symptoms due to in alcoholism characters of from phosphorus . . in severe ansemia tuberculosis uniform enlargement of in wasting diseases - fluke (see Distoma) - gas-containing loculi in - gumma of (see Gumma of Liver) - hard, with definite beaded edge, in cirrhosis . . 407 363 371 366 411 368 365 368 369 246 61 324 370 370 367 392 364 372 324 391 363 615 295 410 651 303 415 367 ,366 696 76 366 240 392 363 373 42 370 373 412 391 367 56 392 369 649 194 363 106 408 367 825 414 414 414 414 87 41 "J 414 414 414 231 368 (see Liver, contd. - hard nodules on, in second- ary carcinoma . . - very hard . . - hobnail, with ascites - hydatid cysts of Hydatid Cysts) - injiu'y, abscess of liver from - lardaceous (see Lardaceous Disease) - large and smooth in stenosis of bile-ducts . . 365, - lateral mobility in hepato- ptosis - lobes, abnormal - lobulation, when present, due to previous disease, not mal-development - local enlargement in gumma of liver - lower edge normally palpable under right ribs on deep inspiration in thin people - lymphadenoma of, absence of jaundice in pain in tenderness in . . diffuse form of . . firm edge of liver in nodular form of . . undetectable in life . . smooth surface in uniform enlarged liver in - melanotic sarcoma of, melanuria due to - neoplasms of, causing pleu- ritic effusion - normal situation of - nutmeg (see Nutmeg Liver ; and Liver, Congestion of, Venous) - pain in (see Pain in Liver) - palpation of normal - peritonitic rub over - primarv cancer of (see Car- cinoma of Liver, primary) sarcoma of, indistinguish- able from carcinoma . . - pulsatile 61, 1O6, 370, 407, diagnosis from transmitted movement from aorta hypertrophied heart - pushed up by abdominal tumours . . by ascites . . - relatively larger in children than adults - Hiedel's lobe of (see Riedel's Lobe) - rotation round horizontal axis in hepatoptosis from upward extension of right renal tumour . . - rupture of, haemoperitoneum from - sarcoma of (see Sarcoma of Liver) - secondary cancer of Carcinoma of Liver) - shrunken, in cirrhosis - slight depression in phragmatic pleurisy - smooth in chronic universal perihepatitis fatty degeneration Hanot's cirrhosis health lardaceous disease and hard m general con- gestion - soft, in fatty degeneration . . - splenomegalic cirrhosis (see Cirrhosis of Liver, Spleno- megalic) (see dia- 412 60 60 408 406 723 404 370 404 414 414 414 414 414 414 414 414 414 822 123 404 644 413 764 407 407 406 40G 406 393 717 60 405 412 414 410 404 414 407 414 LIVER, STREPTOTRICHOSIS OF— LUNG FIBROSIS OF 933 JAvir, could. Loss of consciousness (see Coma ) Luii/j, compression of, could. - stroi)totricliosis of (see - weight (see Weight, Loss of) by ascites . . 324, 668 Actinomycosis o£ Liver) Love, loss of weight due to . . 848 - - big heart . . . . 324, 667 - suppuration, subphrenic Lower extremity, pain in (see carcinoma of the liver . . 667 abscess from 720 Pain in the Lower Ex- empyema 324 - swelling of, rectus abdominis tremity) 487 flbroid lung and bronchiec- muscle mistaken for 723 - jaw (see Jaw) tasis from 324 - s-.vellings in situation of . . 722 - limb, tables of innervation greatly enlarged spleen 324 667 - syphilis of (see Syphilis of of muscles of . . 542, 543 gumma of liver . . 667 Liver^ Ludwig's angina, oedema of hepatic abscess . . 667 - tender (see Tenderness over face or neck in . . 459 hydatid cyst of the liver 667 J.iver) lityalism due to . . 590 liver tumour 324 - tenderness in the chest from Lumbago, always bilateral . . 476 by mediastinal new growth 667 affections of 77G - association with sciatica . . 487 pericardial effusion 324, 667 - tonsue-like projection of - diagnosis from pelvic disease 477 - - pleural effusion 324, 331 667 right lobe of 40-1 t\imours . . 47G skodaic resonance in 332 - transposition of 404 - exclusion of abdominal or in splenomeduUary leu- - tropical (see Liver, Acute pelvic growths in dia- kasmia . . 667 Congestion of) gnosis of . . 476 by subphrenic abscess 324 667 - tropical abscess of (see nervous disease in 47G thick pneumonic lympli 324 Abscess, Hepatic) organic disease in 476 tubular breathing in . . 332 - tuberculous, undiaguosable - from myalgia of the back . . 507 - destruction of, elastic fibres clinicall.y . . 414 - pain in the back in . . 476 in sputum as evidence of 701 - tumour of (see Liver, En- - simulated by spondylitis - disease, albuminuria in . . 18 larged) deformans 787 ascites in . . 61 - turned-up edge, in peri- - tenderness of the spine in 785 causing enlarged right hepatitis . . 60 Lumbar cushion 458 ventricle . . 245, 246 - umbilicated nodules in - plexus, muscles innervated pancreatitis IIG 60, 270, 412 by 542, 543 chronic, cedema of legs - various tumours of 360 - puncture in cerebrospinal from 461 - venous congestion of (see Liver, fever .. .. 328, 598 epileptiform convulsions in 172 Congestion of Venous) diagnosis of cause of pro- haematemesis in . . 294 - wandering (see Hepatoptosis) longed pyrexia 609 heart failure from 461 Lividity, extreme (see Cyanosis) cerebral conditions. . 558 insomnia in . . 356, 359 Lobar 'pneumonia (see I'neu- meningitis orthopnoea in 359 monia) 328, 464, 563 ,643 pain in temporal region 783 Lobelia in diagnosis of asthma 582 radicular pain in arm 494 tenderness in chest from 77G Locking of joint in osteo-ar- diagnostic characters of epigastrium froni 783 thritis 384 fluid obtained from . . 338 - embolic infarct, sudden pain. from displaced cartilage 888 in general paralysis of dyspnoea, cyanosis, and Lockjaw in hysteria . . 464 the insane 269 haemoptysis in . . 320 - tetanus . . 162, 463, 652 post-basal meninaitis . . 328 - emphysema of (see Emphy- - (see Trismus) - reQJon. definition of 722 sema) Locomotor ataxy (see Tabes left, organs normally con- - endothelioma of, gangrene Dorsalis) tained in 722 of hand from 287 Loin, aching in (see Aching in spleen bulging . . 688 - fibrosis of, albuminuria in 18 Lom ; and Pain in Loin) various tumours felt in 729 alterations of resonance in 332 - colicky pains in, from faecal right, intussvisception apparent enlargement of accumulations . . 393 causing tumour in 727 liver from depression - draggmg sensation in, in organs normally con- due to . . 405 hydrocele 522 tained in 722 ascites in . . 61 - filling out of, by cystic renal various inflammatory breathing abnormalities in 246 tumour . . . . 393 G89 swellings in. . 727 — with bronchiectasis, abun- - - in perinephric abscess . . 391 tumours felt in 726, 727 dant expectoration in 246 by renal or suprarenal visible peristalsis in . . 727 causes of 324 tumour 729 - vertebrae, carcinoma of, pain clubbing of fingers in. . 324 - injury, perinephric effusion in the testicle in . . 524 diagnosis of . . 324 of blood after . . 392 Lumbo-sacral plexus and fcetid sputum in 246 - pain in (see Pain in Loin) branches, diagram illus- physical signs of 324 - swelling in, in ureteric trating (Ficj. 143) 544 cavernous or amphoric calculus . . 135 tumours affecting, causing breatliing in . . 246 - tenderness (see Tenderness in paraplegia 561 clulabing of fingore in Loin) Lung, abscess of (see Abscess 128,129, 193,246 324 - tumour due to ftecal accu- of Lung) congestion of liver in . . 370 mulations. . 393 - actinomycosis of . . 322 cough in . . 246 London, ringworm parasites in haemoptysis in . . 317 cracked-pot sound in . . 246 272 273 - acute cedema of, in acute crackling rales m 332 Long flexors of the toes, spinal Bright's disease . . 466 - - cyanosis from 18G nerve roots supplying . . 543 - anchovy-sauce sputum from diagnosis of phthisis from 246 - thoracic nerve, muscles abscess of liver bursting dyspnoea in 246 supplied by 550 through . . 323 enlarged right ventricle spinal roots derived - aneurysm of aorta ruptur- due to . . . . 245, 246 from.. 550 ing into . . 318 epigastric pulsation in . . 246 Loose body in joint, diagnosis - aspergillosis of 322 from epithelioma of bron- from displacement of haemoptysis in . . 317 chus 324 semilunar cartilage 389 - carcinoma of (see Carcinoma foul sputum in . . 246 in osteo-arthritis 389 of Lung) haemoptysis in . . 2i6 Lordosis 183 - cirrhosis (see Cirrhosis of heart displaced with - in achondroplasia . . 212 Lung ; and Lung, Fibrosis 129, 193, 232, 246, 330 332 - congenital dislocation of of) 317 failure from 61, 186, 464 525 hip 277 - collapse, in aortic aneurysm 482 hypertropliic osteo-arthro- - and kyphosis combined . . 183 from bronchial stenosis 322 pathy in 390 - myopathic, illustrated 183 - compression of, absent impairment of percussion - secondary in rickets 214 1 breath and voice sounds in 331 note in . . 246 93 f LUNG, FIBROSIS OF— LYMPHANGITIS Lung, fibrosis oj, contd. Lupus erythemalous, contd. Lymphadenoma, conld. increased resonance and diagnosis from granulosis - bronchial obstruction from 343 vocal fremitus in 332 rubra nasi 714 stenosis in 324 inspissated mucus in 324 lupus vulgaris. . 449 - cerebral haemorrhage in . . 302 from mediastinal nev7 other forms of erythema 656 - of cervical glands, diagnosis growth . . . . ^ .. 121 psoriasis 657 from tuberculosis 420 - - orthopnoea in . . --' . . 4G4 ringworm 65G - characteristic temperature palpitation in . . ' . . 525 rosacea 268 chart in (Fit/. 168) 017 passive congestion of liver erysipelas simulated by 781 - no characteristic differen- from heart failure in . . 370 of hands and face 656 tial leucocyte count in . . r,[i5 periodic cyanosis from . . 579 involvement of lips in . . 403 - chloasma in. . 574 physical signs of 193, 232 nodules of 449 - commencement usually in polycythEemia in 579, 580 scabs and scales in 656 glands of neck . . 41 G retraction of chest wall scales with 268, 657, 711 - course of . . . . 303, 695 from . . . . 193, 194 scarring in 268, 272, 656 658 - deposits in abdominal wall in 715 scoliosis with . . 180, 193 sex incidence of . . 781 - distinction between lympho- shortness of breath with 579 simulating chilblains 656 sarcoma and Hodgkin's shoulder drawn down in 246 tenderness of scalp from 780 disease . . . . 417 695 spinal ciurvature from . . 246 - vulgaris, affection of cartilage - enlarged abdominal lym- tactUe vocal fremitus by 808 phatic glands in. . 725 increased in . . 246 fingers by 266 axUlary glands in (Firj. tubular breath sounds in 332 age incidence of 449, 808, 812 119, p. 417) . . 421 vomiting with . . 844 apple-jelly nodules in cervical glands in 421 - fluke (see Paragonunus 603, 655 812 groin in 738 "Westermani) bones never eroded by . . 808 femoral glands from 734, 738 - gangrene of (see Gangrene in carias of spine 564 fibroid lung and bronchi- of Lung) characters of 808 ectasis from . . 324 - growth of, progressive loss of cheek, ectropion and glands in 64, 76, 303, 416, of weight from . . 322 epiphora from 250 599, 617, 695, 715 - hvdatid cyst of (see Hydatid crusts with 448 liver and spleen in 59, 303 366 C^st) description of 448 portal glands in 58, 362 - infarction of (see Infarction diagnosis from carcinoma 808 - epistaxis in . . 302 of Lung) epithelioma 449 - fibroid lung and bronchi- - injuries causing surgical leprosy 450 ectasis from 324 emphysema 231 lupus erythematosus . . 449 - general lymphatic gland - mottling of, in phthisis 120 multiple benign sarcoid 452 enlargement in . . 416, 617 - new growth, blood-stained rodent ulcer . . 449 809 - hajmatemesis in . . 294, .302 pleuritic effusion in 322 scrofulodermia 449, 603 - haemoptysis in 318 sputum in . . 322 syphilis •808 - hsemorrhage from mucous breaking down pneumo- yaws 449 membranes in . . 649 thorax from 578 epithelioma starting from 803 - heavy sweats in . . 649 bronchial stenosis in . . 322 involvement of lips in . . 403 - and Hodgkin's disease, sy- diagnosis of . . 322 Koch's tuberculin test in 812 nonymous terms with effects of 185 of larynx (see Larynx, most authors 417 gangrene from 578 Lupus of) - increasing anaemia with . . 738 haemoptysis in 317, 322 of leg 812 - intermittent pyrexia in . . 738 heart displaced in . . 330 leprous nodules simula- - jaundice in . . . . 362, 366 particles of growth in ting 450 - ieucocytosis in 617 pleuritic effusion in 322 nodules of 448 - leucopenia in 401 in sputum in 322 of nose 448 - liver changes in (and see physical signs of 322 discharge due to 204 Liver, Lymphadenoma of) pleuritic effusion in 121 322 occasional implication of 303, 414 pneumothorax from . . 578 glands in 449 - lymphatic gland enlarge- profuse haemorrhage in 322 penis 677 ment in . . 58, 362, 416, red-currant-jelly-like scabs in . . 655 421, 599, 695, 734, 738 sputum in . . 322 scarring from 448 - myelocytes in . .29, 303, 695 varicosity of thoracic tuberculous ulcer of palate - cedema of legs from 459, 461 veins in 322 with 640 - paralysis of vocal cord in . . 538 - obstruction to root of, by ulceration with . . 448 - pericarditis in 122 aortic aneurysm 322 of larynx 226 - peripheral neuritis in 76 - passive congestion of, in von Pirqust's skin test in 812 - pleuritic effusion in 122 mitral stenosis . . 245 Lymphadenoma (Hodgkin's - possibly a chronic tuber- - rupture of aortic aneurysm Disease), general (fig.W^) 417 culosis 420 into 322 - absence of ansemia in 695 - prognosis in. . 303 - secondary deposits in hyper- breaking down of glands. . 420 - purpura in . . . . 596, 599 nephroma 455 definite blood changes in - pyrexia in {Fig. 168, p. 617) - sporotrichosis of (see Sporo- 64, 695 32, 609, 016, 649 trichosis) fixation of glands in 416 420 - rigors in 649 - thrombotic infarction 320 of leucocTtosis 64, 366, 599. - severe anaemia in 459, 649 695 - wounds and contusions, 617, 695 - spleen enlarged in 64, 76 , 86, gangrene of lung from 287 288 splenic enlargement in . . 695 303,416,420,617,692,695 738 Lumbricals, nerve supply of suppuration in . . 416 - thrombotic infarction of 542, 550 - acute 695 spleen in. . 700 Lupoid, miliary benign, dia- - albuminuria in 17 - varicose thoracic veins from 343 gnosis of lupas and sar- - amenorrhoea in 23 - wasting in . . 649 coma from 451 - anaemia in 303, 366, 459, 617, Lymphangioma circumscrip- Lupus erythematosus affecting 6l9, 695, 715, 738 tum S33 fingers 266 - ascites in.. .. 58, 64, 122 age incidence of . . 833 sebaceous ducts 657 - basophile cells in . . 303, 695 vesicles in 833 age incidence of . . 449, 781 - bleeding gums in . . 85 - of the cord, diagnosis from atrophy of ears in 658 from mouth in 302 irreducible hernia 741 baldness from 84, 85, 781 - blood changes in (and see Lymphangitis, causing blubber course long of . . 781 Antemia) . . . .41, 417, 695 lips 746 — diagnosis from favus . . 272 examination negative in 617 - of penis 515 LYMPHATIC GLANDS, ABDOMINAL— MEDIASTINAL 935 Lymphatic glands, abdominal (and see Lym|ili;itir uiunds, Portal ; Lyniphatic i,'laiKls, Betroperitoucal ; etc.) calcified . . . . 725 caseous. . . . . . 7l!5 cystic . . . . . . 725 enlarged, in oln-onic peritonitis . . . . 725 Hodgkin's disease . . 725 malignant disease . . 725 tuberculous perito- nitis .. G91, 725 — axillary, enlarged (Fi{f. 119, p. 117) 421, 732 ia carcinoma o£ breast ■121, 743, 745 chronic mastitis . . 74.S diagnosis between inflammatory and malignant 421, 743 in herpes zoster 479, 714 Hodgkin's disease 59, 417, 421, 617 inflammatory 421, 731, 743 in leukaBmia 59, 421 malignant . . 718, 745 in prurigo ferox . . 531 simulating brachial neuritis . . . . 492 tuberculous . . 421, 744 — bronchial, in sputum . . 704 enlarged, cyanosis from 4G6 - diagnosis Iroin aortic aneurysm. . . . 422 chronic mediastinitis 422 mediastinal growth 422 dyspnoea from . . 466 in Hodgkin's disease 617 inflammatory, rarity of bronchial stenosis from . . . . 422 laryngeal paralysis from . . . . 422 in lymphatism . . 423 obstruction from . . 422 stenosis of innominate vein from. . . . 422 vena cava by . . 422 .T-rays in diagnosis . . 617 tuberculous, almost always due to infected milk 427 caseous, in sputum. . 704 cough due to . . 176 frequency of . . 427 general tuberculosis from . . . . 427 hemoptysis from . . 318 irritative hiccough due to . . . . 313 irruption into bron- chus . . . . 406 marasmus from . . 427 meningitis from . . 427 opening into tracliea 709 - periodic febrile at- tacks from . . 343 stenosis of bronchus from . . . . 324 - ar-rays in diagnosis of 617 caseous (and see under the various groups of glands, e.g.. Lymphatic glands. Cervical, Tuberculous, etc.), anosmia with . . 36 lichen scrofulosorum associated with . . 529 mesenteric, causing ob- struction . . . . 151 — cervical 421 acutely inflamed after scarlatina . . . . 674 diagnosis from mumps. . . . 674 Lymphatic glands, cervical, contd. acutely inflamed, dys- phagia from . . 674 sore throat from. . 674 with sore throat and pyrexia sometimes the only symptoms of scarlet fever. . 674 sources of infection in .. .. 674 stiu:-neck from . . 674 — - carcinomatous, diagnosis from tuberculous . . 421 sites of primary growth 420 vocal cord paralysis from . . . . 538 enlarged (Fig. 119, p. 417) 13, 417, 420 age incidence of . . 421 due to carcinoma of oesophagus . . 296 epithelioma of ear 419, 468 German measles 418, 607 hospital sore throat 419 length of history in diagnosis of . . 421 from local septic ab- sorption . . . . 420 in Ivmphadenoma 59,421,465,617 _ tracheal obstruction from . . . . 465 lymphosarcoma . . 421 from malignant thy- roid gland . . 492 otitis media. . . . 420 pediculosis capitis . . 420 sarcomatous, rarity of 421 after scarlet fever . . 420 secondary growth in 421 tuberculous . . . . 564 from ulceration of the tongue . . 815 in epithelioma of face 449 fixation to deeper parts 417 leukaemia . . . . 59 lupus of face . . . . 449 malignant . . 465, 812 stridor from . . 710 tracheal obstruction from . . . . 465 normal anatomy of 731, 732 obstruction to trachea by .. 465, 710 paralysis of vocal cords from 538 stiff-neck from inflam- mation of . . . . 708 tuberculous, general account of . . 420, 421 paralysis of vocal cords due to . . 538 phthisis not related to 420 scrofulodermia with 449, 529 tuberculous lesions elsewhere w ith . . 420 enlarged in German measles 418 — epitrochlear, enlarged in digital chancre 266, 422 in infective synovitis of finger . . . . 422 rheumatoid arthritis 39,379 femoral, area of drainage of 738 diagnosis from femoral hernia 738, 740, 743 from hydrocele of hernial sac . . 733 enlarged . . 422, 738 in groin in . . . . 738 prurigo ferox . . 531 inflammatory . . . . 734 — - - hi lymphadenoma . . 734 Lymphalic (/lands, /emoral, coiitd. malignant . . . . 734 position of . . . . 738 gastric, enlarged in lymph- adenoma . . . . 55 palpable in epigastrium 75!) iliac, area of drainage of 738 enlarged, causes of . . 422 in malignant growtli of testis . . . . 202 S3condary to inguinal or femoral glands 738 swelling in right iliac fossa from 730, 736 inflamed, asymmetrical oedema from . . 455 malignant . . . . 735 palpable in left iliac fossa 735 in malignant disease 422 per rectum . . . . 422 in peritonitis . . . . 736 position of . . . . 738 inguinal, area of drainage 738 carcinomatous 209, 630, 738 site of primary growth 423 enlarged . . . . 422 buboes from 422, 675 ' - from carcinoma of rectum . . . . 036 urettoa . . . . 209 from chancre . . 675 on scrotum . . G81 constitutional sym- ptoms with . . 422 in epithelioma of labium majus . . 423 penis . . 676, 677 perineum . . 678 scrotum . . 679, 765 epitheliomatous 718, 738, 739 pain without signs of inflammation in 739 herpes genitalis . . 830 zoster . . . . 479 in Hodgkin's disease 017 inflammatory 675, 676, 738 from local irritation 738 sepsis . . 421, 422 in lymphadenoma . . 738 lymphatic leukaemia 739 melanotic sarcoma. . 423 pediculus pubis . . 738 primary syphilis 675, 678, 681 secondary carcinoma 423, 769 in sypliilis . . 209, 769 m-etliral discharge . . 422 lymphadenomatous . . 59 position of . . . . 738 sarcomatous . . . . 739 from soft sores on penis 675, 676 suppurating, from balanitis . . . . 675 tuberculous . . . . 738 lumbar, enlarged in car- cinoma of rectum . . 636 testis . . 520, 766 mastoid, earache from inflammation of . . 230 mediastinal (and see Lym- phatic glands. Bronchial) enlarged . . . . 422 fibroid lung and bron- chiectasis from . . 324 hiccough due to . . 343 in Hodgkin's disease 617 lymphadenomatous 334 obstructing bronchus 324 pyrexia due to . . 773 tachycardia from 772, 773 .r-rays in diagnosis of 617 936 LYMPHATIC GLANDS, MEDIASTINAL— MALARIA Lymphatic glands, mediastiiml, contd. primary new growth arising from . . 826 sarcoma of . . • . . 322 — - - in secondary carcinoma 419 secondary deposits in, causing paralysis of vocal cord . . . . 538 suppuration in . . 417 tuberculous, hiccough due to . . . . 343 irritating vagus nerve 772 obscure ill-health due to 773 obstruction to right bronchus from . . 773 — mesenteric, enlarged . . 422 in lymphatism . . 423 palpable in epigas- trium . . . . 725 seldom palpable . . 422 tuberculous, intestinal obstruction from . . 151 — occipital, enlarged, in Ger- man measles 417, 418, 410 Hodgkin's disease . . 419 impetigo of the scalp 419 leukaemia .. .; 419 pediculosis capitis 417, 419 seborrhneio dermat- itis of scalp . . 419 syphilis 417, 419 tuberculosis . . 419 — pelvic, enlarged . . . . 422 in carcinoma of bladder .. ..307 rectum . . . . 636 epithelioma of bladder 630 popliteal, abscess from suppuration of . . 762 enlarged . . . . 702 from local joint infec- tion . . . . 423 septic absorptions 423 — portal, enlarged, jaundice from 362 leukfemic . .58, 362, 366 lymphadenomatous 362, 366 jaundice in . . 366 malignant . . . . 362 pressure on portal vein by 58, 692, 696 tuberculous.. 58, 362 ascites with . . 59 bile-duct obstruction from . . . . 366 jaundice with 59, 366 malignant 58, 365, 422 secondary to colon. . 366 ovary . . . . 367 pancreas . . . . 366 rectum . . . . 366 stomach . . . . 366 obstruction of bile- duct by . . 58, 365 — pre-auricular, various causes of enlargement of 419 — retroperitoneal, carcinoma of, obstruction to inferior vena cava by . . . . 825 secondary to ovary 826 testis . . . . 826 varicose abdominal veins from . . 825 enlargement of . . 422 sarcoma of . . . . 825 — submaxillary, enlarged. various causes of 419, 420 from carious teeth.. 419 malignant 419, 420, 749, 812 pain in . . . . 419 in pharyngitis . . 419 Lymphatic glands, submaxillary, enlarged, contd. from septic absorp- tion from mouth 419 suppurating.. .. 419 - septicaemia from. . 614 leucocytosis in . . 400 in tonsillitis 419, 708 - Supraclavicular, enlarged 421 from abdominal growths, various . . 421 in carcinoma of colon 091 mamma . . 421, 743 stomach ..351, 421, 691 malignant peritonitis 57 secondary growth in 9, 123, 223, 278, 351,^421, 691, 803, 812 - - syphilitic 417, 209, 260, 533, 605, 675, 678, 681, 813 tuberculous, matting of 417, 420 in spinal caries . . 564 LYMPHATIC GLAND EN- LARGEMENT, general account of , . . . . 416 ("and see under Lymphatic G-lands, Abdominal ; Lymphatic Glands, Ax- illary ; etc.) ascites in . . . . 64 blood count to exclude leukaemia in . . 419 in chloroma . . . . 599 German measles . . 253 Hod?kin's disease 42,59, 64, 70, 303, 416, 599, 617, 695, 715, 734 leprosy . . . . . . 424 leukaemia 31, 59, 76 599, 617, 093 lymphosarcoma 695, 715 multiple benign sarcoid 451 mycosis fungoidss . . 804 in prurigo feros . . 532 ringworm . . . . 275 Still's disease . . . . 40 syphilis 533, 675, 738 tuberculosis 419, 421, 738 • leukaemia (see Leukaemia, Lympliatic) - obstruction, abdominal, ascites in. . . . . . 58 asymmetrical oedema from 450 from cellulitis . . . . 455 elephantiasis from 450, 810 Lymphatism 423 - deaths under ana?sthetics due to 423 - doubtful whether it is really a pathological state . . 423 - enlarged lymphatic glands in 423 - infantile convulsions in . . 170 Lymphocytes 28 - in cerebrospinal fluid 139, 339, 340, 489, 558, 643 tuberculous meningitis 558, 043 general paralysis of insane . . 139, 269 tabes 489 - in blood, in typhoid fever 402, 097 - large hyaline, relative in- crease in malaria 303, 369, 377, 402, 615, 649, 698 - in Hodgkin's disease . . 76 - pernicious anaemia . . 76 - in leukaemia 32, 59, 366, 693 - normal blood count . . 28 Lymphoma (see Lymphadenoma) Lymphosarcoma, absence of leucocytosis in . . . . 695 pathognomonic blood changes in . . . . 417 - of abdominal wall . . 715 Lympliosarcoma, contd. - affection of spleen slight in 417 - albuminuria in . . . . 17 - anaemia in . . . . . . 715 - of caecum 729 - cervical glands . . . . 421 - distinction between Hodg- kin's disease, lymphaden- oma, and. . . . . . 695 - eosinophilia in . . . . 249 - generalized enlargement of lymphatic glands in 416, 417, 695, 715 - jaundice in . . . . . . 306 - rapidly fatal . . 417, 695 - relation of chloroma to . . 44 - similarity to acute lymph- adenoma . . . . . . 417 MCBUENBY'S point, ten- derness over, in appen- dicitis 500 M'Call Anderson, psoriasis rupioides of . . . . 654 Mackenzie, re heart pains . . 778 - re pain in the back from disease of the rectum. . 788 heart (Fig. 204) . . 788 liver (Fig. 204) . . 788 stomach (Fig. 204). . 788 uterus (Fig. 204) . . 788 lI'Kerron, re fatal infantile metrostaxis . . . . 430 Macrocytes (Plate II, Fig. B) 28 MACULES 423 - absence of subjective sym- ptoms with . . . . 424 - of early nodular leprosy . . 450 - in erythema multiforme . . 531 - itching in drug rashes . . 424 - in measles . . . . . . 607 - subcutaneous, in typhus fever 099 - syphilitic, (Fig. 121) . . 425 becoming papules 425, 532 colour brought out by coolness . . . . 420 diagnosis from drug rashes 426 measles . . . . 426 seborrhoea corporis . . 426 tinea circinata . . 426 versicolor . . . . 426 distribution . . . . 425 evanescence of . . . . 425 measles-like character of 425 Maculo-papules . . 424, 528 jMadura foot 809 Magnesium in intestinal sand 652 - phosphates, acid and alka- line reactions of . . 573 " Main bote " in Friedreich's disease . . . . . . 104 Main-en-GrifEe (see Claw-hand) Main succulente in syringo- myelia 128 Malar flush in mitral stenosis 61, 526, 773 of myxoedema 43, 259, 454 - process, hyperplasia in acro- megaly 632 Malaria 34 - acetonuria in . . . . 4 - active congestion of liver in 371 - aestivo-autumnal, jaundice in 371 - ague-cake spleen in. . . . 693 - albuminuria in . . 17, 301 - algidity in . . . . . . 35 - anaemia in 27 37, 303, 459, 698 - blood changes in . . 34 - brachial neuralgia in . . 492 - cachexia from 114, 459, 401, 574 - characters of atticks in . . 649 - characteristic pyrexia of 34, 698 - Cheyne-Stokes respiration in 125 - chill in 615 MALARIA— MASTODYNIA 937 Malaria, contd. - cirrhosis of liver in. . - cold and hot stages of - coma in . . . . 35, - crescents in blood in (Plate XII, Fig. E, p. 696) . . - cure by quinine 583, 649, - diagnosis from abscess of liver 369, 371, - - pyaemia . . . . 615, - - relapsing fever . . - - typhoid fever - Jiazo-reaction in . . - diminution of leucocytes in - eosinopliilia in - functional bruits in - gansrene in - geographical distribution of 693, - ha?mat€mesis in 294, 302, - hsematuria in . . 301, - ha?moglobinuria m - hyperpyrexia in - impotence in - jaundice in . . 301, 362, - leucocvtosis uncommon in 371, 400, 615, - leucopenia with 303, 369, - - relative increase iu large hvaline Ivmphocytes in 303, 369, 37i, 402, 615, 649, - loss of weight in - malignant, coma in - - diagnosis from yellow fever 301, - menorrhagia in - CBdema of legs in 459, - pain and tenderness in the scalp from - parasites in blood in (Plate XII, p. 696) 35, 369, 371 583. 615, 649, 650, 693, most typical stage at onset of ague fit rapid disappearance after quinine - peripheral neuritis in - pernicious, crescents in - polyuria in . . . . 581, - purpura in . . - pyrexia due to . .609, 615, - quinine in diagnosis of 615, dosase of . . - relationship to blackwater fever - relative increased leucocyte count in diagnosis from hepatic abscess . . 401, - rigors in . . . . 647, - skin pigmentation in 424, - spleen, enlarged in 302, 303, 692, 693, - sweating in. . - thyroid gland swelling in . . - tinnitus from - wasting from Malformations, congenital (see Congenital Malformations) Malignant disease, absence of pyrexia as a rale in - - albuminuria in . . - - amenorrhoea in . . ansemia in . . 37, bed-sore in chylous ascites in eosinophilia in . . functional bruits in loss of elasticity of skin in multiple serositis in pains in limbs in. . pigmentation of the skin in simulated by alcoholism loss of weight due to old age Malignant disease, conld. 371 and syphilis, not distin- 583 J guished by pyrexia . . 136 I - (and see Carcinoma ; Epithe- lioma : Sarcoma ; etc.) 373 - endocarditis (see Fungating 650 I Endocaditis) - scarlet fever (see Scarlatina 408 : JIaligna) 650 Malingering, aortic aneurysm 373 invading spine, mistaken 615 for 198 - apparent hyperpyrexia in 698 I - bullae caused by . . 248 - carcinoma invading spine 106 mistaken for 282 - convulsive form of 160, 169, 464, 698 - distinction from hysteria . . 303 - fatigue in . . 305 - hsematemesis from swal- 315 lowing blood in . . 294, 344 - htematuria simulated by 347 I aniline dyes in . . 371 I - haemoptysis in - imitation of deafness by . . 649 ' epileptic convulsions by 402 I fits, describe:! . . '. . paraplegia by . . 562, - - strychnine poisoning by 698 ! tetanus by 848 - insomnia type . . 356, 136 - lockjaw variety of - nemrasthenia simulating . . 373 - oedema of limbs induced by 428 - pain-in-the-chest type 461 - perspiration in - professions of insomnia in - quivering of eyelids in - risus sardonicus variety 651, 373, Mallein in diagnosis of glanders 698 JIalpresentations, dystocia due to Malt liquors as cause of obesity Malta fever, absence of diar- 371 rhoea in . . 6 agglutinating reaction in 373 507, 583 arthritis in . . 376, 596 I bacteriuria in 622 bronchitis in 698 characteristic tempera- 615 ture chart of (Fig. 163) - constipation in . . - diagnosis from typhoid fever - enlargement of spleen in 402 gastric derangements in 648 geographical distribution 575 goat's milk as source of 615, infection in . . 507, 698 headache in 615 micrococci in blood in 792 507, 612, 794 orchitis in 69 perspiration in . . pyrexia in 506, 609, 611, rheumatic pains in limbs in . . . . 503, 617 rigors rare in 17 technically a septicaemia 23 Mamma, deficiency of deep 616 tenderness in, in locomotor 718 ataxy 58 Mammary abscess (see Abscess 249 ilammary; and Mastitis, 106 Acute) 718 - neuralgia (see Mastodvnia) 123 - swelling 742, 743", 744, 503 Manchester epidemic of arseni- 718 cal neuritis . . 77, 849 Mandible (see .Taw) I Mania, acute, inplumbism 849 1 38, 139, 173, 652 389 464 295 820 317 191 160 173 567 464 464 359 801 787 457 479 464 359 160 652 603 227 453 612 612 507 83 507 612 506 612 507 507 506 612 507 650 507 506 612 506 647 650 Mania, conld. - delirium in . . . . . . 195 - insomnia in.. .. 356,358 - pupils in . . . . . . 594 - temporary following epileptic convulsions . . . . 169 JIannerisms, motor tics as . . 160 Manson, re dhobie's itch . . 275 - re yaws and syphilis . . 450 Manufacturing districts, gas- tric ulcer in . . . . 298 MARASMUS 426 - in cyclical vomiting of infants 426, 843 - from defective feedin; - infantile, gangrene in - keratomalacia with - subnormal temperature in - tuberculous, tubercle bacilli in faeces in Marie, re spondylose rhizo- melique . . Marriage, when permissible in case of urethral discharge Marrow, hyperplasia of m leuksmia in pernicious anaemia . . Marsh cachexia Marsh's test 95 Mask facies of paralysis agitans 265 Massage in avoidance of contractures - effects on clironic rheu- matic pains - influence on cedema of legs in convalescence . . - in insomnia with high blood-pressure . . - of prostate . . - in rheumatoid arthritis . . Masseter muscle, paralysis of Mast-cells Mastication difhcult, in bulbar paralysis . 427 282 807 621 427 787 209 776 776 115 165 507 459 359 208 379 775 92 159 etiology of trigeminal - imperfect, dyspepsia - influence < neuralgia - muscles of, in bulbar palsy Mastitis, acute, due to cracked nipples fluctuation in breast in . . formation of abscess in. . during lactation in the new-born . . pain in the breast in . . during pregnancy at puberty purulent discharge from nipple in . . 20S pyrexia in shivering at onset of skin red and cedematous in 743 swelling in breast in . . 743 - - not uncommon in virgins 743 - chronic, characters of swell- ing in . . . . 743, 745 diagnosis from carcinoma 43, 745 354 495 687 743 743 743 743 743 743 743 743 743 743 743 fibro-adenoma. . enlargement of axillary glands in - - forming cyst 202, 743, frequent affection of opposite breast in from tuberculosis purulent discharge from nipple in vague pains and tender- ness in breast in - serous discharge from nipple in . . Mastodynia, association with pelvic disease 744 938 MA STOD YNIA—MED ULLA OBLONG A TA 479 479 547 327 263 229 254 58C 498 17 20 .. 376 .. 282 03, 42C, 668 .. 426 of Mastodynia, contd. - iu pregnancy or lactation . . - pain in the chest from 477 - redness, swelling, and ten- derness of breast in Mastoid abscess (see Abscess, Mastoid; - disease, cerebral abscess due to headache in - - spastic brachial mono- plegia due to . . - process, hrperplasia in acro- megaly tender in otitis media . . - swelling with thrombosed cavernous sinus . . Masturbation, priapism from Match manufacture, phos- phorus poisoning from Matches in urethra . . Match-heads, jihosphorus poisoning from taking . . Maxillary segmental area, pain in, in iritis and glaucoma Measles, albuminuria in - albumosuria in - arthritis in . . - cancrum oris in - coryza in - cough in - crescentic character eruption in - dehrium in . . - diasBosis from dengue erythema scarlatii orme . . German measles . . macular syphilides small-pox. . - diazo-reaction in . . - and diphtheria associated - empyema after - eosinophilia after . . - epistaxis at onset of - eruption macular in - gangrene in. . - German (see German Measles) - infantile convulsions in - Koplilrs spots in . . - laryngitis in . . .. 226. - leucocytosLs uncommon in - loss of smell sensation in . . - malignant, hfemoptysis in - menorrhagia in - nerve deafness after - cedema of face, neck, and arms from - pain in limbs at onset of . . - purpura in . . . . 596, - rigors in . . . . 647, - scaly eruption with - simulating a cold . . - sore throat in - swelling of eyes and face in - talipes from thrombosis following - Tooth's peroneal atrophy after . . . . 71, - tuberculosis following Meat-fibres in motions in chronic pancreatitis Meatus urinaria?, redness of small, frequent micturi- tion from Jlockel's diverticulum causing acute obstruction Median nerve, muscles supplied by paralysis of skin distribution of spinal roots derived from - paralysis, diagnosis of Volk- mann's contracture from 426 194 506 170 203 465 400 668 .318 428 190 461 505 597 650 655 203 670 459 131 560 427 1.35 207 438 151 550 552 659 550 Mediastinitis, acute,causes of episternal fullness in fiillness of intercostal spaces in mediastinal crepitation resembling pleural fric- tion in . . pain behind sternum in rarity of . . tenderness in back from over sternum in - chronic (see Mediastinum, Fibrosis of) Mediastinum, abscess in (see Mediastinitis, Acute) - aneurvsm in (see Aneurysm) - caseous glands in (see Lym- phatic Glands, Mediastinal) 484 483 483 786 483 826 826 776 242 484 484 185 128 422 484 826 826 343 773 484 123 - congenital fibroma of - dermoid cyst of, varicose thoracic veins from - disease of, tenderness in the chest from - fibrosis of, adherent peri- cardium associated with age incidence of . . anasarca in aneurysm and new growth simulating one another ascites in.. .. 61,63,484 cardiac troubles in . . 484 clubbed fingers in diagnosis from enlarged bronchial glands dyspnoea in fibrous, in rheumatism . . gummatous hiccough in irritation of vagus nerve by . . . . 772 lividity in obscure cases of . . obstruction to superior vena cava by . .461, 746, 826 oedema of face, neck, and arms from 296, 458, 461 pain in the chest in . . 478 behind stsmum in . . 484 palpitation from 526, 528 paralysis of vocal cord from 538 pleurisy and pericarditis preceding sense of tightness and dragging in the chest in shght degrees of chronic tachycardia from tuberculoas varicose thoracic veins from 484, 826 - gumma of, efiects of . . 458 obstruction to superior vena cava by . . . . 461 cedema of face, neck, and arms from . . 458, 461 - hydatid cyst of . . . . 826 varicose thoracic veins from. . - lymphatic gland, affections of (see Lymphatic (Jlands, ilediastinal) - new growth in, alteration of voice in anasmia in ascites in bronchial stenosis in . . cachexia in . . clubbed fingers from . . compression of lung by cough and expectoration in . . . . 176, 483 cyanosis in . . . . 296 diagnosis of . . . . 465 from aneurysm 296, 483 bronchial glans . . 422 343 484 63 772 826 826 483 483 61 324 483 128 667 Mediastinum, new growth in, could. disturbance of heart in 483 dyspnoea in enlarged right supra- clavicular gland in fibroid lung and bron- chiectasis from gangrene of lung in . . hsematemesis froni 294, 296 haemoptysis iu 176, 483 hiccough in . . . . 343 illustrative case . . 296 inequality of pulses from 593 irritating vagus nerve 483 421 324 288 773 582 777 777 343 465 121 483 465 96 48 S mistaken for astlima . . hysteria intercostal neuralgia obstructing bronchus . . great veins . . superior vena cava 461, 826 trachea . . . . 710 oedema of face, neck, and arms from 456, 458, 461 orthopncea from 465, 407 pain in the chest in 478, 483 side and down arm in 483 pleuritic effusion in . . 121 pressure on trachea and bronchi in . . . . 483 pyrexia in . . . . 483 sense of tightness of chest in . . . . 48' skodaic resonance due to 607 stridor from . . . . 710 symptoms, physical signs and effects of tachycardia from tightness in chest from tracheal obstruction by varicose thoracic veins from 296, 343, 465. 483, 773, 826 a;-rays in diagnosing 422, 465, 474, 483, 582 - rupture of aneurysm into. . 140 - sarcoma of, illustrative case - tumour of (iacluding aneur- ysm), general diagnosis of displacement of cardiac impulse in intercostal nerve pain in interscapular pain in . . local bulging of chest wall from mechanical explanation of orthopnoea in . . 465, 467 muscular atrophy in arm from . . . . . . 74 unilateral enlargement of chest from. . . . . 192 a;-rays in diagnosis of 422, 474 from asthma . . 582 - veins, obstruction in new growths of pleura . . 118 Medical examination for life assurance, transient poly- uria due to . . 581, 583 - men, digital chancre in . . 266 Medicines causins ptyalLsm . . 590 Mediterranean Malta fever in 506, 613 Medulla oblongata, bulbar paralysis due to lesion in 159 degeneration of, from alcoholism Cheyne-Stokes respira- tion from dissociative anaesthesia from . . hiccough from . . paralysis of vocal cords from . . 538, 539 30 193 641 124 666 343 MEDULLA OBLONGATA— MENINGITIS. SPINAL 939 Medulla ohluiii/alu, could. degeneration of, from plumbism . . . . 225 syphilis . . . . 224 liaMnorrhage into, diagnosis from bulbar palsy . . 687 dysartliria from . . 687 iiiUucnee on blood distri- bution 619 heat distribution . . 610 lesions causing ataxy . . 08 diabetes mellitus . . 585 polyuria . . 583, 585 softening in, diagnosis from bulbar palsy . . 687 from dysarthria . . 687 - - spastic paralysis of upper limb from . . . . 547 - - tumour of, asj'mmetrical muscular atrophy in . . GST diagnosis from bulbar palsy 687 dysarthria in . . . . 687 laryngeal paralysis due to .. .". .. 539 - - vomiting centre in . . 842 ilegaloblasts . . . . . . 28 ifegdlocytes (Plate II, Fig. B) 28 - in pernicious anosmia . . 76 ilegalospores in ringworm . . 273 Meige's disease . . 45C, 460 MEL./ENA (and see Blood per Anum) . . . . . . 428 Meiancholia, catalepsy with . . 651 - high blood-pressure in . . 96 - insomnia in.. .. .. 358 - irritability in . . . . 360 - perversion of appetite in . . 50 - speechlessness in . . . . 682 Melanogen . . . . . . 821 Melanotic carcinoma of genital organs or extremities . . 802 naicroscope in diagnosis of 802 - sarcoma of eye, enlargement of pre-auricular gland in 419 inguinal glands 423, 739 IVlelanuria .. .. 820, 821 - bromine water test for . . 821 - ferric chloride test for . . 821 - du3 to melanotic sarcoma 423, 821, 822 - simulated by alkaptonuria 822 indicanuria . . 821, 822 - sodium nitroprusside test for 821 - urine darker on standing . . 821 Melon-seed bodies in teno- synovitis . . . . . . 179 Membrana tympani, appear- ance of in otitis media . . 230 - - In'peraemic and swollen in otitis media . . . . 469 petechiiE on . . . . 468 lacerated in fractured base 467 perforated in otitis media 4G9 rupture from foreign body in meatus . . . . 468 head injuries without fracture . . . . 468 in otitis media . . 230 Membrane in faeces (see Foeces, Mucus in) Membranes, adherent, dystocia due to 227 - early rupture of, dystocia due to ... . . . . 227 Membranous colitis (see Colitis, Membranous) - dysmenorrhoea described 219, 220 - rhinitis (see Rhinitis, Mem- branous) - vasrinitis, Hakes from . . 211 MEMORY, LOSS OF (.Amnesia) 25 due to frontal cerebral tumour.. .. .. 798 Memory, loss of, could. for recent events in alco- holic peripheral neuritis 505 - detects in general paralysis 172 - illusions of, in chronic alco- holism 172 - for written words, centre for storage of . . . . 683 Meniere's disease, cause of 190, 828 coma in . . . . . . 828 deafness in . . . . 828 nausea in. . . . . . 828 pallor of the face in . . 828 recurrence of attacks in 828 sudden onset of vertigo in 828 syphilis of ear simulatins 828 tinnitus in . . 794, 828 vertigo due to . . 828, 847 - - vomiting from 828, 844, 847 Meningeal ha;morrhage (see Hasmorrhage, Meningeal) Meninges, not coloured in jaundice . . . . . . 361 - disease of the cervical, pain in the upper extremity in 491 - new growth of, compres- sion of cord by . . . . 561 pain in the back in . . 476 - spinal tumours causing hyperassthesia . . . . 667 paraplegia . . . . 561 - tumour of, headache in . . 327 Meningitis, albuminuria in . , 17 - bedsore in . . . . . . 286 - cerebral symptom of 558, 563 - Cheyne-Stokes respiration in 125 - choroidal tubercles in . . 341 - coma in . . . . 136, 642 - constipation in . . . . 149 - convulsions in 139, 169, 172, 173, 341, 558, 563, 642 - deafness from . . . . 191 - diagnosis of encephalitis from .. .. 139, 558 from fungating endo- carditis.. .. .. 614 otitis media . . . . 229 superior longitudinal sinus thrombosis from . . 558 - in fungating endocarditis.. 614 - giddiness in . . . . 642 - headache in 139, 326, 327, 328, 350, 359, 563, 622, 642, 847 worse at night . . . . 326 - hemiplegia in .. 340, 341- - hydrocephalus due to . . 557 - hyperpyrexia in . . . . 344 - increase in specific gravity of cerebrospinal fluid in 338 - incontinence of urine and fspces in . . . . . . 642 - infantile diplegia due to . . 556 - insomnia in . . . . . . 356 - irritability in . . .. 350,359 - Kernig's sign in . . . . 350 - leucocytosis in . . . . 401 - lumbar puncture in dia- gnosis of ...328, 464, 563, 643 - muscular twitchings in . . 642 - occipital headache in . . 327 - opisthotonos in . . . . 464 - optic neuritis in 139, 341, 464, 563, 642 - pain in the back in 475, 476 - paralyses in . . . . 642 - paraplegia from 556, 561, 563 - photophobia in . . . . 350 - polymorphonuclear cells in cerebro-spinal fluid in . . 643 - pulse-rate in . . . . 98 - purpura in diagnosis of cerebrospinal fever from otiier forms of . . . . 598 Meningilis, contd. - pyrexia in . . . . 558, - rarity of rigors in . . - retraction of tlie head in 328, 359, 641, 642, 699, - rigidity of face muscles from - sensory disorders in - simulat 190 798 798 798 684 659 190 498 266 582 4 836 838 831 831 831 831 714 601 451 532 530 394 528 403 942 MILK— MOUTH Hilk, caseons glands from Mitral stenosis, conXd. Mononuclear cells (see Lym- 343, 427, 773 embohe infarction of lung in 320 pihocytes) — caras, jnfaintile colic due i>o 136 after endocarditis 240 Monoplegia, abnormal gait in 278 — iiscsiiaise from nipple at enlarged right xentricle — brachial (see Paralysis of abncsnnal time . . 202 in 243 Extremity, Upper) — goaf sj as source ot infec- false bradxeardia in 97 — crural (see Paralysis of one taon in UTalta iexer 507 fibroid hmg and bronchi- Extremity, Lower; - iKTeiaxm in ike neir-bcKm. . 743 ectasis from . . 324 - inf antile 155 — - at pubeirr 743 general account of 245 - talipes in . . 131 — ■DLLbarenloMS from S43, 42 <, hEemoptxsis in . . 317, 320 Mons xeneris, herpes of 830 564, 691, 773, 848 heart failure in . . 464 Monsters, dystocia due to 227 - -caberraikjiQS peritoTittififrom 651 historx of acute rheu- Moore's test for glycosuria 290 — jellow, in jaimdioe 361 matism or chorea in 320 773 Mooren's ulcer, account of 807 13 TlVgr'c f^raTnp 177 induration of lungs in . . 245 age incidence of. . 807 1! jliT aseitffi . . 58 hxiditx in 764 radium in the relief of 807 — urlELe ("see Ghjlnria) malar fiush in . . •:26, 773 Morbus cEeruleus. causes of 579 Wilroy's lisease, cedema of leg mechanism of bruits due to 107 clubbed fingers in 128, 129 iii r^j.jf. 127,12<1rrr(y-Tna"k-ers. meremy ©oi- thiill due to . . 790 hohc gastritis 297 stjuTQCT 2n 38 pulmonary aUieroma in cirrhosis of hxer. . 410 Hitral area 789 245, 320, 323 Morphia, abdominal pain from 473 — - STSDolic broils oxer 101, 102 regurgitation from 107, 247 - albu-minuria from . . 16 — and aortdc disease oomiiaed 237 pulsation of lixer in 764 — amenoirhcea from . . 23 - disease, aeoentoaiion of rapid irregular heart in 61 - Cheyne-Stokes respiration heart sounds in . . => rarity before pubertx . . 62 from 125 — - oerebral embolism from 1S8 155 reduplicated pulmonarj - coma due to 137 — — diTriTTiisT^safl arij'iptnt*' m . .. 49 second sound in 639 - habit, symptoms worse when — - xenons congestion of lirer in407 second sound ia. . 108 drug is not being taken 527 — resurgitation.' in adherent shortness of breath in . . 578 — iTifa utile convulsions from 170 I'erieax'ixam . . 243 slapping, short jBrst — leucopenia from 401 — - from alcioholism. . 243 sound in . . 320, 526 - multiple prick marks from — - boae disease leading to . . 241 smaH, intermittent pulse in 245 habit of injecting 527 — - eai'diac impulse displaced tachycardia from 245, 772 - palpitation from . . 525, 527 otmrards in . . 332 thrombotic infaTCtion of - reducing body in urine due to 290 — - eanses and signs of lung in. . 320 - tremor from . . 795, 797 102, M3, 239 xariouB bruite of 107, 108, 109 Morphoea, baldness from 84 — — clubbed nngers in 128 lIoebius'B mxopathx, nbriilaiy — diagnosis from lines albicante 5 402 — - enlarged left xentricle in 232 contractions rare in 158 from leucodermia 575 - - from loag-eontinued orer- - sign in Graxes" disease 244, 253 — pigmentation of the skin in 424 exertion 244 Hole, epithelioma starting in 803 Morton's disease 488 — - s-sneral aocxrant of, 238. 239, — hxdatidiform, chorion-epi- Morvan's disease . . 112, 285 240, 241, 242, 243 thelioma following 434 muscular atrophy in 73 — - hsemoptrsis in . . 320 xaH'inal discharge from. . 211 painless whitlows in 285 - - heart f liilTrre in . . 464 — pigmented lumbar xrith superficial gangrene in . . 285 — - hjpienrojhj of the heart in 102 spina bifida occulta 557 syringomyeha and 563 — - impulse disjilaeed in 102 - sarcoma starting in 803 Mosquito bites, lumpy swell- — - onhopncfca in 464 — tubal, origin of 436 ings from 747 — — palpitation in 525 Mollities ossium, association and malaria 34 - — shortness of breath -vnxh 103 ■H-ith pregnancy • . 369 pruritus from 588 — - STstohc- t'roit of . . 102 description of" .. 269 xesicles from 834 - thriH due to . . 790 distinction from fragiiitas Motor aphasia (see Aphasia, Motor) — Stenosis 2 ossium . . 269 - ties, origin of 159 — - aJ.isenc* of bniii isftih 61, 526 geographical distribution 269 Mottling of lung apices in — enlarged left xentriele in 526 spontaneous fracture in 269 phthisis . . 120 - histarx of acute rheu- MoDuscum contagiosum, char- Moulds in sputum 705 matism Txith 61 acters of . . 805 Mountain air, shortness of — - aeoentnaied second sound distinction from myKoma 805 breath due to 101 in 330 microscope in diagnosis of 805 Mountaineering, ep^taxis from 251 — - age incidence of . . no simnlatinsr chancre 805 " Mousey " smell in f axus — — albuminuria in . . 18 teratosis f oBicularis . . 806 270, 271, 272 — - ascites in. . . . 61 764 xaricella 805 Mouth, affection by bullous - - blood-pressure in 18. 64, 96 — fibrosum of xulxa . . 771 eruptions 114 — - bronnhial st>enosis in . . 324 Mongolism desmbed 216 - affections of, causing dys- - - cardiac bmiis -srith 773 — d^tinguished from " myx- phagia (and see Stomatitis^ 225 - impulse displaced in . . 345 cedeme iroste " . . " . . 216 - athetotic moxements of . . 154 - '_- eereiTal embolism in .. 338 — double-iointedntss in 216 - bitter taste in, in actixe con- - - eharacteristac thrifl and — f aeiffi of 263 gestion of lixer . . 371 • bruit of 345 diagnosis from cretinoid 264 - bleeding nasxi of . . 325 — — ciobbed fingers in 128 — heart affection -with 21'j - breathing, adenoids and - - congestion of lixer in . . 370 - illustrated (Fig. 68) 217 tonsils from 672 - - diapram > Onychia, causes of . . . . 445 - and tuberculous changes in eyelid associated . . 4 15 Onychogryphosis, association with ichthyosis . . . . 445 Onychomycosis . . . . 445 - in favus . . . . . . 275 Onychorrhexis . . . . 445 Oozing after operations in jaundice . . . . . . 598 Operation, abdominal (see Laparotomy) - anal, coli bacilluria after . . 83 - anuria following . . 45, 4S> - in diagnosis of actinomyces 736 new growth of epididymis 767 of testis . . . . 766 torsio testis . . . . 521 - gangrene of lung after . . 288 - genital, coli bacilluria after 83 - hypothermia after . . 346 - importance of early, in pneumococcal arthritis . . 375 - infarct of lung after . . 322 - injury causing extroversion of bladder .. .. 587 - neurasthenia after. . . . 787 - cedema after . . . . 456 - pseudo-elephantiasis from 456 - pyaemia from . . 372, 649 - rectal, coli bacilluria after 83 - retention of urine after 49, 441 - surgical emphysema after 231 - tetany after . . . . 802 - on tonsils, cure of enuresis by 248 - urinary fistulse after . . 442 Ophthalmia, gonorrhoeal . . 376 - neonatorum . . . . 255 amblyopia from . . . . 836 corneal opacity from 836, 839 gonococcal arthritis from 376 nystagmus from 453, 836, 83i> perforation of cornea from 830 polar cataract from . . 836 total blindness from . . 83i> Ophthalmic nerve, herpes of 781 Ophthalmoplegia (and see Stra- bismus ; and Pupils) in bulbar paralysis . . . . 159 - in plumbism . . . . 38 OPHTHALMOSCOPIC AP- PEARANCES, notes on (Plates VI 1, VIll) .. 461 OPISTHOTONOS ..463 - in hysteria .. .. .. 162 - meningitis . . . . . . 642 - strychnine poisoning . . 652 - tetanus 162, 652, 802 Opium, headache from . . 328 - constipation relieved by . . 744 - poisoning, bilateral loss of movement in . . . . 345 Cheyne-Stokes respira- tion in. . . . . . 125 coma from 137, 344, 345 diazo-reaction in . . 198 hypothermia in . . 138, 344 pinpoint pupils in 138, 345 pontine haemorrhage simu- lating 345 Oppler-Boas bacillus in gastric contents in gastric car- cinoma 351, 353, 355, 845, 84G Opponens minimi digiti, nerve supply of . . . . . . 550 - poUicis, nerve supply of . . 550 Opsonic index in diagnosis of gonorrhoeal arthritis . . 376 tuberculous caecum . . 736 testis . . . . 519 ^ Optic atrophy from atoxyl . . 836 from cerebellar tumour 643 colour-blindness from . . 840 OPTIC A TROPH Y—OSTEO-A RTHRITIS 951 <')/)lic nlrapliii, could. total bliiKiuess from . . 839 in con'-reiiital cerebral diplegia .. ..800 dilatation of sphenoidal sinus . . . . . . 255 disseminated choroido- retinitis . . . . 838 sclerosis IVi, 5-17, 505, 838 Friedreich's ataxy 71, 560 glaucoma . . . . 838 - - hereditary . . 837, 838 with idiocy .•. .. 557 from lead. . . . . . 83G in Little's disease . . 154 peripheral constriction of field of vision in . . 838 primary, ophthalmoscopic appearance of (Plate Vlll) 4(i2 from quinine . . . . 836 - chiasma, lesion in causing total blindness . . . . 839 - - - hemianopsia . . . . 335 Optic disc, ophthalmological appearances of (Plates VII, VIII) .. . . 461 coloboma of . . . . 462 in disseminated sclerosis 800, 838 glaucomatous cupping of (Plate VIII, p. 463) 257, 838 hi tobacco amblyopia . . 836 - nerve, compression of, by dila- tation of nasal sinuses 840 lesions, sudden blindness from 839 new growths of, increasing hypermetropia with . . 255 - - - - unilateral exophthal- mos in . . . . 255 and tracts, connections of, illustrated (Fig. 101).. 334 - neuritis (Ptoe VIII, Fig. K, p. 463) 139, 598, 840 absence in migraine . . 582 in acute encephalitis . . 139 from atoxyl . . . . 836 cerebellar abscess . . 565 tumour.. .. 565, 643 cerebral htemorrhage . . 98 tumour (Plate VII, Fig. K, p. 461) 98, 173, 292, 341, 350, 547, 686, 782 with Oheyne-Stokes respir- ation . . . . . . 125 in cases of convulsions . . 172 - - diabetes . . . . . . 292 - - diagnosis of hypertrophic astigmatism from . . 463 in dilatation of sphenoidal sinus . . . . . . 255 - - fungating endocarditis 9, 10, 76, 314, 598, 613 from increased intracranial pressure . . . . 686 lateral sinus thrombosis 651 lesions of central nervous system . . 328, 585 meningitisl39, 341,464,563,642 otitis media . . . . 230 - - from plumbism . . 38, 139, 836 - - quinine . . . . . . 830 - - recent, ophthalmoscopic appearances of (Plate VII) 462 retinal oedema in . . 462 from retrobulbar neuritis 840 simulating albuminuric retmitis . . . . 462 in spinal meningitis . . 464 superior longitudinal sinus thrombosis . . . . 139 - - swelling of disc in . . 462 Ojitic neuritis, conld. in tuberculous meningitis 612, 699 uncommon in dissemin- ated sclerosis . . . . 565 - radiations, lesion in causing lu^iuianopsia . . . . 334 - thalamus, liyperpyrexia .. 344 lesion of, causing dissocia- tive anaistliesia .. 666 - - intention tremor. . . . 800 - tract lesions, hemianopsia from . . . . 334, 595 rarity of blindness from 839 pupil reflexes in 594, 595 Oral sepsis, anfcmia in . . 36 in etiology of dyspepsia 354 gastritis from . . . . 352 septicasmia from . . 650 Oranges, sore fingers from . . 266 Orators, pharyngitis in . . 673 Orbicularis palpebral, epiphora from paralysis of . . .. 250 hysterical spasm of . . 166 watchmaker's cramp of. . 177 weakness in myopathy.. 260 Orbit, cellulitis of, cavernous sinus thrombosis due to 253, 254 - disease of, headache in . . 327 - growth in, diplopia from . . 200 unilateral exophthalmos 254 - ivory exostosis of . . . . 754 - cedema of, from throm- bosis of cavernous sinus 651 - periostitis of, unilateral ex- ophthalmos due to . . 254 - suppuration in, meningitis from .. .. ..642 - tumour of, epiphora from. . 250 pulsatile, due to arterio- venous aneurysm . . 764 due to osteosarcoma. . 764 unilateral exophthalmos due to . . . . 254, 255 Orchitis, acute, association with epididymitis (and see Epi- didymitis ; and Epididymo- orchitis) . . . . . . 765 due to mumps . . . . 765 post-typhoidal . . . . 765 scrotal swelling due to . . 765 due to urethritis. . .. 765 - atrophy of testis after 79, 454, 519 - causes of . . . . . . 79 - chronic, diagnosis from syphilitic orchitis . . 520 history of injury in . . 520 tuberculous (see Testis, Tuberculous) - diagnosis from sarcoma . . 520 - due to gonococci . . . . 454 - liability of undescended testis to recurrent . . 523 - in Malta fever . . . . 507 - scrotal sores due to . . 679 - syphilitic, absence of pain on pressure in . . . . 520 thickening of cord in 519 aching in inguinal or lumbar region in . . 519 atrophy of testicle after 519 congenital . . . . 519 diagnosis from chronic orchitis . . . . 520 neoplasm . . . . 520 diffuse interstitial . . 519 enlargement of testis in 519, 520 gummatous . . . . 680 epididymis unaffected in 519 nodules on testis in . . 519 hydrocele with . . . . 519 prostate and vesiculae seminalcs unaffected in 520 Orchitis, syjthililic, rmitd. sense of weight in the scrotum in . . . . 519 tendency to involvement of botii testes in . . 520 Orcin in Bial's test . . . . 290 Organ of Corti, nerve deafness from changes in . . . . 190 Orientation, jihysiology of 199, 200 ORTHOPNtEA .- 464 - acute, fruiii jiulmonary em- bolism . . . • • . . 320 - in chronic nephritis . . 14 - dyspnoea with . . . . 220 - in heart disease . . 358, 704 and lung diseases 186, 359 - laryngeal or tracheal obstruc- tion, diagnosis of . . 465 - mechanics of . . . . 359 - in mitral stenosis . . . . 764 - with pleuritic elTusion 121, 122 - in severe bronchitis and emphysema . . . . 186 - from thyroid gland tumour 792 Orthostatic albuminuria . . 19 Orthotonus in tetanus . . 162 Osazone crystals in Cam- midge's test . . . . 115 in m-ine testing . . . . 290 varieties 291 Osmic acid test for chyluria. . 126 Ossicles, caries of . . . . 470 Ossification, excessive foetal, dystocia due to . . . . 227 - premature in infantilism . . 214 in progeria . . . . 214 •• of tendon simulating exos- tosis . . . . 754, 763 Osteitis, chronic, of head and neck of femur after ty- phoid fever . . . . 376 of lower end of femur, diagnosis from endosteal sarcoma . . . . 763 - deformans (i^i!7«.47, 48, p.l82) 753 bending of bones in 183, 753 death from multiple sar- comata of bones in . . 753 diagnosis from syphilitic osteitis. . . . . . 753 dyspnoea in . . . . 758 - - illustrated . . . . 182 increased size of head in 183 kyphosis in . . ..183 lengthening of bones in 753 neuralgic pains in . . 753 senile nature of . . . . 753 thickening of bones in . . 753 - syphilitic 782 diagnosis from osteitis de- formans . . . . 753 - tuberculous, secondary ar- tliritis from . . . . 378 Osteo-arthritis . . . . 39 - afebrile course of . . . . 384 - affection of spine in . . 384 - of ankle 384 - bony outgrowths in 383, 384 - confusion with syphilitic pains 386 - crepitus in . . . . . . 179 - destruction of cartilage in 384 - diagnosis from other forms of arthritis . . . . 385 - - gout 383 rheumatoid artliritis 379, 384 sciatica . . . . . . 384 - dwarfism from . . . . 214 - eburnation of bone in . . 384 - of elbow 384 - enlargement of joint in . . 384 - erosion of cartilage in . . 384 - fixation of joint in . . . . 384 - flail joint from . . . . 384 952 OSTEO-ARTHRITIS—0 VARY Osleo-arthritis, contd. Osteomyelitis, contd. Otitis media, contd. - crrating of joint in . . 384 - acute 750 thrombosis of cranial - Heberden's nodes in 384 arthritis from (see Ar sinus from 650 - liip frequently afiected in. . 384 thritis. Acute Secondary) lateral sinus or jugular - Of knee 384 diagnosis from erythema vein in 123 localized tenderness in . . 384 nodosum 751 tinnitus in 470 pain in . . 384 necrosis of bone in 751 tuberculous, ab.sence of semimembranosus bursa - chronic, diagnosis from en pain and pyrexia in . . 469 frequently distended in 762 dosteal sarcoma . . 757 deafness and tinnitus in 469 sensation, on palpation, long duration of . . 751 perforation of tympanic of wet sand in a bag . . 384 - - swelling on a bone from 751 membrane anteriorly in 469 stiiEness in 384 - gummatous 752 rapid bone destruction in 469 - and kyphosis . . 183 214 - suppurative, anaemia in . 39 unilateral headache in . . 326 - locking of joint in . . 384 Osteopsathyrosis, dwarfism vertigo due to . . 470 828 - loose body in joint in 389 from " 213 vomiting from . . 229, 844 - monarticular type . . 384 Osteosarcoma, crepitus in . 179 Otorrhagia 468 - muscular atrophy slight in 384 - egg-shell crackling in 17 7, 764 OTORRHEA 467 - nipping of synovial fringes in 389 - of orbit, pulsatile . . 764 - in caries of ext. auditory - outgrowths of, simulated by - pulsation in . . 177, 17 0, 764 meatus 469 . , dorsal " pads " on fingers Os uteri stenosed, a cause of - cerebellar abscess . . 565 (Figs. 114, 115) . . 385 dysmenorrhcea . . 219 - from condylomata of meatus 469 - preference for large joints. . 384 pin-hole . . 219 - diphtheria . . . . 469 602 - primary afEection of carti- Otalgia (see Earache) - examination of ear in 470 lage and bones in 384 Otitis, acute hemorrhagic - from suppurating sebaceous - similarity to arthritis in with hemophilia 468 cyst of meatus . . 469 syringomyelia 388 influenza 468 - tenderness of ear in 469 tabetic artliritis 388 pain in. . 468 Otosclerosis, deafness in 829 - in small joints 384 petechia on tympanic - fixation of stapes in 190 - spondyhtis deformans with 787 membrane in 468 - middle-ear deafness in 190 - subcutaneous nodules in . . 375 - media, acute, paroxysma - tinnitus clue to . . 793 829 - swelling of bones in 754 pain with pyrexia preced - vertigo due to 829 in femoral region from . . 734 ing discharge in. . 469 Otoscopy in cases of otorrhoea 470 - temporo-mandibular 230 ,384 adenoids causing . . 2.30 Ova of ankylostomura duo- - - simulating trismus 801 and albuminuria 13 denale in faeces . . 94 - thickening of synovial mem- broncho-pneumonia in 321, 578 - bilharzia, illustration 93 brane in . . 384 bubbling noises in ear in urine . . 313 - ulnar deviation in (Fig. due to . . 793 - distoma hepaticum 364 108) 380, 385 cerebellar abscess from . . 644 pulmonale in sputum . . 325 - of WTist 384 cerebral abscess from - intestinal parasites, examin- Osteo-arthropathy, bony swell- 98, 173, 341 ation of fpecps for (Fiijs. ing in 754 cervical glands enlarged 420 152, 154, p. 569^ 94, 569, 570 - enlarged fingers in . . 128 characters of discharge in 469 - paragonimus "Westermani in - hypertrophic pulmonary .. 390 chronic, characters of sputum 705 apparent enlargement of discharge in . . 468, 469 Ovarian abscess 621 joints in 390 complications of . . 98 Ovaritis, undue abdominal in bronchiectasis 390 convulsions from 229 aortic pulsation suggesting 592 chronic empyema 390 - - deafness hi . . 190, 470 - diagnosis from recurrent clubbing of fingers with 390 delirium in 229 appendicitis 729, 737 - - - confusion with acromegaly 391 diagnosis of cerebrospinal - dysmenorrhaja due to 737 enlarged bones in (Fig. fluid from a serous dis- - ovaries enlarged and irregu- 118; 390 charge from . . 468 lar from . . 220 fingers in 128 meningitis from 229 Ovary, absence of activity of 707 erosion of cartilage m 390 eczema of ext. auditory sterility due to . . 706 in fibrosis of lung 390 meatus in 468 - atrophy of . . 24 greater frequency in empyema from . . 123 - carcinoma of fsee Carcinoma) upper extremity . . 390 in enteric fever . . 648 - cyst of, albummuria from 17 with subclavian aneurysm391 external ear swollen and ascites in 58 thickening of synovial inflamed in 469 dipping in through fluid membrane in 390 gangrene of lung from . . 287 in diagnosis of 759 Osteochondritis, syphilitic . . 386 headache in .... 327 bearing-down pain from 473 Osteoscopic pains, pains worst hyperagsthesia acustica in 190 cha.racliers of fluid from 52 on getting warm in bed 503 lateral sinus thrombosis diagnosis from ascites in secondary syphilis . . 503 from . . . . 186, 578 52, 717, 759 761 Osteogenesis imperfecta, brit- membrane hyperaimic and distended bladder 730 tle bones in 213 swollen in 469 fibromyoma of uterus 429 dwarfism due to (Fig. 65) 212 meningitis from 642 liydati'd cyst . . 761 leading to osteomalacia 213 optic neuritis in . . 230 kidney tumour 393 softening of bones in 213, 214 pain in the ear in 22 1, 470 pancreatic cyst 758 Osteoma (Fig. 194) . . 754 paralysis of chorda tym- phantom tumour 433 - exophthalmos due to 255 pani from 775 renal tumour . . 392 - of jaw 748 perforation of tympanic retroperitoneal lipoma 761 - pelvic, dystocia due to . . 227 membrane in . . 469 from unruptured ectopic Osteomalacia described 213 pneumococcal 375 gestation 760 - dwarfism in . . 212, 213 polypi in ear from 468 urachal cyst . . 730 761 - eosinophilia in 248 pulmonary embolism from dysmenorrhcea with 219 - following osteogenesis imper- 123, 186, 578 felt per rectum . . 638 fecta 213 pyrexia in 229 frequent micturition from 438 - kyphosis or scoliosis from 214 referred pain in vertical gas in 711 - muscular weakness in 213 and temporal areas in 498 impacted, frequent mic- Osteomyelitis, albumosuria in 20 in scarlet fever . . 674 turition with . . 438 - eosinophiUa in 248 septicajmia from 614 jaundice in 367 - fungating endocarditis from 314 suppurative.. .. 230,498 ieucocytosis with suppur- - of ilium 737 tenderness over mastoid in 229 ating . . 400 - rigors m . . . . 648 649 of scalp in 781 , 783 median position of 392 OVARY— PAIN 953 Ocary, cijsl of, mntd. Ovary., luinour of, conld. Oxaluria, conld. nephritis from . . 8 absence of distmctivo - frequent micturition from 438 - - obstructing labour 228 blood changes in 691 - hoBmaturia in . . 3U4, 311 inferior vena c;.va 825 menstrual disturbance in 429 - lumbar aching in . . 311 obvious pelvic origin of 392 movement with respira- - nocturnal enuresis and 248, 471 - - palpitation from 526, 528 tion . . 691 - normal amounts of 471 pelvic swelling due to . . 757 ascites witli 367, 393, 759 - from oxalic acid poisoning 297 physical signs of . .52, 717, 759 breaking down, anaemia in 39 - pain in the testicle in 524 pneumaturia caused by 57G diagnosis from jiregnant - in paijcroatitis 116 ruptured . . 730 uterus . . 758 - priapism from 585 - - - spasmodic pelvic pain renal tumour . . 391 Oxybutyric acid in urme 4, 292 from . . 509 splenic tumour 691 Oxygen, effect on convulsions 172 simulating sciatica 74 tuberculous peritonitis 691 Oxyhaemoglobin 12 solid feel in very tense 758 uterine fibroid 758, 759 - reduction by ammonium succussion splash in 711 difficulty of diagnosis of 759 sulphide . . 314 - - swelling in iliac fossa direction of growth 393 - spectral absorption band of 95 due to . . 737 double, amenorrhoea with - in urine in hiemoglobinuria 314 — twisted, ascites with . . 759 24, 429, 691, 759 Oxyphile corpuscles . . 28 constipation with 153 dyschezia from . . 1.50 Oxyuris vermicularis . . 569 deep-seated pelvic pain dystocia due to . . 227 bleeding and mucus due to 93 in 508 fixation of growtli in . . 759 no blood cliangcs with . . 33 diaijnosis from appen- uterus with tenaculum description of 94 dicitis with pregnancy 7G1 in examination tor eosinophilia with 249 dysmenorrl) oea 220 pedicle of . . 758 grinding of teeth 293 pain in right side of impaction of, sacralgia in 509 priapism from . . 585 abdomen in 500 jaundice in . . 362, 367 Ozaena . . . . . . 99, 204 simulating renal colic 392 length of uterme cavity Ozonic ether test for pus 623 spasmodic pelvic pain usually unaltered in . . 429 from . . 509 menstruation undisturbed PACHYMENINGITIS, head- tumoiur from . . 153 by .. .. 758, 759 ache in . . 327 vaginal examination in microscope for exact - cervical 493 diagnosis of . . 500 diagnosis 759 claw-hand in .. 127 128 varicose abdominal veins often inseparable from radicular pain in arm in 493 from 825 uterus . . 759 simulating bracliial neu- - dermoid cyst of, diagnosis pedicle of . . 75S, 759 ritis 492 from ectopic gestation.. 760 pelvic swelling due to 757 758 - chronic hypertrophic ha;- - disease of, anaemia in 36 physical signs of . . 691 morrhagic, alcoholism and causing araenorrhoea 23 , 24 rapid emaciation in 759 .S3Tphilis causmg . . 563 eosinophilia in . . 24S secondary portal glands in 367 diagnosis of spinal - - pain in the back in 476 simulating movable kidney 727 caries from 563 - - referred pain in area sterility due to . . 706 paraplegia from 563 of tenth dorsal nerve in 509 uterus drawn up by 691 - paralysis of upper extremity vomiting with . . 844 vaffinal examination in from 555 - ex'cision of, obesity after . . 454 diagnosing 691 Pacific Islands, filariasis in . . 33 - fibroma of, ascites with . . 759 Over-eating, active congestion Pads, association with Dupuy- - growths of, amenorrhoea with 24 of liver fi-om 371 tren's contraction 385 - hj-pera;sthesic patches over. - obesity from 453 - confusion with osteo-arthritic in hysteria 667 Over-exertion, acute dilatation out-growths 385 - imperfectly developed in of heart due to . . 243 fibrous nature of . . 385 infantilism 218 - causing mitral regmrgita- - on dorsal aspect of fingers - inflamed (see Ovaritis) tion .. .. 239, 243 (Fi(is. 114, 115) . . 385 - in inguinal canal, diagnosis - cramp from . . 177 - supraclavicular, in cretinism 259 from fibromyoma of - enlarged heart from 232, 243 Paget's disease, age and sex round ligament . . 741 - tenderness of spine from . . 785 incidence of 802 - insufficient activity of, Overgrowth of tibia after crusts in . . 803 amenorrhoea from 707 injury 132 description of 802 anremia from . . 23 Over-work, brachial neuralgia distinction from eczema 803 ^ nervous symptoms in 454 from 491 duration of 802 obesity in 453, 454, 707 - cramps from 177 intractability of . . 803 - pain in, diagnosis from - dyspepsia from 354 retraction of the nipple in 803 ureteral calculus . . 627 - insomnia from 357 Pain, absence of, in progressive - prolapsed, pelvic pain, from 508 - loss of weight due to 848 muscular atrophy 545 dyspareunia from 221 - malarial relapse due to . . 36 - acute in furunculosis of ear 469 - region of, hypersensitive in - neurasthenia from . . 506 general, in limbs in inflam- hysteria . . 509 - night terrors from . . 447 mation of lung 503 pain in, in carcinoma of - pain in back from . . 476 in hysterical joint 83 cervix . . 510 - spasmodic contraction from 159 - anaesthetic skin 475 - referred pain m, in extra- Oxalate of calcium in urine, - caused by pressure of aortic pelvic disease. . 509 ("see Oxaluria) aneurysm on oesophagus 482 in hysteria 509 Oxalic acid poison mg, coma - described as colic by patients 133 limits of 509 due to . . . . 137, 346 - as epileptic aura, in brain in pelvic disease 509 hypothermia from . . 346 lesions 81 - sclerosis of, pelvic pain from 508 oxaluria from. . 297 - at external abdominal ring. - secretion of, effect on men- OXALURIA 470 in epididymo-orchitis . . 518 struation . . 430 - catarrli of urinary passages from ureter calculus 514 - shifting dullness in flanis from 444 - generalized, in acute polio- with malignant tumours of 393 - diagnosis from renal calculus 311 myelitis . . . . 555 559 - small cystic, dysmenorrhcEa - " dumb-bell " crystals in - importance of presence or in . . 219 urine in (Fig. 130) 470 absence of tenderness - and thyroid gland, inter- - dyspepsia in 311 with 475 relationship 454 - after eating rhubarb, goose- - from inflammation 478 - tumour of ("and see Carci- berries, or tomatoes 311 - inliibitory, in joints, mis- noma of Ovarv ; and - " envelope " crvstals in lu-ine taken for paralysis 545 Ovary, Cyst of) " m (Fig. 130)" 470 - insomnia from 356 954 PAIN, LIGHTNING— PAIN IN EXTREMITIES Fain, contd. - lightning, of tabes . . 350, 562 - loss of weight due to . . 848 - over lower part of sternum, heartburn causing . . 48i - on moving neck and head, in spinal meningitis . . 162 - in muscles and joints mis- taken for paralysis . . 545 - niggling, in legs, in tabes dorsalis . . . . . . 489 trichinosis . . 504, 801 - in paralyzed muscles in mul- tiple neuritis . . . . 551 - perinephric abscess . . 392 - peripheral neuritis 66, 559, 661 - popliteal abscess . . . . 762 - preceding the eruption in herpetic trigeminal neu- ralgia . . . . . . 496 - pricking, in glans penis in tubsrculous cystitis . . 628 - in plumbism . . . . 136 - pyelonephritis . . . . 394 - relief by salicylates in acute rheumatism . . . . 375 - severe, associated with anfes- thesia . . . . . . 475 in lower spine, in gumma of Cauda equina . . 563 - significance of absence or presence of, in trans- verse myelitis . . . . 564 - from spasm of levator ani 221 - subnormal temperature in conditions associated with 621 - supra-orbital, from eyestrain 495 - and swelling of external auditory meatus in furun- culosis . . . . . . 469 - in syphilis . . . . . . 386 in syphilitic pseudo- paralysis ... .. 387 - universal in cerebrospinal meninsitis . . . . 643 PAIN, ABDOMINAL.. .. 472 in acute gastritis . . 845 from aneurysm . . 299, 368 in appendicitis . . . . 133 biliary colic Cand see Colic) 846 from corrosive poisoning 297 - - diaphragmatic pleurisy.. 645 - - in duodenal ulcer . . 300 extra-uterine gestation 436, 500, 646 general in gastric crises . . 473 Henoch's purpura 380, 381, 600, 846 - - influenza . . . . . . 505 intense from perforative peritonitis 644, 721 intestinal neuralgia . . 134 obstruction 133,153,350,846 in lead neuritis . . . . 77 mesenteric embolism or thrombosis . . . . 90 pancreatic hsemorrhage . . 292 pancreatitis 90, 292, 646, 846 due to perforation in typhoid . . . . 622 peritonitis . . 472, 718 pneumonia . . 133, 645 Pott's disease . . . . 134 relapsing fever . . 373 (right side) in hepatoptosLs 407 salpingitis . . . . 500 twisting of pedicle of ovarian cyst . . 500 - - in ruptured tubal gesta- tion .. .. 500, 640 presnancy . . . . 760 spasmodic, from intus- sus<:;cption . . . . 727 from spondylitis deformans 787 90 92 592 627 442 488 421 Pain, abdominod, contd. in subdiaphragmatic pleu- risy 133 thoracic diseases . . 133 from torsion of retained testis . . . . . . 742 tuberculous peritonitis 56, 719 ulceration of the intes- tine . . from ulcerative colitis . . undue aortic pulsation . . due to lureteral calculus - in anal region after micturi- tion in vesical carcinoma - ankle and foot in anterior crural neuralgia - In ankle (see Joints, Affec- tions of) - in aortic aneurysm, mode of production - arm (see Pain in Extremity, Upper) - axilla from enlarged axillary glands right, from hepatic abscess 651 PAIN IN BACK (and see Back- ache) . . . . . . 474 from abdominal aneurvsm 222, 296, 299, 322, 728, 789 aortitis . . . . . . 789 arteriosclerosis . . . . 789 in biliary colic . . . . 500 carcinoma of rectum . . 636 from cholangitis.. .. 789 clironic pancreatitis .. 135 colitis 789 with compression paraplegia 78C from constipation . . 789 coronary artery sclerosis 789 disease of the rectum (Fig. 204, p. 788) ..150,636,788 uterus (Fig. 204) 788, 789 examination of chest and abdomen in . . . . 47G from gall-stones. . 500, 789 gastric ulcer . . 298, 789 carcinoma . . . . 789 gastritis . . . . . . 789 heart disease (Fig. 204) 788, 789 in hysteria . . . . 788 inflammation of uterus . . 789 invagination of rectum.. 150 during labour . . . . 789 from hver disease (/"ifir. 204) 788 malignant disease of the vertebrae . . . . 786 menstruation . . . . 789 myocardial fibrosis . . 789 in neurasthenia .^ .. 494 new growth of liver . . 789 nutmeg liver . . . . 789 from pleural adhesions.. 789 new growth . . . . 789 pleurisy . . . . . . 789 in relapsing fever . . 698 from renal calculus . . 500 sex incidence of.. .. 789 from spinal caries . . 785 stomach disease (Fig. 204) 788 with stone in pancreas 135 tricuspid regurgitation.. 789 with typhoid spine . . 787 PAIN, BEARING-DOWN .. 473 - in bladder due to bacilluria 616 stone 818 tuberculous cystitis . . 629 vesical carcinoma 438, 630 - In bone an early symptom in endosteal sarcoma . . 756 in scurvy-rickets . . 753 - in breast in mastitis . . 743 mastodynia . . . . 479 multiple cystic disease . . 744 - cardiac (see Heart) PAIN IN CHEST ..477 aneurysm . . 322, 848- from angina pectoris . . 7 78 anginal, during formation of dissecting aneurysm 482 from biliary colic . . 846 and at bottom of sternum in diseases of oesophagus 484 from disease of wall . . 477 dyspepsia . . . . 779 flatulence.. .. .. 779 gall-stones . . 363, 846 gastric ulcer . . . . 779' hepatic abscess . . . . 779 intercostal myositis . . 776- pleurisy (see Pleurisy) pneumothorax (see Pneumo- thorax) pulmonary embolism 185, 320 splenic infarction spondylitis deformans . . subphrenic abscess superficial inflammation - in chondromata - with cystic kidney disease - delirium due to severe - dull boring, in tabes dorsalis - in dysmenorrhoea, its varie- ties described spasmodic - in ear (and see Ear, AfEec- tions of) from acute otitis media (behind) in mastoid abscess glaucoma lateral sinus thrombosis with middle-ear deafness in otitis media . . 229, - elbow (see Joints, Afllections of ; Arthritis ; and Osteo- arthritis) PAIN, EPIGASTRIC from undue abdominal aortic pulsation in arsenical poisoning carcinoma of stomach catarrlial jaundice corrosive poisons from duodenal ulcer gall-bladder disease gall-stone obstruction 280, - - gastric crises in tabes dolorosa disorders ulcer . . 40, 295, gastritis . . hypersthenic dyspepsia . . irritant poisons . . from liver disease with obstruction to small intestine pancreatic colic . . diseases pancreatitis 135, 280, 431 from pericarditis phosphorus poisoning . . tabes dorsalis in variola - in ervthromelalgia PAIN " IN EXTREMITY, LOWER from arterial throm- bosis in bladder affections . . carcinoma of cervix . . of the spbie . . diabetes . . . . 75 embolism . . . . 286 hip disease . . . . 357 early, insomnia from 357 popliteal aneurysm . . 762 - - spinal caries . . . . 785 - - spondylitis deformans 787 321 699 787 720- 478 755 310- 195 664 219. 509 409 230 257 651 190 470 484 .. 592 92, 297 299, 691 . . 365 . . 845 .. 295 .. 779 363 485 779 298 298 354 845 153 135 486 724 777 373 847 301 284 486 286 491 rao 543 PAIN IN EXTREMITIES— PAIN, PELVIC 955 PAIN IN EXTREMITY, UPPER anassfchesia witli - - - from aneurysm 222, in angina pectoris 350, aortic incompetence . . atrupliic palsy with . . in axillary abscess from cardiac or aortic disease cervical caries . . rib . . 128, 554, pachymeningitis 128, deformity of cervical spine in - - - in inflammation of spinal nerve near posterior root fjanglion - - - loss of tendon jerks in arm with lumbar puncture in dia- gnosis of cause of . . in malignant disease of cervical spine from neuritis . . oculo-pupillary pheno- mena with . . radicular, in interven- tricular tumour shooting down in medi- astinal growth multiple cystic disease of breast spastic paraplegia with in syringomyelia tenderness of cervical spine in a:-ray examination cervical spine in PAIN IN THE EYE .. from conjunctivitis - - corneal ulceration cyclitis from eyestrain . . in glaucoma from inflamed sinus in influenza from iritis relief under the atropine - - retrobulbar neuritis PAIN IN THE FACE.. in antral empyema - after food in gastric ulcer 89, - flitting from joint to joint in acute rheumatic arthritis - in foot as aura in Jacksonian epilepsy . . in metatarsal neuralgia from suppurating corn . . - forehead from iritis and cyclitis - over gall-bladder from gall- stones . . . . 280, - in general congestion of liver - girdle (see Girdle Pain) - in great toe in anterior crural neuralgia . . in gout . . - groin from renal calculus 308, colic - hands in acropariesthesia . . - in head (see Headache) - round the heart in stomach disorders . . - in heels in calcanodynia . . - hips from spondylitis defor- mans (and see .Joints, Affections of ; Arthritis ; and Osteo-arthritis) - " hunger " ('see Hunger Pain) PAIN IN HYPOCHONDRIUM, LEFT from gastric disorders of 495, frontal 205, 255, 256, use of 494 494 494 493 545 494 493 483 447 494 554 300 407 381 846 500 493 484 488 787 500 PAIN IN HYPOCHONDRIUM, RIGHT 499 abscess of liver . . 309 in active congestion of liver 371 acute yellow atrophy. . 370 from biliary colic .. 135 distoma hepaticum . . 364 dragging in carcinoma of liver . . . . 412 general congestion of liver . . . . 407 hepatoptosis . . 407 gall-bladder disease . . 779 gall-stone . . 135, 363 from hepatic abscess 369,651 liver disease . . . . 779 in movable kidney . . 500 phosphorus poisoning 373 - in hypogastrium in bacteri- uria . . . . 84, 616 - - from cystitis 312, 627, 631 with obstruction in colon 153 from prostatitis . . . . 631 retention of urine . . 45 urachal cyst . . . . 730 PAIN IN ILIAC F0SS;E .. 501 from faecal obstruction 501 right, from appendicitis 135, 313, 729, 736, 737,780 appendicular colic in 134 carcinoma of caecum 729 some causes of . . 134 recurrent at men- strual periods, due to appendicitis . . 737 to tenderness of ovary . . 737 spastic constipation 145 - in inguinal glands 675, 676 region in acute epididymo- orchitis . . . . 517 in carcinoma of cervix 510 due to retained testis 740 - intercostal, from aneurysm 222 herpes zoster . . . . 777 in mediastinal tumour . . 478 from pressure on inter- costal nerve . . . . 479 spinal abscess . . . . 479 caries . . . . . . 478 growth 479 injuries . . . . 479 PAIN, INTERSCAPULAR .. 474 from gallstones . . . . 474 in gastritis . . . . 484 from spinal caries . . 474 PAIN IN JAW .. 501 - in joints (and see Artliritis ; and Osteo-arthritis^ in acute rheumatism . . 671 in association with anti- toxic serum rashes . . 597 erythema nodosum . . 450 hfemophilic arthritis . . 388 Henoch's purpiu-a 380, 600 - - hysteria 389 intermittent hydrartlirosis 387 nodular leprosy . . . . 450 peliosis rheumatica . . 599 in pneumococcal arthritis 375 sudden, in displacement of semilunar cartilage 388 syphilitic synovitis . . 386 in tuberculous disease . . 385 - in kidney, pricking, with calculus . . . . . . 306 - knee in hip-joint disease . . 278 in osteo-arthritis . . 384 (and see Joints, Affec- tions of) - labium majus from renal calculus . . . . . . 135 PAIN IN LIMBS, GENERAL '>0l> as a rule worse on movement . . . . 50.^1 in alcoholic neuritis . . 78 dengue . . . . . . 506 Landry's paralysis . . 567 in neuromyositis . . 504 paralysis agitans. . . . 796 peripheral neuritis . . 66 tabes dolorosa . . . . 507 yellow fever . . . . 372 - in liver, with cholangitis . . 650 cholycystitis . . . . 650 from pyle[jhlebitis . . 640 secondary carcinoma . . 412 venous congestion . . 407 - in loin (and see Backache ; and Pain in the Back;, aching, from movable kidney . . . . . . .31l> in anuria . . . . . . 45 and back in phosphatic diabetes . . . ■ 57? in bacteriuria . . 84, OIG with calculus in pancreatic duct . . . . . . 13.5- chronic pancreatitis . . 13.> due to colitis . . . . 727 in epididymo-orchitis . . 518 from fscal accumulations 393- in influenza . . . . 610 malignant growth of colon 393- of kidney . . . . 39-> perinephric abscess . . 500 polycystic disease of kidneys . . . . 39(> from prostatitis . . . . 491 referred from opposite side 394 from renal calculus 46,308,846- colic . . . . . . 516- infarction . . . . 314 lesions . . . . . . 306. tuberculosis . . . . 309' stone in pancreas . . 135 thickening round appendix 39.^ ureteric calculus . . . . 13» - lumbo-sacral region, attacla of, in pyosalpinx . . 632 - malar region from iritis and cyclitis . . . . 256 - on micturition (see Micturi- tion, Painfril) - in mid-orbital region in astigmatism . . . . 49S - mouth from corrosive poison- ing 297 - nail in onychia . . . . 445 - naso-labial area in caries of canine tooth (Fig. 132) 497 - in neck, (and see Sore Throat; and Stiff Xeck) . . . . 70S in aortic aneurysm . . 482 cervical cari&s . . 673, 70S from fracture of cervical spine . . . . . . 70!> in liyoid area in tongue affections . . . . 498 in ear disease . . 4'.iS from mumps . . . . C74 referred, segmental areas of 4!)S in syringomyeha . . •'iol - neuralgic, in osteitis defor- mans . . . . . . 755 disseminated sclerosis . . 665 - nose from iritis and cyclitis 2^6 - " ovarian region " due to hj-steria . . . . . . 509- PAIN, PELVIC .. 50S from appendicitis . . 032 cryptomenorrhoea . . 22 in ectopic gestation . . 760 with salpingo-oophoritis 220, 760 956 PAIN, PENILE— PALMS PAIN. PENILE 510 Pain in shoulder, contd. Palate, contd. from alieotion. of trigonal right, from biliary colic 135 500 - paralysis of.. .. 224, 775 regioa of bladder 441 carcinoma of liver 412 from bulbar or pseudo- ill carcinoma of bladder from gall-bladder disease 779 bulbar paralysis 640 311, 441, 512 630 gall-stones ..135,363 778 causes of . . 640 cystitis . . . . 441 512 hepatic abscess 309, 409 651 m diphtheria 77, 181, on erection in ohordee . . 516 liver disease . . 779 640, 687 842 with prostatitis 515 - in side (left) hi injury of ascribed to influenza . . 640 with hacmaturia, in vesi- spleen 700 course of 640 cal disease 306 mediastinal growth 483 Klebs-Loffler bacilli in . . 640 from herpes 515 in pneumonia 372 nasal quality of voice in 040 ,687 impaction of calculus pyonephrosis 624 regurgitation of food 210, 311 441 - in soles of feet in gout 382 through the nose in . . 640 after micturition, causes of 513 gonorrhoeal arthritis . . 376 after removal of tonsils during micturition 512, 515 - spastic constipation 144 or adenoids 640 from penile hajmatoma . . 51G - spinal region (see Pain in Back) syphilitic 040 prostatitis 441 - spleen in fungating endo- - pemphigus, etc., of 114 renal tuberculosis 629 carditis . . 237 - perforation of, diagnosis of scalding . . 207 - sternal region (see Pain in cause of . . 640 from tuberculous bladder Chest) malignant 640 441 628- - behmd sternum m growth mercury and iodide in ureteral calculus impacted in anterior mediastinum 483 diagnosing cause of . . 640 near bladder . . 627 - sudden intense, in tabes microscopic examination vesical calculus 312, 441, dolorosa . . 507 of edge of ulcer in 628 629 - in teeth from glaucoma . . 257 diagnosiag cause of . . 040 PAIN IN PERINEUM, causes 516 - temporal region from disease regurgitation of food ill acute cystitis . . 627 of upper bicuspids 783 through nose from 040 bacteriuria 84 heart disease . . 783 syphilitic 237 from ectopic testis 516 lung disease . . 783 traumatic 640 gouty eczema 516 stomach disease 783 tuberculous 640 in prostatic disease 442, PAIN IN TESTICLE 517 "Wassermann's test in 491, 631 in testicular abscess . . 680 diagnosing cause of . . 640 - precordial (and see Heart; due to new growth 766 - reflex, absent in hysteria . . 509 and Pain in Chest), in from renal calculus 308, 840 impaired in bulbar palsy 687 acute dilatation of heart 243 ureteric calculus 135 - sarcoma of . . 640 endocarditis .. 239 - in thighs, from carcinoma of - scarring of, from sjiihilis . . 237 from ruptured valve . . 23S rectum 93 - squamous-celled carcinoma in angina pectoris 582 in obturator hernia 740 of 670 aortic disease 233 from renal calculus 308 - syphilitic ulcer on . . 237 ,813 incompetence . . 481 ureteric calculus . . 135 spirochaetes in scraping arteriosclerosis . . 14 - in throat from corrosive from . . 640 clironio nephritis 14 poisoning (and see Sore - tuberculosis of . . 640 673 from dyspepsia . . 481 Throat) 297 sore throat from 670 fibroid heart ■241 - toe from ingrowing nail 486 tubercle bacilli in scrap- flatulent dyspepsia, in- - tongue from carcinoma . . 812 ing from 640 crease after exertion . . 481 trigeminal neuralgia 495 usually associated with onset after a meal . . 481 - tooth from dental caries . . 496 phthisis or lupus . . 640 in myocardial affections 18 - due to twisting of pedicle - unaffected in herpes of myocarditis 241 of ovarian cyst simulating tongue 831 pericarditis . . 480 777 renal colic 392 - unilateral palsy of, absence - from pressure on ceso- PAIN IN UMBILICAL RE- of articulatory defect in 687 phagus, in aortic aneur- GION 524 PALLOR 27 ysm 482 due to sebaceous cy^t 324 - acute, in duodenal ulcer . . 300 - rectal, from abscess 6. -So - urethral due to epithelioma 767 in gastric ulcer . . 298 prostatitis . . 628 , 631 with discharge . . 441 - in acute nephritis . . 48 rectal carcinoma 636 from impacted calculus 441 ,442 - cachexia alkalina . . 115 — referred (see Referred Pain) - along vertebral column in - an indication or not of - renal, with bladder tumours 311 neurasthenia 494 anaemia . . 27 in renal angle from ureter - in vulva (and see Dyspareunia) - in infantile scurvy . . 599 calculus 514 after micturition, in cystitis 442 - from internal haemorrhage colic (see Colic) with vesical carcinoma 442 646 780 tuberculous kidney 312 in kraurosis 770 - local, symmetrical, of ex- -*in retention of urine 440 prolapse of urethral tremities, in Eaynaud's - sacral region, from car- mucous membrane 770 disease . . 490 cinoma of rectum 93 from ureteric calculus . . 135 - in M^ni^re's disease S2S — over saero-iliac joint from urethral caruncle 770 - pyoneplirosis 390 joint disease 739 varicocele of vulva 770 - tuberculous joints . . 39 — In" scalp, from diabetes - wrist (see Joints, Affections Palmar fascia, Dupuytren's mellitus . . 784 of ; Arthritis ; and Osteo- contracture of . . 167 liysteria . . 784 arthritis) Pahnaris brevis, nerve supply malaria . . 784 Painful coitus (see Dysparaunia) of 550 neurasthenia 784 - micturition (see llicturition. - longus, nerve supply of . . 550 rheumatism 784 Painful) Palms, arsenical hyperkera- syphilis . . 782 - swallowing (see Dysphagia) tosis of 87 - scapular region in some Painter's cramp 177 - burning pain in, in acro- cases of cervical rib 492 Painters, plumbism in 136 paraBsthesia 493 - in shoulder, due to coronary Palate, ataxy of 69 - congenital syphilitic condy- sclerosis . . 778 - bilateral paralysis of, dys- lomata of 446 in diapliragmatic pleurisy 480 arthria from" . . '686 ,087 - papulo-squamous syphilo- — gastritis . . 778 - carcinoma of 673 derms of 532 phthisis . . 778 - cleft (see Cleft Palate) 640 - pityi-iasis rubra pilaris of . . 658 referred from diaphragm 779 - endothelioma of . . 42f ,640 - prm-itus of . . 588 left, in abscess of left lobe - cumma of . . . . 670 ,073 - tingling and numbness in, of liver 409 - inflammation of 673 in acroparaesthesia 493 PALPEBRAL FISSURE— PAPULES 957 Palpebral fissure, narrowing of, in cprvical sympa- thetic paralysis . . - - - in lesions o£ 8th cervical and 1st dorsal seg- ments - - slanting direction in Mon- golian idiocy . . unequal, confusion of ptosis with - - widened in facial paralysis PALPITATION - from abdominal pain - in acute endocarditis - aortic disease - in chlorosis . . - chronic nephritis . . - enlarged heart from over- exertion . . - exophthalmic goitre 792, - fibroid heart - with flushing - heart disease . . o.'iS, - mitral regurgitation - myocardial degeneration . . - myocarditis . . - neurasthenia - with parenchymatous goitre - paroxysmal tachycardia . . - in stomach disorders Palsies (see Paralyses) Pancreas, affections of, fatty diarrhoea in glycosuria in some cases of, 360, 486 - - microscopical characters of fceces in pain in epigastrium in . . palpable tumour in some reaction in urine in tenderness in epigastrium from ^ calculus of . . - carcinoma of (see Carcinoma of Pancreas) - cyst of, absence of " edge " and " notch " in tumour due to Cammidge's reaction in diagnosis of . . chronic indigestion with diagnosis of ascites from from ovarian cyst ferments in fluid from . . general account of glycosuria with . . inflation of stomach in diagnosis of jaundice with pale bulky stools with . . pelvic swelling due to . . - - simulating hepatic cyst. . usually behind stomach - defects tested by Sahli's corpuscles - epigastric swelling due to. . - extract of, in infantilism . . - lesions of, subphrenic ab- scess from - normal situation of - swelling of, ana?sthetic in diagnosis of physical signs of . . - tumours of, causing jaundice 366 Pancreatic artery opened by gastric ulcer . . . . 298 - calculus (see Calculus) - catarrh, jaundice and colicky epigastric pam in . . 365 - colic, signs and symptoms of 135 - diarrhoea, white stools in . . 197 - disease and infantilism . . 216 glycosuria in . . . . 292 tests for presence of . . 30-1 247 553 203 590 533 525 528 239 233 303 13 244 , 797 241 208 481 238 333 241 500 792 772 484 480 177 486 486 480 779 090 724 53 758 53 724 724 090 724 724 090 210 724 216 720 724 724 from 361 210 394 090 360 690 116 90 116 117 591 Pancreatic disca.sc, coitld. undigested muscle in stools in - hajmorrhage (see Ha;mor- rhage, Pancreatic) - incompetence, signs of - jnicf find fnt iliLrestion Pancreatic reaction (see Cam midge) - tumour, diagnosis renal tumour splenic tumour jaundice in physical signs of. (see also Pancreas, Cyst of ; and Carcinoma of Pancreas) Pancreatitis, bile pigment in urine in . . . . . . 110 - Cammidge's reaction in 115, 280 - causes of . . . . . . 116 - a common cause of diabetes 117 - diagnosis of . . . . 485 - faeces in - hsemorrhage from bowel in - indicanuria in - occult blood in iceces in . . - ptyalism in . . - acute, " acute abdomen " due to . . . . 431, 485 biliary colic in . . . . 153 collapse from . . 292, 724 constipation in 153, 292, 724, 846 epigastric pain from . . 724 fat necrosis with 153, 431, 846 frequent absence of rigid- ity of abdomen in glycosuria in immediate laparotomy in laparotomy in diagnosis of 724^ meteorism in nausea in pain in epigastrium in . . pancreas seldom felt in passage of flatus in pyrexia from severe abdominal pain in 292, 484, 846 shock and collapse in . . 484 simulating intestinal ob- struction . . 431, 846 perforated gastric ulcer 431 tenderness over pancreas in 846 vomitmg in 292, 724, 844, 840 — hjemorrhagic, abdominal distention with . . 640 fat necrosis with . . 646 hiccough in . . . . 342 laparotomy in diagnosing 646 pain in upper part of abdomen from . . simulating general peri- tonitis intestinal obstruction tympanites with vomiting and constipa- tion with - chronic, bulky offensive stools in . . Cammidge's reaction in 135, 280 clay-coloured stools with cysts resulting from diagnosis from gall-stones 265, 363 new growth . . . . 265 enlarged gall-bladder in 135 epigastric pain in 135, 486 tumour from . . . . 724 fat in stools in 155, 265, 292 fatty iridescent stools in 364 gall-bladder enlargement in 280 431 292 431 846 431 840 431 724 153 724 646 646 646 646 646 364 724 724 Pancrealilis , chronic, contd. gall-stone disease and 135, 486 glycosuria in 135, 292, 724 - - jaundice in 135, 280, 292, 301 363, 724 obstruction of common bile-duct in . . . . 302 paroxysmal epigastric pain in . . . . 280 pigmentation in.. 135, 292 recurrent jaundice in 303, 724 rigors in . . . . 135, 292 tenderness and pain in . . 724 undigested meat in stools in 292 - - wasting in . . 135, 292 Pandemic chorea .. 156,157 Pannus in trachoma . . . . 807 Panophthalmitis from corneal ulceration . . . . 806 -diphtheritic 807 - gonococcal . . . . . . 807 - from herpes frontalis . . 807 Papilloma of bladder, carci- noma simulating . . 030 cystoscopyin 441,512,514,630 cystitis from . . . . 630 diagnosis from carcinoma 030 fragments in urine 300, 630 hsematuria from 304, 305, 311, 514 pain in penis from 511, 513,514 profuse recurrent hsema- turia in. . . . . . 512 pyuria due to . . 623, 630 retention of urine from . . 441 simulated by ureteral calculus . . . . 514 sloughing of . . . . 630 sudden, profuse, pain- less hsemorrhage in . . 305 stoppage of urine by 439, 514 urethra obstructed by . . 514 - - villous . . . . 308, 511 - bleeding gums due to 86, 8S - duct, bloody discharge from nipple in . . . . 202 - of kidney, hematuria in 304, 30S haemonephrosis in . . 308 hydronephrosis in . . 308 renal enlargement in . . 308 - of larynx mistaken for asthma 582 - rectal haemorrhage from . . 93 - of scrotum . . . . . . 679 sloughing, diagnosis from hernia testis . . . . 681 - ureteral . . . . . . SOS - urethral 209 - vulval, gonorrhoeal . . 709 Papillomatous ovarian cyst, ascites in . . . . 58 PAPULES 528 - absence of scarring from . . 528 - in anthrax . . . . . . 003 - congenital syphilis.. .. 446 - in dermatitis herpetiformis 831 - development into pustules 601 - in eczema . . . . . . 831 folliculorum . . . . 528 marginatum . . . . 275 - granulosis rubra nasi . . 714 - herpes zoster . . . . 830 - impetigo contagiosa . . 831 - Jacquet's infantile erythema 446 - lichen planus . . 657, 832 ruber planus . . . . 658 - lupus vulgaris . . . . 80S - and nodules, differences between . . . . . . 448 - in pityriasis rubra pilaris . . 058 - scabies . . . . . . 831 - of severe goose-skin 528, 530 - small-pox . . . . 005 - sycosis vulgaris . . . . 002 938 PAPULES— PARALYSIS OF HAND Papules, contd. Paralysis agitans, contd. Paralysis, could. - syphilis 425, 446, 532,604,709 ,832 slowness of speech in . . 259 - conditions simulating 545 - syphilitic, anal and genital 447 sphincters normal in 796 — and cramp associated 177 - in typhoid fever 697 stiffness in 541 - of cranial nerves in cerebral - typhus fever . . 371, 699 tremor in 541, 794, 795, 798 syphilis . . 173 - vaccinia 834 absent early in 548 muscular atrophy in 75 - varicella . . - . . 833 - in alcoholic neuritis 551 - crossed (see Hemiplegia) Papulo-pustules, description of 528 - amyotrophic lateral sclerosis 131 - of detrusor muscle, difficult Papule - squamous syphilo- - of anterior crural nerve . . 541 micturition from 440, 443 derms 532 - Of arm (see Arm, Paralysis o f) - diaphragm after diphtheria 77 Papula-vesicles, description of 528 monoplegia of 547 in Landry's paralysis . . 567 Paracentesis abdominis, chronic - atrophic, in acute polio- unilateral. . 341 peritonitis from repeated 55 myelitis . . 128 - diphtheritic, muscular at-. necessity for catheteriza- - of back muscles, scoliosis rophy in.. 76 tion before 717 from . . . . 180, 181 palatal . . . . 559 650 perihepatitis from 60 - bilateral adductor in hysteria 798 regurgitation of food - thoracis, haemoptysis after 317 supranuclear facial, in cere- through nose in 202 liydropneumothorax from 712 bral diplegia 154, 535, 686 - Duchenne's, injury at birth pneumothorax from 577, 578 - birth, athetosis from 155 causing . . 552 Paracusis Willisii, in oto- - Brown-Sequard type (see - Erb's, extent and causes of 552 sclerosis . . 190 Brown-Sequard) - of ext. popliteal nerve, signs 543 Paradoxical dilatation in - bulbar, atrophy of muscles rectus, effects of . . 201 hour-glass stomach 353 of hand in 687 with facial paralysis . . 536 Paraesthesia (and see Sensation, mastication in 687 PARALYSIS OF EXTREMI- Abnormalities of) tongue in 591. 641, 686 TIES .. .. 539 545 - in arms from pressure of diaonosis from bilateral in diphtheria . . 77 640 cervical rib on brachial supranuclear facial para- from syphilitic pseudo- plexus 593 lysis 536 paralysis 387 - disseminated sclerosis 565 bulbar haemorrhage . . 687 PARALYSIS OF EXTREMITY, - hysteria 166 myasthenia gravis 225 UPPER 545 - subacute combined degener- pseudo-bulbar . . 641 hand in Tooth's pero- ation of the cord 493 softening 687 neal atrophy 71 - tabes dorsalis 493 tumour of bulb 687 importance of history - transverse myehtis 74 difficulty of speech and in . . 545 Paraffin workers, epithelioma swallowing in . . 159 withoutmuscular atrophy 540 of scrotum in 679 dribbling of saliva in 500 641 PARALYSIS OF ONE EX- Parageustia 774 dysarthria from . . 686 TREMITY, LOWER 539, 540 Paragonimus AVestermani, dysphagia in leg with muscular hEemoptysis from 705 159, 224, 641, 687 842 atrophy 541 Paraldehyde, foul taste from 774 electrical reactions of spastic, electrical re- Paralysis of abdommal mus- tongue muscles in 687 actions in 540 cles 181 fibriUary contractions of from tumour of cauda - agltans, absence of tremor tongue in . . 159 686 equina 74 with 796 gangrene of lung in 288 without muscular bent and rigid carriage in 796 gradual progress of 641 686 atrophy . . 539 bread - crumbling and insidious onset of 686 - of eye muscles in myasthe- cigarette-rolling move- lesions causing . . 641 686 nia gravis 225 ments in 796 loss of taste due to 774 ,775 PARALYSIS, FACIAL (Figs. defective winking in 262 nerves afEected in 159 136-140) 533 differentiation of myxoe- ophthalmoplegia in 159 athetosis with 530 dema from 259 palatal paralysis in 640 atrophy of face from . . 75 expressionless face in 259 796 paresis of lips and tongue in 641 Bell's, contracture from 165 exuberant laughter in . . 262 vocal cords in . . 687 bilateral, interference with facies described (Fig. 86) 261 progressive muscular atrophy labial articulation in. . 687 festinating gait in 278, 796 associated with 73 641 in Landouzy-Dejerine flexion of arm in 548 reflexes in 687 myopathy . . 687 gait in . . 278, 541, 548 796 regurgitation of food peripheral neuritis 687 general account of 796 tlirough nose from 202 ptyalism in 591 influence of will on tremor of 796 - cardiovascular lesions in . . 546 and brachial monoplegia 547 sleep on tremor of 796 - cerebral, associated move- contracture from 534 537 msomnia m 358 ments in . . 548 epiphora in 250 lateropulsion in . . 796 convulsions of children in 169 and hemiplegia . . 336 loss of power in one arm - from cerebral tumour 350 herijes with 536 in early stgaes of 548 - of cervical sympathetic, ab- keratitis from 807 in one leg in 541 sence of blushing in 247 590 nerve, syphilitic (Figs. mistaken for hysteria . . 548 diminished tension of 158, 159) .. 589 590 neuritis 548 lobe of eye in 594 peripheral 536 monotonous voice in . . 796 enophthahnos in 247 simulated by facial hemi- muscular rigidity in 796 loss of pupillary sensory atrophy (Fig. 141) . . 537 weakness in . . 796 reflex in " . 594 supranuclear 534 normal reflexes in 541 palpebral fissure dimin- taste defects in . . 774 775 paresthesia in . . 706 ished from 247, 546 - of fifth nerve, abolition of - - propulsion in 796 ptosis from 247. 590, 594 wihktng reflex in 807 ptyalism in 591 pupil constricted from anosmia from. . 608 reflexes normal . . 548, 796 247, 546, 590, 595, 792 arrest of lachrymal retraction of eyelids in . . 262 pupils unequal in 595 secretion in. . 807 retropulsion in . . 796 stimulation of, dilata- dryness of nose from . . 668 shuffling in . . 541, 796 tion of the pupil in 594 595 hypopyon from 807 simulated by cerebral sweating due to 247 insensibility of cornea in 807 softening 796 from thyroid gland tu- keratitis from . . 807 mercurial tremor 797 mour. . 792 - general, of insane (see General writer's cramp 177 - of ciliary muscle after Paralysis of the Insane) slow emotional develop- diphtheria 77, 224, 640 - of hand, ischa-mic, from ment in 262 - circumflex nerve . . 552 injury to forearm 552 PA RA L YSIS, HPPOGLOSSA L— PA RA TH YROID 959 I'lirali/.iis, cmiUl. J'arali/.iis, could. - liy|KiL'loss;il, atroiiliy oC - ill ]M'riplicral neuritis (see Neu- toii;,'iio from 7") ritis, Multiple Peripheral) - ill hy.st(,'ria (see iiystoria, - of pliarynx, progressive . . 224 I'ara lysis in) - iiriinary muscular, patient's - infantile, abnormal gait in ■s^a method of raising himself in 132 - - acquired, choreiform move- talipes in 132 ments in 155 - progressive bulbar, fibril- clefeetive speecli in . . 15.5 lary contractions in 158, 159 epilepsy from. . 105 - pseudo-bulbar (see Pseudo- - - - mental deticicucy in . . 155 bulbar Paralysis) tremors in 155 - pseudo - hypertrophic (see tropliic lesions in 155 Pseui lo-hy pwtrophic Mus- - - of arm, (Fiy. 7) . . 70 cular I'aralvsis) cousins claw-foot 127 - jitosis due to (I'if/s. 156-159) 590 muscular atrophy in 70 - ptyalism from difficulty in — - plantar rellex in . . 81 swallowing in 591 preceded by paraplegia 544 - retention of urine from 441 reaction of degeneration in 131 - of sciatic nerve, causes and scoliosis from 180 signs of . . 542 talipes in . . 71, 131 talipes from . . 132 ulceration of the leg in . . 811 - serratiis niagnus 551 - - vasomotor and trophic - sixth nerve, effects of 200 lesions in 131 - sometimes absent with cere- - of inferior oblique, effects of 201 bral liirmorrliage 138 rectus, eltects of . . liOl - from spinal cord lesions, - intercostal muscles in Lan- pain in . . 545 dry's paralysis . . 567 muscles, scoliosis due to 181 - internal popliteal nerve . . 543 - superior oblique, effects of 201 rectus, effects of . . 201 rectus, effects of . . 201 - intestine, in cord affections 432 - supranuclear 534 - Jacksonian epilepsy with.. 101 - - facial bilateral (Fig. 140) 535 - Klumpke's, cause and effects 553 - of suprascapular nerve 551 - Landry's (see Landry's I'aral} sis) - tliird nerve . . 595 PARALYSIS, LARYNGEAL.. 537 from tumour of mid- - - abductor, orthopna.-a In 465 brain . . 798 bilateral, aphonia in 687 - tibial muscles, talipes from 132 from bronchial glands . . 422 - tongue in bulbar paralysis 641 cancer of cesophagus 296 progressive 224 central nervous system - transient, in Jacksonian changes in 539 epilepsy . . 161 diagnosis from laryngitis 537 - in tuberculous meningitis. . 612 dyspucea from . . 53!) - uhiar (and see Ulnar Paralysis) gangrene of lung m 288 disturbed function in other in myasthenia gravis . . 225 parts with 574 progressive 224 diagnosis of Volkmann's simulating suffocative contracture from 552 oedema.. 539 loss of sensation in 128 traclieotomy required for 539 - of vesical sphincter, inconti- - - urgent dyspnoea from . . 537 nence of urine from 440 (aiid see Paralysis of Vocal - vocal cord by aneurysm . . 222 Cord) bilateral 538 vascular degeneration in bulbar palsy 687 associated with 539 dry cough due to 175 lesions of internal caji- functional 538 sule causing flO lesion of one recurrent - of both legs (see Paraplegia) laryngeal nerve 687 - lips in bulbar paralysis 641 voice little altered in 687 progressive 224 from mediastinal fibrosif- 538 - median nerve 552 stridor from . . 710 - motor nerves of bladder . . 443 syphilitic 710 - nioath in myasthenia gravis 225 from thyroid gland ~ multiple, of cranial nerves, tumour 792 syphilitic . . 590 unilateral organic 538 - in multiple neuritis (see Kcu- - Volckmann's 72 ritis, Multiple Peripheral) I'arametric abscess (see Abscess - of muscles of back, lordosis Parametric) from 183 Parametritis, peritonitis from 644 - musculospiral . . 77, 552 - swelling in iliac fossa due to 737 - of neck muscles in myasthe- Paramnesia in clironic alcohol- nia gravis 225 ism 172 - obturator nerve, signs of . . 541 Paramyoclonus multiplex 160, 799 - ocular muscles in diphtheria 640 clonic contractions of . . 161 (see Strabismus; andl'iipil retraction of the head in 641 Abnormalities of) I'araiiliimosis, jiain in penis in 515 - orbicularis palpebrarum. PARAPLEGIA 556 epiphora from . . 250 - abnormal gait in . . 278 keratitis from . . 807 - from affection of cervico- - of palate 640 dorsal cord 555 after diphtheria 2'2i 842 - athetosis in. . 154 - - (.l3fsphagia from . . 224 - ankle-clonus in 41, 494 786 - - stertor from 707 - ataxic . . 493, 561 565 syphilitic, associated witli abnormal gait, due to . . 277 other cranial nerve palsy 610 Uabinski's sign in 82 Paraplegia, utatic, con Id. cord lesions in . . . . 565 extensor plantar response 493 imjiotence in . . . . 346 increased tendon jerks in 493 - - ijaru'Sthesim in . . . . 493 spastic paraplegia in . . 493 - from bilateral cerebral soften- ing 563 - causes of, in adults . . 561 in children . . . . 556 - combined scleroses of the cord 493, 667 - from compression 270, 194, 786 lialiiiiski's sign witli . . 786 girdle sensation in . . 289 increased knee-jerks with 786 pain in the back with . . 786 retention of urine in . . 441 tenderness of spine with 786 zone of hyperesthesia in 786 - congenital spastic, diffuse kyphosis with .. .. 182 talipes in . . . . 131 - contractures in .. ..164 - diminished power of mictu- rition in . . . . . . 443 - in disseminated sclerosis . . 547 - extensor plantar response in 494 - in Friedreich's ataxy . . 71 - functional . . . . . . 567 - girdle sensation in.. .. 289 - hysterical . . . . . . 69 - increased knee-jerk in . . 494 - infantile . . . . . . 155 convulsions with. . .. 170 - Landry's paralysis.. .. 567 - in Little's disease . . . . 154 - from malignant disease of the vertebra; . . . . 786 - meteorism with . . . . 432 - from primary lateral sclerosis 567 - radicular pain in arm in.. 494 - sensory disorders with .. 563 - simulated by malingerers 567. 786 - spastic 439 and ataxy . . . . 565 exaggerated knee-jerkwith 397 of infants and children, athetosis in . . . . 154 primary, impotence in . . 346 from spinal caries . . 558 talipes in . . . . 131 - sphmcter trouble with 348, 411, 786 - in spinal caries . . . . 181 loss of sphincter ani control in . . . . 558 - due to spinal hoemorrhage 787 - sudden, from spinal caries 270 - from superior longitudinal sinus thrombosis . . 643 - syringomyelia . . 73, 554 - transverse myelitis.. .. 73 - typhoid spine . . . . 787 Parasites in blood in malaria (see Malaria) - bile-duct obstruction from 364 - cachexia from . . . . 114 - disco vcrv of vjixa in faaces 621 PARASITES, INTESTINAL(see Worms, Intestinal) - pruritus caused by . . 588 Parasitic affections, anaemia in 33, 37, 459 albuminuria in . . . . 17 Charcot-Leyden crystals in stools in . . . . 118 eosinophil ia in . . . . 249 oedema of legs in 459, 461 - jaundice . . . . . . 361 Parath3^roid glands, clonus from excision of . . . . 161 - insufficiency, tetany from.. 178 960 PARATYPHOID FEVER— PEMPHIGUS Paratyphoid fever, agglutina- tion test for . . 611, 697 B. paratyphosus in . . 697 bacteriuria in . . . . 83 diagnosis from tuberculosis 611 influenza . . . . 611 typhoid fever . . 611, 697 - - prolonged pyrexia in . . 609 splenic enlargement in 692, 697 - - symptoms like those of benign typhoid . . Oil Paraxanthin bases, uric acid derived from . . . . S17 Paresis (see Paralysis) Parietal lobp, aura in tumour of SI Paris, ringworm parasites in 272 273 Parkinson's disease (see Par- alysis Agitans) Paronychia, causes of . . 445 Parotid abscess, discharge through auditory meatus . . 470 Parotiti S, acute specific (see Mumps) - diagnosis from periostitis . . 747 - earache from . . . . 230 - epididymo-orchitis in . . 517 - pain in the face from . . 495 - swelling of face in . . . . 746 - testicular abscess in . . 680 Paroxysmal hoemoglobinuria, general account of . . 315 - headache in disseminated sclerosis . . . . . . 328 in neuralgia . . . . 326 - movements in epilepsy . . 160 - pain in intestinal colic 133, 472 - tachycardia, brought on by fright or shock .. •• 772 destinetion from Graves' disease . . . . . . 772 duration of attacks in . . 772 faintness from . . . . 772 general account of . . 772 lack of strength in . . 772 numbness of extremities in .: .. ..772 palpitation in . . 525, 772 pins and needles in ex- tremities in . . . . 772 pulse-rate in . . . . 772 sex incidence of . . . . 772 Parrot's nodes in congenital syphilis . . . . _ 427, 752 Parturition (see Labour) --' ^ Passion, rupture of cortical veins during . . . . 131 Patellar clonus, indicative of organic nervous disease 398 method of eliciting . . 398 Patent ductus arteriosus, ab- sence of cyanosis with 129, 184 symptoms with . . 790 bruit of . . 104, 184 no clubbed fingers with 129 persistent, cyanosis, clubbed fingers, and polycythemia rare in 579 systolic thrill due to 184, 790 - foramen ovale causes no symptoms . . . . 184 - septum ventriculorum, bruits of 104, 105, 184, 579 clubbed fingers witli . . 129 cyanosis from. . . . 184 enlarged heart in . . 244 morbus ca?ruleus from 579 and pulmonary stenosis associated . . 244, 579 systolic bruit of . . 579 thrill with . . . . 184 Paver nocturnus . . . . 357 Pavy's albuminuria . . . . 19 - solution in estimation of glycosuria . . 290, 291 Pawlik's grip in abdominal palpation in pregnancy 228 Pears, false intestinal sand from 653 Peas, oxaluria from . . . . 471 Peau lisse with syringomyelia 128 Peckham fat boy . . . . 454 Pectinens, nerve supply of . . 542 Pectoralis major, nerve supply 550 pseudo-h3'pertrophy of.. 560 spinal nerve root supplying 556 wasting in phthisis . . 72 - ramor, nerve supply of . . 550 Pectoriloquy with bronchi- ectasis . . . . 324, 703 - in fibroid lung . . 232, 246 - lobar pneumonia . . 186, 702 - phthisis . . . . . . 319 Pediculi, carbolic acid com- press for, carboluria from 822 Pediculosis, anaamia from . . 419 - cervical gland enlargement in . . 417, 419, 421, 708 - diagnosis from prurigo . . 532 - eosinophilia in . . . . 249 - irritation of skin at back of neck with . . . . 419 - pruritus in . . . . . . 588 - purpura due to . . 596, 597 - scalp tender from . . 780, 781 - stifi: neck from . . . . 708 - pubis, enlarged glands in groin from . . . . 738 extent of infection in . . 447 - vestimentorum, purpura from 597 Peelinc ('see Desquamation) Peliosis rheumatica, absence of valvular heart disease in 599 age and sex incidence of 600 distribution . . . . 599 erythema in . . . . 600 joints affected in . . 599 purpura in . . 596, 599 pyrexia in . . . . 599 relation to acute rheum- atism . . . . 121, 599 slight influence of sali- cylates in . . . . 600 soreness of throat in . . 599 theory of origin of . . 600 Pelvic grip in abdominal palpa- tion in pregnancy . . 228 - pain (see Pain, Pelvic) - peritonitis (see Peritonitis, Pelvic) Pelvimeter, Skutch's, use of, in pregnancy . . . . 228 Pelvis, abscess of (see Abscess, Pelvic) - adhesions causing acute intestinal obstruction . . 152 - affections, frequency of mic- turition w'ith .. .. 817 - beaked or rostrate.. .. 212 - bones, new growths of, pelvic swelling due to . . . . 757 - cellulitis of, absence of local peritonitis in . . . . 760 always due to labour . . 760 burrowing along round ligament to groin . . 760 diagnosis from pelvic abscess . . . . 760 pelvic swelling due to 757, 760 uterus fixed by . . . . 760 vaginal fornix bulged by 760 - chondroma of . . 737, 761 - congestion of, causes of . . 508 deep-seated pelvic pain in 508 - contracted in achondroplasia 212 dystocia due to . . 227 - deformed in rickets . . 212 - diseases of, constipation in painful . . . . . . 144 diagnosis from lumbago 477 Pelvis, diseases of, contd. frequency of micturition in 438 mastodynia in . . . . 479 sacralgia in . . . . 509 - displacement of, causing prolapse of uterus . . 586 - fracture of (see Fracture of Pelvis) - glands enlarged in, causes identical with those of mes- enteric gland enlargement 423 - growth in, bearing-down pain from . . . . 473 bilateral hydronephrosis in 311 cartilaginous . . . . 761 complicating pregnancy 761 continuity with pelvic bones 761 diagnosis from salpingo- oophoritis . . . . 761 sciatica. . . . . . 487 enlarged mesenteric and retroperitoneal glands in 422 - - fixity of . . . . 737, 761 nephritis from . . . . 8 paraplegia due to . . 561 due to pelvic abscess from appendicitis . . 632 pelvic swelling due to . . 761 rarity of . . . . . . 761 rectal examination m diagnosing . . 487 741, 761 peripheral sarcomatous simulating neuritis . . . . 562 talipes from . . . . 131 vaginal examination in diagnosing . . . . 487 - hfematocole in (see Hsemato- cele. Pelvic) - impaction of lower end of spleen in . . . . . . 688 - infection by tuberculosis of kidney . . . . 310 - Inflammation in, acute, severe pam m pelvis in . . . . 508 causing amenorrhoea 23, 24 diagnosis from sciatica . . 487 kinking of bowel from . . 147 rectal examination in diagnosing . . . . 487 simulating sciatica . . 74 vaginal examination in diagnosing . . . . 487 - injury or inflammation of, causing nerve paralysis 542 - method of measuring in pregnancy . . . . 228 - sarcoma of (see Sarcoma of Pelvis) - swelling in (see Swelling in Pelvis) due to urachal cysts . . 757 - tuberculous disease, ure- thral passage of faeces in 264 - tumours of, or cauda equina simulating neuritis . . 562 diagnosis from renal tumours . . 392, 393 difBcult micturition from in female . . . . 439 dislocated spleen causing 691 dystocia due to . . . . 227 muscular atrophy in . . 74 oedema of legs from . . 456 physical signs of . . . . 393 Pemphigus, affecting fingers 266 - albuminuria in . . . . 17 - bleeding gums in . . 86, 88 - of the buccal cavity . , 225 - buUsB in 110, 111, 113, 602, 654 - crusts in . . . . . . 654 - diagnosis from cheiropom- " 1 pholyx . . . . . . 832 impetigo . . . . . . 602 PEMPHIG US— PERIODIC POL Y URIA 961 Pemphigus, coiUd. - eosinophilia in . . 114, 249 - foliaceus distinguished from pityriasis rubra . . . . 658 - - scales and crusts in . . 654 - marked systemic disturb- ance in . . . . . . 602 - neonatorum . . . . 446 - - bulks in .. .. 110, 116 relation to impetigo . . 441 - pruritus in . . . . . . 588 - simulated by urticaria bul- losa . . . . . . 850 - skin stainins: in . . . . 654 - vegetans, distinction from condylomata . . . . 654 gangrene from . . . . 654 Pendulous abdomen, hepato- ptosis in . . . . . . 406 in cretinism . . . . 259 Penguin-type of dwarf . . 214 Penicillium glaucum in sputum 705 Penile pain (see Pain, Penile) - sores Csee Sores, Penile) Penis, absence of erections of 346 - calculus in, frequency of micturition from . . 438 - carcinoma of (see Carcinoma of Pente) 676 - chancre on . . . . . . , 676 - continual erection of . . ' 585 - curved (see Chordee) - diabetic eczema starting on 4-17 gangrene of . . . . 266 - epithelioma of (see Carcinoma of Penis) - erections of (see Erections, Penile) - fracture of, chordee due to 125 - gumma of cms, diagnosis from tuberculous caries of pubes . . . . . . 767 from epithelioma . . 677 syphilitic chancre . . 677 - - mercury and iodide in diagnosis of . . . . C77 origin as small elevated nodule . . . . . . 677 sore due to . . . . 674 ulcer with thin edges and yellow sloughy base 677 - hasmatoma of . . . . 516 - cedema of, in acute nepliritis 458 - pain in (see Pain in Penis) - painful erections in prostatic abscess . . . . . . 515 - pustules on, in herpes pro- genitalis . . . . . . 675 - sarcoma of crus, diagnosis from tuberculous caries of pubes . . . . . . 767 - scabies of . . . . . . 447 - soft sores on . . . . 209 - swelling of, in balanitis . . 674 - ulceration of (and see Sores, Penile, and Carcinoma' of Penis) . . . . . . 674 in balanitis . . . . 674 gummatous (see Penis, Gumma of) from herpes . . 675, 830 - tuberculous . . • • 674 association with ad- vanced tuberculosis elsewhere . . . . 677 from infection in Jew- ish circumcision . . 677 shallow, painful, mul- tiple ulcers in . . 677 - vesicles on, in herpes pro- genitalis . . . . 675 Pentose, distinction from glucose in urine . . . . 290 - osazone crystals from . . 290 290 290 400 355 87 648 Petitose, coiifcl. - reduction of bismuth by . . - in urine, tests for . . 115 Peppermint oil, leucocytosis from Pepsin, test for Peptic ulcers . . Peptonuria (see Albumosuria) Perchloride of iron, dryness of mouth due to . . extreme thirst due to . . Perforated gastric ulcer (see Gastric Ulcer. Perforated) Perforating ulcer (see L'lcers, Perforative) - of intestine in enteric fever - palate (see Palate, Perfora- tion of) Peri-arthritis (see Arthritis) Pericardial rub (see Eub) Pericarditis - in acute rheumatism - angina pectoris from - in Bright's disease - canter-rhythm in . . - cardiac dullness increased in 242 impulse displaced in . . 242 - characters of friction sounds in 480, 481 to-and-fro 104, 480 - clubbed fingers m . . - distinction of rub from bruit - a first symptom of chronic nephritis . . - heart failure in - and mediastinitis . . - mitral regurgitation from 239 - occurrence without pyrexia - orthopnoea in 121, 671 .. 480 15, 122 242, 639 128 106 15 464 61 242 622 464 pain in the chest in 478, 777 epigastrium from . . 777 precordial from . . 480, 777 - pale anxious expression in 480 - palpitation in . . 525, 526 - persistence of rub after commencement of effusion 480 - in severe blood diseases . . 122 - shortness of breath in . . 480 - suppurative, from acute necrosis of bones . . 650 from periostitis . . . . 650 in pyoemia . . . . 650 - svstolic bruit in . . 102, 104 - - thrill due to . . . . 790 - tenderness in chest from 776, 777 Pericardium, adherent . . 464 albuminuria with . . 18 ascites from . . 61, 62 - - bruits with . . . . 243 - - cardiac impulse displaced m 242 clubbed fingers in . . 128 diastolic collapse of veins with 242 shock in . . . . 242 dilated precordial veins in 242 general account of . . 242 heart enlarged in . . 332 failure from . . . . 464 mitral regurgitation from 239, 242, 243 obscure cases of . . . . 123 orthopnoea from . . . . 464 palpitation in . . 525, 526 peculiarities of cardiac impulse in . . . . 242 physical signs of . . . . 62 precordial bulging in . . 242 - - signs of . . . . 103, 104 systolic mitral bruit in 102, 103 retraction in . . 103, 242 therapeutic test of . . 243 varieties of . . . . 62 Pericardium, conld. - branches of vagus, relation to cough . . . . . . 175 - diseases of, shortness of breath in . . . . . . 101 cyanosis in . . . . 186 displacement of impulse in .. .. 330, 332 - effusion into, compression of lung from . . 32-i, 667 - - and enlarged heart, simi- larity of symptoms . . 242 fibroid lung and bronchi- ectasis from . . . . 324 raising of apex beat in . . 332 skodaic resonance due to 667 swellingof chest wall from 194 - infection by bacillus coli 711 - opened by epithelioma of oesophagus . . . . 711 foreign body in oesophagus 711 - rupture of aneurysm intol40,482 subphrenic abscess . . 711 - succussion sounds in . . 711 Perichondritis of arytenoid cartilages, sore throat from 670 - thyroid cartilage simulating enlarged thyroid gland.. 791 Pericolitic abscess (see Abscess, Pericolitic) Perigastric abscess (see Abscess, Perigastric) Pericolitis from stricture of intestine . . . . . . 146 Perihepatitis, ascites m 55, 60 - and chronic peritonitis 55, 412 - chronic universal . . . . 412 - in cirrhosis of liver . . 409 - enlarged liver from . . 55 - obscure cases of . . . . 123 - Irom paracentesis abdominis 60 - svphilitic . . . . . . 60 - turned-up liver edge in . . 60 - in venous congestion of liver 407 Perimeter in mapping out hemianopsia . . . . 333 scotomata . . . . 838 Perinephric abscess (see Abscess, Perinephric) - effusion of blood due to injury of loin . . . . 392 diagnosis from renal tumour. . . . . . 392 possible origin from renal suppurative condition 392 urinary changes with 392 - infiltration in malignant disease of colon . . 393 - inflammation causing pleu- ritic effusion . . . . 123 Perineum, abscess in, leucocy- tosis from . . . . . . 400 - bromidrosis of . . . . 714 - chancre of . . . . . . 678 - condylomata on, diagnosis of 678 - ectopic testis in . . 523, 740 - epithelioma of (see Carcinoma of Perineum) - herpes genitalis of . . . . 830 - injuries of, causing prolapse of uterus . . . . 586 - Jacfj net's erythema of . . 446 - lacerations of, dvspareunia from . . ' . . . . 221 - micturition through fistula in 442 - pain in (see Pain in Perineum) - rigidity of, dystocia due to 227 - sores of (see Sores, Perineal) Periodic breathing (see Cheyne- Stokes Eespiration) - effusion into joint in inter- mittent hydrarthrosis . . 387 - polyuria without apparent cause . . . . . . 582 61 962 PERIOSTEAL ABSCESS— PERITONITIS Periosteal abscess (see Abscess, Periosteal) Periosteum, fibroroa of, rarity of 755 - htBmorrhage beneath, in scurvy 85 - lipoma of, rarity of . . 755 - recurrent fibrosarcoma of. . 204 - syphilitic thickening of .. 519 - tender in infantile scurvy.. 599 - thickening of, in acromegaly 753 Periostitis,abscess in heart from 650 - albumosuria in . . . . 20 - alveolar, diagnosis from parotitis . . . . . . 747 - anaemia from . . . . 89 - acute (and see Abscess) . . 750 - - simulated by scurvy- rickets.. .. .. 753 - chronic, diagnosis from gumma . . . . . . 752 sarcoma . . 756, 763 - - long duration of . . . . 751 - - operation in diagnosis of 751 - - thickening of bone from (Fig. 192) . . . . 751 a;-rays in diasrnosis from sarcoma (Figs. 196, 198, 199, p.' 754, 756).. 751 - in enteric fever . . . . 648 -gummatous.. .. .. 681 trigeminal neuralgia in 496 - of mastoid -process, pain behind ear from . . .. 230 -' orbital, unilateral exophthal- mos due to . . . . 254 - pericarditis from . . . . 650 - popliteal swelling due to 761, 763 - syphilitic, diagnosis from periosteal sarcoma . . 756 - tuberculous, bones commonly- affected by . . . . 752 diagnosis from syphilitic 752 Peripheral nerve, effects of dividing . . . . . . 661 distribution (Plate XI, p. 663) 551 lesions causing ataxy . . 65 muscular atrophy in . . 72, 75 - neuritis (see Neuritis, Multiple Peripheral) Perirectal abscess (see Abscess, Perirectal) Perisplenitis, friction sound in 499 - obscure cases of . . . . 123 - pain in left hypochon- drium in . . . . . . 499 Peristalsis and borborygmi . . 96 - palpable in intussusception 92 PERISTALSIS, VISIBLE, con- ditions causing . . 570, 571 in acute obstruction . . 152 - - with carcinoma of colon 91, 145, 147 - - in chronic intussusception 92, 148 constipation due to deficient 143 - - in excluding gastric atony 713 gastric, due to pyloric or duodenal obstruction 134, 352, 570, 713, 723, 725 - - Hirschsprung's disease 148, 718, 724 with hypertrophic stenosis of the pylorus . . . . 845 in intestinal colic . . 473 obstruction, 151, 152, 267, 350, 431, 571, 723, 727 thin adults . . . . 724 Peritoneal adhesions (see Adhe- sions, Peritoneal) - band, intestinal obstruction from 431 - cavity, free gas in, causing obliteration of liver dull- ness . . . . . . 406 Peritoneal cavity, contd. free gas in, simulated by meteorism . . . . 716 gas in (see Meteorism) - fluid in (see Ascites and Peritonitis) encysted, pelvic swelling due to . . . . 757, 761 P_eritoneum, diseases of, causmg ascites . . . . . .-53, 57 - hydatid disease of . . . . 720 - primary carcinoma of . . 57 - rupture of aneurvsm into.. 482 Peritonitis, acute general abdominal distention in 134, 472, 644 pain from 472, 644, 718, 846 after abdominal iujury 644, 646 abortion . . . . 644 operations . . . . 644 from abscess of kidney . . 644 liver . . . . . . 644 spleen . . . . . . 644 albumosuria in . . . . 20 from appendicitis 55, 431, 644, 780 bands from, causing ob- struction 151, 152, 431 borborygmi absent in 97, 431, 644, 645 - from Bright's disease 14, 63 - carcinoma of the colon . . 645 - - after childbirth .". . . 644 and colic, points of dis- tinction iDetween . . G44 - collapse in . . . . 346 - constipation in . . 147, 153, 472, 644, 718 - danger of morphia ad- ministration in . . 472 - diagnosis of . . . . 431 from intestinal obstruc- tion . . . . 431, 645 laparotomy in . . . . 645 suppurative pylephlebitis 614 - diarrhoea in . . . . 644 - drawing up of legs in 472, 644 - - dry furred tongue in . . 431 mouth in . . . . 774 - dullness of the flanks iu. . 644 - - from duodenal ulcer 55,644,780 - - dysentery . . . . 55 - embolism . . . . . . 432 - - endometritis . . . . 644 - - extreme thirst from . . 789 - - facies Hippocratica in 431,644 ■ - a first symptom of chronic nepliritis . . . . 14 ■ - fluid in abdomen in . . 644 ■ - foul breath in . . . . 98 taste in . . . . 774 ■ - frequency of micturition in 644 ■ - furred tongue in.. .. 774 - - from gastric ulcer 55, 644, 780 ■ - gall-bladder rupture 281, 644 - - general account of . . 644 ■ - gonococcal . . . . 55 - - from growth in hver . . 412 ■ - hiccough in . . . . 342 - history of gastric or duo- denal ulcer in . . 431 - hypothermia in . . . . 346 - immediate laparotomy needed for . . . . 846 - immobility of abdomi- nal wall in . . . . 472 - impaired note in flanks in 431 - importance of early dia- gnosis in . . . . 472 - indicanuria in . . . . 349 - leucocytosis in . . 472, 645 - liver dullness lost in 404, 644 - meteorism in . . 431, 644 - nausea in.. .. .. 472 Peritonitis, acvte general, contd. non-suppurative, ascites in 55 causes of . . . . 55 pain increased by pressure in 473 local at onset of . . 472 paralysis of bowel in . . 472 from parametritis . . 644 perirectal abscess . . 55 phrenic neuralgia simulating479 pleuritic effusion from . . 122 pneumococcal . . . . 55 prostatic abscess . . 55 pulse, increasingly rapid in . . . . 431, 472 rapid in . . . . 644 wiry in . . . . 472 pyoperitoneum from . . 717 pyosalpinx . . 55, 644 pyrexia in 134, 153, 155, 472, 718 retention of urine in . . 644 retraction of abdomen at onset of . . . . 472 rigid abdomen in 134, 153, 431, 644, 846 rub over liver or spleen in 431 from ruptured tubal ges- tation . . . . 646, 780 septicemia from. . . . 60S — Simulated by acute hsemor- rhagic pancreatitis . . 646 colic . . . . . . 645 diaphragmatic pleurisy 645 d'issecting aortic aneur- ysm 646 embolism of mesenteric artery . . . . 646 pneumonia . . 472, 645 ruptured abdominal aneurysm . . . . 64G suppurative nephritis 646 thrombosis of inferior vena cava . . . . 646 from stercoral ulcer of bowel . . . . . . 55 supervention on intestinal obstruction . . 431, 644 — tenderness of abdomen in 134,153 — thoracic respiration in . . 644 — tuberculous . . . . 55 — from tuberculous ulcer of bowel . . . . . . 55 — in typhoid fever 55, 431, 648 — various causes of . . 644 — - vomiting in 434. 472, 718, 844, 84() — wasting with . . . . 718 — chronic, " doughy " feel of abdomen in . . . . 472 — dull feeling of heaviness in 472 — enlarged abdominal lym- phatic glands in . . 725 — fluid in peritoneal cavity in 472 — localized, followed by con- stipation . . . . 147 — loculated ascites -n-ith . . 51 — masses of thickened peri- toneum felt in . . .. 472 — - omental tumour from 406, 472 ■ simulating malignant growth of stomach 472 • tumour of colon . . 472 - periliepatltis in . . 60, 412 - in severe ansmias . . 64 - simple, ascites in . . 55 causes of . . . . 55 constipation with . . 56 vomiting with . . 56 - tubercle -the commonest cause of . . . . 472 hydatid, account of . . 719 intestinal adhesions with ascites in . . . . . . 56 PERI TONITIS, MA LIGNA NT—PHA R YNX 063 Peritonitis, contd. - malignant, abdominal dis- tention from . . . . 718 ascites from . . 57, 718 atypical mitotic figures in cells in . . . . 718 diagnosis o£ . . . . 718 haemorrhagic ascitic fluid with 718 loss of weight from . . 718 multinuclcar endothelial cells in fluid from . . 718 palpable lump in . . 718 - pelvic, causes of . . . . 508 deep-seated jielvic pain in 508 dysmenorrhita from . . 219 - - from infection after labour or abortion . . . . 508 pleuritic effusion from . . 123 - tuberculous 422 abdominal distention in 152 masses in . . . . 719 pain and tenderness in 710 swelling from.. .. 715 acute . . . . . . 55 aftection of umbilicus in 71G age incidence of . . . . 691 anaemia in . . . . 719 ascites in 50, 51, 56, 152, 691 bands or adliesioas from, causing obstruction 151, 152 blood per rectum fron, . . 719 Calmette's reaction in . . 091 chronic intestinal obstruc- tion from . . . . 719 constipation in . . . . 719 diagnosis from ascites in cirrhosis of liver . . 618 ovarian tumour . . 691 splenic tumour . . 691 diarrhoea in . . . . 719 enlarjred abdominal lym- phatic glands in 422, 725 frecal discharge from um- bilicus in . . 691, 716 fistula from . . . . 51 - - inflammatory and caseous masses in abdomen in 1 52, 422 inoculation of guinea-pig in diagnosing . . . . 57 leucopenia in . . . . 401 nausea in . . . . 719 obliterative form . . 719 fx-dema of abdominal wall in 691 omental tumours in . . 724 pain in the umbilical region in . . . . 524 physical signs of . . 691 purulent aiscliarge from umbilicus in . . . . 691 pvoperitoneum from . . 717 - - pyrexia in 472, 618, 691 siqiulated by cirrhosis of the liver ' . . 618, 719 malignant disease . . 724 urachal cyst . . . . 730 swelling in left hypochon- drium in . . . . 691 tuberculin in exclusion of 719 tuberculosis elsewhere in 691 tuberculous glands with 691 joints with . . . . 691 umbilicus reddened in 50, 472 unsterilized cow's milk as cause of . . . . 691 varieties of . . . . 56 V. Pirrjuet's reaction in 691 Peri-urethral abscess (see Ab- *«t scess, Periurethral) Perleche in association with impetiginous stomatitis 404 - - impetigo contagiosa . . 404 vesicular erythema . . 404 616 574 351 361 639 36 251 76 639 Perleche, contd. - contagious character of . . 403 - diagnosis from herpes . . 404 mucous patches of syphilis 404 - licking of lips in . . . . 403 - lips liot and hyperaemic in 403 - peculiarity to children . . 403 - streptococci as cause of . . 403 Pernicious ansmia . . 27, 30 absence of leucocytosis in 64 albuminuria in . . 10, 17 anaesthesia from.. .. 667 arsenic in . . . . 38 arsenical neui-itis in . . 77 ascites in . . . . 62, 04, 122 Habiaski's sign in . . 82 bleeding gums in . . 85 blood changes in 30, 76, 303, 619 canter-rhvthm of heart in ■ 639 characteristic tempera- ture chart of (Fig. 167) cholasma in colour index in 26, 30, 64, 352, 616 cord changes in 76, 82, 667 diagnosis from carcinoma of stomach . . 303 jaundice dilatation of heart from fatty change in early stages of . . epistaxis in facies in . . fatty heart from - - haematemesis in haemoptysis in haemorrhage from mucous membranes in hyperaesthesia from impotence in infarcts in jaundice in lemon-yellow skin in - - leucopenia in loss of weight in 30, marrow changes in megaloblasts in . . muscular atrophy in myelocytes in nerve deafness in symptoms in . . noises in the ears from oedema of legs in palpitation from pearly whiteness of con junctivae in pericarditis in . . periodic acute diarrhcea in 196 peripheral neuritis in 76, 77 pleuritic effusion in . . 122 poikilocytosis in . . 616 progressive weakness in 30 ptyalism due to . . punctate basophilia in . - - pyrexia in 32, 616, 649 prolonged in . . . . 609 rigors ui . . . . . . 649 severe and progressive anaemia in . . 459, 649 shortness of breath in . . 100 simulated by ankylosto miasis . . aplastic antBmia gastric carcinoma spleen enlarged in stomatitis in sweats in . . - - tenderness of ribs in of the sternum in uric acid in urobilinuria from 303, 361, 818 wasting in . . . . 649 62 294, 303 .. 318 649 .. 667 . . 347 .. 10 . . 361 616, 849 .. 40 649, 849 .. 776 .. 303 76 29 .. 191 .. 30 794 459, 461 361 122 590 30 570 42 .. 351 692, 695 .. 590 .. 649 .. 776 . . 776 .. 817 Peroneal atropliy (see Tooth's Peroneal Atropliy) - muscles, affection in infan- tile paralysis .. 131, 132 - - spinal nerve roots supply nerve supply of . . Perspiration (see Sweating) Pertussis (see Whooping-cough) Pes cavus Possnries, vaginal discharge 543 542 133 210,211 from Petechi;!} (see Purpura) Petit mal headache after . . relation of aurae to spasmodic twitchings in transitory aphasia in Petroleum, constipation bene- fitted by use of . . Peyer's patches, enlarged in lymphatism Pfeiffer's bacillus in influenza 505 Phagedaena oris - of leg Phantom tumours abdominal swelling from amenorrhoea with anaesthetic in diagnosing 721 bulging abdominal wall in conditions simulated by diagnosis of ascites from due to diaphragmatic con- traction disappearance on deep breathing muscular contraction pro- ducing . . occurrence at menopause pelvic swelling due to 757, 761 persistence during sleep 721 sex incidence of . . signs of . . - simulating appendicular abscess cholecystitis . . gastric carcinoma gumma of the liver . . hepatic abscess pregnancy . . 721, 761 suggestion treatment of 721 Pharyngeal branch of the vagus, relation to cough '. . 174 Pharyngitis, in alcoholism . . 136 - association with laryngitis. . 673 tonsillitis . . . . . . 673 - cheilitis glandularis in . . 403 - diagnosis by examination of pharynx . . - from excessive smoking use of the voice . . - exclusion of new growth in diagnosis of syphilis in diagnosis of . . tuijerculosis in diagnosis of 673 - gangrene of lung in. . . . 288 - hoarseness from . . . . 673 - micro-organisms causing . . 670 - occupations causing 070, 673 - ready tiring of voice in . . 673 - sore throat from 670, 673 - submaxillary lymphatic glands swollen in - in sl,^5hilis . . Pharynx, affections of, causing dysphagia . . 22; ptyalism - bleeding, haematemesis from swallowed blood in 294, 295 - carcinoma of (see Carcinoma of Pharynx) - chicken-pox eruption m 670, 673 171 329 81 160 686 143 423 610 86, 88 . 811 . 721 713 761 761 761 433 53 761 761 721 761 721 53 721 721 721 721 721 673 673 673 673 673 419 591 591 964 PHARYNX— PHTHISIS Phari/7U-, contd. Phosphorus poisoning, contd. Phthisis, contd. - gangrene of lung after opera- delirium ia 373 - chronic, fibroid lung and tion on . . 288 diagnosis from acute yel- bronchiectasis from 324 - paralysis of . . 775 low atrophy of liver . . 373 clubbed fingers in 128, 129 - progressive weakness of, in diminution of chlorides in gangrene of lung in 287 bulbar paralysis. . 224 urine in 373 - coagulation of sputum in 704 - rliinoscleroma of . . 805 drowsiness in 373 - consonating rales in 319 - small-pos eruption in 673 from eating match-heads - cough in . . 101, 175, 176, 185, - snail-track ulcers of, in or rat paste 373 319, 480, 577, 620 secondary syphilis 672 extreme thirst in 373 - cretaceous pellet in sputum 704 - spasm ot 225 fatty lieart from 62, 87, 241 - cyanosis in . . 185 - syphilitic stenosis of 225 liver in . . 87, 414 - deficient respiratory move- - ulceration of, earache from 230 great destruction of albu- ment in . . 319 Phenazone, reducing body in minous tissues in 373 - diagnosis from apical bron- urine due to 290 hajmatemesis in.. 294, 297 cho-pneumonia . . 321 Phenol, gangrene from 282 haemorrhages in . . 373 of fibroid lung from 246 Phenylalanin, relation of al- headache in 373 from gangrene of lung . . 321 kaptonuria to 822 increase of ammonia co- sporotrichosis of lung 322 Phenyl-glucosazone crystals . . 290 eflBcient in uriae in 373 syphilis of bronchus . . 325 Phenyl-lactosazone crystals . . 291 jaundice in . . 362, 373 typhoid fever 611 Phenylhydrazine in sugar liver enlarged, in 363, 373 - diarrhcea from 197 testing . . 115, :390, 818 in match manufacture . . 87 - diazo-reaction a grave sign in 198 Phimosis in balanitis. . 674 nausea and vomiting in 373 - early shortness of breath in 101 pain in the penis in 515 necrosis of jaw from 87, 747 - elastic fibres in sputum 319 701 - causing infantile convul- pain in epigastrium in . . 373 - empyema from 120 sions 170 post-mortem appearances 373 - fatty heart in 241 - chancre obscured by 675 priapism caused by 586 - family history in . . 848 - enuresis with 248 - - ptyalism due to . . 590 - fibroid 129 - frequency of micturition in 438 rapid feeble pulse in 373 vocal cord paralysis from 538 - priapism from 585 respiration in . . 373 - foetid sputum in 321 - pyuria due to 631 simulating acute gastritis 845 - foul breath caused by 99 Phlebitis, csdema of one leg from 459 suicidal origin of . . 373 - - taste in . . 774 - - face, neck, and arms from 458 tenderness in right hypo- - general, diagnosis from - pain in the leg from 486 chondrium in . . 373 broncho-pneumonia 615 - pyrexia due to 621 in epigastrium in 373 - gingivitis in 87 - (and see Thrombosis) total nitrogen in urine - hsemoptysis in 123, 176, Phlegmasia alba dolens, after in 373 185, 317, 319 labour . . . . . . ■ 810 urinary changes in 373 various causes of 319 during pregnancy 810 Phosphotungstic acid test for - headache in . . 328 infective thrombus albumose 20 - hernia of the lung in 194 causing . . 45G 810 Phossv jaw 87 - hydropneumothoras from 712 ulceration of leg from 810 PHOTOPHOBIA 574 - impairment of resonance in 319 Phloroglucin in urine testing 290 - from conjunctivitis 255 - impotence early in. . 347 Phocomelus 214 - corneal ulceration . . 806 - indigestion an early sign . . 350 Phonation (see Speech) - with electric blindness 840 - insomnia in. . 359 Phosphates in acute Bright's - in iritis 255 - knee-jerks exaggerated in 397 disease 12 - major trigeminal neuralgia 495 - lardaceous disease from 10, 096 - in boiling test for albumin 5 - meningitis . . 350 - liability to, in congenital - dissolved by acid . . 623 - snow blindness 840 heart disease 320 - effects of hsematuria on Phrenic nerves, compression - lichen scrofulosorum with 529 colour of . . 12 in aortic aneurysm 482 - lining of cavities by granu- - and nucleo-proteid, difBculty diaphragm supplied by 779 ,842 lation tissue in . . 701 of distinguishing in urine 471 diphtheritic paralysis of 77 -■ local muscular atrophy in . . 73 - physiology of, in urine . . 572 hiccough in irritation of - long neck and sloping shoul- - simulated by urates 815 342, 343 ders in 191 - turbidity of urine due to 208 - neuralgia (see Neuralgia, - loss of appetite in 319 - variation in amounts nor- Phrenic) . . 478 weight in.. .. 319, 847 mally excreted . . 572 Phtheiriasis, chloasma in 574 - malaise at onset of . . 620 Phosphatic diabetes (see Dia- Phthisical cachexia, albumi- - mistaken for rheumatism of betes, Phosphatic) nuria in . . 17 the shoulder 778 PHOSPHATURIA 571 impotence in 347 - nausea and vomiting in early 350 - absolute 571 Phthisis (and see Pulmonary - night sweating in 319, 577 714 - diagnosis from chyluria . . 126 Tuberculosis) - pain in chest in, various pyuria 623 - absence of abnormal apical causes of . . 480 - sacralgia from 510 signs in . . . . 319 577 m umbilical region in . . 525 - in simple ulcer of bladder 630 tubercle bacilli in sputum 704 - pleurisy in, chronic 480 Phosphorus poisoning, ab- - acute, rigors in 647 and pneumothorax in . . 578 sence of leucin and - advanced, indicanuria in . . 349 preventing pnevmaothorax 578 tyrosin from urine in . . 373 - alar or flat chest in. . 191 - pleuritic efiusion in 123 712 acute irritant symptoms in 373 - albuminuria in 17 - pneumococci in 701 albuminuria in . . 17 - albumosuria in 20 - pneumothorax from 577, 578 albumosuria in . . 20 - anaemia in . . 27, 36, 39 620 - prolonged expiration in . . 319 anuria in . . 45, 48 - bronchial breathing in 319 - prominence of one clavicle in 319 ascites in 62 - bronchophony and pectorilo- - ptyalism in . . 591 black vomit in . . 373 quy in 319 - pulmonary aneurysm ua . . 319 bleeding gums in 85, 87 - caseous mass iu sputum in 704 - purpura in . . 598 burning epigastric pain in 373 - with cavitation, abundant - pus cells, tubercle bacilli. chemical analysis of vomit 845 foul sputum in 651 703 elastic fibres in sputum in 319 collapse in 373 affection chiefly of upper - pyrexia the earliest sym- - - coma in . . 373 lobes . . 703 ptom in many cases of . . 620 concentrated acid urine in 373 nummular sputum in . . 700 - pyrexial albuminuria in . . 17 concentration and viscidity simulating gangrene of - rapid in diabetes . . 292 of bile in 373 lung 288 - rarely associated with tuber- convulsions in . . 373 tubercle bacilli in 703 culous joint disease 366 PHTHISIS— PLEURIS Y 965 PlilhisU, conld. - not related to tuberculous cervical glands . . . . 420 - retraction of cliost wall in 194 - rigors in . . . . 048, 051 - secondary pyogenic infec- tion the cause of many of the symptoms of . . G51, 701 - simulation by aneurysm . . 322 anorexia nervosa . . 850 hydatid cyst of lung . . 323 - - neurasthenia . . . . 317 pneumonia . . . . 321 sarcoma . . . . . . 296 - sputum in . . . .1)9, 319, 577, 578, 700, 701, 704 - staphylococci in . . . . 701 - streptococci in . . . . 701 - succnssion sounds in cavity 711 - sudden acute pain in chest from pneumotliorax aris- ing in . . . . . . 577 - suggested by cough which wakes patient . . . . 176 - tenderness in chest from 778, 779 - testicular atrophy in . . 80 - tiredness at onset of . . 620 -. tubercle bacilli m . . 99, 577, 578, 703, 704 - tuberculous stomatitis in . . 591 affection of mouth with. . 814 laryngitis in . . . . 674 ulceration of intestine . . 90 of palate with.. .. 640 tonsil from . . . . 672 - unequal vocal fremitus in . . 319 - unknown almost in infancy 427 - vomiting in.. .. .. 844 - wasting in . . . . 185, 319 - a;-rays in detection of 120, 319, 736, 847 Physiological albuminuria . . 19 polyuria in . . . . 584 Physostigmine, pupil constric- tion from . . . . . . 595 Pianist's cramp . . . . 177 Pica 50, 115 Picric acid, discoloration of skin and conjunctiva by 575 poisoning, xanthopsia in 840 test for glycosuria . . 290 Pied-en-grifEe (see Claw-foot) Pigeon feeders, aspergillosis in 705 - iDreast in rickets . . 191, 212 Pigmentation, buccal 38, 843, 849 - of conjunctiva? in octaonosis 822 - scars after svphilides .. 604 PIGMENTATION OF SKIN .. 574 - - in Addison's disease 38,843,849 arsenical . .88, 76, 87, 411, 423 in bronzed diabei;es .. 411 chloasma . . . . 424 clu-onic pancreatitis 135, cirrhosis . . - - from drugs exophthalmic goitre - - leucodermia malignant disease morphcea rheumatoid artln-itis syphilis sclerodermia Still's disease tinea versicolor . . in uterine lesions von Kecklinghausen's disease. . . . 781 xerodermia pigmentosum Pigmented crescents, ophthal- moscopic appearances of (Plalc VIP, Pigments in urine, abnormal, method of precipitation. . 244, 39, 292 40 424 792 424 718 424 378 237 424 418 276 114 804 804 Piles (see Ilaimorrhoids) Pillows if liigli may cause head- ache on rising . . . . 337 Pilocarpine, ptyalism due to. . 590 Pimples (see Papules) Pinguecula, conjunctivitis dis- tinguished from . . . . 256 - from exposure to weather. . 256 Pink eye, epidemics of . . 256 Pins and needles in extremi- ties in paroxysmal tacliy- cardia . . . . . . 772 peripheral neuritis . . 505 - in oesophagus, hiomatemesis from 297 - rectum . . . . . . 635 - urethra . . . . . . 210 " Pits " in small-pox. . . . COS Pitting, absence of, in cedema from obstructed lymphatics 456 - on pressure in (rdcma . . 456 Pituitary body, enlargement, polyuria from . . . . 585 hypertrophy of, in acro- megaly 335, 585, 749 hemianopsia from . . 335 - secretion, effect on menstru- ation . . . . . . 430 Pityriasis, diagnosis from ring- worm of scalp . . . . 274 - rosea, distribution . . . . 658 diagnosis from erythrasma 276 pityriasis rubra . . 658 psoriasis . . . . 658 seborrhoea corporis . . 658 syphilides . . . . 658 tinea circinata . . 658 versicolor . . . . 276 macules in . . . . 424 pruritus in . . . . 588 rare below elbow or knee 658 scales in . . . . . . 658 - rubra (Plate X) . . . . 658 absence of bullje in . . 658 itching in . . . . 658 papules in . . . . 658 death from . . . . 658 diagnosis from eczema . . 658 erythema scarlatini- forme . . . . 253 pemphigus foliaceus . . 658 pityriasis rosea . . 658 psoriasis . . . . 658 impaired health In . . 658 - - scales in . . . . . . 658 sequel of another lesion. . 658 - rubra pilaris, of fingers . . 266 soles and palms . . 658 diagnosis from derma- titis exfoliativa . . 530 lichen ruber planus 530 psoriasis . . . . 530 distribution of . . . 530 health unaffected in . . 530 papules in 528, 530, 658 plucked-fowl skin in . . 530 pruritus in . . . . 588 scales m . . 655, 658 slightness of itching in 530 - versicolor (see Tinea Versicolor) Placenta, adherent .. .. 227 - causes of delay in delivery of 229 - origin of eclampsia in . . 172 - prtevia, hcemorrhage from 436, 437 need for early delivery in 437 signs of . . . . . . 437 Plague, bacteriological dia- gnosis i7i . . . . . . 418 - gangrene in.. .. .. 282 - generalized glandular en- largement in . . 416, 418 - purpura in . . . . . . 596 - rigors in . . . . . . 647 Plantar fascia, gonococcal inllammation . . . . 376 - reflexes (and see Babinski's sign) 81 asymmetrical, with coma 137 in hysterical monoplegia 541 infantile paralysis . . 81 paralyses from intra- and extra-medullary lesions 546 relation of ankle-clonus to 44 in sciatica . . . . 487 extensor (see Babinski's sign) Plantaris, nerve supply of . . 542 - longus, liability to spontan- eous rupture . . . . 597 Plants as cause of bullfe . . 110 Plethoric habit, epistaxis from 252 Pleura, B. coli infection of, causing pneumothorax 577, 578 - carcinoma of, bloody effusion in 118 - cohesion of layers preventing traumatic pneumothorax 578 - effusion into, fiom bronchial obstruction . . . . 121 - endothelioma of, gangrene of hand from . . . . 287 - gas in (see Pneumothorax) - insensitiveness of . . . . 777 - new growth of, displacement of cardiac impulse m . . 330 pain and tenderness in back from . . . . 789 pleuritic effusion in 118, 121, 322 - pneumothorax from gan- grene of . . . . 577, 578 - rupture of aneurysm into 482 Pleurisy from abscess of lungs 649 - in acute rheumatism . . 671 - with aortic aneui-ysm . . 482 - clubbed fingers in . . . . 128 - cough from.. .. 176, 480 - danger of regarding as pleuro- dynia . . . . . . 478 - disappearance of pain with effusion in . . . . 480 - distinction from pleurodynia 776 - with effusion in chest (see Pleuritic Effusion) - empyema after . . . . 650 - in enteric fever . . . . 648 - intercostal tenderness in . . 479 - leucocytosis moderate in . . 401 - and mediastinitis . . . . 61 - mistaken for hysteria . . 777 indigestion . . . . 351 intercostal nem-algia . . 777 - pain in the back from . . 789 - - chest in . . . .478, 479, 480 increased by movement 479 relieved by unmobaliz- ing chest . . . . 479 epigastrium in . . . . 485 left hypochondrium in . . 499 limbs in . . . . . . 505 right hypochondrium in 501 - in phthisis . . . . 480, 578 - pleuropericardial rub in . . 481 - in pneumonia . . . . 480 - rigors with . . . . . . 650 - rub in .. ..479,481,499 - secondary to abscess of liver 409, 651 subphrenic abscess 501, 721 - shortness of breath in . . 101 - simulated by herpes zoster 830 - systolic thrill due to . . 790 - tenderness in chest from 776, 777, 779 in back from . . . . 789 epigastrium from . . 779 966 PLE URIS Y, DIA PHRA GMA TIC—PNE UMONIA PleurUy, contd. Flumbism, contd. Pneumococci, could. - diaphragmatic, abdominal - cerebral symptoms in (and - pyelonepln-itis due to S3 pain in . . . . 133,645 see Saturnine Encephalo- - in sputum, in lobar pneu- rigidity from . . 645 pathy) 38 monia (Plate XII, Fig. 0, distribution of paia from 779 - cohc in . . 136, 144, 798 p. 696) 702 frequent absence of rub in 480 - coma due to (see also Satur- no proof of pneumonia . . 702 pain in chest in . . 478 nine Encephalopathy) 137 139 - ulcus serpens 807 near costal margin in. . 473 - constipation in (Fig. 36, p. 14 ^) - urethritis due to 83 about the crest of the 136, 144, 153, 507, 798 Pneumonia (and see Broncho- shoulder in . . 479 - deafness from 191 pneumonia), abdominal pain simulating phrenic neu- - deliriimi due to 195 in 133, 472 64.-, ralgia . . 479 — diagnosis from renal colic. . 500 rigidity in U45 general peritonitis 645 - djrsphagia from 225 - absence of signs in chest in shght depression of liver in 405 - epileptiform convulsions in 3 73 some cases of . . 702 Pleuritic effusion (and see Chest, - foul taste in mouth from . . 774 - albuminuria in 12, l.S, 1' , 18 serous effusion in) 120 121 - general abdominal pain in . . 473 - albumosuria in 20 ajgophony in 332 - gout in 507 - anaemia in, suggesting em- - - ascites with 62 - granular kidney in . . 144 pyema 39 blood-stained from new - headache in . . 328 - biliary catarrh in . . 372 growth in lung 118 322 - high blood-pressure in 485 507 - bleeding gums" in . . 85 from inflammation . . 118 - impairment' of sight in 77 - bromidrosis with . . 714 cardiac impulse displaced - impotence in 346 - bronchial casts in sputum. . 704 by .. ..232,330 764 - infantili.«m from 215 - casts in sputum in 704 - character of fluid in 118 121 - intestinal motor activity in- - Cheyne-Stokes respiration in chronic nephritis, afirst hibited in . . 144 in . . 125 symptom of 15 - irritabihty in 360 - consolidation of lung in . . 372 communicated pulsation in 764 - lead in urine in . . 87 525 - cough from . . . .175, 176 372 compression of lung in 324 331 - leucopenia in 401 - crisis of, need for stimulants - - confusion of hydatid cyst - meduUa degeneration from 225 at 622 of liver with 415 - muscular atrophy in 7 1 profuse perspiration after 702 depression of liver from - neuritis from sudden drop in tempera- large right-sided 405 77, 131, 165, 492, 506, 507 797 ture at . . G22 empyema following 119 of external popliteal nerve 543 - cyanosis in . . 186 fibroid lung and bronchi- - obscure sources of . . 77 - deep-seated . . 702 ectasis from 324 - occupation in diagnosis of. . 473 - deficiency of chlorides in heart failure from 525 - optic neuritis due to 139 836 urine in . . 186, 321 372 from infarction of lung . . 123 - pain in epigastrium in 486 - delay in appearance of phj-- - - immobilization of dia- limbs in . . 507 sical signs in 480 diaphragm by 721 umbiUcal region only com- — delirium in . . 194 latent, witli shortness of plaint in some cases . . 525 - in diabetes . . 292 breath . . 101 - palsies in 144 - diagnosis from peritonitis . . 472 from new growth 118, - paralysis of limbs in 797 suppurative pylephlebitis 614 121,185 322 - pimctate basophilia in 30 - diazo-reaction in . . 198 palpitation in 525 - rise of blood-pressure in.. 485 - dry mouth in 774 particles of new growth of - simulating general paralysis - dullness in the chest from . . 645 lung found in . . 322 of the insane 797 - empyema after 119, 323, 650 - - physical signs of . . 192 muco-membraneous colitis 486 slight value of leucocyte pneumotliorax with 480 - symptoms of . . 3S , '<^ count in diagnosis of . . 401 after tapping for 577 578 - talipes due to 131 - endocarditis in . . 103 314 shrinkage of one side of - tetany in 178 - in enteric fever 648 chest from . . 193 194 - tremor in . . . . 795, 797 - eosinophilia after . . 248 skodaic resonance over . . 667 - wrist-drop in . . 77, 507 798 - fibroid lung and bronchi- - - tuberculous, inoculation of PNEUMATURIA 576 ectasis from 324 guinea-pig in . . 121 - association with foeces per - foul taste in. . 774 unilateral enlargement of urethram . . 264 633 - fungating endocarditis from 314 chest from 192 intestinal fistula 576 - furred tongue in 774 a:-rays in diagnosis of 721 Pneumobacilli in sputum in - gangrene of lung from - rub Csee Rub, Pleuritic; lobar pneumonia 702 287, 578, 703, 712 Pleurodynia, definition 478 - cerebrospinal fluid . . 340 - gradual resolution in 702 - distinction from pleurisy . . 776 Pneumococcal arthritis, general - hsemoptysis in ..317, 320 321 myalgia . . 507 account of 375 simulating phthisis 321 - pain in the chest in 477 - infections, bacteriuria in . . 83 - heart impulse displaced in 330 - pneumonia mistaken for . . 480 pleurisy with 122 - herpes facialis in . . 186 372 - tenderness in chest from . . 776 - middle-ear disease . . 375 - hyperpyrexia in 343 of muscles in 478 - peritonitis, acute . . 55 - hypothermia after convales- Pleuropericardial rub (seeEub, Pneumococci, acute laryngitis cence . . . . 346 1 'leuro-pericardiai; from 185, 226, 465, 466, ■- infantile convulsions from 170 Ple.xus patellaj nerves, skin 670, 673 709 — in influenza. . . . 505 610 distribution of . . 659 tonsilhtis from . . 670 frequently fatal . . 505 Plucked-fowl skin in pityriasis - in ascitic fluid 57 sputum like that of muco- rubra pilaris 530 - bronchopneumonia 615 purulent bronchitis . . 702 Plumbism, albuminuria in . . 16 - in cerebrospinal fluid 340 - inhalation, gangrene of lung - amblyopia with 830 - circulating blood . . 650 Ul . . 703 - amenorrhcea from . . 23 - empyema from . . 119 122 - initial rigor in 372 - anaemia in 36, 37, 38, 13G, - fungating endocarditis 237, 614 - jaundice in . . . . 362 372 144, 507, 798 - general septiciemia 642 - leucocytosis m . . 39, 401, 645 - anuria In . . . . 45 , 48 - in healthy persons 702 - liver engorged in . . 372 - arteriosclerosis from . . 144 507 - meningitis due to . . 339 642 - lividity in . . 645 - bleeding gums in . . 85 , 87 - in nasal discharge . . 203 - loss of knee-jerks in 399 - blue line on gums in 136, 144, - nephritis due to 83 - mistaken for hysteria 777 473, 507, 525, 551, 645, 798 - pharyngitis from . . 670 intercostal neuralgia 480, 777 - brachial palsy in . . 551 - in phthisical sputum 701 pleurodynia 480 - cachexia in . . 115 - pleurisy from 122 - pain in chest in ..372,478 480 - central scotoma from 836 - pyelitis due to 625 - physical signs in 186, 701, 702 PNEUMONIA— PONS VAROLII 90/ Pneumonia, contd. - pleurisy in . . 122, 372, 480 - pneumococcal arthritis in.. 375 - pneumococci in blood in . . 650 - - in sputum in (Plate XII, p. U9G).. .. 321, 702 - pneumothorax from . . 578 - polyuria after . . 582, 583 - prognosis in alcoholics . . 194 - jiulse relatively slow in . . 372 respiration ratio in 321, 372 temperature ratio in . . 097 - pyopneumothorax from . . 712 - pyrexia in 321, 372, G22, 702 and crisis of . . . . 186 - resolution delayed in . . 324 - respiration rapid m 372, G45, 702 - - ratio ui .. 321, 372, 691 - right basal, special associa- tion of jaundice with .. 372 - rigors m 372, 647, 648, 650 - rub in . . . . . . 372 - secondary to abscess of liver 409 - septic, gangrene of lung from 703 haemoptysis in . . . . 371 - shortness of breath in . . 101 - simulated by general miliary tuberculosis of lung . . 703 - simulating general peritonitis 645 - skin flushed, dry, pungent in 372, 702 - skodaic resonance with . . 667 - spleen enlarged in.. 692, 698 - sputum rusty in 175, 186, 320, 372, 700, 701, 702 various colours of . . 702 - - viscid in 320, 321, 372, 700, 702 - sudden onset of 321, 372, 701 - technically a septiccemia . . 650 - temperature curve (Fig. 188) 702 - urate deposit in . . . . 815 - vomiting in.. .. .. 622 - working of the nares in . . 645 - .f-rays in diagnosis (Fig. 99) 321 Pneumonokoniosis (see Cir- rhosis of Lung) Pneumoperitoneum, causes of 711 - succussion sounds in . . 711 PNEUMOTHORAX .. .. 577 - absence of breath sounds in 480 pain in some cases of . . 480 symptoms from . . . . 578 vocal fremitus in. . .. 480 - acute dyspncea in . . . . 185 onset in half the cases of 480 - causes of . . . . . . 577 - cyanosis in . . 185, 480, 577 - dyspnnea in . . . . 480 - with fluid, succussion with 193 - from gangrene of pleura 577, 578 - heart failure in . . . . 464 displaced by 232, 330, 480, 712, 721 - hremoptysis from . . . . 577 - liver depressed by . . . . 405 - in lobar pneumonia . . 578 - loss of movement of chest on aft'ected side in . . . . 4§0 - onset insidious in many cases 480 - orthopnoea in . . . . 464 - pain in the chest in 193, 478, 577 aggravated by breath- ing in . . . . 480 severe sudden at onset 480 - partial 577 - in phthisis 578 - physical signs of 193, 480, 577 - pleural effusion in . . . . 480 - prostration in . . . . 480 - rapid feeble heart's action in 480 - sense of " something giving way " at onset of . . 480 - simulated by subphrenic abscess . . . . . . 578 PneumoUtorax, contd. - symptoms caused by . . 577 - tubercle bacilli in sputum in 578 commonest cause of . . 185 - tympanitic resonance in . . 480 - unilateral enlargement of chest from . .192, 193, 480 - .r-rays in diagnosis of 480, 577 Poikilocytosis (Plate II, Fig. E) 28 - in pernicious anajmia . . 616 - severe anaemias . . . . 620 Poisoning (and see various poisons, e.g. Arsenic ; Cor- rosive; Irritant; Opium; Phosphorus ; Ptomaine ; Shell-fish ; Strychnme ; etc.) - anuria in . . . . . . 45, 48 - bleeding gums hi . . 85, 87 - clironic, causing amenorrhooa 23 irritant, diarrhoea from . . 197 - condition of skin in . . 195 - delirium from . . . . 195 - diazo-reaction in some cases 198 - fatty degeneration with as- cites in . . . . . . 62 - hfematemesis in . . 294, 297 - hypothermia in coma due to 346 - jaundice due to . . 362, 373 - nystagmus following . . 453 - universal oedema from . . 458 Polariaietry in quantitative estimation of glycosuria 291 Polio-encephalitis, acquired paralysis of childhood from 155 - athetosis after . . . . 155 Poliomyelitis, acute anterior, acute onset of . . . . 562 - - in adults . . 73, 562 atrophic palsies in 128, 544 claw-hand in . . . . 127 contractures after 163, 165 convulsions in . . 128, 555 defects of growth, deform- ities, etc., in . . . . 555 diagnosis from peripheral neuritis . . . . 559 electrical reactions in 70, 555, 558, 559 — ■ generalized pains in . . 555 headache in . . . . 128 infantile paralysis from 70, 559 lymphocytosis in cerebro- spinal fluid in . . 339 muscular atrophy in para- lysis of.. ..70, 158, 558 paralysis of arm in . . 555 paraplegia due to 557, 561, 562 pyrexia in . . 128, 555 reflexes in . . 555, 559 rigors in . . . . . . 647 talipes from . . . . 559 vasomotor changes in . . 555 vomiting in . . 128, 555 - chronic anterior, fibrillary contractions in . . . . 158 - claw-foot from .. .. 127 - diagnosis of transverse mye- litis from . . . . . . 74 - Landry's paralysis an acute variety of . , . . 567 Politzer's acoumeter, illustrated 188 Polycystic disease (and see Cystic Disease) . . . . 48 of kidney, general account of 396 POLYCYTH/EMIA ..579 - m congenital heart disease 244. 247, 790 - cyanosis and enlarged spleen 187 - delirium from . . . . 195 - dyspnoea associated with . . 580 - low colour index with . . 580 - in mitral valve disease . . 38 Polycythoemia, contd. - pulmonary stenosis . . 247 - shortness of breath in . . 100 - splenomegalic (see Spleno- megalic Polycytha>mia) Polydipsia (see Thirst, Extreme) Polymorphism of syphilides446', 533 Polymorphonuclear cells in cerebrospinal fluid in meningitis . . 558, 643 in normal blood count . . 28 - leucocytosis (see Leucocytosis) Polymyositis, acute, anorexia in 504 diagnosis from trichinosis 504 erythematous rash in . . 504 oedema of extremities in 604 pain in muscles in 503, 504 - - pyrexia in . . . . 504 rigidity of muscles in . . 504 tenderness of muscles in 504 Polyorrhomenitis . . . . 123 - acute hvdrocele in. . .. 522 Polypus, aural 408 bleeding from ear due to 468 - - deafness from . . . . 190 tinnitus due to . . . . 793 - nasal, with accessory sinus inflammation . . . . 255 anosmia from . . . . 60S epistaxis due to . . . . 250 headache from . . . . 327 - - impairment of taste fi'om 775 loss of taste due to . . 774 obstruction to nose by . . 668 with rhinitis . . . . 204 snoring due to . . . . 669 - placental, vaginal discharge from . . . . . . 211 - rectal 635 diagnosis from carcinoma of rectum . . 635, 636 piles . . . . . . 635 difficulty of palpating . . 635 haemorrhage in . . . . 93 multiple in many cases. . 635 passage of blood and mu- cus in . . . . . . 635 - urethral, shown by the endo- scope . . . . . . 208 - uterine, metrostaxis from. . 436 characters of . . . . 435 metrorrhagia from 433, 435 simulating inversion of uterus . . . . . . 587 malignant growth . . 435 prolapse of uterus . . 587 vaginal discharge from.. 211 Polvplasmia . . . . . . 26 POLYURIA 581 - in azotic diabetes . . 583, 584 - causes of . . . . 581, 583 - in chronic nephritis 15, 48, 102, 103, 303, 331, 437, 579, 583, 584 - clearing up of serous effusion 582 - diabetes insipidus . . 579, 789 mellitus 292, 437, 507, 579, 789 - due to examination for life insurance.. .. 581,582 - hysteria . . . . . . 789 - in lardaceous disease 48, 696 - with movable kidney 310, 729 - periodic . . . . . . 581 without apparent cause. . 582 in hydronephrosis . . 500 - in phosphatic diabetes . . 572 - polycystic disease of kidneys 396 - polycythsemia with . . 579 - in pregnancy . . . . 293 - pyelonephritis . . 48, 626 - renal tuberculosis . . 48, 626 Pons varolii, lesions of (and see Haemorrhage, Pontine) ataxy with . . . . 68 PONS VAROLII—PRIMARY MUSCULAR DYSTROPHIES Pons varolii, contd. Postural causes of tahpes . . 132 Pregnancy, contd. Chevne-Stokes respiration - changes, influence on pains - haemorrhage in early months with 125 due to perigastric adhesions 486 usually due to threatened . crossed hemiplegia vnXh. 336 - influence on bruits. . 105 abortion . . 758 deafness from . . 190 Pot-belly in rickets . . 695, 724 - heart impulse displaced in 330 ,332 hyperpp-exia from 346 Potassium chlorate, haemo- - hyperinvolution of uterus priapism in 586 globinuria from . . 314 after 706 spastic paralysis of upper ptyalism due to 590 - impetigo herpetiformis in 113 limb from 547 purpura from . . 596 - almost impossible with car- Popliteal abscess (see Abscess, - iodide (see Iodide of Potassium) cinoma of body of uterus 436 Popliteal; - salts, polyuria after 582 - importance of examination Popliteal artery, aneurysm of Potmen, plumbism in 136 during 227 (see Aneurysm, Popliteal) Pott's curvature, shortness of - leucocytosis normal in 399 cedema of leg from 456 breath in . . 101 - lineae albicantes in. . 402 - exotosis (see Exotosis, Popli- local prominence of spine - mastodynia in 479 teal; in . . 134 - menstruation possible up - glands (see Lymphatic simulating colic . . 134 to the third month in . . 758 Glands, Popliteal) from spinal caries 564 - method of examination in 228 - nerves, external and inter- tenderness and rigidity of - moUities ossium in 269 nal, signs of para lysis of . . 543 spine in 134 - nephritis in. . . . 8, 11, 16 talipes from paralysis of 132 - fractme causing talipes . . 132 - neuritis of . . 75 injury of internal, causing Pouches, oesophageal 224 - occlusion of rectum in 638 claw-foot 12G bougie in diagnosis of . . 842 -. palpation of foetal parts in 758 (see also External Popli- symptoms produced by 842 - pelvic swelling due to 757 758 teal Xerve) .T-rays and bismuth in - phlegmasia alba dolens in . . 810 - swelling (see Swelling, Popli- diagnosis of . . 842 - polyuria in . . 293 teal) Pouting of lips in mTopathy - ptyalorrhoea in 592 - reins, thrombosis in 456 {Fig. 81) . . 260 - pyelitis in . . 625 - vessels, pressure on due to " Powdered wig " deposit m - pyosalpinx after . . 737 separation of the lower urine in oxaluria 470 - relation to acute yellow epiphysis of femur 763 Pozzi, cochleate uterus of. atrophy . . 302 PopUteus, nerve supply of . . 542 sterility from . . 219, 706 chorion epithelioma 434 Porencephalus. . 558 - syndrome of, in endometritis 429 metrostaxis 436 - cerebral palsies from 155 Preacher's hand (see Claw- - in retroverted uterus (see - convulsions in .. 170, 172 hand) Uterus, Eetroverted - dwarfism with 214 Pre-aurioular gland (see Lym- Gravid) . . 758 Pork, colic due to . . . . 136 phatic Gland, Pre-auricular) - signs in ectopic gestation. . 760 - trichinosis infection from Precipices, vertigo on 827 of normal . . 52 437 504, 801 Precipitancy of defaecation . . 348 - simulating ascites . . 52 717 - urticaria from 746 Precocity, sexual, suprarenal distended bladder 730 Port wine, priapism caused by 586 tumour associated with 729 phantom tumours 433, 721 761 Portal glands (see Lymphatic Precordial pain (see Pain, - softening of fibroid in 759 Glands, Portal) Precordial) - swelling of breasts in 743 - pyaemia (see Pylephlebitis) - thrill (see Thrills, Precordial) in right iliac fossa due to 737 - thrombosis (see Pylephle- - veins, dilatation of, in ad- thyroid gland in. . 791 bitis, Adhesive) . . 301 herent pericardium 242 - tetany during . . 3, 178 - vein, obstruction, albumin- Precordium, bulged in mitral after . . 802 uria in 300 regurgitation in children 238 - thirst increased in. . 293 ascites ui 58, 300, 301, 696 in adiierent pericardium 242 - tinnitus increased by 793 causes of ..53, 692, 696 Pre-glycosuric state, obesity in 453 - tumour with, diagnosis of. . 759 dilated abdominal veins Pregnancy, acetonuria in 4 - ulceration of leg in 810 in 300 - acute mastitis in . . 743 - uraemic amaurosis in 839 gastric congestion in . . 300 - albuminuria in 17 - uterine casts in 220 hoematemesis in 294, 301 - albumosuria in 20 haemorrhage in . . 435 with jaimdice 301, 696 - amenorrhoea due to 23, 24, - uterus in 7r.8 nausea in 300 350, 758, 759 - varicocele of vulva with . . 770 obstruction to bile-dnct 696 - amaurosis in . . 836, 839 - vomiting in.. ..579, 843 844 oedema from . . 300 - with appendicitis . . 761 acetonuria in 4 oesophageal varices in 300 - appetite increased in 293 diagnosis from indigestion 350 spleen enlarged in 692 696 perverted in . . 50, 774 in morning 437 vomiting m. . . 300, 843 - ascending nephritis in 16 polycythaemia in 579, 580 Porter-like urine in septicemic - bacilluria in 16, 51, 82 615 toxic factor in 843 jaundice . . 372 - breast changes in . . 350, 743 Pre-hemiplegic chorea, move- Porters, kyphosis in . . 183 - bullous eruption in • . . 111 ments in . . . . 156, 157 - spinal bursa of 183 - chorea in . . 156 Prepuce, epithelioma of, enlarged Post-hemiplegic athetosis . . 155 - constipation following 148 inguinal glands from 423 - chorea . . . . 156 157 - diagnosis of . . 24 - herpes of . . . . 209, 830 Post-mortem wart . . 266 from ovarian tumour . . 758 - swollen and oedematous in Post-partum haemorrhage (see uterine fibroid . . 758 balanitis . . 674 Haemorrhage, Post-partum) - discharge of milk from nipple - ulceration of, in balanitis . . 674 Post-pharj'ngeal abscess (see during . . . . 201, 743 Presentations, abnormal foetal 228 Abscess, Post-pharyngeal) - dyschezia in 150 Pressure, relief to trigeminal Posterior basal meningitis - dysmenorrhooa cured by . . 219 neuralgia by 495 ("see Meningitis) - eclampsia with . . 160, 172 Presvstolic bruit (see Bruit) - inferior cerebral artery, - efi'ect on neurotic dys- PRIAPISM (see Erections, Penile) thrombosis of, ataxy from 666 pareunia . . 22'' Pricking, pruritus described as 588 dissociative anaesthesia - enlargement of uterus in . . 350 - sensation in eyes, from from (Fig. 184) 666 - epileptiform convulsions in 109 error of refraction 328 - scapular nerve, mascles sup- - fluctuation in 758 in miliaria rubra 831 plied by . . 550 - flushing in . . 268 Prickly heat, pruritus in 588 spinal roots derived from 550 - foetal lieart sounds in 758 Primary lateral sclerosis (see - tibial nerve, skin distribution 659 - elycosuria in 293 Sclerosis) Posthitis a cause of priapism 585 - haematoma of vulva in 770 - muscular dystrophies (see Postural albuminuria 19 - haemoglobinuria in. . 315 Myopathy) PRIMULA OBCONICA—PSEUDO-HERMAPHRODITISM 969 Primula obconica, buUre from 110 Proslate, enlarged, contd. Proslalitis, cmtd. Printers, plumbism in 13G changes in stream of urine - urethral passage of faeces Proctitis, urethral passage of from 439 from 264 fieces from 204 coud(!- catheter in 440 441 Prostration, from febricula . . 505 I'roctoscope, in rectal afleotions 100 - - cystitLs with G27 - in Henoch's purpura 600 Progeria, anirina pectoris in . . 218 diagnosis of 311 - influenza, disproportion- - arteriosclerosis in . . 218 difficulty in micturition in ately severe in . . 505 699 - baldness in (Fig. 70) 218 311 439 - from pneumothorax 480 - emaciation in 218 distended bladder from 52 , 730 - profound, in traumatic anuria 4') - premature decrepitude in.. 218 frequency of micturition in - in pyaamia . . . . 372, 649 ossification in 214 311, 438, 440, 581 817 - tropical abscess of liver 369 Progressive bulbar paralysis, ncpliritis from . . 8 - typhus fever . . 371 , 698 fibrillary contractions in priapism from . . 585, 586 - after urinary operations . . 49 (and see Paralysis, Bulbar] in prostatitis . . 627 631 Protargol, leucocytosis from 400 158 159 of puberty 248 Proteid, Eence-Jones' 21 - muscular atrophy 16, 72, 73 127 pyelitis in 025 Protozoa in malaria (see Malaria) absence of pain in 5^5 pyonephrosis from 626 Prurigo, character of papule of and bulbar paralysis rectal examination 439, 441 ,638 528, 531, 532 associated . . G41 residual urine with 438 - diagnosis from eczema, urti- claw-hand in . . 127 retention of urine with 45 440 caria, psoriasis . . 531, 532 contractures in 163 165 septic urethritis from self- scabies and pediculosis . . 532 exaggerated reOexes in 127 catheterization in 680 - ferox, age incidence of 532 fibrillary contractions in - gonococcal infection of 207 characters of papules of. . 531 158, 159 - massage of . . 208 distribution of . . 531 palsy of one leg in 544 - palpation per rectum 307 intense itching in 531 R.D. in 73 - sarcoma of, hard fixed swell- lymphatic gland enlarge- simulated hj gonococcal ing felt per rectum 638 ,ment in . . 531 ,532 arthritis 377 - suppuration in, perineal sore mitis 531 syringomejiia 73 from 677 pustules in 531 Tooth's peroneal (see - swollen and hot and tender relation to acanthosis . . 531 Tnoth'sl in acute prostatitis 207 simulated by urticaria . . 531 Professional cramps . . 177 - tenderness of, in acute pros- skin changes in . . 531 Projection, physiology of 199 tatitis 031 - pruritus in . . 588 Prolapse, anal, haemorrhage in 93 prostatic abscess G31 - simplex aigu, resemblance of - of ovaries (see Ovaries, - tuberculous, absence of penile papular erythemn to 531 Prolapsed") 508 pain in 512 PRURITUS (and see Itching) 588 - and pilfi-S. association of . . 93 associated with renal - aflecting napkin region 447 - of urethral mucous mem- tuberculosis . . 626, 694 - ani from thread-worms 569 brane simulating urettiral tuberculous bladder - associated with cutaneous caruncle . . 770 312, 441, 513, 629 678 diseases . . 588 PROLAPSE OF UTERUS .. 586 epididymis . . 629 - bath 588 albuminuria from 16 testis . .518, 519 678 - in cheiropompholyx 111 anatomical considerations 586 deposits in 6.30 - dermatitis herpetiformis . . 113 causing cerebral haemor- epididymitis with 767 - herpes gestationL« . . 111 rhage . . 10 pain in the perineum 516 - hiemalis 588 congenital extroversion of perineal sinus from 678 - papules causing . . 528, 533 bladder simulating . . 587 prostatic abscess in 6.32 - senilis 588 sacralgia in 509 rectal examination in 307 519 - tenderness of scalp from 780, 781 - - simulated by inversion of rounded nodule felt in - universalis . . 588 uterus . . 587 prostate per rectum in 678 - vulvas from thread-worms 569 polypus of cervix 587 secondary tuberculosis else- Prussic acid in gastric con- ulceration of vagina from 211 where in genito-urinary tents, recognition by smell 844 - - vulval swelling due to . . 768 system . . 632 Pseudo-angina without cardiac Proliferating papillomatous Prostatectomy, urethritis fol- or vascular disease 483 ovarian cyst, ascites in . . 58 lowing 767 - diagnosis from true angina Prolonged pyrexia (see Pyrexia Prostatic abscess (see Abscess, pectoris . . 482 Prolonc'ed^ Prostatic) - neurotic origin 482 Pronators, nerve-roots supply- - calculus, effects of . . 512 - never fatal . . 482 ing . . 556 - threads in residual gonor- - occurrence at any age 482 - nerve supply of 550 rhceal catarrh 444 - onset frequently at night. . 482 Proptosis (see Exophthalmos) Prostatitis, bacteriuria in 83 - sex incidence of 482 Propulsion in paralysis agitans 796 - chronic, muco-pus in 208 toxic (tobacco, tea, coffee) Prostate, adenoma of 307, -ill 511 - diagnosis from acute cystitis 627 origin of some cases of 482 absence of penile pain from 511 - difficulty of mictiurition in. . 511 Pseudo-bulbar paralysis (see characters 441 - following urethritis also Hemiplegia, Double) 686 hematuria in . . 304, 311 206, 515, 627, 631 no atrophy of tongue in pain in perineum in 516 - frequency of micturition in 591, 641 rectal examination in 438, 511, 631 bilateral supranuclear fa- diagnosis of . . 512 638 - from non-gonococcal ure- cial paralysis in 535 - calculus of (see Calculus, thritis . . . . 206 515 and bulbar paralysis dis- Prostatic) - pain in hypogastrium in . . 631 tinguished . . 224 641 - carcinoma of (see Carcinoma legs from . . 491 dysarthria in 686 of Prostate) loins from 491 facial spasticity in 686 - disease of, pain in lower penis in 441, 510, 511, 513 515 loss of control of emotion- extremity from . . 491 perineum in . .491, 516 631 al expression in 686 after micturition in . . 441 rectum from 628 palatal paralysis in 640 penis from 510 suprapubic, in . . 631 ptyalism in " 591 perineum in . . 442 - painful erections with 515 Pseudo-diarrhoea in dyschezia 142 - enlarged 311 - prostate enlarged in 627 631 Pseudo-elephantiasis due to - - age incidence of . . 440 hot and tender in 207, 631 l_vmph-gland obstruction 456 albuminuria from IG - pyrexia in ..207, 511 631 - vulval swelling from 768 bilateral hydronephrosis - rectal examination of 511 631 Pseudo-hermaphroditism, from 311 - retention of urine due to 207, 631 changes of genital organs 706 bleeding from 305 - sequela of gonorrhcea 515 - sterility due to 706 970 PSEUDO-HYPERTROPHIC PARAL.—PULMOXARY TUBERC Pseudo-hypertrophic muscular paralysis, muscles affected in . . . . . . 555, 560 age and sex incidence. . 560 difficnity of lifting pa- Tient by shoulders . . 561 electrical reactions in 70 familial character of . . 560 fibrUlarr contractions rare in . . . . 158 mode of " climbing up himself" .. .. 560 paraplegia due to . . 557 no sensory or sphincter changes in . . . . 560 -waddling gait in 277, 561 Pseudo-leukseniila infantum (Fm. 2) .. .. 42, 694 absence of leucocyiosis in 694 age incidence of . . . . 694 ascites in. . . . 64, 122 blood changes in . . . . 64 chronic, cause of . . . . 694 lymph glands not enlarged in 5S9 cedema of legs from 459, 461 pericarditis in . . . .^ 122 pleuritic effusion in . . 122 purpura in . . . . 596 recovery from . . . . 694 relation to rickets or con- genital syphUis 42, 695 severe anieniia in 459, 694 spleen enlarged in Fig. 2. p. 42) ' 64, 599, 692, 694 symptoms of . . . . 42 Pseudo-neuralgias, diagnosis of 498 Pseudo-nystagmus . . . . 452 Pseudo-cedema of legs in myx- cedema . . . . . . 585 Pseudo-pelade of Brocq . . 85 baldness from . . . . 782 relation to alopecia areata 782 sclerodermia . . . . 782 tendarness of scalp from 780 Pseudo-tabes . . . . . . 66 Pseudo-trichinosis (see Poly- myositis, Acute) Pseudocyesis . . . . 166, 721 Psoas abscess (see Abscess, Psoas) Psoas bursa, distended, com- cated pulsation in . . 741 diagnosis from aneur- ysm of external iliac artery . . . . 741 impulse on coughing in 739 ingninal swelling from distention of . . 741 irreducibOity of . . 741 isith osteo-arthritis of hip joint . . . . 741 position external in fe- moral vessels . . 7.39 reducibUity . . . . 7-39 translucency of . . 741 - muscle suppuration and lordosis 183 Psoriasis, afieetion of elbows, knees, and extensor sur- faces by . . 447, 530, 656 of nails in . . 275, 445 - age incidence of . . . . 533 - anidrosis with . . . . 714 - baldness from . . . . 84 - in bathing-drawers area . . 447 - complexion associated with 657 - description of eruption of.. 657 - diagnosis from eczema . . 657 lichen planus . . 529, 627 lupas erythematosus . . 657 j>apular syphilides . . 533 pityriasis rosei . . . . 658 rubra . . . . . . 658 pUsiris . . . . 530 531, 579, 596, Psoriasis, conid. - diagnosis from prurigo f erox . . ringworm of body scalp seborrhcea - eosinophOia in - involvement of hps in - parts specially affected by - pityriasis rabra after - pruritus in some cases of . . - recurrence of - scale.? in . . . . 655, - of scalp, diagnosis from favus - slightness of itching with . . - sore fingers from - rupioides of M'Call Anderson - and KyphUis distinguished. . - unimpaired health with . . Psorosperms, method of demon- strating . . Psychalgias (see Pseudo-netir- algia) - neurasthenic pain with no physical basis Psychical weakness, motor ties associated with Psychosis, Korsakow's, in al- coholic peripheral neuritis Pterygium of nails Ptoniaine poisoning, acute diarrhcea from agglutination serum test as cause of bullous der- matoses due to Graertner's baeillns oedema of face, neck, and arms in polycythaemia in ptirpura in severe diarrhcea in vertigo from wasting with PTOSIS (/'if^s. 156-9). . - from cervical sympathetic paralysis . . 247, 546, 594, - of colon, constipation due to {Fig.'Z9) - (and see Gastroptosis ; Glenard's Disease; Hepato- ptosis ; Visceroptosis) - in conjunctivitis - from facial paralysis 536, - hysterical - in myopathy - tabes PTYALISM - bacteriology in dia,gnosing cause of . . - from fixation of jaw - ftmctional . . - mercurial . . . . 37, 86, - in trigeminal netu-algia - Wassermann's reaction in. . Ptyalorrhcea, functional 590, - relation to tic douloureux. . Pubes, acute necrosis of, grave constitutional symptoms in scrotal swelling due to - tuberculous caries of, dia- gnosis from gumma of crus penis sarcoma of cms penis Puberty, acne vulgaris at - albuminuria of - anorexia nervosa at - breast changes at . . - delayed in infantilism - effect on nocturnal entiresis - enlargement of jjrostate at - epi'staxis of . . 251, - menorrhagia at - mUk in breasts at 202, 532 532 275 274 656 249 403 657 658 588 533 657 271 657 266 654 658 657 803 498 494 160 505 444 196 597 114 597 597 579 827 69 589 792 147 590 589 166 260 262 590 591 591 592 797 495 591 592 592 767 767 767 767 603 19 849 743 218 248 248 252 430 743 Puberty, coiUd. - premature appearance of, j ^ associated with liypeme- phroma . . . . . . 690 - priapism at. . . . . . 586 Pubic hair, early develop- :_ cj ment, with hypcmephro- ►! ma 690 - region, sycosis vulgaris of . . 602 Puckering of skin . . . . 745 Pudic nerve inflamed, dys- pareunia from . . . . 221 Puerperal fever, endocarditis in 103 infection of uterus in . . 649 offensive vaginal dis- charge in . . . . 649 rigors in . . . . 648, 649 simulating rheumatism . . 650 - infection, pelvic peritonitis from 508 - sepsis, pelvic abscess from 760 septicaemia in . . . . 698 Puffiness of ankles in acute nephritis . . . . . . 48 - eyelids in myxoedema . . 259 - face in acute nephritis . . 48 - joint in haemophilic arthritis 388 Pulmonary and aortic regurgi- tation distinguished . . 247 - aneurysm (see Anetnysm, Pulmonary) - area, systolic bruits over 104, 105 - artery, arising from aorta. . 184 - atheroma, mitral stenosis a cause of . . . . . . 323 - branches of vagus, relation to cough . . . . . . 175 - diseases, ascites in . . . . 61 causing enlarged right ventricle . . . . 246 chronic, hypertrophic osteo-arthropathy in (and see Osteo-arthropathy) venous liver congestion in 390 407 101 321 107 107 247 247 247 105 579 shortness of breath in . . - embolism sudden death in - gangrene (see Gangrene of Lung - osteo-arthropathy (see Osteo- arthi-opathy) - regurgitation,' catises of . . causing diastolic bruit . . enlarged right ventricle in 245 from fungating endocar- ditis mitral stenosis . . - second sound, reduplicated in mitral regurgitation . . - stenosis, acquired . . - - bruits of 104, 105, 184, 247 clubbed fingers and toes with . . 104, 129, 247 cyanosis in 104, 184, 247 dyspnoea in . . . . 247 with patent interventri- cular septum . . 244, 579 polycythaemia in 247, 579 right ventricle enlarged in 245, 246, 247 symptoms Of . . . . 247 systolic thrill due tol84,247,790 - svstolio bruit in normal chil- " dren 105 - thrombosis (.see Thrombosis, Pulmonary) - tuberculosis (and see Phthisis) miliary, absence of pul- monary signs in some cases of quick breathing in . . pyrexia with weakness and anorexia at onset 612 612 CIS PULMONARY TUBERCULOSIS— PUPILS, UNEQUAL 97 r Pulmonary tuberculosis, contd. Pulse, rapid, contd. Pupil, contd. pain in limbs in . . 503, 505 ]meumothorax 480 - in Graves' disease . . 201 - valve, fungating endocardi- jiroportion to tempera- - immobile in epilepsy 160. tis of 321 ture in tropical abscess general paralysis 172 - veins, rupture of aortic of liver. . 408 - irregular, due to adherence aneurysm into . . 482 relapsing fever . . 698 to corneal ulcer . . 594 fulpy knee Csee Arthritis, small and intermittent, in dislocation of the lens 594 Tuberculous, of Knee) mitral stenosis 245 from injury to tlie eye . . 593 Tulsatile liver (see Liver, Pul- with subphrenic abscess720 721 in insanity 595 satile) - relatively slow in cerebral due to old iritis . . 593- - swelling Csee Swelling, Pul- abscess . . . . 547, 771 persistent pupillary mem- satile) influenza 771 brane . . 593. ia the orbit Csee Orbit, tuberculous meningitis 771 rupture of the sphincter 593 Tumour of Pulsatile) typhoid fever 196, 610, in tabes . . 595- Pulsation of arteries in aortic 697, 771 - large in myopic eyes 594 disease 23:!, 2l0, 247, 764 yellow fever 301, 373, 771 - membrane persistent 593 marked in exophthalmic - and respiration ratio in - peculiar light reflex in hemi- goitre 2'J:-1 764 pneumonia 372 anopsia 595 - capillary, in aortic disease - during rigors 646 - pinpoint, in opium poison- lOG, 240 - in simple colic . . 133, 645 ing .. .. 138, 345 - cessation of, in one or other - slow in cerebral tumour . . 782 pontine haemorrhage 138- of the accessible arteries cretinism 259 - reaction in hysteria 160 in fungating endocarditis 613 myxoedema 259 - reactions of, in hemianopsia 336 - epigastric Csee Epigastrium, - splashing, in aortic disease 240 uroemic amaurosis 839- Pulsation in) - sudden halving in Stokes- Pupil reflex to light, loss of - expansile with aneurysm 235, Adams syndrome 527 Cand see Argyll Robertson 476, 786 - and temperature ratio in Pupil) 594 in iliac aneurysm 741 normal conditions 622 in alcoholic intoxica- - in eyeball from local aneu- in pneumonia.. 697 tion 594 rysm 255 typhoid fever 372, 697 bilateral character of 594 - meningocele . . 254 - variations in mitral regur- in cerebral tumour . . 594 - osteosarcoma .. 177, 179 gitation . . 238 in 70 to 90 per cent - pelvic sarcoma 741 - water-hammer, in aortic of cases of tabes 594 - psoas bursa 741 regurgitation 106 epilepsy 594 -transmitted aortic. 306 - Csee also Bradycardia and general paralysis of by carcinoma of pancreas 59 Tachycardia) the insane 594 ovarian cyst 691 PULSES, INEQUALITY OF.. 592 due to injury 594 PULSATION. UNDUE AB- - unequal, from aneurysm in some intracranial DOMINAL AORTIC 592 222, 236, 732 diseases . . 594 age and sex incidence 592 from cervical rib 128 493 593 mania 594 diagnosis from abdo- congenital cerebral diplegia 800 never found in health 594 minal aneurysm 728 764 femoral, from iliac aneu- jmclear lesion causing 594 feeling of discomfort in 592 rysm 741 retained in acute en- - use of ear in detecting slight 235 tibial, in popliteal aneur- cephalitis . . 594 Pulse in acute general peri- ysm 762 stimulating of cer- tonitis 431, 472, 644 Pulsus paradoxus in adherent vical sympathetic 594 yellow atrophy . . 370 pericardium 104 in syphilis" . . 594 - in aortic disease' 106, 2."3, Puncta laclirymalia, mal-posi- tabes 594 234, 235, 237, 240, 247 526 tion of, causing epiphora 250 tumour of corpora - appendicitis 736 Punctate basophilia (Plate //"> 30 quadrigemina 594- - in catarrhal jaundice 365 PUPIL, ABNORMALITIES OF 593 - reflexes, in ciliary paralysis 594 - chart of rheumatoid arthritis - appearance of, in conjunc- description of the four (Fig. 106) 377 tivitis, iiitis, and glaucoma 257 normal . . 594 - collapsing, in aortic regurgi- - Argyll Robertson Csee Argyll dilatatory in sensory and tion 240, 247 526 Kobertson Pupils) emotional reflexes 594 - disproportionately rapid in - blockage of, by iritis 839 in diphtheritic neuritis . . 77 rheumatoid arthritis 378 - changes from affections of hemianopic, description of 595. — in eiKJof'arditis 239 cervico-dorsal cord 554 to " light " and " accom- - exhaustion of obstructed in tabes . . 262 modation " 594 labour 229 - contracted, acute encephalitis 594 loss of " convergent ac- - feeble and irregular, in brain disease, ultimate commodation " with re- fibroid heart 241 replacement of dilata- tention of " light," in in toxic cases of diar- tion in all cases 594 :neningitis 594 rhoea 196 cervical svmpathetic para- myelitis 594 in myocardial degeneration lysis '.. ..247,590 ,792 paradoxical, definition of 595. 241, 333 526 in hypermetropic eyes . . 594 retained with dilated pupil - increased rate, after exercise. intracranial abscess 594 in acute mania 594 in dyspepsia 526 - - - growth . . 594 in tabes . . 595. - irregular in organic cerebral paralysis of cervical sym- unilateral . . 594 disease 328 pathetic 546 in unilateral lesion of optic tuberculoias meningitis . . 174 in spinal lesions . . 553 tract . . . . 594 ,595. - in jaundice . . 361, 365 370 tabes 594 - size of, variations with age - paroxysmal tachycardia . . 772 urajmia . . . . 45, 46, 195 of patient 594 - radial, diminished from cer- - dilated in acute mania . . 594 Pupils, small, in encephalitis 594 vical rib . . 493 from belladonna 773 - unequal, in aortic aneurysm - rapid and feeble ; from in glaucoma 840 222 595. corrosive poisoning 297 with retention of light carotid aneurysm 595. in fevers . . 771 reflexes in catalepsy . . 594 coma 137 after hajmorrhage 140, in epilepsy 594 general paralysis 172, 195 , 595. 298, 646, 717 780 stimulation of cervi- in glaucoma 595 and irregular, in arsenical cal sympathetic 59^ iritis 595. poisoning 92 - double aperture of 198 , 199 from use of mydriatics . . 595 in malignant scarlatina . . 301 - eccentric, from tumour of myotic drugs . . 595 phosphorus poisoning . . 373 mid-brain. . 798 m organic cerebral disease 328. 972 PUPILS, UNEQUAL— PYLEPHLEBITIS Pupils, unequal, contd. Pus, contd. Pycemia, contd. from physostigmine 595 — collections, indicanuria due to 821 - rigors in possibly of no significance - in expectoration . . 176 372, 598, 647, 648, 649, 650 in slight degrees 595 - - from empyema bursting - septic skin rashes in 650 in tabes . . 595 through Ivmg . . 323 - and septicaemia, relationships third nerve paralysis 595 liver abscess ruptured into between . . 650 trigeminal neuralgia 595 lung 369 - simulating acute rheumatism 650 unilateral cerrical sympa- - extrapleural, simulating em- enteric fever 650 thetic lesion . . 594 595 pyema 119 gout 383 — - from unilateral intra- - with gas in pleural cavity . . 577 - subcutaneous abscesses in 649 cranial lesion . . 595 - greenish yellow, in pneumo- - from subperiosteal abscess 750 Purgatives, colic from 1+1 coccal arthritis . . 375 - sudden onset of . . 649 - constipation due to 848 - under pressure, polymor- - suppuration in joints in . 649 - in distinguishing scyhala phonuclear leucocytosis - suppurative pericarditis in 650 from other abdominal associated with . . 400 - sweating in. . . . 3' ■2, 649 tumours . . . . 501 723 - not under pressure, no leuco- - symptoms of 45 — intestinal obstruction 151 cytosis with 400 - temperature chart of 614 - loss of weight due to 848 - per rectum, from ruptured - tenderness in spine in . 785 Purin bases, uric acid from . . 817 abscess 635 - thyroid abscess in. . 792 PURPURA 595 — sterile in liver abscess burst- - imafiected by quinine 650 - albumosuria in 20 ins through lung 323 - vomiting in. . 649 — anfemia with 36 PUS IN THE STOOLS 600 Pyelitis 16 - bleeding gums in . . 85 in anal fistula . . 92 - aching in loin in . . 625 - and cerebral embolism 138 colitis 501 - in acute fevers 625 - in cerebrospinal meningitis 643 dysentery . . 501 - due to B. coli 625 — cirrhosis of liver 696 - in urine (see Pvuria) - bilateral in cystitis 625 — definition of 595 PUSTULES .." 601 - cystoscopic appearances in - diagnosis from capillary - of acne 531 (Plate V, Fig. C, p. 308) 6 25,628 naevi 595 - in bromide eruption 603 - diagnosis from chronic cys — ecchymoses or bruises in . . 595 - congenital syi'hilis . . 446 titis 628 - eplstaxis in. . 251 - dermatitis herpetiformis . . 831 - dry harsh skin in . . 625 - from flea bites 596 - dimpling of, in large acumi- - glazed tongue in . . 625 — in fungatins endocarditis nate syphilides . . 604 - from growth in bladder . 625 38, 76, 237, 338, 610, 613 - eczema 831 - haematogenous infection in 625 — gastric erosions in . . 298 - granulosis rubra nasi 714 - hyperpyrexia in . . 344 - haematemesis in . . 294, 302 - herpes progenitalis 675 — infections elsewhere wich. 625 — hematuria in . . 305, 314 - impetigo contagiosa 654 - with intestinal afiections . 625 - haemoptysis in 318 - lichen scrofulosorum 529 - from involvement of ureter — Henoch's (see Henoch's Pur- - malignant (see Anthrax) in carcinoma of uterus . 625 pura) - microscopical character of - kidney enlarged in 500, 625 - in leukfemia 31 contents . . 601 - little pus in acid urine in . 623 — menorrhagia in . . 428, 430 - in miliary abscesses of new- - micturition frequent in 438, 625 — metrorrhagia due to 433, 435 bom 601 - pain in the right hypochon — in morbus maculosus of - prurigo ferox 531 drium in . . 500 Werlhof .. .. 596, 600 - rhinophyma . . 805 - pneumococcal 625 - persistence of discoloration - ring of, in anthrax . . 603 - in pregnancy 625 under preKvure in 595 - scabies . . 654, 831, 832 - prostatic enlargement 625 — in scurvy . . . . 85, 302 - in scrofulodermia . . 603 - pyonephrosis from ureteral — scarlatma maligna . . 301 - small-pox . . 605, 655 829 obstruction in . . 396 - from septic infection of - syphilis . . 440, 532 833 - pvrexia in . . 625 umbilical cord . . 90 - transition of papules into 001 ,528 - pyuria in . . 500, 623, 625 - small-pox . . . . 301, 605 - in vaccinia . . 834 - from renal calculus 438, 62 5, 627 - typhus fever . . . . 371, 699 - varicella 833 - rigors in . . . . 6- 5, 648 - vibices or lines in . . 595 Pustules in varioliform syphil- - simulating nocturnal enuresis 248 — yellow fever . . 301, 373 ides 601 - staphylococcal 625 - fulminans .. .. 596 600 - from vesicles 829 - streptococcal 625 theory of causes of 600 Putrefaction, emphysema from 231 - in stricture . . 625 diagnosis from scurvy . . 302 - intestinal, borborygmi due to 97 - tenderness in loin in 025 — hjemosiderin in the macules indicanuria from 97, 349, 821 - from tubercle of kidney 438, 626 foUowins . . 424 - ■- muscle fibres in fteces in 268 - in tyiihoid fever 625 - haemorrhagica, blood per urinary sulphates in 97 - urinarv chansres in.. 018, 625 anum in . . 90 Pyaemia, abscess of chest wall ia 478 - from urinary obstruction . 625 montli in 600 in heart from 650 Pyelonephritis (see also Pye - nose in . . 600 - diagnosis confirmed by litis) 16 hasmaturia in 600 blood-cultures . . 598 — albuminuria in excess of the hemorrhage from bowel in 600 from malaria 650 pus present in . . 620 purpuric rash in. . 596, 600 - diarrhoea in 649 - anuria with . . 45,48 theory of causes of 600 - emaciation in 372 - due to bacillus pyocyaneus 83 - macular 423 - embolism in 649 - bacteriuria in 83 - rheumatica, age incidence of 380 - gangrene of lung in 288 - commonly bilateral 394 diagnosis from Henoch's - hyperpyrexia in 343 - haematogenous infection in 625 purpura 380 - jaundice in . . . . 362, 372 - kidney enlarged in . . 394 (see Peliosis Rheumatica) - leucocytosis in . . 400 649 - from obstruction in lower - simplex . . . . 596 607 - metastatic abscess in 649 urinary tract 395 - subconiunctional, causes of 256 - muscular atrophy in 76 - polyuria in 626 Pus in actinomycosis. Gram- - after operations and wounds 649 - pus casts in urine in 626 staining mycelium in . . 748 - peripheral neuritis in 76 - pyuria in . . 394, 62 3, 625 small }-ellow granules in 748 - portal (see Pylephlebitis) - recurring rigors in . . 648 - cells, gonococci in . . 211 - progressive loss of strength in 372 - renal abscess due to 625 in sputa of phthisis 319 - prostration in . . 372, 649 calculus causing . . 627- urethral discharge not a - purpura in . . . . 596, 598 pain in . . 394 bar to marriage 209 - from pyorrhoea alveolaris 87 - uraemia in . . 625 - in the chest 119 - pyrexia in 343, 372, 614 649 Pylephlebitis, adhesive, ascites in 301 — chocolate coloured 279 - rapid pulse in 372 enlargement of spleen in 301 PYLEPHLEBITIS -PYREXIA 975 301 301 301 20 369 58 649 614 614 614 614 649 Pi/lcplilcbitis, adhesive, contd. ha^matemesis iu melaena in - - sudden onset of . . - alburaosuria in - after aijpeiidicitis 59,369,614,649 - duo to appendicitis in 60 per cent of cases. . - ascites in - colour of fieces in . . - diagnosis from aiipeiidicitis peritonitis pneumonia typhoid fever - diarrhoea m. . - hasmatemesis in . . -94, 301 - jaundice in 59, 362, 370, 372, 649 - leucocytosis in . . . . 400 - liver enlarged in . . . . 370 - multiple abscesses in liver from .. 369, 408, 649 - pain in liver from . . 649 - pleuritic effusion from . . 123 - pyrexia due to 609, 621, 649 - rigoi-s in 09, 362, 370, 648, 649 - septicfemia from . . 614, 698 - tenderness of liver from . . 649 - vomiting in . . . . . . 649 Pylorus, carcinoma of (see Carcinoma of Stomach) - enlarged, diagnosis from enlarged gall-bladder . . - hypertrophy of, in congenital pyloric stenosis . . - normal, palpable in epigas- trium situation of - obstruction of, by calcified retroperitoneal cyst from carcinoma . . - - causing constipation cicatricial - - colicky pains of congenital, p.m. findings m 426 due to spasm from wrong feeding . . . . 427 persistent vomiting 426, 845 constipation due to . . 144 and wasting in. . . . 845 differentiation between inflammatory and ma- lignant. . . . 35; dipping in diagnosis of . . extreme tlm-st due to flatulence and other symptoms in . . gastrectasis from 712, 789 HCl in stomach contents 353 history of previous gastric ulcer . . . . . . 352 from hj'-pertropliy of pylorus m infants . . 723 increased area of tym- panitic resonance in . , - - lactic acid Offler-Boas bacilli m . , sarcinaa in vomit with 353, 355, 713 from spasm . . . . 723 spasm of, in dyspepsia.. 354 perhaps the real cause of "congenital" pyloric stenosis stagnation of stomach contents in symptoms produced by - - torulaj in vomit hi tumour in visible gastric peristalsis in 134, 352, 570, .'>71, 713 vomiting in 134, copious in a'-rays in diagnosis of yeasts in stomacli m 406 426 724 713 723 144 723 134 211 626 396 624 395 396 626 626 713 134 789 267 134 3.'!3 353 426 353 845 134 353 713 843 . 353 . 134 53, 355 I'yodermia, no leucocytosis with 400 I'yometra, metrostaxis from 436 - in old women Pyonephrosis, growtliof bladder causuig - diarrhcea in - disappearance of jiyuria in - fluctuation in - liydronophrosis causing - intermittence in size in pyuria in. . . . 396, - kidney enlarged in 391, 394, 583, 624, 626 - pain in side in . . . . 624 - pallor in . . . . . . 396 - pelvic swelling due to . . 757 - polyuria in . . . . . . 583 - prostatic enlargement causing 626 - pyrexia in . . . . 396, 624 - pyuria in 396, 583, 623, 625, 626 - renal calculus causing 309, 396, 626, 627 tuberculosis causing . . 626 - round smooth outline of . . 395 - sense of tenseness and elasticity in - symptoms those of causative lesion plus suppuration. . - sweating in. . - ureteral obstruction causing 396, 625 - uretliral stricture causing. . - urine normal in " closed " - uterine carcinoma causing . . - .T-rays in (Fig. 97, p. 309). . Pyopericardium, cliurning sounds in . . Pyoperitoneum from pneumo- coccal or tuberculous peritonitis Pyopneumopericardium, suc- cussion sounds in Pyopneumothorax - from bronclio-pneumonia - cacliexia witli - due to gangrene of lung . . - needling of claest in dia- nosis of . . . . 711, 712 - from obstruction of bronclius 712 - pneumonia . . - pulmonary infarct. . - pyrexia witli - rigors with . . - simulated by subphrenic abscess - subphrenic, general account - succussion sounds with . . - .r-rays in diagnosis of Pyorrhoea alveolaris, aneemia in 36, 39 bleeding gums due to 86, 87 chronic joint lesions from 278 foul breath due to . . 99 gastritis from loss of weiglit due to . . ptyalism due to . . purpura from pyrexia in retraction of gums from . . secondary effects of septic arthritis from septiCcEmia from stomatitis from . . Pyosalpjnx - aching lumbo-sacral pain in - acute peritonitis from - albumosuria in - anaemia in . . - diagnosis from appendicitis - dysmenorrlioea with 220, 632 - felt per rectum . . . . 638 vaginam . . . . 638, 737 - frequency of micturition in 438 - fullness of vaginal fornices in 632 395 626 396 627 620 626 626 396 711 717 711 577 712 712 712 712 712 712 712 712 721 711 712 297 848 590 600 620 641 87 375 698 590 760 632 55 20 39 737 Fyosalpinx, could. - infective peritonitis from . . - leucocyte count in diagnosis from typhoid fever - leucocytosis in . . 400, - leucorrhcea in - malaise in . . - pelvic swelling due to - periods profuse in . . - pleuritic effusion in - pneumaturia in - after pregnancy - pus in stools from rupture of - pyuria from . . 624, rupture into bladder 624,631 spasmodic pelvic pain from . . - septicaemia from . . - vaginal discliarge witli Pyramidal tract, lesions of, ab- sence of abdominal reflexes with . . . . 546, ankle-clonus with effects on reflexes extensor plantar reflex with . . . . 82, 546, facial paralysis from . . mcreased knee-jerk witli paralysis of upper ex- tremity due to Pyrexia, absent in spastic constipation endocarditis - in active congestion of liver 371, - acute gastritis mastitis . . nephritis . . otitis media pancreatitis poliomyelitis . . 128, polymyositis prostatitis 207, 511, yellow atrophy . . - in alveolar abscess . . echinococcus disease - anthrax - antitoxic serum rashes - appendicitis 133, 145, 153, 31 - axillary abscess - bacteriuria . . - bullous dermatoses - carcinoma of ctecum liver stomacli . . - in catarrhal jaundice - cellulitis - cerebellar abscess . . - cerebral abscess embolism tumour - in children, a bad night suflicient to cause excitement as a cause of due to febricula . . moderate, with tonsillitis, suggestive of diphtheria observations on . . onset of zymotic disease causing of unexplained origin, discussion of . . without discoverable cause - cholangitis . . . . 499, - cliolecystitis - cirrhosis of the liver 40, 362, 368, - colic . . . . 363, 500, - convulsions . . - crises of, in meningococcal meningitis in pneumonia - cystitis . . 312, 512, 620, 729, S9 362. 64-t 401 401 632 632- 757 632 123. 576 737 601 632: ,632 509' 698. 737 547 547 44 547 534 546- 145- 103. 407 845- 743. 48. 469- 724 555. 504 631 370^ 747 416 60.S. 597 135, 730 731 84 114 729 413 229 365. 45^ 565. 341 138. 341 021 621 621 622 621 622 618 622 650 650 410 645 622 642 186 627 974 PYREXIA— PYURIA Pyrexia, contd. - distinguishing intestinal obstruction and peritonitis 133, pontine h.'emorrliage and opium poisoning. . - distoma hepaticum infection - tlie earliest symptom in some cases of typhoid fever and phthisis - in endocarditis - epidemic jaundice . . - erysipelas (Fig. 166, p. 61-1) 698, - erythema nodosum - exhaustion of obstructed labour - frequently absent in tuber- culous disease of joints . . - in fungating endocarditis 9, 10, 38, 76, 103, 314, 368, 370, 593, - from gall-stones 278, 280, - gangrene of king . . - gonorrhcea . . - gonorrhoeal arthritis - gout 382, - gumma formation in con- genital syphilis . . - Henoch's purpura . . - hepatic abscess 324, 369, 408, - herpes zoster - Hodgkin's disease . . 32, 609, 616, 649, - hysterical - with inflamed axillary glands - influence on pain in limbs. . of potassium iodide on syphilitic - in influenza 505, 010, 651, - jaundice, significance of absence of - kala-azar - leukfemia 32, 609, 617, 620, - malaria 34, 35, 371, 615, 622, - Malta fever - in mediastinal growth - meningitis . . . . 622, - Milroy's disease - neurotic association with pelvic symptoms diagnosis of sex incidence of . . - otitis media - in peliosis rheumatica - pelvic peritonitis . . - in perinephric abscess - periods of, in leuiaemia . . - - lymphadenoma . . - - severe anosmias . . - in peritonitis 134, 153, 472, - pernicious ana3mia 32, 33, 616, - pleurisy - pneumonia . . 186, 321, 372, - pontine haemorrliage - due to prolonged convulsions - witli prostatic abscess - post-critical, in pneumonia, suggestive of empyema - post-operative, not neces- sarily infective in the first forty-eight hours PYREXIA, PROLONGED in Addison's anaemia bacilluria blood diseases broncho-pneumonia carcinoma . . 609, children, obscure origin of some cases of . . cirrhosis of liver 609, erysipelas (Fig. 106) . . fatty heart from 138 364 620 622 372 746 450 386 237, 598 363 287 620 377 455 615 380 651 496 738 618 421 50,8 615 362 34 649 698 611 483 642 460 609 618 618 618 229 599 700 392 620 738 620 718 649 118 622 138 169 207 623 009 009 010 609 615 618 609 018 614 62 Pyrexia, prolonged, contd. in fungating endocarditis 612, Hodgkin's disease 609, infectious diseases influenza 505, 009, 610, 651, leukjemia . . 609, malaria - - Malta fever 500, 609, miliary tuberculosis neurosis . . the only symptom for weeks in some cases . . in pernicious anaemia pylephlebitis sarcoma . . . . 609, septicemia 343, 609, 614, syphilis . . toxic absorption (alimen- tary) in children tuberculous peritonitis . . typhoid fever typhus fever - in renal tuberculosis - in prostatic afi;ections - pseudo-leokffimia . . - with pustular syphilides . . - pyemia . . . . 372, - pyelitis - pylephlebitis - pyonephrosis . . 396, - with pyopneumothorax . . - relapsing fever . . 33, - relatively low in influenzal bronchopneumonia - in renal colic tuberculosis - rlieumatoid arthritis - rigors - salpingo-oophoritis. . - scarlet fever - septicaemia . . - in septic arthritis . . - severe anemias 32 - with sinus thrombosis - in spinal meningitis - with splenic tumour - subperiosteal abscess - subphrenic abscess 501, - sudden drop m. crisis pneumonia in typhoid, suggestive of perforation . . - due to suppurating gums . . - in suppurative meningitis. . nepliritis . . - syphilis 371, 014, 615, influence of potassium iodide on - testicular abscess . . - tonsillitis . . 620, - in traumatic aniuria - tremor from - in trichinosis - tuberculous meningitis peritonitis 56, - with typhoid spine. . - typhus fever - ulcerative colitis - urethritis - after urinary operations - in von Jaksch's disease - yellow fever PYREXIA WITHOUT OB- VIOUS CAUSE, blood cultures in affections of gums, nose, or throat vagina, rectum, or urethra Calmette's reaction hi due to deep caseous glands coli bacilluria 39, 301, 620, 558, 720, of 622, 504, 472, 301, 623 616 009 699 617 615 Oil 612 618 612 016 609 617 650 614 618 018 697 610 135 511 42 607 649 625 649 024 712 373 321 500 135 378 040 760 674 650 375 649 650 162 691 750 721 022 432 620 642 640 672 615 680 672 49 795 801 174 691 787 698 727 207 49 42 373 Pyrexia icil/iout ohvious cause, contd. ear disease . . . . 620 faecas in . . . . 621 fungating endocarditis 623 gall-stones . . . . 621 genito-urinary tubercle 621 leucocytosis in . . 620 osteomyelitis . . . . 620 ovarian abscess . . 621 parasites in blood . . 020 phlebitis . . . . 621 pylephlebitis . . . . 621 renal or vesical calculus 621 sores on fingers or toes 020 Widal's reaction in . . 620 Pyriformis, nerve supply of . . 542 Pyrocatechin in cerebrospinal fluid 203 PyrogaUic acid, haemoglobin- uria from . . . . 314 Pyrosis (see Heartburn) PYURIA 623 - with albuminuria . . 15, 623 - appendicitis . . 313, 632 - bacilluria 83, 576, 615, 848 - due to biUaarzia hfematobia 630 - casts m, in pyelitis and pyelonephritis . . 628 - in catarrh of urinary pas- sages . . . . . . 444 - catheter in diagnosing renal from vesical causes of . . 624 - characters of deposit in . . 623 - contamination with a leu- corrhoBal discharge . . 031 pus from behind a phi- mosis . . . . 631 - in cystitis 221, 312, 512, 623, 627, 628, 030, 631 - cystoscopic appearances in diagnosis of (Plate V, Fig. B, p. 308) . . . . 024 - diagnosis from phosphaturia 574, 623 from urates in urine . . 023 - epithelial cells in urine in . . 023 - examination of urine for tubercle bacilli in . . 026 - from extension of ulceration of intestme to bladder 624, 633 - due to iliac abscess. . .. 632 - intermittent, in pyonephrosis 396, 626 - lavage of bladder in distin- guishing renal and vesical 624 - liquor potassae test for . . 623 - microscopic characters of pus cells in - ozonic ether test for - in papilloma of bladder - due to pelvic abscess - persistent in gonorrhoea . . - due to prostatic abscess . . psoas abscess in pyelitis - pyelonephritis - pyonephrosis - pyosalpinx . . - in renal abscess 623 623 630 631 626 631 632 500, 623, 625 394, 625 ..396, 583, 626 ..032 . . 626 calculus 10, 40, 308, 312, 626 enlargement . . . . 689 - - tuberculosis 10, 136, 310, 394, 019, 026 - - tumoiu: . . 10, 367 - due to rupture into bladder of an extra-urinary abscess 631, 632 - simple ulcer of bladder . . 630 - simulated by urates . . 815 - sudden cessation in pyo- nephrosis . . . . . . 624 - from suppurative nepliritis 646 -- ureteral calculus 514, 627 - urethral stricture . . . . 631 PYURIA— RECTUM 975 J^i/iiria, contd. Riile.i, contd. Reaction of degeneration, contd. - urethritis . . . . 030 , G31 - crepitant, from pulmonary partial 634 - uriiiarj' changes with 62.'i , U2 1 infarction 321 in peripheral neuritis 66, - ill vesical calculus. .012, 513 C29 - in infarction of lung 321 g;i, 75, '188, 506, 559 562 - with vesical growth 47, 311, - non-consonating, with bron- progressive muscular 512 G.HO chitis and emphysema . . 18G atrophy 73 tuberculosis ."12, 513 U28 - and rhonchi in emphysema 246 in Tooth's neuro-muscu- - sticky basal, in inllucnzal lar paralysis . . 132 ,560 QUADE.ATTJS femori;;, iiorvc bronchopneumonia 321 transverse myelitis at supplj' oi: 512 Banula, ptyalism due to 591 lumbar enlargement . . 563 - lumborum, spinal nerve root Rarefaction of bones in tabetic - of vaginal secretions 210 supplying 513 arthritis . . 388 - Wassermann's (see Wasser- Quadriceps extensor femoris, Rash due to drugs G03 maun's Reaction) clonus o£ . . IGl serum (see Serum Bashes) (and see Electrical Reac- nerve supply of . . 542 - erythematous, at onset of tions) - spinal nerve root suppl3'mg 543 dengue 506 Reading, difficulty in, due to Quartan fever 34 - " mulberry " in typlius fever 371 post-diphtheritic ocular Quinine, amblyopia from 83G - " petechial " in typhus fever 371 paresis 640 - central scotoma from 83G - in pyeemia and septicaemia 650 - pain behind eye intensified by 498 - cure of malaria by . . G49 - roseolar, beginning on hands - relation of word blindness - in diagnosis of malaria 5S3, G98 and wrists in the relapse of to power of 685 - dosage in malaria . . G15 dengue 506 Eeceptaculum chyli, ascites - no effect of, in pj-femia G50 - in secondary syphilis 615 from obstruction of 58 - headache from 32S - typhoid fever, rose-red flat- rupture of, chyluria from 126 - lia?moglobinuria from 314 tened papules in . . 697 Rectal crises of locomotor ataxy 562 - influence on malaria para- - typhus fever, charactera of - polypus . . 635 sites 371 371 699 - shelf due to secondary malig- - nerve deafness from 191 - (and see Bullae; Macules; nant deposits in pelvis . . 639 - optic neuritis or atrophy from 83G Papules ; Pustules ; Vesi- - tenesmus, association with - purpura from 596 cles ; etc.) bearing-down pain 473 - relation to blackwater fever 315 Rat paste, phosphorus poison- - trouble in cerebellar tumour 565 - scaly eruption due to 655 ing from . . 373 disseminated sclerosis . . 565 - tinnitus from 794 strychnine poisoning from 652 locomotor ataxy 562 Quinsy, asymmetry of 671 Rat-like facies of microcephaly 214 transverse myelitis 74 - bursting of abscess in 671 Bay fungi (see Actinomycosis) (and see Incontinence of - dysphagia in . . 225 591 Raynaud's disease, affection of Faeces) - enlargement of submaxil- extremities in 284 Recti muscles, divarication of lary lymphatic glands m 419 hands in 490 (see Divarication of the — ptyalism from 591 toes m . . 490 Recti) - sore throat from . . 670 albuminuria in . . 17 abdominal, divarication - stertor from 707 alteration of response to causing visible peristalsis 570 - trismus simulated by 801 galvanism in . . 634 Rectocele 587 Quotidian fever 34 buUiE in . . . . 110, 112 RECTUM, ABNORMALITIES coma m . . 136 FELT PER 634 EiLBBIT, opaque nerve fibres diagnosis from erythro- - abscess of (see Abscess Rectal) in . . 4G2 melalgia . . 284 490 sacrum felt per . . 638 Kabbit-skin workers, mercurial intermittent claudication 490 - ballooned, with obstraction 153 neuritis in 77 senile gangrene 284 - blood per (see Blood per Habies, delirium in . . 195 gangrene m (Plate IV, Anum ; and Melsena) - leucocytosis in 400 and Figs. 95-6) 282, 283 284 - bulging from cystocele 587 - slightness of fever in 195 hcemoglobinuria in 315 - carcinoma of (see Carcmoma Racing, albuminuria after . . 19 local asphyxia in 490 of Rectum) lladial artery thick and tor- syncope in 490 - congenital absence of lower tuous m chronic nephritis 204 cedema of face, neck, and portion of 637 - nerve, skin distribution of. . 659 arms from 461 - constipation from stricture of 150 Radicular pain in arm (see Pain legs in . . . . 459, 461 - diseases of, pain in the back in Extremity, Upper) recm-rent necrosis in 284 in (Fig. 204, p. 788) 476, 788 Eadium in relief of Mooren's severe pain in 490 lower extremity from 491 ulcer 807 simulated by cervical rib 493 - enlarged, from atony 149 Iladius, myeloid sarcoma of ergotism 287 - enterolith in 635 (Fig. 197) . . 755 756 sore fingers from . . 266 - examination of, in abscess - thickening lower end of, in swelling of hands or feet in 459 of sacrum 638 rickets . . . . 181 182 REACTION OF DEGENERA- acute prostatitis 511, 628 631 Railway spine, account of . . 787 TION .. 488 633 aneurysm of internal iliac tenderness of tjie spine in 784 - - absent in myopathies . . 70 artery . . 638 tremor in . . 795 in acute poliomyelitis 70, appendicitis . . 729, 736 Rainbow vision in conjuncti- 555, 558 appendicular abscess . . 638 vitis 840 amyotrophic lateral scler- colic 135 — - in glaucoma . . 257 840 osis 565 in bearing-down pain . . 474 Rales, apical, from aortic atrophic palsy of arm . . 549 - - bladder affections 306, aneurysm 322 cervical rib 554 307, 311, 312, 514, 638 - bronchitie . . 192 diagnostic uses of 634 calculous disease of the - characters in bronchiectasis faradic current in G33 prostate . . 512, 515 193, 703 galvanic current in 633 carcinoma of bladder 307, 311, - consonating, with fibroid indication of presence of 312, 512, 514, 628, 630, 638 lung 232 lower neurone lesion . . 634 colon . . . . 367, 501 from growth of lung 322 in infantile paralysis 131, liver 60 in phthisis 319 558, 559 peritoneum 57 - crackling, in empyemata of methods of examining for 633 rectum 636 children . . 119 with muscular atrophy . . 69 in cases of diyluria 126 in fibroid lung . . 246, 332 neuropathic muscular 1- of coccyx 635 with fibroid lung and -V atrophy 159 condition like pea or bean bronchiectasis 324 nuclear facial paralysis. . 536 in submucous coat in from obstructed bronchus 296 paralytic talipes.. 130, 131 ruptured rectal abscess 637 976 RECTUM— REFLEXES, LOST Rectum, examination of, contd. constipation . . . . 141 cystic disease of tlie ovaries 638 descending uretliritis . . 515 diasrnosing cause of pus in stools . . . . ■ . . 600 in cases of diarrhoea . . 196 distended bladder felt on 638 in dyschezia . . 119, 150 dysmenorrhoea of virgins 219 dyspareunia . . . . 221 ectopic gestation . . 638 enlarged pelvic lymph glands . . . . 628, 630 - fibrous stricture of . . . . 636 - fistula of, pneumaturia from 570 foreign bodies in. . . . 635 fracture of coccyx . . 638 gonorrhoeal enlargement of vesiculiE seminales . . 638 hsematuria . . . . 307 hydatid disease . . . . 58 impacted calculus 139, 514, 627 for internal haemorrhoids 635 intestinal obstruction 151,152 intussusception 92, 148, 196,636 ischiorectal abscess . . 638 fossfe . . . . 635 of lower end of ureter . . 307 in lumbago . . . . 476 malignant iliac glands . . 422 method of making . . 634 new growth of ovaries . . 638 in sacrum 635, 638, 761 vagina . . . . 638 in obscure loss of weight 847 pyrexia . . . . 620 obturator hernia . . . . 740 oedema of one leg . . 456 ovarian tumour . . . . 367 in parametric abscess . . 638 paraplegia from peripheral neuritis . . . . 562 pelvic abscess . . . . 760 growth . . . . 487 hsematocele . . . . 760 inflammation . . . . 487 pessary in vagina . . 638 for polypus . . . . 635 in prostatic abscess 511, 632, 638, 678 adenoma . . 512, 638 carcinoma . . 512, 638 enlargement 439, 441, 638 tuberculosis . . 307, 678 pyosalpinx . . . . 638 in rectal abscess 635, 637 rectal speculum in . . 635 in recto-vaginal fistula . . 636 recto-vesical fistula . . 636 of sacrum . . . . 635 in sarcoma of prostate . . 638 sciatica . . . . . . 487 scybalous mass felt on . . 635 sigmoidoscope in . . 635 in suspected malignant disease in the abdomen 638 for thickenmg of ureter. . 694 in tuberculosis of prostate 519 testis . . . . . . 519 ureter . . 513, 626, 629 vesiculae semmales . . 638 tumour of cauda equina 74 in ureteral calculus 627, 638 uterine enlargement or retroversion . . . . 638 vesical calculus . . . . 638 of vesicute seminales . . 307 vesicula; seminales palp- able only when diseased 638 - fibrous stricture of, dyschezia from . . . . . . 150 - hscmorrhage from (see Blood per Anum) Rectum, contd. - hair-ball in . . . . 635 - inconthience of faeces (see Incontinence^ - invagination of dyschezia due to . . . . 150 - lesions of, causing surgical emphysema . . . . 231 - loaded, causing priapism in elderly men . . . . 586 dj^stocia due to . . . . 227 - malformations of, descrip- tions of (Figs. 170-173) 637 causmg mtestinal obstruc- tion . . . . . . 151 - mode of examination of . . 634 - mucus from (see PcEces, ilucus in) - new growths of, sacralgia in 510 - occlusion by foetal head . . 638 - operation on, coli bacilluria after 83 retention of urine after 441 - pain in (see Pain Rectal) . . m acute prostatitis . . 628 - pemphigus, etc., of . . 114 - polypi of (see Polypi, Rectal) - pressure on, bearing-down paui from . . . . 473 causing dyschezia . . 150 - proctoscope examination in strictui-e of . . . . 150 - sense of fullness and weight in, from piles . . . . 92 - Stricture of, due to carcinoma of rectum . . . . 636 common positions of . . 636 constipation from . . . . 150 fibrous, annular or tubular character of . . . . 636 rectal examination in . . 636 - suppuration romid, scrotal fistula from . . . . 679 - tenderness per (see Tender- ness per Rectum) - ulceration of (see Ulceration of Rectum) - villous tumom's of, hfemor- rhage in . . . . . . 93 Rectus abdominis, local rigidity 644 contracted, simulating intra-abdominal tumour 723 - externus, paralysis of . . 201 - inferior, paralysis of . . 201 - mternus, paralysis of . . 201 - superior, paralysis of . . 201 Recurrent laryngeal nerve paralysis, causes of (and see Paralysis of Vocal Cord) 538 Red blood corpuscles, normal numbers of . . . . 579 - nucleus, intention tumour from lesion of . . . . 800 - vision, or erythropsia . . 840 Red-currant-jelly sputum . . 322 Redness of skin (see Ery- thema) Reducing bodies in urine, drugs giving rise to . . 290 other than glucose . . 290 REDUPLICATION OF HEART SOUNDS .. .. 2, 039 in acute cardiac dila- tation . . . . 243 arteriosclerosis . . 039 diagnosis from canter- rhytlim . . . . 639 mid-diastolic bruit. . 639 in granular kidney . . 639 hypertrophy of the left ventricle . . . . 331 mitral stenosis 108, 320, 639 regurgitation . . 239 relation to accentuation 639 Redux crepitations in lobar pneumonia . . . . 702 Reeling, from cerebellar lesions 69 - in tabes dorsalis . . . . 827 Referred pain, absence of ten- derness on firm pressure 475 in affections of the tongue 498 area of 10th dorsal nerve in gall-bladder disease 509 intestinal affections 509 kidney and ureter disease . . . . 509 uterine, tubal or ova- rian disease . . 509 from diseased to sound side in renal disease . . 394 ear disease . . . . 498 errors of refraction . . 498 frontal sinusitis . . . . 498 glaucoma . . . . 498 head and neck, segmental areas of (Figs. 132-135) 498 Head's segmental areas, in visceral disease . . 498 with hypersesthesia 475, 494 iritis . . . . . . 498 nasal inflammation . . 498 neck and arm in angina pectoris . . . . 482 shoulder in diaphragmatic pleurisy . . . . 480 suppurative otitis media 498 testicle, causes of . . 524 tuberculous hip disease . . 386 Reflex centres in spinal cord, diagrams illustrating (Figs. 146, 147) . . ' . . 566 - extensor plantar (see Ba- binski's Sign) - winking, abolition of, in paralysis of fifth nerve . . 807 Reflexes, abdominal, absent in amyotrophic lateral scler- osis . . . . . . 554 disseminated sclerosis 547 lesion of pyramidal tract 546 pressure on cervical cord 494 primary lateral scler- osis (Figs. 146, 147) 507 spastic paralysis of upper extremity . . 547 in paralysis from intra- and extramedullary le- sions . . . . . . 546 spastic paralysis of one leg 540 - asymmetrical, with coma 137 - in Brown-S^quard paralysis 540 - corneal, in facial paralysis 535 - in congenital defect of cortex . . . . . . 558 - deceptive, in paraplegias of infancy . . . . 557 - deep, in "Werdnig-HofEmann paralysis . . . . . . 158 - in disseminated sclerosis 174, 547 - during epileptic convulsions 109 - exaggerated in paralytic talipes .. .. 130, 131 progressive muscular atrophy . . . . 127 - functional paraplegia . . 567 - gastric . . . . 591, 723 - general paralysis .. .. 172 - hysteria 157, 166, 541, 518, 567 - increased in earliest stages of peripheral neuritis . . 505 neurasthenia . . . . 506 - lost, in neuromyositis . . 504 neuropathic muscular atrophy of infants . . 158 peripheral neuritis 505, 562 in transverse myelitis at lumbar enlargement. . 563 REFLEXES— RETINITIS PIGMENTOSA 977 Reflexes, contd. - in myopathies . . 70, 560 - palate, absent in liyst«ria.. 509 impaired in bulbar para- lysis 087 - in paralysis from intra- and extrameduUary lesions o-lC - - due to peripheral neuritis 659 - plantar (see I'lanfcir Redoxes ; and Babinski's Sign) - pupillary (see Pupil, Abnor- malities of ; and Pupil Reflexes') - retention of, in encephalitis 594 - in rickets . . . . . . 158 - spastic paralysis of one leg 539 - transverse mj-elitis . . 7t - unequal and exaggerated in hemiplegia . . . . 337 - (and see Knee-jerk, Pupil, and Ankle-clonus) Refraction, errors of, burning, pricking, or watering of eyes from . . . . 325 - - defective visual acuity due to 838 headache due to 327, 328, 495 hemicrania due to . . 495 migraine due to .. .. 495 neuralgia in (and see Eye- strain) 498 pain and tenderness in mid-orbital reijion in., 498 strabismus due to . . 709 supra-orbital pain due to 495 Regeneration of cut nerve, order of return of sensi- bility in 661 - after diphtlieria 77, 181 REGURGITATION of food through the nose 202, 639, 640 - in bulbar or pseudo- bulbar paralysis. . 640 diphtheria 77, 181, 224, 559, 640, 842 from oesophageal pouch 224 - milk in healthy children . . 842 - mitral (see Mitral Regurgita- tion) - pulmonary, diastolic bruit in 107 - tricuspid (see Tricuspid Regurgitation) Reinforcem?nt as an aid in eliciting Ihe knee-jerk . . 397 Reinsch's test. . . . . . 92 Relapsing fever, abdominal pain and tenderness in . . 37.'. acute onset in . . . . 698 blood changes in (Plate XII, p. 696) . . . . 33 chills in 698 contagious character of 698 diagnosis from malaria.. 373 epidemic character . . l!49 epistaxis in . . . . 373 famine in etiology of 373, 698 general account of . . 649 geographical distribution 649 hfematemesis in . . . . 873 hyperpyrexia in . . . . 344 - - hypothermia in conva- lescence from . . . . 346 jaundice in . . 362, 373 liver enlarged in . . 373 pain in back in . . . . 69S rapid pulse in . . . . 698 rarity of 698 - - rigors in . . 647, 648, 649 spirochfEta ohermeieri in the blood in (Plate XII, Fig. /, p. 690) 373, 649, 698 spleen enlarged in 373, 692, 698 sweating in . . . . 698 temperature curve of 373, 698 Religious excitement, pan- demic chorea caused by Remittent fever, purpurn in Renal abscess (see Abscess, Renal) - calculus (see Calculus, Renal) - cells and tube casts with cliyluria . . - clianges of arteriosclerosis - colic (see Colic, Renal) - crises of locomotor ataxj- . . - cystic tumours, albuminuria 157 596 120 14 15 352 329 359 579 579, 580 .. 583 579 582 - disease (and see ISriglifs Disease), blood-pressure high in . . . . 96, 331 chronic, diarrlioea hi . . 197 cystoscopic appearances in 624 diminished appetite in . . 49 displacement of cardiac impulse in . . 330, 331 dyspnoea in . . 579, 580 - - eosinophilia in diagnosing asthma from . . . . 249 epileptiform convulsions in 172 exaggeration of knee-ierks 397 - - gastritis in headache in msomnia in periodic cyanosis from polycythiemia in polyuria in shortness of breath from - dyspnoea, asthma mistaken for - enlargement (see Kidney Enlarged) - epithelium in urine in lu-e- teric calculus - pain (see Colic, Renal ; and Pain, Renal) in affected side in im- pacted ureteral calculus from involvement of ureter in carcinoma of bladder - pelvis, fistula of, causing pneumatiiria tailed epithelial cells from - suppuration, absence of leucocytosis if ureter un- blocked . . - tube-casts (see Casts.Renal) - Tuberculosis (see Kidney, Tuberculous Disease of) - tumour (see Kidney, Tumour of) - veins, thrombosis of Rennin in stomach contents, test for . . Reno-reflex pain Residual urine with prostatic enlargement Resin, bullfe in workers among - a source of fallacy in tests for albumin Resonance deficient, from an- eurysm in bronchiectasis in fibroid lung from growth of luni from pulmonary infarction 321 in phthisis . . . . 319 skodaic (see Skodaic Resonance) 514 514 400 8, 9 394 .. 703 324, 332 .. 322 Resorcm, black urine from Respiration, Cheyne-Stokes (see Cheyne-Stokes Res- piration) - influence on heat loss - jerky, in chorea - puls3 and temperature ratio in normal conditions - rapid from abscess of lungs phosphorus poisoning 820 619 156 622 649 373 pneumonia 186, 372, 645, 702 Respiration, contd. - ratio in pneumonia . . 697 - sighing with hremoperitoneum 717 - slow in cerebral abscess . . 547 - tlioracic in general peri- tonitis . . . . . . 044 Respiratory blood pump in orthopnoea . . . . 467 - distress, severe, diagnosis between lungs and larynx as site of origin of 466, 167 - movements, abdominal, ab- sent in ascites . . . . 51 deflcient in phthisis . . 319 - muscles, effect of hydro- phobia on . . . . 103 Responsibility, loss of weight due to 848 Rest, coma as indication for 137 - influence on pain due to cervical rib . . . . 491 - treatment in diagnosis of chlorosis .. .. .. II - urine increased during . . 581 Rests, adrenal (see Adrenal Restsj Restlessness in acute rheu- matism . . . . . . 622 yellow atrophy of liver 370 - and anuria . . . . . . 48 - from chronic alcoholism . . 797 - intestinal colic . . . . 473 - rickety children . . 170, 782 Retained products of con- ception, metrostaxis from 436 - testicle (see Testis, Ectopic) Retching, definition of . . 842 - tenderness in epigastrium from . . . . . . 779 - in undue abdominal aortic pulsation . . . . 592 Retention of urine (see Mictu- rition, Abnormalities of ; and Urine, Retention of) Retina, changes m, in urcemia 329 - detachment of (Plate VIII, Fig. T) .. .. 463, 839 sudden blindness from . . 839 - oedema of in optic neuritis 462 Retinal artery (central), em- bolism of, ophthalmo- scopic appearance of (Plate VHP) .. .. 403 - changes in chronic nepliritis 48 - haemorrhage (see Hemor- rhage in Retma) - nerve fibres, opaque, oph- thalmoscopic appearances of (Plate riP) .. . . 462 - vein, central, ophthalmo- scopic apDearance of tlirombosisof (Plate Till) 402 Retinitis, albuminuric, ambly- opia with nystagmus from 836 in cerebral haemorrhage 138, 563 with Cheyne-Stokes respi- ration . . . . . . 125 in chronic parenchymatous neptoitis . . . . 454 renal disease 1, 13, 14, 56, high blood-pressure con- ditions . . . . . . 526 102, 103, 122, 240, 303 ophthalmoscopic appear- ance of (Plate VIII) . . 402 with shortness of breath 101 simulated by optic neuritis . . . . 463 in uraemia 350, 830, 839 uncmic amaurosis with. . 839 - pigmentosa, constriction of field of vision in. . . . 838 familial character of . . 838 62 97! RETINITIS PIGMENTOSA— RHINITIS 792 293 465 63 103 103 838 840 840 840 838 Rctiyiitis pigmentosa, could. night bliniiness in . . 838 nyctalopia in . . . . 841 - - ophthalmoscopic appear- ances in . . 838, 841 Retraction of abdomen (and see Rigidity of Abdomen) in tuberculous meningitis 612 with colic . . . . 134 - of the eyeball Csee Enoph- thalmos) - eyelids in G-raves' disease. REtRACTION OF GUMS . RETRACTION OF HEAD, causes of . . 641, 642, 643 - - in meningitis 328. 359, 641, 642, 699, 709 - of intercostal spaces in laryn- geal obstruction. . - ribs, systolic in adherent pericardium - - without adherent pericar- dium Retrobulbar neuritis, affection of one eye only . . central scotoma from 837, 838, 840 occurrence in young adults 838 ophthalmoscopic appear- ances may be normal with optic neuritis from pain and tenderness in eye from rapid recovery from sudden blindness from 839, 840 onset of .. '.. 838 Retroflexion of uterus (see Uterus, Retroflexion of) Retroperitoneal glands fsee Lymphatic Glands, Retro- peritoneal) - lipoma (see Lipoma, Retro- peritoneal) - tissues, rupture of aneurysm into Retropharyngeal abscess (see Abscess, Retropharyngeal) Retropulsion in paralysis agi- tans Retroversion and flexion of uterus (see Uterus, Retro- version of) Retroverted gravid uterus (see Uterus, Retroverted Gravid) Rhabdomyoma of kidney Rheumatic arthritis (see Arth- ritis. Acute Rheumatic; Rheumatic diathesis, brachial neuralgia in Rheumatic myositis diagnosed from torticollis . . - tonsillitis (see Tonsillitis, Rheumatic) Rheumatics, lightning pains of tabes described as Rheumatism, acute - - albuminuria in . . . . 17 - - albumosuria in . . . . 20 - - anaemia in . . . . 38 aortic disease from 233, 237,481 - - arthritis in . . . . 378 - - bromidrosis with . . 714 - - cerebral embolism from. . 138 - - in Children, chorea in . . 504 - - - diagnosis from growing pains . . 504, 507 endocarditis in . . 504 inflammations of fibrous tissues in . . . . 504 - — muscles often the cliief seat of pain in . . 503 pain in the epigastrium in485 140 796 395 167 489 Rheumatism, acute, in children, contd. sore tliroats in . . 504 chorea in. . 156, 504, 548, 671 contractures following. . 167 coronary sclerosis mistaken for 778 delirium of grave signifi- cance . . . . . . 194 diagnosis from dengue . . 506 endosteal sarcoma . . 756 Henoch's purpura . . 380 rheumatoid arthritis . . 378 endocarditis with 103, 236, 239, 671 eosinopliUia after . . 248 epididymo-orchitis in 517, 518 erythema nodosum in . . family history in fibrous mediastinitis in . . fungating endocarditis in gall-stones mistaken for gastritis mistaken for . . generalized erythema in history of, in cerebral em- bolism . . . . 338, 563 chorea . . . . 156, 548 671 671 826 314 778 778 671 mitral stenosis hydrocele in hyperpyrexia in 194, 344, rare in . . infantilism from . . inflammation of soft palate, uvula, and fauces in iritis and cyclitis in joint pains from. . leucocytosis in . . lumbago from menorrhagia in . . - - mitral disease from stenosis from . . multiple serositis in myocarditis in . . nausea in night terrors in . . nodules of age incidence of of elbows and scalp orchitis from pain in the back in limbs in muscles in, worse on getting warm in bed and tenderness in scalp from . . pericarditis in . . phthisis mistaken for pleurisy in with effusion in prominence of articular manifestation in adults non-articular manifesta- tion in children restlessness in scarlatinal scleritis and episcleritis in simulated by puerperal fever pyaemia trichinosis simulating occupation neu- roses . . . . scarlet fever . . swelling of thyroid gland 320 522 622 344 215 672 250 671 400 . . 428 I 102, 240 320, 773 I . . 123 i .. 241 .. 671 .. 447 . . 452 .. 452 .. 804 79, 517 475, 476 503, 504 on 503 784 671 671 121 504 622 376 256 6.50 650 504 178 671 792 484 784 79 - tabes mistaken for - tenderness of spine from - testicular atrophy after - tonsillitis in 239, 419, 671 - urate deposit in . . . . 815 - uretliral discharge due to 206 - valvular heart disease from . . . . . . 526 - various manifestations of 121 - vomiting in . . . . 671 Rheumatism, contd. - chronic, no cardiac affection in adults as a rule in . . 507 effect of change of weather on the pains of . . 507 massage and movement on 507 impairment of general health in . . . . 507 increase of pain and stiff- ness after rest in . . 503 pain chiefly in joints in some cases . . . . 507 muscles in some cases 507 less after movement 503, 507 pseudo-ankylosLs in . . 507 seldom a sequel of acute 507 - gonorrhceal (see Arthritis, Gonorrhceal) - muscular '^see Myalgia) diagnosis from brachial neuralgia . . . . 492 from tetanus . . . . 162 jiain in the back in . . 476 Rheumatoid arthritis, absence of bony outgrowths in (Fiff. 108) .. ..379 endocarditis in . . 379 grating in . . . . 379 , suppuration in . . 379 acuteness of first attack . . 378 age incidence of . . 378, 379 ansmia in . . . . 39 chloasma in . . . . 574 contractures in . . . . 167 correspondence to StUl's disease . . . . . . 418 diagnosis from acute rhdu- matism.. .. ;. 378 osteo-arthritis 379, 384 disproportionately rapid pulse in . . . . 378 enlarged glands in . . 39 epitrochlear gland in. . 379 fixation of joints in . . 379 freckles in . . . . 378 gradual disappearance of 379 loss of appetite in . . 39 weight in . . . . 39 muscular atrophy in . . 379 pain in the back "from . . 476 parts affected by . . 378 pa.ssive movements and massage in . . . . 379 pigmentation in . . 39, 378 pyrexia in. (Fig. 106, p. 377) 39, 378 recurrence of . . 378, 379 sex incidence of . . . . 378 simulating occupation neuroses . . . . 178 skiagram (Fig. 108) . . 379 spindle-shaped interpha- langeal joints in (Fig. 107) 378 stiff neck from . . . . 708 sweating of hands and feet in 378 temperature curve of (Fig. 106) . . . . 377 ulnar deflection of fingers in (Fig. 108) 380 Rhine valley, moUities ossium in 269 Rhinitis associated with cor- neal ulceration . . . . 806 - atrophic . . . . . . 204 anosmia fi<, multiide (see Polyor- - - hysteria . . 041 710 Shortness of) rlioiiicnilis) inguinal hernia . . 740 Shoulder, affection by acne Serous effusion in cacliexia intermittent hydrarthrosis 387 vulgaris . . 531 uijuosa 115 - - locomotor ataxia 502 - - in osteo-arthritis and gout 383 in diest Csee Chest, Serous lupus erytlicmatosus 781 - drawn down in fibroid lung 24G Ktfusion in) - - maligiuuit disease of tliy- - high, in apoplectic cases . . 191 multiple . . 123 roid gland 791 emphysema 191 polyuria in clearing up of - - muco-membranous colitis 727 - fall on, causing Erb's palsy 552 58-J, 581 myxoedema 4 GO - line® albicantes on 402 - membranes, inllammation - neurotic pyrexia. . 018 - muscles affected in ITenoch's of in chronic nephritis . . 13 - - P.iget's d isease . . 802 chorea electrica . . 157 leukiemia 32 pain and tenderness in - multiple benign sarcoid of. . 451 severe lilood diseases.. 122 back 789 - osteo-arthritis of, with spon- Serratus magnus, atrophy of 5fi0 paroxysmal ha-moglobi- dylitis deformans 787 nerve supjdy of . . 550 nuria . . 315 - pain in (see Pain in Shoulder) paralysis of 551 - - - tachycardia 772 - papular syphilides of 532 spinal nerve root supplying 550 — peliosis rheumatica GOO - paralysis of, in amyotrophic Serum actrlutination reaction pseudo-angina 482 lateral sclerosis . . 554 in riyscntory I'JG pseudohypertrophic mus- - rarity of gout in 383 - ill" .M;ilt:i"rcvor 5(17 012 cular paralysis 560 - sloping, in phthisis . . 191 |iar:ity|iiioid fever fill - - renal calculus 312 - tuberculous disease of 385 - - - ptomaine poisoniuj.' . . 597 rheumatoid arthritis 378 - wasting of, in syringomyelia 285 fand see Wid^ilj splenomogalic poly- Shoulder-joint, adhesions in. - albumin 5 cytliremia 581 simulating circumflex - antimeningococcal, in diag- - - spondylitis deformans . . 787 nerve paralysis . . 552 nosis and treatment . . G-13 - - sterility . . 705 Shoulder-shrugging tic 159 - discharge of, from iiipple . . 202 sulplional poisoning 820 .Shrapnell's membrane, per- - globulin 5 - - syphilitic aortic disease. . 237 foration in, in suppuration - rashes, anorexia with 597 - - typhoid spine 787 in the tympanic attic . . 470 joint pains with 597 - - umbilical hernia 524 Shrieking from intestinal colic 472 lassitude associated with 597 undue abdominal aortic Sick-headache, rigors in 647 muscular pains with . . 597 pulsation 592 Sickness (see Vomiting ; and occurrence !) or 10 days - - Weil's disease 372 Nausea) ■ after injection 597 - relationships of gastric and Siderosis (see Cirrhosis of Lung) pyrexia with . . 597 duodenal ulcer . . 90 Siegle's speculum in Gell6's test 189 purpura with 596, 597 Sexual ateleiosis 218 Sight, shortness of, spinal cur- urticaria from . . 597 - development, precocious . . 215 vature due to 183 - reaction, hydatid 58, 279, - disorders, eit'ect on phos- Sights, repulsive, vomiting from 844 415, 710, 720 pliorus excretion . . 572 Sigmoid colon (see Colon, Sig- for syphilis (see Wasser- imaginary, in neurasthenia 506 moid) niann's reaction) - energy, final outburst of, Sigmoidoscopy in carcinoma of - transfusion, hemoglobinuria causing priapism 585 colon . . 147, 501 735 after 314 - excesses, effect on Bartho- rectum 93 Seventh nerve (see Facial lin's gland 210 - colitis 501 Nerve) impotence from . . 347 - in diagnosing cause of Sewers, sore throat from G73 metrorrhagia from 433, 435 bearing-down pain 474 Sewing machine, menorrliagia priapism from 586 chronic diarrhoea 196 from using 428 - feeling, absence of, -sterility constipation . . 141 - pain intensified behind eye by 498 due to . . . . 700, 707 obstruction . . 267 350 Sex incidence of acroparoes- - intercourse, effect on men- pus in the stools GOl thesia 493 struation . . '13] - in dyschcKia . . 150 acute yellow atrophy 302, 370 - irritation, epistaxis from . . 251 - dysentery . . 501 adiposis dolorosa 478 Sheep, distoma hepaticum in 364 - malignant peritonitis 57 aneurysm 538, 728, 786 Shell-fish poisoning, bulla; from 114 - rectal examination 635 — angina pectoris . . 482 colic due to 130 - stricture of rectum and anus 150 anorexia nervosa 849 oedema of face, neck, anil - ulcerative colitis . . 91 , 92 bath pruritus 588 arms in 461 Signs, Babiuski's(see Babinski's carcinoma of breast 745 Sherrington, decerebrate rigid- Sign) tongue 812 ity of 163 - Chvostek's . . 178 cervical rib 491 Shiga's bacillus in dysentery . . 196 - Corrigan's pulse 100, 107, 233 234 chancre of tongue 813 Shingles (see Herpes Zoster) - Dalrymple's. . 792 - - cirrhosis . . 410 Ships, beri-beri on . . 75, 460 - Dietl's crises (see Dietl's Crises) congenital dislocation of Shivering (see Rigors) - Erb's 178 ' hip 183 Shock, in acute pancreatitis . . 484 - Flint's bruit 108, 109, 234 obliteration of bile-ducts 305 - athetosis after 154 - Friedreich's 104 duodenal ulcer . . 300, 500 - constipation from . . 144 - G-e)le's test for hearing . . 189 dysentery 727 - delirium due to severe 195 - Heberden's nodes 380, 384, 452 enterospasm 473 - diabetes msipidus from 585 - Hegar's in pregnancy 437 exophthalmic goitre 772, 792 - diastolic, in adherent peri- - Hippooratic fades." 431, 644 fa?cal tumours . . 092 cardium . . 104 succussion 193 femoral hernia . . 733 740 - functional dyspepsia after 355 - Hutchinson's hot eye 256 Friedreich's ataxy 1G4 - from gangrenous appendicitis 481 - - teeth 259 SIGNS— 5MA LL-POX . . 350 . . 203 244, 253 427, 752 .. 228 . 06, 67, 665 244, 253, 792 .. 771 3, 178 244, 253, 792 630 415 307 575 809 39 767 173 200 Signs, contd. - Kernig's - Koplik's spots - Moebius's - Parrot's nodes - Pawlik's - Eomberg's . . - Stellwag's - Tache cferebrale - Trousseau's; - Tou (iraefe's Silica in intestinal sand . . 652 Silicosis (see Cirrhosis of Lung) Silken crepitus in osteo-artliritis 179 Silver nitrate as an aid to cyst- oscopy copious precipitate of silver chloride on adding to hydatid fluid - - irrigation of bladder with - - pigmentation of skin from in quantitative estimation of homogentisic acid . . - - test for alkaptonuria Singing in ears (see Tinnitus) Sinus of foot from mycetoma - infections, anaemia in - of scrotum . . - suppuration, cerebral ab- scess from - thrombosis ("see Thrombosis) Sinusitis, polypi in . . Sixth nerve paralysis, effects of Size, abnormal sense of 840, 841 Skeleton, dwarfism due to defects of the . . . . 212 Skene's tubes, gonococci in . . 211 Skiagraphy (see X-rays) SlLeyden crystals in 117 - coagulation test for tuber- culous nature of . . . . 704 - with cough . . . . 175 - Curschmann's spirals in . . 179 - cretaceous pellet in . . 704 - in diphtheria, bronchial casts 704 - distoma pulmonale in . . 25 - dull red from rupture of liver abscess into lung. . . . 369 - elastic fibres in (Fig. 187, p. 701) 185,288, 3i6, 317, 319, 321, 651, 701, 703 as evidence of lung destruction . . . . 701 in gangrene of lung 99, 703 - in empyema ruptured into lung . . . . 99, 578 - eosinophile cells in . . 249 - examination of . . . . 175 in cases of loss of weight 847 empvema.. .. .. 120 - fcetid, "abundant 99, 651, 703 in bronchiectasis 193, 288, 321, 842 99, 28 21, 578 . . 246 88, 321 bronchitis. empyema fibroid lung gangrene of Itmg old phthisical vomicae 34, 288, 651 rupture of liver abscess through diaphragm . . 704 - fragment of new growth in 322, 704 - ingangreneof the lung 99,288, 321 - greenish, in infection with B. pyocyaneus . . . . 704 - hepatic pus in, from rupture of hepatic abscess into lung 176, 323, 369, 409, 704 SPUTUM— STOMACH, DILATED 99 r ''iputum, contd. Staphylococcus, contd. Stiffness of joint, contd. - iiiQuenza bacilli in.. 321, 702 - in phthisical sputum 701 from syphilitic synovitis 386 - iji lobar pneumonia 320 - prostatitis due to . . 83 - of knee from osteo-arthritis 384 - micrococcus tetragenus in 705 - pyelitis due to 625 - - (and see Arthritis) - microscopical examination of 176 - in septicEcmia 372 STIFF NECK isee also Pain in - naked eye appearance of, - simulating gonorrliceal ure- Xeck) 707 unreliable in diagnosis.. 700 thritis 631 from acute cervical adenitis 674 - nummular . . 700 - in sycosis vulgaris . . 602 - - cerebrospinal meningitis 328 - oidium albicans in.. 705 - tonsillitis from 670 and jaw in tetan-js 162 tropicale in 705 - ureteritis from 515 metliod of investigating - ova of paragonimus Wester- - uretliritis due to . . 83, 631 nature of 708 mani in . . 705 Staphyloma, posterior 462 from mumps 674 - penicilium glaucum in 705 " Starchiness " of face in - - myalgia of neck muscles 507 - in plittiisi.s 34, 87, 99, 185, 288, pseudo-bulbar palsy 686 pain in back from 477 325, 578, G51, (i7-l, 700, 701 712 Staring fades of Graves' in post-basal meningitis 328 absence of tubercle bacilli 704 disease 261 - - tetiinus . . . . 463 802 - paeumo-bacilli in . . 702 in paralysis agitans 262 due to sitting in a draught 477 - pneumococci in (Plate XII, Starvation, acetonuria in . ._ 4 Stigmata, venous, from cluronic Fig.O) C9C - aiiicmia in . . . . 37, 459 alcoholism 797 - in pneumonia 175, 186, 330, 321, - cachexia from . . 459, 461 Still's disease, (FiV/. 120) 418 372, 700, 701, 702 - dis.ippearance of phosphates allei.-tion of johits in 418 - repeated copious, from em- from urine in 572 amemia in . . 40, 418 pyema of lung . . 323 - glycosuria in 292 - - corresponds to acute - tubercle bacilli in (Plate XII, - hypotliermia due to 621 rheumatoid arthritis Fiij. K, p. liDU) 87, 99, 700 - leucopenia in 401 in adults 418 no indication, of itself, - marastmis from 427 emaciation in 40 of progressive lung - a2dema of logs in . . 459, 461 lymph elands enlarged in destructioa . . 701 - wastuig from . . 69, 847 40, 416 418 - - - methods of concentra- Status epilepticus 169 pigmentation of skin in. . 418 tion of 701 - lymphaticus (see Lymphatism) spleen enlarged in 40, 418 in phthisis . . 578, 712 Stays, Riedel's lobe due to . . 279 Stings, bleeding gums due to 85 tuberculous laryngitis - spinal curvature due to . . 214 - pruritus caused by . . 588 325, 674 Steam, sore throat from 671 - ve.=icles from 834 and elastic fibres in . . 185 Stelwagon, re bathing pruritus 588 Stinging-nettle, wheals from 850 ~ viscid .. ..321, 372 505 - re vesicular syphilis 832 Stitch, cause of 478 - - rusty . . 175, 186, 372, Stellwag's sign in exophthalmic - pain in chest from 477 700, 701, 702 goitre . . 244, 253, 792 - tenderness in chest from . . 776 - Ziehl-Xeelsen method of Stenosis (see under various organs) Stockbrokers, chronic pharyn- staining for tubercle - mitral (sea Mitral Stenosis) gitis in . . . . 670 673 bacilli in . . 700 Steppage gait. . 66 Stocking and glove anaesthesia Squamous eruptions (see Scales) Stercobilin, absence from in periplieral neuritis Square face of acromegaly . . 263 fseces with carcinoma (Fig. 175) 660 Squint Csee Strabismus) of pancreas 116 Stokers, enlarged heart in 232 Stab, hiemorrhage into cord - in gall-stone obstruction . . 116 Stokes-Adams' disease 172 from 563 - pancreatitis ... 116 bradycardia and other - pneumothorax after 577, 578 Stercoral ulcer of bowel, symptoms of . . 97 - surgical emphysema from 231 acute peritonitis from . . 55 coma in . . 527 Staccato speech in disseminated STERILITY 705 convulsions in 169, 172 527 sclerosis . . . . 3-12, 686 - distinction from impotence 346 new growths in . . 98 Staggering (see Gait) - necessitj' for semen ex- sudden halving of pulse- Staining for blood films 27 amination in 705 rate in 527 - method for gonococci 211, 768 - due to oligospermia 706 707 Stomach, acute post-operative - of Skin after erythema - salpingo-oophoritis 760 dilatation of 342 papulatum 531 - sex incidence of 705 - atonic dilatation of 354 lichen ruber planus 529 - from .T-rays . . 80 - atony of, contramdicated by pemphigus vulgaris 654 Sternomastold, .spasm of hjs- peristalsis and vomiting 713 psoriasis . . 657 tprical 166 - carcinoma of (see Carcinoma sm;ill-pox 605 - clonic contractions of 161 of Stomach) - - sypli Hides . . 532 604 - torticollis due to injury of. . 708 - contents, estimation of - Zieiil-Neelsen's for tubercle Sternum, affection of, in yaws 449 total acidity of . . 355 bacilli 700 tenderness of the chest examination of . . 355 Stammering 688 from 776 excess of mucus in gas- - bladder 439 - carcinoma of, secondary . . 776 tritis 352 - in general paralj'sis 688 - erosion by aneurysm 194, 482 microscopic examination of 355 Stapedius muscle paralysis . . 536 - new growth of, tenderness stagnating in pyloric hyperacusis from 53 7 in the chest from 776 obstruction 353 Stapes, fixed in otosclerosis . . 190 - periostitis of, causes of 776 - - tests for free HGl in . . 355 method of diagnosing . . 189 - swelling on, syphilitic 752 ferments in 355 - pressure on, vertigo due to 828 - tenderness of (see Tenderness organic acids in 355 Staphylococcus, in ascitic fluid 57 of Sternum) (See also Vomit ; and - bacteriuria from 83 STERTOR 707 Vomiting) - in cerebrospinal fluid 340 - distbiction from stridor . . 707 - cough due to 175 - circulating blood . . 650 - during convulsions 169 - determination of mobility of 355 - empyema 119 - in malingerers 173 of size 355 - epididymo-orchitis 518 - Stokes-Adams' disease 97 - dilated - fungating endocarditis 237 - syncope of fatty heart 241 acetonuria m 4 - impetigo . . 113, 601 602 - uricmic 48 asthenic . . 354 - laryngitis . . 670, 673 709 Stiffness of back from abdo- atonic, absence of visible - meningitis (and see Menin- minal aneurysm. .299, 486 ,728 peristalsis in . . 571 gitis, Staphylococcal) 339 642 in dorsal spinal caries . . 474 bismuth meal and a;-rays - in nasal discharge . . 203 from myalgia 607 in diagnosis of 352 - normal urethra 82 - of joint, hysterical . . 389 in carcinoma 351 - pemphigus neonatorum 111 ,113 in intermittent liydrar- causes of . . . . 352 712 - pharyngitis 670 tlurosis . . 387 characters of vomit 845 992 STOMACH, DILATED— STRYCHNINE POISONING Stomach, dilated, contd. demonstration of stagna- tion by treatment iii. . 352 diagnosis from duodenal carcinoma . . . . 725 gastroptosis of 352, 353 from hour-glass stomach 353 of indigestion from . . 352 extreme tliirst due to . . 789 - - in gastric carcinoma . . 846 flatulence in . . . . 267 indicanuria in . . . . 349 large quantities of fluid vomited with . . . . 845 limited value of sucoussion in indicating . . . . 712 percussion tests for . . 352 ptyalism in . . . . 591 from pyloric obstruction 723, 789 colicky pains of . . 134 pylorus sometimes in right iliac fossa . . . . 737 - - sarcinse in vomit with . . 713 simulated by dilated colon 714 -'- simulation of ascites by 717 - - succussion sounds in 352, 711 - - tetany after . . 3, 178, 802 visible gastric peristalsis in 571 vomiting W'ith . . 737, 843 - - wasting in . . . . 737 - disease, constipation in . . 144 - - of negroes . . . . 115 - - pain in temporal region from . . . ; . . 783 and tenderness in back from (Fig. 204) . . 788 - - tenderness in chest from 77G, 779 epigastrium from 779, 783 - downward displacement in general visceroptosis (Fii. 105, p. 353) . . . . 473 - dry cough due to . . . . 175 - flatulence in functional disorders of . . . . 267 - flatulent distention of, pain in left hypochondrium in 499 - hsemorrhagic erosions of, hfematemesis from 294, 298 - herniated into thorax . . 712 - hour-glass, anomalies of resonance in . . . . 353 diagnosis from gastric dilatation . . . . 353 gastric lavage in dia- gnosing . . . . 353 paradoxical dilatation in 353 symptoms of . . . . 845 vomiting from . . . . 843 - inflation of, in diagnosis of pancreatic cyst . . . . 690 for diagnostic purposes 352, 355, 690 - injm-ies, liaematemesis in 294, 299 - methods of examination of 355 - motor insufficiency of, evi- dence from gastric con- tents 844 - normal emptying time of . . 355 situation of . . 722, 727 - pain in . . . . . . 484 - reflexes, ptyalism from . . 591 - rupture of aneurysm into 140 - sarcoma of (see Sarcoma of Stomach) - succussion sounds in normal 710, 711 - ulceration of (see Gastric Ulcer) - vagus nerve sujiplying . . 842 - a;-rays and bismuth in demarcating . . . . 727 Stomach-aclie in Henoch's purpura . . . . . . 600 Stomach-ache and spinal caries confused . . Stomacli-tube in diagnosis of pyloric obstruction Stomatitis, aphthous in childhood ptyalism in - bacteriology in diagnosis of 144 815 815 590 591 86, 88 bleeding gums in - dysphagia in . . . . 225 - enlargement of submaxillary lymphatic elands in . . 419 - foul taste from . . . . 774 breatli due to . . . . 99 - impetiginous, perleche m association with.. .. 404 - loss of taste due to. . . . 774 - malignant . . . . . . 590 - mercurial, 37, 295, 590, 774, 797 - ptyaUsm in . . . . 590 - in scurvy . . . . . . 85 - sprue . . . . . . 197 - suppurative . . . . 590 - in syphilis . . . . . . 86 - tuberculous, in phthisis . . 591 ptyalism in . . 590, 591 - ulcer of the tongue with . . 812 - ulcerative, causes of . . 815 - varieties of . . . . 86, 88, 590 - Wassermann's reaction in 591 Stone (see Calculus) Stonemason's lung . . . . 317 Stools black after bismuth . . 428 - characters in pancreatic insufficiency . . . . 216 STOOLS, FATTY .. 265 - of dysentery, amcBba coli in 196 - examination of in diarrhoea 196 - hepatic pus in . . . . 409 - pale, in obstruction of bile- ducts .. .. 362, 410 - rice-water, in cholera . . 301 - sloughs from Peyer's patches in typhoid fever . . . . 697 - trichinellfe in, in trichinosis 504 - vibrio of cholera in . . 301 Stoutness in etiology of gall- stones . . . . . . 135 STRABISMUS 709 - amblyopia with . . . . 836 - in association with laryn- geal paralysis . . . . 539 - without diplopia . . . . 200 - diplopia from . . . . 709 - in disseminated sclerosis . . 838 - meningitis . . . .350, 359, 563 - myasthenia gravis . . 687 - organic cerebral disease . . 328 - due to syphilis . . . . 640 - tlirombosis of cavernoas sinus . . . . . . 651 - tuberculous meningitis . . 174 Strain, aortic disease due to 2.36, 237, 23S - conjunctival haemorrhage from256 - orchitis from . . . . 79 - rupture of aortic valve from 106 - sudden muscular, spinal lesions produced by . . 787 Strangulated hernia (see Hernia, Strangulated) - fibromyomata of uterus . . - spleen Strangury from retention of mine Strapping in distinguishing growth and gumma of testis Stramonium in diagnosis of asthma . . . . . . 582 Straw, actinomycosis from . . 87 - sporotrichosis from . . 322 Strawberry tongue m scarlet fever 607 434 700 440 521 339, Streptococcus, in ascitic fluid - bacteriuria from . . - broncho-pneumonia - in cerebrospinal fluid - the circulating blood - cystitis - empyema - epididymo-orchitis - erysipelas - fungating endocarditis - and gonococci associated . . - in impetigo . . - laryngitis due to . . 226. 465, 466, 670, oedematous suffocative - meningitis due to - in nasal discharge - nephritis due to . . - normal urethra - perleche from - pharyngitis from . . - in phthisical sputum - prostatitis due to . . - pyelitis due to - in septicaemia - suppurative meningitis - tonsillitis - ureteritis Streptotrichosis of liver Striations on lips in congenital syphilis (Fig. 79) Stricture of cesophagus (see Esophagus) - of urethra albuminuria from associated with carcinoma bilateral hydronephrosis in bougie in diagnosing 439, 440, and calculus associated catheter in diagnosing . . changes in stream of urine from cystitis from dribbling of urine after cassation of stream in - - endoscooe in diagnosing 208, 439, flO, 511, feeble stream of urine in forced urination in gradually increasing diffi- culty of micturition in hydronephrosis due to . . micturition, difficulty in starting in frequency of, in pain during, in in penis during nephritis from . . pyelitis in pyonephrosis from pyuria due to . . retention of urine in from spasm or congestion urethral abscess due to. . calculus behind fistute from 442, 677, l^rethritis from . . STRIDOR - distinction from stertor . . - in larvngeal obstruction 185, 465, - due to potassium iodide . . Strophanthus, bradycardia from Strophulus, papules of - severe itching in . . - varicella simulating - vesicles in . . - wheals in . . Strychnine poisoning, absence of lockjaw in consciousness retained in 510, 623, 45, 83 615 340 650 83 119 518 113 237 377 601 673 709 185 642 203 83 82 403 670 701 612 670 83 415 259 510 16 20f) 310 511 439 439 438 627 6 78 511 511 511 310 439 581 441 511 .«! 625 626 631 440 440 679 677 678 766 709 707 462 709 98 528 850 833 833 850 463 464 STRYCHNINE POISONING— SUPRARENAL TUMOUR 993 Slrychnine poisoning, contd. convulsions in 169, 170, 801 diagnosis by analj'sis 464, 652 from hysteria 464, 652, 801 tetanus . . . . 162, 802 opistliotonos in . . 463, 652 retraction of the he^d in 641 - risus sardonicus in 463, 651, 652 spasms in . . . . 178 - symptoms brought on by toucliiiiK patient . . 652 - - trismus late in . . 162, 802 twitcliinss and convul- sions in from vermin-killers - priapism caused by Stuffy rooms, headache from Stunting in cretinism - Hanot's cirrhosis . . - splenomegalic cirrhosis Stupor in choliemia . . Stuttering (see Speech, Abnor- malities of) Stye, conjunctivitis due to . . Stylomastoid foramen, effects of lesion at Subclavian artery, abnormal aneurysm of ("see Aneur- ysm, Subclavian) unequal pulses from athe- roma of . . Subdiaphragmatic abcess (see Abscess, Subphrenic) Subinvolution of uterus - - menorrhagia from - - metrostaxis from uterine congestion in . . Submammary abscess Submaxillary abscess . . - lymphatic glands (see Lym- phatic Glands, Submaxillary) Subnormal temperature . . 345 Subphrenic abscess (see Abs- cess, Subphrenic) Subscapular nerve, muscles supplied by spinal roots derived from Subscapularis muscle, spinal nerve-root supplying . . - - nerve supply of . . Subthalamic region, hyperpy- rexia from lesions of tumour of (see ilid-brain. Tumour of) . . . . 798 Succinic acid, leucocytosis from 400 Succulent hand in syringo- myelia . . . . . . 285 SUCCUSSION SOUNDS .. 710 - - in abdomen, causes of . . 711 epigastrium, gastric colonic gastric limits of normal with pneumothorax in pyloric or duodenal ob- struction - thoracic list of causes of . . " Sucking in " above the clavicles in laryngeal or tracheal obstruction 465, 642 Sudamen, vesicles with . . 714 Sudan m test for chyluria. . 126 Sudden death from fibroid heart 242 ruptured aneurj-sm 107, 140 Suffocative oedema simulated by laryngeal paralysis . . Suffocation, sense of, associated with flushing Sugar in cerebrospinal fluid . . - sore fingers from handling - in urine (see Glycosuria) _ 802 464 586 327 258 410 369 361 256 537 223 593 429 428 436 429 744 419 550 550 556 550 346 723 352, 723 .. 710 571 193 711 539 268 339 266 Suggestion (fear of pregnancy) causing amenorrhoea . . 23 - in diagnosis of phantom tu- mours 721 - hysteria . . 150, 343, 527 - treatment of functional hiccough . . . . . . 343 paralysis of vocal cords 538 Suicide by phosphorus . . 373 - the result of extreme tinnitus . . . . . . 793 Sulphhoemoglobinuria 184, 187 Sulphanilic acid reagent .. 197 Sulphates, aromatic, in the urine . . . . . . 823 - urinary, ratio of organic to inorganic . . . . 97 Sulphides formed during putre- faction . . . . . . 283 Sulphonal, Cheyne-Stokes respiration due to . . 125 - coma due to . . . . 137 - liasmatoporphyrinuria due to 820 - poisoning, influence of sex on 20 - purpura from effect of taking 59G Sulphur dioxide causing coryza 203 - granules in abscess in actinomycosis of liver . . 415 Sulphuretted hydrogen in urine . . . . . . 187 Sulphuric acid, in Ziehl- Xeelsen tubercle stain . . 700 Summer season, relation to cheiropompjiolyx . . 832 - severe diarrhcea in infants in 579 Sun, erythema from exposure to 252 Sunstroke, headache in . . 329 - hyperpyrexia in . . . . 344 Superciliary ridges, enlarge- ment in acromegaly 749, 753 Superficial cervical nerve, skin distribution of . . . . 659 Snperinvolution of uterus caus- ing amenorrhoea 23, 24 Supernumerary ribs (see Eib, Cervical) Superior gluteal nerve, muscles supplied by . . . . 542 spinal roots derived from 542 - longitudinal sinus tlirom- b'osis (see Thrombosis) convulsions in . . 558 - mesenteric artery, embolism of, in fungating endo- carditis . . . . . . 646 - vena cava, obstruction of, cyanosis from . . . . 184 by aortic aneurysm (Figs. 1-2, 73) 234, 235, 236, 826 aneurysm . . . . 746 bronchial glands . . 422 bruit with . . . . 236 causes of . . . . 461 causing oedema of face, neck and arms 458 by chronic fibrous mediastinitis . . 826 cyanosis from . . 184 in mediastinal fibrosis 484, 746 growth . . 465, 483 mediastinal new growth 826 by new growth 121,188,322 oedema of arms and head from . . 826 face, neck and arms from . . 461 rupture of aortic aneu- rysm into . . . . 482 thrombosis (see Throm- bosis) Supinator brevis, nerve supply 550 - jerks exaggerated in upper neurone lesions . . . . 546 - longus, clonus of . . . . 161 escape in lead palsy . . 77 nerve supply of . . . . 550 spinal nerve-root supplying 556 Suppositories in diagnosis of nature of constipation . . 142 Suppression of urine (see Anuria) Suppuration in accessory nasal sinuses, earache from . . 230 - deep-seated, anaemia in . . 39 - headache in . . . . 328 - leucocytosis due to 614, 62J3, 899 - long-standing, lardaceous disease from 197, 414, 696 causing amenorrhoea . . 23 - in onychia . . . . . . 445 - polymorphonuclear leuco- cytosis as evidence of . . 400 Suppurative meningitis (see Jleningitis Suppurative) - otitis media (see Otitis Media) Supraclavicular glands, dia- gnosis of site of abdominal growth by microscopic examination of . . . . 421 enlarged (see Lymphatic Glands, Supraclavicular) - nerve, skin distribution of 659 Supraorbital nerve region, herpetic eruption of . . 807 skin distribution of . . 659 - neuralgia in iritis and cycUtis . . . . . . 256 - pain from eyestrain . . 495 Suprarenal gland, carcinoma of (see Carcinoma of Supra- renal) malignant disease of, (see also Suprarenal Tumour) .. ..690 normal situation of . . 722 sarcoma of, secondary deposits in cranium from 782 - rests in kidney, hyper- nephroma from . . . . 690 - secretion, effect on menstrua- tion 430 - tumour, abdominal swelling due to 393 no Addison's disease if unilateral . . . . 690 associated with sexual precocity . . . . 729 diagnosis from renal tumour . . . . 690 splenic tumour . . 690 excessive fatness of chil- dren from . . . . 454 filling of loin by . . . . 729 hasmatiiria from involve- ment of kidney in . . 690 jaundice in . . . . 362 laparotomy in diagnosing 690 from renal tumours 393 malignant . . . . 690 obesity with . . . . 454 palpable in epigastrium 725 right lumbar region . . 727 'physical signs of. . .. 690 simulation of renal or hepatic swelling . . 367 premature development of genitalia with . . 454 in right capsule, bile-duct obstruction from . . 367 rounded movable hypo- chondriac sweUing due to 393 simulating enlarged spleen 726, 729 urinary changes, from involvement of kidney in 690 63 994 SUPRASCAPULAR NERVE— SWELLING OF JAW Suprascapular nerve, muscles Swelling, Abdominal, contd. Sicelling of the face, contd. supplied by . . 550 in carcinoma of colon 91 499 subjective sensation of in paralysis of 551 pancreas . . . . 500 690 trigeminal neuralgia . . 495 spinal roots derived from 550 stomach 351, 485 691 vaccinia . . 746 Supraspinatus, nerve supply of 550 classified list of causes of 715 SWELLING, FEMORAL 732 - wasting in phthisis 72 - - constipation from pres- due to ectopic testis 740 Supratrochlear nerve, skin dis- sure of large . . 148 - of foot from mycetoma . . 809 tribution of 659 displacement of cardiac - hyi)ochondrium, left, due to Surgical emphysema (see impulse by . . 330, 332 splenic enlargement 688 Emphysema, Surgical) due to fifcal accumulation 692 - hypogastric, due to bladder 45 - kidney (see Nephritis, Ascen- from intussusception 736 SWELLING IN ILIAC FOSS/E ding) multiple, in tuberculous 735, 737 Svi'abbing of tonsils in dia- peritonitis 152 in psoas or iliac abscess 633 gnosis of tliroat infections 419 orthopnoea from pressure of 465 - - fossa, left, from acute Swallowing, difficulty in (see pancreatic affections 486 diverticulitis . . 731 Dysphagia; due to phantom tumour 761 aneurysm of external Sweat, bloody 715 - - pulsatile 763 iliac artery 735 - coloured from chromidrosis 714 pulsating and expansile, carcinoma of sigmoid 735 - ducts involved in granu- in abdominal aneurysm 486 congenital dilatation losis rubra nasi . . 714 due to splenic enlargement 689 of the colon 735 - foul smelling 714 - - - suprarenal tumour 393 - diverticula simulating - retention, cheiropompholyx tuberculous peritonitis 691 carcinoma in 152 due to 111 tympanitic on percussion, enlarged lymph glands 735 - urinous odour of . . 715 in subphrenic abscess 501 spleen in . . 735 SWEATING, ABNORMALI- SWELLING, AXILLARY .. 731 kidney palpable in 735 TIES OF 714 - of bones in acromegaly . . 753 psoas abscess 733 - absence of . . 714 from gout 754 — - - ulcerative colitis 735 facial in cervical sympa- in leontiasis ossea 753 various tumours felt in 731 thetic paralysis 247 osteitis deformans 753 right, due to actino- in spots of leprosy 424 - - osteo-arthritis 754 myces 736 - in acute rheumatism 375 pulmonary hypertrophic appendicitis 729 736 - bacilluria 616 osteo-arthropathy 754 broad ligament abscess 737 - colic 133, 472 rickets 753 carcinoma of CEecum - crises of locomotor ataxy . . 562 SWELLING ON A BONE 750 729 736 - deficiency of, in myxoedema 585 due to callus 750 - - pylorus 737 - in enteric fever 648 carcinoma 757 chondroma of pelvis 737 - extreme thirst after 789 in chloroma 599 disease of iliuin 730 - in fungating endocarditis 103 237 chondroma (Fig. 195) . . 755 enlarged iliac lymph- - Graves' disease 797 clu-onic abscess . . 750, 752 atic glands 730 736 - from hepatic abscess 651 osteomyelitis . . 751 extension upwards - in Hodgkin's disease 649 periostitis 751 of pelvic swelling 737 - hyperidrosis, in arsenical in congenital syphilis . . 752 hip-joint disease 730 poisoning . . . . 7C , 87 exostosis . . 754 mode of investigating 735 brachial neuralgia 491 fibroma . . 755 movable kidney in . . 729 egg-shell nail associated gumma . . 752 due to osteomyelitis with 445 hydatid cj'st 757 of ilium . . 737 - in influenza 699 inflammatory 750 ovarian cyst 737 - leukJEmia 649 - - injury 750 pregnant uterus 737 - with lightning pains of tabes 489 lipoma 755 psoas abscess 730 - in malaria . . . . 35, 615 mode of examination in pyosalpinx . . 737 - malingering . . 464 oases of 750 Kiedel's lobe of liver 737 - malnutrition 714 multiple in secondary sacro-iliac joint disease 730 - Malta fever 506 syphilis 752 sarcomaof pelvic bones 737 - at night (and see Night painful in scurvy-rickets 753 in scybala . . 729 Sweating) 714 worse at night, in spinal caries 737 in phthisis . . 577, 714 secondary syphilis.. 752 suppurating gall- - pernicious anaemia . . 649 due to sarcoma . . 755, 756 bladder . . 737 - pink tint with 714 subperiosteal extravasation 750 tuberculous caecum. . 736 - profuse, constipation due to 145 - - tender in secondary sy- disease of ilium . . 773 - - after crisis in pneumonia 702 philis . . . . ' 752 tumours from car- in infantile scurvy 115 due to tuberculous disease cinoma of colon . . 152 tropical abscess of liver . . 369 751, 752 thickened diver- - in pyaemia . . . . 372, 649 periostitis 752 ticula . . 152 - pyonephrosis 396 in tyjjhoid fever 752 uterine fibroid 737 - relapsing fever 698 - in breast (see Swellmg, various tumours felt - rheumatoid arthritis 378 Mammary) in . . . . 729, 730 - in rickets 171 - in epigastrium in tropical wandering kidney . . 737 - during rigors 646 abscess of liver . . 369 spleen 737 - in salpingo-oophoritis 760 SWELLING OF THE FACE .. 746 - of ileo-costal space from - sense of, in a dry part, in due to alveolar abscess 746 renal tumour 391 syringomyelia . . 664 anthrax . . 746 SWELLING, INGUINAL (see - in septicaemia 375 boil, carbuncle, or suppur- Inguinal Swelling) - with sinus thrombosis 650 ating wound . . 746 SWELLING, INGUINO-SCRO- - in trichinosis 504 chancre (Fig. 10, p. 86) . . 746 TAL (see Inguino-scrotal - tropical abscess of liver . . 408 dental caries 746 Swelling) - urate deposit with . . 815 epithelioma 746 - at inner side of orbit from - yellow in jaundice . . 361 erysipelas . . 746 ethmoidal inflammation 255 Sweep's cancer . . 765 803 fibroma 746 SWELLING OF JAW, 747, 749 Sweets, blue urine after 823 insect bites 747 - - from extension of cancer - eosin used in colouring of 820 lipoma 746 of tongue or mouth . . 749 - green urine after . . 823 mumps . . . . 746 fibroma . . 748 - red urine after . . 819 820 oedema (see CEdema of Face) due to fibrous epulis . . 748 SWELLING, ABDOMINAL .. 715 parotitis . . 746 fracture . . 747 ascites with various 59 sebaceous cyst . . 746 hacmatoma 747 SWELLING OF JAW— SYPHILIS, CONGENITAL 995 Swelling of jaw, contd. Sycosis vulgaris, contd. Syphilis, contd. injury 747 diagnosis from eczema . . 602 - aneurysm of heart from . . 241 otiontomata 749 ringworm of the beard 274 - angina pectoris from 62 osteoma . . 748 tertiary sypliilis 603 - anosmia from 668 periostitis 747 dropping out of the hairs in 602 - aortic disease from 18, 62, tumours of antrum of of face 654 233, 236, 237, 238 Ilitj'limore 749 leprous nodules simulating 450 - aortitis from . . 38, 106, 481 - - lower 747 parts affected by 602 - arthritis in (see Artluritis, — - ilue to actinomycosis 748 pu.stules in . . GDI, 002 Syphilitic) - - - iilveolar abscess 747 scabs in . . 654 - a.scites from. . . . 55, 60 omIIus from fracture . . 747 slightness of itching in . . 002 - ataxic paraplegia from . . 605 — - carcinoma fand see Car- due to staphylococci 002 - atheroma from . . 233, 238 cinoma of Jaw) 749 Sympathetic, abdomuial : in- - atrophic palsy of one leg mode of examination in 747 fluence on pigmentation 574 from 543 situation often masked - cervical (see Cervical Sym- - balanitis in. . 674 by superficial swcU- patlietic) - baldness from . . 8i , 85 inpr . . 747 Syncope in Addison's disease 38 849 - bleeding gums in . . 85 , 86 - of joints Cand see Artljriti-) 450 - fatty heirt . . 241 - of bone, simulating sarcoma 756 - of legs (see CEdema of Legs) - from gastric ulcer bleeding 298 - bronchial stenosis from 288, multiple, red, tender, in - local, in Kaynaud's disease 490 324, 325, 582 erythema nodosum . . 751 - in myocardial degeneration 333 - bulke in . . . . 110, 112 - of limbs, local, from em- - thymic infantilism . . 215 - cachexia from 17, 37, 114, bolism 237 Synovia! etfusion (see Arthritis 115, 347, 459, 461, 575, 658 - of lips, due to mercury 86 and Synovitis) - and cancer, not distinguished 88 Synovitis from displaced by pyrexia . . " 618 - in lumbar re!:;ion, loft, in semilunar cartilage 388 - cavernitis in penis from . . 516 splenic enlar^oraent . . 688 - in secondary syphilis 386 - cerebral, coma in . . 136 138 SWELLING, MAMMARY (and - infective, anaemia in 36 convulsions in . . 109, 172 see Breast) 742 neighbouring lymphatic endarteritis from 327 337 - in the muscles in trichinosis 504 glands enlarged in 418 422 hemianopsia in . . 335 - nodular, witli varicose veins 450 from pyorrhoea alveolaris 87 liemiplegia from . . 337 - of orbital tissues in cavernous - secondary syphilis . . 386 insomnia in . . 356, 358 sinus thrombosis 254 (and see Artliritis) multiple cranial nerve SWELLING, PELVIC 757 761 Syphilides, circinate tuoercular, paralysis from . . 590 behind uterus in salpingo- diagnosis from ringworm ptosis from (Figs. 156-159) 590 oojilioritis 220 of beard . . 274 thrombosis from 138, 173 503 — ectopic gestation. . 436, 757 tinea circinata 275 varieties of 173 nephritis from . . 8 - combes 533 - chancre of (see (Chancre) retention of urine v/ith . . 45 - distinction from epithelioma 803 - Cheyne-Stokes respiration sciatic nerve paralysis from 542 pityriasis rosea . . 658 from 125 - perinephric (see Kidney from tinea versicolor . . 276 - choroiditis in, ophthalmo- Enlargement) - distribution of 533 scopic appearance of - in perineum due to mis- - impetiginous 604 (Plate VI I) 462 I'l.iced te.stis 523 - itching absent in . . 604 - chronic hypertrophic hse- SWELLING, POPLITEAL - large acuminate, description morrhagic pachymenin- 7G1, 762, 763 of lesion of 604 gitis from 563 - in pubic region due to mis- flat pustular, coppery - condylomata in 403, 404, placed testis 523 areola and base in 604 469, 654 769 SWELLING, PULSATILE 763 764 - miliary 604 soft sore mistaken for . . 769 in aortic aneurysm 561 - papular 532 - congenital, adiposis dolorosa of back in aortic aneurysm 476 diagnosis of lichen scrofu- from 455 cliest w.ill 194 losorum from 530 arthritis in (and see Ar- inguinal, due to aneurysm varieties of . . 532 533 thritis) . . . . 260, 386 of external iliac artery . . 741 - pigmentary, diagnosis of cirrhosis in . . 305 370 popliteal, from sarcoma of chloasma and leucoder- condylomata in . . 427, 446 femur . . 762 mia from 575 convulsions from 170 SWELLING, SCROTAL 764 767 - polymorphism of . . 533, 607 craniotabes in 782 due to cysts of epididymis 767 - pustular . . 532, 601 607 deafness in 259 testis " . . 521 diagnosis from acne 603 depression of nose in . . 259 hoematocele 523 small-pox 607 Dercum's disease due to 455 hydrocele 522 preference for genitals, diagnosis from Jacquet's - supraorbital, from frontal scalp, and face 604 infantile erythema 440 sinus inflammation 255 pyrexia with 607 seborrhoeic eczema 447 - in thigh due to misplaced - raw-ham colour of. . 532, 533 enlargement of head, dia- testis 523 - reaction to mercury, arsenic. gnosis of hydrocephalus - of toe, in gout 381 and iodides 604 from . . . . 557, 558 - tongue due to mercury 86 - scaly 656 - - epiphysitis in . . 386 752 - umbilical region from abscess - secondary cutaneous, coppery erythema of 253 in tuberculous peritonitis 524 colour of . . 604 facies m (Figs. 78, 79) 259, 446 in carcinoma of colon 524 - small acuminate . . 604 family history in dia- pylorus 524 flat pustular 604 gnosis of 695 due to divarication of raw-ham areola in 604 frontal bosses in (Fig. 78) 259 recti . . 524 - varioliform . . 601 hot-cross-bun skull in 752, 782 hernia . . 524 Syphilis (and see Syphilides), Hutchinson's teeth in sebaceoas cyst 524 acetonuria in 4 (Figs. 79, 80) . . 259, 260 splenic enlargement . . 688 - acqnued, enlarged liver in 370 hyperplastic osteitis in . . 782 - at vaginal orifice (see - albuminuria in 13, 16, 17, 86 ,371 infantile convulsions due to 169 Prolapse of Uterus) - alopecia in . . 450 infantilism in 260 SWELLING, VULVAL 768 - amyloid disease from 197 interstitial keratitis in . . 828 - - due to fibromyoma of - ansemia in . . . . 27, 3 •, 38 jaundice in . . 365, 370 vagina . . . . 587, 768 severe, from 459 lardaceous disease from 414 Swimmer's cramp 177 - aneurysm after 223, 238, laryngitis in 446 Sycosis vulgaris, diagnosis of 602 296, 300, 322, 368, lipomatosis from 455 from acne vulgaris 603 483, 486, 538, 564, 728 786 liver changes in 365, 370, 411 996 SYPHILIS, CONGENITAL— SYPHILIS, ULCERATION IN Syphilis, congenital, contd. liver enlarged in . . loose, dry, caf6-au-lait skin, of . . marasmus in - - mental deficiency in napkin-region eruptions in natiform. skull ia ocular symptoms of orchitis in - - osteo-chondritis in Parrot's nodes in 427, pemphigus from.. pseudo-paralysis in 386, pain slight in . . rapid improvement with mercury in . . tenderness in . . pyrexia due to gumma in relation of pseudo-leu- kffimia infantum to 43, - - sallow complexion in scars on lips in . . skin eruptions in snuffles in 427, 446, spleen enlarged in 692, tabes from tenderness of the scalp in tibial deformities in Wassermann's reaction 427, - - wasting in . . . . 370, - corona veneris of . . - cyanosis in . . - cyclitis due to - danger of mercury in nepliritis associated ^ith - diagnosis of . . - diazo-reaction in . . - dwarfing of one or other lobe of liver in . . - dysphagia from - ear affections in . . 469, - endarteritis from (see Endo- arteritis) - enlarged mguinal glands in 738, - epididymitis in - epistaxis in - esthiomfene due to . . - Eustachian tube obstruction in . . - eye paralysis from. . - facial paralvsis from (Figs. 158,159)" - fibroid heart from 62, 241, lung and bronchiectasis from - fibrous mediastinitis in - fingers aifected by . . - fissured tongue from - gangrene in - general paralysis of insane from - giddiness due to - gingivitis in. . - glossitis from - gumma in (see Gumma) - hsemoglobinuria in - herpes progenitalis with . . - herpetic urethritis in - impotence in - incubation period of 675, - infantilism from . . - intermittent claudication from - iritis in . . . . 256, - Jacksonian epilepsy from. . - jaundice from 362, 366, - of law, rarity of . . - lardaceous disease from 10, 411, 414, - laryngeal paresis from 539, - laryngitis in (and see Laryn- gitis, Syphilitic) . . 86, 325, 538, the 269, 812, 370 446 427 260 446 752 259 519 386 752 111 387 387 387 387 615 695 259 259 695 695 695 489 782 260 695 427 532 185 256 590 604 198 404 224 828 769 519 250 769 828 224 589 242 324 826 266 813 282 86 813 315 675 209 347 676 215 489 450 161 371 748 696 640 673 Syphilis, contd. - of larynx, dysphagia in . . 226 hEemoptysis in . . . . 318 - leucoplakia from . . 237, 813 - lips affected m 403, 404, 813 - and Little's disease . . 154 - of liver 411 absence of ascites and jaundice in . . 410, 411 general symptoms in 410, 411 ascites with . . 55, 60 diagnosis from carcinoma of liver. . . . 411, 413 of catarrhal jaundice from 362, 366, 371 from cirrhosis . . 410, 411 hydatid disease of . . 415 enlargement of liver in . . 411 jaundice with large liver m 363 lumpy irregular shape of liver in . . . . 411 rarity of . . . . . . 410 spirochaeta pallida in . . 371 Wassermann's reaction in 371 - loculated hydrocele in . . 765 - lupoid variety of . . . . 449 - lymphatic gland enlarge- ment in 266, 416, 417, 533, 604, 675, 738, 769 - macular eruption in throat 425 - macules in (see Macules, Syphilitic) - medullary softening due to 224, 343 - meningeal, headache in . . 327 - meningitis from (see Menin- gitis, Syphilitic) - mercury in diagnosis of (see below. Potassium Iodide) - meteorism in . . . . 432 - moist anal papules in . . 447 genital j)apules in . . 447 - of mucous membranes . . 371 - mucous patch on fauces or tonsils in . . . . . . 675 tongue from . . . . 813 - multiple tender swellings on bones in . . . . . . 752 - muscular atrophy in . . 76 - necrosis of jaw from 747, 748 nasal bones from 204, 237, 252 - nephritis in . . . . 86 - nerve deafness from 190, 828 - night pains of . . . . 386 - nodes on bones in . . . . 752 - nodules in . . . . . . 449 epididymis in . . . . 519 - obstruction to nose by . . 668 - oedema of face, neck, and arms from . . . . 458 larynx in . . . . . . 466 legs in . . . . 459, 461 - onychia in . . . . . . 445 - orchitis from . . 79, 519 - osteocopic pains in . . 503 - otorrhcea in. . . . . . 469 - ozsena from.. .. .. 204 - pachymeningitis in paralysis of upper extremity from 555 - pain in arm from aortic disease due to . . . . 494 bones in . . . . . . 503 worse at night in . . 752 - pains of, confusion with osteo-arthritis . . . . 386 - pancreatitis from . . . . 116 - papular skin rash in 769, 832 - paraplegia from . . . . 563 - paralysis of palate in . . 640 - paroxysmal hfemo-globin- uria from . . . . 315 - perforating ulcer of foot from 809 - - of palate from 202, 237, 640 Syphilis, contd. - perichondritis in . . . . 791 - perihepatitis from . . . . 60 - perineal sores in . . 677, 678 - periosteal thickening in . . 519 - peripheral neuritis in 76, 506, 507 - pharyngitis in . . . . 86 - pigmented scars from 237, 575 - potassium iodide and mer- cury in diagnosing, 226, 254, 325, 449, 520, 615, 640, 658, 674, 677, 681, 808, 814 - primary, lateral sclerosis from 567 - ptyalism in . . . . . . 590 - pupil reflexes in . . . . 594 - pustules in . . . . . . 833 association with cachec- tic state of health . . 604 - pyrexia in 371, 607, 609, 614, 615, 673 - rarefaction of bones from . . 179 - relation to soft sore . . 738 - rhinitis from . . . . 204 - roseola in 86, 371, 425, 615, 672, 676 - rupial crusts in . . 653, 654 - rupture of heart from 238, 241 - salvarsan in diagnosis of . . 814 - scarring of palate from . . 237 - scleritis and episcleritis from . . . . . . 256 - scrotal sores due to . . 679 - shedding of nails in . . 445 - simulating asthma . . .. 582 carcinoma . . 449, 618 eczema . . . . . . 533 erythema nodosum . . 450 follicular tonsillitis . . 672 gout . . . . . . 386 leprosy . . . . 75, 4-50 lupus . . . . 449, 808 Meniere's disease . . 828 perleche . . . . . . 404 psoriasis . . . . . . 658 rodent ulcer . . . . 449 rosacea . . . . . . 268 scrofulodermia . . 449, 603 Sycosis vulgaris . . . . 603 variceUa . . . . . . 833 yaws . . . . . . 449 - snail-track ulceration of pharynx in . . . . 672 - sore throat from 371, 425, 533, 605, 615, 670, 672, 675, 769 - of spinal cord, paralysis of one leg from . . . . 540 - spmal thrombosis in 432, 563, 564 - spirochreta pallida in 371, 738 - stenosis of bronchus from, mistaken for asthma . . 582 - - pharynx from . . . . 225 trachea in . . . . 710 - Stokes-Adams' disease from 98 - stomatitis in . . 86, 590 - strabismus due to . . 539, 640 - swelling of th3rroid gland in 792 - synovitis in.. .. .. 386 rapid variations in size of joint in 386 tenderness of joint in . . 386 - tabes dorsalis from 489, 539, 562 - tenderness of bones in . . 672 scalp from . . 672, 780 - testis and scrotum, affec- tion of 679 atrophy of, after . . 79 (see Te'stis, Syphilis of) - tinnitus due to . . 794, 828 - tonsillitis from . . 563, 670 - transverse myelitis from 564, 565 - Ulceration inside cheek from 813 of chin in 603 ear in . . . . . . 469 - - face by 808 SYPHILIS, ULCERATION IN— TABES DORSALIS 997 ■Sypfiilis, itlceralion, contd. - - of larynx in.. 1S5, iGG, 710 leg from - lip from . . - nose in - palate in . . - rectum in - skin in - tongiie from - tonsil from - vulva in •119, 811 .. 813 . . 250 237, 640 . . 635 338 237, 812, 813 425, 670, 813 . . 769 - unilateral exophthalmos from 254 - urethral herpes from . . 209 - valvular disease of heart from 526 - vesicles in . . . . . . 832 - vocal-conl paralysis from 538, 710 von .faksch's disease due to 42 Wassernmnu's reaction in, 204, 224, 226, 254, 279, 338, 371, 591, 605, 658, 672, 738, 7J8, 769, 808, 811, 814 in cerebrospinal fluid in 340 - wastinsT from . . . . 69 - yaws no protection from . . 450 - secondary (and see Syphilides^ - - cutaneous lesions of 604, 605 - - swelling on skuU in . . 752 f^y}>hiloderm (see Syphilides) Syringomyelia, abnormal sense of cold in . . . . . . 664 - anivsthesia in . . 388, 664 - anilgesia in.. .. .. 665 - arthritis m . . 285, 388, 563 similarit}' to osteo-arthritis 388 tabetic arthritis 388, 563 - ataxy in . . . . . . 68 - atrophic paralysis of one leg in 544 arms in . . . . 665 - Babinski's sign in . . 82, 554 - brittleness of bones in . . 285 - bulhr in .. .. 110, 112 - Charcot's joints in 285, 388, 563 - claw-hand in . . 127, 285 - diagnosis from leprosy . . 424 - dissociated anaesthesia in 112, 128, 285, 554, 563 - electrical reactions in . . 554 - erythromelalgia in . . . . 490 - frequency of wounds in . . 388 - gangrene in.. .. .. 282 - glossy skin in . . . . 128 - glove type of anaesthesia m 664 - lancinating pains and cramps 128, - main succulente in . - manual deformity in . . ' 554 - Morvan's disease in . . 563 - muscular atrophy in 73, 285, 544, 665 - nystagmus in 128, 453, 554 - pain in the arms in. . . . 554 - painless swelling of joints in 568 - paralysis of arm in . . 554 - paraplegia from . . 561, 563 - parts affected by . . . . 664 - perversion of seasation in 778 - precipitate defecation m.. 348 - preservation of cutaneous sensibility in . . . . 73 - pupil phenomena in . . 128 - reflexes in . . . . . . 554 - scoliosis in . . 128, 388, 554 - sense of drenching sweat in part which is dry in . . 664 - sensory changes in 73, 112, 128, 285, 388, 554, 563, 664, 665 - simulating amyotrophic lateral sclerosis . . . . 73 leprosy . . . . . . 75 progressive muscular atro- phy 73 - spastic paralysis of leg in. . 128 - spontaneous fracture in . . 285 Sifringomyclia, contd. - succulent hand in . . 128, - superficial gangrene in - thermo-ana;sthesia in (Fin. 182) .. .. 664, - trophic changes in . . skin, nails and joints in and vasomotor disturb- ances in - whitlows in . . Systolic bruits (see Bruits, Cardiac) TABES DOLOROSA chronic general pains in the limbs in . . - dorsalls . . 262, 525, - - abdominal colic from . . - - absence of breast tender- ness in . . larynx tenderness in . . ovarian tenderness in . . testicular tenderness in tongue tenderness in. . wasting in acute cyanosis in ' allocheh'ia hi . . 22, anaesthesia in . . 562, analgesia in (Fig. 183, p. 665) 489, 493, 498, deep . . 350, 662, anomalous cases of - - anosmia from Ai'gyll Robertson pupil in 285, 466, 493, 498, 562, 594, astereognosis in . . ataxy in 66, 277, 285, 498, 562, band type of hyper- iEsthesia in bedriddenuess from bladder spasm in trouble in blood-pressure in cardiac crises in . . Charcot's joint i Charcot's joint) chronic general pains in limbs . . colicky pains of . . constipation m . . cord changes in . . crises early in cyTStitia in . . deafness in deficient sensibility muscles in degeneration of auditory nerve in delayed sensibility in . . diagnosis of peripheral neuritis from . . duninished power of mic- turition in subcutaneous fat in . . drooping eyelids in dull, boring, aching pains in legs in . . 489, erythromelalgia in extsrnal popliteal nerve paralysis in facies of (Fig. 87) gait in . . 277, 278, gangrene in . . 282, gastric crises in 350, 473, 485, 489, 562, 665, 844, rise of blood-pressure 350, simulating dyspepsia violent vomiting in 350, general abdominal crises in girdle pain in 289, 484, high-stepping gait in . . 350, (see 350, of 285 285 665 554 128 128 66, 350 Tabes dorsalis, contd. history of syphilis in liypora?st.hesia in - - hypotonia in impotence in individual muscles not weak in intercostal nerve pain in - - intestinal crises in uitolerancc of hot and cold water in . . knee-jerks absent in 285, 350, 398, 466, 473, 562, 847 laryngeal crises in 185,465,562 diagnosis from result of potass, iodide admhiistration . . from syphilitic ul- ceration of larynx paralysis associated with 539 lightning pains in (and see Lightning Pains in Tabes) 350, 489, 498, 507, 562, 664 - - loss of control over sphincters in . . convergent pupillary reflex in lymphocytosis in cerebro- spmal fluid of. . 339, mistaken for gout rheumatism niggling pain in legs in . . numbness in pain in face in, dull boring character of . . in the umbilical region tlie only complaint in some cases of painful crises in . . palpitation m . . 525, paradoxical pupillaiy reflex in parEesthesijB in . . paraplegia from. . perforatbig ulcer of foot in (Fig. 207, p. 809) 285, 562, 809, 811 plantar reflex in . . 81 points for investigation in diagnosis of preponderance in males ptosis in . . pupil changes in. . irregular in small in (and see Tabes Dorsalis, Argj'll Robertson Pupil in) reaction of degeneration absent in . . . . 562 rectal crises in . . . . 562 reeling and staggering in 827 reflexes in 81, 134, 562 renal crises in . . . . 562 retention of urine in . . 441 Romberg's sign in 67, 665 sallow complexion in . . 262 sense of position and move- ment abnormal in 493, 665 sensory changes in, 66,350, 493, 498, 662, 664, 665, 666, 669, 778 shedding of nails in . . 445 simulating gastric ulcer 350 wTiter's cramp . . 177 sphincter trouble in 441, 562 sweating crises in . . 562 symptoms of syringo- myelia simulating . . 563 syphilitic aiiection of heart in . . . . 527 tenderness m chest in . . 777 ulnar analgesia in . . 493 vertigo due to . . . . 827 vesical crises in . . . . 563 562 666 262 346 562 478 665 665 466 466 285 594 489 484 484 489 664 498 524 664 527 595 493 562 489 562 262 262 595 594 998 TABES DORSALIS— TENDERNESS OF BREAST Tabes dorsalis, contd. vomiting in 350, 485, 844, 847 AVasserniann's reaction ■witli wrinkled forehead in - mesenterica, with ascites . . meteorism in simulation by anorexia nervosa 489 262 56 432 850 TACHE CEREBRALE .. 771 TACHYCARDIA ..771 - in acute yellow atrophy . . 370 - causes of . , . . . . 772 - ui diphtheritic neuritis . . 77 - exophthalmicgoitre244, 253, 772, 792, 797, 849 sometimes only evidence of 772 - mitral stenosis . . 61, 245 - otitis media complications 98 - with parenchymatous goitre 792 - paroxysmal . . . . 772 - - palpitation in . . . . 525 - in pyaemia . . . . . . 372 - pyrexial jaundice . . . . 361 - in tropical abscess of liver 369 - tuberculous meningitis . . 98 Tactile vocal fremitus (see Vocal Fremitus) Teenia infection, anoemia in 568, 569 - ecchinococcus in dogs . . 719 hydatid disease due to bladder sf ase of . . . 719 - mediocanellata (i^/^. 150).. 568 - solium (Figs. 148, 149, 152) 568 Tailor's cramp . . . . 177 - sporotrichosis of lung . . 322 TALIPES 130 - in alcoholic neuritis . . 165 - arsenical neuritis . . . . 165 - calcaneus, definition of . . 130 -- cavus, definition of . . 133 - cold and blue feet m 130, 131 - congenital . . . . 130, 224 - from contracting scars . . 132 - from disuse.. .. .. 165 - dystocia in etiology of . . 131 - equinus, definition of . . 130 - from filDrosis and contrac- ture of calf muscles . . 132 - in Friedreich's ataxy 71, 164, 559 - hypierextended toes in . . 130 - hysterical . . . . 132, 166 - from infantile paralysis 71, 559 - inflammation of bone . . 132 - new growths in pelvis . . 131 - poliomyeUtis . . . . 165 - progressive muscular atrophy 165 - in Tooth's peroneal atrophy 71, 560 - trophic ulcers in . . . . 130 - valgus, definition of . . 130 - varus, defhiition of . . 130 Tannic acid, dryness of the mouth and thirst due to 789 Tapping (see Paracentesis Thoracis) Tape-worms (Figs. 148, 151) 567 - diagnosis of muco-mem- branous casts from . . 567 - eggs of (Fig. 152) . . . . 568 microscopical examina- tion of ffeces for . . 569 - eosinophilia from 249, 568, 569 - increased appetite with . . 49 - infection, chlorotic antemia in 568, 570 - simulated by mucous colitis 134, 443, 444 Tar products, bullae in workers among . . . . . . 110 Tarry stools . . . . 89, 316 Tartar, bleeding gums due to 86, 87 - foul breath due to. . . . 99 - retraction of gums from . . 641 Tartrates, transient polyuria from drinks containing.. 581 TASTE, ABNORMALITIES OF 773 - aura of epilepsy . . . . 80 - foul, causes of . . . . 774 - impaired with peripheral facial paralysis . . 536, 537 from paresis of glosso- pharyngeal nerve 774, 775 - loss of, list of causes of . . 774 with hysterical hemian- aesthesia . . . . 666 - metallic, in trigeminal neu- ralgia . . . . . . 495 - offensive, vomiting from . . 844 - perverted, list of causes of 774 Taylor, re splenomegalic cir- rhosis 369 Tea-drinking by children, nervous efEects of . . 357 - excessive, constipation due to 144 pseudo-angina in . . 482 - gastritis from . . . . 297 - insomnia from . . 356, 357 - oxaluria from . . . . 471 - palpitation from . . 525, 527 - polyuria from . . . . 581 - rosacea from . . . . 268 Tears, not coloured in jaundice 361 - explosive bursts of, in double hemiplajia . . . . 258 paralysis agitans . . 262 - first shed on seventh day after birth . . . . 250 - overflow of (see Epiphora) Teeth in acromegaly . . . . 263 - affections, neuralgia frona 781 locality of pain and ten- derness due to . . 783 tenderness of scalp in . . 781 - caries (see Caries, Dental) - in congenital syphilis (Figs. 79, 80) .. .. 259, 260 - defective, in etiology of dyspepsia . . . . 354 gastritis from . . . . 352 - delayed eruption in rickets 182 - displacement of, due to fibrous epulis . . . . 748 - grinding during sleep (see Grindmg of Teeth during Sleep) - impacted wisdom, diagnosis of tetanus from . . . . 162 - pain in, from glaucoma . . 257 - pegged and notched in con- genital syphilis (Figs. 79, 80) . . . . 259, 260 - relation to definite segmental areas in the face, table showing . . . . . . 498 - supijuration in, spreading neuralgia from . . . . 497 - tumours of (see Odonto- mata) - imdue projection in acro- megaly 263 - unerupted molar, pain in the lower jaw in . . . . 501 ar-rays in diagnosis . . 501 Teething, insomnia from . . 357 Tegmentum, intention tremor from lesion of . . . . 800 Telangiectasis of cheeks in chronic alcoholism . . 59 - face in rosacea . . . . 268 - macules due to . . . . 423 - multiple hereditary bleeding 251 - in nodular leprosy . . . . 450 - thoracic from emphysema 826 - in xerodermia pigmentosum 804 Telegraphist's cramp 177, 494 Temperature' (and see Pyrexia) - chart in Hodgkin's disease (Fig. 168) . . . . 617 facial erysipelas (Fig. 166) 614 fungating endocarditis (Fig. 164) .. .. 6ia lobar pneumonia (Fig. 188) 702 Malta fever (Fig. 163) . . 612 pernicious anaemia (Fig. 167) . . . . . . 616 pyaemia (Fig. 165) . . SIS rheumatoid arthritis (Fig. 106) 377 sarcoma of neck and mediastinum (Fig. 169) 617 typhoid fever (Fig. 162) 611, 697 - in diagnosing early disease 620 - elevation in health to 102" F. by strenuous exertion . . 619 - general observations on variations in health and diseas3 . . . . . . 619 - lowering to dangerous or fatal degree from physical exhaustion . . . . 619 - mechanism of maintenance of normal . . . . 618 - pulse, respiration ratio in normal conditions . . 622 - in relapsing fever . . . . 698 - subnormal 345 - sudden changes in, menor- rhagia from . . . . 428 - in tuberculosis . . . . 612 - unexplained oscillations in chronic disease . . . . 619 Temporal lobes, auditorv word centre m (Fig. 185) .. 683 - muscle, paralysis of . . 775 - region, referred pain in, in severe ear disease . . 498 tenderness of . . . . 783 - segmental area, pain in, in iritis and glaucoma . . 498 Temporo-malar nerve, skin distribution of . . . . 659 Temporo-mandibular joirt ab- scess, occasional discharge through auditorv meatus 470 - - osteo-'arthritis of 230, 384, 801 earache ia rheumatoid arthritis of . . Temporo-sphenoidal lobe, ol- factory aura in tumour of Tender spot below anterior iliac spine in neuralgia paraesthetica in neuralgia Tenderness, absence of, in intermittent hvdrarthro- 230 378 80 330 387 475 133 134 - importance of, in relation to pain - of joint (see Arthriti.s) - abdominal, general, absence in smiple coUc . . in colitis peritonitis . . 134, 15S relapsing fever . . 373 tuberculous peritonitis 56, 719 ulcerative colitis 90, 92 - along diaphragm attach- ments, in phrenic neuralgia 478 - in the arm from brachial neuralgia . . . . 491 - of bones in infantile scurvy 85, 115 rickets .... secondary syphilis - breast in mastitis . . mastodynia 171 672 743 479 TENDERNESS IN CHEST— TESTS 999 TENDERNESS IN CHEST .. - - causes o£ - - from liepatic abscess . . - beliind ear from jullamcd mastoid gland . . lateral sinus thrombosis - - - otitis media - of ear in otitis media - - otorrhoea . . - epididymis, acute, in gonor- rliii-al epididvniitis TENDERNESS IN EPIGAS- TRIUM .. - - in arsenic il poisoning .. chronic pancreatitis gall-bladder disease 4SG, gastralgia - gastric disorders. . 779, ulcer 89, 298, 352, - - gastritis . . lieart disease - - liver disease - - lung disease phosphorus poisoning . . stone in gall-bladder . . - - subphrenic abscess -- the eye from retrobulbar neuritis . . - of eyebrow from frontal sinus mflammation - feet from cheiropompholyx in erythema keratodes . . - - ery tUromelalgia . . - of front of thigli in anterior crural neuralgia . . - over gall-bladder in carci- noma of tlie gall-bladder in cholecystitis from gall-stones 280, - - - in typlioid fever - in gluteal region in sciatica - of gums from abscess of antrum of Higlmiore . . - - septic tooth - hands from cheiropompholyx - in hyoid area in ear disease - hypochondrlum from gall- Ijladder disease . . - - gastric disorders . . liver disease phosphorus poisoning . . - subpiirenic abscess - - (and see Pain in Hypo- chondrium) - bypogastrium from perfor- ated gastric ulcer - - - duodenal ulcer TENDERNESS IN ILIAC FOSSA from appendicitis 135, - over inflamed frontal sinus - intercostal space in pleurisy - — intercostal neuralgia . . - of joint (see Arthritis ; Syno- vitis ; and Joints, AiEec- tions of) - over kidney with bacterim-ia renal calculus tuberculosis . . 515, - in limbs (see Pain in Limbs, General ; and Sensation, Abnormalities of) - - neuromyositis - - peripheral neuritis - over liver (localized) in abscess of liver . . 409, - - cholangitis cirrhosis . . from gall-stones . . in general congestion 61, 370, 371, ^ - from heart failure 61, 370, suppurative pylephlebitis - in. loins in pyelitis . . 775 770 779 230 651 229 230 409 700 779 92 724 779 485 783 485 297 783 779 783 373 486 720 840 255 654 451 490 488 499 499 499 371 487 502 502 654 498 779 779 779 373 720 736 205 479 478 84 500 694 504 505 651 369 368 300 407 407 649 625 629 046 Tenderness in loins, conUl. - in renal tuberculosis suppurative nepliritis . . - lumbar region from colitis. . 727 - over McHumey's point in appendicitis . . . . 500 - over metatarsus in meta- tarsal neuralgia . . . . 488 - in mid-orbital region in errors of refraction . . 498 - of muscles in acute poly- myositis . . . . . . 504 multiple neuritis 489, 506, 551 muscular overstrain . . 503 myalgia . . . . . . 478 pleurodynia . . . . 478 in tetany . . . . 178 - over musculospiral nerve in brachial neuralgia . . 491 - in naso-labial area in caries i of canine tooth (Fig. 132) 497 - In neck, posterior triangle of, in cervical rib . . . . 492 in brachial neuralgia 491 from tuberculous gland 420 - of nerve trimks in multiple neuritis . . . . . . 489 - nerves and muscles, absent in tabes dolorosa . . 507 - palms in erythema keratodes 451 - over pancreas in acute pancreatitis . . . . 846 - onpercussionin spinalcaries 181 - in peripheral neuritis . . 661 - of prostate, acute .. .. 207 - pudic . . . . . . 221 - per rectum from obturator hernia . . . . . . 740 prostatitis . . . . 631 rectal abscess . . . . 635 TENDERNESS IN SCALP .. 780 in organic cerebral disease 328 secondary syphilis . . 672 - over sciatic notch in sciatica 487 - shoulder from gall-bladder disease . . . . . . 779 liver disease . . . . 779 - of skull, local, with organic intracranial disease 327, 328 - soles in erythema keratodes 451 TENDERNESS IN SPINE .. 784 in carcinoma of cardiac end of stomach . . 474 gall-stones . . . . 474 gastric ulcer . . . . 474 hydatid disease of ver- tebra; . . . . 785, 786 neurasthenia . . . . 788 Pott's disease . . . . 134 psoas abscess . . . . 739 spinal caries 134, 474, 564 vertebral arthritis . . 785 - spleen in fungating endo- carditis . . . . . . 237 - spots of, in trigeminal neuralgia . . . . . . 495 - of Sternum in acute medias- tinitis . . . . 483, 777 from aortic aneurysm . . 777 behind, referred from oesophagus . . . . 779 mediastinal inflammation 777 tumour . . . . 777 - suprapubic, with cystitis. . 306 - in syphilitic pseudo-paralysis 387 - of syi)hilitic swellings on tibia 752 - of temporal reaion from dis- ease of upper bicuspids. . 783 heart disease . . . . 783 lung disease . . . . 783 stomach disease . . 783 - of testis 518 exquisite in acute epi- didymo-orchitis . . 518 Tenderness of testis, contd. in testicular abscess . . 680 from torsion . . . . 742 - over ulnar nerve at elbow in brachial neuralgia . . 491 - universal in cerebrospinal meningitis . . . . 643 - uterine, from metritis . . 221 - per vaginara, from obtu- rator hernia . . . . 740 - vulval, from Bartholinitis. . 221 caruncle . . . . . . 221 kraurosis . . . . . . 770 - - leukoplakia . . . . 221 Tendo-achillis jerks absent in locomoter ataxia . . 562 Tendon, ossification of, simu- lating exostosis . . 754, 763 Tendon-jerks (see also Knee- jerk ; Babinski's Sign ; and Ankle-jerk) - exaggerated in amyotrophic lateral sclerosis . . . . 554 brachial monoplegia . . 546 -^ - in subacute combined degeneration of the cord 493 - loss of, in atrophic paralysis of arm . . . . . . 549 peripheral neuritis . . 66 - in spastic paralysis of one leg 539, 540 - unequal and exaggerated, in hemiplegia . . . . 337 - sheaths, gonococcal inflam- mation of . . . . . . 376 inflammation in gout . . 382 rheumatic nodules in . . 452 Tenesmus in abdominal angina 487 - carcinoma of sigmoid colon 731 - dysentery . . . . 90, 196, 501 - intussusception . . . . 727 - rectal . . . . . . 473 - tuberculous sigmoid colon 731 - in ulcerative colitis . . 91 - vesical, in acute cystitis . . 312 Tenosynovitis, crepitus in . . 179 - egg-sheU crackling in . . 177 - simulating occupation neu- roses . . . . . . 178 Tenotomy, diplopia after . . 200 Tension of eye in differentia- tion of conjunctivitis, iritis, and glaucoma . . 257 - raised in herpes frontalis. . 807 Tensor fasciae femoris, spinal nerve-root supplying . . 543 nerve supply of . . . . 542 Teres major and T. minor, spinal nerve-roots supplying 556 nerve supply of . . 550 Terror in patient after epileptic convulsions . . . . 169 Tertian fever (see llalaria) Test for acetonuria . . . . 4 - albuminuria . . . . 5 - albumosuria . . 20, 21 - alkaU, for alkaptonuria . . 822 - for arsenic . . . . . . 92 - barium chloride, for carbo- luria 823 - for bile in stools . . . . 197 - bleaching powder, for indican 821 - blood in faeces . . . . 89 - boiling, for albumin, method of avoiding fallacies of . . 472 phosphate fallacy of . . 574 - bromine water, for melanuria 821 - in Cammidge's pancreatic reaction . . . . 115 - for carboxyhffimoglobia . . 138 - caustic soda, for elastic fibres . . . . . . 701 - cbyluria . . . . . . 126 - cystin . . . . . . 187 TESTS— TESTIS, TORSION OF Test, conid. Testis, eciopie, conid. Testis, contd. - diacetic acid in urine 196 in femoral region 734 - malignant growth of (and - diazo-reaction 197 gangrene of 523 see Caroinoma of testis) 520 - ferments in gastric juice . . 355 hernia with . . 523, 740 adhesion to skin only - ferric chloride for alkapton 822 inflammation of, diagnosis in late stage of 520 melannria 821 from strangulated hernia 523 alleged greater liability - fluorescin, for corneal ulcer- in inguinal region 740 of undescended testis ation 806 hability to recurrent trau- to 523 - for free HCl 355 matic inflammation . . 523 blood-stained fluid in - Gmelin's, for bile pigment 819 — new growtli of, diagnosis tunica vaginalis in 520 - for hearing . . 188 from hydrocele of a carcinoma and sarcoma - Huppert's, for bile pigment 819 hernial sac 742 clinically indistin- - for indican in urine 348 821 the tunica vaginalis 742 guishable 520 - iodine for bile pigment 819 omental hernia . . 743 consistence of . . 520 - for lactic acid " . . 355 pain due to, diagnosis diagnosis from chronic - lactose in urine 290 from appendicitis 740 torsion of testis 521, 766 - lead in tirine 77 intestinal colic 740 hematocele 521, 523 - liquor potassse, for pus 623 ^ at puberty in . . 523 hydrocele 520, 521, 522 - meal in chronic diarrhoea. . 196 in perinetun . . 516 740 syphUitic orchitis 520, 766 in examination of disorders proneness to recurrent tiiberculous testis . . 521 of the stomach 355 inflammation . . 523 embryoma the com- gastritis . . 50 recurrent attacks of pain monest form of 520, 766 - for methylene blue in urine 823 in 523 enlargement of iliac and - nitric acid, for bUe pigment 819 retention in abdomen . . 523 lumbar glands in 520 766 indican. . 821 inguinal canal . . 523 testis in . . 520, 766 - for nucleoproteid . . 5, 6 perineum 533 incorporation of epi- - Xvlander's, efEects in alkap- situation at root of penis didymis in late stage 520 T-onuria . . 822 in front of pubes 523 loss of testicular sensa- - occult blood . . 94, 197 upper part of thigh . . 523 tion in 521 - ozonic ether, for pus 623 testicular sensation in the nodular, irregular tu- - for pancreatic disease 364 suspicions swelling in 523 mour in 520 - paralysis of upper extremity 545 varieties of 523 operation in diagnosis - pentose in urine 290 - embryoma of. age incidence from syphilitic testis - the phenylhydrazine and of .. 766 or hematocele 766 fermentation, in con- the commonest new pain in. . . . 520, 766 firmation of glycosuria . . 818 growth of the testis . . 766 simulation of fltiid in - for phosphates, acetic acid 208 constitution of . . 520 tunica vaginalis 520 - phosphatmria . . . . 574 dissemination via lympha- thickening of cord in 520 766 - psorosperms . . 803 tics or veins . . 766 varieties 766 - rennin 355 long course of . . 766 - misplaced (see Testis, Ectopic ) - safranin, negative with metastasis in 766 - pain in (see Pain in Testicle) alkaptonuria 822 semi-malignant nature of 766 - painless nodule in, in tuber- - Sahli's, of pancreatic defect 216 tissues contained in 766 culous disease . . 680 - sflver nitrate for alkaptonuria 822 - encysted hydrocele of 521 - physiological inequality . . 78 - soditmi nitroprusside, for - endothelioma of 766 - reddened soft area in, in acetone 4 - enlarged from abscess 518, 680 testicular abscess 518 for melanuria . . 821 areas of varying consis- - retained (see Testis, Ectopic) - for sugar, Tarious . . 289, 291 tence in malignant . . 520 - sarcoma of (see Testis, - Tiiehnann's 355 due to chronic torsion 521, 766 Malignant Growth of ; - urates in tirine 815 from cyst . . 521 and Sarcoma of Testis) - urinary, in iodism . . 112 in epididymo-orchitis 518 528 - swelling of (see Testis, oedema 457 — — from gumma . . 680. 681 Enlarged) for saturnine encephalo- due to hematocele 521 - syphilis of, adhesion to cover- pathv . . 139 in hydrocele 521 ings in . . 766 Testicular sensation lost in rapid, in malignant disease 520 diagnosis of 519 malignant growth of syphihtie 519, 520, 681 765 from new growth 766 testis 521 - - tubercular disease 680 tubercidous testis 520, 765 syphilitic disease of - examination of in haematuria 307 effects of mercury and testis 766 - excision of, obesity after . . 453 iodides on 520 in undtecended testis . . 523 - fibroid syphilitic . . 519 epididymis unaffected in Testis. absces=! of (see AbsceK - gangrene of . . 523 519, 765, 766 of Testis; - gonococcal infection of 207 hernia testis from 766 - atrophT of (see Atrophy - in groins in pseudo-herma- loss of testicular sensa- Test'cular) phroditism 706 tion in . . . . 765, 766 - carcinoma of (see Carcinoma - growth and gumma of, dis- nodular affection of tunica of Testis; tinguished by treatment 521 vaginalis and albuginea - congenital misplacement (see - gumma of, general description in 765 Testis, Ectopic) 519, 680, 681 - - operation in diagnosis - cyst of. general account of 521 diagnosis from testicular from haematocele or - deficiency of deep tender- abscess . . 680 new growth 766 ness in, in tabes 562 tuberculous testis 680 - - potassium iodide in dia- - ectopic .. .. 78 740 scrotal sores due to 679, 680 gnosing.. .. 520, 766 acnt-e torsion of . . 523 - hernia of (see Hernia of scrotal fistula due to 679 alleged greater UabUity Testis) sense of dragging and to malignant disease. . 523 - inflammatory lesions of (see weight in 519 attacks of pain in 740 Epididymo-orchitis and size rarely three times the causing swelling in femora Orchitis) normal in 765 region . . 733 - injury of, acute epididymo- ulceration from . . 766 diagnosis of 523 orchitis from . . 517, 518 Wassermann reaction in appendicitis from pain hsematocele due to 521 520, 766 due to .. 533 ,740 torsion of testis from . . 766 - tenderness of (see Tender- dullness over 742 vomiting from . . 844 ness of Testis) emptiness of scrotum on - mal-descent of (see Testis, - torsion of, abdominal pain in 742 afiected side .. 523 ,740 Ectopic) diagnosis from growth 521 766 TESTIS. TORSION OF— THROAT Testis, torsion of, contd. strangulated hernia . . tuberculous testis gangrene from . . great tenderness in in Lorse-riders . . - - inguino-scrotal swelling from due to injury . . - operation and histology in diagnosis of . . - - pain in testis in - simulation of intestinal obstruction by - swelling due to . . testicular abscess from. . swelling due to oil, 705, of undescended . . vomiting in - tuberculous - • 79, aching pain in . . - - adhesion to skin . . afiection of bladder from seminal vesicles from - associated with tuber- culous spermatic cord with bladder tuberculosis breaking down and ulcer- ation of nodules in causing ulcer 518,680,706, commencement as nodule in the epididymis 518, - - " craggy," or " bossy," feel of nodules in diagnosis of - - - from chronic torsion . . gummatous orchitis . . - - - malignant growth of . . syphilitic disease of 520, testicular abscess epididymis affected rather than body of testis 519, fistula in scrotum from 518, gradual painless enlarge- ment of nodule in hernia testis from 680, hydrocele with . . involvement of scrotum in spermatic cord in - nodules In epididymis in 307, - painless at first - tender on pressure in in vas in - - - thickening of vas in 519, - - occasional sudden en- largement of long-stand- ing nodule in . . - - onset commonly in upper pole of epididymis . . - - opsonic index in diagnosing primary 518, 521, 080, - - prostatic tuberculosis with 519, rectal examination in . . relative frequency of with renal tuberculosis 394, scrotal fistula due to 518, sores due to . . 679, secondary to other genito- urinary tuberculosis . . prostatic tuberculosis renal tuberculosis vesical tuberculosis . . - - sequence of events in production of cystitis from slow course in many cases - - spread of disease from epididymis to body of testis in T. bacilli in discharge from fistula in Testis, tuberculous, amid. 742 vesical tuberculosis 513, 029 760 vesiculiP seminales aflee- 523 ted in . . 307, 519, 038, 767 742 von Pircjuefs reaction in 521 " 519, 705 - ulceration of, from involve- 742 ment in scrotal epitheli- 766 oma 679 - undescended (see Testis, 521 Ectopic) 521 - various swellings affecting 765,766 Tetanic contractions (see Con- 742 tractions) 765 Tetanus, consciousness retained 680 in 464 766 - convulsions in 109, 652, 801 523 brought on by touching 742 patient 052 394 - definition of . . . . 161 519 - diagnosis from hydrophobia 162 705 - - hysteria 162, 464, 801, 802 680 strychnine poisoning 102, 802 680 - - tetany 162 - drum-stick bacilli in (Plate 523 XII, Fig. T, p. 696) 102, 312 463, 652, 802 - duration of.. .. .. 652 518 - hyperpyrexia in . . . . 343 767 - infection through wound 652, 709, 802 680 - influence of chloroform on 802 - muscular spasms in . . 162 519 - opisthotonus m 162, 463, 052, 802 519 - priapism in.. .. .. 580 766 - prognosis of . . . . 802 080 - retraction of the head in . . 641 521 - rigors in . . . . . . 647 765 - risus sardonicus in 463, 651, 680 652, 802 - simulated by impacted 765 wisdom tooth . . . . 802 679 - soil contamination causing 802 - stiffness of muscles in 463, 802 680 jaw in 162 766 - - neck in . . 162, 652, 709 765 - trismus in 162, 178, 463, 680 " 052, 709, 801, 802 523 - without external wound 652, 802 Tetany, A.C.C. > K.C.C. in. . 634 680 - accoucheur's hand in . . 3 519 - carpo-pedal contractions in 519 466, 802 680 - causes and signs of . . 178 765 - causing convulsions . . 109 - diagnosis of tetanus from. . 102 - from digestive disorders . . 178 680 - epidemics of in young adults 178 - from food poisoning . . 178 518 - gastrectasis . . . . . . 802 519 - infantile . . . . 466, 802 765 - after operation on thyroid glfind 802 078 - in pregnancy . . 178, 802 519 - proa-nosis in . . . . 802 518 - raritv of trismus in . . 801 - from' rickets . . 170, 802 626 - Trousseau's sign in . . 178 679 Tetronal, coma due to . . 137 080 Thapsia, sore fingers from . . 266 Thenar muscles, atrophy of . . 73 680 - wasting in Tooth's neuro- 518 muscular paralysis . . 321 518 Thermo-anffisthesia, definition 660 518 - in lisematomyelia . . . . 664 - from lesion of the medulla 066 - in svringomyeUa (Fig. 182, 629 p."66.y) 563, 664, 665 518 Thermometer makers, mercury poisoning in . . . . 38 '. Thigh, atropiiy in knee-joint 519 I disease . . . . . . 72 - condyloma of . . . . 769 519 I - Jacquet's erythema of . . 446 Thigh, contd. - linese albicantes on . . 402- - lymphatic drainage of . . 738 - muscles, atrophy of, with hip disease . . . . 183 - pain in (see Pain in Thighs) - pemijhigus neonatorum of 446 - scabies of . . . . . . 447 - seborrhceic dermatitis of infants affecting . . 447 - xerodermia of . . . . 530 Third cervical nerve, skin distribution of . . . . 659 - nerve paralysis, dilatation of one pupil in . . . . 595 ptosis from (Fig. 157) 590 THIRST, EXTREME.. .. 789 in diabetes . . 292, 507 insipidus . . . . 584 phosphatic diabtes . . 572 phosphorus poisoning . . 373 polsxythsemia from 579, 580 in pregnancy . . . . 293 - during rigors . . . . 646 Thomas, re olivo-ponto-cere- bellar atrophy . . . . 799 Thoma-Zeiss and Leitz haemo- cytometers . . . . 27 Thompson, re Brown-Sequard paralysis . . . . . . 064 - re distribution of sensation from lesions in the cord . . 662 Thomsen's disease, electrical reactions in . . . . 634 Thoracic aneurysm (see Aneurysm) - duct obstruction, chylous ascites from . . 58 chyluria in . . . . 126 secondary glands along, in abdominal growth 421 - veins, condition of in new growth of lung . . . . 322 - wall (see Chest, Bulging of) Thorax, extension of pedicu- losis pubis to . . . . 447 - gas in (see Pneumothorax) tympany due to . . . . 668 - rickety 212 - secondary deposits in, in carcinoma of breast . . 743 Thorn-apple crystals of urates 815 Threads, prostatic . . . . 444 Thread-worms (Oxyuris) . . 569 - bleeding per anum from . . 93 - a cause of priapism . . 585 - eosinophilia with . . . . 249 Thrill, fluid, with ascites . . 51 in ovarian cyst . . . . 52 - hydatid 720 in liver . . . . . . 415 THRILLS, PRECORDIAL, sig- nificance of . . . . 789 in aortic disease . . . . 233 congenitalheart disease 129, 244 mitral regurgitation . . 238 stenosis . . . . 245 with patent ductus arteri- osus . . . . . . 184 septum ventriculorum 184 pulmonary stenosisl29, 184, 247 Throat, abscess, in, septicaemia from 614 - examination of, in obscure P3-rexia . . . . . . 620 - Klebs-Lofflcr bacUlus in . . 641 - macular eruption on, in secondary syphilis . . 425 - reddening of, in scarlet fever and erythema scarlatini- forme . . . . . . 253 - sore (see Sore Tliroat) - swabbings, examination in cases of laryngitis . . 406 I002 THROBBING— TIBIA 321, 322, 700 Throbbing in aortic disease. . - sensation in undue abdo- minal aortic pulsation . . Thrombosis, asymmetrical CEdema from . . 455, - causes of - in childbed . . - femoral vein . . 186, - gangrene from - infarction from - the central retinal vein (Plate VIII, Fig. 0) 462, sudden blindness from - cerebral . . . . 173, - - acquired paralysis of childhood due to aphasia from, acute onset in ataxy from . . 68, athetosis in coma in . . . . 137, diabetes insipidus in headache in 327, 328, hemianopsia from hemiplegia from 82, 138, 285, 337, after influenza . measles - - monoplegia from talipes from - ui femoral vein embolism after extension to inferior vena cava . . 61, - iliac . . . . . . 9, - of inferior vena cava i - - - - albuminuria from 9,17, - ascites from 61, casts in lurine in cause of hfematuria -^ith 9, nephritis simulated by oedema of legs from 461, secondary to throm- bosis in one leg 61, simulating peritonitis varicose abdominal veins from - of innominate vein, inflam- matory causes of - - varicose thorax veins from - intracardiac, embolism from 155, 173, - intracranial sinus, excruci- ating headache from hemiplegia in . . 337, from otitis media pyrexia with . . rigors with . . 648, - cavernous, causes of dilated frontal veins from exophthalmos in253, 254, limited eye movements with . . mastoid swelling with oedema of eyelids from 253, squint from. . . suppurative meningitis from . . - lateral bronchopneumonia in clottine of internal jugular vein from . . gangrene of lung from oedema over tlie mastoid bone from . . optic neuritis from from otitis media 98, 123, 186, pain in the ear from . . pulmonary embolism from . . 186, rigors with . . 648, 826 820 286 651 338 650 650 650 253 253 G51 254 254 651 651 254 578 321 651 287 651 051 650 051 578 650 Thrombosis, intracranial, contd. lateral, tachycardia in . . 98 tenderness over mastoid process from . . 651 superior longitudinal, cerebral softening from 643 coma in . . 139, 643 convulsions in 139, 558 diagnosis of ence- phalitis and men- ingitis from . . 558 - - - - - general head sym- ptoms in . . 558 _ _ _ headache in . . 139 infantile diplegia due to . . . . 556 paraplegia due to 558 cedema of scalp from . . . . 651 optic neuritis in. . 139 paraplegia from 556, 643 pyrexia in 558, 650 retraction of head in 641 simulating cere- bellar abscess . . 651 - cerebral abscess 651 meningitis 558, 643, 651 vomiting in 139, 558, 651 sweating with . . 650 tenderness over the mas- toid bone from . . 651 thrombosis of internal jugular vein from . . 651 vomiting with 650, 844, 847 - jugular vein from otitis media . . . . 123, 578 - - - secondary to lateral sinus thrombosis . . 651 - mesenteric 432 - - anal haemorrhage in . . 90 - - constipation with . . 153 - - heart or abdominal disease causing. . . . . . 153 - intestinal obstruction from 432 meteorism in . . . . 432 peritonitis from . . . . 432 - of piles . . . . . . 635 - of portal vein ("and see Pyle- phlebitis) ascites in . . . . 58 general account . . 301 - of posterior inferior cerebral artery, ataxy from . . 666 cerebellar arterv, ataxy hi . . '. .. 68 dissociative anoesthesia (Fig. 184) .. ..660 - pulmonary, hfemoptysis from 317 - - infarct of lung from 321, 322 in mitral stenosis . . 320 pleuritic effusion from . . 123 - renal, albuminuria in 8, 9 - saphenous . . . . 9, 486, 825 oedema of one leg from . . 825 - spinal, paraplegia from . . 563 in syphilis . . . . 432 - - transverse myelitis from 564 - of superior vena cava, in- flammatory causes of . . 826 oedema of face, neck, and arms from 458, 401 varicose thoracic veins from . . . . 820 - affecting uncinate gyrus, anosmia from .. ..009 - venous, infarction of lung in 321 - in varicose veins . . . . 450 - white leg from . . . . 450 Thrush, bleeding gums in 86, 88 Thumbs, double-jointed, in Mongolism . . . . 216 Thymic asthma mistaken for spasmodic asthma . . 582 Thymus gland and anaemia . . 215 - enlarged, convulsions of children with . . . . 169 diagnosis of . . . . 46& dullness behind sternum in 465 and infantile convulsions 170 lymphatism . . . . 423 - - stridor from . . . . 710 tracheal obstruction from 405, 710 x-ray shadow of . . . . 405 - fatal syncope . . . . 215 - fatness . . . . . . 215 - and infantilism . . . . 215 - mediastinal new growth arising from . . . . 826 Thyroid abscess in pyaemia . . 792 - cartilage, perichondritis of, in syphilis . . . . 791 - extract, benefit from (see Thvroid Treatment) THYROID GLAND EN- LARGED age incidence of 791, breathlessness with . . in exophthalmic goitre 244, 253, 527, 772, 797, mistaken for asthma obstruction to cesopha- gus by of trachea by veins by onset at puberty palpitation with paralysis due to of vocal cords due to parenchymatous, anje- mia with pressure, effects of relation to exophthalmic goitre slow growth of stridor from . . swellmgs simulating . . tachycardia with tracheal obstruction from - hydatid cyst of - malignant disease of (see Carcinoma of Thyroid Gland) - - movement with larynx on swallowing. . and ovarian inter-rela- tionships tetany from removal of 178, tuberculosis of . . - infantilism (Pig. 07) - insufficiency ' (see Hypo- thyroidism ; Cretinism ; and ilyxcedema) - secretion, effect on menstru- ation - treatment, benefit to myx- oedema from . . - - in cretinism diagnosis of cretinism from idiocy . . 204, of hypothyroidism myxcedenia 42, 259, 454, no effect on adiposis dolorosa enuresis cured by palpitation from 525, reduction of weight by . . - - tachycardia from Thyroidectomy, tetany after 3, 178, Tibia, affection in yaws - bedsore over - deformities in congenital syphilis . . - necrosis of, talipes from . . - overgrowth after injury . . - sarcoma of (J^iV- 196) 754,756, 791 792 792 849 582 792 710 793 791 792 792 538 792 792 792 791 710 791 792 405 792 791 454 792 216 430 400 216 557 454 585 455 248 527 849 773 802 449 285 260 132 132 763 TIBIA— TONGUE 1003 ■Tibia, contd. - swelling on, in secondary syphilis .. .. .. 752 - tuberculous disease of . . 752 Tibial muscle affection in infantile paralysis 131, 132 paralysis, talipes from . . 132 Tibialis anticus muscle, spinal nerve root supplying . . 543 nerve supply of . . . . 512 - posticus, nerve supply of . . 5-12 Tic, convulsive, mild chorea simulating . . . . 156 - douloureux (and see Trigeminal Xeuralgia, Major) . . 495 absence of neurasthenia with 783 pain relieved by pressure 783 and tenderness due to 782 paroxysm brought on by I^ressure . . . . 783 relation of ptyalorrlioea to 592 - spasmodic, a cause of con- vulsions . . . . . . 169 - - muscle twitching in . . 159 Tickling, hiccough from . . 342 Tight lacing, furrow on liver from . . . . . . . . 405 liver depressed by 404, 405 passive hyperoemia of uterus from . . 428, 430 - - Kiedel's lobe from 404, 405 shape of liver in . . . . 405 Tightness in chest, from bron- chitis 480 - - chronic mediastinitis . . 484 mediastinal growth . . 483 oesophagismus . . . . 484 Tilbury Fox, re impetigo con- tagiosa . . 446, 601, 654 Tinea Circinata (and see King- worm ; and Fungous .Vftections of Skin) . . 274 - - diagnosis from oircinate tubercular syphiloderm 275 macular syphilide . . 426 pityriasis rosea . . 658 tinea imbricata . . 276 involvement of lips in . . 403 - decalvans . . . . . . 274 - imbricata, description of . . 275 diagnosis from ichthyosis 276 tinea circinata . . 276 parasitology of . . . . 276 - marginata in bathing-draw- ers area . . . . . . 447 pruritus caused by . . 588 - sycos;s (see Hingworni of the Beard) - tonsurans (see Ringworm) scales in . . . . . . 655 - versicolor, contagiousness low of 276 currant-like masses of spores in . . . . 276 description of . . . . 276 diagnosis from chloasma 276, 575 eczema seborrhoeicum 276 erythrasma . . . . 276 leprosy. . . . . . 276 pityriasis rosea . . 276 syphilides . . 276, 426 distribution of . . . . 276 macules in . . . . 424 microsporon furfur in . . 276 scales in . . 276, 426, 655 Tingling in acropanesthesia . . 493 miliaria rubra peripheral neuritis. . preceding apople.vy pruritus described as in ringworm tabes dorsalis 831 505, 661 . . 173 Tinkling, metallic, with pneu- mothorax TINNITUS - a-iisociated with flushing . . - epistaxis relieving . . - good influence of open air in - increased bj- tobacco - in Mtnitre's disease - middle-ear deafness - nuclear facial paralys.'s . . - otitis media - otosclerosis . . - syphilitic ear disease - tuberculous otitis media . . - varieties of . . - from wax in ears . . Tiredness at onset of phthisis Tobacco, amblyopia with optic disc changes in - central scotoma from 836, - colour blindness from 836, 837, - diminished appetite from - dry cough from - dyspepsia from - gastritis from - headache from - hemeralopia from . . - undue increase of pulse-rate on exertion from - infantilism from - insomnia from - intermittent claudication from - loss of weight due to - nerve deafness from - palpitation from . . 525, - pseudo-angina in . . - retinal cones affected by . . - susceptibility of different people to - tachycardia from . . - tinnitus increased by - tremor from - vertigo from - violent thumpings of heart on getting into bed from - vomiting from Toes in acute gout - affected by scabies. . - athetotic contractions of . . - deformity from boots - dragging of in spastic mono- plegia - examination of, in obscure pyrexia . . - exostosis of . . - hyperextended, in paralytic talipes - pain in, in Morton's disease - in Raynaud's disease Toe-nail, ingrowing . . Tokelau ringworm (see Tinea Imbricata) Toluylenediamine poisoning, blood destruction in jaimdice in Tomatoes, oxaluria from 311, Tongue, affections of anterior portion, referred pain in mental area in . . of dorsum, referred pain in occipital area in - - - lateral portions, referred pain in hyoid area in in sprue . . - angio-neurotie oedema of . . - atrophy of . . . . 69, in bulbar paralvs's 224, " 591, 641, myasthenia gravis - " bald," in scarlet fever . . - not bitten in hysterical convulsions Tongue, conld. 193 - biting of, in epilepsy 171, 046 793 convulsions 168- 268 - carcinoma of (see Carcinoma 252 of Tongue) 793 - chancre of, discussed 81.3. 793 - cornet-player's cramp of . . 177 828 - deep-red colour in diabetes 292- 190 - deficiency of deep tenderness 536 in locomotor ataxy 562- 470 - dental ulcer of . . 812, 814 829 - difficulty in using, a cause 828 of dysphagia 22.> 469 - dry, from belladonna 77.3. 793 and bromi, in acute 467 yellow atrophy 302, 370- 620 with lardaceous disease 4& 836 pyelonephritis . . 48 836 renal tuberculosis 48- 837 and furred in peritonitis in tropical abscess of 431 840 liver 369- 49 in urar^mia 45^ 175 - dyspeptic ulcer of . . 812 3.54 -r electrical reactions of, in 352 bulbar paralysis . . 687 328 - enlargement in acromegaly 26a 841 - epithelioma of (see Carcinoma of Tongue) 527 - fibrillary contractions of, 215 in bulbar paralysis 159, 686- 356 in disease of central nervous system 158- 489 - fissured in syphilis 813 848 - furred in alcoholism 136, 243. 191 alveolar abscess 747 527 appendicitis 736- 482 foul taste due to 774 841 in gastritis ■ . . 49, 29r loss of taste due to 774 527 in peritonitis 774 772 pneumonia 774 793 septicsemia 774 795 severe fevers 774 827 tyfihoid fever and indented, in active 774 527 congestion of liver . . 371 843 - - and tremulous, in chronic 382 alcoholism 59' 832 - gangrene of, in Raynaud's 154 disease 284 132 - glazed in pyelitis . . 62.5- - gumma of . . . . 279, 814 540 median position of 42» - herpes zoster of 831 620 - indented in chronic gastritis 297 754 acromegaly 263. congestion of liver 371 130 - leucoplakia of (Plate XV) 814 488 - movements in chorea 548- 490 - mucous patches on in 486 secondary syphilis 813 - paresis of, in bulbar paralysis 641 - progressive weakness of in bulbar paralysis 224 374 - protrusion in cretinism 25S 362 Mongolian idiocy 263 471 - sore, with papular syphilo- derms 533 in secondary syphilis . . 605- 498 - strawberry appearance of, in scarlet fever and ery- 498 thema scarlatiniforme . . 25.3 - swelling of, due to mercury 86- 498 - swollen, dysphagia due to 225 197 - syphilis of 237, 279, 420, 812 813 457 - taste nerves of 77.> > To - tremor of 79.5- alcohohc . . 238, 243, 368 797 686 cirrhosis of liver 368, 410 687 in general paralysis 172, 796 674 lead poisoning . . 797 paralysis agitans 796. 160 - trichinosis parasites in 801 I004 TONG UE— TRICHINOSIS Tongue, contd. Tooth's peroneal atrophy .. 71 Training, lack of, tachycardia - tuberculous . . 812 814 ankle-clonus in 560 from 772 — ulceration of (see Ulcera- atrophy of leg muscles Trance, hysterical . . 137, 140 tion of Tongue) with . . 128 Transfusion, acute nephritis - unilateral palsy of, absence Babinski's sign in 81 simulated after . . 458 of articulatory defect in 687 claw-hand in . . 127 128 - universal cedema from 458 ,460 - white spots on in aphthous commencing in one leg 545 Transillumination of antrum stomatitis 815 - - - diagnosis of transverse of Highmore {Fig. 62, p. Tonic contraction of uterus . . 229 myelitis from 74 205) .. .. 502 749 — spasms (see Contractions, familial character of Transitional corpuscles 29 Tetanic) {Figs. 8, 9, p. 71) 132 560 Translucency test for cysts Tonsillectomy, death from - - - following whooping- of testis . . 521 lymphatism after 423 cough or measles . . 560 in hydrocele 521, 522 741 — palate paralysis after 640 paralysis of arm in . . 554 - of psoas bursa 741 Tonsillitis, acute, albuminm-ia paraplegia from 557, 559 560 Transposition of great vessels 184 in . . . . 17, 18 plantar reflex in 81 - liver 404 aortic disease after 237 reaction of degeneration - viscera . . . . 184 224 - - dysphagia witli . . 591 in .. .. 132 560 Transverse myelitis (see Mye- earache from 230 - - - reflexes in 560 litis, Transverse) endocarditis complicating 239 talipes in 71, 132, 560 Traube's space, definition of 668 enlarged glands from 419, 708 Tooth-ache, abscess with . . 747 Trauma (see Injury) foul breath due to 99 Tooth-brush, bleeding gums Traumatic arthritis . . 375 pains in the limbs in 503 505 due to 85 Treadler's cramp 177 in peliosis rheumatica . . 600 - retracted gums from 641 TREMOR 791 with pharyngitis. . 673 Tooth-plate ill-fitting, haemor- - in acquired infantile par- phlegmonous 419 rhage due to 87 alysis 155 — - ptyalism with 591 - obstructmg oesophagus . . 222 - alcoholism 136, 172, 238, 258 368 pyrexia in 620, 622, 672 - in oesophagus, htemate- - of arm (see Arm) rigors in . . 647 mesis from 297 - associated with flushing . . 268 sore tliroat from 670 opening into pericardium 711 - causes of . . 795 spinal arthritis in 708 - ptyalism due to defective. . 591 - in congenital diplegia 154,795,800 spondylitis deformans after 787 Tophi in ear, in gout 381 507 - differentiation of choreiform stifE neck from . . 708 - about joints 507 movements from 156 trismus simulated by . . 801 - sodium urate crystals in 381 - of eyes (see Nystagmus) various micro-organisms Torsio testis (see Testis, Tor- - fibrillary in intermittent causing.. 670 sion of) claudication 490 - chronic, diphtheritic 672 Torticollis, clonic contractions 161 - in Graves' disease 244, 253, syphilitic 672 - contracture in 167 772, 792, 849 - - from Vincent's angina . . 672 - description of 708 - head (see Head, Tremor of) - follicular, albuminuria in. . 17 - due to disuse 163 - with hysterical chorea 157 constitutional disturbances 672 - hemiatrophy of face with 167 537 - mfluence of sleep on 795 diphtheria bacilli in 671 - hysterical . . 166 - intention (see Intention Tremor) distinction of Vincent's - due to injury at birth 708 - in Little's disease . . 154 angina from . . 672 - retraction of the head in. . 641 - mercurial . . . . 37, 77 foul breath in . . 99 - scoliosis in . . 1 80, 181 708 - in occupation cramp 177 high fever in 672 - spasmodic . . 708 - paralysis agitans . . 548 leucocytosis in . . 400 Torulse m vomit 134 - peripheral neuritis.. 77, 285 simulating sjT)hilis 672 Trachea, aneurysm rupturing - post-hemiplegic 157 sore throat from 670 into . . 140, 318 482 - rate of various 795 - rheumatic 239, 374, 504 671 - displaced by thyroid gland 792 - tongue (see Tongue, Tremor o age incidence of 504, 671 - epithelioma of, stridor from 710 - unilateral, from' tumour of enlarged submaxillary lym- - irruption of caseating gland subthalamic region 798 phatic glands in 419 into 465 Trephining, indications for nature of some cases of . . 374 - ulceration of, hsemoptysis in 318 in cases of coma . . 137 - recurrent . . . . 121, 671 from malignant thyroid Treponema pallidum (see Tonsils and adenoids, mouth- gland . . 792 Spirochfrta Pallida) breatliing causing 672 - obstruction by aneurysm . . 482 Triceps, nerve supply of 550 - carcinoma of (see Carcinoma causes of . . . . 465, 709 - pseudo-hypertrophy of 560 of Tonsils) diagnosis of 465 - spinal nerve-root supplying 556 — chancre of . . . . 670, 072 by enlarged thymus gland 710 Trichinosis, acute general pains - enlarged, association with epithelioma of oesophagus 710 in the limbs in . . 503 adenoids . . 670 intercostal retraction in 465 - albuminuria in 17 deafness from . . 190 malignant glands in neck 710 - blood-changes due to 33 - - enuresis cured by removing 248 mediastinainewgrowth 483 ,710 - cachexia in . . 115 insomnia fi-om . . 357 orthopncea in 465' - diagnosis from acute gastro- in lymphatism . . 423 stridor from 709 enteritis . . 504 - - night terrors with 448 sucking in above the polymyositis . . 504 - - witli rhinitis 204 clavicles in 465 cholera . . 504 - - stertor from 707 syphilitic . . 710 enteric fever 504 - epithelioma of (see Carci- by thyroid tumour 792 rheumatism 504 noma of Tonsils) after tracheotomy 710 - eosinophilia in 249, 504, 801 - gumma of, simulating car- Traclieal tugging 222 - epidemic 801 cinoma 672 Tracheotomy, haemoptysis after 318 - gastro-enteritis from 504 sore throat from. . 670 - stenosis of trachea after . . 710 - high fever in . . 504, 801 - mucous patch on, in - stridor after 710 - infection from pork 504, 801 secondary syphilis 675 - surgical emphysema after 231 - leucocytosis in 504 — sarcoma of (see Sarcoma of - urgent, from acute suHoca- - muscles affected by 504, 801 Tongue) tive oedema of larynx 185 539 - oedema of face and eyes in 504 - syphilis of 425, 670, 672, 675 813 in bilateral laryngeal - pain and stiffness in the - tuberculous 672 paralysis 539 muscles from . . 504, 801 - ulceration of (see Ulceration for codema of larynx . . 673 - profuse perspiration in . . 504 of Tonsils) Trachoma, corneal ulceration in 807 - rarity in Great Britain . . 504 — list of various acute and - pannus in . . 807 - severe constitutional dis- chronic affections of the 670 - ptosis in 590 turbances in 801 TRICHINOSIS— TUBERCULOSIS 1005 Trichinosis, contd. Trismus, contd. Tuberculosis, absence of clinical - tenderness of the spine in. . 785 - tetanus . . 162, 178, 463, 709 signs for some time in . . 610 - trichinella; in muscles in . . 501 - various conditions simulating 801 - acetonuria in 4 — in stools in 504 Trochanter, great, bedsore over 285 - albuminuria in 17 - trismus from 801 Trommer's test for glycosuria 289 - amenorrhcEa in 23- Tricocephalus dispar (f i!7. 151) 5U9 Trophic changes in skin, nails, - anaemia in . . . . 37, 450, 616 no blood changes with . . 33 and joints in syringo- - axillary abscess in . . 731 as cause of eosinophilia. . 219 myelia .. .. 128, 285 - of bladder (see Cystitis, Trichophyton acuminatum . . 272 - lesions in acquired infantile Tuberculous) - craterilorme 272 paralysis . . 155 - blood changes in . . 450- - cultures, classification 273 infantile paralj'sis 131 - of breast (see Breast, Tuber- - sulphureum 272 - ulcers in paralytic talipes . . 130 culosis of) - violaceum . . 272 TrophcEdema, hereditarj' (see - cachexia from 17, 114, 459, 461 Trichopliytosis (and see Ring- Milroy's Disease) - Calmette's reaction for. worm and Tinea) 272, 273 275 Trophoneurosis, gangrene from 284 fallacies of G21 Tricuspid area, systolic bruits - macules in . . 423 - cell changes in 450- over 106 Tropical abscess of liver (see - characteristic temperature - regurgitation, absence of Abscess, Hepatic) curve of . . 612 bruit with 106 - climate, dengue in.. 506 - in children, anorexia in . . 50^ from alcoholism . . 243 effect in producing active - chloasma in 574 bruits of . . 239 congestion of liver . . 371 - of colon (see Colon, Tuber- in chronic bronchitis and yellow fever in . . 372 culosis of) emphysema 246 - diseases, cachexia from 459, 461 - diagnosis from fungating paiu and tenderness in loss of weight in . . 848 endocarditis^ 6ia the back from . . 789 oedema of legs in 459, 461 influenza . . Gia pulsation of liver in . . 407 severe anaemia from 459 paratyphoid fever 611 secondary to mitral 239 Trousers, ill-fitting, a cause of yaws 450- thrill with 791 priapism . . 586 - empyema resulting from . . 120 - stenosis, presystolic bruit in 110 Trousseau's sign . . 3, 178 - enlarged glands in groin in 738 — thrill with 791 Truss, enlarged groin glands cervical glands in 421 - valve, fungating endocar- from 738 - fatty liver in 414 ditis of . . 321 - ill-fitting, testicular atrophy - functional bruits in 106 Trigeminal nerve, tumour of, from 78 - general, cerebral type of . . 69& neuralgic pain and tender- Trypanosoma gambiense (Plate absence of leucocytosis in 614 ness due to 783 XII, Fig. G, p. 696) " . . 34 acute, leucopenia in 401 - neuralgia from a carious in cerebrospinal fluid . . 340 choroid tubercles in 463. tooth 495 Trypanosomiasis, blood change? diagnosis from bronchitis 344 coryza in 203 in . . 34 typhoid fever . . 69» — earache associated with 230 - lymphocytosLs in cerebro- frequent origin in a tuber- from G-asserian ganglion spinal fluid in 339 culoas bronchial gland 427 disease 496 - trypanosomes in cerebrospina hyperpyrexia in 343 in glaucoma 838 fluid in 340 purpura in . . 596, 598 - - gummatous meningitis 496 Tubal abortion (see Abortion, pyrexia with weakness anc periostitis 496 Tubal) anorexia at oa-set of . . 612 herpes zoster 496 - disease, referred pain in the rigors in . . 647 persistence of pain for area of 10th dorsal nerve in 509 severe headache m 699' months in some cases 496 - gestation (see Gestation, splenic enlargement in 692 69^ iritis 495 Ectopic : and Abortion, tuberculous meningitis a scars of old herpes in . . 496 Tubal) part of . . 612 from tumours at base of ruptured (see Gestation, - genito-urinary, pyrexia in 621 brain 496 Ectopic; and Abortion, - guinea-pig inoculation in of 5th nerve . . 496 783 Tubal; diagnosis of 71& — major . . 495 496 Tube-casts (see Casts, Renal) - haematoporphyrinuria in . . 820 aijsence of sensibility in 496 Tubes, distended Fallopian, - histological diagnosis of . . 814 muscular paresis in 496 causing dyschezia 150 - iritis and cyclitis in 25& age incidence of 495 Tubercle bacilli (see Bacillus) - of joints (see Arthritis. Tuber cutaneous flushing in 495 Tubercles, choroidal (and see culous ; and for Tuber- idiopathic, diagnosis Choroid), with Cheyne- culosis of the Tiscera see from symptomatic Stokes respiration 125 under the different organs. trigeminal neuralgia 496 in meningitis . . 341 699 e.g.. Kidney ; Liver ; Pros- lachrymation in 495 ophthalmoscopic appear- tate; Th3Toid Gland, etc.) photophobia in 495 ance of (Plate VHP) . . 463 - latent, loss of weight from S47 points in diagnosis of 495 - unilateral exophthalmos due pleuritic effusion in 121 reflex spasm of muscles to 254 255 von Pirquet's and Cal- of affected side in . . 495 - (and see Kodules) mette's reaction in salivation in . . 495 Tuberculides (see Scrofuloder- diagnosing 847 subjective sensation of mia) - leucocytosis absent in 620 ,699 swelling in . . 495 Tuberculin in exclusion of uncommon in, except in trophic changes in hair tuberculous peritonitis . . 719 advanced phthisis and and skin in . . 495 - injections ui diagnosing meningitis 40& no wasting in . . 496 chronic abscess of bone 752 - lichen scrofulosorum with . . 52» Trigonal region of bladder, Addison's disease 38 - of Lung (see Phthisis ; and affection of, causing penile latent tuberculosis . . 848 Lung; pain 441 lupus vulgaris. . 812 - lymphatic gland enlarge- Trional, coma due to. . 137 tuberculosis 612, 808 814 ment in (see Lymphatic Triplegia, infantile 155 tuberculous caecum 736 Glands) Triple phosphate crystals in - reaction absent in lung - marasmus in 427 urine (Fiy. 155) . . 573 1 lesions due to oidium - milk in relationship to 84S TRISMUS 801 ; tropicale . . 705 - multiple serositis in 123 - absent in hydrophobia 162 I eosinophilia in positive - cedema of legs in . . 459 , 461 or late in strychnine stage of 249 - onychia in . . 445 poisoning 162 (and see Calmette's Re- - pancreatitis from . . 116 - from alveolar abscess 747 action ; and Yon Pir- - perforation of palate in . . 64& - in hysteria . . 162 quet's Reaction) , - peripheral neuritis in 506 3 006 TUBERCULOSIS— TYPHOID FEVER Tuherculosis, contd. Tympanites, contd. Typhoid fever, contd. — pyrexia prolonged iii 609 - in atonic'constipation 143 differential leucocyte - - the only symptom for - carcinoma of colon . . 367 count in diagnosis from weeks in some cases of 612 - cirrhosis of liver 410 suppuration . . 402 - recrudescence following - diagnosis of ascites from . . 52 distribution of spots in . . 607 measles . . 427 - displacement of cardiac im- dryness of tlie mouth in 774 — shortness of breath in 101 pulse by . . . . 330, 332 Eberth's bacillus in fa3ces 610 - simulation by alcoholism 849 - gastric, over thorax 668 empyema of gall-bladder in 369 anorexia nervosa 850 - in acute haemorrhagic pan- enlarged mesenteric glands - of spine (see Caries of Spine) creatitis . . 646 in 422 - testicular atrophy in 79 , 80 - Hirschsprung's disease 148, 152 epididymo-orchitis in 517, 518 - tuberculin injection test of 814 - loss of liver dullness from . . 404 epistaxis in 90, 251, 697 tests for . . 612 - orthopncea from . . 465, 467 exp.ggeration of knee-jerks — ulceration of palate in 640 - palpitation from . . 526, 528 in convalescence from 397 rectum in 635 - in general peritonitis 644 fatty heart following . . 241 - vertebrae (see Caries of Spine) - physical signs of 52 stools in 265 - visceral, multiple benign - in pneumothorax . . 480 fewness of physical signs m. 697 sarcoid with 452 - pyloric obstruction 134 foul breath in . . 98 - von Pirquet's cutaneous - thoracic, due to stomach or taste in 774 reaction for 612, 814, 847 colon 668 frontal headache at onset of 610 - wasting with 69 Tympanum, effect of nuclear fullness of abdomen .in . . 90 Tuberculous lymphatic glands facial paralysis on 536 furred tongue in 774 (see Lymphatic Glands) Type-setters, plumbism in . . 136 gall-bladder enlarged in - meningitis (see Meningitis) Typhlitis, pain in right iliac 280, 281, 371 - otitis media (see Otitis fossa from . . 135, 501 gangrene in 282 Media, Tuberculous) Typhoid bacilli (see Bacillus gradual onset with lassi- - peritonitis (see Peritonitis, Typhosus) tude and anorexia m. . 697 Tuberculous) - carriers, infected bile in . . 281 hemorrhage m, blanching - ulcer (see Ulceration, Tuber- - fever, absence of clinical due to 622 culous) signs in some cases of . . 610 sudden drop in tem- Tugging, tracheal, due to leucocytosis in 614, 620 perature from 622 aneurysm . . 222 acute diarrhcea in 196 hfemoglobinuria in 315 Tumours (and see Carcinoma ; dilatation of heart from 243 headache ui 90, 610, Sarcoma ; Swellings ; and peritonitis from 55 620, 697 699 mider the various, organs) - - agglutination reaction in lasting several days, - pelvic (see Swelling. Pelvic ; (see Typhoid Pever, with pyrexia, at onset 620 and Pelvis, Tumour of) Widal's Reaction in) heavy sweats in 648 - phantom (see Phantom albumosuria in . . 1 -, 20 hyperpyrexia in. . 343, 622 Tumour) amnesia after 26 - - hypothermia in conva- - pulsatile (see Swelling, Pul- - - arthritis in 376 lescence from . . 346 satile) asymmetrical cedema fol- indicanuria in . . 349 TUMOURS OF THE SKIN .. 802 lo«'ing . . 456 inflammation of bile-pas- - spinal (see Spinal Cord Tumom's) bacihi in blood in 650 sages by typhoid bacilli 371 Tunica vaginalis, various backache with . . 787 intestinal bleeding in . . 90 swellings affecting 765 bacteriuria in 83 - - jaundice in 362, 369 371 Tuning-fork tests for hearing Cheyne-Stokes respira- leucocyte count in diag- 188, 189 tion in. . 125 nosis of deep suppura- Turkish bath, capillary pulsa- coma in . . 136 tion from 401 tion induced by . . 106 due to haemorrhage in 140 leucocytosis uncommon in 400 Turpentine, anuria from 4a , 48 confinement to bed at end leucopenia in 90, 196, - lijematuria from 304 of first week m 610 372, 401, 697 — leucooytosis from . . 400 constipation in . . 610 648 lymphocytes increased in - priapism from 586 continued pyrexia in 697 402. 615 697 — workers, bulla? in . . 110 cramps in 179 menorrhagia in . . 428 Twelfth nerve (see Hypoglossal] cultivation of typhoid meteorism in 432 Twins, antenatal recognition of 228 bacilli from blood in . . 610 diagnosis from perfora- - dystocia due to . . 227, 228 delirium in . . 90, 194 tion 432 Twisting of pedicle of ovarian diagnosis in absence of mild polyarticular ar- cyst, pain simulating renal AVidal's reaction and thritis as precursor of 376 colic 392 rasli 611 muscular atrophy in . . 76 'Twitch, muscular, caused by - - - from appendicitis, signi- necrosis of jaw in 747 fat;gue, etc. 159 ficance of leucopenia 401 nerve deafness after 190 Twitchings before apoplectic fungating endocarditis - - oedema of legs after 459 stroke 157 611, 613 orchitis from . . 79, 765 - of face during rigors 646 general tuberculosis . . 699 osteitis of head and neck in 376 - muscular, in meningitis . . 642 influenza 610, 611, 699 otitis media in . . 648 - iu strychnine poisoning . . 802 - - - malaria . . 615 pancreatitis from 116 Tympanic attic, caries of Malta fever . . 612 perforation in . . 648 711 ossicles in suppuration in 470 paratyphoid fever 611 diagnosis from meteor- perforation in Shrapnell's pulmonary tuberculosis 611 ism . . 432 membrane in suppura- pyosalpms, significance severe abdominal pain tion in. . 470 of leucopenia in 401 from 622 - cavity, bloody purulent dis- septiccemia 611 sudden drop in tem- charge from 468 small-pox 607 perature from 432, 622 - - erosion of internal carotid suppurative pylephlebitis 614 rise in pulse-rate in 432 arter}- from clironic sup- trichinosis 504 periosteal abscess in 752 puration in 468 tuberculous disease of nodes in 752 of lateral sinus from 468 the kidney . . 612 periostitis in 431, 648, 776 opened in fractured base 467 meningitis 611, 612, 699 of rib after 744 (and see Otitis Media) tyiihus . . 597, 610, 698 peripheral neuritis from 76 Tympanites (and see Meteor- ulcerative colitis 91 peritonitis in 648 ism) 431 diarrhoea in 90 pleurisy in 648 - abdominal distention great at onset of 610 pneumonia in 648 from 467 diazo-reaction in . . 198 pneumoperitoneum in . . 711 TYPHOID FEVER— ULCERATION 1007 Typhoid fever, amid. Typhus fever, contd. ULCERATION OF THE FOOT polyuria after . . 582, 583 pyrexia over by twelfth or (and see Foot, Perforating primary infectioa of gall- fourteenth day in . . 610 Ulcer of) 809 bladJer in 372 prolonged in . . G09, 610 from diabetes mellitus.. 809 pulse in . . 372, Gil, 697 rarity of . . . . 597, 698 general paralysis of insane 809 pulse-rate relatively slow - - rash of . . 371, 610, 699 leprosy . . 809 in .. 610, GOT, 771 retention of urine in 099 locomotor ataxy . . 562 pulse-t«inperature ratio in rigors in . . . . 647, 698 - - perforating (Fig. 207) . . 809 372, 697 severe vomiting in 699 - - from peripheral neuritis 809 purpura in 590, 598, 607 slight leucoctyosis in . . 371 - - syphilis . . 809 — very rare in . . 598 splenic enlargement in 692 698 tabes dorsalis 809 pus in stools in . . 601 sudden onset in . . 371 - of frsenum linguae in - - pyelitis in 625 termination by crisis 371 whooping-cough . . 814 [•yrexia the earliest sym- typhoid state in . . 699 - gastric (see Gastric Ulcer) l)tom in many cases of 620 Typist's cramp . . 177, 494 - of glans penis from balanitis 674 - prolonged in 609 Tyrosln, absent from urine in - gummatous (Fig. 208) 811 - - rash in . . 697 phosphorus poisoning . . 373 - of intestine, hsematuria in rhonchi in chest in 697 - in acute yellow atrophy 305, 313, 314 -- rigors in (/"i?. 166) G14, 647, of the liver 302, 370 843 caecum, surgical emphy- 6-18, 650, 651 , G98 746 - relation of alkaptonuria to 822 sema from 231 indicating compiication colon, blood per anum in 92 in .. .. 648, 651 irFFELM^\:N'yS reagent for involvement of bladder in 313 rare in . . 647, 650 tf-stiiiL' L'astric acidity . . 355 pneumoperitoneum from ■ — rose-red spots in 90, 372, UL;auil;t, tryimiiosomiasis in 34 perforation of . . 711 607, 610 Ulceration, "anal, causing spasm - - septic arthritis from 375 the most conclusive of sphincter 150 or stomach, abdominal evidence of 610 - of bladder in acute cystitis 627 tenderness in . . 134 rupture of gall-bladder in 281 biiharzia infection 630 stricture due to . . 146 simulated by pyaemia . . 650 cystoscopy in diagnosis of 630 subphrenic abscess due to 721 sloughs from Peyer's from cystitis . . 629, 630 varieties causing bleeding 90 patches in the stools in 697 frequency of mictiirition in 630 - of larynx, cyanosis from . . 185 spine, painful and stiff in 376 hsematuria from . . 630 dysphagia due to 226 snleen soft in G97 from injury 629 earache from 230 ■" enlarged in 90, 196, 372, intestinal ulceration 633 haemoptysis in . . 318 610, 615, 692, 697 malignant disease 629 ,630 - - oedema of 466 spondylitis deformans after 787 painful micturition in . . 630 stridor from 710 stiffness of hip joint in . . 376 phosphaturia in . . 630 varieties of . . 226, 710 submammary abscess after 744 pyuria in . . 623, 629 630 - - variolous . . 266 swelling of thyroid gland rarity of 630 ULCERATION OF THE LEG 810 in 792 - - simple . . . . 629, 630 - - due to anthrax . . 811 - - talipes from 133 surgical emphysema from 231 atheroma. . 810 technically a septicaemia 650 in vesical tuberculosis . . 629 badly united fracture . . 810 temperature curve of (Fig. - carcinoma of tonsil 672 — Eazin's disease . . 450 1G2) .. .. 611, 697 ULCERATION OF CORNEA 806 bums 810 - - tenderness of spine after 784 anterior polar cataract cold 810 testicular abscess in 680 from 806 in diabetes mellitus 811 atrophy after 79 catarrhal . . 806 from diphtheria bacilli . . 811 tetany in 178 conjunctivitis due to . . 256 in elephantiasis . . 810 tinnitus after 794 dendritic . . 807 epitheUomatous . . 812 transverse myelitis from 565 diphtheritic 807 from excessive standing 450 typiioid spine with 787 epiphora from . . 250 glanders . . 811 without ulceration of intes- with exophthalmos 807 hemiplegia 811 tine 372 from fifth nerve paralysis 807 infantile paralysis 811 ulceration of larynx after fluorescin detection of . . 806 ochronosis from carbolic 226, 318, 466, 710 gonococcal 255, 256, 807 dressings on . . 822 AVidal's reaction in 90, - - in OravRs' disease 807 old age . . 810 196, 372, 610, 620, 697 - - herpes frontalis 807 phagedaena 811 - spine, general account of 376 787 hypopyon from . . 806 relationship of injury to 810 — state in tyjjhus fever 699 iridocyclitis from 806 syphilitic . . . . 449, 811 Typhus fever, absence of iritis from 806 tuberculous 811 sloughs in stools in 699 irregularity of pupil from 594 varicose, characters of . . 810 Widal's reaction in . . 699 lachrymation from 806 in yaws . . 449 acute dilatation of heart in ophthalmia neona- - Mooren's 807 from 243 torum . . 256 - of the mouth (and see onset in 698 pain in the eye from 806 Stomatitis) '. . ..86,88 coma in . . 136 panophthalmitis from . . 806 bleeding gums in . . 86, 88 cyanosis in . . . . 187 phlyctenular 806 - mucous membranes from diagnosis from fungating photophobia from 574, 806 herpes 830 endocarditis . . 610, 614 progressive stages in 806 - multiple, in tuberculous typhoid fever 597, GIO, 698 in trachoma 807 laryngitis . . 325 diazo-reaction in 198 - duodenum (see Duodenum, - nose, epistasis in 250 early prostration in 371, 698 Ulcer of) - oesophagus, surgical emphy- hyperpyrexia in 343 ULCERATION OF THE FACE sema from 231 inspissation of blood in. . 187 (and see Rodent Ulcer; - palate in syphilis . . 237 jaundice in . . 362, 371 and Carcinoma) . . . . 808 - penis (see Penis, Ulceration ofj leucocytosis uncommon in 400 - in fibroma moUuscum . . 781 - peptic, of gums 87 marked nervous symptoms 699 - of fingers in diabetes 266 - perforating, distinction from mulberry and petechial from epithelioma 266 suppurating com 809 rashes in 371 frostbite . . 266 originating from a com 809 occasional outbreaks in leprosy 266 painlessness of . . 809 poorer parts of large lupus vulgaris 266 in tabes . . . . 285, 811 cities . . 698 in Raynaud's disease . . 266 - of pharynx, earache from . . 230 purpura in 371, 596, 597 scleroderma 266 snail-track, in secondary pyrexia in . . 343, 698 from a--rays 266 syphilis 672 looS ULCER A TIOX—URA TES Ulceration, contd. Vheration, tuberculous, contd. Uncinate gyrus, centre for smell G69 - of rectum 473 of bowel, albumosuria in lesion of, anosmia from . , 669 bearing-down pain in . . 473 bleeding per anum in 90 olfactoiy atira in tumour of 80 due to dysentery 635 larynx, cyanosis from . . 185 tumour of, loss of taste gummatous 635 nose, epistaxis in 250 due to . , 774 Imemorrliage in . . 93 from tuberculous cervical Unconsciousness (see Coma) often impalpable 635 glands . . 420 Unequal pulses (see Pulses, sacralgia from . . 510 - of urethra, causing epididymo- Unequal) speculum in diagnosis of 635 orchitis . . 517 - pupils (see Pupils, Abnor- surgical emphysema from 231 from gummata . . 209 malities of) traumatic . . 635 - vagina, discharge from 210 Urachal cysts , . . . 730, 761 tuberculous 635 - vocal cords, diagnosis of pelvic swelling due to . . 757 due to ulcerative colitis 635 laryngeal paralysis from 537 simulated by distended venerea!, haemorrhage in 93 - vulva due to epithehoma . . 769 bladder 730 - rodent (see Kodent I'lcer) due to syphilis . . 769 ovarian cyst . , 730 - Of scrotum in tuberculous Ulcerative cohtis (see Colitis, tuberculous peritonitis 730 testis 60S Ulcerative) Urachus, infiltration by new due to epithelioma G79, 765 - endocarditis (see Fimgating growth . , . . 57, 718 - - syphiUtic . . 680, 681, 766 Endocarditis) - normal condition of 730 rounded with sliarp edges - various, afEections of larmx situation of 722 and yellowish base in 185, 466 - timiour of, in umbilical region 728 summa 6S1 Ulcus serpens . . . . S06, 807 - tumours of . . 728 tuberculous 518, 6S0, 766, 767 Ulna, affection in yaws 449 Uramia, absence of albumin- - septum nasi, epist-asis from 251 Ulnar deflection of hand in uria in 350 - of skin, over chondromat-a 755 rheumatoid arthritis 380 — acetonturia in 4 in epitheUoma . . 803 Umit-ed significance of in - albuminmria in 329, 350, 464 647 erythema indurattmi scrofu diagnosis 385 - albuminuric retinitis in . . 350 "losorum 450 in ost-eo-arthritis (Fig. - amaurosis in . . 836, 839 glanders . . 603 108, p. 379) . . 385 - amblyopia in 836 granular scrofulous, ia - nerve, effects of division of - appetite lost in 350 scrofulodermia 603 (Fig. 176) 661 - Babinski's sign in . . 82 - - from herpes 830 insensitiveness of in tabes - bromidrosis with . . 714 iodides in diagn(Bing dorsalis 665 - casts in urine with . . 329, 464 syphilitic ■ . . 469 muscles supplied by 550 - characteristic odour of in Jacquet's erythema . . 446 skin distribution of 659 breath in . . 350 leprosy . . 75, 450 654 spinal roots derived from 550 - Cheyne-Stokes respiration in 124 Uchen" scrofulosorimi as- tenderness over, in brachial - in chronic nephritis 14 sociat-ed with . . 529 neuralgia 491 - coma in . , 82, 136, 137, 464 ui lupus vulgaris . . 448 - paralysis (see Paralysis, Ulnar) - contracted pupils in 195 - - originating in papules . . 528 Umbilical cord infection, blood - convulsions in 14,45,48,464 647 paia from . . 476 per anum in 90 - delirium in . . 195 rupia 653 short, dystocia due to . . 227 - diagnosis of indigestion from 350 sarcoma starting in ..'' 803 - region, bulging of, by - drowsiness in 329 syphiUtic endarteritis . . 338 enlarged spleen . . 688 - dyspncea in 329 scarring in SH definition of 722 - epileptiform convulsions ia iodides in diagnosis of 449 duodenal carcinoma felt in 725 160, 169, 172, 647 trophic, in paralytic tahpes 130 organs normally contamed - frontal headache in 326, 328, 329 tuberculous 449 in 722 - hsematuria in 329 iQ xerodermia pigmento- in-achal tumours in 728 - severe haemorrhage simu- sum 804 various tumours felt in lating 140 yaws 449 ■ t ■ >^ ^ ^'* 727, 728 - high arterial tension in 350 - stomach fsee Gastric Ulcer) - veins, dUatation in cirrhosis - hyperpyrexia in 34 i - superficial in small flat of Uver . . 409 grave significance of 622 pustular syphiLide 604 UmbOication of growth in - hypothermia in 345 - of t-ertiary " syphilis, dia- liver . . 279, 368, 412 - increase of urea in cerebro- gnosis of lupus from . . 449 - papules in lichen planus . . 530 spinal fluid in . . 339 - throat (see Sore Throat) - pustules in sj-philis 604 - latent 45 ULCERATION OF TONGUE 812 - in smaU-pox eruptions 655 829 - opisthotonos in . . 463, 464 - - in dyspepsia 814 UMBILICUS, PAIN ROUND 524 - pyelonephritis 625 dysphagia due to 225 - affected by scabies . . 832 - reaction of pupils in 839 microscope in diagnosis of 814 tuberculous peritonitis 716 - retinal changes in . . 329 836 simple, with stomatitis.. 812 - bloody sweat of 715 - shortness of breath in 100 in syphihs 237 812 , 813 - eczema intertrigo at 524 716 - simulating a rigor . . 647 tuberculous, age inci- - flatt-ened out from ascites. . 472 - symptoms of 48 dence of 814 - secondary growths at 351, - tremor in . . 795 rare 814 526, 716 718 - trismus simulated by 801 simulating epithehoma 814 - hsemorrhage from, in con- - uridrosis in 715 — — — — gumma 814 genital oblit-eration of - visual defects in . . 329 in whooping-cough . . 814 bile-ducts 365 - vomiting in. . 329, 350, S43 - tonsil in Vincent's angina 67C ,672 - hernia of (see Hernia, Um- Ursemic asthma, mistaken for phlegmonous sore throat bilical) spasmodic asthma 582 from 670 - inflammation of, in new-born 715 Urate fallacy in albumin test 6 sarcomatous 672 from subphrenic abscess 716 - of sodium (see Sodium Urate) syphilitic, sore throat from 670 - intertrigo of . . 716 in gout . . 383 tuberculous 672 - lymphatic drainage of 738 Urates, amorphous , , 815 - of trachea, hsemoppreis in 318 - pain at onset of intestinal - cleared by warming 623 from malignant thvroid 792 coUc at . . 473 -'microscopical appearances of 815 - tuberculous (Fi^. 209)" .. 811 - protrusion of, by ascites . . 50 -.normally white 815 of bladder, frequency of - reddening of, in tuberculous -"simulated by mucus 815 micturition in 581 peritonitis 50, 57 472 phosphates . . 623 815 bowel, acute peritonitis - sebaceous cyst of . . 524 pus 815 from 55 diagnosis from small - tests for 815 abdominal pain and irreducible hernia . , 524 - thomapple and hedgehog t€ndemess with 90 - stretching of by ascites . . 50 crystals of 815 URATES— URIC ACID Vratef, cnntd. Urethra, coiUd. Urethritis, bacteriuria in - tlioniapple in cirrhosis 410 - carcinoma of (see Carcinoma, - causes for . . s,ii-r;ilj,'ia from excess of 510 Urethral) - chordee in . . . . 510, URATES. DEPOSIT OF 815 - caruncle of, dyspareunia - cystitis from . . 627, after biliary colic 500 from 221 - diagnosis from cj-stitis diarrhoea . . 815 general account of 770 - dyspareunia from . . iu (Jistiiifjuishing varieties - contusion of 308 - epididymo-orchitis from 517, of heart failure 815 - discharges from (see Discharge, - fistula" of urethra in — fever 815 Uretliral) - frequency of micturition in with heart failure 815 - the u,se of the endoscope in 208 - gonorrhoea the commonest in hot weather . . 815 ^ epithelioma of (see Carcinoma) cause of . . iiulicative of concentrated - evidence of bleeding from 305 - hjematuria in . . 304, urine 815 - e.xamination of, in obscure - herpetic, irritation during lobar pneumonia 815 pyrexia 620 micturition in . . pink colour of . . G23 815 - fistuke of (see Fistula?, Urethral) - history of infection in rheumatic fever.. 815 - foreign bodies in . . 210 - due to impacted calculus . . after much .sweating 815 - ponococci in female 211, 769 - importance of uric acid uroerj'thrin in . . 815 - gumma in . . 209 crystals in after vomiting . . 815 - hard chancre of 209 - inflammation of spermatic Urea ui acute Brighfs disease 12 - herpes of . . 209 cord in . . - cerebrospinal lluiil.. 339 - impaction of vesical growth - leucocytosis in - diminution in urine in acute in . . 441 - occasionally due to septic yellow atrophj- of liver . . 370 - injections into, epididyrao- infection . . - nitrate fallacy in albumin orchitis from . . 517 518 - pain in the penis in test 6 - injury of, bleeding from during micturition inSlO, L'reter, calculus in (aec Calculus external meatus in 511 - priapism from .. 585, Ureteric; extravasation of inrine in 511 - prostatic abscess due to - dilatation of, cj-stoscopic from fall on the perineum 511 207, 511, 627, appearances in . . 625 faulty passage of instru- - after prostatectomy - diseases of, referred pain in ments . . 511 - prostatitis from 511, 627, area of 10th dorsal nerve in 509 fracture of pelvis 511 - purulent uretliral discharge - fistula of, causing pneuma- great care needed in in- in . . turia 576 strumentation in 511 - pyrexia with - inUammatory affections of, - - haematuria in 304 - p3Tiria due to cystoscopic appearances in 624 from kick or blow 511 - retention of urine in - kinking of, in movable pain in the penis during - smarting and tingling in kidney 500 micturition in . . 510 terminal urethra at onset pain due to, simulating perineum iu 516 - suppuration of glandular biliary colic 500 - instrumentation of, epididy- follicle in . . - obstruction of 11 mo-orchitis after 517 518 - testicular abscess due to.. in bladder tumours 311 - irrigation of, in diagnosis - due to ulceration near a — by calculus (see Calculus, between anterior and stricture . . Ureteric) posterior urethritis 631 - ur-;thral abscess in. . complete, atrophy of kid- of posterior urethritis - ->- irrigation in diagnosis of ney due to 627 028 631 - chronic, gonoccoci often hydronephrosis in 395 - narrowing of, following soft difficult to detect incomplete, uro- or pyo- sores 209 when does infection cease nephrosis due to 627 - normal bacteria of . . 82 pyuria due to . . - palpation of lower end per - obstruction of, bilateral - gonorrhoeal (see Gonorrhoea) rectum 307, .")13, 515 594 hydroneplirosis m 395 - gouty - papilloma of vesical orifice by bladder tumour 514 priapism from . . 585, in papilloma of kidney . . 308 due to epithelioma 767 pyuria due to . . - tuberculosis of, association - pain in, with discharsre 441 - non-gonococcal, epididymitis with vesical tuberculosis 513 - palpable tumour of 209 from — evstoscopic appearances - papillomata of 209 due to instrumentation. . in (Plate V, Fig. D. - passage of fieces through, in - posterior, diagnosis from p. 308.) . . . . 515 625 carcinoma of rectum 633 chronic cystitis . . — kidney enlarged and gas through (see Pneuma- history of uretliral infec- tender in 515 turia) tion in pain and frequency of - pigmented in Addison's disease 574 urethral irrigation in dia- micturition in 515 - polypus of, discharge due to 208 gnosis of in penis after mictu- sliown by the endoscope 208 - septic, acute prostatitis and rition in 513 - prolapse of mucous mem- prostatic abscess from . . — palpation per rectum brane simulating uretliral epididymo-orchitis in 517, 513, 515, C26, 694 caruncle . . 770 due to infection from sim- vaginam 694 vulval swelling due to . . 768 ple leucorrhoea secondary to renal tuber- - prostatic, infection in gonor- - - in prostatic enlargement. culosis 310. 312, 515,626,694 rhoea 518 from self -catheterization — T. bacilli in urine in 515 - rupture of . . 308 pyuria due to . . 623, Ureteritis, bacteriuria in 83 extravasation of urine in 308 testicular abscess in - descending, due to B. coll inabiUty to micturate in 308 - staphylococcal and to stapli3'lococcus . . 515 - smarting and tingling at Urethroscope (see Endoscope) frequency of micturition in 515 end of, in onset of acute Urethrotomy, anuria after . . — non-tuberculous, cysto- urethritis. . 511 Uric acid and calcium oxalate. scopic appearance of - soft sores in. . 209 relationships between 471, ureteral orifice in (Piute - stricture of (see Stricture of cayenne pepper deposits J', Fig. C, p. .308) . . 515 Urethra) of — tuberculous 515 - suppuration round, perineal the clinker of metabolism - pain in penis after mictu- sore from . . 677 diminution in urine in rition in . . . . 513, 515 - tuberculosis of 210 acute yellow atrophy . . Urethra, abscess of fsee Abscess J - ulceration of, acute epididy- effect of biliousness on. . Urethral) mo-orchitis in . . 517 518 deficient exercise on . . - nilculus in (see Calculus, Urethral crises of locomotor excessive eating on . . Urettural) ataxy 562 — excretion in birds 1009 83 206. 675 631 631 221 76* 677 631 511 3ia 209 67* 766 817 523 40O 511 515 67* 58G 631 767 631 511 207 630 207 511 G77 679 766 679 631 209 209 631 818 586 62a 76ft 628 62& 62S 515 51S 518 680 631 68a 631 49 817 816 817 370 817 817 817 817 64 URIC ACID— URINE Uric acid, contd. Urine, abnormal colour of, conta Urme, changes, contd. exogenous and endo- orange-yellow from uro- myxcedema 43 ■ genous sources of 817 bilin . . 818 phosphorus poisoning . . 373 in fevers . . 817 pink, on addition of pyelitis . . 500, 625 628 gravel from 816 alkali after drugs . . 819 pyuria 624 in heart disease . . 817 from chrysoohanic renal colic 500 leuktemia . . 817 acid . / 819 820 tuberculosis . . 626 by no means indicative eosin. . . . 819, 820 tumour 391 of gout 816 liiEmatoporphyrin . . 819 in the stream 438 in pernicious anaemia . . 817 haematuria . . 819 due to vesical calculus . . 512 physiology of precipitation 816 haemoglobinuria 819 - crystals in, in vesical calculus 629 reduction of Fehling's and red, from rhubarb 820 - cystine in (see Cystinuria) solution by . . 290, 818 rosaniline . . 819, 820 - deposit ia, in baciUuria . . 615 - - in urine . . 290 - - saatoain 820 of pus in, in cystitis 628 care required in inter- uroer^vthrin . . 818 - diacetic acid in . . 4 292 pretation of . . 817 port-wihe-coloured from in cyclical vomiting of — crystals (Fig. 212) 816 heematoporphyrin . . 819 infants 426 brown colour of, due to red, from chrysophanic - diminution of chlorides in urochrome . . 816 acid . . 819 820 phosphorus poisonidg . . 373 glycosuria with 817 eosin. . 819 ia pneumonia . . 372 importance in frequent haematoporphyrin 819 820 total solids in, in nephritis 626 raicturition . . 817 haematuria . . 819 in pyelitis . . ' 625 urethritis 817 - hasmoglobinuria 314, 819 urea and uric acid in muciLs with . . 816 rosaniline 819 acute yeBow atrophy 370 oxalats of lime with. . 816 smoky tint from car- - dribbling of, after cessation in relation to renal bolm-ia 822 of stream in uretliral calculus ■ . . 817, 818 yellow, from chryso- stricture . . 511 URIC ACID DEPOSIT IN phanic acid . . " . . 819 - dumb-bell crystals in (see URINE 816 and orange-coloured, Oxaluria) (Fig. 130) . . 470 Uridrosis in cholera . . 715 pigments producing 818 - envelope crystals in (see - in urffimia . . 715 rhubarb 819 Oxaluria) (Fig. 130) 470 Urinary fistute (see Fistulae, santonin . . 819 820 - examination in Eright's Urinary) - senna 819 disease . . . . 12 et seq. - meatus, small, enuresis with 248 - absence of bile pigment in epistaxis . . 251 URINE, ABNORMAL COLOUR tropical abscess of liver 369 oxaluria . . 470 OF 818 chlorides in pneumonia 186 ,321 shortness of breath 101 black, from alkapton- - abundant and pale after - excessive (see Polyuria) uria . . . . 830 822 angina pectoris . . 481 - extravasation of, in injuries carboluria . . 820, 822 - acetone in (see Acetonuria) of the urethra . . 511 after certain drugs . . 820 - agglomeration of oxalate pain in perineum in 51G from choluria 819 crystals indicative of in ruptured urethra 308 gallic acid . . 820 oxalate calcull^s . . 471 scrotal fistula due to . . G79 hEematoporphyrin - albumin in (see Albuminuria) - faeces in (see Faeces passed 819, 820 821 - albumose in (see Albumosuria) per Urethram) haematiiria . . 820 - ammonical, source of error - fat in (see Chyluria) hemoglobinuria in Fehling's test. . 290 - filaments in, "from chronic 314, 820 821 - amphoteric and neutral re- gonorrhcea 207 indicanuria . . 820, 821 actions of 572 - fluorescence in, due to eosin 820 jaundice . . 830 821 - analysis in clironic plumbism 173 - fragments of new growth in 308 melanuria . . 820, 821 - B. coli in (see Bacteriuria) in papilloma of bladder 630 methaemoglobin 821 - bacteria in (see Bacteriuria) - gas passed with (see Pneuma- resorcin 820 - Bence Jones bodies in (see turia) salicylates . . 820, 823 Albumosuria) - glycuronic acid in . . 290 — after salol . . 820 - bile-pigmeated (see Jaun- - gravel in, ia renal cohc 500 uva ursi 820 dice ; and Urine, Abnor- - haemoglobin in (see Haemo- blue, from indigo blue 823 mal Colour of) globinuria) iadoxyl glycuronic - bilharzia ova in (Fig. 13, - heat loss due to evacuation acid 823 p. 93) . . . . 514, 630 of 619 methylene blue 823 - black (see Urine, Abnormal - hippuric acid in 290 brown, from alkapton- Colour of) - hyperacidity of, frequency uria . . . . 820 822 - bladder epithelium in, in of micturition from 438 carboluria . . 820, 822 bacilluria.. 615 - incontinence of (see Inconti- certain drugs 820 - blood-stained (see Haematuria) neace of Urine : and Mic- gallic acid . . 820 - calcium oxalate crystals in turition, Abnormalities of) hffimatoporphyrin . . 820 (see Oxaluria) - increase in quantity in hiematurLa . . 820 - Cammidge's pancreatic re- pyelitis . . 625 hai-moglobinuria 31-1, 820 action in (see Cammidge) of solids in, in diabetes 584 indioan . . 820, 821 - casts in (see Albumin'oria ; - indioan in (see Indicanuria) 290 jaundice . . 820, 821 and Casts) - iodides in . . 87 Inelanuria . . 820, 821 - causes of turbidity . . 82 - lactose in . . 290 resorcin 820 - cayenne-pepper deposit in 816 - laevulose in . . 291 salicylates . . 820 - ceils in, similarity of those - lead in .. . . 38, 87, 136 salol 820 derived from different - leucin and tyrosin in acute uva ursi 820 sources 624 yellow atrophy of liver. . 370 green 187 - changes in acute cystitis . . 512 - lithates in (see Urates) from bile . . 819, 823 — associated with biliary colic 500 - microscopic characters of carboluria . . 822 in carcinoma of liver . . 413 pus cells in 623 methylene blue 823 cirrhosis of liver . . 410 - milky (see Chyluria) in ha?maturia . . 305, 820 cystic disease of kidneys 15 physiological causes of . . 573 hsemoglobinuria 304, 314 819 cystinuria 187 - mucus in (see Mucus in in jaundice 360 cystitis 628 Urine) method of precipitation 820 gastritis . . 297 - normal amount passed 437, 581 orange-red from uro- hydatid cyst of kidney . . 396 in early tuberculosis of erythrin 881 impacted ureteral calculus 514 kidney . . 310 URINE— UTERUS Urine, could. - nucleo-proteiil in (see Niicleo- proteid in Urine) - oftonsivo in biicilluria .. 015 - opalescence in pyelitis . . tj'_'r> and turbidity o£ in renal tuberculosis . . . . (J'JU - overllow incoutinence of, in retroverted tjravid uterus 75fl - oxalate deposit in . . . . 470 - oxybutyric acid in.. -1, 2'.>'2 - pale in renal tuberculosis . . 02G - pancreatic reaction in, in affection of the pancreas J 86 - pentose in . . . . . . 290 - phos])hates in (see Phospha- turia) - powdered wig deposit o£ oxalates in . . . . 170 - pus in (see Pyuria) - reaction of, in bacterial infections.. .. .. 83 - - lia^maturia . . . . ."jO(i with uric acid deposit . . 81(; - per rectum, from ulceration of new growth . . . . G.32 - reducing bodies, other than glucose, in . . . . 290 - renal cells in, in bacilluria (ilo - retention of (and see Mic- turition) 45, 207, 440, 631, G99 in acute prostatitis 207, 631 - - with bladder tumour . . 311 causes of . . . . 440 chronic cystitis from 627, 628 differentiation from anuria 45, 440 - - dribbling per urethram in 440 in general peritonitis . . 644 hysterical . . . . . . 441 - - in impacted urethral calculus . . . . 313 nervous causes of 440, 441 after operations. . . . 49 pain and strangury in . . 440 from paralysis of detrusor 443 primary lateral sclerosis prostatic abscess 207 enlargement . . prostatitis retroverted gravid uterus typhus fever urethral calculus stricture urethritis . . vesical irritability - scanty and high-coloured in active congestion of liver - specific gravity in acute nephritis . . . . 12, 13 chronic nephritis . . 15 diabetes insipidus . . 584 meUitus . . . . 584 high in cirrhosis . . 410 lardaceous disease . . 10 low in amyloid disease 197 in pyelitis . . . . 625 polycystic disease of kidneys . . . . 396 renal tuberculosis . . 626 in mitral regurgitation 240 - spermatozoa in, from bladder irritation in oxaluria . . 4 71 - sjjontaneous coagulation in chyluria . . . . . . 126 - stream feeble in urethral stricture . . . . . . 511 - sudden stoppage in flow . . 439 from impaction of calculus in urethra 511 witli vesical calculus 312 - sugar in (see Glycosuria) - sulphuretted hydrogen in.. 187 - suppression of (see Anuria) 567 G31 440 631 759 699 313, 441 .. 440 . . 207 . . 443 71 Urine, conltl. - sweetbriar odour of . . 187 - tests applied to (see Tests) - tube-casts in (see Cast,s) - tubercle baccilli In (and see Bacillus Tuberculosis) . . 310 in renal tuberculosis 394, 515, 626 vesical tuberculosis 312, 513, 628 - turbid from jihosphates . . 208 causes of . . . . . . 82 - twisted stream of, little signilicance of . . . . 438 - urates in (see Urates) - uric acid in (see Uric acid) - per vaginam . . . . 313 ~ vesical cellular elements without casts in, in cystitis 628 - white deposits in, oxalates 470 - worm-like clots in, in kidney tumours . . . . . . 307 Urobilin, presence in normal ffeces 818 - spectroscopic band of (Fiff. 23) .. 95, 361, 818 - traces in normal urine . . 818 Urobllinuria, causes of .. 818 - in cholangitis . . . . 116 - cirrhosis of the liver . . 818 - colour in . . . . . . 818 - from excessive bacterial action in the intestines.. 818 - in intestinal affections . . 818 - liver diseases . . . . 818 -pancreatitis.. .. .. 116 - pernicious anosmia 303, 361, 818 Urochrome, causing brown coloration of uric acid crystals 810 - normal urine colour due to 818 Uroerythrin in cirrhosis of the liver 819 - colour of urate deposit due to 815, 818 - effect of alkali on . . . . 818 - in heart disease . . . . 819 - high colour of urine due to 818 - increased in hepatic disease 819 - simulating hasmaturia . . 818 Urotropine, hfemoglobinuria from 314 Urticaria from absorption of fluid from hydatid cyst 415 - affecting fingers . . . . 266 - age incidence of . . . . 531 - due to antito.xic sera (see Serum Rashes) - bulte in 850 - and bullous dermatoses . . 114 - burning sensation in . . 850 - desquamation in . . . . 656 - diagnosis from angio-neu- rotio oedema . . . . 746 erythema simplex . . 252 prurigo . . . . . . 531 - distribution of . . . . 531 - due to eating fish or pork 746 - involvement of lips in . . 403 - itching in . . 531, 588, 850 - simulating erysipelas . . 850 papular erythema . . 531 prurigo ferox . . . . 531 scarlet fever . . . . 850 - tache C(^r(ibrale in . . . . 771 - wheals in . . . . . . 850 - bullosa simulating dermatitis herpetiformis . . . . 850 pemphigus . . . . 850 - factitious, htemoglobinuria in 315 relation of epidermolysis buhosa to . . 113, 114 - haemorrhagic, hnemosiderin in macules following . . 424 Urticaria, contd. - papulosa (sec Strophulus) - pigmentosa, distinction from "■ xanthoma multiplex . . 805 itching in . . . . 805 seu nigricans . . . . 575 wheals in . . . . 805 Uterine sound (see Sound, Uterine) Uterus, abnormalities causing amenorrhoca . . . . 23 - absence of, sterility due to 705, 706 - anteversion of due to pen- dulous belly . . . . 227 - backward displacement, bearing-down pain from 473 - bimanual examination for fibromyoma of . . . . 429 - cachexia from lesions of . . 114 - carcinoma of (see Carcinoma of Uterus) - changes in, in pregnancy . . 437 - chorion-epithelioma of (see Chorion-ep ithelioma) - cochleate of Pozzi . . . . 219 sterility due to . . . . 706 - congenital closure of cervix 705 - congestion of, absence of en- largement in . . . . 429 backache in . . . . 429 causes of . . . . . . 428 from certain occupations 430 from constipation . . 430 dysmenorrhoea from . . 219 general venous back- pressure causing . . 430 leucorrhoea in . . . . 429 menorrhagia from 428, 430 metrorrhagia from . . 435 occurrence usually in married women . . 429 in retroflexion of uterus 429 sacralgia in . . . . 509 salpingo-oophoritis . . 429 subinvolution . . . . 429 tight lacing . . . . 430 - contraction of, spamodio pelvic pain from . . . . 509 diagnosis fi-om pains of tubal gestation . . 509 weak, dystocia from . . 227 - defective muscle develop- ment of 219 - dilated in subinvolution . . 429 - dilatation and curettage of, in diagnosing cause of metrostaxis . . . . 436 - discharge from, with sal- pingo-oophoritis . . 760 - disease of, anfemia in . . 36 causing amenorrhcea . . 24 pain in the back due to (Fig. 204, p. 788) 476, 788 lower extremity from 491 referred pain in area of 10th dorsal nerve in . . 509 - displaced, causing albuminuria 10 forwards by pelvic hrema- tooele 760 nephritis from . . . . 8 sacralgia in . . . . 509 - enlarged 429 asymmetrically in fibro- myoma. . . . . . 429 anienorrhoea . . 22, 23 from endometritis . . 220 pregnancy . . . . 350 recognition in rectal ex- amination . . . . 638 - fibromyoma of (see Fibro- myoma of Uterus) - fixation in central position by pelvic abscess . . 7G0 UTERUS— VAGUS Uterus, contd. Uterus, contd. Vagina, contd. - fixation ia lateral position, - rupture of, in obstructed - swelling at orifice of (see by pelvic cellulitis . . 760 labour 229 Prolapse of Uterus) by salpingo-obphoritis . . 220 - sarcoma of (see Sarcoma of - various tumours presenting - growths, histology in dia- Uterus) through the 587 gnosis of . . . . 434, 435 - small adult type, sterility Vaginal casts described 211 metrorrhagia from 433 due to 706 - discharge (see Discharge, simulating prolapse 587 - spasm of, dystocia due to 227 Vaginal) - hoemorrhage from, abnormal - subinvolution of, metro- - examination in appendicitis 729 (see Menorrhagia; Metror- staxis from 436 ascites 717 rhagia ; Metrostaxis) - tuberculosis of, histology in in asymmetrical cedema in the new-born . . 435, 436 diagnosis of 434 of the leg 456 post-climacteric (see Me- metrorrhagia from 433, 435 bearing-down pain 474 trostaxis) - tumours of, breaking-down, bladder tumours 512 - - in tubal abortion 760 anaemia in 39 - - chylm"ia . . 126 rupture . . 760 diagnosis from renal tumour 392 dysmenorrhooa . . 220 - hom--glass contraction. - - fluid thrill from cystic dyspareunia 221 dystocia due to . . 227 degeneration of fibroid 429 ectopic gestation 500, 700 - hyperinvolution of, account hardness in fibromyoma 429 loss of weight 847 of 706 histological examination of 434 obscure pyrexia . . 620 amenorrhoea with 23, 24 706 irregular outline in fibro- obturator liernia 740 - - sterility due to . . 705, 706 myoma . . 429 ovarian cyst 438 - infantile, sterihty due to 705 706 jaundice in . . 362, 367 tumour . . 367, 691 - infection of in puerperal fever 649 - - metrostaxis from 436 palpability of large cystic - inflammatory affections of, microscopic examination renal tumours by 393 pain and tenderness in of curetting in diagnosis pelvic abscess . . 760 back from 789 of malignancy of 759 cellulitis 760 - inversion of, acute, great sacralgia in impaction of 509 growth . . 487, 761 shock in . . 587 soft or cystic in some hasmatocele 760 haemorrhage in 587 degenerating fibroids 429 inflammation . . 487 chronic, simulating poly- swelling in hypogastrium in pregnancy, method of 228 poid fibromyoma 587 from 730 - - pus in stools from 600 simulating prolapse 587 (and see Carcinoma, Fibro- pyosalpinx 632, 638, 737 vulval swelling due to . . 768 myoma) retroverted gravid uterus - misplacements of, menor- - unduly small 219 438, 758 rhagia in . . 428 Uva ursi, dark urine from . . 820 salpingitis 500 - muscle deficient, dysmenor- polyuria after 582 sciatica . . 487 rhoea from 2X9 Uvula, carcinoma of . . 670 673 for separability of uterus relaxation in subinvolution 429 - gumma of . . . . 670, 673 from pelvic swelling . . 758 - normal secretion fi-om 210 - pendulous, dry cough with 175 some causes of frequent - pigmentation in lesions of 114 suggested by cough on micturition 438 - polypi of, sterility due to . . 706 getting in to bed 176 tuberculous ureter 629, 694 - pregnant (see Pregnancy) - sore throat from affections twisted ovarian pedicle . . 500 of 070 ureteral calculus impacted of Uterus) - tuberculosis of 673 near bladder . . 627 rectocele simulating 587 uterine fibroid . . 438 - puerperal infection of, septi- VACCINIA., swellhig on face - growths, metrostaxis from 436 caemia from 698 due to 746 simulating uterine prolapse 587 - rapid enlargement of, from - on face, diagnosis from - haemorrhage in. new-born sarcoma . . 434 anthrax pustule . . 746 infants . . . . 435, 436 - retroflexion of . . 429, 508 - papules, vesicles and pustules - secretions, normal and ab- dysmenorrhcea from 219 in . . 834 normal 210 menorrliagia from 428 Vacciniform ecthyma of in- reaction of 210 pelvic pain from . . 508 fants 446 - tumour simulating prolapse uterine congestion in 429 Vagabond's disease, chloasma of uterus . . 587 - retroversion of 429, 473, 508 m . . 574 Vaginismus associated with diagnosis of sciatica from Vagina, absent, imperforate, dyspareunia 221 pain due to . . 487 or stenosed . . 22, 23, 705 - spasmodic . . 222 dysmenorrhcea from 219 - affection by bullous erup- - sterility due to 706 dyspareunia from 221 tions 88 Vaginitis, acute, pain in peri- menorrhagia from 428 - carcinoma of (see Carcinoma neum in . . 516 pelvic pain from. . 508 of Vagina) - nature of discharge due to 210 recognition of 220 - closure of, sterility due to . . 706 - senile adhesive, metrostaxis per rectum 638 - diphtheria of 211 from 430 not sufficient cause of - distention of, in amenor- Vagus nerve, branches of . . 174 dysohezia 150 rhoea . . . . 22 , 23 inflammation after diph- tender prolapsed ovaries by menstrual fluid in theria . . . . 772, 773 with 221 hagmatocolpos 761 after influenza 772, 773 uterine congestion in . . 429 - epithelioma of (see Carcinoma — irritation by caseous gland vomiting with . . 844 of Vagina) 772, 773 - retroverted gravid, amenor- - flbromyoma of . . 587, 768 aneurysm . . 482, 772 rhcea with 759 - growth of, dystocia due to 227 general account of . . 773 bearing down pain in 473 felt per rectum . . 638 hiccough in . . 342, 343 bladder distention in - haemorrhage from (see Haem- by mediastinal fibrosis 772 52, 730 758 orrhage, Vaginal) new growth . . 772 catheter in diasrnosis of 759 - malfornied, dyspareunia tachycardia from 772 chronic cystitis in 628 from 221 neuritis of 77 difficult micturition from 439 - micturition tlirough fistula pressure of thyroid gland frequent micturition in 438 into 442 tumom- on 792 incontinence of urine in 759 - pemphigus, etc., of 114 supplying stomach 842 physical signs ot 758 759 - rigidity of, dystocia due to 227 various ways in which - - - retention of m-ine with 45 - shortness of, in pseud o- related to cough 174, 175 urine dribbling in 759 hermapiiroditism 706 - nuclei degeneration, paralysis vaginal examination in 758 - stenosis by kraurosis 221 770 of vocal cords due to . . 538 VALERIAN— VESICULAR MURMUR 1013 Valerian, foul taste from . . 774 Valetudinarians, hepatoptosisin -107 Valvular disease (see under Heart) Varicella (see Cliicken-pox) Varicocele associated with renal tumour .. 391, 395 - diagnosis of.. .. .. 523 - - from omental hernia . . 767 omental inguinal hernia 741 - hernia with. . . . . . 742 - impulse on couehini? in . . 523 - pain in tlie testicle in . . 523 - reducibility of . . . . 741 - testicular atrophy from 78, 79 - of vulva . . . . . . 768 in association with preg- nancy . . . . . . 770 rupture of veins in . . 770 Varicose eczema, hajmosideriu in macules followinp: . . 424 - veins (see Veins, Varicose) Variola (see Small-pox) Varnish-workers, bulliB in . . 110 Vas deferens, infection in gonorrhoea . . . . 518 thickening of in acute epididymo-orchltis . . 518 tuberculous, with tuber- culous bladder. . .. 441 in tuberculous testis 519, 680, 765, 767 Vasodilatation, good eilecbs of in abdominal angina 351 Vasomotor affections, ptyalor- rhffia in . . . . . . 592 - changes in arm due to cer- vical rib . . . . 128, 493 syringomyelia . . . . 128 - lesions in infantile paralysis 131, 555 - neuroses, albuminuria in . . 16 causing swelling of hands or feet . . . . . . 459 - phenomena in extremities in neuromyositis . . 504 - system, oedema of legs in affections of . . . . 459 Vater, ampuUa of (see Ampulla of Vater) Veins on cheeks, dilated, in cirrhosis of liver . . 300 - of chest, progressive disten- tion in chronic mediastinitis 484 - diastolic collapse of. with adherent pericardium . . 242 - dilated abdominal, in portal obstruction . . . . 300 frontal and orbital, in ca- vernous sinus thrombosis 253 mammaiy, in pregnancy and lactation . . . . 743 precordial, in adherent pericardum . . . . 242 - - thoracic, from mediastinal growth 296 umbilical, in cirrhosis . . .59 - innominate (see Innominate Veins) - method of determining direction of flow in 824, 825 - of neck, pulsation in cases of pulsation of liver . . 407 in tricuspid regurgitation 106 - popliteal, thrombosis in . . 456 - retinal, dilated and tortuous 462 - rupture of, purpura from 596, 597 - thrombosed, leucocytosis in 400 - varicose, asymmetrical cedema in . . . . 456 VEINS, VARICOSE ABDOM- INAL (Plate XVI, p. 824) 9, 824 in ascites . . . . 51 Veins, varicose, ahdominal, contd. inferior vena cava thrombosis . . . . 61 asymmetrical oedema in 455 in new growth of lung 322 superior vena cava obstruction . . . . 458 - - on legs 733 - - nasal mucosa, epistaxisfrom251 - nodular swellings with . . 450 oesophageal, in cirrhosis 290 orbital, intermittent ex- ophthalmos from . . 255 pain in the leg from . . 486 ])elvic, dystocia due to . . 227 due to popliteal aneurysm 762 relation to saphena varix 733 rupture of vulval . . 768 - - simulated by erythema nodosum . . . . 450 VEINS, VARICOSE, THORACIC (Fig. 73) . . 235, 826, 827 from aneurysm . . 236 due to mediastinal new growth 121, 343, 773 thrombosis m . . . . 456 ulceration of the leg from 810 Vena cava obstruction, inferior (see Inferior Vena Cava) superior (see Superior Vena Cava) Venesection, blood changes after 37 - coma as indication for . . 137 - leucocytosis after . . . . 400 Venous congestion of liver (see Liver, Congestion of. Venous) - thrombosis (see Thrombosis) Ventilation, headache from bad 328 - sore throat from bad . . 673 Ventral herniation of lapar- otomy soar, visible peris- talsis in . . . . . . 570 Ventricle (see HeartJ Veratria, influence on musc-le tone . . . . 161, 163 Vermiform appendix, normal situation of (and see Appendicitis, and Abscess, Appendicular) . . . . 722 Vermin killers, strychnine poisoning from . . . . 464 Vermis, tumour in, effects of gait on . . . . . . 643 Veronal, coma due to . . 137 - poisoning, Cheyne-Stokes respiration in . . . 125 - purpura from . . . . 596 Verruca necrogenica . . . . 266 - plana, cliaraoter of papule of 528 distinction from lichen planus . . . . . . 530 - vulgaris (see AVart) Vertebrae (see Spine) - carcinoma of (see Carcinoma of Vertebra.') VERTIGO 827 - in aortic disease . . . . 323 - associated with flushing . . 268 peripheral facial paralysis 536 - in cerebellar lesions . . 69 - cerebral tumour and abscess 330, 341 - epidemic jaundice . . . . 372 - from intracranial gumma. . 330 - lesions of semi-circular canal 827 - ilinifere's disease . . . . 847 - in meningitis . . . . 642 - non-obstructive anuria . . 46 - nystagmus with . . 453, 827 - objective and subjective . . 827 - in otitis media . . . . 4 70 - preceding apoplexy . . 173 haematemesis . . . . 316 828 48 467 502 G24 .313 440 Vertigo, contd. - due to syphilitic ear disease - uramic - from wax in ears . . Vesical calculus (see Calculus, Vesical) - crises of locomotor ataxy . . - disease, cy.stoscopic appear- ances in . . simulation by appendicitis 632 - epithelioma (see Carcinoma of Bladder) - irritability . . - sphincter lesion?, inconti- nence from . . ... - tuberculosis (see Bladder, Tuberculosis of ; and Cys- titis, Tuberculous) - tumours . . . . . . 441 - ulceration, pyuria due to 623, 629 Vesicants, bullae from appli- cation of . . . . ] 10. Ill - causing chloasma . . . . 574 - used bv malingerers 111, 112 VESICLES 829 - in acute rheumatism . . 375 - anthrax . . . . . . 740 - cerebrospinal meningitis . . 643 - cheiropompholyx . . . . 654 - dermatitis herpetiformis . . 781 - development into pustule 601,602 - differentiation from papules 528 bullae from . . . . 110 - in eczema . . . . . . 714 - erythema multiforme . . 531 - herpes frontalis . . . . 807 progenitalis . . . . 675 zoster . . . . . . 479 - herpetic urethritis . . . . 209 - with hidrocystoma 714, 829 - Impetigo . . . . 602, 608 - from insect bites . . . . 834 - in the mouth in stomatitis 815 - napkin region . . . . 446 - perleciic with . . . . 404 - ring of, in anthrax . . . . 603 - scabies . . . . 60S, 654 - small-pox . . . . . . 605 - syphilides . . . . . . 532 Vesico-colic fistula . . . . 146 Vesiculae seminales, gono- coccal infection of . . 207 gonorrhoeal thickening of 638 inflammation of, pain in perineum in . . . . 516 pain in the back from diseases of the . . 476 not palpable per rectum normally . . . . 638 palpation per rectum 307, 519, 638 - tuberculous .. . . 394 association with other genito-urinary tuber- culosis 307,312,513, 519, 626, 629, 638, 694, 767 deposits in . . . . 630 with tuberculous bladder 441 testis . . . . 680 nodules felt on rectal examination 519, 638 pain in perineum in . . 516 Vesicular murmur, absent in pneumothorax . . . . 430 lung compression . . 331 affected in a unilaterally enlarged chest . . 192 deficient in bronchiectasis 703 emphysema . . 186, 246 with fibroid lung . . 324 fluid in chest . . . . 193 from growth of lung . . 322 obstructed bronchus . . 296 in pneumothorax 193, 577 I0I4 VESIC ULA R M URM UR— VOMITING Tesicidar murmur, contd. deficient on right side in large hydatid cyst of liver . . . . ' . . 415 Yibioes ia purpura . . . . 595 Vibrio in cholera . . . . 301 Vicarious menstruation (see Menstruation) Villi, chorionic . . . . 220 Villous carcinoma of bladder (see Carcinoma of bladder) of rectum, haemorrhage in 93 Vincent's angina, bacteriologi- cal diagnosis of . . . . 672 distinction from diph- theria and follicular tonsillitis . . . . 672 enlargement of subniaxil- lary lympliatio glands less common in . . 419 foetor of breath in 99, 672 fusiform bacilli and spirilla in . . . . 670, 672 laryngitis from . . . . 670 pharyngitis from . . 670 prognosis good in . . 672 resistance ito treatment. . 672 sore throat from . . 670 tonsillitis from . . 670, 672 ulceration of tonsil in 670, 672 Violinist's cramp . . . . 177 Visceroptosis, constipation due to (Fig. 39-) . . . . 147 - displacement of kidney in 473 - - liver in . . . . . . 473 - - stomach in . . . . 473 - dull dragging abdominal pain in . . . . . . 473 - illustrated . . . . . . 147 - insufEicient defcecation due to 148 - profile of abdomen in . . 473 - a--rays and bismuth meal in diagnosis of . . . . 473 Visible peristalsis (see Peristal- sis) VISION, DEFECTS OF .. 834 - double (see Diplopia) - loss of, in glaucoma . . 257 - normal characters of 834, 835 - peripheral constriction of field of, causes of 666, 838 - spiral or concentric limita- tions of in hysteria . . 837 Visual disturbance transitory in migraine . . . . 329 - word centre . . .. .. 683 agraphia in lesions of 685 Visuals, definition of . . .. 685 Vitiligo, diagnosis of chloasma from 575 Vitreous, hfemorrhage into, erythropsia due to . . 840 sudden blindness from 839, 840 - hazy in glaucoma . . . . 838 Vocal cords, ataxy of . . 69 inflammation and ulcera- tion of, diagnosis of laryngeal paralysis from 537 paralysis (see Paralysis of Vocal Cord) fremitus decreased or lost in a deformed chest . . 192 in emphysema . . 192 with pneumothroas . . 193 in fibroid lung . . . . 193 tactile, absent in pneumo- thorax . . . . . . 480 decreased in bronchial obstruction . . 296, 322 increased in emphysema 246 fibroid lunar. . 246, 332 unequal in phthisis . . 319 176 226, 673 538, 539 .. 483 673 Voice, abnormalities of (see Speech, Abnormalities of) with cough in laryngitis laryngeal paralysis mediastinal growth - excessive use of, clironic pharyngitis from - lost, with normal cough. In hysterical aphonia . . - monotonous in paralysis agitans . . . . . . - nasal, after diphtheria 77, 181, 559 in myasthenia gravis . . 687 with paralysis of palate 640, - ready tiring of, from chronic pharyngitis myasthenia gravis - reduction to whisper in hysterical aphonia - sounds absent in bronchi- ectasis lung compression deficient, from obstructed bronchus or absent in pneumo- thorax in fibroid lung increased in emphysema - test, for hearing, whispered Voices, hearing of, as epileptic aura Volatile oUs, bullae in workers among Voltmann's contracture 132, of forearm (Fig.iZ, p. 166) 72, 166, 552 Volvulus, great abdominal distention from . . - intestinal obstruction from - pain In left iliac fossa in . . - of sigmoid colon - TomitincT with Vomit, absence of free HCl in, in new growth of stomach (and see Gastric Contents) - black, in acute yellow atrophy . . phosphorus poisoning . . yellow fever . . 301 - hepatic pus m, from rupture of liver abscess into stomach . . - sarcmfe in, in new growth of stomach (Fig. 92, p. 267) VOMITING - in abdominal angina - acetonuria in - in active congestion of liver - acute encephalitis . . 139, 547 general peritonitis 431 472, 644, 718 meningitis . . 139, 563 pancreatitis 292, 646, 724 poliomyelitis . . 128, 555 rheumatism . . . . 671 - - without diarrhoea, maras- mus from . . . . 426 yeUow atrophy of liver 302, 370 - in Addison's disease . . 38 - aniemic . . . . . . 40 - from appendicitis 135, 729. 736 - In arsenical poisoning 87, 92 - arteriosclerosis - associated with flushing . . - with bacteriuria - in biliary colic - from carcinoma of CEECum colon duodenum stomach . . 299, 357, 485, 691 - central causes of . . 843, 844 687 96 687 703 331 296 324 246 188 110 165 152 431 501 713 153 691 302 373 373 409 691 841 351 4 371 297 328 268 84 135 729 367 725 178 350 56 845 . . 737 .. 737 . . 353 426, 843 4S 841 364 300 350 341 713 229 153 846 845 644 847 Vomiting, contd. - in cerebellar abscess . . 651 - cerebral abscess 547, 651, 68G - cerebral, account of 341, 847 absence of nausea in . . 847 tumour 173, 292, 477, 547, 686, 782 I - of cerebral type 328, 585. - of children, tetany in . . - in chronic intestinal obstruc- tion peritonitis - from cohc . . 133, 363, 500, 645 - collapse after severe . . 346 - due to colon inflammation 727 - with constipation. In hyper- trophic stenosis of" the pylorus - copious, from carcinoma of pylorus . . in gastTectasis pyloric obstruction - cyclical, of infants. - with cystic kidneys - definition of ' . . - in distoma hepaticum in- fection - duodenal ulcer - early phthisis - effortless, in cerebral tu- mour and abscess - in excluding gastric atony - exhaustion of obstructed labour - ffficulent in appendicitis . . gastro-colic fistula general peritonitis hysteria . . intestinal obstruction 134. 151, 431, 845, 846 sex incidence of . . . . 692 - of fermenting fluid in pyloric or duodenal ob- struction . . . . . . 571 - in gall-stone colic . . . . 363 - gastric causes of . . . . 843 - in gastric crises of tabes 350, 485 - from gastric fermentation 267 - - ulcer 40, 89, 298, 352, 485 - gastritis . . . . 297, 352 relief of pam by . . . . 484 - glaucoma . . " . . 494, 838 - Henoch's purpura 90, 380, 600 - hypothermia after severe. . 340 - hysterical, carcinoma of stomach mistaken for . . diagnosis of Indigestion from - in influenza - intestinal obstruction 133, 151, 153, 431. 571, 645, 727, 733, 736, 741, 845 peritoneal, and general visceral causes of - Intracranial gumma or tumour . . - Intractable, in acute yellow atrophy of liver . . - in intussusception . . 727, 736 - Irritant or corrosive poison- ing 674 - lead poisoning . . . . 77 - Jf^ni^re's disease . . . . 828 - meningitis 174, 341, 350, 359, 622, 642, 699 - m^aine 329, 837, 838, 840, 847 - morning, in alcoholism 238, 243, 368, 797 In pregnancy . . . . 437 - neuro-muscular mechanism of 842 - non-obstructive anuria . . 46 - at onset of scarlet fever . . 843 - in otitis media in children 229 508 350 505 846 844 336 302 VOMITING— WA STING 1015 Vomiling, could. Vulva, conld. W asp-sting, bleeding gums - pancreatic lijemorrhage 292, 046 - implantation cyst of 768 due to 86 - paroxysmal in tabetic crfees 350 - kraurosis of (see Kraurosis Wassermann's reaction 37 - pliospliorus poisoning 373 Vulvae) - - in ane\irysm 786 - imeumonia . . 622 - cysts affecting 768 - - cerebrospinal fluid 340 - portal obstruction.. 300 - diabetic eczema starting in 447 - - chancre of the tongue . . 813 - of preK'tumi'y (see Pregnancy) - elephantiasis of 770 - - cntineous lesions of secon- - in iituniaiue iioisoning 196 - endothelioma of . . 768 dary syphilis 533, 005, 672 - witli pULTpenil eclampsia.. 172 - epithelioma of . . 768, 771 - - in diagnosis of syphilitic - pyainii.i (M9 enlarged inguinal gland pyrexia . . 615 - with pyloric obstruction 131, from 769 - - digital chancre . . 422 :i53, 713 - fibroma of . . . . 768, 771 _ - epithelioma 813 - recurrent periodical or cy- - furunculosis of 768 _ - general paralysis of the clical of children 42G, 843 - hasmatoma of 770 insane . . 139, 269, 340, 360 extreme thirst from 789 - inflammatory afTections of 768 - - gumma of bone . . 752 - in renal colic 500 - .Tacquet's erythema of 44r, - - - liver . . . . 279, 371 - rickets 171 - lipoma of . . 768 - tongue 420 - severe, in cerebellar abscess - molluscum fibrosum of . . 771 - - lymphatic gland enlarge- or tumour 565 - mucous cyst of 768 ment . . 417 in infants. . 426 - neuroma of . . 768 - - paralysis of leg from syph- loss of fluid from tissues - oedema of . . . . 768, 770 ilitic meningitis 544 due to. . 579 - pain in (see Pain in Vulva) _ - of perineal chancre 678 - - polycythasmia in 579, 580 - papilloma of 768 - - in ptyalism 591 - - in pregnancy 579 - pigmentation of, in Addison's - - 7tli nerve paralysis 590 typhus fever 699 disease 574 - - In syphilis 75, 86, 204, 209, 224, - simulated by bronchiectasis 842 - pruritus of . . . . 569, 588 226, 254, 325, 371,417, 615, 658, merycism . . 842 - pseudo-elephantiasis of . . 770 675, 738, 769, 808, 811 814 - with sinus thrombosis 139, - sarcoma of . . 768 - contrenital . . 427, 695 558, fiSO, 651 - sebaceous cyst of . . 768 _ of liver 60 - strangulated hernia 741 - soft cliancre of, vulval - of jaw . . 748 - suppurative nephritis 646 swflliiiL' from 768 - testis . . 520 pylephlebitis 649 VULVA, SWELLING OF 768 - - syphilitic arthritis 386 - tenderness in epigastrium - sypliilisfif, siiinilating tuber- - chancre 675 from 779 culosis 769 - on face 747 - from torsion of retained testis 742 - tenderness of (sec Tenderness _ endarteritis . . 338, 340 -- in trojiical abscess of liver 369 of Vulva) - gland enlargement 417 - ulcerative colitis . . 727 - tertiary syphilitic lesions of 768 - laryngitis 674 - undue abdominal aortic - tliread-worm infection of . . 509 - testis . . 766 pulsation . . 592 - tuberculosis of, vidval swell- - - tabes 489 - unBmia . . 45, 329, 350 ing from . . 768 Wasting in acute leuk.Tmia . . 649 - urate deposit after. . 815 - ulceration of 769 - from anorexia nervosa 69 - in variola . . 301 - varicocele of, associated with _ carcinoma 69, 91, 93, 413, 636 ,737 - wasting with 69 pregnancy 770 - with cholera 09 - in whooping-cough. . 467 - various new growths of . . 768 - chronic (and see Cachexia) 508 Von Basedow's disease Csee Vulvitis, acute, clinically all - from cirrhosis of liver 69, 410 Exophthalmic Goitre) forms more or less alike 768 - diabetes . . . . 69, 507 Von Graefe's sign 244, 253, 792 - dyspareunia from . . 221 - with diarrhoea 69 Von .Taksch's disease ("see - enuresis with 2d8 - - in adults, suspicion of Pseudo-leukajmia) - gonorrhoeal, diagnosis from. carcinoma of rectum . . 636 Von Pirquet's reaction 38 simple 768 - diseases, apparent enlarge- in diagnosis of chronic vulval swelling from . . 768 ment of liver in . . 405 abscess of bone 752 - leukoplakic, confusion with - - enophthalmos in 247 — - latent tuberculosis 847 kraurosis vuIvee . . 770 - - fatty heart in 241 lupus vulgaris 812 vulval swelling from 768 _ liver in . . 414 marasmus from obscure - simple, diagnosis from gonor- _ distention of stomach 737 tuberculosis . . 427 rhoeal 768 - with dysentery 69 negative in anorexia ner- - great, in cyclical vomiting vosa 850 WADDLING gait in con- of children 843 - - not very trustworthy . . 736 genital dislocation of hip 277 - from hepatic abscess 69 in pleuritic effusion 121 - in pseudol'iypertrophic para- - in Hodgkin's disease 649 for tuberculosis 612, 814 lysis (and see Gait) 277 - from malaria 69 tuberculous disease of Walking, abnormalities of . . 277 - muscular (see Atrophy, testis . . . . 529 765 - delayed from cretinism . . 557 Muscular) - — peritonitis 691 idiocy 557 - obscure, in children, prob- Von Recklinghausen's disease, Little's disease . . 154 able cause tuberculous affection of scalp in 781 paraplegia in children 556 ,557 absorption from milk . . 427 distinction from fibroma rickets (and see Gait) . . 557 - in pancreatitis . . 135 292 molloscum . . 781 Warmth in bed, increase of - with peritonitis 718 neuro-fibromata in . . 781 some pains by . . 503 - in pernicious anromia 649 nodules in 804 - effect on pain in erythro- - phthisis . . . . 185 319 pigmentation of skin in melalgia . . 490 - with ptomaine poisoning . . 69 781 804 Wart, diagnosis of syphilitic _ in renal tuberculosis 135 scalp tender from 780 781 tubercle from 532 - galpingo-oophoritis with sup- thickening of nerves in 804 - epithelioma starting in 803 puration . . 760 Vulva, angioma of . . 768 - hypertrophy of papules into 528 - from sarcoma 69 - carcinoma of (see Carcinoma - ichthyosis developing into 5.30 - starvation . . 69 of Vulva) - post-mortem 266 - syphilis 69 - chancre of . . 768 - sarcoma starting in 803 - - congenital 370 - circinate sj'philoderm of . . 532 - scrotal . . . . 679 765 - of tongue (see Tongue, - condyloma" of, diagnosis - simulating lichen planus . . 5.30 Atrophy of) from soft chancre 768 Washerwomen, acroparaes- - with tro]iIcal abscess of liver 408 - cracked and fissured from thesia in . . 493 - from tuberculosis 69 leukoplakia 221 - nail staining in 444 - ulcerative colitis 69 - dermoid cyst of 768 - sore fingers of 266 - vomitmg 60 ioi6 WASTING— WRIST Wasting, contd. Werlhofs disease . . 596, 600 Wolf bite, hydrophobia from 801 - vomiting and constipation West Indies, yellow fever in 372 Wolffian body, retroperitoneal in hypertrophic stenosis WHEALS 850 cysts derived from 725 of the pylorus. . 845 - in dermatitis herpetiformis 831 Wool-workers, anthrax in 603, 746 - (and see Weight, loss of ; - lichen planus 832 Word blindness, hemianopia and ilarasrnus^ - mode of production of 850 with 684 Watcti test for hearing 188 - relation to erythema 850 inability to read in 684 Watchmaker's cramp . . 177 nodules . ." 850 lesions causing . . 684 Water, insufficient consump- papules . . 850 relationship to defects of tion of, as cause of consti- - in urticaria . . 252 vision, speech, etc. 684, 685 pation 145 pigmentosa 805 varying degrees, and Water-brash (see Heartburn) - vesicles on . . 850 difficulty of analysis of 684 Water-drinking, plumbism from 3 36 WTieezing in emphysema 526 with word deafness 684 Water-hammer pulse in aortic Whetstone crystals . . 816 - centre, auditory, importance regurgitation 106, 107, 233 234 Whip-worm (Fig. 154) 569 in acquirement of speecli 683 Watering of eyes from error of Whiskers, extension of pedicu- lesion of, word deaf- refraction 328 losis pubis to 447 ness from . . 684 Wax in ear, deafne?s from . . 467 WTiisky-drinking, polyuria from 581 and visual, situation of dry cough from Hi 175 Whispered voice test for (Fig. 185) . . . . 683 eczema of external audi- hearing 188 - deafness from destruction of tory meatus from 468 Whistle, inability to, from centre 684 purulent discharge due to 467 facial paralysis . . 533 examination of a case of 684 tinnitus from 467 in myopathy 260 lesions causing . . 684 Tertigo from . . 467, 828 Wliite corpuscles (see Leuco- relation to power of Waxy renal tube-casts 7 cytes) speech, writing, etc. . . 084 - sijleen in lardaceoas disease 696 - tongue, or cachexia aquosa 115 WORMS, INTESTINAL 567 Weakness of back muscles, White-leg (see Phlegmasia alba bile-duct obstruction from 364 scoliosis from 180 dolens) causing increased appetite 49 - in Bright's disease . . 90 Whitlow, a.Tillary abscess due to 731 enuresis with 248 - carcinoma of colon 91 - causes of 445 eosinophilia with 249 - of the limbs in chronic alco- - leucocytosis in 400 insomnia from . . 357 holism 797 - oedema of face, neck, and grinding of teeth with . . 293 - mascular, in general paraly- arms from 458 infantile convulsions from 170 sis 172 - painless, in Morvan's disease 285 leucocytosis with 620 paralysis agitans 796 - septicemia from . . 698 micturition frequent from 438 - in neurasthenia 506 - with .syringomyelia 128 285 night terrors from 3f.7 448 - at onset of phthisis. . 620 - thrombosis of veins from. . 826 priapism in infancy from 585 - progressive, from growth of Whooping-cough . . 400 465 vomiting with . . 844, 846 lung 322 - abra=ion of fraenum lingua? in 320 - - (see also Tape-worms, etc.) in pernicious anasmia . . 30 - bacilli in sputum in 705 Worry as cause of functional - tremor from 795 - bronchitis simulated by . . 705 dyspepsia 355 Weather, effects on chronic - cough after.. .. 175, 176 - constipation due to 144 rheumatic pains . . 507 - hcemoptysLS in . . 317, 320 - ill-effect on neurasthenia . . 788 quantity of urine 581 - hernia of lung from 194 - influence on trigeminal sore throat 672, 673 - infantile convulsions in . . 170 neuralgia . . 495 - pain in chest in phthisis - leucocytosis in 400 - insomnia from 357 varying with 480 - orthopncea in 465 - loss of weight due to 848 Weber's test for hearing 189 - paroxysmal cough in 467 - malarial relapses due to . . 36 Weeping (see Epiphora) - rupture of cortical veins in 131 - neurasthenia from . . 506 - in eczema . . . . 714, 831 - subconjunctival haemorrhage - and professional cramp . . 177 Weichselbaum, meningococci in . . 256 - ptyalorrhoea caused by 592 of (see Meningococci) - swelling of eyes and face in 459 Wounds of the abdomen. Weight carrying, scoliosis from - Tooth's peroneal atrophy infective peritonitis from 644 180, 181 developing after 71, 560 - in the chest, surgical emphy- - in hypochondrium, feeling - ulceration of fraenum of sema from 716 of, in catarrhal jaundice 365 the tongue from. . 814 - infection of tetanus tlu-ougU 162 - increasing, in myxoedema . . 585 - vomitincr in . . 467 844 - on the neck, siirgical em- - lifting, subconjunctival hse- Widal's test in diagnosmg physema from. . . 716 morrhage from . . 256 cause of prolonged pyrexia 609 - pneumothorax after 577. 578 WEIGHT, LOSS OF .. 847 typhoid fever from - pyaemia from . . 372 649 - - from carcinoma 147. 1.50, 295, pysemia 650 - septicemia from . . 698 299, .322, 351, 718, 724, 725 ,736 frequent failure of 610 - of thigh, talipes from 131 due to change of sur- negative fallacies of 610 - in the trachea, surgical em- roundings 848 - - in paratyphoid fever 697 physema from . . 716 Crraves' disea.se . . 244 797 positive, not necessarily Wriggling, mild choreiform Hirsciisprung's disease . . 718 indicative of tvphoid 611 movements causing 156 in infants (see Marasmus) in tynhoid fever' 90, 196, Wrinkles, diminution of in methods of e.xamining 281, 327, 620, 650 697 facial paralysis . . 533 in cases of 847 "Wind (see Flatiilence ; and Wrist, athetotic flexion of . . 154 in pernicious anremia . . 30 Meteorism) - flexion of, in brachial mono- rheumatoid arthritis 39 Winged appearance of scapula plegia 546 sarcoma . . 756 ia paralysis of serratus in paralysis from chorea 548 ulcerative colitis 727 magnus . . 551 - flexor contracture of in - sense of, in gastritis 352 Winking, absence of, in para- arsenical neuritis 105 Weil's disease 372 lysis agitans 2|62 — gonococcal artliritis of 376 albuminuria in . . 17 - diminished, in Graves' disease - gout in 382 jaundice in 362 253, 261 - h37)ertrophic osteo-arthro- purpura in 596 - involuntary, in facial par- pathy in . . 390 rigors in . . 647 alysis CFig. 139) . . 534, 537 - lichen planus affecting 657 Weir-Mitchell treatment in Winter, bronchitis with em- - multiple benign sarcoid of 451 functional wasting 850 physema in 186 - osteo-arthritis of . . 384 Werdnig-Hoffmann progres- - cough (see Cough) - pruritus of . . 588 si%'e m.u.scular atrophy of Wisdom tooth impaction - scabies of . . 447, 588 832 infants 158 simulating tetanus 801, 802 - tuberculous disease of 385 WRIST-DROP— ZYMOTIC DISEASE 1017 Wrist-drop from plumbisni 38, 77, 507, 551, 798 Wrist-jerks, unequal in heuii- plegia . . . . . . 337 Writer's cramp 177, 494 AVritiug, difficulty in, in supra- scapular nerve paralysis 551 - effect ol word-deafness or word-blmdness on power of 684, C85 Wry-neck fsee Torticollis) XASSTTHELASMA. planum . . 3G0 - tuberosum in jaundice . . 360 Xanthin bases, uric acid derived from . . . . 8J7 - in urine, reduction by . . 290 Xanthoma claaracter of papule 528 - diabeticorum . . . . 805 - macules in . . . . . . 424 - multiplex . . . . . - 805 - planum . . . . . . 805 Xanthopsia from amyl nitrite 840 - cannabis indica . . . . 840 - from jaundice . . 360, 840 - picric acid . . . . . . 840 - santonin poisoning . . 840 Xerodermia, distinction from licben scrofulosorum . . 530 - papules of . . . . . . 530 - scales in . . . . . . 655 - pigmentosum, age incidence 804 - - characters of . . 802, 804 diagnosis from freckles.. 424 influence of season on . . 804 - - macules in . . . . 424 superficial ulcer? in . . 804 telangiectases in.. .. 804 watery tumours in . . 804 white atrophic spots in . . S04 yellow crusts in . . . . 804 Xerosis of the conjunctiva in keratomalacia . . . . 807 X-rays in abdominal aneurysm 4_86 - acromegaly . . . . 5*85 - acute secondary arthritis. . 378 - affections of antrum of Highmore.. .. .. 502 - aneurysm, aortic (Fig. 74, p. 236 ; Fig. 131, p. 483) 107, 223, 23C,, y22, 422, 465, 474, 477, 483, 582, 786, 790 of external iliac arterv. . 741 - - fusiform . . . . " . . 238 popUteal . . . . . . 762 - asthma . . . . . . 582 - atony of pelvic colon . . 149 - bone growths or caries . . 270 - bronchial or mediastinal lym- phatic gland enlargement 617 - calculous anuria . . . . 47 - callus . . . . . . 757 - cardiac displacement . . 332 - cause of cough . . . . 176 radicular pain in arm . . 494 - cervical caries .. 477, 708 - - rib . . 75, 128, 493, 554 - chronic abscess of bone . , 752 - congenital dislocation of hip 183 - constipation 141, 142, 144, 145, 146, 147 - diaphragmatic hernia . . 712 - dilatation of stomach . . 352 - d isease of lumbo-sacral spine 488" - distinguishing empyema from subplirenic abscess mediastinal growth from aneurysm oxaluria from calculus . . sarcomafromperiostitis 751,763 - - subphrenic abscess from pyopneumothorax . . 712 - duodenal obstruction . . 571 - dysphagia . . . . . . 224 721 483 311 X-rays, contd. - egg-shell crackling . . 177, 179 - endosteal sarcoma (Figs. 197, 199, pp. 755, 756)757, 763 - erythema from exposure to 252 - excluding aortic aneurysm 593 - exostosis (Fig 194, p. 753) 754 of frontal bone . . . . 255 - foreign bodj' in oesophagus 297 - fracture 179 of jaw . . . . . . 747 vertebrae . . . . . . 787 - gastroptosis (Fig. 105) . . 353 - gout (Fig. 113) . . . . 383 - growth of spine .. .. 182 - haemoptysis .. .. 318 - Hirschsprung's disease . . .433 - hydatid cyst of lung (Fig. 100) 323 - impacted ureteral calculus 514 - locating pus in chest . . 119 - mediastinal growth . . 465 lesions . . . . . . 185 tumour . . 422, 474, 582 - mediastinitis and new growth 61 - mottled shadows in phthisis 319 - movable kidney and renal calculus . . . . . . 583 - necrosis of jaw . . . . 748 - odontom:it:u . .. .. 749 - (Esophageal obstruction . . 223 pouch 842 - orbital periostitis . . . . 254 - organic stricture of intestine 146 - osteo-arthritis . , . . 380 - osteosarcoma .. .. 179 - pain in the arm . . . . 491 - - back- 476 - - chest .. .. -- .. 479 - para;iysis from spinal cord lesions , . . . . . 543 - periosteal sarcoma (Fig. 196, p. 754) . . . . 756 - phthisis . . . . 319, 736 - - eAi\j(Fig. 27) .. 120, 847 - pneumonia (Fig. 99) . . 321 - pneumothorjtx 480, 577, 578 - popliteal swellings . . . . 763 - pyloric obstruction' 134, 144, 571 - pyonephrosis (Fig. 97, p. 309) 396 - renal calculus fi^i^. 97, p. 309) 500, 626 tuberculosis . . . . 626 - rheumatoid arthritisfJJ'ij.llO) 380 - sarcoma (Figs. 196, 197, 198) 179, 754, 757, 763 of lower jaw . . . . 7-18 pelvis . . . . . . 741 - scar, epithelioma starting in 803 - in sciatica to exclude organic disease . . - sLmiinrity of sarcoma and chondroma under - sore fingers from . . - spinal caries . . 181, 474 - splenomedullary leukaemia 3L - spondylitis deformans . . 787 - sterility caused by . . 80 - in stomach disorders 712, 727 - subnhrenio abscess 501, 578, 720, 721 - talipes . . . . . . 132 - testicular atrophy from 79, 80 -■ thorax examinations . . 37 in paralysis of vocal cord 538 tumour or aneurysm of . . 75 - thymus gland enlargement 465 - transparency of bones in rheumatoid arthritis (i^'ig'. 110) 380 - tropical abscess of liver . . 409 - tuberculosis of kidney . . 310 - tumour of pelvic bones 737, 741 of spine . . , . . . 525 488 755 X-rays, contd. - unerupted teeth . . . . 501 - ui-eteric calculus 47, 135, 311, 627 - vesical calculus (Fig. 98, p. 312) .. .. ..629 - visceroptosis . . 147, 473 YAWNING in test for functional and organic Ijaralysis of arm . . 548 Yaws 449 - absence of giant cells in . . 450 glandular enlargement in 449 heredity in . . . . 450 syphilitic symptoms in.. 450 - affection of clavicle, ster- num, ulna, tibia, in . . 449 legs, ankles, lips in . . 449 of metacarpal and meta- tarsal bones in . . 449 - blood changes in . . . . 450 - cell changes in . . . . 450 - diagnosis of lupus from . . 449 of tuberculosis from . . 450 - frambccsial excrescences of 449 - nodular skin changes in . . 449 - raspberry-like granulations in 655 - scabs in . . . . . . 655 - similarity to syphilis . . 449 - syphilis .no protection from 450 - ulcers in . . . . . . 449 Yeast cells in gastric contents 267, 353, 355, 845 - pneumaturia due to . . 576 - in sputum . . . . . . 705 - sugar differentiation by . . 290 Yellow fever, albuminuria in 17, 301, 373 anuria in . . . . 49 black vomit in . . 301, 373 bleeding gums in 301, 373 coma in . . . . . . 136 constipation in . . . . 372 cyanosis in .. ..187 diagnosis from acute yellow atrophy 372, 373 dengue and malaria . . 373 malignant malaria . . 301 falling pulse with rising temperature in . . 373 gangrene in . . . . 282 geographical distribution 372 - - headache in . . 301, 372 hasmatemesis in.. 294, 301 — '■ haematuria in . . . . 305 haemoglobinuria in . . 315 liyperpyrexia in . . 344 incubation period of . . 372 inspissation of the blood in 187 - - jaundice in 301, 362, 372 loss of weight in . . 848 pain in back and limbs in 372 petechia} in . . . . 301 purpura in . . 373, 596 pulse relatively slow in 301, 771 rigors in . . . . 372, 647 sudden onset with rigor in 301 Yellow spot, cones very numer- ous at . .' . . . . 835 affections of, causing am- blyopia with nystagmus 836 - vision . . . . . . 840 ZIEHL-lfEELSRN method of staining tubercle bacilli 700 Zimmerlin's myopathy, fibril- lary contractions in . . 158 Zinc sulphate, vomiting from 843 Zona (see Herpes Zoster) . . 830 Zygomatic muscles, wealmess of, in myasthenia gravis 260 - process, hyperplasia in acromegaly . . . . 26^ Zymotic diseases Tsee Fevers) 5327.11 JOHN WRIGHX AND SONS LTD., PRINTERS, BRISTOL.