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About Google Book Search Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web at|http : //books . google . com/ mi^m Gift Dr. Gran*> Self ridge Medical Diagnosis WITH SPECIAL REFERENCE TO PRACTICAL MEDICINE A GUIDE TO THE KNOWLEDGE AND DISCRIMINATION OF DISEASES BY J. M. DA COSTA. M.D.. LL.D. / PHYSICIAN TO THE PENNSYLVANIA HOSPITAL, ETC. ILLUSTRATED . . . . • • NINTH EDITION, REVISED PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY IQOO Wo EXTRACT FROM PREFACE TO THE FIRST EDITION. My chief aim in writing this work has been to furnish advanced students and young graduates of medicine with a guide that might be of service to them in their endeavors to discriminate disease. I have sought to offer to those members of the profession who are about to enter on its practical duties a book on Diagnosis of an essentially practical character, — one neither so meagre in detail as to be next to useless when they encounter the manifold and varying features of dis- ease, nor so overladen with unnecessary detail as to be unwieldy and lacking in precise and readily applicable knowledge. In executing my undertaking, two plans offered themselves : either to describe morbid states in compliance with the usual pathol(^caI classification followed in treatises on the Practice of Medicine, or to group them according to their marked symptoms. The former plan would have been far the easier, but the latter seemed to me the more suitable for a volume of this kind ; and, although it has involved much labor, and has rendered the task much more difficult of accomplish- ment, its advantages appeared to me so great that I have adopted it throughout. That this attempt at a purely clinical classification is not perfect, I am fully aware. But, with all its shortcomings, I venture to hope that it will not be devoid of value. Some of the statements made may appear too absolute, and as not taking sufficient notice of the many exceptions that may arise. But it was impossible to avoid this without lengthy discussion : and even in Copyright, 1890, by J. M. Da Costa, M.D. Copyright, 1895, by J. M. Da Costa, M.D. Copyright, 1900, by J. M. Da Costa, M.D. :\ :•:.-:: : •• 2 ..: . • •••••• •••• •• ••« PRINTIO BY J. B. LIPPINOOTT COMPANY, PHILAOIkPHIA, U.t.A. L) II PREFACE TO THE NINTH EDITION. Considerable new matter has been incorporated in this edition, especially in the chapters on the Diseases of the Stomach, on the Blood, and on Fevers, as well as whatever of bacteriological interest has proved of value for diagnostic purposes. Fresh illustrations, too, including some skiagraphs and colored plates, have been added. By a revision of the text, and the rewriting of such portions as now, with our more definite knoyrledge, admit of greater precision of ex- pression, the additions have not enlarged the book ; indeed, the differ- ent size of the page and a new type have made it a smaller and more convenient volume. All the fresh matter has been added in accord- ance with the clinical classification inaugurated when the work was originally written, and which has proved a useful plan. I express with pleasure my indebtedness to Dr. Eshner, Dr. Woodbury, and Dr. Leflfmann for valuable.aid, as^well as to Dr. Leonstrd:fcr.the excellent skiagraphic pictures. Th^ 7 Jaundice 567 Acute Diseases of the Liver attended generally with Slight Enlargement of the Organ, and with more or less, though rarely much. Jaundice 572 Acute Congestion 572 Acute Hepatitis 572 Inflammation of the Gall-Bladder and Gall-Ducts 577 Acute Cholecystitis 580 Acute Cholangitis 582 Acute Diseases characterized by a Decrease in the Size of the Liver and by Deep Jaundice 582 Acute Yellow Atrophy 582 Chronic Diseases attended with Enlargement of the Liver, and with slight or no Jaundice 584 Chronic Congestion 584 Chronic Hepatitis 586 Abscess of the Liver 0. 586 Fatty Liver 592 Waxy Liver 592 Cancer of the Liver 593 Hydatids of the Liver 600 Chronic Diseases attended with Decreased Size of the Liver, and with Ab- dominal Dropsy ()04 Cirrhosis 604 Chronic Atrophy of the Liver 610 SECTION IV. ABDOMINAL ENLARGEMEXT. General Abdominal Enlargement 610 Ascites 610 Partial Abdominal Enlargement 617 Abdominal Tumors 617 SECTION V. ABDOMINAL PUIilATION. Aortic Pulsation 628 Abdominal Aneurism 629 CHAPTEK VII. ON THE URINE, AND ON DISEASES OF THE URINARY OROANS. Urine. 632 Color 635 SjHJcific Gravity 636 Reaction 6:^7 Changes in the Quantity of the more Imiwrtant Constituents (>38 12 CONTENTS. PAGE Presence of Abnormal Substances in the Urine ? ()50 Sediments 671 Urinary Organs 675 Diseases of the Kidney of which Pain is a Prominent Symptom 675 Acute Painful Nephritis 675 Nephralgia 676 Diseases marked by an Albuminous Condition of the Urine, associated with more or lees Dropsy 680 Acute Bright's Disease. '. 681 Chronic Bright*s Disease. 688 Diseases associated with Purulent Urine 700 Acute Cystitis 700 Chronic Cystitis 701 Abscess of the Kidney 702 P>'eliti6 704 Disorders in which a very large Amount of Urine is discharged 707 Diabetes 707 Chronic Diuresis 711 Disorders in which little or no Urine is discharged 712 Suppression of Urine % '. 712 Retention of Urine •. . 713 ' CHAPTER VIII. DROPSY. Dropsy, according to its Seat and Extent 715 Dropsy, according to its Causation 716 CHAPTER IX. DISEASES OF THE BLOOD-VESSELS. Diseases of the Arteries 719 Arteritis 719 Atheromatous Changes 721 Diseases of the Veins 721 Phlebitis ! 721 Diseases of the Capillaries 722 CHAPTER X. DISEASES OF THE BLOOD. General Considerations 724 Antemia 7.37 Pernicious Anfemia 740 Leucocytosis 745 Leukaemia 746 Addison's Disease 751 Pyajmia : 754 Septica?mia 757 Thrombosis and Embolism 759 Scurvy 764 Purpura 7C)6 CONTENTS. 13 CHAPTER XI. RHEUMATISM AND GOUT. PAGE Acute Rheuniatifliu 768 Chronic Rheumatism 772 Gout 775 Arthritis Defonnans 778 Rickeus ' 780 CHAPTER XII. FEVERS. General Considerations 783 Continued Fevers 784 Simple Continued Fever 784 Catarrhal Fever 785 Typhoid Fever 789 Typhus Fever 807 Cerebro-spinal Fever 812 Relapsing Fever 819 Yellow Fever 82:i Dengue 828 Plague mo Malta Fever , 831 Glandular Fever 831^ Periodical Fevers 8;W Intennitt-ent Fever KM\ Remittent Fever 841 Pernicious or Congestive Fever 846 Tj'pho-Malarial Fever 852 Eruptive Fevers 853 Scarlet Fever 85:^ Measles 858 Rubella 8(U SmalliKix 8<>4 Erysipelas 8(i8 CHAPTER XIII. DISEASES OF THE SKIN. General Considerations 871 Erythematous Diseases 873 Piipular Diseases 875 Vefiicular Diseases 877 Bullous Diseases 879 Pustular Diseases 88() Squamous Diseases 882 Maculae 884 New Growths 884 Hv-pertropliies 886 14 CONTENTS. PAGE Paraaitic Di8ea8es 88S Altered Gland-Secretions 891 Nervous Affections 892 CHAPTER XIV. POISONS AND PARASITES. Poisons ^ 893 Acute Poisoning 893 Irritant Poisons 893 Narcotic Poisoning 897 Chronic Poisoning 902 Parasites 911 Vegetable Parasites ' 91 1 Animal Parasites 913 Index 927 LIST OF ILLUSTRATIONS. FIG. FAOE 1. Sphygmograph of Marey 35 2. Dudgeon's Sphygmogtaph 35 3. Sphygmogram enlarged 36 4. Self-registering Thermometer 39 5. Seguin'g Surface Thermometer 39 6. Surface Thermometer, with coil at ex- tremity 39 7. Temperature Chart in Simple Continued Fever il 8. Temperature Chart from a (^ise of Re- mittent Fever 42 9. The Centres in the Human Brain .... 52 10. Right Homonymus or Lateral Hemiar- nopsia 53 11. The .Esthesiometer of Sieveking .... 68 12. Carroirs .Esthesiometer 69 13. Mathieu's Dynamometer 91 14. Hutchinson's Teeth 123 15. Laryngoscopes 235 16. Laryngoscopic Examination 2:% 17. Lar>'ngeal Image, as seen in the Lar}'u- gnscope 2:i7 18. The Stethometer 264 19. The Stethogoniometer 2a'> 20. The Pleximeter 266 21. Percussion Hammer 267 22. Hawksley's Stethoscope 272 23. The Double Stethoscope 272 24. The Phonendoecope 273 25. Diagram illustrative of the Main Forma of Feeble Respiration 276 26. Diagnun illustrative of Rilles 281 FIG. PAGE 27. Elastic Fibres of Pulmonary Tissue . . 296 28. A Spiral Magnified 296 29. Charcot-Leyden Crystals 297 30. Tubercle Bacilli (in colors) 299 31. Casts from a C^ase of Plastic Bronchitis . 308 32. Appearance of the Chest in Emphysema 310 33. Beginning Infiltration in Phthisis . . . 316 34. Cavities in the Lung in Phthisis .... 318 35. Temperature Chart in Pneumonia ... 335 36. Diagram illustrative of Perfect Pulmo- nary Consolidation, such as happens in the Second Stage of Pneumonia . . 337 37. Temperature Chart in Broncho-Pueu- monia (in colors) 343 88. Diplococcus I^eumonise of Fraenkel . . 314 39. Pncumococcus (Dipl(xx)ccus) of Frled- laender 345 40. Roughening of the Pleura from Inflam- mation 347 41. Large Effusion occupying the Left Pleu- ral CaN-ity :U8 42. Physical Signs in Pneumothorax .... 354 43. Topography of the Heart 368 44. Diagram showing the I^oints at which the Separate Valves may bo IL^tencd to 374 45. Position of the Heart, and Distention of the Pericardium with fluid, in Peri- carditis 400 46. Hypertrophied Heart, lying in its Posi- tion in the Chest 410 47. Dilated Heart, the Right Ventricle opened 413 15 16 LIST OF ILLUSTRATIONS. riir. PAGE FIG. PAGE to. Narrowing of the Aortic Orifice by 69. Blood-Mixture, as seen with the Square Vet^retAtions 422 Micrometer Ruling of the Moist- 49. [nsuAcient Mitral Valves permitting Chamber of Malassez ?27 Regoigltation of the Blood . ... 423 70. Daland's Hsmatokrite 72S ■ii). .ST»h)gmogram of Aortic Insufficiency . 425 71. Hxemoglobinometerof Cowers 730 ol. sphygmogram of Mitral Regurgitation 425 72. Chart showing Blood-Changes in Chlo- 52. Klebfr-Loeffler Bacilli 448 msis 737 ■M^ Ranilts of Abdominal Percussion . . . AiS» T^. Blood in Pernicious Ansnnia 742 •>4. sarcins Ventriculi 480 74. Temperature in a OKe of Influenxa . . 788 5a. Comma Bacillus of Koch, from Culture . 75. Temperature in Tj-phoid Fever 791 in Blood-Serum 564 ! 76. Eberth T>-phoid-Fever Bacillus, from a 56. Doremus's Ureometer 640 57. Greene's Ureometer 610 Potato Culture 798 Diplococcus Intracellularis 815 ^. Crystals of Uric Acid 612 ; 78. Spirillaof Relapsing Fever 822 59. Mixed Urates 644 ' 79. Temperature in Yellow Fever K>5 4). Earthy Phosphates in the Urine .... 616 80. Temperature in Tertian Intermittent a. Calcium Oxalate Crystals 651 , Fever 837 «1 Albumin Test-Glass 660 , 81. Temperature Chart in Remittent Fever M2 »K. Leucoc}*tes in the Urine 669 | ?s2. I'igment in the Blood in Malarial Ca- 64. Epithelial Casts and Cells from the Kid- , chexia 851 neys in a Case of Acute Bright's Dis- i Nl. Temperature in Variola 865 ease 681 i W. Temperature in Varioloid 887 65. Fatty Cai>ts and Epithelial Cells filled I S'>. Temperature Chart in Facial Erysipelas 9B» with Fat, as seen in Discharge from 86. Acarus Scabiei 880 a Fatty Kidney tW 1 87. ssegments of Tienia Solium 915 «5»5. H>-aliue or Waxy Casts from the Urine . 695 88. HetuU of Ta'ni;e 915 C <:iranular Casti». or <.>k»ts covered with ' 89. Triehina in Recent Human Muscle . . 920 Di^inct^rrAtinj Epithelium and Gran- 9).>. Trichina .^^piralis. Magnified .'WO times . 901 ules tW ' 91. Trichina (."ansule with Shell-like Cal- ->. P* .taiu'-i Pipette ?J6 carei^us Deposits 82 vrj. Eiu'ai«uled Chalky Concretions in Mus- cle, due to Dead Trichina? 922 MEDICAL DIAGNOSIS. INTRODUCTION. GENERAL CONSIDERATIONS. The study of any complicated subject leads of necessity to its arrangement into branches. Closely connected as these are, and form- ing always parts of a whole, they are not only capable of distinct treatment, but frequently become more intelligible as they are so treated. This is made very manifest in investigating disease. The extent of ground covered by the inquiry has rendered it imperative to map it out into various provinces, which, however intimately united, may be with convenience separately surveyed. One com- prises the laws and facts . common to individual affections ; in another is gathered together all relating to their causes; another embraces the consideration of their detection and the full recognition of their nature. It is the purpose of these pages to examine this department somewhat minutely, and especially that portion of it coming within the range of the practitioner of medicine. In so doing it will become apparent how diagnosis, for such the distinction of disease is techni- cally called, is partly a science, partly an art; a science, because it comprehensively takes account of general facts, and of principles based on those facts ; an art, because it demands a cognizance of the means, and their application to arrive at the desired result. To consider, then, medical diagnosis in all its bearings, it will be necessary not only to hold up to view the morbid states met with in the examination of the sick, but also to inquire in what manner they may be most readily recognized and explored, and how their differ- ences may be made available in the discrimination of one ailment from another. In a study of this kind, an investigation of symptoms plays unavoidably a prominent part. In truth, the detection of disease is A^ 2 17 18 MEDICAL DIAGNOSIS. the product of close observation of symptoms, and of correct de- duction from these symptoms, The first requirement therefore for an accurate diagnosis is to leam to recognize morbid signs. But the art of observation this implies is not easy, and cannot be thoroughly acquired except by practice. No one aspiring to become a skilful observer can trust exclusively to the light reflected from the writings of others ; he must cany the torch in his own hands, and himself look into every recess. The knowl- edge obtained from reading is, however, serviceable in this way: it aids in overcoming one of the main difficulties at first experienced, — to know where to look and what to look for. There are in almost every aflFection some symptoms which can hardly escape the merest beginner; but also some which do not appear on the surface, and wliich to find taxes the skill of the experienced physician. And it is especially in this search after hidden signs that medical information as well as cultivated tact is demanded. Now, to recognize the manifestations of disease, whether they are or are not readily perceptible, we have to employ our eyes and ears, our sense of touch and of smell. Formerly we could go no farther than these senses unassisted would carry us. But science has lent its aid, and furnished means by the help of which we can detect clearly what before we could not detect *at all, or of which at best we caught only a glimpse. We now possess instruments of pre- cision by which we ascertain with accuracy the size of organs and their play. With thermometers we tell the degree of heat of various parts of the body. Specific-gravity bottles, and other measures de- vised for the purpose, inform us of the relative gravity of fluids. The microscope gives at a glance insight into matters which the «aked eye fails even to perceive, shows us crystals in secretions, en- ables us to count the corpuscles in the blood, and to detect minute and disease-causing specific organisms. The larj-^ngoscope demon- strates the appearance and the movements of the organ of speech. The ophthalmoscope informs us of the state of the vessels in the brain. And chemistry is rendering our knowledge of many morbid states amazingly complete. Then the sagacity of comparatively modem times has taught us how a disciplined ear may detect the workings of disease in cavities into which the eye cannot penetrate ; and with the marvel of the Rontgen rays we can now see what is going on in the interior of the body. The effect of all these improved methods of study has been to give an immense impetus to clinical research, and to lead to the construction of a solid groundwork, in striking contrast with the looseness of former times. The advance in diag- GENERAL CONSIDEBATIONS. 19 nosis thus attained fomis, indeed, one of the most pleasing portions of medical history. When, by means of the aided or unaided senses, the symptoms of the malady have been discovered, the next step towards a diag- nosis is a proper appreciation of their significance and of their rela- tion towards one another. Knowledge and, above all, the exercise of the reasoning faculties are now indispensable. The daily habit of investigating disease ; a scrutinizing study of the anatomical lesions ; chemistrj', with its most searching analyses ; the microscope, with the wonders it reveals, are all of little use, unless we have been taught the necessity of placing in connection with one another the morbid signs they lay bare, and of considering in individual cases their respective value. Were it otherwise, the science of diagnosis would be simply a matter of memory. It is, however, this very analysis of symptoms and the lengthy process of induction attending it which make medical diagnosis so difficult. Nor is it reasoning on the ascertained facts alone that is required; the premises may be but probabilities ; for, in truth, diagnosis deals at times with the logic of probabilities as much as with the logic of patent facts. Now, we are greatly aided in appreciating morbid signs, and in in- terpreting them correctly, by already existing knowledge. We look to landmarks which our predecessors have erected, and the gradually accumulated science of semeiology, rightly employed, furnishes the clue to the discovery of the disease. Thus the stores which medicine has laboriously collected during centuries can be used with advantage by all, and exist for the good of all. But besides this knowledge, the laboratory, with its facilities for solving new and obscure clinical problems, is of immense and constantly growing advantage. But an acquaintance with semeiology is far from being the sole guide to diagnosis, nor does it at once help to a recognition of the malady. There are few symptoms in themselves distinctive; and often a symptom may be due to one of several causes. Semeiology informs us of these different causes ; but to find out the precise mean- ing of the abnormal manifestation in an individual case, we have to draw our inference from all the signs encountered ; to compare them with one another ; to seek out those that are in the background. We are thus arriving, step by step, at the explanation of the morbid ap- pearances, the starting-point in deduction always being what is known of the affection the presence of which is suspected, and the symptoms of which we are contrasting with those before us. For the conclusion to be valid and exact, it is of course requisite that each part of the testimony have the proper position assigned to it. In reasoning cor- 20 MEDICAL DIAGNOSIS. rectly on symptoms, the same laws apply as in reasoning correctly on any other class of phenomena: the facts have to be sifted and weighed, not merely indiscriminately collected. And while* this in- tellectual act is being performed, much collateral evidence is to be sought before a final judgment is given ; especially is it necessary to view the symptoms with constant reference to the age, sex, and habits of the patient, and to the circumstances amid which the dis- order develops. To accomplish all this effectually, the physician has need of much " and varied knowledge. He must be master of something more than of the information supplied to him by semeiology. He must be an anatomist to pronounce with certainty on the seat of the malady ; a physiologist to appreciate the state of the great centres and the aber- ration of function. Above all, he * must be a pathologist in the full sense of the term : he must understand the antagonism between dis- eases ; the frequency with which they coexist ; the influence of re- medial agents on them ; and be cognizant of their natural history and of the general laws governing them, — for how else can he form an estimate of morbid action while in progress ? Then it is desirable that he should be aware of what are their current divisions and classifica- tions. From what has already been represented, it is evident that he must also be a correct reasoner ; for even a good observer will, by bad reasoning, arrive at a faulty diagnosis ; just as sometimes a bad ob- server may, by the same process, blunder into the truth. There is, indeed, no end to the extent of knowledge which may be brought to bear in working out a conclusion regarding the character and seat of a malady. The habit of observation once acquired, information of the most varied kind will, by an accurate reasoner, be made tributary to the completeness of the diagnosis. Every fresh acquirement tends to enlarge our powers of insight. Just as in nature, tie higher we ascend, the more fully lies the view before us. Having thus indicated the elements of a thorough diagnosis, we may next inquire in what way this is most easily arrived at when at the bedside. The main facts of the case on which the deductions are to be based are of course first elicited. We lay hold of these main facts, and especially of those that are the most direct signs of the morbid action. They are coupled together, and the inquiry is started as to what organ they indicate as the seat of the malady. This often has been already determined by the very method of the examination ; and we therefore proceed at once to investigate the precise nature of the disorder by analyzing the symptoms and the previous history. Sometimes, however, the site of the disease docs not admit of being GENERAL CONSIDERATIONS. 21 definitely fixed upon, or we can only in a general manner decide upon the function impaired. Again, as in idiopathic fevers, we may find no signs, of local disease, — merely those of a general disturbance. In any of these instances clinical experience steps in to explain the phenomena as far as possible, and to inform us in what affections they occur. It may be only in one ; then the desired goal is at once attained. But, as above stated, there are few signs in themselves pathognomonic. It is therefore to be ascertained which one of the dis- orders is before us that special pathology teaches may >1eld the symp- toms encountered. One of these is taken up. Its symptoms are placed side by side with those present. They accord in some respects, but not in all. Moreover, in searching for some of the phenomena which the supposed malady gives rise to, these are not found. The view is abandoned and another taken up. It agrees in all particulars. The diagnosis is made. Yet, when the diagnosis is thus arrived at, we have still to determine, before it can be considered as complete and can be acted upon, whether or not any other morbid state exists, and to take into account the patient's general condition and his indi- viduality. To cite a case in illustration. A person consults us for a cough brought on by exposure. He has been ill for four or five days, having been previously in good health. We notice, on examining him, that his breathing is hurried, and that he has fever ; the lower portion of one side of the €hest is dull on percussion, and the respiration there is wanting; the action and sounds of the heart are normal. The facts point to the lung or its covering as the seat of the malady. We know, furthermore, from the history and the febrile symptoms, that we have to deal with an acute affection. What are the acute pul- monary affections ? Acute bronchitis ; acute phthisis ; acute pleurisy ; acute pneumonia. In all occur fever, cough, and disordered breath- ing. Is it acute pneumonia ? No ; for, nothwithstanding there is in this complaint, in addition to the general symptoms mentioned, dulness on percussion, the dulness is associated with a blowing respiration ; whereas in the case before us no respiration is heard. Let us look at the sputum, and see if it be tenacious and rusty-colored. It is not ; it is thin and frotliy. But acute pleurisy may explain all the signs. The patient, too, when questioned, states that he had at the onset a sharp pain in his side ; and this, we are aware, takes place in pleurisy. The vocal vibrations, likewise, are noticed to be absent on the affected side of the chest, which, when measured, is found to be enlarged. This corresponds in all points with what happens in. pleurisy in the stage of effusion. The disease is, therefore, acute pleurisy in the 22 MEDICAL DIAGNOSIS. stage of effusion. We finish the diagnosis by ascertaining the exist- ence or non-existence of other maladies, and by taking note of the severity of the complaint ; that it has occurred in a young and robust person of good habits ; and that the symptomatic fever is very active. This process of arriving at an opinion is the simplest. It is one in which the investigation of the case is to some extent carried on while the deductions are being made. And it is astonishing how rapidly it may be performed by habit. The mind works uncon- sciously, and a decision is, to all appearance, formed intuitively, which surprises the inexperienced by its readiness and precision. This method aims, so far as the symptoms permit, at a direct diagnosis. But, in truth, it is often what is called differential, — that is, it takes cognizance of and dwells on the essential signs by which one disease can be discriminated from another resembling it. Sometimes, instead of attaining the desired result in the manner proposed, we are obliged to judge of the nature of the malady en- tirely by finding out what it is not. The various diseases capable of producing all, or even some, of the striking symptoms observed, are enumerated. Tliey are one by one considered and set aside, until by this process of pure exclusion the mischief is brought to light. Thus, to use again the example just given, we should have to assign reasons why the disease is neither acute pneumonia, nor bronchitis nor acute phthisis, and in this way determine it to be acute pleurisy. But to prove what a thing is by proving all that it is not is a very tedious process, and we must be quite certain that really all morbid states which may give rise to the symptoms encountered are thought of and inquired into; otherwise our conclusion may be fallacious, though reasoned out in the most logical manner. Moreover, our knowledge of many pathological conditions is so imperfect that we are not fully cognizant of, or able at once to discern, the more char- acteristic signs; nor can the symptoms be taken hold of and ar- ranged in such a way as shall permit us to make nice distinctions without a lengthy and laborious plan of procedure. Owing to these drawbacks, diagnosiH by exvluaion is not, on ordinary occasions, much employiMl, nor, indeed, is it to be recommended. Yet in difficult and obscure cases, where the accustomed i)athway is blocked up, it may enable us to i)ass by obstacles otherwise insurmountable. But can we by this or by any other road always reach a certain diagnosis? We camiot, and for several reasons. The patient may deceive us, wilfully or unintentionally. It may be necessary, for the conflmmtion of the opinion formed, to obtain an accurate history of the cose, and cin*umstanct»s may rend(»r this impossible. The dis- GENERAL CONSIDERATIONS. 23 order may be so rare that its symptoms are not understood. There may be several lesions present, the signs of one masking or neutral- izing the signs of the other. The first of the causes mentioned is a source of error difTicult to guard against. To escape punishment, to avoid disagreeable duty, to excite compassion, to obtain a compliance with unreasonable wishes, or sometimes from the mere love of deception, symptoms may be stated to exist which do not exist, or may be imitated and artificially produced. Persons who thus feign disease are numerous. They are found in all occupations and in all classes of society. They abound in the army and navy. Hysterical women and hypochondriacs help to swell the list. These, indeed, suflFer mostly some inconveni- ence, but exaggerate it immensely, and, by deceiving themselves, end by deceiving, unless he be on his guard, their physician. On the other hand, disease actually in progress may be carefully concealed from motives of delicacy or from fear of the consequences. An incorrect diagnosis from want of a proper history does not, on the whole, occur often. Patients are generally very willing to give a fiill account of themselves and of their distresses. Sometimes, how- ever, the reverse happens. Pain or mental anxiety and sorrow may be wearing the body out while the suflFerer obstinately persists in hiding the cause of his waning health. We meet also with indi- viduals so stupid that the most elaborate cross-examination fails to elicit anything like a connected history. Again, we may be unable to do so from the patient having lost the power of speech or being unconscious. In the rarity of a disease we have a serious drawback to its recog- nition. This may occasion an error of diagnosis in a twofold man- ner. The more distinctive symptoms may be so little understood, and the prominent features be so nearly identical with those of a malady with the manifestations of which we are well acquainted, that a conclusion of the presence of th6 latter forces itself almost innnediately on the mind. Or, the disorder may give rise to phe- nomena wholly unknown, nothing but the autopsy revealing their true meaning. Every physician encounters such cases. It is true that the progress of science and the aggregation of clinical facts are from year to year bringing them into a narrower circle. Yet, are there not still diseases, nay, groups of diseases, that have eluded dis- covery to the manifold means of research of the present day, as they have to the accumulated experience of the past ? But the most serious obstacle to a precise diagnosis lies in the fact that frequently lesions coexist. Disease is a very complex state, and 24 MEDICAL DIAGNOSIS. when one portion of the economy gets out of order, another is apt to follow. Then a part contiguous to one chronically aflfected may be attacked with acute disease; or remote sympathetic derangements become very prominent. A thorough examination of the case is the only safeguard against error. These, then, are the various causes which render a diagnosis un- certain, or wholly unattainable. Let us add to them one that does so temporarily. There are disorders the early inanifestations of which are so much alike that it is next to impossible to tell with which of several we have to deal. In fevers this often happens. Here, how- ever, a few days will almost always solve the difficulty. But not so in other diseases. It is only after a much longer period that the appearance or disappearance of a striking symptom, or the greater prominence a hitherto indistinct sign assumes, enables us to reach a decision. In some such instances, the treatment becomes the touchstone of the diagnosis. Now it may be asked. Does this demonstrate that the diagnosis of a case is not necessary for its treatment ? Not at all. It simply proves that we are sometimes obliged to aim at removing symptoms \vithout understanding their source. But it does not prove that if we understood their source we should not be better able to remove the symptoms. The physician who undertakes to relieve disease simply by attempting to allay its symptoms, regardless of their cause, and without understanding their true relation and significance, is groping in the dark. His treatment is vacillating ; drug replaces drug ; alleviation is taken for a cure ; and the experience obtained is utterly untrustworthy. One great advantage, indeed, of attending carefully to diagnosis is, that it enables us to use remedies knowingly and \vith decision ; to appreciate what they are eflfecting ; to abstain from such as must be injurious. There is less needless meddling, more calmness ; the treatment rises above the consideration of the moment, and takes into atcount what is for the patient's ultimate good. But, in basing the management of a disease on its diagnosis, . we must never be unmindful how important it is to found that diagnosis on a general sur\'ey of all the circumstances ; how neces- sary not to assign prominence tb minor points ; and how the extent of the aflFection, the circumstances under which it has occurred, the sympathetic disturbances produced, and the vital state of the patient, belong, rightly considered, quite as much to the diagnosis as the recognition of the precise seat and exact anatomical character of the malady, and are, in truth, frequently its more important part. CHAPTER I. THE EXAMINATION OF PATIENTS, SYMPTOMS OF GENERAL IMPORT, AND SOME OF THE INSTRUMENTS EMPLOYED IN THE DIAGNOSIS. To elicit the facts of a case by a careful examination is, as has been stated, the first requisite for diagnosis. To conduct, however, a clinical inquiry with precision and facility, requires continual prac- tice, and is rendered easier by following some well-digested plan. The advantage of adopting a method is clearly seen, if the attempts of a beginner be watched. He wanders in his search from one part of the body to another, attracted by diflferent symptoms in turn; pointless question succeeds to pointless question ; and a conclusion, almost certainly erroneous, is finally jumped at, or an acknowledgment made of inability to arrive at any. Now, there are several ways which have been proposed to over- come this embarrassment. One of the principal consists in first questioning the patient vnlh regard to his history. His age ; his occu- pation ; the diseases from his childhood up ; liis habits ; his constitu- tion ; the affections hereditary in his' family, are all minutely inquired into. After this the origin and progress of the existing disorder are traced, and the remedies ascertained that have been used against it. The present condition is then explored ; each organ or each system being in turn interrogated. The investigation is now regarded as complete ; the facts are considered, and the diagnosis, prognosis, and treatment determined. This method of examining is termed the gyw- thHical or historical. The analytical reverses the order. The present condition is first ascertained, and subsequently the patient's history or anamnems. Both of these courses have something to recommend them, and to both there are objections. The synthetical method is the more purely scientific ; but it is too full, and calls for too much labor, to meet the requirements of- ordinary professional life. It is much better adapted for recording cases in the pursuit simply of pathological knowledge, and decidedly the best where the' history is obscure and the symptoms are ill defined. The plan which I habit- ually prefer is to take a general survey of the history and of the promi- nent symptoms, and, having thus obtained some clue to the part most likely to be aifected, to explore this with care. For instance : we are 26 26 MEDICAL DIAGNOSIS. brought to the bedside of a patient for the first lime ; we inquire how long he has been ill ; how that illness began ; in what way he is now disturbed, — whether he has pain, or what is the main source of his annoyance. ^Vhile questioning him, we are scanning his appearance, the position of the body, his movements, his manner of breathing. The hand is applied to the skin : the pulse is felt ; the tongue is looked at; the temperature is taken. Partly from this examination and fiarlly from the historj', some organ is fixed upon to be specially investigated : say pain in the epigastric region and vomiting are com- plained of, — our attention is directed to the stomach. We explore this organ, its [)hysical state and its functions. Then we look to the parts that are anatomically or physiologically most nearly related to it. which are, in the case cited, the intestines and the liver. The examination is completed by taking heed of the condition of other portions of the body ; by reviewing the history of the case ; and by endeavoring to elicit fully such points as bear upon the diagnosis, which the mind, consciously or unconsciously, has begun to frame. Then a balance between the symptoms is struck, the diagnosis is recast, modified, or extended, and the treatment is decided upon. There is some repetition in this plan, but it is the one which ap- pears practically the most suitable. It has the advantage of bringing together the marked features of a case, and especially those most clearly indicative of the general or vital condition. But whatever 8<;heme is chosen, it should, for us to become proficient in it, be as constantly and closely adhered to as the varying circumstances of disease will permit. Yet to acquire thoroughly the habit of exam- ining with accuracy and care, and also to obtain the full fruits of experience, it is indispensable to keep written records. This, too, should, so far as possible, be done according to a uniform design, since it both prevents us from overlooking important symptoms and enables cases to be more readily compared. I subjoin a schedule that is based on the plan of examination just mentioned. Date of examination ; name ; age ; color ; place of birth ; present abode ; occupation or social state ; in females, whether married or not, number of children, and date of last confinement ; how many miscarriages. History. 1. Hvftory antecedent to present disease : Constitution and gen- eral health — Hereditary predisposition — Pre\ious dis- eases or injuries or taints — Habits and mode of life ; hygienic influences to which exposed, etc. EXAMINATION OF PATIENTS, ETC. 27 2. History of present disease : Its supposed exciting cause — Exposure to contagion — Date of seizure — Mode of inva- sion ; subsequent symptoms in order of succession — ' Previous treatment. Present Condition of Patient. Height and weight. 1 . General symptoms : p ... ( in bed — mode of lying ; \ out of bed — movements ; gait and station ; ^^P'^^^lof^*^^' countenance ; Skin; Pulse ; Temperature ; Respiration — as to frequency, character, etc. ; Tongue ; {appetite ; tliirst ; condition of bowels ; General state of urinary secretion and urinary analysis ; Sensations of patient : pain, etc. 2. Examination of special regions, parts, and functions, begin- ning with the one presumably the most affected, and embracing, wiienever practicable, microscopical exami- nation of the blood and bacteriological studies. Diagnosis. Treatment. Remarks. The history is here placed first ; then the symptoms of general import, such as those furnished by the pulse, the tongue, and the temperature, are made to precede the examination of special regions. These general symptoms are of great value in the recognition of dis- ' ease, and of yet greater value in determining its treatment. They are more than the mere physical signs of textural affections ; they indi- cate vital conditions, and partly from their importance, and partly from their not being linked to disease of any organ in particular, they demand a separate and detailed consideration. Position of the Body. — By noting whether the patient is in bed or out of bed, — how he lies, or how he walks, — a general idea may be formed as to the acuteness of an attack, the impairment of strength 28 MEDICAL DIAGNOSIS. it has produced, and sometimes even as to its nature. Let a person who has been actively attending to his usual occupation be suddenly confined to his bed, and the inference that the disease is an acute and a severe one will be commonly correct ; certainly so, if no mishap to the" organs of locomotion have necessitated a resort to the recumbent position. When the patient lies for a long time on his back, it is gen- erally from exhaustion, or from paralysis, or it is owing to the pain which pressure or motion of any kind occasions. Such is the cause of the dorsal decubitus in peritonitis, and in rheumatism. Lying steadily on the back \vith a disposition to slip down in bed is a form of dorsal decubitus witnessed in low fevers. Lying fixedly upon one side may, as a rule, be looked upon as an indication that the action of the lung of this side is impeded, and that the respiration has to be carried on with the other. The patient may be confined to bed, yet unable to lie down in it, on account of the distress in breathing to which the recumbent posture gives rise : he leans forward, or sits erect. This necessity of breathing in the upright position, or *' or- thopnoea," is a form of dyspnoea encountered especially in diseases of the heart, or where fluid is effused into the air-cells or into both pleural cavities. If a person is able to be about, his posture and movements become important manifestations of his condition. The young and the strong walk erectly, quickly, and firmly ; the aged and the weak, stoopingly, slowly, and with difficulty. In diseases of the spine the body is bent ; so, too, in affections of the larger joints of the lower extremities. When, after a fever or any other prostrating malady, the patient leaves his bed, he totters, moves slowly, and is soon obliged to rest : returning strength brings with it a quicker and steadier gait. In some diseases of the brain the movements are very uncertain; in one-sided palsy the affected side lags, or its motions, if it can be moved at all, are laborious. Excessive and uncontrollable movements are observed in mania and in chorea ; trembling motions in states of ex- treme debility, in shaking palsies, and in the delirium of drunkards ; irregular motions and positions chiefly in hysteria. The gait is always to be closely studied. We find it of special significance in affections of the nervous system and of the muscles. It is very erratic, from side to side, in locomotor ataxia, and there is almost total inability to walk in the dark. In paralysis agitans the tremors are associated with a festinating gait, each step becoming more rapid than the last, and a fall is only averted by seeking support. In spastic paraplegia the legs drag behind; in walking each leg is rigidly brought forward, the toes having a tendency to catch the EXAMINATION OF PATIENTS, ETC. 29 ground. In pseudo-hypertrophic paralysis occurs a peculiar oscillating or waddling gait, from weakness of the extensors of the knee and hips ; there is also much difficulty in rising from the ground. In Thomsen's disease it may also be for some time impossible to rise from the floor, and the gait is at first impeded by tonic spasm of the muscles. Station^ or the power of preserving an erect position while stand- ing, is often as characteristic as the gait. It should be noted while the eyes are open, while they are shut, and while the feet are placed alongside each other \vith the heels and toes touching. Under both the latter circimistances the station is always less certain and the swaying of the body more marked. Tested with an instrument invented by Weir Mitchell,^ Hinsdale * found in the normal man and woman the average sway, while the heels and toes were touching, to be about an inch in the forward and' backward line, and three-quar- ters of an inch laterally. Children sway to a greater extent than adults. Closing the eyes increases the sway about fifty per cent. In locomotor ataxia station is much disturbed and the sway greatly increased ; so it is in disease of the middle lobe of the cerebellum. In the attacks of aural vertigo all power of standing may be lost. General Aspect — ^Expression of Countenance. — A bulky aspect of the whole body is the result of corpulency or of universal anasarca. In the exanthemata, too, a general tumefaction may take place. A partial increase or a swelling arises from the local extrava- sation of fluid or air into the cellular tissues. If air, the tissues crepitate under the finger ; if fluid, the skin pits under pressure. A swelling may also proceed from an inflammatory thickening or from a tumor or any morbid gro\Vth. A diminution in bulk is a more frequent symptom than an aug- mentation. It may occur rapidly, as in Asiatic cholera. More gener- ally the wasting is gradual, and is an indication of defective nutrition. It happens in the course of protracted fevers, and in most chronic diseases, especially in those attended with constant discharges. Emaciation is most readily recognized in the face. But it is not the only striking alteration observable in the countenance when health has failed. There may be pallor, sallowness, a livid hue of the lips, a puffy appearance of the eyelids, a flush on the cheeks. Now, these changes in the features, added to the expression which pain or special trains of thought produce, make up the physiognomy of disease so pregnant with meaning. * Amer. Journ. Med. Sci., 1887. » Ibid., April, 1887. 30 MEDICAL DIAGNOSIS. Among the countenances most frequently met with is that of apathy and stupor. The eye is dull and listless ; the face pale or flushed* This look is common in fevers of a low tj^pe, and is often combined with blackish accumulations on the lips, gums, and teeth. Unnatural fulness and congestion of the features are sometimes observed in enlargements of the heart, and oftener still in habitual drunkards. The same aspect is seen in apoplexy and in tj-phus fever. LfOcal congestions on the cheeks and nose are met with in obstructive diseases of the liver, especially in cirrhosis, and in the endarteritis of old persons. A pinched expression is found when there is intense anxiety or pain, or a wasting malady attended with constant suflFer- ing. It is specially observed in acute peritoneal inflammation. When very marked, and accompanied by change of hue, it is the face which Hippocrates has so graphically described. In the great master's own words, " a sharp nose, hollow eyes, collapsed temples ; the ears cold^ contracted, and theii lobes turned out ; the skin about the forehead being rough, distended, and parched; the color of the whole face being green, black, liAdd, or lead-colored." This is the physiognomy of approaching death, and generally its speedy forerunner, except in those cases in which the expression proceeds from want of food, from protracted vigils, or from excessive intestinal discharges. The face of shock, with its great pallor, its anxious or frightened look, and its fixed or oscillating eye, often with a contracting pupil, is a face seen after severe injuries, and as such familiar to the surgeon. But in many of its main traits it may be also met with in diseases that make a sudden and overwhelming impression on the nervous system ; for instance, it is at times encountered in cerebro-spinal fever and in cholera. Besides these lineaments, which may be said to be common to several diseases, we read frequently in the countenance the signs of special disorders. A dusky flush on the face, if associated with rapid breathing, is almost a certain indication of inflammation of the lung. Puffiness of the eyelids in a pallid person is most apt to be expressive of Bright's disease. A bluish color of the lips shows plainly that the venous circulation is interfered with, or that the blood is but imper- fectly aerated. The cyanosis is also recognized in the blueness of the nails and the duskiness of the whole surface. Then there \s the chronic pallor of the anaemias with the pearly eye and the yel- lowish tinge of the pallor in chlorosis ; the straw-colored anaemic hue of malignant disease ; or we note the jaundiced, melancholy look of an hepatic affection; the downcast expression and mobility of the features in hysteria; the thickened upper lip, delicate skin, and fair EXAMINATION OF PATIENTS, ETC. 31 complexion of scrofula ; the sallow countenance and peculiar notched teeth that indicate inherited syphilis ; the bronzed skin of suprarenal disease ; the puffy, vacant face of myxcedema ; and the various traits which tend to mark not only the special diathesis, but also the peculiar temperament, with the morbid tendencies that belong to it. Skin. — By the state of the skin we can, to a great extent, judge of the activity of the circulation and of the character of the blood. Moreover, it is a fair index of the secretions, and of the condition of the system at laiige. When, after pressure on the skin, the blood re- turns slowly to the surface, it denotes a sluggish capillaiy circulation ; when rapidly, an active one. Coldness of the surface indicates a weakened capillary circulation, and is met with at the invasion of acute diseases, and when the nervous power is greatly depressed. If the heat of surface succeed a cold skin, we know that reaction has taken place, that the circulation has again become active. Protracted coldness, whether attended with dryness or with clamminess, is of evil augury ; it implies seriously diminished vital force. The cutaneous covering is pale whenever the blood is poor and watery. Black spots may be seen, due to extravasation. Ofttimes the surface is overspread with eruptions, some of which bear a close relation to disorders of internal organs, while others are connected with febrile or general maladies ; and others, again, are owing to a disease of the texture itself. Tension of the skin is met with in acute affections accompanied by active excitement. In wasting and prostrating ailments, on the other hand, the skin feels very relaxed and soft ; and in those pro- ducing rapid emaciation, it is inelastic and lies in folds. Pulse. — The pulse enlightens us on the action of the heart, and on the state of the artery itself and of the blood. In a healthy adult a beat of some resistance is felt, recurring from sixty-five to seventy- five times in a minute. It becomes slower with advancing years, though it may rise in the very aged. The pulse of infancy is from one hundred and ten to one hundred and twenty ; that of a child three years old, from ninety to ninety-five. Warmth quickens the pulse ; so do rapid breathing, forced expiration, and the process of digestion. In the recumbent position and during sleep it falls. For purposes of comparison, the pulse should be, so far as possible, taken under similar conditions. At the bedside we study in the pulse its frequency, its rhythm, its volume and strength, and its resistance. Increased frequency of the pulse denotes increased frequency of the*heart's action, and arises from any cause that excites the heart. 32 MEDICAL DIAGNOSIS. Hence exercise, rapid breathing, mental emotion, or restlessness will occasion the nmnber of beats to exceed the average of health as readily as fevers or acute inflammatory diseases. In great debility, too, the pulse rises ; and the more depressed the vital condition, the higher the pulse becomes. In exophthalmic goitre the pulse is gen- erally very frequent, and rapid heart action may show itself without any other obviously abnormal state, as in tachycardia, a disorder in which the pulse may considerably exceed two hundred beats in the minute. Under the influence of suggestion the cardiac action may be made very much more rapid or slower.^ As a sequel of influenza there is often very rapid heart action. The heart may thus quicken from so many and such varied causes, acting temporarily or per- manently, that increased frequency of pulse, taken by itself, has no signiflcant diagnostic meaning. A slow pulse, too, happens in many different states, — ^in cold, in exposure to wet, in icterus, in protracted convalescence from acute disease. It is also produced by an intense and prostrating shock, or is found coexisting with pressure on the brain, with melancholia, with atheroma, with fatty heart. A permanently slow pulse is also met with in irritative lesions of the cerebral centre^, among them in spherical or pediculated thrombi, in altered state of the circulation in the medulla, and in injuries to the pneumogastric. It is not unusual in instances of very slow pulse, or brachycardia, to observe two or three abortive beats succeeding a strong beat. In some persons the pulse is naturally very slow. The rhythm of the pulse is often perverted. Instead of the beats following one another in regular succession, they are unequal, or one or two intermit. An irregular pulse occurs from digestive disorder, from gout, from litheemia, from the excessive use of tobacco, tea or coffee, or from nervous exhaustion ; it is less frequently the indication of a cerebral or cardiac lesion. It is sometimes a difficult beat to count ; and we must be careful not to regard at once a pulse as irreg- ular because it appears to intermit. The seeming irregularity may be caused by the fingers slipping from the artery, which they are very apt to do after they have been on the vessel for some time. Where every other beat is uneven in size, thus showing a beat of greater, followed regularly by one of lesser, altitude, though the rhythm may be regular, we have the pulsus alteniaiis. Where a beat is dropped, — in other words, where the heart-beat is not transmitted to the artery with sufKicient force to be felt, — it is designated as an * Sgobbo-Nuovo Rivista, 1, 1892. EXAMINATION OF PATIENTS, ETC. 33 abortive beat. Two imperfect or abortive beats occurring in rapid succession, and followed by a long pause and generally by a distinct beat, form a linked beat. The volume and strength of the pulse are of much more importance than either its rhythm or its frequency. Volume and strength are often associated, and are much alike ; but they are not identical. When the beat of the artery is large, we call it a full pulse. This is ONving to the distention of the vessel with blood, — its complete expan- sion \vith ever}' beat of the heart. A full pulse is, therefore, the pulse of plethora ; the pulse of the young and robust in health, or in in- flammator>' diseases; the pulse in the early stages of fevers, or in obstruction of the capillaries. It is usually a pulse of power, just as its opposite, a tmiall pulse, is usually the pulse of debility. Yet a full pulse may be produced by the distention of an artery which has lost its tone, and which the finger easily compresses. Such a pulse, the "gaseous pulse," a pulse really of low tension, denotes exhaustion, and proves that a full pulse and a strong pulse are not always synon- ymous. Into the idea of strength something more than mere fulness enters. A strong pulse is a pulse heightened in all its natural charac- ters. It has more fulness, but, in addition, more impulse, and less compressibility, than an ordinary pulse. A strong pulse, therefore, indicates activity of the contraction of the heart, and a normal, per- haps increased, tonicity of the arterial coats. It is found in active inflammations; also in hypertrophy of the heart. Its opposite, a weak pulse, betokens want of force, often want of healthy blood. It is generally small as well as weak. Yet as the full pulse is not always strong, neither is the small pulse always weak. The small choked pulse of peritoneal inflammation may be fine and \dry, but it is not a weak pulse. We also find a small pulse of high tension in mitral stenosis and in contracted kidney. The resistance or tension of the pulse is another valuable guide. A Aarrf, tense pulse denotes increased contractility of the arteries, and generally high-wrought power. It tells us that the blood is being driven with force along the arterial system. But it also tells us that the irritation has implicated the coats of the arteries themselves, or that there is obstruction in the capillaries. A tense pulse is met with in active, violent inflammations, and sometimes, though not often, in states of extreme and continued excitement without inflammation. It is almost needless to add that changes in the coats of the arteries may also be a cause of a hard and resistant beat, the common cause of the increased tension in elderly people. W^here no local altera- tions are present, and where no acute symptoms explain the sym- 8 34 MEDICAL DIAGNOSIS. paibetk- ifishnbuK^ of the heart aDd aiiefial sy^enu the faigii aiiexiiQ tensian wiH be cGanmoiihr fouDd asscidaled with hrpertFo^ihT of Ibe left rentrk-Je, with inlerEtitial Dephiitk. with disease of the saprartsiMl capsule^ with ^ut or lithemia. or with se|:»ti('aBiiiia. The oppodte of the hard pube is the 4k«7? ot compresahle pulse. This implies deficient iin|:>ii}scai. and Ices of tc»De in the TesseJ : it is thf poise of jow fcxeis. of defailitT. of tamfiat weakness. Bol it is alsou wien fcGowing a t^fise stale oif the arteiy. the pulse which de- notes retnnmig heahh. and daii^r jiasscnL When the p»iiise is of iow lectaon, arni al the saiDe time frequent, it max show Qciui«e ieais wiiL each <^citraction of the be^ji. This di'-Tod'. {•litse is mosi cfien met wiii iii iexeis cd a jow fcirm and pi^e- c^diiur or dirnnf ihr '."rctiiuaDtv cif heiDC»niia5«es. The rei»oTmd is chiefix due lo the osdliaiDcci of the <*c«3miJi c»f bjixid in the arteaies- and is xery muti influeatv*i bx thtar eiastidix. Wth iowe^M leiQskffl and iuiiTtiased eiasiidnr cif Uir rcites. ditrc^tisaii ttet-cimes oi»xic»T2s, «^iedal7 wi± a la^i gr:';^';an-:g«. In oid }:«eTS)cais. in whcon the fToais of the an£2ies are iseiastii. 'Scr^tisii: is bTn ie^iiix usaited. Snii are Uir mehzauss arai-iied to ibr xarictiis chaiai'iejs rf tbe pufie. Te: zitey d:. ncc zdteiL i^PiS'tsL* :Lemsrl"xes thus isciiaiei The iabowiziiC are AS^salx i-cnijniiei- arid i*ear this ^Tji'mrtaS.-!^ : A hard. mL fre-gaenn in^iuse oriTizs ri Ardxe irfia^.TTiarkgis. ai>d in mas: cif ^hr anire &»aases -nf rics: zierscos. A hard jms^ in! :r giAT.. r»:«^zj 5r:c if zz^f^cziecced wiih ^cixhir FTnijiianfe. itsaos i: ihe sasyd-^ic: of ar^Mt or ctf r^^iafcl ^sease, cr of ar afieaaL id uie citry isstii. A x^^ist. tTiCnraiiieL aui fr-ri»^— " i^^iiise is n.t-: whi. i: a jai^ pitic- ^' TTrfurnmsHS-n^g. •♦tiji^w "itr JtiutLTagL, 4ts i. er:e::as^ i»ea5- lauiiB- £3ss:r3i£. A freaifeiin i*iLst-. luL :c snatL iim zjic :ecs*r, is ±»r j«:issr :c r>:«t ^:gdciii: iex-es- ani "vxi lULziei jiw trcsa.c is iits: iic :: be A T^^ry irfOoeiE imfirt- inn ^^irr it^irr azlc ^•:c:iiir::as-ru«r. is tbe A i»iiSir ivjiiKiiL mic '.OiiuicFtactir X. ±s rijT:'^— . is i-r^r^.-fL >:-r ate J5 :a*e ^irtjji^jjr-ni^i irx^im-ei ztj Ittr^x Tk. 1 ^ >iiri: izrv^- EXAMINATION OF PATIENTS, ETC. 35 *with facility, and we know at once in how far these irregularities belong to one beat or to a succession of beats. Double beats, too, not appreciable to the hand, are easily detected. Indeed, the sphyg- mograph proves the phenomenon of dicrotism to exist in almost every person. The rebound may occur during the systole or the diastole of the vessel ; and instead of one, there may be four or five of the secondary pulsations. Fig. 1. Marey'8 sphygmograph attached to the wrist. Its tracings are shown by the white lines on the black background. The mode of adjusting the instrument, and of proportioning the pressure of the spring, has something to do with the kind of delinea- tion obtained ; and to secure greater accuracy, a number of modifica- tions have been made, chiefly with the view of registering the amount of pressure. The sphygmograph of Dudgeon (Fig. 2) is simple and Fig. 2. Dudgeon's sphygmograph. much employed. The system of levers is the same as in Marey's, but the slip of paper moves in a different direction. To show the tracing distinctly, smoked glass or mica, or paper smoked over a lamp or by burning camphor, is much used ; and the 36 MEDICAL DIAGNOSIS. Fig. 3. tracing may be preserved by dipping it in an alcoholic solution of shellac or of benzoin, or of a varnish of benzoin and methylated spirit, in the proportion of one to six. On every tracing the amount of pressure employed should be noted. Manifold have been the sug- gestions to obtain the steadiest application of the instrument to the forearm and the greatest development of the tracing. Lorain ^ has proved that raising the arm to a vertical position gives a much more ample trace ; and Richardson * shows that with the body in the hori- zontal line, the dicrotic wave becomes more prominent. When we apply the sphygmograph for clinical purposes, we study in its tracing the line of ascent, the summit, and the line of descent. Each pulsation is composed of these three parts. The line of ascent^ the upstroke, tells us the manner in which the blood enters the vessels. The more rapid the flow, and the more quickly the artery distends, the more strictly vertical the line. The force, too, is indicated by this line, or rather by its height : hence when the muscles of the heart contract powerfully, either from enlargement or from overaction, the line is both vertical and high. Yet the strength of tlie ventricular contrac- tion is far from being the only cause in- fluencing the amplitude of the tracing. Indeed, as we may note in old persons, a large volume of the artery gives considerable height to the lines of ascent ; so does a long interval between the pulsations, or the obstruction of the vessel below the point where the obser- vation is made. Low tension in the arteries or in the capillaries has the same effect ; whereas when the passage in the ultimate ramifi- cation of the vascular system is difficult, the lever descends slowly by a convex line, and is soon again raised by the next pulsation. When the contraction of the heart is feeble, the line of ascent is not vertical or high, but oblique and short. In aneurisms of the thoracic aorta — indeed, in an aneurism interposing anywhere between the heart and the radial artery — ^an oblique and short upstroke is also met with. The line joining the summit of a series of pulsations, or the maxima of tension, is generally a straight Une ; a similar imaginary Sphygmogram enlarged.— a, b, up- stroke, or line of ascent ; a, b, c, percus- sion-wave; c, d, c, tidal, or predicrotic wave ; d, e,f, aortic notch ; e, /, g, dicrotic waye ; /, g, diastolic period. 1 The Asclepiad, 1886. * Le Pouls, Paris, 1870. EXAMINATION OF PATIENTS, ETC. 37 line connecting the bases, or the minima, is apt to rmi parallel to it ; but irregularity of pulsation leads to irregular lines, and the lower line may be irregular while the upper is straight. Irregularity of the base line is seen in marked dyspnoea. The summit of the pulsation informs us of the time during which the entrance of blood balances the onward flow. A pointed, distinct summit-wave belongs to vigorous contraction of the heart-muscle. The summit may be a horizontal line of some length. This broaden- ing of the apex happens in high and prolonged arterial tension, such as from the slow contraction of a strong heart, fulness of the vessels, or obstruction in the capillaries; an extended plateau is also met \viih in induration or ossification of the arteries. In some instances we find a little hooked point preceding the usually transverse mark of the summit. This occurs by the rapid movement of the lever, and is generally a sign of regurgitation co- existing \vith obstruction at the aortic valves. In aortic narrowing of marked degree the summit-wave is indistinct or absent; the line of ascent is oblique and gradual, and may show a break near the summit. The line of descent is sometimes purely oblique, and the more rap- idly the pressure is lessened in the arterial system, the more oblique is the line. It often shows a series of undulations. The first of these waves is called the tidal wave ; it is still part of the systole and onward flow of the blood ; the decided subsequent wave is specially called the dicrotic or great secondary wave. The closure of the aortic valves with the second sound of the heart happens just before the dicrotic wave ; the exact time is marked by the aortic notch ; the dicrotic wave represents the diastole of the heart. The tidal wave is laiige, but the dicrotism badly marked, in atheroma. In high ar- terial tension the dicrotic wave is also ill pronounced, and the line of descent is very gradual. In mitral narrowing, the line of descent is long, but is broken by small pulsations. The sphygmograph requires care and practice in its use, and, on the whole, it is of much more avail in investigations on the exact action of medicines — where, indeed, it is of great value — than in aiding us materially in questions of diagnosis or in decisions on treat- ment. At all events, I do not think that it supersedes the older and more usual means of research. Perhaps records of pulse-traces in which the amount of pressure has been carefully noted will enable us to judge more accurately than we can now of the state of the cardiac muscles in disease. An instrument aiming at even greater accuracy than the ordinary 38 MEDICAL DIAGNOSIS. sphygmograph is the sphygmochronograph} It is similar in its con- struction to the sphygmograph of Dudgeon, but it enables us to measure the curves of the tracings, and to ascertain the exact time of each part. Normally capillaries do not pulsate. We judge of their dilatation by the flush, of their contraction by pallor. But in certain patho- logical conditions they beat, as may be observed in the capillary flush. We may note the capillary pulsation in instances of chlorosis and of aortic regurgitation. The capillar}^ flush has generally to be brought about artificially by pressure on the skin, the nails, or the lips. We can then perceive the pink changing in color with each pulsation, or disappearing after it. The most marked changes are observable at the peripherj' of the pink patch. In those rare instances in which the capillary pulse is i-eguiigitant and of venous origin, as in tricuspid regurgitation, we find venous pulsation everywhere, and the capillary pulsation precedes the radial heat. Temperature of the Body. — The thermometry of disease is indispensable. The thermometer used for clinical purposes should be very sensitive, and requires to be from time to time compared with a standard one, and verified ; it should be self-registering. The detached part, or the index, is set by bringing it down below the lines of the scale by a rapid swing of the arm ; a magnifying front allows the degrees to be easily read. Very delicate but fragile thermometers, registering in a minute or less, have of late come into use. Metallic thermometers are neither so cleanly nor so trustworthy as those made of glass. As surfiaice thermometers for localized thermometrj' various instru- ments have been suggested. I habitually employ one which has the mercury in a fine coil at the expanded extremity, and which is self- registering. We should first obtain the heat of a corresponding well part, and then leave the bulb for five minutes on the suspected abnor- mal structure. Better still is it to apply two instruments at the same time ; one on the sound, the other on the unsound side. In all obser- vations the heat of the body, as ascertained in the axilla, should equally be noted. The surface temperature is, as a rule, lower by upw^ard of one or by several degrees than the general temperature. We find it so on the chest, on the abdomen, and on the head. The temperature, too, is not on corresponding sides entirely the same, at least not on the head. There is almost always a slight inequality in the temperature of the ' Jaquet, Zeitschrift flir Biologic, 1891 ; and MUhll, Deulsch. Arch. f. kiln. Med. 1892, xlix. EXAMINATION OF PATIENTS, ETC. 39 Fig. 4. Fig. 6. 9 ^& Self-Regi«tering Thei- xDometer, showing the index marking 99° F. shortly after an obser- Tation. iSeguln's Surface Thermometer, modified to be self - register- ing. Surface Thermometer, >vith coil at ex- tremity. It may be, if necessary, kept in place by a thin elastic band. 40 MEDICAL DIAGN08I8. two sides of the head; Gray* demonstrates that when at rest the temperature of the left hemisphere is the higher, which accords with Broca's statement. And the observations of Amidon^ have shown that excessive use of a group of muscles may generate heat, in the cortical centres presiding over them, sufficient to manifest itself to surface thermometers placed on the scalp ; emotional and intellectual activity Lombard has proved will do the same. The mean tempera- ture of a healthy man's head is fixed by Maragliano and Seppili, as the result of many observations, at 36.13° C. (97.03° F.) for the left side of the head, and 36.08° C. (96.9° F.) for the right.^ These tem- peratures are higher than those given by Broca and Gray. Broca places the frontal region on the left side of the head at 35.43° C. (95.79° F.), on the right at 35.22° C. (95.39° F.). The parietal region on the right side is fixed by Broca at 92.8° ; by Gray at 93.6° on the right, and 94.4° on the left ; the vertical by Gray at 91.7°, and the occipital at 91.9° ; the whole side of the head by Broca at about 93° ; the entire head at places remote from these points at 93.5° by Gray.* In furious mania a temperature of 36.9° C. has been observed, and a rise of temperature has also been noted over brain tumors, cere- bral abscesses, and tubercular inflammation.* But, on the whole, cerebral thermometry has not proved itself of much value. As regards the abdomen, Peter ^places the normal mean of the parietes at 35.5° C. (95.9° F.), and the same observer records the normal temperature for the chest-walls at about 36° C. (96.8° F.). Certain diseases change the temperature locally. Thus, in neuralgia the heat near the painful points may be markedly raised. So, too, is it sometimes in some parts of the surface in hysterical women. In hemiplegia the paralyzed limb may show a higher temperature than the sound one; and over spots where there is inflammation or wnere decided tissue-change is going on there is a rise in local temperature. Weir MitchelF has called attention to the manner in which posture afl'ects surface temperature. It is, for instance, less by 0.4° C. to 1° C. on the dorsum or sole of the foot when standing than when lying down. But to return to general thermometry. The clinical thermometer * Chicago Journal of Mental and Nervous Diseases, 1879. * New York Archives of Medicine, April, 1880. ' Translated in Alienist and Neurologist, St. Louis, Jan. 1880. * New York Archives of Medicine, 1879, vol. ii. * Eskridge, Transactions of the College of Physicians of Philadelphia, 1883. * Communication to the Academie de Medecine, quoted in Medical Times and Gazette, Dec. 1879. ^ Medical News, Jan. 1894. EXAMINATION OF PATIENTS, ETC. 41 may be put under the tongue or in the rectum ; but the most suitable site in adults is the axilla. The bulb is pressed into the armpit and kept in close contact with the skin for five minutes, except when the delicate minute thermometers are employed. The thermometer may be conveniently introduced just below the skin covering the edge of the pectoralis major muscle ; and, to insure exactness, the axilla should be kept well covered. In using the thermometer in the mouth we must be careful that it be not used soon after anything hot or cold has been taken. The effect of heat m the mouth is more prolonged than of cold.^ In all cases of importance, not less than two observations should be made daily, and, so far as possible, every day at the same hour. Between seven and nine o'clock in the morning, and about seven o'clock, or somewhat earlier, in the evening, are regarded as the most Fig. 7. No^ Kctnu . Date . . . DUiease Uij of Motiift DU«^ ' J3t567S9lOIl I! 13 M 15 le 17 Ifi 1$ 30 21 23 33 ^< 25 3B 27 26 M 30 il J2 M 3< 35 UK IKMEtftlVEMr Ur KEUr Hr ME wcHT'vtuE'ur uebcf MrvRAir VFUiT v: Hrwr uf^JtEur ifmE wr A^Vt hx ^^^;:T \\ T T 1: ' 1 J :T TT i: '""f T""f^""T'"""i 1 _L 1: 1 ='f' ' i' ,n>J ^ J: J... 4... ^^- .. j ^.. ^^-.^ T ^ ITTT ^^1 ' 1 1 = ]; 1 jj 1 , "P ^ 1 T : li ,«r:s:?^?;;T::::T l;i '-. \ ■ Ji "■s 1 - i ■ ....J ... : 101:-+--- — -- -ft- -- -- '^r - \-- I v-jt^— -1 «a::::::::x^T-t I "■ If ' T " 1: [ ; [ 1 1 ': 1 J t -W «^ . . ^.: ^ . ^ ,= 1 J 4 1 : 'i : : ■ i : j: T ^ 1 1 ^T = PuUc T T T 1iri| _ "[ A. 1 \ f" \ ^ ' 1 11 \'' 3 1 1 \ V "^ 1 \ V p 1 ci — 3( \ U: 1 ^ t r -«- 4 -.-^ X f '1 - rs 3i ■J -A / : ^ fi t? i ^ ' 1 U l^rl ^Vla"^^ ■< 1 1 " J ? 1 i.^ L- ^ ^t ^' jtI - tH LT -^ "* V lJ ^ J H — "f ^ _ ni- r^ Sii - M « 3 — ^ ^ -»^ t; 7-f ' 1 ■? ■^ — * t r^i a .^i — ! 1 ^^ ^-H _. ^ ~' ~ -fT r r 1-^ rH |4 ^ ^ T 5 ^- — (^ ™ -51- —I — 1 , " i j 1 1 Pulw m b'''" J ?h; ,'- !***; ,,-' «^.< _.-' ■fi j«4 ^'' ?•» x" n.-^ ^"^ ^'' ,''^ n«Hr. r-^ '--H ,=^«iv .'' ??t^ ^.'' ^^*.* lit ,^'' ?-^ ..-' »> ^^r' " ,.'' ,.-' _,'' T>*i- 9 10 10 n 11 12 12 13 u » 14 15 15 16 Temperature chart, from a case of remittent fever in a sailor at the Pennsylvania Hospital (No. 1570). The red lines show the intermediarj- temperatures. show the pulse and the respiration graphically, the chart of Crozer Griffith is excellent. In discussing pneumonia, farther on, one of these charts is shown. In temperate climates the average heat of the body, as measured in the axilla, is estimated at 37^ C. (98.6° F.) ; ' that of freshly voided ^ It may he useful, for Uie sake of comparison, to recall the fiict that one degree of Fahrenheit is equal to five-ninths of a degree of the Centigrade thennomeler, and four-ninths of a degree of Reaumur ; and also that the freezing-point of the EXAMINATION OF PATIENTS, ETC. 43 mine is about the same. This, at least, is the case in the axilla ; in the rectum it is not quite one degree higher, and is very steady ; in the mouth it is somewhat lower. In the groin, where, in children, it may be most convenient to take it, the temperature is apt to be lower than in the axilla. The body temperature rises with the temperature of the air, and fluctuates slightly during the day, being in temperate climates, accord- ing to the most trustworthy observers, lowest between two and eight in the morning, and highest late in the afternoon. It is heightened by exercise and reduced by sustained mental exertion, and changes even when we are at rest. But, as a rule, with the exception of very active exercise, no cause save disease induces a variation of much more than one degree ; even in the extreme heat of tropical climates the animal heat does not surpass 99.5°. Thus a temperaiture above this, or more than a degree below the average stated, when persist- ent, indicates some morbid action in the economy. At all events, it does so in adults ; in very aged persons a temperature of 97° may still be normal ; while, on the other hand, the range may be as high as in infants. In children, in whom the temperature, as a rule, is somewhat higher than in adults, the daily range is much greater. It falls rapidly in the evening, and is very much influenced by food and by crying. In the new-bom it is about 99.8° to 100.4° in the rectum. It falls fix)m early infancy to puberty. The rectal temperature of young children ranges between 99° and 99.7° ; under six years of age the mean is 99.4°. The maximum is attained in the afternoon. During the first three or four months of life the temperature, Henoch asserts, has, from slight causes of faulty nutrition, a marked tendency to go below the normal. A further point, too, to be taken into account in those of all ages is, that the temperature is somewhat influenced by food and stimulants and by prolonged application of the thermome- ter. And these are the elements which make deductions from single observations or comparatively slight changes untrustworthy. In high altitudes, as Keating^ has observed, there is a tendency to hyper- pyrexia. In ordinary cases the pulse and temperature rise synchronously, first is placed at 32° ; that of the othefs at zero. To convert Centigrade into Fahrenheit, we multiply by 9 and divide by 5 ; to convert Reaumur, we multiply by 9 and divide by 4 ; and when above zero, in either case, add 32. To convert Fahrenheit above zero into Centigrade, we subtract 32, multiply by 6, and divide by 9. ^ International Medical Magazine, Dec. 1892. 44 MEDICAL DIAGNOSIS. and ever}' degree above 98° F. corresponds with an increase of ten beats of the pulse. The fever temperature ranges from 100° to 106°. When it exceeds this, the patient may be looked upon as in great danger, except the rise be due to malarial fever. Under these circumstances it is rapid, occurring in a person who but a few hours before was healthy. In tyi)hoid fever a temperature of 105° is a proof of grave disease. In some severe cases of yellow^ fever the heat in the armpit has been noted as 108°.^ In pneumonia a tem- perature above 104° is a symptom of a verj*^ serious seizure ; so, too, is it in acute rheumatism a symptom either of danger or of some complication. Stability of temperature from morning to evening is a good sign ; the temperature remaining the same from evening till morning is a sign that the patient is getting worse. In convalescence the temperature declines until it attains its norm, or even falls some- what below this. If after the defervescence the thermometer again indicate a decided rise, it shows a return of the malady, or the super- vention of some complication or new disorder ; and the persistence of even a slight degree of abnormal heat after apparent convalescence is a sign of imperfect recovery, or of the existence of some lingering secondary complaint. Further, in cases of low fevers, the skin, par- ticularly of the hands and fei't, may feel cool at the same time that the instrument in the axilla marks 104°. Specific forms of febrile diseases have their characteristic varia- tions of temperature. In measles, for instance, the temperature rises towards the breaking. out of the rash, reaches its height with the period of eruption, and in the twenty-four hours succeeding it falls rapidly. In scarlet fever the thermometer marks 105°, or upward, at the beginning, and the heat only gradually subsides. Typhoid fever has its characteristic record ; so have the malarial fevers theirs. The temperature of tetaruis rises to great heights before death. A temperature about 107° is almost certain to be the forerunner of a fatal issue. But recovery may take place. In a case of cere- bral rheumatism under my charge^ the thermometer marked 110° in the axilla, yet the patient got well. In an instance of injury to the spine after a fall, reported by Teale,^ the young lady lived though tlie temperature reached above 122° and rang(jd for days between 112° and 114°. A remarkable case has also been reported of hysteria and intercostal neuralgia, in which in one axilla the temperature * Wragg, Chark'slon Medical Journal, vol. x. * Soe Amer. Joum. Med. Sci., Jan. 1875. ' Transact. Clinical Society of London, vol. viii. EXAMINATION OF PATIENTS, ETC. 45 registered 117° F. and in the other 110°, but the patient recovered.^ Galbraith * has reported a case in which the thermometer registered 151°, and Jones* that of a girl, fourteen years of age, in whom the temperature rose to over 150°. In neither instance was the extraor- dinary heat attended with evil results. Duckworth reports * a case in which the thermometer marked 228° (108.9° C). In all these ex- traordinary temperatures the possibility of deception practised by hys- terical patients must be borne in mind. The temperature may be temporarily very high from emotion. I saw this once in a frightened child which had previously had but slight fever, and E. S. Tait has reported the same in the puerperal state.* On the other hand, the thermometer may show a depression in temperature below the normal. The body heat often falls at the be- ginning of acute peritonitis. It is low after severe loss of blood, or if exposure to cold happen in alcoholic intoxication, during convales- cence from acute diseases, and in melancholia. It is depressed by various poisons, and has been observed down to 93.9° in carbolic acid poisoning.* It is low in the insane. It may be only a fraction above 89° in the axilla in cholera. From any other cause it rarely, even in extreme collapse, sinks below 92°. Though having its widest range of applicability in fevers, in other than febrile states, too, the thermometer assists greatly in diagnosis and prognosis. It is invaluable, in many instances, in discriminating between functional and organic affections. It aids in the study of apoplexy, of palsies, and of hysterical affections, and tells the true story in cases of feigned disease. It also enables us to judge whether increased frequency of pulse be due to fever or to debility ; and it indicates that sweating which is not preceded by a previous elevation of temperature is the result of exhaustion and not of fever. There is a continuous rise of the heat of the body in all cases in which a deposition of tubercle is taking place actively in any of its organs, and more especially in the lungs ; while, on the other hand, I have noticed that in cancerous affections the heat of the body is but little influenced, and is sometimes even below the normal standard. Tongue. — ^When a patient is told to put out his tongue, it is not to see whether this organ is the seat of disease, but because experi- * Philipson, London Lancet, April, 1880. ' Joum. Amer. Med. Assoc, March, 1892. » Memphis Medical Monthly, Oct. 1891. * Archives of Gynaecology, New York, Oct. 1891. * Obst. Soc. Transact., 1884. * BSlumler, in Quain's Dictionary of Medicine. 46 MEDICAL DIAGNOSIS. «D<:^ lias taught ilisd the tongue is a mirror, more or less perfect of tinr f:oniii^fAi of tlie digestive functions, and that it reflects the com- f/Wx'yjii of thWI rONOSIS. be sure, in drawing our inferences, that the abnormal aspect is not due to tlie food partaken of or to medicine. It^ color is also modified by the character of the occupation. Thus, as Chacibers tells us, there is a smooth, orange-tinted coating on the tongues of tea-tasters. A local cause somotimes gives rise to a thick, opaque coal. For in- stance, decayed toolli may produce a yellow sheathing on one side. Affections of the fauces also occasion a deep-yellow hue. Again, there are many lioalthy persons who wake up every morniJig with their tongues covered, more especially at the back, with a heavy coating, which wears off after a meal. In some diseases the epithelium, which is either formed in exces- sive quantities or not thrown off, collects between the papDIte, leaving them uncovered and prominent. This is especially noliced in scrofu- lous children. When the epithelium is sticky and adherent, it winds itself chiefly around the filiform papillae, elongating them and giving to the surface of the organ a /lirrcrf appearance. Althougii tins kind of tongue, as almost every other variety, is met with now and then in persons who are not ill, yet it may be generally looked upon as de- noting disease. It occurs sometimes in chronic diseases of the ab- dominal viscera, but much oflener in grave acute maladies. The tongue, on the other hand, may be bare of its epithelium or imper- fectly covered with it. We meet with this in certain instances of scurvy, or in cases of chronic diarrhoea and dysentery with great prostration, in which the tongue is often found to be red, smooth, and dry, or in attendance on cachexias, as the malarial Again, a denuded tongue is common in scarlet fever, and not infrequent in ty{)hoid fever. In scarlet fever it has a strawberry look. This is sometimes also seen in pneumonia. The state of the digestion and the character of the discharges have so close a connection with the nutrition of the body that they become impnrtatd general symptoms. But, for the sake of convenience, their value will he inquired into wtiiJe discussing Uie diseases in the recog- nition of which they occupy the foremost place. A tew words here, however, on the sensations of patients. Sensations of Patients. — Sick persons are sul^Ject to many dis- agreeable feelings. They complain of chills, of heat, of languor, of restlessness, and of uneasiness ; but their most constant complaint is of pain. Now, pmn may he of various kinds ; it may be dull or gnawing; it may be acute and lanchiating. In its duration it may be permanent or remitting. A <:/«// pain is generally persistent. 11*^^ most often present in congestions, in subacute and ctxronic inflar tions, and wliere gradual changes of tissue are takir^ place EXAMINATION OF PATIENTS, ETC. 49 the pain of chronic rheumatism, and shades oflf into the innumerable aches of this malady. The only acute affections in which it is apt to exist are inflammations of the parenchymatous viscera and of mucous membranes. Acvie pain is in every respect the reverse of dull pain. It is usually remittent, and not so fixed to one spot. It is met with in spasmodic affections, in neuralgia, and, with extremely sharp and lancinating pangs, in malignant disease. Pain varies much in intensity ; it is sometimes so extreme as to cause death. We have to judge of its severity partly on the testimony of the sufferer, partly by the countenance, and partly by the attending functional disturbances. The latter are not to be overlooked, for they enable us, to some extent, to appreciate whether the torments* are as great as they are represented to be. The seat to which the pain is referred is far from being always the seat of the disease. A calculus in the bladder may produce dragging sensations extending down the thighs ; inflammation of the hip-joint gives rise to pain in the knee ; disorders of the liver occasion pain in the right shoulder. Pain felt at some part remote from that affected is either transmitted in the course of a nerve involved, or is sympathetic. The same abnormal action does not always create the same kind of pain. Inflammation, for instance, causes different pain as it in- volves different structures : the pain from an inflamed pleura is not the same as that from an inflamed muscle. Speaking generally, the tissues themselves seem to determine the form of pain more cer- tainly than does the precise character of the morbid process. Thus, pain in diseases of the periosteum and bones, no matter what may be the exact nature of the malady, is mostly boring and constant ; in the serous membranes, sharp ; in the mucous membranes, dull ; and in the skin, burning or itching. Pain produced by pressure is called tenderness. It indicates in- creased sensibility, and is most constantly associated with inflamma- tion. Yet tenderness may be present without inflammation; the tenderness, for example, of the skin in hysteria. Commonly it is combined with pain occurring independently of pressure ; but a part may be tender and not painful. CHAPTER II. DISEASES OF THE BRAIN AND SPINAL CORD, AND OF THEIR NERVES. Before entering upon a consideration of the affections of the nervous system it is proper to recall a few salient points connected with its structure and functions indispensable to a recognition of its derangements. We have constantly to bear in mind that there are in its composition nerve-cells composing ganglia, which are for the most part originators, and nerve-fibres, which are for the most part con- ductors, and besides, a peripheral termination of these conductors, which forms a peripheral nervous system, chiefly concerned in re- ceiving and distributing impressions. Then, too, of late years much stress has been laid upon the nerve-cells, including the cell-body and its processes, and for each of these separate cell units the name neu- ron has been adopted. The most important process of the nerve- cell is the axis-cylinder, or the neuraxon. In the brain and spinal cord are the principal nervous centres which originate and control, and of the brain especially our knowledge of the subject of locali- zation and special function of particular points has become so ex- tended that it is made the basis of accurate diagnostic knowledge, which has of late years assumed the greatest practical importance. Cerebral Localization. A knowledge of the centres in the brain is a necessity for both diagnostic and surgical purposes. This knowledge has been acquired in part by experimental observations upon the lower animals, in part by clinical and pathological observations, and in part by electrical stimulation of areas of the cortex in the course of surgical operations upon human beings. The localization of human cortical centres is indicated in the an- nexed sketch. It should not be forgotten that in all such diagram- matic representations the picture represents the fact but poorly. The tMia* kalv^ of :t)iQ ^aiije bBajq; a/je ufilike. Moreover, there is never an^ ksid'tocf 3r£t fiae: diyiJ&ig pn^, centre from its neighbor. If they 60 DISEASES OF THE BRAIN AND SPINAL CORD. 61 do not actually overlap, the centres certainly pass into one another by indefinable gradations. The strength of the stimulus modifies the definiteness of limitation, and many facts go to show that the unaffected hemisphere has often a certain power of substitution, whereby it can take up the function of its injured fellow. It must be borne in mind that not muscles but movements have cortical representation, and that movements on each side of the body are represented in the cortex of both sides of the cerebrum, though in preponderant degree in that of the opposite side. On the other hand, there is, at least in the case of articulate speech, a location of the unique controlling centre singly upon one side or the other according as the person is right-handed or left-handed. The prefrontal region — i.e., that anterior to the motor area — ^is the scat of the higher mental processes. The movements of the lower extremities are represented in the upper fourth of both cere- bral convolutions, the gray matter concerned extending in a mesial direction to the paracentral lobule, posteriorly to the superior parietal lobule and anteriorly to the first firontal. Movements of the hip and knee are localized near the centres for the shoulder-movements ; movements of the great toe somewhat above, at about the junction of the middle and posterior thirds of the leg area ; movements of the other toes still farther back ; movements of the ankle between the areas for knee and great toe. Movements of the spine and trunk are most strongly represented in the mesial aspect of the hemisphere in advance of the area for the movements of the lower extremity. The cortical area governing the movements of the upper extrem- ities occupies the middle two fourths of the central convolutions, extending posteriorly to the interparietal fissure and anteriorly to the firontal convolutions. This area contains from above downward subareas for the movements of the shoulder, elbow, wrist, thumb, and fingers respectively. The area in which are represented the movements of the head occupies the lower fourth of the central convolutions, including the entire operculum, with the posterior portion of the third firontal and the dorsal lip of the fissure of Sylvius. The movements represented in this area, from above downward, are the orbiculo-palpebral, those of the angle of the mouth, and those of the lips and tongue. The movements of the platysma are probably represented in the posterior and inferior portion of this area. The centres for the movements of the larynx and pharynx are located in the anterior part of the lower- most portion of the anterior central convolution, and behind it is the 62 MEDICAL DIAGNOSIS. centre for the movements of the lower jaw. Those of the head and eyes are in the most anterior portion of the motor zone. In the lowest portion of the ascending frontal convolution, and extending into the posterior portion of the third left fron|al convo- lution, lies the centre for articulate speech, lesion of which causes motor aphasia. This is usually, though not always, associated with DISEASES OF THE BRAIN AND SPINAL CORD. 63 inability to express thoughts in Avriting, — agraphia. But our complex power of thought-expression is made up of two other elements that are sensory ; there must be psychical comprehension both of the heard and of the seen word. The centres intermediating these functions have been made out with some approach to definiteness. Lesions of the first temporal convolution produce word-deafness, or inability to comprehend the meaning of words though not deaf to other sounds. In the same way, word-blindness, or inability to understand the import of written or printed words, follows injury of the angular gyrus. Fig. 10. Right Homonymous or Lateral Hemianopsia, from Lesion of the Left Visual Cxntbb of THE Cortex or Left Optio Tract.— ^1, dark left nasal half-field from blind temporal half of retina ; A\ dark right temporal half-field from blind nasal half of retina ; B, left eye ; Bf, right eye ; C C, left and right optic nerres, composed of the crossed bundles of fibres ; 2), iX, left and right crossed bundles; £, B, left and right occipital lobes; F, F, left and right posterior oomua; Q^ &, "optic radiation" of Gratiolct ; H, W, optic chiasm ; /, r, angular gyrus ; K, region of optic thalamus, geniculate body, and quadrlgeminal bodies, collectively tenned the primary optic centres ; Jf, IT, cuneus of the occipital lobe, the cortical visual centre. The left cuneus and optic tract are shaded, to show lesion of these parts and the influence of the lesion upon the retineo. In reference to the cortical visual centre there can be little doubt that it is located in the occipital lobe, and especially in the cuneus. The production of hemianopsia from lesions of the occipital lobe, in accordance with the conclusions of Seguin,^ is shown in the accom- panying diagram (Fig. 10). Complete cortical blindness may be con- sidered as a bUateral hemianopsia. The macula is also represented ^ Journal of Nervous and Mental Diseases, 1886, No. 1, and Nov. 1887. 4 64 MEDICAL DIAGNOSIS. in the cortex. Dimness of sight in the opposite eye, with, as a rule, concentric diminution of the field, or crossed amblyopia, depends upon a lesion in the angular gyrus. The auditory centre is most likely in the middle of the first tem- poro-sphenoidal convolution and related to the auditory nerve of the opposite side. The centre for smell is very probably on the medial surface of the temporal lobe at the anterior extremity of the uncinate convolution and in connection with the olfactory nerve of the same sijie. The cortical centre for taste is referred to the limbic lobe. The location of the centres for tactile or cutaneous sensation is also in dispute, but it appears probable that, if not identical with, they are at least contiguous to those of the motor functions of corresponding parts.^ The muscular sense and the stereognostic sense seem to be represented especially in the cortex of the motor and parietal convo- lutions. A geographical centre, a centre for determining locality, is claimed to have its seat in the occipital lobe, near the visual centre ; a naming centre has been located in the third temporal convolution, and a writing centre in the second frontal convolution. The psy- chical, or mental, processes have as their centres those parts of the cortex that have not been found to possess any special motor or sensory function, and particularly the prefrontal lobes. It is often a matter of much importance, especially with reference to brain surgery, to determine on the skull the seat of the underlying cerebral centres. Broca, Horsiey, and Reid have especially investi- gated the subject, and from their and other researches we are sure of these facts : Under the frontal bone lie almost the entire frontal, middle, and about three-quarters of the upper frontal convolutions. The tem- poral bone covers the temporal lobe, except its anterior extremity and its posterior fifth. The occipital bone covers the greater part of the occipital lobe ; the remainder of the cortex is beneath the parietal bone. The ascending frontal convolution starts somewhat lower that beneath the anterior inferior angle of the parietal bone in front of the prolonged line of the fissure of Rolando. In front of the precentral sulcus, the lower half of which is parallel to and behind the coronal suture, lies the root of the lower frontal ; the root of the ascending parietal is behind the ascending frontal. The upper end of the fissure of Rolando corresponds to a point half an inch behind the middle ^f a line measured from the root of the nose upward to the occipital protuberance, and the fissure extends obliquely downward and for- ^ See Dana, Journal of Nervous and Menial Diseases, Oct. 1888. DISEASES OF THE BRAIN AND SPINAL CORD. 66 ward, at an angle of 67 degrees, to within a short distance of the fork of the Sylvian fissure. The fissure between the middle and lowest fi-ontal convolutions is under the temporal ridge. The central con- volutions are about an inch on each side of the fissure of Rolando ; the centres for the leg, arm, and face lie on each side of the fissure. The angular gyrus is immediately behind the most prominent portion of the parietal eminence. The first temporal convolution is over the ear and mastoid process below the Sylvian line. This situation is determined by drawing a line from the external angular process of the frontal bone to a point three-quarters of an inch below the most prominent part of the parietal bone. Sensory Centres, and CondtLcting Paths, The sensory centres and the conducting paths by which the fibres unite the various parts of the brain, whether sensory or motor, and of the spinal cord, are not so definitely made out as the brain-centres have been ; particularly uncertain are we as to the course of the sensory paths in the medulla, pons, and peduncle. The sensory centres for the muscular sense and the sense of touch are supposed by JHorsley and others to be in layers of cells in the motor cortex. But the centres for sensory impression are also claimed to be the hippocampal convolution and the gyrus fomicatus, and, generally, the occipital and temporo-sphenoidal lobes. Volitional impulses originate in the motor cortex, and pass by converging fibres through the white substance of the hemisphere to the internal capsule, thence beneath the optic thalamus, to enter the cms cerebri, and through the pons, reaching the medulla, where the larger number of fibres cross to the opposite side of the cord to form the lateral or crossed pyramidal tract. The smaller fibres that con- tinue onward form the anterior or direct pyramidal tract ; these de- cussate in the cord at various levels. This constitutes the upper segment of the motor path of Gowers, which terminates in the gan- glion-cells of the anterior horns of the cord. The lower segment consists in the fibres that originate in the efferent proc^ses of the ganglion-cells and pass to their peripheral distribution in the muscles. The fibres for the so-called cranial nerves leave the pyramidal columns as they approach the level of their nuclei on the opposite side of the medulla, to reach which they cross the median line some- what in advance of the decussation of the remainder of the pyramidal tracts. A lesion in any part of the upper segment of the motor path, be- tween the cortical cells and the ganglion-cells of the anterior horns, 56 MEDICAL DIAGNOSIS. is followed by descending degeneration in the pyramidal trapts. The resulting paralysis is attended with increased reflexes, unchanged or but slightly changed electrical reactions, and little or no wasting of the muscles. A lesion in any part of the lower segment, between the gray matter in the cord and the terminations of the nerves in the muscles, gives rise to paralysis characterized by wasting, qualitative electrical changes, and impairment or abolition of the reflexes. Sensory impressions reach the brain through the posterior roots of the cord, passing by the posterior and lateral colunms in several tracts, most of which decussate in the cord. The sensory fibres for the muscular sense are supposed not to decussate in the cord, but in the medulla. There is reason to believe that the paths for common tactile im- pressions, for painful impressions, for the conveyance of thermal impressions, and of the muscular sense, are distinct ; that for the first coursing through the posterior column, those for the second and third through the antero-lateral ascending tract, and those for the last through the postero-median column and the direct cerebellar tracts. Lesions of the peripheral sensory segment are attended, in addition to the impairment of sensibility, with abolition of the related reflexes. Lesions of the cord involving the posterior and lateral columns are attended with ascending degeneration in the postero-median and pos- tero-extemal columns, the direct cerebellar and the antero-lateral ascending tracts. Spinal Localization. A centre for spasm is thought to be in the medulla at its junction with the pons, and is carried by the vagus ; the cardio-inhibitory centre is in the medulla ; the respiratory centre is in the medulla between the nuclei of the vagus and accessorius ; the vasomotor centre is in the medulla ; so is the sweat-centre in the medulla, with subordinate spinal centres. The following facts will prove useful in localizing or determining the extent of a lesion of the spinal cord : Paralysis of the small rota- tors of the head and of the depressors of the hyoid bone points to involvement of the first and second cervical nerves ; paralysis of the levator anguli scapulae to involveihent of the third cervical ; paralysis of the stcrno-mastoid, of the upper neck-muscles, and of the upper part of the trapezius to involvement of second, third, fourth, and fifth cervical; paralysis of the diaphragm to involvement of the fourth and fifth cervical ; paralysis of the serratus, flexors of the elbow, and supinators of the foreann to involvement of the fifth and sixth cervi- cal ; paralysis of the shoulder-muscles to involvement of the fourth, DISEASES OF THE BRAIN AND SPINAL CORD. 57 fifth, and sixth cervical ; paralysis of the extensors of the wrist and fingers to involvement of the sixth and seventh cervical ; paralysis of the extensors of the elbow, of the flexors of the wrist and fingers, and of the pronators of the forearm to involvement of the seventh and eighth cervical ; paralysis of the lower neck-muscles and of the middle part of the trapezius to involvement of the sixth, seventh, and eighth cervical and first dorsal ; paralysis of the muscles of the hand to in- volvement of the eighth cervical and first dorsal ; paralysis of the intercostals to involvement of the dorsal nerves from the first to the tenth ; paralysis of the lower part of the trapezius and of the dorsal muscles to involvement of the dorsal nerves from the second to the twelfth; paralysis of the abdominal muscles to involvement of the dorsal nerves from the seventh to the twelfth, and also the first lum- bar ; paralysis qf the cremaster and flexors of the hip to involvement of the second and third lumbar ; paralysis of the extensors of the knee, of the adductors, extensors, and abductors of the hip to involve- ment of the fourth and fifth lumbar ; paralysis of the lumbar muscles to involvement of the second, third, fouriJi, and fifth lumbar nerves ; paralysis of the peroneus longus, the flexors and extensors of the ankle to involvement of the fourth and fifth lumbar and first sacral nerves ; paralysis of the flexors of the knee to involvement of the fifth lumbar and first sacral ; paralysis of the intrinsic muscles of the foot to involvement of the first and second sacral ; paralysis of the perineal and anal muscles to involvement of the third and fourth sacral nerves. Loss of sensibility on the scalp points to involvement of the first, second, and third cervical nerves ; on the neck and upper part of the chest to involvement of the second, third, fourth, and fifth ; on the shoulder to involvement of the fourth and fifth ; on the outer aspect of the arm to involvement of the fifth and sixth ; on the radial aspect of the forearm and hand and on the thumb to involvement of the sixth and seventh; on the inner aspect of the arm, on the ulnar aspect of the forearm and hand, and on the tips of the fingers to in- volvement of the seventh and eighth cervical and first dorsal ; on the front of the thorax to involvement of the dorsal nerves from the first to the tenth ; over the ensiform cartilage to involvement of the sixth and seventh dorsal; on the abdomen to involvement of the dorsal nerves from the seventh to the twelfth, and also the first lumbar ; at the umbilicus to involvement of the tenth dorsal ; on the upper part of the buttock to involvement of the twelfth dorsal and first lumbar ; in the groin and on the scrotum to involvement of the first and second lumbar ; on the outer, anterior, and inner aspect of the thigh to in- 58 MEDICAL DIAGNOSIS. volvement of the second, third, fourth, and fifth lumbar nerves; on the hiner aspect of the leg to involvement of the fifth lumbar ; on the lower part of the buttock, on the posterior aspect of the thigh, and on the anterior, posterior, outer aspect of the leg and foot to involve- ment of the fifth lumbar and the first, second, and third sacral ; on the perineum and about the anus to involvement of the third, fourth, and fifth sacral ; and on the skin between the coccjrx and anus to in- volvement of the fifth sacral and the coccygeal nerves. Loss of the scapular reflex points to involvement of the fifth, sixth, seventh, and eighth cervjcal and first dorsal nerves ; of the epigastric reflex to involvement of the fourth, fifth, sixth, and seventh dorsal ; of the abdominal reflex to involvement of the dorsal nerves firom the eighth to the twelfth, and also the first lumbar nerve; of the cre- master to involvement of the first, second, and third lumbar ; of the knee-jerk to involvement of the second, third, and fourth lumbar; of the gluteal to involvement of the fourth and fifth lumbar and the first sacral ; of ankle-clonus to involvement of the fifth lumbar and first sacral ; and of the plantar to involvement of the first, second, and third sacral nerves. Let us now look at the derangements of the nervous system. But first let us examine a few symptoms and morbid states having a general significance rather than a specific connection with any malady. Temperature Variations. — These are not uncommonly induced by organic disease of the brain. Elevation may take place indepen- dently of febrile disease, as from irritation of the striate body or of portions of the cortex, and in conjunction with hemorrhage into the pons or medulla, vascular obstruction, and the epileptiform and apoplectiform attacks of general paralysis. The temperature is ele- vated also when infectious or inflammatory disease of the brain is present, such as tubercle or abscess, or meningitis. On the other hand, organic disease of the brain is often seen with subnormal temperature, for instance, extensive arteriosclerosis, old softening, and general paralysis. Circulatory Phenomena, — Apart from febrile complications the pulse may be accelerated in disease of the medulla, or of degenera- tion in or about the vagus nucleus, or in consequence of irritation of portions of the cortex. Irritation of the vagus nucleus induces retardation of the pulse. This may result directly, as from inflam- mator}' processes in or about the pons aiid medulla ; or indirectly, as from increased intracranial pressure, such as attends hydrocephalus, haematoma of the dura mater, ventricular hemorrhage^ brain tumor, DISEASES OF THE BRAIN AND SPINAL CORD. 59 or from meningeal irritation or other reflex influence. The pulse fre- quency may be reduced to 40. Acceleration succeeding retardation is of unfavorable prognostic import. Respiratory Disturbances, — These are observed together with coma, especially in disease of the medulla oblongata. The breathing may be accelerated and shallow, sometimes with intermissions ; but more commonly it is slowed and deepened, and the pulse also is slowed. The breathing may be stertorous, or assume the Cheyne-Stokes type. In deciding that the respiratory derangement is from brain disturbance care must be taken to exclude disease of the lungs, of the heart, and of the kidneys. Vomiting. — When of cerebral origin vomiting is unattended with pain, nausea, or retching, and while it may be induced by food, it often occurs independently of the taking and also of the character of the food. It may result through reflex influences, as from meningeal irritation, or through direct irritation of the vagus nucleus, from in- creased intracranial pressure and in coma. It is especially common * in association with disease of the medulla, and particularly with tumors of the posterior fossa of the base of the skull. The more direct symptoms of disorder of the nervous centres are manifestations of deranged intellection and deranged sensation. DERANGED INTELLECTION. The great instrument of the intelligence, the brain, manifests its disorders, whether primary or merely sympathetic, by derangement of thought of every conceivable degree and kind, — from dulness and confusion of the intellect to its utter perversion and prostration. When one intellectual function is disturbed, generally all are, or soon become so ; yet we may find impairment of judgment and of imagi- nation without deterioration of memory or of the powers of attention. One of the most marked signs of mental infirmity is an impaired memory. This is especially encountered in chronic cerebral diseases, or in such nervous affections of uncertain seat as epilepsy. Another signal of mental derangement is loss of judgment, or rather loss of power to appreciate the logical sequence of ideas ; still another is depression of mind, or its opposite, exaltation. All these abnormal conditions may happen in acute as well as in chronic maladies, but they are more striking in the latter, and afford more aid in the diag- nosis ; and they may or may not be joined to appreciable textural changes. To the psychologist their significance is very great, as they are often the premonitory symptoms of that departure from mental health which terminates in confirmed insanity. 60 MEDICAL DIAGNOSIS. In acute disturbances of the brain delirium, stupor or cpma, and insomnia are often prominent symptoms. Delirium. — This is a wandering of the mind, manifesting itself by the expression of ill-associated thoughts, of the incongruity of which the patient is not conscious. It occurs most frequently in those of susceptible nervous system, and is more common in the young than in the old. It is almost invariably united with restlessness, and increases as night approaches. The character of the delirium is various. There is first the quid delirium, of a low or passive type. The patient mutters incoherent words, moans without any assignable reason, or lies silent, with his eyes open, his mind occupied with his vague illusions, and taking no notice of what goes on around him. If strongly aroused, he gives a rational answer, but not a long or a connected one, for he soon returns to his dreams and his over-changing hallucinations. He picks at his bedclothes, moves in bed, and may even try to leave it, although he is easily prevented from so doing. Then there is a delirium of somewhat more active type, still, on the whole, quiet ; the patient wanders, yet not boisterously. He is irritable, and often does not show that his mind is disturbed, except in some one particular, — in irascibility about trifles, or in expressions and modes of thought foreign to his nature. An active, Jierce delirium presents different characteristics. Tlie patient is wild, noisy ; he sings, screams, gets out of bed ; his face during the excitement becomes congested; the eye is bright, often fiery. Now, all these forms of delirium occur in many different mala- dies, and are far from being of necessity linked to an organic cerebral aflfection. As a rule, we find the low, quiet delirium in conditions of vital exhaustion, particularly in those depressed states of the nervous system which are connected with quickened vascular action, and with a deterioration of the blood, as, for instance, in the low fevers. The fierce delirium may, however, be associated with prostration or depraved blood. Thus, the delirium of pneumonia is sometimes of a violent kind, o\ving to the maddening effect of the ill-oxygenated blood on the brain. In most of the ordinary fevers the delirium is of a moderate type ; in inflanmiatory diseases of the brain and in acute mania it is fierce. The delirium of unemia is apt to be active. If the delirium be due to cerebral disease, it is associated with head- ache ; the headache of pyrexia generally disappears with the onset of delirium. Delirium is not difficult of recognition; yet we must be careful DISEASES OF THE BRAIN AND SPINAL CORD. 61 not to confound witli it night terrors, those troubled dreams to which ailing children are so liable, and which occasion confusion of thought on first awaking, and until consciousness is fully aroused. Delirium is most likely to be mistaken for insanity. There is this palpable dif- ference : an insane person is commonly in good health in all save his intellect ; a delirious person is ill, and exhibits evidences of his illness besides his delirium. It is true that, when the patient is first seen, doubt may arise ; but it is not of long duration. In the mania ap- pearing occasionally after epileptic fits, or taking their place, there may be doubt until we obtain a clear history. Most perplexing are the cases in which insanity follows or attends inordinate drinking. But this is a subject which we shall discuss in reviewing mania a potu. Another perplexing group of cases is furnished by the occurrence of that singular fonn of delirium which has been called the delirium of immition, or of collapse. Its outbreak is sudden, like an attack of mania, but it is found to be combined with a feeble pulse, with a skin bathed in perspiration, with cold hands and feet, — ^in a word, with the signs of great prostration or of collapse. The seizure happens usually early in the morning, and is unexpected, for it occurs com- monly at tlie end of the febrile state, and when the condition of the skin and pulse bespeaks convalescence. The exhausted nervous centre betrays itself in the sudden mental wandering, which has generally this characteristic, — there is but one fixed delusion, and tliis one connected with the subjects which have most engrossed the mind before the illness.* The seizure lasts from six to forty-eight hours, and at its termination the patient is apt to awake out of a sleep with a calm mind, remembering, perhaps, his hallucination as a vivid dream. There may be more than one attack, but this is not common ; and the duration is materially abridged by opium and by the employment of stimulants and nourishment. The form of de- lirium under consideration is not simply a sequel of defective brain nutrition in fevers. It may also succeed exhausting discharges and drains from the system, or inability to obtain or to digest the proper amount of food. Thus, it may happen in malignant diseases of the stomach ; also in mere gastric irritability and persistent vomiting. The most marked instance of this kind of mental wandering I have encountered was associated with functional gastric disorder, wliich prevented enough food from being retained. In this patient the hal- lucination was on one subject, — a business matter which had been annoying him greatly just before his illness became decided. Delirium is at times simulated. This differs from real delirium by 62 MEDICAL DIAGNOSIS. the absence of all other signs of Ulness, and by the sameness of the mental wandering. In a case of feigned delirium I met with, the man whined when spoken to, and pretended to rave ; but his ideas always ran on the same subject, and he was very solicitous about his food, and about other matters of which a delirious person takes no notice. Delirium is more or less continuous ; once delirious, a patient remains so for some time, and until the exciting cause subsides. In this re- spect hysterical delirium is exceptional ; it does not last long, or it intermits and then reappears. Derangement of Oonsciousness. — This may be of any grade, from simple clouding to complete loss. In the mildest degree, aomno- lencii, the individual has an appreciation of his surroundings and can respond when addressed, sometimes intelligently. In more profound impairment of consciousness, sopor, the in- dividual lies half asleep and responds but sluggishly to sensory irriliition, although he can be readily roused. He answers in mono- syllables ; is still capable of limited movement, and has a confused notion of his surroundings. Left to himself, he at once relapses into sleepi which is at times attended with mutterings. A still more pronounced degree of impairment of consciousness constitutes the phenomenon called stupor. The patient lies in a deep shnnbcT, from which he cannot be roused save with great difficulty, and when roused he answers reluctantly and briefly, and soon re- sumes his hcuivy sleep. The expression of his face is dull, yet now and then a my of intelligence, excited by some object to which his nttcMition is attracted or by some pleasant reverie, flits across his filatures. Swallowing is possible, and the reflexes are preserved, possibly exagvft^rated. Stupor is met with in several cerebral affec- tions, and after an epileptic fit. It is also frequently seen in typhoid fev(T, or as the result of narcotic i)oisons. But there is nothing pathognomonic jil)out it in these various conditions, notliing by which we can judge positively of its origin. (WifF is complete loss of consciousness: perception and volition nn^ alike suspended, and there is an appearance of tlie profoundest slei^p. The face wears a confused look: the pupils are sluggish and contracted or dilated ; the mouth is open, the tongue dry. All conscious and imcons(*ious n^sjtonse to sensory irritation is lost. Shouting or shaking will not arouse the individual. The extremities an^ n^laxed and the n^lt^xes an^ abolished. Swallowing is impossible, and the spluncter ani is no longtT resistant. The brealliing may be rhythmic, but it is frecjuently irn^gular; at times it is retarded and full, at other times of Chevne-Slokes character: towards the close it DISEASES OF THE BRAIN AND SPINAL CORD. 63 becomes stertorous and stridulous. Incontinence .of urine and of faeces develops. Coma always betokens a serious disturbance of the functions of the brain. It is often witnessed m cerebral lesions, as from pressure of blood or fluid in brain-substance or in ventricles, more rarely from tumors, abscesses, or thrombosis. The most complete coma is seen in apoplexy ; it comes on quickly, and is attended with noisy respiration and a slow pulse. Another, form of coma, scarcely less complete, is caused by narcotic poisoning ; it, however, does not ap- pear suddenly, and when from opium is associated with contraction of the pupils. Profound intoxication with alcohol induces coma, but the attendant symptoms, as a rule, make the association clear. The coma of fevers and of acute diseases, whether cerebral or not, is also gradually produced, but, unlike that due to the toxical efifect of opium, is ordinarily preceded for days by insomnia, by delirium, and by other signs of cerebral disturbance. The coma of epilepsy is recognized by its following epileptic seizures. In the coma of Bright's disease the cause is made manifest by finding albumin and tube-casts in the urine, and by the evidences of preceding uraBUiia. Uraemic coma may, however, come on suddenly and pass ofif suddenly. It is, as a general rule, associated with dilated pupils. Coma also sometimes occurs in connection with diabetes. Under such circumstances ex- amination of the urine will reveal the presence of sugar, perhaps also of acetone and of diacetic acid. Sometimes a person appears to be comatose when his intellect is but little disordered. He may be paralyzed, and not have the power to communicate his ideas from crippled articulation or aphasia. This state is distinguished from coma by noting that the. patient's attention is always directed to the questions asked him, nay, that he strives to answer them, but cannot ; and that generally he has lost control over the. muscular movements of one side of the body. Coma must not be confused with syncope^ which depends upon cerebral anaemia, is usually of brief duration, and, except feeble heart action, is unattended with noteworthy symptoms. Insomnia. — The deprivation of sleep is a concomitant of cerebral congestion and of the earlier stages of cerebral inflammation. But a person may be sleepless from excessive pain, from exhaustion, from grief, from mental excitement or fatigue, or from the too free use of cofifee or of tea; sometimes insomnia is engendered by habitually working late at night. Insomnia often precedes or attends delirium, as appears in typhoid fever. Among purely nervous affections it is most marked in delirium «4 MEDICAL DIAGNOSIS. tn»iiions. It is a very troublesome symptom ; but, occurring in so many iil)normnl conditions, it cannot be looked upon as having a distinct and si)ecific diagnostic value. DERANGED SENSATION. The signs of i)crvoriod or impaired sensation are numerous. They may bo cither due to an alteration of the general sensibility or be the signals of a den\nginncnt of a nerve of special sense. Let us look at a few. Hyperedsthesia. — An exalted sensibility of surface nerves — of tlu>se of tlie skin, the mucous membranes, or even of those of deeper- seattHi strnctun^s — may seem to be due to niflammation. We may, as a rule, distinguisli the {>eripheral sensitiveness from the tenderness of suhjai'ent intlanunation by its extension over a lai^r surface; by divp pn^ssun^ imHiucing no mon* \mn than a light touch ; by the alienee of signs of functional disturbance of the part involved ap- IKmMitly in intlannnatory disease : by the unifonnity of the painful sensidion, ni> matter how long the duration of the disorder, though the sensitiveness exhibits distinct intermissions and exacerbations. llyyvni^tlu^ia is not cKvsely connivtinl with organic diseases of the bniin or of the spinal cimi. Indeed, it is in them not common, nor, as a rule, highly develojHHi. Hy far the nu^t usual causes of Inivni^thesia art^ imjnn erisluni bUuHi and hysteria. Sometimes h\fH^n\^thesia is pnHiuced by rheumatism or by ginit, by lith«emia, or bv disturtvnue of the ftnution of the kidney. It is further met witli in epidemic inOnenra ; in hydn^phobia : in inrtanunations in intenial caxitii^ inxolving the g;mglia of the gn\d symyvdhetic: after the use of ergx^t and of opium : and in some disi^isos of the skin. It also attends jvmAxsms of neundgia, as witnessiHl in the exquisite sensi- ti\eiu\^ of the skin during an attack of ttc fy\nYt»j-: the (gainful s^vMs, tiH\ in tlie course of Uval ne\indj:ias art\ when not the K^ult of neuritis, hxjvn^^thetivaK Uxivn^sthesia attends the irritative stj^^ of it\rtan>mation of stM\sor\ nerxes tV\Mn whatever caust\ Ti^e s^\^t o: the heighten*sl sensihilitx is onlinarilx in the skin, in the distribr.ti^v.i of the uUan*snjs nerxes. Yet hxjv^m^thesia may «lTivt the r.erxfs of the sj^^vicU st uses, nunnfesti^i*: i*so*;:\ for instanee. by intolcT^n^v of ^ijsht or of soinul. Uut this xarictx of hv}x^m^thesia iHwi hen- Iv but alaid^si to, as xxe sl\ai) pnser.r.x :ivk mon^ fully at the s^i>s xxf djs;;:rtv^n*v of th*e dejvi^i or, irritation of the \vnphenr. Vicrx^s, v>r of a oerebral ci>iitry\ ixr of the .vndtu tij>j: tUxn^s ^xf the spi^.va'. cv^ni t^^ivcisdly of thi^^ %>f tho |v\^t*^ri*xr \\x)umns. Ilx(vr^>st)u'sia is ixftoi^ coiyoinod DISEASES OF THE BRAIN AND SPINAL CORD. 65 to perverted sensation, and not a mere increase. When a painful sensation is more acutely felt than normal, it is called hyperalgesia. Sensibility to pain is most readily tested by a pinch or a prick, or by a mre brush with a faradic current. Let us now look at hypersesthesia in connection with affections of the nervous system, especially with those of the brain and cord. Hyperassihesia is general and combined with signs of organic disease. — ^We find this in tumors pressing upon the pons Varolii and corpora quadrigemina, or in alterations or injuries of the posterior columns of the cord and those producing irritation in the course of the con- ducting fibres, in some cases of cerebral meningitis, and in spinal meningitis in which the posterior nerve-roots are implicated. We have in all these conditions a hypersesthesia more or less extensive, and often combined with hyperalgesia and with pain. In making up our minds as to the cause of the extended hyperaesthesia, the sensi- tiveness in diffuse neuritis, in general neuralgias, and in reflected irri- tation to the posterior columns, especially in hysterical subjects, must always be remembered. Hypercesthesia is limited to one side. — Limited hyperaesthesia be- longs much more closely to spinal than to cerebral disease. We also find it in connection with special neuralgias, and the sensitive skin shows augmented electrical sensibility. In some instances of limited as well as of more extended hyperaesthesia nothing abnormal can be detected, and the disorder must be, with our present knowledge, set down as a neurosis, one concerning which it remains uncertain whether it be of central or of peripheral origin. AnsBsthesia. — Loss of sensation, or anaesthesia, is of various de- grees. It may be complete or partial, — ^a perfect absence of sensibility or its mere benumbing. It may be of cerebral, of spinal, or of periph- eral origin. It may involve only common tactile Sensibility, or in varying combination and degree also the sense of pain, the muscular sense, the temperature sense, and stereognostic sense. In the parts affected with anaesthesia the nutrition is less active, the temperature is diminished, and there is a feeling of numbness. Frequently the circulation in the skin is retarded, occasioning a perceptible lividity and discoloration of the surface; or there are coexisting trophic changes, such as glazing of the skin and grayness of the hair. The electrical sensibility is diminished, and is made very manifest by the use of the wire brush with either the faradic or the galvanic current. In hysterical anaesthesia this is a particularly striking feature. Loss of sensation has a much more constant connection with organic affections of the nervous centres than increased sensibility. 66 ' • MEDICAL DIAGNOSIS. which, however, may precede it. In the insane, especially in mono- maniacs, anaesthesia is common, and ordinarily very extended: so, too, in general paralysis. Indeed, with few exceptions, an extended anaesUiesia points to an affection of the nervous centres. It may in these organic cases be both general and very complete.* Localized anaesthesia may be an eariy sign of degenerative change, and precede for a long time an attack of apoplexy with arteriosclerosis. If tlie defective sensibility be owing to a spinal malady, it is gen- erally found in the lower extremities, and coexists with paralysis. Anaesthesia of spinal origin is usually indicative of the sensory con- ducting paths in the posterior colunms having been disturbed or altered ; when about the body, as in transverse dorsal myelitis, there is mostly a zone of hyperaesthesia above the zone of anaesthesia. A limited area of anaesthesia, Allen Starr ^ has demonstrated, is caused by a limited lesion in the spinal cord, and the situation and shape of the area of anaesthesia tell us the level of the lesion. In hysterical paraplegia, in paraplegia from hypnotic* suggestion, or that following railroad or other iiijuries, the line of lost sensibility is, as Charcot* has shown, very significant; it excludes the genital organs. In accordance with the well-known law of the decussation of sensitive impressions in the cord, disease, if only of one posterior half^ is followed by lost sensation on the opposite side of the body. One- sided anaesthesia, affecting even the face up to the middle line, is sometimes met with in hysterical subjects or after typhoid fever.* Hysterical hemianaesthesia is generally on the letl side. But strictly limited one-sided anaesthesia is more apt to be found in a distinct brain lesion, and the particular affection occasioning the hemiancBs^ thema is disease of the wliite substance just outside of the optic thalamus, of the posterior part of the internal capsule, on the. side of the brain opposite to the side of the body which shows the anaes- thesia, or damage to the fibres which conduct sensation through the pons or the crus. A lesion involving the upper part of the pons may give rise to " crossed anaesthesia," — namely, loss of sensibility upon the same side of the face and upon the opposite side of the body. Hemianaesthesia is a not uncommon symptom between the attacks of hystero-epilepsy. A localized form of anaesthesia happens now and then in conse- quence of an affection of the fifth nerve. The extent of loss of * As in a case reported by Winter, quoted in Schmidt's Jahrbuch, 1888, No. 1. > Amer. Journ. Med. Sci., July, 1892. ' (Euvres completes, iii. ^ Calmet, Bulletin de la Societe Medicale des H6pitaux, 1876. DISEASES OF THE BRAIN AND SPINAL CdRD. 67 sensation depends much upon the part of the nerve at which the cause of disturbance is seated. The skin of the nose and cheek may become devoid of sensation; the reflex movements of the muscles •of the face may cease; the conjunctiva, or the whole surface of the eye, or one-half of the tongue, may be deprived of sensibility. Only one of these phenomena, or all conjointly, may be encountered, ac- cording as part of one, or one, or all of the branches of the fifth nerve are affected. Sometimes, as Romberg proves, trigeniinal arues- thesia is of rheumatic origin. When it is complicated with disturbed functions of adjoining cerebral nerves, it ms^y be assumed that the cause is seated at the base of the brain. Anaesthesia is stated to be sometimes the result of reflex action. It may thus, arise in disorders of any of the viscera, and from an irri- tation of any sensitive nerve. It has, for instance, been observed in both lower limbs in sciatica. But in nearly all of these instances of supposed reflected nerve irritation there is really a neuritis. Diminished or lost sensibility to touch generally goes hand in hand with diminished or lost sensibility to pain, but the sensibility to pain may be augmented. This '' anaesthesia dolorosa" is most commonly met with in multiple neuritis, and in spinal meningitis and myelitis from pressure. Very often numbness and other altered sensations are complained of, and yet the whole is subjective ; when tested, anaesthesia is not found. In endeavoring, indeed, to form an opinion of the existence or the completeness of anaesthesia, we do not trust to the patient's state- ments. We touch the part lightly with the finger or a feather while his eyes are shut, and the skin is pinched or a pin used to ascertain the extent of the impaired sensation. Or we resort to means by which we can make accurate comparisons ; and one of the best is to pursue the method employed by Weber, wliich consists in determining how closely the points of a pair of compasses sheathed with cork may be approximated on the skin and yet be felt as two distinct points. An instrument for the same purpose, called the " aesthesiometer," was invented by Sieveking (Fig. 11), and is very much the same as the lighter one of Brown-S^quard now in common use. An instrument combining the principle of the beam compass with that of the mathe- matical one has been contrived by Ogle, and one with ivory points, by Manouvriez. In Carroll's aesthesiometer each arm is bifurcated, having, one blunt and one sharp end, thus enabling us to test pain as well as touch. The points of the aesthesiometer, whether blunted or sharp, should^ be put down lightly and simultaneously, and parallel with the direction of the cutaneous nerves ; at all events, the same 68 MEDICAID DIAGNOSIS. relative direction should be preserved in making comparative esti- mates. To understand any results obtained regarding the tactile sense, it is necessary that we should be aware how this differs in some parts* of the body. Most works on physiology contain an account of the researches of Weber and of those w*ho have prosecuted the inquiry he started ; yet a few of the conehisions may be here mentioned. At Fig. 11, The {Battii^oixktiter oi f^. the tip of the tongue two points can be readily distinguished when separate from each other ^V ^^ ^^ inch, or half a Paris line, one and a half millimetres ; at the palmar surface of the third phalanx the limit is one line ; on the palmar surface of the second phalanx, two lines, the same on the red surface of the lips ; on the palm of the hand, the cheek, and the extremity of the great toe, five hues; on the back of the hand, at the knuckles, eigtit lines ; at the lower part of the forehead, ten lines ; on the skin over the patella and the dorsum of the foot, eigliteen Ihies ; over tlie middle of the arm, the thigh, and over the spine, thirty lines ; on the back, sixty millimetres is common. But these observations are found to vary somewhat even in healttiy persons, sgme being able to distinguish at a shorter dis- tance than others. Besides the impainnent or loss of tactile discrimination, the altered sensibility may show itself in the loss of the faculty of feeling pinch- ing, pricking, and other acts which excite pain, ''analgesia;" or in insensibility to tickling ; or in the want of appreciation of heat or cold, *' altered temperature sensibility;'' or in the loss of ttie sen- sation wliich attends muscular contraction, whether produced by the will or by an electrical current. Now, it is in individual cases always of importance to note which particular kind of sensibility is affected. DISEASES OF THE BRAIN AND SPINAL CQBJ). 69 Fig. 12. In sclerosis of the cord the sensation is retarded rather than lost.* A form of perverted sensibility, which may or may not be associated with anaesthesia, consists in the sensibility being more or less perfect, while there is doubt as to the side touched ; indeed, the touch is commonly felt at a corresponding part of the other limb. This allochma ^ is gen- erally found in association with organic spinal disease ; but it may also manifest itself in hysteria. A sufficient explana- tion of the erroneous reference of impres- sions is wanting. In a case recorded by Ferrier* the reversal showed itself also in the reflex reactions. Tickling the sole of one foot caused retraction of the other ; tickling the inside of one thigh produced flexion of the other. Occasionally a single sensory impression is perceived as two or more; tliis is known as *' polya?sthesia," and is most often met with in locomotor ataxia. Sensibility to temperature has a close connection with sensibility to pain; but not always. There may be crossed pa- ralysis of the thermal sense, while other senses are undisturbed.* Sometimes the temperature sense is exaggerated or dimin- ished, or much perverted, and cold objects feel hot, and the reverse. Then points may be found in the skin where only cold, others where only heat, is appre- ciated. To test heal, a heated spoon or a test-tube filled with hot water is the readiest means; to test cold a sponge that has been dipped in cold water or a piece of ice is best. Muscular ance^ihesia has been mentioned. It is closely connected with the power wa possess of estimating weight,, the ** muscular sense ;" and the loss of ability to perceive differences in small weights, or the impairment of the sense of muscular movement and effort, is its most common fonn. It is really distinct from the sensi- * Vulpian, Archives de Physiolojjfie, t. i., No. 8. * Obersteiner, Brain, July, 1881. » Brain, Oct()l)er, 1882. * Case reported by Weir Mitchell, Tmns. Assoc. Amer. Phys., vol. vii., 1892. 6 Carroll'H resthesiometer. 70 MEDICAL DIAGNOSIS. tiveness of the muscles to pressure or to electrical stimulation, which may be also wholly wanting. The loss of the power of appreciating muscular contraction, as well as the deficiency of sensation, is most readily tested by the use of the faradic current ; the contraction of the muscles produces no feeling. Muscular anaesthesia is frequently combined with inability to de- termine the posture of a limb when the eyes are closed ; it may or may not be associated with cutaneous anfesthesia. It is not uncommon in hysteria and in locomotor ataxia. Here the loss of the apprecia- tion of the position of the limbs and of the sense of muscular effort is the usual variety. When the muscles are completely paralyzed, the muscular sense cannot be tested. The muscular sense has been localized by Allen Starr and McCosh at the junction of the superior and inferior parietal convolutions, behind the posterior central con- volution.* In testing for the muscular sense, the eyes of the person on whom the test is made should be kept closed, and objects used should be of unifonn size. To detect the difference in weight, and thus the resistance to contraction, Gowers ^ recommends leather balls containing weights from two drachms to two pounds. The weights are placed in a bag, suspended by a string to the parts to be tested. The recognition of objects by the sense of touch, stereognosis, is not rarely impaired by lesions of the cortex, especially in the central and parietal regions. Paraesthesia. — ^This is a perversion of sensation, not an exal- tation. It does not disclose itself by pain and tendeniess, but by itching, by formication, by unnatural feelings of various kinds, such as the feeling of tingling, of pins and needles, of goose-flesh, of thrill- ing, of flushing, of the trickling of cold water, of shock-like sensa- tions, or of a sense of tightness, as in the girdle pain. It is generally purely subjective, though it may be influenced by touch. . A form of pardesthesia is acmparccdhema. This is chiefly characterized by numbness of the extremities. It is encountered in women at the menopause, and in those who do washing, scrubbhig, or sewmg. It may be also found hi men, and by some is believed to be a neurosis, by others a neuritis.-^ The alterations of sensibility discussed manifest themselves chiefly in connection with external impressions. Let us now look at some abnormal sensations which are not objective, but subjective, — arising ^ Ainer. Jouni. Med. Sci., Nov. 1894. ' Diseases of the Nervous System, vol. i., 2d ed., 1893. ' Sinkler, Medical News, Aug. 1894, p. 178. DISEASES OF THE BRAIN AND SPINAL CORD. 71 independently of external impressions. Headache and vertigo are of this character. Headache. — In everj- case of headache we must first ascertain that the pain really originates within the cranium, and that it is not owing to supraorbital neuralgia ; to rheumatism of the scalp ; to dis- ease of the bones ; to periostitis, syphilitic or otherwise ; or to affec- tions of the ear. To accomplish this is generally not difficult. An inquiry into the histor}' of the case, the locality of the pain, and its augmentation on pressure in most of the disorders named, furnish evidence which decides the source of the cephalalgia to be external to the cranium. Another possible cause of headache, always to be kept in mind, has been made clear by the labors of eye-surgeons. It occurs in persons who have headache more or less intense, with abnormal sen- sations in the skin of the scalp, and at times vertigo and spasm of the eyelids and occipito-frontal muscle. The near use of their eyes increases their distress. When the eye is carefully examined, an optical defect is found, especially hyperopia or astigmatism. Again, we may have defective vision, with sleeplessness and severe headache, dependent on decayed teeth, and disappearing with their removal.* Having settled that none of these conditions are present, we have to determine the probable cause of the headache, — a question the solution of which depends frequently more upon the symptoms attend- ing the pain than upon its character. But let us glance at some of the common causes and characteristics of intracranial headache. Headache is a rarely absent symptom of dinease of the brain. In acute inflammation it is generally agonizing, and, while subject to exacerbations, conthmous ; it is associated with fever, with vomiting, and A\ith delirium. In abscesses of the brain, in softening, and in similar affections which run a chronic course, the headache is less violent, and only occasionally paroxysmal ; it is usually accompanied by signs of disturbed intellection and of deranged motion. In tumor of the brain the headache is apt to be severe and paroxysmal, but intellection is not at first much affected. In congestion of the brain the pain is dull, increased by stooping or lying down, by long sleep, and by bodily or mental fatigue ; its concomitants are a flushed face, a throbbing of the arteries of the neck, an eye-ground in which the vessels, especially the veins, are turgid, and a heated head, with in- creased temperature, as shown by the surface thermometer. A form of congestive headache, apt to be relieved by bleeding at the nose, is ^ Case reported by Ogle, Medical Times and Gazette, Aug. 1872. 72 MEBICAL DIAGK08LS. often seen in young people at ttie age of puberty : the attacks are brougtit on by running or other violent exercise. In diseases of the meninges, especially those of a chronic character, the pain is constant and fixed, and sonietiines very sharp. The latter kind of pain when persistent is also significant of disease of the superficial brain struc- tures in contact with tlie meninges, and is usually telt at the place on the head which corresponds to the seat of the lesion within the skiilL Nej*vo}w or neurahjic hc^adache is most common in women, espe- cially in ansemic women. It is unremitting and very severe, yet of short duration ; but after it is over there is great lassitude, and even some local soreness. It is not altended with rise of temperature, or with any signs of disturbance of the brain, except at times with a conf\ision of vision and an inability to carry on a connected train of thought. Anything that agitates the nen^ous system i>roduces an attack ; stimulants and food often relieve it. To the class of head- ache under consideration may be refeiTed many cases of^ migraine. But migraine^ megrim, sick headache, or hemicrania, lias certain symptoms which set it apart. Tlie pain is usually attended with nausea and vomiting, is generally at tirst one-sided, and is accompa- nied, or more often preceded, by visual disorder, such as a bright spot gradually enlarging. The disturbance of vision begins suddenly, last- ing perhaps for tialf an hour before the hinidaclio hegins, and is at times associated with tingling on one sidt\ with difticulty iti speech and con- fusion of ideas ; sometimes there is distorhanre of Jieariug. The headache often begins in the temple, and is very severe ; it spreads over the head, it may extend to tlie neck, or may leave the sitie originally alTected to become agonizing on the other. There may be soreness of the head with the pain, and there is often pallor of the fece, and a contraction of, one pupil. Coldness of the extremities ii not uncommon, and the ]>atient vomits bile. Ttiis bilious vomiting often terminates the attack, which comes on only in paroxysms. Mi- graine is frequently met With in gouty or litluTmic persons, and the urine is of high s|)ecitic gravity, and coidains an excess of uric acid and urates, though, during the attack itself, no such increase may bej met with. It is sometimes excited by reflex influences sucIj as ey strain, nasal or pharj'ngeal disease, dental caries, gastric disturbance, or uterine or menstrual derangement. S^paihetw headache is foiuid nuiinly in connection with disorders of the uterus and of the alimentary tube, and is often worse in thi morning, before food has been laken. Headache may be dependent upon various poimm, whether gen- erated in the system or introduced from without ; for instance, in BIS£1A6£]3 OF THE BRAIN ANB 8PI!^AL CORD, 73 diseases of the kidney the retention of a laige quantity of urea in Ih^e blood becomes the cause of persistent pain in the head. In torpidity of Uie liver, in lead poisoning, in opium eaters, in drunk- ards, after the use of strychnine or of \BTge quantities of quinine, headache is common ; and it is verj^ Ukely that in persons with fatuity assimilation certain ptomaines give rise to headache. In studying headache as a s\Tiiptom, we must always note what influence position and movements of the head^ and percussion and palliation, have on the pain : whether, for instance, stooping, swing- ing the head from side to side, or rising rapidly from the horizontal to the erect posture affect it, and cause it to he cond>ined with ver- tiaroxysms, sometimes in t!ie middle of the night or in the early morning, and is associated with a dnlU heavy ache in the head, and with more or less gastric disturliance* often following indiscretion in diet. Yet the tongue may be clean, and the digestive disorder so slight that it is only by the after-symptoms, by the relief afforded by at- tention to diet, and by remedies acting on the digestion, tliat we clearly make out the cause of the vertigo. Between ttie altacks the patient is free from the affection ; thougti there are cases of more ctironic kind, in w^hich a certain amount of giddiness is present lor long periods witli only cornt>aratively short intervals of freedom. The giddiness may become aggravated into a severe attack if the stomach be for a long time em{)ty. In gastric vertigo there is tio loss of consciousness. Tlie pathology is obscure. Woakes^ has endeavored to establish a direct nenoos comninnication betw^een the stomach and the labyrinth to explain the vertigo. Others regard the irregularity in the cerebral circulation produced by tlie gastric dis- order, ana?niia or hypera^rnia, as the cause. Very similar to gastric vertigo is the vertigo of malassimilation in connection with llikmnm. The history of the case, the shite of the urine, the striking ctiange which foHow^s diet and treatment that alter tlie formation and elimination of uric- acid, distinguisli litha-mic vertigo, Another form of vertigo of eccentric origin is that associated with partial deafness or ringing in tlie ears. Again, there may be an atTection of the internal ear, the senucireular canals of the labyrinth especially being the seat of an inflanimation, and the vertigo set in suddenly. Its onset is apt to be associated with vomiting, with sud- denly developed tinnitus, ^lih pain produced in the atlect^'d ear by the slightest noise, and with symptoms of apoplexy or a tainting con- dition. Such cases, to which Mrnit»re particularly has called atten- tion, may very speedily terniinate fatally, Bui the acute seizure, which is by far ttie most conmion beginning of the aural veHi(/o, may leave betiind gidthness and a persistent unsteadiness in standing and walking, or a tendency to go tbrward or backward^ or a reeling gait. These, with the intense vertigo and the vomiting, the persistent noises in ttie ears, the unimpaired consciousness, and the deafness, be- come valuable signs of Meniere^s disease. The deafness shows espe- cially in defect of power of hearing vibration conducted through the skull. It is often one-sided, generally on the side of the marked tin- * DISEASES OF THE BRAIN AND SPINAL CORD, 75 nitiis, and never absolute. Again, it may be noticed that there is deafness for certain groups of musical sounds, which Knapp accepts as proof that the disorder has extended to the cochlea. In some instances the patient has a tendency to turn to one side or to walk round and round in a circle ; and he is always miserable, although his general health suffers but little. The disturbance of the equilibrium is not always present ; there may be disturbance of hear- ing without it. The vertigo is generally the most prominent symptom of the disease, and persistent vertigo not epileptic in character or obviously associated with an organic brain affection is nearly always aural. The dizziness is very apt to be severe, to come on in parox- ysms, and to be excited by some effort or movement. It becomes associated with palloV, with faintness, with vomiting, and in part it remains even between the paroxysms. During these the roaring in the ears may or may not be increased, but signs of eye-disturbance are very apt to show themselves. The disease may result from any process that involves the labyrinth and the nerve-endings. It is more common in men than in women, and is very rare in young persons. It may come on after cold and exposure, or originate in gout or in syphilis. It has also been observed in men working under ground and breathing compressed air.^ All cases of aural vertigo do not set in suddenly ; some are slight, others are very severe and do not cease until the hearing is totally lost. Many cases progress slowly to re- covery. Aural vertigo in its milder forms may be met with in aflfec- tions of the ear that have had their origin in catarrhal inflammation travelling along the Eustachian tube. A peculiar variety of paroxysnuil vertigo has been observed in Switzerland, France, and Japan, associated with weakness of the extremities, drooping of the eyelids, and mental depression, but with preservation of consciousness. These attacks may occur very fre- quently or be months apart. They have been described by Gerlier, and the disease is known by his name, or as paralyzing vertigo. Toxaemia has been suggested as the probable cause. To return to vertigo connected with cerebral or cerebro-spinal disease. There is a kind which Trousseau especially has described. The abnormal sensation is very short in its duration, but severe ; the patient momentarily loses all consciousness. The vertigo recurs at uncertain times : while actively engaged, sometimes while in bed and half asleep. The head feels heavy after an attack, and the mind is temporarily stupefied; otherwise the health is good. This type of * Curaow, Lancet, 1894, No. 3715, p. 1088. 76 MEDK AI> DIAGNOSIH. verti^'O is dangerous. It is oftL^i Hie prrcuvHor of epUepm/, and after a time becomes associated with coDvulsions, Another kind of vertij^o is that wldch arises from onnrork of the brain^ very Ukely connected witli temporary hypera*mia. At limes giddiness is ilie only syniiitnm of disorder, and is present for many years, the patient enjoying oHierwise exeelh^nt liealfii, I have known a number of instances of this ej^sridiat veiiigo in which tlie tendency appeared to have been inherited. If it do not brerdi ont until late in life, it is a matter of more serious concern. In laryngeal vertigo^ there is a close connection witli epileptic seiz- ures. The chief symptoms are lirklin^^ or burnini^^ in Hie larynx, fol- lowed by verti*i:o, loss of consciousness, and spasmodif movements in the face and limbs. The larynx is healthy ; but in a case observed by Somnierbrodt a polypus existed, removal of which cured the affection. Allied to vertigo is the condition known as aMama-abnma, the most marked characteristic of which is difliculty in standing' and walking^. Consciousness is not lost, hot sometimes there is a sense of giddiness. The affection is a manifestation of hysteria, of which other symptoms are likely to be present. Besides headache and vertigo, there are various unnatural sensa- tions, such as a feeling of nionioidary unconsciousness without giddi- ness; a feeling wuthin the cranimn of w^oighl, of constriction; the feeling described as a rush of blood to the head ; ocular spectra, and other false perceptions of many kinds and of eve it gradation. But I shall do no more than advert to tins subject, and shall now consider some of the morbid phenomena of the special senses, particularly of the senses of sigtit and hearing. DERANGEMENT OF SPECLIL SENSES. Vision.^The sense of vision may be exalted, impaired, or per- Terted in disorders of tlie brain, whetlier organic or foiiclionaL It is exalted ui inHammalion ; impaired, even totally lost, in softening, in tunioi-s, in apoplexy, and during violent hysterical attacks simulating apoplexy. Perversions of the sense of vision are more frequent than its abolition, and probably more peculiar to cerebral affections. They are of all kinds, — some of great conseiiuence, others of but little. Mu^em volUanim^ or the appearance of spots and various small objects floating before the eye, have the latter significance ; for tliey may happen in almost any form of cerebral disturbance, also in ana&mia, in cardiac mal- DISEASES OF THE BRAIN AND SPINAL CORD. 77 adies, in the neuroses, and in states. of nervous exhaustion. They are simply the shadows of vitreous opacities or retinal vessels upon the retina, and have nothing to do with anything but the local condition, wliicli is without significance. Of other manifestations of deranged sight, such as illusions, ocular spectra, and phantasms, I shall only state that they are more common in sick headache, and in derangement of the mind, temporary or permanent, than in recognizable organic dis- ease of the brain. Yet they are found in affections of certain parts of the brain ; for in disease of the posterior lobes, as Hughlings Jackson has observed, colored \ision and optical illusions are frequent. The appearance of the eye is often of as much significance as the derangement of sight. In some cerebral maladies the eye has a fixed stare; in others the eyelids are constantly moving: but the latter is a sign more frequent in chouea, local spasm, and hysteria. Great brilliancy of the eye is often noticed in meningitis and in insanity. Derangements of the ocular mechanism may be the result of remote causes, or, themselves primary, may become the starting-point of dis- order elsewhere. In the first case their study is valuable to the gen- eral diagnostician as indicative of the seat, nature, or stage of many diseases in other parts of the system ; in the second case the diagnosis as well as the therapeutics of the distant and related disease is depend- ent upon the appreciation of the ocular derangement. It thus becomes evident that the abnormalities of the visual mechanism are of the highest importance in many systemic affections, particularly in disease of the cerebro-spinal system. Let us first briefly consider the idiopathic derangements of the eye that induce derangements elsewhere. Both in origin and in result these are essentially functional. So far as relates to the eye they consist cliiefly either in abnormalities of refraction, classed under the general head of ametropia, and comprising hyperopia, astigmatism, myopia, and presbyopia, singly or combined ; or in incoordination of the ex- ternal ocular muscles, commonly called insufficiency. The results of ametropia and muscular insufficiency are conveniently called eye- strain; and this condition generally evinces itself not so much in ocular or visual symptoms as in functional ner\'ous derangements, often far removed and apparently disconnected. For example, it is a well-established fact that eye-strain is prone to produce headache, especially in young women after the age of puberty. These head- aches are usually frontal, but may also be occipital, less frequently of the vertex or diff'used. Eye-strain is at times the starting-point of choreic symptoms, and even, though this is rare, of genuine 7X A1E1>1CAL l)lAGX()t5I6. ruujiriJ. <.a&i-> liavH been report «:*d ' sliowin*: thai the same cause iitii.v produ«;. luijrtioual ;zaslric deraii^'cnieiits. hysteria, melancholia. uii;eed to exhaust tlie possDjilities of a reflex neurosis Uu» \v o' uiar aijijoriiiality or to soiiit- oilier peripheral irritation. H>p»*ioj>uj arid iiyperopir asUinuaiisui are much tlie most frequent a»^ur«ir •/ r>< -:?iraiij. and by ilie aid ol a mydriatic, followed by i»-.si.- vvitii {'ilk: lriai-]Hij.s<'«. ilie dia^Miosis of the existence and amount o* till .our< I- ot irrilativi' .strain. Muscular ins utTicienoy is the next most Iji (jutiit resbyopia may sometimes cause iL 'i'urninj.' now to tin- consideration of those r/«««c in almost any part of the organism may give indi- 4'ations of its Jiature and location in the eyes. These symptoms^ I'ithej sin^rly or cuijibinod. are of a threefold nature: <'hiint^es in llic t-.xternal appearances, and visible to the naked eye. <'hiin^[u\i a dc;rree that many are compelled to iniiyn ijivahiahjc kn«*\vlrdj.'t'. unhss they can avail themselves of the >t I \ h i .^ III an rxpt rt. I Aniunfj tii«' t itiiniil tihiunmitl'it'ni* ( ff thfcj/fi* i^wepiion must, of ii»ui.-i . lii>l in- niaile iii Mil II jinal disrasrs as have no systemic rela- hnji- Mil h a> ri I hv iiii.M -. < iiiiv/f^liniis nv intlammations of the lids tiiid i HiiiiHii (iva. tjiii li.tiii.t. ^'hiuiMiiia. cataract, congenital anomalies, ,1, llir|ic> .H.-lir ..j.l.!lni;iiiii U-. a jHriphrral neuritis of the oph- lli.iliiiii In. null ft tin nnii II. i^.. I- a dan-rn»us and painful malady, tiili N II iit'l .4l^\.^\^. . %x,i.. I.. i..ai . .ni».»M ii .- jl--r:.t a- i'!i«.- ol the niiliu SATUptomS of llh allc.li.Mi wi'hil I V , l.!!.;i.:... .i'.n. UiseaSfS of the nUOleUS OF ,.i Uu j..ou.iU'«. »•; II. 1 :::::. .^.\^'. ..-i ,■: ;:- v-i i.tLalriiii division may DI8EA8ES OF THE BRAIN AND SPINAL CORD. 79 Next in importance is a class of diseases due to external infection that generally points to a source of contagion elsewhere in the or- ganism. Cases of localized tuberculosis of the conjunctiva have been reported v^rherein the handkerchief has perhaps carried the bacillus to the eye. Gonorrhoeal ophthalmia is a constantly recurring disease in ophthalmic practice ; but the most frequent and frightful is the ophthalmia of the new-born, — ophthalmia neonatorum, — due to in- fection during labor with the vaginal discharges of the mother. It is said that the greater part of the blindness of the world is due to this wholly preventable disease. Affections of the conjunctiva or lids may have their origin in dis- eases of the adjacent skin or mucous membrane, and extend to the eyes by simple contiguity of structure. A close connection frequently exists between hay-fever, catarrhal and other diseases of the nasal mucous membrane, and similar conditions of the conjunctiva. Arcus senilis, a ring of grajish tissue-change about the corneal limbus, betokens generalized atheromatous or fatty degeneration, chiefly arterial or cardiac. Interstitial 6t diffused keratitis is nearly always the result of inherited syphilis. Of tlie remaining aflfections of the external parts of the eye in- dicative of general or internal disease, the most important are those pertaining to the muscles of the eye or movements of the globe. Tliey easily fall into two groups, — those of the external and those of the internal muscles. Sirabisrmis, or squint, may be due to local causes, such as injuries, or cold, etc., but it usually arises from a lack of equal or balanced power among the twelve external muscles, and to ametropia and anisometropia. The distinctive subjective characteristic of squint is double vision. In examining for strabismus we observe whether the eyeball is turned inward or outward. In paralysis of the external rectus we have ordinarily an internal or convergent squint, in paraly- sis of the internal rectus an external or divergent strabismus. In palsy of the superior rectus there is inability to raise the eyeball in a proper manner above the horizontal level ; inability to lower it below indicates palsy of the inferior rectus. Strabismus due to local causes must be distinguished from true paralytic squint due to more cen- trally located lesions. It must also be distinguished from spastic action of tlie muscles caused by irritative intracranial injuries. In both the latter cases there is a conjugate or common movement of both eyes to one side or to the other, called conjugate lateral deviation ; the head often shares in the lateral movement. In spastic irritative lesions of the cortex the eyes are turned from the side of the injury ; 80 MEDICAL DIAGNOSIS. in paraJylic or destructive lesions they are turned towards it. The eyes, as has been said, look at the lesion in paralysis, away from it in spasm. The syiMiiluiH, however, owing to its frequently tempo- rary existence, and also to the fact that it may arise as an indirect symptom, must not be relied upon except in conjuoelion with others and wlien continuing for several weeks.* The seat of the lesion may be in the cortex, the internal capsule, or the pons ; in the latter case the symptoms are direct and the delation of tlie eyes is the reverse of that given above : the eyes in paralysis look away from the lesion ; hi spasm, towards it. If in lesions of the pons the sixth nerve nucleus be included, there is, of course^ paralysis of the external rectus, so that the corresponding eye cannot be rotated outward past the niiddle line, whilst the other eye cannot be rotated inward piist the nuddle line. This associated movement of tlie other eye will not be impaired if the injury to the sixth nerve be between the nucleus and the globe. Owing to the peculiar position of its nucleus and the long course of exit of the sixth n^rve^ its exclusive paralysis is the most frequent of single nen^e palsies. It is peculiarly lialjle to paralysis from indi- rect or pressure causes, but if connected with paralysis of the oppo- site side of the body and witli other symptoms of brain disease, it clearly points io a lesion of the pons* In consequence of the close anatonucal relatiojis of their nuclei, palsies of the sixth and facial nerves are frequently associated. Other nerves originafiTig in the pons are liable to inq>lication. Next to the sixth the third fierve is the one most otten paralyzed, and in proportion to the number of twigs involved and the completeness of their fialsy is there a probability of a lesion at tlie base of the brain. The various pjiraiyses of the external ocular muscles are usually attended with double vision, fUplopia . Ptmis may exist either with or without involvement of other ttiird-nen^e brandies, but in any case tlie value of the droop of the upper eyehd as a localizuig symptom is somewtiat indeteraiinate. If of one eye alone, ptosis usually indicates a cortical lesion, unless due to evidently local causes. In f>araly?is of the third nerve we have, besides the ptosis, dilatation of ttie pupil of moderate extent. Inability' to close the eyelids is associated with paralysis of the facial nerv^e. As regards the natiu^e of the lesion, the ocular symptoms gen- erally give little definite indication. * The direct sytiiptomf* an* those intimately < it' pendent upon the lesion of i pari ; the mclir«?<'t or distiinl symptoms are lliose «Jue to dist urban cm2s of circula- tion, to pressure, to Uie reflex or inhibitory eflfecls at otlier points than the seat of iiyury. DI8EA8E8 OF THE BRAIN AND SPINAL CORD. 81 Abnormalities of the pupils are understood by remembering that the third nerve controls the contractile mechanism and the cervical sympathetic the dilating mechanism. Hence an unusual diminution or increase of either innervation, especially of the first, causes alter- ations of the pupils at once. Irritative cerebral lesions thus produce contraction, whilst lesions which destroy cerebral function produce morbid dilatation. The state of the pupil in tumors, hemorrhage, and inflammatory conditions of the brain may thus furnish us with most serviceable indications of the extent and destructiveness of the injury. When but one pupil is abnormal, the rule above given serves to indicate lesion of the corresponding half of the cerebrum, irritative or paralytic according to the degree of the injury. Yet one- sided contraction, like one-sided jiilatation, may also be owing to tumors at the root of the neck. Hemorrhage or effusion into the pons or lateral ventricles, when small or irritative, produces con- traction ; but if large, permanent dilatation. Certain drugs, such as opium, contract the pupil ; belladonna, chloral, and cocaine dilate it. We also find dilatation of both pupils in chlorosis. If the foot be pricked, the pupils dilate, provided the iris be uninjured and the sensory columns be intact. In epileptics this reflex excitability is greatly diminished.^ The pupillary reaction to light may be useful in diagnosticating the location of a lesion, whether beyond the corpora quadrigemina or not. If beyond, the pupillary reflex will be retained, despite the loss of sight. Lesions of the spinal cord and of the sympathetic nerve produce results the reverse of cerebral disease: irritative lesions dilate, paralytic lesions contract. In this connection the Argyll- Robertson pupil — the light-reflex lost, the accommodative reflex re- tained, of a myopic pupil — is of value as indicating, often early, scle- rosis of the posterior columns of the cord. When hemianopsia is due to disease of the optic tract, the pupil fails to react to the stimu- lation of light reflected upon the blind half of the retina ; contracting, however, if the lesion be situated in the cerebral hemisphere. Fared-- ysis of the accommodation may exist independently of pupillary in- volvement, and its significance is that of paralysis of other branches of the third nerve. Paralysis of many or of all the muscles of both eyes, ophthalmoplegia^ is usually due to a lesion of the nuclei of the supplying nerves. It is especially due to lesions of the nuclei in the gray matter of the Sylvian aqueduct. II. Abnormal changes in the fundus of the eye may be of great * Lawson, West Riding Reports, vol. iv. 82 MEDICAL DIAGNOSIS. diagnostic value, arid in almost every case of circolaton^ or nervous disease the ophtlialniosiope jj^ives vaUud>le hints conceniiug the gen- eral disorder. Witli few exceptions these changes are symptomatic, and do not arise from local disease. We stiould invariably examine with tlie ophtlialmoscope the eyes of patients suspected of having disease of any part of the cerebro- sphial nervous system. Chanjres in the eye, indeed, ollen occur early enonj^li to be the first certain sign of disease, and tlds, too, witli- out any impah-ment of sight; on the other hand, lesions uidicating cerebral or other organic atTection have tx-en found in cases hj widch fiuhuv of sigld was alone complained of. But particulaily is the ophthalmoscope valntd>Ie m enabling ns to diilereidiate oi^anic from functional affections, It tells us of extension of congestion or of in- flammation of the brain to flie internal structures of the eye, or of the amount of resistance oll'ered to tlie circnhitiun within the cranium. This resistance may either arise from a marked ** coarse" lesion, or may make itself felt through the syinjiatlretic nervous system. The clianges in connecOon with organic disease have been ob- sen-ed chiefly in the retma^ the optic disk, and the choroid. In using the ophf/tainio,^copcfor rnvdiraf diitfpKMw we pay ()aTticular atterdion to these strnctnres; especially do we note the disk, its color and size, and the pigment around its edges, the region of tlie macula, tlie size and appearance of the arteries and veins, whether diminislied, en- larged, or tortuous, whether there are -exudations or hemorrhages in the course of the vessels, and in what [lart of the eye-groond tlie patclies are most marked, Iltfptnrntiff, or increased redness, is due to local causes ; and the fundus changes in myopia, astigmatism, retinitis pigmentosa, and some forms of choroiditis are also to lie excepted. In diseaseji of the blood and tlie blood-making oi'gans, the indications are remarkal:)ly clear, Iidinai hvmorrlHtf/fM are a common concomitant of such gen- eral diseases as albimiinaria, di^d)etes, anaemias, cardiac valvular dis- ease, arterial, atheromatous, and fatty degenerations, chronic malaria, ajld other febrile conditions, DnfMifmn of the emtrai artcrtf of the retina^ causing nnilaleral blindness, points to cardiac valvular disease- There is a grayish discoloration ai^out the macula, with a central cherry-red spot. Tortuosity, beading, bulging, and irregularities in the size of the arteries, witli pressure on the veins, tedema, and hemorrhage, are indicative of arteriosclerosis. Simple anwniia is at once recognized by the transi>arency of the blood-columns, and lukwmia m\d jjvnncioiiM nu(rmia pvodnvi} characteristic chang(*s in Uie eye-ground, especially^ the last, with retieal oedema and hemorrhages, DISEASES OF THE BRAIN AND SPINAL CORD. 83 disk-discoloration, arterial pallor, and venous distention. Albuminuric rdinUis is common, but not invariable in albuminuria. The typical fundus changes consist in an eariy stage of haziness of the papilla and central pari: of the fundus, slight hemorrhages, and faint grayish discolorations. Later, white dots or splotches are grouped about the macula, or, flame-like, radiate from it. Striate hemorrhages are scat- tered over the fundus, the papilla is oedematous, and its limits are obscured. The ophthalmoscopic signs of diabetic retinitis are very similar. Visual disturbances, however, do not, in either case, stand in any exact ratio to the defects of the eye-ground. Atrophy of the optic nerve^ recognizable by the whiteness or discol- oration of the disk, failure of vision, even to blindness, may some- times seem to have no remote causes, but is commonly associated with, or is a result of, diseases or lesions of the spinal cord or the brain, toxic substances in the blood, papillitis, etc. Fapillitvt^ optic neuritis, "choked disk," is a symptom of most decided diagnostic value. The picture is easily recognized, consisting in a swollen red disk, the edges and vessels of which are obscured by a " woolly," striate blurring extending to the adjacent retina. This condition is always symptomatic, and in the large majority of cases points to tumor of the brain, though other intracranial diseases may produce it. From papillitis, however, nothing can be argued as to the nature or location of the tumor or other affection. It is often not a late symptom, and unimpaired vision may coexist. Optic neuritis has been observed after measles and scarlet fever, also after malaria and typhoid fever.^ Choroidal inflammatiom are chiefly distinguishable by the striking color and pigment changes of the fundus. Plastic choroiditis is com- monly secondary to meningeal affections and prostrating fevers ; puru- lent choroiditis, to local or general infection or septicaemia. Dissemi- nated and central choroiditis, or choroido-retinitis, is frequently the result of syphilis. The choroid is peculiarly liable to become the seat of tuberculous growths. III. Passing now to the consideration of purely subjective visual derangements^ it becomes highly necessarj^ to determine first whether such defects are due to refraction-errors, insufficiencies, and other local causes, or if they are secondary and symptomatic. Unless other indications are present, the complaint of headache, especially if frontal, weariness or pain of the eyes after near work, affections of the lids and conjunctiva, conjoined with general irritability and func- ^ While, Journal of the Amer. Med. Assoc, Oct. 1893. MEDICAL DIAGNOSIS. linnal gastric derangements, almost invariably indicate eye-strain as primar}\ Simple inability to see distant objects eleiirly, willinnt ntljcr sjTnptoms, local or general, indicates myopia. Ambltppifi, due to the excessive indnl^^ence in tobacco or alcoliol, has but a single ol>jective sign : an iiousnal pallor of the temporal portion of the papilla. There is deterioration of visual acuity, to whicli subnormal color-perception may be added. Amblyopia some- times occurs also as a rnariitestation of hysteria and in association with migraine. It has hirther been ol)served as a symptom of intoxi- cation with cjuinine, iodotbrm, lead,* or atler sexual excesses ; or the defectivt* acuteness of vision sliows itself as a day-blindness or as a night*l>lin(lness ; or takes the fVirm of conl railed lields of vision, or of color-blindness. Marked visual deterioration of a single eye should lead to inquiry for extra-local causes. It may be due to disease of the correspondifij.' oplic nerve. When ametropia has been excluded and the above-descriljed ophttialmoscopic signs are wanting, ilie cause must be sought in disease of otlier organs. Paresis, and even paral- ysis of the accommodation, and visual failure, are not infrequent as reflex tu^itrmi'>f from peripheral irritation of other parts. Cases of abnormalities of dentition and other dental troubles producing such visual defects hiiw been frequently reported. Menstrual difficulties, mast iu*bati OIK the inlluence of pregnaui^y and lactation, may some- times account for obscure ocular troubles. Hemeraloi>ia, night-blind- ness, due to delicient nutrition of the general system, has been traced to insutTicient footl.^ Modifications of the color-fields have been found chiefly in hys- terital jiatients, Tlie field for red and green, always the narrower, shows the restriction most markedly. The most important ocular sign of cerebral disease, and one in- variably pointing to irdracranial alleetion is hemiauojma^ or loss of vision of the lialves of the fields. The most common variety is that called homonynions lateral hemianojisia, in which ttie loss is either of the temporal half of one eye and of the nasal half of the other, or vice i^ermi, a vertieal line nearly througli the centre being the dividing line. There are ttu-ee other tonus of hemianopsia, called temporal, nasal, and altitudinal, in which the halt-iields are respec- tively the two temporaK the two nasal, with the dividing line, as pre\iously, perpendicular, or the two dark half-fields are the upper * De Siiiweiriilz, The Toxic Aniblyo|>i.'Ls, 1896. * Kubli, Archiv f\ir Augeiibeilkyinie, June, 1887, who descriljes three hutidrtst and twenty cases occurring during the Russian church-f^i^ls. DISEASES OF THE BRAIN AND SPINAL CORD. 85 or the lower halves, with the dividing line horizontal. These three varieties are seldom met with, and, from the peculiar anatomical re- lations of the optic chiasm or commissure, are readily recognized as the results of lesions of this part, either at one side or the other, above or below. Homonymous lateral hemianopsia always indicates lesion beyond the chiasm. If the hemianopsia be "relative," — in- volving only a pari: of the perceptions of light, form, and color, — it must necessarily proceed from a partial lesion of the common visual centre situated in the cuneus of the occipital lobe.^ But if the hemianopsia be absolute, — with complete, loss of light, form, and color sense, — the lesion may be eitlier one affecting the entire visual centre of one side, or one rendering wholly functionless the fibres of one radiation, internal capsule, or optic tract. If the latter were the case there would almost certainly be other intercurrent or general symptoms, such as paralysis of other cranial nerves, hemianaesthesia, some form of aphasia, or hemiplegic symptoms. A symptom of great value in locating the lesion of hemianopsia is the hemiopic pupil. Convergence of a narrow cone of light upon the insensitive half of the retina yields no pupillary reflex if the lesion be in the optic tract; if the pupil, under such stimulus, contract, the lesion must be beyond the tract. The intracranial affection giving rise to the hemianopsia may be of malarial origin, and it and the associate cerebral symptoms ^^^ll disappear under active antimalarial treatment.^ ilind-blindnessy physical vision, but failure to realize the psychical import of the things seen, sometimes a symptom of general paralysis and obscure cerebral disease, indicates a cortical lesion in the occipi- tal or occipito-temporal lobe, near by if not conterminous with the visual centre. Hearing. — As regards the sejise of hearing^ the same may be said as of vision. It, too, is perverted and impaired in various cerebral affections. Yet, to be certain that the cause of the difficulty is cere- bral, the ear must first be examined with reference to any physical imperfection ; and in doing so we may by means of the otoscope get an idea of the vascularity of the drum, and be led from this to infer the condition of the vessels of the brain. We must also examine the throat and the condition o£ the Eustachian tube, for catarrhal inflam- mation extending to the middle ear may give rise to a form of aural vertigo. * Se^in limits the centre to the cuneus ; Nothnagel makes it include also the posterior portion of the superior occipital convolution. * See my paper on Malarial Paralysis, with eye examinations hy Harlan, in International Clinics, vol. iii., Ser. I., Oct. 1891. 0 86 DAI. DIAGNOSIS. Great acotpness of hearing and inhilerance of sound are gpner- ally syni|iionjs of extreme nervous irritability, or of beginning cere- bral inflanjination. Deafness may be owing to softening of portions of the brain ; but F'errier tells us that it is not rnet with in destructive lesions of ttie cortex. Deafness is also found as a tt^mporary and by no means tmfiivoraljle synjptom in the continued IVvers. Imaginary^ sounds and rint^ing noises in the ear, or tmniim minum^ are frequent arconipaniments of rerel>ral disorders. But llu* latter is encountered in so many different conditions — in diseases of the cerebral vessels, in congestion of the l>rain, in Meniere's disease, in affections of the heart, in atKenna — that it is a sijrn of little moment : and, in truth, its most usual cause is local, — namely, an arcuniuhition of wax in the meatus. There is a fonn of retlex, the so-called i/imitwal refrx described by Gellti, the disappearance of which is of value, provided we have been able to exclndi' disease of tlie ear. In healHi, wlien a vibrating tuning-fork is placed before one ear, while pressure is made by means of a Potitzt^r bajr on the canal of tlie other» a diminution of tlie sound of the fork is noticed. In disease of tlie cervical cord tJiis rellex dis- appears. Derangement of tlie reflex action jilays a most important part in the study of diseases of the nervous system. Each action is brought about by a sensor)^ nerve that conveys the impression to the centre, by a motor nerv^e that transmits the imj>ulse from the centre to the peripher)% and by a rellex centre between the two m the spinal cord connecting tlie roots of tlie sensory and motor nerves, which with them forms the '* rellex arc/* The reflex centre is to some extent under brain control. There arr two forms of rellexes \o be especially studied, — the 4'utaneous or stijierficiah |»roduced by stimulating the skin, and the deep rethj'xes, the moscle or tendon reilexes, evoked by lapping muscles or tendons. T\w MujterJuvtfJ may bi' almost everj^where €*xcited by tickling or gently stimulating tlie skin. The most usual ones to be noted are the reflex of the sole of the foot, [\w piattfar irfftw ; and that of tlie palm of the hand, I he pahmr refea\ The former, wlien normal, attests the integrity of the rrOrx arc at llie lower end of the cord ; the palmar reflex, contnicllon of the digital llexoi-s by tickling the palm, indicates a nonrial stati* ul' the reflex arc through a greater part of the cervical enlargement. Otht^r superflcial reflexes which may be mentioned are the ereituiMer rejlvj', llie drawing up of ttie testicle excited by stimu- DISEASES OF THE BRAIN AND SPINAL CORD. 87 lating the front and inner side of the thigh, and originating in the cord at a point between the first and second lumbar pairs ; the ghdeal reflex, the contraction caused by irritating the skin over the buttock, and showing the integrity of the cord at the fourth and fifth lumbar nerves; the abdominal reflex^ a contraction in the abdominal walls caused by scratching the skin on the side of the abdomen, and de- pending on the action of the cord from the eighth to the twelfth dorsal nerve*; the epigaMric reflex, an epigastric dimpling produced by stimulating the side of the chest in the fifth or sixth intercostal space, and indicating integrity of the cord from the fourth to the seventh pair of dorsal nerves ; the scapular reflex, a contraction by stimulation of the scapular muscles, and bespeaking the integrity of the reflex arc at the level of the upper two or three dorsal and lower two or three cervical nerves ; the erector spin(e, show^ing itself by stimulating the skin along the border of the erector spinae muscle, the contraction of these muscles showing the healthy state of the cord in the dorsal region. Other reflexes of indeterminate utility are the platysma reflex^ dilatation of the pupil upon pinching the platysma myoides muscle. Among cranial reflexes, the more noteworthy are the iris-contraction upon exposure of the retina to light ; the eyelid-closure from irritation of the conjunctiva ; the pharyngeal, laryngeal^ and palatal reflexes (cough, swallowing, etc.) from irritation of these parts ; and nasal reflexes, as in sneezing. The aural reflexes are of some value in ap- preciating disease of the cervical part of the cord.' In disease these superficial reflexes are often absent. Thus, disease of one cerebral hemisphere diminishes or destroys them on the other side, the para- lyzed side of the body. In pregnancy all reflexes are increased. The superficial reflexes are nmch influenced, increased or diminished, by psychical causes.^ The reflex phenomena connected \\\\h the tendons give us the best illustration of the so-called deep reflexes. The tendon of the patella is the one most readily studied ; and if, the body being bent forward, we strike abruptly the tendon of the patella just below the knee-cap, after rendering the ligamentum patellae tense by flexing the knee at a right angle while one knee-jonil rests upon the other, or the leg hangs loosely over a supporting arm, a sudden contraction takes place in the quadriceps femoris muscle, and the foot is jerked upward. When very slight, the knee-jerk is most readily elicited by a tap with the percussion hammer. This reflex is largely due to a ' Amer. Joum. Med. Sci., Dec. 1888. * Jeii'lrassik, Deulsches Archiv fur kliiiische Medicin, April, 1894. 88 MEDICAL DIAGNOSIS. muscle reflex action de|»endent upon Ihe spinal eorcL There are Several instruiiieiils Ibr measuring ihe knee-jerk. A good one is that of Hayne's.' The knee-jerk is found in heallh, ami is markedly increased in disease of tlie pyramidal Iracts, in lieij^ldened UTital:»iliiY of the gray substance of the spinal cord, in many tumors of the bniin, in cerebro- spinal sclerosis, in lateral sclerosis, alter epileptic seizures or unilateral convulsions, in spinal uTitahilily/-^ It is absent in locomotor ataxia, even at an extremely early ugv of tins atTection. It is also abolished in inlaniile paralysis, hi destructive lesions of tlie lower part of the cord, hi neuritis of tln^ lower extreiiiiti<'s, in advanced stages of pseudoliypcrtrophic paralysis, and, lenipuranly at least, as pointed out by Huglilings Jackson, in nienin^tis and in instances of emphysema and other maladies in whicli the hhH»d has become venous to an ex- treme degree.^ Exceptiojjally it may be absent in liealthy persons ; I have known it so in three brotliers. The tendo-Ai'hilfiji jerk is dieited by tap}>in}^^ tlie tendon when the leg is extended and the foot flexed. If tliis reflex be exaggerated it may appear when tbe ninscles on the arderior jiai't of the leg or the tibia are struck. This constitutes {\w froid'iap rontrudion, Tlie bkeps trfvx is developed by lajiping the tendon of tiie biceps. This leads to coidraction of the biceps muscle. Its meaning is tlie same as that of the knee-jerk. Tapping on the front of tlie wrist gives rise to conlraction in the llexoi-s of the hngers ; striking the tendon of the trkepH above the olecranon causes contraction in the triceps. This is es[)ecially marked in the irritable muscle of the early and late rigidity of hemiplegia. Another deep reflex is ihe perimkitL It is produced hy tapping the bones of the forearm or leg, which gives rise to active contraction of the muscles, and indicates a disease of the spinal cord, especially amyotrophic lateral sclerosis. A slight jaw-jerk, elicited by striking the lower jaw obliquely w^hen the mouth is sliglitly oiienerl, is present in health, and exaggerated in spastic states. Under the latter conditions active flexion of the great toe gives rise to clonus; The im-rfjirju described by Sinkler, is met with only when the knee-jerk and ankle clonus are highly developed. The great toe is strongly flexed ; immediately involuntai7 flexion of the foot follows, then of the leg, and of the thigh on the pelvis. In some instances of disease the reflex phenomena ai^e produced 1 PhiU, Med. Joum,, April 1, 1899. " Hughlin^ Jackson, Mediwil Times and Gaietle, Feb. 1881. *BriU Med. Journ., 1892. Nu. 1614. DISEASES OF THE BRAIN AND SPINAL CORD. 89 on the side opposite to the one acted on. These crossed reflexes are not unfrequently met with in posterior spinal sclerosis, and are not merely associated contractions. A tap on the tibia near its middle generally induces contractions of the quadriceps femoris ; and it is often followed by contractions of the quadriceps of the opposite leg when both the pyramidal tracts are diseased.^ The phenomenon called reinforcement of a reflex may have its use and significance in the diagnosis of doubtful or obscure cases. In testing the muscular power of the hand by the dynamometer, it is well known that one hand has greater power if the other hand be forcibly and synchronously clinched. Any reflex is heightened by coincident muscular exertion of other parts than those being tested, and, if a desired reflex be difficult to elicit, it may be brought out by muscular tension of some other part of the body. Strong irritation of the skin acts in the same way. So slight an outlay of force as that of winking will increase the force of the knee-jerk, if correctly timed.^ When the muscle is cut off from connection with the spinal centres, as in the late stages of locomotor ataxia, the reflex and any reinforcement are alike impossible. Very similar to the knee phenomenon is the foot phenomenon, or ankle clonus^ although its reflex character is more doubtful. It is pro- duced if the foot be suddenly brought into complete flexion by the hand pressed against the sole, the leg being semiflexed, and still more readily if subsequently the tendo Achillis be quickly tapped. A kind of convulsive shaking of the foot results, dependent on alternate contraction and relaxation of the anterior tibial and calf muscles. Ankle clonus is at times, but not often, observed in healthy persons, although it is susceptible of being cultivated ; in lateral sclerosis it is developed to an extraordinary degree. Indeed, it is marked in the class of affections in which the knee reflex is excessive. When pro- duced solely by sudden passive tension of the muscle, it is indicative of structural change in the spinal cord.^ Wrist clonus may be induced in the late rigidity of hemiplegia by pressing the hand backward so as to produce extreme extension at the wrist. A muscle-jerk \s obtained by directly striking a muscle, as, for instance, the quadriceps femoris ; a contraction ensues. The muscle- jerk may be manifest when the tendon-jerk has ceased ; it may be, ' Ross, op. cit. , vol. i. 'Mitchell and Lewis, Tendon- and Muscle-Jerk, Amer. Joum. Med. Sci., vol.' xcii., 1886. 'Gowers, Diseases of the Nervous System. 90 MEDICAL DIAGNOSIS. indeed, found to be exaggerated. Unlike the tendon-jerk, therefore, it is independent of disease or injury to the motor or sensory nerves of a nniscle, or of damage to its related spinal centre. If a muscle be suddenly relaxed, a slow tonic contraction follows which may last for some minutes. The phenomenon is best witnessed in the tibialis anticus, but is rarely seen in the muscles of the arm. This jmrdoxical muscular contraction has no definitely ascertained value. It is sometimes met with in the early stages of locomotor ataxia. DERANGED MOTION. The chief manifestations of deranged motion resolve themselves into the phenomena called paralysis, ataxia, tremor, spasms, and con- vulsions. ParaJysis. — When we speak of paralysis, we mean a loss of the power of motion, although there is the impulse of the will to move tlie aflfectod part. It is true, there is also a paralysis of sensation, a complete anaesthesia, which may be conjoined with the paralysis of motion ; but the latter often happens alone, and is the morbid state meant when we use the word i>aralysis without qualifying it. A slight, incomplete paralysis is called '* paresis," and this term is especially employed when the loss of power exists without demonstrable organic change. Paralysis may involve one member, and is then known as mono^ plet/ia, such as brachial or crural; one-half of the body, hemiplegia; both sides of the body, diplegia ; of the lower extremities, paraplegia. When power is lost in the extremities on one side and facial muscles on tlie other side, the jvaralysis is designated '* alternate" or " crossed." Palsy may come on rapidly or appear slowly. But under any cir- cumstances it is not a disease, but a symptom. The causes which give rise to ix\mlysis may be thus summed up : Paralt/.^iis due to a lesiou oraui/ morbid t^oud it iou of the nervous centres. — Hemorrluigi^ into or softening of the central nervous textures, or any other pn>cess which materially alters or compresses them, or in- terrupts the nuiin conducthig i^iths, occasions loss of power in the piirt over which their intlueni'e in health extends. The complete jKiralysis attending most of the diseases of the brain and of the spinal con! belongs, then^fon\ in this category. But besides these jKilsies of org;\nic origin there are junctional fHihie.^, depondtMit upi>n what, so far as we an^ aware, is simply a functional derangtMuent of the gnwt centn^s of innervation. Hysteri- cal piiralysis, and that occurring afttT overwork or excesst^, and from nervous exhaustion, ari^ examples. 92 MEDICAL DIAGNOSIS. grariH jmmdopftralkitmi^ the designation ^'iven by Jolly ^ to a peculiar condition cliaracterized by undue readiness of fatigue of voluntary muscles after onlinary functional activity. In fatal cases no distinc- tive or constant lesion lias been found, Parali/ms due to the prej^envc of pokon^t in the 4rp^parenlly indej>endent complaini, which may assume eitlier the quotidian or tertian type, and in which both sensation and motion may be affected. How these poisons oj»eVate, whether by intertering with tlie nutrition of ttie ner- vous centres ami weakening their generating force, or by enfeebling the conducting power of the nerves, or, as some of them nndoubfedly do, by setting up a neuritis, is not fully detennincd. The palsies coming nnder this head, being for the most fjarl furu tional, are not ordinarily intractable. Those due to malaria sliow tlie Uialarial cor- puscles in the blood,* and yield speedily to decided doses of qtiinine. Similar to (he palsies of poisons and certain cachexias are the palsies after acute diseases. Yet structural changes have been found in these paralyses of supposed blood origin, and many of tliem are owing lo neuritis. All cases of periodle paralysis are not due to malaria ; a number of instances have, indeed, been recorded which were not.^ They are characterized by transitory and recurring muscular weakness of vary- ing degree and distribution, but without otber constant or distinctive symptoms. Sometimes there is diminished electric irritability of the affected muscles. There may be also enfeehlement of the reflexes, sensor)' plienomena, and increased thirst. In some cases, further, a family tendency is present. In a thoroughly studied case of John K. Mitcheirs five instances happened in the mother's family. The con- dition was thought to be autotoxic* In paralyzed parts the nutrition and secretion are disturbed and the cbcnlation is sluggish; they are frequently swollen and cBdem- atous, the pulse is w^eaker than in tlie sound members, and the * Berliner klinische Wocliensclirin, 1895, No. 1^ p. 1. ' See a paper publislied J)y [iie in nie International Climes, 1891, vol iii. * An elaborate study of this subject has t>een published by Taylor, Jouniul of Nervous and Mental Diseases, Sept. and Oct. 1898. * Transactions of the Assoc, of Amer, Phys.^ 1899» DISEASES OF THE BRAIN AND SPINAL CORD. 91 Paralysis due to a lesion in the course of a nerve, — The nervous force may be properly generated, but the nerve-fibres may be incapable of conducting it. For instance, if a nerve be wounded or compressed, paralysis of the muscles which it supplies takes place. Palsy from this cause is local, and is apt to show marked nutritive changes in the affected part, such as glossy fingers and swollen joints, and to be associated with pain. Paralysis due to an affection of the nerves at tlmr extremities. — ^An illustration of such a disorder is. the palsy resulting from exposure to cold. Peripheral palsies lead quickly to atrophy of the muscles. They are, from their very nature, local, and conmionly remain so. But many peripheral nerves may. become implicated, and extensive palsies result, as seen in multiple neuritis. Motor paralysis due to cold may be met with as a family affection. It has been noticed as thus happening in twenty-two persons, and is clearly described by Rich.* On exposure to cold and damp, especially after depressing conditions, the muscles become fixed and immovable in tonic spasm. Respiration, cardiac action, cerebral phenomena, and sensibility are unchanged ; the muscles of deglutition are affected if cold substances be swallowed. There is intense desire to urinate, but ho derangement of micturition ; the sphincters are undisturbed. Motor power returns gradually and progressively on exposure to heat. Recovery is followed by a sense of exhaustion. The disease is hereditary through many generations. It affects both males and females. Paralysis due to serious interference vnth the circulation, — This kind of palsy is observed if the principal artery of a part be obliterated. It is sometimes •noticed as a transient phenomenon after the liga- tion of a large artery. If the vascular supply of the brain be inter- fered with by the occlusion of a vessel, whether by embolism or by thrombosis, the hemiplegia that results is more permanent and very marked. Far advanced arteriosclerosis may also be among the causes of palsy. Paralysis due to a morbid state of the muscles. — It is doubtful if it be correct to call that paralysis in which the nervous system is not primarily or particularly concerned. Yet certain forms of rheumatic palsy and of muscular atrophy in which the nervous implication is uncertain, but which entail loss of muscular power, may be mentioned here. A loss of muscular power simulating paralysis is seen in myasthenia ^ Medical News, Aug. 26, 1894. 94 MEDICAL DIAGNOHI8. dej^Tee of abolition of musi'ular motion, carefully contrasting it, when one sided, with tlie movements of tlie other side. Is the motion completely abolislied or only impaired? what muscles particularly are affeetiHl ? are concerted movements possible or is there incoordi- nalion? and is the gait ilisturbedi' Moreover, what amount of nms- cular effort is required io overcome special resistance? how is the balancing: power? and how are delicate and combined movements executed when the eyesight is withdrawn? When the power in the arms is only impaired, not lost, we ascer- tain the degree roughly by ttie strengtli of t he grasp. But w^e can do so accurately by a dynamometer. Of tliese, the best is that of Mathien (Fig. 13), consisting of a steel ring^ slightly elastic, which is pressed firndy in the hand and records the pressure. The ability of the patient to preserve an erect position, dafion^ must be noted as well as tlie degi^ee of mrafiug, and whetlier he does so when the feet are brought together and ttie eyes closed (Rombei^'s Fig. VX lign), or also when the eyes are open, wliich bespeaks a much higher degree of disorder. The normal sway with tlie eyes open is in adults about half an mch forward and baekwai'd, and tliree-quarters of an inch laterally. With the eyes closed it is much greater. But the most valuaJjle agent by which to judge of the state of ttie muscles is dedriclfy, especially tlie forms of it known as the induced current, or ** faradization,"'' and the constant current, or galvani- zation/' and the action of eacli must be separately studied. The parts to be examined sliould be in similar positions. We must begin with a weak cmTent, and tlie wet electrodes are placed, one on the muscle itself, the other on some other part of tlie muscle or some indifferent point. Tliis is the direct exeUniton of the muscle. Or the nmscidar action may be evoked by stimulating the motor nerve sup- plying the muscle to be tested. This is itidireet vxciiatioi} ; and in healthy muscles the same strength of current will })roduce the same amount of contraction whether muscle or motor iicrve be stinuilated. It is also important to break the current by slow interniptions - DISEASES OF THE BRAIN AND SPINAL CORD. 96 especially in employing the galvanic current, to compare the positive (anodal) and the negative (cathodal) opening and closing contractions of the diseased with those of the sound side. In both currents, too, we should ascertain what' the quantitative changes are, — ^w^hether the muscles react under a feebler current than is usual or require one of great strength to move them. The response depends upon the in- tegrity of both the muscle and the motor nerve. If this be preserved, contraction takes place with every change in a current of sufficient force. With every interruption and with each establishment of the current the muscle can be seen to contract in health, provided the intervals between breaking and making of the current be not too short. The readiness of response to the faradic current is alike, whichever pole is applied to the muscle or nerve, and also when the current is made and broken; but. With the galvanic current, the readiness of reaction varies both with the electrode used and with the making and breaking of the current. Diminished or lost electro-muscular contractility is a most valuable sign in destructive diseases of the cord. • Indeed, speaking in general terms, we may say that it belongs to spinal palsies, while the electro- muscular contractility is intact in cerebral palsies. But this is only true of spinal palsies when the muscles are .separated entirely from the influence of the cord: those supplied by nerves having their origin in healthy spinal texture preserve their normal irritability. In fact, if the uninjured part of the cord have become irritated, or more vascular, the muscles having a nervous connection with it may show increased susceptibility to the electric current, and more energetic contraction. We also find diminished electro-muscular contractility when the nerve itself is injured ; when there is a mere local change in the muscular texture of the helpless part; and as the result of certain poisons, as of opium, lead, rheumatism, or other blood- poisons, which lower the power of nerve, of muscle, or of nerve- centre. We find it also when there has been long disuse of a limb, as in old cases of hysterical palsy, and even of cerebral palsy. But this is temporary, not permanent; for using the battery for a few days makes the greatest change in the electro-muscular contractility. As already stated, the electro-muscular contractility is normal in the forms of palsy due to brain disease. The palsied limb may have, indeed, its muscles more powerfully convulsed by a current of the same intensity than those of the sound side are, and then we may infer, as Todd ' and Althaus ^ have shown, that the paralysis is due to * Clinical Lectures on the Nervous System. * Medical Electricity. 96 MEDICAL DIAGNOSIS. brain disease of an irritative character. In recent hemiplegias, what- ever their origin, increase of electric excitability is not uncommon. The response of muscle to faradic stimulation is called faradic excUd- bility; and the remarks made are based on the effects obtained by- faradization. With reference to the galvanic or continuous current, or galvanic exeifabilUy^ we find that in a healthy state of the muscles the galvanic current wDl give the same results as faradization, whether muscle itself or its motor nerve be acted on. Healthy muscle and nerve react most readily to galvanic stimulation when the negative pole is applied and the current is made, and, successively, when the positive pole is applied and the current is either broken or made, and, finally, when the negative pole is applied and the current is broken. This so- called '' normal formula" may be represented graphically as follows : K.Cl.C. n A v. p .' K.O.C. ; in which K (cathode) stands for the nega- tive pole, An (anode) for the positive pole, CI (closure) for the making, and 0 (opening) for the breaking of the current, and C for the mus- cular contraction. In diseased conditions galvanism may show the same or it may show^ different reactions from faradism. The muscles of a palsied part may respond actively to galvanization and not at all to faradization. We observe this when the muscular tissue has be- gun to atrophy and to degenerate in consequence of extensive lesions of the cord, in degenerative affections of the motor roots, in trau- matic nerve lesions, and in diseases of the peripheral nerves. While the faradic excitability declines or is lost, the galvanic excitability not only remains, but may be even exaggerated ; and in this '' reaction of degeneration" (De. R.) there are also complete changes in the normal laws of electric muscular contraction ; the anodal closing contraction equals or even exceeds the cathodal closing contraction, tlie cathodal opening contraction declines in the same manner. There is a deviation from the normal order of response, and thus we note qualitative and not merely quantitative modifications. Again, we may find dissimilarities by interrupting the galvanic current, and these may vary whether the current be rapidly or slowly broken. Thus, Russell Reynolds has shown us that in certain instances of facial palsy Ironi exposure to cold, or in paralysis of the limbs fi'om the same cause, or in lead palsy, the nmscles act as little under tlie rapidly hilerrupted galvanic current as under faradization ; but if the galvanic current be slowly interrupted, they exhibit a greater amount of irritability than do the healthy muscles. In these (lases it is found that the muscles are primarily affected, and the application of slowly DISEASES OF THE BRAIN AND SPINAL CORD. 97 interrupted galvanism is rapidly of much service. If is» indeed, well in all cases of palsy, whatever be the form of battery employed, to note the differences in^ the contraction of the muscles produced by slow or by rapid interruptions. Statw or Franklinic electricity may also be employed for purposes of diagnosis. We meet with instances where muscles contract under its use which do not respond to either the faradic or the galvanic current.^ As already stated, a muscle may be indirectly acted on ; one mois- tened electrode is placed over the motor nerve which controls the muscle, the other over its body. In inflammation of the nerve irrita- bility of the muscle, both galvanic and faradic, is increased ; in de- structive injuries it lessens and disappears. It is always well to note the indirect as well as the direct muscle excitation. Put it has not, for purposes of diagnosis, proved itself as generally valuable. We should endeavor to place the one or other of the sponges exactly over the seat of chief nerve-supply in the muscle ; and the ascertainment of the nerve poiht or points that correspond with the entrance of the motor nerves into the muscles has been made a matter of much study. Experience, indeed, proves that from these motor points, determined with infinite care and labor by Ziemssen, knowledge now accessible in any work on medical electricity, and in most on nervous diseases, the readiest control of the muscles is obtained. When the muscles react under electricity the contraction is felt, and the '' electro-muscular sensibility" is more decided the stronger the contraction. Hence we almost always find increased electro-mus- cular contractility with increased electro-muscular sensibility. But the latter may exist alone, as we mostly observe in myalgias. On the other hand, the relationship between diminished contractility and sen- sibility may be changed, as we find, for instance, in the striking want of sensibility to the current in hysterical paralysis. The electric re- actions of the skin, well tested by a metallic brush, as a rule go hand in hand with the reactions of the muscles, increase in sensitiveness with them, decrease Avith them. Such are the chief facts with reference to the diagnostic applica- tions of electricity in paralysis. There is yet another mode of inves- tigation which we constantly bring into use, one also in which the action of the muscles particularly gives us valuable information con- cerning the state of the nervous system, — the testing of the reflex excitahilUy, But we have already examined into the derangement of * See an excellent summary of the diagnostic value of Franklinic electricity by Bernhardt, Samml. Klin. Vort., No. 41, Feb. 1892. 98 MEDICAL DIAGNOSIS. the reflex system, and sliall only add liero a few general clinjcal facts. We find tlie reflex exettiibility diiiiijushed in disease of the ^I'ay sub- stajiee of the rnrd. in disease of the sensory root-fdbres, which thus become incapable of (oodnctin^ ttie ini[)ression, and in disease of ttie motor fibres, wliich fail to impaii Uie motor impnlse. In the laller c^se there is coexisthig paralysis of motion ; in the second, aiiaes- thesia. Increase of reflex excitabilily, producing twitching or even violent irregnlar movement on x^V}' slight stinudation, is found in all uTitativc lesions wliich have increased the excitability of the gray substance of the cord ; as when this is disturbed by inflammation, or compressed by a tumor, or heightened by certain drugs, such as strychnine. Increase of reflex excitability is also found in piirts below a lesioq, when this gives rise to descending degeneration- hi the pyramidal tracts. As regfirds tiie action of the brain, ttiere are instances in whirh, if all power of appreciating impressions be lost, as in overwhelming cerebral apoi)lex!es, reflex action may bo everywhere suspended. On the other hand, irritation traiisferreci I'rom diseased lo healthy parts of the brain may produce spasms or palsy phenomena ; or the reflex actions may be ex( ited in other parts of the body, as the nniscular r-ontraetions in the legs during catheterization or in colics. Here the seat of the perverted reflex action is entirely hi the reflex areas of tlie cord. All these n marks tell us how to examine paralysis. Having now studied the modes in which Ihis is investigated, 1 shall merely recall tliat to find out tlie cause of the difficulty we have to take into ac- count the history of the case, and the attenchng symptoms, nen^ous and otherwise; and in ehciting these we should ne%'er forget to bring out prominently those shown us by the opthalnioscope, and by ex- amination of the uriite and of the heart. Let us proceed to the clinical study of palsies. HEMIPLEGIA. We shall first consider that fonn which almost always results from brain disease. — hemiplegia, or one-sided palsy. Tliis state of Ihings may aft'ect alt the voluntary muscles on one side of the body ; but it generally exists only in tliose of the limbs and face ; the eye. neck, and trunk muscles escape largely, thougti not entirely. Neither the k^gs nor the arms can mrotiruded, fe' * DISEASES OF THE BRAIN AND SPINAL CORD. 99 ordinarily slowly pushed out towards the palsied side ; the articula- tion is imperfect. But the rule with respect to the face being paralyzed on the same side as the rest of the body has its exceptions. Should the lesion be seated in the brain, above the crossing of the facial nerves, both face and body are paralyzed on the side opposite to the diseased spot. Should, however, the lesion involve the facial nerve-fibres at a point below or after their decussation, theue will be paralysis of the face on one side and the limbs on the other, the facial palsy being direct, and that of the body being crossed. Now, according to Gubler, this cross paralysis is always, indicative of a lesion of the pons Varolii, close to which the facial nerves origi- nate, and through which the nerve-fibres for the limbs pass before they decussate lower down. But we must remember that there are rare cases of " alternating hemiplegia," due to a combination of lesions, one affecting a cerebral lobe on one side and the facial nerve oTi the other. Even when the lesion is unilateral, we may meet with exceptional cases ; and, as Bastian ' points out, the lesion may be sit- uated in the pons, the palsy of face and limbs not being alternate, provided the disease occur in the upper or anterior part of one lateral half, implicating the fibres of the facial above their sites of decussa- tion. With reference to the other cerebral nerves, should we find any of them paralyzed on * one side and the body on the other, we shall generally be correct in assuming that the palsy is not due to dis- ease on both sides of the brain, but is rather a disturbance of the aflfected nerve near its origin or in its course, and on the side on which the brain is injured, while the paralysis of the limbs is on the oppo- site side. Anatomical researches which have traced connecting nu- clei on the floor of the fourth ventricle and elsewhere explain these alternating palsies. Hemiplegia, as already stated, results, in the vast majority of in- stances, from cerebral diseases. IJence we find it commonly associ- ated Avith disordered mental powers, and other signs of a brain lesion. The superficial reflexes are, as a rule, though not invariably, dimin- ished ; the deep reflexes are exaggerated. The rectum and the blad- der perform their functions. The non-paralysed side is not wholly Iree from signs of disorder. Mills ^ has given us an interesting study of its condition, and we see that considerable loss of power and associ- ated movements with any on the paralyzed side are common. ^ Paralysis from Brain Disease. * The Nervous System and its Diseases, 1898. 100 MEDICAL DIAGNOSIS. Hemiplejria €aiiset] by an afrectioii of oiie-hall' of tlie spinal cord, near its lie^anning, is not conibiiied witli a rteeay of iho mental facul- ties, but the rmist'les of the chest and al^domen are involved in the paralysis. whi( h Uiey are not in cerebral henii[^legia, unless the lesion be very extensive. Then in sphud hemlplefpn there is a zone of an- aesthesia on a level with the Irsion. and eoexisting antesthesia, as Brown-S^quard has shown, on the side opposite to the lesion and the muscular palsy, and the temperature sense is impaired* as is the sen- sibility to pain ; the palsied liirih givrs evidenci^s of vasomotor paral- ysis, has at first a hi^^ier temperature, and is hypertesthetic ; reflex adion is inrreasrd \m the side of the lesion, the muscular sense is impaired, and the umbiheus is with every act of inspiration draw'n tow^ards the sound side. We possess a further test in electricity : unlike wliat we find in cerebral prmilysis, the electro-muscular con- lra<'tility is greatly lessened or is lost. Spinal hemiplegia, or "'herni- para[>ie^ia»" iis it is more often called if the lesion be low down, oc(*iirs from injuries, tumors, syphilitic disease of the cord, and locfil- ized sclerosis. Spinal henuplej^da is more persistent in the leg than it is in tlie arm. In Ijeimplegia due to cerebral disease recovery is more rapid and more nearly perfect in the leg than in the arm. But supposing that we have setlled the hemiplegia to be cereliral, the points next to he investigated are, where is the lesion situated? and what \b its nature? Now, the former question, concerning the (frKffommtl iltarpwAis. may be answered in a general way by stating that the disease is on the side opposite to the palsy, if the lesioti, as it almost always is, be seated alicrve the point of decussation of the pyramidal columns of the medulla; for a lesion below the decussa- tion gives rise to ]>alsy on the same side, and a lesion on a level with it, to double-sided palsy. Lesions of the posterior segment of the in- ternal capsule give rise to typical hemiplegia; sometimes with hemian- ijeslhesia and loss of tlie special senses. Lesions of thecor|)Us striatum cause motor and sensory symptoius only when they involve the in- ternal capsule. T]w same is true of disease of the optic thalamus, except that mobile sjjasm and incoordination of movement liave been observed to follow lesions of its mid*he third. The nearer the lesion to the surface, the more marked are the mental phenomena, tlir^ greater is the tendency to sjjasms in the limbs, but the more limited is tlie palsy ; and tlie faiilier the disease extends towards the udernal cupsule, tlie more extensive does the paralysis of motion l>ei*ome. We may l\irther distinguish the palsy which ensues from tliat caused by an aftection lower down, as of the pom Varolii, by observing tliat, besides the peculiar crossed pai^alysis DISEASES OF THE BRAIN AND SPINAL CORD. 101 of the face and limbs, we find giddiness and a tendency to vomit ; either loss of the conjugate movement of the eyes towards the side of the lesion, or conjugate spasm with nystagmus ; jerkings of the muscles of the face on the side opposite to the injury ; sensations of tickling in the face ; one-sided facial anaesthesia, with a loss of sense of taste on the corresponding side, though with unimpaired motion of the tongue ; rigidity of the limbs, and spasm of the muscles supplied by the fifth nerve; disturbance of respiration and of the heart; albuminuria; glycosuria; high temperature. Should we encounter paralysis of sensibility and motion on one side of the body, and both sides of the face be palsied as to motion and sensation ; should the recti muscles of the eye be paralyzed, and taste be lost over the anterior part of the tongue, we may infer that the injury is seated rather above the lower portions of the pons, and afifects the spot where the facial nerve and part of the trigeminal cross.' Hyperpyrexia is not uncommon after the onset of an acute lesion of the pons, and in acute lesions convul- sions^ are also usual, as is marked contraction of the pupils. In lesions involving the central parts of the pons, paralysis, mostly un- equal, of both sides of the body, with impaired sensation, irregular facial palsy, difficulty in deglutition and articulation, is the rule. Lesions of the lower and inner part of the orm cei^ebri are recog- nized by an alternate paralysis, in which the third nerve is palsied on the aflfected side of the brain, showing us want of action of the mus- cles of the eyeball, except the external rectus and superior oblique, ptosis, a dilated pupil, a tongue deviating to the paralyzed side, some difficulty in articulation, the palsy marked in the arm and leg, and coexisting with increased local temperature, vasomotor disturbance, and very defective sensation. Acute lesions of the medulla are likely to destroy life; in case they do not, the resulting symptoms are often bilateral and include derangement of the functions of the bulbar nerves. Besides these well-attested facts, the brilliant researches of the day on the localization of cerebral functions have solved, and are still solving, many problems as important to the physician as to the physi- ologist. Let us look at some of the additions to pathological knowl- edge which appear the most certain, premising that in localization only symptoms that are permanent are of value, since any lesion, an acute lesion especially, may for the time being cause vascular or in- hibitory disturbance in adjacent parts. We must also be mindful of * Brown-Sequard, Dublin Quarterly Journal, May, 1865. * Gowers, Diseases of the Nervous System. 7 102 MEDICAL DIAGNOSIS. Broadbent's law, that one-sided movements can be excited from either hemisphere, and tliat the loss may be soon compensated by the hemi- sphere with which they are not habitually associated. This becomes often manifest in damages of the cortex. We shall first glance at lesions of the vioior zone,, including tlie as- cending frontal and parietal convolutions, the anterior two-thirds of the superior parietal lobule and paracentral lobule, parts supplied by branches of the middle cerebral arter>\ A lesion of these cortical structures causes paralysis of motion without marked loss of sensation. The hemiplegia is more or less complete according to the extent of the motor area involved. It is on the opposite side to that of the disease, and neither the nutrition nor the electric contractility of the palsied muscles is impaired. The cmiieal hemipk^ia^ when sudden, is less frequently accompa- nied by loss of consciousness, is rarely complete from the first, alfect- ing, perhaps, at the onset only the face, an arm, or a leg, and is soon followed by rigidity of the palsied parts. It is apt to be transitory, to show slighter differences in temperature between the two sides, and to be accompanied by localized pain in the head, which may be elicited by percussion over the seat of the lesion, and by temporary aphasia.^ There is no impairment of sensation in lesions of the motor cortex.^ Limited palsies, monoplegias^ are much more com- mon in disease of the cortex than in disease of deeper parts. The leg alone is affected in lesions of the medial cortex or those near to the longitudinal fissure. Irritative lesions of the cortex have as their most characteristic sign unilateral convulsions. In disease of the middle third of the central convolutions the convulsions generally begin in the hand. Disease of the ascending frontal convolution, behind the inferior frontal, gives rise to paralysis of the face, lips, and tongue. Lesions confined to any one of the gray caiiral ganglia^ where the internal capsule is not involved, do not afford any special feature by which they may be distinguished from common cerebral hemiplegia. There is paralysis of motion only, which, Charcot^ tell us, is gener- ally transitory. If the anterior two-thirds of the posterior limb of the internal mpmle be involved, the palsy is still exclusively of mo- tion, though it is more or less persistent, and ultimately accompanied by muscular contractions ; if the posterior third be also involved, we ^ Ferrier, Localization of Cerebral Disease. "^ Mills, The Nervous System and its Diseases, 1898. ' Lectures on Localization in Diseases of the Brain, New York, 1878. DISEASES OF THE BRAIN AND SPINAL CORD. 103 have in addition cerebral heniiansesthesia. Smell may also be lost on the anaesthetic side, and hemianopsia be met with. In disease of the angle and posterior segment of the internal capsule we have hemi- plegia of the ordinary type. Indeed, in lesion of the corpus striatum the hemiplegia is permanent only if the internal capsule be involved in the damage. A lesion of one optic tract or of the cortical visual centre in the occipital lobe will cause bilateral homonymous hemianopsia ; a simi- lar eflfect is sometimes produced by a lesion of the corpora geniculata on one side. There may be considerable hebetude, but no other marked symptom of an affection of the brain except hemianopsia. In lesions, also, of the prcefrontal Jobes^ that part which, in its relation to the skull, is roughly bounded by the coronal suture, there is no disorder either of motility or of sensibility. The manifestations are simply those of restlessness and unsteadiness of mind, mental apa- thy, impairment of judgment and reason, and other psychical disturb- ances ; a tendency to make jokes has also been noted.^ Yet the frontal lobes of one side may be totally destroyed without changes in mind or character.^ There is no motor paralysis except of the foot. Late in the case, among pressure and invasion symptoms, we may find motor aphasia, nystagmus, and unilateral convulsions.^ In dis- ease of the temporosphenoidal lobe we have deafiiess in the ear oppo- site to the lesion, if left-sided sensory aphasia, and sometimes con- vulsions with preceding auditory aura. There is no hemiplegia. The nature of the paralyzing lesion, the pathological diagnosis^ can be arrived at only by a careful scrutiny of all the facts of the case. A sudden paralysis occurring simultaneously with coma almost always has its origin in an apoplectic effusion, more rarely in cerebral em- bolism or thrombosis. A sudden paralysis without coma is generally due to plugging of the vessels. A gradual development of palsy in- dicates some chronic cerebral disease, such as chronic endarteritis with altered brain nutrition, or a tumor, or any affection compressing the nervous substance. We may also gain much knowledge by care- fully exploring the organs of circulation and the kidneys. Thus, a paralysis found to be conjoined to a cardiac malady or to a diseased state of the arteries is, in all likelihood, owing to a clogging of one of the cerebral arteries, and to consequent tissue-change in the cere- bral structures. When the kidneys are seriously disordered, the ^ Oppenheim, **Geschwlilste des Nervensystem, " in Nothna^Fs System. * Case of Bailey, ** Hemiatrophy of the Brain/' Amer. Joum. Med. Sci., March, 1809. ' Mills, Cerebral Localization in its Practical Relations, 1889. 104 MEDICAL DIAGNOSIS. hemipjegia is likely to be caused by some chronic disease of the brain or its vessels, the result of an altered nutrition. The ursemic con- dition itself seems also capable of causing loss of power, sometimes of hemiplegic type. In paralyzed limbs we are apt to meet ^vith rigid states of tlie muscles due to tonic spasm, which, when they produce spastic mus- cular shortening, are called contractures. Under ether or chloro- form anaesthesia these disappear. When the paralyzed limbs exhibit a rigid state from the moment of or soon after the attack, the early rigidity points to an irritative lesion, such as a compression of healthy brain-tissue by an apoplectic clot. Late rigidity, if persistent, generally becomes associated \vith wasting of the muscles, and with central de- generation of the motor tracts. It is generally combined with excessive tendon reflexes, muscle jerk, and \\ii\i ankle clonus. Under excite- ment the paralyzed arm and leg may be strongly flexed, and automatic movements may occur when the patient sneezes.* We may also on the palsied side meet with tremors ; with attacks of true spasms, happen- ing particularly in the arms; with joint-disease and nodes; and with choreic movements, a condition to which, under the name of *' post- paralytic chorea," Weir Mitchell * has called attention. In some cases of hemiplegia there is much pain in the stricken limb. The pain may precede returning motion, and is thus of favorable augurj'. But in limited disease of the internal capsule affecting the sensor)'' path the pain in the palsied limbs may persist through life. In old hemi- pl^as the surface temperature is lower than on the non-paralyzed side. Hemiplegia may be feigned} But the results of electricity, espe- cially where altered sensibility as well as defective motion is simu- lated, and the test proposed by Hughlings Jackson, that the arms do not, as in real hemiplegia, fall forward when the patient stoops, but are retained at the side, will usually detect the fraud. MONOPLEGIA. When we have limited lesions we have limited palsies, and re- searches on localization are teacliing us more and more accurately to recognize the centres affected in these palsies ot special parts, or of one limb, or of a group of movements. Of course, in making a diag- nosis of the paralysis benig due to disturbance of a special nen-e- ' Ross, Diseases of the Nenous System, 1883, vol. i. p. 187. * Amer. Joum. Med. Sci., Oct. 1874 : also Med. News. April, 1893. • For an instructive case see London Lancet, April, 1874. DISEASES OF THE BRAIN AND SPINAL CORD. 105 centre, we must be careful to exclude, as the cause of the local palsy, peripheral affections, and those in the course of the nerve supplying the stricken pari:, and also to make it clear that the lesion is not spinal of very circumscribed kind. In monoplegias the palsy is never complete. Furthermore, it is always important in a given case to separate the symptoms which may be due to invasion of or to press- ure on adjacent centres from the localizing symptoms of the main lesion. Let us now take up some of the limited palsies dependent on cerebral disease, especially in the motor areas of the cortex. One arm only is paralyzed. — Here we find the lesion in the as- cending parietal and the ascending frontal convolution on the side opposite to the palsy, and the disease is limited to the middle third of the convolutions. If the lesion be double, as in a case referred to by Bourdon,^ both arms are helpless. But, whether single or double, with the damaged motion there are unimpaired sensation and electro- motor contractility. Disease of the ascending frontal opposite the upper half of the inferior frontal convolution gives rise to palsy of the lower part of the face except the lips. One arm and the same side of the face are paralyzed. — In this " brachio-facial monoplegia" the lesion is in the central region of the cortex, towards the middle or lower third of the ascending convolu- tions in the facial and arm centres. It is a purely motor palsy, asso- ciated, however, usually with aphasia when the disease is left-sided. The main movements of the muscles of the upper part of the arm are kept, while those of the hand are lost. Palsy, of cerebral origin, limited to one side of the fa^^ without the arm being implicated, is rare ; the cortical disease is in the centre for the facial r^on. The affection is usually left-sided, and is apt to become complicated with aphasia. The lower part of the face bears the brunt of the palsy ; unlike Bell's palsy, the orbicularis and the upper part of the face are but little, if at all, disturbed ; ^ further, there is no disease of the tem- poral bone to explain the localized palsy by an injury to the facial nerve. The tongue is also very generally implicated. The kg only is paralyzed. — This is a very rare form of paralysis, and presupposes a lesion limited to the motor centre for the leg. The centre for the leg and foot is fixed by the researches of Horsley and Schaefer as occupying the uppermost portion of the ascending frontal and parietal convolutions. In some of these cases of " crural » Bull. Soc. Anal., 1874. ' This is strikingly illustrated in a case reported by Guiteras, Phi la. Med. Times, Nov. 1878. 106 MEDICAL DIAON081B, monoplegia'' on record the asceritling parietal and superior parietal convolutions have been foujid diseased. Sensation is not atfected ; the ami is apt to become gradually mvolved in the palsy ; in Fenier's case^ the lesion was in tlte quadrilateral lobide on the internal aspect of the hemisphere and in tlje U|jper extremity of the ascending parietal and frontal convolutions. There are many other kinds of limited palsies of cerebral origin, sucli as of the tongue, f/lomiO]Jf*f/ia, of the face and tongue, faelv- Umjiial monopkykt, of the eye muscles, oculmnotor monoplegia, and half blindness, hemkntopsia, to all of which I can only refer, since our knowledge is not definite enough to lay down concise conclu- sions for diagnosis. In part, too, they will be discosseil farther on. It must, however, be added that in all these limited palsies trace- able to disease of the brain we are apt to have such symptoms as are common in bmin affection, —headache, giddiness, and Uie like. These aid us in understanding the nature of the disorder. PARAPLEGIA. This difiFers from hemiplegia in the palsy occurring on both sides, yet being, in the vast majority of instances, limited to tlie lower or the upper extremities. Its almost invariable cause is a lesion of the spinal cord. In truth, if we call hemiplegia jiaralysis from bniin dis- ease, we may call paraplegia paralysis from spinal disease. Paraple- gia is genendly due to a marked organic lesion ; but there are cases in which it exists independently of any recogniscable structural change, and in which it results from poisons, from fatigue, from excesses. The disorder generally comes on slowly. At first the patient only loses the steadiness of his gait ; gradually he is deprived of all power of motion, but the intellect and the nerves of special sense remain un- affected. If the lesion be in the lumbar part of the cord, the palsy is confined to the lower extremities and to the pelvic muscles ; if the dorsal portion be attacked, we find, in addition, signs of paralysis of the abdominal walls and of the sphincters, tympanites, and somewhat impeded breathing. In disease of the upper section of the cord there is coexisting palsy of the upper extremities, with dilated, sluggish pupils, and difficulty m deglutition and in respiration. In the muscles supplied by ner\^es which originate in heallhy maiTow, involuntary contractions or refiex phenomena can be induced, — are, indeed, gen- erally exaggerated, — and the striking effects of strychnine, when given in doses sufficient to produce its peculiar .muscular spasms, are mani- DISEASES OF THE BRAEST AND SPINAL CORD. 107 fested. The palsied muscles, in the majority of the affections occa- sioning the paraplegia, undergo wasting, and often do not respond to the electrical stimulus. Paraplegia is generally more marked on one side than on the other, and the paralysis of motion is apt to be associated with complete an- aesthesia. When, as sometimes happens, the mischief is limited to a lateral segment of any part of the cord, there is paralysis of mo- tion on the same side of the body, and of sensation on the other. Preceding, or even attending, many cases of paraplegia, is a symptom which belongs exclusively to affections of the cord : a spasm of the flexor muscles of the lower limbs, so powerful that the anterior parts of the thighs come almost in contact with the abdomen, while the heels are drawn up so as to touch the back of the thighs.^ Let us now take a cursory view of the different forms of spinal paraplegia. ^ SUDDEN PARAPLEGIA. Spinal Hemorrliage. — Sometimes the paralysis occurs suddenly, and in consequence of an injury to the spine, of a displacement sub- sequent to a disease of the bones, of blood extravasated into the canal, of poisons, as the lathyrus sativus,^ or of bulbar or spinal dis- order from sudden displacement of the cerebro-spinal fluid following blows on the head.' When either of the first two causes has led to the sudden palsy, the diagnosis is materially aided by the history of the case, and by a close examination of the vertebral column. But if there be no signs of a disease of the bones or of the intervertebral cartilages, we may suspect a spinal hemorrhage to have produced the sudden and complete paraplegia, developing as it does in a few min- utes ; and this suspicion becomes much strengthened if violent local- ized pain in the back exist or have preceded the rapid palsy, if the patient be unable to retain his urine or faeces, and if the affected limbs be relaxed and largely deprived of sensation. The seat of pain corresponds to the seat of the apoplexy. The pain occurs in dis- tressing paroxysms and passes along the course of the nerves com- pressed by the extravasation. Where the hemorrhage is meningeal, there is more persistent pain, with rigidity of the spine, spasms of the legs, slighter disturbance of sensibility, much less quickly in- creasing paralysis, and there is more apt to be spasmodic retention of ^ Brown-Sequard's Lectures on the Nervous Centres, p. 114. * Irving, Indian Annals, No. 12, referred to in Brit, and For. Med.-Chir. Rev., Oct. 1860. • Duret, Traumatismes cerebraux, Paris, 1878. 108 MEDICAL DIAGNOSIS. urine. The absence of early fever distiiig-uishes the spinal hemor- rhage from spinal meningitis ; subsequent fever bespeaks the occur- rence of this as a complication* The muscular spasm is sometimes so severe that it has been niistakeu for tetanus, whicli lacks the \io- lent pain in the back. The most conunon causes of sphial hemor- rhage are blows and falls on the back or falls on the feet. It is also met with in diseases with hemorrhagic tendencies, in convulsive affections, and in the course of iiiyeliUs, Hemorrhage into the mem- branes may result from the rupture of an aneurism of a vertebral arter\\ Paraplegia sometimes develops in persons who emerge directly from compressed air into the ordinary atmosphere, as, for instance, divers and workers in caissons. There may be besides numbness and tingling, nausea and vomiting, headache^ vertigo, a sense of throbbujg, palpitation, oppression of the chest, bleeding from the nose, and loss of consciousness. The condition is believed to be due to sudden setting free of gases dissolved in the blood as a result of the increased pressure. But besides these causes, others lead rapidly to paraplegia. Soften- ing of the cord may have progressed latenliy until the degeneration destroys the continuity of tlie conducting tubules, when palsy at once takes place. Then there are cases follow^ing violent exercise or sexual excesses, cases for w*hich neittuT during life nor after death an oi^nic cause can be assigned/ anil wliich are regarded as due to enfeeble- ment of functional power. The disorder is much more apt to come on quickly than graflually, and rest imd a tonic trealnient are likely to be followed by decidedly good etrects. But in regard to all these cases of ftmctional palsy, ttie same as in regard to reflex palsies, science is more and more narrowing their number by finding some orgaiuc affection in the cord, otlen secondary to «in ascending neuritis. Indeed, their ven' existence is now for the most paii denied. Acute Ascending Paralysis.— Yet another variety of paraple- gia which may happ*Mi rajiidly is (Jiat form which has been described as acnte aaeendhn; ptirttitf^is, or Landry's paralysis. 11 may come on ailer fatigue and exposure in persons in perfect healtli, genenilly in men between twenty and forty years of age. Usually there is little or no fever except at the onset. Numbness and Ungling, and slight pain in the lower extrenuties, are soon followed by loss of muscular power, which, in tuni, goes on rai^idly, generally in a tew days, to complete * For instance. Case XYIIL in Gull's series in Guy's Hosp. Rep., voL iv,. 0d Series. DISEASES OF THE BRAIN AND SPINAL CORD. 109 paraplegia. The legs are relaxed and immovable, the muscles of the tnmk are next affected, then the upper extremities become implicated, and sensation, which at first was normal, is somewhat enfeebled though never to a marked degree ; occasionally the arms are involved before the legs. The patient is restless, sleepless, but his intelligence is, as a rule, imimpaired, and we find no bedsores and no palsy of the bladder or rectum. The respiration and circulation in the progress of the disease become embarrassed, inability to swallow occurs, there is acute enlargement of the spleen, and sudden death ensues within a month from the time of the seizure,^ or, indeed, the case may end fatally in less than a week. But all cases do not run so rapid a course ; and, in truth, we meet with instances in which the disorder is rather chronic than acute, or is arrested. The muscles do not atrophy, and their electrical excitability is unimpaired, which is a very valuable diagnostic test. About the reflexes the statements are conflicting. It is most likely that at first both the superficial and the deep reflexes are absent, and that they do not return, certainly the knee-jerk does not, except when the paralysis passes away. Jaccoud ^ tells us that in the cases he observed the reflex movements were abolished. In Mills's case ' which recovered, both the superficial and deep reflexes were completely lost. The disease occurs generally be- tween the ages of twenty and forty, and follows toxaemias and infec- tions, such as influenza, diphtheria, typhoid fever, and smallpox. Gowers mentions a case following pelvic cellulitis.* The malady is looked upon as being an affection of the peripheral nerves, though the central nervous system is not infrequently involved. Toxic in- fluences of invading micro-organisms are thought to give rise to it.* The disease which most resembles acute ascending paralysis is acute progressive or multiple neuritis. But here sensation is rapidly lost, and so is the electrical excitability. Multiple Neuritis. — When nerve after nerve rapidly inflames, or the inflammation occurs at one time, an extensive palsy is quickly developed. The disease is an affection of the peripheral nerves, though it has the misleading symptoms of a spinal malady. It attacks both sexes, is most common between the ages of thirty and fifty, and, though it may follow altered blood-states or rheumatism, or be due ^ As in the case reported by Hayem, Travaux de la Society Medicate d' Obser- vation, tome ii., 1867 ; see also Leyden's Klinik der Riickenmarkskrankheiten. ' Clinique Medicale. * Transactions of the Assoc, of Amer. Phys., vol vii., 1892. * Diseases of the Nervous System, 3d ed., 1899. * Cramer, Centralblatt flir Pathologie, Jan. 1892. no MEDICAL DIAUN08IB, to exposure, by far its most frequent cause is clirouic alciiolisui. It has been obsen^ed in the sequence of a number of infectious diseases, toxtemias and septicceniias, and also as a result of tlie medicinal administration of arsenic, of lead^ and of silver. It has generally an acute or a subacote beginning, with decided increase in temperature. At first vague, then more decided pains are felt in the extremities, chiefly in the fingei-s and toes, and these pains soon become darling or biu*niiig and oiay occur in paroxysms. Tlie pain is often preceded by tingling aJid by cramps, is increased by motion, and is associated with tenderness of the affected nervT-trnnks and with both skin and muscle tenderness of the parts to which tJiey are distributed ; finally this increased sensibility may give way to ana*sthesia. , Tite palsy shows itself often llrst in the arms, the earliest loss of power beuig evident in the extensors of botli sides. Soon liie muscular weakness is seen also in the legs, and tlie trunk muscles and face muscles may become involved. But the first signs of palsy may be in tlie legs, and manilt^st itself in a poculiiir gait. The sym- metrical character of the palsy is always noticealile, as are also the double \^Tist-drop and foot-drop. The piirts attected waste, and lose their reflex excital>ility ; the loss of ttu' knee-jerk is especially pro- nounced. The muscles do not react to faradization, though they may to galvanism ; often, indeed, they present the reaction of degeneration : the oeiTcs are uninfluenced by the electric stimulus. (Edenui of ttie arms and legs is fretjuent, and profuse sweating is not uncommon. Sometimes muscular incoordination is the most prominent symptom. The disease may run on to complete palsy of f he limbs in less tlian two weeks, and deatli result from paralysis of the respiratory muscles ; or the aflection may pass into a ctironic condition, and a slow unprovement, with return of power in the muscles, take place. In protracted cases contraction of unopposed muscles occasions de- formities, and there are arthritic adhesions, glossy skin, and thicken- ing of the skin. The diagnosis is generaUy easy- The tingling in tiie extremities, the cutaneous and muscular sensitiveiiess, tlie distribution of ihe synij>- toms, the early development of muscular weakness, and the palsy of the extensors distinguish the disease from rheifmatiRm, In some in- stances, where it is diflicult to eUcit tendeniess of nen^e-trunks, or w^here this sjinptom is wantuig, where the muscular tenderness is not marked, where, moreover, t!ie palsy is slight and incoonJination of movement is observed, the similarity to lommoior ataa-kt is great, and the eye-symptoms of this aflection aJone, if present, will help to a correct conclusion. Further, girdle-sense and lightmng-pains are DISEASES OF THE BRAIN AND SPINAL CORD. Ill absent in peripheral neuritis, while wasting is not generally observed in posterior sclerosis. In ordinary cases the greatest resemblance is to those instances of am metallic poisons the disonier b coo- ^ued to the anns. as in levari pK>isoning. or is found in the aims fiist aijd subsequently attar^ks the legs, as in the nenritis of flr^»»nira; poisoning, fn malarial neuritis the legs are first attacked* and tb^ neural malady may be confinerl to them. The nenritis dne to ffipih theria often gives rise to paralysis of the palate, of the fauces, of at- commodation. and of the lower extremities, at times closely sma- lating locomotor ataxia. Neuralgic pain of irregular dxstribation. wSh' sugar in the urine, is characteristic of the neuritis of diabetes. In alcoholic neuritis all the limbs are affected, the pains are very seTere, and both aides of the fere may become involved- Symptoms much the same with reterenre to the distribution of the motor and sensory disturiiance happ»*n in the multiple neuritis firom cold. In the toxic cases the iSai^e fs aJao ?ipt to be involved, and the optic nerves seem to be only in them Verted. The s\Tnptoms due to the neuritis of leprosy resemble great):!? thfi^ of syringo-myelia. In pyemic and septicsemic cases there are the history and the pyrexia to guide us. In the multi- ple neuritis of influenza comparatively little pain occurs: but con- siderable palsy, some facial paralysis, and difficulty of swallowing are not uncommon. Multiple neuritis may occur in the old without ob^^ous cause. In some cases it manifests a peculiar tendency to recurrence. IxFECTious PARALTr^Fi*. — Tliese are specially seen in children, and are mostly of the spinal or f>^'ripheral type, though they may lye cere- bnil, or o( Mur in varierl rombinafion. We may find them affecting tin* two arms or the two U-^. or all four limbs. Many of the cases «u'<' clearly iiisfiin^e?i of multiple nenritis, others of neuritis associated Willi myelitis: the pfilny i.^ frequently very wide-spread. These infec- tious paralyses :»r*' nofir^d after influenza, tj-phoid fever, measles, 8('url(»t fever. diphfhrrliagic form of pachymeningitis interna having tlie same causes as h;enialotna of the dura mater of the brain, and often accompaJiying it. Myelitis.— Myelitis ]>resen(s many of the same symptoms as spinal menuigitis, with which, in fad, it may be associated. Fre- quently llie symptoms come on by slow de^Tees, anti the paraplegia, a very distinctive symptom, gradually becomes complete. There is strong knee-jerk with ankle cloruis. Contractions of the muscles are uncommon, and not permanent, iirdess late in the disease j the muscles are usually flaccid; there is comparatively little pain, none on pressure at any piart of the spine, or on motion, and anaesthesia sooner or later shows itself. Further, we generally, though not con- stantly, lind the urine alkaline, and, as a rule, retention of urine and a want of control over the rectum exist, bedsores fonii readily, and the temperatm-e of the palsied is lower than that of the healthy parts. In acute cases there are, as in acute spinal meningitis, raised tem- perature and a frequent pulse. The fever is moderate and irregular. There is pahi hi the t)ack, not increased by movements, and pain in the limbs preceded by numbness or burning. In many instances we ^ notice erection of the penis. Spasm m the extensor muscles is^H always of signincam'e. Ftellex movements in the relaxed palsied ^ Ihnbs are gradnally abolistied as tlie process of intlanunation and softening affects the gray matter of the cord. In dorsal myelitis the trunk rellexes are impaired, but the reflex excitabilily remains ex- cessive in the parts supplied by nerves arising below^ the level of the gi'eatly diseased centres. In disease of the lumbar enlargement the knee-jerks are wholly lost. An altered sensibility to heat and cold, when, for instance, a sponge soaked in warm w^ater or a piece of ice is applied to the spine over Uie mflamed spot, has been sjioken of as a diagnostic lest ; in eilher case the sensation, when the diseased part is reached, changes to a burning sensation, Tliis symptom is, however, far from conslant, and cannot DISEASES OF THE BRAIN AND SPINAL CORD. 115 be accepted as conclusive. There is a zone of hyperaesthesia at the level of the lesion, and corresponding to this a zone of constriction or " girdle pain." Below the level of the lesion the loss of sensation is complete. The paraplegia, even in acute cases, is not suddenly developed. Yet we meet \vith exceptions. There are instances in which it comes on almost as rapidly as in spinal hemorrhage. These are mostly instances of hemon-hagie viyeliti^; yet even these are generally preceded by tingling in the limbs and other sensorj^ disturb- ance, and there is fever, but not the acute spinal pain of hemorrhage. A paralysis of the bladder may be the first symptom of myelitis, and paralysis of motion and of sensation quickly follow.^ Myelitis may be the result of cold and exposure, of over-exertion, of sj^hilis, of peripheral irritation, of pressure, as from disease of the vertebrae, of tumors, connected with the bones or membranes, of parasites, of aneurisms, encroaching on the cord and setting up dis- ease there, of injuries to the cord, or of concussion of the spine after railw^ay accidents. It is sometimes met with in the course of measles and of smallpox, and of typhoid and typhus fevers and toxic blood- states, such as gout and syphilis. Compression as a cause has been noted in the cervical as well as in the other portions of the spine. Paralysis of the arms, with dilated or contracted pupil and very slow pulse, is among the chief symptoms of the " cervical paraplegia." Pain in the limbs, hypersesthesia, muscular contraction, spasms, and great reflex irritability are among the earlier symptoms of this as of all the other forms of myelitis from pressure ; but as the case pro- gresses the reflex irritability is lost. Yet recover>% almost complete, is possible.^ Unilateral flushing and sweating have been observed and a retro- pharyngeal abscess may form. When the dorsal region is involved obvious deformity may be present. The paralysis of the lower ex- tremities develops late and progresses slowly. Radiating pains are present, and the knee-jerks, occasionally absent at first, finally become exaggerated. Compression of the lumbar cord is attended with loss of control of the sphincters, while the knee-jerks are lost. In looking at the symptoms which mark the extent and exact site of the inflammation, we find in the common form, where tlie disease affects a considerable portion of the thickness of tlie cord, — transverse myelitis, — with the ordinary symptoms of complete para- plegia and anaesthesia, that the reflex excitability is lost in the parts ' Erb, in Ziemssen's Cyclopaedia, vol. xiii. ' Buzzard, Brain, April, 1880. 116 MEDICAL DIAGNOSIS. supplied by the nerves coming from the afifected portion of the cord, and is preserved or increased in the parts supplied by nerves arising from the cord below the diseased area/ and the muscles respond to the electric current. This is not the case in central myelitis, which, moreover, usually runs a rapid course, in which there is speedy loss of sensation and of reflex action, and in which muscular atrophy soon shows itself. In disseminated myelitis, a form where several foci of in- flammation are present, there are lulls and exacerbations, tlie paral- ysis is not so constant nor so complete, although it may be in all four limbs, spastic symptoms are not uncommon, and the disease develops itself after acute maladies, as after smallpox. Hemorrhagic myelitis is usually central ; the paraplegia comes on in less than an hour. In children the anterior comua are apt to be affected, and the disease is known as poliomyelitis. Spinal Scleroses. — Sclerosis of the spinal cord may be primary or secondary. The latter is represented by the descending or ascend- ing degenerations that follow lesions of brain, cord, or posterior nerve- roots. In the former are included the so-called system diseases, — posterior sclerosis, locomotor ataxia, and lateral sclerosis. The scle- rosis where brain and cord both suffer, we shall discuss with the forms of tremor ; posterior sclerosis of the cord produces the symp- toms of locomotor ataxia, not of palsy. Lateral Sclerosis. — Primary sclerosis of the lateral columns in which the anterior horns are not affected shows the group of symp- toms described as spasmodic dorsal tabes by Charcot, or spastic spinal paralysis by Erb. It is characterized by a sensation of weakness in the back, a gradually increasing loss of muscular power in the lower extremities, proceeding slowly from below upward, and associated with reflex spasms and persistent muscular contractions, with- in- creased tendon reflex, but without impairment of sensibility, or trophic disturbances, or bedsores, or vesical disorder. The muscles are well nourished, or only very slightly wasted ; the gait is peculiar, the walk being on the toes, and as the foot touches the ground a trembling happens. Sometimes there is marked contraction of the adductors of the tliighs, and the knees are in contact or even crossed. The function of the sphincters may be enfeebled or lost. No cerebral symptoms whatever exist; the electrical excitability is either normal or somewhat lessened. In rare instances the disease begins in the upper extremities; it is almost always of very slow ' According lo Bastiaii, total transverse lesion high up in the cord abolishes the knee-jerk. DISEASES OF THE BRAIN AND SPINAL CORD. 117 development. Occasionally it terminates in recovery. It is most likely that the disease consists essentially in a primary sclerosis of the pyramidal tracts, or of the terminations of their fibres in the motor cells of the gray matter. But whether the group of symptoms may not be produced by various lesions of the cord is not settled. To an infantile form of degeneration of the lateral columns McLane Hamil- ton has called attention. Loss of power in the lower extremities, muscular contractions without marked atrophy or greatly impaired electro-muscular contractility, such as happen in infantile paralysis, increased skin and tendon reflexes, and absence of sensory disturb- ances or brain-symptoms, are the chief signs of the affection.^ When sclerosis affects the lateral columns, and is combined with degeneration of the great ganglion cells in the anterior horns of gray matter of the cord, the portion which has a controlling influence over nutrition, marked nutritive changes happen in the palsied part, such as we find in progressive muscular atrophy. But this amyotrophic lateral acleroms^ as Charcot has termed it, is from the onset an atrophy of a whole muscular group. It is a disease closely allied to progressive muscular atrophy, and, beginning in the arms, affects as a rule, the four limbs successively, produces strange deformities in the wasted and palsied limbs, that are agitated by fibrillar movements, extends to the hypoglossal and the pneumogastric nerves, and thus determines death. Tumors of the Cord. — Tumors of the spinal cord, either grow- ing from it or its membranes, or originating in the vertebrae and com- pressing the nerve-structure, occasion paraplegia. The symptoms vary with the situation and extent of the growih. They depend first upon the irritation, and later upon the compression, caused by the new formation. We suspect the affection if we have signs of a grave constitutional malady attending the slowly progressing palsy, if this be more decided on one side than on the other, and if anaesthesia be found on the side opposite to that in wiiich the palsy is marked. The severe pain over the locality of the disease, at first neuralgic, then becoming constant, is aggravated in paroxysms. The pain is gener- ally felt on one side first, and is associated with tenderness and rigidity of the spine, and muscular spasm or rigidity in the limbs. Yet, unless we have distinct evidence of tumors elsewhere, the diag- nosis is never more than an uncertain one. If multiple tumors exist, it may be made positive. Strong proofs of syphilitic infection point to the spinal symptoms being due to a syphilitic growth ; and signs of scrofula or tubercle in the lungs or in other internal organs, make ' Transactions of the American Medical Association, 1879. 8 IIH MKWCAL DIAONOSLS. II llki'ly lliiil Mimilar morbid prrxJucts are the cause of the palsy. Slidiihl II Kriiilimlly prr)^f-H»irig fiaralysis suddenly show symptoms of lu'iilr iiiyi'liliM ill a pcrHon with the constitutional cachexia just men- IIoimmI, wi' liav<» an additional reason for supposing the affection to be Inhrrnilar and lo be rapidly exlendingJ Lymphadenomas elsewhere iiiaki* il c'xIrcMiioly jirobable Ihat the spuial symptoms are owing to one or Hi'vrral nC llirin in the cord. Yet the spinal symptoms in the affec- lloii may be really due to my(?litis. In all cases of suspected tumor wo muHl be rarefiil to ascertain that bone-disease is not the cause of \\\v nymploniH. Tlu* idwenc.e of sharp pain and the uniformity of the imlny tui both sides are points of distinction as against tumors. The early signs of tumor of the cord suggest hysteria. Rollox Paraplegia. — Functional disturbance of the cord from irrilalion causing an inhibition of spinal centres is supposed to give rise lo the so-called n^llex palsies. Worms in the intestines may \Hvasioii (hem. Hut the most marked of them is the paraplegia con- Hi'quenI upon thsease (»f the l)ladder. Yet it is very doubtful whether Iherx^ is not always in these ri^llex paralyses organic disease, especially HU ascending neuritis, ami it is unlikely that reflex palsies have any r\>\ and frwiuontly its just as sudden disappear- A"vv'. '.ts v\»uui\^ vMi gvucniUx under ttio iniluence of some powerful sJ'.'.x^savv, v^i>ce. s^rt\r all attiuk of hxstorical convulsions: the absence >^. ><■> >V-'^ ^*' "^^ scnv^v»s U*c.x, iV.o \av>iv^ :\4tr.rv* v^:* the ^vi-sy. <<^metimes hemiplegia, x% ':•'.;; *',.x ;\ .^> . u* :v,.*\.^ \\h/, uv-ir <:rM^ tfxcitement: and the AVxv x^ xx' s'- ':v.\'\ ":.\.v';' •;> i.ri 'rr,--i:h: or. in the seemingly *. . .".^wx \- •>. V-,- • :!N'r\" ^r-,- *\■r^v•.^ >'v.*i-:rl:i2?< iioees in the ears, iv-' «k XV. .>,<\ , • .>k i.- .: xx>;.M* ;c.T iiscurlvjLnioet? showing >. . .xv.Wxx >x V ^' x\\,. ^ /. ■. I. ■ > jL"v: -jsfAbere. The nius- . * v .\,v>.'* ' ,vcx',x ,\ .. . i^ s.jl"vv u -•/•-:*:■: ytfricvclT under both •v vVt^-x .4 V* \ v^ vt ' **^- r*'; ;\vCr>-CL:':25^:uiir sensi- DISEASES OF THE BRAIN AND SPINAL CORD. 119 bilily is either diminished or abolished. In some cases galvanic sen- sibility is lost.^ We never find the reaction of degeneration. Hyper- aesthesia, but much more generally anaesthesia, sometimes only on one side, is observed, and this also may involve the special senses and affect the muscles. But muscular anaesthesia may be absent in hysteria. Rapid changes occur in the sensibility under strong electric currents, and there may be a transfer of the loss of sensation from the disordered side to the healthy side, caused by stimulating the side of the hemi- anaesthesia, — ^by mustard or by the faradic brush, or by certain metals, such as gold, or by v^ood, — or, indeed, by strong mental impressions. The eye-symptoms, as Charcot has pointed out,^ are peculiar. There may be an amaurosis, but there is no alteration of the papilla ; the constricted field of vision is concentric, not, as in locomotor ataxia, star-shaped, and red is the color that is seen longest. Then in hysteria the eyebrow on the affected side is lower than on the other side, while in true paralysis it is more raised on the side affected. Nystagmus is never observed in hysteria; but hemianopsia may be met with in grave instances. Persons affected with hysterical palsy are striking types of a nervous constitution, and, as Sir James Paget ^ mentions, show a singular readiness to be painfully fatigued by slight exertion. The palsy may seize only upon one limb, or upon pari of one limb, or upon special muscles, as those of the pharynx and oesophagus, the larynx, the intestines, and the diaphragm ; or it may, although it more rarely does, assume a hemiplegic or a paraplegic form. Hys- terical hemiplegia presents a peculiarity in the gait, on which Todd * lays great stress. " In walking, when the palsy is pretty complete, the leg is drawn along as if lifeless, sweeping the ground." It is not swung round, describing the afc of a (circle, as it is in ordinary hemi- plegia. The palsy is almost invariably left-sided. It is apt to be con- joined to left-sided ovarian tenderness, and to very decided anaesthe- sia, which passes beyond the paralyzed part to the nearest portion of skin and mucous membrane, though, as a rule, still limited to the same side. Thus we find the pituitary membrane of one nostril rendered insensible, if the loss of feeling affect the face. In hysterical paraplegia we find the same incompleteness of the * Wood, Nervous Diseases and their Diajrnosis, 887. ' International Clinics, vol. i., 2d Ser., 1892. ' Xen'ous Mimicry of Organic Diseases, in Clinical Lectures and Essays, Lon- don, 1875. * Clinical Lectures on Paralysis and other Affections of the Nervous System, Lecture XIII. 120 MEDICAL DIAGNOSIS. palsy and the same response to electric tests already mentioned, and we are also verj- apt to have the symptoms of spinal irritation. Hys- terical contractions of the muscles especially affect the lower extrem- ities, though they are not uncommon in the arm. These hysterical contractures generally come on quickly, appear to be permanent, and to be associated with loss of power, but disappear as suddenly as they showed themselves. Yet they may really become permanent and combined with sclerosis of the cord, and we may find them associ- ated with tremor, and with exaggerated knee-jerk. Ankle clonus has also been observed by Charcot as occurring in hysterical paral- ysis. Gowers. however, thinks that true persisting ankle clonus be- speaks secondan' oi^nic disease in the motor parts of the cord, while a spurious, irregular clonus, now ceasing, now renewed by a fresh contraction of the muscle, is characteristic of hysteria. Very similar to hysterical paraplegia is the paraplegia produced by hypnotic suggedion. Charcot and Longues* have called attention to the fact that in this as well as in the functional paraplegia met with after railroad and other accidents, the so-called traumatic hysteria^ there is an anaesthesia in the palsied legs which follows the fold of the groin and excludes the genital organs. The same line also en- ables us to distinguish between hysterical parapk^gias and those of organic origin. One of the most difficult points with reference to hysteria is to distinguish the hysterical symptoms that arise in sclerosis and in my- elitis, or that follow injuries to the nenous system, from the manifes- tations of pure hysteria. Notliing but a careful study of the indi^idual case, of the historj', of the reflexes, of the electric reactions, of the line of the anaesthesia, of the state of the muscles themselves, laying stress on the absence of muscular wasting, also of girdle pains, and of incon- tinence of urine and of fanes in pure hysteria, will save from error. Rheumatic Paralysis. — Rheumatic paralysis resembles hysteri- cal paralysis in being ordinarily limited. It may affect any muscle or any group of muscles in the body : sometimes the rheumatic poison disorders the portio dura, and we observe, in consequence, facial palsy ; or it may fasten on the radial nerve, and we have groups of muscles in the forearm palsied. Rheumatic paralysis is recognized by the histon' of the case : by the evidences of a rheumatic attack ; by the rapid development of the palsy : by the luiin which usually attends it; and by its beuig unaccompanied by symptoms strictly referable to a disease of the nerve-centres. It may or may not be * Charcot, (Euvix^s Complete?, t. iii. p. 448. DISEASES OF THE BRAIN AND SPINAL CORD. 121 attended by ansesthesia. The muscles themselves, certainly in those cases in which they, rather than a large nervous branch, are primarily and chiefly affected, are readily acted upon by electricity, unless their structure be altered; and the electro-muscular sensibility, though it may be lessened, is not abolished. Lead Palsy. — Paralysis from lead poisoning occurs primarily, and sometimes only, in the extensor muscles of the arm, occasioning the well-known wrist-drop. It generally begins in the extensor com- munis, then affects the radial and ulnar extensors. Gradually other muscles become involved : there is loss of power in the ball of the thumb, in the deltoid, and in the triceps, but not in the supinator longus, or in the intercostal muscles, or in those of the lower extremi- ties. Tlie disturbed muscles on both sides of the body waste, entirely lose their irritability to electricity, and soon show the reaction of degeneration. The patient is weak ; his movements are tremulous ; he has the characteristic blue line on the gums, is obstinately consti- pated, is subject to colic, and lead can be found in the urine. Some- times the poison seizes upon the brain, and epileptic convulsions and other signs of a serious cerebral affection appear, and we find marked optic neuritis. From the locality of the palsy, in addition to the accompanying symptoms and the knowledge of the man's employ- ment, the diagnosis is usually arrived at with ease. Paralysis pro- duced by an affection of the radial nerve shows the greatest simi- larity. Yet here the supinator muscles as well as the extensors, but upon one side only, are affected, which is not the case in lead paralysis, where both sides are affected and the patient can carry the hands supine. Lead palsy may be met with in children.^ Diphtheritic Paralysis. — Diphtheritic paralysis is a sequel of diphtheria which follows an attack of the disease within a fortnight or two months, and, therefore, after the patient is to all appearance fully convalescent. It may be very localized, merely affecting the palate or the pharynx ; or very general, fastening upon both of the lower extremities, and even upon the upper. When extensive, it is ushered in by a change in the voice and a throat-palsy ; there is diflfi- cully in swallowing, fluids are regiUYitated through the nose, and the saliva dribbles from the mouth. Paralysis of accommodation and strabismus and double vision are not uncommon. The paralysis of the extremities ensues gradually ; day by day the muscular power is more and more enfeebled. The loss of motion is often preceded by formication, and attended by a certain amount of anaesthesia. The * Cases of Sinkler, Medical News, July, 1894. 122 MEDICAL DIAGN08I8. furadic ek*alsies. Thus, we do or do not, though in |Niint of fact we usually do, find the paralysis associated with pain in the head, with optic neuritis, with sleeplessness, vertigo, impaired memory, and sickness at the stomach. Decided vertigo is prone to take plai'c wlu^n* the syphilitic affection has led to disease of the ves- sels, and is apt to be the forerunner of local softening and of hemi- plegia, Wlu^n disease of the membranes has happened, headache is seven\ and local s^vasms or convulsions occur. The same symptoms ari» tMU'ountt^riHl when tlien^ is a gn^wth in the hemisphere, wliich is very apt to 1h* nt^ir the siuface : though here again the form of mis- chief may Iv conHviratively latent, the jxitient may have only occa- ^tuially ronvulsions« aiui tl\e ivinilysis be slight or improving, yet a fatal \>\ma nwv follow a few convulsions. Instances of this have couh* under my ol^er\ation, I^\it. as a r;U\ syphilitic jvmilysis dix^ not tenninate £aitally. In truth, the t^s^^ with wluch the jvilsy and its attending phenomena nuv<»!\ \h"',d ti^ tn\i:!r.ei:!, vnr.s or.o of t:-e traits of the malady. v>r\i:!uiri'y a!ifeots (arsons younger ;v.\rx>s^ dtiviivi-.^:: iij<»q t&^>ase of the hv bnc:: : jcm that its numifesta- ru.r; -v >Y:v,r-:t':rv'Xi? sy§tec: in whiih • >. t>jLn."> jL^r^ULvly scai:evL the potson iVher vviv.- ^v: u^:v,r^^ arv^ — :ha !h;i!i :!uv^' :**- \\:\ovt we r*!,vi ;v.v v.or\v'V,s vo* .:!\s. ,i'..i ;:<;y\uv'> . t^^v.N Atv >^*» ' *:"^ ^*\i .^ivri v\:>s xv»*> .^vir.i. :v'n'v <\v*' ::>; Af;v UiTH > s^s ^ '*-.*: A'':-.'rV v- >Nvv 'JS ,t '^,v\v^ "' r\>",: '. ,-:' <> v^"."*^ DISEASES OF THE BRAIN" AND SPINAL CORD. 123 may attack any part of the nervous system, and paraplegia dependent upon disease of the cord is not very uncommon. A progressive multiple palsy of cerebral origin, clearly affecting dissociated muscles, is usually syphilitic, and is mostly due to several patches of gum- matous meningitis. At times a rapid, almost universal paralysis, as Buzzard notices, occurs in syphilitic subjects. This is most likely of peripheral origin. It is among the peculiarities of syphilitic palsy that the lost electro-muscular contractility returns rapidly.^ Erb has called attention to an association of symptoms regarded as characterisfic syphilis of the cord. They come on gradually at first, but may then rapidly develop. They are increased reflexes, with but little muscular rigidity, slight spastic gait and muscular weakness, disorder of the bladder functions, and disturbances of sensation in the legs in the form of paraesthesia. The symptoms are confined to below the waist. Fig. 14. ^&?^ Hutchinson's teeth, in the ease of a girl eleven years of age, at the Pennsylvania Hospital. In syphilis the mischief to the nervous system may not happen for years after the infection, of which the history is often very obsciu'e. The disorder may be the result of an inherited taint But such cases rannot be recognized unless there are other signs of syphilis than the suspected nervous symptoms ; and chief among these signs are the evidences of periostitis in the long bones and of disseminated choroi- ditis in the fundus of the eye. Then there is that valuable test of congenital syphilis discovered by Mr. Hutchinson, — a malformation of the two upper central permanent incisors, which consists in their being narrower at their cutting edges than at their insertions, and often notched. The same observer has called attention to diffused ^ Engle, Philadelphia Medical Times, Dec. 1877. 124 MEDICAL DIAGNOSIS. ojMirity of the ooniea and to diseased nails as being common among the manifestations of the inherited disease. Paralysis also may occur, as in the case reported by Bartlett ; * but it is very rare. LOCAL PALSIES. The forins of j^aralysis which have just been noticed are mainly surh as are designated as partial. When the loss of power is ver}* limit iMi, the jvalsy is spoken of as local ; most of these local palsies an* [H^ripheral, and the result of neuritis. Facial Palsy. — Of the local paralyses, of particular importance from its frtHjuency, is facial, or Bell's palsy. The disease consists in an affection of the portio dura of the seventh nerve. In conse- quence of the deranginnent of this motor nerve, neariy all the mus- clt»s of one side of the face lose their faculty of motion, and, as it is tlu»ir play which gives exprt^ssion to the countenance, the appearance of the face is extraoniinan-. The eyelids are open and fixed; the featun^s are rigidly composed on one side of the face, but reflect everj* changi* of feeling on the other : the mouth is distorted, being drawn to the unafft^ted side : the nasolabial fold is efliaici^ : the eye waters ; and in the old the furrows disappear from the fon^head. In some cast^ the velum (lalati is involved in the paralysis. The impaired musclt^ waste : their electric irritability is diminished and degenera- tivt* rt^clions may be present. Sensation remains unaltered so long as the fifth nt-rvr is not disturbed. The i-auses of the palsy are such as influence the di^tIes;sed nerve in its i\>urst» or at :ts f ^riphery : a womnl : mum{.^ : ear-disease : exjK>?ure to iv^M : rfc-r^unLatisra : syphiJis. The m«.^ cvMumon 'cause is a Keuriti? 4^:«:: <*:C-d a5e:tir;^ the nerve within the Fallopian canal. Hie inaLady i? r^^y &t;ri:uitwate\l frvMU the &itrsal (msy of disease of thr brai::: by iL-r LZiit-Liry to v:I«.>?^ the eyr liils. owin^ to the paralysis of thr .rTDrijre palftrfcriTJi:: : by the abe>erK*e of hetidache. of ver- t^.\ of virii'Jil .i.rJiisioc. or A^t?s of ii>:r.:ory: by the much more iv^i^ l-r^ :b: Jt:r. 5a:T«:tlT 'jvjl :harjL:t':r of the luralysi^. the affected iiij:>»:!':< tVt:: iill::;*^ to i^iiri-itUto L:: bilavrju or eciotiooal move- ui-Lits: an'-i^ cX'-ic i:i sli:?:: 't^Iorj^ of th- iwoe. by the k\?t eleetro- i!Liu:>*.^LJLr :v tL*-rd»-'Ci*ity. In sev-rv cJL^its. Lixke^L th«e niui?cl'es soon c^a:?^ t: r:sjoi.«i *o runi'lisitioci. whil.: thi:' ^v-jLiiii: irritabCity i? pre- served A::«-i rv.fi ii»ri:^!i:-zQe.t. Jiii'i :h-t r:'ii«:do£i of de^tieratioG i? very tcdrt-'L E»:«.tTi«: sdniilatii.H: :l th-r <.li:?<:a5»:>i •-:»erv'e shows that it •4:-U»:i y ..:s*r< :'< ■e.\;LtjL:L:':y. roch :.^ iird-li?!::: JLi:«i t<.» fyLv;jLtii>«u. DISEASES OF THE BRAIN AND SPINAL CORD. 125 The observations of Erb enable us to tell with considerable accu- racy the exact part of the nerve affected. They take into account well-known anatomical and physiological facts, and lead to these conclusions. If there be complete palsy of all the facial branches with the exception of the posterior auricular nerve, the lesion is in the main trunk of the facial, exterior to the Fallopian cafial. If the auricular nerve be also implicated, the lesion is within the Fallopian canal below the origin of the chorda tympani, the most common seat of the affection. If taste and salivary secretion be disturbed on the side of the tongue corresponding to the palsy of the face-muscles, the lesion is between the points where the chorda tympani and the tympanic branch are given off. If in addition the sense of hearing be abnormally increased, we may infer that the nerve is affected between the tympanic branch and the geniculate ganglion, and at the latter point palsy of the palate is superadded; and higher, up to the entrance into the brain, disorders of taste happen. Eventu- ally implication of other cranial nerves, as of the auditory, also occurs. Cases of facial-nerve palsy generally recover. Sometimes, how- ever, the recovery is incomplete, and a rigidity with some contraction of the affected muscles takes place, which, when slight, may make the sound side appear relaxed, and the diseased side seem the normal one. In rare instances the facial palsy is on both sides. Now, in this double facial pahy the lesion may be within the cranium, such as compression by a tumor, or may affect the^ nerves while passing through the medulla and pons in their farther course. When depend- ent simply on a local affection, and therefore limited to the manifes- tations of paralysis of the portio dura, we find the same causes at work which give rise to the one-sided disease. Exposure to cold and rheumatism are the most frequent ; but syphilis is also among them. In an instance detailed by Todd, in which there was disease of the temporal bone, the portio mollis was also implicated. The face is immovable, or nearly so, and the palsy is generally more complete on the left side than on the right. The muscles do not respond to elec- tricity, or respond imperfectly, and we notice, as in the one-sided malady, that a continuous current may excite their action, while faradization does not. Nay, the two sides may give different results in this respect,^ most likely caused by different conditions of exudation and of pressure on the affected nerves. Case of Baerwinkel, Schmidt's Jahrbuch, Bd. cxxxvi. No. 1. 126 MEDICAL DIAGNOSIS. Paralysis of the Nerves of the Ann. — Paralysis of one or more nerves of the arm is very often encountered. It may happen from rheumatism, from cold developing a neuritis, from traumatism or fracture, or from the pressure of a gro\vth ; but its most common cause is accidental compression. A person falls asleep with his head on his arm, and a temporary palsy results ; or it may follow the use of a crutch. In truth, the disorder may be taken as the type of tlie pfikies by compression, and we find that the electro-muscular contrac- tility depends on the severity of the nerve-lesion ; as a rule, there is reaction of degeneration. Sensory symptoms are slight or wanting ; often there is numbness or tingling. The nerve most frequently paralyzed is the musculo'Spiral, or its main branch the radial, and we observe palsy of the extensors of the wrist and the fingers, and of the supinators. In the loss of power in these muscles, in the mode of onset, and in the unilateral affec- tion we find the differences between the palsy under consideration and the wrist-drop of lead palsy. When the median nerve suffers, the pronators, the radial flexor of the wrist, the flexors of the fin- gers,— except the ulnar half of the deep flexor, — the abductor and flexors of the thumb, and the first and second lumbricales are para- lyzed ; while sensibility is impaired or lost on the palmar aspect of the thumb, the index and middle fingers, and adjacent portions of the ring-finger, and often on the dorsal aspect of the last phalanx of the index and middle fingers. Involvement of the ulnar nerve shows itself in palsy of the ulnar flexor of the wrist, the ulnar half of the deep flexor of the fingers, the muscles of the little finger, the interossei, the third and Tourth lumbricales, the adductor and inner head of the short flexor of the thumb ; and impairment of sensibility in the parts of the hand and fingers not supplied by the median and radial nerves. From those diseases of the spinal cord Avhich begin with arm palsy, the local malady is distinguished by the tenderness in the course of the nen^e, and the one-sided paralysis. The same signs separate this ann palsy from the loss of power in the wrists, arising from atrophy of the muscles in the overworke9 parts, occurring in undernourished per- sons, as in poorly fed and hard-worked shoemakers.* iVbout other local palsies, as of the pharynx and oesophagus, of the larynx, of one side of the palate, of the tongue, of the muscles of the eye, of the diaphragm, of isolated muscles of the trunk, and of the extremities, it is impossible here to enter into particulars. But there * Chambers on the Indijj^eslions. DISEASES OF THE BRAIN AND SPINAL CORD. 127 are some forms of local palsy which, from their striking interest, it is necessary to describe, the most important of which is the paralysis of the tongue and parts concerned in deglutition. Bulbar Paralysis. — Bulbar palsy can scarcely be considered a local palsy. It has a close relation to progressive muscular atrophy, yet, from a clinical point of view, its main manifestations are those of disorder of special nerves. In this bulbar or ghsso-loAio-laryngeal paralysis, the first symptoms which are likely to attract attention are, that the tongue seems less supple and the utterance becomes nasal or thick, the food lodges between the teeth and cheek, and the saliva dribbles from the lips and comers of the mouth. As the paralysis progresses, articulate speech is almost lost, as is the reflex action in the throat ; the shape of the tongue is altered, it generally dwindles, and at times shows twitching of its fibres, or lies motionless in the mouth; the posterior nares can no longer be closed by the velum and muscles of the posterior palatine arch ; deglutition becomes very difficult, and the patient is tormented with hunger. Reflex irrita- bility of the mucous membrane of the larynx is frequently lost ; the respiratory movements are unusually weak, and fits of suflfocation ensue. The general debility becomes extreme, and the patient is apt to perish by the sudden stoppage of the heart's action. The disease is unmistakable. Double facial palsy resembles it most ; but here the tongue is not involved, and the eyelids remain open ; on the other hand, in bulbar paralysis the lower part of the face only is motionless. This condition must be distinguished from so-called pseudo-bulbar pahy, depending upon bilateral inflammatory or destructive lesions of the cortical centres for lips, tongue, and pharynx, or their centrif- ugal paths. The acuteness of onset, perhaps with apoplectic phe- nomena, the absence of wasting and of electrical alterations, and the presence of other symptoms, such as hemiplegia of ordinary or of alternate type, differentiate the cerebral from the bulbar affection. Symptoms of bulbar palsy may, however, result from an acute lesion, such as hemorrhage, inflammation, or softening of medullary nuclei, and be sudden in onset. The chronic affection is generally of rather slow development and slow but relentless progress ; but it is not nearly so chronic a malady as progressive muscular atrophy, which may last from ten to twenty years, while the bulbar paralysis has, like lateral sclerosis, an average duration of from one to three years.* Progressive bulbar paralysis has its seat of lesion in the medulla oblongata, in the motor nuclei, which undergo a degenerative atrophy ; ' Mobius, Schmidt's Jahrbuch, No. 2, 1882. 12H MEDICAL DIAGXOSIS. Hiui wi* innU*rHiiiii(l iUtt main Byrnptoms when we reflect on Ihe hUi'M wUlt'h i'imntti'i iUtt hyfK^glossal, the spinal accessory, the vagus, uni\ \Ui* fiU'Uil, iUitU*r Uh* (ii'Ki^riationH ynytudlvenm grarU jMfeudo-paralt/tica and UMtknih' hiilhtir jjarah/Hut a <;on(lition has been described characterized by Wi»iikrii*HH of voluntary musclos, especially of those controlled by Um< liiilbiir ni»rv<*H, or by undue fatij^e after ordinary activity, Avithout wiiHtluK or willioul rliariKCB In n^flexes or in sensibility. Remissions and i*\iin*r\m[umH an» cornrnon, and may occur suddenly. The affected niUHch'H ri'Hpond nonniilly to (»l(»ctric stimulation except that to tetan- IxhiK rurn'filH llir rrHponw' ^tows gradually feebler and feebler. The ufTnctlon Ih bolirvi'd to be of toxic orijrfn. With reltTeiirr to all lli(*se local palsies we are sometimes much porplrxrd lo know if lh(» palsy bo the result of beginning disease of lht» brain or npinnl cord, or if it be purely local. To speak first of Ihi* l»rain: the cerebral syniploms may not be marked, or they may hv HO ronlnidiclory as to ailTord no rt^al help in diagnosis. Wlien, liowever, \vt» discovtT, as we gtMJenilly can, that the palsy aflfects luusrles which an* supplied by ditlerent nen'es and such as have no nMuunuunUion witli one anothtT, we may set down the complaint as having a ctMilral origin. As n^^'-anls the distinction from spinal affec- tions, ttu* almost inmstantly single-sidtni diameter of the symptoms in loral i^lsit^s, untl tlieir doublt^sidtHl oliaracter in spinal affections, nn* verv iuiiH^rtaut, The strikingly synuuetrical kind of the palsy Hiul tlie element of |Kiin ar\^ featun^s of ^\it diagnostic significance iu the widt^spn^ud ivriplienU jKmilystMSt as stHMi in nuiltiple neuritis. r.VLSUii VXKNMtXntl^ \YHH MAKKEl^ MlSil'LAR W.VSTIXG. Ttier^* iai a ^rrvnip of jKiIsit^s esjHvially markt^l by wasting of the mus\'U^. In <».>nio affections alr^^ady disk'iiss^rxi we have found wasting wuon^ the symptom^k as at times in myelitis, and iu cervical pachy- metiiit^itis witli considerable i.taiLiai^* to the iier\*e-r.>ots. where atr»>- phv of the arms ha^a'ens. .Vcaitu atn.»phy of the m.uscles of the trtutk and 'iztrbs is oi^.er? ii.:et with m the advar!ced stages of pn.^'eres- ^ve bu'bor vara.' > sis. But u\ all these a:?!"ectii'ns th»ere are Di»?rv 'iis- tiiKti>e ->> tnpt'.^ms. l*i ^i.^'me arfections 'he wastirrg of die mrjsi:Ies is the v'^^'-emirterft \'ix^:ij>:. This is panic' i.'ar*v the case in pn.icresave muscular acr^.^piiy a/ id in 'h^ -esse ti do! varaly>?is of ■.•hiJ«ihooiL Prognwaive Muscular Atropliy.— This rnrji of - wastirur paisy" is -iue 'o ivrMu*- -.t >abai;ute iev^nerative chan^Hs in the ^rav aidtier oi liie anc»: riur ions of ::ie iviiiih :opi. parriciiiany tiie DISEASES OF THE BRAIN AND SPINAL CORD. 129 large ganglion-cells, sometimes in association vnth similar changes in the peripheral motor nerves and the pyramidal tracts. The affected muscles undergo atrophy of varying degree and extent. Progressive muscular atrophy is a disease of adults, and essen- tially of men who use their muscles continuously and violently. Its most striking sign is increasing inability to perform certain move- ments. When the muscle chiefly concerned in the attempted motion is examined, it is found to have dwindled. Soon other muscles fol- low ; and their wasting, too, is accompanied by further muscular weakness. The disorganizing muscles twitch, and tapping them sharply causes a marked contraction of the fibres. These muscles of the face, as a rule, escape. In the affected part the circulation becomes languid ; it is also very susceptible to cold, and its temper- ature is lowered ; there is a feeling of numbness in it, but rarely pain ; to pressure it is soft and yielding. The muscles most fre- quently attacked are those of the hand, the flexors and supinators of the forearm, the biceps, the deltoid, and the other muscles of the shoulder. Sometimes the disease begins in the trunk and the lower extremities ; but it is most common to have it marked m the upper extremities and to find only weakness and spasm in the lower. Some- times, also, bulbar symptoms, with weakness of the muscles of the lips and tongue and of the pharynx an^ larynx, appear, and changes are found in the medulla analogous to those present in the cord. The decrease of the muscular fibres gives rise to strange and palpable de- formities, and, when the muscles of the trunk are involved, to ex- traordinary positions of the body, in consequence of all antagonism to the healthy muscles having been removed. In the parts affected the reflex action is lost ; even the deep re- flexes disappear. We see this happening with the knee-jerk just so soon as the muscles of the legs become flaccid and begin to waste. To the electric currents, both faradic and galvanic, the muscles respond feebly; still they respond, and in portions where there are many sound fibres they contract energetically. The degree of response de- pends, indeed, on the degree of disorganization and wasting. Ex- citability to the galvanic current remains much longer than that to faradization ; the reaction of degeneration is likely to be present. From cet'ebral hemiplegia progressive muscular atrophy differs by its much more gradual invasion, by the rapidity but want of uni- formity of the muscular atrophy, by the lost reflexes, by the dimin- ished electric excitability, and by the absence of disordered intellect and of other signs of disease of the brain. Difficulty in articulation and in deglutition may occur in either. From geftieraJ spinal paraly»is it is VM MEDICAL DIAGNOSIS. du4(no8liphy seizes upon the muscles in this malady, the fibrillation, and the bt^gimiing of the wasting in the thenar muscles and the inter- ossei. Hirst * points out the occurrence of muscular atrophy as a phenom- enon of htfifteriiu The peculiarity of tliis form of wasting is its uni- lateral or cinumsiTibed character, though sometimes it is general. Ttie rtTognition dept^nds upon the psychic state of tlie patient and the occurnMice of hysterical or hystero-epileptic convulsions. Tlie muscular atrophy due to degeneration of the anterior horns of tlie spinal con! liitTers from that due to nmitiple neitriti^ in its pn>gr^'2^ive rather than rt»trogressive character, but especially in the alv?ence of symptoms of sensory derangement. Ttie most ilitlicult iliffertuitial tiiagnosis we may be calleil upon to make is to ilistitiguish certain castas of pn^rrt^ssive musi.ular atrophy frv>m bulfhtr ^[n////x4x. hi truth, the two affections often coexist. The diii^uosis depends upon the distribution of the symptoms, the morbid pD-K-ess being essentially the same in the two sets of cases. In the one the arms, and sometimes also the It^, suffer: in the other the tonjrae, the lips, the phar}*nx, and the lanux. EVfei-tive DISEASES OF THE BRAIN AND SPINAL CORD. 131 pronunciation pointa to the bulbar malady. Failure of the respira- tory power is common to both. Local atrophies may be mistaken for part of the general disease. There is, for instance, an affection, mvilaieral proff^resdve atrophy of the /ace, in which gradual wasting of one side of the face occurs, of the soft parts first, and then of the deeper tissues. The facial hemiatrophy follows blows and contusions, abscess of the ear, influenza, typhoid fever, or, as in Cohen's case, an attack of erysipelas. It begins with a discoloration of circumscribed spots, a white or yellowish discolor- ation ; the subcutaneous fat disappears, and the beard and eyelashes change. Sensation is, as a rule, not affected, nor are the electrical reactions changed.* But in progresssive muscular atrophy the face almost always escapes ; if it be affected, it is so on both sides. AciUe or chronic joint-inflammations are attended with weakness and wasting of the muscles moving the affected parts. The extensors usually suffer, occasionally also the flexors, and rarely distant muscles. An- other limited atrophy is a wasting from overuse of muscles^ seen es- pecially in the small muscles. of the hand. It shows no tendency to extend. Paralyzed muscles atrophy, and may subsequently undergo de- generative change; but the distribution differs from that of pro- gressive muscular atrophy, and we lay stress on the symptoms that usher in and that attend the paralytic state. In the condition known as syringomyelia, in which the central gray matter of the spinal cord is replaced by gliomatous tissue that breaks down and gives rise to the formation of a cavity, we have fibrillar contractions in the affected muscles and atrophy, with resulting de- formities. But symptoms of sensory derangement appear earlier and are more pronounced. Common sensibility is generally unchanged, where there is inability to distinguish heat and cold, and often also to appreciate pain. The sphincters are not disturbed ; the knee-jerks are normal or exaggerated. The muscles waste, rapidly lose their faradic excitability, and the reaction of degeneration is finally established. The symptoms, on the whole, are of slow development, and show themselves cliiefly in the arms and in the upper part of the trunk. There is unsteadiness of motion, with muscular weakness rather than paralysis, and trophic disturbances in the skin, such as thickennigs, eruptions, ulcerations, are marked ; so are arthropathies. In the legs * See cases, Journal of Nervous and mental Diseases, New York, March, 1880 ; Schmidt's Jahrbuch, No. 7, 1881 ; St. Louis Alienist, April, 1881 ; and Skyrme, Brit. Med. Journ., March, 1892. V42 M£DICAL DIAGNOSIS. th#rre may be spastic paresis. Inequality of the pupils and nystagmus are not unusual. Deviation of the spine is common ; it was present in half the cases analyzed by Bruhl.^ A large number of cases origi- nate in injuries to the back.^ A case presenting symptoms of syringo- myelia has been recorded in which after death gummata were found on either side of the brachial enlargement of the cord.' The disorder described by Morvan and called by his name, and also '^painless whitlows," presents symptoms of syringomyelia in conjunction with those of peripheral neuritis. At first there may be neuralgic pains in the hands, followed by anaesthesia and muscular wasting, and the formation of whitlows that undergo ulceration, and are attended with necrosis of the phalanges. The altered vasomotor condition is also shown by the elevation of temperature in the weak- ened limbs, the red spots or the intense flushing of the surface, and the ease with which the skin blisters. There is another disease resembling progressive muscular atrophy which may be here mentioned, the singular affection endemic in parts of Japan, known there as kakke^ and probably identical wth the disease called in India and BrazD beriberi. The generally accepted view is that beriberi is an infectious disease, developing under con- ditions of high temperature and moisture, and presenting the sjinp- tonis of a multiple neuritis. Observations made in Japan render it likoly that the cause of the neuritis is generally poisoning by damaged rice, and it is said that attention to the diet has almost banished the disease from the Japanese navy.* It has also been thought to be due to absence of fat from the dietary. Four types of the malady are rt^c%'nized, — an mcompletely developed or rudimentary form; an atrophic form ; a dropsical form, with or without atrophy ; a perni- cious or cardiac form. The most conspicuous symptoms are impair- ment of motion, with wasting and diminution in mechanical and elec- trical irritability, sensory changes, circulatory disturbances, aboUtion of the knee-jerks, diminished secretion of urine, and albuminuria. A form of progressive muscular atrophy, known as the peroneal tj^pe, and described by Charcot, Marie, and Tooth, usually sets in early hi life, ulVecting llrst the muscles of the foot and leg, sometimes those of the hand and forearm, and extending upward. In addition to weakness and wasting, sensation is deranged and degenerative elec- * Ktude lie la syriugomyelie, Paris, 1890. ' Guy HiDsdale, Syringomyelia, Philadelphia, 1897. » Be«^vo^ Lancet, vol. ii., 1893. p. 1252. * Takaki. Report of the Japanese Navy, 1886, quoted in Sojous's Annual, voL i.. 1S$8. DISEASES OF THE BRAIN AND SPINAL CORD. 133 trie reactions are present. The condition is dependent upon neuritis and it occurs in famifies. Club-foot is a common resulting deformity. It is sometimes a matter of extreme difficulty to distinguish cases of what are called progressive mvseulor dystrophy^ where there is no appreciable central nervous lesion, from the progressive muscular atrophy under consideration. When the former disease happens in children the distinction is not so difficult ; for the age, and the circum- stance that not infrequently several members of the family are aflFected, in some of whom it may assume the pseudo-hypertrophic form, show what it is. But in adults there may be great uncertainty. The ex- tremely slow progress of the disease ; its not unusual beginning in childhood ; the fact that the muscles of the forearm and hand escape, as a rule, while the face is "sometimes involved, as well as the latis- simus and the lower half of the pectoralis, that it aflfects males far more commonly than females, and that it is congenital, are some of the characteristic points. Fibrillary twitching of the muscles is want- ing, the deep reflexes are enfeebled, and the electric reactions un- dergo only quantitative diminution proportionate to the degree of wasting. Several types of the disease have been described, the idiopathic^ the pse^ido-hypertrophic^ the juvenile or scapulo-humeral^ the infantile or fa/no-scapah'humeral^ and the hereditary^ but the distinctions are not readily maintained. All present in common hereditary or family distribution, onset early in life,^ preponderance among males, progres- siveness of course, weakness and wasting, sometimes preceded by apparent hypertrophy of various muscles, lessening of mechanical and electric irritability and of deep reflexes. The gait is peculiarly waddling, and extraordinary attitudes are assumed in attempting to rise from the ground. The lesions in the muscles consist in increase in size of some fibres, with diminution of others, degenerative changes, and more or less increase in the interstitial connective and fatty tis- sues. The wasted muscles undergo shortening and contraction, and various deformities result. The function of the sphincters is, as a rule, preserved ; intelligence is not affected ; and sensibility is unimpaired. Infantile Paralysis. — In this disease, also known as essential paralysis of children, and acute anterior poliomyelitis, rapid wasting of the muscles is the striking feature. It is pre-eminently an aflfection of early childhood, and, as shown by Wharton-Sinkler, occurs much ' Destarac, La Medecine Modeme, 1894, No. 89, p. 1387, has reported a case of pseudo-hypertrophic paralysis in a man sixty-eight yeai-s old, without heredi- tary predisposition. |;i.| MKDICAL DIAGNOSIS. iiuivt' (oininonly in Hiinirnor than in winter. It happens most fre- <|iii'nlly during tin? flret dentition, and is often ushered in by fever, by (IIiiitIhph, niniH(ta or vomiting, and by convulsions. The palsy comes on <|uirkly, ^mcrnlly before the fever-disturbance has passed away; or an entire limb, or even both legs and arms, may almost from the onnel he Hflecled. In any case the palsy becomes plainly discernible UH llie lever Hulmides. It is apt to begin in one limb and in a few (lnyn lo heconu* wid(»-8pread. But it disappears, except from a par- lleular region in which the muscles quickly waste. Yel \\\v palsy may at llrst shift ; it passes away from some limbs, (»r llxt^s upon others or upon dittertnit groups on different sides of the body. It nm^ly, however, remains as palsy of more than one side, and is not associaiteii with loss of sensibility. There is often decided riM'overy within six months Irom the onset of infantile paralysis; alUuni>rh st»nie loss of power may be pennanent. The aflTected nius- cli\< an^ apt lo begin lo atrophy after the paralysis has lasted a month, uml when Iheir wasting is miirkiHl they no longer respond to the fa- nidic curn^U* though they amy still n^ot strongly under the galvanic curnMil ; Iml gradually this excitjilnlily, tiH\ is lost. Both the super- lU'ud an\i tendon r^^tlexes art^ lowertnl or abi^lished. After six months or a \ i\^r s^nue faradie irritjilnlit v is apt to n^tum. Tlie functions of lUe Mad\ler an\l r^vtuui iu\^ Yer>' seldom afftvtevl. In protracted \\^sv*. ivnuaiieut shortening of uuiscU^ liapjvns. cvHitraction of the j\uuts tales plaw. and atrv^phv of jvrtions of the ix^s^ius system wvur^ v*r mthor a want of its devolopiueut in the K^ted ( syr/.rcociis. the «xvasional n-:Tvvv?t:!!iov* frv^ii* vvrt;w:i jurts. a:v,i thr s;dS?»:»4i:«>^t c*v.::r?e. sef^irate v-^ ji ,l^j(^rv*:>a> ^^- v,:v4) :;ii; :*::,* avw-uv: :rr, TX-irvni-r turI:T with ?ui., i^ JLi:«" * -' >;*•/>' .■>?»:■•*' ■'rsi " ■-■^•; v ;>>*:■•:< JT'-'ti.v.c 'itt nt:trLi- On ■ t • I ! t. v* r* 1 1; >• • .' •■ ;, » .' I • :>» ^ •• «i* *iX', *.? •: . >: • IST.-^'J ■. ■ *; if ; * i J . ;£ i£T»i. r*2tr *:f >i" ;^ :jji* I* .*' \i» V ' » -ii'S "^ '. *ir 1 ». * "u < ;r ♦r^ "»; jits'* vifci ,':c_::- *■'>. DISEASES OF THE BRAIN AND SPINAL CORD. 135 of the cells of the anterior horns. With reference to this acute atrophic spinal paralysis or acute anterior polwmyelitu^ we have learned that often complete or nearly complete recovery from the threatening symptoms takes place, and that it is probably due to a systemic infection. From the foregoing remarks it might be inferred that children are only subject to palsies that are. spinal. But this is not the case. We find in them a whole group of cerebral palsies^ — not nearly so frequent, it is true, as the spinal group, but palsies in which the lesion is cere- bral, extending from any pari: of the coriex to the pyramidal tracts of the cord, and broadly distinguished from the spinal palsy by height- ened reflexes, unchanged electrical reactions, loss of power with dis- ordered movements or spasm, and retarded growth of the aflfected parts. We may find either hemiplegia, bilateral hemiplegia, or para- plegia as the form of paralysis. In some instances the affection fol- lows delivery with the forceps ; like spinal infantile palsy, it has been observed after infectious diseases. Under the first condition it is probably due to meningeal hemorrhage ; under the second, to either hemorrhage into brain or membranes, or to vascular occlusion. Sometimes the disease begins with fever accompanied by convulsions ; these may be followed by marked coma. The hemiplegia is most persistent in the arm, and is apt to be associated with spastic con- traction, producing a peculiar gait. Post-hemiplegic chorea and mobile spasm and athetosis were observed in a considerable number of cases analyzed in Osier's elaborate monograph.^ Convulsive seizures on the paralyzed side or general epilepsy are yet more com- mon, and the intelligence is enfeebled. In the bilateral form of hemiplegia the legs are more involved than the arms ; spastic contractions of the muscles of the extremities are most marked ; the mind is very much afl'ected ; sensation is not disordered. Destruction of the motor centres of the cortex is the essential lesion in bilateral spastic hemiplegia.^ In the spastic cerebral paraplegia of children McNutt ^ found descending degeneration in the pyramidal tracts ; the disease is limited to the lower extremities ; there is no muscular wasting ; the gait is stiff or cross-legged. The malady usually exists from birth, and follows a difficult labor. The * The Cerebral Palsies of Children, 1889. See, also, Sachs and Peterson, Study of Cerebral Palsies of Early Life, based upon one hundred and forty cases. Journal of Nervous and Mental Diseases, May, 1890 ; and Sachs, Samml. Klin. Vortr., No. 46, 1892. * Osier, op. cit, * Amer. Joum. Med. Sci., vol. i., 1885. 136 MEDICAL DIAGNOSIS. intellect is impaired, though not always markedly so. Wood ^ states the aflfeetion to be the result of sclerotic and atrophic changes in the brain. Before proceeding, we will examine the main forms of paralysis which we have been studying, arranged in a tabular form, and chiefly with the view of ascertaining the seat of lesion, premising that the statements must be received rather as generally true than as abso- lutely so. TABULAR VIEW OF PARALYSIS. SymptoTM. Inability to move leg and arm of one side. Sensation unimpaired, unless posterior third of posterior limb of capsule involved. Paralysis of mus- cles of lower part of face ; mouth drawn towards healthy side. Elec- tro-muscular contractility preserved. Reflex excitability of the tendons exaggerated. Seat of Lenon, Corpus striatum, involving internal cap- sule, both on side opposite to the Same symptoms, dependent on involve- Optic thalamus, ment of internal capsule. Mobile spasm and incoordination in para- lyzed parts. Pons Varolii, on side opposite to palsy of limbs. The part affected is below decussation of facial nerve. Same symptoms, but paralysis of face, with anaesthesia, on opposite side to that of arm and leg, and usually marked ; conjugate paralysis or spasm of eyes ; difQculty in deglutition and articulation. Heightened tempera- ture ; convulsions ; contracted pupil. Urine may contain sugar or albumin. Early rigidity of paralyzed muscles. Same symptoms, but face paralyzed on Pons Varolii, and at level of decussation both sides. of facial nerve. Paralysis of arm and leg and lower part of face on one side ; third nerve para- lyzed on other side ; defective sensa- tion ; vasomotor disturbance. Crus cerebri on side corresponding to paralysis of third nerve. * Nervous Diseases and their Diagnosis. DISEASES OF THE BRAIN AND SPINAL CORD. 137 TABULAR VIEW OF FARALYSIS,— Continued, Symptoms, Seat of Lenon. Paralysis of motion of face, arm, or leg, Cortical part of brain in motor zone on soon followed by rigidity ; sensation side opposite to palsy, may be impaired. Reflexes, super- ficial and deep, increased. Convul- sions. Medulla oblongata. In the cord throughout its section above the lumbar enlargement, as in trans- verse myelitis of the dorsal cord. Motion more or less completely affected on both sides of body, except in face ; paralysis of hypoglossal, glosso- pharyngeal, and spinal accessory nerves ; often rapidly fatal. Both legs and lower part of trunk para- lyzed as to motion ; loss of sensation ; some wasting of muscles ; loss of power over bladder and rectum ; re- flex excitability in legs heightened, trunk reflexes impaired ; electric con- tractility diminished or lost ; trophic changes ; paralysis of muscles of res- piration in some instances. Both legs paralyzed, muscles of legs flaccid ; feet extended ; anaesthesia ; incontinence of urine from the start. Superficial and deep reflexes lost. Rapid wasting of muscles. Reaction of degeneration. Trophic changes. Arms as well as legs paralyzed ; arms Cervical region of the cord, as in cer- flaccid, legs spastic ; otherwise symp- vical myelitis, toms much the same ; affection of pupils. In the cord in lumbar enlargement, as seen in myelitis of these parts. Paralysis irregular in degree and dis- tribution, relaxation of muscles, sen- sation unimpaired, only transient loss of control over bladder and rectum ; marked lowering or extinction of re- flex excitability in the palsied muscles and tendons ; lost electro-muscular contractility to faradic current ; usually reaction of degeneration ; rapid mus- cular atrophy ; no bedsores ; if dis- ease become chronic, muscular con- tractions. Anterior horns of the cord, as in de- generation^of the cells in acute polio- myelitis. 9 138 MEDICAL DIAGNOSIS. Ata.xia. Loss of co-ordination of muscular movement, which in the legs shows itself especially in the gait, and in the hands in the difificulty of executing delicate movements, but which strangely contrasts with the muscular power that is present, is found in general paralysis of the insane, multiple neuritis, and diphtheritic paralysis. But the ataxia is most constant and marked in locomotor ataxia. Locomotor Ataxia. — In this disorder we have uncertainty of motion and seeming palsy ; or, in the words of Duchenne, who gave it the name of progressive locomotor ataxia, it consists in " a pro- gressive abolition of the co-ordination of movement with apparent paralysis contrasting with the integrity of muscular force.'' The patient is not deprived of the power of motion, but of the power of controlling his motion : hence he staggers in his walk, or cannot walk at all without support: ; the muscles are obedient to the will, but the peripheral impressions by which motor impulses are guided are im- properiy or imperfectly conveyed. Locomotor ataxia is identical with a form of palsy clearly recog- nized by Todd, and with the malady described by Romberg as tabe^ dorscUis; from the lesion it exhibits, it is often called posterior' scle- rosis^ degeneration of the posterior columns of the cord, and of the posterior nerve-roots being its main cause. A wasting of the nerve- fibres of the peripheral spinal sensory nerves has also been foimd. The affection is a very chronic one, lasting many years. It is a disease of adult life, and it occurs far mofe commonly in men than in women. It may originate without assignable cause, or may follow alcoholic excess, or exposure to cold, or injury or inflammation of the cord, or is hereditary. It has been observed to follow pernicious anaemia.* It is most frequently found to be associated with a history of syphilis. Among its eariy symptoms are piercing pains, lightning- like or similar to electric discharges, in the lower extremities ; en- feeblement or loss of knee-jerk ; disordered gait ; diplopia or other disturbances of vision, which may be attended with the "Argyll- Robertson pupil," — a small pupil that does not respond to light, but does respond to accommodation, — or with paralysis of the sixth or the third pair ; and a zone in which sensation is greatly impaired on a level with the third, fourth, fifth, or sixth dorsal vertebra.^ * Putnam, Amer. Journ. Med. Sci., March, 1895 ; also Burr, University Medical Magazine, Apri(, 1895. * Hitzig, in Ziemssen's Cyclopaedia, article "Atrophy of Brain." DISEASES OF THE BRAIN AND SPINAL CORD. 139 Following these phenomena, or making its appearance with them, is a difficulty in co-ordinating movements and in maintaining the equilibrimn of the body. It is manifest in attempting to walk with the eyes closed or in the dark ; and the patient is unahle to take a step, or to stand erect with his feet in juxtaposition, witjiout swaying and losing his balance. This, the so-called Romberg symptom, is not pathognomonic, but it is very valuable in the diagnosis of the earlier stages, and so is the difficulty in placing the foot on small surfaces, in buttoning the clothes, or in walking backward. Nor can the patient stand upon his toes, or upon one foot. Another symptom is Fraenh^Fs symptom, or hypotonia, the power to straighten the legs completely when at right angles to the body. Yet the stumbling gait is not connected with true paralysis. The muscles can act vigorously, are well nourished, contract readily when faradized, except in advanced stages of the disease, and show neither tremor nor spasm. The feet, in walking, are raised high in air and brought down upon the heel or upon the whole sole. The cutaneous reflexes are generally, yet not always, impaired ; there is absence of the patellar tendon reflex in both knees. Sensibility is markedly diminished, pinching and pricking the foot may scarcely be felt, con- tact with the floor may not be appreciated, perception of sensory im- pressions may be delayed, girdle-sense is often present, and the tactile sensibility may be almost gone ; but all kinds of curious sensations are complained of. The power to appreciate differences of tempera- ture may, though it does not always, remain, and there is a delay in the perception of pain. The muscles, too, lose their sensibility. It is not unusual to have pains in the region of the fifth nerve. The intellect is unimpaired, unless frequent attacks of vertigo and epileptic seizures should be among the symptoms. The eyesight fails more and more, there is loss of color-vision, and an atrophy of the optic nerve may produce irremediable loss of sight ; the hearing, too, may become much affected ; and signs of valvular disease of the heart, especially of the aortic valve, show themselves. The fiuictions of the rectum and bladder are not markedly disordered, though retention of urine and sluggish action of the bladder are not infrequent. The sphincter ani is often weak, but constipation is common. There is loss of sexual power. Dropsy and local sweating are met with, and so is swelling of the joints, without redness and usually without pain. But the joint affection may appear, as Charcot has taught us, be- fore the loss of power of co-ordinating movement. In time, it may be rapidly, the articular extremities of the bones disappear, and the 140 MEDICAL DIAGXOSI& joints undergo a kind of dislocation. The shafts of the bones, too, show defects of nutrition, and spontaneous fractures hapf>en. The teeth drop out of the atrophied alveolar processes, and so may parts of the bones themselves ; * the tendons tear ; the tongue may dwindle on one side ; the spine becomes curved. Herpetic, bullous, and pempliigoid eruptions or ecchymoses may appear during or subse- quent to exacerbations of the lightning pains. Perforating ulcer of the foot has also been observed among the trophic changes. Among some of the less common symptoms is drooping of the eyelids, accompanied by weakness of all the muscles attached to the eyeball, and a sense of the face being covered by a mask.' Another symptom, more frequent, is the occurrence of spasms and pain in the epigastric region, with attacks of vomiting. These gastric crises, as tliey have been termed, may be found to happen in those who complain much of fulness in the abdomen and of unsatisfied hunger. They have even been known to lead to vomiting of blood. Buzzard* shows the symptoms to be dependent upon sclerosis affecting the nucleus of the vagus. There is always in these gastric crises acid fermentation, but hydrochloric acid is also constanUy found.* There are at times attacks of laryngeal spasm in ataxics. Arthropathies ofU»n happen in those who present laryngeal or gastric crises. These two forms of crises are by far the most ft'equent. But, in addition, we have intestinal crises, urethral crises, rectal crises, genital crises, renal crises, cardiac crises, and others, in which, as the chief symptom, violent paroxysms of pain occur, that pass away and are found not to be connected with any organic change of the seemingly (lis(»asr»d part. The true meaning of these pain crises, as well as the distiiKtUon from the visceral affections they simulate, is detected in the al)aont knee-jerk and in the other symptoms of the ataxic malady. In considering the diagnosis of locomotor ataxia, let us first exiimine how it differs from general imralysis of the insane. Both maladies are very chronic in their course, and in both there is loss, or certainly impairment, of muscular co-ordination. In the one case, howtjver, it exists with tremors, with thickness of speech, with de- ni(»ntia, with peculiar delusions, with exaggerated knee-jerks. Then, in locomotor ataxia, the hands are rarely affected; indeed, should, in process of time, the upper extremities share in the disorder, there is * Ni'wmark's case, Medical News, Jan. 26, 1895. • Hulchinscm, Transact. Royal Medico-Chimrg. Soc., 1879. • Diseases of the Nervous System, 1882. * Cathelinean, An-h. Crt'n. de Med.. April, 1894. DISEASES OF THE BRAIN AND SPINAL CORD. 141 in them often rather cutaneous anaesthesia, with some trembling, than an obvious failure of co-ordinating power. It must also be remem- bered that the two diseases sometimes exist in combination. With reference to the distinction of progressive locomotor ataxia from most of the diseases of the spinal cord, the extreme rarity of muscular spasm in ataxia must be dwelt on ; from spinal paraplegia the result of myelitis it differs in the fact that the muscles act with strength, the patient can flex and extend his legs and kick vigorously, while in spinal myelitis the affected limbs cannot move, though the knee-jerk may be excessive. The lightning pains are not entirely to be trusted to in diagnosis, for they may happen in acute myelitis as well as in spinal pachymeningitis and in disseminated sclerosis. The absence of the knee-jerk in locomotor ataxia is of very great value. Its presence, in addition to the tremor, the nystagmus, and the scan- ning speech, distinguishes disseminated cerebrospinal sclerosis. But mixed symptoms may exist from the different forms of sclerosis being combined. In ataxic paraplegia we have both disease of the posterior and lateral columns and a combination of the symptoms of spastic paraplegia and of locomotor ataxia. The knee-jerk is exces- sive, ankle-clonus is present, and there are extensor spasms in addi- tion to weakness and to the incoordination ; but no lightning pains or loss of light reflex attend the ataxia, as in tabes. Putnam and Dana have described cases presenting chronic sclerosis of the posterior and ktteral columns, especially of the pyramidal and cerebellar tracts, which are very puzzling. Among the symptoms are numbness in the extremities, progressive loss of strength, and wasting. The knee-jerks are at first exaggerated, but later they are enfeebled or lost, and paraplegia develops. The lower extremities suffer in greater degree than the upper. Mental symptoms may appear. There is a chronic degeneration of the spinal cord having its chief seat in the posterior columns and the lateral pyramidal tracts, which mostly develops in childhood. It is often hereditary, usually occurs in families, is probably congenital in origin, and has as its chief symp- tom ataxia. This disease is known as Friedreich's ataxia, and also as hereditary ataxia, and is of very long duration. The disorder of co- ordination shows first in the lower extremities, and advances up- ward, at last affecting the organs of speech. The patellar tendon reflex is generally abolished; nystagmus and vertigo are frequent; while in the later stages spasms and contractions of muscles, curva- ture of the spine, want of control in keeping any part of the body quiet, and palsies, are not uncommon. Unlike what takes place in locomotor ataxia, we note no disorder of cutaneous sensibility, no 142 MEDICAL DIAGNOSIS. lancinating pains, no atrophy of the optic nerves, no Argyll-Robertson pupil, no trophic lesions, no visceral disturbances.^ From diphtheritic paralysis we distinguish tabes by the history of the malady, the absence of pain, and by the paralysis of accommoda- tion and of the palate that precedes the muscular weakness. Loss of knee-jerk exists in both, and occasionally incoordination is met with in the former. In multiple neuritis this, too, may happen ; but the marked muscular and nerve tenderness, the changed electric re- actions, the normal pupils, the absence of the lightning pains, the more decided loss of muscular power, and, usually, the evidence of alcoholism, tell the true meaning. A diminution or loss of the muscular sense — that guiding sense by which we judge of the position of the limbs, by which we are con- scious of their movements — occasions difficulty in diagnosis, since in locomotor ataxia the muscular sense may be also deficient. On the other hand, in the former morbid state the motion may be somewliat impaired, for, as in tabes, the feet may feel numb in standing and in walking, and the patient be unable to walk in the dark. But there is this difference : where merely tlie muscular sense is affected, he can walk and perform all movements, even those of a complex nature, without vacillation, so long as his eye is fixed on them and super- intends and gives them direction ; while in tabes the derangement of muscular co-ordination renders, even with the aid of sight, the move- ments uncertain and irregular. Then cutaneous anaesthesia is apt to coexist with this malady. The treatment, too, will throw light on a doubtful case : the local use of electricity will usually cure the loss of muscular sense, as seen principally in hysterical paralysis ; it has no curative effect in ataxia. Irrespective of the affection of muscular sense, the greatest simi- larity to locomotor ataxia I have seen has been in several cases of hysteria; one in particular, in a very anaemic woman, resembled it closely ; and it may be a question whether the nutrition of the parts affected in ataxia was not disordered, and the nervous structure functionally disturbed. I desire particularly to call attention to tliese cases, which can be distinguished by their history, the .usual coexist- ence of anaemia, and the absence of severe darting pains. Yet pains may also happen in the hysterical complaint, as in a case I saw with Dr. Webb;^ but this is uncommon. Moreover, tlie apparent want * For an admirable analysis of cases, see Crozer Griffith's paper in the Transactions of the College of Physicians of Philadelphia, 1888. Sanger Brown, Chicago Medical Recorder, Feb. 1892, publishes a veiy striking family tree. ^ Aftier. Joum. Med. Sci., Jan. 1876. DISEASES OF THE BRAIN AND SPINAL CORD. 143 of muscular co-ordination is more irregular in its manifestations, the knee-jerk is not lost, — though rigidity of the limbs may make this very difficult to ascertain, — and the cases recover. So, I think, may cases of locomotor ataxia due to special causes. For I have seen cases in syphilitic patients, typical in everything except perhaps the severity of the neiualgic pain, essentially typical in the muscular phenomena and in the inability to walk with closed eyes, in which a gradual and nearly complete recovery took place. Here the lesion was probably removed or greatly influenced by the anti-syphilitic treatment, and a true or extensive sclerotic degeneration of the affected parts did not take place. Disea43e8 of the Oerebellum. — Diseases of the cerebellum pro- duce many of the phenomena regarded as peculiar to locomotor ataxia. But the gait of the patient is that of a drunken man : when attempting to walk, he leans to one side, moves in arcs of a circle, or describes zigzags; and when standing erect, his body swings back- ward and forward, or from side to side, though his feet remain quietly fixed on the ground. In ataxia, on the other hand, the mus- cular contractions in the erect position or during attempts at walking are strong and sudden, more like spasms, yet not spasmodic, and have as their object to keep the body in the line of gravity ; and the walk, though accomplished with difficulty, is straight, not reeling; the affected person, too, while he is walking, does not take his eyes off the ground or off his feet, from fear of falling ; but he is not giddy. The peculiar gait of cerebellar affections is particularly found when the middle lobe is involved. Disease spreading from the cerebellum gives rise to hypoglossal, facial, and other local palsies. In diseases of the cerebellum we find vertiginous sensations, especially during attempts at locomotion, which may be easier and straighter with the eyes shut than with them open ; vomiting, particularly at the onset of the complaint, aggravated or brought on by the erect posture ; nystag- mus; severe headache, occipital or frontal, when the head is bent; defective vision, but with normal pupillary reaction, or double vision, though the eye-disturbances may or may not be associated with choked disk or optic neuritis; no diminution either of power of motion or of sensibility, unless from pressure on adjacent parts ; and in some instances rotary movements and hemiplegia. Rotary move- ments are regarded as a special proof of affection of the cerebellar peduncles. The knee-jerks are sometimes wanting, sometimes exag- gerated; there are no leg-pains. When the disease is localized in one hemisphere of the cerebellum, it may cause no symptoms. 144 MUDICAI. DIAOXCR&IS. Aot inToiuLXuj aigiiatioD of tbe fcodr. cr o^ pan of it without njLiied mos^iLar oo&tnction or impediiDriit to voiimiaunr moTement, m IiDg depieMs iqicA a w^akroing of the mnstnLsiT and i>efTOf2s sTstiei&s. It k eommoc in oid a^. in conva- ksce&De from dehOtatiDg diseases, in hystcfia. in Dearasthenia, and dartE^ chills. Wsis is most common between twenty-five and thirty-five, and lusts for ymirs. One of its striking features is that long delusive jH^riinis of markiHl improvement occur. The di^cription given shows the dissimilarity between it and (xinUysis ;igitan$. The most difiicult diagnosis is as r^ards Fried- mcirs atiixi;u when, as it Oirasionally does, disseminated sclerosis hapivns in the young. The distuii>ance of co-ordination in the &mnor malady and the common loss of knee-jeiiL are the most obvious ditTei\MUvs, Thoix^ i;? a form of disi'aso in which the symptoms appear like th\Vi»^ of di^ominutiHi si^lonvsis, and are yet due to an infectious pro- iV!?5?^ jiiuh AS iioarlot fever, measles, variola, typhc»d fever, and in- fiut^:;:a. The tnnnor a^:)nravateil by intention, the scanning speech, thr* ^:r\v^;sr^*: >4\ the dull expr^^^^on of feict^ and general air of stupidity, tht* 5iv*#:K 4::;iit with exa^^rateii deep reflexes, are ov^nimon to both. Nx'^^'.v.us ivAs. however, not Ixvn observed in ti^ ptmtdixlitMminaUd ^•v<--c*ck Av.^i the ca:^^ nwver. They art in their general character, t'-Xxn^'t :.; :":.<- ts^xvw'. syniptonvsi tl«: ApV'r^>xi!:Mite them to sclerosis, >?; .x^.^s&uxi* \\hkh «i ji'.s^^ ort^TTOii aftt^ various acute in- ;?^»,.,j; 5i. •;r,^s:N. >;;: :ViAriiVl *:;-.; jvTSi^s:^::: ir.kk-v ionixs is wanting, 4fe> s?^ JL5J!. :r?: ;«iiv.:A>-riN:%\, \xh;.v A:v.t^ho#aA c^' :ht lower extrenii- :!.s ?< ..M>. :iv:'> ^^ X vri>!;v.:. Iv. >.>?C;rsi, iit^.-.ul^y in micturition i!t ,>:;**. . .: ;is5<^'r. ..»A:;\i or ..'i^fc;;^JiT . 147 There are other, though far less common, forms of tremor con- nected with organic disease, such as the post-hemiplegic tremor and the tremor in apa^modic tabes. In both the history of the case and the attending muscular disorder, with the violent but rhythmical tremors on attempted motion in the latter affection, are of great significance. As an organic tremor, too, may be classed that of old age. In this senik tremor the trembling is most probably due to degenerative changes in the motor tract. At first it happens only on voluntary movement, stopping during repose and sleep, though ulti- mately it continues during rest as well as during motion. It begins in the hands, but extends markedly to the neck and head, and finally becomes very much like the tremor of paralysis agitans. Dana,^ studying this and other forms of tremor with great accuracy by means of Dudgeon's sphygmograph, states senile tremor, indeed, to be the evidence of an abortive form of paralysis agitans. Functional Tremors. — There is a group of tremors in which there is no organic cause, or at least the cause is so fine as to elude detection. Toxic tremors belong to this group, and we will look at their characteristics. Alcoholic trem^or occurs only on movement. It is irregular, and of considerable range. It is very pronounced in the arms, face, and tongue ; in the legs it generally shows itself only when they are put in action, as in an attempt to stand. It is associated, in acute casjes especially, with great restlessness, and muscular twitchings are not uncommon. The trembling is usually worse in the morning. Then, too, in its diagnosis we lay stress on the habits of the patient. Tobacco trem^yr is a fine tremor which more especially happens in the hands. It is sometimes seen in the tongue, which is smooth and shiny, and is apt to be combined with a relaxed skin, an irritable heart, and feebleness of sight. Lead tremor is also a fine tremor. It is irregular in its distribution, usually seen in the hands, increased by motion, and not limited. It is often associated with beginning weakness of the extensor muscles of the forearm, with a blue line on the gums, and may involve the lips and tongue. In arsenical tremor the trembling is wide-spread. There is also some diflRculty in co-ordination, with beginning muscular paralysis, darting pains in the arms and legs, and diminution of tactile sensi- bility. Mercurnal tremor, another variety of tremor, usually appears first » Medical News, Dec. 1892. 148 MEDICAL DIAGNOSIS. in the tongue and face, and later extends to the arms and legs. It is increased by emotion and effort, and is recognized by observing that the trembUng and the incessant movements stop when the shaking limb is supported. Then the gradual manner in which the disease appears, its occurrence among persons whose occupations predispose them to the absorption of mercur>', the wakefulness, the disorder of the digestive oi^gans, and the sponginess of the gums, form a group of phenomena ver)' characteristic. Adhenic tremor^ such as follows debilitating disease, is fine, is in- duced by voluntarj' movement, and is most marked after exertion or fatigue. Hynterical tremor may be fine and irregular, or coarse and rhyth- mical. It is usually induced by emotion and movement, although the second variety may occur independently. The tremor that commonly attends exophthalmic goitre may be regular, but is often coarse and jerky, and occurs only on movement There is a fonn of functional tremor which is found to be uncon- nected with any obvious cause and may last through life. This ejfffential tremor^ to call it by that name, comes on often in young persons and lasts through life. It is generally fine, but sometimes irregular and unequal, and is apt to be associated with other hyster- ical manifestations ; it is sometimes verj' severe, as in the case re- corded by Lloyd,* in which marked hysterical anorexia coexisted. It shows itself most markedly in the hands, is made worse by excite- ment and by attempts at motion, and to a great extent, but not en- tirely, ceases during rest. It is not associated with any other motor disturbance, and I have known it in persons of high intellectual en- dowments. It may not come on until middle age, is not dangerous, but is not curable. In an instance that came under my observation the father and the son, a young man, both had it at the same time to an equal degree. Kindred to it is the hereditary tremor described by Dana, which also is a fine tremor, that does not interfere with co-ordi- nation, and which affects especially the upper extremities. It begins in infancy or childhood and continues during a lifetime, without shortening life. It is often brought out by an infectious fever, ceases during sleep, and may become associated with slight contractures of the fingers.^ * Amer. Journ. Med. Sci., Sept. 1893. * Ibid., Oct. 1887. DISEASES OF THE BRAIN AND SPINAL CORD. I49 Spa43in8 — Convulsions. Both thqse terms are applied to involuntary muscular contrac- tions, with, perhaps, this diflference : the word spasm is used when we wish to express the idea of less extensive muscular derangement, and especially when the muscles of oiiganic life are believed to be in- volved; and convulsions, when the disorder affects the muscles of the whole body, or at least many muscles at once, and chiefly those of volition. Spasms may be clonic or tonic. In clonic spasms the muscles are agitated by successive contractions and relaxations of their fibres. In tonic spasms the muscles are rigidly set, and retain for a time tlieir contraction, in spite of every effort on our part, or on the part of the patient, to relax them. The most marked type of this disorder is seen in tetanus ; the most perfect illustration of clonic spasms is furnished by hysteria. Convulsions may be accompanied by a loss of consciousness, and abolished sensibility, as in epilepsy; or they may coexist with un- clouded thought and unaltered sensibility, as in tetanus. What their immediate cause is, it is very difficult to determine. General evidence fevors the cortex of the brain or the medulla as being the centres dis- turbed ; but the irritation need not be direct, it may be reflected to them. Of their exciting cause we may say that, in those of suscepti- ble nervous organizations, any extrinsic irritation, such as teething or disordered digestion, leads to a fit. Further causes are diseases of the brain ; sudden interference with the circulation ; profuse hemor- rhages ; anaemia ; contaminated blood ; the toxic influence of lead. Children often have convulsions as the precursors of febrile diseases. Convulsions have further been observed as a result of rupture of the stomach.^ In point of diagnosis it is of great importance to distin- guish whether their inroad is or is not symptomatic of a cerebral lesion. If there have been a previous manifestation of a brain affec- tion, we may assume the convulsions to be the signal of cerebral mis- chief. Practically speaking, when convulsions are among the first signs of a malady, they are not apt to depend upon a disease of the brain ; and even if recognized to form part of the symptoms of a cerebral lesion, we may conclude that the lesion has not reached its highest degree of development, but is still, as it were, irritative. Besides separating convulsions or spasms in conformity with their centric or their eccentric origin, we must always attempt to ascertain 1 OTarreU, Lancet, vol. i., 1894, p. 1243. 150 MEDICAL DIAGNOSIS. the particular nature of the cause. If centric^ is it congestion, inflam- mation, a tumor, sclerosis, or other lesion of the brain or mem- branes? or is it the convulsion due to influences the cognizance of which is not within our horizon ? If eccentric, is it owing to an im- pure or impoverished blood, to retained poisons, to ptomaines, or is it peripheral from ner\'e lesion or intestinal or other visceral irrita- tion ? and in how far reflex ? To solve these questions is often very difiicult, and nothing but a careful analysis of all the phenomena of the case enables us even to approximate the truth. Among the most extraordinary forms of spasm connected with increased reflex irritability of the cord is the so-called saUaiory spasm, in which so violent a spasm of the legs takes place when the patient's feet touch the floor that he is thrown into the air. In some instances, as in one described by Bamberger, palpitation, dyspnoea, and ine- quality of the pupils also existed. Other forms of tonic or clonic spasm happen from Teflex irritation of certain nerve-tracts, and these func- tional spasms produce for the time being the most singular contortions and deformities. Rhythmic movements of the head, associated with nystagmus, are occasionally obsen^ed in infants and young children. The osciUation is sometimes horizontal, sometimes vertical, sometimes both. Many of these children are rhachitic, some are epileptic. Occasionally there is an antecedent history of traumatism. In some cases the condition is connected ^vith defective light in the crowded dwellings of the poor, necessitating almost constant artificial illumination.^ Friedreich has described as " paramyoclonus multiplex" a condi- tion of clonic spasm often recurring in paroxysms and involving the arms and legs and face and neck. The movements are increased by emotion, and may be controlled by voluntary effort. Closely associated with spasms are other kinds of irregular mus- cular movements, such as cramps, — a contraction of short duration of one or of several muscles, occurring in paroxysms and attended with severe pain ; rigidity, — a more lasting tonic contraction of the muscles ; and the jerking movements of chorea. Now, some of these, especially localized spasm and even rigidity, have a strong connec- tion with the seat and character of the lesion. Thus, broadly speak- ing, if we have spasm, perhaps alternating with chorea-like move- ments, confined to one arm, one leg, one group of muscles, we may infer an irritative lesion in the cortical motor area, affecting in this monospasm the centre presiding over the motion of the disordered * Lewi, Medical News, Nov. 10, 1894. DISEASES OF THE BRAIN AND SPINAL CORD. 151 parts. Early rigidity in the muscles, especially after hemon'hage, is apt to be associated with increased faradic and reflex excitability, but the contracted muscles become relaxed during sleep; in late rigidity the contraction or " contracture" is increased by movements, whether voluntary or passive. DERANGED NUTRITION AND SECRETION. Derangements of nutrition and secretion are especially manifest in paralyzed limbs or after nerve-wounds. But these obvious altera- tions need here only be referred to ; it is the intention to speak rather of the less palpable phenomena, the trophoneuroses, in which, at first sight, the nervous system is not so distinctly concerned. For in- stance, there is to be noted the rapid development of blisters and bedsores in connection with marked cerebral and spinal lesions ; the skin may become the seat of diverse eruptions, undergo modifica- tions of color and structure, the secretions may be augmented or di- minished, the muscles and joints show textural changes, swellings may happen aflfecting various portions of the body, either external or internal, — ^yet all be due to disturbed nervous influence, and the real disorder be in parts very different from where it appears. Then we find the trophic symptoms of atrophy of the muscles in acute polio- myelitis and in Friedreich's ataxia, in the latter aflfection often associ- ated with blueness and coldness of the feet from vasomotor change. To particularize with reference to a few of the derangements mentioned. There is the aflfection described as herpes zoster^ in which the vesicles encircling half the circumference of the trunk are not a primary skin disorder, but the local expression of irritation of a nerve, — most generally of a dorso-intercostal neuralgia. Then we encounter instances of large vesicles or bullae accompanying other neuralgias, as of the sciatic ; and attacks of erythema having their origin in facial neuralgia. Furthermore, various kinds of spots and blotches, and thickenings of the periosteum and of the skin, have been noticed after this and other forms of neuralgia ; and we have eruptions of zoster in chronic myelitis and rashes limited to the limbs affected with pain in locomotor ataxia ; and eczema of ner\'^ous origin produced by reflex irritation in disorders of the urinary organs ; ^ and ichthyosis of the lower extremities in chronic spinal diseases. Oftentimes, too, these morbid appearances on the skin are com- bined with evidences of altered secretion. Thus, in a case related by Parrot,* in addition to the neuralgic paroxysms attended with san- * Ord, St. Thomas's Hospital Reports, vol. vii., 1876. * Gaz. Hebdom., 1869 ; Handfield Jones on Nervous Disorders. 152 MEDICAL DIAGNOSia guineous exudations at ttie painful parts, there occurred, at times, bloody sweating of the knees, thighs, hands, and face. Lachrymation was noticed in nearly half the eases of trigeminal neuralgia analyzed by Notta ; * and one-sided furring of the tongue is a not uncommon phenomenon in this complaint. Associated with these e^sidences of altered secretion may be signs of altered nutrition, such as iritis, cor- neal clouding, and inflammation of ttie fascia or of the periosteum in contact mth the aching nerve. Let us add Ihat these manifesta- tions of perverted nutrition are not confined to neuralgic disorders. Trophic changes occur also in diseases of the central ner\^ous system. Thus, inflammatory affections of the joints have been observed to follow cerebral hemorrhages, and various spinal maladies, particularly acute myelitis ; local dryness of the skin occurs in unilateral atrophy of the face, and in some cases of syringomyelia ; a form of joint- mischief, of hydrarthrosis, has been speciafly described in locomotor ataxia by Charcot ; afiections of the joints have also been observed in syringomyelia; and the perforating ulcer of the foot has been found by BalP and Fayard^ to be often connected with locomotor ataxia. Perforating ulcer of the foot has, however, also been noticed in Morvan's disease. (Edema happens also as a vasomotor change. Weir Mitchell* points out swelling of the limbs in menstrual periods. Furthermore, we find local oedematous swellings occurring in various parts of the body associated with intestinal disturbance, sometimes periodically and with an hereditary tendency, and this angio-iieurotic a^denm has been reported by Osier* as affecting members of a family for five generations. Among the phenomena of altered secretion connected \^ith ner- vous affections, one of the most striking is e^cemive »weafinff. In lesions of the cervical sympathetic on one side, we may have strictly uni- lateral sweating of the face and neck, the other side remaining per- fectly dry;* and greater vascularity and increased temperature are concomitants. In lesions of the abdominal ganglia, profuse sweating also happens, and is ai>t to be combined with impeded secretion from the mucous coats of the bowels, as we at times find in instances of abdominal aneurism. Not that excessive sweating, whether localized » Arch. Gen. de Med,, 1854. 'Trans, of Internal. Med, Congress^ vol. ii,| London, 1881, » These de Paris, 1881. * Amer. Joum. Med. Sci., July, 1884. * Ibid., April. 1888. * Afl in the case recorded by W. Ogle, Med.-Chir. Trans., vol. lii. DISEASES OF THE BRAIN AND SPINAL CORD. 153 or general, is always linked to an aflfection of the great sympathetic ganglia. We find local sweatings limited to the hands and feet with- out any signs of other disorder. And general sweatings, irrespective of those of colliquative character attending phthisis, or of those of malarial diseases, happen after low fevers, in influenza, in inactive states of the liver, and in some persons go on for years without obvious cause. It may be that in these cases the sympathetic system is really at fault, at least in so far that there is a reflex derangement of the vasomotor nerves, and of course, then, of the subcutaneous blood-vessels and of the glands they supply. But these are not questions which we can here consider. Indeed, the why and the how of all these changes of secretion and nutrition attending nervous aflfections are still very uncertain. To return to the clinical phenomena. Besides the external mani- festations of altered secretion and nutrition, there are certain changes in internal organs, the expression of nervous derangement. There is, for instance, exophthalmic goitre; the pneumonia that results from injury to the vagus ; the ophthalmia, which may even pass on to per- foration of the cornea, that happens after paralysis of the trigeminus ; the kidney disease which follows chronic spinal aflfections. From the preceding pages it will have become apparent how many of the nervous complaints are functional, or are at least of necessity so regarded, though science is steadily narrowing their number. In consequence of the uncertainty respecting the functional aflfections, doubt is thrown over any anatomical or pathological classification of nervous diseases. I subjoin a table of the main aflfections, arranged according to their supposed sites. In several of the disorders re- garded as functional modem research has indicated the probable organic cause. But from the point of view of the physician it would be premature to hold to a fixed lesion, and I contend rather for the classification being useful clinically than unimpeachable pathologically. Nor will it be adhered to in the description of nervous aflfections, which will be traced according to divisions formed by groups of symp- toms and not in obedience to a pathological classification. TABLE OF THE AFFECTIONS OF THE BRAIN AND SPINAL CORD. Cerebral Organic . ' HyperaBmia. Anaemia. Meningitis in its various forms. Hydrocephalus. Abscess. ^ Softening. 10 164 MEDICAL DIAGNOSia TABLE OF THE AFFECTIONS Cerebral Organic . Junctional . Cerebro-Spinal . Organic . f\incf tonal . Organic SPINAL Function*!! . OF THE BRAIN AND SPINAL CORD.— Qyntimied, Sclerosis. Hemorrhage (Apoplexy). Thrombosis. Embolism. Tumors, etc. Aneurism. Glosso-labio-laryngeal paralysis. Syphilitic affections. Delirium. Insanity (?). Hypochondriasis. Headache. Trance. Cerebro-spinal meningitis. Disseminated cerebro-spinal sclerosis. Paralysis agilans. Simple senile paraplegia. Hydrophobia. Tetanus. Occupation-neuroses. Epilepsy. Catalepsy. Ecstasy. Chorea. Hysteria. Neurasthenia. Hypenemia. Anaemia. Spinal meningitis. Myelitis in various forms. Softening. Atrophy. Si'Ierosis. Loi^omotor atiixia. Spastic paraplegia. Hereilitiir>' ataxia. Ataxic paraplegia. Spinal apoplexy. Tumors, etc. Syriugi>myeHa. Syphilitio afTei»tions. lV>v:ressive muscular atrophy. Spinal irritation. Spinal exhaustion. TnMUitr. Keflex s^Kisuis due to irritation of the cord. Acute asivnding paralysis. Mvotonia. DISEASES OF THE BRAIN AND SPINAL CORD. 155 Acute^ Affections of which Delirium is a Prominent Symptom. This clinical group embraces the diflferent forms of meningeal in- flammation, deliriimi tremens, and acute mania. Acute Meningitis. — By this term is understood an inflammation of the membranes of the brain, especially of the arachnoid and of the pia mater, or acute leptomeningitis. The dura mater is far less fre- quently attacked ; very rarely, unless the morbid action be of syphi- litic origin, or have extended from the bones of the cranium, or resulted from an injury. The disease generally presents two well-marked stages. The first, or the stage of excitement, is characterized by intense headache, great restlessness, vomiting, a hard, frequent pulse, slow in propor- tion to the temperature, injected eye, often with a contracted pupil, strabismus, an increased sensibility to light and sound, obstinate con- stipation, irregular respiration, stiflfness of the muscles of the neck, and soon by active delirium, and by convulsions. The temperature rarely exceeds 103° F. In the second stage the extremities are cold, the pupils dilated, the pulse is feeble and slower, and intermitting, or becomes extremely rapid and thread-like ; involuntary passages occur ; there is utter loss of mind and of sensibility, — in one word, coma or collapse. In this stage the temperature may fall below the normal, or may reach 106°. Not every case, however, has all these symp- toms, or goes at once from the stage of excitement to that of collapse. There may be a well-defined period of transition, during which drowsiness appears. Again, the disease may be arrested before the signs of prostration are evident. The attack may be preceded by sick stomach, buzzing in the ears, and vertigo, or it may set in with severe pain fixed to the forehead and increased by movement. In some cases it begins with delirium or convulsions. On the other hand, these signs may be absent.* Among the symptoms of the affection, even in the earliest stages, a persistent pain attacking one or both knees, violent, intensified on motion, unrelieved by local means, and connected neither with swell- ing nor with any other change in the form or appearance of the joint, has been particularly noticed.^ Another sign, as of every form of meningitis, including the epidemic cerebro-spinal, is the so-called Kemig's sign, — an inability to extend the leg when the thigh is flexed at a right angle with the body. * In a paper by Church, in St Bartholomew's Hospital Reports, vol. iv., several cases without delirium are narrated. * Lund, quoted in Amer. Joum. Med. Sci., Oct. 1864. 156 MEDICAL DIAGNOSIS. The malady may pass rapidly through its stages, so rapidly that their distinctive features become confused and blended. Generally it does not last less, or much more, than a week. There is marked emaciation attending it. Acute meningitis is brought on by alcoholism, by exposure, by depressing cares, by intense application to study, by a blow or fall upon the head, by disease of adjacent structures, or by syphilis ; or it may occur in the course of chronic nephritis, of the wasting diseases of children, or of infectious processes, such as measles, scarlatina, smallpox, typhoid fever, and pyaemia, though it is rare under all these circumstances ; finally, it may be due to pneumonia or to inso- lation. Bacteriologically it is chiefly owing to the meningococcus or to the pneumococcus meningitis, and this not only in connection with pneumonia, but as a separate malady. Meningitis sometimes aflfects mainly, or wholly, the coverings of the convex portion of the brain ; at other times the inflammation is limited to the base. Meningitis of the convexity is not infrequently purulent, and, if puru- lent, temperatures of 104° to 105° are usuad. It generally comes on suddenly, and is found to be connected with disease of the bones of the skull, with ear-disease, or to follow exposure to the rays of the sun. Severe headache, intense delirium, hypersesthesia, spasms in the facial nmscles of one side and in one or both arms, and hemi- plegic weakness are among the most marked symptoms. According to Duchatelet,^ meningitis of the base may be discriminated by remis- sions in the delirium, and by the coexistence of spasmodic symptoms with profound and early coma. In some cases acute muscular pains with defective motor power, a clear mind until late in the disorder, a temperature of 105°, have been specially noticed.* Moreover, the longer duration of the malady, the delirium of varying intensity and later appearance, the intervals of clearness, and the late and incom- plete palsies, are regarded as significant of this simple basilar menin- gitis.^ Then persistent vomiting, paralysis of cranial nerves, marked rigidity of the neck, and early optic neuritis point to the base ; optic neuritis is indeed rare in meningitis or meningo-encephalitis of the convexity. Yet there is no certainty in the diagnosis. Nor can we be sure of the membrane chiefly involved in the meningeal inflam- mation. Inflanmiation of the dura mater, or paehymeningitis^ has the least severe and striking symptoms. It is most commonly noticed as * Inflammation de TArachnoIde, p. 230. * Dowse, Medical Times and Gazette, Feb. 1874. ^ Huguenin, in Ziemssen's Cyclopaedia. DISEASES OF THE BRAIN AND SPINAL CORD. 157 due to extension from caries of the bone, to injuries of the head, to syphilis, or to sunstroke. A form of inflammation of the cerebral meninges characterized by extravasation of blood between the dura mater and the pia-arach- noid is known as henwrrhoffic paehyitieningiiis. It has been observed most commonly in the chronic insane, and in cases of chronic alcohol- ism. Among the symptoms to which this condition gives rise are apoplectiform seizures, headache, somnolence or coma, muscular weakness, nystagmus, smallness of the pupil, optic neuritis, headache, and vomiting. Acute meningitis is not always easy of diagnosis. Leaving out for the present the other disorders belonging to the same group, such as acute mania and delirium tremens, it may be confounded with (Jerebritis ; Acute Softening; Intracranial Tumor ; EIar Disease; Head Symptoms of Continued Fevers ; Head Symptoms of Acute Rheumatism : Head Symptoms of Acute Ulcerative Endocarditis ; Head Symptoms of Pneumonia; of Pericarditis. Cerebritis. — ^There is little appreciable diflference between acute inflammation of the brain-tissue and inflammation of the meninges. In truth, what we commonly call meningitis is not infrequently also cerebritis ; since the diseased process extends readily from the tunics of the brain to the adjacent cerebral substance. We note, acute cerebritis generally as the result of an injury to the head, of contigu- ous inflammation, of ear-disease, of septic influence, or of acute infective disease. We may suspect the brain-structure to have become involved if the sense of vision or of hearing be suddenly perverted ; if the convulsions, the agitation of the limbs, and the tremors be very marked ; if they occur chiefly upon one side ; and if palsy of the limbs or face rapidly appears. The paralysis is generally hemiplegic. Where the palsies are limited, or the spasms or irregular choreic movements strictly unilateral, we may infer that the disease is limited, that we are dealing with an dcute focal encephalitis. Where the brain structure is extensively involved, diffuse encephalitis^ there is long- continued torpor of mind and body, and, in their valuable analysis of cases, Kneass and Brown * look upon this state of vacuity as of decided diagnostic value. The disease occurs especially in the young. » Brain, vol. xvi., 1893. 158 MEDICAL DIAGNOSIS. Acute Softening. — The fonn of acute softening which simulates meningitis is that associated with delirium. Acute softening is almost always the result of arterial occlusion from embolism or thrombosis, or of venous thrombosis; arterial thrombosis is by far the most common cause. The existence of disease of the heart or of the blood-vessels, or of contracted kidney, gives us for the most part the clue to the case. The palsied side has often a decidedly higher tem- perature than the other side. The general temperature is that of fever, and may be high, 104° or more. In the cases of acute soften- ing in ver}' old persons, where an atheromatous state of the blood- vessels of the brain exists before the clogging, the rapid softening that may follow is apt to be preceded by restlessness, some mental confu- sion, and signs of a general breaking up of nerve-force ; it is soon associated with disturbances of the bladder and rectum, and leads to coma. In the cases which I have seen there was neither much head- ache nor febrile disorder. In rare cases there is a primary actUe hemon'hagic encephalitis without obvious cause, though it is likely that the inflammation starts in the blood-vessels. In its main features it is similar to the acute encephalitis of children, where, however, the lesion is most apt to be cortical. In the primary acute encephalitis of adults punctiform hemorrhages are noticed.^ The chief symptoms are rapidly develop- ing coma and hemiplegia. The knee-jerks are presented, though there may be crossed tendon reflexes in the lower extremities. A significant feature is the extraordinarily high temperature, especially before death. In the latter respect, it is like what is sometimes ob- served in recent hemiplegia following embolism or hemorrhage. Intra^anial Tumor, — A rapidly growing tumor or one of latent course may give rise to symptoms resembling those of meningitis, but the unchanged or steadily increasing paralysis, the marked optic neuritis, the progressive character of the symptoms, and the absence of febrile phenomena should suggest the cause. Ear Disease. — Occasionally disease of the ear, with or without extension to the membranes or sinuses of the brain, may be attended with deceptive symptoms, the nature of which will become clear upon examination of the ear. In middle-ear disease severe headache, vomiting, high fever, delirium, convulsions, and retraction of the head indicate meningitis or abscess. Head Symptoms of Continued Fevers. — In all the varieties of con- tinued fever, but especially in tjT)hoid and typhus, cerebral symptoms iStrUmpell. Deutsch. Arch. f. Klin. Med., Bd. xlvii., 1890, p. 63. DISEASES OF THE BRAIN AND SPINAL CORD. 159 at times arise which bear a strong resemblance to those of menii^tis, but without even traces of inflammation. How, then, are we to distinguish these fever cases from menii^tis? or how ascertain if meningeal inflanunation be really before us as a complication, as it sometimes is, of the fever? Unfortunately, there is no sign abso- lutely diagnostic. Cerebral auscultation aflfords us no help, for the blowing sound that is at times perceived is not constantly present in meningitis, and may be heard in health. As matters stand, a diag- nosis can be established only by a close consideration of all the symptoms, and of the history, especially of the onset ; by searching for the eruption of typhus or typhoid fever ; by a careful study of the temperature curves; and by taking note of the expression of the countenance. The character of the delirium will be of service ; it is ordinarily much more active when the membranes of the brain are inflamed, and is attended with throbbing of the arteries of the neck and face, — a symptom, however, not conclusive, for it may be noticed in low fevers, — and not infrequently with convulsions. The relation between headache and delirium may be of aid. In general diseases headache ceases when delirium sets in ; in men- ingitis the two coexist. Then, too, we may lay stress on optic neuritis ; on retraction of the head, if present ; on the more intense headache ; on the vomiting ; and we may attach some, but not too great, importance to the red line made by drawing the nail across the forehead, — the menii^tic streak. The most valuable differential sign is the loss of the knee-jerk, a loss that is apt to happen, at least temporarily, in meningitis. Head Symptoms of Acute Rheumatism, — The morbid manifestations are like those of acute meningitis : restlessness, headache, and violent delirium, succeeded by coma ; besides, rheumatic involvement of the muscles at the back of the neck may cause retraction of the head. The delirium is commonly of gradual approach, but it may come on suddenly. Generally it does not appear until the patient has been suffering for at least a week with acute rheumatism ; and the sweats and swollen joints point out the malady with which it is combined. Examinations of the head, in cases which have proved rapidly fatal, fail to reveal, save in rare instances, any evidences of inflammatory action within the cranium. The abnormal signs are, as a rule, more properly attributable to the rheumatic poison seizing upon the brain, and to the altered condition of the blood. They are at times found to be connected with the setting in of inflammation of the membranes of the heart, or of pneumonia, or with albuminuria, or with plugs of ft 160 M£DICAL DIAGX06IS. fibrin in the capillaries of the brain« and are frequently associated with a very high temperature.' Head Symptoms of Acuie fTwro/ire EndocarditU. — ^The severe headache, the delirium, the somnolence, which may attend ulcerative endocarditis cause it to be confounded with meningitis. Generally, however, the fever is of a typhoid type : and the high temperature, the rigors, the marked swelling of the spleen, the absence of optic neuritis, are very significant, and so are the cardiac murmurs. Head Symptoms of Pneumonia; of Pericarditis. — In both these maladies delirium may be met with of a character so active as to lead to the belief that the brain is involved in an inflammatory dis- ease. The diagnosis is cleared up by a careful examination of the chesL Then we may lay stress on the violent delirium being unat- tended with spasmodic movements or with paralysis. The form of pneumonia which is mostly associated with delirium is inflammation of the upper lobes. True meningitis sometimes attends pneumonia, and is with great difficulty distinguished from the mere disturbance of the cerebral circulation just mentioned, unless persistent vomiting, and pressure on a cranial nerve, or optic neuritis show us the real meaning of the brain affection. Tubercular MeningitiB. — ^This is not a rare disease in children. It is a meningitis pre-eminently of the base, incited by the tubercle bacillus. The premonitor}' signs of the malady are of great importance. The child has generally been ailing for some time ; is restless, pee\ish, sleeps badly, complains of headache, and is troubled with a fr^uent, short cough, and with constipation. To these symptoms are soon added thirst, a slightly coated tongue, vomiting, a dry, feverish skin, an accelerated pulse, and grinding of the teeth, constituting the promi- nent features of the first stage of the affection. After four or five days the second stage is reached, and the brain symptoms become more clearly developed. The child shuns the li^t, puts the hand frequently to its head, and utters now and then a peculiar, sharp, distressing cry. At night the headache becomes worse, and is attended with fleeting delirium. A slight strabismus is observable, and the eyeballs oscillate. The pulse is very irregular in its rhythm, sometimes rapid and intermitting, tlien slow. The vomiting ceases, ' For a collection of cases. I may refer to a paper on Cerebral Rheumatism which I published in the American Journal of the Medical Sciences, Jan. 1875. Dr. Posner. in the German tmnslation of this book, points out that the use of salicylic acid, now so much employed, may ^ive rise to confusing cerebral symp- toms, such as headache, vertigo, hallucinations, even delirium. DISEASES OF THE BRAIN AND SPINAL CORD. 161 and there may be a remission in the symptoms, with restored intelli- gence ; but the pulse remains irregular, the temperature is moderately elevated, the bowels are even more constipated than before, and the abdomen appears retracted. The third stage is one of complete stupor, accompanied or preceded by convulsions. The expression of the face is idiotic ; the pupils are dilated ; there is subsultus, and one side of the body is paralyzed. Deglutition is difficult ; the surface is covered with cold sweats. This condition may last for days ; repeated convulsions hasten its termination. Can we distinguish the formidable complaint from ordinary menin- giiis f Seldom from menii^tis of the base ; generally from menin- gitis of the convexities. As regards the discrimination from the former malady, we are enabled to pronounce the affection to be tubercular meningitis, if we are familiar with the patient's antece- dents, and are cognizant, previous to the seizure, of the presence of scrofula of bones or joints, or of tubercle in any of the internal organs, or are able at the time to detect scrofulous glands or tuber- cular phthisis. But without knowledge of this kind a positive diag- nosis is impossible : we have nothing to direct us except the proba- bility that the case is tubercular, because most instances of meningitis of the base are of that nature. This uncertainty does not exist with reference to the usual form of simple meningeal inflammation. We may generally distinguish the tubercular malady by its occurrence in an unhealthy person; by its insidious approach; by the absence of violent delirium; by the appearance of convulsions, not early, but late in the disease; by the far less violent headache, and the less degree of febrile excitement; by the notable remissions in several of the cerebral signs ; by the chest symptoms, and the long duration of the affection. The ophthalmoscope gives no certain information ; tubercles are not commonly found in the eye-ground, only optic neuritis or choked disks. Tubercular meningitis is ordinarily attended with an eff'usion of serum into the ventricles, and it is plain that many of the symptoms are attributable to pressure of the fluid on portions of the brain. Now, how can we separate the malady, acute hydrocephalus as it used to be called, from dropsy of the brain or chronic hydrocepha- lus t Partly by the history of the case, and partly by the normal size of the head; for the water on the brain is not sufficient in amount nor is it there long enough to produce an appreciable aug- mentation of the cranium. Then, in chronic hydrocephalus the symptoms manifest themselves for years, from childhood even to adult life. The signs of a profound cerebral lesion appear gradually. 162 MEDICAL DIAGNOSIS. the special senses are by degrees enfeebled, but it is a long time before they are wholly abolished, or before complete loss of consciousness takes place. As r^ards the diagnosis between tubercular meningitis and acute hydrocephalus^ it need only be stated that the latter affection is in the vast majority of cases a synonym for the former. Yet we occa- sionally meet with instances in which acute hydrocephalus occurs unconnected with tubercle. It runs then either a latent course, or appears as an acute malady with symptoms similar to those of acute meningitis, a seroiLs meningitis, beginning with fever or with convul- sions, and often attended with marked choked disks, with intense restlessness, succeeded by drowsiness, and having periods of inter- mission of the symptoms and of apparent improvement ; the pulse and temperature show great variations. Towards the end severe convulsions are common. The complaint, unlike tubercular menin- gitis, happens in pre\iously healthy children, b^[ins suddenly, and is of short duration. But the effusion may remain, and the disorder lead to chronic hydrocephalus. There is a functional disturbance of the brain to discriminate firom tubercular meningitis, — the hydrocephaloid disease described by Marshall Hall. It has a stage in which the little patient is restless and feverish, and a stage in which the countenance becomes pale, the breathing irregular, the voice husky, the pupils dilated and unin- fluenced by light, and in which somnolence, coma, and even general convulsions occur. The symptoms indicate cerebral ansemia and nervous exhaustion. They generally come on after an enfeebling attack of illness, especially subsequent to protracted diarrhoea or loss of blood; sometimes they follow premature weaning. In the history of the case ; in the less tendency to vomiting ; in the irreg- ularity of the pulse ; in the flaccid and hollow state of the fontanel, so dissimilar to its prominent and tense condition in inflammation; and in the arrest of the threatening signs by stimulants and by tonics, — we find the guides which enable us to decide against the existence of an organic disease of the brain or its membranes. But other aflfections besides those of the brain may be confounded with tubercular meningitis, such as typhoid fever and pneumonia. From typhoid fever tubercular meningitis may be distinguished by the frequent vomiting ; by the retracted abdomen ; by the constipation, except in instances of coexisting acute intestinal tuberculosis ; by the normal size of the spleen ; by the irregularity of the pulse ; by the oc- currence of convulsions and anaesthesia, and other signs of profound motor and sensory disturbance ; by the lower heat, the thermometer DISEASES OF THE BRAIN AND SPINAL CORD. 163 seldom rising above 102°; by the absence of the serum-reaction of the Widal test. I have never seen an eruption in tubercular menin- gitis ; but Barthez and Rilliet speak of fugitive, imperfectly formed rose-spots being present in rare cases. The duration of the two complaints affords no help in diagnosis, since the one may last as long as the other. Tubercular meningitis may be confounded with the aciite affec- tions of the lungs^ especially acute pneumonia, which, in children es- pecially, are not uncommonly associated with delirium and other brain symptoms. But the temperature is much higher; and a close ex- amination of the chest reveals the cause of the disturbance of the brain. As regards acute phthisis the difficulty is sometimes great, for there may be in tubercular meningitis also signs of tubercular deposition in the lungs. The high temperature of acute tuberculosis and the course of the cerebral symptoms, should these be present, would alone be conclusive. As a point in the diagnosis of the tuber- cular meningitis of children, with reference to the attending chest symptoms, Gee^ mentions that the chest heaves equally on both sides, yet over a very large part, or even the whole, of one side, no respiratory sound is heard. Tubercular meningitis is not so rare in adults as has been sup- posed, and presents, as Seitz in his admirable monograph has shown, marked features of pain in the head and temperature variations,^ ex- hibiting a fever of moderate type, with irregular remissions. The deposit of tubercle both in adults and in children may not be con- fined to the head. Indeed, the observations of Liorilli* teach that the spinal cord is frequently implicated. The points of diflferential diagnosis of the tubercular meningitis of adults are much the same as with reference to the disease in childhood. Yet one disorder is more apt to be confounded with it, — hysteria. Indeed, in young women the onset of the malady may de- velop very misleading hysterical symptoms. But on close examina- tion we find the traits of the cerebral malady, — the temperature record of the atteftding fever, the unequal pupils, the divergent stra- bismus, the optic neuritis, the trophic changes in the skin, the incon- tinence of urine, the local beginning of the convulsions. Cerebro-Spinal Meningitis. — Now and then cases of menin- gitis are encountered in which the inflammation affects simultane- ^ Reynolds's System of Medicine, vol. ii. * Die Meningitis tuberculosa der Erwachsenen. * Archives de Physiologrie, 1870. 164 MEDICAL DIAGNOSIS?. ously the membranes of the brain and of the spine, and in which the symptoms of the cerebral malady are found to be blended witli severe pain along the vertebral column, with retraction of the head, with convulsions, with rigidity of the muscles, with perverted cutane- ous sensibility, — in short, with the phenomena denoting spinal menin- gitis. But such sporadic cases are of rare occurrence. Generally cerebro-spinal meningitis is not met with save as an epidemic disease that belongs clearly to the group of fevers, with which it will be de- scribed. But here may be pointed out the extreme difficulty of recognition of the sporadic non-epidemic cases. The early retraction of the head, the eruption, the temperature record of cerebro-spinal fever, the bacteriological results of lumbar puncture, are the most valuable diagnostic signs. Pneumonia, so common in this, may, as some cases mentioned by Gowers prove, also happen in the sporadic malady. Deliriiun Tremens. — The prominent trait of this complaint is delirium, associated with trembling and with sleeplessness. It occurs in intemperate persons ; yet such is not always the case, for we may find an affection identical with mania a potu in those who are not in- temperate in the ordinary acceptation of the word, but whose ner- vous system has been racked by persistent mental anxiety, or by the use of other than alcoholic stimulants. I have seen such cases firom the constant taking of chloral and of paraldehyde ; and they may be noticed in morphine-takers. Generally, however, delirium tremens is brought on by the abuse of intoxicating liquors. It is a current belief, and one which has found much favor among habitual drinkers, that a diminution or a sudden discontinuance of the accustomed beverage is followed by an onset of delirium. This may happen ; but it is generally the reverse ; it is a long-continued and unusually severe debauch w^hich terminates in an attack of mania. Let us look a little more closely at the mental wandering. It is very rarely fierce ; nor is the patient taken up wholly with his delu- sions. He pays a certain amount of attention to surrounding objects, answers, perhaps in a rambling manner, the questions put to him, but fancies that animals are running around on his bed or are crawl- ing on the walls, and is thereby, or by some equally distressing illu- sion, kept in horror and in dread. Or he imagines himself to be en- gaged in his ordinary occupations, and gives minute directions as to what he wishes done ; tries to get out of bed, yet is quite tractable when thwarted in his efforts. He is very restless, his hands are con- stantly moving, and his delirium, to use the grapliic epithet of Watson, DISEASES OF THE BRAIN AND SPINAL CORD. 165 is a busy one. With it are associated sleeplessness, a frequent, soft pulse, utter loss of appetite, a moist, coated tongue, and a clammy skin. The tremor is irregular, wide in range, affects particularly the arms, face, and tongue, and is only induced on attempted movement. There is often, besides, spontaneous muscular twitching. The tem- perature is usually elevated, though rarely to a considerable degree ; it seldom reaches 103° F. How are we to distinguish the malady from one to which it bears a certain resemblance, — aeiUe meningitis f Taking clearly expressed examples of each, we find the following marks of distinction : the pulse is different ; tense and hard in meningeal inflammation, it is yielding and soft in delirium tremens. The skin and tongue are dry and feverish in the former affection, moist in the latter. Then the char- acteristics of the delirium are dissimilar : and in the one disease the mental wandering is combined with severe headache, but not with tremors ; in the other, with tremors, but not with headache. Yet in actual practice the diagnosis is not always so easy as it might appear to be at first sight, and here and there we meet with cases presenting symptoms the exact meaning of which it is puzzling to determine. The difficulty is mainly occasioned by extreme cerebral congestion, or by inflammatory action, having been produced by the same exciting cause that has brought on delirium tremens. In this blending of two morbid states, the pulse is, or soon becomes, tenser than in pure mania a potu ; the temperature is apt to be higher, and the irritability of the stomach more marked and more persistent. In some instances, convulsions, strabismus, and deep stupor — carefully to be distinguished from the sleep which often announces the termi- nation of mania a potu — set all doubt at rest. But when these signs are not present, we have to judge of the mischief that is going on within the cranium chiefly by the activity of the fever and by the appearances of the eye-ground, by finding choking of the disks. Yet caution is necessary in accepting as evidence phenomena which may be of diverse origin : the marked fever may be the result of, what is very frequent in delirium tremens, an intercurrent or coexisting pneu- monia, or of a pulmonary apoplexy, as in a case I have seen. Then, again, we must not overlook the fact that in instances of pneumonia of the apex a delirium very similar to that of mania a potu may happen. There is another point connected with the diagnosis of the malady which it is necessary to mention, and chiefly for the purpose of calling attention to a common error. The fact that a person known to be of bad habits is affected with delirium is received as a sure indication that the mental delusions have been produced by the abuse of ardent ](;€ MEDICAL DlAGNOSl!-. upM^, H^A iiitf}' may bfr owlij;^ to other causes: to ier^ff. to a tk- '>f^niJ Ifjflaiijiiialioij : to acute mania. To aToid being (i*-'-'*3Ted- we ixjiiM lay iiir*^6'>i ratiier orj tbe spe^.-ial character of the deiixiuzcL and on the ^ymyU^ms witij which it is combined, than od its lotre {ineseiKe. In 'Afier wordi». delirium iij iijebriaies is not of nc^ciessatT tbe frnit of int/^mj^raii^^r. In discussing acute mania we shall rBtora to this subj^r^rt, Wfiefj delirium tremens ends fatally, death takes place from ex- tiaustjon^ Thi latal issue is occasionaUy broogbt on by an inter- current inflammation. esf>e<:ially of the lung, or by disease of the kidneys and unemia. S^jmetimes. after the subsidence of tbe ui^nt cerebral symptrjms, the patient dies verj- unexpectedly, and thene are no morbid apiK-arances in the brain or its membranes to account for the alirupt extinction of life. In many instances of tbese sudden deaths, a large amount of serum is found in the ventricles, or in the Kubarachnoid spai;es. Acute Mania. — It would be out of place to attempt to give, in a work of this kind, a detailed account of any of the forms of insanity : but, in its acuh? variety especially, it resembles other affections of the nervous sysU-m so closely ttiat it cannot be wholly passed over. There are two disorders with which acute mania is chiefly liable to be nra striata and the Inttrnffl rapstfh\ or at tlie same time into the optic thalamic and we hnd only one-sided paralysis. If the lesion be in both liemispheres, the palsy is on botli sides of the body, althou^di more com|}lete on one side than on the other. Yet a double-sided ]jalsy does not justify iui absolute opinion that the ex- travasation of blood into the brain-substance is double-sided ; it be- tokens also an extravasation into the ventricles. But ventrictthr fiem- orrhiujr is distinguislied by j>rofoiind coma and by tonic contraction of tlie nuiscles, or l>y Ionic alternating willi clonic spasms, and rigidity of tlie niuscles either on one or on both sides occurs ; the respiration is much einljarrassed, and tlie lireatli-sounds are obscured by rales* It is cornnioii in the very ynung and in tlie old. and paralysis is fre- quently absent, thougit it may be gcncrat,' Ventricular hemorrhage is mt>re oflen secondary titan primary, the blood having torn its way into the cavily. Hemorrtiage hnnted lu Hie fhalumm may give rise to no symptoms unless the iuteriml capsule be damaged, when slight bemiplegisu hemianesthesia, and hemianopsia, with mobile spasm and motor inriM>rdination, are apt to show themselves, Hemorrtiage into i\w vorpmut quadritjtmitia presents most trequently this combination of symptoms : muscular incoordination, iinpairment of sigld and alteration of the pupils. CtnMftfr hcmorrhuijr gives rise to very temporary li»ss of consciousness, to unsteadiness of movement, and to frequent vouating ; vision is not affected. Ininstiinces in which there is hemiplegia it may or may not be on the same side as the lesion. In hemorrtiage irdo fnic-tialf of the ji/o/i^, there is palsy of tlie extremi- ties on one side, and of the face on the other/' The laijiiis are often contracted, though they may be dilated and inactive. Disturbanct* of respiration is conuuon. In lesions of tlie pons, too, as in those of the medulla, we have high and rapidly rising temperature almost from the onset, and we find an exception to the rule tliat the lateral deviation of the eyes and head, a sign so commonly presenti in apoplexy, is towards the side of the brain affection."* Ana'stliesia and double- ^ Saridt»rs, Ami»r. Jtmrn. Med. Sci.. ^iily. 1881. *Gul>ler, iynueiW^ HebdoTiiHckire. !8o8, 1859. * Baslian, Paralysis fronj Brain Di^inst. DISEASES OF THE BRAIN AND SPINAL CORD 171 sided palsy are often met with, aitd initial: convulsions are very com- mon, and are sometimes limited to the le«fs. There is voniiting as well as hyperpyrexia. Ilemnrrlia^e into the fimhiiht is almost always immediately fatal ; shoulfl the patieril survive, symptoms of bulbar paralysis will he present. In coiiicttl bleerlings we anj apt to have loea!ized convulsions and but slight palsy. Extravasation into the cetrbrum ovale gives rise to similar symptoms, if it occur just beneath the cortex. Hemorrhage limited to one vnw n'rebri causes paralysis of the extremities on the opposite side and of the third nerve on the same side as the lesion. Hemorrhaj^fe limited to the arac/inold^ with the blood poured into the subarachnoid spaces, occasions ordinarily pain in the head, somno- lency, and profound coma without paralysis, and without ana-sthesia or slow pulse, but mtli relaxation of the inuscles, and sometimes witli convulsions; now and then the symptoms assume, to all appcanniee, a remittent course. It is a very fat^l form of apoplexy, iircurring chiefly in new-bom children, and after injuries to ttie head, or from the jriving way of a diseased and wii^eoed artery, or in consequence of a ruptore of one of the sinuses of the dura mater. When the ellusion of blood takes place between the dura maler and the arachnoid, it is {.generally the ultimate result of an inflamma- tion and of subsequent eiianj^es of the inner surface of the diu*a mater: and on close ini|uiry the precursory syniptoms of a disease of the membrane may be traced, perhaps, by the constant and local- ized pain, and the nocturnal restlessness. But tlie symi>loms nf the ln^mnJuifjie pacht/meniiif/ifi^ or hiiuKtfomtt are oJjscure. It hapj>ens generally after fifty years of age, in the decn-pit, in tlie insane, or in those sufTering from pernicious anaemia, scurvy, empliyserna, whoo[Hng- cough, alcoholism, or after head injuries. When the cyst ruptures in the thickened membrane, which it may not do for years, the signs are those of im ap4>plectic condition, lasting' for eight or fen days. Head- ache, voniiting, nystagnms, and optic nemitis m'e among the imiin symptoms. Let us now inquire how the diagnosis of a|Hiplexy can be deter- mined, and how this condition may be distinguished irom otlier states which produce rapid loss of consciousness, or sudden jjaralysis. Not to mention tipilepsy,— the phenonu^'na of which we shall farther on contrast with those of apoplexy, and shall observe to difler chiefly* in the proiuinence of the <'onvulsive seizures ; or nu-ningitis, — hi wtiicli fever, headache, and other signs of an acute cerebral disease precede insensibility ; or a Innior,^ — which, save in the rarest instances, leads only very gradually to a comatose condition : or sunstroke, — 170 MEDICAL DIAGNOSIS. than the cause of the cerebral pressure; it could be detected with greater certainty were it not that the extravasation so often takes place into an already diseased brain. The order of firequency in which hemorrhage occurs into various parts of the brain is as fol- lows : central ganglia, cerebrum ovale, cortex, pons, cerebellum, me- dulla, crus cerebri. In the majority of instances the blood is effused into one of the corpora striata and the internal capsule^ or at the same time into the optic thalami, and we find only one-sided paralysis. If the lesion be in both hemispheres, the palsy is on both sides of the body, although more complete on one side than on the other. Yet a double-sided palsy does not justify^ an absolute opinion that the ex- travasation of blood into the brain-substance is double-sided ; it be- tokens also an extravasation into the ventricles. But ventricular hem- orrluige is distinguished by profound coma and by tonic contraction of the muscles, or by tonic alternating with clonic spasms, and rigidity of the muscles either on one or on both sides occurs ; the respiration is much embarrassed, and the breath-sounds are obscured by rales. It is common in the verj'^ young and in the old, and paralysis is fre- quently absent, though it may be general.^ Ventricular hemorrhage is more often secondary than primarj% the blood having torn its way into the cavity. Hemorrhage limited to the thalamus may give rise to no symptoms unless the internal capsule be damaged, when slight hemiplegia, hemianesthesia, and hemianopsia, with mobile spasm and motor incoordination, are apt to show themselves. Hemorrhage into the corpora quafhigcmina presents most frequently this combination of symptoms : muscular incoordination, impairment of sight and alteration of the pupils. Cerebellar hemorrhage gives rise to YQTY temporary loss of consciousness, to unsteadiness of movement, and to frequent vomiting ; vision is not affected. In instances in which there is hemiplegia it may or may not be on the same side as the lesion. In hemorrhage into one-half of the jl^o/w, there is palsy of the extremi- ties on one side, and of the face on the other .^ The pupils are often contracted, though they may be dilated and inactive. Disturbance of respiration is common. In lesions of the pons, too, as in those of the medulla, we have high and rapidly rising temperature almost from the onset, and we find an exception to the rule that the lateral deviation of the eyes and head, a sign so commonly present* in apoplexy, is tiL)wards the side of the brain affection."* Anaesthesia and double- ' Sandoi-s, Ainer. Joum. Med. Sci., July, 1881. - (Juhlor, Gazelle Hebdoiiiadaire, 1858, 1859. ^ liastian, Paralvsi-s from Brain Disease. DISEASES OF THE BRAIN AND SPINAL CORD. 171 sided palsy are often met with, and initial' convulsions are very com- mon, and are sometimes limited to the legs. There is vomiting as well as hyperpyrexia. Hemorrhage into the nieduUa is almost always immediately fatal; should the patient survive, symptoms of bulbar paralysis will be present. In cortical bleedings we are apt to have localized convulsions and but slight palsy. Extravasation into the cerebrum avale gives rise to similar symptoms, if it occur just beneath the cortex. Hemorrhage limited to one crus cerebri causes paralysis of the extremities on the opposite side and of the third nerve on the same side as the lesion. Hemorrhage limited to the araehnoid^ with the blood poured into the subarachnoid spaces, occasions ordinarily pain in the head, somno- lency, and profound coma without paralysis, and without anaesthesia or slow pulse, but with relaxation of the muscles, and sometimes with convulsions ; now and then the symptoms assume, to all appearance, a remittent course. It is a very fatal form of apoplexy, occurring chiefly in new-bom children, and after injuries to the head, or from the giving way of a diseased and widened artery, or in consequence of a rupture of one of the sinuses of the dura mater. Wlien the effusion of blood takes place between the dura mater and the arachnoid, it is generally the ultimate result of an inflamma- tion and of subsequent changes of the inner surface of the dura mater; and on close inquiry the precursory symptoms of a disease of the membrane may be traced, perhaps, by the constant and local- ized pain, and the nocturnal restlessness. But the symptoms of the liemorrhagic pachymeningitis or hiemaiama are obscure. It happens generally after fifty years of age, in the decrepit, in the insane, or in those suflfering from pernicious anaemia, scurvy, emphysema, whooping- cough, alcoholism, or after head uijuries. When the cyst ruptures in the thickened membrane, which it may not do for years, the signs are those of an apoplectic condition, lasting for eight or ten days. Head- ache, vomiting, nystagmus, and optic neuritis are among the main symptoms. Let us now inquire how the diagnosis of apoplexy can be deter- mined, and how this condition may be distinguished from other states which produce rapid loss of consciousness, or sudden paralysis. Not to mention dpilepsy, — the phenomena of which we shall farther on contrast with those of apoplexy, and shall observ^e to differ chiefly* in the prominence of the convulsive seizures ; or meningitis, — in wliich fever, headache, and other signs of an acute cerebral disease precede insensibility ; or a tumor, — which, save in the rarest instances, leads only very gradually to a comatose condition : or sunstroke, — 174 MEDICAL DIAGNOSIS. struggling, and the symptoms become suddenly much ameliorated after the inhalation of ammonia. In narcotic poisoning, especially if from opium, the pupils are much contracted, and we are likely to encounter a gradual intensification of the coma. The patient, however, unless death be close at hand, can be momentarily roused from his deep sleep ; and his calm, slow breathing is unlike the stertor of apoplexy. But when the hemorrhage has taken place into the pons Varolii, the diagnosis is very difficult, especially if the bleeding be extensive, for then we are apt to have a contraction of both pupils, and the respiration may not be stertorous ; nor is there always at first paralysis. A symptom of great diagnostic significance, too, is the occurrence of convulsions. Still, this may happen in opium poisoning, and is not very rare in children. Nitrobenzole, which operates as a narcotic poison in vapor as well as in a liquid state, may, in rapidly fatal cases, produce coma, which may be mistaken for the insensibility of apoplexy. But the poison is detected by its strong smell, resembling that of bitter almonds.' Poisoning by drinking chloroform gives rise to many of the symptoms of apoplexy ; it is discerned by the odor of the breath, by the quick and tumultuous heart action that accompanies the stertorous breath- ing, by the relaxation of the Ihnbs, by the deathlike aspect of the face, by the widely dilated pupils, and by the complete general anaesthesia.* Chloral insensibility is often preceded by vertigo and pains in the legs and arms, and is attended with flushing of the face, injected conjunc- tiva, a weak intermittent heart ; the pulse may, however, be slow and full. Hydrocyanic acid poisoning produces profound insensibUity, often attended by convulsions, and by peculiar breathing, — short in- spiration with labored, prolonged expiration. The breath has the characteristic odor of prussic acid. Urceniia, — The strong point in the diagnosis is that the coma is preceded by convulsions ; exceptional instances are few indeed. An examination of the urine conduces, of course, to certainty ; but, for obvious reasons, it cannot always aid us at once. Moreover, albu- min— not, however, in lai^e amounts — may occur in the urine after an apoplectic stroke, and after convulsions not uraemic. Puff)- eye- lids and swollen ankles, coma not profound, peculiar stertor seeming to emanate from the mouth, and pupils normal or dilated are symp- toms that belong to uraemic coma. Unilateral convulsions or loss of power are indicative of cerebral mischief, and tell against uraemia. ^ Taylor, Guy's Hospital Reports, vol. x., 3d Series. * As in the ctise reported in L' Union Medicale, Oct. 1864. DISEASES OF THE BRAIN AND SPINAL CORD. 176 Diabetic Coma. — Diabetic coma generally begins, not abruptly, but with somnolency which passes into coma; it is often preceded by great oppression, and is attended with a rapid, weak pulse, but not with hemiplegia or other local palsies. But the chief distinction is by the tests, fiarther t)n described, which show an acid intoxication. Syncope— rAsphyxia, — The loss of consciousness in either of these states is as striking as in apoplexy. But there is this decided differ- ence: the suspension of thought and of volition in a fainting-fit is due to failure of the circulation : hence the pulse is hardly or not at all felt, instead of being full, as in apoplexy. Further, the pallor of the face, the quiet or sighing respiration, the well-preserv^ed re- flexes, and the short duration of the syncope mark plainly the one affection from the other. And with reference to asphyxia, the turgid and livid face, the bluish lip, the distressed and embarrassed breath- ing preceding the convulsions, and the loss of consciousness, show clearly that the disturbance affects primarily the lungs and not the brain. Acute Softening, — ^This state is so closely connected with cerebral embolism or thrombosis that an appreciation of the history of the case, and the causes that lead to occlusion of the vessels, tells us the meaning of the cerebral symptoms. Rapid softening, too, at times happens around a clot. In acute softening the mental phenomena are always obvious, the mind is much more obtuse or impaired than it is after the shock of cerebral hemorrhage is over. Durand Fardel * regards as a significant sign of acute softening an increased secretion from the mouth and eye. Sudden Extensive Paralysis tmthoiU Coma, — This is not a trait of apoplexy, but rather of occlusion of the large vessels. Sudden exten- sive paralysis without coma is ordinarily owing to the breaking down of a softened brain, most apt to have followed this occlusion ; but it may be due to hemorrhage into the spinal column. Palsy from this source, unlike that caused by cerebral hemorrhage, is almost invari- ably double-sided, is accompanied by severe spinal pain, and, if the extravasation have taken place into the spinal meninges, by tonic spasms, like those of tetanus. Protracted Sleep, — ^While recovering from acute diseases, the sick often sleep profoundly and for a long time. Yet there is little likeli- hood of confounding this with the sleep of apoplexy ; for the ante- cedent circumstances reveal the meaning of this restoration of nature. Sometimes, however, persons sink into a deep and prolonged slumber ^ Maladies des Vieillards. 17B MEDICAL DIAONOSI8. witliout a!iy previous ailment. Medical literaiure furnishes a num- ber of mich instaneos. In one recorded by Cousins/ the teudeney to soninoletiry lasted ibr years. The patient frequently slept three, anfl sometiiues live, days at a time. When he awoke tie was well. In a case whieh I saw with Dr, Weir Mitchell," the slumberer was aroused out of her trance several Umes by the exciting infhienee of electricity ; but Ihis finally lost its efl'ect, and she relapsed into a sleep from which she awoke no more. These cases may ^ive the impression of apo- plexy, yel they do not resemble it strictly. They are unlike it in the gentle, noiseless breathing ; in the feeble pulse ; in Ihe occasional motion of the boy him, Tninsactinns nf Col log:** of PhyBicians, of Philiulelphia, 1856. ' St^t* cases in liCclure XVL, Buzziird on Diseases of Uie Nervous Systeni* 1882. * Lancet, July 15, 1898. Another sleeping yrirl is mentioned, ihiti., Jidv 21*. 1893, DISEASES OF THE BRAIN AND yFIN.\L CORD. i: tonus were much amended. She began to ^ain flesli, and to take exercise witliout fatigue. She was, howe\^er, troobled with head- ache, and witli pain at the lower part of the abdomen. On one occasion in the evening I ordered her some cathartic medicine ; and in the morning slie was better than usual, and in tlie h%'o]iost spirits. A few hours afterwards I was sent for, and found her insensible. She had complained of a sedden, sharp cramp near the unihilicus, and had then ceased to speak, Slie remained unconscious for about twelve hours ; yet not wtiolly so, for every now and then slie opened her eyelids, muttered a word or two, a pleasant smile flitted over her countenance, but she soon relapsed into deep slumber. Her thumbs were drawn inward : she had occasional convulsive move- ments : the breathing was rapid, but not noisy ; the pulse feeble, — at first slow, then frequent: her eyes squinted in the most decided manner. Stimulants and antispasmodics were freely given, but with- out much benefit, for she recovered from her lethai^ only with the settinff in nf the most violent paroxysmal pains in the abdo- men, shooting down the thighs and accompanied by contractions of the muscles and by exquisite local tenderness. The next day, with- out much abatement of the suflering, .she was perfectly conscious ; but still she had an internal squint, — nay, was totally blind, and remained so for two days. During tJiis time a menstrual discharge began, which in \niri relieved the abdominal pain, but it was not fully relieved until alter the passage of lai^^e fecal masses. It is needless to [)oint out how this display of hysteria differed from ai>oplexy. Aphasia, — The faculty of speech may be interfered with by various lesions of the brfun and of tlie pons and tlie medulla. Of these, some cause only disturbance of articulation, wliile others derange the higher speeeli processes. From the fii"st result cUflicult or defective articulation, dysarthria or anarthria ; from the second, the group of phenomena included in the designation aphama. Though this is really a mere symptom, it is so prominent as seemingly to constitute the disorder. By aphasia is meant loss of tlie faculty of expression of thooglit, in consequence of loss eitlier of the faculty of speech, or of that of communicating thougld by writing or by gestures. The patient may be deiirived of tlie ability of expressing himself in one of tliese ways, or in all. The loss of speech is the most common, and is apt to be associated with a very decided impairment of memory and an enfeeblement of intelligence. The disorder may l>e lenijio- rary, lasting but a few hours or some days, or it may contiiuie for montlis or years. During its course the aflfected person is incapable 178 MEDICAL DIAGNOSIS. , of nj(!alling words to give utterance to his ideas ; or if he can recall the words to the mind, and thus think, he cannot express them. V(jry often the patient has but a few words at his control ; he says ** yes" or " no" for everything ; or he uses wrong words, know- ing perhaps that they are wrong, and sometimes only those of a pro- fane kind; or he confuses merely some syllables in the words he employs ; or he may not be able to utter an intelligible expression. Y(»t, while* in this condition, there is no defect in the tongue, or lips, or palate, to account for the inability to talk ; the act of swallovdng is easily pcTformed ; and even where the aphasia is complicated vrith heiniph^gia, it is not difficult to discern that the imperfect articulation and thick speech that may attend the palsy are not the cause of the ainguhir disturbance of expression ; a disturbance which will mostly show itself not simply by the failure to utter words, but also by the inal)ility to recollect them and write them down. Indeed, it is neces- Siiry to bear in mind that, while these states may coexist, they also nuiy be pn^sent separately. Thus, there may be inability to express thought in speec*h, — motor aphasia or word-mutism. With this there IS often assoinaled injibility to express thought in writing, — agraphia. Then, Ihen^ may be inalMlity to comprehend spoken language, — wonl-iit\iftiess ; or* written or printed language, — "alexia." Most |>ationts understand perfectly well what is said to them; some can n\id to themselves : and, unless the general intelligence be percepti- bly atTtvtiHi, they can expn^ss themselves by signs and gestures. In some cases then^ is rather li^ss of memon\ and forgetfiilness and iH^nftision, and ivrhai^ a consequent use of wrong words : but when pnnnpttHl the won! is at once sjn^ken. Wherv the power of expres- sion only is Uvjst, but the ^H^Wvption of thought-symbols is still l>n^s^M>t. the term ** motor aph;isia" is used. Where the latter is K>st. it is oustomarx' to s|H\^k of the aflVvtion as "sensory aphasia:" wont-^tt\inu\!5s and alexi;) an^ fonns of this. Again, there are cases in \vhi\'h wonls and idt>as remain, but in which the power of form- iiV cvvnryvt s^MiteUi^^ is ^\dlY im|>5un\i, or is lost. This has been iMi)>t\1 "* ak;it:ipl)asia'' or {viraphasia, S'lii^ V :* the toi^th^ arv^ by iu> mt>ans always to be regarded as ;i^^)vii:sVA, %Mr \x^r> ot^en tht^^ have a Kv;*! oaiise. such as a sore tongue ^\r Miv x>r A rfvarj^ tiX>ll\ m^tti^^ the ti^^^u\ prvxtiKioar unusual sensa- A;^hd(99A fe xitHV!^xk^nt u|\m\ ^iissie*!^^ :?i:i;atx\i in the frontal convo- hrtiins^ ir, the^ $»t>*: .v* artvnUte '.a^^m^^ -*^ *i>t^ iK>?Jerw poui of the ^ \V^i. :*. TVvr.'.fcs X M.Y<%u H^^-rt*. v.x t. DISEASES OF THE BRAIN AND SPINAL CORD. 179 third frontal convolution of the left side of the cerebrum. This ex- plains why the hemiplegia which may accompany aphasia is almost invariably right-sided. But it may be left-sided, if the corresponding parts of the right hemisphere have become the main centre of speech, as happens not infrequently in left-handed persons.^ R has been fur- ther shown that the disturbance will be in the cortical substance of the speech-centre, of the auditory centre, or of the visual .centre, or in the association-fibres, according to the form of aphasia. With the first, motor aphasia especially results, with the others, sensory aphasia. The function of speech is subserved through sensory and motor processes. The former have to do with the reception of impressions from withqut, principally through hearing and sight, and the centres for these are in right-handed persons respectively in the first temporal convolution and in the angular gyrus on the left side ; the motor speech processes originate in Broca's convolution. In disease de- stroying the latter and causing motor aphasia, the patient understands, but can speak but few words or syllables ; in disease affecting the sensory centres, the auditory and visual appreciation of words is im- paired or lost. When the first left temporal convolution is the seat of lesion, " auditory aphasia" or " word-deafness," with loss of hear- ing in the opposite ear, results, and words are wrongly used, and speech fails to convey any ideas. The words are heard merely as sounds. The patient fails to recognize his mistakes in speech, and is unable to correctly repeat words spoken to him. Disease of the angular gyrus on the left side gives rise to " visual aphasia," or *' word- blindness," or even to " mind-blindness," the patient being unable to recognize words or objects through vision. There thus result alexia and perhaps agraphia, together with loss of vision in the right half of the visual fields. Aphasia may be due to functional as well as to organic disease. In cases of aphasia of short duration and without palsy, there is prob- ably merely congestion ; in protracted cases, and those in which we find persisting hemiplegia, a large clot, or softening, or abscess, is likely to be present ; embolism of the middle cerebral artery on the left side is prone to be the cause in cases thaj are associated with valvular dis- ease of the heart and that have come on suddenly. Thrombosis from enfeebled nutrition will explain some of the cases of aphasia noticed * The speech-centre is not invariably situated on the left side in rij^ht-handed persons, nor on the right in left-handed persons, as cases reported by Wadham (St. George's Hosp. Rep., 1868, iv. 246), Dickinson (Bastian, Aphasia and other Speech-Defects, 1898, p. 90), and Collier (Lancet, March 25, 1899, p. 824) amply demonstrate. 180 MEDICAL DIAGNOSIS. during convalesretice Irom grave acute maladies. Thai consequent upon congestions ends in more or less rapid recover)^ ; in the oilier forms, usnally, eillier no bnprovemenl follows, or only a very partial gain of words lakes plaee. Ocasionally we meet with aphasia in hysteria or in epilepsy, in aeute infections diseases, in toxaemias, and in urtemia, or we encounter aphasia intimately connected with a syph- ilitic cachexia, and dependent most prohal)ly npon disease of llie arte- ries. Transilory a])hasia has heen observed in the course of pneu- monia. The complication usnally appears tow'ards the second or third day of the disease, behig ordinarily preceded by headache and vertigo, and sometimes by numbness and tingling on the right side of the body. It may set in abniptly, without loss of consciousness, or be preceded by an apoplectiform seizure. There may be, in addition, Iransient palsy of the right side of the body. The manifestation is thought to be due to the action of the toxic products of the disease process.' Aphasia may become manifest subsequent to attacks of vertigo, or to a paralytic stroke preceded or not by llie ordinaiy signs of an apo- plectic fit. Under these circmnstances tfie diagnosis cannot be defi- nitely made until consciousness has returned, and we liave an oppor- tunity of examining the state of the mind, and of the tongue, and of ttie muscles cont'erned in articulation, remend)ering ttiat if lliere be merely difficulty in articulation the case is not one of aphasia. Sunstroke. — ^Persons exposed to the scorcliing rays of ttie sun in midsummer oflen become dizzy, and fall to tlie ground insensible : they have had a sunstroke. The attack either takes place wtiile the patient is still exposed to the sun, or. in rarer instances, he reaches his home with a staggering gait and a suffused face, giddy, faint, suffer- ing from a dull, oppressive pain in the head, having a constant desire to micturate, and aller some hours becomes unconscious. However the onset, the hisensibility whicli occurs is generally complete, although it may be so but for a few miimles. Associated with it are a frequent pulse, a skin harsh and warm and sometimes very hot oti Ihe fore- head, stiallow, noisy brcatliing. ditficulty in swallowing, conlracted or, more generally, cUlated pupils, and relaxalion of the limhs. Scanty urine, delirium, and convulsions^ which may or may not depend on ura:*mia, are not uncommon. When w*e contrast these symptoms willi those of apojjlexy, we find the following marks of disiinction : the pulse is not slow and lull, but frequent and often feeble ; there is more difficulty in deglutition, but a less snoring respiration ; the coma does not ordinarily remain as » Chanlemesse, Semaine M<5dicale, 1893, No, 73, p. 682. DISEASES OF THE BRAIN AND SPINAL CORD. 181 complete for so great a length of time, for soon the patient may be, temporarily at least, roused from his deep sleep ; and no hemiplegia, no paralysis, either of the limbs or of the cheek, occurs. The tem- perature of the body is very high, 104° to 109°, and not below the normal, as it is at first in apoplexy. The after-symptoms, too, are different : in cerebral hemorrhage, paralysis ; in sunstroke, feebleness of movement, but no paralysis. In the former, no marked, persistent headache ; in the latter, headache, more or less chronic, always aggra- vated by walking in the sun, and often for months accompanied by signs of an exhausted nervous system, and in some instances by epi- leptic convulsions. The question with regard to the discrimination of these morbid states is one of great practical value, as on the conclusion arrived at depends our therapeutic action ; and generally it is readily determined by paying attention to the variance in the symptoms mentioned. But it must be confessed that we sometimes meet with ambiguous cases, — cases in w^hich the signs of nervous exhaustion produced by exposure to heat are blended with those of cerebral congestion or hemorrhage excited by the same cause, and in which, when they terminate fatally, the autopsy shows not simply a changed blood, or pulmonary conges- tion, but turgescence of the cerebral vessels, or an extravasation. It may also be difficult to distinguish between sunstroke and acute alco- holism, particularly because those who drink freely are very prone to the disease. The chief distinguishing trait is in the high temperature of sunstroke, and the normal or lowered temperature of alcoholism. The remarks just made refer to the most common form of sun- stroke,— that attended with more or less sudden Joss of conscious- ness. But there are cases in which the abnormal manifestations come on gradually, and in which the patient at no time becomes in- sensible. The chief symptoms are intense headache, nausea, pros- tration, and inability to perform any work requiring sustained attention. All these signs appear after protracted exposure to the sun ; and they mend but tardily. In truth, in the slowly developed disorder, the subsequent nervous exhaustion and the paroxysms of headache are often much more persistent than are the same phenomena when they follow what seems to be the more violent form of the malady. Among the sequelae of these apparently incomplete attacks are irritability of the bladder, incontinence of urine, and irregular action of the heart. But nothing is as striking as the loss of mental and bodily energy. The symptoms of ** insolatio," or sunstroke, may be induced by prolonged atmospheric heat while the patient is in-doors and not ex- posed to the rays of the sun. Such cases of heat-stroke are known I HZ MEDICAL DIAGNOSIS. t// ^M:riir in India even at midnigfat They may be preceded by a iMfiij^r of extreme weariness, by inability to sleep, by loss of appetite, tty f^iruitipation and frequent micturition, and by deficient perspira- tion ; or the si$ais of extiaustion. followed by more or less complete if0(^fnj»ilijlity. apfx^ar without distinct prodromes. Cases of the kind und'.'r cHu^ideration may or may not show an increased or high tem- |idically and last IVoin a lew minutes to a few hours. Catalepsy may be mistaki»n lor apoplexy, or even for death. It dilVt^i-s from apoplexy by its thniuent recurrence : and further, during an attack tlu* t\Ves an^ wide open, the pupils, although dilated, are * II. r, WihhI. TluTiuio KVvor. or Sunsln>ke. * Aj4 in tho last' rt^iHut«Hi by Uist^uo, Anhives in^ntiTaU»s de Medeoine, tome i.. * WV'^ SihmuU** JuhrluWiier. lUl. oxx. \k 801. DISEASES OF THE BRAIN AND SPINAL CORD. 183 very susceptible to light, and there is an absence of stertorous breath- ing as well as of the characteristic relaxation of the muscles or of the paralysis of apoplexy, — for the limbs are outstretched, or held in every conceivable annoying or painful position ; yet as soon as con- sciousness is restored their movement fully returns. The pulse is not retarded; on the contrary, although feeble, it becomes very frequent. The perplexing affection varies from a kindred state, ecstaay^ in tins : in the latter the loss of consciousness is not complete ; the patient is merely insensible to external objects, because he is intensely absorbed in some vision present to his imagination, or in the contem- plation of some subject to him of all-engrossing interest. But he is not statue-like; on the contrary, his countenance is animated and earnest, and he talks, declaims, sings. There is a curious form of the disorder, which Sir Thomas Watson describes. It is an imperfect kind of catalepsy, called daymare, the affected person being incapable of moving or speaking, yet cognizant of all that goes on. These seizures of temporary deprivation of mus- cular power, without unconsciousness, are thought to depend upon a diseased state of the blood-vessels of the brain. Feigned catalepsy may be distinguished from the true disease by tlie muscles quickly showing signs of fatigue, which they do not in real catalepsy. A pressure-drum, Charcot* found, fixed at the ex- tremity of the outstretched limb in a person who feigns, will in a few minutes, in place of the straight, regular line, show crooked, very un- dulating traces, and the same irregularity is seen in the tracings of the pneumograph applied to the chest. Catalepsy may be artificially induced, as we know from the inter- e.sting experiments on hypnotism which of late years have been made. Catalepsies of particular groups of muscles, or partial cata- iepsies, can also be artificially excited. In the rare condition known as trance^ or leihargy, there exists a state resembling sleep, from which the person can be roused witli difficulty, if at all. It is principally associated with hysteria, although it has been observed as a result of excessive mental application and after exhausting disease. The patient is usually pallid. The ex- tremities are, as a rule, relaxed, although they may be rigid for a time, and there may even be convulsions. The eyelids are closed aijd the eyes turned upward and to one side ; the pupils vary in size, but react to light. Reflex action is usually lowered. Respiration and ' Third volume of Clinical Lectures, 1889. 184 MEDICAL DIAGNOSIS. circulation are greatly enfeebled ; the peripheral temperature is sub- nonnal. An attack lasts firom a few hours to weeks. Cases in which it occurred without any ob\ious prenous aihnent have been men- tioned while discussing protracted sleep. In narcolepsy there occur sudden short {>eriods of day sleep, from which, however, the indi- vidual ijxn be roused. These may recur spontaneously, or be induced by peripheral impressions ; at times we find the condition in diabetic or gouty patients. The affection described as African lethargy^ or deeping siekneJis, attacks negroes, principally on the west coast of Africa, and is char- acterized by somnolence of progressive degree, usually leading to great emaciation and to a fatal termination. Among its marked symptoms are drooping of the upper eyelid, puffiness of face, muscular tremor, itching, papular eruptions, a feeling of coldness even when lying in the broiling sun, and enlargement of the cervical, parotid, and sub- maxillary glands. The disease is thought by some to be due to the presence in the blood of the Filaria sanguinis ; by others to a lesion of the pituitary body. It resembles beriberi, but does not show the hy|)eroBsthesia of muscles, the abolished knee-jerk, the muscular atrophy tliLs presents. Diseases marked by Convulsions or Spasms. Epilepsy. — Epilepsy is a disease the chief manifestation of which (consists in recurring attacks of sudden loss of consciousness, attended with convulsive movements. The patient falls to the ground, without thought, without feeling, without the power of voluntary motion. He utters ofton a short, piercing cry, then a fearful struggle begins. The logs an* stiff, and turned hi ward ; the head is tossed backward, or from side to side ; the mouth is distorted, the lips are covered with foam ; the arms are outstretched and rigid, or thrown about with great force ; the eyelids are half closed ; the teeth are gromid togt^ther, and the tongue is thrust between them, and often severely bitten. The foce is often pale at the outset, but with the continuance of tlie tonic spasm the aspect becomes cyanotic. In a short while the rigidity gives way to clonic convulsions and the whole body may be agitated by violent movements, wliich may involve one side in gnnitor degriH^ than the other, and during which sometimes urine is passeil. (Gradually the convulsive movements become less violent and cease altogt^lher, and tlie patient passes into a deep sleep, from which he awakes fatigued and exhausted, and dull in intellect. But these symptoms disappear, and he returns to his normal state of healtli. The attack giMienilly occupies only a few minutes. In some cases, DISEASES OF THE BRAIN AND SPINAL CORD. 185 however, the patient scarcely emerges from one attack before he enters upon another. This condition is known as the status epilepticus^ and it may be kept up for hours. Yet every paroxysm does not present the same phenomena, or run the same definite course. In many the attack is preceded by strange sensations ; by a peculiar train of thought ; by retching ; by the feeling of a puflf of air ascending from the extremities to the head. This '*aura epileptica" is, however, far from constant. Moreover, it may exist and hardly be perceived : it may be an unfelt irritation starting from some peripheral nerve in any part of the skin, or from some oi^gan not deeply seated, as the testicle, and its point of departure may be detected by observing, during the fit, in what neighborhood the first, or the most violent, or the most prolonged contractions occur. In very rare instances sudden spasms of the face and chest occur, with arrest of respiration, and with a subsequent clonic convulsion, yet with so little unconsciousness that it remains doubtful whether it has happened at all. Some seizures are very light, — a transient suspension of conscious- ness, a slight twitching of some of the muscles, a fixed gaze, perhaps a decided impression of vertigo, and all is over. These abortive fits, the petit mal, or minor attacks, are very apt to precede by some days a severe attack, or several of them may take the place of the more turbulent form of the disorder. And they, like the graver epileptic convulsion, may present strange irregularities. They may manifest themselves, for instance, only in bursts of unmeaning laughter ; ^ or intellectual derangement replaces the ordinary convulsive attack ; ^ or there is mental wandering, with disposition to commit acts of violence. The attacks of epilepsy which are chiefly characterized by vertigo are distinguished from all other forms of vertigo by the loss of con- sciousness, however slight, they also present, and by the absence of any giddiness in the intervals. In nocturnal epilepsy ecchymoses on the face, conjunctival extravasations, a severe headache on awaken- ing, and a sore tongue, may indicate what has happened in the night. The epileptic paroxysm does not always pass off without leaving some trace of the profound disturbance it has occasioned. It may be followed by hemiplegia. Whether this be due, as Hughlings Jackson* asserts, to exhaustion of the nerve-centres following the excessive discharge of nerve-force bringing about the convulsion. ' George Paget, British Medical Journal, Feb. 1859. * Thome, on Masked Epilepsy, St. Bartholomew's Hosp. Rep., vol. vi. ' After-Eflfects of Epileptic Discharges, West Riding Reports, 1876. 12 IH« MEDICAL, DIAGNOeia a in f'f'tinifi that the. palsy is very transient. Another sequel of the «lfa/k w aphasia; another, loss of voice; another, abdominal tender- ticnn. Am Hoards f^alsy, however, we must remember that epUeptic nu may follow hemiplegia due to a vascular lesion, so-called post- lirmlpf/'f/U' rpil^'pny. In Ww int^ffvalH between the seizures the patient is not in reality wolL tlJM temper is irritable, and his mental faculties slowly but cer- hiirily (l<'l(?rionile. The loss of memory, particularly, is very marked; II rid dcmenlia ih not an unusual complication of long continued npilepHy. In some epileptics there is much excitement or a curious nMMiliil Hlali^ pnM!e(ling thcj seizures, or a violent and dangerous mania may Inllow lli(»m. Again, as I have noted in common with several olmorverM, a Ic^mporary albumirmria is not unfrequently met with at Ihr l(«nninali()n of the piU*oxysm. Tnn' t'pilepHy is probably owing to functional or nutritional rhangt»M in the corti^x of the bniin, giving rise to excessive activity of n(»rvr-(rlls leading to periodic discharges of nerve-force. Its most potent lanm* certainly is hereditary predisposition. Convulsions due to v\A\k'\ irritation, to orgtuiic brain disease, and to toxic blood-states may h^sult in true epilepsy. It is thus that tlie malady originates in liyurit^s of nerves, in diseases of the skin, of the stomach and intes- tines, antl of the uterus, in the irritation of worms, or in consequence ot' eon^jx^nital phimosis,* or of chronic nasal catarrh.^ Now, it is ver}* important to disrriuunate In^tween true epilepsy and conrulsiom of tf>\vH/t**o oriyiM ; and to arrive at a conclusion is possible only by a thorxMi^h examination of all the constitutional sjmiptoms. and by ^s^vHaini<\|: tlie startin^-innnt and tracing the course of the aura. The vas^^s in whivh the aun^ is intemipteit and the paroxysm arrested bx A ^^^\t\^n^ an^ woU known. Noiluui^^ cites an instance in which ttu"^ ;;v,rA Kyun witli invuJiar son^tions in the stoniach. and the ^lUA \>as stopjHxt b\ swaUowix^ tab*;t^-«;alt. Coovulaons may i\ir5V»i'^r V .<^i'»«i *',*.»«,>?>,• .;.?* o iV^rf^^jJ* i?w^v>^. — such as a tumor. ^xs:^^^.; ..\v»v, r/, 5l.c ^>t>:;4v,, a :?y}>h;,:tk ;afTvtii>a of the membranes, ^vr j; /,?<:, ;rt\i:">^v^ >\: :h<' hr^ir, ;^Tvxiuvi\5 bx ^ti^k^fts^e of the skull-cap, — V* :j;-,,, /» ,';,;x .v*S';\A:fc;-^»r\\n^:55> a:*Vv:::>j: :ht .vnex of tlie bnin: or it Viv^x \ ,v,,v :,^ x\A:;rx K,\v,. ^^r x::k:;v, 'r.^.xxi fu". v>f abnormal in- i*^v:i,. X AS ,.'. ,^>A!&;>? .r ::vr 'i>.v.>:'x^ i!:::nc i::;Taiic«i^T oo the ** -.-'.w ,N ;.v ,v^>ci :;v,;:>; "iV^r^ic :ih puviX3rsm it i? im- ., / ,V',vv . V v , -^irx-,:;-? ,V ::•: ATAx-^iarin^ ; but in the DISEASES OF THE BRAIN AND SPINAL CORD. 187 interval we may often do so by close attention to the history of the case, and by noting whether the patient enjoys the usual health of epileptic subjects, or presents signs of a chronic cerebral disorder, especially steady headache, palsies of cranial nerves, optic neuritis, vomiting. Romberg tells us that where aflfections of the bones of the head lie at the root of the complaint, the fits are readily induced by pressure upon the skull. Convulsions are often found in connection with ear disease, and especially with purulent otitis.^ In those who inherit syphilis idiopathic epilepsy may happen. Limited convulsive seizures are connected with disease of special convolutions ; and if we have a convulsion which is limited, either a tonic or a clonic spasm of a group of muscles, we may from this mono- spasm diagnosticate an irritative lesion in the motor centre presiding over the disturbed part, though in the hemisphere opposite to the spasm. The irritative lesion is usually a meningo-encephalitis. The spasm most frequently originates in the hand, but we may also find it limited to a group of muscles in the face, or in the leg. At first there is no loss of consciousness during the seizures, but as the spasms spread and become unilateral, consciousness is lost. Convul- sions due to syphilitic diseases are, for the most part, of the kind just described, and are the chief form of the cortical or so-called Jaekso- nian epilepsy. In masked epilepsy there is often an epileptic vertigo, with loss of consciousness and with twitching of some muscles, but the patient does not fall. Much has been said of the distinction between epilepsy and convul- sums. Now, as regards the seizure itself, there is no appreciable dif- ference : the only diversity consists in the recurrence of the attack after intervals of comparative health, and in the non-existence of any dis- turbance from which convulsions are likely to arise, such as reflex irritation, organic brain disease, or a toxic blood-state. In young children the diagnosis may be a difficult matter ; but the fits of epi- lepsy, very rare in them, are distinguishable by the dulness of intel- lect, and the slow mental and bodily development, observable in the intervals. The diseases which are most apt to be confounded with epilepsy are hysteria and apoplexy. The former — ^like all the rest of the group now under discussion, like chorea, like tetanus, like hydrophobia — is discriminated by the absence of that perfect suspension of conscious- ness that takes place in epileptic seizures ; and there are other marks of distinction, to which we shall presently refer. In apoplexy, as in * Ormerod, Brain, April, 1883. 188 MEDICAL DIAGNOSIS. epilepsy, we meet with loss of consciousness, sometimes with con- vulsions. But these are, on the whole, rare, and coma precedes and does not follow them, as happens in epilepsy. Then, stertorous breathing and a slow, full pulse are not observed in epilepsy. Epi- leptic patients bite their tongues; this does not occur in apoplexy. In epilepsy the paroxysm seldom lasts longer than from ten to fifteen minutes before consciousness returns and before the convulsions cease ; in apoplexy the insensibility is of much longer duration. Epilepsy is not usually followed by paralysis ; apoplexy is commonly. There is sometimes a close resemblance between syncope and abortive epilepsy, pdU mal. But they occur under widely diflferent conditions ; and the loss as well as the return of consciousness is less abrupt in the one than in the other. Epilepsy is at limes feigned ; yet impostors cannot feign it com- pletely. They may bite then* tongue ; they may imitate the stertor, the foam at the mouth, the convulsions, the thumb drawn inward towards the palm, the confused air on awakening ; they may sunulate, although they rarely do so, the indifference to pain ; yet there is one feature of the real attack they cannot copy, — ^the insensibUity of the iris. No matter how skilful the dissembler, his pupils must contract when exposed to a strong light, they must dilate when the stimulus is withdn\wn. Unfortunately, there are several difficulties in making this test an absolute one. In the first place, the pupils, during a fit cannot be always rt^adily obser\'ed. In the second place, not in everj' case of epilepsy are they perfectly immovable ; in some, though slug- gish, Ihey TViwi to light. Again, as proved by Keen, violent muscular motion instantly dilates the pupil, and so long as the movement con- tinues, St) long will the iris act sluggishly, even when exposed to a bright light. Thus, muscular spasms alone, even when simulated, \\u\\ eaust^ the pupils to be dilated and inactive. A test more gen- i^rally useful is the administration of ether. \\Tien given to an epi- U'\A\\\ its lli>iisnuHlic aflVvtion is chiefly met with in young jM^iNons, espoi'iall) in girls appnxiching Uie age of puberty. It is chanu'teri;e\t by irrt^ular elonit* s(Kisms of groups of muscles under the inlhuMuo of the will, and nuunly of those on one side of the b\Hh» tt^^ther with nu»si \ilar iiutV^miination. But the patient is not * Kiv\\, MxtxholU A^\^l V»MvluMasinodic action of the papillary muscles, — llie same spasmodic action that is seen in the striated muscles of the face and of the extremities. The disease is rarely fatal : but its duration is ver>* variable ; for, although it may be acute, lasting for six weeks or more, it may con- tinue for months, even for years, and relapses are frequent. There are in chronic cases no attending cerebral symptoms, yet the menta! feculties are not in a perfectly liealthy state, Ttie intellect of a choreic child develops slowly, and is enfeebled while the tiisorder lasts. Ill some cases [Kiralysis supervenes ; but it is not permanent, nor, indeed, of long duration. But those who tiave been clioreie remain subject to nerv^ous disorders; and I have known several instances in which the couiplaint has been, in atler years, followed by epilepsy, A cliromc progressive form of chorea sometimes develojis late in life, with, in many instances, a history of hereditarj* transmission. The movements in this Iluntim/ton'ti chorea usually appear first in the face and upper extremities, and gradually extend, and there is disturbance of speech. In the hereditary cases mental changes are common and sometimes pronounced, and gradual dementia is ob- served. In some parts of Italy there has Jieen noticed an afT'ection characterized by sudden, shock-like nmscular contractions, witli pro- gressive palsy and wasting, and known as ekctrleal chorea. Of its nature and cause we have no defniite knowledge. So-called hiffderical chorea consists in general spasmodic movements occurring in hysterical subjects, but the movements are far more regu- lar and rhythmical than those of true chorea, and are usually deliberate and of wide range. The diagnosis of chorea is generally easy. The peculiar habit some children or even older persons get into of winking; or jerking the head, or of making other strange movements, the '' habit-chorea'' or "■ habit-spasm,'^ as it has been called, is really a fonn of spasmodic tic, and is distinguished by its gradual development and its limitation to a single muscle, or grnu]> of muscles, or of associated muscles. This liEibit-spasm is not infrequently of reflex origin, as from the teeth or from eye-strain, but cases occur to which no cause can be assigned. Cliorea with loss of power on one side, "• paralytic chorea," is recog- nized in cliililren by the occasional choreic movements, and by the loss of power which happens gradually. Chorea from eye-strain is, as a ready test, discriminated by using atropine. Dr. Hansell employed this in many cases at my clinic with quick results. Atropine paralyzes the ciliary muscle; no effort of DISEASES OF THE BRAIN AND SPINAL CORD. 191 accommodation can then be made ; therefore muscular twitching, as well as headache or other functional disturbances from disordered accommodation, must cease after an interval of time long enough to break up the habit ; chorea from constitutional causes will, of course, be unaffected by atropine or other paralysis of the ciliary muscle. Chorea differs from the spasms of acute cerebral disease by the absence of fever, of delirium, and of coma, though we must bear in mind that we sometimes have elevation of temperature and mania in the chorea of pregnancy ; from epilepsy^ by its being continuous, by the non-existence of unconsciousness, and by the rarity with which the muscles jerk at a time when epileptic convulsions are frequent, — at night ; from tetanus it is chiefly distinguished by not exhibiting tonic spasm. Paralysis avians is, like chorea, attended with disturbed muscular movements. But we find weakness of the muscles and persistent tremor rather than spasmodic contraction and want of con- trol over muscular motion. Then the history of the case, and the signs of general decay associated with the trembling, clearly distin- guish paralysis agitans. In cerebrospinal sclerosis, the scanning speech, the increased patellar tendon-reflex, the nystagmus, the occur- , rence of the jerks only when the muscles are put into motion, are most significant. Both affections, too, are encountered in persons older than are generally subject to chorea; especially in paralysis agitans. Multiple sclerosis happens, however, also in children, 'and we meet with cases of paralysis agitans affiliated to chorea ; like it, too, originating in fright. But they differ in the motions repeating themselves rhythmically and symmetrically on the two sides of the body,^ and in presenting nothing of the irregular and rapidly changing character of the true choreic movements. Convulsive tremor, a paroxysmal affection in which severe muscu- lar tremor arises several times in a day, differs from chorea in not being continuous, as it occurs in attacks lasting from fifteen to twenty minutes, and passing off gradually. The unrestrainable tremor affects the face, the arms, and the trunk, but not the lower extremities, and is associated with increased sensibility of the skin of the disturbed parts. Clonic spasms occurring as sudden contractions or shocks, and affecting pre-eminently the upper part of the limbs, have been delineated by Friedreich as myoclonus multiplex ; the muscular irrita- bility is much increased. In athetosis, the condition described by Hammond, there is con- stantly recurring mobile spasm of the fingers and toes, with inability ' As in the case recorded by Sanders, Edin. Med. Journ., May, 1865. 192 MEDICAL DIAGNOSIS. to retain tliem in any position in which they may have been placed. Groat tendency to distortion exists in the spasm, and we find, on the whole, much resemblance to localized chorea. But headache, vertigo, slowness of speech and of thought, numbness of the affected side, and pains in the parts which are the seat of mobile spasms, give us a very different clinical picture from chorea. During the spasm the fingers may be spread wide apart, giving the hand a characteristic appearance. Athetosis is most common in hemiplegics, especially in the cerebral hemiplegia of childhood, and coexists with contractures. It is supposed to be due to disease of a cortical motor centre. It has been observed to be bilateral in idiotic children. Similar to it is the mobile spasm that may be noticed in palsied limbs, the post-hemiplcffk choral. But here there is an admixture of tremulous movements. Facial .^pa^m differs from the spasmodic contractions of chorea in being always of equal intensity, and in the grimaces being strictly conlined to the face, manifesting themselves in the same group of muscles, and generally existing only on one side of the face. Many cases of facial spasm are due to errors of refiraction ; in others it is the result of corticiU disturbance or disease, or due to irritation of the fila- ments of the fifth nerve in the laclurj'mo-nasal canal. The spasm may bo also of n^note reflex origin, as from disorders of the uterus. There are also ciises apparently idiopatliic. In conrukire ticy as described by the -FnMich, tlie facial spasm is combined \Wth signs of hysteria and with mental changt^s. irW/c-r/ cnnnp, iui affection in which even* attempt at writing at once priniuoes sjmsmodic action of the muscles of those fingers that an* bnnight into play, is sejxurated from chorea by its occurrence in individuals who have strained their muscles in using a pen continu- ously and rapidly : by the almost instant cessation of the spasm when the aftlictiHl ^vrson ce;ises to write : and by the ease with which the tliigx^rs jH^rform other motions and aiv capable of being used for everj' pur^H^o except the one which has brought on the disorder. Pain, iimitoit to the afftvted ^Kirt, or num* extensive, often attends this afftvtion, at times induceii only by writing, at oUier times spontane- ous, Then^ may also Iv woiikness with or without spasm, and trvnior, and KviU vasinuotor manifestations, such as glossiness or lui^Ht lUscoloration of the skin and undue heat and sweating. An ttudo^^iis ^^^mpUiint, an " ivcujKition neun^sis," too, is encountered ill i^tw«$tr\^?2?\:^ : also in telegraph-v^jn^rators, particulariy those who llie Mor^* ui^lriiment, Thes<^ cramps, and all those of a similar [ cau^Hl In the iHvu^vition, such ;is in piani>-players, in violinists, I in tyi^-^writ^'i^ car-\irivoKs stout^masons* c^sur^te-makers, shoe- DISEASES OF THE BRAIN AND SPINAL CORD. 193 fitters/ have the same diagnostic sign that has just been mentioned as charcteristic of writers' cramp, — namely, that the spasm befalls only those muscles the overstrain of which has led to the affection, and that it ceases when the fatigued muscles are kept at rest or are brought into action for a different purpose. A form of cramp like that of writers' cramp happens in those engaged in preparing photo- graphic plates ; * and I have seen it in turners, engaged in what is called " oval turning." There is a disorder, closely allied to chorea, which consists in repeated violent bobbings of the head, lasting many minutes at a time. These salaam convulsions^ as Sir Charles Clarke called them, are a very obstinate complaint. They are most commonly met with in children, but have been known to occur in adults^ and to lead frequently to impairment of the intellect.* From tetany chorea differs in the spasm of the former being inter- mittent, remittent, or continuous and tonic, and not constant and clonic. The nodding movements of the head, sometimes lateral, sometimes rotary, with nystagmus, observed in rhachitic and ill- nourished infants are unlike those of chorea. Hysteria. — Hysteria manifests itself for the most part in two forms, in convulsive paroxysms, or in local hysterical disorders. The description of hysteria here will deal chiefly with the symptoms of an hysterical paroxysm. Most of the local hysterical affections have been, or will be, considered in connection with the diseases they ape ; and to attempt to scrutinize or to interpret connectedly all the false and contradictory signals this perplexing malady hangs out, is, in a work of this kind, manifestly impossible. An hysterical fit may set in suddenly, under the influence of some violent mental emotion ; but more generally it is preceded by altered spirits, by a sensation of pressure and of constriction at the pit of the stomach, which feeling ascends to the throat, and is likened by the patient to the rising of a ball. She becomes much agitated, sobs, laughs, her muscles contract violently, or she lies motionless, and ap- parently without the power of motion, until her seeming insensibility is disturbed by something she disapproves of, or fears. The heart palpitates ; the breathing is often accelerated, irregular, and heaving ; the pupils are dilated, their reflex gone.* 1 » Moyer, Medical News, Feb. 1893. ' Napias, Gazette Medicale de Paris, No. 40, 1883. ' Levick, Amer. Joum. Med. Sci., Jan. 1862. ^ Henry Barnes, Liverpool and Manchester Hospital Reports, 1873. » Karplus, Wiener Med. Wochens., No. 62, 1896. 194 MEDICAL DIAGNOSIS, Tliese hytserica! outbursts tHtler from the spasms of ehorm by the remissions^ the patient remaining^ at times for months free from the convulsive movements. Moreover, there is not even partial or apparent unconsciousness in chorea. It is true tiiat this malady and hysteria are sometimes combined, or rather ttial chorea happens in hysterical subjects, and is then brought about by imitation, and is apt to come on suddenly ; yet it is remarkable how rarely fits of hysteria take place in those affected with ctiorea. It is sometimes very dilllcult to distinguish between paroxysms of hysteria and of epilepsi/ ; and it becomes the more ditlficylt if the epi- leptic seizures occur in liysterixysm generally of longer duration. Paroxysm not followed specially by sl«*ep ; patient often, after attack tenniuates, wakeful and depressed in spirits. Rarely occurs at night. Often connected with disorders of the uterus or ovaries, or of menstrua- tion. There are, tiowever, spasms that occur in hysterieal patients which, tltoiigii a fonetional nen^ous afTection, appear like a blending DISEASES OF THE BRAIN AND SPINAL CORD. 195 of hysteria and epilepsy. Charcot ^ particularly has called attention to this hystei^o-epUepsy, and describes its distinctive traits as consisting in premonitory symptoms of rather long duration, and exhibiting an aura which, starting in most cases from the ovarian region, advances progressively to the head. The cry is prolonged and modulated, not shori: like the epileptic cry. The convulsions are identical ; but, instead of entering subsequently upon a stage of snoring, the hystero- epileptic sobs, laughs, gesticulates violently, or is delirious and subject to hallucinations. In the ovarian form of hystero-epilepsy, pressure upon the ovarj' ^vill invariably modify the symptoms, if not com- pletely arrest the attack ; whereas in epilepsy no such effect is pro- duced. In the cases of hystero-epilepsy with repeated attacks, the tem- perature scarcely rises above the normal, as it rapidly does under similar circumstances in epilepsy. There is no epileptic vertigo ; there are no abortive fits. The malady is not rarely observed in men and in children. Hysteria is a psychoneurosis, and not an affection merely of parox- ysms. In the intervals between them — there may be no paroxysms at all — we find peculiar and significant manifestations which should be understood, lest they be taken as the signs of other maladies. We observe an extreme susceptibility of the nervous system, \vith defec- tive will-power and imperfect self-control ; irregular or depraved ap- . petite ; flatulent dyspepsia ; constipation ; interrupted, sighing respi- ration; rapid action of the heart; varied hyperaesthesias, such as tenderness in the epigastrium or in the course of the spinal column or over the ovary ; that peculiar pain in the left side which distresses so many hysterical and anaemic women ; and anaesthesia often con- fined to a circumscribed area, to a single member or to one side of the body, and often profound. Besides these, we encounter mani- fold local hysterical ailments, such as hysterical paralysis, hysterical aphonia, hysterical tremor, hysterical anorexia, hysterical peritonitis, hysterical affections of joints, hysterical pain in the forehead, hys- terical haemoptysis, hysterical barking cough, hysterical sweating, hysterical suppression as well as hysterical retention of urine. Hys- terical laughter has been found to occur on a large scale as a form of epidemic convulsion.* There may be hysterical deafness, or hys- terical amaurosis, or retinal hyperaesthesia, or crossed amblyopia. J. K. Mitchell and de Schweinitz ^ consider disturbance of color-sense * Lectures on Diseases of the Nervous System. See also Richer, l5tudes cli- niques sur Hyst^ro-^pilepsie, Paris, 1881. «D. W. Yandell, Brain, Oct. 1881. ' Journal of Mental and Nervous Diseases, vol. xix., No. 1, p. 1. 196 MEDICAL DIAGNOSIS. eotmnon in hysteria. They have found reversal in the normal se- quence of colors to he usudly present in cases attended with anaes- thesia. Muscular atrophy has been observ^ed as a manifestation of hys- teria;* a low-grade optic neuritis has led to the supposition of cerebral tumor ;^ and a case has been recorded closely sunulating syringo- myelia.'* In hysterica]- insanity a suicidal tendency is often noticed. Hysteria is met with in the male, especially alter rail^vay acci- dents. Hysterical paralysis may also happen in either sex, in the shape of tierniptegia, of monoptegia, or of paraplegia, and may be of extremely long duration,* As regards hysterical hemiplegia, it is remarkable tliat it does not afTect tlie face ; yet there may lie an Ijys- terical facial pamlysis.* Hysterical headaf'he, Ciiarcot tells us, like syphilitic, increases al night, and is similar to the tremor from metallic poisons. Hysterica] tremor is most common in the hands and arms. Hysterical contractures may oceur in botli arm and leg; complete anaesthesia causes Ihem to disappear temporarily. Tlie reflexes in hysteria may be nmcli deranged. As Goodell *^ well says, strange and misleading reflexes come from Uie loss of brain control over the in- subordinate lower nen^e-cenlres. In to.rk' kt/sk'na, such as we obsen^e after chronic lead or mercurial [>oisoning, tremor, anaesthesia, palsies, and anorexia or hyslerical vondting are ollen observed, — much oftener than hyslerical paroxysms. Fever is not a symptom of hysteria. Yel occasionally we meet with cases that it is dilTicult to explain in any other way, and hys- terical disturbance of the heat-centres with extraordinarily high tem- peratures certainly happen. We may also have fever in hysterical local diseases, as in hysterical meningitis, in hysterical peritonitis. The distinction between these hysterical pseudo-maladies and the diseases they simulate is Hir from being an easy task. We liave to take into account the patient's age and sex ; w^hether or not she has sulTered Irom paroxysms of hysteria; how the pain is intluenced by pressure ; the great tendency to exaggeration and deeeplion ; and Uie signs of functional disorder of the apparently affected part. We may thus avoid mistakmg a phantom for a true disease. Yet there i^ another and opjjosite source of error quite as strenuously to be ' Hirst, DtniLsclie medicinisehe Worhenschrif!, 1894, No. 21, p. 459, * Mills, Th*! Nprv;ous Svsteiii and its Diseases, 1S9S, p. 527. ■ Wichniann, BerliriHi' kliiiisdin WoiliHiisdirill, 181»5. Na. 12, p, 252. *See crises reported by Morion Prince, of Ivvenly-nine, twenty-eight, and twenly-mne years' duralioii, Amer. Journ. Med* Sci., Jwly, 1892. * Babjnski, SocirHe Medicale des Hopitaux de Paris, 1892. * Medical News, Jan 6, 1804. DISEASES OF THE BRAIN AND SPINAL CORD. 197 guarded against. The complaint may be really an organic one, oc- curring in an hysterical patient, and concealed, or exaggerated and complicated, by the symptoms of hysteria. In all such doubtful cases we must accord great weight to the extent of functional and constitu- tional disturbance accompanying the local morbid state. Then, too, hysterical symptoms may be prominent in certain brain and cord affections. I have repeatedly noticed them in cases of cerebral em- bolism ; and Brown-S6quard and Seguin ^ have shown their frequent occurrence in lesions of the right hemisphere. In hysterical attacks connected with a cerebral neoplasm, the urea and the phosphates in the urine, Gilles de la Tourette* shows, are diminished, while in epileptic seizures connected with brain tumors they are increased. Hysteria may also complicate myelitis and lateral sclerosis. Hysteria is sometimes feigned, — feigned to elicit sympathy, or to procure compliance with wishes or caprices. Nor is the simulation of the disorder an outgrowth of our civilization. The epigrams of Martial prove how common the feigning of hysteria was among the Roman women. Tetanus. — ^A very fatal disease marked by persistent rigid con- traction of the voluntary muscles, particularly of those of the jaw, with violent brief exacerbations. This distressing malady, as we see it, is generally traumatic, follow- ing a wound, or an injurj' ; for idiopathic tetanus is very seldom met with in temperate climates. But in hot countries, or in those in which sudden alternations of temperature are common, it is not a rare disease, and is indeed frequent among new-bom children. The malady is also seen in the puerperal state. The symptoms of tetanus depend upon the action of a poison gen- erated by a special micro-organism, the bacillus tetani. This is a long, slender bacillus, found commonly in the superficial layers of earth, and growing best in the absence of air and light. It is usually met with in the local lesion. In the so-called idiopathic cases the channel of microbic infection eludes detection. The muscles ordinarily first affected are those of the jaw and neck ; there is a stiffness about them which the patient is apt to attribute to having caught cold. Sometimes, however, the disorder exhibits itself primarily in the external respiratory muscles. When the malady is fiilly developed, most of the muscles are stiff and hard, the jaw can- not be opened, — ^whence the common name of lock-jaw, — and there * Archives of Electrology and Neurology, May, 1875. » Quoted, Lanoet, May, 1893, p. 1083. 198 MEDICAL DIAGNOSIS. is much difficulty in speaking and in swallowing. The face is dis- torted, presenting the " risus sardonicus." With these symptoms we usually find rigidity of the muscles of the abdomen and of the limbs, and a distressing pain at the pit of the stomach, dependent upon spasm of the diaphragm. Besides the permanent contraction of the voluntary fibres, exacerbations of spasm take place, during which the muscles become very hard. These paroxysms are accompanied by intense pain, and recur with increased severity and fi^equency as the disease advances to a fatal termination. When at their height, the body becomes curved, the patient merely resting upon his head and heels. This is opisthotonos; while the setting of the jaw, especially when its muscles alone are affected, is called trismus. The trunk may be b^nt fon\^ard, — einprosthotonos ; or to one side, — pleurothotonos ; or the trunk and neck are rigidly extended in a straight line, — orthotonos. The spasm relaxes during natural sleep or induced narcosis. At the height of the attack the body is covered with copious perspiration. Notwithstanding the striking muscular disorder and the exhaust- ing pain, there is little constitutional disturbance ; the pulse may be quickened, but it preserves its volume until the last stage is reached ; and there is no fever, certainly not in the earlier stages, nor is the intellect afl'ected. Yet the temperature shows extraordinary varia- tions. The thermometer may mark an increase of several degrees in the evening,^ and towards the end indicate a heat of 110° F., even eontmuing to rise after death. When tetanus results from an injurj* to the head, and more par- ticularly in the distribution of the fifth nene, there is often, in addi- tion to the initial trismus, paralysis of the face on the same side as the injury, and spasm on the opposite side. Tetanus runs an acute or a chronic course. Some cases last three weeks, and when of such long duration are apt to recover. But gen- erally the malady terminates fatally before the eighth day. Few complaints an^ likely to be confounded \\i\h tetanus ; yet these few resemble it in many n^spects closely. For instance, one of the fn^aks of hysteria is to take the appearance of tetanus ; and tonic spasms dependent upon an afl'ection of the spinal cord or medulla oblon^rata, strychnine poisonnig, or hydrophobia, may accurately sim- ulate its symptt)ms. , IIi/atvriiHtl tetanus is distinguished from the real disease by being preceded by, t)r attendetl with, fits of hysteria; by the age and sex of the imtient ; by the absence of pain : by the occasional occurrence of * lV^»*. ilinioal S«HMoty*s Tnuis;ictions, 1872. DISEASES OF THE BRAIN AND SPINAL CORD. 199 clonic instead of tonic spams ; and by the intennission every now and then of all muscular rigidity. Moreover, the influence of the mind upon the seeming tetanus is very striking. If within hearing of the patient the employment of cold to the spine, or of the cautery, be threatened, or, better still, if the latter instrument be actually made ready for use before her, an extraordinary subsidence of all stiffening and starting of the limbs takes place. Hysterical trismus is more common than extended hysterical tetanoid spasm, but, besides the symptoms of hysteria just mentioned, the absence of rigidity in the neck is very significant. Tetanic spasms symptomatic of an afl'ection of the spinal cord are separated from tetanus by the different history ; by no violent exacer- bations being brought on, as they are in tetanus, by slight movements, or by an attempt at speaking, or by any reflex irritation ; by the ab- sence of marked remissions ; by the rigidity being almost always lim- ited to the extremities, — except in the case of meningeal apoplexy in the cervical region, in which the tonic contraction in the upper extremity is associated with stiffness of the neck ; by its association wth altered sensibility ; and by the setting in of palsy before the malady terminates. In the tetanic spasms which may occur in scarlet fever, in typhus, in smallpox, or in pyaemia, and which are the result of an irritation of the cord produced by the poisoned blood, the rigidity runs so un- certain a course, appears so quickly, disappears so suddenly, perhaps not to return, or only to reappear after a considerable interval, that there is little likelihood of confounding the muscular disorder with tetanus. Tetanus diflfers from meningitis in the absence of pyrexia, of headache, and of vomiting ; in the early presence of trismus, which, indeed, in meningitis may be wholly wanting ; and in the fact that the spasms in this are generally only induced .on attempted movement, whereas in tetanus the reflex irritability is so great that they are in- duced by the slightest touch. In eerebro-spinal fever the resemblance is much closer; yet the whole history of the disorder, the marked headache and mental symptoms, the fever, and the progress of the case, are such as to prevent error. With muscular rheumatism tetanus can only be confounded at its onset ; but the muscles of the jaw are not rigid in rheumatism. Another form of symptomatic rigidity requires it to be distinguished from tetanus, — a local rigidity, owing to irritation of the nerve supply- ing the stiffened muscles ; as, for instance, a spasm from irritation of the peripheral or the central tract of the motor portion of the fifth, the so-called masticatory spasm of the face. The ailment may be of reflex origin, the exciting^ cause being a decayed tooth, a wound, or 2fH) MEDICAL DIAGNOSIS. I'XprmiJN' io coUl ; or it may exist in connection with apoplexy, or with fin inflfirnrnalion of the brain. Its main marks of distinction firom the fri»rriiw of Maiiun an;, that it is purely local, is often of long contin- Uitw'v^ m not painful, has no paroxysms of aggravation, is not com- bined with impaired deglutition, and is not dangerous.^ Similar HpMMrn huH alHo hoA*n observed as a result of irritative lesions of the p(HiM, Huch UH a new growth, or vascular disease, affecting the motor nuclruH of th(^ (Iflh ns:teiMd contractures. l^'^Ar^x x^iftVrs :\^^«^ .^'xx^tv^i.)* :^*w*«. ixhsorred in rickets or in severe ^strv^^r,^>!it;:>A' oA55irri;. bx th< s}\*s:v^ of this beii^ much more tran- si? AJ^: u^ S^ r.i:vh r.:o«v msuricd in the fingers than r.-: iV U\>!:^ K;:: :V,o ^t?s:;r.-. txv.x is chi-rV oca* oc ot^pv^^and many re- ^^:\x , vfir;\N;\\>A' s;\Asc,; as oV,> a ;^h: :\cr« cc' :ftany. This malady >iA.,xvv.>: /:-.v',> /* rv'*;^, ■'.::•?; ;>//^*"r^'c, jfc? a s*^c/-yC rf exhaus^^ diar- rNvvjt A*,-r ,\yv>^..r, ;/ ,\v,:. av.%: .v. v,.rsiiT5£ ,-c r- fw^s^ant wcmen: ■ ^.A-^ A>^/ Nv ,'»N<:-xvvx ,- , '^v •.••';*,: vir T»-J:h iiiitiiuicci ct the stem- ji?,' .1 •.* iVc •^^•r.''/^^ /» ;x ^r.^-r/ku pUiTt.i. h has bei«n desmihed A-^ Av ,'-i ^w ' j; ,.,o.^, ..... vcr. A^'.^ :r»: s^T/ijc^rons 4nf S:<- Ibose of DISEASES OF THE BRAIN AND SPINAL CORD. 201 ergot poisoning.^ The disease is not a common one in this countr}'. Crozer Griffith * has analyzed seventy-two cases reported in America. The symptoms of strychnine poisoning are almost identical with those of tetanus ; yet there are some characteristic differences. The spasms from strychnine do not supervene upon exposure to cold, or upon a wound, but follow within about two hours or less the taking of some solid or liquid. They come on suddenly, with violence, with epigastric pain and early reflex excitability. The tetanoid convul- sions affect simultaneously nearly all the voluntary muscles of the body, but with greatest intensity those of the trunk and spine, pro- ducing very early — within a few minutes, commonly — ^a marked opis- thotonos, which in tetanus does not appear, if it appear at all, for many hours or days after the seizure. On the other hand, the stiff- ness of the jaws, which is among the very earliest signs of tetanus, is not at first perceived in strychnine poisoning, and, if it occur, occurs only imperfectly. Further we do not see the frightful tetanic face, with its knit brow and horrid grin ; we do not observe intermissions in the convulsions, or difficulty in swallowing ; and in from ten min- utes to two hours after the commencement of the attack the patient dies or recovers. Finally, let us contrast tetanus with hydrophobia. Both showing the reflex functions of the spinal cord to be in an exalted condition ; both being spasmodic affections lasting ordinarily but a few days; both taking place, the popular opinion to the contrary notwithstand- ing, at all periods of the year ; both presenting violent paroxysms of convulsions, which are often excited by the slightest touch or jar to tlie body ; both frequently occasioning torturing pain near the pit of the stomach ; both ensuing commonly upon an injury ; both usually augmenting in intensity from hour to hour, — these ghastly maladies are yet dissimilar. The one results from infection with a specific bacillus often present in earth ; the other from infection with the virus of a rabid animal, most commonly the dog or the wolf. The one has a short, the other a long period of incubation. In the one, deglutition may be difficult ; in the other, it is next to impossible, all attempts at swallowing, especially of fluids, exciting the most dis- tressing spasmodic dysphagia. In the one, early rigidity of the mus- cles of the jaw happens ; in the other, there is no such rigidity. In the one, the breathing may or may not be interfered with; in the other, the spasms of respiration are almost as marked a feature as * Stated in the German translation of this hook. * Trans, of the Assoc, of Ainer. Phys., vol. ix., 1894. 18 202 MEDICAL DIAGNOSIS. the spasms of deglutition. Then the irritability of temper in hydro- phobia ; the fierce manner of the patient ; his rabid, perhaps maniacal paroxysms ; the constant thirst ; the accumulation of string}' mucus about the angles of the mouth ; the vomiting ; the acute sensibility of the surface ; the trembling of the muscles ; the clonic instead of tonic spasms ; the husky voice ; the strangling sensation in the throat, — are phenomena too striking to render an error in diagnosis likely. The temperature is, as a rule, elevated, and in direct proportion to the intensity of the other symptoms. Towards the close it may reach a high degree, and it sometimes continues to rise after death. Some of the points here referred to serve also to distinguish hydrophobia from acute mania, and from hysteria. For, as in tetanus, we find this erratic complaint simulating the terrible disease. In truth, it is the opinion of some, of Dulles^ especially, that the great majority of cases of supposed hydrophobia are of this character. Functional Spasms. — ^There are spasms that take place in vari- ous parts of the body, sometimes clonic spasms, sometimes tonic spasms, which occur without apparent cause, and are more or less continuous or persistent. In time they may lead to contractures and deformity, or they may pass away. They may be of hysterical origin ; but these are not now under discussion, rather the spasms that take place in one or both legs, sometimes in the arms, occasionally in the muscles of the face, which occur in those who are not hysterical sub- jects, and are not traceable to any lesions. Pressing on particular points may at once excite them ; on the other hand, there are " press- ure-points'' which when acted on will cause the convulsive move- ments to be arrested. The trophic disturbance that attends them is usually very slight. Tonic contractions are apt to alternate with clonic spasms, or there may be only complete tonic spasm during attempts at moving certain muscles. At times spasms of the internal muscles, as those of deglutition or respiration, may coexist ; or the spasms may be limited to these muscles. The disorder is sometimes hereditary. There is a curious form of spasm, a tonic contraction of the mus- cles, which impedes locomotion. It shows itself when the muscles are first put into action after a period of rest, or after an unexpected irritation, as striking the toes against a stone in walking, and is aug- mented by nervous dread about it. Happening, as it generally does, in the lower extremities, it leads there to muscular increase. This * Transactions of the College of Pliysicians of Philadelphia, 3d Ser., vol. xvi., 1894. DISEASES OF THE BRAIN AND SPINAL CORD. 203 Thomsen^a disease, or congenital or transient myotmie, has been known to originate in sudden fright.^ . It begins commonly at an early age, and is hereditary ; it is persistent, although no organic cause for it has been detected. In one fatal case post-mortem examination disclosed the existence of hyperplasia of the muscular tissue, without appre- ciable lesion of the central or peripheral nervous apparatus.* The difficulty is most marked in the morning, on first rising, attempts at movement causing the muscles to become rigid and the joints fixed : yet if exertion be persevered in, the spasm becomes less and less, and continued walking is possible until after another period of rest. The spasm is aggravated by attention and emotion, and very rarely affects the muscles of the face. Electrical and mechanical irritability are heightened. Sensibility and reflex excitability are unafl'ected. The chief difference between Thomsen's disease and paramyotane,^ which is also a fiimily afl'ection, is, that in the latter spasm is not started by voluntary movements and is more permanent ; the marked spasms may last several hours. They are excited by cold and allayed by warmth. Paramyotone may be associated with ataxic symptoms. A family type of congenital myotone is described by Eulenburg,* and intermittent congenital myotone by Martin and Hausemann,* in both of which exposure to cold was followed by tonic spasm of various muscles. The irritability of the affected muscles was dimin- ished. It is not impossible that future investigation may disclose some relationship between the spasmodic conditions here described and some of the forms of functional palsy previously detailed. Hiccough. — As a form of local spasm may be here mentioned the curious phenomenon called hiccough, an intermittent, sudden contraction of the diaphragm. It is a matter of doubt whether this is connected with irritation of the respiratory centre, or is a spasm from irritation of the phrenic nerve, reflected, it may be, from the pneumogastric, or direct. Its symptoms are a spasmodic contraction of the diaphragm, followed by a sudden closure of the glottis with a short, cough-like noise. It may occur in brief paroxysms of varying duration, or go on by day and night, and result in wearing out the 1 Case of SchSnfeld, Berliner klinische Wochenschrifl, July, 1883. ' Dejerine and Sottas, Compt.-rend. hebdom. des seances de la Soc. de Biol., 1893, No. 23, p. 669. * Gowers, Diseases of the Nerves and Spinal Cord, vol. i., 1899. * Neurologisches Centralblatt, 1886, No. 12 ; Jahresber. ilber die Leist. u. Fortschr. i. d. ges. Med., xxi. 2, p. 164. * Arch. f. path. Anat. u. Physiol, u. f. klin. Med., cxvii. 7, p. 687; Jahres- ber. iSber die Leist. u. Fortschr. i. d. ges. Med., xxiv. 2, p. 76. 2(14 MKDICAL DIAGXOSIJ*. Mtn'fij(fh of fJi^f {latK-nt. It b rnet with in various afTections. both of \Uf ftcryouH Hyhif'tii anri of the orsophagus. stomach, and intestines. In Hofii^' irmfanrrf-s it Ls rh-arly of rheumatic, or goaty, or uraemic. or oftii-r toxw'iiiir: ori^n. When traceable to the nervous system, it may he centric, due U) the* pn.'ssure of localized inflammatory exudation, or of ft new j(rowtti, or be the result of reflected irritation. When uiel witli in (liHciiseH of the stomach, the irritation is peripheral and cIcftHy reflerted. In persons with atonic and flatulent dyspepsia or cfthirrhal' conditions of the stomach, hiccough is not an uncommon Myniptoni. Iliccougli is also seen in diaphragmatic pleurisy, in dysen- tery, in appeiMlicitis, in peritonitis, and in disease of the heart. Irre- Hpe( tive of IIm* caus(»H that are distinctly centric, or are peripheral and refleclcd tliroiiKli tin* pneuniogastric nerve, cases of hiccough occur that cannot be Iniced to any obvious cause, and in which it appears i\H a pnre neunmiH. These are apt to be among the most obstinate oneH ; many of them occur in hysterical subjects. DiseaseB of ni-Begulated or Deficient Nerve-Force. The (liHcaHcH wliich principally belong here are hysteria and neu- ranllienia ; in holli then* is also marked psychic perversion. Hysteria luiM ahu»ady Immmi described in its most striking form, — the convulsive. TIiIm lu'inp* it into the ^Toup marked by convulsions or spasms, with Nvhirli it is most conveniently considert»d. Nourtisthenia. — The weakness of the nervous system shows ilMcir as a p'nen\l state of nervous exhaustion, or as the nervous weakness ol special |mrts, such as cen^bral neurasthenia, spinal neuraslhi^nia* sexual neurasthenia, ^istro-intestinal neurastlienia, c^u^liac ntMn'asthenia* and vasomotor neun\sthenia. There are no >*lri\l dilVchMices between thcvse forms, and, even in these local mani- IcNlalions, the e\i\lences of a ^^neral neurasthenic state may be \\\\\\\\\. N\Mn*aslhenia nuu be fnnn inln^ni nervous weakness; or aM|uii\\l n>»n< stniin of life, anxiety, worn*. k>ss of sleep, eye-strain, t\>M\i cOott uiadi^ too siHMt artor exiuuisting diseast\ from prolonged nhutal l;d^M^ tmdcrtakcn In thiv^e who Wd in-iloor lives; or trau- nudu . <^>« M^e. cnisxu^;.> a!^^ nu'wa> a^iidents. VUx v\i\\p*xM ^x o* !!'.c i:\r.ini', lu urasthenic state are manifold. ri^x \N^ <^ K\ ' , r,».!\ \>x\ivv.vv>, wl.ivh N\or.:t^ jvunfiilly manifest on any r::s^-\ :^ r.-o K>s§s of weight, and a de- \* ;t:..v.i ;uui. in women, hysterical \ A .0, \ w sinrits aiv general, though .V< A r«>:. ih'Cfv is i^isomnia* as well ^ . : v.: Nvixi. jvtin at the back of the xVt^{,i;i:^>\ l\SV. \ .^V " \-:Cci. iA; p^\vvx,\ oi >U'>;s*-.\*,/ r's \.\\ '.',Nri \'v^;^»''"> .itv' »*. Hluvr\/'..->'X .X .; V,' ' . . \\ ' :.*. x"*x ,^ xV'x-/ .' \\ . ,fc,-. ,: '.,' , "AN^; DISEASES OF THE BRAIN AND SPINAL CORD. 205 neck, and inability to fix the attention on any subject for long, cer- tainly to do so without fatigue. All business aflairs, even the smallest, become a source of worry, of annoyance, of self-reproach. The temper is irritable, and the patient is constantly talking of himself, his symptoms, his sufferings. The appetite may remain good, but it is often impaired, and there is a condition of nervous dyspepsia with lithsemic urine. The eye is sensitive, and aching in the eyeball after reading or flashes of light are complained of; there is, indeed, a very familiar neurasthenic asthenopia. Inequality of the pupils and their dilatation and drooping of one eyelid are usual. Both the deep and superficial reflexes are increased, and hyperaesthesia, especially in- creased sensitiveness to pain, is common. Then there are pain or aching in the back and spine, and various neuralgic pains and dizziness. In some instances the psychical phenomena preponderate. There is intense dread of one object or the other, of people, of things, of dis- ease, of insanity, curious and imcontrollable thoughts run through the mind, and suicidal tendencies may show themselves. The will-power is greatly impaired ; there is an inability to come to any decision. The vasomotor disturbances show themselves by flushes of heat, sweat- ing, and throbbing of the abdominal aorta, as well as general arterial throbbing and imperfect capillary circulation, with coldness of hands and feet and numbness. Accordingly as one or the other group of symptoms preponderates, we have different local types established, and among these the cere- bral and the spinal may be very confusing, and readily lead to the supposition of organic disease. The cerebral I described years ago in the first edition of this work (1864) as " exhaustion of brain power," and pointed out how it difl'ers from the phenomena generally attributed to softening of the brain. It is encountered among overworked professional men or those engaged in laborious literary undertakings. It sometimes comes on suddenly, with signs like those of collapse ; more generally it is slower in de- velopment. Its manifestations are a slight deterioration of memory, and an inability to read or write, save for a very short period, although the power of thought and of judgment is in no way perverted. Nor is the power of attention more than enfeebled : the sick man is fully capable of giving heed to any subject, but he soon tires of it, and is obliged from very fatigue to desist. He passes sleepless nights, is sub- ject to ringing in the ears, cannot bear much exercise, is troubled with irregular action of the heart, with a frequent desire to urinate, and with neuralgic pains in the face or a feeling of soreness in the head ; but he does not generally lose flesh, and his digestion is unimpaired. 206 MEDICAL DIAGNOSIS. Many remain in this condition for months, and then slowly r^fain their health. What the precise disturbance of the brain consists in is uncertain : it is possible that the nutrition of the oiigan has been inter- fered with from overuse and worry. The phenomena of this cerebral neurasthenia, as it is now customary to call the disorder, differ from those' of softening by the absence of, or at least by the far less per- manent and marked, headache, by the comparatively unimpaired intel- ligence, and by the non-occurrence of spasms or of paralysis, and of the causes that generally produce softening. Cerebral neurasthenia may be mistaken for the earlier stages of general paresis. But though they have signs of nervous weakness and exhaustion in common, and even some of the psychic manifesta- tions, yet the slowness of speech, the tremor of the tongue, the condi- tion of the pupil, generally myotic and with impaired reflex, and the change in character denote the paretic affection, in which, moreover, there is often a history of syphilis or of alcoholism. In the more ad- vanced stages of the malady the impaired gait, the almost unintelligible speech, and the delusions leave no doubt that we are not dealing vrith neurasthenia. Spinal neurasthenia manifests itself by pain and tenderness of the spine, intercostal neuralgia, aching pain in the legs, numbness and tingling in the extremities, some defect of co-ordination, as shown in the gait and in writing, and these symptoms may simulate beginning locomotor ataxia. But there is no Argyll-Robertson pupil, there are no lightning-like pains, and no sensory disorders, for the sensation is only subjectively disturbed, and the reflexes are either normal or increased. There may be much difficulty in distinguishing these cases of spinal neurasthenia from those of so-called nutritional disease of the spinal cord, which Gowers has specially described. The symptoms, indeed, are the same, except that aching in the back and legs is more pronounced; that aching in the legs at night is complained of; that there is always increased knee-jerk ; that even the shortest walks pro- duce at once a sense of fatigue in the legs ; that these show some falling off in nutrition ; and that there is a history of a fall, or of an acute illness, such as typhoid fever or acute rheumatism, or of sexual excesses. Then the general neurasthenic symptoms are absent or are not marked. In sexual neurastlienia there is great irritability of the sexual organs, prostatorrhoea and spermatorrhoea are complained of, and their importance immensely exaggerated; there is pain in the testi- cles, also generally greatly exaggerated, and constant dread of im- DISEASES OF THE BRAIN AND SPINAL CORD. 207 potence. In women, derangement of the menstrual function is not uncommon. The diagnosis of neurasthenia is frequently difficult, as we have to depend so much upon the statements of the patient. Moreover, it is a diagnosis often incorrectly made by the physician, and too readily acquiesced in by the patient, who is not loath to believe himself the victim of "nervous prostration." This is, indeed, onepf the greatest of difficulties ; the lazy, the irresolute, the self-indulgent have a name under which they dignify their failings, or shelter theu* shortcomings. Then ill health associated' with the beginnings of organic disease in various organs is very apt to be pronounced neurasthenia. No diag- nosis of this ought ever to be made until after the closest search for a structural affection, and especially for lesions in the nervous system, kidneys, stomach, and blood; a large number of cases of so-called neurasthenia turn out, indeed, to be a disease of one of these parts. Neurasthenia is most apt to be confounded with hysteria and with hypochondriasis, and what makes the diagnosis at times very perplexing is that there may be an association of the morbid states. In hypochondriasis, almost exclusively a disease of males, there are actual delusions concerning the physical state, which may, however, be very good; not so in neurasthenia, though there is often great dread of disease. The paroxysms of hysteria, its peculiar mental characteristics of exaggeration and deception, the emotional disturb- ances, the crises, the alterations in vision, the contractures, the anaes- thesias, the hysterical palsies, and the great range of hysterical symp- toms distinguish it. Diseaaes characterized by Gradual Impairment of the Mental Faculties with Paralysis. Chronic Softening. — Softening of the brain may be caused by nutritive changes consequent upon a diseased state of the cerebral vessels, or by an inflammatory disease spreading from the meninges to the brain, or taking place around new formations and old lesions. It may also follow cerebral hemorrhage. But its chief cause is occlu- sion of the cerebral arteries from embolism. In rarer instances the plugging is due to a thrombosis. The middle cerebral arteries are the most common site of the emboli, and degeneration and softening occur in the territories supplied by the obstructed vessels. What- ever the cause of the softening, the symptoms are much the same. They are briefly these : gradual impairment of intelligence ; weaken- ing of memory ; headache ; vertigo ; muscular debility ; cutaneous hyperaesthesia or anaesthesia ; formication and numbness ; and slight 208 MEDICAL DIAGNOSIS. or partial palsies, particularly of the muscles of one side of the mouth, or of one eyelid. Then there is not unfrequently defective articulation, wth great irritability of temper, nausea and vomiting, extreme sensitiveness to sounds, and painful feelings in various parts of the body. As the local mischief advances, the paralysis becomes more decided, assuming generally the hemiplegic form ; and spasms, either tonic or clonic, or epileptic convulsions, occur. In the diagnosis of softening the most important point, is the recognition of the state that has led to it, the meningo-encephalitis, the apoplexy, the diseased blood-vessels, or, above all, the embolism which has started the process which, in place of an acute coiu^e, is pursuing that of a slower degeneration. The older descriptions of softening are very fallacious. Many cases of cerebral neurasthenia, many of general paresis, were covered by this term, and the sec- ondary results of morbid processes in the brain were looked upon as the primary disease. We shall next inquire how such cerebral maladies as congestion, anaemia, abscess, and atrophy may be distinguished from softening. Congestion is discriminated by its being very rarely a persistent state. It may be active or passive, — resulting on the one hand firom an increased supply of blood, and on the other hand from interference with the venous return. An acute attack produces the symptoms of apoplexy ; a more lasting congestion is recognized by tracing the cause which has led to the fulness of the vessels, — such as a disease of the heart or of the abdominal viscera, — and by noting that, although the patient suffers from dull headache, from disturbed sleep, from jerking of the muscles, from pulsation of the carotids, from vertigo, these signs are far from constant, and come and go for a long time without any material disturbance of the functions of the brain being perceptible. The finding of optic neuritis or choked disk, or the presence of paralysis, would determine against congestion. Cerebral anaemia, occurring suddenly, produces unconsciousness, or dizziness or stupor; or, if general, convulsions. When more gradually induced, it manifests itself by drowsiness, sighing respira- tion, distressing headache, often referred to the vertex ; by a pale face and uninjected eye with largo pupil ; by derangement of the special senses ; by the vertigo and the other symptoms of cerebral disorder being relieved in the recumbent position ; and by a feeble pulse and cool forehead. Then, in tracing its history, we are apt to find that it occurs in those who have been exhausted by debilitating diseases, or by repeated hemorrhages, or by albuminuria. The cliief distinction from softening lies in the history of the case ; the aspect DISEASES OF THE BRAIN AND SPINAL CORD. 209 of the patient, and the absence of palsies, or their passing nature, must be taken into account. But we must not forget that anaemia is also the first stage of softening due to vascular occlusion. Abscess of the brain arises under the same conditions as cerebritis ; but pyogenic micro-organisms play a very important part in the mor- bid process. The most constant clinical association is with disease of the ear ; suppurating processes in other parts of the body, such as ab- scesses in the lungs or fetid bronchitis, are also not infrequent causes. The symptoms are referable in part to the inflammatory process, in part to the presence of the purulent accumulation. The acute cases get progressively worse ; in cases which pursue a chronic course an initial inflammatory stage of brief duration is succeeded by a latent period, sometimes of considerable length, and this in turn by a ter- minal stage, ending rapidly in 'death. Among the early symptoms are headache and vomiting, in association with febrile disturbance often attended with chills. Involvement of the cortex or subjacent white matter may cause local spasm ; extensive disease, general con- vulsions. Paralysis and delirium may be also present. The acute period lasts from a few days to several weeks. In the latent stage, which may continue from a month to some years, decided manifesta- tions may be wanting. Often there is headache ; occasionally there are convulsions ; at times slight mental disturbance exists. Elevation of temperature, and recurrent rigors followed by sweats, also happen in abscess. Optic neuritis is as often absent as present. Constant headache and vomiting are among the most prominent symptoms. Though hemiplegia is met with not unusually, it is generally slight. The terminal stage which marks the rupture of the abscess may set in abruptly or gradually, with increase in the headache and mental symptoms, with vertigo, vomiting, derangement of consciousness, convulsions, and paralysis. Few cases of abscess of the brain, as Lebert* has shown, last ]ong(?r than eight weeks. Abscess of the brain may be latent, and the sudden rupture of the abscess may give rise to symptoms undis- tinguishabie from those of hemorrhage, undistinguishable unless we can infer an abscess from a disease of the bones of the head, or from some points in the history of the case. Atrophy of the brain is especially observed in old age, and, when marked, may be the cause of the general decay of cerebral functions noticed at this period of life. It is very generally connected with ' Archiv flir Path. Anat., Bd. x. See also Gull's paper in Guy's Hospital Reports, 3d Series, vol. iii. 210 MEDICAL DIAGNOBIB. difTused s<:lerosis. As a rule, it occasions no distinctive symptoms; it has been specially observed in idiots. The brain is sometimes undersized from defective development The diminution may be general or unilateral, or even circumscribed. Partial atrophy is a common result of meningeal hemorrhage during birth. In some in- stances it follows meningitis early in life. Similar processes may also take [>lace during intrauterine existence. These varying conditions give risf* to diverse symptoms, among the most common of which are mental defect, hemiplegia, convulsions and mobOe spasm. The differences between softening and cercfrra/ nmradhenia havt* been already considered, and those between it and tumor will pres- ently engage our attention. Tumor. — ^Tumors of the brain give rise to a great diversity of signs, actcording to their locality, their size, and their nature. Let us first examine the symptoms by which we may infer their existence. The presence of a tumor in the brain is rendered probable if, in addition to vertigo, to vomiting or to a disposition to vomit, or to head- ache, violent, but paroxysmal and neuralgic in its character, we find impairment or loss of vision, or indeed of any special sense, and epi- leptiform convulsions not followed by any greater deterioration of health than previously existed ; if with these signs of cerebral irrita- tion the hitellect is not at first markedly disordered, nor the articula- tion affected ; and if paralyses do not show themselves until a long time after the headache, and are even then limited to the myscles of the eyeball or of the face, or to the muscles of the extremities of one side of the body. As a further sign of cerebral tumor we may class optic neuritis or choked disk. It is a curious fact to be borne in mind that cerebral tumors occur in males more than twice as frequently as in f(?mal(»s. It may also be noted that the larger number of cases are in the young or in those in the prime of life ; the aged are re- markably exempt. The commonest forms of tumor are tuberculous, gliomatous, sarcomatous, and syphilitic. Less common are carcino- mata and parasitic tumors. Before the evidence of a tumor is con- siden»d conclusive we must exclude other chronic cerebral maladies, (especially softening, abscesses, and chronic meningitis. We separate chronic Hoftening by noticing that the headache caused by a tumor is much more constant and violent, having paroxysmal exacerbations ; that the intelligence remains for a long time intact, sav(\ p(»rliai)s, in a weakening of the memory ; that optic neuritis is a usual acc()nii)anhnent ; that motor and sensory disturbances are less fre(|uenl and promlnc^nt, but convulsions far more so. Further, cere- bral tumor is more common in early life, chronic softening in late life. DISEASES OF THE BRAIN AND SPINAL CORD. 211 Disease of the heart or of the blood-vessels, or Bright's disease, or, especially, the history of an embolic seizure, points to the latter state. Remissions, or inten^als of apparent improvement, occur in both morbid conditions ; but they are more perfect and of longer duration in tumor than in softening. The differential, diagnosis between tumor and abscess is more difficult. We may conclude the latter to exist, if the cephalalgia be sudden in its development, and uniform and general, instead of neu- ralgic and limited. Then epileptic convulsions, drowsiness, paralysis and coma succeed one another much more rapidly and, except convul- sions, are present much more constantly in abscess than in tumor, — indeed, epileptic fits are about as often absent as present.* Further, optic neuritis and localizing symptoms are more common in tumor than in abscess, and this shows especially in the palsies of cranial nerves. If, moreover, we obtain the history of injury to the skull, or find a discharge from the ear, or pain upon pressure over the mastoid process, or a chronic disease about the head, or protracted suppuration in any part of the body, we may safely infer that an abscess, not a tumor, is the cause of the evident cerebral mischief. Abscess, like tumor, chiefly affects males. Chronic meningitis, an affection sometimes complicating tumor, is discriminated by laying stress on its etiological relations, — such as blows upon the head, diseases of the cranial bones, syphilis, rheuma- tism, alcoholism, chronic tuberculosis, — and by observing its frequent though irr^^ar accessions of fever, the great irritability of temper, the dulness of intellect, the loss of memory, and the nocturnal de- lirium. The pain, too, is duller and more diffused than in tumor, and there is more vertigo. The localizing symptoms are not so definite and fixed, nor the convulsions as distinctly epileptiform in type. Yet convulsive movements of some muscles are common, and may be even followed by incomplete paralysis. Meningitis may be excluded if optic neuritis or any marked alteration of the disks be found early in the case. Indeed, optic neuritis is absent or is very slight in chronic meningitis. Yet the diagnosis is often very difficult, especially between tumor and syphilitic or protracted tubercular meningitis. Thrombosis of the sinuses of the brain may occasion partial palsies, with symptoms of cerebral pressure, like those of tumor, and cannot • be distinguished except in the instances in which we find distention of the collateral circulation shown in the fulness of the veins of the * Thas, they occurred in only thirty-eight cases of abscess of the brain out of seventy-three collected by Gull and Sutton (Reynolds's System of Medicine). 212 MEDICAL DIAGNOSIS. nose, temple, and forehead, and injection and oedema of the forehead and eyelids. Convulsions, further, are very rarely among the symp- toms ; and generally these are more similar to the manifestations of meningitis than of tumor ; coma is not uncommon. When primary, the condition is usually a result of enfeeblement of the circulation and altered blood state in exhausting or wasting diseases, especially those of infancy and old age. In children with marasmus, or in adults with caries of the skull, or purulent ear disease, marked cerebral phenom- ena may lead to the .correct inference of thrombosis. Secondary thrombosis is most often met with as an infective process from adja- cent disease, especially chronic suppurative disease of the ear, and there is local oedema and tenderness over the mastoid and internal jugular. Portions of the disintegrating thrombus may be carried into different parts of the body, and embolic phenomena appear. In the marasmic cases the symptoms are often those of the hydrocephaloid disease of Marshall Hall, with which it may be associated ; hemorrhage into the cortex of the brain is common. The precise seat of the tumor is difficult to determine. An affec- tion of the special senses or of cranial nerves points to disease near to, or at, the base of the brain ; and the probability of this view is much strengthened if there be paralysis of the face on the side oppo- site to that of the extremities, and if vigorous inspiration, during which the brain falls and presses the morbid mass against the w^alls of the base of the skull, cause or increase pain ; whereas, so says Romberg, in tumors on the upper surface, forced expiration produces a like result. In cases of tumor of the pons or the crus^ particularly when tubercular, incoordination of the arm similar to the jerky move- ment of disseminated sclerosis is met with ; but it is unilateral, not bilateral as in sclerosis. In tumors of the cerebellum we have head- ache, severe vomiting, nystagmus, staggering gait, spasms, and rigidity ; the knee-jerk may be absent or increased ; there may be no marked alteration of the optic disks, or, as de Schweinitz has pointed out, the appearances may be those usually regarded as indicative of albu- minuric retinitis. Tumors in or near the cortex of the brain give rise to localized convulsions on the opposite side of the body. In tumors of the frontal lobes there are marked psychical symptoms ; and ataxia, such as we observ^e in cerebellar disease, is, Bruns has proved, a very significant symptom. In tumors of the Rolandic region monospasm and unilateral spasm precede or attend the increasing paralysis. In determining the exact position of brain tumors we must make use of the researches on the localization of the cerebral functions. The difficulty of applying this extending knowledge to the diagnosis of DISEASES OF THE BRAIN AND SPINAL CORD. 213 tuniors at the bedside is, that they may give rise to circumscribed in- flammation around them, or to irritation in even more remote parts, and that the special manifestations of the disorder of the pari: affected by the tumor are thus blurred or obscured. Then we must also bear in mind that several tumors may be present. In endeavoring to determine the seat of the tumor it is necessary to distinguish as clearly as possible the difference between the results of generalized pressure or distant effects, and those due to direct and localized influences. It is only the constant abnormal symptom that points out the location of the lesion. Paralyses, pareses, spasms, which change in intensity or affect now one, now another set of mus- cles or organs, show that the centres are disordered only indirectly and temporarily, and that the true position of the neoplasm is to be sought elsewhere. Another indication is derived from a consideration of the relative intensity of the different symptoms. The less com- plete a paralysis, or the less energetic the spasm of a certain set of muscles, the less certain is the injury to be localized in their centres, and the reverse. Too much dependence must not be placed on the subjective location of the pain. Diffuse pressure may cause more pain at a point far removed from the growth than its immediate neighborhood. But when spasm or paralysis of a limited set of muscles exists, as in cortical epilepsy, and the pain is located by the patient at a point corresponding to the topographical position of the corresponding centres, the deduction becomes quite certain that the lesion is at this point. When from other indications the inference is probable that the growth is in the cortical substance, the additional symptom of pain makes the diagnosis more sure. It is manifest that in all tumors of the cortex, or of the white sub- stance immediately beneath, the symptoms will be unilateral and in- clude convulsions. When both sides of the body are about equally afl'ected, the tumor must be placed at the base of the brain, unless the growths be multiple and situated in symmetrical parts of the two hemispheres. Where the symptoms are more intense upon one side of the body than upon the other, the weaker symptoms are to be attributed to the distant or indirect effects of pressure. Paralysis, of course, is a symptom of more profound disturbance than spasm or convulsive movement. The last is therefore probably due to an irri- tative or indirect effect, or to a slowly growing neoplasm. The exist- ence of papiUitia^ optic neuritis, or choked disk^ is in a suspected case of tumor among the most conclusive signs of intracranial neoplasm. But, unfortunately, it gives scarcely an indication either of the nature or of the seat of the new growth. Yet since the papillitis may precede 214 MEDICAL DIAUNQHIH, other symi>tnms, since also no deterioration of vision may have been noticed by tlie palient, a eareful opthalmoscopic exaiinnation should always be made when there is any thought of the existence of tumor. Can we form an opinion of tfie jiahd-e of a tumor of the brain from any of the signs referable to the eerebral malady? We cannot: the character of the pain has been Ihon^hl to be of great significance ; but the testimony to prove ttiat it is so is in the liighest degree un- satisfactory. We may sometimes, however, from the liistory of the case, or from the existence of some of the rnanifeslalions of special cachexia, draw a coiTect inference. In gliomatom brain tumors, Virchow has pointed out, there is often the history of a blow. They are usually single, and most comoion in the cerebral hemispheres, and occur next in frequency in the cerebellar hemisphere ; then in the central ganglia^ pons, medulla, crus, and corjiora quadrigeniina. Gli- omala are comparatively frequent in children. Sarrfimafa develop in the brain or in the membranes, or from the bones, particularly at tlie base. They diller from gliomata in being circumscribed and not in- filtrating. Tithemdom groicfhs are oilcn multijjle and most frecpjenl in the cerebellum ; they are also found in the pons, central ganglia, cms, medulla, and corponi quadrigeniina. If we find tiisease of the lungs, or any evidences of scrofula, and the patient be young, we shall probably be right in conjecturing the tumor of the brain to be a mass of tubercle ; but if tJie sutlerer be advanced in years, and exhibit tumors in various parts of the body, or other signs of a cancerous diattiesis, we Uiay with reason aljle cer- tainty presume the tumor mthin the skull to be caarcmm. Sifphllitir tumors are mostly cortical, rait'ly cerebellar, grow rajjidly, and are greatly influenced by antisyphilitic treatment. Other kinds of tumors and deposits can scarcely be said to be wittiin tlie rt^ach of diagnosis. Cyats seated in the superficial portions of the brain either occasion no symptoms or give rise to lieadache, to attacks of vertigo, to vomiting. and to epileptic seizures, but very rarely to palsies. The symptoms mentioned are far more apt to be present when the cysts occupy the lateral ventricles ; then epileptic convulsions are rarely absent, Tlie manifestations of an aneurmn witinn the cmnimn are those of an ordinary tumor, and the afTection is not distinguishable excep! when the symptoms are referable to tlie presence of a tumor in the course of a cerebral vessel, and we find present a cause of aneurism, such as syphilis or chronic endocarditis with vegetations, or decided indications of disease of the vessels in other parts of the system,* ' James H, Hutdiinsoii, Pennsylvania Hospital Repori^, vol. ii. DISEASES OF THE BRAIN AND SPINAL CORD. 215 A small aneurism may occasion no symptoms ; one large enough to exert pressure on adjacent structures may be attended with head- ache, often pulsating, usually continuous, sometimes paroxysmal; vertigo ; mental dulness and irritability ; occasionally convulsions ; paralysis ; bilateral hemianopsia ; * rarely optic neuritis. Neither the presence nor the absence of a subjective feeling of pulsation and of a murmur, whether in the carotids or the vertebral or the basilar arteries, and audible on auscultation of the skull, has a positive significance ; for, notwithstanding the cases of Jonathan Hutchinson ^ and Humble,^ in which the diagnosis was made during life, the detection of a mur- mur, as I know from observation, is not a certain sign. A murmur, moreover, is not uncommon in rickets. Even a pulsating tumor pro- truding through the skull may not be due to an aneurism, but be caused by a glioma, as in the case mentioned by Mills.* Aneurism of the internal carotid artery may cause blindness on the same side, paralysis of the third, and of the ophthalmic division of the fifth, nerve, impairment of the sense of smell, and hemiplegia. Aneurism of the anterior cerebral may occasion many of the same symptoms, although the muscles of the eyeball usually escape. Aneurism of the middle cerebral is usually attended with hemiplegia and convulsions. Aneurism of the basilar artery causes extensive damage, with widespread paralysis, including the cranial ner\'es ; con- vulsions are rare. Qeneral Paralysis. — This fatal cerebral malady, known also as general paresis and dementia paralytica, is the result of a diffuse in- terstitial meningo-encephalitis ; the spinal cord may become second- arily affected. Clinically, the disorder is marked by impairment of the powers of locomotion ; by an inability to articulate distinctly, — a symptom which precedes the deranged locomotion ; by the expres- sionless countenance ; and by failure of memory and complete per- version of the mental faculties, amounting, in fact, to insanity. The palsy is peculiar : indeed, except towards the end, there is, in the usual sense of the term, no palsy in the limbs at all ; there is rather a want of control over their co-ordinate action, displaying itself first in the hands by clumsiness of movements and irregular hand- writing, and in the gait by uncertainty and a swaying from side to side when the patient attempts to walk. The impairment of the muscular movement gradually extends : tremulousness in the muscles * Case of Mitchell and Dercum, Nervous Diseases by American Authors, 1895. * British Medical Journal, April, 1875. » London Lancet, Oct. 1876. * The Nervous System and its Diseases. 1898. 216 MEDICAL DIAGNOSIS. of expression is noticed ; the speech becomes more inarticulate, until scarcely a word can be distinguished; and the patient cannot rise without being assisted. The reflexes are not uniformly affected ; the knee-jerk is often exaggerated, but in some cases reflex contraction of the tendo Achillis is wanting. As the disease advances, the cuta- neous sensibility is greatly diminished or is lost. The pupils are un- equal, generally contracted and sluggish. The mental derangement is often manifested by an exaggerated sense of personal power or importance, and fancies of great wealth ; the moral feelings greatly deteriorate ; sometimes there are maniacal outbreaks and epileptic attacks, or alternating periods of excitement and depression. Decep- tive remissions in the progress of the disease may take place, but the termination is invariably fatal. Death is often preceded by convulsive attacks and by coma, or by painful contractions of the muscles of the trunk or the extremities, or by obstinate diarrhoea, or by pulmonary aff'ections. Pneumonia is especially common.^ The early signs of general paralysis of the insane are difficult to recognize. A change in character, in moral sense, in pow^er of men- tal attention, and in judgment, absent-mindedness, and weariness easily brought on by brain-work or by any physical exertion, are very significant in a middle-aged man, if joined to alteration in handwriting and some impairment in executing delicate muscular movements. With these symptoms there is commonly, as Folsom* mentions, loss of flesh. In more advan(*ed stages there is not much doubt about the malady. It diff*ers from other fonns of extensive general paralysis in being far less of a real palsy. It is certainly far less complete than the extensive paralyses which follow lesions of the upper portion of the spinal cord, or which are consequent upon the poison of lead, or of malaria, or of diphtheria. Its association with marked disturb- ance of the intellect and its psychic symptoms furnish, moreover, a diff*erential test of great value, and not merely with reference to the general palsies just mentioned, but also as regards neurasthenia, the trembling movements of old age, of progressive muscular atrophy, and of chronic alcoholism. In one of its forms, as Westphal points out, there is a strong resemblance to locomotor ataxia in the signs of disturbed co-ordination, sensory impairment and absence of knee- jerk, with incontinence of urine ; but the tremor in the muscles of the lips and face and the perverted mental state become of greatest ' Crichton Browne, Brain, Oct. 1883. * Transactions of Association of American Physicians, 1889. DISEASES OF THE BRAIN AND SPINAL CORD. 217 significance. In some cases, moreover, changes in the posterior and lateral columns of the cord have been found after death, in addition to those present in the brain. On the other hand, the ataxia and the palsies distinguish the disease from mere senile dementia. Then, too, general paresis is a disease of early manhood and of middle age, and follows syphilis, mental overstrain and anxiety, alcoholism, or sexual excesses. The defect in the articulation and the attending tremor of the lips, and in some instances the occurrence of apoplectiform seizures, accompanied by considerable elevation of temperature, may cause the disease to be mistaken for cerebrospinal sclerosis. But in this affection, while the embarrassed, scanning speech coexists with great helplessness of manner, with oscillation of the eyeballs, with tremor manifesting itself only on emotion, with paresis of the lower limbs, and finally ^vith permanent contractions, we do not notice decided alienation of mind ; there is nothing more than general enfeeblement and blunted emotional faculties. Paralysis agitans may be confounded with general paralysis of the insane. But in paralysis agitans the voice is not really tremulous ; there is rather a monotonous tone and uncertain utterance, which, with the fixed features, the sensation of excessive heat, the peculiar gait and attitude, the unaltered cutaneous sensibility, the tremor ever present except during sleep, and the very long duration of the symp- toms, characterize the disease. The intellect becomes obscured towards the end of the malady, but not before. Diseases characterized by Enlargement of the Head. Chronic Hydrocephalus. — The signs of dropsy of the brain are progressive enlargement of the head, and a perversion or a gradual loss of one or several of the special senses, of the mental faculties, and of the power of voluntary motion. The child cannot bear the weight of the head ; the gait is tottering and uncertain. The intellect, slowly but certainly, becomes deranged. As the malady advance^, strabismus, partial palsies, epileptic convulsions, vomiting, cutaneous amesthesia, and loss of sight, of smell, and of taste are observable ; the bowels become very constipated ; and a copious secretion of tears and of saliva is not infrequent. Before death takes place, which sometimes does not happen for years, the child ordinarily becomes idiotic. A few cases recover; fewer reach adult age with the brain compressed by the accumu- lated fluid ; in still fewer the disease does not develop until after child- hood. If the patient survive until adult age, the size of the skull is 14 218 MEDICAL DIAGNOSIS. generally immense. I saw. some years since, a young man. twenty- two years of age. whose head measm^ fully two feet and a half in circumference. He could walk unaided, but often fell. He was half idiotic, and subject to epQeptic fits ; yet he had sufficient intelligence to understand what was said to him, and in his chQdish way to do as he was told. Hydrocephalus may result from meningitis, from interference with the circulation through the veins of Galen, or from obstruction to the free movement of the cerebro-spinal fluid : occasionally no causative condition can be recognized. The skull is sometimes very large without dropsy of the brain existing. The cranial bones may slowly thicken to an extraordinary degree from sj^jhilis, or from unkno\vn causes. The head may be ove^gro^vn, and its bones thickened and spongy, as in rhachiiis; or it may be large when there is no disease. These states differ from chronic hydrocephalus by the absence of cerebral symptoms : and in doubtful cases we may resort to the ophthalmoscope as a means of diagnosis. The vessels of the eye, even in the early stages of chronic hydrocephalus, enlarge, and in proportion as the serum compresses the brain we find an increase of vascularity in the retina, with dilata- tion of its veins, and with an increase of the number of its vessels : complete or partial serous infiltration of the retina ; and an atrophy, more or less perceptible, of the optic nerve. These lesions vary with the age of the disease and the amount of serous effusion ; but none of them exist in rickets. Then in rickets the tendency is to spasm of the glottis, to diarrhrx^a, — and the head is rather square-shaped than globular. In very rare instances the size of the head has been obsen'ed to be increased in the cerebral palsies of children due to hemorrhage or embolism. Hypertrophy of the Brain. — It is very questionable whether such a disease as a true hypertrophy of the brain exists. The enlarge- ment, when not due to an unrecognized hydrocephalus, is mostly a oongenital malformation, or is found in children in connection \\i\h rickets, with changes in the brain of a sclerotic kind, or with those alterations caused by a defect of brain substance to which the name porencephalus has been given, but where, at the same time, in other portions of the brain extensive cell infiltrations and connective tissue changes may haj^jien. It is stated that, in hypertrophy of the brain, unlike hydroc(»])halus, wh(?n the fontanelles are touched, the sensation is that of a solid substance. DISEASES OF THE BRAIN AND SPINAL CORD. 219 Diseaaes characterized by Enlargement of Various Parts. Acromegalia. — In this peculiar and uncommon affection, first described by Marie, enlargement of the hands and feet occurs, as well as of the head, and especially of the face. Often bones and soft tissues both take part in the change, although the muscles may un- dergo wasting, with resulting weakness. The hands become broad and spade-like; the face assiunes the shape of an elongated oval; the jaws, the malar bones, and the supraorbital arches are promi- nent; the forehead is receding. Spinal curvature is common. The disease occurs in young adults and pursues a chronic course ; in rare instances it has been met with in children, especially in imbeciles. Changes in the pituitary body are constant ; in some cases a tumor has been present, and in these headache, optic neuritis, and visual derangement have been obsen^ed. Somnolence, headache, and atrophy of the optic nerve are frequent. Sometimes changes in the thyroid gland have been noted, either enlargement or diminution in size. Occasionally dulness on percussion over the upper portion of the sternum has existed, and this has been attributed to persist- ence of the thymus gland. Rheumatic or neuralgic pains are not in- frequent ; and the tongue, lips, and nose may show striking increase ill size, while the nails are small in proportion to the great growth of the bones in the hands and feet. Acromegalia may affect only one side of the body. In (/igantism there is symmetrical growth of all the bones and parts of the body, but there are neither ocular nor cerebral symptoms. Nor are there in leontiasis^ in which the enlarged face is said to re- semble that of a lion. In myxoedema the tumefaction is not confined to the extremities, but is very general, and depends not upon changes in the bones, but upon a peculiar infiltration of the connective tissues. The skin is thickened and adherent to the subjacent tissues, and not pliable as in acromegalia. The face is " moon-shaped," and the jaws and malar bones are not projecting. In the condition known as oHtciiis defoi-mans, or PageCa disease^ the changes in the bones of the face give to tliis the appearance of an in- verted triangle. Besides, the disease attacks the long bones of the body, which undergo deformity ; the spine curves ; the face is not in- volved. Certain chronic diseases of the lungs and pleura are attended with enlargement of the terminal phalanges of the fingers and toes, and of tlie distal epiphyses of the bones of the legs and forearms. 220 MEDICAL DIAGNOSIS. The finger-nails are curved, and the vertebral column is often bent. The changes are, however, usually restricted to these parts, and the disorder is not likely to be mistaken for acromegalia. Diseases characterized by Paroxysmal Pain. There is a group of nervous disorders characterized solely by pain, confined ordinarily to one nerve. These nervous pains bear the ge- neric name of neuraleen described by Charcot (vol. iii. of his Clinical Lectures) as being at times among the forerunners of general paralysis. * On Megrim, London, 1873. 224 MEDICAL DIAGNOSIS. relieved by warmth. Moreover, there is almost always other evidence of rheumatism, and the pain is intensified by pressure ; whereas in hemicrania, although the hair may be sensitive to the touch, strong pressure on the forehead, and even on the hairy part of the scalp, does not increase the pain, may, indeed, afford relief. In periostitis affecting the bones of the head, particularly when syphilitic, we may find the same violent pain as in hemicraiiia. But there is considerable tenderness on pressure, the parts attacked are swollen and less elastic than the healthy portions, and the pain is especially severe at night. Sciatica. — ^This is sometimes a neuralgia following the course of the sciatic nen^e, but often it is a neuritis. The seat of the greatest suffering is generally the lateral surface of the thigh ; tlience the pains extend to the popliteal space, and in some instances along the anterior part of the leg. Often, too, the patient complains of an aching near the sciatic notch and in the loins. The pain is more or less steady ; but it has its periods of fierce exacerbation, and damp, cold, and pressure augment it. When the nerve is inflamed tliere is tenderness on pressure over the course of the nerve. Pressure on localized points always develops pain, and the points that are most marked are on the lower end of the sacrum, on Uie side of the trochanter opposite the emergence of the great and small sciatic nerves, various points on the posterior aspect of the thigh, one at the head of the fibula, and one behind the outer ankle. The disease is obstinate, and lasts for weeks or months. It in- terferes with locomotion, because of the distress which movements of the leg and foot occasion. It is much more frequent in men than in women, and is a very rare disease in children. Generally it de- pends upon exposure to cold, or upon the rheumatic diathesis, or upon a neuralgic predisposition, or upon an irritation affecting the nerve before it leaves the pelvis, the result not unusually of sexual disorder, or of pressure from a gravid womb, or from an accumula- tion of faeces in the lower bowel. In many instances it is connected with gout, in others with anaemia, wdth syphilis, with disease of the hip-joints, and it may be, although it very rarely is, symptomatic of cerebral disease. Occasionally it is due to reflex excitation of the nerve. Sometimes it occurs after forced marches or long rides; probably in many of these cases, however, the sciatica is rheumatic. It is seldom double, except when of diabetic origin, or when due to compression from a growing tumor in the pelvis or from enlaiging cancerous vertebrae Sciatica, when of long duration, leads to loss of motor power in DISEASES OF THE BRAIN AND SPINAL CORD. 225 the leg, to tingling, and to anaesthesia ; and certain nutritive changes are observed in the limb, which is found to have dwindled, or there may be oedema. When the disorder is the result of neuritis, there is generally decided and persistent tenderness, — in pure neuralgia there is not much, — and movement and position have marked influence on the pain. Further, the history of the case in pure neuralgia, the spontaneous pain, the usual anaemia, and the previous occurrence of, or the coexistence with, other neuralgias, are very significant. Occasionally the neuritis ascends to the cord. An effusion within the sheath of the nerve may, according to Fuller, be inferred when a patient who is suffering from sciatica com- plains of a dull aching or a benmnbing pain in the limb, causing it to feel swollen, and when tliis sense of numbness and increased bulk has succeeded to pain of greater intensity, accompanied by cramps and startings and more or less inability to move the limb. The disorders which are most likely to be confounded with sciatica are : rheumatma of th^ muscles and fibrous sheaths around the hip- joint ; affections of the joint ; and pains caused by irritation of the kidney. The first is very readily distinguished. It is generally, what sciatica is rarely, double-sided ; and the pain is dull, diffuse, not paroxysmal, not limited to the sciatic nerve and its area of distribu- tion, nor as much increased on pressure as that of sciatica. But, practically speaking, this kind of rheumatism is seldom seen unless associated with rheimiatic inflammation of the sciatic nerve. In affections of the hip-joint the suffering is increased by standing wath the weight of the body thrown on the diseased leg. Moreover, the pain does not descend in the course of the sciatic ; is not associated with tenderness of the nerve ; the aspect of the limb points to the disorganization that is going on ; the leg shortens. Yet, before ad- mitting this as a mark of difference, it must be ascertained by careful measurement; for, in consequence of muscular contractions, the affected limb in sciatica may appear to be shorter than it is. The main points of distinction between sciatica and a nervous affection of tlie hip-joint are the usual combination of the latter with hysteria, the verj^ superficial tenderness, and the fact that the pain is apt to ex- tend over the whole thigh. Irritation of the kidney causes pain shooting down the thigh. The distress exists, however, in the course of the anterior crural nerve, is therefore not localized in the sciatic, is unassociated with tenderness, but is accompanied by a frequent desire to pass water, and by other signs of disorder of the urinary function. Sciatica is sometimes /eigr?icd, especially by soldiers. But the copy MEDICAL DIAGN08IB. is rarely a very accurate one. Impostors complain of pain on press- ure and on motion, but are ignorant that ttie pain is prone to exacer- bate after intervals of comparative quiet, and to increase in violence as night approaclies. Their fancied torment is constant, but does not prevent tliem from sleeping ; they wince when the muscles of the thigti are touched, yet, if their attention be diverted, the hand may be pressed along the sciatic nen^e without any sign of tenderness being manifested. General Crural Neuritis. — In tliis disease, much rarer tlum sciatica, there is extensive inflammation of the fd9rous sheaths cov- ering the luinbm' and sacral plexns ; in consequence many of ttie nerves of the leg are involved at their origin, and there are signs of widespread neuritis. There is pain along the course of several nerves, and motion is somewhat impaired, and there may be nuis- cular atrophy ; tlie tenderness of the nerve-ti-unks is most apt to be found near the pelvis, and this is an important sign as distinguishing the complaint from disease of the spinal cord. The pain is sometimes reflected to tJte sound side, Tlie knee-jerk is usually increased. The disease occurs mainly in gouty or rln-umatic persons, and is apt to be of considerable duration. It may affect pre-eminently a single nerve, as the ant(4'ior crural ; and tlie sensory phenomena, especially anaes- thesia on the Iroiit of the Ihigh, are then very marked. Brachial Neuritis* — This is a rare and very peqjlexing form of neuritis : more stri<'tly sj)eaking, it is usually a perineuritis, — a pri- mary uifiammalion of tlie sheaths of the branches that form the brachial plexus. It is a disease of the latter part of life, met with chiefly in the rhenmatic or gouty. The pain is very great, and comes on in paroxysms ; but, in^espective of these, a dull pain or ache is constmtly present. The pain hns its seat above the claricle, in the axilla, in the region of the scapula, and the inner part of the shoulder- joint. It lancinates to the neck and chest, and sometimes along the course of the arm, giving rise there to a sense of weight and heat. Motion will induce the pain, even walking may. There is sensitive- ness of the skin near the aflTected paii, and tlabbiness and sHght w^asting of groups of nmscles, which may even prevent the reaction of degeneration ; over the atrophied muscles aniesthesia is at times met Avith. Tliere may be |)ersistent tenderness of the nerv^es near their origin, but this is not always easy to determine ; the mfluence of movement in evoking pain is always striking and almost immediate. During the paroxysms of [uiin, wliich are most apt to come on in tlie latter part of the day, wlien fatigued, there is a sense of constric- tion at the upper part of the chest with some shortness of breathing, DISEASES OF THE BRAIN AND SPINAL CORD. 227 and in consequence the disease, when left-sided, — ^and it happens that all the cases I have seen have been so, — is apt to be mistaken for angina pecioria. This occurs the more readily since both affections are diseases of advancing years, and there may be coincident degen- erative changes in heart or arteries ; and irregular heart action is not an unusual attendant. The great difference, besides the exact seat of pain, is that in brachial neuritis some pain or tenderness is always present, and always intensified by movement, and that we do not have the rapid appearance and disappearance of the agonizing paroxysms that distinguish angina ; the local changes in the muscles in brachial neuritis are also of value. These, too, help us, in addition to the per- sistent tenderness and the influence of motion on the parts, in distin- • guishing the cases of pure brachial neuralgia from brachial neuritis. In some instances, in place of rheiunatism or gout causing the neuritis, we observe it after contusions or dislocations of the shoulder, or from the pressure of enlarged glands or tumors. In any case, owing chiefly to the constancy with which the arm is kept quiet, fixity of joint and arthritic changes may supervene. There is a form of rheumatism in which the interstitial tissue of the nerves and muscles is affected, to which Gowers has given the name of neuromycmHa^ which very closely resembles brachial neuritis, with which, indeed, it may be combined. Here the mere expec- tation of movement produces pain, as do passive movements and compression of the nerve-endings by voluntary contractions ; the muscles are tender, and the joints, usually the shoulder-joint, may become fixed and the seat of adhesions, and add to the rigidity and the inhibition of movement. The pain in neuromyositis is altogether connected with motion or the expectation of motion, and there are no paroxysms of spontaneous pain, as is so marked a feature of brachial neuritis. CHAPTER III. DISEASES OF THE UPPER AIR-PASSAGES. SECTION L DISEASES OF THE NOSE AND ASSOCIATE ORGANS. The nasal ehambei's, pharj^nx, larynx, and trachea constitute tlie upper air-passages. As the disorders of the nose and tlie naso- pharynx, or the space between the plane of the posterior nares and a liori^ontal line drawn tliron^ih the lower end of the soft palate, be- long laiigely to a class which requires sui^rical treatment, a brief review will be ^Wen in this place of those only that have features of medical iuterest. The fi-onfai mtmvH are m direct connection witli the nasal chambers, and, in case of occlusion of their normal outlet, there is an accumulation of secretion, wliich may cause hmdaeh^. This is likely to occiu* especially in the catarrhal inflammation attending intluenza, in which the headache may continue for w^eeks until the inflammation subsides, or the patently of the outlet is restored. The headache may be associated with vertigo. Tumors may develop from the mucous menibrane lining tlie frontal sinuses, of tlie same character as those of the nasal ehanibers ; and the larv^ae of insects, or mature forms, such as centipedes, find their way at limes into these cavities and there cause pain and irritation. Frontal mtutM diseases are to be distinguished Jrom mipraorMtal neuralgia^ migrmnt\ and rerehral dii^*'fiM' by careful inspection of the interior of the nose, by examination with the cun^ed probe to test the openness of the canal, by the presence of tenderness and other local signs of inflammation, such as swelling or discoloration, and by the history of the case. The ajferiion^ of the antrum Highmonajiitm, or maxillar>" sinus, are similar to those of the frontal sinuses, and are more surgical than medical Many of Ihese cases are attended by a pain above the corre- sponding eye, and may be mistaken for migraine and the neuralgia of frontu! mnus dUea^r, Tlie diseases of the nasal chambers may be divided into acute and chronic. Among the former are coryza, acute rliinitis, hay-fever, hemorrhage or epistaxis, hydi*on*hoea, mycosis, and abscess. Promi- 228 DISEASES OF THE NOSE AND ASSOCIATE ORGANS. 229 nent among the second class are rhinitis, hypertrophic and atrophic, cirrhosis of the mucous membrane, ethmoiditis, thickening and devia- tion of the septum, rhinoscleroma, new growths, specific destruction by tuberculosis, syphilis, lupus, and malignant disease. Another division might be made into local affections and those occurring in eruptive fevers and other acute diseases. For instance, in scarlatina, smallpox, typhoid fever, and diphtheria, swelling with increase of secretion and ulceration may occur, while in rheumatism and influenza peculiar changes are noted. Many, probably most, of the instances of marked deviation of the septum and associated ab- normalities are not evidences of disease, but are due to former fractures with unreduced dislocation, or to heredity. Bryson Dela- van has found asymmetry in the nasal chambers to be the rule rather than the exception. As regards affections of the nose attended by mucous or purulent discharge and more or less obstructed breathing, it is well to bear in mind the possibility in children of there being a foreign body in the nose, and in older patients rhinoliths are sometimes detected upon rhinoscopic examination. In one remarkable case described by War- ren,* the breech-pin of a gun was discovered embedded in the right nasal fossa, where it had been driven by the explosion of a gun, several months previously, and its presence in the nose had not been suspected. Coryza, or a/mte catarrh^ is a general affection, which manifests itself by inflammation of the mucous membranes of the nose es- pecially, but other mucous surfaces of the air-passages may be previ- ously or subsequently affected. It often follows exposure to cold and dampness, and attacks those principally of lowered vitality. lihiniiiH may be due to local irritation, as rough manipulation, operations upon the nose, or strong applications. It may be confined to one nostril. Upon inspection, the mucous surface is of a bright red color in cer- tain locations, the turbinated erectile tissue is engorged, shows abra- sions, and bleeds readily. The fossa may be obstructed to a greater or less degree by inflammatory swelling of the mucous membrane, and the secretions vary in density from a clear serous fluid to a caseous or fibrinous exudation. To the latter the names of rhinitis caseosa and rhinitui fibrinosa have been applied. Cases with marked oedema have been reported under the title of rhinitis iedematosa? Diphtheria of the nose may occur independently, but is usually a concomitant or sequel of faucial diphtheria. At the present day the ^ Surgical Observations, Boston, 1867. 'J. C. Mulhall, Trans. Am. Laryng. Assoc, 1893. 230 I^IEDICAL DIAGNOSIS. presence of the Klebs-Loeffler barillus is relied upon to decide the diagnosis of diphtheria, altliougli iliis Diicro-organism has occasionally been found in alTections of the tliroat and nose, wliich give no clinical evidence of beijip diphtherifie, and it is present in many cases with purulent discharge tToiii the nose. An acute catan*h is sometimes an early symptom of some specific disease, of meu^k^, for instance. Nasal catarrh accompanies enisip^Ias and influenza. Nasal catarrh may bo also produced by the administration of remedies, as of the iodides, or, by the inhalation of tirugs, such as ipecacuanha. At cer- tain times of tlie year, when the air is filled w^itli pollen from tlie artemisia absintliifolium, or ra^'-weed, the ailanthus tree, or from roses or passes, many persons soUtT from wliat is <'alled hay-fever, hay- asthma, rose-cold or hypera^stlietic rhinitis, which has for its most marked si^-n the reappeai'ance of the symptoms upon the same day each year, suggesting a strong neurotic element. Daly, Roe, and Sajous have shown the dependence of many of these cases upon nasal abnormalities. A severe purulent rhinitis of acute form may be caused by accidental gmiorrha'al mfrfihm of the none; the history of the case gives the explanation, and the discovery of the gonocooc^i^l the demonstration, Naiitil hiffteorrhftn is flislinguislied from ron/za by the excessive flow of a serous flnid from the mucous membranes, especially over the turbinated bodies, i^vhich are pale and sodden. The aflection is unilateral, but it may be bilateral. Unlike hay-fever, it happens at all seasons, thoo*:h, Mke hay-fever, it is found in neurotic subjects. It may occur in paralysis of the trifacial nerve, or as a result of head injury, and may be associated with polypi, or myxoma of the nose ; it is at times of months' duration.' Arierimclcroms afl'ecting tlie vessels of tlie mucous membrane of the nose is evidenced by a special disposition to coryza and ]»haryngeal catarrh, with local congestions and tendency to nosebleed. Such patients are especially liable to obstruction of the niisal passages by temporar>' swellings which are foUow"ed by free etTusion of watery secretion.'* In cerebrospinal rhijiorrhfca there is constant dripping from the nose of a fluid of specitic gra\ity about ICKJo from which mucus and proteids are absent, and which on boiling reduces Fehling's solution.^ Jfaml hemorrhage may indicate a general condition of tlie vascular * As iu ji case repcirted by C. E. Beim before the Larynfrologica] ABBOciailcili ■ Jtuntis T. Whittaiter, Pennsylvania MedioU Journal, Feb. 189^, p. 459. • St Clair Thomson on Cerchro-Spinid Rhinorrhtva, 1899, DISEASES OF THE NOSE AND ASSOCIATE ORGANS. 231 system, a degeneration of the arterial coats, vnih or without increased tension. Occurring after the middle period of life, in a person other- wise apparently healthy, it suggests the likelihood of apoplexy or con- tracted kidney. It is important to distinguish between those cases in which the blood only passes through the nose, and those in which the blood comes from the nose. A rhinoscopic examination, both anterior and posterior, is essential to an exact diagnosis. In nasal hemorrhage the blood very frequently comes from the septum low down, w^here it can be easily inspected. Post-nasal catarrh has for its prominent symptoms the dropping of mucus from the soft palate into the throat, and the expulsion, usually in the morning, of masses of gelatinous mucus or of hardened crusts from the naso-pharynx, giving rise to the unpleasant habit of hawking and spitting. In such cases rhinoscopic examination reveals inflam- mation of the mucous membrane in the vault of the pharynx, and the glandular tissue, or so-called " pharj^ngeal tonsil,'' may be hyper- trophied and form polypoid excrescences, or large adenoid tumors that may entirely occlude the posterior nasal openings. Digital ex- ploration is a valuable means of diagnosis, especially in children. Deafness may be caused by occlusion of the Eustachian tubes, and mouth-breathing is a necessarj' sequence. Snoring, dryness of the throat, and night-terrors occurring in children, may also be due to this condition. A form of post-nasal catarrh, of less severity, attends posterior hypertrophies and other abnormalities of the nose attended by increase of secretion. The diagnosis is made by rhinoscopy. In glanders the purulent or sanious discharge from the nose is at- tended with erysipelatous blush on the nose and cheeks, characteristic pustules on the fece and in the nasal passages, and the symptoms of pyaemia. The chronic forms of rhinitis accompanied by catarrhal thickening of the septum or of the turbinate bodies, atrophy or cirrhosis of the mucous membrane, and the development of cysts, polypi, or papillary fibromata, are recognized by careful rhinoscopic examination, and belong to surgery rather than to medicine. In former times ozaena was regarded as a disease, but it now is recognized as an attendant upon chronic atrophic rhinitis, in wliich the secretions dry into crusts which undergo putrefactive changes, and thus produce the oftensive odor. In cirrhosis there are contraction of the mucous membrane and evidences of atrophy, without decided (catarrhal symptoms, thus showing a constitutional origin. Hypertrophy of the mucous mem- brane is considered as a preliminary stage to atrophy ; and the pro- duction of polypi, or of myxoma, or, more rarely, of libroma, is not 232 MEDICAL DIAGNOSIS. an uncommon result. Hypertrophies are distinguished from new growths by their situation, color, density, and immobility ; new growths being in abnormal situations, of peculiar color, and pedunculated ; for instance, polypi are white and glistening, cysts are white, papilloma may look like a small bunch of grapes. The diagnosis of papillary hypertrophy from true papilloma, papillary fibroma, depends upon its location, appearance, and the microscopic details, which also distin- guish the latter from epithelioma and sarcoma. Abscess most fre- quently appears in the septum, when it occurs in the nose. In making the diagnosis between benign and malignant growths, the rapid development and general appearances of the latter are usually depended upon as conclusive. At the same time the diffi- culty is enhanced by the danger of benign growths becoming trans- formed in their character. Bosworth reports a case in w^hich sar- coma developed after polypi had been operated upon rather harshly by means of forceps, and a similar case is narrated by Heyman.^ Traumatism has been also observed to result in fibrosarcoma and other malignant growths of the nasal chambers. The reflex disorders arising from naso-pharyngeal obstruction, by hypertrophies or new growths, have been studied by a multitude of clinical observxTS. Obstinate headache, asthenopia, earache, persist- ent cough, and vertigo are symptoms of special cases of nasal dis- order. Voltolirii first directed attention to the fact that nasal polypi may be the cause of asthma^ and a deflected septum and hypertrophic rhinitis are also claimed as causes by Bosworth. Weber showed that diseases in the upper air-passages readily produce turgescence and swelling of the bronchial mucous membrane. Glycosuria has been known to originate in nasal obstruction, and to disappear when tliis was removed.^ ^Va.ya/jL^o/y/>i apparently may cause spasmodic stric- ture and difficulty in urinating, as in a case reported by Mulhall ; ' the stricture was at once relieved by the removal of the nasal polypi. RhinoHcleroma is a form of new growth allied to round-celled sarcoma, characterized by the appearance of flat, slightly raised patches which are smooth on the surface and of ivory-like hard- ness, and which first appear at the edges of the nostril, spread to tlie upper lip, and do not ulcerate. Von Frisch discovered in the growths little bacilli, resembling the pneumococcus of Friedlander, and like the latter eiica})sulated, but dilTering from it in its response ^ Revue Mensuelle dc Laryrij^olo^'ie, 1888, p. 24. ^ Bayer, Kevue de Larynjjolo^ne, 1894, xv. 19. •*' American Larj'nj^'olo^rical Association, 1892, p. 42. DISEASES OF THE LARYNX AND TRACHEA. 233 to staining by Gram's method. Inoculation has failed thus far to re- produce the disease in the lower animals.* The lesion may gradually extend into the tissues of the mouth and nose and to the larynx. Rhinoscleroma is to be distinguished from syphilis, epithelial cancer, and keloid. It differs from venereal disease mainly by its very chronic course, the absence of softening or ulceration, and its absolute in- tractability under every kind of medication. From epithelioma it can be discriminated by its smooth, glistening surface, its hardness, the absence of bleeding or ulceration, and its persistently local char- acter. The history of the case and its general appearance distinguish it from keloid, which has the puckered, white, and irregular outline of scar-tissue. SECTION II. DISEASES OF THE LARYNX AND TRACHEA. Of these affections those of the larynx are far the most frequent and the most readily recognized. There are, indeed, symptoms in laryn- geal diseases which at once direct attention to the seat of the malady. The larynx is the organ of speech : hence changes in the voice consti- tute the most striking manifestations of disorder. These changes varj' in degree. The voice may be merely hoarse or completely lost. In young children the different tone of the cry corresponds to the altered voice of adults. The alteration of the voice depends almost wholly upon an affection of the vocal cords, and this may be organic, such as inflammation, oedema, ulceration, cicatrices, and morbid growths ; or it may proceed from perverted or impaired innervation. Very often the hoarseness or loss of voice is caused by diminished tension and want of certain and prompt action of the vocal cords, whether connected with structural change or not. The same cause gives rise, for the most part, to the modifications of the voice, which • show themselves as huskiness in speaking, or in the loss of certain jiotes in singing. Next to the voice in diagnostic importance stand the character of the breathing and the cough. The breathing is labored and diffi- cult, and is frequently perceived to be noisy, and coarse or shrill, — the so-called laryngeal stridor: a sign encountered whenever the orifice through which the air has to pass is narrowed, either tempo- rarily by a spasm, or more permanently by any state which gives rise to a constriction of the parts ; for instance, by swelling of the mucous membrane, or diphtheritic deposit. * Text-Book upon the Patho^nic Bacteria, by Jos. McFarland, Philadelphia, 1898. 16 234 MEDICAL DIAGNOSIS. The difficulty in breathing is in some cases slight ; in others great One of the peculiarities of laryngeal dyspnoea is its tendency to recur in paroxysms, during which the patient appears to be in imminent danger of strangling. These fits of suffocation are produced mostly by a spasm of the intrinsic muscles, particulariy the adductors of the larynx. Attacks of dyspnoea also arc met with in cases of paralysis of the abductors of the larynx, or paralysis of the posterior crico- arytenoid muscles. The attacks occur in pure spasm of the glottis ; in croup ; in oedema of the larj^nx ; in ulceration and in polypi of the larynx. The cough of laryngeal affections presents frequently the same peculiarity as the dyspnoea, — it happens in paroxysms. Another pecu- liarity, although not one so constant, is its harsh and ringing tone. The cough is often short and dry ; sometimes it is followed by muco- purulent expectoration of roundish shape, or by a blood-streaked sputum, or by the spitting up of false membrane. It is readily ex- cited by the act of swallowing, its seat is referred by the patient him- self to the windpipe, and is especially troublesome at night. Pain is not so unusual a symptom of laryngeal disease as either cough or changed breathing. In chronic affections it may be, indeed, wanting. It is rarely severe ; often more a sensation of tickling, of burning, or of uneasiness than of actual pain. It is apt to extend dowTi the trachea to the upper part of the sternum. Sometimes it is increased on pressure, as in acute laryngitis and in ulceration of the mucous membrane ; and it may be also augmented by tlie act of swallowing. By the symptoms, then, of altered voice, cough, dyspnoea, and, in some cases, of local pain and difficulty in deglutition, we recognize a laryngeal affection. But to do so with accuracy, the larynx must be hispected with the laryngoscope. It may be either circular, square, or oval. The circular mirror occasions least irritation. The larger tlu» mirror we can employ, the better is the image. The mirror is in some cases all that is necessary to practise laryn- goscopy. It is heated in wann water or over a lamp and then intro- duced into the back of the mouth in the manner presently to be described ; the person to be examined having been placed with liis face towards the sunlight, so that its rays may strike the laryngeal mirror. But examinations by direct light are practicable only on clear days and at lortain periods of the day. Usually we require a second mirror to illuiuinate the throat and the laryngoscope. This mirror is of cinnilar form, about three inches and a half in diameter, and with DISEASES OF THE LARYNX AND TRACHEA. 235 Fig. 15. a focus of about fourteen inches. It may be either attached to the head by means of a band, or worn on a pair of spectacle-frames, or placed on a movable stand, or affixed to a lamp. When the frontal band is made use of; the observer may either place the mirror opposite to one of his eyes, and look through the central perforation, or adopt the easier method of wearing the reflector on his forehead. The light may be concentrated directly into the throat by a lens or a bull's-eye condenser, or by a conibinaUon of lenses attached to a metallic frame fastened to a lamp, as in the well-known apparatus of Tobold numerously modified. A good light to employ is coal oil ; the most convenient, an argand or a Welsbach gas-burner. I have used the electric light very satisfactorily, A portable electric light is obtainable by the aid of a small storage battery, which can be used at the bedside. To examine the larynx by artilkial light, we should proceed thus. The patient, sitting in an upright position, with his head inclined slightly backward, is placed near a lamp, burn- ing with a steady, brilliant light, the flame of wiiich is behind and about on a level with his eyes. He is directed to open his montli widely^ to put out his tongue, and to hold between two fingers its point enveloped in a sofi napkin ur handkerchief. If he cannot accomplish this readily, the examiner must hold the protrudetl tongue, or a tongue-depressor must be em- ployed. The observer now seats liiniself di- rectly in front of the patient, and nearly a foot from the mouth. Putting on his spectacles or frontal band, he throws a disk of light into the i^*^"«oscopes of vw^ous shape; back part of the mouth ; he tlien rapidly intro- not quite natural size. 36 MEDICAL DIAGNOSIS. duces the lar^Tigeal mirror, previously heated in warm water or over a lamp and its proper lemi)erature ascertained by touching his own liand or cheek. The mirror, great care being taken not to bring it in contact with the tongue, is placed \^ith its back against the uvula, which, with the soft palate, is pressed backward and upward ; Hie lower surface of the laryngoscope should be lirnily applied to, or, if* this be found to occasion too much irritation, should be held near, the posterior wall of the pharynx. The inclination of the mirror varies with the position of the patient and the parts we wish particu- larly to explore. As a general rule, it may rest at an angle of about forty-five degrees. Fio. la. ^'/T' Imfyngcmcopic ^LMmlna^tm, as niBd« wltK the reflector Attached Ua a spcsctacle-fnuiie. When one of the ordinar}" stationary larjngoscopic lamps is employed, the reflector is attached to the lamp by a freely movable brass rod, and the light concentrated on it is thus thrown into tJie mouth. In the lar>'ngeal mirror the image is readily perceived. We see the epiglottis, the glottis, t>ie cartilages, the true vocal cords, the superior thvTo-arytenoid ligaments or ventricular bands, and in some cases even tlie rings of Uie trachea. We may be able to discern each DISEASES OF THE LARYNX AND TRACHEA. 237 Fio. 17. v L»r>ii^eiii iinage, a* s^n in ' gcofie under favonible clrcui pariion of the laryngeal aijerture with distinctness, or it may take several examinations to do so. In health, the color of the various parts is v^ry different. Stoerck has well described it in likening that of the epiglottis, the interior of the larynx below the glottis, and of the cricoid cartilage, to the coloration of the conjiyictiva of the eyelid ; aiid the hue of the arj^epiglottidean Iblds and the prominences of the arytenoid leartilages to that of tlie gums. The [mucous membmne of the trachea 'between Uie rings is of a pale pink color ; the vocal cords have a white, |listening look, Mackenzie takes spe- "cial notice of the whole of the under surface of the epiglottis being in some cases of a bright-red hue ; and Gibb points out that in negroes the cartilages of Wrisberg have a yellowish tinge. The lan»^ngeal in^age in the mirror bears this relation to the real ion of the parts : the right vocal cord of the person who is ex- led is seen on the left side of the mirror, and the left vocal cord on Uie right ; or, to state the matter in a Ibrm easy to be remembered, the cord which corresponds to the right hand of the fjatient is the right, that seen towards his left hand is the left. The epiglottis ap- pears in tlie larjmgoscope at the upper portion and behind ; so do the other structures that lie in front. The arytenoid cartilages show" at its lower portion, and towards the front. To judge of the movements of the vocal cords, we tell the patient alternately to inspbe deeply and to utter, as a prolonged high note^ a ^sound like **ah/' During this the vocal cords are closely approxi- mated and stretched, and the epiglottis, in fact the whole larj^nx, is somewhat elevated ; wtiile during a full inspiration the cords are far and hence the glottis is wide open. To obtain a satisfactory fht of the deeper-seated parts, we must bear in mind that the more horizontally the surface of the mirror is placed, the more distinctly they come into view. For the exploration of these structures, and particularly of the trachea, the light must be tlirown from below up- ward upon the laryngoscope. To elevate the larynx decidedly, and especially to bring the epiglottis fidly into view, tlie patient should in a high pitch pronounce e£ as in the word see. In some, laryngoscopy is easy ; a conclusive examination may be 238 MEDICAL DIAGNOSIS. made at the? first attempt. In others, a course of training is required to subdue th(* sensibility of the fauces, which may be general, or be Iinnt(»(l to a very small spot. As a means of overcoming the diflficulty, suckinji^ small pieces of ice, or the previous administration of bromide of potassium, or the local use of a solution of cocaine from two to five per cent., is useful. But the best means is skill in the use of tlie instrument, — its rapid and decisive handling. The admijiistration of an anaesthetic may be, however, necessarj\ This is especially the ciise in refractory children suffering with papilloma or other conditions demanding ocular inspection. To overcome pharyngeal and larj-ngeal n^Hexes, Scanes Spicer* recommends the cautious use of a ten per cent, spray of solution of cocaine, and, for removal of salivary secre- tions, the free use of dry mops of absorbent cotton-wool. In some persons with verj' irritable throats, 1 have obtained good views by prt^ssing the instrument against the roof of the mouth, in- stead of passing it back into the pharj'nx, and by altering the position of the head a little, tilting it more backward. The epiglottis, and the slrucfun^s at the entrance of tlie windpipe, are thus readily enough bnnighl into view : with the deeper j>arts we do not succeed so well ; but in many ciises we get sutlicient guide for topical applications. Then^ an^ further obstacles, such as a rising up of the tongue, greatly enlarginl tonsils, a long uvula, a pendent epiglottis, all of which at linu^s inlerferi^ with our investigations. But in any case we should not endeavor io make the view more satisfactor)' by constantly alter- ing the pi^ilion of the mirn^r. It is better to introduce it repeatedly than to shirt it oflen when introiiuooil, or to keep it for any length of time in the |viUiont*s mouth. Digital examination of the larj'nx with tht^ iudo\-tu\gxT is an oxpiniient of value in oliiidreD and others who will not ivrniit larvngv^iopy. It i? practised for diagnostic purposes in lar\ ugwil a^lema, and in now gi\>wths, such as papilloma. lMn\ t examination i*:' the larynx can be made in a certain propor- tiiM\ \^f \ asos b\ Kiivteiirs iustnmiont, which is a modified tongue- deprt^ssor i v^ntn\ ti\i w i\\\ an e\vtnv?^viH\ The epiglottis and plianux ha\i:u Kvv: |\i;:::exi witii iWiiine, or the ^>atieDt moderately anaes- tl;oti:i\i. ti.i^ ir.strunur.: ;:> ;:::rv\iuvt\i into the mouth so that by its .ay Ih^ p;;i;t\l strongly forward, and the lir.c w:::; :he eye of the physieian. This : :::e r\ tuovul of new growths or foreign l\\;,<':i Wo^vt: V.a< <'::o\\v. how :ho X-tavs may be utilized to locate vr\-^v. l\\i;.*> ;v. :':;o aovA av.v: .vsk^yho^o^;. ;izhl to determine the aui ::\o iv*sv' o; :::o :o:*^uc '.ar\ : A Iv »^r\^*,Vj:^,t o,;rtv:".\ i :vo:'. ^\i IS a'so v;sv :u' to ax: H; V'.-.-.v . jLU-i ^'^.v.vj. LkNadnMi. Ort. 1$94. DISEASES OF THE LARYNX AND TBACHEA. 239 relative position of a probe and the foreign body. Some new growths may also be detected in this manner.^ If the mirror be passed behind the uvula, and the reflecting sur- face directed upward, the posterior nares may be examined. To practise rhinoscopy, however, the mirror should be small and fixed to the shaft at a right angle. The patient is directed to keep his head erect, or bend it slightly forward, and while his mouth is wide open a strong light is thrown to the back of the throat. But before the rhinal mirror is placed in position, a tongue-depressor is applied, with which the back of the tongue is well pressed down, and which may be given to the patient to hold. To get the uvula out of the way, a palate-hook may be used, by which means the uvula, with a portion of the soft palate, is gently drawn forward and upward, the handle of the hook being held to one side of the mouth : Voltolini's palate-hook widens the pharyngo-nasal space satisfactorily, or Sajous's soft palate- elevator may be employed. But by instructing the patient to breathe through the nose and to breathe heavily while the mouth is open, we obtain relaxation of the muscles of the soft palate, and in most cases, after a little training, may dispense, for diagnostic purpose, with the palate-retractor. The mirror, with its reflecting surface upward, is now passed along the tongue-depressor, until it reaches the posterior wall of the pharynx. By then raising somewhat the handle of the mirror, we obtain a view of the vomer ; and by slanting the mirror first towards one side and then towards the other, the posterior nares and the orifices of the Eustachian tubes may be inspected, and the vault and posterior wall of the naso-pharynx. The chief diseases of the larynx, grouped in accordance with their main features, may be arranged as follows : Acute Organic Diseases. Congestion, or hyperaemia. iDflammation of the mucous membrane of the larynx — Acute laryrig:itis. GSdema of the larynx. Acute affections of the larynx I Catarrhal and pseudo- membranous laryngitis- and trachea as met with p^j^ ^^^ ^^^^ m children. j Specific affections — Syphilis, tuberculosis, lepra, diphtheria, erysipelas, typhoid, etc. Chronic Organic Diseases. Inflammation of the mucous membrane of a part, or of the whole — Chronic laryn- gitis in its various forms — ^Abscess. Destruction of the cartilages. 1 Journal of Laryngology, 1896 ; Gould's Year-Book, 1897, p. 1020. 240 MEDICAL DIAGNOSIS. Growths and tumors of various kinds. Ulcers, simple and specific. Muscular degenerations, occurring after acute infectious disease (such as typhoid fever). Affections of the Nerves. Spasm of the larynx. (Spasmodic croup and laryngismus stridulus.) ( Functional, or purely nervous aphonia. (Hysterical, or due Nervous aphonia. < to debility.) ( Organic, due to paralysis of the muscles of the vocal cords. Chorea of the larynx. Acute Laryngeal Affections. Acute Laiyngitis. — In its mild form, acute laryngitis is neither an unconmion nor a dangerous disease. In its severe form it is much more unconmion, and very much more dangerous. When it is slight, it occasions simply hoarseness ; a feeling of tickling and irritation in or near the lannx ; a trifling, though annoying, cough, or rather a constant disposition to clear the throat, more than a cough; and, owing in a great measure to a co-existing inflammation of the fauces, some difficulty in swallowing. The disorder passes oflf in the course of a few days. When the inflammation is violent, and especially when it involves tlie submucous tissues, Uie symptoms are much aggravated. The rt^spiration bei^omes seriously impeded ; with each breath a wheezing or whistling noise is heard. There is but little expectoration, and the cough is distressing and painful, and has a harsh sound. The voice is hi^irse. or sinks into a scan^ely audible whisper ; the windpipe is tender when presseil. There is in the throat a feeling of constriction, ditViculty lit swallowing, and fever, with a full pulse and flushed fece. If the Oiise ad\imce unohei*ked, the countenance becomes distressed and [vale, the lips bluish, the pulse irregular, and death sets in with all the signs of dotioiont attrition of the blood and of strangulation. Tlu^ dist\iso in its graver fonn runs a very rapid coarse. If in a few days after its Invinning no improvement show itself, life does not last long. Somotimos death takes place on the first day of the attack ; it nm^lv \\*^\its for the sixth. ity^t^M of the lanmgeal mucous mem- brane is often the oons^Hjuenoe of the inflammation and the cause of the dai\^T. The niarki\i symptoms of the ivrilous complaint prevent it trom Wxix^ overliH^ktHt, and n^uler its ilis^^rimination easy. There is fever with d\spn\\\i in the »?t*^.rc y*h}sf^<>^uir\ tTrnicction* : but the voice remains uimltertM. and thoy exhibit plnsii^al sig!is which acute laryngitis does not, — the\ !^ho\v nilt^, or al^riOnn,V* retspiraticMh-sounds : while in DISEASES OP THE LABYNX AND TRACHEA. 241 laryngitis the murmur of the lungs is that of health, although it is sometimes enfeebled by the impediment in breathing, or obscured by the shrill sound which issues from the larynx. We find difficulty in swallowing and some hinderance in breathing in tonsillitis; but in- spection of the oral cavity immediately detects the source of the dis- order. There is difficulty in swallowing in pharyngitis^ but there is not embarrassed breathing, or a peculiar voice, or cough, and the fauces appear dusky and injected, while they are but slightly affected in laryngitis, unless inflammation of the larynx have supervened upon that of the throat. An affection of the larynx occurring only in winter, laiynffitis hie- mails, has been described by Mulhall, in which the secretions form ad- hesive crusts, producing difficulty in speaking, or more often aphonia. This is to be diagnosticated from laryngitis sicca, which is a part of a general process, and follows pharyngitis sicca and atrophic rhinitis. There is a peculiar form of inflammation of the larynx, diffuse cellular laryngitis, a diffuse inflammation of the cellular tissue, with lymph or pus infiltrated in the submucous tissue, to which attention has been called by Henry Gray.^ It is a formidable affection, which bears a strong likeness to erysipelatous laryngitis, but, what is not by any means constantly the case in this disorder, the symptoms begin in the fauces and larynx ; and, wholly unlike erysipelatous laryngitis, the submucous tissue is primarily attacked, and the neck becomes greatly swollen from the effused products around the larynx, trachea, and oesophagus filling its cellular tissue. The disease begins with chills, soreness of throat, and fever, soon succeeded by dyspnoea, by a dusky hue of the fauces, by enlargement of the tonsils and of the glands in the neighborhood of the jaw, and by great difficulty in swallowing. The neck increases greatly in size, the fever assumes a low type, and the patient either sinks gradually or dies asphyxiated, perishing sometimes rapidly from a speedy increase of the laryngeal tumefection. Other forms of inflammation of the larynx to which attention has of late years been called are hemorrhage laryngitis, an acute catarrh of the larynx, attended by bleeding from the inflamed membrane, and laryngeal rheumatism. This generally happens in persons of rheumatic diathesis, is attended with considerable pain, and may or may not be associated with other signs of rheumatism.^ There are cases in which laryngeal symptoms are marked, and cases without ^ Holmes's System of Surgery, vol. iv. * Archambault, Th^se de Paris, 1886. 242 MEDICAL DIAGNOSIS. them. Roos reports ^ several instances of rheumatic angina that ter- minated in attacks of general rheumatic arthritis. The principal features of rheumatic angina are excessively painful deglutition, red- ness and swelling of one or both tonsils; the disease is of slow de- velopment, and occurs usually without abscess-formation. It has been suggested that the joint aflfections are really secondary manifes- tations, pseudo-rheumatic in character, and that the polyarthritis belongs to the category of attenuated pyaemic infections. H. L. Wag- ner has found articular rheumatic affections following follicular amyg- dalitis, in which bacterial investigation showed that the syno\ial fluid obtained by tapping the joint contained the same micro-organisms as .were found in the diseased tonsil.^ Follo^ving inflammation or ulceration of the larynx, various irregu- larities may occur as the result of cicatricial contraction, or adhesions between the cords, which may be studied with the aid of the larjTigo- scope. There are usually alterations in the voice, with attacks of dyspncra simulating asthma, and impairment of general nutrition. CEdema of the Larynx. — The danger in acute laryngitis of any kind is much aggravated by the precise seat of the disease. When the inflammation takes place immediately around the glottis, and causes a serous fluid to transude, cedevnaious laryngitis^ the peril is greatly increased. The inspiration is audible, noisy, hissing, and labored ; there is a distressing sensation of constriction or obstruction in the windpipe, and the patient makes repeated efforts, by swallow- ing or by hawking, to clear liis throat of the substance w^hich seems ti^ bo clogging it. His difficulty of breathing is intense, and occurs in frightful jmroxysnis, sometimes of a quarter of an hour's duration, in which strangulation appears to be imminent ; and, indeed, often these jKUionts do perish by strangulation. This grave disease, miema of the hrytur. sometimes follows an ex- tensii>n of the peculiar inflammation of the throat in the exanthemata, or is o( erysipelatous origin, and it occasions death quickly, and amid gn\U sutVering. But the anlenia may arise without preceding acute inrtaiuiuation, whether this be spiviflc or not. It may result from long-i'ontinued pn^ssun^ on the trachea or larjiix, or, in exceptional instances, occur in connection with Bright's disease. Again, an eflfu- siiM\ i^f serum may cause death suddenly in a person who has been laboring' imdor a chrvHiic laryngeal disorder. Such cases of oedema * Uhouni.itu* AtY^vtvoiw of tho l^mlv duo to Tonsillar Disease, Trans. Amer. DISEASES OF THE LABYNX AND TRACHEA. 243 of the larynx are distinguished from those of active laryngeal inflam- mation by the absence of fever, of local tenderness, and of marked difficulty of deglutition. It is true that, if the oedematous affection ensue upon a chronic inflammation of the larynx, tenderness and an impediment in swallowing may be observed. But the history of the malady and the non-existence of fever leave little room for error. The diagnostic sign proposed for oedema of the larynx — the swell- ing of the epiglottis, as ascertained by the touch — cannot be relied upon, because this swelling does not always exist to an obvious de- gree, and even when it does exist, is. not readily determined by the finger. In the acute. cases of oedematous laryngitis the laryngoscope shows a bright-red mucous membrane ; sometimes the tumid epiglot- - tis presents the appearance of two round red swellings. It is gener- ally erect, tense, and turban-shaped. The oedema, in rare instances, may be altogether below the glottis. Croup. — Croup is inflammation of the larj^nx and trachea ; but it is something more. It is a spasmodic action of the muscles of the larynx, which spasmodic action gives rise to much of the peculiar cough, the stridor, and the paroxysms of dyspnoea, so characteristic of the disease. As croup is thus an affection composed, as it were, of several distinct elements, it differs somewhat according as one or the other of these elements preponderates. Thus, the inflammation may be comparatively slight, yet the spasm plays a very prominent part ; or the inflammation may be very severe, and result in the for- mation of a false membrane. To the first class belongs the disorder known as false croup, catarrhal croup, spasmodic croup, spasmodic laryngitis ; to the second, the true or membranous croup. False or Caian-hal Croup. — This is one of the most common dis- eases of childhood. Its seizures happen chiefiy at night ; and the child that has gone to bed well, or perhaps fretful from teething, or with indigestion after a hearty supper, or with a slight catarrh, wakes up suddenly in a state of alarm, breathing with difficulty. It coughs with violence at short intervals, and the cough is loud and ringing and hoarse; and so are the voice and the cry. Each inspiration is at- tended with that shrill, " croupy" sound which, once heard, is never forgotten. The face is flushed, the pulse frequent, the . temperature but little above the normal. The paroxysm continues in this man- ner for about an hour: the breathing then becomes quiet, the child falls asleep, and rests well until towards morning, when the attack is apt to be renewed. The little patient may, however, escape this alto- gether, and keep well ; or else the paroxysm recurs the next night, or for several nights in succession. In the intervals the voice and respi- 244 MEDICAL DIAGNOSIS. ration are natural, there is little or no fever, little or no cough. Yet sometimes a cough occurs, during the day, which has every now and then a croupal sound ; the voice, too, is slightly hoarse. Catarrhal, or false, croup most frequently follows exposure. It is very rarely fatal. The laryngoscope shows marked congestion with swelling of the mucous membrane and copious muco-purulent secre- tion. Cases in which the inflammation is extensive and severe, with- out having led to a plastic exudation, and in which the inflammation is apt to be chiefly subglottic, approach in their persistency and in the character of their symptoms very closely to true croup. Indeed, one form of the complaint may run into the other, warranting the assump- tion that they are not two diseases, but only two forms of the same disease. Spasmodic croup may be a symptom of abnormalities, such as of hypertrophies or of adenoid growths in the nose or pharynx, and, if persistent, should suggest a digital or rhinoscopic examination. The main element in the production of the symptoms of false croup is undoubtedly spasm of the glottis. But laryngismus stridulus^ as laryngeal spasm or spasm of the glottis is called by many, is a neu- rosis which, while it may complicate any affection of the larynx and trachea, may also exist independently, from central, or direct, or reflex, causes of irritation. The laryngeal spasm may, therefore, form a distinct disorder, which differs from catarrhal croup by the absence of all inflammation and by several circumstances which proclaim its non-identity, such as its usual connection with rickets, and its fre- quent association with other convulsive symptoms, — ^with distortion of the face, rolling up of the eyes, spasmodic contraction of the hands and feet, and general convulsions. Laryngismus and tetany are ofl:en associated ; indeed, by many laryngismus is looked upon as the laryn- geal expression of tetany. The Trousseau sign of tetany — pressure upon the large arteries and nerves of a limb developing a paroxysm of tetany — is said to be never absent in the laryngo-spasm.* Some cases of supposed purely nervous laryngeal spasm in chil- dren are undoubtedly symptomatic of laryngeal growths, or of paral- ysis of intrinsic muscles, and are really attacks of dyspnoea due to lar}'ngeal obstruction. Lar>'ngoscopic examination should be made in severe cases, even though an anaesthetic be required. Laryngis- mus stridulus is an afl'ection of children under two years of age. Crying may bring on the attacks, the child dying of suffocation or during convulsions. In some cases mentioned by Mackenzie, the attack assumes the form of a sudden, almost soundless, spasm that * Escherich, Address l>efore the Tenth International Congress. DISEASES OF THE LABYNX AND TBACHEA. 245 does not relax until life is extinct. Spasm of the glottis in infants may be caused by an enlarged uvula, as in cases reported by Hugel : ^ and Eustace Smith* cites a case of laryngeal stridor in a three months old infant, continuing since birth, in which adenoids were discovered in the naso-pharynx and removed by curetting, with complete relief. In laryngismus, as in croup, the seizures are apt to take place at night. Generally the child has been fretful from teething, or from gastric or intestinal irritation, when suddenly an attack of difficult' breathing occurs, accompanied by several loud, crowing inspirations, and by threatening suffocation; yet the paroxysm is not associated either with cough, or fever, or altered voice, or a materially changed cry. A fit of this kind may be repeated twenty or thirty times a day. It may terminate fatally in a short time ; usually, however, the paroxysms are spread over weeks, or even over a longer period. In addition to the frequent combination with other convulsive symptoms, the protracted duration of the disease, and the absence of febrile disturbance, of hoarseness, and of cough, point out the distinc- tion between laryngeal spasm and catarrhal or spasmodic laryngitis. From bilateral palsy of the abductors of the glottis, laryngismus is readily distinguished by the great and persistent difficulty of breathing in this affection, which is a disease of adult life. Laryngeal spasm also occurs in the laryngeal crises of tabes ; the absent knee-jerk and the ataxia tell us its meaning. In the adult, glottic spasm produces symptoms to which the name of laryngeal vertigo has been given; the attack comes on suddenly, the patient gasps for breath and becomes unconscious and asphyxi- ated. In such cases there is often attendant disease of the pharynx. True or Membranous Croup. — ^True croup is a formidable affection, in which there is inflammation that results in the formation of a false membrane. The plastic exudation is found lining the larynx, extend- ing at times into the trachea or down into the bronchial tubes. With rare exceptions, cases of membranous croup are the result of infec- tion by the Klebs-Loeffler bacillus, and are, therefore, to be regarded as laryngeal diphtheria. We shall farther on examine into this formi- dable affection, and determine in how far the non-diphtheritic cases can be distinguished. Let us here speak of the manifestations of ordinary membranous croup. In the early stages of membranous croup we have the same stridu- lous breathing and brazen cough as in catarrhal croup. Gradually * MUnchener Medicinische Wochenschrift, 1898, No. 44. " Lancet, March 19, 1898. 246 MEDICAL DIAGNOSIS. the voice alters and becomes suppressed, and the signs of laryngeal obstruction become more evident, and shreds of membrane are expectorated. The application of a stethoscope to the larynx or trachea does not give us much information as to the exact seat and the extent of the affection of the windpipe. Still it is not without value. It may enable us to judge of the position of the exudation, for we may occasionally hear a vibrating sound, as if a membrane were being tossed to and fro by a current of air. In a case that came under my notice some years ago, this sign was perceived with great distinctness at the lower part of the trachea and towards the commencement of the left bron- chial tube ; and, at the autopsy, at precisely this point was found a thick layer of membrane lying unattached in the tube. Auscultation of the lungs, by showing to what extent the air is still capable of en- tering them, furnishes us with a clue to the degree of the lar}^ngeal obstruction. Membranous croup is a disease not apt to be mistaken. When we take the symptoms collectively, — the ringing cough, the peculiar res- piration, the dyspnoea aggravated in paroxysms, the changed voice, the fever, the expectoration of shreds of membrane ; when we regard the comparatively short duration of the disease, — there is, with the exception of the ever-present question of diphtheritic origin, generally but one interpretation of the phenomena possible. It is, of course, of the utmost consequence to distinguish between spasmodic laryngitis or fahe croup and membranous croup. The symptoms of the latter are far graver and more continuous, the fever is decided. But there is only one proof positive, — finding the mem- brane in what is coughed up or vomited up, or by a laryngoscopic examination. The disorders, excluding diphtheria, which, next to false croup, are most likely to be mistaken for membranous croup, are: acute laryngitis, (i^dema of the larynx, retropharyngeal and retrolaryngeal abscesses. Acufe laryngiiiH in its ordinary form, such as we see in adults, is a very rare disease in children. Acute catarrhal laryngitis is in them closely connected with the phenomena of spasmodic croup ; and the' croupy symptoms, the changed voice, the barking cough, the paroxys- mal dyspna^a, the slight or absent dilliculty in swallowing, tell us what we are dealing with. In membranous croup these signs also are in- tensified, and we are apt to have high fever. A form of lar}'ngitis, however, hapjiens in children, which is very liable to be considered as (Toup : it is the seconiUiry laryngitis of the cxanihemata^ especially of DISEASES OF THE LARYNX AND TRACHEA. 247 variola and scarlatina. Attention to the history of the case, and to the circumstance of the inflammation having spread from the throat downward, will aid us greatly in forming a correct opinion of the disease. Yet the diagnosis is sometimes one of extreme difficulty, and examination by the microscope and culture tests will be needed to determine whether or not it is diphtheritic. (Edema of the larynx resembles croup, in its severe or its mem- branous form, in the dyspnoea, the fits of suffocation and of coughing, the altered voice, and the noisy inspiration. It resembles it further in the fact that most of the symptoms do not disappear in the intervals between the paroxysms. Here is certainly a strong likeness. But the cough has not the croupal, brazen sound ; expiration is comparatively unembarrassed; there is no fever, unless the oedema occur in the course of an acute affection ; and, above all, oedema of the glottis is a disease of adults. Again, the history of the case often guards against error, for oedema of the larynx happens frequently, perhaps most fre- quently, in those who have been long laboring under chronic or ulcer- ative laryngitis ; it is also seen among the toxic effects of iodide of potassium. In cases in which we are able to use the laryngeal mirror, the peculiar oedematous look of the parts is readily recognized. Retropharyngeal abscesses share with croup the symptoms of dysp- noea, stridulous .respiration, and altered voice. They do not share with it the peculiar cough; and, further, in croup there is not the difficulty in swallowing, or the evident tumefaction and stiffness of the neck, nor can a tumor be recognized by the touch, as it can be when an abscess is seated behind the walls of the pharynx. Moreover, the dyspnoea and the voice present somewhat different characteristics. In the case of abscess, the former is greatly augmented, or paroxysms of it are brought on, by attempts at 'deglutition ; it is always preceded by dysphagia, is increased by pressure against the larynx, and is aggravated by the horizontal position. In croup, the patient seeks relief by throwing his head back, and, although he loses his voice and speaks in a hardly audible whisper, still the words are sufficiently distinct ; while an abscess gives a nasal or gluttural tone to the voice, that often makes it impossible to understand what is being said. RHrolaryngeal abscesse^i following inflammation of the areolar tissue of the retrolaryngeal space present dyspna^a, attacks of suffo- cation, and cough like those of croup, and run, moreover, generally an acute course; but they also present dysphagia and severe pain, occasioned by pressing on the thyroid cartilage.' * Goix. Archives Generales de Medeciiic. Oct. 1882. 248 MEDICAL DIAGNOSIS. Abscess of the larynx bears a strong resemblance to retropharyngeal abscess, and may be, like it, mistaken for croup. Abscess of the larynx in its acute and primary form is not a frequent disease ; rare in adults, it is still rarer in children. No swelling can be detected in the pharynx to account for the pain, the cough, the difficult breathing and impeded swallowing ; but on close observation it is found that the larynx projects, and that there is induration at the posterior maigin of the thyroid cartilage. The neck is not markedly swollen, as in diffuse inflammation of the areolar tissue. With the laryngoscope, we observe a circumscribed swelling, red at its base, and often yellow- ish at its apex. We do not find, as we so commonly observe in croup, that both inspiration and expiration are interfered with ; the latter, indeed, may be both unembarrassed and noiseless. Abscess of the larynx may have unsuspected causes. Poli' re- ported a case in the discharge from which the sulphur-yellow granu- lations of aiiinamycosM were detected. Watson Williams * found the GalTky typhoid bacillus at the base of ulcers and in the structures of the larynx. Further, croup may be mistaken for tonsilitis, for capillar}' bron- chitis, for whooping-cough, or for the presence of foreign bodies in the larynx or trachea. But tlie points of distinction are evident. In totmllitii*, or in totwillar abscesses^ the breathing is not at all, or but very slightly, impaired ; and a glance into the mouth is sufficient to nnoal the real nature of the malady. So it is in peritonsillar abscesm, where otherwise the suftbcative attacks that are prone to happen \\\\^\\\ be misleading, in capillary bronehiiw there is dyspnoea, as in croup ; l)ut the dyspna^a is unremitting, and associated with fine n\les ill the lungs, and not with a ringing cough, a harsh tracheal bn^ithing, a hoarse voice. In whooping-cough, paroxysms of coughing and (»r obstructed n^spiration occur: but then follows the distinctive whiH^p : and then* is no fever, the voice is not husky, and the cliild di^os not sulVt^r between the s^H^lls. Foreign bodies in the windpipe give rise to slridulous bn^athing and to cough, but they do not often niiuiic cnuip closely enough to deceive : and the absence of the pecu- liar nuigli and of fever, and the historj* of the case, prevent error; so also does allention to the fact that the signs varj' as the foreign luuty shirts its position. Kurthennon\ as Gross* points out, the em- Ku'rassed bn^dhing caused by a foreign body is chiefly found in expindion. ' »i,u:, ttu a«>'l» iVspiUli, Naples. May 14. 1894. * Journal of Uu'^^^»^»^v> auil Otoli^'v. Oot. 1894. " * On Koi>M):u l^slu^ji lu tho Air-l\*ssap»s. DISEASES OF THE LARYNX AND TRACHEA. 249 The diagnosis of membranous croup has been considered connect- edly, because it is convenient and practically useful to so consider it, and because I am still of the belief that there is such a disease as a membranous laryngitis which is not diphtheria, though it is rare. The strong points in the diagnosis of non-diphtheritic membranous croup are : the gradual origin and the slow deepening of the symp- toms ; the fact that no membranes appear in other localities ; that the disease has a laryngeal onset, — though this may happen also in diph- theria,— and, above all, the absence of the Klebs-Loeffler bacillus in any shreds of membrane in the expectoration. In discussing laryngeal diphtheria the matter is further examined into. Ohronic Laryngeal Affections. Of the chronic diseases of the larynx, chronic inflammation of the mucous membrane and thickening and ulceration are the most common. Chronic Laryngitis. — Alteration of the voice, cough, and an uneasy feeling in the larynx are the main symptoms. The cough is at first dry, but when of any standing is followed by a yellowish opaque expectoration. It either presents nothing peculiar in its tone, or else is harsh and barking. The breathing is little, if at all, em- barrassed, except when the mucous textures are greatly thickened or ulcerated. In that case there is dyspnoea, the respiration is apt to be noisy and the voice completely lost, because the vocal cords have also suffered. There is, moreover, considerable pain on press- ure ; the sputum is muco-purulent, or else purulent and streaked with blood ; and sometimes, if the cartilages also be involved, fragments of them are expectorated, and by the touch we recognize the changed state of the tube. The symptoms of chronic laryngitis are mostly not purely local. Chronic laryngitis is frequently, indeed, found to be connected with a broken constitution, because the inflammation of the larynx, both in its simple and in its ulcerated form, is often combined with tubercu- losis, or with syphilis. In every patient, therefore, suffering from chronic laryngitis, we must endeavor to ascertain whether either of these morbid conditions is present. Chronic laryngitis frequently turns out, on thorough examination, to be laryngitis linked to a serious pulmonary difficulty ; or we detect ulcers in the pharynx associated with those in the larynx and cicatrices, and are enabled to trace clearly the ravages of constitutional syphilis. As seen with the laryngoscope in chronic laryngitis, hyperaemia, general or partial, is present, associated in cases of long standing with 16 2f/; MEDICAL. DIAGXOeia f:hfmt\hni!tf\(t arid uriifomi swelling of the mucous membrane; the vr^aJ rroniij are often uneven at their edges, and there may be, chiefly \n:\yM:i:u the ar)'tenoid cartilages, superficial ulcers. PapDlary growths u\tni cases of aphonia due to want of strength in brwdhiiig, — to want of power in expiration. KnlurgiHl bronchial and cenical glands, or an aneurism which c\Mupn^sses tlu^ laryngt^d nerves, also produce hoarseness, and ulti- uudely complete Kviis of voice. Under such circumstances there is a jihort anigh, attendiHi often with loud tracheal rales ; and we observe attacks of il\spi\a\i, with a noisy, hissing inspiration. The practical los^Mi which all suoh cases tt>ach, is to rvmeniber that the symptom c\Mtsivlo!\\l mvxst vhanut eristic of ilirv^uio larvi^real inflammation— the altotwl WMv'T^ ina\ ^vv.ir \vt:on no laryn^tis exists: also to examine \x ith the uin i\^'\v5vvjy\ a!ul to !,oto the offtvt of jmJst of the muscles, the r>^*u*t of :ur\t^pr\S2iui>\ h: thv>n»cio aneurisiuu pinssm^ sjrmp- DISEASES OF THE LARYNX AND TRACHEA. 251 toms — sudi as dyspnoea and altered voice, with paralysis of laryn- geal muscles — may be produced either by pressure upon the recur- rent laryngeal nerve, which on the left side passes around the arch of the aorta, or upon the vagus. Pressure upon the vagus will give rise to abductor paralysis of the corresponding side, with adductor spasm of the laryngeal muscles of the opposite side, the spasmodic movements being intermittent. Pressure upon the one recurrent nerve causes one-sided abductor paralysis, the degree of pressure determining the amount of paralysis ; thus, when complete, there is entire loss of voice, when incomplete the voice may be hoarse, whis- pering, or unimpaired. This condition of one-sided abductor paralysis may be caused by pressure from an enlarged cervical gland, by aneu- rism of the arch of the aorta, and by various forms of mediastinal tumors. Pressure upon one vagus, inducing double adductor spasm, produces serious dyspnoea and difficult phonation ; but pressure on one of the recurrent nerves may occasion intermittent dyspnoea that is usually not troublesome, and scarcely affects phonation. Major's researches have given us much of this definite knowledge. Now, in the nervous forms of aphonia just mentioned, with the exception of those caused by pressure, the loss of voice is due to de- ficient power, and the cords move sluggishly or not at all. When the disorder reaches a high degree, we perceive, on looking into the laryngeal mirror, that the vocal cords do not approximate as the patient attempts to say a or o. But, besides these cases, owing to general want of force, we find cases of spasm of the tensors of the vocal eorck with most peculiar, partially interrupted voice ; and of absolute paralysis of individudl muscles^ as of one adductor of a cord ; or of one or both posterior crico-arytenoids, or abductors ; or of the crico- thyroids, or tensors. In some of these there is considerable dyspnoea, with noisy breathing ; in all the laryngoscope affords the only means of diagnosis. In paralysis of the external tensors of the vocal cords, the crico-thyroid muscles, there is inability to use the higher notes with freedom ; the voice is rough or entirely lost, and viewed with the mirror we find a wavy outline of the glottis, convexity of the upper surface of vocal bands on expiration and phonation, and slight concavity on forcible inspiration. The contraction of the muscles, which in the healthy subject can be felt externally during phonation, is completely absent. This form of disorder most fi-equently results from overstraining the voice ; it may be caused by cold,* and is apt to be bilateral. Palsy of the thyro-epiglottic muscles has* its usual origin ^ Msgor, Proceed. Amer. Laryng. Assoc, 1892, p. 10. 262 MEDICAL DIAGNOSIS. in diphtheria. The epiglottis stands erect, and does not move during attempts at deglutition. In palsy of the relaxors of the vocal cords, the thyro-arytenoid muscles, the deep tones are nearly gone. It is often unilateral, and comes mostly from overexertion of the voice during catarrhal laryngitis. Viewed in the laryngeal mirror, the edges of the cords do not approach in the median line, and they seem excavated. In paralysis of the posterior crico-arytenoid mus- cles, tlie glottis is seen as a narrow slit, becoming still narrower during inspiration. There is no disturbance of voice, and scarcely any sign of laryngeal catarrii, but there is marked and noisy laryn- geal dyspnoea. This paralysis of the abductors may happen from compression of the recurrent nerves by an organic stricture of the a^sophagus.^ Alex. W. MacCoy has reported three cases of bilateral abductor paralysis during or after typhoid fever, which he attributed to degeneration, the result of the fever process, in the posterior crico- arj'tenoid muscles.* Bilateral paralysis of the adductors is a common disorder occurring in connection with locomotor ataxia and affections of the brain and of tlie medulla. Paralysis of the muscles of the larynx occurring in typhoid fever lias been observed by Mendel and Bonlay^ and Ludwik Przedborski.* It happens both during the fever and in convalescence. Nearly all of the muscles of the larynx may suffer in tliis way ; the paralysis appears first in the constrictors of the glottis, and spreads to the remaining adductors; finally the abductors are alTectiHi, and ultimately a total palsy of the recurrent laryngeal nerve is the result. Rei*overj' of function may follow in from one to three weeks. There is a tendency for the affection to become chronic, yet the prognosis is usually favorable. AMien the abductors of the hirynx iuul the posterior orico^antenoids are both paralyzed, the vocal conls renuiin near the meiiian line, and do not separate during the act of inspiration : such oases are liiible to perish fix)m suffocation during an attack of dyspna\u Tliomas* has reported a case of paralysis of botli nvurriMit Uu-yngi^il nervt^ consecutive to typhoid fever, which ho found to bo duo to iliffuso neuritis. Unilateral paralysis of the adductors is nioro rariM it aocom(Kuues malignant disease of the ivsophi^jus, anourisni of tho aorta, and, exceptionally, metallic poison- * Cas*- of l>iyAi\ii!u AiuuiK-s dt^ Maladies de I'OwiUe. 1887. * Svtiou ou l>t\^UvY and l^ryu^^Kvy. Colle^ of Ph3r5iciaiis of Philadelphiaf rinladvlphu\ M^slioal JounuL ISi^. * Ai\*luM*s vWtK do M»Hi. : Ko\uo do Lar>-i\^>liyie. 1895. * KUn. YortnVv. N. V., No. ISe, M.i>\ IS??. * Uowio do U\i\ix^>uvio. lS^>Ii. No, iiV DISEASES OF THE LARYNX AND f RACHEA. 253 ing, as lead and arsenic. It sometimes follows exposm'e to cold, or attends rheumatism or phthisis. When met with in connection with paralysis of the same side of palate or tongue, it is centric, at times bulbar. E. Fletcher Ingals has described cases thought to be hysteri- cal in ori^. We also encounter sensory neuroses of the larynx, and among these hyperaesthesia is common. Chronic laryngitis, or rather its chief symptom, loss of voice, is at times feigned; and the deception may be kept up for an indefinite period. Yet we possess, in the use of anaesthetics, the means of detecting the fraud at any moment. Just before the impostor falls into the deep sleep produced by ether, or as he is recovering from the insensibility it occasions, his will no longer controls his voice, and he speaks in his natural tone, or even screams violently. Now, under the term chronic laryngitis, which formeriy, for want of more precise knowledge, was made to embrace most kinds of chronic diseases of the larynx, many diflFerent morbid processes are embraced, the exact nature and seat of which we may discriminate by the lar}'ngoscope. Thus, the disorder may be wholly, or almost wholly, confined to the epiglottis. We may find this structure highly congested and enlarged ; we may be able to note that it is pendent, neariy completely covering the glottis; and it is frequently the seat of ulceration. The attending symptoms in any case are those re- garded as characteristic of a greater or less degree of laryngeal inflammation. In instances of ulceration there is soreness with pain in swallowing, hoarseness and irritative cough, followed at times by blood-streaked expectoration. The ulceration may terminate in total destruction of the epiglottis. A turban-shaped swollen epiglot- tis is often met with in phthisis associated with pyriform swelling of the arytenoids. Pallor of these structures, indeed of the whole larynx, is one of the early signs of pulmonary tfiberculosis, as Cohen has pointed out. When the vocal cords are affected, we recognize in the laryn- geal mirror either their reddening in part or entirely, or their in- duration and thickening, or we observe oedematous swelling in and around them, or their ulceration; and we can usually detect during breathing and phonation their impaired action. The in- flammatory redness may be only in one cord. Small collections of mucus are often found adhering to diflFerent parts of the laryn- geal membrane. Now, all these conditions are generally com- bined with marked aphonia; the voice, indeed, may be reduced to the merest whisper. Venous congestion of the larynx is so rare an affection that Mackenzie has met with but four cases of 264 * MEDICAL DIAGNOSIS. it/ In making our diagnosis we must always be careful to find out if the laryngeal phenomena be not secondary, forming part of a gen- eral morbid state, such as dropsy, tuberculosis, syphilis, or changes in the blood. Chronic hypertrophy of the ventricular bands is the result of inflammatory thickening, and, as Tauber* proves, occurs mostly in those who use the voice much in their professional voca- tions. Turck has given the name of " chorditis tuberosa" to a condi- tion of the vocal bands in singers, in which are found in the upper plane of the bands a peculiar uneven surface and white opaque spots as large as poppy-seeds.* It has been suggested that capillary fibroma or even malignant disease may have an inflammatory origin. Paralysis of one vocal cord may exist, with immobility of one side of the larynx, and yet voice may be preserved ; the healthy cord, as in cases narrated by Bosworth, swinging over to the paralyzed side, so as to make up for the loss of power on that side. Voice may even exist, to a restricted extent, not only without vocal cords, but after entire extirpation of the larynx, as in the remarkable case reported by J. Solis Cohen,* in which the larynx was removed for malignant growth, and the trachea permanently fixed in the neck. After gulping some air into the gullet and throat, the patient was able to talk, and even to sing, by skilfully using his pharyngeal muscles. Alteration of the voice, mumbling speech, as though there were some difficulty in closing the glottis, while the movements of the vocal cords appear normal as seen with the laryngoscope, without true aphasia, is mentioned by John N. Mackenzie as a symptom in a case of bulbar disease.* Diseases of the cartilages and of the perichmidrium are most fre- quently encountered in connection with tuberculosis, syphilis, and typhoid fever. The affection often begins in the submucous tissue, and the ulceration spreads until the cartilaginous parts of the larynx are involved. The arytenoid cartilages are generally first attacked; and portions of these cartilages may be thrown off and expelled. At times pus is formed wliich gives rise to swellings that can be recog- nized by the aid of tlie larj^ngeal mirror ; sometimes a displacement of the cartilages takes place, before any portion of them is completely separated, and the most distressing and dangerous attacks of suffoca- tion result ; or the perichondritis may lead to the development of > Diseases of the Throat and Nose, vol. i., 1880. • Cincinnati Lancet, 1887. ' Klinik der Krankhciten dcs Kehlkopfes. Wein, 1866. * Pharyngtnil Voico, Trans;iclions of the Amer. Laryng. Assoc., 1894. •Transactions Amer. Lan-np. Assik., New York, 1891, p. 6. DI8EASEH OF THE LARYNX TllACHEA. 265 bone-substance and a constriction of the tube. In some instances the purulent collection presses on a vocal cord, whieli, witti the laryngo- scope, may seem to be immovable, Tliis instrument reveals very generally the ravages the disease has committed ; and we are thus enabled to form an opinion as to how far the destruction has progressed, and whicii of the soft parts as well as of the cartilages are involved. Leaving out the frequent perichon- dritis and cai-ies of the cartilages wliich follow the deposition of tuber* c/t\ we find in laryngeal phthisis considerable swelling and ulceration of the epiglottis, and often semisolid pyriform swellings of the arj'- epiglottic folds. Tlie tliiekening is more regular and imiform than that of syphilis, and the tuberculai* uh^crs not lai^^e and solid as In this afIeclion» but small and numerous, and both vocal cords are in- volved ; while in this as in every other respect syphilis is more apt to be local and unilateral. Tubercle bacilli are found in the discharge from the laiyngeal ulcer, and in catarrhal ulceration the ulcers are generally very superficial and on the vocal cords. The symptoms of larj^ngeal phthisis are difOculty in breathing and in swallowing, local pain and soreness, a greatly altered or a lost voice, and a distressing, harsh cough, which is followed at times by purulent expectoration. Besides, we find the manifestations of disease of the lungs. But it occasionally tiappens that we encounter cases of tuberculous ulcers mUi abundant bacilli, in which no lung disease exists; and it is not uncommon to find the tid}ercular disease of the lar>'nx preceding that of the lungs. At times we note syphihtic and tubercular ulcers in combination. We may also meet with catarrhal ulcers where there is tubercular disease of the lungs. A means of diagnosticating sj/phi- litic affections of the larynx from others has been proposed and prac- tised by Justus/ It is based upon the fact that after the use of mer- cury by inunction or by hypodermic injection in a patient affected by sj'philis, a shaqi fall in the percentage of iMemoglobin occurs, within the few hours immediately following the introduction of the remedy into the system. Later, the proportion of haemoglobin increases to a point above where it was before, Justus observed the sudden fall of ten to twenty per cent, in the heemoglobin, following tliis use of mer- cury, in over three hundred cases of sypliilis. No effect of tlie kind was observed when the mercur}^ was administered by the mouth. Ttiis has been called Justus's test, and has been found applicable to cases of ulceration of the lary^nx, in which there was a doubt as to the character of the disease. 256 MEDICAL DIAGNOSIS. The diagnosis between pachydermia of the larynx and the inter- arytenoid tumor of phthisis is that in the latter the swelling is dis- tinctly a tumor, with more or less well-defined margin. The color is usually red or pink ; in pachydermia it is whitish-gray or only slightly pink.^ Ulceration occurs in pachydermia only exceptionally and as a complication ; it is common in phthisis of the larynx. As the result of disease of the cartilage and of the perichondrium, especially as the result of the process of cicatrization, we may have stricture of the larynx and trachea ; for this is, in truth, the most common origin of laryngeal stenosis. The inspiration is prolonged and noisy ; the voice is generally, although not of necessity, affected. There is dyspnoea, and with the laryngoscope we can see how greatly the caliber of the tube has been encroached upon. Cicatrization is common after syphilis, but Cohen's case* proves that it may occur spontaneously also in tubercular ulcerations. Adhesions may be con- genital, a web-like membrane uniting the vocal cords through a part of their extent, as in a case of Morell Mackenzie's. According to Paltauf,' primary stenosis of the larynx may be caused by scleroma, which may develop early in the larynx. The diagnosis depends upon the detection of the characteristic minute structures. Ulcers in the posterior walls of the larynx give rise, as a rule, to distresshig cough. Tumors of the larynx and polypoid growilis in its interior have as their symptoms cough, altered voice, a steadily in- creasing difficulty in breathing, and attacks of suffocation for which notliing in the lungs or heart or great vessels accounts. But the laryngoscope alone tells us the true meaning of these symptoms. New growths may occur in the larj^nx, of the benign form. Papil- loma, papillary fibroma, is probably the most common ; myxoma is rare ; fibromyxoma and fibroma unusual. Malignant disease in various forms may affect the structures of the larj^nx. A positive diagnosis can be made only with the aid of the microscope. Yet the detection, at the seat of the larynx, of a growing tumor, accompanied by severe cough, by sanious sputum, by signs of destruction of tissue, by perichondritis and exfoliation of the larj'ngeal cartilages, by hemor- rliiiges, and by emaciation, warrants the diagnosis of cancer^ whetlier or not much pain be present. This may be confinned by the subse- qui'Til rapid development of the malignant disease, associated witli a musty odor of the breath, distress in swallowing, bloody expectora- * MoBri(le, E(Jinl)urirh Medical Journal, April, 1893. 2 Amor. Jouni. Med. Sci., Dec. 1888. »Sajous, Annual of Univ. Med. Sci., 1893. DISEASES OF THE LARYNX AND TRACHEA. 257 tion, and cachexia. In some instances gangrenous pneumonia occurs. Polypi in the larynx may sometimes be seen by depressing and drag- ging forward the tongue until the epiglottis is brought into view. But as regards polypi, or, indeed, any form of morbid growth, we possess in the laryngoscope the only certain means of detecting them. These larj'ngeal growths vary much in size and in color; they are often seated at the anterior free edges of the true cords, or still more gen- erally just above or just below their origin, and are, as a rule, readily discerned. Sometimes they may exist for years, merely producing changes in the voice and some cough, but no very great distress ; or they may lead to fits of strangulation and to sudden death. It is impossible to be sure of their nature without repeatedly examining portions of them. PapUlomaa are usually cauliflower-like or in bunches; they occupy most frequently the vocal cords, while sar- comas are oftenest found at the anterior portion of tlie larynx. Cysts of the vocal cords are much rarer than other forms of growths ; they sometimes rupture spontaneously, and the hoarse voice quickly clears.^ Myxomata of the larynx and the epiglottis, according to Van der Poel,^ may be manifestations of pernicious anaemia. They differ from cysts in being a pure, gelatinous growth characterized by stel- late fusiform cells embedded in a homogeneous, or finely fibrillated, soft, basement substance. Many cases that are classed as cysts would come under the head of myxoma if the aid of the microscope had been sought. Before concluding these remarks on diseases of the larynx, it may be thought necessary to point out the differences between them and diseases of the trachea. But affections of the trachea need not be separately considered. Lying between the larynx and the bronchi, the trachea commonly shares in their disorders. Thus, we have seen croup to be a malady in which both larynx and trachea are involved. Slight inflammation of the trachea occurs constantly in slight attacks of laryngitis or of bronchitis. Ulcers in the trachea may exist without ulceration of the larynx ; but then they usually escape detection. Sometimes, however, they reveal themselves by a constant pain at the lower portion of the neck and the upper part of the sternum, joined to all the symptoms of ulceration of the larynx except the impaired voice. Morbid ffrowths^ too, occur in the trachea, — cancer, carcinoma, syphilitic growths, — as they do in the larynx, ^ Heinze, Archives of Laryngology, New York, 1880. ' American Laryngological Association, 1890. 258 MEDICAL DIAGNOSIS. and the tube may be altered in form and in structure. Vegetations also form in the trachea after tracheotomy.^ We can make use of the laryngoscope to assist us in the diagnosis of any of the forms of tracheal disease referred to. Yet the instrument is not always avail- able; for it is only under favorable circumstances that the entire extent of the trachea can be seen. In narrowing of the trachea the bronchial tubes are also at the same time often narrowed. The stenosis may be caused by external compression, as from a goitre, from an aneurism, or from a mediastinal tumor ; or the constriction may be due to some cause, such as new formations, in the walls of the tubes. The chief symptoms are the same in either case ; and they are, long-drawn-out respiratory acts, noisy breathing, especially in paroxysms, dyspnoea, particularly marked in inspiration, epigastric retraction, . feebleness or absence of vesicular murmur, with clear pulmonary resonance, loud wheezing heard with the stethoscope at or near the place of constriction, and voice slightly, if at all, impaired. This, the normal appearance of the larynx as shown by the laryngoscope, and the almost imperceptible motion of the windpipe during breathing,* are of great value in dis- tinguishing a tracheal stenosis from a laryngeal affection. A bronchial stenosis is chiefly discriminated by the signs of the constriction being one-sided, and attended with marked thrill of the thoracic wall of the affected side, and with loud sounds issuing from it, loud enough to be heard at a distance. Subglottic oedema may be detected by the laryngoscope on deep inspiration. Over the trachea, the tracheal breathing may have become inaudible in stenosis of both main bronchial tubes.^ * See cases collected by Petel, Des Polypes de la Trachea, Paris, 1879. * Gerhardt ; also Riegel, in Ziemssen's Cyclopaedia. ' Aufrecht, Deut. Arch. f. klin. Med., Iviii. 4 and 6, 1897, p. 484. CHAPTER IV. DISEASES OF THE CHEST. An examination of the diseases of the chest must be prefaced by a description of the methods of investigation which have given to their diagnosis such certainty. The same methods may be appUed in the study of the maladies of other parts of the body, but they are of special service in the recognition of thoracic disorders, and will be here, therefore, most appropriately considered. The discrimination of disease by the eye, the ear, the touch, in fact, by the direct aid of the senses, is called physical diagnosis ; the signs thus ascertained are connected with perceptible alterations in the material properties or physical nature of structures, — such as alterations in their form, their density, or their sounds, — and are known as physical signs. Physical signs are, then, the exponents of physical conditions, and of nothing more. But as the same physical conditions may occur in various diseases, so may the same physical signs occur in various dis- eases. An isolated sign is, therefore, not diagnostic of any particular malady. It reveals usually an anatomical change; but it does not determine the disorder occasioning this change. The subject may be much simplified by laying less stress on individual signs, and by group- ing them t(^ether according as their association becomes distinctive of certain well-marked physical states. Morbid anatomy tells us in what diseases these states are commonly found. It is in conformity with these views that I shall attempt to delineate the signs of thoracic affections. For the sake of convenience, the surface of the chest has been mapped out into regions. Various arrangements of these have been made by diflFerent authors. The simplest division of the chest is into anterior, posterior, and lateral surfaces. The regions into which the anterior stuface may be, for practical uses, subdivided, are an upper region, extending from just above the clavicle to the fourth rib, and a lower region, firom the fourth rib downward. Posteriorly, also, there are an upper and a lower part of the chest to be specially examined. It is hardly necessary to say that all these regions are double, — the 259 260 MEDICAL DIAGNOSIS. same on each side of the chest. Many more divisions are usually made ; but they are perplexing to the student, and of doubtful value. The artificial boundaries generally laid down are, indeed, too minute, and yet not minute enough ; they are too minute for ordinarj' pur- poses, not minute enough when it is desirable to localize a physical sign. Whenever this is requisite, instead of resorting to the names of the regions usually employed, I think it preferable to designate the seat of the sign with reference to some fixed anatomical point. This may be done for the anterior part of the chest by indicating the dis- tance above or below the clavicle, or near what part of the sternum, or at which rib, or spreading over how many intercostal spaces, the sign in question is perceived. At the posterior part of the chest, the spinous ridge of the scapula, its lower angle, and the spinal column, serve as landmarks. For most clinical purposes, it is only needed to study the region above the spinous process of the scapula, as separate from the space below. But in some instances it may be necessary to notice the region between the scapulae, interscapular, or that extend- ing from the lower angle of the bone to the limits of the chest, infra- scapular. Let us now examine the different methods of physical diagnosis, particularly in their relation to pulmonary diseases. SECTION I. DISEASES OF THE LUNGS. The Different Methods of Physical Diagnosis, and the Physical Signs of Pulmonary Disesuses. INSPECTION. If the chest be examined with the eye, w'e obtain an idea of its form, size, and movements. In health this inspection shows us that the two sides of the chest are, to a great extent, symmetrical in form, as w^ell as in si/^e and in movement. Both sides rise equally during inspiration and sink equally during expiration. On both sides the motion of inspiration is longer than that of expiration, and the pause between them extremely slight. This reHpiratory movement Ls visible over the whole thorax. In males it is most distinct at the lower portions of the chest ; in females it is most perceptible at the upper. In healthy adults the lungs ex- pand from sixteen to twenty times in a minute. In certain pulmonary DISEASES OF THE LUNGS. 261 affections, especially in pneumonia, the number of respirations often exceeds fifty in a minute. But hurried breathing and changed move- ments of the thorax occur independently of diseases of the lung, as in an hysterical paroxysm. Where the diaphragm does not descend, as in consequence of peritonitis or of abdominal dropsy or of tumors, the breathing is rapid, and is perceptible at the upper parts of the chest. Again, the thoracic movements may be distinct on one side and hardly noticeable on the other, as in pleurisy or in pneumo- thorax. Lastly, as happens in some cerebral lesions, the motions of the chest may be very slow and labored, or irregular, or they may have apparently ceased, and the breathing be altogether abdominal. The foita of the chest is sometimes strikingly altered. Congenital malformations and curvatures of the spine modify it; so do intra- thoracic affections. Frequently the chest presents a retracted or an expanded look. Retraction denotes diminished size of the lung, and, if one-sided, is usually indicative either of chronic changes in the lung-tissue, as in chronic pneumonia or in tubercular lungs, or of false membranes vrhich bind dovrn the lung ; or it is found in a very marked manner in empyema with external opening. Expansion of the chest is met with in emphysema, in pneumothorax, and in pleu- ritic effusion. A local or partial expansion, or bulging, may be encountered in the latter disease, or it may depend on thoracic tumors, on pericardial effusions, or on hypertrophy of the heart. A mode of inspection of value in certain cases is the diaphragm phenomenon to which Litten ^ has called attention. In a person lying with his feet pointing towards a window, there can be seen during deep breathing a shadow from about the seventh to the ninth rib ; it flits down during inspiration, it ascends during expiration. This shadow is nearly or wholly absent when fluid or air occupies the pleural cavity ; also in obliteration of the cavity by adhesions ; in intrathoracic tumors at the lower part of the chest ; in pneumonias of the lower lobe, and in extensive emphysema of the lungs. Tumors under the diaphragm or accumulations of fluid in the abdomen do not impair the sign, unless they are very large, nor do enlargements of the liver or spleen. The shadow phenomenon becomes thus of much value in distinguishing morbid states above from those below the diaphragm. Litten holds that when the excursion of the diaphragm during forced breathing is less than two and a half inches the condition is abnormal. In very fat persons the shadow cannot generally be seen ; muscular weakness very decidedly limits it. It is also much limited in phthisis, as both ^ Deutsches Medicinische Wochenschrift, 1892. 262 MEDICAL DIAGNOSIS, Rutjipf* and Cabot ^ pruve^ but its diniinulion may show only on the atTerted side, A new and most valuable means of inspection has been discovered in the Rontgen lifjhf. These X-ray examinations have solved the problem of kmkint,^ nnder the skin and maJcing deep*seateil parts visible, and of giving us photographs for permanent study, while by the adaptalion of a simple instrument, tlie fluoroscope, or by the fluoroscope screen, we can do so more quickJy and see the parts in motion. Tiiere are immense possil)ihties in this new mode of in- spection ; and while, thus far, it has proved itself of the greatest use to surgery in detecting, for instance, changes in the bones, fractures, dislocations, and foreign bodies, it has also shown i^s value in medi- cine. Among its contril)utions to tliis we may note the information it gives us concerning rickets, gouty deposits about the joints and under the skin, rheumatoid arthritis, tlie presence of renal calculL Ver>' valuable is the added insight gained by X-ray examinations in diseases of the lungs and heart, especially in giving us accurate in- formation as to the size and movements of the latter. In the recog- nition, too, of arteriosclerosis and of thoracic as well as abdominal aneurism, the rays have proved themselves of the greatest use, par- ticularly as they have enabled «s lo detect them in tlie early stages. As regards the lungs, we liave gained much precise topograptiieal as well as palholr^gical knowledge.^ The exact relations of the bronciiial tree to both the posterior and anterior thoracic walls have been clearly ascertained by skiagraphy.* On the posterior wall in the adult Oie course of the left bronchus is found to be from a point to the right of the fourtli thoracic spine to a point on the eighth rib three inches to tlie left of the spine ; the course of the right bronchus to a point on the eighth rib two inches to the rigtit of the spine. With reference to the anterior wall of the chest, the point of bifurcation in the adult is just internal to the junction of the lower border of the second costal cartilage with the sternum ; in children it is opposite the third chondro-stemal ariiculation. The fluoroscope is better for jnost examinations of the lungs than the X-ray photograph, or skiagraph; it is much quicker, and shows us the parts in motion. The patient is best examined standing lip. * Berliner klinischp WiJ€J:u?iischriE, No. \i., 1897. * Uedicj^l News, April, 1899. ' See cases ptiblished in several valuable contriljiitjoii^ by F, H. Winiams, Medical News, vol. Ixxii, ; tbe American Jotinial of the Medical Sciences, June, 1899 ; also the Transactions of ttie Assmiation of American Physicians, 1897. * Blake, Amen Joum. Med. Sci., Marcb, 1899. I l» k M I i s. f 8 "2. H i* ■2. 264 MEDICAL DIAGNOSIS. MENSURATION. To iiu^asiire tlie rinimiferenee of Uio chest or of the abdomen, or to ascertain the tlistauie from one portion of the surface lo the other, a graduated tape is all that is required. To attain the former object, the spinous process of a vjTh'bm is eliosen as a fixed |)oint, and the tape is Uieiire passed rouiiil the body lo the ineiUan line, lirst on one side^ then on the other, taking care that it be applied evenly to the skin, and that Ihe level of fhe measurement be Ihe same on both sides. If we wish to obtain tlie longitudinal diameter, the hue from the clavicle to the base of the chest is taken. Where the chest is deformed, a chain with links may be used in place of the tape. In estimating the size of I lie chest in disease, it must be borne in mind that even in health its two sides vary widely. The half-circle on the right side is, in rigid-handed persons, at least half an inch larger than tlie half-circle on the left. But the measurements, to be Irnsted, nnisl he [jerformed while the patient is holding his breath in expiration. In inspiration the girth of the chest is increased from two to three inches, fn well-devel- Fuj. IH. oped men it measures at llie upper part, at the level of tlie nipples, about thirty-three to thirty-four inches dur- 11 ig expiration. Otis,^ as the result of one thousand measurements, gives the average girth in men as 34 inches in repose, and 3ii.l inches inflated; and in well-developed women as 29.5 in repose and 31.5 inflated; while the depth of chest in repose in men is set down at 7.5, and in women at 6.9 inches. If it be desirable to ascertain in how far the respiratory acts modify the di- mensions of the chest or of the abdo- men, this may be readily effected by tlie higenious *' chest-measurer" of Siiison, or by the '' slethometer'' of Quam or of Can'oll, or by the instrunterit of Dem^ny ; or the respimtory curves can be traced and studied by the atmograph of Burdon Sanderson, or by the pneumograpli. The Iransverse diameter — the breadth — of the chest may be deter- mined by means of a pair of calipers, arranged specially ibr the pur- Tll* SJteth ometer of ( in n i n , Th e lx)3c is placed on the ^tenuirn, and the string cftrried iimund the «hesin to be p^^nii^n), — unless it bo the fault of striking with great fciiw. rnrri* ^ rcussion is of use only when the sound of deep- be bn>ugl)t out. The pVxiiseier: ftN^ti luituTm! si«e. It m^v DISEASES OF THE LUNGS. .267 The main sounds elicited by percussion may be designated as dull, clear, and tym- panitic. Of course, these, like all other sounds, may differ in strength, in duration, and in pitch. A dull sound denotes absence of air. It is the sound both of fluids and of solids. It is, thus, the sound sent forth from the air- less viscera, — from the liver, spleen, and heart. When it takes the place of the pul- monary sound, it bespeaks consolidation, from whatever cause induced, or the pres- ence of something which checks the normal vibrations of the lung-texture. Dulness is always associated with an increased sense of resistance to the percussing finger, and over parts emitting it the vibrations of the tuning-fork, which Bass has introduced into diagnosis, are weak, while they are loud over normal pulmonary structure. A clear sound is produced by a series of marked and unhindered vibrations which are emitted from a substance containing air. As thus defined, a clear sound evi- dently is yielded by percussing any air-con- taining organ. But custom has restricted the employment of the term clear to denote the peculiar resonance obtained by striking over pulmonary tissue. When, therefore, a clear sound is spoken of, it means a sound having the nature of that of the lungs, or of normal vesicular or pulmonary reso- nance. A tympanitic sound, on the other hand, is a non-vesicular sound, having the char- acter of that of the intestine. Wherever heard, it indicates the presence of quanti- ties of air in conditions similar to that con- FiG. 21. ^& ¥ia. ZL— A serviceable model of a percussion hammer; not quite ustoral site. The india-rubber is screwed to the Ting, which has a diameter of from five-eighths to three-quarters of an Inch. The metallic ring is attached to a steel stem with a very decided spring. The pointed portion of the india-rubber is used to strike wlthion the pleximeter. 268 MEDICAI. DIAGNOSIS. tained in the intestine, — namely, emlosed in walls which are jielding^ but neither tense nor very ttiiek. When ellrited over the ehesl. it nmy be only the transmitted soinut nf a distended stoniaeh or colon. But generally a t)Tnpanitie sound over the seat of the Uiiigs is ex- pressive of emphysema, or of pneumotliorax, c»r sometimes of a eavity, or of a^dema of the lungs. Again, as Skoda has taughl us, it occurs in moderate pleural effusions above the level of the liquid. The tym- panitic sound is distingTiished chietly from the clear sound or pulmo- nary resonance by its more ringing character and its higlier pitch. If the ca^^ty communicate with a large colunni of air in the bron- chial tube, the note on percussion varies, as pointed out by Wintrich, accordingly as the patient opens or closes his mouth. It is more markedly tympanitic and higher in i)itch when the mouth is wide open. Altering the position from a sitting to a horizontal one, when the cavity is partially filled with fluid, Gerhardt has siiown changes the tynipamlic percussion note, and 1 have observed it to be markedly altered — ^indeed, to disappear — on a full held inspiration.* As modilieahons of tlie tym|janilic sound may be viewed the am- phoric or mdallw sound, and tlie vranM-pof or crtK^ed-mdtd sound. The Orst of these is a concentrated t)^npanitic sound of raised pitch, and denotes a large ca\ity with firm, elastic walls. Tlie second is not unfrequently found associated witii it. It requires for its development a strong, abrupt blow of the percussing linger while the patient keeps his mouth open. Tlie condition thai usually occasions the sound is a cavity conmiiinicating with a bronclual tube. It is also met \rith tin- combined wilh an excavation, iis in the bronchitis of children, in pleurisy above the seat of effusion, near a pericardial exudation, in enqihysema, and in certain instances of pneuniotliorax. Indeed, any disorder in which the chest walls remain very yielding, and in which a certain amount of air contained in the lung or pleura is, by sudden percussion, forced into a bronchial tube, will occasion tliis cracked- metal sound. In addition to the character of all these sounds, we study their de/p^ee^ or amount of fulness : such changes as are expressed by ** more or k^ss,'^ ''diministted or increased/^ Thus, a clear sound may be increased, owing to stronger vibrations and a larger quantity of air, yet not lose its distinctive pulmonary character, as happens often, for instance, when the air-cells ai'e dilated ; the sound of the large intestine is fuller, more tympanitic, than that of the small mtestine, and so forth. ^ Amer, Joura. Med, Sci., July, 1875. DISEASES OF THE LUNGS. 269 With charif^es in fulness or volume of sound go liand in hand change's in its pitch. Increased volume is linked to lowered pitch, diminished voliune to higher pitcli ; but so is increased tension. To sum up the chief results of percussion, as above described : QcALtTT, on Character op Sound. CuEAR :^Pres*'ni'e of uW, — ;ls in the lung- tissue. DrLL : — Solidification or cjnrnpression. Tympanitic : — Certain amount of air enclosed in a structure or cavily the wails of which are not too tense. Mdniiiv ; — ^Large hollow space, with firm but elastic walls. Crackfil-metal sound: — ^UsualJy a cavity communicatintf with a bronchus. DeOREE, or biTENStTY- Anj (yf the sounds mentioned may he dimituj^hcd or incrca»ed in intensity as Uie conditions which produce thein are modi tied. Pitch. Heightened or lowered as amount of air or as tension is altered. If it be desirable to obtain a more distinct idea of the soimd than can be done by the ordinary method of practising percussion, it may be accomplished by resortuig to auHcaliatori/ percmmon, — a method that consists in listening, witli a stethoscope appUed to the parietes, to the sounds elicited by percussion. It is a means of delermining with ■ accuracy the boundai'ies of or^^ans, as of those of the lungs or hearty [Or of the liver or spleen, and yields particulai'ly good results when ied out with the double stethoscope. The percussion sound will also be found to vary with the respira- tory movement, and useful informatic»n may be obtained by the ap- preciation of the note elicited by percussion while the breath is held Rafter a full insiiiration or in a prolonged expiration, — a method of losis wtiich I liave introduced under tlie name of re^pimtori/ per- em * As a standard for comparison in dist:'ase, the results of respiratory percussion in health must be earefidly determined. It will be found tliat in the normal chest, anteriorly, a full held inspiration increases the resonance, makes the sound fuller, and raises the pitch ; but, making allowance for the cardiac region, the resonance below the apices is relatively less increased on the left than on the right side. * Amer. Joum. Med. Sci,, July, 1875; see also Friedreich, Deutsches ArHiiv ftir klin, Med., Bd. xxvi.» couliniiing these observations. 270 MEDICAL DrAONOSIB, Posteriorly, we find in the supraspinous fosste, and on a line towarcls the spinc% tliat a fult inspiration makes the percussion soiuid ' fuller and raises the pitcli, especially on the riglit side. In the inter- scapular and infraseapular rej^nons the tone on gentle percussion is disiinctly pulnionarj' and the pitch moderately high. On the lett side an admixture of tympanitic resonance may he detected, particularly in the infraseaimlar region, Tlie pitch is somewhat lower in tlie left scapular and infrascapular region than in tlie right, A full held in- spiration elevates tlie pitch, increases the resonance very much, and makes the difference hetween the sides less apparent. A held and complete expiration greatly lessens resonance, makes tlie tone less full, and lowers the pitch on percussion. Percussion of thr Hmitkif Che^t. The sound elicited by striking a healthy chest differs in accord- ance with the part percussed. Tlie ftnitrior portion renders a clearer sound than the posterior, on account of the slighter thickening of the thoracic walls. But the pulmonary resonance is not, even anteriorly, alike at all parts. The portion of lung above tlie claWcle yields a sound which becomes somewtial tympanitic as the trachea is ap- proached. Percussion is diUlcnlt in this region, as it is almost impos- sible to apply the fmger or pteximeter closely to the surface. Over the clavicle the sound sent forth is clear at the centre of the bone ; at its scapular extremity it is duller; towards the sternum it becomes of higher pitch, and mixed with the sound of the bone. In the region bounded iibove by the clavicle, and below by tlie upper mai^in of the fourth rib, the resonance is very marked. In fact, the sound of this region may be taken as a type of tlie pulmonary sound: it is very clear and distinct, and but little resistance is offered to the per- cussing finger. Yet a slight disparity generally exists between the two sides. On the right side the sound is somewhat less clear, sliorter, and of a higher pitch, than on the left. FYom tlie fourth rib down- ward, on the right side, the resonance of the lung on strong percus- sion, is found to be sliglitly deadened ; near the sixth lilj tlie perfectly dull sound indicates that the liver has been reached. On the right side, during full inspiration^ the liver is pushed downward for the space of an inch or more ; and tlic dull sound on percussion begins, therefore, lower down, and on a Ime corresponding to the displace- ment of the organ. On the left side the heart deadens tlie sound Irom the tburtli to the sixth rib, and, in a transverse direction, from the sternum to the nipple. This dull sound is lessened in extent during inspiration, and DISEASES OF THE LUNGS. 271 in cases of emphysema ; indeed, under any circumstances in which the lung more completely covers the heart. Lower down, owing to the liver reaching over to the left side, and to the presence of the spleen and a portion of the stomach, the sound rendered on percus- sion consists of a mixtin-e of the dull sound of the solid viscera and of the clear sound of the lung with the tympanitic sound of the stomach. The latter character of sound predominates when the stomach is empty. Over the upper part of the sternum, to the third rib, the percussion sound is slightly tympanitic ; at the lower part, the heart and liver cause this tympanitic or tubular character of sound to give way to a dull sound. Position exerts some influence on the results of percussion. On exchanging the recumbent for the erect posture, the pitch of the sound on the front of the chest is raised. At the posteinor portion of the chest the sound varies materially according to the part percussed. Directly on the scapulae the sound is duller than between the bones, or than below their inferior angles. Beneath the scapulae a clear sound is emitted as far as the lower border of the tenth rib ; here, on the right side, the dulness of the liver begins. Strong percussion, however, causes the dulness to be- come manifest higher up. On the left side, below the angle of the scapula, the percussion sound may be tympanitic if the intestine be distended; or it may be rendered slightly dull by the spleen. In and under the axilla the sound is very clear. But on the right side, at the lower border of the sixth rib, dulness becomes perceptible ; at a corresponding situation on the left side, the sound is clear or tym- panitic from distention of the stomach ; and at the ninth or tenth rib, dulness and a sense of resistance to the finger disclose the presence of the spleen. AUSCULTATION. Auscultation, or listening to sounds, informs us of the play of oiigans, and furnishes us with the most trustworthy means of studying their action. The method practised by Laennec, the discoverer of auscultation, was the mediate^ or by the stethoscope. Another method has since his time grown up, — the immediate, or the direct application of the ear to the chest. For ordinary purposes, this is the best ; but where it is desirable to analyze circumscribed sounds, as in diseases of the heart, the stethoscope is preferable. Stethoscopes are made of various materials and of different shapes. One of moderate length, with an ear-piece which fits the pavilion of the ear, and with the extremity not too much expanded, is to be pre- ferred. The material is of less importance. I like best those of gun- 272 MEDICAL DIAGNOSIS. Fig. 22. Hawksley's stethoscope, with detached ear-piece. Fig. 23. metal, introduced by Hawksley. Of late years double stethoscopes have been much employed. The instrument invented by Cammann, of New York, consists of two tubes, the extremities of which are placed into the ears. It has since been modified by making the tubes attached to the ear-pieces of flexible rubber and detachable. But it has also been improved by arranging it to cut off ex- ternal sounds.^ A similar kind of stethoscope is the differential stethoscope of Alison, by which each ear X receives simultaneously the sound from a different re- gion. It is very little used. The most recent addi- tion to our means of study- ing sounds is the phonen" doscope of Bianchi.* It consists of a metallic box about the size of a large watch, with two vibrating plates. Two elastic tubes serve as conductors, and, with a small buttoned rod secured to the lower plate, any point to be specially localized can be examined. Fig. 24 shows the instrimient. The phonendoscope is valuable because it is readily applied, and does not produce ex- aggerated sounds. It is of especial use for the outlining of organs, as a substitute for auscul- tatory percussion as ordinarily practised. Rubbing the surface with the index-finger over the part to be examined takes the place of per- cussion with the finger or the hammer. For purposes of comparative auscultation it is also valuable, and several persons can listen at the same time by using different instruments, or by attaching more elastic tubes to one. The phonendoscope is of marked service in studying muscular sounds, and of undoubted value in cardiac diagnosis. While The double stethoscope, original model. ^ Described by Knapp, Medical Record, Nov. 9, 1895. ' See Transactions of International Medical Congress at Rome, 1894 ; Comptes- Rendus de la Societe de Biologic, 1896. DISEASES OF THE LUNGS. 273 all the claims made for it have not been substantiated, I believe it to be a distinct addition to our means of auscultation, and better than the double stethoscope. I have certainly used it to advantage. In auscultating, the following rules are to be borne in mind : 1. Place yourself and your patient in a position which is the least constraining and permits of the most accurate application of the ear The phonendoecope, natural size ; the elastic tubes are, however, much shorter than in the real instrument. The small rod above is screwed on when needed for purposes of minute localization. or stethoscope to the surface. Above all, avoid stooping, or having the head too low. 2. Let the chest be bare, or, what is better, covered only with a towel or a thin shirt. 3. If a stethoscope be employed, apply it closely to the surface, but abstain from pressing with it. This may be obviated by steadying the instrument, immediately above its expanded extremity, between the thumb and the index-finger. 4. Examine repeatedly the different portions of the chest, and compare them with one another while the patient is breathing quietly. Making liim cough or draw a full breath is, at times, of service, espe- cially the former, when he does not know how to breathe. 274 MEDICAL DIAGNOSIS. Sounds of Respiration in Health and in Disease. The ear applied over the trachea of a healthy person, and subse- quently over the lungs, discriminates two dissimilar sounds, which may be severally taken as starting-points. The first is plainly blowing, both in inspiration and in expiration. It is heard over the larynx and trachea ; and in a slightly modified form, as a less intense and hollow sound, at the upper part of the sternum ; and sometimes, owing to the closeness of large bronchial tubes to the surface, it is perceived between the scapulae, on a level with their ridges. It is occasioned by air passing through the tubes, and is known as the tubular or the bronchial sound. The sound over the lung-tissue is different: it is much softer, more gradually formed, of lower pitch, mainly inspiratory, and almost im- mediately followed by a shorter and far less distinct expiration. This is the vesicular murmur, — produced in the finest bronchial tubes and air-cells by their expansion and contraction. The expansion gives rise to the distinct breezy inspiration ; the noiseless contraction of the elastic walls of the vesicles and the passage of air back into the smaller bronchial tubes cause the short, indistinct, sometimes almost inaudible expiration. But the vesicular munnur is not exactly alike at different parts of the lungs. It is, as a rule, better marked over the upper lobes than over the lower, and more clearly defined anteriorly than posteriorly. Nor is the sound of the two lungs pre- cisely the same ; a disparity may generally be noticed at the apices. Most authors describe the vesicular murmur as more intense on the right side. Investigations instituted to determine this point lead me to agree with Flint that the reverse is the case. More expiration, a higher pitch, therefore more of the bronchial element, is presented by the upper portion of the right lung ; but a stronger, more vesicular inspiration belongs to the left lung. The murmur of the air-cells, then, is the sound which the ear encounters when it is placed over the greater part of the chest. Bronchial respiration is constantly engendered in the tubes of the lung; but, either because it is overpowered by the sounds of the myriads of expanding air-vesicles, or because the pulmonarj' tissue is a bad conductor for a deep-seated sound, or perhaps because the sound requires consolidated tissue for its perfect production, bronchial breathing is not heard over the chest, except at the very limited space indicated, unless the action of the air-vesicles have been suppressed. Disease, however, gives rise not only to changes as absolute as suppression of I he vesicular murmur and its substitution by a bron- DISEASES OF THE LUNGS. 275 cliial respiration, but also to certain modifications of the murmur, which serve as valuable guides in diagnosis. Thus, the vesicular murmur may be abnormal in its intensity, or in its rhythm, or it may have lost some of the elements of its distinctive character, such as its softness. Changes in the Vesicular Mnrmnr. — The changes of the munnur which are of importance may be summed up as follows : r Increased, or puerile breathing ; Alteration in Intensity < Diminished, or feeble respiration ; I Absent respiration. j- Divided and jerking respiration ; Alteration in Rhythm -j Alteration of length of expiration relatively to I inspiration. Alteration in Character Harsh respiration. IivtenBity, — An increase of the vesicular murmur is called suppk- vientary respiration, or, from its resemblance to the breathing of chil- dren, puerile respiration. It depends upon an increased action of the air-vesicles ; more air, or air with greater force, entering them. The sound is simpjy a loud, distinctly vesicular respiration ; both inspira- tion and expiration being augmented in duration and loudness, but retaining their relative length. Peurile breathing is not in itself a sign of any disease. It indicates rather greater activity and energy of the part over which it is heard, which activity makes up for the deficient action of other parts. In this manner effusions compressing one lung, one-sided deposits, or obstruc- tion of the bronchial tubes by secretions, necessitate a supplementary respiration in tlie healthy portion of the same lung, or in the other. A diminution of the vesicular murmur, or feeble respiration, con- sists in a lessening of the whole sound without change in its character. But the relation of inspiration to expiration does not remain the same as in health. In the large majority of instances the inspiration suffers most, and the expiration does not diminish in proportion ; a circum- stance explained by reference to the states which occasion the di- minished vesicular murmur. These are varied ; but their causes may be reduced to four : 1. Any cause which obstructs the passage of air and prevents it from fully reaching the pulmonary tissue. Foreign bodies lodged in the trachea or bronchi ; affections of the larynx ; considerable thick- ening of the mucous membrane of a bronchial tube ; its compres- sion, or the accumulation in it of secretions, or its contraction by a spasm, — all diminish the quantity of the air and the force with 276 MEDICAL DIAGNOSIS. Fig. 25. Dia^rmm illustrative of the main forms of feeble n^spiratioii : a, from distention of the cellH in vesicular emphysema ; 6, from dei)oslt8 in the pulmonary texture ; c, from ftKolid liody ((/) loiiKwi in a bronchial tube, which hati \i\\ to iiartial, or, in some spots, to complete collapse of the air- vesicles. wliicli it reaches the vesicles, and hence reduce the strength of the murmur. 2. Deficient respiratory action. This may arise either from general debility ; or from impairment of the ner\'^ous force, as in paralysis ; or from local pain, as in pleurisy or in pleuroP- dynia. 3. Causes which interfere mechan- ically with the free expansion of the air-cells. Pleuritic effusions, by com- pressing the lung-tissue, will of course diminish the vesicular murmur; so, too, will morbid growths, or malfor- mation of the chest. Comparatively slight deposits in the pulmonary tissue of tubercle or of lymph obliterate some air-cells, and prevent others from un- folding, and, by having impaired their elasticity, diminish their soimd. The same loss of elasticity happens in em- physema ; the over-distended cells cannot expand much more, they iu*e rigid and more or less fixed ; the vesicular murmur is therefore feeble. 4. The respiratory murmur may be imperfectly transmitted to the ear, owing to intervening fluids or solids. To this category belongs the enfeebled murmur so constantly met with in fat persons. As so many conditions occasion a feeble respiratory murmur, it is only by association with other phenomena that it acquires much im- portance. Taking the diseases in which the sound is most frequently found, it may bo stated that, if a feeble murmur be combined with dulnoss on percussion, it signifies a tubercular deposit, or a pleuritic etlusion : the fornuT, if at the upper, the latter, if at the lower part of the lung. If it be connected with increased clearness on percussion, distention of the air-ci^lls is its cause. A vesicular murmur, feeble throughout both lungs, with the percussion sound unaltered, arises fi*oni general debility, or from obstruction of the upper air-passages. Where the feebleness of the murmur is found to change from place to place, it is dependent u\Hn\ a loose fort^ign body which is shifting its positiiMi in the bronchial tubes. Joinetl to unwillingness to expand the lung, on acci>unt of the piiin lhertl>y brought on, feeble respiration denotes pleun.>dynia or beginning pleurisy. An niliial respiration harsh respiration liiffers merely in d^ree : it is mixed with mort^ of the vesicular sound, is less blowing in inspira- tiou, and, when priniuoed by condensation, is not associated, owing to the smaller amount of deposit j;iving rise to it, with so much duUiess on percussion. Bronchial Respiration. — Purely broncliial respiration may ex- DISEASES OF THE LUNGS. 279 hibit the same modifications as the vesicular murmur in respect to rhythm and intensity. But neither its rhythm nor its intensity is of significance ; its character is. To hear well-defined bronchial respira- tion is, in the majority of cases, to meet with complete consolidation of the pulmonary tissue. It is thus that in extensive infiltrations and in hepatization of the lung we find the bronchial or blowing breath- ing so marked ; particularly so in the latter morbid state, for the most distinctly blowing, or tubular, respiration is heard in pneumonia. The bronchial breathing encountered in disease resembles more that heard in health over the larynx or trachea than that heard over the larger bronchial tubes. It entirely replaces the vesicular sound, which has for the time being ceased to exist. It differs from the normal vesicular murmur by its higher pitch ; by its occurrence equally in inspiration and Jh expiration; by its blowing character, especially in expiration; and by the pause between inspiration and expiration. Harsh respiration resembles it most ; but this, or vesiculo- bronchial respiration, is, as already stated, a transition from vesicular to bronchial breathing. Whether bronchial respiration be owing, as Laennec taught, to a better transmission of the sound of the tubes through the solid lung ; or whether it be produced, as Skoda declared, by consonance, is not of much consequence for diagnosis. The important practical fact connected with this form of respiration is, that it happens when the pulmonary tissue is condensed ; this, in the laige majority of cases, takes place from exudations or deposits, in a small proportion only, from compression by growths or effusions. At times bronchial respi- ration is also met with in severe cases of asthma in which the air does not expand the air-vesicles. A variety of bronchial respiration, at least so far as the quality of the sound determines the point, is that significant sign, cavemaua respiration. This is essentially a blowing sound ; yet it is not always distinct during both inspiration and expiration, being often only per- ceptible in the one, and mixed in the other with gurgling. It is less diffused, more hollow, and of much lower pitch than ordinary bron- chial respiration, and is apt to alternate with gurgling. Hollow spaces of any kind — from abscesses, from bronchial dilatation, from breaking-down cheesy degeneration, from softening tubercle — ^give rise to it. Its comparatively low pitch may cause it to be confounded with the vesicular murmur. With reference to this it is only necessary to recall that the vesicular murmur is devoid of all blowing quality. Amphoric respiration is a blowing respiration engendered in a large cavity with firm walls. Its peculiar character is owing to an 280 MEDICAL DIAGNOSIS. echo from the walls of the cavity. It may be humming and of low pitch, or decidedly ringing and metallic. Amphoric or metallic respi- ration is always indicative of a large cavity ; the sound is rarely met with in phthisis ; much oftener is it heard over the cavity which is formed between the layers of the pleura, by the entrance of air. Another variety of breathing connected with a cavity is the so- called meiamorphomng breath sounds to which Seitz has called atten- tion. It occurs only in inspiration, and consists of a very harsh sound, which lasts for about one-third of the period of inspiration, when it is continued as blowing respiration, attended with metallic echo or ordinary rales. The cause of the phenomenon is the air entering through a narrow opening to reach the cavity. Flint ^ re- gards this sign as a variety of w^hat he calls broncho-cavernous respi- ration. The sound of expiration in broncho-cavernous breathing is bronchial, high in pitch, and indicates a cavity situated near a portion of consolidated lung. In vemcnlo^avernous respiration the cavity is surrounded by comparatively intact pulmonarj^ tissue, and this gives an admixture of vesicular sound. New or Adventitiovis Sounds. — ^These consist of soimds wliich have no analogue in the healthy state, and which are not, therefore, moiUlications of the normal respiration. Of this kind are the rales; crackling : the friction sound. Nearly all ralcs^ or rhonchi, are sounds which are generated in the air-tubes by the passage of air through them when contracted or when containing fluid. In the first case are occasioned dr}% in the sei'ond, moist rales. Rales may occur in inspiration or in expiration, or during both acts. They may obscure or entirely take the place of the natural murmiu^. They may have their seat in the upper air- tubes, or in any division of the bronchi. A\Tien in the larynx or in the trachea, they are called tracheal rales ; of these the death-rattle is an exami>le. When in the bronchial tubes, they are designated bn>nchial niles ; and, as this is their most frequent situation, the term rale means a bronchial nile unless the location be specially indicated. Ory niles an\ for the most pari, produced by the vibration of thit k fluids which the air cannot break up, and which temporarily narn>w the caliber of the tube. When this narrowing exists in the smaller bn^nchial tube, the sound wliich results is high-pitched, — aihihiiit : when in the larger, unless the caliber be much altered, it is K>w-pilched, mori* musical, — mmomu^. A similar difference is ob- served with n^fertMice to the moist or bubbling sounds. When the ^ Uvtvtn^s on Thysiiwl Kxplonition of the Luiigs, 1882. DISEASES OF THE LUNGS. 281 fluid is thin, whether it be mucus, blood, or serum, and breaks up into large bubbles, large bubbling sounds are occasioned ; when it separates into small bubbles, small bubbling sounds are the conse- quence. The latter, for obvious reasons, generally take place in the smaller tubes. Fig. 26. ^-^^^ /Mm/\SMS. Sonorous, bubbling. Small bubbling. ^W /J9/ Mj "^Jl^ Sibilant. Crepitant. Diagram illustrative of rftles. The narrowing in one division of the tube gives rise to dr>', the fluid in the other to moist, rftle«. The rAles at the termination of the tube and in the air-vesicles are the crepitant or vesicular rftles. Neither dry nor moist rales are persistent, but vary in intensity, or shift their position, as the air drives the liquid which gives rise to them before it. Dry rales are particularly prone to be dislodged by coughing. When they are uninfluenced by the act of breathing or of coughing, they do not depend upon the presence of secretions, but upon a narrowing of the air-tubes from the pressure of surrounding tumors, or from a fold of thickened mucous membrane, or by a spasm. It has just been stated that rales are, for the most part, produced in the bronchi by the passage of air through fluids there contained. This is their most frequent seat ; but they are not limited to the tubes. Similar conditions may give rise to rales in other places. We find liquids in cavities breaking up into large, sharply defined, bubbling rales, the so-termed cavernous rale, — gurgling ; or having in cavities of considerable size a ringing metallic character ; and again, the pres- ence of fluid in the air-cells occasions a minute rale, the crepitant 18 282 MEDICAL DIAGNOSIS. This vesicular rale, or crepitation^ is a verj' fine sound, or rather a series of very fine uniform sounds, occurring in puflfs, and limited to inspiration. It resembles the noise occasioned by throwing salt on the fire. Its name indicates its seat. It is caused by the agitation of fluid in the air-cells or in the finest extremities of the bronchial tubes ; or, to adopt a view now held by many, by the forcing open during inspiration of the air-cells agglutinated by the exuded lymph. The first stage of acute pneumonia is the state in which this rale is mostly engendered. , The rales, including crackling, may be thus grouped : Bronchial Rales. Dry or vibrating f Low-pitched (sonorous). sounds. 1 High-pitched (sibilant). Moist or bubbling f Large bubbling (mucous). sounds. 1 Small bubbling (subcrepitant). Vesicular RAles. | Crepitation. ( Crackling (?). RiLE OF Cavities. | Hollow bubbling, or gurgling. ( Metallic rales. CrackUtifji is a sign closely connected with rales, and, though its mechanism is undecided, it is regarded as a rale. It consists of a few fine and readily discerned crackling sounds which happen generally in cases of puhnonarj' tubercle, of which, therefore, they are consid- ered as diagnostic. The distinction between crackling and the crepitant rale is puz- zling. The chief difference is in the number of the sounds. Crackling is a few fine sounds lin\ited to inspiration, and heard commonly at the apex of the lung. Crepitation is a number of fine sounds limited to inspiration, but more diffuse, and heard generally at the base. The sound is similar because the conditions giving rise to it are similar. Ht>lh depeiul upon tenacious fluid or semifluid matter in the ultimate structurt^ of the lung: in the one case it is tubercle or cheesy degen- eration, in the other usually the exudation of beginning inflanunation. The cn\ckling which indicates soflening, as of tubercle, — called by some authors nudist crackling, by others clicking, — ^is a succession of sminds like small moist niK^, only less liquid than these, because lm\iki»\g-up tubon^le is not very fluid. AMien cavities form, and the fluid matter in tliem is ;igitatod by the ingress and egress of air, the largi^ bubbling, ringing n\le of cavities, or guii^ng, is occasioned. Ury cnukling, moist crackling, and gurgling accord then with the on^pitant nilo, snmll bubbling, and larg\^ bubbling sounds, and happen in tho pnyn^ssive sIj^^s of intiUration ;uid softening of deposits, and jtMiowUy in thw^o of a tulvnuilar nature. DISEASES OF THE LUNGS. 283 Pleural friction, or the sound due to the rubbing together of rough- ened pleural surfaces, consists of a number of abrupt superficial noises heard in inspiration and expiration, rarely in either alone. Its seat is not usually extended, for it is, as a rule, only audible over portions of the lower part of one side of the chest. Sometimes it is so creaking and intense as to be distinctly perceptible to the hand as well as readily recognizable by the ear. But it may be so much like crepitation that even long practice in auscultation will not enable us to determine at once whether the fine sounds we hear are the friction of a roughened pleura, or the vesicular rales of an inflamed lung. Nor is it, in some cases, less perplexing to discriminate between fine friction sounds and fine moist rales. By the sound alone it is often impossible ; concomitant phenomena must be taken into account. A friction sound is mostly confined to a smaller space, and is unin- fluenced by cough ; while cough changes the position and the distinct- ness of rales. Yet even this rule is not absolute. A fine friction sound may be temporarily increased during the deep breathing which follows the act of coughing ; on the other hand, the influence which cough exerts on the small moist rale is not so great as on the largei bubbling sound. As for the more marked character of moisture which a rale is said to possess, that only aids us in some cases. The features most at variance between the Mction sound and crepitant rales are : ttiat the friction phenomena are not strictly limited to inspiration as are the vesicular rales, are not seldom coarser in expiration than in inspiration, acre less uniform, and that their seat is more cir- cimiscribed. Their production nearer to the ear may assist us, but does not always. The reason why some of the finer friction sounds resemble so closely fine moist rales or crepitation is apparent when we reflect that the irregularities in the pleura may be slight, and be surrounded by fluid which keeps them moistened. Bruen has called attention to the value of making the chest walls immovable.^ When the chest is fixed, especially at the lower two-thirds, by the hand of an assistant, and the ear or the stethoscope is applied over the doubt- ful sounds, they will be found to have disappeared if of pleural origin, but to be still discernible if rales. The creaking or grating varieties of Mction are much easier of recognition than the finer forms. Their discrimination from rales is readily affected by noticing the rubbing and harsh character they possess. * Physical Diagnosis. 284 MEDICAL DIAGNOBIS. Attiintitafion r^f ike Voice, When the ear is applied to the tliorax of a healthy person who speaking, a confused hum is perceived, most distinct in adults who possessors of a deep voice, and tremulous in the aged. Now, the normal vovftl remnanve, for by that name the ill-defined vii>rations are called* is more marked on the i%ht than on the lell sitle, and eorre- sponds to the vesicular murmur. Over the bronchial tubes a more concentrated sound strikes the ear. This, termed brom^hophann, ac- cords with bronchial respiration, and, when detected over ttie lung, denotes, ^vith rare exceptions hereafter to be referred to, the same as broncliial respiration,— increased density of j^ulmonary tissue caused by pressure or by deposit. Any norma! vocal resonance which is augmented passes by degrees into broncliophony, and has a meaning similar to it. Of tiie sound known as bronchophony there are several varieties the mmple hmmhophony just exjilained, — observed in pneumonia, in any form of consolidation \ tlie hollow, mventam rmw, or peelc rilocfuy ; and tlie bleating variety, or mpphontf The latter, indicative* of a Ihin layer of Ihiid between compressiHl lung and the ear, is a^ sign generally too transitory to be of murh diagnostic value; and pectorilrKpiy, if by this be understood what l>aennec meant, — com^ plete transniission of articulated words, — is of no special significaneej as it may be met with where no cavity exists. But if the term applied to a wellMlefined chest-voii'e, of hollow character, and heard' as such cner a comparatively limited space, pectoriloquy is a distinct physical sign, and really deserves the ntime of cavernous voice. TWs is piirticularly true of whrnpfrimj pectoriloquy. Over lai^e cavities tlie voice is peculiarly ringing and mtifiiiic. The conditions wliicli produce amphoric or metallii^ voice are the same as ttiose which occasion any of the amphoric or metallic phenomena. Be the respiration meta]lit% be the voice metallic, be tlie rales metallic, tliey are all caused by a cavity lai-ge enough and with walls firm enough to reflect, to echo tlie sound. Bronchophony and anq^horic voice are insLmces of increase anijfl change of character of tlie normal votal resonance. A dlminhher^^ vovttl rtwmanve occurs when the lung is compressed by air or lluid, in pleuritic effusions, or in pneumothorax ; or when it is greatly tended with air, as in extreme cases of emphysema. Clinically s|)eak- uig, the sign is most oHen encountered in pleuritic eflusions. Tlie vibrations of the voice may be feii as well as heard. The vibration detected by placing tlie hand over the thorax when the patient speaks, the roral fn'miiuit, is, like (he voice, increased h consolidation of puimonary tissue, and diminished by fluid or 4 the pleura. Its relations to the voice are. however, not uniform ; ing i ive^ s a 4 disfl DISEASES OF THE LUNGS. 285 somefinies with increased density of the lung^-tissue there is no in- creased freniittis, altlioiigli there is increased ohest-voice* In wrimen the sign is valueless ; indeed, its main iinj>ortance is derived from Us uhstmee in eases of pleuritic effusions. Like ilie chest-voice, it is most marked on the right side. liales, when extensive, sometimes cause a vibration to be trans- mitted to Uie eldest walls, as do the fluids in cavities. The former phenomenon is called the hmnchial f remit ns, the latter the pav^rnous frcmUits, A Iriction sound that may be felt is designated as the pleural fremihw. The Combination of the Physical Signs, and the Examination of Patients aflfeGted with Disease of the Lungs. In the preceding pages isolated physical signs have been discussed. But if in the investigation of disctise we were to trust solely to iso- lated signs, our conclusions would be incomplete and unsatislaclory. All the methods of physical exploration most be employed, the results obtained compared with one another, and the attending symptoms carefully inquired into and brouglit into connection with the physical signs, before a diagnosis is made, Ttie manner of investigating by these methods has been detailed : it need not here be rej>eated. But wtiat may be repealed is, that tliere are two lungs ; that it is incumbent always to explore botli, and, as we proceed, to compare the action of one with tliat of the other. As many of the signs elicited by the various methods of pliysical diagnosis depend on the same physical conditions, they may be studied in groups. The following will be usually found to be associated : Association of Physical Sioks. Perccwiok. AUSCULTATION OS ' AUSCULTATION Vocal PRKunTtrs. Ph^'hical Cokdition. RESFlIIATiajf. OF Voice. Ck«r V«*icular KonnAl vficftl 0Dlm paired. Lung'tisBue heaUhy or nearly murmur or reson&ace. bo; at ftoy mte, no In- Its lUfMllfieii.- creofied density of liin^- tion. tvmie from deposit or from pressure. Bronchiitl, BniTH'htii^hojvy Uwremed. SolldUicyition of pulmonaiy or harsh structure. Dull resijJmtloTi, Aliwjtii respi- At^Hpnt vttfoe. Diminl!?he*i or £ffu8ioD into pleural gae. ^ ration. absent. TjTDpMlltiJC... .. Qivcroout or Uticerraln ; Uncertain : Incj^iuied quantity of air feeble aocoTd- caverocMJi or nwistly Ai- within the *.'he»t. or air con- log to cause. diminished. minUhed. fined In particular points ; cavity or U> over-4l»tention of Uie air-cells. Amphoric or Amjihoffc or AinphiiHt; or MosUy dimlii' lArge cavity with elastic mi^lic nnM»lllc mettkUIr -d. walls. Or»rke^ with its age. Verj^ young children may be examined either in a lying or sitting posture in the lap of their nurses, or may be held in the arms of an attendant, who is directed to present the different parts of the thorax successively to the ear of the physician. From the cry, when studied with the ear applied to the thoracic walls, we obtain the same indications as from the vocal resonance. Infants between two months and two years breathe irregularly, and about thirty-five times in a minute. Between the ages of two and six years the average number of respirations in the same space of time is twenty-three. The breathing is also of a different type from that of the adult ; it is abdominal, and can be more readily counted by noting the rising and shrinking of the abdomen than by watching the slight movements of the chest. Before proceeding to the discussion of the symptoms of pulmo- nary diseases and of the diseases themselves, let us group the latter according to their anatomical seat. Diseases of the Lungs and their Coverings. Bronchial Tubes Inflammation, or Bronchitis ; Acute Chronic . Lung-Tissue Dilatation ; Narrowing ; Diseases of bronchial glands ; Spasm of muscular fibres or asthma, Congestion ; Hemorrhage ; Apoplexy ; Oedema ; Collapse ; i Hypertrophy ; Of large-sized tubes. Of capillary tubes. Ordinary chronic ca- tarrhal form. Putrid bronchitis. Fibrinous bronchitis. DISEASES OF THE LUNGS. 287 Diseases of the Lungs and their Coverings. — Continued. Inflammation, or pneumonia, in varied fonns ; Induration ; Abscess ; Cirrhosis ; Gangrene ; Lung-Tissue { Emphysema ; Tuberculosis, chronic and acute ; Pneumoconiosis ; Cancer ; Deposits, such as syphilitic, etc. ; Parasites. ' Inflammation, or pleurisy ; Empyema ; Pleura } Hydrothorax ; Haemothorax ; Tuberculosis ; . Malignant growths. Pleura akb Lu«o | Pneumothorax ; (. Perforations and fistulous openings. 1 Pleurodynia ; Walls of Chest \ Intercostal neuralgia ; Abscesses, etc. The Principal Symptoms of Diseases of the Lungs. Of the symptoms about to be mentioned, not one belongs exclu- sively to pulmonary diseases. We have met with some of them in studjing laryngeal complaints ; we shall meet with them again in ex- amining the affections of the heart. And in investigating them here we shall not view them simply with reference to morbid states of the lungs, but shall indicate their general relations to diseased conditions, even at the risk of discussing what might in part be more appro- priately discussed elsewhere. The symptoms which it is proposed more specially to sift are dyspnoea, cough, and haemoptysis. Dyspnoea. — Dyspnoea means difficulty of breathing. It is accom- panied mostly by a sense of uneasiness and suffocation, and by increased frequency of the respiratory act. But increased frequency of breathing may exist without difficult breathing. The respiration may be slower than natural, yet laborious. Dyspnoea depends upon various causes. Feeble persons are sometimes troubled with it after the slightest exertion. It may be temporarily produced by any bodily or mental excitement. It is ob- served when the play of the diaphragm is interfered with, and the 288 MEDICAL DIAGNOSIS. lun^' cramped in its expansion. This is its cause in ascites, in ab- dominal tumors, and in pregnancy. It may occur in perverted inner- vation, as in hysteria, or in connection with cerebral affections, from want of power in the respiratory muscles, or it may be due to morbid blood conditions, as in anaemia, scurvy, uraemia, and septicaemia. It is, however, most frequently met with as a prominent symptom of the disorders of tlie larynx and trachea, or of the heart, and in the various diseases of the lung and pleura, whether idiopathic or secondary. Being common to so many morbid states, it is not diagnostic of any. Dyspnoea is usually aggravated by position. When the patient lies on his back, the respiration becomes more difficult. The form of dyspncL'a in which the sufferer is obliged to remain in the erect pos- ture in order to breathe, is termed orthoprwea. This is witnessed in extensive pleural effusions, in pneumothorax, in oedema of the lung, and in affections of the mitral or tricuspid valves. Dyspnoea may come on in paroxysms, and constitute the only, or certainly the principal, symptom. This is the case in asthma. Asthma, — Asthma consists mainly in a spasmodic narro\ving of the bronchial tubes, caused by contraction of their circular muscular fibn^s. Its chief symptom is distress in breathing, occurring in par- oxysms, iuid attended with wheezing. These spasms may be preceded by a feeling of suffocation, or they may come on suddenly. The pa- tient Wilkes up out of his sleep, finds himself wheezing and with a fit of the disease fully on him. He continues to respire with great diffi- culty, sits upright in bed, or walks about the room gasping for breath. His look is anxious, the face pale, and the color of the lips shows that tJie blood is not properly aerated. In spite of the struggle to get air \\\\o the lun^, the chest moves but little, and when the ear is placed on it, no vesicuhir murmur is heard, simply the same loud wheezing that is pen^eptible to the by-standers : or bronchial breathing at the upper i^irt of the chest, or sonorous and sibilant rales are detected, due for the most i^ui to the narrowing of the bronchial tubes, and disiippearing with the s^viism. These dry rales are chiefly expiratory, and the lung's an* very full of air, and displace the diaphragm down- wanl by several intercostal s^vwt^. At the end commonly of some hours the tit jvjisses otY with copious exj-HH^toration. and as suddenly as it oanu\ Hut it uuiy last for days, ameliorating in the daytime, oxaoerlvitii^: at ni^Mit, and only ceasing gradually. WTiere it fire- quentlv nvurs it j:ivos rise to markeil omaoiation. The oxvitin^ causes of tlu^e bn^nchial spasms are various. In some ivrsons tlien* is no apv^irtMit rtwson for the attack ; in others it is brvM^Hxt on by t)\e inha!atioi\ of irritating fumes or of disagreeable DISEASES OF THE LUNGS. 289 vapors. In some it is preceded by digestive disorder, or by bronchial catarrh; in others, again, an interruption to the free circulation of blood in the lung, or a disturbance in the sexual organs or in the uri- nary secretions, seems to occasion it. It is not unusual to find, on closely questioning patients, that for some time prior to the asthmatic paroxysm they have passed a scanty, dark-colored urine. During the attacks Leyden found in the sputum peculiar crystals, farther on de- picted. Another interesting fact connected with the paroxysm has been pointed out by Curschmann, — the presence on the turgid, swollen mucous membrane of the bronchioles of a characteristic viscid exudation. This generally shows in the sputum in little pellets that have a spiral structure, very easily discerned by the microscope. Now, whatever be the exciting agent that calls the bronchial spasm into existence, the symptoms of the attack of asthma are the result of the spasm. Yet asthma is not ojiea-as^ure neurosis. The seizure itself is the expression of perverted nervous action. But there are generally permanent conditions present, such as disease of the brain or medulla, of the heart, of the lungs, of the ovaries, of the kidneys, of the stomach, or of the nose, — as polypi or hypertrophic rhinitis, — which act as constantly piedisposingjsauses to these seizures, and lead to attacks, either by direct irritation of the pneumogastric nerves or through the medium ofJhe_reflex system. Emphysema especially is a fruitful source of spasmodic asthma. Asthma has been noticed to replace other neurotic affections, such as epilepsy.^ The detection of the causes inducing an asthmatic fit may be diffi- cult ; but tlie diagnosis of the fit itself is not so. No disease of the lungs or bronchial tubes is likely to be mistaken for it, because no disease of either gives rise to the same symptoms. The dyspnoea of pleurisy or bronchitis is not paroxysmal, nor is it attended with wheez- ing. Some of the affections of the larynx and trachea bear a nearer resemblance ; yet they, too, announce themselves by different symp- toms. Asthma may be distinguished from ormij) by the entire absence of fever, and by its lacking the peculiar hoarse voice and cough which appertain to the forms of this malady. The age of the patient is also very different : asthma is as rare in a child as croup is in an adult. (Edema and spasm of the glottis differ from asthma by the much more markedly paroxysmal nature of the difficulty of breathing, by the shorter duration of the seizures, and by the absence of the loud and continued wheezing. The sensations of the sufferer, too, indicate correctly the seat of the obstruction. And so they are apt to . • * Lancet, June 10, 1893. 290 MEDICAL DIAGNOSIS. do in some of the paralyses of the vocal apparatus^ where noisy dyspnoea happens, and is aggravated in paroxysms. Further, we are aided here by the aphonia, by the inspiratory character of the stridulous breathing, by the absence of chest rales, and by the obvious lesion seen in the laryngeal mirror. A large goitre pressing on the trachea may give rise to dyspnoea and to a noisy sound in breathing ; but the cause of both is easily traced to the tumor in the neck. The most deceptive condition is when the glands of the neck enlarge suddenly and press on the trachea. I had, some time since, a young man under my care for acute bronchitis. He was progress- ing favorably, when one day he presented himself, breathing with great difficulty, and each respiration attended with a noise like the wheeze of asthma. I should have regarded him as having been attacked with asthma had I not, in looking at his neck, detected the group of enlarged glands. Marked dyspnoea may be occasioned by the pressure of an aneu- risinal tumor, or by an organic disease of the heart. But the stridor and the persistent difficulty of respiration in the first, aggravated though it may become in paroxysms, and the constant want of breath in the second, are not likely to be mistaken for the wheezing and the paroxysmal dyspna^a of asthma. True asthmatic seizures may both produce and be produced by a disease of the heart. But w^hat is called " cardiac asthma" is not often a spasm of the bronchial tubes : it is usually only a paroxysmal dyspnoea, or a temporary increase of the dyspnoea, dependent upon a decided obstruction to the circulation in the lungs, and not accompanied by wheezing. So, too, renal asthma is only very rarely a true bronchial asthma^ being usually an aggravated form of dyspnoea associated with chronic Bright's disease. So-called thymic asthma is a severe dyspnoea accom- panying enlargement of the thymus gland, and aggravated in parox- ysms. It is especially met with in children. There is a peculiar form of difficulty of breathing connected m\h a loss of power in the diaphragm. When the disorder is fully devel- oped, even the slightest effort gives rise to a feeling of suffocation and to accelerated respiration. The voice is much enfeebled. But the most significant sign of the paralysis is, that during inspiration the epigastrium and the hypochondria are depressed, while the chest dilates ; and the converse takes place during expiration. If there be merely a lessened power of the diaphragm, these phenomena are ob- served only during forced breathing ; a paralysis of one-half of the muscle occasions them on one side alone. Duchenne adds another unportant diagnostic tost of a paralyzed state of the diaphragm, — DISEASES OF THE LUNGS. 291 naniely, that if the phrenic nerve be galvanized, the diaphragm acts again with proper strength, and during inspiration the abdomen rises simultaneously with the thoracic walls. To discriminate the cause of the impaired or lost muscular force, — whether this be due to a lesion of the nervous system, or to inflammation of the muscle or of the adjacent textures, whether produced by rheumatism or by lead poisoning, or originating in progressive muscular atrophy, — we have to rely chiefly upon the history of the case. In rheumaiism of the dia- phragm, an absence of the vesicular murmur over the lower por- tions of the chest ; respiration effected by the upper ribs exclusively ; tense, hard abdominal walls ; want of power to strain so as* to aid the bladder or intestines in expelling their contents, with darting, stabbing pain from the spine to the margin of the ribs on each effort to inspire, — have been particularly noticed.^ In fatty degeneration of the diaphragm, which ofl:en coexists with a fatty heart, we find, in its last stage, great distress and difficulty of breathing, and death may rapidly follow the embarrassed respiration.* Another form of dyspnoea is the so-called Cheyne-Stokes r€»pira^ Hon. It consists in inspirations at first short, then deeper and more and more labored, till the paroxysm is at its height ; then becoming shorter, and more and more shallow, until the breathing is suspended. The pause lasts from one-quarter of a minute to a minute, when the respiration begins again in the same manner, first faint, then a little stronger, then still stronger, until it reaches its height, when it again subsides in a descending scale, to end in the same stand-still. This kind of breathing is a very bad sign. It is apt to happen when from some cause the supply of arterial blood is cut off from the respiratory centre in the medulla, or from this and the adjacent vasomotor centre. It is rare in diseases of the lungs, much more common in fatty heart, in disease of the aorta, in tubercular meningitis, in apoplexy and affec- tions compressing the medulla, in uraemia, and in sunstroke. It may be found in cases that recover, and be of long duration.^ Cough. — Cough is a sudden and violent expiration, having usually for its object the expulsion of some annoying substance from the air- passages. But it may be purely nervous, and unconnected with the presence of any irritating matter in the respiratory organs. There are several kinds of cough : according to the amount of expectoration. ^ Chapman, Boston Medical and Surgical Journal, July, 1864. * Callender, London Lancet, Jan. 1867. ' As in the case of granular kidney, reported in the Clinical Society Transac- tions, vol. xxiii., 1890. 292 MEDICAL DIAGNOSIS. a cough is dr>'^ or moist ; according to its origin, it is laryngeal, tracheal, bronchial, sympathetic, etc. A dry cough is indicative of irritation. This is often seated in the larynx and the trachea, or in their vicinity, or in the bronchi, or in the lung itself. An elongated uvula, and many of the diseases of the nose or the pharnyx, give rise to a dry cough: it happens, too, in pleurisy and in the early stages of phthisis. In disorders of tlie larynx and trachea the cough is attended with a peculiar shrill noise, or a hoarse sound. But the irritation may not be situated at all in the respiratory system. Affections of the liver, stomach, intestine, uterus, or brain will occasion an obstinate dry cough. It is also pro- duced by dentition, by diseases of the ear, by the presence of worms in the intestinal canal, by disorders of the heart, and by thoracic aneurism. Again, it may be strictly nervous. The brazen cough of hysteria is dry ; indeed, nearly all sympathetic coughs possess a dry character. A moist cough may succeed to a dry cough. The moist cough depends, for the most part, on the presence of fluid in the bronchial tubes or the lung-structure. It attends bronchitis with free secretion, oedema of the lung, the more advanced stages of all the forms of phthisis, and pneumonia, when the exudation is breaking up. It is generally accompanied by a free expectoration, which varies in appearance and amount with the morbid state causing it. Cough is frequently preceded by a sensation of tickling in the larynx, to which the patient is apt to refer his whole disorder. It is much affected by position. Lying down often increases its intensity. Sometimes a cough occurs in severe paroxysms. In various laryngeal affections, in abscess of the lung, in consumption, and in bronchial phthisis, such fits of coughing are observed. But in no complaint are they so constant as in whooping-cough. ]\liooj)i7ig- Cough, — This is essentially a disease of childhood, and the result of an epidemic influence and of contagion. The peculiar spasmodic cough succeeds to a catarrh of more than a week's dura- tion. During the paroxysms the eyes fill with tears, the child's face is injected and anxious, and its whole appearance shows how it is suf- fering for want of breath. The air in the lungs is expelled by a series of abrupt spasmodic expirations, when a long-drawn inspiration, attended with a whoop, temporarily puts a stop to what appears to be threatening suffocation. The rest is, however, short. The cough recommences, and is again followed by the loud whooping inspiration. It continues in this manner until, after a copious expectoration of stringy mucus, or after vomiting, the paroxysm ceases, and a more DISEASES OF THE LUNGS. 293 lengthened calm ensues. These fits of coughing repeat themselves at varied intervals during the twenty-four hours. They are very fre- quent at night. Yet the child's health remains good, in spite of the violence of the attacks and the length of time they are spread over. The spasmodic cough lasts for weeks ; the whoop then ceases, the cough loses its ringing sound, and gradually leaves entirely. It is only in comparatively rare instances that it persists, and is followed by the development of tubercles in the lungs ; just as it is only in exceptional instances that bleeding from the nose or lungs, petechiae on the fore- head, or ecchymoses of the conjunctivae happen during the violent coughing. In about one-half the cases the cough is violent enough to produce ulceration of or around the freenum linguae, from the force with which the tongue is propelled against the teeth. Fre- quently the ulcer is covered with a grayish exudation; it is never noticed before the paroxysmal stage is well established. Sugar is at times found in the urine. As an early symptom of whooping-cough, photophobia with dilatation of the pupils has been observed.* Con- vulsions are in very young children not infrequent. Whooping-cough is often associated with measles. An aflfection of so long duration, marked by such a peculiar sign as a whoop, is of easy diagnosis. Yet there are certain conditions with which it may be confounded. In its first stage, before the char- acteristic cough sets in, it may be mistaken for acute bronchitis. There is, indeed, at this period, no means of distinguishing between the two disorders, except by taking into account the tendency to choking, to flushing of the face, and to vomiting in whooping-cough ; for it is only seldom that the cough possesses from the onset a decided ring. And bronchitis is in fact the most frequent complication, or, to state it more accurately, almost an essential element, of the malady. It is usually present in a mild form at the start; it outlasts the parox- ysmal stage. At the height of this, a severe attack of acute bronchitis or of broncho-pneumonia may temporarily mask the special traits of pertussis. Again, occasionally acute bronchitis may exhibit parox- ysms of spasmodic cough. But the want of the nervous element in the disease, the absence of the whoop and of the recurring flushing of the face as well as of the vomiting, the dyspnoea between the parox- ysms, the decided fever, do not permit us to be long in doubt. A disease less easy to discriminate from whooping-cough is tuber- culization of the bronchial glands, or bronchial phthisis. It, too, pro- duces a ringing paroxysmal cough. It, too, occurs in children. There * Huguin, quoted in British Medical Journal, Sept. 26, 1891. 294 MEDICAL DIAGNOSIS. is, however, this difference : the enlarged bronchial glands are apt to press on the surrounding parts. This becomes manifest by the en- gorgement of the veins of the neck, by the lividity and puffiness of the skin, by the difficulty in breathing and in swallowing. The char- acter of the voice, also, may change ; and yet there may be no abnor- mal physical signs in the chest. But often there is dulness on per- cussion between the scapulae, where the swollen bronchial glands lie, and impaired respiration in portions of the lung. The symptoms are those of pulmonarj' phthisis, with which the disease, indeed, may be associated : there are emaciation, and the same loss of strength, the same sweating at night, the same hectic fever, the same tendency to diarrhoea. At times the affection of the glands induces a caseous pneumonia, — in reality tubercular. Now, when we compare these phenomena with those presented by whooping-cough, we miss the whoop, the vomiting accompanying the fits of coughing, the ulceration or tearing of the fraenum of the tongue, — a symptom usual, at least, in decided cases, — the epidemic or contagious origin, and the distinct periods, first of catarrh, then of spasmodic cough, then of gradual decline. We see, on the contrary, an affection of more gradual and uniform progress, which often proves its existence by special signs, among which a venous hum, heard when the stethoscope is placed upon the upper bone of the sternum while the child bends back the head, has been particularly noticed.^ When emaciation, hectic fever, and marked cough are met with in the last stage of whooping-cough, it is always highly probable Uiat this has been followed by a tubercular deposit, and finding tubercle bacilli in the sputum confirms this view. It is not likely that such cases will be mistaken for those instances of pulmonary consumpUon in which violent paroxysms of coughing occiu*. The age, the origin, the histor>' are different. Equally dissimilar are the history and the symptoms m other spasmodic coughs, such as those of hysteria and of some laryngeal affections. The Sputum. — The consistency of the expectoration varies very much. When it is viscid and tough, it contains a lai^e amount of mucus or muco-pus, and depends generally upon inflammation or a high degree of irritation of the bronchial membrane or of the lung parenchyma. When it is less tenacious, it has far less mucus, and a preponderance of pus. When fluid and full of air, it floats ; when dense and without air, it sinks. Fluid sputum forms a homogeneous mass ; dense sputum assumes a round or irregularly round shape. ^ Eustace Smith, Loudon Lancet, Aug. 1876. DISEASES OF THE LUNGS. 295 When these purulent masses float in a thinner expectoration, we have the coin-shaped or nummular sputum, so common in instances of pulmonary cavities. The quantity of the expectoration varies greatly in different dis- eases of the lungs. In the most acute stages, or in spreading inflam- mations, it is usually small, and increases as the difficulty lessens. In bronchial dilatation, in pulmonary abscesses, especially when they burst, and in the voiding of a collection of pus in the pleura through the bronchial tubes, the amoimt discharged is very large, and consists almost entirely of pus. The color of the sputum depends a great deal on its constituents. When mucous, it is white ; when muco-purulent, yellowish or yel- lowish-green; when purulent, generally greenish or of a yellowish- green. It is also tinged by bile, by pigment, and by blood. Sputum consists chiefly of water, serum, albumin, mucin, nuclein, and many salts, such as the chlorides of sodium and magnesium, the sulphates of sodium and calcium, and the phosphates and the car- bonates of sodium, of magnesium, and of calcium. It has an alkaline reaction. In certain diseases, especially in putrid bronchitis and in gangrene of the limg, it contains ferment that acts like the pancreatic ferment.^ Microscopically examined it exhibits pavement, columnar, and alveolar epithelium, leucocytes, blood-globules, various forms of crys- tals, such as the slender needles of the fatty acids, fibrinous coagula, bacteria, fungi, and elastic fibres. The alveolar epithelium is mostly of elliptic shape, and often shows little fat drops or pigment particles. The fatty acids and the elastic fibres are encountered in diseases in- volving disorganization of the lung-tissue. Mould fungi, forms of leptothrix, and sarcinae have been specially noticed. The latter are smaller than the sarcinse ventriculi. The fungi are most common in the sputum from cavities, in putrid bronchitis, and in gangrene. The leptothrix masses are readily recognized by their blue stain with a solution of iodine and iodide of potassium. Elastic fibres in the sputum are very significant ; they indicate lung-destruction. They may be found as a bundle of fibres, or in the shape of the alveolar lung structure. In the latter instance they are even a more valuable sign than in the former. Elastic fibres are met with most frequently in tubercular lung-destruction, but they also occur in abscess and in gangrene of the lung, in cavities from bron- chitis, and, according to Jaksch, in pneumonia, even where there is no * Stadelmann, Zeitschrift filr klinische Medicin, xvi., 1889. 296 MEDICAL DIAGNOSIS. abscess. The most certain way of finding the elastic fibres is to liquefy the sputum by means of caustic soda, or to boil it in a solution of caustic soda or potassa ; the particles that fall to the bottom of the vessel can be readily removed and placed under the microscope. Fig. 27. Fig. 28. Elastic fibres of pulmonar>' tissue, after treats ment witli caustic soda. A spiral macmified. Spirals are structures also possessing considerable significance. They have been studied especially by Curschmann, who traced them to an exudative inflammation of the bronchioles. They are most common in asthma, and bear a close relation to the Charcot-Leyden crystals which are often embedded among the coils. They have also been found in pneumonia. They consist chiefly of a substance allied to mucin, and are large enough to be detected in the sputum with the unassisted eye, though their peculiar structure and the central thread are recognized clearly only with the microscope. Fibrinous coagula are found in the sputum of pneumonia, of diph- theria that has extended into the lung, but especially in plastic bron- chitis, where they furnish a very valuable diagnostic sign. They are moulds of the ramifications of the finest bronchial tubes, whitish in color, of arborescent appearance, and consisting of fibrin. They are small in pneumonia, and do not generally occur in any number ; should they be numerous the gravity of the case is greatly increased. They can be seen with the naked eye, or studied with a low magnifjing power. In the description of plastic bronchitis a fibrinous mould is depicted. Diflferent crysUtls can bo discriminated only with the microscope. We find cholesterin crystals in the sputum of tuberculosis and in abscess of the lung; the long, thin needles of maif[aric acid more DISEASES OF THE LUNGS. 297 especially in pulmonary gangrene and in putrid bronchitis. In the latter disease and in empyema breaking into the lung there have been also noticed by Leyden tyrosin crystals. Crystals of hsematoidin follow a hemorrhage retained for a time in the bronchial tube. If the blood- crystals be conjoined to cells, they indi- cate, according to Jaksch, a previous Fig^29. hemorrhage ; if any large number of them exist free, they point to a rupture of an ab- scess from neighboring parts into the limg structure. Uric acid crystals are encoun- tered in the expectoration of gouty patients. The colorless, sharply pointed, octahedral or rhomboidal crystals described by Leyden and Charcot, and named after them, occur in various conditions, as in acute bronchitis ; Charcot-Levden crystals. in the blood, mtestinal tracts, and bone- marrow of leukaemia ; but particularly in asthma. There they seem to have a direct connection with the attack. They are found in the sputum as little, round, yellowish bodies, but require a microscope for satisfactory study. They are soluble in warm water, in ammonia, in acetic acid, and in the mineral acids, and are supposed to be phosphate of ethylenimine. Sputum very frequently contains parasites. In it may be foimd the scolices and free booklets of echinococcus, the actinomycosis fungus, the amoeba coli, and others. Sputum full of amoebae is thin and oily. They generally get into the lung from hepatic abscess fol- lowing amoebic dysentery. But the parasites of most consequence are the vegetable parasites, especially the bacilli and the cocci. Now, there are many bacilli and cocci that are not linked to any special morbid condition. But these have no particular diagnostic value; the pathogenic organisms are of the greatest importance, and most important is the tubercle bacillus, which is revealed by its significant action towards certain stains, an action that it shares only with the bacillus of leprosy. If the bacillus be exposed to an aniline dye dis- solved in an alkali, imlike other pathogenic and non-pathogenic minute oi^ganisms, it retains the color on the subsequent addition of decolor- izing reagents, such as acids and alcohol. There are many different tests based on this principle. The one of Koch, as modified by Ehrlich, is still, I think, the favorite; though the Ehrlich-Weigert method is also much employed. The Koch-Ehrlich method is as follows : A small drop of sputum is spread very thinly over the sur- face of a cover-glass, a second cover-glass is laid upon this, and the 19 298 MEDICAL DIAGN08IS. two are pressed together and then separated by sliding one over the other. The thin layer on the surface of the cover-glass we select to test is dried by holding it over a gas or an alcohol flame, the side of the specimen being up. The dry sputum is now stained by letting the cover-glass lie for twenty-four hours at ordinary temperature in a saturated solution of aniline oil in water, made by adding the oil drop by drop to distilled water in a test-tube until the mixture becomes tur- bid, when it is filtered ; a few drops of a saturated alcoholic solution of fuchsine, of gentian violet, or of methyl violet, are then added. At the end of this time all the component parts are stained, including the bacilli. The cover-glass is now lifted and immersed for a few seconds in a mixture of one part of nitric acid to three parts of water, until the preparation, previously red, becomes yellowish-green. The preparation is then placed in alcohol of seventy per cent, until no more color is given off; the color disappears, except that of the tubercle bacilli, which are red. We can then counterstain the other parts blue by immersing the cover-glass for a few minutes in a two per cent, watery solution of methyl-blue or of malachite green, unless gentian or methyl-violet has been employed, when Bismarck brown must be used for the background. The cover-glass is then washed in absolute alcohol, dried, and the preparation mounted in oil of cloves or in Canada balsam. There have been many other processes proposed, among which those of Ziehl-Neelsen and of Gabbett, in which carbolic fuchsine instead of aniline water fuchsine is employed, are much used. The latter is excellent for rapid staining.^ The cover-slip is kept for firom two to five minutes in a cold carbolic fuchsine solution, and then coimterstained with a methylene-blue sulphuric acid solution, two grammes of methylene-blue to one hundred grammes of a twenty-five per cent, solution of sulphuric acid. The preparation is then rinsed off in water ; the tubercle bacilli show the marked red stain. As seen when stained, tubercle bacilli are fine rods, absolutely motionless, of the diameter of a human blood-corpuscle, and forming spores of oval outline. Their presence in any number is proof of the existence of tuberculosis ; when but few are found it is a question whether they may not have accidentally got into the air-passages. Another valuable micro-organism in the sputum is the pneumo- coccus, especially the one described by Fraenkel as characteristic of * See, for clear descriptions of the different processes, Schenk*« Manual of Bacteriology, translation, London ; and Abbott's Bacteriology, 4th edition, Phila- delphia, 1899. DISEASES OF THE LUNGS. 299 pneumonia; it has, however, also been detected in the saliva, in abscesses, in meningitis, and in empyema. Two cocci generally are found together. It is depicted in discussing pneumonia. Let us here examine only the process by which it is best discerned, which, more- over, is a most valuable one in the discrimination of many micro- oi^nisms, the process of Gram. Gram's decolorizing method makes use of an aqueous solution of iodine and iodide of potassium : one part of iodine, two parts of iodide of potassium, and two hundred and fifty parts of water. The prepa- ration is previously stained in aniline water solution of gentian violet, made in the usual way by shaking up in a test-tube filled with water one to two cubic centimetres of aniline until an emulsion is formed, which is filtered, and to which enough of a concentrated solution of gentian violet has been added to render the liquid of a dark color. Fig. 30. hrJ \;^- '»?^ -^^ .v. ^- i , ^ Tubercle bacilli. The iodine solution is then washed out of the tissues ; the bacilli or cocci are easily isolated by the stain. The prepared section or cover- glass should be slowly, but completely, warmed in Che aniline solution of the gentian violet, either on the water-bath or over the flame, then laid from one to two minutes in the aniline water solution of gentian violet, and subsequently placed in absolute alcohol until the color is discharged. The bacteria show the stain of gentian violet ; the tissue may be double-stained red vrith picrocarmine or other dyes. This method of Gram is of the greatest value in distinguishing micro-organisms. For instance, it separates the pneumococcus of Friedlaender, which does not stain with it ; and the bacilli of cholera, of typhoid fever, and of glanders do not retain the stain. HaBinoptysis. — Sputa are streaked with blood in bronchitis. 300 MEDICAL DIAGNOSIS. intimately admixed with blood in pnemnonia ; but it is only when a certain quantity of pure blood is expectorated that the complaint is regarded as haemoptysis, or hemorrhage from the lungs. Now, a pul- monary hemorrhage may be an idiopathic affection ; but it is not often so. It is mostly symptomatic of a grave disease of the lungs or of the heart. It is at times a discharge that takes the place of a suppressed flow of blood from another part of the body, as in vicarious menstrua- tion. Among diseases of the heart, mitral disease is most generally connected with haemoptysis ; among diseases of the lungs, tubercu- losis. But it may also occur in gangrene, in bronchial dilatation, in abscess, and in the early stages of pneumonia. We also meet with it in congestion of the larynx, in purpura, in typhoid and typhus fevers, and in arthritic subjects. When called to a person who has been spitting blood, we have first to solve the question. Where does the blood come from? It may issue from the nose or mouth ; from the trachea ; from the oesoph- agus or stomach ; it may stream from an aneurism which has burst into the air-passages ; or it may be that the lung is bleeding. When in epistaxis the blood, instead of flowing out of the nostrils, flows backward, it is coughed up. But on the patient inclining forward, it will issue from the nose. The color of the blood is not florid ; and it can be seen trickling down the pharynx. Inspection is of equal service when the blood comes from any part of the oral cavity ; especially if it proceed from the gums. Their swollen state, their spongy appearance, and the readiness with which they bleed when pressed, point out at once the source of the hemorrhage. Loss of blood from the larynx and the trachea^ or from the (mophagm, is exceedingly rare ; and when it does occur, it is depen- dent upon some local lesion, such as an ulcer,. or the presence of some foreign substance that has been swallowed. By attention to the history, then, we can recognize the cause and the seat of the hem- orrhage. The blood itself furnishes no certain mark of distinction. Occasionally the hemorrhage takes place into the interior of the larynx, and only a very small quantity of blood is expectorated. Cases of hemorrhagic laryngitis are usually connected with catarrhal inflammation of the windpii)e, with or without ulceration ; they are accompanied by severe dyspnoea, and with the laryngeal mirror the blood can be seen trickling down the windpipe. When blood is vomited from the stomach, it is preceded by a feel- ing of weight and uneasiness in the epigastric region, and sometimes by decided nausea. The ejected matter consists of a dark grumous blood, thus altered by the gastric juice, and is often mixed with DISEASES OF THE LUNGS. 301 broken-down food. Its dark color is invariable,, except where an artery has been laid bare by an ulcer, in which case a sudden dis- charge of florid blood takes place. There is not commonly more than one act of vomiting ; the blood which remains in the stomach passes into the intestines, and goes off with the stools. Hsematemesis is attended with tenderness at the epigastrium. It is usually symp- tomatic of an organic aflfection of the stomach, liver, intestine, or spleen ; it may, however, depend upon the swallowing of irritating poisons; or happen in fevers or in scurvy, or as a substitute for suppressed discharges. The blood which gushes out of the mouth when an aneurism opens into the air-passages is red and arterial. It spurts out in jets, and the patient rarely long survives the hemorrhage. Should this not prove quickly fatal, we are seldom at a loss to determine the cause of the bleeding ; for we find the physical signs of the aneurismal tumor. But when the blood comes from the lungs^ it is of a character, and is connected with symptoms, totally diflferent from any of those just mentioned. The bleeding is preceded by a sense of weight and of uneasiness in the chest. The patient perceives a saltish taste in the mouth and a tickling sensation in the larynx, when suddenly the mouth fills with blood, or, after a slight cough, he expectorates a quantity of light-red and frothy blood. His anxiety becomes great ; the skin is covered with a cold sweat ; the pulse is quick and bounds under the finger. He spits up more blood, and this continues to come up at varying intervals and in changing quantities all day, or for several days, or even for a much longer period. It is at first pure blood, or mixed with the sputum ; is red and not coagulated, and frothy, except when the hemorrhage is very profuse. But after one or two bleedings, the matter which is coughed up contains dark clots, being the blood which has been retained somewhere in the air- passages since the previous attack. The blood is never, at the onset of the hemorrhage, dark and grumous ; yet in rare cases it has more of a venous than of an arterial hue. The amount which is brought up at one bleeding ranges from one to two drachms to as many pints ; but the quantity that comes out of the mouth is by no means an index of the quantity extravasated. The blood may be effused into the pulmonary structure, and but little be expelled. After the description above given, it is unnecessary to point out the marks of discrimination between blood ejected from the lungs and blood from other parts. The symptoms are diflferent ; the blood itself is diflferent. And listening to the chest detects bubbling sounds in the air-tubes ; still, to find these is not requisite for the diagnosis 302 MEDICAL DIAGNOSIS. of pulmonary hemorrhage, and indeed, while the bleeding is going on, the patient's welfare forbids an extended thoracic examination. The bleeding is mostly owing to an aflfection of the heart or the lungs, and is exceedingly prone to be repeated. Yet the lungs may bleed frequently without there being an organic lesion within the chest to account for the hemorrhage. I had, some years ago, a patient under my care who had been spitting blood daily for five years. Although enfeebled by the loss of blood, his general health remained good. His lungs and heart appeared to be sound. Another patient had pulmonary hemorrhages at varying intervals for eighteen months. He finally died of exhaustion ; but he never pre- sented any physical signs of thoracic disease. In another case that 1 watched for years, the repeated hemorrhages were found, at the autopsy, to be unconnected with disease of the lungs. In these instances the hemorrhages recurred often. But we meet Avith robust persons in whom the loss of blood follows active exercise or exertion, and is not apt to be protracted or to be repeated. In such cases, of which I have seen a number in soldiers sent to hospitals after the fatigue of a long march or the excitement of a battle, simple congestion of the lungs is probably the cause of the disorder. Except under the circumstances mentioned, haemoptysis is a grave symptom. It is not dangerous as regards its immediate termination, but dangerous because it is, usually, the indication of a serious malady. Few die as the direct consequence of the hemorrhage, but many die of the disorder of which the hemorrhage is the consequence. Diseases in which Clearness on Percussion is met with and constitutes a Valuable Sign. Some of these ailments are acute, others chronic ; and nearly all have as their prominent symptom a cough, and are affections, or follow affections, of the bronchial tubes. Acute Bronchitis. — This is an acute catarrhal inflammation of the bronchial mucous membrane, which occurs idiopathically, or happens as a secondary complaint in the course of fevers, of rheuma- tism, and of cardiac disorders. Bronchitis varies considerably according to the tubes involved. The symptoms of acute bronchitis of the large and middle-sized tubes are, a sensation of tickling in the throat, soreness or pain behind the sternum and along the lower ribs, a slight oppression in breathing, and a paroxysmal cough. Let us add to these pain in the Umbs, coryza, and a fever of moderate intensity, rarely reaching 103° F., and we have the main phenomena met with during the onset and DISEASES OF THE LUNGS. 303 at the height of an attack of ordinary acute bronchitis. The fits of coughing in the earlier stages are followed by a clear, frothy ex- pectoration, which, as the cough becomes looser and less fatiguing, changes from an almost transparent fluid to a yellowish or greenish sputum. This may be uniform or streaked with blood ; it may be small in amoimt, or in considerable quantity ; and it consists chiefly of pus cells and of large, round, alveolar cells with some blood-corpuscles. The fever soon leaves ; but long after it has ceased, the patient still has a cough and expectoration, both of which only gradually disappear. The physical signs may be inferred from the lesions. As there is no condensation of pulmonary tissue, there is no dulness on percus- sion, the thickening and injection of the bronchial mucous membrane not being sufficient to modify materially the normal resonance. But these conditions must alter the respiratory murmur. They bring out more of the bronchial element of sound, hence more expiration with the coarser inspiration. — in other words, a harsh respiration ; or the swelling obstructs the entrance of air into the air-vesicles, and enfee- bles the vesicular murmur. Again, new soimds, the rales, are pro- duced ; first dry, then moist. This succession of the rales is, however, not absolute, and depends, to a great degree, on the density of the fluid in the bronchial tubes. Dry rales, mixed with moist, may be perceived even in the later stages of acute bronchitis, and long after the febrile signs have ceased. In fact, the tenacity alone of the exu- dation determines the nature of the rales, and even somewhat their exact character ; for every dry rale is not precisely like every other dry rale, nor every moist rale equally moist. With reference to size, the sonorous rales and the large bubbling sounds prevail when the disorder attacks the larger tubes. Sometimes, when the bronchial inflammation is severe and extensive, we find a sound which seems to be neither a dry nor a bubbling rale, but rather a compound of both, — a dry sound, yet not continuous, giving the idea of being caused by the breaking up of fluid. Or, there may be a mixture of the sounds of respiration with the rales, occasioning a peculiar kind of breathing, one in which we can recognize neither a distinctly vesicular nor a distinctly bronchial element, nor a well-defined rale. All these states are dependent upon the amount, and, above all, upon the condition, of the exudation in the bronchial tubes. But they indicate nothing beyond the fact that there is an exudation present which is very large in quantity and tenacious in character. When the sounds are of the indeterminate nature just alluded to, the vibrations produced in the tubes are apt to be transmitted to the parietes of the chest, occasion- ing with each respiration a marked fremitus. 304 MEDICAL DIAGNOSIS. The diagnosis, then, of acute bronchitis is determined by the cough, the fever, the expectoration, and the signs of clearness on per- cussion, diffused rales, or harsh respiration. From all those diseases of the lung which result in the consolidation of the pulmonary tissue, such as pneumonia and tuberculosis^ we distinguish bronchitis by the absence of dulness on percussion. Some cases of dcvte tuberculosU on account of the sudden invasion of the malady and the general diffusion of the physical signs, are liable to be mistaken for acute bronchitis ; but the different progress of the disorder usually clears up all doubt. Error in diagnosis is more likely to arise from the habit, when the signs of bronchitis have been made out, of not look- ing farther ; forgetting that it is far from always idiopathic, and par- ticularly its frequent association with the eruptive fevers, such as measles and smallpox, with typhoid fever, with influenza, or its occurrence in rheumatism and in malaria. CapiUary Bronchitis. — ^This is a disease of the aged and of young children. It begins with an acute inflammation of the larger bronchi ; or the disorder may from the onset affect the smaller tubes. In either case, signs of obstructed circulation soon manifest themselves ; there is lividity of the lips and cheeks, with hurried breathing, a rapid pulse, an anxious countenance, great restlessness, moderate fever tempera- ture, and a cough, followed by viscid expectoration. As the malady advances, the color of the skin and the mucous membranes shows more and more the want of properly aerated blood ; the sputa cease with the failing strength ; and in old persons delirium and coma, in young children convulsions, mark the closing struggle. The physical signs are those of ordinary bronchitis, but modified by the seat of the malady. High-pitched whistling sounds, accom- panied or superseded by ver}' fine moist rales, denote the smaller size of the tubes involved. The resonance on percussion is clear, or very slightly difterent from that of health. When materially duller, it indi- cates that the pulmonar}' tissue itself shares in the inflammation, or that it has been exhausted of its air and has collapsed. The parts of the lung which the physical signs prove to bear the brunt of the disease are the lower lobes. In the upper there may be large niles and sonu» fine ones ; but it is low down and at the poste- rior portion of the chest that the fine sounds are most abundant. Yet wlien the inflamnuition is extensive, and the accumulation of secre- tions and morbid products great, quantities of small rales are heard at every imrt of tlie chest. Like the num^ usual kind of acnite bronchial inflammation, capil- lary bnuichitis is liiible to be mistaken for acute lobar pneumonia and DISEASES OF THE LUNGS. 306 foT phthisis. And in the majority of cases the same rules serve for its discrimination ; the absence of percussion dulness and the diffusion of the morbid sounds are here again of the utmost value. The rapidity of the attack and the signs of suffocation might mislead into the supposition of the existence of oedema of the glottis, of laryngitis, or of croup; errors in diagnosis which the detection of fine chest rales will prevent. Capillary bronchitis which really merits the name is a very rare disease, though I believe it to exist. What is called capillary bron- chitis is for the most part catarrhal pneumonia or broncho-pneumonia one of the most common, as it is one of the most fatal, of the diseases of childhood. Like capillary bronchitis, the disease affects both lungs. It is commonly observed in connection with measles, whooping-cough, influenza, or diphtheria ; it is especially seen in children previously in impaired health, or scrofulous, or rhachitic. It is apt to be attended by cerebral symptoms, — ^indeed, it may set in with these, — by rapid breathing and paroxysms of dyspnoea, and by high and irregular fever, ranging between 102° and 105°. As the inflammation is limited to the lobules, it yields but imperfect signs of consolidation. The bron- chial breathing is rarely very marked ; crepitant rale is not usually perceived, or can scarcely be distinguished from the small bubbling sounds of fine bronchitis ; and, from the usual association with in- flammation of the fine bronchial tubes, it is in individual cases often extremely difficult to say whether portions of the lung-tissue are con- solidated. Theoretically, broncho-pneumonia may be distinguished from capillary bronchitis by the dulness on percussion ; practically, this aids but little. Dulness on percussion is in children difficult to elicit ; and, again, a dulness may be temporarily produced in capillary bronchitis by collapse of the pulmonary tissue. Broncho-pneumonia may or may not be preceded by bronchitis of the fine tubes. We may suspect that the inflammation has affected the lobules, if the breathing be very rapid, the fever severe, and the temperature, which is rarely above 102° in the preceding bronchitis of the finer tubes, rise suddenly by several degrees; if the cough lessen as the pneumonia develops ; if laryngeal symptoms arise ; and if, in addition to rales, not very diffused, spots of dulness, which do not change their seat, and do not disappear under respiratory percus- sion, be discerned, and plastic pleurisy appear as a complication. On the other hand, when there are early and marked signs of deficient aeration of blood ; when the child seems to suffocate from want of power to expectorate ; when a multitude of fine dry and moist sounds are heard at every part of the chest, and little or no corresponding 306 MEDICAL DIAGNOSIS. impairment of resonance on percussion is detected, — we know that the capillary bronchi are extensively filled with pus and morbid se- cretions, and that true suffocative catarrh is threatening life. Capillary bronchitis is a rapid disease ; catarrhal pneumom'a runs a much slower course, lasting perhaps weeks, and showing a temperature record that is marked by great alternations between morning and evening. Chronic Bronchitis. — ^The symptoms and signs of chronic bron- chitis are not very different from those of the ordinary form of acute bronchitis. The duration of the complaint and the absence of fever, except during marked subacute or acute exacerbations, are the chief distinguishing elements. Yet the cough, although on the whole chronic, is far from being constant. It may disappear almost alto- gether, and then reappear with more than its previous severity ; and this state of things may go on for years, undue exposure and change of season aggravating the disorder. The sputa vary, even more than in acute bronchitis, in tenacity and quantity. There may be merely a small quantity of yellowish matter expectorated in the morning, or an almost continued flow from the bronchial tubes, — bronchorrhoea. The physical signs differ accrordingly. A harsh or feeble respiration, and few or many, either dry or moist, rales, are present, in conformity with the state of the bronchial mucous membrane and of the secretions. The sound on percussion is clear, and this, with the diffusion of the signs discerned on auscultation, is of great importance. Excessive secretions some- what hnpair the pulmonary resonance, but only temporarily ; for with the shifting secretions shifts the verj' slight dulness. One of the most important points in the diagnosis of chronic bronchitis is to attend to the manner in which it arises. It may follow a seizure of acute bronchitis, or be the result of recurring attacks of subacute character ; it may appear as a primary affection, or it may follow the exanthemata ; or, again, it may complicate some previously existing disorder, as Bright's disease, rheumatism, litha?mia, gout, psoriasis, or eczema, and be directly traceable to the constitu- tional taints of these maladies ; and its symptoms will vary and be influenced by those of the general malady to which it is subordi- nate. In the ordinary idiopathic malady the general health, as a rule, suffers but little. In some instances, however, emaciation takes place, and the disease simulates phthisis. This is particularly the case in the bronchial aflections among knife-grinders and coal-miners, also in those of granite-masons, of sandpaper-makers, of flax-dressers, and of potters. The resemblance becomes still greater when superadded DISEASES OF THE LUNGS. 307 bronchial dilatation and fibroid induration of the lung produce physical signs like those of pulmonary consumption. A chronic catarrhal inflammatian of the mucous membrane of the nose may be mistaken for chronic bronchitis, with which, indeed, it may coexist. But when occurring uncombined, there are no rales in the chest or altered breathing-sounds indicative of disorder there, though there may be a cough, from the throat being also affected. The secretion, too, fit)m the nose is very copious and of muco-puru- lent character, the upper part of the nose looks somewhat flattened, and the sense of smell is impaired, — not one of which signs is met with in chronic bronchitis. A minute inspection of the nasal mem- brane or a rhinoscopic examination is of most value. It seems almost unnecessary to speak of the differential diagnosis between chronic bronchitis and rose cold and hay asthma. The coex- istence of marked signs of irritation of the eyes^ the nose, and the throat; the appearance of the distressing affections at a particular period of the year ; the fixed time in which they run their course ; their occurrence in those of neurotic constitution and having an irri- table nasal mucous membrane ; the almost instant relief on leaving the regions where the attack has been brought on and on reaching favorable localities; the depression of the nervous system; and, on the other hand, the less decided signs of bronchial affection, — clearly distinguish the maladies. We meet occasionally with a form of bronchitis in which the expectorated matter is solid. This plastic bronchitis presents all the usual signs and symptoms of bronchial inflammation. It may be chronic or it may be acute. It is most frequently chronic, with occa- sional acute or subacute exacerbation. The disease extends in this way over weeks, months, or even years, and is apt to end in complete recovery. But in its acute form it is a complaint of great danger and accompanied by much dyspnoesi,, and has led to death by suffocation.^ Males, as we find by looking at the cases which Peacock * has col- lected, are more often attacked than females. The same carefully collated observations show that the disorder affects more commonly the upper than the lower part of the lungs. As regards the physical signs. Fuller,^ who has met with a number of well-marked examples of the complaint, states that there is weakness or entire absence of breathing over the affected portions of the lungs, and that, from at- ^ Andral, Clinique Medicale. ' Transactions oT the Pathological Society of London, vol. v. • Diseases of the Chest. 308 MEDICAL DIAGNOSIS. Fig. 31. Cast from a case of plastic bronchitis. tending collapse, complete and rapidly developed dulness on percus- sion may ensue. But the only absolutely diagnostic phenomenon is the peculiar membranous material expectorated. In form this may be either in thin shreds, or moulded into an accurate cast of a bron- chial tube and its ramifications. The expectoration of the firm bodies is sometimes attended with copious haemoptysis. The casts consist of layers of fibrin in which leucocytes and alveolar epithelium are embedded. Leyden's crystals and Ciirschmann's spirals may be found. The disease is most apt to occur in the spring months. The little, round, solid pellets which consumptive patients, or even some per- sons in good health, cough up from time to time are the result of a plastic bron- chitis on a limited scale ; but in a cer- tain proportion of chronic cases decided plastic bronchitis and tuberculosis are associated. A kindred disease to plas- tic bronchitis has been described as *' bronchiolitis exudativa." The sputum is grayish and very tenacious, and full of spirals wliich come from the bronchioles. Gradually increasing dyspnoea and attacks of asthma are prominent symptoms.^ Another variety of chronic broncliitis is putrid bronchitis. This may happen in connection with bronchial dilatation or with chronic pneumonia, or without these conditions ; occasionally it appears after a suppurative pleurisy which has broken into the lung. There is fever with irregular temperature ; at times chills occur. The distressing cough is followed by a copious half-liquid sputum, extremely offen- sive, and containing little yellowish plugs, the so-called Dittrich plugs. The peculiar odor is thought to be due to a micro-oiiganism, espe- cially to a short, slightly curved bacillus described by Lumnitzer.* Cases of putrid bronchitis may be mistaken for gangrene of the lung; but the odor is different, and they lack the physical signs of lung- destruction and elastic fibres in the sputum. We must, however, bear in mind that putrid bronchitis may terminate fatally by induced pneumonia or pulmonary gangrene. Sometimes it produces deatli by metastatic abscess of the brain. » Cursrhiiiiinn, Doutsch. Arch, fiir klin. Med., Nov. 1882. « Wien. Mediz. Presse, May, 1888. DISEASES OF THE LUNGS. 309 Emphysema. — A distention of the air-cells is a frequent sequel of chronic bronchitis. It may happen in only one lung; but the air-vesicles of both are usually distended. The effect of this is to obliterate some of the capillaries, and to interfere with the flow of blood through the lungs. From this proceed the feeling of con- striction and the dyspnoea, the anxious look, the bluish lip, of em- physematous patients, and the tendency the disease has to pro- duce dilatation or dilated hypertrophy of the right side of the heart. Emphysema is essentially a chronic malady ; but in its course subacute attacks of bronchitis occur which much augment the diffi- culty of respiration. The embarrassment in breathing is, indeed, the most prominent of the symptoms. It is not so much the difficulty of getting air into the lung, as it is of getting it out, which annoys the patient. He breathes as if he had no object but that of forcing the air out of the pulmonary tissue. And this task is often aggravated by spasmodic narrowing of the bronchial tubes ; hence it is very common to meet with the loud wheezing of asthma in those whose air-cells are permanently dilated. In long-standing cases of the dis- ease the patient looks cachectic, is cyanosed, the shoulders are rounded, the chest is barrel-shaped, and dropsy of the feet is noticed. There may be also a chronic cough, which may be dry and occur in paroxysms of marked intensity. The physical signs of emphysema are easily deducible from the pathological conditions. The distention of the lung-tissue explains the great prominence and fulness of the chest, and the displacement of the liver or heart. The ringing clearness on percussion — at times almost tympanitic in its character — ^and the increased resistance to the finger have the same cause. Nor is it difficult to understand how the loss of elasticity in the dilated air-cells will give rise to an unchanged note on respiratory percussion, to prolonged expiration, and to a feeble inspiratory murmur. If bronchitis coexist, the signs on auscultation are necessarily somewhat altered. The respiration is harsh, or intermixed with dry and moist rales. The former espe- cially assume great prominence, and are heard as sonorous, or still oftener as sibilant, rales, during the prolonged and labored act of expiration. Occasionally a crackling sound is heard in emphysema.^ When the emphysema is partial, all these signs are limited ; when it is more general, they are diffused. If the upper lobe of the right lung or the lower lobe of the left, * Gerhardt, Berlin, klin. Wochenschr., March 12, 1888. 310 MEDICAL DIAGNOSIS. which, according to Louis/ are the parts most frequently aflfected, be emphysematous, the visible local bulging might mislead into the idea of the prominence being due to an aneurismal tumor, or to the pres- ence of fluid in the pleural cavity. Any doubt will, however, be dis- pelled by a careful examination of the chest. The dulness over an aneurmnal tumor ^ its pulsation, and its sounds, are diflFerent from the Fig. 32. Appearance of the chest in a patient suffering from a high degree of emphj'sema. The hevt is displaced. The other physical signs are extreme percussion cleamew ; a feeble, hardly^Midible inspiration ; a ver>' prolonged expiration. exaggerated clearness on percussion and the changed respiratory murmur of an emphysematous lung. Pleuritic effasiiyns produce a bulging at the lower part of the thorax. But, although there may be a very clear, or rather a tympanitic, sound above the fluid, the absolute dulness over it shows that the prominence of the chest is not caused by distended air-vesicles. When the emphysema is extended and general, displacement of the liver or heart results; and this, taken in connection with the dilatation of the chest and the dyspnoea, may cause the disease to be mistaken for pneumothorax* The differences are pointed out in the discussion of this complaint * Meinoires de la Societe Medicale d' Observation, tome i. DISEASES OF THE LUNGS. 311 We shall only here add that the aflfection of the heart, the torpid^ displaced liver, and the presence of albumin in the urine, in emphy- sematous patients, may call away attention from the primary pulmo- nary cause. An effusion of air may take place into the areolar tissue uniting the lobules. There are no physical signs peculiar to. this interlobular emphysema ; they are exactly the same as those furnished by dilata- tion of the air-cells, except that a dry friction-sound and a large, dry crackling, both of which occur occasionally in vesicular emphysema, are much more common. Its suddenness and the external emphy- sema which follows are specially indicative of the disease. The latter is detected under the jaw, or at the base of the neck, and yields a peculiar crepitation. Yet the extravasation of air into the areolar tissue of the neck is not a constant attendant. Besides, the possi- bility of a crepitating swelling in the neck being due to a rupture of the bronchial tube or of the larynx must be borne in mind. The rupture of the air-cells which gives rise to interlobular em- physema is brought about by any severe effort, by violent coughing, by laughing, or by the throes of parturition. It has also been known to happen in the course of pneumonia or of pulmonary hemorrhage, and to have caused sudden death. Its most frequent association is with whooping-cough. A compensatory emphysema is met with when distention of the air- cells takes place in the unaffected lung or in an unaffected lobe. It generally occurs at the anterior margins, and is developed by the high tension in the air-vesicles that have to do more duty. It is chiefly found in extensive pleural effusion, in pneumothorax, and sometimes in pneumonia. The physical signs are those of ordinary emphysema. In all the disorders which have just been treated of, the resonance on percussion has been dwelt upon as a most valuable sign. Before proceeding to consider the diseases in which dulness is encountered, a few words may here find their place on a morbid condition in which clearness rapidly gives way to dulness, and dulness changes quickly back into clearness. As, moreover, the complaint to which I allude — collapse of the lung — has a close connection with bronchitis and em- physema, its consideration is at this time fitting. The chief cause of collapse of the limg, or post-natal atelectasis, is accumulations in the bronchial tubes. No air can enter the air- vesicles ; the residual air in them is gradually exhausted, and the disordered portion of lung is reduced to a state as if it had never breathed. But, although in the majority of instances this post-natal 312 MEDICAL DIAGNOSia atelectasis is brought about by catarrhal secretions in the bronchial tubes which cannot be expectorated, any want of power to fill the cells of the lung with air may lead to their collapsing. In some of the typhoid forms of acute and chronic diseases, in the pulmonary congestions of the aged and enfeebled, and in those occurring just prior to death, Jarge portions of the lung-tissue may collapse simply from inability to breathe with sufficient force. We also meet with collapse of the lung in whooping-cough, in compression of the lung from pleural effusion, and in rhachitis. The physical signs of collapse are not satisfactory ; the symptoms vary with the conditions producing the disease. Neither voice nor respiration is characteristic. The most usual physical sign is dulness on percussion, with an absence of all respiration, or with a blowing sound, which is faint and not so distinct as in pneumonia. The dul- ness is not so great, may be changed during respiratory percussion, and in cases dependent upon inspissated mucus may disappear sud- denly when the obstructing cause is removed. Yet collapse of the lung is at times a state of long duration. Should a pneumonic process affect the collapsed portion, the dulness is stationary, and we are apt to find the high but variable temperature of broncho-pneumonia. Under ordinary circumstances the temperature is normal or sub- normal. Afl:er collapse the breathing becomes very difficult. The patient makes intense efforts at inspiration ; owing to the non-expansion of the lung during these efforts, the ribs move inward and recede, instead of moving outward as in ordinary breathing. This sign, the suddenly increased dyspnoea, and the appearance of dulness in special areas, unaccompanied by marked bronchial breathing, are, in a case of bronchitis, the most trustworthy indications that collapse of the lung-tissue has taken place. Yet where the collapsed lobules are small and scattered through the lung, these signs are not at all present, and the diagnosis is uncertain. The dulness is wanting; and the peculiarity in inspiration may not be observed. When collapse affects a large portion of lung, it much resembles lobar pneumonia. The fever, the absence of retraction of the chest wall, the crepitant rales, the tubular breathing, distinguish tliis, and bronchophony is much more marked. How nearly collapse resembles broncho-pneitvionia has already been indicated. The diminution in volume of portions of the chest, the shifting character of the physical signs, and the speedy re-entrance of air into parts that had shown signs of condensation, are the most trustworthy points in diagnosis. In pleural effusions the distinguisliing signs are the flatness on percus- DISEASES OF THE LUNGS. 313 sion and the absence of breath-sounds, of bronchophony, of fremitus ; besides, we do not find the retraction of the chest walls, and the extremely rapid, superficial breathing. Diseases in which DiQness on Percussion occurs. The diseases of the lungs in which dulness on percussion is met with are all those in which compression or consolidation of the pul- monary tissue takes place. Especially do we find dulness, and the physical signs which accompany it, in the phthises, in pneumonia, and in pleurisy. Phthisis. — Phthisis presents itself in a chronic and in an acute form. The chronic variety is by far the most fi-equent. It is essentially " the consumption," which is such a scourge to the human race. In by far the greatest number of instances this consumption is linked to tubercular disease. And although we can recognize a non-tubercular form, I shall, unless it be otherwise specified, use the term phthisis as meaning tubercular disease. Beginning usually with a short and insidious cough, with a feeling of lassitude, and a decHne in general health ; attended at times fi'om the onset with a pain in the affected lung and a somewhat quickened circulation ; or giving the first indications of its existence by the occurrence of a hemorrhage, — the disease becomes fully established, with symptoms which hardly need a.detailed description. The harass- ing cough ; the disturbed digestion ; the steadily augmenting debility ; the short breathing ; the exhausting night-sweats ; the hectic fever ; the deceptive blush which this imparts to the cheek ; the increased lustre of the eye ; the singular hopefulness ; the temporary improve- ments ; the relapses ; and the greater vividness of the imagination, so strongly contrasting with the waning frame, — are phenomena with which sad experience has made not only every physician, but many a fireside, familiar. The most constant of all the symptoms are the hemorrhage, the cough, and the emaciation. The cough is at first dry, or followed by a frothy expectoration. As the disease advances, the sputa thicken. They become greenish in color, streaked with yellow, and " nummular," consisting of large greenish masses of a rounded form, wliich do not sink in the cup containing them, but float imperfectly in a thin serum. This expectoration is, however, by no means pathogno- monic; it is occasionally encountered in chronic bronchitis. In the last stages of consumption the sputa are often homogeneous, and have a grayish, purulent aspect. Examined microscopically, they show alveolar epithelium, pus-cells, exudation corpuscles, and elastic 20 314 MEDICAL DIAGNOSia tissue, the most distinctive of which is the elastic tissue of the alveolar walls. Yet the only absolute sign in the sputum is the bacillus tuber- culosis. Its presence bespeaks tubercular disease, its absence, on several examinations, is a strong argument against the existence of this affection. The numbers found in the sputum bear a direct rela- tion to the extent and gravity of the complaint ; in arrested tubercle they become very few or disappear. In lung destruction from syphilis or from chronic pneumonia, in the non-bacillary form of fibroid phthisis, in cavities from bronchial dilatation, in gangrene of the lung, the bacillus is not observed. But failure to find the bacillus is not as valuable and conclusive evidence as finding it ; yet a fevsr of the bacilli may be met with in the sputum from accidental lodgement in the air- passages. In rare instances, the cough remains slight throughout the malady; but generally it is a distressing feature, and is particularly worrying at night. Sometimes its \dolent paroxysms bring on vomit- ing. But vomiting and other gastric symptoms occur irrespective of paroxysms of coughing. In truth, anorexia, nausea, and vomiting are often very prominent and early symptoms, and may exist where no obvious lesion of the gastric mucous membrane is foimd ; dilatation of the stomach attending the dyspeptic symptoms is not uncommon. Some shortness of breath is usual ; dyspnoea is rare. Elarly anaemia, with increase of the blood-plates,. is another frequent symptom. Among the loss constant symptoms of pulmonary consumption are a troublesome and rebellious diarrhoea connected with catarrhal in- flammation, with fistula in ano, or with tuberculosis of the bowel chronic laryngitis and chronic pharyngitis, hypertrophy of the mam- mary gland, more common in men than in women, and the red line around the border of the gum. In some persons this gingival line is a men* streak : in others it is more than a line in breadth ; in none is it a certain indication. A sign which has a much more definite con- nection with tubercular disease of the lungs is the appearance of the nails. The end of the finger is somewhat clubbed ; the nail is curved, prominent in the centre, depressed at the sides, its surface slightly cracked, its appearance bluish. A similar nail is, however, seen in chronic pleurisy and in diseases of the heart. The laryngeal symp- toms are apt to be a very distressing complication, and mostly end, no matter how they begin, in tubercular laryngitis. This, and the laryngoscopic appearance of the ulcers have been described when trt\'iting of laryngeal diseases. Fever is a very constant and significant symptom of pulmonary tuberculosis. Indeed, the temperature may be greatly elevated for DISEASES OF THE LUNGS. 315 several weeks before we find physical signs indicative of the depo- sition of tubercle, or of an undoubted increase in the already existing deposition. Furthermore, the rise in the body heat closely corre- sponds to the activity of the deposition of tubercle. If the tempera- ture be decidedly and permanently elevated throughout the day, there is active deposition. When the temperature is normal, the deposition in the lungs has ceased, and the tubercular process is arrested or retrograding. It may be also normal or even subnormal in very chronic cases. The morning temperature in tubercular phthisis is often higher than the evening temperature, though we frequently see the reverse. Very generally the maximum temperature is reached in the after- noon ; sweats occur in the evening, and there is a drop of two or three degrees towards morning. The temperature chart of the hectic fever may simulate that of a remittent or an intermittent fever, and the frequent occurrence of chills and the sweats make the resem- blance still closer. In the last days of the disease the temperature may fall greatly. The thermometer has been made use of in another manner in the diagnosis of tubercular consumption. Peter ^ calls attention to the advantage of local thermometry. A surface thermometer is applied firmly in front of the chest in the second intercostal space, and if the temperature is higher there than on the other side, or than normal, it is because there are tubercles underneath. In beginning tubercu- losis the increased local heat is in proportion to the extent of the lesions. In health the temperature of the chest walls is about 36° C. (96.8° F.); it may rise in tubercle to 37° C, or more, and in con- sumption with cheesy degeneration still higher, surpassing the general fever heat of the body. The symptoms which precede a fatal termination are various. Patients may go on failing for years ; or an intercurrent attack of acute tuberculosis, of pneumonia, of tubercular meningitis, or of tubercular ulceration of the intestines, may at any time result in death. The tendency of tubercular matter is to soften and destroy the textures among which it is infiltrated. It may undergo, at any period in its course, a retrogressive development, by shrivelling up, or by passing into a calcareous state. When situated in the lungs, it seeks the apices by preference; it is rarely limited to one lung, although one lung is usually the most diseased, and often at the beginning of the malady is alone aff'ected. Tuberculosis is not merely a local com- ' Clinique Medicale, tome ii., 1879. 316 MEDICAL DIAQN081B. plaint, but stands in connection with a peculiar, tainted state of the constitution, wljethcr tliis be produced by infection irorn tlie products of the bacilli or not; hence the symptoms of phthisis are not solely the expressions of the condition of the lungs. In accordance with the laws atTecting tubercular depositions, we have three stages of phthisis, which are to be borne in mind when examining the pht/fncal m/ns: 1. Incipient stage, or beginning deposition ; 2. More complete deposition, occasioning consolidation ; 3. Stage of softenuig and of the formation of cavities. Fio. 33. Sltght pennmioii dulii€«.,. Feeble or harsti respiration, ProlOBgod expiration SxigBenited nsplmtlon Bosdnning liifHtratlou ; ma^ises of tutx^rclc havt^ acHnimulivtw^l. but the intervening lum^-tiisne U «till heulthy, L A few scattered tubercles do not cliange the normal percussion resonance ; nor do they appreciably alter the natural breath-sounds. But as soon as the deposit is sufficient to impair the elasticity of the lung-tissue or to increase its density, a relative loss of clearness on percussion on one side, and modifications of the vesicular murmur, such as feeble or jerking inspiration, or a prolonged expiration, may be ascertained. The dulness is readily detected by percussing the patient with his mouth open and during a fixed expiration, or the dilference between the two sides becomes very manifest during held i inspiration,^ — ^in other words, respiratory percussion will jiid us. To find tlie dulness at the upper part of the chest posteriorly, the position DISEASES OF THE LUNGS, 317 of crossing the arms and clasping the shoulders is very advantageous. In a certain number of cases, with the slight dulness on percussion and the changed breathing is associated a blowing sound in tlie sub- claTian or in tlie pulmonary arter>\ A iimrmur is, indeed, at times present in the pulmonary artery long belbre any other physical indi- cation of tubercle is discernible. All Uiese physical signs may be accompanied by rales of various kinds. What makes them significant is, that they occur at Uie upper purtinn of tlie lung, whether anteriorly or posteriorly. If, therefore, any moclifjcation of the vesicular mur- mur, or any adventitious sound limited to the apex, exist ; if there be a slight dulness on percussion above or under the clavicle, or in the supraspinous fossa; if this coincide with flattening of the anterior surfat^e of the chest, especially on one side, witli defective expansion of the thorax and shortness of breath, with a cough, and falling off in general health. — the diagnosis of beginning tubercular disease is almost positive. But these signs possess now less value to us Uian formerly, for the detection of bacilli would be of greater import than any or all of them. 2. As the infiltration advances, the signs become more decidedly those of consolidation. Greater dulness on percussion at the upper portion of one or of both lungs, scarcely influenced by respiratory percussion; more resistance to the percussing finger; stronger vocal resonance ; a sinking in of the side most affected, and often soreness to the touch over tlie diseased part ; a very harsh murmur; or, when the infiltration surrounds the bronchial tubes, a distinct blo\\ing res- piration,— are all present in varying degree, and all denote consolida- tion. And chronic consolidation at the apex has, in the large ma- jority of instances, but one inter|)retation. — phthisis. In the second stage, as w^ell as in tiie first, we often meet with superadded signs of bronchitis which occasionally mask the respiratory sounds, with fric- tion-sounds from local pleurisies, or with tine crackling. We may also encounter a whilling murmur, the so-called cardio-pulmomirif murmur produced by the beat of the heart against the pulmonary texture, and especially heard in inspiration. 3. The diseased organ now passes into a state of sollening, or rather some portions of the lung begin to soilen, while others remain indurated, and in yet others fresh infiltration takes place. Moi.st crackling or pei-sislent moist rales indicate that softening has begun. The broken-down material may be expectorated, and the malady for a time be stayed ; but such is not often the case. The area of the softened mass widens ; cavities form ; and in addition to the moist rales, to the physical phenomena of tlie second stage, and to the in- 316 MEDICAL DIAGNOSIS. plaint, but stands in connection with a peculiar, tainted state of the constitution, whether this be produced by infection from the products of the bacilli or not ; hence the symptoms of phthisis are not solely the expressions of the condition of the lungs. In accordance with the laws afifecting tubercular depositions, we have three stages of phthisis, which are to be borne in mind when examining the physical signs : 1. Incipient stage, or beginning deposition ; 2. More complete deposition, occasioning consolidation ; 3. Stage of softening and of the formation of cavities. Fig. 33. Slight percussion dulness. . . Feeble or harsh respiration. Prolonged expiration Exaggerated respiration Beginning infiltration ; masses of tubercle have accumulated, but the intervening lung-tissue is still healthy. 1. A few scattered tubercles do not change the normal percussion resonance ; nor do they appreciably alter the natural breath-sounds. But as soon as the deposit is sufficient to impair the elasticity of the lung-tissue or to increase its density, a relative loss of clearness on percussion on one side, and modifications of the vesicular murmur, such as feeble or jerking inspiration, or a prolonged expiration, may be ascertained. The dulness is readily detected by percussing the patient with his mouth open and during a fixed expiration, or the difVerence between the two sides becomes very manifest during held inspiration, — in other words, respiratory percussion will aid us. To find the dulness at the upper part of the chest posteriorly, the position DISEASES OF THE LUNGS. 317 of crossing the arms and clasping the shoulders is very advantageous. In a certain number of cases, with the slight dulness on percussion and the changed breathing is associated a blowing sound in the sub- clavian or in the pulmonary artery. A murmur is, indeed, at times present in the pulmonary artery long before any other physical indi- cation of tubercle is discernible. All these physical signs may be accompanied by rales of various kinds. What makes them significant is, that they occur at the upper portion of the lung, whether anteriorly or posteriorly. If, therefore, any modification of the vesicular mur- mur, or any adventitious sound limited to the apex, exist ; if there be a slight dulness on percussion above or under the clavicle, or in the supraspinous fossa; if this coincide with flattening of the anterior surface of the chest, especially on one side, with defective expansion of the thorax and shortness of breath, with a cough, and falling oflF in general health, — the diagnosis of beginning tubercular disease is almost positive. But these signs possess now less value to us than formerly, for the detection of bacilli would be of greater import than any or all of them. 2. As the infiltration advances, the signs become more decidedly those of consoUdation. Greater dulness on percussion at the upper portion of one or of both lungs, scarcely influenced by respiratory percussion ; more resistance to the percussing finger ; stronger vocal resonance ; a sinking in of the side most affected, and often soreness to the touch over the diseased part ; a very harsh murmur ; or, when the infiltration surrounds the bronchial tubes, a distinct blowing res- piration,— are all present in varying degree, and all denote consoUda- tion. And chronic consoHdation at the apex has, in the large ma- jority of instances, but one interpretation, — phthisis. In the second stage, as well as in the first, w^e often meet with superadded signs of bronchitis which occasionally mask the respiratory sounds, with fric- tion-sounds from local pleurisies, or with fine crackling. We may also encounter a whiffing murmur, the so-called cardio-pidvumary murmur produced by the beat of the heart against the pulmonary texture, and especially heard in inspiration. 3. The diseased organ now passes into a state of sofl:ening, or rather some portions of the lung begin to soften, while others remain indurated, and in yet others fi-esh infiltration takes place. Moist crackling or persistent moist rales indicate that softening has begun. The broken-down material may be expectorated, and the malady for a time be stayed ; but such is not ofl:en the case. The area of the softened mass widens ; cavities form ; and in addition to the moist rales, to the physical phenomena of the second stage, and to the in- 318 MEDICAL DIAGNOSIS. creasing debility, night-sweats, and hectic, the signs indicative of a cavity are noticed. Prominent among them are the cavernous voice, especially in whispering, and the hollow breathing. But the hollow, cavernous respiration may be caught only in expiration, or it may be tempomrily superseded by very large bubbling sounds, — gurglirig. Fig. 34. Cavemou8 resjiiratioii. Gurgling. Cavernous voice. Amphor^ peXCIlfBifXL Amphoric rnpintlon. Amphoric Titoe. Cavities of varioas sizes. Again, over small or over deep-seated cavities none of these sounds may be perceived ; and, in truth, even when they exist, their limita- tion to a particular locality is an element in the diagnosis of a cavity almost as important as their presence. The results of percussion over an excavation are not always the same. They depend much on the thickness and tlie state of the walls of the cavity. If dense, percussion yields a dull sound ; if thin, a tympanitic, or its varieties, a cracked-pot or a metallic sound. If only a certain amount of indurated tissue intervene between the cavity and the surface of the chest, a singular sound, a mixture of dull and tympanitic, is produced. If healthy lung-tissue form the walls of th(j excavation, the sound is clear, or nearly so. Moreover, in all cases the })itcli and, to some extent, the character of the sound ai'e changed by percussing over the cavity while the mouth is kept open. When it is shut, the sound elicited is of lower pitch. On inspirator}- percussion, Uw previously iympanitic or mixed sound be- comes dull. Another sign by wliic'h we may judge of tlie existence > H 320 MEDICAL DIAGNOSIS. it be on the left side, and if alterations of the vesicular murmur cor- respond to it. When the dulness is not discernible, we have to depend on the history of the case, especially as to family, likelihood of exposure to infection, the occurrence of blood-spitting, the limita- tion of the physical signs to the apex, the persistency of the cough, and the falling oflF in general health, out of proportioa to the local lesions. Where the deposition is at all extensive, an erroneous diagnosis of bronchitis is with ordinary care impossible, unless, as is always highly improbable, phthisis should be complicated with emphysema, or the tubercles be quiescent, and so diffused as not to impair the resonance on percussion. Under the latter circumstances especially, the occasional tympanitic character of the sound over the seat of the tubercular deposition is liable to be misconstrued into increased clear- ness on percussion, and into a disproval of the existence of phthisis. When tubercle and emphysema coexist, the percussion note may really be pulmonary and like that of healthy lung ; the respiratory sound becomes much feebler; generally, too, the dyspnoea is in- creased; the temperature is higher than in pure emphysema. But the most certain sign would be the tubercle bacilli in the sputum. A difficult diagnosis may be at times the distinction between chronic bronchitis and the phthisis of old people. This, indeed, often happens in a latent form, and is very slow in its development ; the temperature may be normal or subnormal. Besides the microscopic examination of the sputum, auscultation alone is of much value, since the chest remains resonant on percussion, owing to the dwindling of the muscles of the thorax, the ossification of the ribs, and the rare- faction of the lungs. In the stage in which the signs of consolidation become well defined, phthisis may be mistaken for any of those conditions that occasion the physical signs indicative of greater density of the lung- tissue, and that are accompanied by cough and by loss of flesh. Such are particularly pneumonic consolidation, pleuritic effusion, and can- cerous deposits. Chronic Pneumonic Consolidation, — Chronic pneumonic consolida- tion, or chronic pneumonia, gives rise to many manifestations wliich simulate consumption. These are cough, emaciation, and the local si^ms of chronic condensation, — increased voice and fremitus, sinking ill of the chest wall, feeble inspiration and prolonged expiration, or a fully developed bronchial respiration. But in pneumonic consolida- tion the history usually points to an antecedent acute affection ; the health is not so much impaired ; there has been no hemorrhage, DISEASES OF THE LUNGS. 321 although the sputa at times may have been streaked with blood ; and the dulness on percussion and the other physical signs of consolida- tion are, for the most part, perceived over the lower lobe of one lung. In many of these cases interstitial fibroid changes ultimately take place in the lung, and we thus have a chronic interstitial pneumonia, which allies the cases closely to fibroid phthisis. Yet it is clinically convenient to keep them apart, as the consolidation may slowly dis- appear, and the retraction of the chest and other features of fibroid phthisis as ordinarily seen are not present. This position of the physical signs is of great importance. Yet there are two sources of fallacy which may arise. On the one hand, tubercles may, by way of exception, be seated in the lower lobe ; on the other, chronic pneumonic induration may aflfect the apex. When an infiltration of tubercle takes place in the lower lobe, its distinction fix)m chronic pneumonic consolidation is very difficult. Our surest guides are attention to tlie pathological law which teaches that con- sumption is not met with in an advanced state in one lung alone, and the examination of the sputum for bacilli. Not finding these, and the absence of serious general symptoms, will determine the real nature of the case when an inflammation of the upper lobe has resulted in its persistent induration. I adduce a few instances, by way of illus- tration : A gentleman was imder my care for years, in whom, after pul- monary inflammation, signs of condensation remained in the upper part of the right limg. He did not sufl'er at all, except from attacks of acute bronchitis, to which he was very liable. During these he lost flesh ; but when they passed off he rapidly regained it. He had a chronic cough, but it was very slight. After the lapse of a number of years I lost sight of him. In another case, with a similar history, I found dulness on percus- sion, prolonged expiration, and a Mction-sound limited to the apex of the right lung. There had been a continuous cough, but very little constitutional disturbance, and no hemorrhage. The abnormal signs lasted for a year, and then almost disappeared under a succession of blisters, and the cough ceased. In yet another patient, a man seventy- five years of age, the dulness at the right apex had for years remained stationary. In all instances of doubt between chronic induration and tuber- cular disease, important information is drawn from watching whether the physical signs undergo changes in the hitherto healthy portions of the lung. To the presence or absence of the bacillus tuberculosis in the sputum the greatest weight must be attached. 322 MEDICAL DIAGNOSIS. A great and complicating difficulty in the differential diagnosis grows out of the circumstance that tubercular disease may be devel- oped in a lung in a state of chronic induration. We find persons in good health seized with inflammation of the lung, which is followed by persistent consolidation, and in the course of time by tubercular phthisis. Indeed, many of the reported cases of tubercle affecting primarily the lower lobe of the lung are, in reality, cases of tubercu- losis following chronic pneumonic ^ consolidation. The history is usually as follows. A person in all respects healthy is attacked with an acute pulmonary affection. He recovers from it, but with a trifling cough, with a persistent dulness on percussion, and with feeble respiration, heard over a portion of one of his lungs. He continues ailing, though not positively ill, when, without any apparent cause, after a time varying from a few months to years, his cough increases, the expectoration augments greatly and becomes decidedly purulent, the temperature rises, and he emaciates rapidly. Hemorrhage may or may not happen ; profuse night-sweats occur ; and the physical signs, which have been stationary for a long time, now begin to change. The dulness extends; and, instead of the enfeebled respi- ration, a harsher, blowing respiration is perceived over the affected part, and moist crackling and the signs of a cavity follow. If doubt still exist as to the nature of the malady, the advance of the disease will clear it up. True to the laws of tubercle, a deposit takes place in the lung previously sound, and not at the lower portion, but at its apex. At all stages a minute examination of the sputum will tell us when the bacillar infection takes place. It is supposed by many that the tubercle bacilli have existed in the lung prior to the inflammatory dis- ease, or may, indeed, have caused it. But this is not often borne out by the clinical histor}\ It is more likely that the bacilU have lodged in the damaged organ. Cases of the kind with the cheesy changes in the lung and the disintegrating products of the inflammation form the variety of phthisis that was not long since asserted to be a special dis- ease, piieumonic phthisic, but which w^e no longer doubt to be only a cUnically somewhat different variety of tubercular affection. These remarks apply almost equally whether the original seizure was a croupous pneumonia or a catarrhal pneumonia. Yet there are some special points which the chronic consolidation attending a chronk catarrhal pneumoma exhibits. In the first place, the history of a pre- ceding acute catarrhal attack is clear, or there have been a series of attacks, after one of which the lung was left solid, and since which the patient has been prone to take cold, and is easily put out of DISEASES OF THE LUNGS. 323 breath. Now, he may come under our observation in the midst of one of these broncho-pneumonic seizures, and we may watch him for months with the signs of consolidation over a portion of one lung, whether at base or apex, or with affected points, often symmetrical, in both ; further, there are night-sweats, fever with decided evening exacerbation, diarrhoea. Gradually these urgent symptoms yield ; he gets about, but a spot or spots of consolidation in one or both lungs do not go away for a long time ; or the chronic catarrhal pneumonia may remain as such, or pass into pneumonic phthisis, which really means tubercle. When this happens, great variation between morn- ing and evening temperature, simulating a malarial fever, increasing cough and dyspnoea, marked sweats, decided emaciation, announce the event : while the physical signs show extending dulness, crackling and fine moist rales, over the affected spots or in parts not previously diseased, and ultimately cavities. At all stages repeated examinations of the sputum for tubercle bacilli are of decisive value. Oironic Pleurm/, — A persistent cough attended with emaciation and with dulness on percussion is common to chronic pleurisy and to phthisis, and is a cause of many errors. But the seat of the dulness at the lower part of the thorax ; its much more absolute character ; the almost entire cessation of all breath-sound; the diminished or absent vibration of the chest walls when the patient speaks ; the dila- tation of the affected side, — are in striking contrast with signs most manifest at the apex, with the distinctly prolonged expiration, with the rales and the evidences of beginning softening. Nor are the symptoms of a pleuritic effusion as grave as those produced by phthisis. Even where the fluid filling the chest is pus, we do not find hectic fever so intense, emaciation so great, or night-sweats so constant and exhausting ; and the patient coughs less, and never spits up blood. In those cases of chronic pleurisy in which the side, in- stead of being dilated, is retracted, the diagnosis is more difficult. Attention to the seat of dulness being at the lower part of the chest, to the diminished respiration, voice, and fremitus, and to the shrinking affecting only one side of the thorax, will, however, serve as the foundation for a correct conclusion. Tubercle may complicate pleuritic effusions. We suspect this by the occurrence of hemorrhage, and by the marked emaciation and hectic. We can only be sure of it by finding signs of deposit on the non-affected side, and by tubercle bacilli in the sputum. Tubercular pleurisy may be a one-sided as well as a primary disease. It is not always accompanied by effusion. There may be only great and irregular thickening of the* pleural membrane attended with variable 324 MEDICAL DIAGNOSIS. fever, with coarse firiction, with much pain, and with or without bacilli in the scanty expectoration. Chronic double pleurisy is verj' apt to be associated with a tubercular affection of the lungs, but it may be rheumatic, or may occur without obvious cause. Pulmonary Cancer, — Cancer of the lung shares with tubercle the cough, night-sweats, hemorrhage, gradual wasting, as well as the signs of pulmonary consolidation. But cancerous formations are usually limited to one lung. Only ope side of the chest is flattened or distended. Over the cancerous lung the percussion dulness is great. There is either loud, blowing respu^tion, or, if the mass have compressed or obliterated a bronchus, enfeebled or absent breathing and absent tactile fremitus. We find no rales ; but all the signs of consolidation are more perfect than in tubercle. Owing to a cancerous deposit in the mediastinum, the dulness at times extends beyond the median line. Paroxysmal dyspnoea, enlargement of the clavicular lymph-glands, and prominence of the large veins on the chest and arms are common. Fever is generally absent. Cancer in the lung may soften ; yet the signs of softening are rarely as manifest as they are in tubercle. The sputa are purulent, or like currant-jelly or prune-juice, and show no characteristic bacilli Further, a cancerous tint of the skin may be present ; and cancerous tumors in other parts of the body become absolute evidence in favor of a deposit in the lung being cancerous, since, with very rare ex- ceptions, cancer and tubercle do not coexist. The character of the pain must be also taken into account. In tubercle, it is transitory and shifting; in cancer, it is much more constant, and much more severe. SyphilUw Disease of the Lungs. — Syphilis may occasion a specific form of bronchitis, preceding the syphilitic eruption; or produce gummata, which may soften and be eliminated, and which form in the lungs towards their periphery and base ; or give rise to chronic interstitial pneumonia of the base. When syphilis manifests itself in the pulmonary structures, it produces most of the phenomena of phthisis. The chief differences are, that the nodules affect generally only one lung, most frequently the right, and principally the base or the lower part of the upper lobe ; that they remain circumscribed, not spreading to the surrounding textures ; and that they occasion, as a rule, neither haemoptysis, nor fever, nor night-sweats, nor decided emaciation, nor marked cough or rales, but dyspnoea out of proportion to the local disease. The most common physical signs are dulness on percussion, deficient fremitus, altered vesicular breath-sounds, and obvious sinking in of the supra- and infraclavicular regions ; in DISEASES OF THE LUNGS. 325 some instances signs of destruction of the lung are found. Still, the syphilitic aflfection can be distinguished with certainty only by the history of the case, by the thickening of the periosteum of the head of one or both clavicles, and the perichondrium of one or more of the upper cartilages, with frequently a tumefaction of the soft parts between them and the skin, and by substernal tenderness. In all cases we must be careful that the thickening at the upper part of the chest walls and the altered resonance thus occasioned be not looked upon as signs of a tubercular consolidation ; and as regards the ten- derness, pain on pressure is met with at the lower part of the sternum in a large number of phthisical cases. S}T)hilis of the lung may also be associated with syphilitic lesions in other organs, especially in the larynx, and we may find considerable cough, with emaciation, diarrhoea, and albuminuria. But even then there are no night-sweats and fever attending the emaciation, the great debility, and the marked dyspnoea. The diagnosis of syphilis has been made by microscopical examination of the sputum, finding nucleated granular cells, shrivelled nuclei, spindle-cells, and remnants of a finely striated stroma.^ To the absence of tubercle bacilli in doubtful cases great weight must be attached. Fibrous pleurisy and pleuritic effusions are comparatively frequent; even small cavities occur in the lung.' In rare instances syphilis of the lung runs an acute course, simulating acute pneumonic phthisis. The preceding diseases are most likely to be confounded with the stages of consumption prior to softening and the formation of cavi- ties. Next let us review those affections which, like phthisis, occasion the signs of excavation, and which, therefore, may be mistaken for its third stage: they are, chiefly, bronchial dilatation, abscess, and gangrene of the lung. Bronchial Dilatation. — A dilatation of the bronchial tubes takes place in two forms: either the tubes are uniformly dilated and like the fingers of a glove, or else they form cavities by undergoing a sac- cular enlargement. The former variety furnishes the symptoms and physical signs of a case of chronic bronchitis attended with copious expectoration. The percussion clearness may be slightly lessened, owing to the condensation of the surrounding pulmonary tissue ; the respiration may be more strictly bronchial ; but otherwise both symp- toms and signs are those of chronic bronchial inflammation. In the * Sokolowsky, Deutsche Medicinische Wochensohrift, Sept. 12, 1883 ; Cube, also Guntz, quoted in Schmidt's Jahrbuch, No. 6, 1882. ' Satterthwaite, Boston Medical and Surgical Journal, June, 1891. 326 MEDICAL DIAGNOSIS. globular form of dilatation we meet with all the sounds of tubercular excavations : the hollow, blowing respiration ; the hollow, well-trans- mitted voice ; gurgling ; even metallic tinkling. In the acute cases, Wilson Fox ^ has observed the metallic quality of the rales to be ven' distinctive. Yet all these phenomena are in strange contrast with the almost unimpaired health, and with the non-occurrence of hemor- rhage, of night-sweats, and of emaciation. Still hemorrhage does happen in a certain proportion of the cases. Pain, Lebert has shown, is among the early manifestations of the disease. The temperature is normal, except during acute or subacute attacks of bronchial in- flammation. Thus, when we find the signs of a cavity, and when the general symptoms do not indicate profound constitutional disturbance, we may suspect a bronchial dilatation. This suspicion becomes a cer- tainty, if the cavity be at the middle or the lower portion of the lung, if the resonance on percussion be but little impaired, and if the slight dulness is not increased by inspiratory percussion, and, for the most part, follows, and does not precede, the auscultatory signs of a ca\ity. We find further evidence in the stationary character of the physical signs: for months they do not change. They are often associated with unilateral interstitial pneumonia or pleurisy, and with retraction of the chest. The expectoration of bronchial dilatation is more abundant than that of consumption, is apt to be purulent, acid, of oily appearance, and in chronic cases fetid, suggesting, indeed, at times, the existence of gangrene. It does not contain tubercle bacilli, and shows elastic fibres only if there be ulceration. As regards the cough of dilated bronchi, it is persistent, and only at times relieved by expectoration, which varies in copiousness according to the size of the sac, and chiefly occurs after a spell of cougliing in the morning. Skoda ^ describes, as a peculiar physical sign present in sacculated bronchial dilatation, a large and coarse crackling, called by him the large bubbling, dry crepitant rale. In a case which came under my observation, the diagnosis was made by this auscultatory sign. The patient, a boy aged twelve years, had swallowed a bone, wliich lodged in a bronchial tube and gave rise to bronchitis and bronchial widening. He died subsequently of acute meningitis, and the bone was found firmly embedded on one side of the globularly dilated bronchial tube. ^ Treatise on Diseases of the Lungs and Pleura, London, 1891. '^ Percussion and Auscultiition. DISEASES OF THE LUNGS. 327 Bronchial dilatation is observed, as in the instance just mentioned, after impacted foreign bodies. It is also met with after whooping- cough, after long-standing chronic bronchitis in which the bronchus has been weakened by inflammatory changes, and in connection with cirrhosis of the lung. But there are many cases to which Granger Stewart^ has particularly called attention that are due to atrophy of the bronchial wall, and that probably result from a constitutional defect. In these primary cases the disease comes on insidiously. Pulmonary Abscesses. — Abscesses of the lung may form in the course of acute pneumonia, but are not then likely to be mistaken for chronic phthisis. Different is it with abscesses which are developed three or four months after an attack of pneumonia, and where the lung-texture has remained partially consolidated. I have seen not a few examples of chronic induration of the lung terminating in this way. A man who was shot through the lung was seized, soon after the injury, with inflammation of that organ. Percussion dulness and blowing respiration continued at the lower part of the left lung. One day, after exertion, he suddenly expectorated a considerable amount of pus. The signs of a cavity were detected at once ; but they sub- sequently disappeared, and perfect recovery took place. In another case of pneumonia, the disease in like manner lapsed into a chronic state. Five months after the acute attack, the evidences of an exca- vation became manifest at the edge of the right scapula, and existed there for two months ; then, so far as physical signs could prove, the cavity closed. Instead of the hollow, blowing respiration and gur- gling, only a somewhat roughened vesicular murmur was perceived. Such is, however, not always the termination. The abscess may grow larger and lai^er, until the entire lung is destroyed ; amphoric percussion note, amphoric respiration, amphoric voice, and, at times, metallic rales, being the physical signs observed. Lung abscesses differ from bronchial dilatation in not being perma- nent and fixed. They have this in common with tubercular excava- tians, — ^they change. They increase like these ; but, further, they do what tubercular cavities do not, they decrease. Their physical signs are in every respect like those of all cavities, and vary with the size of the excavation. Sometimes metallic respiration and voice may be heard over it; or perforation of the pleura produces the signs of . pneumothorax with effusion. In fortunate instances the pus is ex- pectorated, or the abscess opens externally, and a cure is thus estab- hshed. But very large abscesses are apt to wear out the patient. * Twentieth Century Practice, vol. vi. 328 MEDICAL DIAGNOSIS. Hectic fever and occasional hemorrhage attend them ; yet neither is so constant a symptom as it is in consumption. The sputa are usually copious, purulent, full of elastic tissue, and fetid, differing in this re- spect from the expectoration of phthisis, which is only temporarily fetid, if the secretions decompose iij the cavities. Again, abscess of the lung may be distinguished from tubercular disease by being ordi- narily situated at the base of the organ ; by its following pneumonic consolidation, although there are exceptions to this rule, chiefly in septic conditions ; by the occurrence of copious expectoration being often sudden ; but especially by its limitation to one lung. The other lung remains healthy. It may enlarge, and its murmur be more dis- tinct ; but the sounds denote its texture to be normal. Abscess of the lung is not infrequent in suppurative diseases of the nose, or larj'nx, or oesophagus. It is still more common from em- bolic infection. The small amount of constitutional disturbance which pulmonary abscesses sometimes entail is remarkable, and the physical signs of a large cavity are in strange contrast with the regular pulse, the almost undisturbed breathing, the slight cough, and the healthy complexion. What has been called "dissecting pneumonia," a suppurative inflammation starting mostly in the peribronchial tissues, dissecting the lobules, and subsequently destroying the parenchyma, leaving nothing but the bronchial ramifications and vessels, has symptoms that are in the main those of abscess, of which, indeed, it forms a variety. The absence of fetid breath and of fetid sputum distinguishes it from gangrene.^ Pulmojuiri/ Gangrene. — This disease also yields the signs of an ex- cavation. It occurs either as diffused or as circumscribed gangrene, after pneumonia, especially aspiration pneumonia, or typhoid fever, after wounds of the lung, from blows on the chest, from poisoned blood, diabetes, pressure of an aneurism, or from emboli in tlie pul- monary tissue. The symptoms are : great prostration, dyspnoea, a very pale face, a quick pulse, hemorrhage, emaciation, and a cough, followed by profuse purulent sputa of a greenish or brown color. But nearly all these symptoms happen also in phthisis. What is characteristic of gangrene is the extreme fetor of the expectoration and of the breath. The sickening odor is not perceived during each act of breathing, but mainly after coughing, and, as it were, in jets. • It is the sYiiiptom by which, especially if taken in connection with the ^ See an elaborate paper by Hutiiiel and Proust, Arch. (Jen. de Med., Nov. 1882. DISEASES OF THE LUNGS. . 329 signs of breaking up of the pulmonary tissue and the sputum, gan- grene is with certainty recognized. The cavity is found in only one lung, and generally at its lower part. This is of aid in discriminating between phthisis and gangrene ; but it does not distinguish between a gangrenous excavation and a simple abscess of the lung. The only positive proof of gangrene of the lung is, as just stated, that the signs of breaking down of the pulmonary tissue are accompanied by a dis- gusting and more or less persistent fetor of the expectoration and of the breath ; sometimes a sickening, faintly sweetish smell, sometimes fecal, oftener that of putrescence. I say persistent, because local gangrene, on a small scale, occurring around tubercular cavities or in bronchitis, may give rise to temporary extreme fetor of the breath. But it is only temporary, and therefore not liable to lead to fallacious inferences. The expectoration may be fetid in cases of bronchial dilatation or of abscess of the lung, but is never brownish, as is not uncommon in gangrene ; and neither it nor the breath has the pecu- liar gangrenous odor. In rare instances pleurisy with fetid effusion may occasion a fecal smell of the expectoration and breath, which is gradually lost.* The fetid sputum of fetid bronchitis is not associated with any signs of breaking down of the lung. Yet in considering the diagnosis regarding bronchial dilatation we must not overlook the fact that, as Dittrich and Traube* have shown, this bears a marked relation to gangrene. Decomposition takes place in the secretions retained in the bronchial dilatation, and ulceration of the coats may ensue, leading to a gangrenous process in the sur- rounding tissue. Now, as just mentioned, the sputum even in bron- chial dilatation may become fetid. As, moreover, it, like gangrenous sputum, may present a dirty greenish-yellow color, and separate on standing into three distinct strata, of which the uppermost is frothy though dense, the second serous, and the third dense, containing pure pus and detritus ; as, further, we meet in both aflFections with little solid masses of particularly oflFensive odor full of fat and fine needle- shaped crystals of margaric acid, — we may have to depend, for a dif- ferential diagnosis, on finding with the microscope pigment grains and masses of elastic tissue. Pulmonary Actinomycosis, — This rare disease resembles tubercular disease of the lung in presenting cough, fever, wasting, and a muco- purulent expectoration. The attending fever is of irregular type, sometimes like that of typhoid fever, more generally like hectic fever. * As in the case reported by William Moore (Dubl. Quart. Joiirn., May, 1865). * Gesammelte Abhandlungen. 21 330 MEDICAL DIAGNOSIS. The physical signs are mostly those of tubercular deposit The absolutely distinctive feature is finding the ray fungus in the sputum. Besides the lungs, other parts of the body may be involved, such as the jaw, the aUmentary canal, and the subcutaneous tissues. With reference to other affections which are sometimes mistaken for pulmonary tuberculosis, owing to emaciation and an attending cough, such as intermittent fever, anaemia, dyspepsia, chronic diar- rhoea, chronic laryngitis, and chronic pharyngitis, the physical signs are different, and an examination for tubercle bacilli is conclusive. In the remarks on the diagnosis of pulmonary consumption, the complaint has been assumed to be progressive ; in rare instances it retrogrades. The signs by which such retrogression can be discov- ered are not very fixed. In those cases in which many tubercles undergo a cretaceous transformation, calcareous particles are coughed up ; the signs of softening cease ; fibroid changes take place in the affected lung ; the apex flattens ; and a feeble murmur \v\\h prolonged expiration, or a harsh respiration with slight dulness on percussion, is all that remains to indicate that tubercular disease has existed. The cough stops, and flesh and strength return. We meet occasionally with instances in which the physical signs of an infiltration into the lung-tissue depart with tolerable rapidity. They occur in those who have a decidedly scrofulous aspect, en- largement of the glands of the neck, or a scrofulous inflammation of the eyes. In accordance vAW\ the acknowledged identity of scrofula and tubercle, we are forced to admit that the disease in the lungs is tubercular. Yet the connection with the enlaiiged lymphatics; the circumstance that the diminution in size of the glands is often fol- lowed by increased pulmonary deposits ; that these depositions are very beneficially influenced by treatment ; that they disappear some- times altogether, or only reappear months afterwards; that hemor- rhage is not among the symptoms, — all make it a question whether there be not a scrofulous disease of the lung independent of a tubercu- lar, one pursuing more the course of an external scroftilous disease, one, moreover, which presents a much more favorable prognosis than ordinar}' consumption. Among scrofulous children cases like these mentioned are not uncommon. The disorder certainly differs from the ordinary forms of pulmonar}' tuberculosis, and it is not bronchial phthisis. It does not present the paroxysmal cough, the signs of pressure on the trachea or the large bronchi, and the dull sound on percussion between the scapulae, which are the common accompaniments of enlarged and tuberculous bronchial glands. In- deed, the bronchial glands are not of necessity involved. DISEASES OF THE LUNGS. 331 The Acute Affections of the lAings accompanied by Diilness on Percussion, The acute diseases of the lungs are bronchitis, pneumonia, pleu- risy, and acute tuberculosis. They have some signs and many symp- toms in common. They all present fever; they are all associated with more or less dyspnoea and thoracic pain ; they all occasion a cough. The symptoms and signs of acute bronchitis have been dis- cussed. It has been pointed out that the want of intensity of the fever, and particularly the unimpaired resonance on percussion, separate bronchial inflammation from all affections that occasion con- solidation or compression of the lung-tissue. We may then proceed to examine the other acute pulmonary affections. Acute Tuberculosis. — When tuberculosis runs its course rap- idly, it is known as acute, tuberculosis, acute phthisis, or galloping consumption. This formidable complaint is met with at the close of other diseases, especially of fevers ; but exposure, toil, and anxiety are also among ijs predisposing causes. The disorder often begins with a severe chill : fever follows ; at first like any fever with anorexia, quickened pulse, and elevated tem- perature, but soon accompanied by exhausting night-sweats and rapid emaciation, which, in connection with the intense restlessness and prostration, the high temperature, and the supervention of delirium, may cause the febrile disturbance closely to resemble typhoid fever. The symptoms that point to the thoracic malady are the accelerated breathing, the cough, the copious expectoration, the pain in the chest, and the spitting up of florid blood. The physical signs are not always the same. If the tubercles be scattered through the lungs, no signs are perceived but those of diffused acute bronchitis ; indeed, the sputum is of the same kind, and tubercle bacilli are not found,* or are infrequent. More commonly the signs are like those of chronic pulmonary tuberculosis, and associ- ated with the fever and prostration we find the percussion dulness of a deposit, or the evidences of the destruction of the pulmonary tissue, furnished by coarse moist rales, and cavernous breathing. Tubercle bacilli are then usual. When the malady assumes the form resembling chronic pulmo- nary consumption, the diagnosis from bronchitis is not perplexing; but when its phenomena are similar to those of acute broncliitis, the recognition of the tubercular affection may be impossible. Tliis ' Von Jacksch, Klinische Diagnostik. 332 MEDICAL DIAGNOSIS. remark applies particularly to the distinction of the miliary form, acute miliary tuberculoma^ from bronchitis of the finer tubes. From this the diagnosis can be effected only by taking into account that repeated chills, rapid emaciation, and profuse sweats are wanting in the bronchial affection ; that the temperature is not so high, nor so irregular ; that the rales are more abundant and more perceptible at the lower part of the chest ; and that, perhaps, the breathing is not so hurried or so difficult. Moreover, with the intense dyspnoea there are generally frequent and violent fits of coughing, and marked chest pains, in the acute tubercular malady. Yet none of these signs are convincing proofs. The presence of dulness on percussion, or the sinking in at the upper part of tlie chest, the occurrence of hemor- rhage, the finding of the tubercle bacillus, if present, the eruption of miliary tubercles in other organs, and the longer diu^tion of the case are alone conclusive evidence in favor of the acute tubercular disease. Hemorrhage is, however, by no means so constant in the acute as in the chronic form of the affection. Much the same symptoms will enable us to distinguish between acute tuberculosis of the miliary form and bronchopneumonia^ except that we can draw no inference from the dulness on percussion, further than that its early occurrence, with the bronchial symptoms, points to the pneumonic malady ; its later occurrence, after the grave symptoms, to the tubercular. When the dulness on percussion is marked, acute tuberculosis may be mistaken for ordinary pneumonia. But the signs of deposit and of softening in both lungs, and the seat of the lesions at the apices, show differences from a disease which, in the large majority of instances, is one-sided and at the lower part of the lung, which exhibits a characteristic sputum, and in which breaking up of the pulmonary tissue is so rare. Yet there are cases of acute phthisis that display symptoms and signs very puzzling, and strongly simulating those of pneumonia. A person in perfec^tly good health is seized, after exposure, with cough and fevgr. They are ac(*ompanied by dyspnoea, and soon we find signs of consolidation of the lower lobe, or of one lung. The dulness on percussion does not disappear under treatment; and a hollow, blowing respiration and gurgling, usually first perceptible at the angle of the scapula, gradually appear, and indicate the formation of a cavity. Emaciation, which began from the onset, progresses more rapidly, and goes hand in hand with extreme prostration and profuse perspirations. Tin* sputa are copious and purulent, but at no time mixed with blood. The other lung is normal. The case remains DISEASES OF THE LUNGS. 333 in this condition for several weeks, the patient temporarily improving under stimulants, yet, on the whole, growing weaker and tormented with fever of very irregular type. A slight roughening of the inspira- tory murmur, or dry rales at the apex of the unaffected lung, attract attention, and dulness on percussion and the signs of deposition become there more and more manifest. A post-mortem examination exhibits nearly the whole of one lung converted into a uniform yel- lowish or grayish mass of tubercle, and containing one or several large excavations; not a vestige of healthy lung-structure is to be seen. Scattered tubercles are found in the other lung, and mainly at its apex. The case just described is one of a group which every physician has met with. The beginning of the case as one of pneumonia or broncho-pneumonia, the persistent consolidation, the occurrence of rales and of subsequent dulness on percussion at the upper part of the previously unaflFected side, the continuance of the disease, and the prostration and sweats which accompany it, permit us to foretell its nature and the probable fatal termination, even without the positive evidence of tubercle bacilli in the sputum. Such cases were not long since classed as aeiite pneumonic pkthwis^ and looked upon as inflammatory, with resulting caseous infiltration, and its disintegration. With our present knowledge of the bacillar origin of consumption, they are explained by supposing that the tubercle bacilli have fastened readily on the altered lung, or that they have occasioned the attending inflammatory process. Acute phthisis may simulate other affections besides those of the chest. It has at times the delirium and prostration, the dry tongue, and the bronchial rales of typhoid fever. The diarrhoea and the abdominal symptoms are, however, wanting. Yet simultaneous depo- sition of tubercles in the intestine may cause these ; and in this case the chief mark of difference from typhoid fever is the absence of an eruption. Besides, the Widal test is negative, and the thermometric record shows great and sudden variations, to the extent, perhaps, of six or seven degrees, bearing no relation to the number of respira- tions or to the beats of the pulse. In the blood there is great de- crease in the leucocytes, with a relative increase in the polynuclear cells. As there is also a decided diminution of the leucocytes in typhoid fever, but little importance can be attached to the blood- examination in the diagnosis between typhoid fever and acute tuber- culosis.^ Acute tuberculosis lacks the eye-phenomena, the gastric ' Warthin, Medical News, Jan. 1896. 334 MEDICAL DIAGNOSIS. disturbance, the rigid muscles, the convulsions, of mening^itis ; else the active delirium it occasionally produces might be attributed to inflammation of the membranes of the brain. Acute tuberculosis sometimes progresses with extreme rapidity. I have seen a case terminate in thirteen days. It is almost invariably fatal. Yet it has its periods of deceptive improvement : the disease may proceed speedily towards softening, and then remain for a time stationary. In some instances the termination is the result of compli- cations, as of tubercular meningitis, or of erysipelas of the throat and the bronchial tubes. Acute Pneumonia. — Inflammation of the lung, or "croupous pneumonia," is, in its symptoms, the type of the acute pulmonary affections. The hot, dry skin, the flushed face, the quickened pulse, the extremely rapid breathing, the thoracic pain, the cough, and tlie peculiar expectoration, point out at once the acute nature of the attack and the organ that is disturbed. Beginning commonly with a cliill, or wth flushes of heat, the disease progresses with the symp- toms indicated. The expectoration is characteristic. It consists at first of a glairy mucus; soon it. becomes more viscid, and acquires the appearance dependent upon the admixture of blood Avith the mucus and exuda- tion matter, to which the term rusty-colored has been given. This rusty sputum is pathognomonic of pneumonia; yet cases run their course without it. The expectoration is sometimes like prune-juice, or it is purulent. Both augur badly : both indicate that destruction of the lung-tissue has begun. The shortness, or increased frequency, of breatliing is another marked symptom. The patient draws from forty to eighty breaths a minute ; but the pulse, although rapid, does not quicken in propor- tion. Pneumonia, therefore, forms an exception to the rule that with greater frequency of breathing the pulse rises. This perverted pul« respiration-ratio may be made an important element in the diagnosis. The febrile symptoms are ordinarily severe ; still, they are not asso- ciated with decided cerebral disturbance. Headache is conmion; delirium is rare, and, when it occurs, is indicative of danger. In drunkards it may take the form of delirium tremens. The flush on the cheek is so decided that by this and the hurried breathing alone the disease may often be recognized. The flush is generally most obvious when the inflammation afl'ects the apex of the Imig. Herpes is also a common symptom. The temperature rises abruptly, and on the first or second day at- tains 103° to 105° F. In cliildren and in robust adults it is specially DISEASES OF THE LUNGS. 335 high. It shows little change, except an evening exacerbation and a marked morning remission of from 1.5° to 2.5° for five to nine days. Between these days, sometimes on the fifth, generally on the seventh day, it falls abruptly, and a true crisis occurs. The temperature may sink to the norm, or even below it, and then another, though not marked, rise take place. At times there happens on the fifth day a partial but decided drop, soon again followed by ascending tempera- ture. This pseudo-crisis is apt to occur in cases that become pro- FiG. 85. mi HIE, OAILT AVr.: PAY at eiicJiBi miv^H^tmrn Temperature chart In pneumonia. The observation was begrun on the first day of the disease. The^crisis commenced towards the end of the fifth day, and continued through the sixth to the leventh, with a secondary rise on the sixth. The chart is typical, except that the fever tem- perature throughout was about a degree lower than is usual. There was a slight right-sided pleurisy, but no attending bronchitis. longed. It is, too, in this class of cases with slow resolution that a gradual termination of the fever is often observed. Sometimes the course of the fever is marked by sudden elevations and striking remis- sions. This is more common in double than in single pneumonia, and seems to correspond with fresh invasions of lung-tissue. The urine is high-colored, and that of fever. Nitrate of silver does not precipitate its chlorides. They commonly disappear during consolidation of the lung, and their reappearance shadows forth re- turning health. The vanishing of the chlorides from the urine hap- 336 MEDICAL DIAGNOSIS. pens also in other acute affections ; but in pneumonia it is most absolute. Pneumonia often exists in combination with other maladies. We find it in association with meningitis, and we must therefore always examine any cerebral symptoms with care ; we note it in connection with endocarditis, which may coexist with meningitis ; while its asso- ciation with pleurisy is so common that this can be hardly looked upon as a complication. Among the rarer symptoms are jaundice, parotitis, croupous colitis, milk leg, and transitory aphasia, appearing on the second or the third day. The physkal »i{/n8 vary with the effects of the inflammation. In the first stage, or that of engoiigement and beginning exudation in the air-cells, there is only a slight impairment of the normal resonance on percussion. The vesicular murmur is at first somewhat altered; it may be feebler or harsher. But soon are heard witli each act of inspiration, and limited to the inspiration, numerous rapidly evolved, very fine, crackling sounds, the " crepitant" or vesicular rales. As the exudation becomes firmer, and the tissue of the lung solidi- fies by occlusion of the air-cells, all the signs of complete consolida- tion are discerned. We find in this stage of red hepatization decided dulness on percussion, unchanged by full inspiration ; blowing respi- ration in its purity, high-pitched and tubular-sounding ; bronchophony ; and increased vocal fremitus. Rales from the accompanying bron- chitis are heard with extreme distinctness through the solidified tissue ; so are the sounds of the heart. A crepitant rale is still here and there perceptible, or the ear catches a pleural friction-sound. AVhen the exudation is reabsorbed or expectorated, the signs of consolidation become less and less perfect. A vesiculo-bronchial suc- ceeds to the bronchial breathing. The dulness on percussion lessens ; crepitant rales — not, however, so fine as at the onset of the affection, and mixed with larger moist rales — return ; the cough increases ; the expectoration becomes more copious, loses its tenacity and rusty color; the dyspnoea diminishes, — all phenomena indicative of the breaking up of the exudation, and of the return of air into the vesicles. If, instead, the exudation be converted extensively into pus, and the lungs soften, the physical signs are the same as in the second stage. The rarity of excavations of sufficient size explains why gurgling and the signs of a cavity are not perceived. We suspect the miscliief that is going on within the chest from the protracted dyspnoea, the increasing rapidity of pulse, the purulent or brownish sputa, the pinched features, tlie dry tongue, and the mental wandering. Recovery may take place even then. Tliis third stage is indeed not so much an abrupt, sud- DISEASES OF THE LUNGS. 337 denly established process, as it is tlie extension and greater diffusion of a state that may be found in portions of the lung which to the eye have still all the appearance of red hepatb.ation. It is often impossi- ble to determine that the stage of purulent infiltration or gray hepati- Percussiou dulness. . Bronchial breathing Bronchia] Toice Increased fremitus . . Diagram illustratiTe of perfect pulmonary consolidation, such as happens in the second stage of pneumonia. zation has arrived; and death may take place long before the lung presents the condition which pathologists term gray hepatization. We may suspect, from the symptoms, that the pulmonary tissue is seri- ously damaged. But we can never know it, unless we find the physi- cal signs of extensive softening ; and this we very rarely do. True abscess of the lung is extremely infrequent. The morbid phenomena, physical signs and symptoms of the malady correspond, then, usually in this manner : Stage of engorgement and beginning exuda- tion. Pneumonia. Crepitant rale ; slight per- cussion dulness. Cough ; beginning dysp- noea and rapidly devel- oped fever. II. Stage of solidification of lung-tissue (red hep- atization). Percussion dulness ; bron- chial respiration ; bron- chophony ; often a pleu- ral friction-sound. Rusty - colored sputum ; dyspnoea ; cough ; tem- perature generally above 103**, with decided even- ing exacerbations and morning remissions. 338 MEDICAID DIAG0NSI8. III. Stage of softening (^ray hepatization). The same physic^il signs as in Ihe second stage ; tin less large ahscessos have for mi' d. Chills, prostration, puru- lent or brownish spu- tum ; generally high tenip<^niture, 104*^ to U)[i°^ or upward. Here is a disease which presents such striking symptoms and signs in nearly all its phases, in which the sputa are so peculiar, the physical signs so distinct, that error is dirtlciilt. It becomes still more so, if a few of the pathologir-a! peculiarities of pneumonia be borne in mind : the fact that it is rarely double ; that it comparatively seldom affects the upper lobe of tlie lung, and that it is generally accompanied by the signs of pleurisy or of bronchitis. In some instances sudden disturbance of tjie circulation takes place with the rapid development of cyanosis. These symptoms bespeak a heart-clot, or an acute dila- tation of the right side of tlie tiearl. Delayed resolution is most often encountered in apex pneumonia. Let us now contrast pneumonia with Ihe various diseases of the lungs wjtii which it may be confoorHled. \\i its first Bhige, on account of similar signs, the acute inOanmiatory disorder is sometimes mis- taken for (XMlema of the lung, or tor ttie pulmonary engorgement in some fevers, or for other kinds of congestion of the lungs, and stilt more fi'e(|uently these morbid states are mistaken for it, Puhnonury 03f/cmfi.— This consists in the transudation of serum into the air-vesicles. It may be acute, the result of sudden conges- tion, stich as that following uijuries of the brain or irritation of the par vagum ; or it may arise at the termination of acute atTections of the lungs. It is more usually, liowever, chronic, and is seen as a dropsy of tlie air-cells, associated with dropsies elsewhere, and in connection with organic disease of the liver, heart, or kidneys. The characteristic manifestations of osdema — be it acute or ctironic — are embarrassed breatliing, exi*ecloration of frothy serum, and erei>itating and fine bubbling sounds diffused over both lungs, and dependent upon the Ouid in the air-cells and small bronchial tubes. It presents, thus, many points of similarity to the first stage of acute pneumonia* The dyspncea, the crepitation in the lung, may well mislead; but we cannot err, if the frothy sputum, the general distribution of the rales, their somewhat coarser character, the bluish lip, the noisy breathing, and the absence of fever be taken into account. In acute a?deraa these signs are hot the precursors of death. In chronic oedema the rales are pei'sistent, and so is the great dilllculty in respiration. Pulmonanf Engonjemeni in Fevera. — In fever of low type a crepi- tant rale, which might be supposed to be a proof of beginning inflam- DISEASES OF THE LUNGS. 339 mation of the lung, is often heard at the back part of the chest. The sound is the consequence of pulmonary congestion, with probably slight efifusion into the finest bronchial tubes and air-vesicles. It is perceived over both lungs ; and this, taken in connection with the history of the case, with the absence of decided shortness of breath, and with the rale not being followed by dulness on percussion and blowing respiration, shows that it is not dependent on inflammation of the pulmonary tissue, Pnimonary Congestion, — Besides the lung congestion just referred to as occurring in fevers, we have other causes producing a marked congestion, or "hypostatic pneumonia." We find it in enfeebled heari^ and in mitral and tricuspid disease, in those whose blood is impoverished and who are for any length of time bedridden, in in- stances of acute rheumatism, and due to the pressure of tumors. In the dependent portions of the lungs the manifestations of congestion show themselves first ; they are, besides the signs of impeded circula- tion and of deficient aeration of blood, slight expectoration, scarcely any fever, varying shortness of breath, somewhat impaired resonance on percussion at the lower part of the chest, — generally more over the right than over the left lung, — feebleness of respiratory murmur, and a few fine and coarse moist rales. The sputum contains numerous epithelial cells, and blood pigment in various stages of change. The congestion in all the instances mentioned is passive, and either hypostatic or mechanical. An active congestion of the lungs is a rare condition, though it may come on after strenuous exertion, during mountain climbing, or as subsequent to extreme heat or cold. The physical signs are the same as those of passive congestion ; the sputum is apt to contain more blood. There is little, if any fever; and the history of the case, the stationary character of the physical signs, and their double-sidedness, distinguish the congestive disorder from pneumonia. In its second stage, owing to the cough and dyspnoea, and in part, also, to some similarity in the physical signs, acute pneumonia may be confounded with pulmonary apoplexy, acute pleurisy, acute phthisis, and acute bronchitis. Pulmonary Apoplexy. — An effusion of blood into the texture of the lung is generally, although by no means invariably, accompanied by external hemorrhage and by great difficulty of breathing. Over the effiised blood there is dulness on percussion, and the ear hears an enfeebled or bronchial respiration. Around the seat of the mishap it encounters moist rales. Now, here are signs bearing some resem- blance to those of pneumonia. But we miss from among them the 340 MEDICAL DIAGNOSIS. decided fever. We note, on the other hand, not blood intimately mixed with the expectoration, but pure blood, florid or sooty-looking, almost devoid of air, not in large amount, at times surrounded with muco-purulent matter, and ordinarily voided for a number of days. On close scrutiny a grave disease of the heart is generally detected. Then we frequently find the branch of the pulmonary artery leading to the infarcted part plugged by an embolus, which has been formed in the right cavities of the heart or been washed in through the general venous system, and commonly aflfects the right lung. Again, we have more pain than in pneumonia, and the dyspnoea is diflferenL In pneumonia it augments up to the height of the malady. In pul- monary apoplexy it is greatest, and it is very great, when the blood is extravasated ; after that it declines. Yet the two aflfections often co- exist. The closure of the vessel produces a pneumonia from em- bolism, or the blood acts as a foreign body, and around it is lighted up an inflammation of the lung-structure, which is apt to have its seat in the posterior part of the lower lobe of the right lung ; further, the inflammation may be the starting-point of caseous degeneration ; or sloughing or gangrene may result. Pneumonia from embolism may be also caused by a pyaemic con- dition, and the clots may have their origin in bedsores, in ulcers, and in various forms of suppuration. The plugs are saturated with ichor, and metastatic abscesses supervene. The symptoms are the same, and we can make a diagnosis only by the history ; tliere are tlie same circumscribed spots of consolidation, and the same kind of pain, which is also often found to be associated with a localized pleurisy, some- times followed by effusion. Pulmonary apoplexy is met with in connection with other than thoracic afl*ections. Observations by Brown-S^quard and by Ollivier have proved its association wuth central nen^ous lesions, and have demonstrated its occurrence on the same side as the brain-lesion;* w^iich is not the case with reference to the ordinary acute pulmonary diseases, for these Rosenbach has shown to be much more &*equent on the paralyzed side of the body, and therefore, generally, on the side opposite to the cerebral mischief. Pulmonary apoplexy, or " hemorrhagic infarct," is also met with in malignant fevers. Of the other diseases mentioned which resemble pneumonia, the distinguishing points need not be here fully described. Actde pleuruy will be farther on more particularly studied. With regard to acide phthms^ it is only necessary to repeat that cases are encountered, * Arch. Gk'n. de Med., Aug. 1873. DISEASES OF THE LUNGS. 341 apparently of pneumonia, in wtiich, after the symptoms of acute inflammation of the lung pass off, those of phtliisis come into the foreground. With reference to acute bronchitis^ I shall merely recall that no percussion dulness is yielded by an inflamed bronchial mem- brane. Percussion is thus of signal value in the diagnosis of pneu- monia. In fact, when bronchitis complicates pneumonia, and loud, dry rales take the place of the blowing respiration, it is our only trustw^orthy guide. A single tap on the chest which elicits an abso- lutely dull sound tells the difference between pure bronchitis and the inflammation of the bronchial mucous membrane which accompanies inflammation of the parenchymatous structure of the lung. The form of pneumonia most liable to be mistaken for bronchitis is the pneumonia of childhood or of old age, hrancho-pneumoiiia or catarrhal pneumonia. But the disease may also occur in adults of any age. Broncho-Pneumaniu, — It mostly supervenes upon acute bronchitis, except in instances in which it arises from inhaling irritating gases. The spread of the disease to the lung-texture is attended with rapid rise of temperature. When the disorder attacks adults, it is apt to seize upon those debilitated by previous disease ; it much more com- monly affects the upper lobes than does acute croupous pneumonia, and is generally bilateral. As the broncho-pneumonia merely solidi- fies lobules, the signs of marked consolidation are wanting, or are perceptible over only a small space. Crepitation is not common, but small moist rales are; bronchial breathing and increased fremitus show only over limited points; and the sputum is not rusty and viscid, but catarrhal. Cough and expectoration, sometimes absent in croupous pneumonia, are always present in broncho-pneumonia. Catarrhal pneumonia, or broncho-pneumonia, is often noticed as a complication of the infectious fevers, especially measles and diph- theria. It is the form of pneumonia developed when particles of food pass into the larynx and bronchial tubes, — aspiration or deglutition pneumonia. Catarrhal pneumonia pursues a much slower course than* croupous pneumonia, and generally yields only gradually. The consolidation may continue stationary for weeks, showing a fever with marked daily remissions and exacerbations, like a hectic fev^r, and then slowly disappear. As interstitial inflammation of the bronchi and alveolar walls is distinctive of the disease, and as the perivesicular structures are markedly involved, persistent local consolidation from interstitial pneumonia or fibroid phthisis often follows. On the other hand, caseous degeneration and breaking-down of the lung-texture may follow, or extended tubercular infiltration become manifest. 342 MEDICAL DIAGNOSIS. Whether the bacillus finds in the consolidated lung a ready lodging, or the broncho-pneumonia is originally excited by the bacillus, phthisis is, in truth, in adults a not uncommon termination ; in children, too. this may happen, or rhachitis may develop, or an ill-defined but persistent cachexia, with a great tendency to catch cold. There is a form of broncho-pneumonia, described as tuberculov* aspiration broncho-pneumonia^ that follows hemorrhage from tubercu- lar cavities. It is usually preceded by active physical eflFort, and its first manifestation is a hemorrhage.^ An aspiration .pneumonia may also follow haemoptysis from other causes, or be met with as the con- se(|uence of aspirated particles from a bronchiectatic cavity, or from an empyema that has ruptured into the lung, or after tracheotomy, or in cancerous affections of the larynx and oesophagus. It not unusually leads to suppuration. Pneumonia often shows itself in an epidemic form, and is now generally looked upon as an infectious disease, a lung fever ; indeed, except as a matter of clinical convenience, it should not be described with pulmonary diseases. The evidence of a micro-organism as its cause is very strong. The diplococcus pneumoniae w^as found inde- pendently by Pasteur and by Sternberg, and has been fully studied by Fraenkel, after whom it has been named. It is present in the buccal secretion of a certain number of healthy persons. Its association with catarrhal pneumonia is not so close as with croupous pneumonia. In truth, the bacillus of tubercle at times excites this, making a specific broncho-pneumonia from the start ; the staphylococcus and the strep- tococcus pyogenes may also induce it, as Northrup's observations clearly prove. The cocci are best stained in dilute alcoholic solutions of tlie aniline dyes, and are readily seen in preparations colored by Gramas method. In this respect they dilfer from the pneumo-bacillus of Friedlaender, which is also found in a certain proportion of pneu- monic lungs, but does not retain the stain after going through the process. The Fraenkel coccus is elongated or round, enveloped in a capsule, and often found in pairs. The micro-organism of pneumonia generally appears at the height of the^malady. It has been found in the blood, in the meningitis tliat at times attends pneumonia, in the accompanying pleurisy, and in the lung complication of ulcerative endocarditis. The organism is also met with in other conditions than in connection with pneumonia, as in pericarditis, peritonitis, acute synovitis. Biiumler, Deutsche Medicinische Wuchenschrifl, No. 1, 1898. DISEASES OF THE LUNGS. 343 Fio. 37. omnc*L hOTit ZB ^ ^..,.,.. „■ ,. .1- [■ liTi-^r^-- -„r- -_j f ' 1 1 1 1 1 rr i^i II 1 1 II I m IT T t Wi r i m mi i h < i ■ hi 7 |!T^ i i ■ 1 1 t i tt^ fT; ." ytu* \ ■ j t n » \ i r t m ' i f i i ttt]« gfgy °' 344 MEDICAL DIAGNOSIS; There are some varieties of pneumonia that present clinical features of a peculiar kind. Apex pneumonia is one. It is more usual in children than in adults, and the frequency with which cere- bral symptoms arise and draw away attention from the chest is a matter of common observation. The cases, as a rule, are severe, and the temperature is high. Double pneumonia diflfers in nothing from ordinary pneumonia except in the severity of the symptoms. The cases, unless speedily fatal, are generally of longer duration, and the temperature is less characteristic, for the reason that it rarely happens that both lungs are affected at the same time. Double pneumonia is rare ; what is called double pneumonia is generally inflammation of one lung and heavy congestion of the other. Latent pneumonia is Fig. 38. The diplococcus pneumonlte of Fraenkel ; the cocci axe stained dark blue, the capeules are unstained . ( After von Jaksch. ) not often seen except in the aged. There is but little fever, and it is only by the physical signs that tlie disease can be recognized. Mtgra- lory pneumonia, a condition in which different parts of the lung are successively involved, is not a frequent disease. The temperature shows a tendency to sudden falls, with rapid rises whenever a fresh part of the lung is involved. Some of the older clinicians, especially Wunderlich and Trousseau, regard the disease as having a close connection with erysipelas. It is always very important to find out whether pneumonia is primary or intercurrent in some other malady, such as in rheumatism, Bright's disease, diabetes, the exanthemata, influenza, the typh-fevers, or in septic states. At times it is distinctly noticed to follow contu- sions of the chest. As has been already said, it may be epidemic. DISEASES OF THE LUNGS. 345 By the symptoms and physical signs we cannot distinguish the spo- radic and simple cases from those of the infectious malady. Further bacteriological research may solve the matter. There are two other forms of pneumonia which, as they present somewhat peculiar symptoms, require further to be noticed. They are typhoid pneumonia and bilious pneumonia. Fig. 39. Pneumococcus (diplococcus) of Friedlaender, without the capsule, from a pure culture up(m gdaiin from the sputum in a case of croupous pneumonia at the Pennsylvania Hospital. (Drawn by Dr. Joseph Leidy, Jr.) Typhoid Pneumonia, — ^The term typhoid pneumonia is applied by some to the inflammation of the lung which may complicate typhus or typhoid fever ; it has been also made to include an idiopathic fever in which the aflfection of the respiratory organs is occasionally wanting. To neither of these maladies rightly belongs the name typhoid pneu- monia, since in both the inflammation of the lung is but an incidental accompaniment. Then under the name of pneumo-typhus a disease has been of late years described, especially by German clinicians, in which typhoid fever begins with a well-defined pneumonia, that for the time being throws the enteric symptoms into the shade. Typhoid pneumonia is pneumonia with symptoms of a typhoid type, and marked by rapid failure of the vital powers. The malady is noticed as a consequence of phlebitis ; as supervening in cases of erysipelas, of Bright's disease, and of delirium tremens ; or as the sole apparent aflfection. It happens not infrequently in epidemics, 346 MEDICAL DIAGN08IS. and is very often observed among negroes. Its ravages on the plan- tations of South Carolina and Georgia are sometimes frightful. It is, also, very fatal in jails, and among troops in the field serving under unfavorable hygienic conditions. The physical signs are those of the sthenic form of the disease, except, perhaps, that the crepitant rale is less frequent. Most of the same symptoms, too, show themselves : cough, short breathing, and pain in the chest. All of these may be very marked, or so trifling as hardly to direct attention to the lungs. There is, however, one symp- tom characteristic and constant, and but one, and that is the great tendency to sinking. As regards the expectoration, it may be rusty- colored ; yet occasionally, even in the early stages, it consists of pure blood. The pulse is quick, but weak ; dark sordes often collect on the teeth and gums. Pain is absent in some cases, and extremely acute and of a radiating character in others. Concerning delirium, we know that it is much more common than it is in the sthenic variety of pulmonary inflammation, except this affect the apex in children. The flush on the face is usually of a dusky hue, but not invariably : a pink-colored blush, extending sometimes all over the body, has specially attracted attention. The disease is always dan- gerous, and, as Stokes^ points out, resolution is extremely slow. Chronic hepatization, with or without a low hectic fever, or a lurking congestion, may continue for weeks. The symptoms of typhoid pneumonia are at times strangely mixed with those produced by other conditions. In many districts in which the complaint is prevalent, it bears the distinct impress of malaria. Again, articular symptoms seem to predominate in some regions of country, and in some epidemics. Gibbes* speaks of an acute pain in the back part of the eye, in the ears, or in the side of the neck, attended with stiffness of the muscles ; and of a swelling of the tonsils, and of the submaxillary and sublingual glands. Bilimts Pneimonia, — Jaundice and other indications of hepatic and gastric derangement are not usual in ordinary sthenic pneumonia. They may be occasionally caused by the inflammation spreading to the liver, or may be of blood origin. But in the pneumonia so gen- eral in the spring and the autumn in the miasmatic regions of some of the Southern and Western States of this country, hepatic symp- toms are common, and mark a special type of the disease, known as malarial pneumonia or bilious pneumonia, or by the familiar name of '' bilious pleurisy." * Diseases of the Chest. * Amer. Joum. Med. Sci., 1842. DISEASES OF THE LUNGS. 347 This form of inflammation of the lung is simply pneumonia, sthenic or asthenic, on whose features the stamp of malaria is im- printed. The chill with which it begins is usually protracted, and is followed by pain in the side, by fever, by hurried breathing, and by cough. The pain in the side, which depends upon accompanying pleurisy, is sharp, and renders the respiration irregular. The sputum is at times rusty-colored, while at others a frothy and bloody serum or pure blood is expectorated. The fever is much more paroxysmal than in the other varieties of the malady. This peculiarity, and the obvious symptoms of hepatic and gastric disorder, arc indeed the only distinguishing traits of bilious pneumonia. The febrile exacerbations are stated by Manson, of North Carolina, to be preceded, during the Fio. 40. PrIctioD sound . Roughening of the pleura from inflammation ; a small amount of fluid has begun to collect morning hours, by an insensible chill, — a coolness of the ends of the nose, fingers, and toes, which, in grave cases, extends over the entire extremities. The rusty sputum has been noticed to occur intermit- tently in undoubted diplococcus pneumonia.* In cases of malarial pneumonia the malarial parasite has been found. The physical signs are those of ordinary acute pneumonia. Bron- chial breathing and bronchophony are said to be more often absent, Mader, Wiener klinische Wochenschrift, viii. 22, 1896. 348 MEDICAL DIAGNOSIS. or to appear and disappear rapidly. It is certain, if this be true, that in these instances the malady could not have been inflammation, but was more probably a collapse of the pulmonary tissue occurring in the course of malarial fever. Acute Pleurisy. — Acute pleurisy has been so often incidentally mentioned that a description of its main points will here suffice. It comes on from cold or exposure, or from injuries to the chest ; but a great many cases are secondary to some general or infectious malady. Fio. 41. Examination of the posterior portion of the chest while a lai^e effusion is occupying the left pleural cavity. The first effect of the inflammation is to redden the pleural mem- brane ; an exudation of a soft, grayish, easily detached lymph then takes place. This constitutes the first or dry stage of the disease; and if the two inflamed surfaces unite, the disorder does not pass beyond this stage. Often, however, along with the exudation of lymph occurs an effusion of serum, which produces a special train of phenomena, and gives rise to the second .stage, or that of liquid effusion. The physical signs of the dry stage are impaired movement of the chest, a feebler respiration, and a friction sound of varying extent and DISEASES OF THE LUNGS. 349 intensity. The first two signs are caused by the patient instinctively refraining from expanding the lung, because of the pain it occasions. The mechanism of the friction sound, its nature, its superficial char- acter and want of uniformity, have been pointed out in a previous part of this chapter. In the stage of effusion the physical signs differ according to the amount of fluid the pleural cavity contains. A mod- erate quantity of liquid only constricts the lung-texture, and leaves the bronchial tubes intact; a large accumulation compresses every- thing ; it drives all air out of the lung, pushes it into a small space against the vertebral colimm, and displaces the liver or heart. Where- ever the fluid accumulates there is dulness on percussion. When the patient is in the erect posture, the flat sound on striking the chest and the sense of resistance to the finger are marked at the lower part of the thorax, since th^ fluid naturally settles there. The line of dulness is, however, not the same in front as it is behind. It is generally much higher behind, and alters, of course, with the changing quantity of effusion, and somewhat with the position of the patient. When he lies upon his face, the fluid gravitates, if not circumscribed by adhe- sions, towards the anterior chest walls, and the •percussion dulness posteriorly becomes far less perceptible. The peculiar curve of the percussion line often found has been specially described by Calvin Ellis, and is named by Garland the letter S curve.* Another sign of a pleuritic eff'usion is the one found by Kellock.^ It consists in per- cussing posteriorly with force on the ribs of the side suspected with the right hand, while the left hand is placed firmly on the lower part of the thoracic wall just below the nipple. The vibration of the rib struck posteriorly is felt by the left hand in front with greatly increased distinctness, if fluid be present in the pleura. Where the efi'usion is extensive, the intercostal spaces are widened and their depressions eflfaced. The side is distended, fluctuation may be perceived, and, owing to the absolute compression of the limg, no sound is heard over the chest when the patient breathes, or speaks, or coughs. In more moderate collections of fluid, the cessation of sound is not so absolute. There is an ill-defined, deep-seated respi- ration, and the voice reaches tlie ear with tolerable distinctness, and occasionally with a peculiar bleating resonance attending it. But, as large collections of fluid are more common than small ones, the former set of phenomena are, at the height of the disease, more frequent than the latter. Occasionally the expiration has a metallic sound, and there ^ Piieumono-Dynamics, 1878, and New York Medical Journal, Nov. 1879. » Lancet, March 28, 1896. 22 360 MEDICAL DIAGNOSIS. are resonant rales suggesting a cavity. These pseudo-cavernous signs are most apt to be met with in children. Above the liquid there is increased resonance on percussion, or a tympanitic sound, Skoda's sound. This tympanitic sound is more manifest at the upper part of the chest in front ; it may be, indeed, found in front when it does not exist behind. In some cases the sound has an amphoric, in others a cracked-metal, character. When the ear is applied above the line of percussion dulness, it recognizes occasionally a friction sound ; and near the spinal column posterioriy, where the compressed lung lies, it perceives almost invariably distinct bronchial respiration and bronchophony. When the fluid begins to be absorbed, the voice becomes more audible over the seat of the effusion, the vocal vibrations may be felt by the fingers, and the respiration is again .heard. But for a long time it continues enfeebled, and its character is indeterminate; it is neither vesicular nor purely bronchial. As more and more of the fluid disappears, the voice becomes more and more distinct ; a friction sound finally shows that the roughened surfaces have come in contact ; and the dulness on percussion is replaced by a far clearer sound. False membranes now unite the two plurae ; the intercostal spaces resume their normal shape ; and the chest is eitlier restored to its natural size, or is left somewhat contracted. The bronchial breathing near the vertebral column persists for a long time. These physical signs have been discussed first because they are the most important elements in the diagnosis of pleurisy. The symp- toms, indeed, often hardly attract attention; and if we trusted to them, we should be groping in the dark. Pleurisy mostly begins \nth a chill, followed by fever and by a dry, irritating cough. The most distinctive, though not a constant, symptoni of the first stage is the sharp, acute pain, the '' stitch in the side.'' It is commonly felt under the nipple or in the axilla, and is somewhat increased on pressure. Its seat by no means always corresponds to the seat of the friction sound. As the effusion takes place, the pain disappears, dyspnoea be- comes evident, and the patient ordinarily lies on the affected side. The febrile symptoms and dry cough continue ; yet neither is marked, and both disappear long before the fluid is entirely absorbed. The decubitus is generally on the affected side. Pleurisy may be idiopathic, coming on generally after exposure to cold and damp ; or it may be an attendant upon other diseases of the lungs, such as pneumonia or tuberculosis, or may accompany measles, scarlatina, typhoid and typhus fevers. It may also be caused by wounds of the thoracic walls, by rheumatism, gout, Bright's dis- DISEASES OF THE LUNGS. 351 ease, diphtheria, pyaemia, cirrhosis of the liver, and other morbid states. We may, too, though rarely, meet with a primary acute tuberculosis of the pleura, which may rapidly become suppurative. The malady with which acute pleurisy is most likely to be con- founded is acute pneumonia. Both are affections occasioning dysp- noea; both are, in the majority of cases, one-sided; both present dulness on percussion. But the dulness in the latter disease is fer less absolute than in the former ; nor do we, save in rare instances, meet with a tympanitic or an amphoric percussion sound in pneu- monia, while in pleurisy, as we have just seen, it is far from unusual above the level of the fluid. In the few cases in which a tympanitic or an amphoric sound is perceived in pneumonia, the peculiar tone is most obvious over the consolidated tissue. The other physical signs of the two diseases show still less simili- tude. The absence of respiration, of vocal resonance, and of thrill is in striking contrast with the loud blowing respiration, the strong chest-voice, and the increased vocal thrill of pneumonia. There are, however, exceptional cases of pleuritic effusion, in which bronchial breathing is heard all over one side of the chest. Especially does this happen if pneumonic consolidation accompany the effusion ; but even in simple compression of the lung, and where the collection of liquid is not extensive, bronchial respiration may be perceived. The difficulty of distinguishing from pneumonia such cases of pleurisy, in which probably the lung-tissue is compressed around the bronchial tubes, is great. As aids in diagnosis, we seek for dilatation of the chest; we note the peculiarities of the breathing, which, although blowing, is mostly fainter than, and unlike, the high-pitched, brazen respiration of pneumonia ; we find that the percussion dulness over the upper part and where the bronchial respiration is most distinct is not very great, and, especially, that it disappears on respiratory per- cussion ; we observe that the voice is less strong and ringing, and has, perhaps, a bleating tone ; and we take into account the appear- ance of the sputum and the character of the fever. On the other hand, pneumonia may present itself in a form almost undistinguish- able from pleurisy in the stage of effusion ; it is when the bronchial tubes as well as the lung structure are filled with a fibrinous exuda- tion. In this rruissive pneumonia we do not find either tubular breath- ing or fremitus attending the flat percussion note, and it is only by noting the absence of displacement of the heart or the liver, the \do- lent coughing spells, and observing the fragments of moulds of the bronchi in the expectoration that a conclusion can be arrived at. In the first stage of pleurisy the pain might cause the disease to be 362 MEDICAL DIAGNOSIS. confounded with pleurodynia or intercostal neuralgia. In all three pain is the prominent syihptom. Let us see how it diflfers in each : Pleurodynia. — Pleurodynia is described as a form of muscular rheumatism. But frequently it is myalgia, or a pleurisy which does not pass beyond the dry stage. Of this nature are most of the fugi- tive chest-pains from which phthisical patients sufiFer. Yet there are cases in which no signs whatever of pleurisy exist, but which are at- tended with as much pain as pleurisy. The pain of pleurodynia is often, indeed, excessively severe; the patient refrains from deep breathing, since every motion of the chest increases his suflFering. The pain is augmented by movements of the arm and by pressure, and is generally associated with tenderness. Pleurodynia shares with pleurisy the feeble respiration and the want of action of the aflfected side. It differs from it by the absence of friction sound and of fever; by the shifting pain, often double-sided ; and by the greater tenderness of the chest walls. Intei'costal Neuralgia, — In anaemic women and in consumptives acute thoracic pain is not uncommonly the result of an intercostal neuralgia. The same want of expansion of the chest and the same enfeebled breathing as in pleurodynia are here noted, also the same absence of fever and of pleural friction. The distinguishing maits of intercostal neuralgia are: its intermittent character; its fipequent association with uterine disturbance, especially with leucorrhcea, and the limitation of the tenderness to special points in the course of the aflfected nerve. Valleix has drawn attention to three painful spots which are tender to the touch : one at the exit of the nerve from the spinal column, the second in the axillary region, and the third near the sternum or in the epigastric region. It is on the left side that we are most apt to find intercostal neuralgia, and between the sixth and ninth ribs that the painful places are usually detected. Pain occurs also in diseases afifecting the lung-texture. There is pain of a dull nature in pneumonia, of a more severe character in cancer. But the pain is so dissimilar, and the coexisting symptoms are so unlike, that the confounding of these maladies with pleurisy, on a(*counl of the pain, is not likely. Diseases presenting Dilatation of the Chest, Displacement of the Liver or Heart, and Dyspncsa. A group of diseases may be here studied, all of which occasion more or less dilatation and prominence of the chest, and all of which are attended with decided shortness of breath. In the recognition of emphysema, pneumothorax, and pleuritic effusion, the dilatation, of DISEASES OF THE LUNGS. 353 the thorax forms one of the main elements ; moreover, it is often combined with marked dyspnoea and with displacement of the liver or heart. These affections, then, may be examined in the same connec- tion, and compared with one another, and incidentally with several less common diseases which present similar manifestations. The history and signs of emphysema were given when treating of the diseases accompanied by clearness on percussion. It was then mentioned that in many instances the prominence of the chest is cir- cumscribed. Such cases cannot be mistaken : the bulging is too lim- ited. But when the emphysema is more general, and an entire side of the chest or the whole chest becomes dilated, or when the inflated lung displaces the liver or heart, the affection comes into the group under consideration. A patient seeks advice for shortness of breath. His chest is inspected, and looks enlarged. The physical signs prove that the disease is not one of the heart 01; an aneurism. What, then, is it ? Is it an effusion into the pleura ? is it an intrathoracic tumor ? is it pneumothorax ? is it emphysema ? A tap on the chest goes far towards showing whether it is the former. If the sound rendered be resonant, it is not liquid in the chest that is producing the disturbance, nor, except under rare circumstances, an intrathoracic tumor: the disorder is either pneumothorax or emphysema. Pneumothorax. — ^Of all thoracic maladies, pneumothorax is the one the similarity of which to extensive dilatation of the air-cells is the greatest. In both, the large quantity of air occasions increased clear- ness on percussion ; in both, there is considerable and persistent difR- culty of breathing ; in both, the distention of the chest and the dis- placement of organs may be obvious. In pneumothorax, however, the symptoms and signs are associated with ' different conditions. Pneumothorax is an accumulation of air in the pleural cavity, but it is something more : the entrance of air is soon followed by the effusion of Uquid. Air is let into the cavity of the chest by the pleura being perforated by wounds, or through the diaphragm by malignant disease of the stomach or the colon, or, as is most common, by its partial destruc- tion consequent upon disease of the lung. It is in this way pneumo- thorax originates in the course of tubercular softening, of gangrene, of pneumonia, or from the bursting of a distended air-vesicle or of a dilated bronchial tube.^ In the large majority of instances it occurs in tubercular patients. When air passes from the lung into the pleura, it usually happens * Case recorded by Taylor, Prov. Med. Journ., vol. i., 1842. 354 MEDICAL DIAGNOSIS. during a paroxysm of coughing. The pain which ensues is most in- tense ; and with it there is suddenly developed dyspnoea. If death do not take place, symptoms of pleurisy with effusion manifest them- selves ; and, as in pleurisy, the patient lies ordinarily, but not invari- ably, on the affected side. The distinctive marks of pneumothorax are furnished by its physi- cal signs. The ingress of air into the pleural cavity widens the chest, Fig. 42. Physical signs in pneumothorax on the right side. The heart is observed to Im displaced towards the left, as actually happened in the case from which the outline was taken. The peicuasion refo- nance on tlie right side was tympanitic, extending somewhat over the left margin of the fitemum ; the fremitus was annulled ; the voice metallic. effaces the depression of the intercostal spaces, and occasions an ex- tremely clear, or, more correctly speaking, a tympanitic, sound on percussion. The air prevents the lung from expanding : hence there is an enfeebled or absent respiration, except near the spinal colunm, where the compressed organ lies, and where the breathing is bron- chial. The hand, if laid on any other portion of the chest, feels, when the patient speaks, no thrill, and no vocal vibration is detected by the ear. When the perforation has not closed, and tlie air rushes into the artificial cavity produced by the separation of the two sur- DISEASES OF THE LUNGS. 355 faces of the pleura, the respiration is amphoric, or it, the voice, and the rales are all accompanied by a distinct metallic ring ; respiratory percussion, too, changes the sound elicited, rendering it duller. Drops of fluid falling into the cavity, or the bursting of bubbles on the surface of the liquid in the pleura, are echoed to the ear with a metallic sound, and are often heard as a silvery tinkle. A metallic echoing sound is also obtained if the ear be placed on the back over the affected side while a coin is tapped on another coin in front. The presence of fluid in the pleural cavity gives rise to a dull sound on percussion at the lower part of the chest, which changes readily with the position of the patient, and to a splash, perceptible to the ear and to the finger, when the thorax is suddenly shaken. This continues until the effusion increases, and until the opening closes, the air disappears, and the case resolves itself into one of chronic pleurisy, — ^the most favorable termination of pneumothorax. Now let us compare the physical signs with those produced by emphysema. The sound on percussion in both is very clear, or is tympanitic ; more so, however, in pneumothorax, which, in addition, exhibits dulness at the lower part of the chest. The respiration in both is feeble. But it is feebler in pneumothorax, and not accom- panied by a long, laborious expiration ; besides, it is often amphoric, and attended with metallic voice and tinkling, — phenomena which dilated air-cells cannot occasion. Moreover, there can be no splash- ing sound in emphysema, and this always exists in pneumothorax, except in those rare instances in which there is no fluid in the pleural ca\ity ; on the other hand, the displacement of the heart is generally much greater in pneumothorax, and the dilatation of the chest more apt to be one-sided. Yet too much stress has been laid on the latter point as a means of distinction ;' for emphysema may be one-sided, and, on the other hand, pneumothorax may occur on both sides. In some cases we are aided in the discrimination by noticing that bulging is perceptible over the displaced heart, and that a metallic echo fol- lows the cardiac sounds. The physical signs of the two diseases are thus very different ; so, too, are many of the symptoms. Difficulty of breathing exists in both. But in emphysema it takes generally the form of asthma ; besides, it does not set in suddenly and with inten- sity, and remain intense. In pneumothorax the patient remembers to have been seized with a pain in his chest, since which period he * has been continuously short of breath. Yet there are exceptions to this: there are cases in which the symptoms occasioned by perforation of the pleura are from the onset so slight as not to attract the least attention. Such cases cannot be 356 MEDICAL DIAGNOSia recognized, save by their physical signs. Among these, dilatation of the chest, with the widened intercostal spaces, the displacement of the liver or heart, and the exaggerated and altered resonance on per- cussion are most valuable in preventing the disease from being con- founded with some affections which in other respects give rise to many of the same phenomena. In large cavities, for instance, the respiration and voice may be metallic; metallic tinkling, nay, even succussion, may occur. But the prominent chest, the extremely clear, tympanitic, or metallic sound on percussion, bordered by the line of absolute dulness due to the effusion, are not met with. The history also is different, and the dyspna^a is not so great. The same dissimi- larities will prevent us from mistaking for pneumothorax a pneumonia in which the percussion sound over the consolidated lung is tjinpa- nitic. And a study of the physical signs, too, will at once enable us to discern whether the difficulty in breathing — ^though it be suddenly developed, and apparently under circumstances which make the swallowing of a foreign body seem likely — be due to this cause, or to perforation of the pleura and pneumothorax.^ There is, however, a morbid condition which exhibits nearly all of the signs and many of the symptoms of pnemnothorax, and which, were it more frequent, would be the source of constant errors of diagnosis, — diaphragmatic hernia. Of this rare affection we know but little. Yet, what w^e do know of it teaches us that a protrusion of the abdominal organs through the diaphragm will generally dilate one side of the chest, compress the lung, displace the heart, and result in dyspncea ; and, as the stomach or intestines are, for the most part, the viscera which find their way into the chest, metallic tinkling and a tympanitic sound on percussion are detected. These are also signs of pneumothorax. There is, in- deed, no mode of separating the two diseases, except by attention to the liistory of the case, by noting that the dyspnoea of the former suddenly appears and as suddenly disappears, that it has often existed from birth, and that the metallic tinkling happens when the patient is not breathing, and is mixed up with the rumbling sound arising in tlie stomach or intestine. It has been made a question whether we can distinguish ordinary cases of pneumothorax from these very rare ones which are supposed to occur tcUhout jyerforation. Now, even admitting that such really happen, as a sequence, for instance, of decomposition in pleuritic effusions, there are no signs by which we can recognize them with * As in a case of the disease described to me by Dr. Walter F. Atlee. DISEASES OF THE LUNGS. 357 certainty. It has been claimed that there is no antecedent history of a chronic pulmonary affection, particularly of phthisis, that there is not that suddenly occurring severe pain and extreme dyspncea, that the sputum and breath are never offensive, that metallic tinkling is absent, or rare and inconstant, and that the amphoric breathing is not so well developed or so clearly defined. If in a case of perforation, however, the opening have closed, the physical signs are the same. Cihronic Pleurisy. — Chronic pleurisy is the third of the group of more usual affections characterized by dilatation of the chest, by dis- placement of the intrathoracic viscera, and by shortness of breath. It is true that acute pleurisy in the stage of effusion would, strictly speaking, find here a place; but the acute symptoms bring it into another class, with which it has been more conveniently described. Chronic pleurisy is established if the fluid, after an acute attack, be not absorbed, or if an accumulation of liquid take place gradually, in consequence of subacute inflammation of the pleura. It is also found, especially in its purulent form, in a number of infectious dis- eases, parliculariy scarlet fever and typhoid fever. This form is also seen to follow pleuro-pneumonia and perforation of the pleura by softening tubercle. Chronic pleurisy has no constant symptoms, and is often remsurkably latent : the patient frequently does not remember to have had acute pleurisy. He is not commonly troubled with much cough, nor is the want of breath so great as might be expected ; he is not capable of talking for any length of time, or in a loud voice, but he does not really suffer from dyspnoea. His general health may remain good, and no emaciation occur. In some persons, on the other hand, the loss of flesh, the quickened pulse, the sweats, the paroxysms of hectic fever, are so marked as to produce a close resemblance to the last stages of tubercular consumption ; and there ai*e cases with misleading marked vasomotor phenomena, with flushing and sweating of one cheek and dilatation of the pupil. While the differing symptoms rather hide the pleurisy from detec- tion, the physical signs render it easy of recognition. These signs have been studied in describing the effusion in acute pleurisy. It is only necessary to recall that the most significant are absent respiration and voice, a flat sound on percussion, with a vesiculo-bronchial or a bronchial respiration above the seat of the liquid. The intercostal spaces are strikingly widened; their depressions are effaced. They are, indeed, sometimes convex, and the finger pressed on them detects a distinct fluctuation. During the act of breathing, the diseased side is almost motionless, presenting a strong contrast to the obvious play of the healthy side. The lung which is not disturbed increases in 358 MEDICAL DIAGNOSIS. size. Its murmur is more intense, sometimes harsher ; and the per- cussion sound over it is exceedingly clear. In some cases it becomes emphysematous. The heart or liver is displaced. A lateral curvature of the spinal column is apt to take place, and the shoulder remains fixed and stiff during the respiratory acts. To distinguish whether the fluid is collected in one cavity or in several, in other words, whether unilocular or multUocular, is generally impossible. Jaccoud* has, however, called attention to some points which aid in arriving at a conclusion. If we have a zone in tlie dulness where vocal vibrations are preserved, as at the posterior part of the chest from along the vertebral column towards the sternum, and beyond this zone no vibrations are perceived, we may infer that the effusion is divided by a band of pleural adhesion ; if the voice and fremitus be preserved, although weakened, over the whole extent of the dulness, — except in a zone of a few finger-breadths at the lower part of the chest behind, — while no tympanitic sound is elicited under the clavicle, we may conclude that the pleurisy is multilocular. When adhesions to the diaphragm exist, the normal movements during respiration at the epigastrium and hypochondrium are reversed, and at each inspiration a marked depression of the inferior intercostal space is perceptible. Effusions into the pleural sac may last for a long time, and lead to death by progressive exhaustion ; or the patient may recover by the fluid being absorbed, or by its finding a vent through the bronchial tubes or the thoracic walls. But the chest is rarely restored to its former state. The lung was too much compressed, or is still bound down by too firm adhesions, to resume its full function. The walls of the chest sink in around it, and the side is flattened, is duller on percussion, and presents a feebler breathing than the other lung, which remains somewhat enlarged. The heart generally returns to its normal position, but the shoulder on the affected side is apt to show a permanent depression. Notwithstandmg the decided character of the physical signs, chronic pleurisy is frequently overlooked; and we hear of patients whose pleural cavity is filled with pus being pronounced incurable consumptives, because they are emaciating and have hectic fever and clubbed nails ; or being treated for disease of tlie heart, on account of the displacement of that organ, and of dyspnoea and oedema ; or being dosed with mercury, for an imaginary disorder of the liver; or being subjected to courses of (juinine and arsenic, to check a rebellious ague which the chills and paroxysms of fever at times simulate. ^ Bulletin de rAcadt'jmie de Medecine, 1879. DISEASES OF THE LUNGS. 359 These physical signs are the same whether the fluid be serum or pus. The character of the fluid produces, indeed, no distinctive changes either in the signs or in the symptoms. We suspect empyema if the emaciation be great and accompanied by decided leucocytosis, high temperature, and hectic fever; but I have known pus in the chest with a temperature scarcely above the norm, and, on the other hand, the accumulation not to be purulent with a temperature of 103°. Baccelli has proposed a new and simple test to determine the character of the fluid, which, on the whole, I believe to be of use. It consists in ascertaining accurately how the voice penetrates, espe- cially the whispered voice. If easily and thoroughly transmitted, the liquid is serous and homogeneous ; if with difficulty, it is fibrinous or purulent ; if not at all, it is the latter. In cases of doubt I have long been in the habit of using a hypodermic syringe and removing with it enough of the fluid for microscopical examination. In those rare in- stances in which pulsation is noticed, the fluid is only seldom sero- fibrinous ; empyema is the rule, and may or may not be associated with an external pulsating tumor. The mici'oscopic and baderiologieal examination of the exudation will give us valuable information. In rare instances the fluid consists of fat-globules and of masses of cholesterine.^ In cases of hemor- rhagic pleurisy the hsemoglobinometer will inform us accurately as to the amount of blood in the exudation.^ We find it, indeed, full of blood and altered blood constituents in hemorrhagic pleurisy, a form which pleurisy may assume in cirrhosis of the liver and low fevers, but which is more frequently found in cancerous, and sometipies in tubercular pleurisy. In the latter disease, contrary to expectation, tubercle bacilli, as we know from the observations of Ehrlich, are often absent. There is a group of cases in which, either in a serous or a purulent exudate, we detect the diplococcus pneumoniae ; here there may or may not have been a preceding pneumonia. Cases in which the diplococcus pneumonia? is met with are apt to set in with acute symptoms like pneumonia, and are generally of favorable prog- nosis. In septic pleurisy the streptococcus is found, and especially, as Koplik has shown, the streptococcus pyogenes ; staphylococci are also met with. These are much more serious cases, both as to dura- tion and as to recovery. A sterile fluid points to tuberculosis. Pleuri- sies with the typhoid bacillus are sero-fibrinous and of medium gravity.' ' Debove, Soc. M^d. des H6pitaux de Paris, tome xviii., 1881. * Henry, Medical News, April 14, 1888. » Femet, Bull, et Mem. de la Sw. Med. des H6p. de Paris, 1896, p. 145. MEDICAL DIAGNOBI8. Leaving out pulnionar)' consumption, sinct* the points of differ- ence have been ah*eady dismissed^ the affections willi which rliroruc pleurisy, while the pleura is full of liquid and the chest enlarged, is liable to be eonfounded, are : Emphysema and Pneumothorax ; ixthathoracic tltmor ; Enlargement of the Liver ; Enlargement of the Spleen: Abscess in the Thoracic Walls ; Pericari>ial Effusion; HvDHtrrHORAX. Empht/mina and J'tirHmofhorax. — Tliese, altliough such diiTerent diseases, are grouped together because they give rise, like chronic pleurisy, to a dilated chest, and to displacement of the liver or heart. But the otlier signs aljove jHiinted out, which indicate the presence of air, are so striking tliat an error in di*i^oosis can only be the result of carelessness. Infrtfi/iorffnc Tumor, — A tumor within ttie chest may occasion the same dLstention of its walls, the same displacement of organs, the same dulness on percussion, and the saiue absent respiration, as an eflFusion of liquid into the ph-ura ; yet the signs are not exactly alike. There is ijo llucluation ui the bulging inlercostal spaces; the vocal fremitus is not so constantly abolistied; and the level of the dulness is not rtianged by altering the patient*s position. Nor is the flal soimd so uniform or so strictly limited as that produced by fluid : amid the dulness may be detected here and there a spol yielding on percussion a clear sound. A tumor hi the chest, moreover, presses on the nerves, or bronchial tiibes, or great vessels, and thus gives rise to severe pain, and to dyspiitea and signs of interrupted circulation far more evident than those caused by pleuritic effusion. It not infre- quently grows into the mediastinum, and then leads to prominence of the sternum, and to dilatation of both sides of ilie chest. These phenomena are found, whatever be the nature of the morbid growth. As most of the thoracic tumors are cancerous, we are otlen assisted in our diagnosis by discovering a cancer in other parts of the body, as well as enlarged cer\^ical glands, and by noting the severe pain in the chest, the harassing cough, and the expectoration of blood or of a pecuhar jelly-like substajice. Yet these evidences, wliile they aid us in establishing the fact of a new growth in the thoracic cavity, do not by any means determine its situation. We cannot say with cer- tainty whether the abnormal formation is situated exclusively in the lung, or in the pleura, or whether it affects both. When Uie tumor DISEASES OF THE LUNGS. 361 occupies the mediastinal spaces, and is not cancerous, it is most likely a sarcoma. Lymphadenomata come next in firequency.* In children, sarcoma is a more frequent neoplasm than carcinoma.^ In those cases in which an effusion into the pleura complicates an intrathoracic tumor, attention to the history and to the signs of pressure alone apprises us of its presence. Yet both signs and symp- toms may simulate so closely those of chrpnic pleurisy as to render a differential diagnosis impossible. Nay, friction sounds, a stitch in the side, and fever may be produced by a c' orifice is seated opposite the junction of the cartilage of the third rib with the left edge of the sternum. Near it, very slightly lower, but placed more obliquely, are the aortic valves. The aorta then proceeds from left to right, and ascends to the upper border on the second costal cartilage on the right side; thence it crosses, under the sternum and in front of the trachea, to the left DI8EA8ES OF THE HEABT. 369 side. The pulmonary artery is found in the second intercostal space on the left side, enclosed in the pericardium, and passes to the carti- lage of the second rib, where it bifurcates. The size of the heari; is about that of the closed fist. Its mean weight in adults is between eight and nine ounces. Only in very large persons does it exceed this. The organ exhibits, when in action, a wonderfully perfect mech- anism and regularity of movement. Its cavities contract on both sides at the same time, and distend on both sides at the same time. It then rests for a short period. The contraction of the ventricles occasions the impulse which is seen and felt in the fifth intercostal space. While the blood is flowing in and out of the heart, the valves are kept in constant motion. Their play makes itself known by two distinct sounds of unequal length, which are produced mainly by their opening and closing. The first sound, long and dull, is caused by the forcible closure of the valves at the auriculo-ventricular openings. Yet it is not a purely valvular sound. The stroke of the heart against the walls of the chest, the muscular contraction itself, and the flow of blood into the aorta and the pulmonary artery aid in its formation. The first sound corresponds, therefore, to the closure of the auriculo-ventricu- lar valves, to the impulse of the heart, to the opening of the valves at the orifice of the aorta and of the .pulmonary artery, and to the passage of blood along the arteries. The second sound is short, abrupt, and ringing. It results Irom the sudden closure of the semi- lunar valves. During its occurrence the blood rushes tlirough the opened mitral and tricuspid valves, and dilates the ventricles. Examination of the Heart by the Different Methods of Physical Diagnosis. Before proceeding to examine the heart, we inquire into the his- tory of the case, and into such symptoms as the expression of the face, the appearance of the eye, the condition of the capillary circu- lation, the presence or absence of dropsical swellings and of cough, the state of the breathing, the character of the pulse, and the fre- quency and violence of the palpitations. The cardiac region is then explored by the eye and by the hand ; the size of the organ is esti- mated by percussion, and, lastly, its sounds are studied by tlie steth- oscope. These different methods are most conveniently practised when the patient is in an easy position, leaning back in a chair or propped up with pillows in bed. To examine them more in detail : 370 MEDICAIi DIAGNOSIS. INSPECTION, Inspection detects on the chest of some healthy persons a slight protrusion over the seat of tlie heart ; yet tliis is fer from being con- stant or even the general rule, When the lieart is liy{)ertropliiecl^ or when fluid has accumulated in the pericardium, we perceive a marked prominence in the pra-*eordial region* A depression at the lower part of this region may be natural ; a verj' evident depression is almost always the result of an attack of pericardial inflammation. Yet neither prominence nor depression is a very important sign. One much more so, wliieli inspection shows, is tlie impnli^e of the heart. This is seen where the apex beats against the walls of the chest : between the fifth and sixth rihs, about an inch inward from the nipple and two inclies downward. It is for tlie most part confined to this point, and appears as a brief raising of the integument, occur- ring with great regularity of succession. In lean persons it is very distinct ; in fat persons it is generally not at all perceptible. Its seal, even in those who are in perfect health, is not always exactly the same. It is changed by different positions, and by the dLslention of the stomach after a full meal or by flatulence. It is most modified by the acts of respiration. During a long-drawn inspiration the heart descends somewhat and the expanded lung sweeps it inward, and the impulse becomes discernible in the epigastrium. During a fixed expi- ration the beat moves upwai*d, and appears more extended and weightier. The changes produced in its situation by disease, both thoracic and abdominal, are many. It is tilted upward and outward by the left lobe of an enlarged liver. It is displaced by various affec- tions of the lungs and pleura. It is forced up by a pericardial eflii- sion. It is visible lower down and over a larger surface in enlarge- ments of the heart ; but even then it is most distinct at the aj)ex. The apex beat lies without the line of tlie nipple in most children up to the fourtli year.* The alteraUons in the character and force of the impulse an? as diversified as those of its seat. But they are more readily appre- ciated by the hand than by the eye. PALPATION. The extent and force of the beat are changed in a number of car- diac afTections, both functional and oi>,^anic. Both are temporarily increased by powerful excitement ; both are permanently augmented * J, Mitchell Bruce, Enlargement of the Heart, in Keating' s Cyclop«dia of the Diseases of Children, vol. ii. DISEASES OF THE HEAET. 371 by hypertrophy. In dilatation and pericardial effusion, the extent over which the stroke is felt is greater than in health ; but the impulse is feeble, and in the latter disease irregular and wavy. Softening of the texture of the heart, diseases of the brain, some morbid states of the blood, many infective fevers, and a low condition of the system will also enfeeble the beat. The hand, when laid on the praecordial region, perceives at times two impulses. This double impulse is often recognizable in health, especially in thin persons. It becomes still more evident in hyper- trophy with dilatation of the ventricles. One of the beats is systolic ; the other corresponds to the diastole. Bouillaud cites examples in which the diastolic stroke was double. All these modifications of the impulse stand in direct connection with the action of the ventricles. The auricles, save in some rare instances in which they are dilated and their walls thickened, give rise to no perceptible movement in the chest wall. The sounds of the heart can be analyzed by placing the hand over the cardiac region. They will be felt, the one as a long and dull, the other as a short and distinct, vibration. The motion is due to the play of the valves, and disappears with their destruction. The fingers applied over the heart perceive at times a peculiar thrill, or a rubbing movement. The first — called by Laennec, from its resemblance to the purr of a cat, the purring tremor — is nearly always indicative of a valvular lesion, especially of mitral obstruction. The second is caused by the to-and-fi-o motion of a roughened pericardium. PERCUSSION. Percussion affords the readiest means of judging of the size of the heart. The patient is placed in a recumbent position; then, by a series of moderately strong taps, we proceed downward from near the middle of the left clavicle, until a dull sound, accompanied by decided resistance, tells that we are striking over a solid organ. The point at which this dull sound begins is over, or immediately at the low^er border of, the fourth cartilage. It corresponds to the upper limit of the portion of the heart which is left uncovered by the lung. The superior border of the dulness having been thus ascertained, we next percuss on the right side of the sternum, on about a level with the fifth rib, and progress across the bone. At, or very near to, its left edge we find marked resistance and a duller sound. Here we draw our second line, and continue to strike straight across the cardiac region up to the point at which a clear, full note demonstrates that 372 MEDICAI. DIAGNOSIS. the piilijioiiaiy tissue is resounding. This determines tlie transverse diajueler of the Iteart, — at least so far as it can be mapi>ed out on the chest. The apex of the organ and its inferior surface remain to be fixed. The first is readily done by advancing in an oblique direction fi'om the already ascertained right border. But we can save ourselves this trouble by feeling for 11 je impulse or by listening for it with a stethoscope. The inferior surface can be circumscribed by prolonging the line of the dulness on percussion of the upper border of the liver, and then judging by the greater amount of resistance and the fall in pitch that the heart hiis been reached. The dulness elicited by percussing the cardiac region is not so absolute as that of tlie liver or of some other solids. II is mixed with the sound of the lung-tissue, or with tlie resonance of the sternum. Nor is it a representation of the size of the entire organ. It simply portrays Llie more su[)erlieial portion, wtiich is uncovered by the lungs. In women it is |jarti( nlarly difficult to define these limits. It can be done only by ha\ing the ntammary gland drawn to one side while percussing. It is equally difficult in children, as the space over w^hicli the dulness is perceived is very small. In adults I he dulness ordi- narily si»reads over two, or nearly two^ intercostal spaces. Its trans- verse diameter in a grown person of medium size is about Iwo inches and a half. In tall, broad-chested men it is upward of three inches. Such, at all events, is the resoll of measurements 1 have made. The range of the dulness is clianged by a number of causes, physiological as well as pathological. A full inspiration alters it materially, by bringing tlie lung down over the lieart, and by dis- plariiig Ihe t^rgan itself. The up[jer border of the percussion dulness shifts to Uie extent of an intercostal space. Below the nipple, between the Htlh A'--v>;» •'••/♦^^ mnmfy urtewy valme* •.»^--*.- NiN • ' % .N. %fc*-v»> M *.*iVO C^ >*0 DISRATES OF THE HEART. 375 During a full inspiration, the sounds at the interspace between the second and third costal cartilages on the left side disappear almost entirely, and become faint at the aortic cartilage. The first sound at the apex lessens also very much in distinctness, but it is better heard at a new point of impulse, visible towards the median line and just below the cartilages of the ribs. During a full expiration, the extent over which the heart-sounds are perceived is increased. The sounds grow in loudness in any functional disturbance of tha heart. When the organ is palpitating violently under strong nervous excitement, they may become short and sharp, and sometimes so loud and ringing as to be audible to the by-standers. They are often per- manently louder than in health, and are shorter and more clearly defined when the walls of the heart are thinned. This is particularly the case with the first sound. When the walls of the heart are thick, the first sound over the hypertrophied portion is apt to be dull and prolonged. The first sound is weakened if the structure of the heart be softened : hence it is feeble in some low fevers, and in fatty degen- eration of the organ. It is also less distinct when there is a want of tone in the muscle, or when the mitral and tricuspid valves are thickened. To determine whether a dull first sound at the apex be due to an injured mitral valve, or to an alteration of the muscular power of the heart, Flint advises to place the stethoscope over the apex of the heart, and then on the outside of the left nipple to isolate the element of impulsion, which unites with the valvular element to form the complex first sound. If there be a marked impulse over the apex, but if by means of the stethoscope placed to the left we perceive no sound which possesses a valvular character, or hear a sound only fidntly valvular, we infer that the mitral valves are damaged. The second sound is not so liable to be changed as the first. It is rendered somewhat duller by a thickening of the semilunar valves ; on the other hand, it is more ringing when they are thin, and in great functional excitement of the heart, and in altered blood conditions, as in lithaemia or in gout. The sound, indeed, always becomes more distinctly accentuated if the column of blood closes the valves forci- bly. This occurs not infrequently in hypertrophy of the ventricles, especially the left, and in the increased tension of the vessels in con- tracted kidney and in arteriosclerosis; it afl'ects the second aortic sound. Accentuation of the second sound also takes place where a decided obstruction exists to the passage of blood through the lungs, and in mitral valvular disease. In the latter conditions it is over the pulmonary artery alone that this accentuated second sound is audible. 376 MEDICAL DIAGNOSia Both the sounds are occasionally obscure. This happens when fluid has accumulated in the pericardium. The sounds may be changed in theu* relative proportion to each other, and the pauses between them be lengthened or shortened, or else the sounds may intermit from time to time. From this perverted rhythm we do nol derive any definite instruction as to the condition causing it. It may be associated witli organic disease or exist without it. The same piay be said of reduplication of the sounds of the heart. The second sound is the one which is generally split. Yet both of them maybe doubled, or one may be doubled over one part of the heart and not over another ; so that four or three sounds are counted to each beat of the pulse. The cause of the reduplication is the want of syn- chronous action of the two sides of the heart. The direct value for diagnosis of the altered movement is not great. Yet there is some value to be attached to the changed rhythm. Thus, the peculiar alter- ation of the sounds, which causes us to hear three sounds during the action of the heart, two of them in the diastole, producing the rhythm that has been' likened to the gallop of a horse, is often found in con- tracted kidney and in arteriosclerosis. It is particularly heard over the mitral and tlie tricuspid region. Fraentzel ^ has noted the frequent occurrence of this gallop rhythm in typhoid fever and in croupous pneumonia, and looks upon it as a sign of grave cardiac weakness ; it is also a sign of serious import in chronic Bright's disease. Such, then, are the modifications which the healthy sounds present At times we meet with sounds which do not in the least resemble those naturally heard, and which overshadow them or take their place. They are called nmnmirs^ and are mainly produced either within the heart or on its surface. Those munnurs that are ejidocurdial haye a common quality : they are more or less blowing. Yet the sound is not always of tlie same character or pitch. It may be low-toned, it may be high-pitched; it may be soft, it may be harsh ; it may resemble the blowing of a bel- lows ; it may be musical ; it may be filing, or rasping, or sawing. The ingenuity of every listener exerts itself in tracing a similarity to some familiar noise ; but to little practical purpose. These different sounds teach us nothing certain as to their source. They are, moreover, not at all tunes the same in the same case, since the heart when excited may emit a sound different from that which it does when it is beating quietly. * Kraiikheiteu des Herzens, Berlin, 1889 ; see also CuflTer and BarbilUon, Arch. Gen. de Med., 1887. DISEASES OF THE HEAKT. 377 A blowing sound originates in the altered relation of the blood to the part over which it moves. This general statement opens the way to the consideration of the specially acting elements, both in the blood and in the heart itself. Usually a cardiac murmur springs from a change at one of the orifices. This may be either a narrowing or a roughening, which interposes a local obstruction to the flow of the blood ; or it may be an insufficiency to close the opening. . In the latter case the blood, regurgitates, and a murmur is occasioned by the deviation of the direction of the current and the establishment of another. This sub- version of the course of the circulating fluid, added to its increased velocity and force, is the chief source of those temporary blowing sounds not infrequently perceived when a heart is greatly excited, while both its valvular apparatus and its muscular texture are healthy. Obstruction to the circulation, with, perhaps, altered position of the heart, is the cause of the cardiac murmurs in pleurisy and in pneu- monia. But we meet often with instances where none of these causes are present, and where altered blood is the foundation of the murmur. Thus, to sum up the subject, we find murmurs that depend upon organic change, and murmurs that are unconnected with any struc- tural alteration ; and these inorganic murmurs are due either to an unnatural condition of the blood or to temporarily perverted action or position of the heart. The murmurs, however caused, have different effects on the sounds of the heart. They either accompany the sound throughout the whole or a part of its duration, and thus obscure it, or else they take its place and hinder it from being generated. In time of their occurrence they" correspond to the contraction or to the dilatation of the heart, and therefore to the first or to the second sound ; at least, they do so practically. It is true, they may immediately precede or succeed either sound, or fill mainly the intervals of silence between them, or occur early or late in the sound; but attention to such minute divisions, except in the case of the presystolic murmur, is for most purposes unnecessary. In point of fact, it is often difficult enough to say whether the murmur we hear is systolic or diastolic. The readiest method of judging of the time of the production of a murmur is to feel for the impulse while listening with the stethoscope. The blowing sound which agrees with the beat of the heart is sys- tolic ; the one just before the systole is presystolic ; the one between the beats is diastolic. When a murmur is once established it attends each motion of the 378 MEDICAL DIAGNOSIS. heart that can give rise to it ; but it is not always equally perceptible. It may become vet*y faint, or disappear entirely, by the patient changing his position. It is sometimes manifest only when the heart is acting strongly. Indeed, it always requires a certain force and velocity in the passage of the blood to generate a murmur. Yet overaction of the heart may* be as destructive of its distinctness as diminished action. This is, however, a matter that, should it be desirable for diagnosis, we can control by the administration of medicines like digitalis, aconite, or veratrum viride, provided their use be not contra- indicated. A murmur is sometimes heard by the patient himself, or is audible before the ear is placed over the heart. It may be perceived as an abrupt blowing sound, apparently coming out of the mouth. I have met with a number of such instances. The murmur is nearly always systolic. Posture exerts a decided effect upon murmurs. A blowing sound distinct in the recumbent position may become very faint or dis- appear when the patient stands erect, and the reverse holds good, although less common ; anaemic murmurs are thought to be more intense in the recumbent position.^ Pressure, too, has an influence upon the abnormal cardiac sound ; it notably augments it, and often raises its pitch. Yet pressing the stethoscope against the chest does not occasion as much alteration in endocardial as it does in peri- cardial sounds. A murmur may be obscured by the respiratory sound ; and the natural sounds of the lungs may be mistaken for blowing sounds in the heart. Certainly the resemblance is often great; but blunders may be readily avoided by listening to the heart while the patient suspends his breathing. Having ascertained positively the existence and the time of occur- rence of an endocardial murmur, the next thing is to determine its exact seat, and, if possible, its immediate cause. The seat of the murmur is judged of by the place of its greatest intensity, and by the relation this bears to one of the four points for the clinical examina- tion of the heart above described. If it be most distinct at or near the apex of the heart, it is produced at the mitral orifice ; if immedi- ately above or at the ensiform cartilage, it is generated in the right ventricle and at the tricuspid opening. If we hear it most plainly at the sternum, somewhat towards its left border on a level with the third intercostal space or even the fourth rib, and with equal or ^ James H. Hutchinson, Amer. Joum. Med. Sci., April, 1872. DISEASES OF THE HEART. 379 nearly equal distinctness at the second costal cartilage on the right side, we are enabled to decide that it is developed at the origin of the aorta. The pulmonary artery is not often the seat of a murmur. When it is, this is clearly perceptible in the second intercostal space on the left side, and extends, if the valves be diseased, to the junction of the third left cartilage with the sternum ; although we must bear in mind that occasionally in mitral affections the murmur is loudest in the pulmonary area, or, as Naunyn has shown, not exactly over the artery, but rather an inch and a half or more from the left edge of the sternum in the second interspace. Any of these situations may be the site of a distinct murmur occupying only one sound of the heart; or being produced in both, — one murmur taking place with, the other against, the current of blood. Yet it rarely happens that the murmur is strictly limited to one of these positions: it will mostly extend in various directions from its point of intensity, growing fainter and fainter as this is left. A blowing murmur thus transmitted may drown the natural sounds of the heart at the parts not diseased. But when one orifice alone is affected, we can usually hear the sounds at the other valves. They may be obscured, but still they exist ; and it is a vast aid when they are heard, since they set the limits of the disease. How important is it, then, to examine each portion of the heart separately, as much for the purpose of saying what is not as what is deranged ! If satisfied as to the seat of the murmur, we naturally turn to inquire into its origin. -Is it caused by an alteration of the valves ? Is it unconnected with any appreciable change of structure in the heart? There is nothing in the murmur itself which will tell us posi- tively. As a rule, it is true that a harsh murmur results from organic disease, and a soft murmur is inorganic ; but we judge with much more certainty by the time of the occurrence of the blowing sound and by the accompanying phenomena. A murmur presystolic or diastolic is organic ; a systolic murmur may or may not be organic. A murmur arising from an impoverished state of the blood is systolic, generally soft, of low pitch, is perceived over the base of the heart, and is accompanied by a humming sound in the veins of the neck. It may be heard over the right base, or on the left side over the pulmonary artery; although Balfour maintains that it is not really over the pulmonary artery, but about half an inch or more to the left of the pulmonary area, and is not an arterial, but an auricular sound. Throughout the consideration of the endocardial murmurs, they have been treated as originating at the seat of the valves. In truth. ZH() MEDICAL DIAGNOSIS. it te there that they are formed. Still, they are occasionally due to morbid states in the body of the ventricle, or in the auricle. But in either case this is ven* rare. As regards the auricles, they jield bo appreciable sound in health, nor are they in disease, except rarely, the source either of sound or of murmur. A blowing sound is not of necessity limited to the heart : it may be transmitted all over the arterial system. Yet it would be a great mis- take to 8upi)ose that every murmur heard over the arteries is connected with a disease of the heart. It is often but the sign of impoverished blood, or a sound dependent upon local roughening or narrowing of the tube. The latter may be temporarily producQ^ by the pressure of a stethoscope. Lvi us now^ examine the sounds which originate on the outside of the heart. These pericardial murmurs have all a common source: fhey all result from irregularities on the membrane. Like the pleura, fh(» smooth serous covering of the heart moves noiselessly in health; but when it is roughened by a deposit of any kind, the fiiction of its surface pves rise to a sound which may be single, but which is usu- ally double. The character of this sound is variable. It may be a to-and-fro rubbing murmur, or it may be grazing, or scratching, or milking, or wliistling, or clicking and resembling the valvular sounds. It has but one quality which is constant, and tliat is its superficiality. Hy this superllciality ; by tlie strict limitation of the sound to the nyion of tiio heart ; by its altering from time to time its precise seat; by its ^nvater extent and intensity when the patient bends forward; by its orcasional increase, and even change of character, on external pn\ssun^ : by its foUowiiig, rather than occurring with, the movements of the iieart : and by the sensation of friction which it communicates to the tin^T, — we know that the sound heard is produced on the sur- face of I lie iioart. Yet, in spite of this array of points of diflFerence. it is often dirtioull to distinguish a pericardial firom an endocardial nmnuur. An orrt>r not easy at liu\es to avoid is the foil are to discriminate between the pnsystoUc ajvx mmnnur. regarded as characteristic of mitral constriction, ai\d a poricanlial friction localized near the apex. The v>nl\ Irustwortliy innnts of distinction are that the pericardial souvvd chaUi^ s in its iiualitv and loudness : that it is rendered stronger anvi c!un,*:\\i in pitc!; by prt^ssui\^ exerted with the stethoscope, and tl;at tl;c stvo:^i sovmd at tb.o le:^ Iviso is unaltered. A tVix tio:; Sv^r.tu: ;< pn^r.e to :r.;isk the natural sounds of the heart. At Jiv,u s, iilti^^vul; Vu\;r\i . vcr the carviiao r^pon, it is not due to in- TUtti;,,A:;x>r, of t>tc j\ n.uniiur.:. Tr.e t^SLiKiation may be chi the snr- DISEASES OF THE HEART. 381 face of the pleura adjacent to the pericardium, and the murmurs be caused solely by the movements of the heart, with the rhythm of which they coincide. Sometimes, again, the sound heard in the car- diac region is in reality the rubbing of an inflamed pleura. If any doubt exist, let the patient be told to suspend his breathing. As this is stopped, the pleural sound ceases. Such is a brief description of the different physical signs met with in examining the heari:, both in health and in disease. Their impor- tance for diagnosis it is difficult to overestimate. A knowledge of the physical signs is the solid foundation, without which any structure that may be raised will soon tumble to pieces. The Gheneral and Local Symptoms of Diseases of the Heart. It is not easy to say what are and what are not the symptoms that belong to diseases of the heari:. There are vital manifestations directing attention to the heart which are not associated with any change in its structure ; and most serious changes in its structure may occur without any of these vital manifestations. Yet we often find a significant group of symptoms that accompany an affection of the heart. Some of these attest directly the organ disturbed, such as pain in the cardiac region and palpitation. Others are the indirect and more remote expressions of its derangement, such as cough, dyspnoea, hemorrhages, dropsy, disorders of the brain and nervous system, engorgement of the abdominal viscera, a peculiar state of the arteries and veins, and the aspect of the face. It is unnecessary to do more than mention some of these, since several have been already described in connection with pulmonary complaints, and there is nothing in the cough or in the shortness of breath by which we can absolutely determine it to be caused by a disease of the heart. The same with respect to hemorrhage ; there is nothing characteristic about it. It simply proves the eflForts of the blood-vessels to relieve themselves of the strain which the disturbance in the flow of blood has put on them. The capillaries and the smaller blood-vessels give way first ; partly from the reason just assigned, and partly from the altered state of their coats, a common associate of cardiac disease. These hemorrhages are prone to happen from the bronchial tubes and the lungs, and the blood is expectorated ; but they may also take place directly into the pulmonary tissue, or into or from any part of the body. Their danger is in proportion to the amount, to the impor- tance of the function of the structures into which the blood is effused, and to the possibility of its finding an outiet. The peril is greatest when the blood is poured into the brain. 24 382 MEDICAL DIAGNOSIS. Cardiac Dropsy. — ^The dropsy caused by disease of the heart is met with in different situations : in the cellular tissues, in the perito- neal and pleural cavities, in the pericardium, in the ventricles of the brain and under the arachnoid, in the air-cells of the lungs, — ^in &ct, in any pari: where fluid can exude, and where there is a space which can receive. In anasarca dependent upon a cardiac lesion, the dropsical swell- ing begins about the ankles and feet. The accumulation is much in- fluenced by position ; the feet are more puffy towards evening, when the patient has been all day in the erect posture, and least so when he gets up in the morning. The dropsy is most constantly found to be associated with disturbance in the flow of the venous blood, and therefore with disorder of the right side of the heari^ particulariy with a dilatation of the cavities. It may be permanent or not. Its extent certainly does not bear a constant relation to the extent of the cardiac disease. It bears a more constant relation to the amount of venous congestion, and to the impoverishment of the blood. Derangement of the Oircnlation. — Unmistakable evidence of tlie obstruction to the flow of blood through the veins is afforded by their prominence in diff'erent portions of the body. This is espe- cially manifest in the superficial veins of the neck, which, moreover, when the tricuspid orifice is permanently open, exhibit a distinct pul- sation with each beat of the heart. The turgid condition of the venous system is rendered equally obvious by the livid tinge of the skin and the bluish color of the lip, and by ramifications of fine bluish vessels on the surface. But the arterial system may also be gorged, and we may find the capillaries and the smaller arteries seemingly ready to burst. The conjunctiva is then highly injected, and the cheek has a coarse, red look. This change in tlie color and appear- ance of the face, the thickening of the eyelids, and the prominent eye, make up the peculiar physiognomy of a chronic cardiac malady. The state of the larger arteries is very variable, and mainly according to the nature of the disorder and the condition of the cardiac w^alls and of the blood-pressure. The pulse may be small and tense ; it may be full ; it may be rebounding ; it may be very irregular ; and it is often out of all proportion to the forcible action of the heart. The derangement of the circulation of individual parts manifests itself by special symptoms. It shows itself in the brain by attacks of cerebral congestion ; by vertigo ; by violent headache, occurring in spells, or, less acute, in dull persistent ache, increased on exertion,— a form especially met with in children. We see evidences of the con- gestion of the nervous system in the disturbed dreams ; in the sudden DISEASES OF THE HEABT. 383 starting up from sleep ; in the irregular action of certain muscles ; in the spots which float before the eye. It is possible that the strange sense of insecurity and the irritability, of which patients afflicted with a cardiac malady complain, are produced by the same cause. At any rate, whether produced thus or not, they are remarkable symptoms. There is no disease which unnerves more than a disease of the heart. Indeed, the mere fear of its presence gives rise to restlessness and gloom, and breeds timidity in those who would look any external danger boldly in the face. The disordered flow of blood through the abdominal viscera occa- sions oiganic changes and a disturbance of the functions of the several organs. Thus, the liver increases in size, or undergoes other altera- tions which interfere more or less seriously with the elimination of the bUe ; or the kidneys no longer secrete as in health, but become much engorged and drain off the albumin of the blood ; or the spleen sus- tains textural transformations. These states all tend to give rise to more and more dropsy, and hence to more and more suffering. The symptoms which point most directly to the heart itself are palpitation and irregularity of action, and pain. These symptoms denote that the function of the organ is disturbed, or that its innerva- tion is in some manner deranged; but they denote nothing more. They are, therefore, common to functional derangement which occurs associated with structural changes in the heart, and to purely func- tional derangement. Cardiac Pain. — Pain in or over the heart is met with in both acute and in chronic diseases ; yet it is not a regular or well-defined symptom of either. When we reflect that the heart may be pinched, may be torn, without exciting any suffering, it will be readily under- stood why its disorders do not occasion much pain. Indeed, many a case of enormous enlargement of the heart, or of profound textural alteration of its walls or valvular apparatus, is unaccompanied by pain. Still, we meet with instances in which distress at the heart and various uneasy sensations are among the more marked symptoms of a chronic cardiac lesion ; and we even find persons complaining of a persistent pain in the heart, which extends to the left side of the neck and arm, in whom this symptom has preceded the signs of a disease of the heart or of its great vessels. The greatest suffering happens in the obscure malady termed angina pectoris. Angina Pectoris. — The disease occasions paroxysms of intolerable anguish. These come on suddenly, and pass off as suddenly. Their main feature is an agonizing pain in the praecordia, as if the heart were being firmly grasped by an invisible hand, or as if it were being 384 MEDICAL DIAGNOSIS. torn to pieces. The pain is, however, not limited to the cardiac re- gion; it radiates in various directions, shooting to the back, to the neck, and especially down the left arm. But this is not all : worse than the pain are the intense anxiety and the feeling of impending death. The heari: palpitates during the fit. Yet, if we judge by the character of the pulse, its movements are not always materially dis- turbed; for this may be but little altered, and regular; very gen- erally the arterial tension is high. Again, there may be a decided difference between the pulses, the left being almost or quite imper- ceptible.^ The face is generally pale. Difficulty in breathing, con- trary to what might be expected, is not a prominent symptom, and is, in fact, often wanting, while sometimes there is asthmatic wheeaang, or the breathing is irregular and of the Cheyne-Stokes variety. Gid- diness, spasmodic seizures, temporary coma, perverted sensibility, occasionally attend or follow the cardiac attack, and so does peri- carditis.^ The duration of the fits is as uncertain as are the causes which excite them. They may cease in a few minutes ; they may last an hour. They come on rapidly, without any assignable reason, though they are generally produced by exertion, by fatigue, by exposure to cold, or by mental emotion. However provoked, they are always dangerous. The heart may stop beating during the paroxysm. " My life is in the hands of any rascal who chooses to annoy and tease me," was a saying of John Hunter's. And in truth, after he had suffered for years from these seizures, his irascible temper brought on one in which he expired. It happens sometimes that the second attack follows at a short inten'^al the one by which the disease first declares itself, and proves fatal. Latham^ narrates the historj^ of two cases of this kind. In one, life ceased in a fortnight after tlie first seizure ; in the other, in ten days. Nay, it may be cut short even in the midst of the first manifestation of the malady. Such was the death of Arnold of Rugby.* On the other hand, I have had a patient under my care who for weeks at a time has five or six attacks diiily, kept in check, but not wholly averted, by nitrite of amyl ; and in another patient as many as forty occurred in one day. The immediate conditions on which the symptoms of the attack depend are veiled in obscurity. Whether they be or be not produced * Hamilton Osgood, Anier. Journ. Med. Sci., Oct. 1876. '^ Clin. Soc. Transact., vol. xvii. p. 82. •' Lectures on Diseases of the Heart, vol. ii. * Stanley, Life and Correspondence of Thomas Arnold. DISEASES OF THE HEART. 385 by temporary increase of weakness in an already enfeebled organ ; whether a cardiac spasm occur or do not occur ; whether the pain and the sensation of approaching death be or be not caused by an acute distention of the heart with blood, — we do not know. All we do know positively is that the excessive pain abruptly appearing and disappearing points to deranged innervation. Yet we can go a step fariber; we can say with certainty that angina pectoris is not often an uncomplicated neuralgia. Modern research has taught us that these outbreaks of a cardiac neurosis are frequently linked to some structural change. This structural change, so far as we can now see, is, however, not at all times the same. The list of disorders of the heart and arteries which angina pectoris may accompany is, indeed, very long. There is hardly an affection of the walls or cavities of the heart, scarcely a morbid condition of the arteries that nourish it or spring from it, with which the distressing malady has not been observed to be associated. It has been found as an attendant on changes in the coronary artery ; on every form of valvular disease ; on thinning of the parietes of the heart ; on adherent pericardium ; on fungoid growths springing from the apex of the organ.^ It has been thought that combined with all of these states is fatty degenera- tion, which thus would be at the root of the angina.^ Whether this view be correct or not, it is certain that fatty degeneration is very often conjoined ^vith angina. But fatty degeneration occurs also without angina, as does disease of the coronary arteries, and we are thus forced to admit that, however frequent the association, some un- known element is still the determining cause. Yet arteriosclerosis, general or localized, in the heart or aorta, with changes in the myo- cardium, is the most common obvious lesion. In influenza and in diabetes angina is also met with. During the attack, as Brunton has shown, there is a vasomotor spasm of the smaller vessels, with a rise in blood-pressure and increased tension in the arteries. Angina pectoris is now very generally ranked among the vaso- motor neuroses. But evidence is not wanting, as Peter's cases prove,* that neuritis of the cardiac plexus, the neuritis itself being consecutive to aortitis, is the cause of a certain number of cases. Angina pectoris is easy of recognition. The points to ascertain are, whether it is linked to an organic cause, and to what oi^ganic cause, or whether it is a pure neurosis, either primary or reflected. It * B. Travers, Medico-Chirurgical Transactions, vol. xvii. * Quain, Medico-Chirurgical Transactions, vol. xxxiii. * La Semaine Medicate, March, 1892. 386 MEDICAL DIAGNOSIS. may be a question whether those severe pains in the region of the heart, which occur in feeble anaemic persons after unaccustomed exertion, or which are brought on by the excessive use of tobacco or of tea, or which happen in rheumatic or gouty subjects, especially while suffer- ing from indigestion, are real angina, or whether they may be sepa- rated from this affection. They differ Irom it, irrespective of beii^ far less violent and less radiating, by the circumstances leading to an attack, and by their constant association with palpitation. Interco^d neuralgia with palpitation might be mistaken for angina ; but the pain- ful spots in the course of the affected nerve, and the comparatively slight suffering, distinguish it. In truth, it is a complaint seated only in the thoracic walls, and referred by the patient to the heart. Great irritability of the heart, attended with faintness, with sensations of sinking, with flushing alternating with pallor, and with pain, due most likely to a neurosis of the cardiac plexus, is discriminated from true angina by the palpitations, by their connection Avith pain which never rises to tlie anguish of angina pectoris, by the periodical nature of the !)ain, its nocturnal occurrence, and its duration for one or two hours, ^flen, too, tliis apparent or false angina is found in persons who are hysterical, or are subject to neuralgia, or are laboring under a disorder of one of the abdominal viscera, and is then clearly reflex. It must bo, however, admitted that the distinction between true and false angina is one of degree rather than of kind. Another complaint that may be confounded with angina is what may be called iHirdiac epilepsy. In this rare affection intense pain in the nyion of the heart happens in paroxysms. But unconsciousness, however temporary, occurs also, and the pain is apt to follow rather than to priH'ede the unconsciousness. Yet it may outlast it, and be- come associatinl with twitching of the muscles of the fece and with other s^Kismodic movements. These, the unconsciousness, and the time at which the (min happens, distinguish the malady from those instances of angina in which, owing to the severity of the pain, the (Kitient i^isses into a pn^tracteil faint. Palpitation. — This arist^s in Viirious affections of the heart, or- ganic as well as function^. It bears no positive relation to any sptvial canliac malady. So, toi>, with irregular riiytlim of the heart's action, with wliich jvUpitation is often combined, and w^liich, when linked to a disease of the oi^iuu generally means failing heart-muscle. lUit ^Kilpitation, with or withoiit irrvyular rhythm, may take place in a somul heart, disturUnl teniponirily by the condition of the nervous s> stem, .or of the digestive onrans, or by toxic influences. Often the puls;Uious v^t' tlio b.oart Nvonie stronger, more extensive, DISEASES OF THE HEART. 387 and more perceptible, from mere nervous excitement. But it is not necessary to detail the symptoms of a purely nervous palpitation. Every one has experienced them. Every one knows that there is a feehng of slight constriction about the chest, with a hurried breathing, and a strange sensation as if the heart were leaping from its place. Every one is also aware that the organ is felt thumping against the walls of the chest, and with a force which shakes them. The popular notion, that the heart is the seat of the emotions, is based on these striking evidences of its disturbed action. During an attack of palpitation the cardiac sounds are clear and ringing ; in neurasthenics and ansemics, or if the cardiac excitement be prolonged and violent, a systolic murmur at tlie apex or left base is not uncommon. Persistent rapidity of cardiac action, or tachycardui^ may happen without obvious cause in persons apparently healthy. It is very com- mon in irritable hearts and in exophthalmic goitre. Spender^ has called attention to its occurrence among the earlier signs of rheuma- toid arthritis. The extreme frequency of the action of the heart is in some instances remarkable. I have known it to beat over two hundred times in the minute. The disorder may occur in paroxysms, described as " cardiac nerve storms'' by H. C. Wood.* Great rapidity may be joined to a condition in which the two sounds are precisely alike, and the pauses of equal length. This foetal rhythm, or embryo- cardia^ is a sign of heart debility, and is most frequently seen in con- nection with marked dilatation, or in fevers. In gallop rhythm the cardiac sounds are split, most often the second. It is generally found associated with the weakening heart of arteriosclerosis and of inter- stitial nephritis. On the other hand, the heart-beat may be very slow, less than thirty times in the minute. We may find this slow action, brady- cardia^ both in functional and in organic maladies, though it is most likely that the nerve-centres are in both affected in the same way.* Bradycardia is often associated with atheroma of the aorta or of the coronary arteries. It is also met with in a number of instances of fatty heart and in old-standing valvular disease. Its association with jaundice, with uraemia, with lead poisoning, with feeble heart action during convalescence from fevers, with apoplexy, with epilepsy, with * On Osteo-Arthrilis, London, 1889. ' University Medical Magazine, March, 1891. • See an interesting analysis of ninety-one cases, by Prentiss, Transact. Assoc. Amer. Phys., vol. iv., 1889. 388 MEDICAL DIAGNOSIS. affections of the medulla and the cervical cord, and with melancholk is well known. FUxNCTIONAL DISORDERS OF THE HEART. It has just been stated that the direct symptoms of a cardiac dis- order— pain, palpitation, irregular action — are met with when no recognizable structural change has taken place. Under such circum- stances the affection of the heart is termed functional, and its symp- toms are those mentioned, variously combined, sometimes the one predominating, sometimes the other. These functional disorders are very much more frequent than the organic. They are, for the most I)art, produced by direct excitement of the heart, or by its being sym- pathetically disturbed by a source of irritation away from it, or in the system at large. The symptoms may be said to constitute the disease. Functional Disorders characterized by Palpitation, asso- ciated or not with Change of Rhythm. We have already briefly mentioned the causes of augmented action which are associated with organic changes, and those which occasion tompomr)' disturbance of the heart. A more lasting form of palpita- tion is engendered when the organ is kept constantly excited by a derangtHi condition of some viscus remote from it ; by the use of stimulating substances ; or by some general morbid state. Thus, a disordered stomach or liver leads to a reflex disturbance of the heart, which ceases if the disorder of the stomach or liver be remedied. In gt)uty, litluvmic, and rheumatic persons the heart frequently pulsates with incn^ased quickness, and sometimes with marked irregularitv. SptH'ial articles of diet, especially tea or coffee, produce palpitation; so iloes the inonlinate use of tobacco and of alcohol. Overwork, worry, inuuoderate dancing, masturbation, and excessive sexual indul- gtMu*e, but {Kirticularly masturbation, are prolific sources of continued imlpitation. Women who are hysterical, or whose uterine functions un^ disonlertHl, suffer frv^m ^Kilpitation. So do anaemic persons and neunisttuMuos complain of the beating of the heart. A tnniblesome kind of (vilpitation is that attended with marked i»vNt:rfA?'v7v i^f tlto action of the lieart, displaying itself by the beat boiivg now slow, now f;ist, or oivasionally intermitting. Sufferers n\Mu Uttuvmia or v^nit, or old jvrsons with feeble digestion, are par- tirularU Uablo to it. Tliis form of (xilpitation is not without danger. U is pr\M\o to Iv assiviati\i with an iteration in the structure of the h^>art, smh as tiaMnncsji of the ^-ails. DISEASES OF THE HEART. 389 Some who experience fits of palpitation faint away during these. But the almost complete suspension of the movements of the heari: which characterizes an attack of syncope has no definite connection with any fonn of palpitation, nor, indeed, with any form of cardiac disorder, organic or functional. In those who are subject to attacks of palpitation or to irregular action of the heari:, the organ may finally become enlarged. A peculiar irregular action of the heart has been much discussed under the name of hemiaystole. Leyden describes cases in which with every two beats of the heart only one beat of the pulse is felt, and attributes this to the right ventricle contracting alternately with the left. Different explanations have been given of the fact, but the observations of Riegel and Lachmann, while they do not strictly confirm the alternate action of the ventricles as the cause of the phenomenon, point to irregular contraction of the muscles of the heart as the cause.* We sometimes meet with a singular form of functional disturb- ance of the heart which leads to textural changes, and to which Graves called particular attention. It consists in a long-continued excitement of the organ, as evidenced by its increased force and rapid and irregular action, which is followed by a swelling of the thyroid gland, pulsation of the arteries of the neck, and prominence of the eyeballs. This disease, exophthalmic goitre^ is most commonly observed in women, and connected with hysteria, neuralgia, or uterine disturbance; it has in some instances an evident origin in worry or in shock. It is generally considered to be owing to an aflFection of the cervical sympathetic nerve. But its cause is far from certain. There are those who hold it to be a neurosis of the /nerve- centres, especially of the vagus centre ; and the detection of ptomaines in the urine is thought to be a proof that this apparent neuro-cardial malady is really consequent upon secondary disturbance of the nervous system due to poisonous products from the thyroid. The most characteristic sign, the greatly accelerated heart's action, varies much in extent. All the signs may remit or may become aggravated from time to time, and especially during a severe attack of palpitation. The turgescence of the thyroid gland arises quite in- dependently of the usual exciting causes of bronchocele. It is ac- companied by a pulsating thrill similar to that of an aneurismal varix, and by a distinct throb. At an advanced period of the com- plaint, these signs subside, and the gland becomes more solid. Iri- * Virchow's Archiv, Bd. xliv. ; Deutsches Arch. f. klin. Med., Bd. xxvii. p. 393. 390 MEDICAL DIAGNOSIS. deed, the whole aflfection may disappear, and the gland, the eyes, the beat of the carotids, the action of the heart, all return to a normal condition. On the other hand, hypertrophy and dilatation may re- sult from the cardiac palpitations, or the malady be noticed in asso- ciation with valvular disease, under circumstances which make it a question whether this has followed it or is a mere concomitant The protrusion of the eyeball is often combined with a symptom that Graefe particularly observed, — a want of agreement between the movement of the lid and the raising or depressing of the glaiic^. The palpebral aperture is wide, owing chiefly to spasm of the upper lid, and this spasm of the elevator of the upper eyelid is held to be pathognomonic.^ Another symptom of importance is trembling of the hands. The tremor is fine, and, as Charcot pointed out, affects the whole hand, but not individual fingers. There is also, as Charcot shows, greatly lessened resistance to the galvanic current ; but this sign is not of much value, as Cardew * has found the electric resist- ance to diminish greatly whenever the skin is moist. Other symp- toms are cramps, usually at night, epistaxis, oedema of the legs and eyelids, lessened respiratory expansion, moderate elevation of tem- perature, sensation of heat, flushed and moist skin, paroxysmal attacks of diarrhoea, atony of the large intestine, intermittent sweU- ing and pain in the joints, pigmentation, urticaria, pruritus, bulimia without gain in flesh, emaciation, glycosuria, migraine, rheumatic symptoms, and mental derangement. All the physical manifesta- tions of the disease are double-sided ; and this, with the unchanged state of the pupils, serves to distinguish it from those rare cases* where a thyroid growth pressing on the sympathetic on one side produces symptoms of exophthalmic goitre, including the palpita- tions. In the distinction from ordinary goitre, the absence of eye and heart symptoms is of most value. There is also no murmur heard over the enlarged thyroid gland ; whereas in Graves's disease a con- tinuous murmur there is most common, and is, indeed, looked upon by Guttmann as of the greatest diagnostic importance, especially aiding us in those doubtful cases in which the exophthalmos is wanting. My own experience confirms this statement. There is another form of functional disorder of the heart so pecu- liar as to demand a special notice. It is the curious cardiac malady * Abadie, La France Medicale, vol. ii., 1881. '' Lancet, Feb. 1891. ^ Eulenberg, Zienissen's Cyclopaedia. DISEASES OF THE HEART. 391 of which we saw so many examples in soldiers during our civil war, to which I gave the name of " irritable heart^^'' and which we also find occurring in private life. Its main symptoms are habitual frequency of the action of the heart, constantly recurring attacks of palpitation, and pain referred to the lower portion of the praecordial region. The palpitations come on chiefly during exercise, but may also take place when the patient is quiet, and in many cases happen most often at night, thus interfering with sleep. Those who are subject to the dis- order complain much of headache and of dizziness, and especially of being thus affected when suflering from palpitation. The pain is generally dull and constant, but is often also described as shooting, and as taking place only in paroxysms. Its chief seat is near the apex, and it is combined commonly with excessive cutaneous sensibility. Often there is pain nowhere else in the body ; but in some instances the cardiac distress is associated with pain in the back, which itself is not unusually connected with the excretion of oxalate of lime by the kidneys. The action of the heart is very rapid, and in many instances its rhythm is irregular. The impulse is slightly extended, but not forci- ble, like that of hypertrophy : it is rather abrupt and jerky. As a rule, to which I have met with but few exceptions, the sounds of the heart are modified as follows: the first sound is short, some- times sharp, resembling the second sound; at other times it is extremely deficient and hardly recognizable ; the distinctness of the second sound is much heightened. We either hear no murmurs in the heart or in the neck, or they are inconstant. The area of per- cussion dulness does not appear to be augmented. The pulse is almost always easily compressible; it may or may not share the character of the impulse. It is usually very much influenced by position, falling rapidly twenty beats or more when the erect posture is exchanged for the recumbent. The increased frequency of beat is not connected with increased frequency of respiration, for often with a pulse of one hundred the respirations scarcely exceed twenty in the minute. The disorder is very obstinate, and improvement comes but slowly. The cause of the morbid cardiac impressibility is difficult to ascer- tain. It seems in many instances to have followed fatiguing marches ; in some, to have occurred after fevers or diarrhoDa ; it was not con- nected with scurvy, or with the abuse of tobacco. That it was not due to anaemia was proved by the general aspect of the men, which was often that of ruddy health. Similar conditions of the heart occur from excessive dancing, excessive smokkig, and certain occupations, 392 MEDICAL DIAGNOSIS. such as glass-blowing. For a fuller consideration of the subject I refer to observations elsewhere detailed.* Yet another form of functional cardiac disorder is the one which I have described under the name of cardiac asthenia^ or heart exhaus- tion. It shows essentially the signs of a weak heart, and follows long-continued worry and overwork. There is rapidity of cardiac movement with very feeble action, and a great tendency to faintness. The breathing is singularly undisturbed. The impulse of the heart is weak, the first sound short, valvular, the capillary circulation defective. The duration of the cases is a long one, and recovery takes place but gradually. In the cases that are not purely nervous, but in which the hoart-muscle is enfeebled, shortness of breath and functional djuamic apex murmurs are often noticed.* These, then, are the principal varieties of functional disorder of the heart. It is hardly necessary again to state that the physical signs present the most certain, if not the only, means of distinguishing the functional from the structural affection. They show us that neither the size of the organ nor its sounds, with the exceptions above men- tioned, are materially different from what they are in health. The irritable heart just described, as indeed other forms of func- tional heart disorder, may pass into oi^ganic cardiac disease by the constant overaction of the heart. And overadion or strain may also. as I have proved in tlie publications just referred to, lead to valvular affection, sometimes by preceding hypertrophy, at other times by a slow process of inflammation or disorganization engendered at or near the seat of the valve. Of this I published several instances in tlie *' Memoirs of the Sanitarj' Commission." Others have been brought forward by Allbutt^ that happened among persons engaged hi vocations requiring sustained and oft-repeated muscular effort,— such as litters, smiths, sawyers. And in his elaborate monograph, Seitz * has detailed several fatal cases in which the symptoms of a fatigued heart, due to strain, were followed by extensive dilatation without valvuliu* disease. Leyden, too, has added to our accurate knowleilgo of the subject.* * Mtnlioal Memoirs of Uie I*. S. Sanitary Coiumlssion, 1867 ; American Journal of tho Meilioal Soieiuv^. Januiiry. 1S71 : and Uie Third Toner Lecture, Smithsonian Institution. 1S74, **0n Strain and Overaction of the Heart" where also the forms of irritable heart oivurriug in civil life ;ire described. * Anier. Jouni. Meil. Sci.» April, 1S94. * St. Gtvrv^^'s Hvx^pital Re^x>rt5, IS72. * Die relvnuistrkMvgun^ dt^ Herxens. lS7o. * Die Herikrankheiteu in Kol^* von Uet^enmstrvn^ng, Berlin, 1886. DISEASES OF THE HEART. 393 ORGANIC DISEASES OF THE HEART. Organic diseases of the heart may be classified as follows : Organic Diseases of the Heart. Diseases affecting the walls of the heart, and mostly changing the size of the cavities. Diseases affecting chiefly the walls alone . of membranes. Inflammations . • * • * i of muscular { structure. Diseases of the valvular apparatus Hypertrophy. Dilatation. Atrophy. Fatly degeneration. Parenchymatous degeneration. Fibroid heart, cardio-sclerosis, etc. Malformations. Rupture of the heart. Injuries and wounds. Aneurism of the heart. New growths and parasites. Endocarditis. Pericarditis. Myocarditis (Carditis). Diseases affecting the pericardium << Valvular diseases. Chronic pericarditis. Hydropericardium. Haemopericardium. Pneumo-hydropericardium. New formations on pericardium : cancer, tul)ercle, etc. Abnormal positions. Closure of openings of right heart. Opening between the ventricles. Narrowing and closure of pulmonary artery, etc. These are the organic diseases of the heart, save the rarest. But let us study the cardiac maladies according to their symptoms and signs rather than according to their anatomical classification. Congenital diseases . Acute Diseases presenting Pain in the Cardiac Region ; the Symptoms of a Disturbed Circulation ; and a Change in the Sounds of the Heart, or their Replacement by Murmurs. All the acute aflfections of the heart come under this head. In all, the sounds are either changed in their character or are replaced by murmurs. This is certainly true of endocarditis and pericarditis. All the acute disorders give rise, further, to more or less pain, and to anxiety of expression ; in all there is fever ; all are prone to occur in 394 MEDICAL DIAGNOSIS. connection with other morbid conditions, and especially with a con- taminated state of the blood. • In all, moreover, the symptoms of a disturbed circulation are met with : palpitation, irregular action of the heart, deranged flow of blood through the capillaries of diflferent oi^ns, and a tendency to dropsical accumulations. That these symptoms are not so clearly defined as in some of tlie chronic cardiac maladies is owing to the shorter time the complaint lasts. Acute Endocarditis. — Acute inflammation of the lining mem- brane of the heart is very rarely a primary disease. It sometimes results from violent eflforis, or from blows or other injuries to the chest. It is often connected with an acute infective process or a viti- ated condition of the blood, as in pneumonia, in chorea, in cancer, in scarlet fever, in pyaemia, in puerperal fever, in Bright's disease, or in diabetes. But its most frequent association is with articular rheumatism. The chief source of danger in endocarditis is the tendency the in- flammation has to limit itself. It is confined to, or is most strikinglT developed at, a part which bears least of all any impairment, — at the valves, — and often leaves behind it some permanent disoiiganization of their delicate structure. But it does not generally aflfect the entire valvular apparatus : that of the left side is usually alone the seat of disease. What morbid anatomy thus teaches, explains the occurrence and situation of the principal sign by which endocarditis is recognized. The roughness of the surface over which the blood flows, the minute vegetations, interfering with the function of the valves, occasions a distinct murmur, which is mostly confined to the mitral and aortic openings ; it may be preceded by an altered character of the first sound or its reduplication. Besides this blowing sound, there are other signs worthy of note. It is true, they do not form so leading a feature of the disease ; still, they aid in its correct appreciation. The excited heart beats with augmented force, and sometimes with great irregularity, as the not unusual doubling of the second sound at the base proves. The size of the organ is not notably increased, except in those cases in which its cavities are choked with blood or fibrin-clots. The pulse corre- sponds to the action of the heart ; yet not so closely as might be ex- pected. It is, for the most part, frequent and strong. It beconaes irregular, one beat being strong, the next weak, if the circulation through the heart be seriously obstructed ; it may be feeble while the heart is thumping with violence against the walls of the chest The general symptoms are not uniform. Ther^is usually a sense of uneasiness around the heart, \nlh a fever showing a temperature DISEASES OF THE HEART. 395 ranging ft^m 101° to 103°, a short cough, palpitation and some irregu- larity of cardiac action, difficulty of breathing, and anxiety depicted on the countenance. To these are not uncommonly added turges- cence of the face, headache, slight delirium, gastric irritability, diar- rhoea, and rigors, followed by sensations of heat. Pain in the heart is rare, and is not likely to happen unless the pericardium or the muscular walls be implicated. In some cases an eruption of subcu- taneous fibrous nodules occurs, especially in the rheumatic endo- carditis of children. Now, where these symptoms are present; where they manifest themselves in one whose system is in a state in which endocarditis is apt to take place ; and where they are accompanied by a blowing sound recently and rather suddenly developed, — we are certain that inflammation is working its changes in the lining membrane of the heari. Yet some circumspection is requisite before arriving at this conclusion. A murmiu* may be attended with febrile signs and not be dependent upon acute endocarditis. The sound may be of organic origin and chronic ; or it may be engendered in the course of an idio- pathic fever, and the lining membrane of the heart be unaltered. In the first instance the murmur is oW, and results Irom some chronic injury to the valve, the attending fever being an accidental complication. Here is undoubtedly a difficult case for diagnosis. We see the patient for the first time; he has fever; his heart is acting strongly : a distinct blowing sound is perceived over it, How are we to tell that his complaint is not acute endocarditis? We have no absolute means of deciding that it is not. Yet by careful inquiry we can usually come to a knowledge of the truth. If the patient do not recollect to have suffered previously fi^om dyspnoea or palpitation ; if the cardiac excitement be well defined ; if the face denote distress ; if the accompanying symptoms indicate a state that is prone to be com- plicated with endocardial inflammation, — it is this disease under which he is laboring. Then the murmur is not so rough, is not often heard except during the systole, and may be changeable in its seat, which an old-standing murmur never is. Besides, it is not associated with those signs of enlargement which are invariably found when the valves have been for any length of time affected, unless the acute inflamma- tion occur in a heart the valves of which have been previously spoiled. Under such circumstances, we can only conjecture what is going on within the oigan firom its increased excitement, and, if I may take my own experience as the general rule, from the character of the blowing sound undergoing^ alteration. It is rendered often less distinct, nay, it is even entirely muffled, by the products of the recent inflammation. 396 MEDICAL DIAGNOSIS. But how are we to distinguish between the soft murmur arising in the course of fevers, and that resulting from effused lymph ? It, too, is not rough. It, too, happens with the impulse. It, too, is preceded by a lengthening of the first sound. Here is assuredly a strong re- semblance; yet by no means an identity. The blowing sound in fevers does not exist until the blood is profoimdly altered. In endo- carditis it takes place almost as soon as the disease begins. The heart in fevers is not so directly disturbed in its action, and we do not find symptoms, local as well as general, which show that the circulation is obstructed. The blowing sound is rarely at the apex, but more over the body of the heart. To this some weight may be attached, since the murmur of endocarditis is very apt to be heard at the apex. But to no fact ought as much weight to be attached as to the one first mentioned, that the murmur takes place early and not late in the disease. Throughout this description of endocarditis, only simple, uncom- plicated cases have been kept in view ; yeb it is not often that the malady is seen in so pure a type. It is more generally accompanied by the friction sounds and other signs of acute pericarditis, and by the swollen joints, the painful movements, the acid perspirations, of acute rheumatism ; or by the characteristic appearances on the skin of ery- thema marginatmn ; or by tonsillitis ; or by the kidney symptoms of Bright's disease ; or by the evidences of chorea, or of gonorrhoea, pya?mia, or septicaemia. Nor is a murmur in endocarditis invariable. When the seat of the inflammation is not near the valves, a murmur is not generated. There may be also none if no vegetations exist on the valves, and perhaps in states of the exudation with which we are at present un- acquainted. We cannot, under such circumstances, detect an attack of endocarditis. Yet it may be even then strongly suspected to be present if great excitement or irregularity of the heart manifest itself in a person who is laboring under a disease which predisposes to en- docardial inflammation, such as rheumatism. Clots of fibrin may form in the heart, and they or the vegetations which stud the valves be washed into the circulation. The fortmition of dots in the cardiac cavities, if at all extensive, announces itself by a sudden appearance or a sudden augmentation of the symptoms of ob- structed circulation and of marked dyspnoea; the pulse is ft^uent and feeble, the action of the heart becomes exceedingly irr^^lar, its sounds are indistinct, or a more or less distinct murmur is heard, and the extent of the praecordial percussion dulness is increased. Great anxiety, nausea and vomiting, delirium, turgid veins in the neck, and DISEASES OF THE HEART. 397 fits of fainting, are also among the manifestations of the clogged blood in the heart. Yet these phenomena are not absolutely distinctive, for excessive dilatation without heart-clot will give much the same ; and Walshe records that the effects of a rupture of a sigmoid valve or of a tendinous cord, during the acute endocardial disease, will give rise to symptoms exactly similar to the obstruction of the circulation re- sulting from polypoid concretions in the heart. When these thrombi form from other causes than endocarditis, as from heart palsy or morbid states of the blood unconnected with inflammation, the symp- toms are not different. Portions of the clots, or of the vegetations on the valves, are sometimes washed into the current, and the embolism occasions symptoms that, before we were aware of the damage to which the detached masses may give rise, appeared inexplicable. But now — when we see the circulation speedily diminished or arrested in a limb, and the limb becoming painful, swollen, or beginning to mor- tify ; when we find that the flow of the blood through the brain has become suddenly disturbed, and the muscles of one side drop para- lyzed; when the difficult breathing becomes rapidly still more diffi- cult, while there are no signs of a superadded affection of the lung, nay, while the power fully to expand the lungs remains unimpaired, or while an effusion of fluid into the air-vesicles follows the dyspnoea — we know what has happened : we know that a broken-off piece of fibrin has been driven into the artery of the limb, or into the brain, or into the branches of the pulmonary artery, and, being too large to go any farther, has stuck fast, and has given rise to all these sudden and sad consequences. Sad indeed they are ; for, even if the plugs do not lead to an immediately fatal result, they lay the ground- work for structural alterations in any tissue in which they become impacted. Injium'niation of the aorta may occasion many of the symptoms of acute endocarditis ; at all events, it may do so when the upper part of the aorta is implicated. But it is not a condition that can be dis- criminated vrith certainty. The most significant signs are hurried respiration, a sharp, rapid pulse, tumultuous action of the heart, pain in the praecordial region, often greatly increased by movements, and also felt along the course of the spine, burning pain referred to the sternum, great anxiety. The history of the case points to gout, alco- holism, syphilis, or malaria. There may be paroxysms of pain such as occur in angina and a loud systolic blowing sound. When the abdominal aorta is affected, we notice strong local pulsation, and a marked murmur will be heard with greatest distinctness at or near 26 398 MEDICAL DIAGNOSIS. the seat of the inflammation. In some cases of aortitis, Bright ^ ob- served an extremely high degree of morbid sensibility over all parts of the body, which caused the patient to scream with pain when his wrists were merely touched. The disorder is most apt to happen in cachectic persons ; and it has been repeatedly observed in those attacked with erysipelas, or after operations and injuries.* Dissimilar causes may lead to different sites of endocardial inflam- mation. Thus, puerperal endocarditis is apt to localize itself in the right heart. It has pulmonary complications, and the progress of the disease is often slow ; it may last several months.' There is a form of endocarditis which may be here briefly men- tioned,— ulcerative endocarditis. It is not common in this countir. although I have seen a number of instances. It occurs mostly in connection with low forms of rheumatism or ^vith blood-poisoning, and the symptoms of this, or of pyaemia, or a low septic fever, are apparently the prominent features of the case, or it may happen as subsequent to pneumonia.* The ulceration perforates the valves, and may extend into the muscular structure of the heart ; pneumonia or pleurisy, embolic formations, and infarcts and metastatic abscesses in various parts of tlie body are among the common attendants,— pneumonia is especially frequent. The perilous aflection shows an endocarditis developing amidst the symptoms of profound blood- poisoning and prostration, although these physical signs may be masked by a pericardial complication. Marked and recurring chills, like those of malarial fever, but coming on irregularly ; a temperature of 105° to 107° ; an extremely rapid pulse, becoming suddenly much slower, though very irregular; profuse sweats; vertigo; delirium followed by stupor ; dry tongue ; vomiting and diarrhoea ; jaundice ; tenderness over liver and spleen ; and scanty, albuminous urine,— are among the prominent features of the malady. As regards the thoracic symptoms, there may be oppression, dyspnoea, and pain, yet these sj-mptoms may be wholly wanting. In some instances a peculiar diffused rose rash, here and there mixed with papules and spots of ecchymosis, is noticed ; in others there are capillary embolisms. By some, ulcerative endocarditis is looked upon as diphtheritic ; indeed, when it has happened during puerperal fever, diphtheritic exudations have been found on the mucous membrane of the vagina and uterus. It is certain that the pyogenic cocci are constantly present, generally ^ Guy^s Hoepitai Reports, vol. i. * Chevers, 1^^., voL n., and 2d Series, vol. i. ; Osier, Gulstonian Lectures. * LuKt el Ettling^er, Archives Generales de Medecine, Jan. 1891. lib Pbjsiologie, Aug. 1886. DISEASES OF THE HEART. 399 streptococci, staphylococcci, and pneumococci, and are found not only in the heart, but also in the infarcts in the spleen and liver. Death is the common ending, — either by gradual exhaustion, or suddenly by the tearing away of the injured valves. The disease is extremely rare in children. It is more often mis- taken for typhoid fever than for any other disease. But it is also mistaken for typhoid pneumonia, for cerebro-spinal fever, and for hemorrhagic smallpox. When ulcerative endocarditis happens hi connection with malarial poisoning, a not infrequent association in Africa, its seat of predilection is in the aortic valves.^ The most common type of the disease is the typhoid type. The malignant endo- carditis may become engrafted on a chronic valve lesion. Its clinical association with a suppurative wound or puerperal disease is common, and we find it also in abscesses in the throat, and in combination wth suppurative meningitis. The cardiac symptoms may be very obscure, and the occurrence of embolism during a febrile process be the first sign to explain their meaning. Rigors are common, and are the cause of malignant endocarditis being frequently mistaken for malarial fevers. High fever is the rule, and is an important element in the diagnosis. But I have met with instances, proved such by the autopsy, in which fever was almost absent. Acute PericarditiB. — Acute inflammation of the serous mem- brane of the exterior of the heart is very similar to that of its interior. It is developed under the same circumstances. It is found in rheu- matism, in gout, in Bright's disease, in scurvy, in alcoholism, in scar- let fever, in septic processes, or as an extension of inflammation from pleuro-pneumonia ; it is very rarely idiopathic. The pericardial mal- ady exhibits the same frequent association with rheumatism as the endocardial malady; it presents the same symptoms. Nature has not, indeed, drawn a very strict line of demarcation between the two diseases. When one exists, the other is very apt to attend it. Yet we do meet with endocarditis without pericarditis, and more often still with pericarditis without endocarditis. The anatomical effects of inflammation of the pericardium are like those of acute pleurisy. The pericardium becomes injected and dry ; plastic lymph accumulates on its surfaces, and especially on tlie sur- face which fits tightly around the heart. This stage of the disease corresponds to the dry stage, or plastic stage, of acute pleurisy. It may have the same termination by the two roughened surfaces ad- hering. But it is often followed by a stage of efl'usion. The effusion Lancereaux, Arch. Gen. de Med., April, 1881. 400 MEDICAL DIAGNOSIS. may remain stationary or be absorbed, and the nigged portions of the membrane be placed again in apposition. The characteristic sign of the plastic stage is a friction sound. Yet the friction sound is not always the same in extent or in character, because the deposited lymph is not always the sanie in extent or in character. The sound is like the crumpling of parchment, or the crt»aking of new leather, or it is grazing, or like a series of irregular clicks. It is single or double, and is prone to mask the natural sounds of the heart. But these are all points which have been already de- scribed : we shall merely add that when the friction develops itself Fig. 45. Ilhistration of the }Hie^iti«)n of the heart in pericarditis, and of the distention of the pericaidium with fluid. The heart-S4>unds an' indistinct, except alH>ve the effusion : the impulse is feeble. The extent and shaiv of the i vn'USiiion dulnei<^ may lie judged of by the appearance of the distended »t. undtT our observation, and with signs of excitement of the heart, it is as distinctive of intlannnation of the pericardium as a recent blowing sound is, under the same circumstances, distinctive of inflammation of the oiidocanlium. When the pericardial effusion takes plat^, it ceases : but only gradually, and not always completely : and in any rase it is not umounnon for the ear still to recognize the friction sound at the kise of the heart and around the origin of the great vessels. The percussion ilulness due to the effusion is generally consider- able ; and its contour is characteristic. When the patient is in the DISEASES OF THE HEART. 401 erect posture, it is pyramidal ; when he lies on his back, or changes from side to side, the outline of the flat sound is somewhat altered. Rotch,* in an elaborate inquiry into the matter, points to the dulness in the fifth intercostal space to the right of the sternum as occurring even in small effusions; and Roberts,^ in his excellent monograph, speaks of the valuable aid afforded by it to surgeons about to tap the pericardium. Another significant sign connected with the dulness is that, as Bamberger has taught us, an area of dulness near the angle of the scapula which coexists with bronchial breathing and increased fremitus, and which is perceived when the patient is erect, is greatly ' influenced by position. It disappears, and with it the other signs mentioned, as he leans forward, to return as the erect posture is resumed. In cases of considerable effusion, the intercostal spaces of the cardiac region widen, the eye recognizes a distinct bulging, and the dulness on percussion reaches far upward, to the second, or even to the first, rib. Within the space of dulness is sometimes seen an irreg- ular, wavy motion ; and what the eye detects the hand feels. But no movements, or only slight movements, may be perceptible in the praecordia. The heart, with its point pushed upward and outward by the accumulating liquid, has to struggle to reach the walls of the chest. Its contractions are irregular; its impulse is feeble, or all appreciable impulse has ceased. The sounds heard through the mass of fluid seem distant and muffled. Yet the second sound over the upper part of the sternum and at the base of the heart retains its sharpness. During the stage of absorption the apex retin-ns to its natural posi- tion ; the dulness gradually disappears ; the sounds and the impulse regain more of their normal character; the friction murmur reap- pears, and then ceases, leaving not infrequently the two surfaces of the pericardium adhering. We cannot foretefl how long it will take the disease to run through its different stages. Death may occur in less than thirty hours, the heart being paralyzed by an enormous effusion ; on the other hand, the acute attack may last for as many days, and then leave serious traces. But whatever stage the malady be in, it can be recognized only by the physical signs : by the friction, the peculiar percussion dulness, the enfeebled impulse and heart-sounds. ^ Boston Med. and Surg. Joum., 1878, vol. xcix. ; also article ** Diseases of the Pericardium,'* in Keating* s Cyclopaedia of the Diseases of Children, vol. ii. • Paracentesis of the Pericardium, Phila., 1880. 402 MEDICAL DIAGNOSIS. There are ho general symptoms that prove a pericarditis to exist There are symptoms by which we may infer that pericarditis is present ; but there are none which absolutely belong to it and would prevent it from being overlooked. The symptoms usually met with are those of inflammation of the endocardium, but with more decided local evidence of disorder. We find the anxious expression; the fever, not generally high ; the oedema ; the same uncertain or irregular pulse. But there is more pain over the heart, — ^acute, severe pain, shooting to the left shoulder, augmented by movement, in(»'eased by pressure, and associated with epigastric tenderness ; there is more dyspnoea, because the distended sac presses on the lung ; a dr}% irri- tative cough ; and sometimes difficulty in swallowing. Yet everj^ one of these symptoms may be absent. The pulse may be r^:ular ; the breathing not perceptibly accelerated or laborious ; and even the im- portant symptom of pain, though this is rare, may be wanting from the beginning to the end of the disease. When the action of the heart grows weaker and weaker, the circu- lation becomes more irregular. The beat of the artery at the wrist is feeble, and intermits ; the veins of the neck are prominent ; the skin is cold and pale ; the extremities are oedematous. These are always symptoms of grave import. If next we inquire with what complaints acute pericarditis is likely to be confounded, inflammation of the endocardium and inflam- mation of the pleura occur at once to the mind. To contrast the signs of the first two maladies, for the slight difference in their symp- toms has already been mentioned : Endocarditis. Pericarditis. Blowing sound ; excited action of the Friction sound ; excited action of the heart. heart. Slight, if any, increase of percussion In stage of effusion, marked and ex- dulness. tended percussion dulness. Impulse strong. Impulse wavy and feeble. Sounds normal or more distinct, except Sounds feeble and inufQed, except at at site where murmur is heard. base ; no blowing sound. Such is the distinction of pure cases of each disease. Still, as already stated, the affections are often combined. It is not imcom- mon to hear with the friction sound a distinct endocardial murmur. But there is sometimes a difficulty of another kind in tlie way of a precise diagnosis. The murmur produced on the outside of the heart may simulate so closely the murmur produced in its interior that it is almost impossible to discriminate between them. The DISEASES OF THE HEART. 403 former may completely possess the blowing characters of the latter. Mostly, however, it is rougher ; more prone to be double ; and each division is like the other, equally rough, equally superficial-sounding, equally lacking in strict correspondence to the systole or to the diastole. And, above all, the sound alters at times both in situation and in character with amazing rapidity. Perceived now as an ordi- nary bellows murmur on the left side, it is after the lapse of some hours heard as a rough rasping sound on the right. These changes have a high degree of value. But they are not of constant occur- rence ; and to say that it is sometimes impossible to tell a pericardial from an endocardial sound is to say no more than is borne out by every-day experience. In the stage of effusion pericarditis is not likely to be mistaken for endocarditis. Pleurisy gives rise to some of the same symptoms and signs as pericarditis. It develops a Mction sound; it occasions dulness on percussion, dyspnoea, and cough. But the physical signs are in different situations. In the one disorder they are in the region of the heart, and are confined there ; in the other, they are spread over the whole side of the chest, and are most perceptible at the back. This is true of the dulness, and, for the most part, of the friction sound, which, when of pericardial origin, is rarely heard posteriorly. At times, however, we meet with very puzzling cases. A Mction sound discerned over the heart may be in reality produced in the adjoining pleura. The patient is directed to suspend his breathing ; the Mction sound does not stop. Now, the inference from this would be that the sound originates in the pericardium; and in the large majority of instances this is a correct inference. But it is not always so. The Mction may have its seat in the pleura and be caused by the movements of the heart. There are no absolute means, besides the intermission of the sound during some of the beats of the heart, as well as during some of the acts of breathing, especially in expiration, of detecting in these rare cases the true seat of the disease. Then, both in pleuro-pneumonia and in phthisis there may be a pleuro- pericardial friction, from an attending pericarditis. It also is much influenced by the respiratory acts. During deep inspiration it lessens or disappears ; expiration intensifies it. To confound the dulness on percussion caused by liquid in the pericardiimi with that due to liqwid in the pleura, is a mistake the more likely to happen, because the two serous membranes, and indeed the lung, are often involved in the same inflammation. But a peri- carditis uncomplicated with pleurisy or with pleuro-pneumonia does 404 MEDICAL DIAGNOSIS. not change the clear sound at the back of the chest save in rare cases of enormous accumulation of fluid. Effusion into the pleura gives rise to a flat sound anteriorly ; to a still more perceptible dulness at the inferior portion of the chest posteriorly ; and the sounds of the heart remain unaltered. These, then, are the diseases with which acute pericarditis is liable to be confounded. There are several chronic cardiac maladies which will occasion some of the same signs and symptoms : such are thin- ning of the ventricles with distention of the cavities, and a dropsy of the pericardium. But the history of these affections is different, and their signs, although similar, are not precisely the same. The drojoji of the pericardium is associated with dropsies elsewhere, and with some obvious cause accounting for the watery effusion, and at no stage of its existence does it exhibit a friction soimd, while albumm in the urine, oedema of the lungs, or hydrothorax are common at- tendants. A double friction sound at the right base may cause a plastic pericarditis to be mistaken for aortic regurgitation. But the marked coexisting hypertrophy in this affection, the unchanging char- acter of the abnormal sounds, and the peculiar pulse, guard against error. There is another complaint of which pericarditis sometimes bor- rows the garb. The thoracic symptoms may be latent, but the dis- ease may produce the symptoms of extreme gastric irritation or inflammation. Nausea and vomiting are marked, and tenderness on pressure in the epigastric region. All the remedies are directed to the stomach ; and at the post-mortem examination the physician stands amazed at finding this viscus healthy and the pericardium full of serum or pus. An inquiry into the state of the heart might have saved him from a serious blunder. Another grave error which may be thus obviated is the mistaking of some cases of acute pericarditis, on account of the wild delirium they present, for acute inflammation of the brain. Now, both in endo- carditis and in pericarditis this active delirium may throw all the other symptoms into the background. It is difficult to see why a pericardial inflammation should give rise to such violent disturbance of the brain. It is not at all unlikely that it has its origin, in part, at least, in the contaminated state of the blood which occurs in the affections, as rheumatism or Bright's disease, with which pericarditis is often asso- ciated. However occasioned, it is necessary to be aware that the cerebral symptoms arising in inflammation of the membranes of the heart may entirely draw off attention from the serious lesions within the chest. A fixed delusion of having committed some crime appears DISEASES OF THE HEAKT. 405 to Flint ^ to be a distinguishing feature of the mental wandering; while Sibson ^ in his exhaustive analysis points out, what I have known to happen in more than one instance, that the desponding and taciturn, or, as he calls it, sombre delirium lasts from two or three weeks to as many months. Can we by the symptoms or physical signs tell the character of the fluid in the sac ? We cannot by the signs ; and by the symptoms we can only suspect pus if there be recurring chills, and irregular but high temperature, and if the pericarditis have arisen in the course of a malady that makes the presence of pus likely. Hemorrhagic peri- cardUis can also only be distinguished as a probability by the history. It happens in scurvy and in purpura, and may be an attendant upon tubercle or cancer of the pericardium. Canceroica pericarditis pro- duces also serous or purulent effusion. It is never a primary disease, and it has no characteristic symptom, except it be, in some cases, darting pain in the praecordial region attending the signs of peri- carditis. It is by the history and the evidence of deposit elsewhere that we have to judge. The same is true of tubercular pericarditis. Here the pericarditis is often dry, and the membrane much thickened. Yet an enormous effusion may occur, as happened in a case recorded by Musser.' Let us now inquire in how far one of the terminations of pericar- ditis by adhesion or agglutination of the surfaces can be recognized. In many of such cases, whether there be coexisting dilatation, or hypertrophy, or what is most common, combined dilatation and hy- pertrophy, we find changed rhythm and dyspnoea, oedema of the extremities, and syncopal attacks. Yet these are not special signs of pericardial adhesion. Indeed, there is not a single symptom or sign constant, or by itself characteristic of pericardial adhesion. The most trustworthy signs are a drawing in of the apex of the heart during the contraction of the ventricles, with a depression in the inter- costal spaces becoming visible at the same time, and sometimes with a simultaneous sinking in at the lower half of the sternum ; the limits of the increased, dull percussion sound in the praecordial region re- maining unaffected during inspiration and expiration; a fixed apex beat, uninfluenced by change of posture of the body or by the acts of breathing; diminution of the inspiratory movements in and near the epigastrium ; greatly extended undulatory impulse ; and diastolic * Diseases of the Heart. ' Article ** Pericarditis** in Reynold's System of Medicine. ' Medical Diagnosis. 406 MEDICAL DIAGNOSIS. rebound felt on placing the hand over the seat of the impulse. Enfeeblement or absence of impulse, while it may happen, is much rarer. A sign of value is the one pointed out by Broadbent, a draw- ing in Avith the systole of the posterior and lateral walls of the chest generally most evident between the eleventh and twelfth ribs, and indicative of universally adherent pericardium. Duroziez^ attaches impori^uice to the nipple being kept in constant motion. Friedreich* dwells on a rapid emptying of the veins of the neck during the diastole of the heari:, while with the systole they swell up; and Riess ^ tells us that, owing to the close bringing together of the heart, diaphragm, and stomach, the heart-sounds resound with a metallic ring. The heart-sounds, owing to the frequent association of ad- herent pericardium with valve affections, may be replaced by mur- murs. To the occurrence of a presystolic murmur, Hale White has called special attention. When the pericardial surfaces are exten- sively and firmly united, the eye is struck by the evident depression of the praecordial region. When the pericardium is adherent to the sternum and bands pass off compressing the aorta, " indurated medi- astino-pericarditis," a pulse vanishing with each full inspiration— puUus paradoxus — has been described by KussmauL* The same sign has been noticed by Irvine in cases of adherent pericardium and pleura, and by Traube ^ in exudative pericarditis where the medias- tinum was not implicated. Aran has proved the tendency to sudden death in complete pericardial adhesion. Closely connected with the subject of inflammation of the peri- cardium is that rare affection in which air is present in the pericardial cavity, pn^umo-pei^icardium, or, more strictly speaking, on account of the frequent association with fluid, pneumo-hydropericardiuvi. It oc- curs as the result of injuries, of communication established by disease between the pericardium and the neighboring organs, and in very ex- ceptional instances is due to decomposition of liquids in the sac. Its chief diagnostic features are abnormal resonance over the cardiac region, and a metallic character of the heart-sounds. The tympanitic resonance alters in a most marked manner with changes in the posture of the patient, and is limited by a distinct line of dulness caused by the fluid. The metallic sounds may at times be heard at a distance, and may be attended with sounds of most extraordinary kind, friction ^ Traite oliniquo des Maladies du Coeur. ^ Virchow's Archiv, Bd. xxix. ^ Berliner klinische Wochenschrifl, No. 51, 1878. »Ibid., No. 37, 1873. ^ Charite Annalen, 1876. DISEASES OF THE HEART. 407 sounds mixed with splashing and gurgling, the so-called water-wheel sound, the b7^U de moulin; generally an intermittent sound, at first metallic. The cardiac impulse is feeble or absent. The symptoms of pneumo-pericardium are vague, generally those of a pericarditis, with great difficulty in breathing, high, fluctuating temperature, chest pain, and failing circulation. In point of diagnosis we must be care- ful not to be misled by the modification of the cardiac sounds and the splashing and metallic phenomena due to a dilated stomach. From pneumothorax^ even when encapsulated near the heart, we dis- tinguish pneumo-pericardium by the dulness on percussion to be found over the displaced heart in the former malady, and the am- phoric or metallic respiratory sounds that are heard in addition to the metallic heart-sounds. The discovery by Welch of the bacillus aerogenes capsulatus, and its association with gas forming in the tissues and cavities, will explain instances of pneumo-pericardium follo\ving wounds. The entrance of air may happen, as in the cases of Meigs ^ and of Miiller,^ by a rupture brought about by the pericardial exudation, — in the one case into the oesophagus, in the other into the lung. These cases of ulcer- ative perforation almost all end fatally. Myocarditis. — Of inflammations of the substance of the heart there are two chief varieties, — the acute inflammation of the muscu- lar walls, and the chronic myocarditis or fibroid degeneration. The acute gives rise to infiltration between the fibres of the heart of blood- corpuscles, of proliferating cells, and of leucocytes, and the muscular fibres themselves become granular and degenerate. Local softening and circumscribed abscess, and even gangrene and perforation of the ventricle may result. But we are not enabled to foretell the state of the heart during life, mainly because the muscular structure is rarely aflfected without the endocardium, or still more fi-equently the pericardium, being implicated, and thus the manifestations of these dis- orders occur mixed with those of the myocarditis. Great pain in the cardiac region is the most usual and the most prominent of the symp- toms. The breathing is generally much oppressed ; delirium is often present ; the urine is scanty and albuminous ; the heart fails in power ; and the patient dies in a state of utter prostration or sufl'ocates Irom pulmonary oedema. The pulse, as in endocarditis or in pericarditis, exhibits no uniform character. The statement that it is invariably intermittent, feeble, and quick, is not correct. It is so as the disease * Amer. Joum. Med. Sci., Jan. 1876. * Deutsches Archiv fUr klinische Medicin, Bd. xxiv., 1879. 408 MEDICAL DIAGNOSIS. advances, but it may be full, and not above eighty, long after the distress in the chest is unbearable.^ The temperature may be only slightly elevated or very high. The signs of cardiac failure are quickly developed. The heart-sounds are weak and irregular, and, owing to acute dilatation occurring, the cardiac dulness increases. In purulent myocarditis the temperature shows marked remissions and exacerba- tions, and rigors and sweatings are usual.* Acute myocarditis may occur in rheumatism, but it is most common in pyaemia and io phlebitis. Its occasional association with gonorrhoea has been pointed out, and it may be found Avith or without gonorrhoeal rheumatism.* In children there is a distinctly cerebral form.* Acute interstitial myocarditis and parenchymatous myocarditis, the muscular fibres in both being infiltrated with granules, have no distinctive symptoms. They occur in fevers, particularly in typhoid fever, yellow fever, and smallpox, and in pericarditis, and may be suspected under these circumstances from the feeble heart action. Chronic myocarditis^ or fibroid degeneration, often results from rheumatism, or attends pseudo-hypertrophic paralysis. A very com- mon cause is disease of the coronary arteries, especially obliterating endarteritis of syphilitic origin. The disease is most common in men, and may lead to aneurism of the heart. The diagnosis of chronic myocarditis is as uncertain as that of the acute form. The symptoms are those of a feeble heart : oedema, breathlessness on exertion, cough, hemorrhages into different organs, venous congestions, hydrothorax, occur. In some cases there is pain over the heart or marked anginous attacks occur. The percussion dulness in the cardiac region is some- what increased, and the heart is generally dilated, or in a state of combined dilatation and hypertrophy. The first sound is indistinct, or there is a mitral systolic murmur ; the second over the aorta fe apt to be accentuated or doubled. A significant sign is a want of correspondence between the heart and the pulse-beats ; these are unequal and irregular.'* Some stress may be laid on signs of peri- cardial adhesion, if present. * Salter, Medico-Chirurgieal Transactions, vol. xxii. In several of the cases on record, for instance in the one mentioned by Graves in his Clinical Lectures, there was coexisting valvular disease, which, of course, invalidates the statements as rej^^^ds the character of the pulse, and, indeed, as regards many of the other symptoms. 2 Bramwell, Diseases of the Heart, Edinb., 1884. * Councilman, Amer. Joum. Med. Sci., Sept. 1893. * Mitchell Bruce, Keating' s Cyclopaedia of the Diseases of Children, vol. ii. * Ruble, Archiv fUr klin. Med., 1878. DISEASES OF THE HEART. 409 Ohronic Diseases attended with Increased Extent of Percus- sion Dulness, but with Normal or ahnost Normal Heart- Sounds. To this group belong those diseases which aflfect the walls of the heart or its cavities, without having involved the valvular apparatus, such as hypertrophy and dilatation, — types of the two different states of force and of weakness, but both exhibiting an extent of percussion dulness greater than in health, and heart-sounds not materially changed. Hypertrophy. — Hypertrophy of the heart is an overgrowth of its walls, and usually also of its cavities ; for, although we may have the muscle thickening without the cavity enlarging, nay, even with it diminishing in size, neither this simple nor the concentric hyper- trophy occurs, save in rare instances. It is evident that any one of the chambers of the heart may alone become hypertrophied. But, practically, the state we mean when speaking of cardiac hypertrophy is an increase of the ventricles, and especially of the left ventricle, in its wall and cavity, with a similar, although much slighter, expansion of the right side. The physical and vital manifestations of the heart having out- grown its natural dimensions are these : The pulse is full and strong, and somewhat tense. The face is florid, or else it is pale ; and the mucous membranes of the lips and eyelids are injected. The eyes are bright, and apt to be prominent. The carotids pulsate forcibly under the least excitement. Some persons suffer from headache and giddiness ; in fact, all the symptoms denote a circulation actively — too actively — carried on. Yet the symptoms directly referable to the heart are not marked. There is, as a rule, no pain or irregular action of the heart, nor do violent fits of palpitation occur. What the patient comes to consult his physician about are rushes of blood to the head ; or a ringing in the ears ; or a feeling of weight in the epigastrium which troubles him after a full meal ; or shortness of breath ; or in consequence of the powerful action of the heart, when lying in bed, attracting his attention ; or because he is alarmed about a dry cough, and believes himself the victim of pulmonary consumption. The physical signs are more uniform than the symptoms. We observe a fulness or arching of the prsecordial region, an.d an impulse, strong, heaving, and extended over several intercostal spaces. The apex does not strike the chest walls between the fifth and sixth ribs, but its beat is perceived lower down, usually an inch or more to the outside of the nipple line. The extent of percussion dulness increases. 410 MEDICAL DIAGNOSIS. both longitudinally and transversely; and particularly in the latter direction, if tlie right ventricle be much enlarged. This peculiarity in the expansion of the area of dulness on percussion forms, in truth,— with the greater dyspnoea, and with an impulse more directly per- ceived over the right side of the heari:, near the pit of the stomach, and often out of propori:ion to the compressible and rather smaD radial beat, and with the increased distinctness of the second sound of the pulmonary ari:ery, — the sign that hypertrophy with dilatation has principally affected the right side. Fig. 46. *^j&V|^AJK; All hyt^rtrophied heart lying in its ixx^ition lu the chest. The cause of the lowered apex beftt. and of the extension of the impulse, as well as of the somewhat squarer outline of the incieieed duliu'ss over the enlairgeii organ, is obvious from the shape and position of the beMrt. The tii-st sound of an hyperi:rophied heart is duller than in health, but prolonged and weighty. The second sound is not particularly chungtHl. There are no murmurs, except under rare circumstances, which will be mentioned in discussing valvular diseases. Thus, the grt^atest value of auscultation is that, by showing the sounds but little altered, it enables us positively to exclude a lesion of the valves ; just as the chief sersico of percussion, with reference to an enlaiiged heart consists ui permitting us to distinguish the excited motions of the am- ply disturbed orgiui from the action of a heart the walls of which are DISEASES OF THE HEAKT. 411 thickened ; and as the main use in noting the impulse is that it serves as a means of discrimination between hyperi:rophy and those affections in which the beat is weakened, such as dilatation or a pericardial effusion, or between the dulness in the prsecordial region due to hypertrophy and that caused by deposits in the pleura, in the medias- tiQum, or in the lung. Where there is contraction of the left lung, as from pleurisy or fibroid change, more of the heart is exposed, and the dulness on percussion in the cardiac region is increased, as well as the impulse, which is felt over a larger space and to the left ; but the car- diac sounds are imchanged, and deep inspiration alters the extent of cardiac dulness but little. Hypertrophy may be combined with decided dilatation of the heart. This kind of hypertrophy presents a less dull, prolonged first sound, and the pulse, though full, is likely to be more compressible. Hypertrophy may affect specially any part of the constituents of the muscular walls. Thus, the connective tissue, as Quain has particu- larly called attention to, may be alone concerned in the morbid action. H>T)ertrophy of the heart is found much more frequently among males than among females. Its causes are various. It is common in Bright's disease and in general arterial sclerosis ; continued func- tional excitement produces it ; so does any kind of strain and over- action, and perhaps excessive nourishment. It is found to be common among inordinate beer-drinkers. But the main cause is an obstruc- tion to the circulation, either in the heart or in other organs. It is for this reason that the complaint is so often met with in connec- tion with diseases of the valves or of the large arteries, and that the right side of the heart enlarges when the pulmonary air-vesicles are over-distended. We also encounter hypertrophy in the heart as a consequence of obliteration of the pericardial sac. In the hyper- trophy of chronic nephritis reduplication of the first sound is often noticed. There is a form of hypertrophy of the heart to which attention has been particularly called by Fothergiirs description, — the so-called g(nity heart. Generally there is coexisting chronic contracting kidney. In the first stage we find decided hypertrophy with accentuation or booming of the second aortic sound, high blood-pressure, tense pulse, hardened arteries, and the passage of large amounts of pale urine of low specific gravity. The renal changes may or may not be evident ; we may or may not detect albumin in the urine. In a subsequent stage of the malady there is failure of the circulation. The cardio- vascular phenomena are early made perceptible by the sphygmograph. The full, tense pulse gives a full up-stroke, a broad summit, and a 412 MEDICAL DIAGNOSIS. retarded down-stroke ; the " square-headed tracing" formed is very characteristic of the malady, and bespeaks the fibroid change in the kidney, whether or not albumin be found. In some instances con- siderable cardiac dilatation as well as hypertrophy is present. The high blood-pressure is due to the waste-laden blood. The skin often exhibits little twigs of dilated vessels ; the ear is usually deep red, with a large glistening lobe ; or in spare persons the lobe looks ^rith- ered ; the teeth become blunt and worn down in time ; the hair is apt to be iron-gray. There is the history of gout, acquired or heredi- tary, but there may have been no active outbreak of gout, rather the condition of imperfect assimilation known as lithaemia. Dilatation. — Except in its seat in the ventricles, dilatation of the heart is the reverse of hypertrophy. The cavities are stretched out of all proportion to the thickness of the muscular walls ; these may be slightly thicker than normal, or of natural thickness, or thinner, and apparently hardly capable of supporting the weight of the blood. Almost opposite symptoms and physical signs to those of hyper- trophy result from dilatation. In place of activity and power, every- thing indicates inaction and stagnation. There is a very strong ten- dency to venous congestions and to dropsies. The portal system is gorged. The liver increases in size. The bowels are constipated. The urinary secretion is interfered with, and sometimes albumin is passed. The hearing may become dull. The patient is languid and feeble, and his intellect obtuse. He suffers firom chilly sensations, and from uneasiness in the cardiac region and palpitations. The pulse is small, unequal, and irregular, and the veins of the sur&ce are swollen. The skin around the ankles, and often at other parts of the body, pits on pressure. But, since it is the right side of the heart which is usually the most affected, the lungs show most plainly the effects of the venous stagnation. Breathlessness on exertion or diffi- culty in breathing, niakhig itself at times manifest in paroxysms attended with wheezing respiration ; a chronic cough ; a collection of serum in tlie [)ulmonary structiu^, — all add to the misery which the perilous malady entiiils. And as it is commonly some obstructive disease in the lung's, such as emphysema, which has given rise to the dilatatiiui of the right side of the heart, so this again augments the morbid state o( the luuji^s, and aggravates the s}'mptoms. The physical signs iu\^ very unlike those of h)T)ertrophy. The siuue extended dulness on ^H^r^'ussion exists ; but it is associated with a I'eeble and tlutterin^ impulse, which is in strong contrast with the heaving, poworuil Mow of an hY^H>rtrophied left ventricle, and which at times cannot bo Kvali/iHl, or mav be seen, vet camiot be felt. The DISEASES OF THE HEART. 413 sounds in cardiac dilatation are not always the same. When the walls are thin, they are clearer, sharper, and more ringing than in health ; if, however, the muscular structure be at all degenerated, the first sound is faint and very ill defined. The second is often split, giving rise to the so-called gallop rhythm. But no murmurs are perceived, unless a watery state of the blood produces them, or unless it happens — and it does not infrequently happen — that the dilatation of the heart is conjoined to valves incompetent, either temporarily or permaiiently, to prevent regurgitation. FiQ. 47. A dilated heart, the right ventricle opened. In this case there was no valvular disease. Hence tlxe chaxacteristic physical signs; the increased dulness on percussion, the extended but weak impulse. The first sound was feeble, for the oigan was flabby as well as dilated. In acute dUaJtation of the heart, such as we sometimes see in fevers, or in pneumonia, or after violent exertion and strain, or from shock or sudden fright, or where an hypertrophied heart suddenly fails in power, we have, besides the symptoms of great venous con- gestion, dyspnoea, and rapid, feeble impulse, or impulse irregular, now strong, now weak, temporary systolic murmurs of varying site, chiefly a systolic apex murmur. But the murmur may be near the ensiform cartilage over the tricuspid area, or, as in a case observed by Broad- bent,' over the pulmonary artery. * Heart Disease, p. 241. 26 414 MEDICAL DIAGNOSIS. Dilatation is not always pure; it is met with in every possible degree, and in combination with hypertrophy and valvular diseases. Accordingly, its symptoms and signs are somewhat dissimilar. But one constant feature it preserves; it always holds up to view both the vital and the physical manifestations of a weak heart. Indeed, when an hypertrophied heart dilates, the signs of relative weakness become superadded, the impulse is not so strong as before in com- parison with the percussion dulness, and dropsy becomes a marked symptom. Pure dilatation is likely to be confounded with the dis- eases in which enfeebled action of the heart is encountered, and these are fatty degeneration and a pericardial eflfusion. Patty Degeneration. — This is one of those disorders with the anatomical characters of which we are far better acquainted than ^vith their clinical history. There is, indeed, no sign by which we can positively say that the dangerous disorganization of tlie muscular fibres of the heart is in progress. We may, however, suspect it, if the signs of weak action of the heart — feeble impulse and Dl-defined sounds, especially the first sound — coexist with oppression, with a tendency to coldness of the extremities, with a pulse permanently slow and of low tension, or permanently frequent, empty and irregu- lar, or rigid though weak, and be met with in a person* who is the subject of a wasting disease, or has arrived at a time of life at wliieh all the organs are prone to undergo decay. Something more than a probable opinion is warranted if, in addition, there be ^proof of scle- rotic change in the vessels, or of fatty degeneration elsewhere, such as ' an arctis senilis; or if it be ascertained that the patient suffers from pain across the upper part of the sternum and from paroxysms of severe pain in the heart ; that he sighs or yawns frequently ; that he is easily put out of breath ; that his skin has a yellow, oUy look ; that he is subject to syncope, or to seizures during which his respiration seems to come to a stand-still ; and that he is liable to vertigo, to attacks of transitor}^ unconsciousness, or to be stricken down with repeated attacks having the character of apoplexy, save that they are not followed by paralysis. Now, here is certainly a group of phenomena dissimilar to those of a dilated heart. Let us add that the extent of the cardiac percus- sion dulness remains unaltered, except in those instances in which hypertrophy or dilatation coexists, that dropsies and local congestions are not promuient symptoms, or indeed do not happen at all, and the dissimilarity becomes still greater. A differential diagnosis would, under such circumstances, be anything but difficult. But in point of fact the matter is generally not so easily decided, and there are several DISEASES OF THE HEART. 435 reasons why it is not. One is, that all the features described are rarely combined in the same case ; indeed, one of the most marked, the Cheyne-Stokes breathing, is micommon rather than common, and occasionally occm^ in other cardiac maladies. The second is, because non-fatty softening, the result of a granular mfiltration, as met with, for instance, in fevers, may present much the same vital and physical manifestations. The third is, because a fatty heart has a tendency to become dilated, and the symptoms and signs of the former disease are then merged into the symptoms and signs of the latter. With the organ in such a condition, the practical value of a differential diagnosis is, however, not great. Decided dropsy would indicate that dilatation had happened. The remarks about fatty heart apply particularly to that variety in which the muscular structure in middle-aged or elderly persons has slowly undergone decay, and which is especially seen in men of seden- tary habits, in tipplers, in the gouty, or in diabetics ; disease of the coronary arteries often coexists. But we meet with fatty heart, al- though far less frequently, in yoimg persons, and in a more acute form ; and we encounter it in chlorosis, in pernicious anaemia, after repeated hemorrhages, and after phosphorus poisoning. Poisonous doses of acids, such as nitric, sulphuric, oxalic, are said by von Dusch also to give rise to the cardiac change. Persons who have fatty hearts are subject to attacks of faintness, preceded or attended with aensaiions of great coldness^ or a chill. Sometimes these attacks happen daily, or every few days,. and in such a manner as to give rise to the impression that they are due to malaria. A number of instances of the kind have come under my observation, and I have met with them particularly at the end of fevers or other debilitating diseases happening in those affected with feeble hearts. The seizures, though bearing a resemblance to inter- mittent fever, are unlike it in being associated with signs of great weakness of the circulation or heart failure, sometimes joined to a sense of impending dissolution ; in their irregular a(!cession ; and in their not being followed by fever. In doubtful cases the thermometer by showing the absence of the great rise of temperature of the mala- rial disorder, will materially assist us in the diagnosis. Heart starvation^ to which Fothergill ^ has called attention, has, in the feeble circulation, the cold extremities, the tendency to vertigo, and the pseudo-apoplectic attacks, symptoms common with those of fetty heart. But the malady is not associated with disease of the * Edinburgh Medical Journal, May, 1881. 416 MEDICAL DIAGNOSIS. arteries, and is often an attendant upon general ill nutrition, and worry, and long hours of work and short hours of sleep. A fatty heart sometimes ruptures. The symptoms that are mostly noticed are these: the patient is suddenly attacked with intolerable anguish in the heart ; he presses his hand to it, then faints, and soon expires. Or else he lives for a short time, suffering from feintness, cramps, and difficulty of breathing, and with death plainly written on his face. Chronic myocarditis with fibroid changes in the heart walls cannot be distinguished with any certainty from fatty heart. Extensive arte- rial degeneration, accentuation of the gecond aortic sound, signs of hypertrophy, attacks of palpitation and constant pain in the region of the heart would be in favor of cardiac fibrosis. But not one of these symptoms is convincing proof. Where there is fatty accumulation on the hearty without fatty change of its fibres, — a condition we sometimes find in fat persons whose internal viscera are loaded with fat, — the manifestations are those of a feeble heart, and different from fatty degeneration only in degree. The first sound of the heart is weak and toneless: the pulse is feeble, but, as Walshe tells us, regular. The percussion dulness in the cardiac region is somewhat increased. A sensation of oppression over the region of the heart, or even actual pain, is complained of. There is shortness of breath on taking exercise and sometimes pretibial a^dema. Fatty infiltration may be followed by fatty degeneration. Of atrophy of tlw heart we know very little. All we know is that at times in certain wasting diseases, such as tubercular phthisis, can- cer, and suppurating bone affections, the heart atrophies ; it may also do so. when the pericardium is tightly adherent; and cardiac atrophy is said to happen occasionally after pregnancy and chlorosis. It has not a single symptom nor a single sign by which it can be recognized with certainty. Diminished percussion dulness, clear sounds, and feeble impulse Viiight enlighten us ; but, even in cases where we have not been misled by emphysema of the lungS, or there is no coexisting fatty change, they are too uncertain to be made a basis for diagnosis, or attending lung conditions throw doubt on several of them. There is great tendency to palpitation, and the pulse, Hayden tells us, is quick, all but iiiappre(!ial)lo, yet regular. The X-rays would furnish a valuable means of diagnosis. Pericardial EflPusion. — Pericardial effusion also presents the signs of a weak heart with increased dulness on percussion in the cardiac region, and is liable to be mistaken for dilatation of the organ. DISEASES OF THE HEAKT. 417 But though there are points of resemblance to a dilated hearty there are points of contrast, as the subjoined table shows : Dilatation of the Heart. Chronic Pericarditis with Effusion. Percussion dulness increased in extent, Percussion dulness increased, but often but square in outline. of pyramidal sbape. Impulse in epigastrium. Impulse in third or fourth left interspace, apex tilted upward. Heart-sounds clear and sharp ; some- Heart-sounds feeble and distant-sound- times, however, feeble. ing at the apex, but distinct near the upper part of the sternum. No friction sound. Often friction sound still heard at base. Dropsy ; signs of venous stagnation ; Neither dropsy nor venous stagnation, severe cough, and dyspnoea. Cough and dyspnoea are not such prominent symptoms. The history of the disease shows it to The history frequentiy points to the be gradually developed. acute attack. Diseases of the Heart exhibiting more or less of the Signs and Symptoms of Ehilargement of the Organ, ajid accom- panied by Endocardial Murmurs. Valvular Affections. — These, when not due to congenital mal- formations, are most commonly the result of rheumatic endocarditis, of slowly progressing sclerotic changes, or of heart-strain. A certain number of cases have their origin in some of the fevers, as in scarlet fever, and in septic conditions and blood-changes, as in malignant endocarditis. The different valves are not affected by these causes alike. Rheumatic endocarditis is the principal cause of disease of the mitral valve, especially of mitral insufficiency ; but among prominent causes of this are also alterations in the muscular wall of the ventricle or in the tendinous cords. Aortic insufficiency is generally due to slow sclerotic changes in the valvulets, whether attended with atheroma or not, or to subacute or chronic endocarditis from heart-strain; it may be also owing to the sudden rupture of a valve previously damaged. Mitral constriction is mostly brought about by atheroma- tous or calcareous alteration, as is aortic constriction ; but in mitral constriction we may have also a history of endocarditis in early child- hood subsequent to rheumatism, an exanthematous fever, or chorea. In insufficiency of the tricuspid valve we can trace usually the result of over-distention pf the right heart, such as follows pulmonary con- gestion caused by mitral disease, or of an obstructive disease of the lung, such as emphysema or cirrhosis. Tricuspid stenosis, and the other very rare valvular affections of the heart, — those of the pul- monary artery, — are commonly congenital. 418 MEDICAL DIAGNOSIS. To find the sounds of the heart clearly and well defined, is to know that no disease of the valve exists. When the valvular appa- ratus is disordered, the mischief betrays itself, for the most part, by a murmur. If, therefore, a murmur of any permanence be met with in the heart, especially if it be associated with the signs of eitlier hyper- trophy or dilatation, the inference that valvular disease exists will in the vast majority of cases be correct. Yet it will not be so always ; for there are other morbid stales besides valvular affections wliich engender a murmur, which may be even accompanied by all the manifestations of enlargement of the heart. Malformations, such as communications between the auricles or between the ventricles, or between the great vessels near their origin, or impoverished blood, or a misdirected blood-current, may occasion a murmur. Now, with reference to malfarmatiotis^ their presence in adults, or in children that have passed the days of infancy, is exceedingly rare. The most trustworthy symptom they present is that indicating the admixture of arterial and of venous blood; in otlier words, the symptom of cyanosis, the bluish discoloration of the skin. In addi- tion, we may perceive clubbing of the nails, a tendency to hemorrhage, breathlessness, or dyspnoea, cough, andf irregular action of the heart, and a blowing sound in the cardiac region ; hypertrophy of the heart, especially of the right heart, is also very generally present Still, the recognition of these malformations is always more or less a matter of conjecture. With the aid of more such researches as those of Moreton Stille,^ of Peacock,- of Hochsinger,' and of Th^raum/ we sliall perhaps be able ultimately to discern them with certainty during life. As a few points of assistance, it may be mentioned that commu- nication of the ventricles through the septum gives rise to a systolic murmur at or near the base of the heart not propagated into the arteries, but according to Roger and to Sansom, also heard between the shoulders; that the passage of blood through an open foramen ovale very rarely engenders any sound, though presenting marked cyanosis ; and that, whether coexisting with tliese lesions or not, the majority of instances of cardiac malformation, after the age of tweke, present signs of obstruction at the orifice of the pulmonary artery. In this instance either a systolic or a diastolic munnur may be there ict^ivL'ii; ill the first case the second sound of the heart is weak or * American Journal of the Medical Sciences, July, 1844, ^ Treatiee on MaJformations of the Heart. * Di(^ Aiisriiltfttion des Kind lichen Heraens, Wien, 1890, sur les Affections congenital du €<£ur, Paris, 1S£^5. DISEASES OF THE HEART. 419 wanting in the second interspace on the left side. Mitral disease of congenital origin is very rare. Thrill over the praecordial region is seldom met with, except when congenital defect in the septum exists. Loud, vibratory systolic murmurs heard most distinctly over the upper third of the sternum without attending hypertrophy of the left ventricle point to persistence of the ductus Botalli. A curious result of cardiac malformation has been observed, — ^abscess of the brain without appreciable cause.^ The resemblance borne by cases of fuiictioiial disturbance of the heart, associated Avith impoverished blood, to valvular affections, has already engaged our attention. The age ; the anaemic look ; the seat of the murmur at the base of the heart, as well as at the apex, and its soft character ; the venous hum ; the fact that the cardiac murmur does not entirely supersede the first sound and is followed by a dis- tinct second sound ; that the apex beat is not displaced, and that the murmur is not heard at the back, are all points upon which some stress may be laid ; yet not so much as upon the absence of the phe- nomena of an enlarged heart. But if the question be asked. Are the latter absolute demonstrations of the existence of an affection of the valves? cannot an hypertrophied or a dilated heart, with sound valves, be combined with a condition of blood capable of producing a murmur? — ^we are forced to answer that such is possible. Under these circumstances, the tact of the physician may help him to a well-judged decision ; but the only proof of a well-judged decision is afforded by time, or by the result of treatment that restores the blood to its normal state. A murmur caused, in violent excitement of the heart, by mw- diredion of the current, due chiefly to temporary interference with the closure of the valves, or perhaps owing to altered tension of the valves, — causes the exact working of which. I have elsewhere in- quired into,* — may become a troublesome source of error in diag- nosis, especially when heard over a heart in a state of dilated hyper- trophy or of dilatation. Fortunately, a blowing sound of this origin and in this combination is comparatively rare, and we are enabled to discriminate it from an organic valvular murmur by its not being per- sistent It is much more likely to be heard at the apex, or rather, according to my own observations, somewhat above the apex, than is a murmur owing to changes in the blood ; and it differs from the systolic blowing soimd of mitral disease partly by the peculiarity ^ Ballet, Archives Generales de Medecine, June, 1880. * On Function^ Valvular Disorders, Amer. Journ. Med. Sci., July, 1869. 420 MEDICAL DIAGNOSIS. of seat just mentioned, partly by its non-diftysion, its usual absence at the back of tlie cliest, tlie want of liarstiness in ttie inconstant murmur, and the low pitch. Murmurs of this kind are also caused by obstructive diseases of the longs, without disease of the heart being present. They may t>e brouf^ht out, as John K. Mitchell has shown, by suddenly closing the Iiand tightly.* At tiiues a murmur is heard which Is not dependent on a cardiac affection, but on bmg rhanges. We find, for instance, in consolida- tion of the left apex, especially if the lung be also contracted, a murmur, almost invariably systolic, over the site of the pulmonary arter>^ ; or we may encounter over large cavities with tliin waJls, situ- ated in the neighborhood of the heart, a systolic, cardio-pulmonary murmur, caused, most likely, by the agitation of the air in the cavity, the hetul being quite sound. These, then, are the causes which impair tlie value of the cardiac blowing sound as a sign of a valvular lesion. Yet tht*y do not happen often enough to prevent us from regarding a persistent mumiur as eminently indicative of an organic aiiection of the valves. Let us suppose tliat we are convinced that the murmur is due to a structural lesion. Can we say what its precise nature is? Can we accurately foretell that tlie valve is merely roughened, or that it has undeiTgone calcareous transformation, or that it has been bound down, or that it is lacerated, or that vegetations spring from it, or that its muscolar attachments are sound or unsound? No, assuredly not. The most we can do is to judge whether the orifices through which the current flows are nan*owed, or whether, by the valves not closing, they permit of regurgitation ; and to distinguish even this we have to take into account more the time of the occurrence of the sound tlian its particular character or pitch. Indeed, all distinctions based entirely on either of these are not borne out by clinical experi- ence. Valves incompetent to close the openings at which they are seated may permit a murmur to be generated of any character and of any pitch. It is true that a harsh murmur, like that of a saw or of a rasp, is for the most part occasioned by a contracted orifice with rigid valves. In obstruction at the mitral and tricuspid orifice, the murmur is mostly rough or mmbling. Broadbent^ maintains that a loud and long mnrinur is significant of less slroctural damage and functional imperfection than a short and weak murtnur. A cardiac sound which is rare, but which, when present, is gen- ' Transactions of tlie Co!leg»? uf Physicians of Philadelphia, 1S02. » Heart Disease, 1898. DISEASES OF THE HEABT. 421 erally associated with a narrowed orifice, is a distinct musical tone heard at the mitral or aortic valves. It resembles the cooing of a pigeon ; or the auscultator listens and listens again, and directs the patient again and again to suspend his breathing, before he becomes convinced that the sound is not a sibilant rale in the lung. It is some- times perceived merely at the beginning, or the end, or only in the middle " of an ordinary murmur, and disappears and reappears. Where this rare sound is met with, the valves are usually rigid and unyielding. Yet this is not always the case. Sometimes the nfusical note is produced by the vibrations of clots which impede the rush of blood through the apertures of the heart, or by the loose edge of a valve flapping to and fro in the current. Occasionally, too, we hit upon it in chlorosis ; but only very occasionally, and never unless it be then equally or more marked in the arterial system. We have the authority of Stokes for the observation that it may be suddenly developed and precede the signs of structural alteration of the heart. Schroetter maintains that the musical murmur is due tothe vibration of a fine fibrous band stretched across the ventricle or a valvular orifice.^ It has been already stated that we judge best of the condition of the orifices and of the valves by ascertaining the time at which the murmur occurs. But it is also necessary to recall the state of the orifices during the movements of the healthy heart. During the con- traction of the ventricles, the valves at the auriculo-ventricular open- ings are closed, to prevent regurgitation into the auricles, and the valves of the aorta and pulmonary artery are open. During the dila- tation of the heart the reverse takes place : the valves at the origin of the great arteries are shut, and the valves which act as gates to the auriculo-ventricular apertures are swung back, to allow the stream to flow into the ventricles. If then a murmur occur with the contraction of the heart and the first sound, it is owing to the blood either regurgitating from the ven- tricles into the auricles, or meeting with difficulty in passing into the aorta or pulmonary artery ; if it occur after the contraction of the heart, and correspond to the second sound, it is due to the blood passing through a narrowed mitral or tricuspid orifice, or streaming back into the ventricles through incompetent aortic or puhnonary valves. But can we distinguish at which valve the mischief lies ? Generally we can. By attending to the site of greatest intensity of the murmur, we become aware of the seat of its production, provided it be borne in » Wien. Med. Blatter, No. 1, 1883. 422 MEDICAL DIAGNOSIS. IS . a mind what are the points at which to listen to the different valTi It is, however, also necessary to recollect that, as the whole heart somewhat lowered, these points are rather below what they are k natural state of things. Now, we cannot always say whether more than one valve is fecled. A murmm* in the heart, no matter where it is generated, is usually transmitted all over the organ. If it mask the natural 'sounci^^ Fig. 48. Narrowing of the aortic orifice by vegetations springing from the valves, the structure of which was, indecti, to a grvat extent, destroyed. The engraving illustrates ah«o the physical sigm of aortic constriction. at other valves, it is very difficult, nay, it is often impossible, to ieli positively how many of the valves are injured, unless several spots be detected at which the murmur is intense, yet not alike in character. The valves that most frequently show coexisting disease are the mitral and the aortic, particuhu*ly insufficiency of both, or aortic narrowing with mitral insufficiency. Diseases of mitral and tricuspid are also found to coexist, whether the lesion be regurgitation or narrowing. DISEASES OF THE HEART. 423 In all instances the precise eharacter of the murmur at the iliiTerent sites of the heart is of the greatest significance. Thus tlie nmrmur is the most conspicuous and most constant sign of a valvular lesion. The other signs and symptoms vary greatly in indi- vidual eases. Wliere tlie valves are but sl%'htly afTected, let us say slightly roughened, as tliey sometimes are after an attack of rheumatic endofiarditis, the heart does not undergo any decided change in size ; Fig. 49, ligiriHrtMit mitnU T&lves permittjn^c ]1t^gtl^g1tlltlon of the bk.M>d. The poi^ldon and time of occur- rence of the inoit signlflcaut sign of the affection &r' much more fret|uentiy diseased, and Uieii' derangements lead to hypertrophy rather than to dilatation. Affections of tJie ineit^pid valves are usually connected with dilatatfon of the organ ; hence dropsy, venous lurgescence and albuminous urine are in them more especially observed ; and Blakis- 424 MEDICAL DIAGNOSIS. ton has taught us their frequent association with engorgement of the vessels of the brain, and how this becomes the predisposing cause (rf cerebral apoplexy when in connection with cardiac disease. We also find in them, or rather in tricuspid insufficiency, what Mahot has more particularly called attention to, — a pulsation of the liver correspond- ing to each systole of the heart, perceived by gently depressing the abdominal parietes with the hand on the epigastrium. In combined tricuspid and mitral narrowing we may have the signs of pulmonary- artery regurgitation.^' In high degrees of aortic insufficiency, a sys- tolic apex murmur, as pointed out by Flint, is very often produced by dilatation of the mitral orifice. The murmur diflfers from that over the damaged aortic valves, and may be presystolic in time. In coex- isting aortic and mitral insufficiency the compensatory hypertrophy is arrested. In some cases of mitral reguigitation the mitral murmur occupies only the middle or the latter part of the systole.* In in- stances of disease of three valves, as in the case reported by Shal- tuck,^ double murmurs of dissimilar kind may be heard over the area of the different orifices. All valvular lesions may be combined with pain in the pnecordia, palpitations, restlessness, and disturbed dreams. And according as tlie deranged circulation through the heart interferes with tlie circu- lation in other parts, special symptoms show themselves prominently. Thus, we find those who labor under a mitral disease suffering most from cough, from dyspnoea, and from attacks of cardiac asthma, since it is the lung which has to bear the brunt of the embarrassed flow of the blood. If we examine this organ closely, the physical sounds afford direct proof of its disordered condition. Here and there are heard plentiful moist sounds from fluid which has leaked into air-tubes: here and there the respiratory murmur is roughened, and percussion shows impaired, clearness. This loss of the natural resonance is at times very manifest at the upper part of the lung, and I have known it to give rise to the suspicion of tubercular deposit in cases in which the autopsy proved the pulmonary tissue to be healthy, tliough in a state of extreme congestion. Respiratory percussion renders the sound again clear. Mitral insufficiency generally leads to hypertrophy of the heart ; mitral stenosis becomes associated with dilatation, or there is only hypertrophy of the right ventricle. When the aortic valves permit of regurgitation, this gives rise to * Dyce Duckworth, Clin. Soc. Transact., Jan. 1888. 2 Crozcn- Griffith, Amer. Journ. Med. Sci., Sept. 1892! ' Boston Medical and Surgical Journal, 1891. DISEASES OF THE HEART. 426 eflfects which are perceptible along the track of the arteries. These all look superficiaJ, and beat with apparent violence, from the force with which the thickened left ventricle is driving the blood through the tubes. The pulsation of the vessels may be even seen in the retinal vessels with the aid of the ophthalmoscope. Yet, when the finger is applied to the ari:ery at the wrist, the strength of the beat is not so great as expected. A short, abrupt, jerking impulse is indeed communicated to the finger ; but then the artery immediately recedes, proving that it was only imperfectly filled. This pulse is the only one which gives us any real information as to the state of the orifices of the heart. In general terms, it may be stated that the pulse is small and rather tense when the openings are narrowed. Still, no stress can be laid on this in a diagnostic point of view. The want of cor- respondence between the strength of the pulse and the force with which the heart is acting is often amazing. If the second sound can be heard in the neck over the carotid artery it shows that the regurgi- tation is not large in amount.^ In marked regurgitation a capillary pulse, as seen, for instance in the finger-nails, is common. More information than by merely feeling the pulse can be obtained by studying it with the sphygmograph. But even with this, as thus far developed, we gather in valvular diseases rather corroborative evi- dence than knowledge which is not attainable by other means of diag- Fio. 60. Sphygmogram taken from a patient with aortic insufficiency. The line of ascent does not termi- nate in 08 sharp a point, nor is the descent as sudden, as we sometimes find it. Fig. 51. Sphygmogiam taken from a patient presenting the signs of mitral regurgitation. nosis. Perhaps with further research the instrument may be made available to inform us with certainty of the degree of the valvular imperfection ; and this would be a great step in advance. As regards the most distinctive graphical signs, we obtain them in aortic regurgi- tation,— a vertical line of ascent of great amplitude, a pointed sum- ' Broadbent, Diseases of the Heart, 1898. 426 MEDICAL DIAGNOSIS. mit, and a sudden descent, with comparatively little dicrotism. If there be also marked aortic obstruction, the line of ascent is oblique, or rather the first part is vertical, and following the sharp point is a gradual curve-like rise ; if senile changes in the artery complicate the aortic insufficiency, the sharp-pointed process terminating the line of ascent passes into a more or less horizontal plateau. In instances of decided uncomplicated aortic obstruction there are sloping up-strokes and down-strokes. In mitral regurgitation the pulse tracing is usually very irr^nlar, such as is seen at times in aneurism ; the line of ascent is short and unequal, and the line of descent is disposed to be oblique and to present marked dicrotism. In mitral constriction there is also, usually, irregularity ; it is asserted by Mahomed ^ that the up-stroke is vertical, and that there is, especially after giving digitalis, a secondary and very characteristic contraction of the ventricle manifest in the dicrotic wave. Sansom^ agrees in the main with this observation. But, instead of entering into a detailed description of the pulse, however studied, or of any separate symptoms of valvular disease, let us group tliem togetlier with the physical signs, according to the combination in which we are wont to meet them : Table of Valvitar Diseases. Skat of MrmivR. Muruuir nuist In- U»iL«it» At or new Aix»x o( hi^Hrt. Seat of Dis- ease. Mitral oriflce. Character of Disease. With impulse, means insulB- oiency of valves, permitting of re- gHrgitatioH : after imiHiIso and run- ning into or cor- responding to the seiHmd sound, or. morv accurately si^eaking. gen^^ ally preceding the i!T»t sound, prosysiolic, mtn!in> fM'^ytrinff oi the orifice. Correlative Physical Signs axd Symptoms. In mitral disease the heart very com- monly undeigoes dilated h3rpertropb.T. especially the right ventricle. Wben there is also hypertrophy of the Wft ventricle, it Is not simply mitral lur- rowing. The second sound of the pul- monary artery, heard in the second Wtt inteispace, is sharp, accentuated. Tbe cardiac murmur is often distinctly jer ceived posterioriy on the left side, nm the angle of the scapula. DyspoceaiDd dropsy are piominent sympcoms. ccp<- cteUydyspocBa. Cough is not unosaL and the pulse is not infrequently found to he feeUe and irregular. In some fbrms of mitral narrowing, where the curtains are not too rigid, the muimor is always rough. This b the csk usually with the presystolic murmur. which fe» piv^minently regarded w the $lgn of mitral cooetriction. Butinthii affection all mnrmor may he ahseiiL and a rooghening oi the tii^ sound and doubting of the second be the *' Mtv. -.a'. r.:;it^ Ai.ol iwueUe. May, IS72. - P:.u:.v>c?:< o: Diseases of th* HeaH. 1$$2. DISEASES OF THE HEART. 427 Table of Valvular Diseases. — Continued, 8bat of Muucub. Seat of Dis- ease. Character of Disease. Murmur most in- tense at or near the middle of the sternum, or heard with equal distinctness close to the sternum in the second inter- space on the right side, and thence propagated into the arterial sys- tem. Aortic orifice. With impulse, means narrowing, or obstruction ; with diastole, and taking the place of the sec- ond sound, or oc- curring in both sounds, the first murmur short, means regurgita- tion. Murmur most in- Tricuspid ori- With impulse, re- tense at or very fice.* gurgitation; with near to the ensi- diastole, and tak- form cartilage. ing therefore the and over the place of the sec- lower part of the ond sound, or, Tight ventricle. more generally, preceding the first, narrowing. Correlative Physical Signs and Symptoms. signs ; or there may be at the apex a presystolic murmur and the second sound be lost. In mitral narrowing a thrill in the cardiac region, presys- tolic or diastolic, can be often felt. Mi- tral narrowing is frequently associated with contracted kidney. Hypertrophy of left ventricle, often to a very great degree, the compensation being very decided. All the cardiac sounds may be normal, except at the aortic valve, although they are ob- scured by the murmur. This is dis- tinct in the carotids, and is sometimes as well heard at the ensiform cartilage as over the sternum and on a line with the third intercostal space, or in the third or fourth interspace near the left edge of the sternum. When the orifice is constricted, a purring thrill is fre- quently observed to attend the harsh or musical systolic murmur. The symptoms in aortic valve disease are often remarkably latent. There is very commonly neither dropsy nor dyspnoea. The pulse in regui^tation is abrupt and receding, and all the sux)erficial arteries and the capillaries pulsate. It is not unusual to find a double aortic blowing sound attending aortic regurgitation, probably from slight coexisting obstruction of the ori- fice, though tliis is not always found ; a double murmur is also heard in the carotids and femorals. A mitral apex murmur may be also noticeable. Tricuspid regurgitation exists usually in combination with dilatation of the right ventricle, and therefore with the symptoms of this condition ; with ve- nous congestions, with dropsies, with" difficulty in breathing. On account of the open state of the orifice, the cervi- cal veins may pulsate during the move- ments of the heart; and in all cases they are distended. The pulsatile mo- tion in the neck becomes especially visible when the breath is held in ex- piration. The cardiac murmur is ordi- narily soft, of low pitch, is not trans- mitted into the arteries, and is not heard above the level of the third rib. In some cases it is so feeble as to be with difficulty discerned. In tricuspid narrowing, a very rare disease, there are presystolic murmur and thrill, cyanosis of the face and lips, great dropsy, and distention of the jugular veins, with slight, or without, pulsation. 428 MEDICAL. DIAGNOSIS. Table of Valvular Diseases. — Qmlinmd, Seat of Mitkhur. Adinnur mcwt in- tense at the thind left cofttikl cartl- lage near the stefDum, or even fiomowhat lower, or iri the ieoood ioleirogtal tpbxnb to the lelt of the stern uiit^ Beat of Djs- ELAFE. I^iilmonaxy ori- Chahacter of Disease. With tmjmlsc, is ■narrmving; tjik- log the place of the fiecond sound, rtgurgUxiHon, COHRELATIVE PBYSIGAL SIGKS IKD Sysiptomb. We have little knowledge* derlTcd from clinical obe^nrntion. of disease! of the pulmoHftrj' valves, of all the valves the ones must nirely affi-eted. Nor docs % mumiurla the«>itiiatlon indicated, and hardly audible over the left apex or along the stenium. or in the cotLnse of the great vefusela. having therefore tlie characteristics of a pulmonic murmur, warrant a diaguoslii of dli?ea«e of the valves : for it may tie due to anjeemia ; Ijt' caiJi^t'd by clepoaits at the up^per part of the left lung ; or 1^ ol>sMcrved fmme- diatear in mind that inmrcinstancc* of mitral dlFense, especially pesrui^ia- tion. the murmur is loudest at the pul- monary area, and it may be »o in aortic regurgitation, injlmonary narrowing is almost always congenital, and the Kystollc murmur is Toud and harsh. Pulmonary imuniciency may be al«o congenital, or lue due to malignant endocarditia. In this manner are tlie symptoms and signs of valvular affections associated. Btit it is not exactly the combination and precisely the way in which they happen in ever>" instance, for disorders of several valves may be conjoined. Presummg that we have been enalDled to tix accnrateiy the state of each aperture, there is a point where all our skill invariably comes to a stand-stilK We cannot tell how long it is possible for life to eontinut*, or under what circinnstanres death will happen. It may lake place suddi^nly and most unexpectedly in cases in which tlie amount of disease in the heart is not found to be great ; and, on the other hand, life» and even a toleral^le degree of health, may be maiU' tained witli valves so rigid and unyielding that the point of the knife can, at Uie autopsy, hardly be forced through them. In mitral dis- ease the patient is liable to be w^oru oul by the dropsy and the in- DISEASES OF THE HEART. 429 creasing difficulty of breathing ; and so, too, in that still more serious lesion, — tricuspid regurgitation. In aflfections of the aortic valves the pwitient suffers less, but he is more liable to sudden death. Before dismissing these valvular affections, there are a few other matters which claim consideration, though the limits set to this work will prevent their full discussion. The blowing sound has been in- sisted upon as the diagnostic sign of a valvular lesion, and to insist upon this is to do no more than universal experience warrants. But there are undoubtedly instances in which no murmur reaches the ear to show that the valves are damaged. I shall cite two examples. A man, thirty-five years of age, came under my care, complaining of palpitation of the heart, of occasional attacks of bronchitis, and of shortness of breath. His health was otherwise good. A physical examination of the chest showed the action of the heart to be extremely disturbed : the impulse was strong, and the extent of dulness in the prsecordial region increased. A blowing sound was heard near the apex, but, owing to the great irr^ularity of the movements of the heart, it was impossible to say whether it corresponded in time to the contraction or to the relaxa- tion of the organ. The pulse was small, frequent, and intermittent. The patient continued in this state for seven months, the beat of the heart becoming more and more tumultuous ; but the murmur gradu- ally disappeared. A peculiar clacking sound took its place, which was most distinct near the apex, and was faintly transmitted to other por- tions of the heart. It occurred with but one sound of the heart, — with which could not be determined. For some time before his death he had considerable cough, with a frothy expectoration and great difficulty in breathing. His face and hands had begun to swell. The immediate cause of death was pulmonary apoplexy. The heart was found in a state of dilated hypertrophy, and the mitral valves had been converted into a calcareous mass, which had left but an extremely narrow chink for the blood to pass through. The next case presents, in several respects, a striking similarity. A gentleman, about fifty years of age, who had led a gay and some- what dissipated life, noticed that he experienced difficulty in breath- ing on the slightest exertion. An inquiry into the state of the heart furnished a clue to the dyspnoea. The size of the organ was evi- dently increased, and its rhythm very irregular. The impulse was strong ; but the sounds were normal, except near the apex, where, taking the place of one, was heard a dull but ver>^ marked clack. When the hand was applied over this point, it felt a vibration of very much the same character as that which the ear could hear, and, like 27 430 MEDICAL DIAGNOSIS. this, it was only distinctly perceptible at or near the apex of the organ. The diagnosis of disease of the mitral valves was made, and it proved to be correct. The dyspnoea became greater and greater; the feet, and subsequently the abdomen, were distended with fluid; and the patient died with all the symptoms of an unmistakable valvular lesion. I might cite more such cases ; but these two present the main features of all. All the instances of valvular disease I have met with, unaccompanied by blowing sounds, have been instances of disease at the mitral orifice, and of extreme narrowing of that orifice. They were all attended with excessive irregularity of the action of the heart, and with hypertrophy. They all produced difiiculty of breathing. They all presented the peculiar clacking sound most marked near the apex. In some, another sound, more like that heard in health, fol- lowed it ; in others, not. In some, the blowing sound gradually dis- appeared ; in others, none was perceived when first examined ; and in others, again, it could be caught occasionally, as a very short whiff, along with the clacking sound. In all, the impulse was strong and very variable in its rhythm, and a peculiar movement was felt near the seat of the apex, — ^not the purring tremor that so commonly accompanies the movements of a heart the valves of which are dam- ,aged, but a more localized vibration, similar to the sound the ear hears. These cases are probably of the same nature as those that are every now and then reported as valvular lesions in which the sounds of the heart were normal. I cannot think that with a disease of the valves they ever are so. There may be no blowing sounds present but the sounds of the valve affected must be different fiBom what they are in health ; and it may be said again, in all truth, that to hear the natural sounds of the heart well defined is to be able to exclude a valvular disease. Valvular disease may be at times suddenly developed, fi:om ruptun of a vahukt or of a papillary rnuade by a severe strain. I have known such cases to happen where there was nothing in the history to lead to the belief of previous disease, though often there is some preceding disorganization, such as a granular or a fatty change. One of the most striking diagnostic features is the quickly developed organic murmur attending the signs of disordered circulation and cardiac distress ; another, the occurrence of pain in the region of the heart Rupture may happen in the affected valve of an ulcerative endo- carditis without any extraordinary strain. The previous historj', the sudden aggravation of the cardiac symptoms, will furnish an explana- tion of the accident. DISEASES OF THE HEART. 431 Let me also here briefly discuss another question, — whether the valvular affection shows any signs by which we can recognize it before the development of a murmur. We cannot do so with any certainty ; although marked alteration — such as dulness of sound confined to or most obvious at a particular valve, the signs of preceding or of grow- ing hypertrophy, and, where the aortic valves are concerned, a distinct accentuation of the second sound, while the first has become dull and changed — might make us suspect what is about to happen. A doubling of either the first or the second sound, especially of the latter, is often, according to the observations of Sansom, an early sign of the development of mitral narrowing. Gibson ^ dwells on the doubling of the second pulmonary sound in mitral obstruction at any stage, and on the great tendency to the appearance and disappearance of the doubling ; while Broadbent ' maintains that a mitral systolic murmur which is retarded, following the first sound at a brief interval, shows that the changes in the valve are slight. Displacements of the Heart. The heart is a very movable organ. Its apex is tilted upward by an enlarged liver, by an abdominal tumor, or by a pericardial effusion. It gravitates towards the median line when the walls of the heart have increased in weight and firmness. But these changes are hardly of a nature to attract as much attention as finding a heart beating on the right side of the stemimi. Now, it is not very uncommon to meet with it there; and the question immediately arises, What does this strange alteration in its situation signify, and how is it brought about? It is usually pro- duced by pressure exercised on the heart by accumulations of fluid or of air in the left pleural cavity, and therefore denotes, as a rule, a pleuritic effusion or a pneumothorax of the left side, and is accom- panied by distention of that side. In rarer instances, the heart is pushed across by a highly distended emphysematous lung; in still rarer instances, it is drawn over to the right side by a shrinking of the lung, attended with dilatation of the bronchial tubes, the so-called pulmonary cirrhosis. It is sometimes found on the right side, because it has been forced there by a pleuritic efi'usion and has formed adhe- sions, and when the fluid was absorbed it was unable to return to its natural place. In this case the left side will be markedly re- tracted, and not the right, as it is if cirrhosis of the right lung be the cause of the abnormal position of the heart. » Diseases of Uie Heart, 1898. » Heart Disease, 1898. 432 MEDICAL DIAGNOSIS. The displacement may further have been brought about by a cancerous or an aneurismal tumor, or by any of the abdominal viscera having slipped into the chest through a hernial opening in the diaphragm ; or it may be congenital. But these all are causes whidi seldom exist. Pratically speaking, transpositions of the heart are met with in conection with diseases of the lungs. We shall merely add that a congenital displacement cannot be diagnosticated unless all other causes capable of producing a displacement have been proved to be absent ; and that a dislocated heart is able to perform all its functions. It may even be attacked by acute disease ; the rec- ognition of which,* under such circumstances, belongs to the triumphs of physical diagnosis. SECTION III. THORACIC ANEURISM. An aneurism of the aorta, whether caused by a disease of the coats of the artery or not, whether true or false, may affect any part of the vessel. Yet it is chiefly at the ascending portion and at the arch that it is met with. When it occurs just after the arter)- has left tlie heart, it is prone to elude discovery. Higher up, nearer to or at tlie arch, it more rarely escapes detection. The tumor manifests itself by a local bulging, varying in extent and situation according to the extent and situation of the aneurism. A single rib alone may be raised, or nothing but a fulness may be observed. But some prom- inent spot is generally detected, and when this is percussed it is more n^sistant, and returns a duller sound, than normal. Yet neither the bulging nor the dulness on percussion is of as much significance as tinding a distinct pulsation remote from the beat of the heart. Every time the latter is perceived, an impulse is communicated to the finger at the point in the chest walls which appears to project; that is, usually on the right side of the sternum in the second intercostal space, or in the same interspace on the left side, or immediately imder the top of the bone. Occasionally the beat is double, at times so violent as to shake the head of the listener, and almost always, luiless the aneurism be lilltHi with solid clots, stronger than tlie beat of the heart. The hupulse may be accom^>anied by a distinct thrill. But this is iu>t always pn^sent, and, when present, is not always constant, since it uuiy dis;ippear and n\ipiH\ir. It is thus a serious mistake to regard tt\o thrill as the nniuisile sign of an aneurismal enlargement: yet ^ As t»\ S:ol» :>. <*^^ n;>'n^al palsy frun i\\\ aiu'iuisin liavi> Nvii mon* sjvvially examined into. '^ i;i;isrt»\\. Now York Mfilio.il Jonnial. Sept. 1S94. ' WoM». AuuT. ,K»nrn. Mnt. 5vi.. iVt. 1S74. THORACIC ANEURISM. 441 An aneurism of the descending aorta, between the arch and the diaphragm, produces, if extensive, dulness on percussion and bulging posteriorly, and may exhibit the same physical signs and symptoms as an aneurism in the neighborhood of the arch. A gnawing sensation in the veri:ebraB has been especially noticed; so have difficulty in swallowing and stridor on the left side of the chest. Yet, in spite of the most careful scrutiny, an aneurism of the descending aorta often escapes detection, or its physical signs, as a case recorded by Walshe * proves, may exist to the right instead of to the left of the spinal col- umn, because the vessel has been dragged across the median line by its enlargement. In aneurism of the descending thoracic aoria near the diaphragm, we have expansile pulsation, but not stridor ; there are, as Gibson* points out, marked signs of compression with vesiculo- bronchial or bronchial breathing, and increased vocal resonance at the lower part of the left lung. In aneurisms of the descending aorta, perhaps even more than in aneurisms of other portions of the aorta, we get the greatest help from the Roentgen rays, and cases that can- not be otherwise recognized can thus be diagnosticated. An aneurism of the heart may in exceptional instances produce localized bulging in the cardiac region. But, whether it does so or not, it is beyond the reach of positive diagnosis. We may suspect it if the bulging have been preceded by signs of fibroid degeneration of the walls of the heart. Obstructed coronaries producing the myo- cardial changes are its most common cause. Pericarditis with ad- hesions near the aneurism has been also noticed. In a number of instances we have a syphilitic history. In rare instances we find a varicose aneurism communicating \vith eitlier the ascending or the descending vena cava. These aneurisms mostly present the ordinary signs of a thoracic aneurism ; but, in ad- dition, great venous enlargement above the diaphragm, with oedema of the face and hands and arms ; a purple hue of the face and the upper part of the body, and spots of ecchymosis in the skin ; a jerking pulse ; a purring thrill ; and a whirring systolic murmur,^ diffused all over the front of the chest. The oedema and the symptoms of venous disturb- ance come on suddenly. In occlusion of the vena cava the great venous distention is not accompanied by the physical signs of aneurism, nor by thrill, nor by cyanosis and oedematous swelling.* * Diseases of the Heart. * Diseases of the Heart and Aorta, 1898. * As in Mayne's case, Dublin Quart. Joum. of Med. Sci., Nov. 1853 ; also in Glascow's case, St. Louis Courier of Med., Jan. 1885. * Arthur V. Meigs's case, Transact. Coll. of Phys. of Phila., 1886. 442 MEDICAL DIAGNOSIS. Let us, in conclusion, glance at the other kinds of aneurism within the thorax, — that of the innominate and that of the pulmonary artery. An aneurism of the innominate artery is strictly limited to the right side of the body. It differs from that of the arch by the higher situa- tion of the pulsating swelling ; by the displacement of the clavicle ; by the comparative absence of signs of pressure on the larynx and oesophagus ; and by the fact that compression of the right subclavian and carotid diminishes the beat of the tumor, while it exerts no effect on an aortic aneurism. Such are, at all events, the marks of distinc- tion indicated by the observations in Holland's* excellent memoir. An additional sign is mentioned by Wardrop.* It is that when the innominate is affected, the difficulty will appear first on the tracheal side of the stemo-mastoid ; but on the cervical side, if the aneurism be of the subclavian. In aneurism of the innominate, further, as the tumor is under the right sterno-articular articulation, percussion does not detect any distinct enlargement of the arch of the aorta. An aneurism of the pulmonary artery is a rare disease. Its main phenomena are : a strongly pulsating swelling, perceptible to the left of the sternum, and limited to the second intercostal space ; a marked thrill with each expansion of the aneurism ; and in some instances a rough murmur, which is not discovered at the notch of the sternum or above the clavicles ; lividity of the face ; dropsy ; great difficulty of breathing; and the absence of obvious evidences of pressure.* The situation, too, of the physical signs is important ; yet an aneurism of the arch may occasion a pulsating tumor mainly to the left of the ster- num, and may even break into the pulmonary artery. A mere distinct beating of the pulmonary artery is discriminated from an aneurism of this vessel by the non-existence of a palpable swelling, of dropsy, of embarrassed breathing, of lividity of the face, and by the usually co- existing signs of some consolidation of the left lung. Occasionally we meet under the outer half of the left clavicle with a pulsating tumor presenting thrill and murmur, and dilated veins above. The signs often suddenly disappear. These "mimic" or phantom aneurisms * are apt to come back after excitement and after movement of the arms. They are thought to be due to temporarj' dila- tation of the artery from vasomotor paralysis, limited to a large vessel or to part of it. * Dublin Quarterly Journal, vol. xii. ^ Holmes's Surgery, vol. iii. p. 562. ^ In the case detailed by Skoda, Auscultation and Percussion, the dropsy was great, and the fare cyanotic ; there was no murmur over the pulmonary artery. * See paper by Samuel West, St. Barthol. Hosp. Rep., 1880. CHAPTER V. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. The diseases of this part of the digestive system need not here be described at any length, because many of them have been already considered. Yet some require further examination. MOUTH. Soreness of the mouth, pain in masticating, and a fetid breath are often complained of in diseases of the oral cavity. Let us suppose a patient to present himself with such symptoms. The interior of the mouth is exposed to a strong light, and its different parts are inspected. The gums are noticed to be swollen and injected, and the mucous mem- brane lining the cheeks reddenedl—^\i\s is a state of things observed in the different forms of domodiiia. In the common diffused injlammai,ion, the result of direct irritation, such as the swallowing of hot liquids or corrosive substances, or an accompaniment and consequence of gastric disorder, the redness is marked ; any attempt at chewing is painful ; the taste is impaired ; a flow of saliva takes place from the mouth, and superficial ulcerations occur at its various parts. In mercurial stomatitis there are much the same symptoms; but the more copious discharge of saliva, the pain in the jaws, the spongy gums, the loosening of the teeth, the enlarged tongue, exhibiting their impress, the painful and swollen state of the salivary glands, and the pecuUar nauseous breath, testify to the specific character of the inflam- mation. Ptyalism may be accompanied by ulceration of the lips or cheeks, and followed by caries or necrosis of the bones of the jaw. The sore mouth of scurvy is distinguished from either of the preceding forms by the spongy, purplish, or livid gums, which bleed on the slightest touch, by the eruption or ecchymoses on the skin, and by the other signs which attend a scorbutic state. The gums and the inside of the cheeks and lips are covered mth a whitish curd-like exudation. — This constitutes the form of stomatitis known as thrush, so frequent in infants at the breast, and so con- stantly associated with intestinal disorder, with diarrhoea, ^^'^th colicky pains, and with a feverish skin and a hot, dry mouth. Very similar 443 444 MEDICAL DIAGNOSIS. to it, regarded indeed by some as identical, is the aphthous ulceratioD, to which adults as well as children are liable. Here, too, a whitish deposit is perceived in various parts of the mouth ; it is apt also to be combined with thirst and with gastric or intestinal disturbance, and the breath has a very disagreeable odor. The recognized differ- ence consists in the presence of the superficial or shallow ulcers which may be detected when the white crusts that cover them are removed, and the vesicular nature of the disease during its formatire stage. Then more or less redness surrounds each spot, the ulcers are slightly raised at their borders, bleed easily on pressure, and may be irregular from several running together ; their grayish covering Is soluble in ether, and presents many oil-globules under the microscope. On the other hand, the microscope shows us in thrush a special parasitic formation, the oidium, or mycoderma, albicans. Ulcerations are perceived on the gums^ tongue^ and various parts of the mouth, — We meet with ulcers in the ordinary, in the mercurial, in the scorbutic, and in the aphthous inflammation of the mouth. They are also seen attending the well-known " sore mouth" of pregnant women, and accompanying tuberculosis. But ulceration is apt to exhibit its most horrible features in the sore mouth of sj^philis, and in that essentially ulcerative disease called cancrum cwi*, or gangrenous stomatitis. In the former the fauces as well as the mouth are, as a rule, involved, and the ulcers show peculiarities which we shall presently study. The latter is an affection which prevails especially in enfeebled constitutions. It is seen chiefly in hospitals, and not uncommonly in epidemics. It begins vdth pain in the girnis, and these soon swell, redden, and bleed readily. They are covered with a soft, grayish exudation, which often extends to the soft palate. If the layer of exudation be scraped away, a bleeding, ulcerated mucous membrane comes into view. The breath is most offensive ; a profuse flow of saliva is noticeable ; perforation of the cheek quickly takes place ; the bones may be laid bare, the teeth loosened ; there is usu- ally fever, often of hectic type ; yet the disease does not uniformly progress with activity ; it may last for weeks. Tubercular ulceration is distinguished usually by a chronic course and by the presence of tubercle bacilli in the granulations and in the submucous tissues. The tongue is red and swollen, — Changes in color and in appearance of the tongue occur in general diseases of the system, and more es- pecially in those of the alimentary canal. The tongue is also more or less involved, at all events its mucous membrane is, in the diflferent forms of stomatitis. An abnormal state of the covering of the tongue is, therefore, far from being a sign that the organ itself is primarily affected. IHBEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 445 Occasionally, however, we do meet with aflfections of its deeper structures. Its nerves may be the seat of violent neuralgia ; its mus- cles may be paralyzed ; it may become hypertrophied or cancerous ; it may undergo progressive atrophy ; or it may be in a state of acute if^mmation. The lat.ter is, perhaps, the most frequent of its mala- dies, and is readily recognized by the red, swollen look of the organ, joined to a burning pain in it, and either to great dryness of the mouth or to constant dribbling. The swelling usually begins at the anterior portion, and may become so considerable as to threaten suffocation ; the inflamed tongue fills up the fauces and protrudes out of the mouth, and the unhappy patient can neither swallow nor utter a word. He has active fever, headache, great restlessness, and intense thirst, — symptoms wliich last for several days, and until the inflammation sub- sides. This may run on to suppuration or gangrene ; in some instances it leaves a permanent induration that may be mistaken for a cancerous nodule. Acute glossitis is a dangerous complaint ; fortunately, it is a rare one. Its most frequent cause, as now seen, is direct injury, either from wounds or the stings of venomous insects, or from the introduc- tion of corrosive substances into the mouth. Its most frequent cause formerly was the abuse of mercury pushed to salivation. At times it is observed as a complication of scarlatina or of erysipelas. Other affections of the tongue connected with diseases of its structure have been mentioned in the first part of this volume. Cancer of the tongue produces the greatest alteration in the form and texture of the organ. Syphilis of the tongue gives rise to deep fissures, ulcers, or mucous patches and gummous nodules which may be difficult to distinguish from cancer, except by the history and the absence of pain. As a sign of recovery from syphilis, the tongue may present a peculiar indented appearance, similar to what is seen in the syphilitic liver. FAUCES. The throat, or fauces, — that is, the parts at the back of the mouth which are brought into view when the lips are widely opened, such as the half-arches, the uvula, the tonsils, the posterior wall of the pharynx, — may be involved in the same diseases as the parts situated in front. The contiguity of these structures is in fact such that any morbid action is apt to spread to them, or to extend from them either forward or downward into the pharynx, and even into the larynx. The most common affections of the fauces are inflammation and ulceration, both of which occasion a feeling of uneasiness in the throat, and also diffi- culty or pain in deglutition, and both of which are readily enough detected by the attendant changes in color, swelling, or exudation. 28 446 MEDICAL DIAGNOSIS. In the ordinary inflammation of the fauces, the simple angina, or sore throat, the parts are of a bright-red color, and the uvula is long and swollen, and by dropping on the tongue gives rise to a constant disposition to swallow, although the act of swallowing is attended with pain. Associated with the angina are coryza and febrile disturbance; and, owing to the inflammation travelling up the Eustachian tube, the sense of hearing is impaired. Tonsillitis. — When the inflammation penetrates the substance of the tonsils, as in quhisy^ much the same general symptoms occur as in ordinary angina. But the sense of constriction in the throat is greater; so is the difficulty in swallowing ; and liquids are apt to return through the nose. The voice is thick, and has often a peculiar sound ; it is painful to the patient to talk, and on looking into the tliroat the tonsils may be seen red, prominent, and covered with mucus wliich is not easily detached. Sometimes the swelling is so considerable that the tumid glands fill up the space between the half-arches and leave but a small interval for the passage of food or drink. The lymphatic glands at the angle of the jaw are frequently swollen. OccasionaDy the inflammation extends from the tonsils to the salivary glands ; the submaxillary' and parotid glands swell, and ptyalism takes place. There is not much likelihood of confounding this, a form of secondarjj parotitis, with mumps, in which an outward swelling, visible beneath the ear, is found, but not a swelling within, the throat, and in which no real difficulty in swallowing occurs, except, perhaps, when the tumefaction is at its height, and then only for a short time. Tonsillitis terminates by resolution or by the formation of pus. There are no positive means of ascertaining that the inflammation is going to end in suppuration, although we may suspect that this will be the case when much pain is felt at the angles of the jaws and shooting to the ear, and when the symptoms have been severe and persistent for more than four or five days. Sometimes the pus may be seen through the covering of the tonsils ; but often the vast sense of relief experienced by the patient, and the sudden improvement in degluti- tion, attended, perhaps, with an unpleasant taste, are the only signs that the collection of pus has been discharged. Attacks of tonsillitis are prone to be repeated, and may lead to permanent enlargement and . induration of the tonsils. The enlarged tonsils, attended as they fre- quently are with cervical glandular swellings, may be mistaken for cancer of the tonfflLs, But in this affection sanious offensive discharges from the mouth occur, and, whether the disease be epithelioma or round-cell sarcoma, it extends rapidly; the neighboring Ijniphalic glands are early involved, the palate and the pharynx become impli- BIBEABES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 447 found auivniia, and that gradual failing of muscular power with anjvsthosia, and ;\l>sonro of reflexes, that bespeaks diphtheritic paral- » MolVimoU. MtMlioal News. iVt. 15, 1SS7. * i^uthno. Uiiuvt, April IS. 25. 1S91. ' A o;isi^ hti5 Ihvii r^stmitHi in which embolic obstruction of the pophteal arton iXvunxHi during vvnvalosivniV fr»m an attack of diphtheria, and amputa- tion of tho ulTtvltHl nunulvr Uvame necessary. Rooney, Occidental Medical I'imos, vol. vii,. No. 4. p. ISS. • l.Nonnet, Lvon McMical, J.u.. 4. II. 1S91. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 451 ysis. In rare instances these symptoms occur early in the attack.^ They are attributable to the development of a peripheral neuritis dependent upon the action of the toxic products of the disease. Hemiplegia has been observed in some cases as a result of rupture of a cerebral blood-vessel or its occlusion by a clot.^ Other symptoms of profound nervous derangement have also been recorded, such as peripheral neuritis in which the sense of smell and the muscular sense were lost and profound impressions were referred to corresponding points on the opposite side of the body,^ or with temporary absolute deafness, unsteadiness of gait, and paralysis of the palate.* Further- more, I have known aphasia to follow the depressing complaint. But to look at the diflferential diagnosis of the disorder. It varies widely from stomatitis, from tonsillitis, from pharyngitis, — in truth, from all the ordinary local inflammations of these structures, — ^by the presence of a membrane, by the striking constitutional symptoms, and by the sequelae. The diagnosis becomes unequivocal if, in addition to these, the characteristic bacilli are found on bacteriologic examination of some of the material taken from the throat or the nose. Yet there are certain sources of error against which it is necessary to guard. In simple pharyngitis^ a mass of mucus, in part derived from the nares, is apt to collect on the inflamed membrane, and looks at first sight like the coating from an exudation ; but it may be easily removed, and a closer inspection proves its true nature. In follicular torunllitis^ liquid may ooze from the openings of the follicles on the surface of the swollen tonsils, or little yellowish or whitish points form there. But they are strictly confined to the gland, exhibit no tendency to spread or to coalesce, and are generally small white specks of roundish or oval shape. These appearances constantly occasion mis- takes, especially as regards mild cases of diphtheria. What adds to the difficulty is that follicular tonsillitis is contagious. Should, in an individual instance, the facts mentioned be insufficient to solve the doubt, the microscope can do so ; for it shows the white or yellowish masses to be largely composed of epithelium, with streptococci and staphylococci in abimdance, but not with the true Klebs-Loeffler bacillus. * As in two cases reported by Dabney, Medical News, Jan. 16, 1892, in which they appeared on the first and second days respectively. ' McPhedran, Canadian Practitioner, 1892, No. 19, p. 454 ; Allen A. Jones, Medical News, Oct. 22, 1892, p. 467 ; Edgren, Deutsche Medicinische Wochenschrifl, 1893, No. 36, p. 864 ; C. W. Sharpies, Medical News, Aug. 4, 1894, p. 124. ' Gay, Brain, part Ixiii. p. 431. * Tooth, British Medical Journal, 1893, No. 1680. 452 MEDICAL DIAGNOSIS. Ulcerative stomatitis, the form of stomatitis most likely to be con- founded with diphtheria, and especially with this malady when the exudation lines the gums, is discriminated by the ulceration or slough- ing ; whereas the mucous membrane in the pseudo-membranous dis- ease remains intact, save in the rarest instances. The same feature distinguishes diphtheria from gangrene of the nioufh^ for which, on aci^ount of the extreme fetor of the breath, it is sometimes mistaken, and aids in distinguishing it also from other kinds of stomatitis, as from thrnsh. In the latter, too, the buccal mucous membrane, and not the throat, is chiefly affected, and the abdominal symptoms, and tlu* other constitutional phenomena, are different. So are they in a/ihth(i\ in which, moreover, the superficial ulcerations, which bleed when touched, the unbroken vesicles or pustules in other parts, and the seat of the disorder — usually on the edge of the tongue, on the internal surface of the lips, and on the gums and inside of the cheek — are points to be taken into Jiccount. Besidi^s these affections, there are others which must be distin- guished from diphtheria. We occasionally find cases occurring in epi- iltMuics, and where the membrane is limited nearly altogether to the follicles, and chiefly to the tonsils. As the membrane passes away, ulcerations are obvious. Swelling of the glands of the neck, and ft^ver, but not of acute type, attend this ulcero^membranou^t angina, wliiih, moriHwer, shows a strong disposition to relapses. But, though kindred to diphtheria, and in isolated instances perhaps difficult to iliscriminate, it difters from it in its seat and in its want of tendency to ^spread, in the formation of superficial ulcers, in its less marked con- stitutional depression, and in its invariably favorable termination.^ It is similar to herpes of the tonsils, described by Trousseau. In acute in- tlaiumatitMi ofWxo fauces it is not unusual, especially in certain families, io tind a form of exudation on the surface of the throat due to excessive desi]uaniation of the superficial layer of the epithelium of the inflamed mucous membrane. But a light nibbing Avith a cotton tampon re- nu^ves it, and shows a surface of mucous membrane which is not bleeding or ulcerated. Tlie false membrane of diphtheria is so ad- heriMit to the subjacent tissue that it cannot be wiped ofif, and. if rtMuoved fon^ibly, will leave a bleedijig surface and soon be repro- ducctl. Tlion, as already stateti. there are cases of membranous, or uIcii'raiiHl^ sore Uiroat with membranes that are not diphtheritic, in wlikh Uie Loeffler l^cillus is iibsi-nt, and various forms of streplo- • pK^mr ta te Aifc^r. Joiini. MsmI. :N."'i., July. 1S70. in which I have de- k of tlir iind. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 453 cocci, staphylococci, and pseudo-diphtheritic baciUi are found in the membrane, as in instances observed among soldiers by Cassedebat.* Energetic treatment should be, however, promptly instituted, since these common false membranes may insidiously prepare the way for the culture of the diphtheria microbe. They also, by entering the crypts of the tonsils, may lead to the frequent recurrence of this form of sore throat. In the appearance of the false membrane there is nothing clinically distinctive. Whether there be not still other kinds of membranous sore throat to be separated from true diphtheria is a matter requiring investigation. The pseudo-membranous inflamma- tions of the throat attending scarlatina and measles and other of the exanthemata have been shown not to be diphtheritic, although they seem to predispose to invasion by the diphtheria bacillus.- • There is an acute disease of the throat to which Todd especially has called attention,' and which presents also some strong points of similitude to diphtheria, — ei^y^ipelas of the fames. Like diphtheria, it is a most dangerous ailment; as in diphtheria, the morbid process may extend to the larynx, the mucous membrane be swollen and exhibit a peculiar dusky-red color, the poison paralyze the muscles of the palate and pharynx, and liquids be rejected through the nostrils and mouth. But the difficulty in deglutition differs from that of diph- theria in being present from the onset, and is not attended with enlargement of the glands of the neck, or with the formation of a false membrane. If the erysipelatous inflammation extend to the larynx, there is local pain, with urgent dyspnoea and hoarseness, and usually rapid exhaustion supervenes. In cases of the kind, the sub- mucous tissues of the larj^nx are found extensively infiltrated with pus. Erysipelas of the fauces may happen without erysipelas sho\ving itself on any external part of the body ; on the other hand, erysipelas be- ginning in the fauces may spread to the face.* This erysipelas of the fauces is not a frequent disease ; and it must be stated that there are cases of diphtheria which simulate it very closely. I have seen a number of instances of the malady in which the whole mucous membrane was of a vivid or dusky hue ; in wliich there was much swelling, with an effusion of serum, especially in the submucous tissue of the uvula, causing it to look like a small trans- * Des Angines Couenneuses non Diphtheriques, Arch. Gen. de Med., 1897, p. 885. * Booker, Bulletin of the Johns Hopkins Hospital, vol. iii., No. 26, p. 129 ; Park and Beebe, Medical Record, vol. xlvi., No. 1247, p. 1. * Clinical Lectures on Acute Diseases. * Cases quoted in Schmidt's Jahrbiicher, 1869, No. 1. 454 MEDICAX. DIAGNOSIS. parent bag; in which immense difficulty or even impossibility in deglutition existed, — ^yet in which no membrane appeared for days after the violent inflammation of the throat had set in, and was, when it showed itself, very slight in extent, and out of all proportion to the inflammation. But the constitutional symptoms and the sequelae were the same as those of ordinary diphtheria. In one of the cases of the kind referred to, suppuration of one of the tonsUs took place in con- sequence of the inflammation ; a layer of deposit had coated parts of the tonsils and of the half-arches and uvula. How shall we separate diphtheria from membraiious croup f In the great majority of instances there is no separation, for membranous croup is laryngeal diphtheria. But there may be a membranous croup that is not ; such as follows scalding the throat, irritant poisons, violent laryngitis, or is seen at times in the exanthemata. Now, in cases of non-diphtheritic membranous croup, the disease affects almost al- ways primarily the ^vindpipe. The reverse is the rule in laryngeal diphtheria : it extends from the throat. Further, ordinary membra- nous croup is not contagious, as diphtheria is. The finding of the specific bacillus in the false membrane in a doubtful case establishes the diagnosis. On one symptom we cannot lay as much stress as might be sup- posed: Albuminuria, the elaborate report of the committee of the Medico-Chirurgical Society has taught us,* is not always present in laryngeal diphtheria, owing to the early fatality of the malady ; again, hi certain cases the mere dyspnoea of laryngitis may give rise to albu- min in the urine. Yet when albuminuria is marked, and when it has happened where an aflfebtion of the fauces has preceded the laryngeal implication, it points to an infective cause, — ^to laryngeal diphtheria. Lastly, diphtheria may be confounded with scarlatina. When, indeed, we reflect on the similar appearance of the throat, on the occ^urrence of albuminuria in both maladies, and on the frequency with wliich both are found to prevail at the same time as epidemics in a community, it is not astonishing that one should be looked upon as but a modified form of the other. Allied they certainly are, but not identical ; for the poison of one leads to a thoroughly defined rash, and leaves a protective influence against a second attack, and often also deafness, suppuration of the glands of the neck, and dropsy,— plienoiiiena \\\\\A\ are not encountered in the other. It is true that in very rare instances of diphtheria we encounter a slight erythema * MiHiico-Chirmvical Tniiisiutious, vol. Ixii., 1879. Some of the anatomical points invt>lv»Ml are also well ilisoussed by Wei^rt in Virchow*8 Archiv, vols. Ixi. nml Ixxi. DISEASES OF THE MOUTH, PHARYNX, AND OESOPHAGUS. 455 of the neck and breast, but it is not like the vivid, diflfused rash of scarlet fever. Moreover the exudation in the throat is not exactly similar in the two diseases. In scarlatina it is pultaceous, and not coherent, and has no tendency to spread to the respiratory passages. Bacteriologic examination, further, may disclose the presence of streptococci and staphylococci, but not the bacillus peculiar to diph- theria. Then the albuminuria happens at a different period. In scarlatina it is a sequel rather than a concomitant ; in diphtheria it is a concomitant rather than a sequel. Further, the gravity of the symptom is not the same. In the latter malady it is an indication of danger ; it has not so serious a meaning in the former. Diphtheria may be intercurrent in various maladies: in typhoid fever, in the exanthemata, in pneumonia. A microscopic examination and culture experiments can alone settle whether the membranes are truly diphtheritic or only formations of false membranes. The exu- dation in diphtheria is not always restricted to the -throat. It may show itself in a woimd or on excoriated skin, on the nasal mucous membrane, the conjunctiva, the nipple, the uvula, or aroimd the anus ; it may be foimd coating the stomach, the intestines, and the ramifica- tions of the bronchial tubes. Nasal diphtheria is a very grave form of the malady : it may either be present alone, or coexist with a deposit in the fauces and pharynx. It generally occurs vdth evidences of the septic form ; the symptoms are of a low type, and we recognize the affection by carefully inspect- ing the posterior pharynx and seeing that the membrane extends upward ; by noting the irritated, reddened look of the nostril, even when no membrane can be discerned in it ; and by the coryza, the sense of obstruction in the nose, and the acrid sanious discharge which comes from it. In cases in which the nasal duct and the lachrymal canal are stopped up by the false membrane, tears are con- stantly rolling down the cheeks. Epistaxis is a not uncommon symp- tom ; swelling of the cervical glands may or may not be present. Recent bacteriologic investigation has shown that so-called mem- braiious rhinitis is in reality often of diphtheritic origin.^ And in the enlarged glands in any form of diphtheria the characteristic bacilli are found in the opaque, yellowish masses, consisting principally of fibrin, which they contain.^ Mumps. — This, like diphtheria, is a general disease, and is only here described as a matter of clinical convenience. Parotitis is most » Abbott, Medical News, May 13, 1893, p. 505. * Bulloch und Schmorl, Beitr. zur Pathol. Anatoinie, etc., von Ziegler, B. xvi. H. 2 ; Centralblatt fttr Innere Medicin, 1895, No. 6, p. 156. 456 MEDICAL DIAGNOSIS. commonly seen as an epidemic malady ; but we occasionally encounter a secondary parotitis following typhus fever, scarlet fever, smallpox, measles, and dysentery. In this form suppuration is much more com- mon than in ordinary mumps. The disease generally begins with pains at the angle of the jaw, which are soon followed by a marked swelling, first on one side, then on the other, that results in the head being kept rigid. The tumid glands are sore, and become more painful during attempts at swallowing and chewing, though there is really little, if any difficulty in swallowing. If the patient be made to swallow slowly ten to thirty drops of undiluted vinegar, decided pain is produced in the affected glands, — an old and useful diagnostic test to which Dr. Louis Starr called my attention. The mouth is gener- ally filled with saliva, though it may be very dry ; and tlie hearing may be impaired, or, for the time being, entirely lost, and ringing in the ears is very common. The temperature generally ranges between 101° and 102°, but in cases of orchitis following mumps, or of metas- tasis, I have seen it 104° to 105°. The nervous system may become decidedly aflTected, and the action of the heart weak and irregular. Acute mania has been known to become associated with mumps ; so has peripheral neuritis.^ Parotitis is easily recognized. There is no swelling of the tonsils, hence it cannot readily be mistaken for tonsil- litis. Laveran and Catrin have found a diplococcus in mumps, in tlie secretions of the parotid and other glands, as well as in tlie blood.* In cellulitis of the neck, angina Ludovid^ the swelling may mis- lead, but it is uniform and not confined to the region of the parotids ; the constitutional symptoms are very severe, pointing to an infective malady. Ludwig's angina is met with as an idiopathic aflPection, or in certain fevers, such as scarlet fever or diphtheria. Chronic Sore Throat. — Attacks of angina are prone to recur, and to lead to chronic inflammation of the structures. Now, an affection of this kind is liable, on any exposure, to be kindled into the acute complaint ; besides, it yields at all times some manifestations of a dis- order of the throat. A thickening of the folds of membrane forming the half-arches, a tumefaction of the follicles at the upper part of the phar}^nx,a lengthening of the uvula, are the visible signs of the chronic malady ; a constant disposition to clear the throat, and a dry cough, are often the attending general symptoms. Owng to the habitual coughing, the patient may be suspected to be laboring under phthisis, and be treated accordingly, when the whole difficulty lies not in the lungs, but in the throat. Yet an error in the opposite direction is per- ^ Lancet, April 9, 1887. =« Gazette Medicale, June, 1893. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 457 haps more frequently committed. Tonsils and uvulas are removed, with the view of curing a cough which is really kept up by a source of disturbance in the limgs, in forgetfulness of the fact that, in scrofula, and tuberculosis, chronic enlargement of the tonsils and follicular pharyngitis are by no means unusual. A careful examination of the chest and a bacteriological examination of the sputum ought always to be made, even when inspection of the throat shows disease to be there present. The follicular disease of the throaty or ** clergyman's sore throat," is the most frequent of all the morbid conditions which produce a chronic sore throat. The abnormal condition of the follicles of the pharynx and fauces often extends to the larynx. There are constant hawking and attempts at clearing the throat, and not infrequently roughness of voice or decided hoarseness. On inspecting the throat, the enlarged mucous follicles can be readily discerned ; those on the pharynx are very prominent. In cases of long standing, the follicles may ulcerate, and very commonly they pour out an acrid secretion. But, unless from coexisting enlargement of the uvula, or an altered position of the epiglottis, or a laryngeal or bronchial complication, there is no decided cough. The follicular disease may occur in consequence of repeated attacks of sore throat, or be an attendant upon gastric disorder, or follow constant over-exercise and straining of the voice. Chronic rheumatic sore throat gives rise to pain which is often referred to the hyoid bone, is increased by pressure, and is also felt in the tonsils. Ingals ^ points out that the pain often entirely disappears while the patient is eating, but increases in cloudy and damp weather. There are signs of slight congestion in the throat, and generally in the larynx, yet mostly out of all proportion to the pain. The general health remains good, and we find no fever ; there is apt to be a history of a rheumatic diathesis. Ulcers are not often developed in the fauces during an attack of acute inflammation, except in the specific sore throat of scarlatina ; in chronic inflammation, especially if occurring in scrofulous persons, they are more common. The most profound ulcerations are those of constitutional syphilis, implicating, as they do, not only the tissues of the fauces, but also the parts in front, and destroying both the fleshy covering of the bones and the bones themselves. With regard to treatment and to prognosis, it is of the utmost importance to distin- guish these syphilitic ulcers from those produced by other causes. The coexistence of a cutaneous eruption of a syphilitic character, and * Medical News, March, 1890. 158 MEDICAL DIAGNOSIS. enlarged lymphatic glands, or the history of antecedent syphilis, would lead us to a correct conclusion ; but an acciu'ate history of a syphilitic infection cannot be always obtained. The uteers are not superficial and stationar)% like those resulting from ordinary inflammation, but are deep and have a strong tendency to spread. They are rounded, or of a serf'iginous form, with borders w^ell defined and elevated ; and the inflammation which precedes them is limited to spots, and is not so diifused, nor attended with so much swelling, as the inflammation that exists prior to simple ulceration. The primary lesion is occa- sionally met with, cases of chancre of the tonml being well known to syphilographers. Syphilitic ulcers must be distinguished from tlie deep ulceration with spreading destruction of tissue that occurs in cawxT of ihe foimU? PHARYNX AND (ESOPHAGUS. In describing the affections of the fauces, those of that portion of the pharjnx which is most usually the seat of disease have been at Uie same time described. Indeed, when we speak of acute or chronic pharyngitis, w^e generally mean acute or chrojiic inflammation of the fauces^ to which tlie upper part of the pharynx belongs. Inflamma- tion of the portion of the pharynx wiiich is out of sight when the tongue is depressed is rare. It may be presumed to exist if there be pain and an impediment in swallowing when the food arrives opposite the top of the larynx, while the respiration remains free and the voice unaffected. Abscesses sometknes form betw^een the textures com- posing the pharyiix, and between its posterior Wiill and the cervical vertebne. These rdrophavpigeal absve^sm mostly result from disease of the vertebrae. They occasion great difliculty in deglutition and in breathing ; an altered voice , dull pain and stiffness in the neck : external swelling, which may or may not be cedematous ; and com- monly a tumefaction at tlie back of the throat, which can be seen, or which can be felt with the flnger pressed against the posterior wall of the pharynx. On account of the obstructed respiration and Uie changed voice, the disease is liable to be nustaken for croup. Its dif- ferences have been already enumerated, Retropliaryngeal abscess is often confounded with coryza and tonsillitis, 11 differs chiefly from tuberculosis of the retropharyngeal glands by the presence of tuber- culous lesions of the deep lymphatic glands of the neck.^ It may happen in infancy/"^ ^ See Newman, Amur. Journ, Mi^d, St-i., May, 1892. •SokobfT, Vratch. May, 1891. • See cases of Pollard, Lancet, Feb, 1892. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 459 There is a peculiar form of pharyngeal disease due to the accumu- lation on the mucous membrane of a micro-organism generally sup- posed to be the leptothrix, though Hemenway ^ in his elaborate article pronounces it to be the bacillus fasciculatus. The deposits in this pharyngo-mycosis take place largely in the follicles. Esophagus. — ^The oesophagus is not often the seat of disease. We meet with acute inflammation produced by swallowing boiling water or corrosive poisons, especially nitric or sulphuric acid, or ammonia. The symptoms of acute oesophagitis are usually mixed up with those of inflammation of the pharynx or of the stomach. We may, however, infer its presence if difficulty and pain in deglutition exist for which nothing in the throat accounts, and if these phenomena be asso- ciated with hiccough and with a burning sensation between the shoul- ders, in the course of the tube. (Esophagitis is sometimes encoun- tered in infancy. Of the chronic diseases of the oesophagus, stricture is the most common. The narrowing may take place at any part of the tube, and results from preceding inflammation or ulceration, from cancerous de- generation of the walls, from polypoid growths projecting from the mucous membrane, or from the pressure of a tumor, of an abscess, or of an aneurism ; sometimes it is congenital. The formidable malady manifests itself by an impediment in swallowing; even liquid food cannot pass without great difficulty ; and if the stricture go on in- creasing, the patient perishes miserably by starvation. In addition to the obstruction to the passage of food, we may find a peculiar pain oc- curring at a particular part of the tube, and the patient raises, without cough or vomiting, clots of blood presenting the shape of the stricture. The matter ejected in the attempts at deglutition consists simply of masticated food together with more or less mucus, and, unlike what comes from the stomach, has an alkaline reaction. If long retained, the albuminous materials are macerated ; the starchy materials are in process of fermentation ; fungi are formed hi great quantities, although never sarcinae.* By applying the stethoscope posteriorly, between the shoulders and at the lower part of the neck, while the patient swallows a mouthful of water, a peculiar sound is heard when the water passes through the narrowed portion of the tube. Should there be doubt as to the seat of the obstruction, a bougie will clear up the doubt ; and thus we possess in this instnmient the most valuable diagnostic as well as therapeutic agent. But we must not immediately conclude, because * Journal of Laryngology, Feb. 1892. * Ziemssen, ** Diseases of the (Esophagus/' in Ziemssen's Cyclopaedia. 460 MEDICAL DIAGNOSIS. the bougie meets with resistance, that an organic stricture is present The narrowing may be only spasmodic^ yet give rise to the symptoms of organic constriction. But they are not permanent : at times nour- ishment is readily swallowed, and a full-sized bougie passes with ease. Spasmodic stricture occasionally accompanies ulceration of the larynx: but it is chiefly met with in hypochondriacs and in hysterical women. The latter, indeed, sometimes fancy that they are incapable of s\val- lowing, and reject the food they take without there being even a temporary spasm to prevent its passage. Spasmodic stricture is also observed in hydrophobia and as an attendant on cerebral disease. The distinction of the other causes of stricture is not always an easy matter. In the stenosis arising from syphilis^ we lay great stress on the history. In the strictures due to compression^ we discern the swelling that has occasioned them, and the oesophag^is is apt to be pushed to one side. In strictures the result of cicatrices, we have the gradual development of the affection after an injury or the swallowing of some irritant poison, and the great resistance of* the dense tissues to the sound is very significant. Cancerous narrowing occurs after forty years of age, progresses steadily, and, as Ziemssen has pointed out, is frequently associated with paralysis of the recurrent lar}'ngea] nerves. It may affect the whole middle part of the oesophagus.' Cancer of the oesophagus is most commonly epithelioma. We may get great aid in the study of these organic diseases of the oesophagus from the X-rays. They will also show us readily whether a foreign body is' present, or whether the signs of obstruction are due to the pressure of an aneurism. Rupture of the oesophagus may be met with as the result of pro- tracted vomiting or the introduction of bougies. The accident is apt to occasion great pain. It leads to a rapidly fatal result.' DUaiation of the oesophagus above the seat of a stricture, or with- out a stricture existing, is, on the whole, a rare disease. Its chief symptoms when extensive, are difficulty in swallowing, vomiting, or regurgitation of food, a swelling in the neck coming on after eating and diminishing greatly after vomiting or by pressure, slowly pro- gressing inanition, and at times long spells of delusive improvement The sound may penetrate through the neck of the sac with difficulty, or enter it readily, which largely depends upon whether the sac be empty or full ; once in the sac, the end of the tube can be generally moved about with ease. * Moore, Lancet, London, 1883, i. 13. ^ See for cases, paper by Fitz, Ainer. Joum. Med. Sci., Jan. 1877. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 461 In all the diseases mentioned, the value of the sound as a means of diagnosis has been spoken of. A few more remarks about it may not be amiss. Great care should be always used in passing a sound. The patient's head should be well thrown back, and the instrument passed along the posterior wall of the pharynx with the utmost gentleness. There is a slight resistance as it goes past the cricoid cartilage. When an aneurism or an organic disease of the heart exists, it should not be employed at all. When the sound on reaching a particular spot al- -ways occasions pain, we may infer the existence of inflammation or ulceration at this point, and, in the case of ulceration, some pus or blood is likely to be brought up on the instrument. Should any doubt exist whether the sound has passed into the oesophagus or into the larynx, let the patient be directed to speak ; he can make no noise if the tube be in the larynx. In cases remaining doubtful, a lighted candle may be placed before the end of the tube projecting from the mouth. If the instrument be in the windpipe, the flame will be -wafted to and fro with the currents of air ; if in the oesophagus, this is not observed, except when the tube is in the intrathoracic portion. The diseases of the oesophagus may be studied by means of aiis- cuUation^ listening while the patient swallows food or liquid ; and we owe to Hamburger an elaborate description of the sounds.^ In health, the oesophageal sound is extremely distinct, but of very short dura- tion; the pharyngeal swallowing sound is generally a loud gurgle. In a moderately advanced stage of stricture of the oesophagus, a noise similar to emptying a bottle, " clucking," " gurgling," is perceived ; while in cases of dilatation we are apt to meet wth a sound like that heard when rain driven by the wind impinges on a solid and is de- flected. In cases of very marked stricture or of obstruction by an impacted foreign body, we find that the act of deglutition cannot be detected below a certain point, while it is distinct above. To auscult the oesophagus, the stethoscope should be placed in the vicinity of the hyoid bone, also to the left of the vertebral column from the upper dorsal vertebra downward. This method of exploration has not, however, proved itself of much value. Some cases show that the phonendoscope is of greater service. The disorders of the pharynx and oesophagus have as a common symptom difficulty in swallowing. But we must not forget that other causes may produce dysphagia^ such as paralysis of the muscles of the throat, diseases of the larynx or trachea, particularly ulcerative dis- eases, and aneurismal tumors within the chest. ' Jahrbticher der k. k. Gessellschaft der Aerzte in Wien, Bd. xviii. 29 CHAPTER VL DISEASES OF THE ABDOMEN. The abdominal cavity contains viscera of very varied functions: some form, others break down organic constituents; while others, again, excrete Uie broken-do\Mi material. They SUI, however, labor in one cause ; they all work towards preserving a normal state of the blood, either by preparing fit matter for it or by removing such sub- stances as would be hurtful If they were retained. Any serious derangement of any of these viscera, especially any serious chronic derangement of those which are not simply reservoirs^ must there- fore lead to a deterioration of the blood and to a defective nourish- ment of the body. But these symptoms fnmisli but little information as to the particular oiigan at fault. This we learn to some extent by examining, where it can be done, the secretions or excretions; to some extent by noticing the peculiar appearances of the skin which are produced by alteration of the blood ; and by the exploration of the organs tlirougli Uie parieles of the abdomen. It is, m truth, by means of the pliysical method of investigation that we often obtain the most valuable information, not only as to the seat but even as to the nature of tlie morbid action ; and, although physical exploration of the abdomen does not yield as perfect results as when applied to Uie affections of the tliorax, it still supplies us with an amount of knowl- edge most valuable, and with which it would be difficult to dispense. Let us pass in review the different metliods of physical diagnosis witli reference to abdominal disorders. Methods and General Resulte of Physical Examination of the Abdonaen. INSPECTIOX, By inspection we learn the size, shape, form, and movements of the abdomen. To inspect the abdomen satisfactorily, the patient should be placed in an easy attitude, preferably either standing or sitting. Whenever practicable^ ocular inspection must be made not only from the front, but also from the sides and from the back. In 462 DISEASES OF THE ABDOMEN. 463 appreciating the results thus obtained, it is necessary to bear in mind that the appearance of the abdominal walls is modified by certain physiological conditions. The abdomen is much larger, in comparison to the size of the chest, in childhood than in adult age. It is more voluminous in women, especially such as have given birth to children. It increases in size with advancing years, particularly when a tendency to obesity exists. Its shape is somewhat altered by the pernicious habit of wearing tight stays. Its upper portion is distended after a copious meal. In disease we may observe either partial or general abdominal enlargement. The latter is caused by accumulations of air in the in- testinal canal ; by liquid in the peritoneum ; by an oedematous or obese condition of. the abdominal walls ; or by large tumors which fill up the whole cavity. A partial enlargement is mainly produced by an increase in size of particular organs, or by swelling of the mesen- teric glands, or by tumor, — solid or hernial ; and it is sometimes due to diseases above the diaphragm. A pleuritic or a pericardial eflfu- sion, or emphysema of the lungs, may give rise to a marked fulness below the margin of the ribs. The condition known as enteropfosis^ or splanchTwptosis^ in which there is undue freedom of movement of the abdominal viscera, may reveal itself to inspection by the flaccidity and thinness of the abdominal parietes and their protrusion in the upright posture. Sometimes, also, the outlines of the viscera may be distinguishable. A retraction of the abdominal parietes is perceived in general emaci- ation, and is very obvious in that dependent upon a narrowing of the cardiac or the pyloric orifice of the stomach, or upon chronic diarrhoea or dysentery. It is also noticed in lead colic and in cephalic diseases, especially in tubercular meningitis. There are further changes in the appearance of certain external parts which tend to elucidate the state of the parts within. Distention of the superficial veins indicates that an obstruction to the flow of blood exists in the large veins of the abdomen, either in the portal system or in the vena cava. The lessening of the depression at the umbilicus, unless it be produced by pressure limited to the spot where the umbilicus lies, is a sign of general abdominal enlargement. WTiile inspecting the abdomen, we may see distinct movemetiis. The act of breathing gives rise to motion which is very slight when a tumor or any other impediment interferes with the free action of the diaphragm, and which is much exaggerated by diseases within the thoracic cavity. The rolling of the intestines is sometimes visible on the exterior ; so are at times those shiftings of accumulations of gas 464 MEDICAL DIAGNOSIS. which give rise to a series of jerking elevations ; so, too, are occa- sionally the spasmodic contractions and relaxations of the abdominal muscles. But none of these is as frequently encountered as a pulsa- tion in the epigastric region. The inspection of internal oiigans, such as the stomach, will be considered in connection with those oi^gans. PALPATION. We judge by the application of the hand of the size, position, and consistence of the viscera which are felt through the abdominal walls. We determine whether the parts are firmly attached or movable; whether they are smootli or nodulated; whether they possess a motion of their own ; whether they are tender ; and by tapping with the fingers of one hand, while those of the other are applied to another portion of the surface, we discover, by the peculiar feeling of fluctuation, the presence of fluid in the abdominal cavity. We satisfy ourselves further, by the sense of touch, of the existence and outlines of abdominal tumors, and of the state of the parietes, whether resistant or elastic, cedematous or not ; and we may detect a friction fremitus. In order to use palpation wdth most effect, the abdominal muscles must be relaxed ; and to do this the patient should be placed on his back, and the thighs be flexed on the body. Occasionally it is essen- tial to vary this position ; to turn him from side to side, or to examine him when erect. The amount of pressure, too, should not always be the same. When we wish to examine deep parts, the pressure is increased. The character and the intensity of the pain tliat pressure calls forth often throw considerable light on the disease we are in- vestigating. Thus, if it take deep pressure to produce pain, we are usually right in concluding that the mischief is not superficially seated. The pain of inflammation of the serous membrane is commonly much augmented by pressure, and is of a severe, cutting character. Pain due to inflammation of the mucous membrane of the intestinal tract is duller. All neuralgic or nervous pain, such as that of colic, is, as a rule, relieved rather than increased by pressure, and may be thus distinguished from inflammatory' tenderness. One or both hands may be used in the practice of palpation, and sometimes shock-like manipulations will reveal conditions not otherwise discoverable. • Palpation is used as a means of diagnosis by the introduction of the hand into the rectum. But the method is both disagreeable and not free from danger. Dilatation of the sphincter should be gradual, five minutes at least being allowed for its accomplishment. And, with all precautions, the information obtained may be indecisive. Strictures in the rectum or in the sigmoid flexure of the colon may be readily DISEASES OF THE ABDOMEN. 465 discerned, but a stricture at the lower part of the descending colon may exist, though the hand be unable to discover it. We might with palpation consider the results obtained by the use 'of bougies and of tubes, such as the stomach-tube. But these will be more appropriately considered when discussing the diseases of indi\idual organs. PERCUSSION. Percussion is, in the study of abdominal affections, only less valu- able than palpation. By it we can circumscribe the different organs with accuracy ; we can juc^e of the position of the stomach and intestines ; we can limit the distended bladder, and fix the borders of the liver and spleen. By its aid, further, we can tell whether a dis- tention of the abdomen is produced by air, or by a solid tumor, or by liquid. But, without entering here into particulars as to its use in individual disorders, we shall examine the results when applied to the healthy abdomen. To render percussion a trustworthy interpreter of the state of the abdominal viscera, the patient should be placed in the same position as for palpation. The sounds are best elicited by mediate percussion, and where great accuracy is desirable, we may advantageously make use of auscultatory percussion or the phonendoscope. But for correct deduction we must be acquainted with the relations of the parts which the abdominal walls conceal from view, and take into account that during the digestive process the contents and position of these organs niay vary sufficiently to modify the percussion sound. To begin with the airless viscera. The liver is one of the easiest organs to limit. We determine its upper boundary by striking with moderate force in a line from somewhat above the right nipple towards the lower part of the thorax, until marked resistance and dulness tell us that a solid organ has been reached. At tliis point we make a mark ; then we percuss downward from near the median line, and above the dulness just obtained ; then from the axilla downward ; then posteriorly from beneath the lower angle of the scapula ; and so on, untU the line traced reaches the vertebral column. The dulness thus elicited marks the upper boundary of the liver ; at least of the portion more directly in contact with the abdominal walls. Anteriorly it extends from the lower extremity of the sternum to between the fifth and sixth ribs ; at the side, the dulness is gener- ally in the seventh intercostal space ; near the vertebral column, it is on a level with the tenth or the eleventh, more rarely with the ninth, interspace. The dulness of the left lobe reaches nearly two inches across the median line ; but the heart lies here so near to the liver that 466 MEDICAL r>L\GNOSI8. we cannol with accuracy distinguish \\\e flat sound of Uie one from the flat sound of the other. After the upper border has been (iiirly traced out auteriorly, later- ally, and, if thought necessar)% posteriorly, we determine Ihe hiferior margin of the organ. This is readily effected by percussing down- ward from the already ascertained line of dulness, and noting where the large intestine sends forth its distinct tyjupanitic sound. To determine the lower border correctly, the plexioieter must be pressed firmly on the integuments, and the stroke of tlie finger be sh'ght ; for if it be strong, we obtain the sound of the surrounding hollow \iscera through the thin layer of liver wliich covers them, and before we have arrived at its margin. This mode of procedure is dilYerent from llie one pursued to determine the heiglit to which tlie liver lises, because the position of the parts is different. Superiorly, the lung descends between the surface and that portion of the convex surface of the liver which tils into the diaphragm,, and it requires strong percussion to bring out the dulness of the deep-seated soMd organ. By forcible per- cussion we delect a decided loss of the pulmonar}' resonance at about the fourth intercostal space. The inferior border of the liver, anteriorly, is generally found to lie immediately at, or to project below, the last rib ; posteriorly, we can- not determine ttiis border positively, for it becomes continuous with the dulness occasioned by the right kidney. The lower niaip'n of the left lobe is commonly met with at the upper Uiird of a line drawn from the ensiform cartilage to tlie umbilicus. A distended gall-bladder nuiy cause a strictly outlined dulness below the siirroundi^ng Uver. The percussion dulness of the liver is everywhere lowered by a full inspi- ration. The i^pieen is not so easily circumscribed as tlie liver. Indeed, if the stomach or the intestines be distended, it is difficult to detect the dull sound of the spleen. To find its limits, we must place the patient on his right side, with his legs flexed ; or let him stand erect, and then begin to strike with some force in a line from the axilla to the crest of the ilium. At the nintli, or sometimes at the tenth, rib, tfie sound becomes dull, and there is much gi*eater resistance to tlie fiiiger. Here is the upper boundary of t!ie spleen. We mark the spot, and continue to percuss in the same line until, at about the twelflli rib, we arrive al the lower boundary of the oi^an, as indicated by the distinct tympa- nitic sound of the intestines. After the vertical diameter has been thus ascert^uned, tlie horizon- tal is readily determined by percussing from the median line to a point between the lines which trace the superior and inferior maiigins^ and DISEASES? OF THE ABDOMEN. 467 I by noticing where the sound of Uw stomach gives way to the dull sound of the soUd viscus. When these three points have been de- cided upon, we have learned enou*.dv for i)racltral purposes. We may ilieji, if we choose, jjercoss posteriorlY ; hut we cannot circumscribe e spleen with any accuracy belund, because its dulness becomes continuous with thai of the lell kidney. The average size of tlie spleen is four inches in length and tliree in width ; but it may in a diseased slate increase to twice or three times that size. When the viscus eludes detection by percussion, we may inter it to be small ; provided the stomach and intestines he no! mucli distended with gns. The kltlnetf« cannot be limited with anythioj^ like accuracy, except at their inferior and outer borders, where ttie dull sound they occasion is surrounded by the intestinal resonance. This dulness extends some- what lower during a full inspiration. In seltiuf^ hniils to ttie ^formtrh and itiiiMiius, by means of [ktcus- sion, we tiave to judge more between sounds of dilTereiit dep^ee, but similar to one another, than between sounds of different character. Nor are the tones elicited always Ihe same over tlie same spot ; they vary as the contents of the fioltow viscera vary. W'e can make use of this circumstance for purposes of diagnosis. In percussion of the stomach and of tlie intestines we may often with great advantage resort to auscultatory percussion. The stomach, when not unusually distended witli gas or with food, Tenders a sound which is hollow, ringing, and tympanitic to a certain degree, yet which is not tympanitic as that of the intestine is, I'o determine the boundaries of ihe stomiijch, it is necessary to mark out first Uie lower mai^n of the liver, for it covers a poriion of the stomach ; then the heart and the inner border of the spleen, Tlie part which lies between these solid viscera yields the sound of Uie stomach, mixed at one point, namely, to the letl of the apex of the heart, with the resonance of the lung. NeM' this spot, about opposite to the seventh rib, and on the left of the body of the tenth dorsal vertebra, the cardiac extremity of the stomach is situated ; below it is the bulk of the organ ; tlie pylorus is on the body of the first lumbar vertebra, four to six centimebY'S to the right of the median Ime, on a level with the tip of the xiphoid cartilage, between the right edge of the sternum and a vertical line passing througli the nipple. Fully three-fourths of the stomaeh is to the left of the median line. The cardiac end is immoval>le; llie pylorus, seated from six to eight centi- elres low^er than tlie cardiac, has a moderate mobility ; in infants it is nearer the median line than in adults. 468 MEDICAL DIAGNOSIS. To ascertain the lower border of the stomach, we percuss gently ill a downward direction, until the alteration in sound shows that we are striking over the colon. The difference is at times very obvious, at times very slight. It is readily detected if the stomach contain either solid or liquid ingesta. Availing ourselves of this fact, we may with advantage let the patient swallow a glass of water. By placing him in the erect position, the fluid gravitates to the greater curvature. Fig. 53. Results of aMomlnal percussion, as sot forth in the text. The dark shades indicmte marked dulness: the light shading exhibits a lessening of the clear or of the tympanitic character of the si>und,— an appn^ch to duhioss. and the lino of comparative dulness indicates the lower margin of the stomach, which is generally found one to two inches above the umbili- cus. In men the lower border of the stomach is a little higher than in women ; in worknijr-womon it is higher than in otlier women ; in childri^n under tifleen yoiu^ of ;ige it ven* rarely extends to the um- bilicus : in persons of tilly it is not unusual for it to do sb. In strong, healthy people the whole position of the stomach is more horizontal DISEASES OF THE ABDOMEN. 469 than in weak ones.* Deep percussion is used to limit the superior line, and light percussion the inferior line, of the stomach. Another method to determine the limits of the organ, as well as whether the pylorus is still capable of self-closure in the direction of the duodenum, or is permanently patent, has been proposed by Epstein. It consists in the distention of the stomach by means of carbonic acid, generated by first letting the patient swallow fii)out a teaspoonful of sodium bicarbonate dissolved in a glass of water and then an equal amount of a like solution of tartaric acid. The same end may be attained by direct insufflation by means of inject- ing air into the stomach through a tube. The stomach becomes very much distended, and emits a deep tympanitic note on percussion, unlike that over the intestines ; but if the pylorus be incapable of closure, the' intestines too become swollen, and their tympanitic note is changed. The colon yields, in all its parts, a sound of a purer tympanitic char- acter than the stomach, the note of which is, indeed, in many respects more amphoric than tympanitic. When the tube contains faeces, the sound is modified ; and as these are prone to accumulate on the left side in the descending colon, and especially where this passes into the iliac fossa, it is usually hot so resonant as the ascending colon. The 9nudl intestines^ unless they are filled with fluid or solids, or distended with gas, render a sound of higher pitch and of smaller volume than the surrounding large intestine, and by the less deep-toned sound their position may be accurately determined. Artificial distention of the colon, by generating carbonic acid in it by means the same as just mentioned passed into the lower bowel, has been advocated for diag- nostic purposes by Ziemssen.* It enables us to distinguish with ease the outline of the large intestine, and shows whether there is commu- nication with adjacent organs, such as the stomach, the bladder, or the small intestine. Anomalies of position and form of the bowel give rise to differences in the results of abdominal percussion, as has been well shown in a careful clinical study by Curschmann.^ The position of the viscera in the pelvis cannot be ascertained by means of percussion. It is only when the bladder is much distended, or the uterus augmented in size, that the outline of either can be traced on the walls of the abdomen. • * Obrastzow, Deulsches Arch. f. kiln. Med., Bd. xliii., 1888. * Deutsches Archiv fUr klinische Medicin, Bd. xxxiii., June, 1883. Mbid., Bd. liii., June, 1894. 470 MEDICAL DIAGNOSIS. AUSCULTATION. Auscultation is serviceable in aiding in the detection of an $d)dom- inal aneurism ; and sometimes an enlarged spleen gives rise to a dis- tinct blowing murmur ; or the rubbing of a roughened peritoneum may occasion a friction sound ; but, on the whole, the application of the stethoscope to the abdominal walls is rarely of aid except in de- termining the significance of abdominal pulsation. In health no con- stant sound is heard save that of the aorta ; for the rush of blood through the other arteries, or through the veins, produces no apprecia- ble murmur. When the stomach is distended with air and contains liquid, sounds possessing a metallic character are perceived, wliich an inexperienced observer is apt to consider as originating in the lungs, over which, in truth, they are often audible. Similar sounds, together with succussion-phenomena may be elicited when gas and liquid are present together in the peritoneal cavity, — as a result of perforative peritonitis. The passage of gas through the intestines gives rise to those peculiar noises termed " borborygmi." In cases of stenosis of the bowel a hissing sound is sometimes audible during peristaltic activity. In the pregnant state, auscultation is of value in detecting the pulsations of the foetal heart and the utero-placental murmur. SECTION 1. DISEASES OF THE STOMACH. It is only within the last few years that any attempts have been made to bring to bear on the diseases of the stomach modern means of research. Most of these attempts have had as their aim to ascertain the exact anatomical changes and the modifications in the secretions which give rise to the symptoms commonly referred to perverted func- tion : and they have been successful to a decided degree. The stomach is examined partly by physical exploration by the methods just detailed, and partly by paying attention to the chemical changes which attend the digestive acts. With reference to the physical examination, there are some special nu ans that may be employed with advantage. To determine the rel- ative sensitiveness over the epigastrium. Boas* measures the pressure by an ahjt\^imtta\ The normal tolerance is from eighteen to twenty pounds. In cases of gastric ulcer, pain is complained of at a pressure o\' (to\\\ two to four pounds. The direct application of eiectricitii to tlh^ coats o( the stomach as a test of their motility has been also made * Miiuihoiior Mt^Urinisihe Wo-.'henschrill, Sept, 1898. DISEASES OF THE STOMACH. 471 use of; but, valuable as this agent has proved therapeutically, it has not shown itself valuable diagnostically. Ingenious instruments have been devised for illuminating and in- specting the interior of the stomach. By means of the gastrodiaphane of Einhom,^ which consists of a soft rubber tube through which pass wires connected with a source of electricity and provided with an in- candescent lamp enclosed securely in glass, the size and outlines of the stomach, as well as the density of its wall, can be made out. The patient is, on an empty stomach, first made to swallow, or there are introduced through a tube, one or two pints of water ; the tube is passed into the stomach in the customary manner, and the appearance of the light is observed in a dark room. A reddish luminous zone upon the abdomen indicates the outline and the position of the stomach ; and dark spots may enable us to judge accurately of the ske, shape, and position of tumors. Gastrodiaphany has also been made use of in the diagnosis of oesophageal diverticula, in which, moreover, the swal- lowing sounds are frequently audible.^ The gastroscope of Mikulicz is a more complicated instrument, by means of wliich it is possible to inspect directly limited portions of the interior of the stomach. A revolving sound, the gyrormU^ has been invented by F. B. Turck.' The revolutions can be felt upon the ab- dominal wall, and the various parts of the stomach, especially the greater curvature, accurately located. If the movements of the sound are distinctly felt on the parietes, tumors of the anterior wall and of the fundus can be excluded. It is always important to study the activity of the movements of the stomach, and this is generally done partly by noting how long it will take a trial meal to digest completely, partly by chemical means io be presently detailed. But the object has been also sought to be attained by instrumental aid. With this view, Turck* has introduced a gastric motm'meter^ which consists of a collapsed rubber bag with a fine rubber tube attached that is connected with a manometer ; thus both degree and force of movement are registered. The bag is inflated with air after being passed into the stomach. Another way of deter- mining the mechanical action of the stomach, as well as of recording its movements, is by the gastrograph^ the invention of Einhorn.^ The accurate chemical study of the secretions and of the contents ' New York Medical Journal, Dec. 1892. 'Jung, Amer. Joum. Med. Sci., April, 1900. ' Journal of the American Medical Association, March, 1895. * Proceedings of the American Medical Association, May, 1895. * New York Medical Journal, Sept. 1894. 472 MEDICAL DIAGNOSIS. of the stomach is leading to great advances in the investigation of its affections, as has been proved especially by the labors of Leube, of Ewald, of Boas, and of others. We get the contents of the stomadi for examination from two to four hours after a full or " trial meal." given as a mid-day dinner, and consisting of four hundred grammes of soup, sixty grammes of scraped meat, and fifty grammes of white bread : of this, if the act of digestion have been normally carried on and the chyme have passed on into the small intestine, nothing remains after the lapse of si5c or seven hours but a clear liquid. Ewald has substituted a light breakfast trial meal, a small amount of dry bread or of toast, from thirty-five to seventy grammes, and a third of a litre, about eleven fluidounces, of warm water or weak tea, which, given on an empty stomach, allows the gastric contents to be tested in an hour, a matter often of great convenience. The material for examina- tion is obtained by means of an elastic tube, preferably of soft rubber, about seventy-five centimetres long by six centimetres in diameter, and provided with an opening at its conical extremity and others at the side. The liquid is removed from the stomach by pressure over the epigastrium, or by aspiration by means of a hand ball apparatus. The results of these trial meals should be filtered for accurate exami- nation. When vomiting takes place an examination of the ejecta may yield evidence of tlie digestive and motor activity of the stomach, or of the presence of abnormal elements. The next points to determine are the composition of the gastric juice and its digestive power. We first have to ascertain if the liquid obtained be acid, how great its total acidity, and what its acid nature is owing to. The acid of the gastric juice is hydrochloric. Lactic acid plays no part in the normal digestive process. When tlie latter is present, it is derived from the food, or it may result from the fer- mentative activity of bacteria. Its presence is indicative of stagna- tion of the gastric contents or of hydrochloric acid deficiency. The total acidity one hour after an Ewald test breakfast is normally about ()0. The average amount of free hydrochloric acid is from 20 to 30, or etjual to 0.1 to 0.2 per cent. The best indicator for the total acidity is phenolphthalein. To determine the presence of free acid in the gastric contents, the most delicate reiigent is Congo red, which may be employed in solu- tion or in the fi>rm of paper impregnated therewith. Free acid causes an azun^-blue color ; acid salts have no effect. A solution of methyl- violet may also be employed, wliich is turned into a deep blue ; or tri>prtH>lin, which in a saturated watery solution is a dark yellowish-red liquid that on contact with any free acid becomes dark brown, while DISEASES OF THE STOMACH. 473 with acid salts it assumes a straw-colored tint. To ascertain the pres- ence of hydrochloric acid a good test is Giinzberg's phloroglucin- vanillin solution. It consists of two grammes of phloroglucin and one gramme of vanjUin, with thirty grammes of absolute alcohol. A few drops of this solution, which is of a yellowish-color, added to a similar quantity of a liquid containing hydrochloric acid, when gently heated, turn it at once a bright-red hue ; while the reagent remains unchanged by organic acids, such as lactic or acetic acid. Boas ^ recommends a solution containing resublimated resorcin five grammes, white sugar three grammes, dilute alcohol sufficient to make one hundred grammes. Of this, three or four drops are added to five or six drops of the gastric contents, and the whole is gently heated to dryness ; a bright-red hue results from the presence of free hydrochloric acid. The simplest and quickest test is the dimethyl-am ido-azo-benzol test of Topfer, and it is one coming into general use. Both Hemmeter^ and Stockton^ regard it as the best. A few drops of a 0.5 per cent, alcoholic solution added to the stomach contents develop a cherry-red color if there be free hydrochloric acid. The acidity referable to this is 35 degrees.* To determine the presence of lactic acid, a matter often of very great value for diagnostic purposes, a solution is prepared of ten cubic cen- timetres of a four per cent, solution of carbolic acid, twenty cubic centimetres of water, and one or two drops of a solution of ferric chloride. This has an amethyst-blue color, which in the presence of lactic acid becomes lemon-yellow or canary-yellow. Yet the test is not altogether trustworthy, as sugar, peptone, alco- hol, and other substances also cause a yellowish coloration ; further, it is interfered with by the presence of phosphates and hydrochloric acid in considerable amoimt. To remove these sources of possible fallacy, Strauss * has recommended the following procedure. Into a graduated funnel are introduced five cubic centimetres of gastric juice and twenty cubic centimetres of ether, and the mixture is vigorously shaken. "When the fluids have separated, the lower five cubic centimetres are permitted to escape, and sufficient distilled water is added to make twenty-five cubic centimetres, followed by two drops of a solution made up of one part of ferric chloride and nine parts of distilled w^ater. The mixture is again shaken and the lower watery layer appears of * Diagnoslik u. Therapie der Magenkrankheilen, 3. Aufl., 1. Theil, 1894, p. 149. ' Diseases of the Stomach, 2d edit., 1900. * System of Practical Medicine by American Authors, vol. iii. * Hemmeter, ibid., p. 165. * Berliner klinische Wochenschrifl, 1895, No. 37, cited by Sahli, Lehrb. d. klin. Unlersuch., 1899. 474 MEDICAL DIAGNOSIS. a deep yellowish green when more than one per cent, of lactic acid is present. The presence of volatile fatty acids, butyric acid, acetic acid, etc., ui noteworthy amounts, may be recognized by the characteristic odor. The degree of acidity of the gastric juice is more difficult to deter- mine than the presence of the acids. Ewald recommends, as a ready way, to titrate with a one-tenth normal sodium hydroxide solution, ascertaining the saturation point with litmus paper or with phenol- phthalein. Topfer's test is now much employed for the quantitative analysis of the stomach acids, and enables us to estimate not only the amount of free hydrochloric acid, but also the acidity due to the organic acids and the acid salts, as well as to the hydrochloric acid that exists in combination with the albuminous bodies. In Topfefs method three indicators are used. A few drops of a 0.5 per cent alcoholic solution of dimethyl-amido-azo-benzol added to ten cubic centimetres of filtered gastric juice are titrated with a decinomial solution of caustic soda until the red color due to the free hydro- chloric acid changes to a clear yellow. A few drops of a one per cent, aqueous solution of alizarin added to a second portion of ten cubic centimetres of the gastric juice become, when titrated suffi- ciently \\\\h the solution of caustic soda, clear violet, and the test indicates the amount of free hydrochloric acid, of organic acids, and organic salts. A third portion treated with a one per cent, alcoholic solution of phenolphthalein turns dark red when all the acids, in- cluding the combined hydrochloric acid, have been saturated. From these different data the amount of the entire acidity, as well as of tlie separate acids can be calculated.^ We may test the solvent power of the gastric juice by taking a piece of hard-boiled egg and adding the gastric juice in a test-tube. Heated in a culture oven, the egg albumin, if the gastric juice be nor- mal in pepsin, will be dissolved in about three hours. Propeptone and peptone are determined by the biuret reaction. The presence of the lah-fennenf or rennet-ferment is shown by the coagulation, in -from ten to fifteen niimites, of between five and ten cubic centimetres of fresh, unboiled milk of neutral reaction exposed in an incubator to the action of from three to five drops of gastric juice. In the absence of lab-ferment the i)resence of lab-zymogen is shown by the formation of a dense coagulum within ten or fifteen minutes, when a muture of (Mjual paris of unboiled milk and gastric juice rendered alkaline by limi»-waler is placed in an incubator. After an hour from the time * For examples refer to Hemmeter, loc. cU. DISEASES OF THE STOMACH. 475 Ewald's trial breakfast has been taken there should be no reaction for starch found by Lugol's solution in the filtered liquid of digestion. An excess of hydrochloric acid in the gastric juice quickly checks the digestion of starch begun in the mouth by the saliva, while a deficiency permits its completion. Under the first condition, therefore, the reac- tion for starch will be prolonged ; under the latter shortened. The absorptive activity of the gastric mucous membrane is shown by the rapidity with which iodide appears in the saliva after the inges- tion of one and one-half grains of potassium iodide carefully enclosed in a gelatin capsule. In health the characteristic blue coloration is, as a rule, obtained with starch-paper in the course of ten or fifteen min- utes. This test may be modified so as to indicate the digestive activity of the gastric juice by wrapping the potassium iodide in some im- permeable material fastened with strands of fibrin. Disintegration of the fibrin permits of the escape and absorption of the iodide, and the time of appearance of iodine in the saliva is an index both of digestive and absorptive activity. The motor activity of the stomach is determined by the develop- ment of a violet color on the addition of a drop or two of a neutral solution of ferric chloride to two or three drops of the urine placed upon bibulous paper, after the ingestion of fifteen grains of salol in gelatin capsules at the height of digestion. The violet color shows the presence of salicyluric acid, which is in the majority of persons ob- served in the course of from sixty to seventy-five minutes, and does not persist for more than twenty-six or twenty-seven hours. But there are still many clinicians who prefer the older method of examining the contents of the stomach, after trial meals, with a view to determine the gastric motility. Leube's method consists in removing the con- tents of the organ six or seven hours after a trial dinner, or they may be examined an hour after Ewald's trial breakfast. In either case, the stomach should then contain nothing but the liquid of digestion ; two hours after the trial breakfast it should be empty. If more than forty cubic centimetres are obtained an hour after Ewald's trial breakfast, it shows insufficient motor activity. The symptoms which are constantly met with in derangements of the stomach, whether organic or functional, are loss of appetite, nausea and vomiting, acidity, flatulency, and pain. L1OB8 of Appetite. — ^This manifests itself in various ways. It may amount to absolute repugnance to taking any kind of food, or may be merely an inability to partake of certain articles. What the loss of appetite depends on, we do not know. That nervous influence has something to do with the anorexia, is shown by the sudden dep- 476 MEDICAL DIAGN08IS, rivation of all desire tt) eat wliori any strong improssitm is made on the nurvoiis system, — snch as that caosed by the unexpected receipt of unwelcome news. The collection of epithelium on the mucous membrane is also connerled with a marked diniinulinn of the appe- tite : for ^\ith a long^ue much coated, absolute disgust at the mere thought of taking food of!t?n exists, which yields to relish for food as soon as the tongue begins to clear. Attending lost appetite, we meet sometimes with great emaciation and with signs as if even the small quantity of food taken were not absorbed into, or utterly failed to nourish, the system. There is apt to be sensitiveness over the abdomen, and spots of particular sensitive- ness exist which correspond to the situation of the mesenteric glands. We find, however, no evidence of organic disease, either in the abdo- men or in the lungs : nor does ttiis j>scmh tabm mc^euteriefr. if I may so call it, occiu", like tJie disease it simulates, in scrofulous or tubercu- lar patients. I have met with a number of cases, chiefly in young women with lowered vital force, fond of excitement, and Mying indo- lent lives. Some were hysterical, others not. But in all the complaint seemed to be due to deficient nerve-power, with impaired function of the stomacti, and possibly of the abdominal glands. Ttiis disorder is probably the same as that described by (iull as hysteric apepsia,^ and kindred to the one delineated by Lasegue as hysteric anorexia.* Instead of the appetite being lost, it may be capricious, or even ravenous. There is great craving for food in diabetes. A craving for food is not often combined with a stnicturai lesion of the stomach. Yet we occasionally meet with il in i>ersons affected with gastric ulcer. It is common to find it in those who suffer from neuralgia of the stomach. And sometitnes in cases of mere nenous gastric disturb- ance, with or without pain* there is an extraordinary exaggeration of the appetite, a bulimia : ttie patient eats largely eight or even fifteen times a day, digests his food, yet is constantly hungry. The feeling of thirst does not lessen when the desire for food does. ] On the contrary, it usually increases when tlie latter diminishes, EbLceesive Acidity of the Stomach. — Excessive acidity occurs" firom various causes. The gastric juice may be secreted in gn^at quan- tities, or it may contain an abnormal amount of acid. But excessire acidity is far more frequently due to tlie decomposition of food and to a process of fermentation dependent rather upon an insullicient amount or altered state of the gastric solvent. It then manifests itself only * Trai^sicUons of the Clinical Society, toL tu., 1874. * AirliiTes G«nerales de M^dedae, April, 1S7S. DISEASES OF THE STOMACBL 477 after meals. When the mucous membrane is covered with a tenacious mucus or with thick layers of epithelium, slow digestion and acidity from fermentation result ; because, although the gastric juice is suffi- cient, it cannot mix as readily with the aliment. The acids formed in the stomach are, besides the hydrochloric acid of the gastric juice, lactic acid, acetic acid, carbonic acid, butyric acid, and oxalic acid ; all except the hydrochloric acid are the result of de- composition. Some articles of food produce these different acids in considerable quantities. Thus sugar generates laiige amounts of lactic acid. The mode of detecting these acids, and of establishing whether the extreme acidity is due to excess of hydrochloric acid or to other acids, as tested after a trial meal, has been above explained. In ex- amining for acids, the two acids of greatest value to determine are hydrochloric acid and lactic acid. In determining the acidity of the stomach contents we must first ascertain the whole amount of acidity present in the stomach contents after the trial meal, and then the per- centage of hydrochloric acid. The acids which are created in the stomach may give rise to various disorders. When much acid is present it occasions a sensation of heat which extends along the oesophagus. This " heart-bum" is apt to happen in paroxysms, and is attended with a feeling of constriction or with actual pain at the epigastrium. It simply denotes great acidity, and is common in gouty persons. It probably arises from the action of the acid contents of the organ on the sensitive nerves of the cardia and of the oesophagus, and the acid is mostly owing to fermentative changes. When the acidity is due to increase of hydrochloric acid, from excessive acidity or quantity of the gastric juice, it is the result of a gastric neurosis ; there may be acid vomiting coming on irre- spective of food, and happening in the night or during the early morn- ing hours. What has been called gastroxynsis by Rossbach is a gastric neurosis appearing at intervals mostly after some psychical or mental disturbance, and marked by extremely acid vomiting and headache, like that of migraine. Flatulency. — The gas in the intestinal canal may be merely air which is swallowed ; or it may be generated from imperfectly digested food ; or it may be a secretion from the blood-vessels of the part. In those who suffer from indigestion it is produced in the last two ways, and the patient complains greatly of the annoyance it occasions. It causes a disgust for eating, a feeling of distention, and somethnes actual pain. By interfering with the downward movements of the diaphragm it induces a sensation of constriction in the chest, shortened breathing, palpitation of the heart, and the sleep is broken by uneasy dreams. 80 478 MEDICAL DIAGNOSIS. An expulsion of the gaseous contents of the stomach by the mouth gives rise to eructation^ or belching. The belching wliich follows the decomposition of food has sometimes the taste and the odor of sul- phuretted hydrogen. At other times the eructation is odorless, because the gases formed are carbonic acid, or hydrogen or nitrogen, or some of their comi)ounds. When the gas results from fermentation or de- composition of food, it frequently coexists with acidity occurring only after meals. When it is a secretion from the blood-vessels it happens in an empty state of tlie stomach, and is often relieved by avoiiling too long intervals between the meals. As a cause of flatulence and eructation which it is important ndt to overlook may be mentioned thoracic aneurism.* Marked flatulency is often only a form of gastric neurosis. It is common hi nervous dyspepsia and in hysteria. Nausea and Vomiting. — These are often combined. But some- times there is persistent nausea without vomiting ; sometimes voniit- hig occurs without any or with but slight nausea. Yet they are both occasioned in much Uie same way : what gives rise to one will gt?ner- ally give rise to the other. Vomiting is a complex act. But its causes, alUiough various, niay all be arranged under four heads. It either arises from an irritation of the peripheral extremities of the nen'es which supply the parts more directly concerned m the act itself, such as' the stomach, tlie dia- phragm, and the opsophagus ; or the irritation originates in the centres from which these nenes spring, and is referred to their peripheries; or there is a mechanical obstruction in the stomach or intestines ; or the vomiting is purely sympathetic. Under tlie first' head belongs the vomithig observed in acute or chronic inflammation of the stomach, in iiUer, or in cancer : also that foUowmg a debauch, or tlie introduction of irritating substances into the viscus. Under the second head may be ranged the vomiting which occurs in diseases of the brain ; perhaps, also, that which arises in morbid states of tlie blood, as in uneniia. Under the third head we may class the vomiting in narrowing of the oesophagus and of the pyloric or cardiac extremity of the stomach, in hour-gliiss constriction of the stomach, and in obstructions of the intestine. The fourth gix^up is i*xempUfied by the vomiting hi pn'g- luuuy, in wounds of the extremities, in inflammation of the pt^rito- neum, of the intestines, and of the liver, in renal calculus, and in irritation of the fauces. Connected thus with so many various conditions, the act of vomit- taken by itself, is of little diagiiostie value. It presupposes a Walter F, AUe«, Am^r. Joum. Med. Sci., July. I8d9. DISEASES OF THE STOMACH. 479 certain amount of irritation existing in the stomach, or reflected to it ; but nothing more. As it is allied to morbid states too numerous to be here examined in detail, I shall content myself with making general statements regarding the indications to be drawn from it. When vomiting is observed in a person previously in good health, we may suspect either the invasion of some acute malady, or that some poisonous substance has been sw^allowed. Again, it may come on suddenly from violent mental emotion. When everything that is taken is immediately expelled, the difficulty lies in the oesophagus, or at the cardiac orifice of the stomach, or in an extreme irritability of the viscus ; and this irritability, attended as it often is with unceasing nausea, experience proves to be more frequently due to sympathetic excitement of the organ than to structural gastric disease. But speedy vomiting, generally without preceding nausea, is also among the symp- toms of visceral hysteria. I have known it associated or alternating with extraordinary flatulency. Nervous vomiting occurs where there is no lesion in the stomach or irritation of food as the cause. It is mostly due to reflected irrita- tion of the nerve-centres controlling the act of vomiting, and is often found in disorders of the uterus ; or arises from direct irritation of the nerve-centres in affections of the brain and cord. It is common in hysterical subjects. It is not associated with nausea, and may be of long duration. It is sometimes a primary gastric neurosis, and as such is seen, particularly in neurasthenics, in association with the condition described by Kussmaul as "peristaltic unrest." This is a very annoying symptom, in which there are loud borborygmi and gurgling, especially after eating. The functional vomiting of hysterics presents the curious feature of nothing apparently being retained on the stomach, yet the patient remaining fairly well nourished. There is no nausea with the vomiting. Cases of the kind are sometimes met with where there is no obvious hysteria, but where overwork and anxiety are the cause. As regards the vomiting which is brought about by gastric disor- ders, it is of much consequence to note the period at which it happens, whether. before meals or after meals, and how long afterwards. In some diseases, such as ulcer and cancer, it rarely occurs except when food has been taken. The act of vomiting then affords relief from the pain. In narrowing of the pylorus, it takes place some hours after digestion has begun. But, as vomiting will be described hereafter in its relations to the individual diseases of the stomach, we shall not dwell on what will be more fitly discussed elsewhere. Yet a few words on the characteristics of the ejected matter can hardly be omitted. 480 MEDICAL DIAGNOSIS. The nature and the quantity of the vomit are, of course, most various. The following are its most common kinds : Food or luiuid, mixed with saliva and some mucus, is expelled when the stomach is very irritable, or if an obstruction exist which renders the entrance into the organ difficult or impossible. Half- digested food, in a state of acetous fermentation and veitli a strongly acid reaction, is cast out when there is deficiency of hydrochloric acid, or when the food has been detained for a long time in the stomach. In the ejected matter the particles of food may be rec- ognized ; but when the food has been kept for a prolonged period in the stomach, or when it has passed on into the duodenum and is returned, it is changed into an apparently homc^eneous mass. Examined under the microscope, the structures of the animal or vegetable substances partaken of can even then be detected. Mixc-d with muscular fibre, elastic tissue, starch-corpuscles, and vegetable cells, is found usually a quantity of oil-drops and fat-crystals. Tlie stan*h corpuscles are turned blue by a solution of iodine and iodide of potassium. Sarcimr and yeast fungi are sometimes discovered, by means of the microscope, in the vomit. These organisms are associated Avith the process of fermentation, and are generally ^* ' * attended with copious vomiting. They are small square or slightly oblong bodies, divided into similar smaller portions by cross-lines, and each portion thus formed is again sub- divided; but the markings of the smaller .s^iimM>M»uiouii. squart^s are not so distinct as those of the lai^^r. Tlie illustration shows a mass of sar- cinjv found in the vomit of a patient who suffered fix)m gastric ulcer. Vomit oontiiining sarciiuv is always indicative of structural change in tlio stomacli. It is sometimes found in chronic gastritis of long standing: or in connection with ulcer, and yet oflener \\Hh cancer, and osjHvially in those cases in which the narrowing at the pyloric oxtnMuity has Uni to distention of Uie organ; indeed, any form of dilatation, or a condition preventing the stomach from completely en\pt\ in^: itself, prt^Muinontly ^ves rise to it. SiU\ina vomit has an acivi smell and reaction, and often a peculiar br\^wuisli apjHvuruuvv. After standing, it becomes covered with a dir<>, ftx^thy matter, ake yt\iist. A solution of iodine and iodide of |H>t;issium tunvj^ the s^uxin^' mahc^pany brown or a violet hue; but it » by the lukxvxi^viv that their pivs^?nce can be recognized with (n^ditvt^t cvrtaiutv. The proo^^ss of fonuentation att^idipg the develop- DISEASES OF THE STOMACH. 481 ment of the sarcinse occasions heart-burn and extreme flatulency, and the copious vomiting is a source of relief. Mucus is occasionally ejected in large quantities, both mixed wth food and pure. In chronic gastritis, and in the milder forms of acute gas- tritis, the mucous membrane is covered with a tenacious secretion, and a considerable amount of a glairy or stringy matter is expelled by the act of vomiting. As a general rule, indeed, it may be stated that, when much mucus is evacuated, a catarrhal state of the stomach is present. A thin, watery fluid, looking much like saliva, is discharged in some cases of organic disease of the stomach, as well as in functional derangement of the organ brought on by eating coarse food. Now and then it is met with in pregnancy. This variety of vomiting is known as pyrosis; popularly, as " water-brash." It may be attended with a burning sensation extending to the fauces, and with pain running back to the spine. The fluid is commonly alkaline. Frerichs found that it possessed the power of converting starch into sugar. It is mostly regarded as being formed by the glands at the lower part of the oesophagus, while others hold that it is the saliva which has been swallowed and accumulated in the stomach. Bile may find its way into the stomach, and be expelled by the mouth, imparting to the vomit a greenish or yellowish color and a very bitter taste. The occurrence of bilious vomiting is commonly held to indicate a disease of the liver, or that the patient is extremely ** bilious." It is not a proof of eitlier. It is observed when there is much retching, and when the act of vomiting is protracted and frequently repeated, and is chiefly met with in the various forms of acute gastritis, and on the invasion of some acute malady which gives rise to sympathetic gastric disturbance. Fecal vomiting never depends upon a disease of the stomach. It may be possibly OAving to a fistulous opening between the colon and the stomach ; but such cases are extremely rare. Generally it is due to a mechanical obstruction to the passage of fteces. Occasion- ally it happens in fevers of a low type, or in peritonitis, and is then, perhaps, the result of paralysis of a portion of the intestinal tube, which acts, to some extent, as a mechanical obstruction. The matter that is ejected has the odor of faeces ; but it is of less firm consistence, and of lighter color, because it is the contents rather of the small than of the large intestine. Sometimes it is perfectly fluid. In fecal vomit a considerable number of large comma-like bacilli have been noticed.* Pits in small amount is sometimes found mixed with the vomit in * Von Jaksch, Klinische Diagnostik. 482 MEDICAL DIAGNOSIS. cases of large ulcers in the stomach, simple or cancerous. ^Vhen in (juaiitifies, it is owing to an abscess in the neighborhood of the viscus having poured its contents into it. Still, pus is rarely met with in the matters expelled. And the same can be said of other substances that find their way nito the stomach, like echinococcus sacs and worms, and masses of false membrane. Blood, on the other hand, is not infrequently vomited. Having de- scribed the appearance of the blood when it comes from the stomach, in treating of the diagnosis of hemorrhage from the lungs, I shall, before examining into the circumstances which cause a hsematemesis, merely here recall the fact that it is preceded by nausea and followed by black stools, and that the fluid ejected is generally black, and pre- sents an acid reaction. The quantity of blood lost varies greatly ; but the amount vomited is by no means a proof of the amount effused. The larger portion may pass ofif by the bowels, giving rise to peculiar tarrj stools. Nay, the whole may be voided with the stools. Chocolate-colored material discharged by stool, and due to alkaline fluids acting on the blood after the efifect of acids, is held to be a distinguishing trait between the blood passing by the intestines after a gastric hemorrhage and bleeding from the bowel.^ Ilcinoi-rliage from the stomach is variously caused. It may spring from injurj' to the organ, or from disease of its coat ; it may be vica- rious ; it may be the consequence of disorder elsewhere tlian in the stomach, as of a mechanical obstruction in the portal system ; it may depend upon an altered state of the blood. In the hemorrhage that follows blows or kicks on tlie stomach, an active liyperivniia of the mucous surface is occasioned, which leads to the extravasation of blood. An active arterial hyperaemia also pre- ced(^s the hemorrhage that sometimes follows the swallowing of irri- tixnt poisons. Of organic affections of the stomach only cancer and ulcer are apt to present hemorrhage as a prominent symptom : and of these, agiiin, it 'is much more frequent in the latter than in the former. The blood effused may be so slight in amount as to escajje detection ; and this is especially likely to happen when it is intimately admixed with food or with bile. Yet, by means of the microscope, the existence of blood-corpuscles in the ejected matter can be always demonstrated. The fulness of the vessels may be associated \s\\h degi'neration of their coats, as, for instance, in amyloid d^eneration of the stomach. * Biirlholow, Practice of Medicine. DISEASES OF THE STOMACH. 483 When blood has been detained for some time in the stomach, and has become intimately mingled with the acid contents of the organ, it loses entirely its natural appearance. What is termed " coffee-ground vomit" is blood thoroughly intermixed with other substances. It is the result of a comparatively small or gradual hemorrhage, and as this is the kind apt to happen in gastric cancer, it is common in this aflTec- tion, though by no means limited to it. Vicarious hemorrhage from the stomach is not infrequent, and especially frequent is that which takes the place of the menses. It is not dangerous. The blood escapes at the time of the normal dis- charge, and while the bleeding lasts the stomach is slightly tender, and the digestion impaired. But during the intervals there are no signs of disturbance of the functions of the oi^an, and no pain, both of which are points of importance in distinguishing between loss of blood caused by suppressed menstruation and loss of blood caused by disease of the stomach. Gastric h^hiorrhage, dependent upon a state of passive congestion brought on by an obstruction to the flow of venous blood, is occasion- ally seen in organic afi'ections of the heart. But it is much more common as the result of embarrassment of the portal circulation from tumors or from affections of the liver and spleen. It frequently at- tends, therefore, cirrhosis and enlargement of the spleen, and is often joined to intestinal hemorrhage. In gastric hemorrhage resulting from changes in the blood the ves- sels themselves are toneless, and rupture easily or offer no resistance to their altered contents escaping. This kind of hemorrhage is met with in scurvy, in typhus fever, and in yellow fever. We see tlius that blood is vomited from various causes, and that merely from the occurrence of haematemesis we can determine noth- ing definite as to its origin. Yet the symptom — for a symptom it always is — is of serious import, and when taken in connection with others is of great service in diagnosis. We ought, in chronic cases, first to suspect the hemorrhage to be due to some organic disease of the stomach : when there is no other proof of a structural affection of this organ, we turn to the liver, spleen, or heart for its explanation, or examine, carefully every part of the abdominal cavity, to see whether or not a tumor is the source of the disorder. If occasioned by none of these conditions, its cause lies probably in altered blood, or in sup- pressed discharges. The history of the case is indispensable to any induction. There is, however, one difficulty present in all instances ; and that is, to tell whether the ejected blood has found its way into the stomach 484 MEDICAL DIAGNOSIS. and has been subsequently expelled, or whether the hemorrhage is really gastric. The only method to avoid being mistaken is to scruti- nize closely the liistory and the attending phenomena. Blood may be introduced into the stomach by the bursting of an aneurism, or from an ulcerating pancreas ; or it may have been swallowed during an attack of epistaxis or of haemoptysis, or wilfully, to excite sympatliy or to escape punishment. A strange result of gastric hemorrhage, first noticed by Graefe, is double-sided incurable amaurosis. In some cases atrophy of the optic nerves has been found. The symptoms and lesions have been attributed to occlusion of retinal vessels. To return to the more special symptoms of a deranged stomach. Mcryciwi, or Rumination. — In this condition food that has been swallowed is brought up into the mouth, sometimes by an impulse of the will, but more commonly involuntarily, and remastieated and again swallowed. Rumination is recognized to be purely a neurosis, and may or may not be associated with other gastric disorder. l\t(/ure s;v>tv.ach is full, and worse after a heavy meal than after a l^l.t o»u\ cs-^vv ui!ly v^f a b!aiid siibstanoe like milk, they point to a struc- tural a:Tt\ tu>r.. I: th-. y ^wiur or.Iy when Uie stomach is empty, and ar^^ r\^>;- \c\5 by :V\\i, tV.oy ar^^ iridioative of a functional derangement i\\\i; art^ a: ::::.;> .iv/i--.: to a v -.rv^-.u-: or-raiiic affection : at others they art ,;V:^^- •■' > ^ ^v-.At-Ai >Y::h a ivrtV- t!y soimd state of the visous,and v.v\<: w.:':: a :-:•..:;:;> :.^ :> :r.i\::; :vil:is all over the bodv. or with DISEASES OF THE STOMACH. 485 hysteria or neurasthenia ; or they may appear as the gastric crises of locomotor ataxia ; at others they are brought about by some article of food which the stomach does not tolerate or is unable to digest. The disorder is called gastralgia, or gastrodynia ; it is due to a neuralgia of the stomach. When the predisposition to it exists, exposure to cold and damp, a draught of cold water drunk when heated, sudden and violent emotions, or a collection of wind in the alimentary canal, will bring it on. The predisposition is met with in gouty and rheumatic persons, and in those who are debilitated, — in women who are anaemic, and in men who have been exposed to exhausting influences. Then we also find the gastralgia interchanged with other neuralgic or spas- modic affections, giving way to asthma or to angina pectoris, or, on the other hand, occurring in their place. Clifford AUbutt and others have also pointed out a close connection between gastralgia and aortic regurgitation. The pain varies much in intensity: it is usually severe and agonizing ; but it is not permanent ; intervals of rest and comfort succeed to the paroxysms of distress. During a violent attack, the skin is cold, the pulse slow, there are frequently nausea, vomiting, sometimes fainting, and often sensations of utter prostration. The seat of the pain is in the epigastrium, immediately beneath the ensi- form cartilage, but it radiates both upward and downward, or to the sides. The patient feels as if the coats of the stomach were being violently drawn together, or rent asunder, or rapidly pierced by a sharp instrument. It is sometimes relieved by the recumbent position and by external pressure. But relief depends much on the condition with which the pain is associated. If it be connected with a chronic gastritis or an ulceration, or a cancer, pressure aggravates rather than alleviates it. There is sometimes sensitiveness to the touch in purely nervous gastralgia, and over a considerable part of the stomach ; or slight pressure may augment the pain, but firmly compressing the pit of the stomach will diminish it. It is always important to discriminate between the cases of gas- tralgia that may be viewed as pure neuroses and those in which the paroxysms of pain are combined with a chronic lesion. We infer that we have to deal with instances of the former, when the attacks occur in those whose impoverished blood or enfeebled health predisposes to neiutjgia, and especially if they happen in women laboring under dis- orders of the uterus or of menstruation, and the attacks increase about the menstrual period, or in persons who suffer from neuralgic pains in other parts of the body. But the broadest line of distinction is drawn by the state of the digestive apparatus during the intervals. The dis- 486 MEDICAL DIAGNOSIS. ordered digestion, the pain after eating, the persistent tenderness at the epigastrium, tlie nausea and vomiting, and the other symptoms common in morbid alterations of the coats of the stomach, are not seen in pure gastralgia. A sign generally trustworthy is the alleviation following the taking of food, for which, in truth, there may be a cra\ing ; and occasionally cases of gastralgia are met with in wliih the pain occurs early in the mornings, and is very distressing, but is almost immediately eased by a hearty breakfast. Gastralgia is common where there is an excess of hydrochloric acid in the gastric juice, though Leube states that test meals show, as a rule, but little change. The form of gastralgia which is produced by some article of food that disagrees with the individual is readily dis- tinguished from the other varieties by observing it to be transient and by noting its cause. The indigestible substance imdergoes fermenta- tion in the stomach, and acidity, flatulent distention, and nausea attend the pain, which ceases when the extreme acidity is neutralized by an alkali, or the offending matter is ejected and the gas expelled. The remarks just made apply also, in the main, to other manifesta- tions of perverted innervation of the stomach, such as hyperaesthesia, with or without persistent vomiting, — forms happening usually in weak or hysterical persons, or where menstruation is disordered, — but which in the present state of our knowledge are still conveniently classed with gastralgia as forms of gastric neuroses. The nen'ous filaments, the irritation of which occasions pain in the stomach, whether paroxysmal or not, belong to the vagus ; sometimes, perhaps, the distress originates in the branches of the sympathetic that supply the oigan. But we must be careful not to ascribe the seat of every pain which is felt between the umbilicus and sternum, or re- ferred there, to the stomach. Diseases of tlie pleura, of the heart and its covering, atfections of the intercostal nerves, abscess of the liver, intestinal disorders, rheumatism of the abdominal muscles, may give rise to pain in the epigastric region. Spasmodic pain like that of gas- tralgia may be caused by intercostal neuralgia, by intestinal colic, by disoi^ranization of the tissue of the kidney or of the pancreas, and by the i)assiige-of gall-stones or of renal or pancreatic calculi. The strictly paroxysmal character of the pain, its seat in the region of the heart or shgoting down the left arm, the agitation and distress, the alTtH'ted breathing, the severity of the symptoms, distinguish gasltralgia fn>iu aiu/imt jHctorh, and even pseudo-anginas partake of tlie graver clumu'ter of the disease. In the passage of gall-stones the great severity of the i>;un. the attending nausea and vomiting, the subse- quent jaundice, are most significant. But there are puzzling cases; DISEASES OF THE STOMACH. 487 and what makes the diagnosis more difficult is that in persons affected with gaUstonea gastralgia is not uncommon, and, on the other hand, an attack of biliary colic may seem to be, or is, started by one of indigestion. The localized spots of tenderness, in the course of the affected intercostal nerve, distinguish doubtful cases of intercostal neuralgia from gastralgia. Then, too, a galvanic current removes or greatly lessens the pain of the former. The great safeguard always against error is to bear in mind that painful complaints of the stomach may be mistaken for those enumerated, and to ascertain carefully, in cases of epigastric distress, that there is no cause beyond the stomach to account for it. The nearer, in many instances, the pain is to the median line, or, should it occupy this, the more fixed and confined to a small spot, the greater is the probability of its being dependent upon gastric disease ; and pain of the character alluded to is generally indicative of serious malady. Pain is the last of the symptoms directly referable to the derange- ment of the viscus itself to which we shall advert. But when the stomach is disordered, other organs also suffer, either through sym- pathy, or because the irritation is transmitted to them. The bowels are usually in a sluggish condition ; it is commonly only when the gas- tric acidity is extreme that they are relaxed. The ^iscera within the chest are frequently. disturbed. The patient is annoyed by palpitation and shortness of breath after meals ; and as he feels the agitation of his heart, and finds that always, after he has eaten, his face is flushed, the palms of his hands are hot, and his temporal arteries throbbing, he is apt to fancy himself laboring under a serious cardiac affection. A dry cough, also, is a not unusual concomitant ; but a cough may be the result of coexisting catarrh of the bronchial mucous membrane, or of disease of the lung-structure ; and sometimes the affection of the lungs precedes that of the stomach. Again, we may have an organic disease of the heart leading to the gastric symptoms. So, too, with the kidneys. They may be irritated by the crude material which has made its way into the blood, and which they are called upon to excrete. The urine often contains various abnormal constituents, especially quantities of urates and oxalates. But, on the other hand, a morbid state of the urine may precede the derangement of the stomach, and the indigestion be the secondary rather than the primary ailment. Indeed, we must never be too hasty in concluding, when a disordered stomach is associated with diseases of other viscera, that it is their cause; it may exist as their consequence. Diseases of the liver and intestines are especially prone to induce a gastric affection. 488 MEDICAL DIAGNOSIS. One of the worst results of a disordered digestion is the state of mind it produces. It occasions listlessness and a disposition to look at all events in a gloomy light, and sometimes brings on inveterate hypochondriasis. Aretaeus ascribed to the stomach as its priman power that it acted as the president of pleasure and of disgust, " being, from the sympathy of the soul, an important neighbor to the heart for imparting good or bad spirits." Now, although no one at present would agree with this physiology, who will deny that there is in the remark a germ of truth ? But here, again, we must be careful not to confound cause witti effect ; for want of activity or a distressed state of mind may seriously impair the appetite and subvert the normal action of the viscus. When the nervous symptoms are marked, the disorder is often called rm-vom dy»pepsin. In this, while the gastric symptoms may be light, we may also have the gastric neurosis leading to extreme acidity of the gastric juice, to bad taste in the mouth, increased sali- vation, perverted appetite, to eructations, to flatulency. There may be sensations of distress and uneasiness during the digestive act, and general sensitiveness in the epigastric region, but the gastric motility, contrary to what might be supposed, is not impaired, and the trial meals are digested in their usual time. There is not always increased acidity of the gastric juice. The hydrochloric acid may be normal or diminished in amount. In all forms there are uneasy feelings after meals and great nervousness. Headache, general lassitude, low spirits, at times vertigo and palpitation, are complained of. Nenous dyspepsia is common in neurasthenics and in hysterics. The exact state of the stomach that coexists can be determined only by chemical investigation of the gastric secretion. Leube* maintains that the nervous symptoms are induced, because the nervous system itself is in a very irritable state, and produces morbid digestion. Viewed in this light, nervous dyspepsia is a neurosis, and it is explained how it may become complicated with other gastric neuroses, such as gas- tralgia. But, however produced, its manifestations are evoked by the digestive act. In the sketch just finished of the symptoms encountered in gastric disorders, no attempt has been made to separate strictly tlie signs which belong particularly to alteration of its coats from those which occur in mere derangement of its functions, — ^in other words, I have not tried to dissociate the symptoms of so-called " dyspepsia" from those of actual lesions. And this for two reasons : in the first place, * Diagnose der iniiereii Krankheiten, 1898, vol. i. DISEASES OF THE STOMACH. 489 the most palpable indications of organic disease of the stomach are those of disordered function ; and secondly, there are no symptoms which belong exclusively to functional indigestion. Nor is it possible to present anything like a complete picture of merely furfctional, or, as it is still called by some, atonic dyspepsia ; the combinations are too infinitely varied. The stomach may be the seat of various neurotic disturbances, some of which have already been discussed. Its motor activity may be deranged in the direction of either excess or deficiency, and result- ing, on the one hand, in premature propulsion of the chyme into the intestine, in the development of borborygmi and gurgling or of eructa- tions, in regurgitation or vomiting of food, in rumination or merycism, in spasm of cardia or pylorus ; and, on the other hand, in atony or insufficiency of the cardia or the pylorus. Secretory activity may undergo quantitative or qualitative alteration, Finally, there may result a condition of hypersBsthesia or gastralgia, or abnormalities of appetite. Diseases of the Stomach in which Pain and Soreness at the Epigastrium, and Vomiting, occur. Aflier what has been premised, it is obvious that the structural dis- eases of the stomach present but few symptoms that can be regarded as at all characteristic. Indeed, the only ones which can lay any claim to be so considered — and we have already seen that this claim is not always valid — ^are pain and soreness at the epigastrium, and vomiting. We may, then, take these symptoms as a starting-point in diagnosis, and describe the individual organic afi*ections in which they chiefly occur, speaking first of the acute. Acute Gastritis. — Inflammation of the stomach may be of vary- ing degree and extent. It may involve only the mucous coat, or the other tunics as well. The condition arises most commonly from the ingestion of food improper in quantity or in quality. Aggravated forms of the disorder may result from the introduction into the stom- ach of poisons, such as alcohol, the mineral acids, caustic alkalies, or other corrosive substances. The presence of low forms of vegetable life may be an exciting cause, and sometimes the affection is part of a more general process, as of diphtheria, pneumonia, typhoid fever, smallpox, and rhemnatism or gout. In rare instances the disease is phlegmonous or suppurative. The severity of the symptoms varies with the character and intensity of the morbid changes. There may be merely redness and thickening of the mucous membrane, with in- filtration of the other coats of the stomach ; or there may be desqua- 490 MEDICAL DIAGNOSIS. mation, or the formation of false membrane ; or, finally, suppuration, ne(Tosis, and ulceration. Among the usual symptoms are anorexia, nausea, vomiting, pain in swallowing, epigastric distress and burning, with tenderness on pressure, usually diarrhoea, though there may be constipation. Thirst, headache, and vertigo also are common, and we may find elevation of temperature, generally not. over 102°, with acceleration of pulse, and hiccough, and increased frequency of respi- ration. In severe cases, symptoms of collapse are met with. The milder cases terminate in recovery, or pass into chronic gastric catarrh. The more severe cases may lead to ulceration or to perforation or to rupture of the stomach, to hemorrhage, or to cicatricial narroAving. In phkgftionoxLs gastritis^ of which diffuse inflammation of the stomach w^all with purulent infiltration is the more common form, there is sud- den onset as well as a sense of burning and violent epigastric pain, and vomiting, tenderness, and a feeling of resistance in the epigastric re- gion, and fever. Slight jaundice may also be present, and bilious vomiting ; the vomited matter may contain pus. Peritonitis and signs of collapse are apt to follow.^ The disease is generally priman' and the infection direct, but it may be secondary or metastatic. Tliere are very severe cases of ordinary acute gastritis, involving also the muscular coat, which are undistinguishable except by the absence of peritonitis and the fact that they may recover. I have seen such instances. Membranous gastritis^ a form of gastritis more common in children than in adults, is not to be recognized from any other kind of severe gastritis, unless shreds of membrane and casts are vomited. A mild gastritis is very commonly brought on by a debauch or by the introduction of irritating articles of diet into the stomach. These cases are classed as acute gastric catarrh^ and are popularly kno>vn as severe attacks of indigestion ; that they are owing to an inflam- matory state of the mucous membrane w^as proved by the ocular demonstration Beaumont had of the process in the person of Alexis St. Martin. There is some tenderness at the epigastrium; nausea; vomiting ; constipation, or sometimes diarrhoea ; a coated tongue, and h(^adache. Another common and kindred kind of mild inflammation of the stomach or acute gastric catarrh is that usually called a " bilious at- tiuk." The French designate it expressively as embarras goMriqut, It is a catarrhal aflection, and may be associated with catarrh of other ^ Seo an excellent analysis of the recorded cases by Leith, in the Edinburgh Hospital Reports, vol. iv., 1896. DISEASES OF THE STOMACH. 491 mucous membranes. It may come on from indigestible food, or after cold and exposure ; it sometimes occurs in epidemics. The symptoms are those already detailed. There is nausea, and frequently bile is vomited. We do not usually observe much pain in the epigastrium ; but rather a feeling of uneasiness, and a slight soreness to the touch. The urine is dark and deposits urates ; the tongue is much coated ; there is thirst, with generally a moderate or slight fever, which exacer- bates at night, and is of remittent type, and there may be a yellowish tinge of the conjunctivae. In children acute gastric catarrh may be- come complicated with convulsions, or with symptoms simulating those of meningitis. A form of gastritis is described which occurs in very young chil- dren and leads to softening of the mucous lining of the stomach, a gadromalacia. This softening is most likely a post-mori:em change due to the action of the gastric juice, and especially met with in the subjects of acute gastric catarrh. Kundrat has called attention to the occurrence of gastric softening with vomiting of blood in the brain affections of children, especially in tubercular meningitis. Chronic Diseases oMended with Pain^ Epigastric Tenderness^ and Vomiting, The chronic diseases of the stomach, like the acute, may be con- sidered in accordance with the pain, the soreness at the epigastrium, and the vomiting that attend them. At all events, they are the symptoms common to the chronic diseases which are susceptible of accurate diagnosis. In these chronic diseases vomiting is found to be a symptom of greater diagnostic value than in the acute, — not the act itself, but the appearances of the ejected matter. Further, the phenomena of dyspepsia stand fori;h much more conspicuously. Chronic Gktstritis. — In chronic inflammation of the mucous membrane, or chronic gastric catarrh^ the symptoms of indigestion are persistent and manifold. They vary somewhat according to the extent of the mucous surface involved and the amount of mucus and epithelium which accumulates on it, and also according to the healthy or wasted state of the gastric glands. Generally there is a sensation of discomfort, of weight, and of soreness at the pit of the stomach, ag- gravated by food ; the part is also tender to the touch. Sometimes, even when the stomach is empty, a burning at the epigastrium and an inward fever are complained of. The appetite is impaired or capricious. Fermentation, heart-burn, and flatulency frequently attend the slow digestion of the food ; the tongue is usually heavily coated ; it may, however, be clean. The bowels are constipated. The urine contains 492 MEDICAIi DIAGNOSIS. an excess of urates or of phosphates, or exhibits crystals of oxalate of lime. The patient's circulation is languid; he suffers from chilliness; his spirits are depressed. Not infrequently he is annoyed by thirst, and vomits, after meals, the half-digested food mixed with strings rf mucus. But the vomiting may also take place when the stomach is empty, and the ejected matter is then fluid and colorless. Drunkards who suffer from chronic gastritis often throw up a quantity of glairy fluid on rising in the morning. A colorless vomit, joined to sym|>- toms of long-continued indigestion, is very characteristic of chronic gastritis. The gastric contents removed after a trial meal show a diminution in the amount of hydrochloric acid present, usually in the total acidity also, and in the activity of the digestive ferments ; still, hydrochloric acid is generally present. Absorption from the stomach is retarded, although gastric motility is little if at all impaired. The festing stomach may be empty or contain mucus. Chronic gastric catarrh may involve the mucous membrane or also the other coats of the stomach. The mucosa may be thickened or it may be thinned ; it may be the seat of erosions. The glandular structure may undergo varying degrees of atrophy. All of the coats of the stomach may eventually become sclerotic. When atrophy of the gastric tubules has taken place there is complete absence of hydrochloric acid and of the digestive ferments. Thus, then, the results of chemical examination of the removed gastric contents, the character of the vomit occasionally, more fre- quently the coated tongue, the distress after eating, the soreness at the epigastrium, and the persistency of the symptoms, distinguish the dyspepsia of chronic inflammation of the stomach from that which is purely functional. The causes of the malady are at times obscure. It certainly can- not be traced often to an antecedent acute attack, although those who suffer from the chronic disorder are particularly prone to acute ex- acerbations. It is more common in persons over than in those under forty years of age. It is especially common in gourmands and drunk- ards, and in those who live on coarse food or who eat irregularly. It is often found conjoined with chronic bronchitis, with anaemia, with Bright's disease, with tubercular disease of the lungs, with gout, and with diabetes. Passive congestion undoubtedly acts as a predisposing element, and thus originates the chronic gastric catarrh met with in affections of the heart and of the liver. Chronic gastritis is frequently associated with ulcers in the organ or with cancer, and many of the symptoms of these disorders are DISEASES OF THE STOMACH. 493 clearly attributable to it. Let us inquire whether there are any special symptoms to inform us that something more dangerous than chronic inflammation of the mucous membrane of the stomach exists. Gktstric Ulcer. — Ulcer of the stomach is a disease comparatively rare in this country ; but it is not so in some parts of the Continent of Europe and in England. It seems to be more common in northern than in southern climates. The affection is essentially dependent upon disturbance of the normal relation between the gastric secretion and the circulating blood, in that the one is unduly active and the other is deteriorated in quality. It is more common in females than in males, and between twenty and forty years of age than at any other period. It is generally associated with anaemia, or follows chronic gastric catarrh, or embolic plugging of small arterial twigs, or other disturb- ances of the circulation in the gastric mucous membrane. Amyloid degeneration of the finer vessels, too, occasions these perforating ulcers. The acid gastric juice acts readily and destructively on the weakened tissues. Rarely, gastric ulceration is due to tuberculosis and to syphilis. The ulcer or ulcers, for there are sometimes several present, are seated usually on the posterior wall of the stomach, in or near the lesser curvature and towards the pyloric extremity. The great danger arises from perforation of the coats and subsequent peritonitis. But the ulceration may prove fatal by opening a large blood-vessel. Again, the formation of a gastro-colic or a gastro-pulmonary fistula may lead to death; or the protracted suffering and excessive vomiting may gradually exhaust the vital energies. On the other hand, the ulcers may heal by cicatrization ; and this, William Brinton tefls us, takes place in about half the instances. They may thus form tumor-like masses, or when situated at the pylorus, they may cause obstruction to the passage of the chyme into the duodenum. Perforation, Welch states, happens in about six and a half per cent, of all cases. Recur- rence of the gastric ulcer is not uncommon. In cases which may be regarded as typical, the malady is announced by symptoms exactly like those witnessed in chronic gastritis, — the same uneasiness and pain at the epigastrium, and occasional nausea and vomiting of food, or of a watery fluid. Perforation may at this early stage of the disease most unexpectedly cut short the patient's life. Should perforation not take place, hemorrhage from the stomach, with emaciation and anaemia, next appears. In this way the disease usually continues for months or years, the symptoms remitting from time to time, and showing singular variations in their 31 494 MEDICAL DIAGNOSIS. severity. Welch * states the average duration of gastric ulcer to be from three to five years. The majority of the cases recover. Of the symptoms, pain and vomiting are the most characteristic. Paul is rarely absent ; never, perhaps, except in cases which run i rapid course. It is generally a continuous dull feeling ; sometimes a burning, at other times a gnawing sensation. As a rule, it is rendered more acute within a quarter of an hour after eating, and remains so as long as food occupies the stomach. Its situation is commonly in the middle of the epigastric region, and there it continues strictly limited. At this point, too, there is localized soreness, or even great tender- ness to the touch. Sometimes the pain is seated behind the ensifonn cartilage, or is referred to the right or to the left hypochondrium. It is often associated with a gnawing pain in the low^er dorsal vertebra, which may shoot between the scapulae or down the spine ; but the dorsal pain, like the epigastric, is, on the whole, very fixed, radiates but little, and is most severe when the ulcer is on the posterior sur- face. Besides tliis continued feeling of distress, there occur violent paroxysms of pain, which may last for several hours ; nay, with trifling intermissions, for days. They sometimes come on suddenly w^hen the viscus is empty, but are aggravated by pressure or by food; and, in fact, they are often thus induced. The patient refers the suf- fering chiefly to the pit of the stomach, or to the dorsal vertebra?. He is apt to seek the recumbent posture for its relief. Yet it is remarka- ble that there are at times long intervals during which all pain, whether paroxysmal or not, ceases, and during which food can be taken with- out ijiconvenience. The acidity of the urine is diminished ; the reac- tion may even be alkaline ; the chlorides are diminished or absent. The peculiarities the pain exhibits form, on the whole, the most distinctive symptom of gastric ulceration. The paroxysms just spoken of may be mistaken for a purely nervous gastralgia. Indeed, when it is considered that both disorders are specially apt to occur in anemic women, and in those whose menstrual functions are deranged, it becomes apparent how easily this mistake may be committed. The soreness at the epigastrium ; the persistent symptoms of indigestion ; the excess of hydrochloric acid in the gastric juice ; the increase of pain after meals, — constitute, in a diagnostic point of view, the safe guard agahist error. To these might be added the vomiting of blood, were it not that vicarious hemorrhages are not at all unlikely to take place in young women who are troubled with amenorrhoea. Tliis is, in truth, a matter having a close connection with the diagnosis of * Pepper's System of Practical Medicine, article ** Simple Ulcer of My^ Stomach.' DISEASES OF THE STOMACH. 495 gastric ulceration. Persons who suflfer from disturbance of the men- strual function are prone to be hysterical ; and it may happen that one of the most marked traits of the hysterical disorder is that it manifests itself by tenderness in the epigastric region, and by pain in the stomach. We thus may have the most significant signs of gastric ulcer, occur- ring, as so many cases of amenorrhoea do, in chlorotic young women ; therefore happening in the class among whom ulceration of the stomach is most frequent. Nay, the very history may point to the probability of gastric ulcer.^ Yet, generally, by close attention to all the phe- nomena of the case, we can arrive at a correct conclusion. The ten- derness, as in all local hysterical affections, is great on the slightest touch ; and there is no severe pain posteriorly corresponding to the spot of soreness in the epigastric region. Pressure upon a spinous process may cause pain, but it is not the peculiar dorsal pain of gastric ulceration. Then, in the hysterical complaint there is often hyperaes- thesia of the skin in various portions of the body, and the apparent gastric distress bears no relation to the taking of food, or to the circum- stance of its being of an irritating character or otherwise. The epi- gastric surface temperature is elevated in gastric ulcer, and may even exceed the temperature in the axilla.^ But to return to the vomiting of blood. When this is not trace- able to a suppression of a natural discharge, and when it does not befall a person who suffers from disease of the heart, or liver, or spleen, or oesophagus, it acquires great significance. It is the only kind of vomit at all distinctive of a gastric ulcer ; for the substances ejected present otherwise appearances not different from what they do in chronic gastritis. The blood may be pure and red, but it is more frequently blackened by the gastric juice; and large quantities are sometimes passed by stool. -Now, hemorrhage does not take place in chronic inflammation of the mucous membrane of the stomach, except perhaps in drunkards, or where there is coexisting disease of the liver or spleen. In those instances in which erosions exist on the surface, the vomited mucus may be a little streaked with blood ; yet anything like a profuse hemorrhage never happens. Hence its occurrence in a case with the symptoms of chronic gastritis, cancer being excluded, renders the presence of an ulcer probable. Yet there is a source of fallacy, as I know by having met with such an instance, due to removal of the ovaries in an hysterical woman with marked gastric symptoms, ^ Case under my care, Philadelphia Hospital ; Medical and Surgical Reporter, Feb. 1863. ' Hayem, Revue des Sciences M^dicales, Oct. 15, 1888. 496 MEDICAL DIAGNOSIS. in whose case subsequent hsematemesis repeatedly occurred. It must also be borne in mind that we may have gastric ulceration wilhoul haematemesis, and that in pure hysteria blood may be vomited. The vomiting of the matters taken into the stomach may be imme- diate, or not for some time after the food has been swallowed. Usually it happens speedily, and in some instances so speedily that there seems to be rather regurgitation than vomiting. But this is rare, and in the rarity is a safeguard against confounding gastric ulcer with the vomit- ing of cerebral disease, especially tumor, which I have known to happen in a young woman in whom, moreover, vomiting of blood had occurred. In the regui^tation, then, in the frequently absent nausea, in the clean tongue, — though coating may also be absent in ulcer,— in the want of oppression and weight at the epigastrium, and in the headache, altered vision, and other nervous phenomena, we have the distinguishing traits between gastric and cerebral vomiting on which to lay stress in the diagnosis between disease of the brain and gastric ulcer, or indeed any other serious stomach affection. The attacks of gastric pain that occur in the gastric crises of locomotor ataxia may be misleading. But the absence of knee-jerks and the eye-phenomena explain their mecuiing. Constipation is present in the laige majority of cases of gastric ulcer. Pallor also is a common manifestation. The number of red blood-corpuscles usually undergoes moderate diminu- tion, while the percentage of haBmoglobin suffers a somewhat greater reduction. Perforating gastric ulcer may lead to localized abscess in different situations near the stomach, and this abscess may burst into the peri- toneum, or be discharged externally, recovery ensuing. In some in- stances the abscess forms beneath the diaphragm, and may be mis- taken for pneumothorax. Indeed, this pyopneumothorojc subphrenicui may show physical signs like those of pneumothorax. But it does not extend to the summit of the chest, and there is but little displacement of the heart. Moreover, the history points to long-existing gastric derangement. Pain in the front of the chest or in the abdomen, as the cases of Penrose and Dickinson * prove, is an early symptom, and is soon followed by the physical signs of pneumothorax or of pneu- monia. In concluding this sketch of gastric ulceration, two questions arise which require solution: Does an ulcer always produce the peculiar train of symptoms mentioned ? May not the same phenomena be met with in other disorders ? The first question must be answered.in ^ Clinical Society's Transactions, vol. xxvi., 1893. DISEASES OF THE STOMACH. 497 the negative. Ulceration of the stomach may occasion nothing but the symptoms of chronic gastritis ; and even these may not be marked. The second question is to be answered in the affirmative. There is a disorder with symptoms almost identical with those of gastric ulcer, the corrosive uker of the duodenum. Now, this affection, were it more frequent, would be a constant source of error. It may run an acute, or at least an apparently acute, or a chronic course. In either case it is scarcely distinguishable from gastric ulceration. Trier, from an analysis of twenty-six cases, mentions, among the most important grounds for a differential diagnosis, a sensitive tumor in the epigas- trium, proceeding from adhesion with the pancreas, and jaundice or other hepatic phenomena. But these symptoms are far from constant ; and in acute cases, and in those chronic cases which run a latent course, the diagnosis is impossible. It may be added that the perforating ulcer of the duodenum is much more apt than ulcer of the stomach to remain latent and to lead rapidly to a fatal termination. The most certain signs of duodenal ulcer are the sudden and apparently causeless occur- rence of intestinal hemorrhage, which may recur and be associated with haBmatemesis ; violent attacks of pain referred to the right hypo- chondrium or the epigastrium ; pain in the right hypochondriac region happening two or three hours after meals ; dyspeptic symptoms, gen- erally of moderate degree, and diarrhoea. Duodenal ulcer is thought by some to be almost invariably due to the action of a highly acid gastric juice, and to furnish the best illustration of the so-called " peptic ulcer." It sometimes follows burns of the cutaneous surface. It is most common between thirty and forty years of age, and, as Krauss proves, is ten times more common in men than in women. Where perforation occurs from duodenal ulcer the symptoms are the same as in perforation from gastric ulcer : sudden, agonizing pain, epigastric first, then becoming diffused ; symptoms of collapse, sub- normal temperature, rapid breathing, and vomiting, which soon ceases in the case of perforating gastric ulcer, but continues in duodenal ulcer. There is yet another affection with symptoms like those of ulcer, an affection stUl more serious and destructive, — cancer. Gkustric Cancer. — Cancer is found more frequently in the stomach than in any other organ except the uterus. Of nine thousand one hundred and eighteen cases of cancer which occurred in Paris from 1837 to 1840, two thousand three hundred and three were in the stomach.* Among thirty thousand cases analyzed by Welch the stom- * Walshe on Cancer. 498 MEDICAL DIAGNOSIS, aeh was involved in 21 A per vt^nt The disease is gronemlly priman^ It is most ollen seated at the pylorus ; next in frequency stands the Jesser cun'atore ; then the cardiac orifice and tlie i>osterior wall; most rarely does it involve the whole viseus. We find all the varieties of cancer ailecting the stomach : medullary, adenomatous, scirrhons, colloid, squamous. There may be nodular tumors of varying consist- ency or more or less ditTiise infiltration of the coats of the stomach. Breaking down of the ^^rowth may result in ttie formation of ulcers ; and perforation may take place. Occasionally carcinoma develops in the site of a previoos ulcer. As found by an analysis of two Uiousand and tliirty-eight cases of gastric cancer, three-fourths occur between forty and seventy yeai"s of ageJ Males suffer more commonly than females, and whites far more than blacks. The symptoms of cancer of the stomach are the same as those of chronic gastritis, — pain, tenderness in the epigastrium, fUsordered di- gestion, vomiting. In a more advanced shite of the cancerous malady there may be those of gastric ulcer, hemorrhage being added to the list above given. There is only one symptom disliiictive of cancer, — namely, the existence of a tumor. But let us see if there be anything in the paui and vomiting, or in the circumstances of tlie case, by wliich, even when a tumor cannot be discovered, the presence of a cancer may be suspected. Pain is a very constant symptom ; quite as constant as in gastric ulcer. But the pain is, as a rule, more continuous, much less influenced by the taking of food, and more radiating, being often referred to the right or tlie left hypochondrium. Its cliaracter is very varying. It may be dull, or gnawing, or it may be lancinating. It may be slight, or it may amount to excrocialing agony. But it is a mistake to suppose thai a cancer of the stomach necessarily causes severe or lancinating pain. Again, it should be borne in mind Uiat the part diseased may ulcerate, and then the pain is exactly like that of an ordinary gastric ulcer, and is atfectetl in the same way by food. The most marked seat of tlie pain is sometimes under the shoulder-blade. Vomiting is not an invariable result of cancer ; yet it is a frequent one. The seat of the morbid growth determines, to a great extent, the occurrence of vomiting and tlie period at whicti it will happen. When the body of the stomach is attacked, and the orifices are not obstructed, it may not take place at all ; or, if it take place, it is within a brief time after meats. \Vlien the disease has narrowed the car- diac extremity, vomiting supervenes almost immediately; the food ^ Welch, Pepper's System of Practical Medicine. DISEASES OF THE STOMACH, 499 has hardly been swallowed before it is brought up again. But when, as is much mom comiiion, the pylorus is constricted, the food is not tlirown off UTitil it aUenipIs to (lass ihrougli into tlie intestine ; there- fore not until a considerable time alter meals. With respect to the cliaraeter of the substances ejected, this too depends on the seat of liie cancer, and the lime at which the vomiting occurs. If it ensue several hours after meals, the cast-off matter con- sists of food partly digested* partly in a slate of liiglily acetous fer- mentation. An enormous quantity of acid material, the accunmlalion of several meals, is sometimes brought up during one act of emesis. The ejected matter may be intermingled with blood, and have a black- ish or reddish-brown, '* coiree-ground"" appearance ; or the mucus which is thrown up may l)e tin^'ed with black flakes : in either case we find reduced haanatin. Rarely is any considerable amount of un- mixed blood vomited. Free liydrochloric acid is oflen absent from the vomited contents of the stomach or from the "trial meal/* especially in cancer of the pylorus. But we must not forget that it is also absent in amyloid degeneration, in simple gastric achylia and in atrophy of the gastric tubules, in many fevers, and occasionally in clu*onic gasfTitis. The persistent presence of free hydrochloric acid renders the existence of carcinoma ver}- improbable. It is at times a very difticult diagnosis between cancer of the stomach in winch no tumor can be found and avhylm gaMrica, This absence of secretion of the gastric juice show^s persistent loss of hydro- chloric acid and of ferments, and is found as a primar}^ secretory debility, especially in neurasthenics. But a graver form is associated with atrophy of the gastric tubules, and it is in this affection that, irrespective of the chemical signs, the marked dyspeptic symptoms, the progressive debility and ancemia, and the severe gastralgia make us think of cancer. Vomiting, however, is not a prominent symptom, and, unlike cancer, diarrha^a is. In many cases of carcinoma of the stomach, lactic acid is to be found in the gastric contents after the administration of a special trial meal, free from lactic acid and lactates, and consisting of oatmeal gruel (a tablespoonful of oatmeal to a quart of water) with a little salt/ This phenomenon is rare under other conditions, and though not pathog- nomonic of gastric cancer, when existing with dyspeptic symptoms and absence of tiydroehlorie acid, it is almost conclusive. Microscopic examination may disclose the presence in tlie cancerous particles * Boas, Miinciietier Medieinische Wocbeiiachriit, 1893, No, 43, ]>, S05. 500 MEDICAL DIAGNOBia found in the gastric contents or the washwaler of large numbers of cells showing mitosis, and of characteristic! *' concentrically arranged conglomeraUons of cells;''* also of unusually long, non-motile bacilli,' These bacilli liave the power of formin^^ lactic acid freely. They are not palhognomonic of cancer, since (hey have been met with also in simple hypertrojihic stenosis of the pylorus, but they are very im- portant and signiticant. The Oppler bacillus existed in nineteen out of twenty cases of gastric cancer examined by Kaufmann. In gastric carcinoma, fnrther, the motihty of the stomach is generally much impaired, the ferments are defective or absent, A close study of ttie pain and vomiling may furnish evidence by wliich the existence of a gastric cancer may he strongly suspeelcd. There are a few other circumstances which would strengthen this suspicion : such as the sour eructations, the extreme llalulrncy. Hie persistent fetid breath, obstinate constipation, anorexia with progressive loss of flesh, and the cachetic appearance of the patient, who is pale and iii*ed-looking, or whose face is of a color which seems to \mxe arisen from a combination of the hue of chlorosis and thai of jaundice. Tlie supposed characteristic straw color of cancer is not otlen met with. The temperature is generally below the norm ; but there are exceptional cases in which a moderate amount of irritative fever accompanies the gradual wasting^ QCdema of the ankles is a frequent symptom of the advancing disease. In some instances coma happens similar to diabetic coma, or tetany, as Kussmaul pointed out. There is a form in wliicli rapid enlargement of the liver, some fever, and erythematous eruptions occur.^ The blood presents scarcely distinc- tive changes. The number of red corpuscles is usually diminished, and Ihe percentage of htemoglobin in yet greater degree. The number of white corpuscles may be somewhat increased, with an absence of digeslion-leucocytosis. Acetone and peptone have been found in the urine. Now, should all these symptoms be met with in a person who is steadily becoming feebler, whose age is above forty, in whose family cancer is hereditary ; should cancerous tumors develop themselves in any other part of the body,— the suspicion entertained would be con- verted into a certainly. But it is not often that a case presenting a combination of all ihe symptoms enumerated is met with. I repeat, ilie most distinctive sign is a tumor: when iliis is not detected, uncertainty hangs over any diagnosis of gastric cancer. * Ewald, Klinik der yerdauuiigsirankheilen, 8, Ayfl,, 2. Btand, p. 342. * Oppler, D^ytsw^^he Mediciiiische Wochenschrift, 18£>6, No. 6. ■ Hanoi, Archives Gene rales dc Medeciue, Sept, 1892. DISEASES OF THE STOMACH. 501 To contrast, then, cancer of the stomach with chronic gastritis and gastric ulcer : Chbonig Oastbitis. Oaotrio Ulcer. Pain at the epigastrium some- what augmented by food ; also soreness. Both constant, al- though comparatively slight. Tongue usually heavily coated ; may be clean. Acid eructations. Symptoms of marked. Pain at the epigastrium much augmented by food ; subsides when this is digested ; parox- ysms of pain, a strictly local- ized soreness to the touch in the epigastric region, some- times a painful spot over the lower dorsal vertebrae. Inter- missions in the pain of consid- erable length are frequent. Tongue dry, red, streaked in middle ; or smooth and moist or slightly coated. Eructations occur, are not acid, indigestion Symptoms of indigestion some- times very slight. Sometimes vomiting ; especially morning vomiting in alcoholic cases. No hemorrhage, or but trifling hemorrhage ; at most, blood- streaks in vomited matter. Bowels constipated. No fever. Not much emaciation; no ca- chectic appearance. Not confined to any age. More common in middle-aged or elderly people. Common in alcoholics. Disease may be relieved or cured; is often of very long duration. No tumor. Contents of stomach contain generally free hydrochloric acid. No dropsy. Vomiting usually immediately or soon after taking food; often an early symptom. Abtmdant hemorrhage from the stomach common. Bowels may or may not be con- stipated ; usually are. No fever. Frequently extreme pallor and debility. May occur in middle-aged per- sons; but is most frequently seen in young adults, espe- cially in young women. Duration uncertain; may get well, may run on rapidly to perforation; on the other hand, may last for years. No tumor. Hydrochloric acid in excess in contents of stomach. No dropsy. Gastric Cancer. Pain frequently of a radiating kind, often (laroxysmal, not unusually severe and lanci- nating, but not of necessity as- sociated with soreness; little or not at all affected by food. Pain rarely remits ; never in- termits for any considerable time. Tongue pale and thickly coated. Fetid eructations. Symptoms of indigestion marked. Anorexia ; ex- tremely sour stomach. Vomiting a very frequent symp- tom ; occurs sometimes on an empty stomach ; usually pre- ceded by other symptoms. Hemorrhage not very abundant, but occasioning frequently coffee-ground looking vomit. Bowels obstinately constipated. Intercurrent attacks of slight fever may occur; but tem- perature often subnormal. Progressive loss of flesh, and cachexia; at times hypertro- phy of the peripheral lym- phatic glands, especially above the clavicles. Most common in elderly people ; rarely occurs in persons under forty years of age. Average duration one year ; may be shorter; is seldom longer; very rarely reaches two years. Generally a tumor. As a rule, no hydrochloric acid in contents of stomach ; often lactic acid present. (Edema of ankles often met with. The differences laid down in the table are derived from an analysis of well-marked cases. In the eariy stages of the cancerous malady, a dififerential diagnosis is impossible. Subsequently, as already stated, the detection of a tumor plays an important part in any deduction. But this remark does not apply to cases of cancer of the cardiac orifice, which are rare, and in which a tumor, from its deep situation, almost always eludes discovery. Such cases are, however, discrimi- 502 MEDICAL DIAGNOSIS. natod by their presenting the same signs as a stricture of the oesoph- agus low down ; indeed, they are very constantly combined with a narrowing of the tube, produced by the cancer spreading to it. Cancer at other parts of the organ occasions a perceptible tumor in about three-fourths of all the instances : its situation is, of course, not alwaj-s the same. Where no tumor can be discerned, and particularly if, as may happen, portions of the stomach remain healthy and the diges- tive disturbances are slight, the existence of cancer may not reveal itself by any symptoms, and the case run a latent course.^ In most cases without tumor we shall be rarely wrong in making the diag- nosis of gastric cancer, if there be persistent stomach symptoms in a person of middle or of above middle age, whose digestion has been previously excellent, who has epigastric pain, is losing flesh and strength, is not improved by treatment, and shows an absence of hydrochloric acid in the trial meal. A cancer of the anterior wall produces, as a rule, fulness, resist- ance, and percussion dulness in the epigastric region. A cancer in- volving the greater curvature gives rise to a swelling near the umbili- cus, or to one extending towards either hypochondrium. The tumor formed by cancer of the pylorus is commonly felt plainly a little to the right of the median line, and one to two inches below the carti- lages of the ribs. In women its position is apt to be even lower than this ; and, indeed, in both sexes the situation of the indurated pylorus is very variable. It may be pushed down to near the umbilicus ; nay, it has been discerned near the anterior superior spinous process of the ilium.^ It is rarely found in the left hypochondrium, but not infre- quently in the right. Then it may form adhesions to the liver, wliich viscus at times so completely covers the tumor as to render this impos- sible of detection. The reason why the swelling, in not a few instances, shows itself much lower than the normal seat of the pylorus is obvious. During meal after meal the organ seeks to overcome the resistance offered by the narrowed pyloric orifice, and does so with great and increasing difficulty. The constantly repeated and long-continued struggle leads to hypertrophy of the muscular coat and to distention of the hollow viscus. The tumor may or may not be movable, — generally is not; its surface may be either smooth or nodulated. It may be large and dis- tinct, or small and requiring a careful examination to distinguish it * See report of case under my care at the Pennsylvania Hospital, published in Amer. Journ. Med. Sci., vol. lii., 1866. * See Lebert's cases in Traite pratique des Maladies cancereuses. DISEASES OF THE STOMACH. 503 from the surrounding and more yielding textures. Percussing over it elicits a dull sound, usually mixed with a tympanitic note. The tumor is much more perceptible on some days than it is on others. But is a swelling in the region of the stomach strictly pathogno- monic of gastric cancer ? No ; not even when the swelling has been ascertained to belong to that viscus. At times the cicatrix marking a previous ulcer, or even the indurated and thickened margins of an existing ulcer, may be palpable through the abdominal walls and raise the question of a new growth. A mere fibroid thickening of the pylorus will occasion a tumor, and, moreover, produce symptoms which resemble so closely those of malignant disease at the orifice that I much doubt the possibility of distinguishing during life, with any certainty, between the two affections. Let us take this case, which I saw with Dr. Moss,^ as an example. A woman, aged forty, complained of pain at the pit of the stomach, and of a heavy sensation throughout the abdomen. For some months she had been suffering from indigestion, and had been losing flesh. She had a slight cough, with impaired resonance at the apices. The bowels were obstinately constipated, the tongue was smootli and red, the pulse feeble. She vomited shortly after meals, yet never any- thing but the ingesta. There was no pain on pressure over the pylo- rus ; but a greater resistance to the finger than usual was detected. The further progress of the complaint was marked by incessant vom- iting, only, however, after meals. Once, and once only, did it cease for several days ; and then without apparent causie. As the case drew towards its fatal termination, the patient was much troubled with acid eructations, and had occasionally slight febrile attacks. The distress in the epigastrium increased. About three weeks before her death she w^as seized with lancinating pains under both patellae ; they were ac- companied by pricking sensations and numbness in the legs, and an inability to walk. The pains gradually ceased, but the numbness and loss of motion increased. She died, utterly exhausted by the ab- dominal pains and the incessant vomiting, about three months after she began to reject her food. On post-mortem examination, tuber- cular deposits were found at the apices of the lungs. The abdominal viscera were healthy, except the stomach ; and this, too, was healthy, save at its pyloric orifice, which was so narrowed that the tip of the little finger could hardly be forced into it. The mucous lining lay in folds, but on dissection was found to be perfectly normal. At the pylorus, but only there, the submucous and the muscular coat were uni- * Published in full in the Proceedings of the Pathological Society of Philadel- phia, vol. i. 504 MEDICAL DIAGNOSIS. formly thickened. Examified microscopically, they contained nothing but fibroid tissue, spindle-shaped fibre-cells, and very distinct oiiganic muscular fibres. Now, here is a case which was not cancer ; yet it had the symp- toms of cancer. It is true that the absence of blood and of glairy mucous in the matter vomited, and the indistinctness of the swelling, in spite of the great emaciation, were against the supposition of cancer of the pylorus. Still, no inference based on these data alone could be strictly trusted. The disease was combined with tubercular deposits in the lung. Nor is this the only example of the combination which has come under my notice. And when a tubercular state of the lung has been fairly made out, and there exist at the same time signs of pyloric obstruction, I should make a diagnosis that this is not of a can- cerous nature, but consists simply of an increased development of the submucous coat, with probably subsequent h)T)ertrophy of the muscu- lar tunic. The fibroid thickening may extend throughout the whole stomach, and there may be also hyperplasia of the muscular coat. Such cases dififer from cancer by their long duration ; the absence of hemorrhage, of the peculiar vomit of cancer, and of severe pain ; and by the more uniform gastric swelling. The affection is sometimes observed in spirit-drinkers ; it may be met with in children. Its discrimination from cancer is never a certainty. In a case reported by Cornell,^ which was complicated with tuberculous peritonitis, loss of digestive power was indicated by unbroken starch grains in the vomit The absorptive activity of the stomach tested by iodine was normal. Boas^ states that in these non-malignant cases with pyloric stenosis, though there are fermentative processes, lactic acid is absent. There are other diseases than those of the stomach which may occasion a tumor in its region and are thus liable to be mistaken for gastric cancer. Prominent among these are enlai^gement of the liver projecting into the epigastrium, tumors of the omentum, and diseases of the pancreas and of the kidney. Of course, the stomach symptoms proper are not so marked in these afifections, and in some they may be wholly wanting ; examination of the gastric contents and of the urine, and due regard to the history of the case, will show us the truth about many ; and, after all, the best way of preventing ourselves from falling into error is to seek in any case of supposed gastric cancer for these other diseases, and to see if their chief symptoms are present. * Montreal Medical Journal, Aug. 1892. ^ Munchener Medicinische Wochenschrift, Oct. 1893. DISEASES OF THE STOMACH. 505 Resting with this general statement, I shall not take up the differ- ential diagnosis of all the many affections mentioned ; especially as some are referred to when treating of partial abdominal enlargements and of cancer of the liver. But there are two which may be here specially looked at : one is omental cancer, the other kidney affection attended with marked swelling, such as occurs in hydronephrosis, pyonephrosis^ abscess, hydatids, and morbid growths. In omental cancer there is far less dyspepsia, hemorrhage and coffee-ground vomit are absent, the tumor appears to occupy chiefly the site of the greater curvature, the swelling is, or soon becomes, more generally diffuse, and hydrochloric acid and the digestive fer- ments are present in the gastric contents. In the kidney affections referred to, the history is of great impor- tance, and we include in this history the passage of renal calculi as bearing on some forms of kidney enlargement, especially abscess from impaction of stones ; the limits of the mass, though this may project into the epigastrium, will scarcely be those of a gastric cancer. But the most certain safeguard against error is careful and repeated exam- ination of the. urine and of the gastric contents. As regards the urine, the observations of Rommelaere ^ seem to show that its analysis may be of value in the diagnosis of the different forms of gastric disease. Thus, a cancerous ulceration of the stomach is attended with decrease of urea, and the chlorides are diminished. In simple gastric ulcer these are in normal quantity or in excess ; so is the urea. In spreading gastric ulcer the chlorides are decreased, but there is a normal or increased amount of urea and urates. In a certain number of cases, variously estimated between two and nine per cent., ulcer of the stomach exists first, and then cancer super- venes. This may take the form of a tumor, or the cancerous disease invade the ulcer, and no tumor occur. Such cases are mostly chronic, and present the history of preceding ulcer. The gastric juice generally retains its hyperacidity. There are often signs of a gastric neurosis ; then loss of weight and cachexia are noticed, and want of response to treatment; all unlike pure gastric ulceration. A further significant sign is coffee-ground vomit. But the most conclusive would be fur- nished by the microscopic examination of particles of the morbid structiu'e in washings of the stomach. Dilatation of the Stomach. — ^This happens frequently in con- nection with obstruction of the pylorus, whether cancerous or fibroid, ^ Journal de Medecine de Bruxelles, 1883 ; quoted in the Lancet, Sept. 1 and Oct. 27, 1883. 506 MEDICAL DIAGNOSIS. but it is also met with independently of this structural lesion. The latter form occurs from weakening of the muscular coats produced by malnutrition or impaired innervation, and has been noticed as an attendant upon anaemia or hysteria, or following fevers, or obstruction of the upper part of the bow^el, or compression of the pylorus by an enormous gall-stone/ or, as Bamberger mentions, dislocation of the stomach by omental hernias. Edinger has proved that it may be asso- ciated with amyloid degeneration of the vessels or of the muscular coat of the stomach. The chief signs of a dilated stomach in either forna are the rejection of food mostly in large quantities and retained for days ; fermented and vomited matter containing often torulae and sarcinaB ; extension of the tympaiytic note of the gastric region, de- tected by percussion, to much below the umbilicus ; a splasliing sound when the patient moves, particularly after drinking, and gxuTgling on sudden pressure ; the low line of dulness occasioned by fluids in the distended organ, and the change of the dulness with the position of the patient ; and slowly progressing emaciation. The character of the gastric secretion and that of the contents of the stomach after a trial meal vary with the nature of the causative condition. As a rule, there are increased acidity from the acids of decomposition and diminished absorptive and motor activity. The general nutrition suffers as assim- ilation is more and more interfered with. In doubtful cases the oiigan may be examined and its limits traced by distending it with ordinary air, or with carbon dioxide. Displacement of the right kidney has been observed in a number of cases. The sounds of the heart heard over the dilated stomach often have a metallic ring, but, irrespective of this, peculiar gurgling sounds, sys- tolic in rhythm, and evoked by the action of the heart, have been met with by Franck and other observers. Dilatation of the stomach may occasion serious nervous symptoms. I have known convulsions to occur, and tetany has been noticed.^ The dilatation occasionally hap- pens in an acute manner, and occurs in children ' as well as in adults. As a rule, the muscular coat is not hypertrophied, but, in the cases in which an obstruction at the pylorus exists, this is frequent at first ultimately giving place to atrophy. To tell the atonic cases from those due to narrowing at the pylorus is generally not difficult ; we can detect a hard swelling, or find the resistance with a stomach sound. In cancerous obstruction the gastric juice, as a rule, contains no hydrocloric acid, but we obtain lactic * Minkowski, quoted by Ewald. ^ Bulletins et Menioires des H6pitaux de Paris, t. xx., 1884. ^ Archives Generales de Medecine, Aug. 1884. DISEASES OF THE STOMACH. 507 acid. In other forms of stomach dilatation, particularly in the atonic form/ we find hydrochloric acid, as well as the acids of decomposi- tion and fermentation, acetic acid, and butyric acid. The stomach may be unduly large without giving rise to any symptoms. This condition of megalogastria is to be distinguished from gastric dilatation by the absence of the symptoms of the latter, as well as of derangement of secretion, absorption, and propulsion. Enlargement of the stomach is to be distinguished from displace- ment of the origan, — gastroptosis or GUnard'a disease. The condition is chiefly due to compression of the waist by the corset, or to relaxation of the ligamentous attachments of the stomach, produced hy general debility and emaciation, or to weakness of the abdominal walls, such as follows pregnancies. Gastroptosis is often associated with a similar displacement of other abdominal viscera, — splanchnoptosis or enterop- to»is. There are present, in addition to symptoms of digestive derange- ment and the obvious evidences of the dislocation of the viscera, which are best obtained by inflating the stomach with air or with car- bon dioxide, manifestations of functional nervous disturbance. Among the first are impaired or perverted appetite, epigastric fulness and dis- tention, eructation, acid taste and dryness of the mouth, burning or colicky pains at the pit of the stomach some hours after eating, dimin- ished hydrochloric acid, pain in the back, and constipation alternating with seeming diarrhoea. The nervous symptoms include a feeling of weakness, general irritability, mental depression, headache or a sense of fulness in the head, vertigo, heaviness of the lower extremities, coldness of hands and feet, palpitation of the heart, heavy sleep, and frequently sacral pains. Emaciation takes place, with impoverishment of the blood, acne, and other changes in the skin, and falling out of the hair. In gastroptosis the lesser curvature of the stomach becomes evident after inflation, the pylorus is lowered, the organ is in a more vertical position. A certain number of cases are associated with dilatation of the stomach. Gastroptosis is infinitely more common in women than in men, — ninety per cent, as compared with five, says Meinert,^ — the smallest estimate places it at fifty per cent. Dilatation of the stomach may be confounded with dilatation of th^ large InteMine. But the gastric symptoms of the former malady are of great significance. Moreover, we may make use of the salol test in the discrimination. Salol is not acted upon by the acid gastric * Germain See, Bulletin de TAcademie de Medecine, May, 1888. « Centralblalt fUr innere Medicin, 1886, Nos. 12 and 13. 508 MEDICAL DIAGNOSIS. juice, but is changed into salicylic acid by the alkaline intestinal secre- tion. The salicylic acid manifests itself in the urine of healthy per- sons in from half an hour to an hour, as shown by the addition of a drop of tincture of chloride of iron into the urine giving it a violet color. In dilatation of the stomach salicylic acid does not appear for two or three hours after salol has been taken. Hour-Glass Stomach.^ — During digestion a constriction occurs near the middle of the stomach, almost entirely separating the cardiac from the pyloric half. This state may be a permanent one, and the hmir-glass stomach produce decided symptoms. The hour-glass con- striction may also be congenital, due to the contraction from a cancer or cicatrizing ulcer, or torsion from peritoneal adhesions. It is very rare under the age of twenty, and is vastly more common in women than in men. The history is frequently that of gastric ulceration with intense gastric pain and obstinate vomiting, often of food that has been for some time in the stomach; the more fluid parts of the ingesta are retained ; there are apparent dysphagia, succussion splash in the lower part of the stomach remaining even after lavage, and a peculiar gurgling sound, described by Betz as bruU de glouglou} In- sufflation of the stomach, the gastrodiaphane, and the X-rays have also aided in the diagnosis, which is now assuming considerable interest, as hour-glass stomachs have been recognized and successfully oper- ated on.^ SECTION II. DISEASES OF THE INTESTINES AND OF THE PERITONEUM. In considering the diseases of the intestines, we meet with symp- toms the import of which we have examined in connection with affec- tions of the stomach. We encounter nausea, vomiting, and impaired digestion. These may be sympathetic, dependent upon coexisting gastric disorder, or be the result of intestinal indigestion. In this the signs of indigestion are cliiefly seen by the non-digestion and acid fer- mentation of starchy matter, and the incomplete action on fatty sub- stances. Symptoms wliich in the study of intestinal affections we lay much stress on are pain and the character of the fecal discharges. ^ This has been investigated in an admirable paper on the shape and position of tlie stomach, by Bettmann, Philadelphia Monthly Medical Journal, March, 1899. ' Ciise of Jaworski. Wiener Medizinische Presse, No. 61, 1897. * See reference to cases in Beltinann's paper quoted, and in Perrel TEstomac biUx'ulaire, These de Paris, 1896. DISEASES OF THE INTESTINES AND PERITONEUM. 509 As regards the former, we draw the truest inferences from its kind rather than from its mere occmrence. Alvine Discharges. — ^The faeces consist of about one-fourth solids and three-fourths water. Dry^ hard stools depend upon an absorption of the fluid contents, as in constipation. Watery stools are observed whenever a large quantity of the serum of the blood finds its way through the intestinal coats. They are met wth after the administration of saline purgatives, in serous diarrhcea, and in cholera. Their hue varies : they may be almost colorless, or tinged with yellow. Sometimes, although very thin and watery, they are decidedly yellow; again they are rendered turbid by the dis- semination of whitish flocculi, or cast-off epithelium, or by mucus. Whether they be yellow or colorless depends on the existence or non- existence in them of fecal matter and of bile. In a prognostic point of view, the most colorless evacuations are the most dangerous. The presence of an excessive quantity of mucus renders the dis- charges less consistent than natural. The appearance they present is similar to that of the white of an egg ; or the whitish masses of mucus surround the lumps of faeces, or are intermingled with the fluid alvine discharges. Pus in large amount and unmixed with faeces is discharged only when an abscess has ruptured into some part of the intestine. Stools composed of faeces and pus are encountered in chronic inflammation and in ulceration of the bowels ; and whitish, creamy streaks indicate the presence of the foreign substance. Yet the pus may be so inti- mately blended with the faeces, or with masses of mucus, as to require the microscope for its detection. An excess of hik in the alvine discharges gives rise to evacuations of a yellowish brown or yellow hue. When the alimentary tube is highly acid, the resulting color is green. Both these kinds of stools are commonly called '* bilious ;" but the latter is less absolutely so than the former. A deficiency of bile manifests itself by clayey, sometimes even by almost white stools. Bile-pigment is not found in healthy stools. The stools may contain also concretions of biliary, pancreatic, or intes- tinal origin. Sometimes portions of neoplastic growths are appreciable to the naked eye. A curious and unusual form of concretion passing from the bowel is the so-called " intestinal sand." It resembles de- posits of uric acid or urates, but does not respond to the tests for uric acid, as I have had occasion to note. It is supposed to be a substance intermediate between the ordinary bile-pigments and stercobilin.^ * Thomson and Fer^son, Journal of Pathology and Bacteriology, Feb. 1900. 32 510 MEDICAL DIAGNOSIS. Black stools result from eating certain articles of food, such as blackberries ; from the action of medicines, as iron, bismuth, man- ganese ; from a vitiated condition of the bile and intestinal secretions ; or from the effiision of blood into the alimentary canal. At all events, when the hemorrhage proceeds from the stomach or the upper part of the canal, the stools have a black, tarry appearance ; when from the lower section of the tube, pure blood is passed, or, if it be small in quantity, a blood-streaked mucus. Should any doubt exist as to whether the dark discharges be dependent upon the presence of blood,- let them be diluted with water ; they will assume a reddish tinge if this be the cause of the abnormal color. When blood pigment is present, it is in the form of haematin. The odor of the evacuations is extremely offensive in fevers of a low type, and when the intestinal secretions are vitiated, or bile is ab- sent. Acidity of the intestinal canal, as in the intestinal catarrh of children and of adults, or in rheumatism or gout, imparts to the stools a sour smell and an acid reaction. The reaction in health varies with the food ; it is mostly alkaline. In cases of constipation it may be important to notice the ihape of the passages, because this may show whether an impediment has flat- tened or otherwise altered them. In fevers, as well as in aflfeclions of the intestinal mucous membrane, whether inflammatory or not, we often derive information from studying the form of the voided matter. Figured stools succeeding to fluid passages are always of favorable omen. We also note whether the stools contain masses of undigested matter and its kind. Microscopical examinations of the faeces are not often made, but they may be of great service. They enable us, for instance, to recog- nize with certainty that the yellowish lumps contained in the evacua- tion, or the greasy film which collects upon its surfece, consist of fat The microscope, too, detects masses of muscular fibre, of elastic tissue, of starch-corpuscles, of fat, coagulated albumin, crystals of cholesterin, red corpuscles, leucocytes, and various fungoid growths, micro-organ- isms, and parasites. Among the animal parasites, besides various infusoria and worms, — the main variety of which will be discussed farther on with the parasites, — we find the amoeba coli^ now known to be the chief cause of tropical dysentery. It is one of the rhizopods. varying in size from 0.012 to 0.035 millimetre, and when active has a characteristic movement. Tliis will be best seen if the stage of the microscope be kept warm. The microscope exhibits, in the fecal discharges of all diseases in which the stools readily decompose, masses of crystals of the triple DISEASES OF THE INTESTINES AND PERITONEUM. 511 phosphates ; in acrid stools, yeast fungi ; in typhoid fever, shreds of slough from the enteric ulcers, and bacilli ; in tubercular ulceration of the bowel, tubercle bacilli; in cholera, comma bacilli; and under many varying conditions both in the faeces and in different organs, as well as in peritoneal exudates and in appendicitis, the bacillus coli com- munis. This is, as a rule, a sluggishly moving bacillus which grows readily on gelatin plates, the surface colonies being lai^e and spherical and of a dull white. It is stained by aniline dyes, but is decolorized when treated by Gram's method. The main normal ingredient of fecal matter is mucin.* Phenol, indol, and scatol are common con- stituents. Peptone occurs only in disease.^ One drawback to the use of chemical research for clinical purposes is the uncertain composition of the faeces, owing to the number of elements derived from the food. A large amount of starchy material shows deficiency of the diastatic ferments of the pancreatic juice in the salivary glands. The study of the alvine discharges is of service not merely in intestinal complaints, but equally in the many maladies in which the alimentary tube sympathizes or becomes involved. Ocular inspection of the anal r^on may disclose the existence of hemorrhoids, fistulae, fissures, or prolapse, and digital exploration of the rectum may yield information besides as to the presence or absence of ulceration, neoplasms, stricture, fecal accumulation, as well as to the tone of the sphincter and the sensibility of the mucous membrane, and also as to the condition of contiguous organs. The knowledge thus gained is sup- plemented or confirmed by ocular inspection with the aid of specula. The physical condition of the lower bowel may be investigated fur- ther by means of rectal insufflation of air or gas, or injection of water. As a means of studying intestinal digestion, especially after test meals have passed from the stomach into the duodenum, the ingeni- ous apparatus of Hemmeter* may be employed. The contents of the duodenum can be withdrawn and subjected to chemical and micro- scopical analysis. The activity af intestinal digestion and absorption may be estimated by the administration of two or three grains of iodoform in gelatin capsules hardened with formaldehyde ; with gastric digestion, absorption, and motility normal, the saliva, tested with chlo- roform and nitric acid, will ordinarily yield the rose-red reaction of iodine in from four to six hours.* ^ Hoppe-Seyler, Handbuch. * Von Jaksch, Clinical Diagnosis, 1899. ' Johns Hopkins Hospital Medical Bulletin, April, 1895. * Sahli, Deutsche Med. Woch., 1897, No. 1 ; Corresp.-bl. f. Schw. Aerate, 1898, No. 10 ; Deutsches Archiv f. klin. Med., 61. B., 5. u. 6. H. ; Lehrb. d. klin. Unter- suchmeth., 2d ed., 1899. 512 MEDICAL DIAGNOHIB. But to reriew the uuroniplicated intestinal diseases^ ^grooping them as they niay be recognized by pain and peculiarity in the feeal dis- chaiges, and describing with them the affections of the peritoneum. Diseases attended with Paroxysms of Pain referred chiefly to the Middle or Lower Part of the Abdomen, and not associated with marked Tenderness or with Fever. The type of these is colic. Colic. — This is an intestinal pain, paroxysmal in its character, and usually combined with constipation, hut unattended with febrile symp- toms. The pain is of a severe griping or twisting kind, is commonly referred to the neigid>orhood of the umbilicus^ and relieved by press- ure. Sometimes there is soreness with the pain, and, indeed, a sliglit soreness not infrequently remains after the paroxysm lias passed off- While tiie pain lasts, the countenance wears an anxious, frightened expression ; the skin is cold ; the pulse is depressed. Occasionally there is vomiting, and in severe cases the abdominal walls are tense or raised in hard knots l>y the spasmodic contraction of the muscle. An attack may last only a few minutes, or for several hours. Some persons are very liable to attacks of colic, Tliose who sulfer from indigestion, or are enfeebled by exhausting maladies, are predisposed to them; so also are hysterical, gouty, and rtieumatic individuals. As to the exciting causes, they are various ; and some- what according to its diifercnt causes, colic presents different forms. Let us indicate the more prominent. Golie^ simple and unconmctcd with a dhecme of the bowel. — In tliese cases, generally called spasmodic colic, llie paroxysmal pain may be of diverse origin. It may be tlie result of direct excitation of the periph- eral intestinal nerves by the presence of irritating sul>stances in the canal, such as indigestible food, cold or acid drinks, hardened fiec^es, gases, morbid secretions, ptomaines, worms, medicines, or poisons. It may proceed from an irritation of the central nervous system re- flected to the intestinal nerves. It may be sympatlietic, and produced by a morbid state of the adjacent abdominal viscera. L Colic owing to food difficult of digestion is very common, espe- cially at the time of year wlien fruit is begiiming to ripen. It may be caused by food taken in quantities greater fhan tlie digestive organs can assimilate, Henci^ it is fret|Lient in cliildren at the breast who are overnourishedt and in persons in delicate health with enfeebled diges- tive powers. The ibrm of colic under discussion is often attended with vomiting and diarr!ins. It is in the region of the uterus or the uterine api)en- * i'ast's n^^H^rtoil l»y BanlololnMi and Siebert, quoted in Henoch^s Clinic of Alnlouunal Oisoasos. I havt* nu't with soveral instances of the kind in typhoid DISEASES OF THE INTESTINES AND PERITONEUM. 525 dages that pain and tenderness are first felt. But, independently of the symptoms of the local disorder, there are evidences of a septi- caemia ; we find delirium, black vomit, exudation into the pericardium and pleura. Fortunately, the diagnosis is one we are now less and less often called upon to consider, for antisepsis has almost put a stop to the disease. Partial or local perUonitia is almost invariably owing to a pre- existing morbid condition of some abdominal viscus. Sometimes the circumscribed inflammation is protective rather than calculated to work mischief. It arrests a destructive perforation of the membrane, or it limits the matter discharged to a certain spot ,* it may at least do so for a time, for general peritonitis is very apt ultimately to follow. Partial peritonitis often pursues a subacute rather than an acute course. It may end in adhesions or lapse into a chronic state. Its symptoms are much the same as those of a more general inflamma- tion,— the same fever and constipation, the same pain and tender- ness. The fever does not, however, run so high, and the pain and the great tenderness are much more localized. The abdomen, also, is not so swollen or so tympanitic. But perhaps even more frequently than in general peritonitis are found accurately limited spots of dul- ness on percussion corresponding to circumscribed exudates or col- lections of pus in the peritoneal cavity. Partial peritonitis is more liable than the general disease to be confounded with other disorders. Yet error can hardly arise if we bear in mind that it is precisely with the morbid states of the viscera which lie below the peritoneum that the circumscribed inflammation of the serous membrane is usually connected, and that local peri- tonitis, therefore, frequently attends the very disorders from which we seek to distinguish it. Let us, however, examine into some of the com- plaints with which peritonitis, whether local or general, may be con- founded. They are — ^leaving for consideration elsewhere obstruction of the bowel, appendicitis, and perityphlitis — Acute Gastritis ; Acute Enteritis ; Acute Pancreatitis ; Metritis ; Cystitis and Distention of the Bladder ; Rheumatism of the Abdominal Walls ; Abdominal Hysteria ; Colic. Acute Gastritis. — Acute inflammation of the stomach can scarcely be mistaken for inflammation of the peritoneum, provided attention 88 526 MEDICAL DIAGNOSIS. be paid to the history of the case and to the seat of the pain. The former disorder begins with vomiting, and this continues a prominent symptom ; whereas vomiting is not so constant, nor does it occur so early, in peritonitis. The pain and tenderness are limited to the region of the stomach in gastritis; they are diffused in peritonitis. They may, it is true, be localized when the peritonitis is partial. But acute inflammation of the gastric peritoneum is hardly encountered, save as an attendant on severe inflammation of the stomach, or on destruction of its coats, — ^the form of gastritis which results from irritant poisons. Acute Efiiantis.'^Ententis differs from general peritonitis by the less extended tenderness ; by the seat of the pain near the umbilicus, and its more paroxysmal character; by the comparative absence of tympanites and abdominal tumefaction; and by the greater promi- nence of nausea and vomiting. Yet it cannot be distinguished with certainty from the partial form of acute peritonitis, to which, in truth, some of its symptoms are clearly owing. Acute Pancreatitis, — This is a cause of peritonitis easily over- looked. The pancreatic inflammation mostly arises in consequence of the extension of a gastro-duodenal inflammation along the pan- creatic duct ; or it may follow hemorrhage into the pancreas. In the former case we find sudden pain, deep-seated, constant or paroxys- mal ; tenderness ; and tympany in the epigastrium in the region of the pancreas, with nausea and vomiting. This is gradually followed by peritonitis at the same place, and by a low fever. Constipation is frequent, and, with the other symptoms, has led to the diagnosis of acute intestinal obstruction and to laparotomy. The symptoms of acute panrceatitis may be also produced by extensive fet necrosis of the pancreas. In hemorrhagic pancreatitis the malady runs a rapid course. The disease occurs in persons over thirty years of age. The attack begins with violent pain in the upper part of the abdomen; nausea, vomiting, and abdominal swelling soon follow, and delirium and signs of collapse appear. There is usually constipation. The temperature, as we know from Fitz's* comprehensive study, may remain normal. The disease is most likely to be confounded with acute perforative peritonitis. It usually proves iatal in from two to four days. The hemorrhage may lead to gangrene ; in either case the signs of peritonitis are marked. Hemorrhage may occasion sudden death.- Supj)uratire pancreatitis has much the same symp- ' Middletoii-Goldsmith Leiture for 1889. • Drai>er, TVansaotions of the Association of American Physicians, 1886. DISEASES OF THE INTESTINES AND PERITONEUM. 527 toms; but it does not run so acute a course, — is, indeed, often chronic ; there is apt to be irregular fever. In a case that I saw with Dr. Hulshizer, tlie pain was severe but paroxysmal, repeated chills occurred, there was sugar in the urine, and decided polynuclear leucocytosis.^ Metriiia, — In this the pain on pressure is confined to the uterus and its annexes, and there is little or no tympanites. In puerperal peritonitis with metritiis, the signs of inflammation of the serous membrane mask those of inflammation of the womb. Cystitis and Distention of the Bladder. — Both inflammation and distention of the bla^dder are occasionally mistaken for general acute peritonitis. An acute inflammation of the bladder gives rtse to fre- quent calls to pass urine: yet the act is performed with great diffi- culty, and in severe cases may become impossible ; the bladder dis- tends ; a sense of uneasiness is felt in the perineum ; the region above the pubes becomes tender, and sounds dull on percussion ; there is great restlessness, fever ; at times vomiting and hiccough supervene. Such cases resemble those of peritonitis with suppression of the uri- nary discharge and with strangury. But the urine voided in perito- nitis is simply high-colored, like that of any febrile state. In cystitis it contains large quantities of mucus and pus, and often blood and crystals of phosphates. Again, the abdominal tenderness is localized, and is frequently accompanied by a smarting in the course of the urethra. Neither of these signs is encountered in peritoneal inflam- mation, and, as a rule, the temperature in this is higher. The urinary disturbance which not infrequently takes place in the latter dis- order is attributable to inflammation of the peritoneum covering the bladder. An over-distention of the bladder, not the result of inflammation of its coats, may produce a local tenderness spread over a consider- able portion of the lower part of the abdomen. But the outline of the dulness, which is the same as that of the tenderness, the fact that the patient has generally not passed urine in any quantity for a con- siderable time, the almost normal temperature, and the sudden cessa- tion of the supposed peritonitis on passing a catheter, show the true nature of the malady.' Inflammatian and Abscess in the Abdominal Muscles, — When the abdominal walls become inflamed, symptoms are occasioned that are * Philadelphia Medical Journal, June 11, 1898. ' A case of this kind, occurring after delivery, is given by Lever, Guy's Hospital Reports, 2d Series, vol. viii. p. 41. 528 MEDICAL DIAGNOf^IB. not always easily dislioguished from those of acute peritonitis. The disease is attended wiOi some fever, with piiiii increased by move- ment, by the act of coughing^, and by pressure, and sometimes with excessive tenderness. The seat of the inflammation is generally the rectus muscle and the surrounding cellular tissue. The pai'ts on one side of the umbilicus are commonly attacked^ and it is there that a liard swelling is perceived, over which the skin is rather hot and sometimes red. The tumefaction gradually disappears by resolution, or else fluctuation becomes from day to day more distinct, showing that supi>uration is taking place ; and the pus being dischai^ed, imme- diate relief follows, and the pain and febrile symptoms cease. Now, tile disease rarely rims a very acute course ; it lasts at least a week or two, and often much longer, Wliere much of the muscle is involved, the com[)hiint sinmlates peritonitis, — more, Ijowevor, the partial than tlie general kind. Where the inflammation of tlie mus- cle is not extended, tlie resemblance to inflammatory aflections of the organs lying underneath the point of tenderness is even greater than to inflammation of the peritoneum. Hepatitis, splenitis, and gastxilis have been mistaken for the aiTection of tlie abdominal parietes. These errors can be avoided only by taking into account the absence of dis- turbed function of ttie suspected viscus ; ollen, too, the peculiar swell- ing fm^nishes a clue to the real nature of the case. But as regards signs of disturbed function, we must bear in mind that these are pro- duced occasionally by disorder of the adjoining \iscera. Tfius, we have jaundice in abscesses seated in the walls in the right hypochon- drium,* Abscesses in tlie aiidominal walls are sometimes sympto- matic of a more distant lesion, as of caries of a rib.^ Can we distinguish, witli anything like certahity, between abscesses in the abdominal walls and mstances of partial peritonitis leading to colkdhn^ of piiH in the peritoneai cavUi/f I believe not; for in both there is a tumefaction ; in both the general symptoms are much the same ; and^ as liappens sometimes in peritoneal abscesses, the pus presses its way through the parietes of the id^domen. Yet whenever we find a swelling which has come on gradually, or has followed a blow or a kick on the abdomen, or a swelling which is very hard before fluctuation appears ; wlienever the softening of the tumor is immediately preceded by distinct dulls, and t!ie skhi covering it is tense, and heated, or reddish ; wherever there are no symptoms point- ing to a partial peritonitis, as an attendant on visceral disease, or as a ' As nipnlioiied by Habershoii, Diseases of the AlKiomen, 1878. ^ OppolEer, Wietjer Meciizinische Wochensolirift, 1862. DISEASES OF THE INTESTINES AND PERITONEUM. 529 consequence of general peritonitis, — we may infer that the affection lies in the abdominal walls. But the skin is not always discolored or hot, and the beginning of the swelling is sometimes veiled in ob- scurity. In some instances I have seen, in which there was great doubt, the aspirator drew off a very offensive pus and broken-down material ; and I looked upon this — as the sequence proved, correctly — as indicating abscess in the abdominal walls. Abscesses within the abdomen seated at the upper part, if not caused by abscess of the liver, are, as Bristowe points out,^ largely due to perforation of one of the hollow viscera with circumscribed peritoneal suppuration. But it is not every case of abscess in the walls which is attended with symptoms that render it likely to be mistaken for the results of inflammation. Sometimes the preceding tumefaction is so hard, or it is so long before the process of suppuration sets in, that the affection is more liable to be confounded with abdominal tumors. The most trustworthy points of difference are furnished by fit study of the his- tory of the case ; by the slow growth of the tumor on the one hand, and its far more rapid growth on the other ; by the rise in temperature and by the absence, or at all events the comparative absence, of signs denoting serious disturbance in one or several of the abdominal viscera. Then, in doubtful cases, the aspirator or the exploring needle will be of use. The fluid thus obtained shows, under the microscope, shreds of broken-down muscle and of areolar tissue, mixed, if suppuration have begun, with pus. Again, stress may be laid on the occurrence of chills preceding the softening of the mass. In some patients the inflammation is unaccompanied by any appre- ciable signs ; it leads to gradual changes in the muscular fibres, which do not reveal themselves until the disorganized muscle gives way. The fibres undergo softening or a true fatty metamorphosis, and the slightest force suffices to produce a rupture. Not a few cases have been reported in which one of the recti muscles has been torn asunder during a fit of coughing. The seat of laceration is generally about midway between the umbilicus and the pubes, a little to one side of the median line ; the rent fills with blood, occasioning a circumscribed swelling and rigidity of the abdomen. There is sometimes pain, with nausea, vomiting, and obstinate constipation. Nay, the symptoms have imitated so closely a strangulated ventral hernia as to have led to the performance of an operation.^ » Lancet, Sept. 1883. * Richardson's case, American Journal of the Medical Sciences, Jan. 1857. Further instances of this accident are given by Virchow, in the Wlirzburg. Ver- handl., Band vii. The description of abscesses in the abdominal parietes I have 530 MEDICAI. fOSIH. Rheumatimi of the Abdominal Waih. — Occasionally rheiinruitism attacks the abdominal musdcs, and gives rise to local signs similar to those of perilunitis. But llie pain is not so constant, nor is it spontaneous, as in ttds disorder. It is also less affected by move- ments or by pressure. De(^p pressure causes little or no more pain tlian slight pressure ; and it is oidy when the niuseles are placed on the stretch that the pain is severe, or sometimes, indeed, at all pro- duced. The pain is often one-sidod, ur murh more marked on one side, and we tind no meteorism, and but slightly elevated ienipera- ture, and not the anxious countenance of peritonitis. Moreover, the attack is apt to ha])pen in those of rheumalic tendencies, and there is concentrated, highly arid, scalding- urine. Kheumatic peritonitis may supervene on rheumatism of the alidomiiml walL Abdominal Ht/aferia. — No disease simulates peritonitis more closely than hysteria. The abdomen may be extremely painful to the touch, swollen and distended with gas, fever may set in temporarily, and yet the whole disorder be purely hysterical. To illustrate : An unmarried woman, twenty years of age, consulted me on ac- count of extreme tenderness of the abdomen which had developed in a few days» The abdomen was swollen and tympanitic, and so sensitive that it would not bear tlie pressure of her clotties ; the pulse was frequent ; the skin dry ; the tongue lightly coated ; the bowels constipated ; the countenance expressive of distress. Here was cer- tainly a groui> of symptoms like those of acute peritonitis. But the absence of the wiry pulse, the comparatively slight fever, — slighter, certainly, than was to be expected from such general and great ten- derness,— and the expression of countenance, arrested my attention. I Jbund that the patient had had smiilar attacks previously ; that tliey had come on sometimes shortly before, sometimes shortly after, iter menstmal (jeriod ; but that for several months her menses had ceased to flow. The al>domiJial tenderness was in regality, as she represented it to be, very great ; yet strong pressure produced no more pain than the lightest touch. Nor was the pain increased by deep insi>iration, or by coughing, or by extending the thighs. Taking all these circum* stances into accomit, as well as her a^e and sex, and her nervous temperament, instead of treating lier for acute peritonitis, cold-water injections, mild purgatives, and a mixture of assafa-lida and valerian were employed. Under these remedies, all tlie symptoms of tlie apparent peritonitis speedily vanished. drawn from cases cliiefly coining tinder my own notice, and from manuscript iioles taken by Dr. J. K. Kane at Itie Ptiilcidetpbia Hospital. DISEASES OF THE INTESTINES AN1> PERTTONElUVr • [Tel all cases of abdonunal hysteria do not pass off so quickly ; etimes they are imu h njore persisient, or recur frecpiently. They are. ironi the onset unattended with fever, or, as ttie lliennometer shows, the fever is fitful and soon ceases. The absence of febrile excitement, too, especially if \nken in connectioo \\ith the several localb,ed and more or k*ss distinctly ciiTumscribed spots of tenderness, enables us to distinguish between peritonitis and those instances of neuralgia of nerves supplyuig tite abdoniinal p^nnotes, to which women who are laboring under disorders of llie uterus are so liable. Colic. — As already stated, ttie pain of colic is paroxysmal, and not attended witli fever, or with much, if any, tenderness ; while the pain of an inllamed peritoneum is constant, and associated with the greatest tenderness and with fever. Cases of cohc do indeed occur in wtiirh w^e find fever and some tenderness; but it is likely that in such cases the peritoneum is really in parts injectecl or slightly uiflamed. Tlie same remarks are applicable to those severe paroxysmal pains which accompany the passage of gall-stones or of urinary concretions, or which nc( ur at the menstrual periods. They are frequently spoken of as varieties of colic, and, as far as their discrimination from perito- nitis goes, there is no difference, — ^it rests on the same grounds pre- cisely ; for when there is fever or tenderness on pressure, it is likely tliat inflammation has been set up in timse parts in which, or in the neighborhood of which, the pain is felt. In the so-called uterine colic, an injection of the peritonemn has positively been demonstrated. Chronic Peritonitia. — An acute attack of peritonitis may imper- ceptibly assume a clironic form. Ttie fever graduaily disappears, or at alt events lessens; but the exudations into the peritoneal cavity, whether organized or not, remain, and so do some abdominal pain and tenderness. In tins condition the patient may continue for many months, now and then a fresh mflammation starting up in the peri- toneum and giving rise to acute symptoms, or an intercurrent severe diarrhiJLva leading to rapid loss of strength. Again, the disease may develop slowly, be latent from tlie onset, and may not attract atten- tion mitil the abdomen swells. In all cases, no matter what their origin, if they last for any length of time, debility and emaciation be- come nifU'ked symptoms ; hectic fever is observed ; decided efTusion in the peritonemn is generally noticed ; the legs become cedematous ; and the patient may present the symptoms of septic poisoning and die worn out. Where recovery takes place, the exudation into the peritoneal cavity is eitlier dischai^ed through at^jacent viscera ; or is gi'adually absorbed; or is transformed into tLssue. When the ease terminates in this way, it is apt to leave its traces in a chronic 532 MEDICAL DrAGNOSIB. thi<^keniiig and rouglieninj^ of [\w peiitorieuiih A (nclioii may be often felt Chronic peritonitis of latent origin and leading to ranch thiekeniijg is somelinies fonnd to attend cirrhosis of the liver or cpn- tracted kidney. Under no eirciimstances is chronic peritonitis likely to be an independent atlection. Clu'onic periturn'tis may be confounded with affections of the liver attended by impediment in the portal circle ; and what adds to the difliculty in diiignosis is, that the liver is apt to atrophy in chronic dilTuse peritoneal inflammation. The grealcT and more diftose ten- derness, the evening exacerbations of temperature, the absence of marked dilatation of the abdominal veins^ and the less extensive peri- toneal effusion indicate the latter atfection. Chronic peritonitis is often found in connection with tubercles or with carwer. It then gives rise to very consideralile abdonunal en- largement, and it is with the diagnosis of abdominal enlai^ements that tliese fonns of chronic peritonitis will be considered. Diseases attended with Pain and Tenderness in the Right mac Fossa. Appendicitis. ^ — Inflammation of the appendix is pre-eminently the disease attended with pain and tenderness in the right iliac fossa, Tlie appendix has an average length of four inches, and the diameter of a goose-quill. It lies in the right iUac fossa, but is variable in position. It points for the most part downward, or downward and mward. A. T. Bristow and Fowler* locate for it a central point by drawing a line from the anterior superior spinous process of the ilium to the median line, and placing the central point from two to two and a half uiches within tite anterior superior spinous process. From this central point the appemhx wiJl radiate in different directions, Tlie usual location of the appendix is at the edge of the right recttis njuscle below a line ch*awn from the centre of the umbilicus to the anterior superior spinous process. Appendicitis is essentially a dis- ease of adolescence and of young adults. It presents itself clinically in these forms : acute catarrhal appendicitis ; ulcerative and suppura- tive appendicitis ; perforative appendicitis ; chronic recurring appen- dicitis. Acute catarrhal appendicitis may come on trom exposure to cold and wet. Fowler cites two such cases. Much more generally it is an infectious process due to hardened fecal masses leading by the irrita- tion they produce to exudations in wliich extraordinarj* development * Appendicitis, Philadelphia, 1804. DISEASES OF THE INTESTINES AND PERITONEUM. 533 of bacteria, as of Uie bacterium coli commune, takes place. It may also be caused by other infecting processes or micro-organisms. The fan greater prevalence of appendicitis since the recent wide-spread epidemics of influenza suggests that this subtle poison, too, may act as an exciting cause. The disease may also result from vascular disturb- ances or torsion of the part. It is at tlie bedside always extremely difficult to say what cause has given rise to tlie attack. \Vliatever the immediate cause, whether it be a quickly acting one, or, as is more common, have been silently working, the attack itself is generally sudden, and announces itself by acute abdominal pain, by tenderness in the right iliac fossa, by nausea and vomiting. The pain and the tenderness are very significant. The pain may be referred to the lower part of the abdomen, but it is very often referred to the umbilicus or to the epigastrium. It has, especially at first, the character of colic. It is soon noted to be associated with tenderness, which is chiefly manifest at or near McBumey's point. This corresponds to the outer edge of the right rectus muscle, and is most readily located by fixing a spot midway between the ante- rior superior spine of the right ilium and the umbilicus. The patient lies on his back, because to do otherwise increases the pain, and very often the right rectus muscle is somewhat tense, a fulness or a slight tumefaction can be perceived in the right iliac fossa, and there is some impairment of tympanitic resonance on percussion. Tenderness and swelling, as well as the shape of the appendix, may at times be recog- nized by deep pressure, and palpation of the appendix, as recom- mended by Edebohls,* may thus become of value. In some instances, and I have met with a number of them, the sensitiveness is not in the right but in the left iliac fossa. Again, the tenderness may be at the upper part of the appendix, below, but near, the gall-bladder. Ten- derness is always a very nnportant sign, and when it lessens both in degree and in extent it denotes decreasing inflammation. The nausea and vomiting disappear in the progress of the case, though vomiting may return should there be perforation. If the peritonitis become general, abdominal distention will be marked. Other symptoms met with in appendicitis are moderate fever, constipation, urine diminished and firequently containing albumin and indican. Some cases do not begin so acutely, but are rather subacute. The complaint presents the following history and symptoms : The patient has been suffering for some time fi-om constipation, or alternately from diarrhoea and constipation. He has a dull pain referred principally ' American Journal of the Medical Sciences, May, 1894. 634 MEDICAL DIAGNOSIS. to the iliac fossa, and radiating to the hips. When the iliac region is examined, it is tender to the touch, full and hard, and dull on per- cussion, while around the dulness there is a very' tympanitic sound, if the intestine be much distended. Colicky pains occur from time to time, but are mainly confined to the lower portion of the abdomen. No matter what the beginning, the case in its further progress exhibits varied features : it may end in resolution, and hardened fecal matter is often passed ; or the tenderness in the iliac fossa may become greater, and vomiting, decided fever, and the marked signs of an extending peritonitis appear ; or ulceration of the appendix may allow a discharge of extraneous matter into the peritoneal cavity, which produces violent general peritonitis, or an abscess forms that ruptures and perhaps leads to the same results ; or, again, the bowel may become so paralyzed or so constricted that it can no longer pro- pel its contents, and the patient dies with all the distressing signs of intestinal obstruction. There are other terminations with which experience makes us familiar. The attack may end in a chronic appendicitis, indicated by persistent tenderness and some swelling, pain on walking, and often dyspeptic symptoms and depression of spirits ; or the chronic inflammation may lead to a series of recurring acute attacks. Then as complications in appendicitis we may have thrombosis of the iliac vein, iliac phlebitis, post-caecal abscess, fistula into the bladder or rectum, hepatic abscess. There are two very important questions that always arise in appendicitis : Is there pus present ? Has perforation occurred ? It is always difficult to determine the presence of pus^ and there are no certain signs. Chills are generally absent ; the temperature is of little value. The most trustworthy signs are very decided tender- ness, a local swelling, marked rigidity of the right rectus muscle, and waves of pain in the affected region. Perforation of the appendix is most often seen among healthy young men. It is found chiefly in the form of appendicitis that has been caused by seeds and concretions of various kinds, cherry-stones, and foreign bodies. In a certain proportion of cases the symptoms have been latent until the perforation happened. Its most constant and the first decided symptom is sudden, severe abdominal pain. This oc- curred in eighty-four per cent, of the cases which Fitz in his admirable essay has analyzed.^ The pain is mostly at first in the right iliac fossa, and is followed by tenderness which gradually extends. It may be * Transactions of the Association of American Physicians, 1886. DISEASES OF THE INTESTINES AND PERITONEUM. 535 accompanied by a chill, but I have known pain absent where a chill was decided. Fever, with a temperature of between 100° and 102*^, is next observed ; but it is not constant, for I have met with a temper- ature nearly normal in a case in which a gangrenous perforation of the appendix was found.* A circumscribed resisting swelling in the right iliac fossa, which forms in from two to five days, with impaired resonance on percussion and \\dth a sense of fluctuation from the abscess that develops, and disturbed micturition, establish the diag- nosis. A rectal examination may aid us in detecting the tumor, but, as I know from experience, is not absolutely to be depended on as a means of recognizing the swelling or the pus that has formed. In the majority of cases general peritonitis begins from the second to the fourth day after the perforation. The cases that die from shock die before the second day ; but, as a rule, the collapse comes on more slowly than in other forms of perforative peritonitis. Leucocytosis, Richardson tells us, is invariable in perforative appendicitis. Obliter- ation of the dulness over the liver and spleen is not as often found as in other forms of intestinal perforation. A question that arises is whether we can distinguish inflammation of the appendix from an inflammation of the cascum^ both of which were formerly included under the name typhlitis. There is no cer- tainty in the diagnosis. But these facts will often aid us greatly. Most of the cases of inflammation of the caecum are due to impacted faeces, and the history of preceding long-continued constipation, a re- sisting elongated mass in the right groin, slight pain, and absence of fever, are very significant. Then, perforating inflammation of the caecum is very rare, while perforation of the appendix is of frequent occurrence. Much used to be said about inflammation of the loose areolar tissue around the caecum, perityphlitis, and consequent abscess. But we now know that the abscess nearly always has its origin in disease of the appendix. The collection of pus may find its way into neigh- boring viscera, or be discharged externally, or become encysted, or the sac rupture and fatal peritonitis ensue. The tumefaction which the abscess occasions is generally very evident. When, however, the pus burrows under the iliac fascia, the swelling may be slight. But under such circumstances there appears a characteristic sign: the pain on moving the right foot is intense, because the iliac muscles become involved in the disorder. If the swelling be great, there may be oedema of the foot and numbness of the thigh, from the pressure ^ Seen with Dr. Morton. 536 MEDICAL DIAGNOSIS. on the vein and nerves. Perit}T)hlitis with marked swelling in the right iliac fossa may disappear' without an abscess forming. Chiefly on account of the pain and tenderness, acute appendicitis may be confounded with a number of diseases, prominent among which are colic ; bilious colic ; renal colic ; acute cholecystitis ; per- foration of the gall-bladder; typhoid fever; ulceration of the lower part of the ileum ; obstruction of the bowel ; tumors of tlie kidney, and abscesses hi or around it ; floating kidney ; inflammation of the right ovary ; extrauterine pregnancy ; pelvic haematocele ; pelvic peri- tonitis ; tubercular peritonitis ; abscess in the abdominal walls ; psoas abscess ; liip-joint disease ; abscess of the liver ; distention of the caecum ; cancer of the caecum ; pneumonia. The sudden pain, the acute indigestion, the nausea and vomiting may cause appendicitis at its beginnmg to be mistaken for co/io, espe- cially for bilious colic, but the localization of the pain and particularly the tenderness in the right iliac fossa are very dififerent. On the other hand, the jaundice that attends or follows bilums colic is not a symp- tom of appendicitis, and the pain of this does not radiate to the shoul- der and the scapula. The same localization of the tenderness is of value in distinguishing renal colk, where the tenderness, if it exist at all, is most marked over Poupart's ligament. Moreover, rectal and vesical tenesmus and retraction of the testicle, common in renal colic, are very rare in appendicitis. Yet there are cases of appendicitis at its upper end that are very misleading, and, as in two cases I saw, one with Dr. Keen, the other with Dr. Dupont Smith, only to be recognized by the changing seat of the pain. In Dupont Smith's case tympany was a marked symptom. Pain and tenderness in the right iliac fossa may be the cause of typhoid fever being confounded with appendicitis. But neither pain nor tenderness is great in typhoid fever ; then the characteristic tem- perature record, the nervous symptoms, the diarrhoea, the eruption, furnish striking points of difference. Appendicitis may exist as a complication of typhoid fever, as we shall find while treating of typhoid fever. Ulceration of the lower part of the ileum produces pain and ten- derness in the iliac fossa. But, combined as the ulceration generally is with tubercular disease, the history of the case gives a clue to the nature of the malady. Moreover, diarrhoea occurs, and there is not present a tumefaction dull on percussion. Should, however, perfora- tion of the bowel take place before the patient is seen, and general peritonitis come on, the diagnosis is not so readily made, because we are deprived of the decisive proof furnished by the swelling. DISEASES OF THE INTESTINES AND PERITONEUM. 637 Another difficult diagnosis is at times that regarding obstruction of the bowel; the more difficult because appendicitis may become a cause of intestinal obstruction. In both there is pain; in both constipation; in both vomiting. But the pain in obstruction is not localized, or attended with such a significant seat of tenderness as McBumey's point ; the constipation in appendicitis is not so absolute, and flatus passes ; the vomiting in this disease occurs early, then gen- erally stops; late vomiting is the rule in obstruction, and it becomes fecal. Though fever is not a marked symptom of appendicitis, there is generally some. Acute intussusception has a different history, and makes its appearance suddenly with such peculiar signs that, although it may likewise occasion a tumor in the right iliac region, it can be generally distinguished from appendicitis. Yet, where the latter leads to intestinal obstruction, the diagnosis is not always obvious; and tenesmus and discharge of bloody mucus from the rectum may also happen in appendicitis as well as in intussusception. Moreover, both are diseases to which the young are specially liable. As regards tumors of the kidney and abscesses in it or around it, the situation of the swelling is not exactly in the ileo-caecal region, or at all events it is not confined to this region. The mass of the tumor lies in the loin, or above the anterior termination of the crest of the ilemn ; and the urine contains ingredients, such as pus, or blood, or heavy deposits of urates or phosphates, which show that the secretion of the kidney is abnormal. Moreover, there is no intestinal disturb- ance or marked local tenderness, such as we find in appendicitis. In floating kidney the mobility of the displaced organ, the slight tender- ness, the dyspeptic symptoms, and the throbbing of the abdominal aorta are very significant. The occurrence of attacks of severe ab- dominal pain, with vomiting and fever, may be misleading, but their frequent recurrence and the absence of localized swelling over the seat of the appendix are valuable signs. An inflammation of the right ovary gives ris^e to pain and tenderness in the right iliac region, and to fever. But it is associated with dis- turbance of the uterine functions, with characteristic ovarian pain, and occasions no perceptible swelling. A tumor of the ovary or of the uterus may produce a visible tumefaction ; but, springing as it does out of the pelvis, its exact seat, its bulk, its shape, the absence of marked intestinal symptoms, and a vaginal examination, will permit its cause to be discovered. In acute salpingitis there is the history of infection, absence of vomiting, and but slight degree of abdominal tenderness and rigidity. Extrauterine pregnancy may be mistaken for acute appendicitis in 538 MEDICAL DIAGNOSIS. consequence of the sudden rupture of a sac. But the previous his- tory, the great prostration, the excessive thirst, and a pelvic exami- nation will explain the true meaning of the symptoms. In peine hcemotocele the pain and the suddenness of the attack make us think of acute appendicitis. But the tumor that forms is generally laiiger, doughy ; there are no localized spots of tenderness, no marked intes- tinal symptoms; and the history of irregular menstruation and a vaginal examination will remove all doubt. Ovarian cysts with twisted pedicle, ovarian abscess, pyosalpinx, fibroid tumors, a vari- cose condition of the veins of the broad ligament, and painful men- struation may also be mistaken for appendicitis ; but as Deaver,* in an admirable paper based on extraordinarily large experience, shows, none has the exact combination of signs found in appendicitis. Tlus may exist as a complication of pregnancy. Generally in cKseasea of the gall-bladder the seat of pain and ten- derness is over it, and not in the right iliac fossa, as in appendicitis. But there are exceptions in both affections, rendering the diagnosis very difficult, it may be impossible. The swelling of a distended gall-bladder may be felt very low down, and, on the other hand, appendicitis of the upper part may have its local signs in the neighbor- 'hood of the gall-bladder. Rigidity of the rectus muscle and pain are common to gall-bladder disease and to appendicitis. The pain of acute cholecystitis is, however, more violent ; and so it is, as a rule, in perforation of the gall-bladder than in perforative appendicitis. Still, how deceptive symptoms may be is proved by the published cases of eminent surgeons like Fowler * and like Richardson.* An abscess in the abdominal walls furnishes very many of the signs of abscess around the appendix. The most trustworthy point of distinction is that the former moves with the abdominal walls and is unassociated with intestinal irritation, while the latter is commonJj' so combined. Then the peculiar spots of tenderness, the outline of the swelling, its want of prominence, are unlike what is found in abscess of the abdominal walls. In psoas abscess we have the association with caries of the verte- brae : rigidity or an excurvation of the spine, dorsal pain and tender- ness, testify to this connection. It occurs in scrofulous persons, and, although gradual in its formation, is often sudden in its manifestation; for not unusually a fluctuating, painless tumor appears below Poo- * Appendicitis in Reflation to the Diseases of Uterine Adnexa and Prepwa?* Mediciil News, Oct. 1897. =* Op. cit. » Amer. Joum. Med. Sci.. July. 1898. DISEASES OF THE INTESTINES AND PERITONEUM. 539 part's ligament as the first positive sign of this formidable affection. This is very different from the history of an appendicitis which has led to post-caecal abscess. Moreover, preceding the pointing of the psoas abscess at the spot mentioned, there are often indications of irritation in those muscles in the sheath of which the pus travels ; there is diflQ- culty in extending the leg, wth inability to stand upright. Pelvic peritonitis is not likely to be mistaken for appendicitis, except in those rare cases in which the appendix is lodged in the pelvis. Treves * mentions such a case. He also cites one of tuberculous peri- tonitis the cause of error. While the local signs may be misleading, the previous history, the amount of fever, and the grave constitutional symptoms are likely to aid us to a connect conclusion. In hip-joint disease the inclination of the pelvis, and the inability to move the joint normally, furnish trustworthy points of distinction. It is sometimes difficult to distinguish between appendicitis, espe- cially in its chronic forms, and abscess of the liver ; the more difficult because, as I know by experience, they may coexist, the hepatic abscess being consequent to the appendicitis. Another fact that makes the diagnosis difficult is that the pain and tenderness in appen- dicitis do not always exist in the right iliac fossa, but may be found at various parts of the abdomen ; the abscess following appendicitis may* extend high up towards the liver. In these difficult instances the his- tory of the case, as well as the study of the sequence in which the phenomena appeared, becomes of the greatest value. A distention of the coecum may be mistaken for chronic appendicitis. It gives rise to fulness in the right iliac fossa, and to pain, often of colicky character, but, unless associated with inflammation, not to tenderness or to fever. Purgatives, too, clear out the faeces which accumulate from want of power of the bowel to propel them, and the dulness on percussion vanishes after the free evacuations, and, except when the caecum is loaded with faeces, it is highly tympanitic. In that rare disease, cancer of the ccecum^ there is a fixed, firm swelling ; but it is of very gradual growth, and the disorder generally produces a stricture of the bowel and is associated with malignant disease in other parts of the body. Other affections than those of the bowels may give rise to signs supposed to indicate appendicitis. It does not at first sight seem likely that this would be the case with pneumonia. Yet the mistake has been committed. Pain is sometimes referred to the right groin in pneumonia, and there is soreness there, connected probably with the ^ Allbutt's System of Medicine, vol. iii., article •'Perityphlitis.'' 540 MEDICAL DIAGNOSIS. efforts at coughing and the disordered breathing. Nay, I have known poultices to be applied to the right iliac fossa to relieve the inflam- mation which really was in the chest. An examination of this pari of the body will, of course, at once explain the true character of tlie symptoms. HysteHa may take on the form of appendicitis, but there is no accurately localized tenderness and swelling, nor fever. The wide discussion of the subject of appendicitis and the popular interest taken in it have led to a new form of hypochondriasis. In chronic appendicitis there is at times a strong tendency shown to recurring acute or subacute attacks. In one instance that came under my observation tliere were forty-seven before the case was operated on. Generally in these cases of recurring appendicitis a chronic thickening of the appendix is present with or without adhe- sions, and the tube is narrowed or obliterated ; there is obliterative appendicitis. An induration may nearly always be felt in the region of the appendix, and there is tenderness on deep pressure, and mostly some impairment of general health and symptoms of intestinal dys- pepsia. Indiscretions in diet or active exercise is very apt to bring on an acute attack, and perforation may be the outcome of many. Disorders attended with Constipation, and of which it is a Prominent Symptom. An inactive state of the bowels is often but a concomitant of some .disorder which presents much more striking phenomena. But there are cases in which the constipation is the most important symptom, and in which it furnishes decisive proof of a morbid condition of the intestine. Now, these cases are either those in which the constipation arises suddenly, or at any rate becomes suddenly aggravated, and is often insuperable ; or those in which it is an habitual state, and is not associated with any signs of urgent distress. Intestinal Obstruction. — Intestinal obstruction, when coming on suddenly, manifests itself generally in the following manner: k person, previously in good health, or perhaps of costive habit, notices that his bowels have not been moved for several days, and that he has an uneasy feeling in the abdomen in consequence. He takes the pur- gative ho is wont to employ, but without the usual eflfect. Something more active is tried, and still the bowels remain obstinately bound. Severe colicky pains have in the mean time made their appearance. Ilcf becomes alarmed, and sends for his physician, who sees that there is indeed cause for alarm. The 'abdomen is found to be distended, but not painful, or only slightly painful, on pressure. But through its DISEASES OF THE INTESTINES AND PERITONEUM. 541 parietes may be noticed the violent, rolling motion of tlie imtated in- testine. Vomiting sets in, — first, of the substances contained in the stomach or of a bilious fluid, and, as the case progresses, of ster- coraceous matter. In this way, unless nature or art comes to the rescue, the disease continues ; and signs of inflammation of the bowels, and with them fever, appear as preludes to the fatal termina- tion. Sometimes, however, the patient becomes gradually exhausted ; there are no tenderness and fever, but a cool skin, a quick, small pulse, a countenance ghastly and panic-stricken. Violent paroxysms of pain, alternating with intervals of ease, may occur to the last moment. But, in spite of the utter prostration, the mind generally retains its clearness. Should recovery take place, large quantities of fecal matter are discharged, and the symptoms of the impediment speedily disappear. These phenomena are too striking to permit of errors in diagnosis. Yet errors are of frequent occurrence, because the history of the at- tack and the sequence of the symptoms are not taken into account. Many a person laboring under peritonitis has been violently purged to remove the stubborn constipation believed to be due to a mechanical hinderance in the bowels ; and, on the other hand, many a case of intestinal obstruction has been treated solely with reference to the inflanunation that may attend it, and without regard to the source of the inflammation. Yet it is not ordinarily difiBcult to distinguish which is cause and which effect. A case that begins with severe colicky pains and obstinate constipation, in which, at first, in spite of the pain, there is little or no tenderness ; in which the temperature is normal or subnormal ; in which vomiting and tympany soon occur ; in which fulness on palpation and dulness on percussion may be detected at or above the point of stoppage ; and in which fecal matter is ejected by the mouth after a stoppage of the bowels of a few days' duration, — ^is not primarily, whatever may be the ultimate complications, enteritis or peritonitis. A case presenting almost from the onset fever and great and extended tenderness, in which vomiting of fecal matter, if it happen at all, does not happen until late ; in which diarrhoea is sometimes found to supersede the enduring constipation, — is inflam- mation of the peritoneum, but not a mechanical obstruction. Only in rare instances, and especially when the bowel is invaginated, is the malady so quickly succeeded by inflammation as seemingly to make its appearance with the signs of peritonitis. Perforative peritonitis, with its signs of collapse, shows a much stronger likeness to acute obstruction of the bowel than ordinary peritonitis does. The symptoms dwelt upon as pointing to an intestinal obstruction 84 542 MEDICAL DIAGNOSIS. bear a close resemblance to those of external strangulated hernia. In trutli, they not only resemble but are identical with those of this affec- tion. Hence in every case of obstinate constipation each point which may be the seat of a hernia must be explored by the eye and 'the hand. No motives of false delicacy, no reluctance, should prevent the physician from insisting on a search, the neglect of which may cost a life. It would be foreign to the object of this work to discuss the exter- nal signs by which a strangulation of the intestine at a hernial open- ing manifests itself. It need only be mentioned that it is at the groin, at the umbilicus, at the side of the anus, or through the ischiatic notch tliat the gut descends and forms a tumor, and that these are, therefore, the regions to be scrutinized. Moreover, there are internal hernias that become strangulated, such as a diaphragmatic hernia, a hernia into the foramen of Wihslow. But these are matters more strictly surgical. Yet there is one part of the subject, of importance alike to the physician and to the surgeon, which cannot be passed by < without a few words, since it may be a cause of much perplexity,— namely, the possibility of intestinal obstruction taking place in a person laboring under an irreducible hernia and simulating strangu- lation without any strangulation having occurred. Of this the fol- lowing case furnishes an example. A number of years since I was requested by a physician to see with him a woman, the mother of thirteen children, who had been for days laboring under obstinate constipation. Large doses of me^ curials, croton oil, and turpentine enemata had fiedled to procure a passage, and the patient was becoming much frightened. Nor was her situation free from danger. She had considerable pain in the abdomen; she had been vomiting stercoraceous matter profusely; tlie rolling of the intestines could be plainly perceived. On her right side was a small irreducible femoral hernia, which had existed for years. It was not painful on pressure, nor was the skin discolored; neither did the mass itself communicate an impulse during the act of coughing. Here were signs of a serious impediment to the onward passage of tlie intestinal contents,' as the fecal vomiting and the rolling of the intestines showed plainly. But was it due to strangulation at the hernial opening? Was it an internal intestinal obstruction? An accurate examination of the abdomen did not throw much light on these questions. The belly was moderately tympanitic^ and [)t painful til the touch, except when the pressure was considerable. rottinK i>r the intestines was perhaps more obvious on the left nuwhere could a tumor be felt. Taking all the ciitum- DISEASES OF THE INTESTINES AND PERITONEUM. 543 stances of the case into account, — the fact that the patient was of cos- tive habit ; that she was subject to attacks of colic and of obstinate constipation; that there was nothing to prove that the hernia had recently increased, or was in any way inflamed, — the conclusion ar- rived at was that the case was not one of hernial strangulation, but of internal intestinal obstruction. Copious warm-water injections were thrown into the colon through a flexible tube ; her abdomen was rubbed with mercurial ointment. But all in vain : she continued vomiting fecal matter. Her situation now appeared desperate. She had not had a pas- sage for six days ; she was steadily sinking. Knowing that sometimes the gut may be strangulated at a hernial opening without much pain or tenderness, the counsel of an eminent surgeon was sought, to aid in determining whether this was not the cause of the impediment. He thought it probable that it was. The patient was etherized, and the hernial section performed ; but no constriction was found. The wound was closed, and large doses of opium were administered, so as to mitigate, so fer as practicable, the torture of the only termination to the case which seemed possible. On the day after the operation, the intestines had ceased to roll ; there was no vomiting. But stercora- ceous vomiting reappeared two days afterwards, and the rolling of the intestines was occasionally, although faintly, perceptible. The patient's exhaustion was now extreme ; her pulse was very quick and small; her skin cold, of a dirty look; the odor of the breath and of the whole body offensive ; and the eyes sunken and surrounded by a broad leaden ring. There was slight pain on press- ure between the umbilicus and the sigmoid flexure. The vomiting had ceased,. or occurred only occasionally. Although there was little hope, we had, as soon as admissible after the operation, recommenced rubbing mercurial ointment over the abdomen, and giving injections in the manner before described. This was continued until, to our great gratiflcation, one morning, after a tube had been passed a distance of several feet into the colon, the patient had a copious discharge of tarry fecal matter from her bowels, — seventeen days after the symptoms of complete intestinal obstruction had declared themselves by the occur- rence of stercoraceous vomiting. This case is instructive in more than one respect. It teaches that recovery may take place most unexpectedly after many days ; and, in a diagnostic point of view, it illustrates a difficulty which any physi- cian may have to encounter in attending a patient the subject of a long-standing hernia. Supposing that the symptoms are . altogether owing to an obstacle 544 MEDICAL DIAGNOSIS. at some portion of the intestine wthin the abdomen; can we deter- mine the exact position of the impediment and its nature ? We know how varied are the conditions which lead to sudden and invincible constipation. We know that strangulation from bands and adhesions, or gaps in the omentum, or the pedicle of an ovarian tumor ; thai intussusception ; that twists and knots ; that strictures and tumors ; that abnormal contents, such as foreign bodies, impacted faeces, gall- stones, worms, concretions of drugs, as of bismuth, may all occasion intestinal obstruction. We also know that in certain cases the ob- struction is from spasmodic contraction of the intestine,^ or paralysis of the bowel. Can we distinguish these different lesions at the bed- side ? In certain cases we can, — we can determine exactly both the position and the character of the lesion ; in others there is no clue to an accurate discernment of either. It is possible that in lime the X-rays may give us the desired information. Obstruction of the bowel may present itself as an a^uie or as a chronic malady. The same symptoms occur in both. It is the mode of origin that is different. Nay, the same lesion may occasion in some instances an acute, in others a chronic, affection. Intussusception, internal strangulation, volvulus, impaction of a large gall-stone, are generally acute; strictures, tumors, contractions, and, for the most part, fecal accumulations, lead to chronic obstruction. Then there arc cases that pursue a chronic course, but which terminate in acute ob- struction. In acute intestinal obstruction, the first marked symptom is violent abdominal pain in the region of the umbilicus ; there are eariy and persistent vomiting which becomes stercoraceous, great thirst, and often speedy collapse. Unless peritonitis supervene, we find no fever ; towards the end the signs of septic poisoning may show them- selves. In chronic intestinal obstruction the pain is at first like ordi- nary colic, and gradually becomes more persistent ; nausea is almost constant, but vomiting is not, except towards the end, a pronounced feature, and the constipation only gradually becomes absolute. The abdomen is distended and the seat of gurgling sounds, tenesmus is common, and a tumor, often the result of fecal accumulation, can be felt. The breath acquires a fecal odor; the appetite utterly fisdls. Unless the obstruction can be relieved, the patient dies worn out, and from ptomaine-poisoning. We shall first examine the more common kinds of the acuii form. Among these, hUussusception or invaginatum is frequent and at the same time the least difficult of recognition. Part of the bowel * Archives Generales, Aug. 1868 ; Flint, I^ractice of Medicine. DISEASES OF THE INTESTINES AND PERITONEUM. 545 becomes inverted, slipping into the cavity of the adjoining upper or lower portion. Inflammation is soon set up, produces infiltration of the tissues, and often leads to adhesions between the opposed serous surfaces. The inflammation may spread rapidly over the serous membrane, and the patient may die from general peritonitis. But sometimes in the inflammation that is lighted up at the seat of the ileus lies safety. . It may give rise ultimately to a sloughing off of the invaginated part and its discharge into the bowel, while the mass of adhesive lymph surrounding the seat of ulceration maintains the con- tinuity of the intestinal canal ; thus the inflammation may pave the way to a favorable issue by restoring the caliber of the tube, — suffi- ciently, at any rate, to permit of the transit of its contents. When the intussusception takes place rapidly, a sudden local pain is produced, recurring in paroxysms, and likely to be referred to the seat of the disturbance. The pain is quickly followed by vomiting, by constipation, by tympany, and by tenderness. But the constipa- tion is not so absolute as in other cases of intestinal impediment ; is, indeed, often preceded by diarrhoea. Not unusually, owing to the invaginated bowel remaining open, the liquid contents of the intes- tine pass through the intussuscepted part and produce a deceptive diarrhoea; yet oftener occur tenesmus and discharges of bloody mucus. Both of the latter signs are eminently diagnostic of the lesion. Still more so is feeling the end of the invaginated bowel by an exploration of the rectum, or finding the loosened segment in the stools. But it is only in cases in which the lower portion of the canal is aflfected, or which have been sufTiciently protracted to allow of the curative efforts of nature being accomplished, that signs so pathognomonic are met vnth. Vomiting is not a marked feature of acute intussusception ; it sometimes passes away and returns. The tenderness at first is localized, but spreads as peritonitis spreads; there is rarely tympany. The casting off of the sloughed portion of the intestine is attended with hemorrhage. Whether this be the only cause of the hemorrhage or not, it is undoubted that purging, or sometimes vomiting, of blood, is among the differential signs of intussusception. A sign more valu- able, because so much more usual, and present in about half the cases, is a tumor, frequently of cylindrical shape. Its seat varies with the seat of the lesion ; and as the most common invaginations are those of the ileum and caecum into the colon, or those at the inferior portion of the ileum, it is at the lower part of the belly, and in the right iliac fossa, that the swelling is detected. In the attacks of pain, the tumor becomes harder and lai^ger. When low down in the 546 MEDICAL DIAGNOSIS. rectum, or protruding from it, it has been mistaken for hemorrhoids or prolapse of the bowel. The malady is generally due to irregular peristalsis ; it is some- tinies caused by tumors of the intestines, particularly by lipoma.* The majority of cases of invagination happen in children under ten years of age, and a number are met with in iniants. The course the affection pursues is rapid ; the patient dies generally in less than a week after the occurrence of the accident, utterly prostrated. The cases which get well recover either gradually after the invaginated bow^el has been discharged, or, in rare instances, quickly by the inverted bowel righting itself. Acute obstruction from iivtemol atrangiJatian, as by bands or through apertures, is almost invariably seated in the small intestine. Its most characteristic feature is furnished by the history of a previ- ous peritonitis, an operation on the abdomen, or an appendicitis. There is rarely fever ; the obstruction has a sudden onset and soon becomes complete ; nausea and vomiting set in early ; fecal vomiting usually begins from the third to the fifth day. It is the decided exception to find a tumor; tympany may or may not be marked, but no flatus escapes by the bowel. Of further significance in the diag- nosis of internal strangulation are the occurrence of collapse almost from the beginning ; the frequency with which the disease is found in young adults; the rapid course it runs; the severity of the pain, which is generally referred to the umbilicus ; the intense thirst ; the absence of external or of discoverable obturator hernia ; the absence of visible peristole, — such as happens in stricture,— of tumor, of hem- orrhage, of tenesmus, and of dysenteric symptoms, as seen in intus- susception. Obstruction by a band connected with a diverticulum scarcely ever occurs except in males imder twenty years of age.* Acute obstruction from volvulus or twist begins with severe ab- dominal pain, which soon becomes associated with nausea and vomit- ing and extreme distention; it rarely presents a tumor or visible intestinal coils, or elevation of temperature.* It nearly always aflfects the sigmoid flexure, and is preceded by a history of constipation ; the pain at first is intermittent. There is local tenderness over the dis- tended colon, also tenesmus ; vomiting may be absent The meteor- ism is very great, and peritonitis soon becomes a complication. The * Clos, De r Invagination intestinale, etc., Paris, 1883. ^ Fagge, Practice of Medicine, vol. ii. ■ Fitz, 'Acute Intestinal Obstruction, Transactions of Congress of American Physicians and Surgeons, vol. i., 1889. DISEASES OF THE INTESTINES AND PERITONEUM. 547 constipation is absolute. Tenesmus and dyspnoea are not infrequent. It is commonly met with in men after forty years of age. Obstruction by a large gallstone is apt to occasion severe attacks of colic as the gall-stone passes along the course of the small intes- tine, and is temporarily arrested. There is also vomiting, but no de- cided abdominal tenderness, and no tumor. Similar but less severe symptoms may happen, with periods of entire relief, until the gall- stone becomes impacted, and the constipation absolute. We shall be greatly assisted in the diagnosis by the history of previous biliary colic, particularly if the symptoms are met with in a fat, elderly woman.* The signs of intestinal stone, or enterolith^ are those of a gradual and chronic, and not of an acute, obstruction. Obstruction from the swelling of a foreign body that has become impacted in the intestine can only be discriminated by the history. There are other and rarer forms of lesions than these discussed as leading to acute obstruction, especially connected with the different results of adhesions and matting together of the intestinal coils, but there is nothing in the symptoms to guide us in deciding on the exact nature of the obstacle. Chronic obstruction of the bowel is generally produced by fecal accumulations, by chronic intussusception, or by strictures. Chronic obstruction from fecal a/scumvlaiiona occurs chiefly in women, espe- cially neurotic women. There is the history of a long-standing con- stipated habit, with attacks, perhaps deceptive, of catarrhal diarrhoea, produced by the irritation from the hardened faeces, with oflfensive breath, at times with slight fever. Pain and vomiting occur as late symptoms, and a tumor or tumors are noticed in any part of the large intestine. The tumor is usually painless, and has a doughy feel ; the abdomen is very distended; but, except the occlusion be low down in the descending colon, there is no tenesmus. The consti- pation gradually increases, and, unless relieved, becomes insuperable. Fortunately, it generally can be relieved. Chronic intussusception may extend over months. The symptoms are much the same as in the acute form, save that tenesmus is less common. Tumor, as in acute intussusception, is present in about half the cases. Paroxysmal pain and diarrhoea are generally promi- nent, vomiting is not. Blood is frequently passed with the stools. The patient is apt to die from exhaustion. Stinctures of the bowels are generally cancerous. They mostly occur after the age of forty, and are of slow development. The ob- * Fagge, Practice of Medicine, vol. ii. p. 210. 548 MEDICAL DIAGNOSIS. struction is shown by the alteration in the shape and size of the fecal discharges, which become flattened. But this is far from an invariable rule. In the majority of cases the stricture is at the sigmoid flexure, and often at its lower part. There are paroxysms of pain, disten- tion of the abdomen, and attacks of constipation that become more and more protracted until obstruction occurs, unless death take place previously from the cachexia. Vomiting happens only as a late symp- tom. Tenesmus, bloody discharge from the bowel^ and hemorrhoids are often met with. Treves ^ states that tenesmus is more maiked early than late in the disease. In malignant cases we can generaDy feel a tumor through the abdominal walls. If in addition to the symptoms enumerated, a bougie passed into the rectum meet in its course with a decided obstacle, an error in diagnosis is hardly pos- sible. When, however, the stricture is not accessible to instrumental examination, although we can commonly recognize its presence, we cannot fix its site. The distention above the narrowed part is often so extreme as to lead to displacement of the colon and to an almost uniform swelling of the whole abdomen. For instance, in a case re- ported by Albert H. Smith, the enormously dilated colon had broken loose from its attachments and concealed the rest of the viscera. It was in several places eighteen, in none less than fifteen, inches in circumference.* Other causes of stricture besides cancer, though less common ones, are cicatrization of extensive syphilitic, tuberculous, or dysenteric ulcers. Save in the tuberculous form, there is not marked cachexia, and a tumor can rarely be felt. Obstruction produced by the pressure of tumors external to the bowels cannot be distinguished from that due to intestinal stricture, except it be by the antecedent circum- stances. In all cases of constriciion of the »maU intestine^ however caused, there are signs of indigestion and colicky pains. Tenesmus does not happen, but vomiting is more common than in stricture of the large bowel. A contraction in the small intestine is seen chiefly as the result of chronic peritonitis binding down the bowel, and may lead, like a. stricture, to chronic obstruction.' Fecal accumulations also produce chronic obstruction. With reference to the frequency of the different forms of intestinal obstruction, the elaborate studies of Fitz* give us valuable infonna- * Article ** Intestinal Obstruction/' Allbutt's System of Medicine. * Proceedings of the Pathological Society of Philadelphia, Dec. 1858, vol. L ' Fagge, Guy's Hospital Reports, 3d Series, vol. xiv. * Transact, of Congress of Amer. Phys. and Surg., vol. i., 1889. DISEASES OF THE INTESTINES AND PERITONEUM. 549 tion. Strangulation is the most frequent cause of acute obstruction, occurring in fully one-third of the cases ; a number are noted as fol- lowing operations upon the pelvic organs in women, though the dis- ease is very much more common in men than in women. Intussus- ception comes next in frequency, and is especially seen among children and young adults. Volvulus or twist is mostly encountered in men, and in half the cases is in the sigmoid flexure. Strictures and tumors, that are such usual causes of chronic obstruction, very rarely lead to acute obstruction. Treves,* from an examination of the records of the London Hospital, regards the cases due to fecal accumulation as the most numerous, and those caused by intussusception as more common than those from strangulation. In any kind of obstruction the location of the legion is difficult to determine. There are, however, a few circumstances which may aid us in arriving at such a determination : one is the fact pointed out by Barlow,* that the higher up the obstruction is in the canal, the nearer therefore to the stomach, the smaller is the quantity of urine passed ; another is the early and more persistent occurrence of the vomiting and its want of stercoraceous character, — both of which render it likely that the impediment is in the small intestine and remote from the caecum. Another is the early presence and the greater severity of hiccough when the mischief is in the small intestine, and the greater constitutional disturbance. Another is the absence of tenesmus ex- cept in acute intussusception. Yet another, that by far the largest number of cases of acute obstruction have the lesion in the small intestine, while in the chronic ones it is generally in the large bowel. Sometimes the patient is himself aware of tlie exact seat of the cause of his suflfering; he notices that the injecting tube or the enemata seem to reach a certain point and go no farther ; so, also, with the rumbling of the wind. Again, these borborygmi are especially apt to occur in obstructions of the lai^ge intestines, and, if joined to tenesmus, are signs of some importance. Indican is found in the urine in greatly increased quantities in stoppages of the small intestine. We may also be able to come to some conclusion about the seat of the lesion by finding out how many quarts of warm water we can inject into the large intestine. The location of the pain, too, may furnish a clue to the position of the impediment. If this be in the small intestine, the pain is apt to * Loc. cit. ' Guy's Hosp. Rep., 2d Series, vol. ii. Brinton accepts this statement only in so far as the amount of vomiting, which is apt to be greatest when the obstruction is high up, influences the amount of urine passed. 650 MEDICAL DIAGNOSIS. be chiefly, if not entirely, in the neighborhood of the umbilicus. Another circumstance on which some stress may be laid is the disten- tion of the intestine above the point of intussusception. Indeed, this distention may occasion a visible fulness, sounding extremely tym- panitic on percussion ; at times, too, a slight dulness is found, attended with some resistance at or immediately above the seat of the obstruc- tion. But neither the swelling nor the tympanitic dilatation of the bowel — ^as William Brinton^ has proved — is a certain sign; indeed, with the exception of a tumor dull on percussion and resistant to the touch, there is nothing absolutely indicative of the lesion being at a particular spot. It is hardly necessary to say that a swelling of this kind cannot always be found. Pain and swelling in the right iliac fossa may be caused by an appendieitia^ and the constipation which may attend is most obstinate and in some instances incurable, causing the disease to enter into the category of intestinal obstructions. We have already, when treating of appendicitis, discussed the diagnosis between this and intestinal obstruction. It is in appendicitis important to note that should the constipation have become unyielding, the tumor and the other local signs do not follow the insuperable constipation, but precede it Stress may be laid upon the occurrence of the signs of collapse in perforative appendicitis^ though these may be slow in their develop- ment. In a^eute hemorrhagic pancreatitis there may be also the signs of intestinal obstruction, not to be distinguished except perhaps by the history, the extremely rapid course of the disease, and the marked peritonitis. Symptoms like those of intestinal obstruction may also result from occlusion of the mesenteric arteries by thrombosis or embolism, in con- sequence of atheroma or inflammation of the vessels, arteriosclerosis, or valvular disease of the heart. There may be besides severe ab- dominal pain, vomiting that may become stercoraceous or bloody, tympanites, and signs of collapse. Instead of constipation or in its sequence there may be diarrhoea, with bloody stools. Sometimes a tumor may be palpable. The affected portion of bowel may undeip) ulceration or gangrene. Habitual Constipation. — This is a chronic state, unattended with urgent symptoms of any kind. Yet it is an annoying and very prevalent complaint. The symptoms encountered, independently of the rare and difficult fecal evacuations, are headache,* giddiness, slug- gishness of mind, a want of the natural appetite, anaemia, cutaneous ^ Crooiiian Lectures, and work on Intestinal Obstruction. DISEASES OF THE INTESTINES AND PERITONEUM. 551 eruptions, and, joined as the disorder not infrequently is to derange- ment of the stomach and of the biliary secretion, digestive disturb- ances and a sallow complexion : an altered state of the blood from the absorption of ptomaines may exist. In women there are also often added to the list of evils to which costiveness gives rise, neuralgic pains, palpitation of the heart, cold feet and hands. Infre- quent evacuation of the bowels does not always produce such un- pleasant consequences. It may, indeed, in individual cases be com- patible with perfect health ; for what is costiveness in one person may be a natural state in another.* Habitual constipation is produced by various causes. It may be brought about by the peculiar nature of the diet. It may depend upon a deficiency or a feulty composition of the intestinal secretions, or upon disorders of those neighboring glands which pour their secre- tions into the intestines. It may result from impaired power of the bowel to propel its contents, the consequence either of some mechan- ical interference with its action, or of nervous influences, or of expo- sure to the poisonous eflfects of certain substances, as of lead. To particularize the numerous conditions which furnish illustrations of each of these different causes would serve no useful purpose. A few only need be specially noticed. We have often to treat constipation in those who are dyspeptic and suffer from piles. In them thfire is, in all probability, some con- gestion of the portal system, and not infrequently a constant derange- ment of the flow of blood through the liver. The normal secretion of intestinal juices is interfered vnth, healthy bile is not supplied, and costiveness results. A similar . congestion of the intestinal mucous membrane has its share in producing the constipation which is en- coimtered in disease of the heart. Sometimes, however, enough healthy fluid is poured out within the intestine ; but the inclination to go to stool is resisted, and the liquid that has been mixed with the matter to be voided is reabsorbed. The influence of the nervous system on the alimentary tube is shown by the confined state of the bowels which attends excessive intellectual exertion and violent emotions. And when these states are protracted, they lead to a permanent and annoying debility of the intestine. The colon especially becomes torpid in its action, and all the evil results of constipation show themselves in the most marked degree. Not that an atony of the bowel is always due to psychical * In the American Journal of the Medical Sciences, Oct. 1874, a case is reported in which the constipation lasted eight months and sixteen days. 552 MEDICAL DIAGNOSIS. agencies. Any disorder which induces loss of power in the muscu- lar fibres may give rise to it. We find it in anaemic persons and in those who lead, so far as bodily exertion is concerned, a sluggish life. In some cases — fortunately rare — the weak intestine distends greatly, and becoming unable to propel the accumulated faeces, in- superable constipation occurs. The same complete paralysis of the tube may be brought about by chronic lesions of the brain or spinal cord. Among the diflferent oi^ganic changes in the intestine which, by in- terfering mechankaUy with the peristaltic wave, set up constipation, we find distention of the tube, with atrophy of the muscular fibres ; va- rious infiltrations into the walls, producing a narrowing of the caliber, as in carcinoma ; and adhesions between the serous coats of the in- testines, or between these viscera and the parietes. Of the first, it need only be said that the symptoms are due to the same paralyzed condition of the intestine, whether complete or incomplete, which has been already considered, and which is recognized, so far as it can be recognized, by the history of the case. The second group embraces those infiltrations which result from inflammations, and new growths of different kinds which lead to strictures, and then the peculiarities in the form and size of the faeces, the gradual wasting and exhaustion, and the extreme costiveness, deepening gradually into invincible constipation, furnish a key to the grievous nature of the affection. When the constipation arises as the result of peritoneal adhesions, there are sometimes signs in the case — such as tenderness at a par- ticular spot from still existing inflammation, or partial distention or retraction of the abdomen — which point out its nature. In the ab- sence of these, the history is our only guide, except in those instances in which, as Bright* first informed us, a peculiar sensation is commu- ni(!ated to the touch, varying between the crepitation produced by emphysema and the feel derived from bending new leather in the hand. From long-standing constipation stercoral ulcers may arise. The sacculi of the colon are filled with little, hard, fecal balls, which irritate the mucous membrane and produce ulceration. Mucus, or muco- pus, with stains of blood, is occasionally discharged with the small scybala, and at times there is diarrhoea. * Cases Illustrative of the Diagnosis of Adhesions and other Morbid Changes of the Peritoneum, Med.-Chir. Transact., vol. xix. DISEASES OF THE INTESTINES AND PERITONEUM. 553 Disorders in which Morbid Discharges from the Bowels occur. Matters verj' unlike the healthy alvine evacuations are often voided from the intestinal canal: loose watery stools, large quantities of mucus, pus, or blood, may be discharged. The disorders which occasion these discharges may be here described. Diarrhoea. — Like constipation, diarrhoea will be merely treated of as we meet with it constituting the entire ailment, or at all events its most prominent symptom. There are several varieties of diarrhoea. Difiference in time gives rise to marked varieties, — to an acute and to a chronic form ; and of both it has been already pointed out how often the lesion is an intestinal catarrh. Acute Diarrhoea, — ^Acute diarrhoea proceeds from more than one cause : it may be excited by the irritating character of the food taken, or by impure water ; it may be brought about by the morbid nature of the secretions poured into the intestines; it may be owing to atmospheric influences, — to heat, to moisture, to contaminated air ; it may be caused by chilling of the surface of the body, or by irritant poisons, retained faeces, or worms. It may be occasioned by pyaemia and septicaemia, by reflex irritation, as in dentition, or by mental emotions, and especially by fear. Sometimes it occurs in an epidemic form due to some unknown miasm. Its symptoms are thirst ; abdom- inal uneasiness ; griping pain in the bowel ; pallor ; slight debility ; and frequent fluid alvine evacuations, which may finally become almost colorless. In the diarrhoea caused by a debauch or by indigestible food, nausea and a furred tongue are added to the list of symptoms men- tioned. This kind of diarrhoea is generally of short duration. It is an effort of nature to get rid of obnoxious matter ; and when this is effected, the looseness of the bowels ceases. The variety of diarrhoea under consideration sometimes goes hand in hand with a disturbance of the biliary functions, and the stools discharged are fetid, and present the appearance generally described as bilious. This " bilious diarrhoea," too, is not uncommon in persons whose livers are habitually slu^ish. It is also frequently encountered during the hot months of summer and early in the autumn, and has a tendency to run on. There are cases of diarrhoea attended with pain, considerable soreness to the touch, and, what is not ordinarily met with in diar- rhoea, some febrile disturbance. These kinds of acute diarrhoea, or rather of acute intestinal catarrh, or of muco-enteritis with diarrhoea 554 MEDICAL DIAGNOSIS. as a symptom, are often the consequence of irritant poisoning, or are common as the result of the influence of cold, or of acid drinks and unripe fruit. They are also observed as secondarj' disorders in tlie exanthemata. Chronic Diarrhoea. — In chronic diarrhoea the lesions encountered are much more marked than they ever are in the acute form. The mucous membrane is tumid and discolored ; its follicles are not infre-, quently ulcerated. Chronic looseness of the bowels originates in a diarrhoea which is permitted to continue, either from n^Iect or be- cause the patient remains' for a long time exposed to the original cause. The disorder is apt to prove rebellious. When of long standing, the patient becomes gradually weaker and weaker, and more and more emaciated. The abdomen is sunken ; the complexion is pale ; the eyes are surrounded by a leaden ring. The character of the dischaiiges is various. They are often dark-colored and very offensive. The irri- tability of the intestines never intermits. Perhaps the most persistent irritability of the intestines is found in the diarrhoea to which soldiers are so liable, and which is apt to pass, no matter what its beginning, into the chronic form of the dis- ease. This complaint, which follows impure water, defective diet, exposure, malaria, and scurvy,^ which is generally associated with a morbid state of the lai^ge as well as of the small intestine, and which combines therefore some of the features of chronic dysentery with those of chronic diarrhoea, is one that often clings to its victim through life : many a soldier, in truth, escapes the bullet and the sword, only to die of the intestinal affection long after his return to his home. But chronic diarrhoea, as the practitioner of medicine commonly sees it, is often attendant on general constitutional affections, or on abdominal diseases that have led to a secondary disorder of the secre- tions, or even of the coats of the intestine. Thus, we find chronic looseness of the bowels in scurvy, in pyaemia, in Bright's disease, in scrofula of the mesenteric glands, and in tuberculosis. In the last of these complaints the diarrhoea may be occasioned by changes in the secretions of the intestinal glands ; but it is not seldom dependent upon a true tubercular disease of the intestines, which, like the disease of the lung, leads to softening and ulceration. The dischaiges are generally copious and very offensive, and .show traces of blood. The diarrhoea is continuous and intractable ; the abdomen is retracted, and * Woodward, Outlines of the Chief Camp Diseases, p. 253 ; see also the elab- orate analysis of the alvine fluxes in vol. ii. of the splendid ''Medical and Surgical History of the War of the Rebellion/' Washington, 1879. DISEASES OF THE INTESTINES AND PERITONEUM. 555 presents spots very tender to the touch. There are marked fever and emaciation, and there may be severe intestinal hemorrhage. Yet, after all, only the signs of tubercle elsewhere furnish any positive in- dications by which the true nature of the wasting malady can be dis- cerned. Indeed, it may happen that the reverse of diarrhoea occurs ; for acute primary miliary tuberculosis may simulate an acute intestinal obstruction.* In all cases of suspected tubercular diarrhoea the stools should be examined for tubercle bacilli, and these will be found very generally. Tubercular ulceration is the most prominent type of ulcerative enteritis. But ulceration of the bowel is also met with under other circumstances. We find it in the diarrhoeas of children; it occurs then ssfoUumlar ulceration. Ulceration is also occasionally observed from cancer, or as a solitary ulcer leading to perforation. The seat, of the latter is generally the csecum or colon. Albuminuric ulceration, the careful analysis of Dickinson* shows, is almost invariably asso- ciated with contracted kidney. Simple ulcerative colitis is usually met with in middle-aged persons. It lasts generally about two months,* and is ushered in by abdominal pain, which remains a symptom. There is diarrhoea with very thin movements, but there are no dysen- teric stools ; blood in the dischaiges is common. The diarrhoea may alternate with attacks of constipation ; often there is vomiting. The disease may lead to perforation. Unhealed typhoid ulcers form another variety of ulceration of the bowels. In the diagnosis of all forms of intestinal irritation, we must lay stress on the diarrhoea, on the character of the discharges, on the pain, and on the occurrence of hemorrhage from the bowels. In the discharges, mucus and pus and shreds of tissue are valuable signs. In follicular ulceration little sago-like masses of mucus are met with. The stools may be very frequent; this is especially the case if the ulcer be in the lower part of the colon. Abdominal pain may or may not be associated with tenderness. Pain, as in other forms of colitis, is often referred to the praecordial region. With reference io the frequency of this, Potain* tells us that, of one hundred persons complaining of heart disease, about seventy have an affection of the colon. In the chronic diarrhoea 4>f strumous children there is sometimes a » Thoman, Allg. Wien. Med. Zeit., 1887. ' Med.-Chirurg. Trans., vol. Ixxvii., 1894. • Hale White, Guy's Hosp. Reports, 3d Series, vol. xxx. ♦ L'Union Medicale, Nov. 1894. 656 MEDICAL DIAGNOSIS. scrofulous infiltration into the intestinal walls, sometimes marked scrofulous enlargement of the mesenteric glands, sometimes both, but in some cases neither. Improper nourishment may be here, as in any other form of the diarrhoea of childhood, the exciting cause of the continued purging. At times chronic diarrhoea assumes an irUennittent type^ and its malarial nature is clearly proved by the readiness with which the disorder yields to quinine.^ In this respect malarial diarrhoea differs from a form of diarrhoea we sometimes encounter, in which the pain and discharges come on at an early hour of the day and cease towards evening and during the night. Another form of looseness of the bowels is the membranous. Here the discharges show shreds of membrane, either in connection with the loose stools, or sometimes in such quantities that the whole mass voided seems to consist of them. Griping pains and tenderness usually precede this kind of diarrhoea, which may happen in attacks of a subacute form, or as a persistent and very obstinate disorder: the former variety is the more common. The fecal dischai^es are loose, but occasionally there is constipation. The disease is often associated with peculiar hysterical symptoms or occurs in neuras- thenics. The so-called membranes, in this membranous enteritis, contain a lai^e amount of mucus, as I have elsewhere described.* Dysentery. — Frequent and painful passages of mucus mixed with blood, accompanied by straining and bearing down, are the charac- teristic symptoms of dysentery. In the acute form we find thirst, restlessness, and fever superadded ; and sometimes, especially when the disease prevails epidemically, those symptoms of prostration which are commonly designated as typhoid. Acute Dysentery. — ^The acute disorder is at times ushered in by a chill ; at times it is preceded by diarrhoea. The fever which attends it is not generally intense. It is the exception to find it exceed 103^, and in light cases the temperature is only slightly raised ; the pulse is not tense. More or less pain is always present; it has its seal mostly at some part of tlie colon, and this is tender on pressure. It is intermitting and shifting, and is often accompanied by a feeling of weight near the anus, which causes a continual desire to go to stool. Yet no relief follows the frequent attempts ; the violent straining only adds to the discomfort. * See contribution by Sanford B. Hunt on Diarrhcta^ in Medical Memoirs of the U. S. Sanitary Commission, p. 306. ' American Journal of the Medical Sciences, Oct. 1871. DISEASES OF THE INTESTINES AND PERITONEUM. 557 The matters voided are small in quantity. They consist of blood mixed with mucus ; yet they are composed not simply of mucus, but also of leucocytes, granules, and large quantities of cast-oflf epithe- lium, with many swollen, round or ovoid epithelial cells. The stools are in some cases highly oflFensive, and resemble the washings of meat : in others they are like jelly, or greenish in color. They do not contain faeces, or only here and there small, firm lumps of fecal matter. When the dysenteric inflammation subsides, the bowels are unloaded of their contents ; in consequence, the passage of quantities of small, hard masses of faeces is generally a sign that the acute malady is inclining to a favorable termination. Sometimes the stools are very dark and slimy and have a putrid odor, and here and there pieces of sloughed-oflF tissue can be detected. This kind of stool marks the diphtheritic or gangrenous variety of the malady, though it is not constant even in this. How long it will take for the disorder to run its course, or whether the acute disease will pass into chronic dysentery, cannot be fore- told. Generally this is not its termination ; it very often ends, within a week from its beginning, in recovery. But severe cases occur which are of much shorter duration, in which the symptoms hasten on to complete prostration, and death takes place early in the malady. In these frightful cases — mostly epidemic — collapse may happen with almost the same rapidity as it does in malignant cholera. Dysentery is essentially a disease of hot climates. Eating green fruits, exposure to a chilly night after a hot day, and sleeping on damp ground, are prolific exciting causes. It is occasionally found in com- bination with malarial fevers, or with scurvy. It also occurs from drinking water full of impure substances or micro-organisms, aird is thought to have a bacillus of its own. It may be seen in a sporadic or in an epidemic form. It is very common in armies and in jails. The immediate cause of most of the symptoms is inflammation of the large intestine, and especially of the descending colon. Yet in many cases of dysentery we see phenomena manifested which are clearly not to be accounted for solely by the local morbid appearances, and which show that dysentery mostly belongs to the infectious maladies. In truth, inflammation of the colon may give rise to the symptoms of acute diarrhoea ; for it is a great mistake to suppose that the cause of diarrhoea is to be sought only in some abnormal change in the small intestines. Thus, colitis is not always dysentery ; and dysen- tery is often more than mere colitis. * But, whatever be the ultimate cause or the form of dysentery, we find that it presents peculiarities which render it easy of recognition 35 &M MKDICAI. DIAGSOeia A the bedride. Yel we moit lake food care to ascettaia thai tfae wappoteA ^haatieri^&c teDesmoB mod hUtodf iSmAmgss wn mA reaUfy ^ ammg to pitm^ or to moriiid, especially canceroiBt growtlis in or to onfinafj' liiiHli*d fnHiinfiiatioD tlienL Id the or proeSBBf that h ntodi pun iriieii tfae hardened diiflianpd^ the redom b farced down dnfu^ the efforts^ the i ter eontniets ipannodicallf . Sliai^giiiy and heniQRfaoids are oneoBinion ijniploais ; and, as the eooseqoenee of the inflammation^ eslendinf to the parts artMind the anns, an abseeas wMf foUow. Redal pain often extends to the th%hs. Dyientery is not ^ to be confomided with rfjorrftoKS* This dif- iSeri easentialij from dysentery by the liquid fecal eTscnatioiis, and by the fiict that neither tenesmus, nor bloody stools, nor discharges or mncos occur. Yet in practice we meet with cases which twgin wHh diarrbcea and terminate in dysentery, or befm with dysenteric s]finp- toms and terminate in diarrhcea^ and in which it becomes^ lberefore^| puzzling to say which disorder we are dealing vnHk, There are some clinical varieties of dysentery which it is impor- tant to separate. The ordinary form seen in temperate climates to follow errors in diet or exposure is the catarrhal form. In tropical climates, where dysentery is ver)' common and is met with frequently as an epidemic, we find mostly a kind that is characterized by the presence of the amcAa coli, or amcFJm djf^enimas^ as Councilman and Lafleur' call the micro-organism. Anhoebk dysentery does not^ as a rule, run so rapid a course as ordinary catarrhal dysentery, and local tissue degenerations in the liver, or abscesses of the liver, are com- mon attendants. The abscesses, like tlie discharges from the bowels, contain amoebte. The evacuations, as the disease progresses, lose their dysenteric characteristics, except the mucus, and become very liquid ; the tenesmus disappears. The amoebse are most active in alkaline stools. The diarrhcea has marked exacerbations and remis- sions, and is attended by striking anaemia. The fever is very mod^ erate. In some instances hemorrhage from the bowels, in oUiers peritonitis, happens. It is not unusual in protracted cases for the urine to become albuminous and to contain casts. In tropical climates, too, though also seen elsewhere in persons who have low forms of pneumonia, or who have become cachectic from scurvy, rroin Bright's disease, or from long-standing disease of the heart, a form of dysentery attended by extensive exudation and sloughing of the membranes is met with. The diphiheriUe dysentery^ * Johns Hopkins Hospital Heports, vol i\. DISEASES OF THE INTESTINES AND PERITONEUM. 559 as it is called, has generally h%}i fever, much abdommal pain, great I iro.st ration, and delirium. The discharges are very frequent ; the blood gi*adually disappears from Uiem, Vomiting, especially at the onset, is common. In the progress of the case, which is geneially to a fatal issue, the temperature becomes iiTegular, and hiecoogh is not imcommon. Chronic Dysentejy, — We rarely see chronic dysentery without chronic diarrhoea. At all events, w^e seldom find instances of the former in which the tenesmus and the discharge of blood and mucus mixed with pus are not accompanied by frequent loose alvine evacua- tions, by griping, by the same gradual wasting and the same irrita- bDity of tlie bowels as are encountered in chronic diarrhcea ; nay, the symptoms of the latter may so obscure the true nature of the malady that what has been regarded as chronic diarrhtea turns out, at the autopsy, to be clironic dysentery. The mucous membrane of the colon is found to be extensively mflained ; its texture altered ar*d irregularly thickened; its surface riddled with ulcers. In such cases the patient goes on steadily losing flesh, and has some elevation of temperature; but no pain on pressure or localized distress exists to denote the ravages tlie disease is making in the alimentary tube. Many die from exhaustion ; others, in consequence of abscess of the liver, which chronic as well as acute dysenter>^ may induce. Intestinal Hemorrhage, or Melasna.— This is commonly the result of a mechanical hinderance to the flow of blood througli the liver, as in cirrhosis, or of disease of the heart, or of a ilepraved state of the blood, — such as exists m typhus fever, in yellow fever, in sciu-vy, or in purpura. Occasionally the bleeding proceeds from a fungoid growth in the intestine, or from an ulcer in the duodenum or ilemn, or trom an irivagination, or from fecal impaction, or from an amyloid degenemtion of tlie mucous membrane of the bowel, or is due to a disease of the spleen, or to bursting of an aneurism, or follows extensive burns of the iibdommal parietes. In very young infants a discharge of blood, boUi by the mouth and by the rectum, is not unusual, Tlie blood passed by stool is generally of dark color, like tar. Wlien it is not, we may infer that it flows from the lower part of the intestine and has not had time to become admked with otlier nat- ters. In all such cases, however, w'e must make sure that it does not proceed from hemorrhoids. The exact seat of the hemorrhage cannot be determined ; nay, blood may be evacuated by the bowel and not be poured out at all from the intestine, but from the stomach. In some instances the blood acemuulates in the bowel, and, before Ui4r rUj^M ttiOuUU^i io iU f^lAi»|A are discbai^ed, death resiiht. 'Viki ih' iiWu^'iitu, \friMAtitiU from li/f^rrjorrtioids it is seldom TkariciiE.- In |/'/i/it of tihi^i'pm the first ttiirig to determiae is. that viia h %ik\Hptt^'A (/> titf; t/l'/^MJ i» really blood. Very dark bOioiE sictuiL a: tji/z'/lii lAiukiihitii Uy Iron, riiay niiidead. If doubt exisL wai*rj 51i(»uil b<; iHttinA hu \Ui* HijuA, iUii\, when blood is present, a reddkib liuij^ ^ ifiiparli'l to the wati?r; yet more accurate is it to examine -kxi iiit niirr/>ii/'0|/i; or the n\HH'irim:u\Hi. Wi*. next have hi ai^;eriain the disease with which the iplesr^^. heniorrhnKe in uMirxiated ; and this is often a very difficult Taking. We immi lay the ^eal<*st stress on the history of the case, look fcf the roniplainU — of whuJi most have been above mentioned — that arv ttjil to Klve rise hi the hieedinjf, especially investigating for cirrhosis of the liver; H(*an'hui(( for intestinal ulcers in connection with typhoid fevi'r, or tuherriiloHlH, or a duodenal affection; or examining for the iwiilenn* of scurvy in the ^unis and skin ; or for purpura with its i'hiiriM'leriHlic HpolH ; or for splenic enlargement^ the result of chronic niuluriii or of amyloid degt^neration. Embolism of the superior mes- eiiU^rir uriury may also occasion intestinal hemorrhage. But unless wn liiivr with Ihe bloody stools marked abdominal pains, peritoneal nxudullon, and ohvlouH-causing elements of embolism, or signs of it elnrwlui'e, IhJH diagnosis is most uncertain. Patty DlarrhoBa. — In some cases in wliich fatty matter is voided by tin* lu»Nvel, oil is at the siuue time passed with the urine; in others llu^ urinary necivtion is healthy ; some cases end fatally, others in re- et»vt»ry ; stuiie nw found to be coimected with a disease of the pan- ciH'Us, othei's ai*e not; in some the disorder is not of long continu- uni't\ while in othei^s it lasts, with uitervals, for years. As a rule. tht* tu'iUHH^nct^ of I'allv stools is a matter of serious concern. The ivii>^hiliou of the uuilady is tnisv. The white, fatty masses, or the oily matter which collects on the discharges, are soluble in ether, dna ^w it^ulily pixA'tni to be fat by the microscope. In some instmce:? tho bo\\els aiv consti(KittHt« and lum^^s of hard Gaeces are dischaiTt^i aUu^ with tlie fattv sidvstance. Ttus liappened in a marked example i»f the dis\tr\ler that came under my observation. The patienL a mac K^( tw\ntty-si\ yt^irs of u^\ ^msseil a considerable amount of &t. both k>\ the ivctum and with the unue. Me suffered much firom diiceubUu Hi.«pibil Reports toL L, ukI a 3»- ivaibi\ \lt\iic,U \.ia^^cu\ w^L i\. * Uv oa the Kcvtum. DISEASES OF THE INTESTINES AND PERITONEUM. 561 appetite, but a dislike to fats of any kind. In his case there was, as far as the other symptoms and the physical signs indicated, no tmnor in the region of the pancreas. The man's condition was much im- proved by careful diet and the administration of cinchona and rhu- barb ; but whether permanently or not I cannot say, as I lost sight of him. I have also met with instances of fatty diarrhoea associated with saccharine diabetes and with disease of t^e pancreas. In examining into the subject of fatty stools it must be borne in mind that the clay- colored stools of jaundice, owing to the absence of the emulsifying properties of the bile, contain considerable fat, which may be found in oil-drops or as fine needle-shaped fat-crystals. Diseases attended with Vomiting and Purging. There is a group of diseases in which vomiting and purging are very prominent symptoms. The most important of these are the various forms of cholera. Now, there are several very different com- plaints classed together under the head of cholera. Cholera Infantum. — And first, of the so-called cholera of in- fants. It is an endemic in the larger cities of the United States during the hot months, and one fraught with danger to all young children. It begins generally with diarrhoea. Vomiting soon follows ; and for a time the two go hand in hand ; but, unless the case be of short dura- tion, the spontaneous vomiting ceases, or at all events gives way to occasional exacerbations of irritability of the stomach, while the looseness of the bowels remains, or even augments. The discharges are colorless, or yellowish, or greenish. There is thirst ; sometimes fever. The abdomen may be sunken or swollen ; and it may be tender. Sometimes the disease runs its course within three or four days, at the end of which time the child dies, worn out by the con- stant vomiting and purging. More generally the disorder is of longer duration ; for weeks or for months it continues, the diarrhoea im- proving and then returning with redoubled severity, and kept up or increased by the irritation of teething. The irritability of the intes- tinal canal, and the utter impossibility of retaining enough food to nourish the wasting body, gradually wear out the system. The child before death is wan and distressingly emaciated ; sometimes hypo- static congestion of the lungs, broncho-pneumonia, boils, suppression of urine, plaintive cries, rolling of the head, strabismus, and coma precede the fatal termination. Such is a sketch of grave and intractable cases. Yet very many cases are far from being desperate. Under judicious treatment a 562 MEDICAL DIAGNOSIS. large number are annually saved. Recoveries would bear a still higher proportion to the deaths were it not that the greatest suflferers from the disease, the children of the poor, are unable to obtain the means most certam to restore them to health, — change of air. Ck)oped up in crowded neighborhoods, surrounded on all sides by filth rapidly decomposing under the burning rays of the sun, they are compelled to breathe the hot, noxious atmosphere which, if it do not produce, is certainly a decided agent in keeping up, the complaint The disease is an entero-colitis from milk-infection leading to bac- terial fermentation in the intestines, with enlargement of the solitary glands, and even at times of Peyer's patches. The researches of Vaughan have demonstrated that a ptomaine appearing in nulk, tyro- toxicon, is its most frequent source. Temporary diarrhoeas in chil- dren occurring in hot weather could alone be mistaken for the dis- order. But the fact that they are temporary, not followed by vomiting, and not associated with the grave symptoms of approaching collapse, shows us the difference. Cholera Morbus. — This, or cholera nostras^ is, like cholera infan- tum, a disease of the hot season ; yet it is also observed at other times of the year. But, although the chief predisposing cause is undoubtedly heat, there is generally an exciting cause which develops the disorder, — such as exposure, checked perspiration, drinking lai^ge quanties of ice-water, or imprudence in eating. The attack is char- acterized by spasmodic pains in the abdomen, by cramps in the legs, by rapid loss of strength, and by repeated vomiting and pui^ging. The matter ejected both from the stomach and from the intestines b liquid, and contains a large quantity of bile. In truth, the aflfection is in reality a cholera, a flow of bile, which its more formidable name- sake, Asiatic cholera, is not. Finkler and Prior have found in the stools a comma bacillus, vibrio proteus, which is larger and thicker than the bacillus of Asiatic cholera, but with shorter spirilla, and cul- tures of which, unlike the latter, rapidly liquefy in gelatin, and grow- on potato even at ordinary temperatures. Cholera morbus may be preceded by colicky pains, nausea, and rumbling in the intestines. More generally it comes on suddenly. When at its height, the cramps in the calves of the legs cause the muscles to rise up in hard, knotty masses ; the stools are fetid ; tlie vomiting is constant ; the thirst is great, and the skin is cool or cold. But the patient does not remain long in this condition. In the course of a few hours, or at the utmost of a day, the symptoms mitigate, or yield entirely to treatment ; and, pale and visibly emaciated though he be, he speedily regains his health. Only in some cases the disease DISEASES OF THE INTESTINES AND PEBITONEUM. 563 proves intractable, and, after running on for several days, passes into a state of hopeless collapse. There are not many morbid states with which cholera morbus is likely to be confounded. It may be mistaken, as we shall presently see, for epidemic cholera. We find many points of similarity between it and irritant poison ; but there are also strong points of difference. The vomiting and purging produced by an irritant poison do not come on at the same time : the vomiting precedes the purging, and there may be bloody evacuations. The pain is first in the epigastrium, thence it may spread. Moreover, we often detect signs in the mouth or fauces which prove the irritating character of the substance swal- lowed. The vomiting and the subsequent acute gastritis are accom- panied by fever, which is not the case in cholera morbus. Cholera. — The formidable complaint known as epidemic cholera, Asiatic cholera, malignant cholera, or by the simple name of cholera, has some striking features of resemblance to the disorder just consid- ered. It shares with cholera morbus the vomiting and purging, the cramps, the sudden depression ; but it is an affection of different origin and of much more serious import, and presents symptoms not encoun- tered in the cholera that occurs yearly during the hot weather. And although, on account of the gastric and intestinal disturbances >vhich form so prominent a part of its manifestations, it is here described among the disorders of the alimentary tube, I am doing so for the sake of clinical convenience,* and contrary to sound pathology ; for cholera is not an affection either of the stomach or of the intestines ; it is an epidemic constitutional disorder of the most formidable char- acter generated by a poison transmitted to us from the East. The poison leads to a casting off of the epithelium of the mucous mem- brane of the alimentary tube ; perhaps to changes in the membrane. But the engoiiged veins all over the body ; the exosmosis of the watery parts of the blood ; the frightfully rapid prostration ; the sudden blight which befalls the nervous powers, — are elements which are even more characteristic. The access of cholera is at times sudden and most unexpected ; the patient, previously in good health, is stricken down without warning by the force of the poison. More generally there is a pre- monitorj' stage : a stage of languor, low spirits, uneasiness, headache, and diarrhoea. The effects of the morbific matter are indeed visible in hundreds of individuals who, during the prevalence of cholera, suffer from these premonitory symptoms without any of greater danger arising. Nay, the same influences which give rise to ckol- eraie diarrhoea in healthy persons have the effect of rendering the 564 MEDICAL DIAGNOSIS. bowels of those habitually constipated regular, and sometimes even loose. When the malignant disease is fiairly developed, there is vomiting as well as purging. The contents of the stomach and intestines are first voided, and then large quantities of a rather turbid fluid resem- bling rice-water, with whitish particles like rice floating in it They are the epithelial cells of the alimentary tube, which have been thrown off from the mucous membrane ; and in the dejecta we find the comma bacillus discovered by Koch. This may be seen by examining microscopically the bacilli obtained from a small amount Fig. 55. The oomma bacillus of Koch, from culture in blood-serum. Zeis9 ^ homo, im., Oc. 4. of cholera dejection that has been mixed with an equal amount of alkaline meat broth at a temperatifre of 30° to 40° C. and allowed to stand for twelve hours in an open glass. The cholera bacilli develop on the surface. They are readily stained, in about ten minutes, with a diluted alcoholic solution of fuchsin or methyl violet They are decolorized by Gram's process. After the staining, which must take place with the infected side downward, the cover-glasses are washed in water, dried with the prepared side uppermost, and mounted in Canada balsam. Prior to the staining a drop of the infected broth or a particle from a stool is dried in air, after having been rubbed between two cover-glasses and passed three times through the flame of a Bun- DISEASES OF THE INTESTINES AND PEBITONEUM. 565 sen burner. The bacilli of cholera may be recognized even without the microscope by a rose-violet color, the cAofe?-a reaction, that becomes apparent in a few minutes if a ten per cent, hydrochloric acid solu- tion is added to cholera cultures. The cholera bacillus is confined to the intestine. In the extensive observations made by Shakespeare in India and elsewhere ^ it was not detected in the blood or in the tissues or organs outside of the intestinal canal. The cholera toxine derived from the bacilli has been specially studied by Pfeiflfer. Simultaneously with the vomiting and purging, or very shortly after, come on severe spasmodic pains in the abdomen, and cramps of the muscles of the belly and of the extremities. With all this there are a burning sensation in the epigastric region ; an unquenchable desire for cold drinks ; a cool skin ; a pulse slightly more frequent than normal ; a temperature which may be normal or may fall to about 95° F. ; oppressed breathing ; and rapidly progressing exhaustion. The case now stands on the vei^ge of collapse. Should this follow, the pulse becomes hardly perceptible. The dischaiiges cease, and so do often the cramps. The skin is cold, covered with a clammy sweat, and has a bluish look. The nails and the lips have the same un- natural appearance. The whole body shrinks, and seems at times almost to wither visibly even while under inspection. The counte- nance assumes the aspect of death ; the eyes are sunken and have a glassy look. The temperature is low, it may fall below 90° ; but while very low in the mouth or axilla, it may be 103° or more in the rectum. The intellect is commonly clear; but, when the patient talks, the words fall strangely on the ear. It seems as if a corpse had spoken, and the voice is husky and faint. The tongue and the expired air are cold. No symptom, indeed, has struck me more forcibly than the icy breath. But the symptoms do not always take place in the order described, nor are they all uniformly present. The vomiting and purging may be wanting from the onset, and so too may the cramps. Only one symptom is never absent, — the tendency to early sinking. Sometimes a stage of perfect collapse is reached with frightful rapidity : instead, as is commonly the case, of several hours elapsing before complete prostration comes on, the vital powers are at once laid low by the assault of the dreadful malady. When cholera last prevailed in Phila- . delphia, I attended a woman who, at six o'clock in the morning, was in perfect health, and who, in a little more than half an hour afterwards, was lifeless. There was neither vomiting nor purging; ^ Report on Cholera in Europe and Asia, Washin^on, 1890. 566 MEDICAL DIAGNOSIS. nothing but cramps, stupor, and speedy collapse. Such cases are not uncommon in the home of cholera, — India. Post-mortem inspection shows the thin rice-water fluid locked up in the alimentary canal. Nature makes an effort to eliminate the poison ; but before she com- pletes her task, life is palsied. In those cases that recover, or in those of light character, choi- erine, the vomiting and purging gradually subside, the skin becomes warm, the pulse fuller, the abdominal pain ceases, the urine — which, while the disease is at its height, is not passed, perhaps not se- creted— is again voided, the patient falls mto a refreshing sleep, and, the symptom most favorable of all, bile reappears in the stools. Even in apparently hopeless cases of collapse we may be fortunate enough to witness these favorable changes. But, where the prostra- tion has been great, the reaction is apt to be violent. A decided fever of low type, with rapid pulse and heat of skin, and attended very often by alarming cerebral symptoms, succeeds ; and the urinary secretion, even if it had been restored, becomes again very scanty. Thus the period of reaction brings with it new dangers, and of a kind which are sometimes insurmountable. And this low form of fever, very similar to typhoid, though readily enough distinguished by the preceding symptoms, may last for upward of a week before death takes place or the signs of danger gradually yield. Now, this cholera typhoid may be preceded by scanty urine and marked uraemia, but it may also exist independently of this morbid state, though prob- ably also due to the blood being loaded with broken-down material. In cases in which uraemia sets in, whether it be followed or not by a fever of low type, there is at first but little, if any, heat of skin, and a slow pulse ; the patient is wild, restless, or drowsy ; the kidneys act very imperfectly, the urine is greatly deficient in urea, and usually contains albumin. These are very dangerous cases, and if the secre- tion be seriously retarded for more than twenty-four hours they are likely to perish. Other complications that may arise are pneumonia, pleurisy, suppurative parotitis, and protracted nephritis. In any case of cholera, convalescence is apt to be slow. For weeks or months irritability of the intestinal canal remains; and I have met with instances in which it has never disappeared. In con- valescence, too, we may find constantly recurring cramps in the arms and legs. It would be needless to go into any minute description of the dif- ferences between cholera and other affections ; its features are not to be mistaken. Cholera morbus is the only disorder which really re- sembles it. The dividing-line is drawn by the absence of bile in the DISEASES OF THE LIVEB. 567 dischaiges, the rice-water evacuations, the greater severity and more rapid progress of the symptoms, the bluish color of the surface in the stage of collapse, and the epidemic character of the more fatal dis- ease. In the presence of the cholera bacillus in the evacuations, and in the speedy collapse, lie, even m doubtful cases, the proofs that we are dealing with malignant cholera; for sometimes rice-water dis- charges occur in bad cases of cholera morbus ; occasionally, too, this disorder appears to be epidemic ; but it is only so on a very small scale. To speak more accurately, it is an endemic on a large scale. The mortality of cholera is very various. In many epidemics one- half, or more than one-half, die. In some the havoc is far less. The first cases that occur almost invariably perish ; and, taken altogether, the malady ranks among the most destructive to life. Its epidemic visitations are what the plague was to the Europeans of the seven- teenth century, and what yellow fever still is to the inhabitants of this continent. SECTION III. DISEASES OF THE LIVER. The physical characteristics of disease of the liver have been already discussed. Let us now look at some of the symptoms. Pai7i is one of these. It is generally dull, and radiates from the seat of the liver to the upper portion of the thorax, to the scapula, to the shoulder, and to the umbilicus. Commonly it is persistent and increased by strong pressure. As happens with other symptoms of disease of the liver, with vomiting, with jaundice, it may be noticed that the pain is sometimes strangely periodical, suggesting malaria, but iminfluenced by quinine.^ Digestive troubles are usual accompani- ments of hepatic affections. They are of all grades, from mere indi- gestion to the signs announcing chronic gastritis. Disturbance of the portal circulation is another frequent consequence of. disease of the liver. The flow of blood is interfered with, and the result is seen in the occurrence of dropsy, of piles, of partial peritoneal inflammation, of hemorrhages from the engorged stomach and intestines, and of enlargement of the spleen and of the veins on the surface of the abdomen. Jaundice. — ^The most significant manifestation of hepatic disorder is jaundice. This marked sign shows itself by the yellow tinge im- parted to the skin and to the conjunctiva. Besides, icterus is usually * See on this subject a paper by Cyr, Arch. Gen. de Med., May, 1883. 568 MEDICAL DIAGNOSIS. attended with depression of spirits ; with slow pulse ; with itching of the skin ; with high-colored urine, in which the main ingredients of bile can be detected, and sometimes small quantities of albumin, or hyaline and epithelial casts without albumin ; with constipation, the faeces passed being hard and knotty, and often of bad odor, and almost devoid of color, or of a leaden hue. Jaundice is due to the presence of biliary constituents in the blood ; they get there from the bile, in consequence of some impedi- ment to its outward passage, being reabsorbed and conveyed into the cu-culation ; or it happens because the liver-cells cannot perform their functions ; or because some poison changes the proper relation be- tween blood-destruction and cell-action in the liver ; or the bile pig- ments may be formed directly from haemoglobin without the agency of the liver-cells ; for this, too, is a view of toxaemic jaundice with blood-destruction that seems best to apply to certain cases. The diagnosis of jaundice is easy. The only morbid signs with which it is liable to be confounded are the slightly yellowish hue of chlorosis, or of some cachectic conditions combined with organic visceral disease, and the yellow appearance of the conjunctiva which is natural to some persons. The changed color of the countenance due to chlorosis is told by its association with a bluish-white or pearly- tinted eye, and with pale lips and tongue and transparent ear. The absence of a yellow tint from the conjunctiva is of equal impor- tance in discriminating from jaundice the yellowish hue of cancer, of malaria, of lead poisoning, and of granular kidneys. The history of the case also aids us. The yellow look of the eye sometimes found in health, and at times dependent on subconjunctival fat, is known by the unequal distribution of the color and by the absence of a yellow hue of the complexion. But in negroes — and it is in them especially that we meet with the discolored conjunctiva — we have to judge by the character of the coloration alone. In any doubtful case, the chemical tests for bile-pigment in the urine will solve the doubt. Yet there is a form of jaundice, the so-called acholuric jaundice^ in which neither bile-pigment nor urobilin is found in the urine, but in which a yellowish discoloration of the skin is very marked, and urobilin and other biliary pigments are present in the serum of the blood. It is a chronic disorder, occurring in neurasthenic and in dyspeptic persons, especially in those with hyperacidity.* The coryunctiva has only a very slightly yellowish tinge. When once jaundice has been recognized, the difficulty in diagnosis ^ Hayein, Bull, el M^m. de la See. M^d. des HAp. de Paris, May, 1897. DISEASES OF THE LIVER. 569 may be said to begin. Of the many distinct sources of icterus, which one is before us ? Now, clinically speaking, the causes may be thus grouped: 1. Diseases of the liver. 2. Diseases of the bile-ducts. 3. Diseases of parts remote from the liver, or general diseases leading to a disorder of the viscus. 4. Certain poisons acting upon the blood. In the first two of these causes there is, as it were, a mechanical dif- ficulty impeding or arresting the excretion of bile ; in the third and fourth no impediment exists. 1. The jaundice connected with diseases of the liver is, as a rule, recognized by its association with changed dimensions of the oi^an, and with pain or other palpable signs referred to the hepatic region. It is met with in all disorders of the liver, but does not exist in all in the same degree of intensity. It reaches a high development and is combined with brain symptoms in acute yellow atrophy. In fatty liver, in waxy liver, in cancer, in cirrhosis, and in acute hepatitis, it is not marked, and may be, indeed, absent : in truth, it can hardly be looked upon as belonging to the first-mentioned morbid states. The jaundice of this class of cases is due to interference with the secreting function of the liver-cells. 2. Jaundice arising from disease of the larger biliary ducts, such as their catarrhal swelling ; or in consequence of their obstruction by pressure exercised by a morbid enlargement of the adjacent parts, as of the pyloric extremity of the stomach or the pancreas ; or by tumors, aneiuismal, cancerous, or fecal, closing the orifice of the duct ; or by tumors of the gall-bladder and bile-ducts ; or by the stoppage of the ducts by inspissated bile or a biliary calculus, or by hydatids or for- eign bodies from the intestines, — is a form of the malady in which the icterus is commonly intense. The obstructive jaundice occasions no head symptoms ; and when these are absent in a case of very deep jaundice, when, further, the stools are completely discolored, we are generally correct in attributing the morbid phenomena to an impedi- ment to the flow of bile through the common bile-duct or the hepatic duct. In the jaundice due to reabsorption — precisely the form of jaun- dice, therefore, that happens if any serious obstacle in the biliary pas- sages exist — the biliary acids pass into the blood, and thence into the urine. But this is not a certain sign of obstructive jaundice ; for in the other forms of jaundice, as in the non-obstructive, they may be present, though in lesser amounts, and traces of the bile-acids may be found even in healthy urine. 3. Illustrations of jaundice following some local lesion of other parts of the body, or appearing in the course of an infective disease. 570 MEDICAL DIAGNOSIS. are furnished by the jaundice which happens in some cases of pneu- monia, or in peritonitis, or which is encountered in pyaemia, in remit- tent, in typhus, in relapsing, or in yellow fever. In these fevers the yellow hue is generally found to be connected with structural changes in the organ. But, besides the interference with the secreting action of the cells, the blood alterations in non-obstructive jaundice must be considered ; there is certainly increased corpuscular destruction. But the blood-change may, the observations of Afanassiew and others prove, lead to increased viscidity of the bile, and compression of tlie bile capillaries ; thus the jaundice is really in part obstructive. To recognize the form of jaundice under discussion, we must ex- amine all the viscera of the body with care, laying stress upon the history of the case and the phenomena attending the jaundice. 4. Poisons acting upon the blood sometimes give rise to jaundice very rapidly; for instance, the jaundice from snake-bites or from pyaemic affection is apt to be suddenly developed. As a rule, the tint is light. In the history of the accident and the signs of alteration of the blood we possess the means of distinguishing this form of jaun- dice. Certain mineral poisons, such as phosphorus, copper, anti- mony, come into the same category. Chloroform and ether, too, lead to abnormal blood-changes producing jaundice. The deep jaundice of arsenuretted hydrogen and of toluyindianin is lai^gely obstructive, caused by the irritant action of products in the bile. As a general fact it may be stated that in all these kinds of toxaemic jaundice, the icterus is apt to be light, but the constitutional symptoms are severe ; bile is not wholly absent from the stools. The urine enables us to a certain extent to tell blood jaundice from jaundice caused by liver disorder. We find, besides an excess of urobilin, haemoglobin in the urine, or get from its haematin the haemin crystals of Teichmann. These are obtained by drying urine on a slide, adding a little salt, and then glacial acetic acid under the cover-glass. The slide is heated until bubbles rise, and on cooling the characteristic blood-crystals form. Thus, then, we can bring, clinically speaking, most of the varieties of jaundice under one or the other of the four heads mentioned ; and, roughly speaking, they come really under two, — obstructive jaundice, where the disorder results from obstruction of the common duct, and jaundice without such obstruction. But there are a few kinds of jaun- dice which it is not easy to classify with precision : one of these is the jaundice from mental emotion. As regards this, no satisfactory explanation has been given. All we know is, that violent anger or fright may lead within a very brief DISEASES OF THE LIVEB. 571 space of time to the development of jaundice, and that the quickly occurring discoloration is not dangerous or of long duration. The perverted innervation caused by concussion of the brain leads to a similar kind of jaundice as that from emotion. It is thought by some that a spasm of the bile-ducts obstructs the flow of bile ; by others that the haemoglobin of the blood, instead of breaking up into normal bile pigment, may break up into abnonnal pigment, and that the icterus is really a urobilin jaundice, which gives rise to the icteric skin and conjunctiva. If icterus last upward of two months it is always a matter of some danger, as showing, m all likelihood, an organic Jesion of the liver or of the biliary passages, or unyielding pressure on them. Unfavor- able, too, is it if the discoloration of the skin be attended with cere- bral symptoms, or accompany affections of the blood, or be associated with wide-spread ecchymoses, or a very dark color of the skin. In- deed, cases of *' green" or " black" jaundice generally prove fatal. Before examining the hepatic maladies according to their clinical features, let us look at their pathological classification : Diseases op the Liver. Diseases of he- patic paren- chyma. Hyperaemia. Inflammation quences . . and its conse- Atrophy . . . . Hypertrophy . Degeneration mations . . and new for- Acute congestion. Chronic congestion. Acute hepatitis. Chronic hepatitis. Interstitial inflammation ; cir- rhosis, atrophic and hyper- trophic. Abscess. Softening. Syphilitic hepatitis. Acute yellow atrophy. Simple chronic atrophy. Red atrophy. Partial. General. Fatty liver. Waxy liver. Pigment liver. Cancer. Sarcoma. Lymphatic growths. Gummata. Tubercle. Hydatids. Simple cysts. 572 MEDICAL DIAGNOSIS. Diseases of the Liver. — Continued, Inflammation of gall-bladder ( Catarrhal. (cholecystitis) and gall- 1 Exudative. ducts (cholangitis) ^ Suppurative. Diseases of Occlusion of biliary passages. biliary pas- < Dilatation of gall-bladder. sages. Morbid growths. Foreign bodies ; concretions, such as gall-stones. Biliary fistulae. r Inflammation. Of hepatic artery } Sclerosis. I Aneurism. Of hepatic vein. Diseases of blood - ves- sels. Of portal vein j Suppurative inflammaUon. Thrombosis. Acute Disea43es of the Liver attended generally with Slight Enlargement of the Organ, and with more or less, though rarely much, Jaundice. Acute Congestion. — This arises from organic disease of the heart, from obstructed portal circulation, from irritating food and drink and disturbed digestion, from gastric or intestinal catarrh, or from malarial poison ; sometimes it is caused By a high temperature, by a blow on the hepatic region, by arrest of the menstrual flow, by a protracted chill, by violent exercise, or, as Frerichs points out, by injury to the semilunar ganglia. The acute congestion is character- ized by pain in the right shoulder and loin, by an unpleasant sensation of weight and of tension in the right hypochondrium, increased after meals, and by nausea and vomiting. At the same time the action of the bowels is deranged, being generally too frequent ; the tongue is coated ; there is flatulency, as well as depression of spirits, with loss of appetite and of strength ; and the liver is somewhat enlaiiged. But we find ordinarily only slight jaundice, and no fever. Gradually these signs disappear ; the increased hepatic dulness, however, remain- ing for some time after the gastric and intestinal disturbances have abated. These always bear a marked relation to congestion of the liver, both as cause and as effect. The acute disorder may gradually pass into a chronic hypersemia. Acute Hepatitis. — ^The symptoms of this affection are much the same as those of acute congestion, except that we observe rise of temperature, and in some cases enlargement of the spleen, and albu- min in the urine. The pain is dull, and is increased on pressure, yet DISEASES OF THE LIVER. 573 not much so, unless the peritoneal covering of the liver be involved. But acute hepatitis is not a well-defined affection, and we know little of it except in connection with dysentery, particularly with amoebic dysentery. In hot climates it often terminates in suppuration, and pus collects in the substance of the liver. The occurrence of this, the tropical abscess, as Murchison * calls it, is indicated by recurring rigors, by fever of remittent type, by clammy perspirations, by prostration and loss of flesh. Not infrequently, too, a decided fulness of the side may be noticed, and occasionally careful palpation detects deep-seated fluctuation. After an abscess has formed, the danger is great ; sec- ondary abscess may follow, and the patient is apt to perish from peri- tonitis, or from blood poisoning. Yet recovery may take place. The matter may be discharged through the abdominal walls, or burst into the intestine, or find its way through the diaphragm into the pleural cavity, to be discharged through the lung. But, as the phenomena of abscess of the liver follo\ving acute inflammation are in the main the same as when the suppurative hepatitis is consequent upon otlier mor- bid states, we shall not here consider what we shall presently fully examine. The pyaemic liver abscess is the one of greatest similarity. The maladies resembling acute congestion or acute hepatitis are : PERmEPATITIS ; Inflammation of the Portal Veins ; Pigment Liver ; Chronic Hepatic Diseases with Acute Symptoms ; Acute Non-Hepatic Diseases with Jaundice ; Diaphragmatic Pleurisy ; Acute Infectious Jaundice ; Inflammation of the Biliary Passages ; Acute Yellow Atrophy. Perihepatitis, — Inflammation limited to the serous covering of the liver is not a frequent disease. Unless it be of syphilitic origin, it is scarcely ever observed as a primary affection ; it is generally caused by the extension of inflammation from parts adjacent to the liver, — as from the stomach, intestines, diaphragm, or pleura, — or of a chronic peritonitis ; or it is an attendant upon disease of the liver itself. In the latter case it presents no peculiar symptoms, except that it adds tenderness to the signs of the hepatic malady it complicates. Its most marked signs are, besides the decided tenderness, severe pain upon motion or deep inspiration, and marked increase of the pain when the patient lies on either side ; an occasional grating friction sound ; and a * Diseases of the Liver, 2d edit., 1877. 36 674 MEDICAL DIAGNOBia normal or increased size of the gland. The history of the case^ espedaUr its association with interstitial nephritis, chronic peritonitis or asdles. tenderness over the spleen from coexisting inflammation of its capsuk absence of jaundice, and slight fever are also signs of value. The smaller size of the liver, the absence of tenderness localized over iL and the rapidly forming and, after tapping, quickly recurring dropsr, distinguish cirrhosis of the liver with peritoneal involvement from perihepatitis. The latter affection, certainly the chronic hyperplastic form, has generally an acute beginning and runs a slow course ; the ascites often becomes stationary.^ Iiifiumnudioii of the Portal Veins ; Pylephkbitis. — An inflammation of the portal veins, terminating in suppuration or their infection by a general pyaemia, or through local processes in the portal circle, is very liable to be mistaken for suppurative hepatitis. Nor are there, in truth, any positive symptoms by which we can discriminate between the two maladies. Still, we may suspect that the veins, rather than the structure of the liver, are the seat of inflammation, if, with the signs of acute and painful enlargement of the organ, we find jaundice, thin and copious stools, irregular fever and profuse sweats, occasional chills, emaciation, increase in the size of the spleen, typhoid s)Tnp- toms, without apparent fluctuation or other signs of an hepatic ab- scess ; if there exist pains in the epigastrium or right hypochondrium. or shooting to the lumbar and sacral regions ; if following these symp- toms appear swelling of the veins of the abdominal walls and striking evidences of hectic fever or of peritonitis ; and if these phenomena be encountered in a person who, on account of a previous affection of tlie intestines or the appendix or the spleen, or of any other organ havhig a connection with the portal circulation, is liable to disease of the portal system. Marked enlargement of the spleen is a constant feature of impediment in the portal vein, whether firom inflanmiation or from thrombosis. Pigiimd Liver. — In accumulation of pigment in the liver, which is most common as the result of a deep malarial poisoning* the liver is not the only organ implicated in the morbid process : the spleen is commonly aflected ; the blood becomes anaemic, contains the malarial corpuscles and laige quantities of pigment, and pigment accumulates in the kidneys or in tlie brain. Now, the effect of all this is to occa- sion marked symptoms, besides those referable to the derangement of the liver : for it is not unusual to find grave cerebral distutbaoce. albmiiinuria, hemorrhage &om the intestines, profuse diarrhuea. and Sc'hmaly and Webber, Deutsche Med. Wochenscfanfi, 1899, No. VL DISEASES OF THE LIVER. 575 enlargement of the spleen. The fever that accompanies the morbid condition is apt to be of an intermittent type ; the jaundice is gener- ally slight. In India, pigmentar}' d^eneration of the liver tends to suppurative hepatitis.^ Chronic Hepatic Diseases vnth Acute Symptoms. — We occasionally meet with patients who seem to be laboring under an acute affection of the liver, either some form of inflammation of the liver-structure or of tlie biliary passages, or congestion of the liver, but in whom the acute symptoms have merely supervened upon a chronic complaint. Such cases are puzzling ; we may have to wait for their solution until the acute symptoms subside. In hepatic cancer the sudden and rapid development of the malady amid the signs of acute congestion is not very uncommon. Occasionally the peculiar physical phenomena of individual hepatic diseases, such as the nodular tumors of a malig- nant growth, or the fluctuation of a hydatid cyst, will assist materially in* the diagnosis. Ac\de Non-Hepatic Diseases mith Jaundice. — There are many acute affections, such as pneumonia, pyaemia, puerperal fever, and some forms of sepsis, in which jaundice may coincide with febrile symp- toms and excite suspicions of hepatitis. But the yellowness of the skin which may attend the non-hepatic disorders mentioned is accom- panied by symptoms so different that a mistake is not likely to arise if the history of the case be taken into account and other viscera besides the liver be explored. Diaphragmatic Pleurisy. — Inflammation of the pleural covering of the diaphragm may give rise to symptoms that point to an acute affec- tion of the liver. We find pain in the right hypochondrium, nausea and vomiting, dry cough, and embarrassed respiration. But the pain in diaphragmatic pleurisy is far greater than even in perihepatitis, is more suddenly developed, and is much more aggravated by move- ments and by full inspiration. The diaphragm on one side is im- movable ; the hypochondriac region is retracted ; the breathing is purely costal and short ; the difficulty in breathing amounts to orthop- noea ; the body is bent forward. We often encounter hiccough, great anxiety, sometimes delirium, attacks like angina, a sardonic grin on the features, a cough that comes on in frequent paroxysms ; and al- though, as a case recorded by Andral ^ proves, there may be jaundice, yet this is in reality so generally wanting as scarcely to belong to the symptoms of diaphragmatic pleurisy. Then in this complaint we per- ceive friction sounds, — though the physical signs will not always aid ^ Aitken's Practice of Medicine, vol. ii. * Clinique Medicale, tome ii. 576 MEDICAL. DIAGNOSIS. us, being often uncertain, mostly out of al! proportion to tiie gravity of the general symptoms, and consisting siriiply in enfeebled breath- ing, mill perhai)s ix few fine moist rales at the lower portion of one side of the chest. Fever may be slight or marked ; it is generally ushered in by a chilh There is usually, in adflilion to tJie pain along the cartilages of the false ribs, which is reach! y evoked by pressure, a tender spot in the epigastrimn, on a level with the tenth rib, one or hvo finger-breadths from the tinea all>a. There are shooting pains along tlie clavicle and in the tract of the superficial cervical plexus, and the phrenic nerve of the affected side, pressed on in ttie neck, is very sensitive. The pain on pressure is most intense along the costal insertions of the diapliragm, especially of Hie tenth rib; it is stated that upward pressure ailonts a means of diagnosis, as it reUeves the pleuritic pain.^ The dilftculty in expectorating, owing to the pain^ may be so great as to hasten death, ^ Acutr Injh'iloiw JttHHfUer.^^This malady,* also known as WfiTs (Imase, presents symptoms of an acute hepatitis. But it is probably not a disease of the liver at all, but rather an infectious fever due (o the invasion of a specitie micro-organism througli the gastro-inlestinal tracL Jaeger* has, in cases of Weil's disease, isolated from the urine during life and from the tissues after death a sliort curved rod, pro- vided with cilia, wtiich he designates *' bacillus proteos flavescens/' Weil's disease is marked by jaundice, swelling of the spleen, nephritis, and blood-alteration. It mostly affects vigorous young men in hoi weather; butrlirrs and soldiers are especially liable to it. It has been also obser%^ed in persons who liave bathed in water contaminated by fowls sufTering from an analogous disorder,* and in epidemics. It begins abruptly with headache, dizziness, and decided elevation of temperature. The jaundiee is, as a rule, moderate, the liver slightly swollen and painful ; there is great w^^akness, with delirium and som- nolency, increased thirst, and general malaise, with loss of appetite. Besides albumin and tube-casts, the urine may contain blood ; both bile-pigment and bile-acids are found in it. There are pains in the limbs, especially in the calves ; the bowels are usually loose* The symptoms abate quickly ; from the seventh to the eighth day the tern* perature falls gradually to normal, but the fever may last from ten to ^ British Medical Journal Aug. 1871. * Frank Donaldson, Jr., Amer. Jourii. Med. Sci., April, 1885, * Described by Weil» Deubclies Archiv fUr kliii. Med., Bd. xxxix. * Zeitschrifl fDr Hygi'eiie iind liifektionskraiiklieilen, Dec* 9, 18d2, * Jaeger, ioc, tit. DISEASES OF THE LIVER. 577 fourteen days. A retuni of fever alter a j)erioi1 of its abseruH* from one to seven days may happen, but this retnrn does not last more than three to six days. The eonvaleseenee is extremely slow. Fatal rases have presented fatty degeneraMon of tiie liver, acute paren- chymatous nephritis, and enlargement of the spleen.* The disease resembles rrlapmmj fever, but the spirilla liave not been found in Ihe blood. Nor is defervescence attended with a critical discharge fol- lowed by subnormal temperature. Further, the ascent of the tem- perature of the secondary fever is j^^mdual, wliile that of tlie parox- ysm of relapsing fever is sudden. Tlie return of the fever makes it unlike abortive ti/phoid with bilious symptoms. Then it shows no eruption^ exce()l herpes and an erythema.^ Besides, jaundice and urine containing blood are rare in typliold fever. Between acute yellow utrophij of tlie liver and Weil's disease there is a close resemblance. But the former has a prodromal period, wlule Uie onset of the latter is abrupt The second is attended with elevation of temperature of peculiar range; in the first the tempera- tiu*e is, as a rule, not elevated, aiid may be suJDnormal, and the bowels ai*e constipated. \n acute yellow atropliy the jaundice is gr^idually progressive and tlie liver is at first enlarged and subse- quently reduced in size ; the jaundice of Weil's disease is slight and soon subsides, and tlie hver remains enlarged throughout the attack. In acute yellow atrophy the urine may contain albumin and tube- casts, but there are not the pronounced symptoms of nephritis that WeiPs disease presents. The tendency to hemoniniges is far greater in acute atrophy of tlie liver than in infectious jaundice. The one condition is almost invariably fatal ; the other is, as a. rule, followed by rapid improvement and recovery. WeiFs disease in some respects resembles yellow fever, but it is an all'ection of several paroxysms. Inflammation of the Gall-Bladder and Gall-Ducts. — The symptoms of this vary materially according lo tlie parts specially aflfecled, as well as to the kind of hitlainination, whether suppurative OP not. When the gall-bladder alone is inflamed, we liave choleet^^- titw; when the bile-ducts alone, especially the finer ducts* cholan(/Uw^ whicti is generally infective or suppurative. The most common form of inflanunation by far is inflammation of the ductus choledochus, chiefly at its terminal portion, and catarrhal. Catarrhal Jaundice, — The morbid process is nearly always prop- agated from the stomach or hitestines, and .nausea, fun*ed tongue, a * Jaeger, (o*^, eit, * Fiedler, Deutsehes Archiv f. klin. M»?d., Feb. 1888. 578 MEDICAL DIAGNOSIS. feeling of weight in the epigastrium, feverishness, and diarriiaE-a m persistent hypergemia of the organ, unless, as so often in tropkai hep- atitis, abscess resulL Abscess of the Liver. — In temperate climates we seldom en- counter this affection, save as the consequence of an embolic or py«iiie process in tlie liver, or in connection with some disease of the intes- tines, or of abscesses around the rectum, or as a sequel of gastric ulcer, or of pylephlebitis, or of gall-stones which have produced ulcer- ation of the gall-bladder and gall-ducts and secondary abscesses of the liver, or of traumatism, or of suppurative disease of bones. In hot climates it is not an unusual disease, both in connection with dy«- enterj* and without it. The symptoms of hepatic abscess are obscure. Sometimes the only symptoms are debility, great irritability of the nervocs systesu and irregular slight febrile attacks, llore usually the fiMmutioa of pus gives rise to rigors, leads to night-sweats, and not infreqwotiy to the development of a fever simulating that of a quotkiian or tertxin intermittent or remittent, and attended during certain bonis of the ' St George's Hosp. Rep., roL TiiL DISEASES OF THE LIVER. 587 day with considerable elevation of temperature. Jaundice occurs, but is generally slight, and is often absent. There is no enlargement of the abdominal veins, nor is there, save exceptionally, ascites or oedema of the lower extremities. Dry cough, quickened breathing, and gas- tric disorder, especially loss of appetite, are frequent, and obstinate vomiting, hiccough, and meteorism are not unusual. There is always marked leucocytosis. In the advanced stages of the malady typhoid symptoms are apt to develop. But the disease may be latent. The local signs, too, are far from being always obvious, or indeed uniform. In some instances the hepatic region is more prominent than natural, and we can detect fluctuation over portions of the enlarged gland ; but neither sign is constant, and the latter depends greatly upon whether or not the abscess is deeply seated. Tenderness, either gen- eral or limited, is found only in a certain proportion of cases, espe- cially when the abscess is near the surface. It is frequently associ- ated with a throbbing or a dull pain, which may be transmitted to the right shoulder. According to Annesley,^ this sympathetic pain in the right shoulder indicates that the convex part of the right lobe of the viscus is affected. Conjoined to the feeling of weight, and to the throbbing in the hepatic region, is at times a tension occasioned by pal- pation of the abdominal muscles, especially of the rectus. Twining^ r^^ds this as very significant of deep-seated abscess. The pain of hepatic abscess may be acute, like that of an intercostal neuralgia, and greatly aggravated by cough.^ Cyr * tells us, with reference to the exact position of the abscess, that when it is in the front convex part of the liver there is pain radiating to the chest and shoulder, dyspnoea, but rarely jaundice ; when in the central part of the organ, there are few signs of local affection of the liver itself or adjacent organs, except decided jaundice if the abscess be large. In abscess limited to the under surface, thoracic symptoms are absent, but gas- tric symptoms, especially uncontrollable vomiting, occur ; the pain is apt to radiate towards the groin. A positive diagnosis of abscess of the liver is often a very difficult matter ; for there are a number of affections with which it may be readily confounded. Prominent among these are hydatids, cancer of the liver, actinomycosis of the liver, affections of the gall-bladder, and a pleuritic effusion on the right side. From hydatids of the liver, the febrile symptoms, the disturbed ^ Researches into the Diseases of India. ' Diseases of Bengal. • Malhot, Ahces du foie en Algerie, Arch. G^n. de M^d., Aug. 1899. ^ Traits des Maladies du Foie, 1887. 588 MEDICAL DIAGNOSIS. nutrition, and the pain distinguish an hepatic abscess, except in those cases in which the cyst becomes the seat of suppuration. Under these circumstances error can scarcely be avoided, unless we are fiiUy cog- nizant of the previous history. Cancer of the liver differs from an abscess by its dissimilar liis- tory, by the hard nodular masses, and by the absence of fluctuation. It is only in rapidly growing medullary cancer that we can discern a sense of fluctuation; but even here we can generally distinguish some nodules which do not fluctuate. Further, the marked fever and the other constitutional symptoms are not like what occur in hepatic cancer ; fo;* in this affection, as in all cancers, the tempera- ture, except in instances of large, rapidly spreading growths, is but little affected, — may, indeed, be subnormal. Actinomycosis of the liver may give rise to a collection of pus, and the abscess may discharge through the loins or through the lungs, as in hepatic abscess. The hepatic swelling is painful on pressure, but is unlike that of hepatic abscess in arising suddenly from the parts beneath, and in being surrounded by a firm base in the liver. These characters distinguish it from an ordinary abscess as well as from hydatid of the liver.^ Yet it is by the history, and by finding the ray fungus in pus from other diseased parts of the body, that the diag- nosis is mostly established, for actinomycosis of the liver is almost never primary. Of the affections of the gall-bladder^ the one most liable to be con- founded with hepatic abscess is distention. This occurs either from a closure of the cystic or of the common duct, especially the former, or from cholecystitis, with perhaps a subsequent closure of the duels. In such a case the gall-bladder may become enormously distended with decomposing bile and puriform matter, and thus may be occa- sioned a fluctuating tumor, tender on pressure, and readily mistaken for an abscess. Now, we are sometimes able to distinguish the soft swelling caused by a diseased gall-bladder by its situation, its pear- shaped form, its mobility, its distinct and persistent fluctuation ; by the normal appearance of the parietes of the abdomen ; by tlie ten- derness over the tumor and absence of tenderness over the liver; and by the fact that affections of the gall-bladder are frequently pre- ceded by repeated attacks of violent pain due to the passage of biliary calculi. Then we find little jaundice, or none at all ; and no hectic fever. But to neither of these circumstances can we trust implicitly. For there is apt to be intense jaundice in an affection of the gall- » Harley, Med. Chir. Transact., vol. Ixix., 1886. * DISEASES OF THE LIVER. 589 bladder, if the common duct also be implicated ; and jaundice is, in abscess of the liver, a symptom more frequently absent than present. And with reference to hectic fever, the continued suppuration in the distending sac may produce it, and lead, indeed, to great constitu- tional disturbance.^ Further, these biliary abscesses may, like hepatic abscesses, open externally, or burst into the chest. At times the communication is with the bronchial tubes, and gives rise to very anomalous symptoms. Thus, Simmons * details a case in which there was a tumor in the epigastrium, fluctuating, with a sense of inter- vening air or gas, and resonant on percussion ; a blowing sound was distinctly discerned synchronous with the respiratory act, and occa- sionally accompanied by a gurgling noise; there were no signs of pneumothorax. At the autopsy a biliary abscess was found com- municating with the right bronchus. A pleuritic effusion on the right side is distinguished from an hepatic abscess by the physical signs of the effusion. But abscesses of the liver may open into the right pleural cavity. Then we observe the physical signs of a pleuritic effusion subsequent to those of hepatic abscess. Finally, it generally happens that large quantities of puru- lent sputa are expectorated ; in rarer instances the pus is discharged through the walls of the chest. In the former case, the accumulation of pus in the pleura may be limited ; the inflammation of the pleural membrane may be circumscribed, while the signs of an inflammation at the lower portion of the right lung, dulness on percussion, tubular breathing, and rusty-colored sputa, are evident. These phenomena may subside, and the respiration in parts become inaudible, when a discharge of a large quantity of a reddish or whitish pus takes place, in which the elements of bile and the microscopical appearances of the hepatic tissue may be detected. Gradually this expectoration ceases, and the affected textures heal. But in some instances the discharge never stops, and the patient dies worn out by the constant drain. In subphrenic peritonitis the exudate may occasion a swelling and lead to an abscess producing misleading symptoms. The tumor shows itself chiefly in the left hypochondrium or the epigastrium, and seems to disappear when the stomach is distended with gas, and to increase when the stomach is full ; the colon always lies below the tumor. The constitutional symptoms are those of suppuration ; the chills and irregular fever may be very marked symptoms ; there is *'As in a case reported by Pepper, the elder, Amer. Joum. Med. Sci., Jan. 1857. » Amer. Joum. Med. Sci., Oct. 1877. 87 590 MEDICAIi DIAGNOSia much pain, vomiting, and embarrassed breathing. The Mubpkrf^ik abscesses develop generally as the result of perforation of a gastric or duodenal ulcer. They are very apt to be mistaken for abscess of the liver, and, except by their history and the characters mentioned, cannot be discriminated. These too, chiefly distinguish thent, when they also press upward, firom a collection of fluid in the right pleoral $ae. They often contain air, extend into the thorax, and we then have devel- oped that curious condition described as suhphrewc pyoprntumkothomi, which, when on the right side, is, except for the physical signs, eaalv mistaken for the breaking of an hepatic abscess into the chest The history of the affection is generally significant ; the subphrenic abscess itself is the result of a perforating ulcer of the stomach or of the doo- denum, occasionally of an appendicitis, and at times is preceded by the symptoms of a general or local peritonitis or by the di§chaz]ge of pus firom the bowels, and it sets in abruptly with pain and TomitiQg of bilious or bloody kind. The tumor formed by the subphrenic abscess has the characters just described. The signs of pnemno- thorax subsequently show themselves, as Leyden^ has found, with distinct metallic tinkling and succussion sound Yet, while all hneath- sound is sharply cut off below the fourth or fifth rib, up to this point the normal vesicular murmur is heard on deep respiratioD. and there are no signs of pressure in the pleural cavity or of distention of the chest ; and the maiiLed alteration, by change of position, of the dulness on percussion, bom the exudation at the lower part of the chesL is strictly limited to this part The liver reaches to the ombiiicas or lower, and when a canula is passed into the cavity beneath the dii- phragm and a manometer is attached, inspiration shows increased pressure, expiration the reverse, — exactly opposite, therefore, to what happens if the canula be in the pleura. When an hepatic absce^ forces its way eriemattjf^ it may. prior to its discharge throu^ the thoracic or abdominal walk, occasion difficulty in diagnosis fit)m abscesses originating in these walls. Nothing but a careful consideration of the attending syn^^oms and of the history of the case will lead to a differential dtstinction. Nor does the difficulty wholly cease when the slowly developed tumor, which an hepatic abscess fonns, has opened: since it is fiir from always that we find in the pus the evidences ot the hrokendown liver-tissue, and it is only occasionally that the fluid is of yeOow or greenish color and yields the reactions of bfle« The means of &&- crinunation most to be relied upon is a probe : fior by the def^ to ' Zeits«±Lrift far klm. Xed.. Bd. L DISEASES OP THE LIVER. 591 which it can be passed, the direction it takes, and the feel of the structures it encounters, we are placed in possession of many impor- tant facts. In doubtful cases, also, we employ the aspirator, and a chemical and microscopical examination of the pus, other than that oozuig out of the opening, may tell • the nature of the abscess. In- deed, the aspirator may be made a means of diagnosis of abscess of the liver under some of the circumstances above mentioned, where abscess is closely simulated by other hepatic affections. No harm results from the exploration, even if no abscess be found. Occasionally a hernia through one of the recti muscles is mistaken for a projecting abscess of the liver. I was called some years since to see such a case, in which the opinion that it was an abscess of the liver had been long entertained. The sound of the mass on percus- sion ; the clearly defined limits of the liver ; the absence of hepatic and gastric symptoms, — taught the true nature of the malady. Much has been said of the distinction between the abscesses which are developed in the course of embolism or of pyaemia, " the pyaemic abscess," and the abscess, common in tropical climates, which forms as the result of hepatitis, " the tropical abscess." This kind of abscess is often met with following dysentery. One of its forms occurs in connection with the amoeba coli, though we may have abscess of the liver due to the amoeba without dysenteric symptoms, and tropical abscess irrespective of any kind of dysentery. There is first a patho- logical change in the liver, and then, it is supposed, a microbic infec- tion.^ The points of distinction between pysemic and tropical abscess may be thus tabulated : pYiEMic Abscess. Tropical Abscess. Many in number ; small in size. Usually a single large abscess, seated in right lobe, towards the convexity of the liver. Uniform enlargement of liver ; only ex- Enlargement not unifonn ; bulging of ceptionally bulging of ribs. ribs, or in epigastrium, or in right hypochondrium. No fluctuation ; always pain and tender- Fluctuation usual ; pain and tenderness ness. always absent. Jaundice present in the majority of Jaundice exceptional. cases. Enlargement of spleen usual. Enlargement of spleen unusual. Rigors and night-sweats marked ; often Rigors and night-sweats less marked ; symptoms of blood-poisoning. obstinate vomiting often present. ^Davidson, article ** Suppurative Hepatitis," Allbutt's System of Medicine, vol. iv. 592 MEDICAL DIA6X06I& Pt^mic Abscess. Tbotical Course rapid ; three weeks to three Course less rapid : often exlcDdf \o thrn moDths. or sx mcmtfas. or lon^u-. Arises alter external injuries and opera- Arises in tropicil rfimatrs ciuefir is tions, or suppurating cavities, or ulcer- those who eat and drink lai^j : •jy«. ations, such as ulcers of the stomach entery freqnenllT coexists. or gall-bladder. Fatty Liver. — A fatty liver occurs in drunkards : in cb^e per- sons ; in wasting diseases, especially in phthisis ; in the course of protracted diarrhoea, and sometimes in children after exanthematoos fevers. A knowledge of the sources of fatty liver is the most importani element in the diagnosis; for neither the physical signs nor the symptoms present anything which is characteristic. The physical signs are simply those of an enlaiged painless liver ; the enlaigemeot is generally moderate and uniform, and the lower margin rounded. The symptoms are much the same as those of hepatic congestion, except that there is perhaps greater tendency to diarrhoea. There is no ascites; the amount of jaundice is always very slight : in truth, jaundice is most firequently wanting. Waxy Liver. — This peculiar degeneration of the liver which * forms part of a general cachexia manifests itself rather by the signs of disturbance of other organs than by the direct proof of altered function of the viscus affected. Thus, disordered digestion^ nausea, vomiting, tympanites, discolored stools, and diarrhoea are much more fi-equent than jaundice, which, indeed, is very much oflener absent than present. There is a feeling of fulness in the hepatic region, but no pain : while physical exploration exhibits an increased percussion dulness, and shows the dense organ to have a well-defined though somewhat rounded margin. The enlargement is uniform, but con- siderable ; at times so great that the liver occupies a large part of the abdomen, producing a visible bulging. The smoothness and the r^ularity of outline are lost if waxy liver coexist with diseases of the liver which may harden the organ in nodules, such as cancer, fibroid changes, or cirrhosis. Enlaigement of the spleen is commonly associated with the enlargement of the liver, and in many cases the urine is albumi- nous fix)m waxy disease of the kidneys. Dropsy, as a rule, is not encountered : but in this respect much depends upon the state of the kidneys and of the blood, or upon the existence of secondary peritonitis. DISEASES OF THE LIVER. 593 Waxy liver is much more common in males than in females. It is usually caused by constitutional syphilis or coexists with scrofulous diseases of the bones, with unhealed ulcers, especially rectal ulcers, with long-continued suppuration. In some instances it is associated with cancer or with phthisis, or malaria, or results seemingly from the abuse of mercury. There is always a cachexia. The disease is one lasting for years. In advanced cases, besides the spleen and the kidneys, the stomach and the intestines are apt to be implicated; looseness of the bowels, with dysenteric s)rmptoms arises, and the skin and breath have a musty, disagreeable odor. Now, when we contrast a waxy liver with other hepatic complaints in which the liver is enlarged, we find it resembling most closely the faity and the syphilitic affections. But in the former, although there is enlargement, it is not often so great as in the waxy liver. Besides, the organ feels softer on palpation, and the disorder is not associated with a diseased spleen or kidney, and is much less likely than a waxy liver to give rise to dropsy. Then the history of the case is very sig- nificant. A syphilitic hepatitis, with which indeed the waxy liver is at times combined, is further distinguished by the prominent nodules felt on the surface of the liver. From congestion of the livei^ waxy liver is readily discriminated. A comparatively slight affection in which jaundice is frequent is very different fi-om a malady in which the hepatic disease is but part of a general morbid state and in which jaundice is very infrequent. In leukemic liver we may have consider- able and smooth enlargement, but the history of the case and an examination of the blood tell its true nature. Cancer of the Ldver. — In cancer of the liver the organ is almost invariably large, and sometimes it reaches an enormous volume. It is irregular and uneven, nodules of various size being developed in its substance and projecting from its border and surfaces. These prom- inences are harder than the surrounding hepatic tissue ; but there are exceptions to this rule, for sometimes, especially in the encephaloid variety, the elastic tumors impart, when pressed, a very deceptive sense of fluctuation. The cancerous masses increase, and in some cases with great rapidity. The malignant disease is rarely confined to the liver ; it frequently supervenes upon cancer of the mammary gland, or of the uterus, or of the stomach, or pancreas. It is an affection of middle life or of old age; yet it occasionally occurs in young persons. I have met with two cases of primary cancer of the liver in women not twenty- five years of age, and two in children. In primary cancer of the liver we generally find a history of cancer in the family ; and pro- 594 MEDICAL DIAGNOSIS. tracted grief or anxiety, Murchison tells us/ may precede the de- velopment of the malady, whether a family taint can be traced or not. Cancer of the liver rarely lasts beyond- a year, and it may run a rapid com^e. This is especially the case with primary cancer. The proportion of this to secondary cancer is stated by Hale ^Vhite* as one to twenty-five. In the diagnosis of hepatic cancer, the most important physical signs are the increased percussion dulness in the hepatic region and the uneven surface detected on palpation. The enlarged liver is found extending across the epigastrium far into the left hypochondrium ; it reaches at times lower than the umbilicus, and presses the diaphragm upward; the line of dulness moves markedly downward with full inspiration. The nodules can often be felt distinctly throu^ the abdominal walls, and deep inspiration may reveal a nodule otherwise not perceptible. The diseased organ is painful, and tender to the touch. In cases in which the peritoneal covering is affected, the ten- derness is greatest. And, although any of these three phenomena— the enlargement, the uneven surface, and the tenderness — may be absent, they are tolerably constant attendants on cancer of the liver. The tenderness is rarely wanting. Among the symptoms of hepatic cancer, we find gastric and intes- tinal disturbances; pain in the right shoulder; an annoying cough; rigidity of the abdominal muscles; wasting of the whole body; a cachectic look ; occasional febrile attacks, yet, on the whole, normal or subnormal temperature ; and, in the later stages, sometimes hemor- rhages fi-om the stomach or bowels, and diarrhoea. Ascites, too, is observed, and is generally dependent either upon chronic peritonitis attending the development of the cancer, or upon the pressure this exerts upon the larger branches of the portal vein. Jaundice may or may not be present ; it is frequently wanting. I have seen it intense when the cancerous growth or a cancerous gland pressed on the bile- ducts, and sometimes it is of a peculiar dark-green color. -In any instance it persists until death. There are cases in which all these symptoms are perceived ; in others only some occur, and in others, again, even these few may not be well defined. Indeed, when we consider the amount of deposit which is generally present ; when we regard its character ; when we take into account the necessarily im- paired function of one of the most important glands in the body ; when we reflect upon the pressure which the enlarged organ must ^ Lectures on Diseases of the Liver, 2d edit * Tumors of the Liver, Allbutt's System of Medicine. DISEASES OF THE LIVER. 595 occasion, — ^it is truly astonishing that often so little dropsy, so little jaundice, so little pain, so little constitutional disturbance, are pro- duced by the disease. • Yet in point of diagnosis we can generally discern the malady by the combination of the symptoms and signs indicated. It is only at an early stage of the disease, or when the liver is not enlarged, that we are apt to be in doubt. When the liver is the seat of cancer, but is not increased in size, the recognition of the malady is next to im- possible. In these obscure cases, the persistent tenderness in the hepatic region, accompanying the evidences of disturbed function of the liver, ascites, anaemia, and a cachectic appearance, are the signs most likely to lead to a correct conclusion. In any instance, jaun- dice coming on in a person over forty years of age, lasting for months, and associated with gastric disease and failing health, must, in the absence of a history of gout or of syphilis, be looked upon as pointing to hepatic cancer, if we can exclude cancer of the pancreas. Again, we must remember that loss of flesh and of strength often pre- cedes jaundice and pain, — ^in fact, all signs of disorder of the aflfected organ. Let us pass in review the complaints with which well-marked cancer of the liver may be confounded. Omitting, because elsewhere discussed, hydatids, abscess of the liver, and hypertrophic cirrhosis, they are : Waxy Liver ; Fatty Liver ; Chronic Congestion ; Acute Congestion ; Acute Hepatitis ; Catarrhal Jaundice ; * Syphilitic Liver ; Affections of the Gall-Bladder ; Cancer of the Stomach ; Cancer of the Omentum ; Enlargement op the Right Kidney. Wavy Liver; Fatty Livei* ; Chronic Congestion. — ^A waxy liver presents often as much increase in size as cancer ; moreover, like cancer, it is associated with evident signs of cachexia. The main points of distinction are the smooth surface and uniform increase of the liver in waxy disease, its painlessness and slow progress, its com- bination with enlargement of the spleen and markedly albuminous urine, and the history of the case pointing to long-continued suppura- tion, to constitutional syphilis, or to diseases of the bones, or, in fact, to one of the causes which generally lie at the root of waxy degenera- tion. In the differentiation of cases of infiltrated cancer without dis- tinct nodules, the physical exploration does not aid us, and we have to lay stress on the other points. 596 MEDICAL DIAGNOSIS. A fatty liver is easier to discriminate from hepatic cancer. The occurrence of the non-malignant malidy in the obese, in consump- tives or in drunkards, and the total absence of pain, — in truth, of any decided indications of hepatic disease, except increased size of the organ, — enable us to distinguish between the two affections. The slighter signs of disturbance, both constitutional and local, the dissim- ilar history, and the uniform enlargement of the liver separate chronic congestion from cancer. As a mark of distinction, too, of the can- cerous from all of these non-malignant disorders, Virchow lays stress on the existence of swollen jugular glands ; and a small cancerous induration in the abdominal walls, around the umbilicus, also not infrequently aids the diagnosis. Acute Congestion; ActUe Hepatitis; Catarrhal '^Jaundice, — It is rarely indeed that these ailments are confounded with cancer of the Uver, because the history and the course the latter malady takes are so dissimilar to those of an acute hepatic disorder. Yet there are cases in which the malignant disease is either developed with great rapidity, thus simulating an ordinary acute affection, or has lain dor- mant and passed unnoticed until it begins suddenly to increase. Under such circumstances we may be able to recognize the malignant complaint, if its physical phenomena be well defined ; but if these be not clearly marked, the diagnosis is one of great diCficulty. To cite a case in illustration : A married woman, twenty-five years of age, was admitted into the Philadelphia Hospital on January 14, 1862, with jaundice and slight fever. She stated that she had been in excellent health until about two weeks before, when she caught cold by sleeping in a damp apartment. Her appetite and digestion had been good previous to her present illness, and she had been fully able to perform her household work. Since she was taken ill she had noticed a feeling of weight in the region of the stomach and liver. Rales indicative of bronchitis were found in the chest, and the impulse of the heart was feeble. The hepatic percussion dulness was some- what increased in extent, especially that of the left lobe ; but the outline of the organ appeared regular and even. Tenderness of the abdomen, more particularly in the epigastrium and right hypochon- drium, was also noted. There was nausea, but no vomiting; the tongue was clean ; the evacuations were discolored. Now, here was certainly a patient presenting none of the signs of hepatic cancer, except, perhaps, the tenderness over the enlarged gland. Yet at the autopsy, which was made within a week after her reception into the hospital, and therefore not three weeks from the apparent beginning of the complaint, whitish nodular cancerous spots, many of them soft, DISEASES OF THE LIVER. 597 were found in the substance of the liver, but not at its edges, nor forming anywhere distinct protuberances. The similarity of certain cases of protracted catarrhal jaundice in elderly persons, presenting emaciation, with nausea, retching, and vom- iting, has been above mentioned. The physical signs of the enlarge- ment of the liver may or may not assist us, according to their charac- ter, but uniform enlargement without nodules and absence of marked tenderness would be in favor of the non-malignant view. The same points help us where inflammatory thickening about the biliary pas- sages has happened in consequence of gall-stones. Syphilitic Liver. — As a consequence of constitutional syphilis, the- liver may at times exhibit cicatrices on its surface, and scattered nodules, consisting of connective tissue, and extending into the paren- chyma. This condition is styled syphilitic inflammation of the liver,, or the syphilitic liver. The organ becomes uneven from the contrac- tion of the cicatrized parts, and is apt to be somewhat increased in size, from coexisting amyloid degeneration or interstitial hepatitis.. The patient has a pale, cachectic look, but is not jaundiced,^ except from a temporary catarrh of the bile-ducts ; nor is dropsy present,, unless there be at the same time an affection of the kidneys or enlarge- ment of the spleen. But the most important elements in the diag- nosis are the age of the patient, the history of the case, and the detection of syphilitic cicatrices in the throat. When contrasted with cancer, we find, besides these points, the chief distinctive marks to be: the much more usual absence of jaundice, of dropsy, and of pain, the increase in size of the spleen, the want of local tenderness, — unless this be due to passing attacks of perihepatitis, — the slow growth of the liver, and the smaller size and softer feel of the nodules. There are cases of syphilis of the liver in which an interstitial hepa- titis is chiefly present, and which are scarcely to be distinguished from cirrhosis, except by the history and general evidences of syphilis .. Syphilis of the liver may be hereditary. Affections of the Gall-Bladder. — Dilatation and cancer of the gall- bladder are both very liable to be mistaken for cancer of the liver.. The former aflfection may result from occlusion of the hepatic and common bile-ducts, or it may be owing to the distention of the bladder with an albuminous fluid, — the so-called dropsy of the gall- * No jaundice is mentioned in the cases of Dittrich, Prag. Vierteljahrschr., Bd. vi. and vii. ; of Gubler, M^moires de la Societe de Biologic, tome iv. ; of Bam- berger, Krankheiten der Leber, in Virchow, Pathologic, etc. ; or of Moxon, in Guy's Hospital Reports, 1867. In the cases of Murchison, Diseases of the Liver, 2d edit., 1877, it was a passing or an absent symptom. 698 MEDICAL DIAGNOSIS. bladder. In either instance the bladder may attain an enormous volume, and give rise to a marked tumor at the lower margin of the liver. The prominence is apt to be rounded or pear-shaped, and, except in those instances in which the occlusion is in the cystic duel or at the neck of the gall-bladder, the impediment to the flow of bile is accompanied by intense jaundice and by decided hepatic swelling. In the uniform enlargement of the liver, the peculiar contour of the prominence, the absence of ascites, the paroxysms of pain preceding, not following, as in cancer of the liver, the other marked symptoms, and the history of the case, which not infrequently points to repeated attacks of colic from the passage of gall-stones, we find the clue which permits us to determine that we are not dealing with hepatic cancer. In reaching a conclusion we must, however, bear in mind that distention of the gall-bladder from secondarily enlarged can- cerous glands pressing on the conmion duct often occurs. Cancer of the gaU-bladder is scarcely ever met with in young persons, and is, as a rule, associated with cancerous formations in the liver or in other organs. It is difficult to make out a certain diagnosis of the affection, for it presents a strong likeness both to cancer of the pyloric extremity of the stomach and to cancer of the liver. From the latter it is undistinguishable, unless the situation and form of the tumor be such that we can clearly recognize it as belonging to the gall-bladder. Sometimes it is preceded by a history of gall-stones.* Jaundice, as in cancer of the liver, may be absent or present : in five cases reported by Bamberger^ it was found in all, and was even in- tense. Frerichs, on the other hand, states that in most instances it is wanting. Musser^ finds it reported in sixty-nine out of a hundred cases. In sixty-eight out of one hundred cases analyzed by him a tumor was discovered, the position of which is most frequently in the right hypochondrium and the umbilical region, and which is painful on pressure. There is also gradually increasing pain and a sense of weight in the right hypochondrium. The disease is more conunon in women than in men. The signs of the cancerous cachexia are strongly marked; as a rule, more strongly than in hepatic cancer. In tumors affecting primarily the ducts, there is early and intense jaundice.* GaU'Stones occasionally accumulate in the gall-bladder in such numbers as to give rise to a hard, even nodulated swelling, which * Murchison, op. cit, 2 Krankheiten des Digestions-Apparates. ' Transact. Assoc. Amer. Phyg., vol. iv., 1889. * Rolleston, Med. Chronicle, Jan. 1896 ; Kelynaek, ibid,, Nov. 1897. DISEASES OF THE LIVER. 599 may be mistaken for cancer. But the tumor is generally movable, is not painful on pressure, and does not alter in size, or does so but slowly. Sometimes the patient complains of the feeling of a weight rolling from side to side when he turns in bed, and on palpation a crackling sound is produced, which is readily discerned with the stethoscope. Generally we obtain a history of bilious colic. There may or may not be jaundice ; there is an absence of the cachectic symptoms of cancer. But we must always remember that gall-stones are frequently combined with cancer of the liver or gall-bladder. Cancer of the Stomach. — ^This is discriminated from cancer of the liver by the far more constant vomiting, by the more obvious(* symptoms of indigestion, and by the persistent pain in the stomach. Moreover, the sef^t of the tumor is different ; it is epigastric, or ex- tending downward, but not often passing into the right hypochon- drium, and it shows on percussion a very different contour from an enlarged liver. Yet there are cases in which we are kept in doubt ; especially those in which the left lobe of the liver chiefly is affected with cancer and presses upon the stomach, inducing perhaps — and thus making the likeness still closer — obstinate vomiting. The only traits of distinction are then found in the presence or absence of marked derangement of the functions of the liver, and in the chemical examination of a trial meal. Cancer of the Omentum. — The absence of jaundice, and the unal- tered appearance of the stools, are here, too, of great value in indi- cating that a tumor near or joining the left lobe of the liver is not due to cancer of that viscus. Moreover, the boundaries of the morbid mass are different from those of a diseased liver. But we cannot always trust to this. Cancerous tumors of the lesser omentum may so surround the liver, and correspond so closely to the regular form produced by hepatic cancer, that the two maladies cannot be distin- guished ; at least not by the local signs. Again, a loop of intestine may be thrust across the enlarged liver at a point corresponding to the usual limit of the percussion dulness of its left lobe, thus di\iding the most prominent nodules from the greater portion of the viscus, arid making it appear as if the tumor were to the left of, and below, the stomach, and belonged, therefore, probably to the omentum.^ In such cases we have to depend entirely upon the signs of disturbed liver function. Enlargement of the Right Kidney. — ^A tumor formed by an enlarge- ment of the kidney does not present the same outline of percussion ^ See case, Proceedings Pathological Society of Phila., vol. i. p. 275. 600 MEDICAL DIAGNOSIS. dulness as a cancerous liver. The dulness is, moreover, surrounded by the tympanitic sound of the intestine, and is not lowered by a deep inspiration ; and the signs of disturbed function of the kidney, and an examination of the urine, will generally materially assist the diag- nosis. Still, cases may occasionally happen in which, owing to a peculiar shape of the diseased kidney and to the obscurity of the symptoms, an error in diagnosis can scarcely be avoided.^ Finally, in reviewing the diagnosis of cancer of the liver, we must inquire whether other than cancerous growths, such as sarcoma, melano-sarcoma, myxoma, epithelioma, cysto-sarcoma, angioma, •lymphadenoma, can be distinguished from true cancer. They may produce identical physical signs and symptoms ; indeed, a distinction is impossible, unless the history of the case and finding tumors else- where enable us to make it. Much the same may be said of that rare disease, tubercular formations in the liver. Leuksemic livers may attain enormous size, and be mistaken for cancer ; and the cachexia that attends them makes the error more likely. But the swelling of the spleen and of the lymphatic glands and the microscopical exami- nation of the blood furnish the points in diagnosis. Hydatids of the Liver. — The development of one or of several cysts in the liver, containing within them echinococci, is not, as a rule, a disorder which occasions serious disturbance of the general health. Nor do the hydatids usually give rise to either jaundice, dropsy, or any marked signs of gastric or of intestinal irritation, or to fever, or to local pain. Their most constant manifestations are a decided increase of the size of the liver, and the presence of elastic tumors discernible in the hepatic region. In some instances xanthe- lasma has been noticed. This disorder of the skin, however, is not peculiar to hydatids, but has been observed in connection with other forms of hepatic enlargement associated with chronic jaundice. There is excretion of large quantities of urea.^ The growth of the hydatid is generally very slow, and usually in one direction only, — upward, downward, laterally. Very commonly the hydatid tumor grows from the right lobe. In most cases it attains considerable dimensions, and the liver may be found to encroach upon the lung as far as the second intercostal space, or to extend far down into the abdominal cavity. On percussion, the line of dul- ^ Vidal (Bulletin de la Soci^t^ M^dicale des H6pitaux, 1874) cites errors in diagnosis between tumors of the kidneys, especially hydronephrosis, and diseases of the liver attended with enlargement, like abscess or cancer, made by such masters in our art as Velpeau, N61aton, Gosselin. ^ Posselt, Deutsches Archiv fiir klinische Medicin, Bd. Ixiii., 1899. DISEASES OF THE LIVER. 601 ness either of the upper or of the lower boundary of the viscus, or of both, is perceived to be very irregular, and occasionally on striking a series of abrupt blows we discern a peculiar vibration, similar to the sensation perceived on striking a mass of jelly, and very signifi- cant of the existence of the cyst. 0^ving to the pressure the in- creasing tumor may exert on a(^jacent structures, we observe in some cases dry cough ; palpitation and displacement of the heart ; vomiting ; possibly slight jaundice. A fatal issue may at any time ensue by the hydatid tumor bursting into the pleiura, or the pericardium, or the peritoneum, and leading to violent inflammation ; or by suppuration occurring in the sac, when* the symptoms become those of pyaemia. Urticaria has been specially noticed in connection with the rupture of the cysts. In some countries hydatids are frequent ; it is not so in this coun- try.. In Iceland these growths developed from the eggs of a tape- worm are so common that they cause one-seventh of the human mor- tality. In point of diagnosis, it is not generally difficult to detect the presence of hydatids. The disease differs from abscess of the liver by the want of febrile action, pain, and great constitutional disturbance ; indeed, the latent character of the hydatid tumor becomes of much importance. Its slow growth, too, is very significant. When, as sometimes happens, a hydatid tumor inflames and suppurates, we have nothing to guide us in the differential diagnosis but the history previous to the development of the urgent symptoms. From cancer of the liver we distinguish hydatids by the long duration of the case, by the absence of evident cachexia, of local tenderness, and of un- ^venness of the surface. On the other hand, we have in hydatid tumor the sensation on palpation of elasticity or fluctuation. Under rare circumstances this may happen in medullary cancer, but the rapid growth of the latter and the cachectic symptoms would deter- mine the diagnosis. A distended gall-bladder may, like hydatid tumor, be free from pain on pressure, but, unlike this, it is movable, is pre- ceded by attacks of coUc, is generally accompanied by deep jaundice, and its situation corresponds to that of the normal gall-bladder. An aneurism of the ax)rta differs from hydatids in the severe pain the patient suffers, so utterly dissimilar to the absence of pain or to the mere feeling of tension and weight of a hydatid swelling. Then the pulsation and the other physical signs aid us. In aneurism of the hepatic artery^ which may also present a smooth, throbbing tumor, we are apt to have deep jaundice from compression of the biliary ducts. Pleuritic ^ff\mons have many features in common with those cases of hydatids of the liver in which the growing tumor extends upward 602 MEDICAL DIAGNOSIS. into the chest. All the physical signs of a large effusion may be present, even the dilatation of the thorax and a sense of fluctuation in the intercostal spaces. But the absence of constitutional s}Tnp- toms, the irregular outline of the dulness on percussion of the hy- datid cyst, the great displacement of the heart, and the decided lowering of the upper margin of dulness upon deep inspiration, enable us com- monly to detect the real nature of the disease. When the cyst has opened into the lung and the hydatids are being expectorated through the air-passages, the harassing cough, the copious sputum, and the inflammation of the pulmonary tissue which is apt to be occasioned, may cause the aff'ection to be mistaken for pulmonary abscess or phthisis. The surest marks of distinction are furnished by the changed form of the lower part of the thorax, and by finding bile and the hooks of the echinococci in the sputum. Renal enlargements, such as cysts, hydronephrosis, cancer, are. dis- criminated from hydatids of the liver by the same physical signs that distinguish them from hepatic cancer, — chiefly by the renal tumor having the tympanitic sound of the colon in front of it, by its being but slightly, if at all, affected in position by deep inspiration, and bj the direction of its growth. Moreover, the history and an examina- tion of the urine will greatly assist. Ovarian oysts, unlike hydatids, grow from below upward, are not influenced by deep inspiration, and produce enlai^gements greatest below and not above the umbilicus ; then they have a different out- line on percussion from hydatid liver. But, though we may thus generally distinguish hydatids of the Uver from the maladies which have similar symptoms, there are unques- tionably cases in which it is extremely difficult to arrive at a satisfac- tory conclusion. Under these circumstances, an exploratory exami- nation with an aspirator would be proper. We may detect shreds of striated hydatid membrane, and portions of echinococci. Besides, the character of the fluid will assist us in diagnosis. It is as clear and colorless as water, has a neutral reaction, a specific gravity of 1005 to 1011, and contains not a trace of albumin or of urea, but large quantities of chloride of sodium. No other fluid in the human body, whether in health or in disease, presents these peculiarities. Occasionally portions of the liver are transformed into a mass consisting of connective-tissue stroma and numerous cells filled with a gelatinous substance. The disorder looks like alveolar carcinoma, but it is really multiloeular hydatids, or echinococcus tumors. The centre of the mass suppurates, but even this does not diminish the resistance of the hepatic tumor ; nor is fluctuation, save in the rarest DISEASES OF THE LIVER. 603 instances, perceptible. Elevations may be found, such as we observe in carcinoma and syphiloma : indeed, the affection is not to be distin- guished with any certainty from either, except it be by the history and the attending constitutional symptoms. No jaundice usually accom- panies the hard hepatic swelling ; but in cases in which the bile-ducts are obstructed we meet with jaundice without dyspeptic symptoms or previous paroxysms of pain, and usually without enlargement of the gall-bladder. In cases with icterus, unlike what we find in syphilis or in cancer, there is complete decoloration of the faeces.^ Let us now, in concluding the review of the hepatic maladies which are attended with decided increase of the size of the organ, briefly contrast their most important manifestations. We have found that, as regards the enlargement, they differ materially. Simple con- gestion, chronic inflammation, fatty liver, hypertrophic cirrhosis, da not attain nearly the volume of cancer, of hydatids, of abscess, of waxy disease of the liver. The three affections first mentioned differ, moreover, from all the others, except the waxy liver, by pre- senting a uniform and not an irregularly shaped swelling or an uneven outline of the percussion dulness. Concerning the symptoms, we observe that, although these hepatic disorders all agree in not being characterized by jaundice^ yet this sign is more commonly present and more distinct in some than in others. In hydatids, and in the syphilitic liver, there is no yellow hue of the skin or of the conjunctiva ; so, too, as a rule, in waxy liver. In fatty liver and in abscess it is, on the whole, most fre- quently wanting. The same may perhaps be said of cancer, yet not infrequently there is deep jaundice in this malady. In chronic congestion, in chronic inflammation, and in hypertrophic ciprhosis,. we ordinarily find j'aundice, though it may be but a slight yellow tinge of the skin and the eye. With reference to dropsy, we are not apt to encounter it in any of the hepatic affections under considera-' , tion except cancer, and waxy disease when more than the liver is implicated. It is in these two complaints, also, that the most obvi- ous signs of a cachexia are met with ; while in abscess we find fever^ and, perhaps, the greatest constitutional disturbance. As regards pain, the fatty liver, hydatids, simple hypertrophy, and the waxy liver are painless ; the most painful are cancer, acute chole- cystitis, and abscess. Pain is a less prominent symptom in syphilis of the liver and hypertrophic cirrhosis. ^ See the cases of Friedreich and of Niemeyer, referred to in Niemeyer's Practice of Medicine. €04 MEDICAL DIAGNOSIS. Chronic Diseases attended with Decreased Size of the Liver, and with Abdominal Dropsy. Cirrhosis. — Increase of connective tissue producing hardening of tiie organ is the underlying change in all forms of cirrhosis of the liver. The atrophic form with its granulations of various size, the " hobnail liver," is the most common form, and alcohol the common cause. But this cause does not explain all cases : in some, the malady is connected with syphilis ; in others, with malaria ; in others, with anthracosis ; in others, with infective diseases ; in others, again, it cannot be attributed to any known agency, and has been stated to be due to microbic infection. Again, there may be granular livers in which the fibroid tissue is formed between the lobides, and which never contract, — an interstitial hepatitis, or hypertrophic cirrhosis. Cirrhosis is essentially a disease of middle-aged men ; it is for less common in women, and rare in children.^ In the first stage of cirrhosis, the ordinary or alcoholic cirrhosis, as it is sometimes termed, the organ is somewhat increased in size; then the bulk becomes lessened. It is, however, doubtful whether the stage of enlargement invariably precedes that of shrinking: the process of reduction constitutes not infrequently the first change. But, without entering into this question, we may state that there are no symptoms by which we can recognize the disease at an eariy period, for the symptoms at first are the same as those of chronic congestion, — dull pain, perhaps tenderness at the hypochondrium and pain referred to the shoulder, disordered digestion, and a sallow or a slightly jaundiced hue of the skin. Nor can we say, even after the stage of contraction is fairly developed, — and it may never reach the point of the hobnail liver being really small, — that the diagnosis of the affection is always possible. It may rest on no stronger grounds than finding in a person who is known to be a spirit-drinker, **a tippler," an intractable ascites, without obvious cause for the dropsy. The dropsy, due to the obstruction of the portal circulation, consists tliroughout strikingly of ascites ; as it increases, oedema of the legs may be developed, and passing albuminuria, from pressure on the renal veins, or beginning cirrhosis of the kidney. Besides the dropsy, the other clinical features of the malady are not very marked. The most significant signs consist in the diminu- tion of the percussion dulness in the hepatic region, and the detection, by the touch, of firm, irregular granulations on the margin and under ' See, however, cases by Howard, Transact Assoc. Amer. Phys., 1887. DISEASES OF THE LIVER. 605 surface of the liver. But both these signs are very difficult to discern, on account of the distention of the ahdnmfin with fluid, and the dis- placement of the liver this may occasion. In fact, it is often only after the performance of paracentesis that the abdominal walls will permit us to judge with any accuracy of the shrinking and altered state of the organ. This is especially true with reference to palpa- tion ; as regards percussion, it may be possible, even when the abdo- men is still full of dropsical effusion, to detect the lessened extent of hepatic dulness. Irrespective of these phenomena, we find at times other mani- festations of disease which assist us in the diagnosis of cirrhosis. They are enlaiigement of the spleen ; dilatation of the veins of the abdomen ; gastric and intestinal derangements ; hemorrhoids ; marked loss of flesh and strength ; jaundice coming and going, never very striking; a decidedly cachectic appearance, with sunken features; and hemorrhages from the nose and mouth, or from the stomach or intestines, or into internal cavities. Hsematemesis in an alcoholic must always arouse suspicion. The increase in size of the spleen is fer from constant, and rarely reaches a considerable extent. There is often pain over the region of the liver and spleen, and occasional at- tacks of perihepatitis and of peritonitis occur. The dilatation of the abdominal veins is not perceived until an advanced stage of the dis- ease, and is sometimes connected with a peculiar vascular net-work, stretching from the umbilicus upward and downward, and, as Sappey * was the first to describe, with a decided enlargement of the epigastric and mammary veins, the blood flowing through the former in a re- versed direction from what it does in health, — namely, not towards the liver, but from it to the veins of the abdominal wall, and thence to the vena cava. Other external veins share in the enlargement ; the veins of the legs may be varicose, and the venous twigs on the cheeks become developed. In some cases an irregular but moderate fever not exceeding 102.5° is also noticed ; very generally there is none. Another symptom to which I have had my attention strongly directed is the presence of small amounts of sugar in the urine. Thus, in two cases which I saw with Dr. Simpson, Trommer's test readily detected sugar in the urine. In the one case the secretion was scanty ; in the other it was abundant. One had lasted for several years, and was slowly developing ; the other had existed about sixteen months, and was rapidly progressing. Cerebral symptoms due to a toxic cause sometimes appear. They * Bulletin de T Academic de M6decine, tome xxiv. 38 606 MEDICAL DIAGNOSIS. show themselves frequenthr in a delirium of mild type, attended with ct>nfu?ion of persons and places^ The delirimu is often like that of nramia. but there ts nothing in the urine to account for it It may not show itself until towards the ciid of the disease : on the other hand, it may be of long duration. In a case I saw with Dr. Lloyd, it lasted four months. Coma and conTuisions also occur occaaonally. The gastric and intestinal derangements, the result of a congested or indamed mucous membrane, an^ rarely wanting: they manifest themselTes by fiaulii^ appetite, impaired d^^tion. both gastric and intestinal, momii^ sickness^ flatulency and cv^cst^ation. or the fre- quent Toktix^ of paie-5XHored stcN>ls or attacks of dtaLnh^iea. The jaundice very raxeiy attaizts a h^ decree. It shows itself usually in a yrflowish tir^ of the skin and conjuixiTa : but even this hue is often absent and we nnd the pale skin aihi {:«eary eye of anapmia Yet not ooe of these symptoms is rvaljy characteristic : they become so only when xiewed in ccnn-ecdoc with ibe drofjey. with the kwt! s^n:^ in the hep«ttic r>?g*x:. with the histc-ry of the case, and with the absence of any ofgani: disease c-: tbe s:oEL*rfi or the intes- tine, whkh n*.^.t explain them. Tben i-e aj^ c-c* the patient* gener- aliy aboTr ±.ir:y-dTe years, an-d his bobcts. nus: re takr:: into acKXHUiL Tte ciT*:\>?2s csf your^ children is ^eii-rmHy »ri-r tv iiierrted syphi&. Goc: serf "US :c rre^iis^rKXse :o ±-r disease. Murjiis*:- :el.s us that the cve^tkc v-c* ±e "iTtr wbih deselects pv.: rer-'irrs :: a&r?boL. 0Jrrtx>s5s c: ie "iTrr os^^r r»e::z:TS i:sssix*s^ed with *:ci:r :iSrirv'JLo?2s< A: unir^ virrti-Asa? r-::::s jl ru6i xrnse.- 5vrir»rC is *■»>"•*♦*: ■ ' •V.ta"..* ^':-.»"*'."'j:.* I: is i.r: fn- ir:-i Trriii irrv^ruiar 5:TTr ::' r;^.:r:t::: :r ir.:£rr._:::tr.: :>it. "T"."-!": i-vji-r-i tcJL»ii>ent o-f IfssJr-r-v: rrcol Ti:!r-:6:c :•: vj?fvt. ru: .ir*:-?. s'nr-.i.tirL:. TTLth sCkti: ;a:ii:- iijj-r ij:>- r-rri-jo: ' ' r:u:i?::: :<: :ht <.:?= :: :^- -.-tT. T^ iii5ect>Mi aI'JQC '-T- >ti.i~t> T-:._r;5 :; -lv, v-:\i ,iTjL j.-.: ivj.; .L^^ Ai—ly -^ v* * '^yi iriz-ml S;>:tr.-. *^~--";i: rr;s*^ "^ -:.:^v"j .us --ivr^.'rjs jziti rcriL-r::: 2i.»t£±rj£i^25. A sL:::.Jar i:J^5:•i:s^: js r_.:-: -r..^ ... .l,'ir*:C i r^rrb.-^as with DIBEASES OF THE LWER 607 or ** inlerstiliuj hepatitis,'' or eiirholic enlai^ement. It may be found iti alcoholics, hut often sliows itself without recognizable cause. It is irequently noticed in young persons. It has much the same symp- toms as atrophic curhosis, and is uudistinguishable, except by the increased percussion duhiess it presents, and by the si^ms of entailed hver being usually attended with more decided and much more con- stant jaundice and greater tendency to protracted fever and lo peri- tonitis. Pain over the liver and spleen, due perhaps to attacks of perihepatitis, is not uncommon. Ascites is al:)sent or slight. The edge of the enlarged liver is hard and not irregular; ttie gall-bladder is not distended- A peculiar mawkish odor of t:he breath lias been spoken of as present.* Dilatation of the abdominal veins is generally absent. The disease usually begins with the signs of congestion, acute or clironic, with jaundice, and with some pain in the right hypochon- drium, and lasts for years, terminating in a slow cachexia ; at the end there are marked jaundice and diarrtir^a, and the patient sinks into a t\^>hoid state. Ascites may be, as already indicated, wanting through- out ; or, as is more usual, it comes on late in the malady. The disease is, in my experience, not infrequently complicated with a fatty liver, fonning *'a fibro-fatty liver." In some instances of hypertrophic cirrhosis tliere is organic disease of the heart. The infectious nature of hypertroptuc cirrhosis has been often atllrmed. Cirriiosis of tlie liver due to mahinai infevHon is also associated with enlargement, at times ven' great. It presents, moreover, a per- sistent chronic jaundice, wliich may last for years, and is combined with marked enlargement of the spleen and manifestations of the malarial poisoning. Bleeding from the nose, gums, and intestines is frequent ; itropsy and distention of the abdominal veins are absent.* The disease I believe to be a very rare one. Let us now look at the distinction between ordinary cirrhosis and some of tlie maladies wliich resemble it; and first let us compare its traits with those of other hepatic affei^liom. From diseases of the liver attended witli enlargement, such as waxy liver, fatty liver, and chronic congestion, fully developed cu'rhosis is discriminated by the presence of ascites and the other signs of seriously obstructed portal circulation, by the diminished, or certainly not augmented, size of the organ, and by the different histoid' of the disorder. From hydafiiJs of the liver we diagnosticate cirrhosis by the irregularity of outline of * Duckworth, SL Bartlif^lomew's Hospital He[>orts, 1874. ' Laiicereaax, qunled in Sajoui's Annual, 1888, p. 385. 608 MEDICAL DIAGNOSIS. the enlarged liver in the fonner complaint, by the sense of fluctuation, and by the comparatively unimpaired general nutrition of the body. Cancer of the liver is unlike cirrhosis in the distinctness and size of the protuberances, in the obvious hepatic enlargement, in the less marked ascites, and in the normal size of the spleen. But when a cirrhosed liver is associated with syphilitic nodules, or when its volume is augmented by waxy infiltration, the discrimination from cancer becomes a matter of extreme difficulty; indeed, it may be impossible to avoid erroneous conclusions. Hypertrophic cirrhosis may also be very difficult to distinguish from cancer, except by the history of alcoholic dyspepsia, and, though large and nodudated, the liver is rarely so tender, and the nodules, if they can be felt at all, are small, and ascites is not, as in cancer, a frequent symptom. Syphilitic hepoMtis cannot be distinguished from hypertrophic cir- rhosis, save by the history of the case and feeling the gummata. In some instances there is distinct fever, which subsides imder iodide of potassium. The general health may be but little disturbed. In the interstitial hepatitis due to inherited syphilis, enlaigement of the liver and jaundice occur. We shall now consider and compare the clinical traits of some diseases of the liver producing, like ordinary cirrhosis, atrophy of the organ. As the result of repeated attacks of perihepatitis, we find great thickening of the capsule, with fibrous bands passing into the interior of the organ, and some atrophy. This condition, described as simple induration of the liver, is met with chiefly in connection with constitu- tional syphilis, though it is also seen following a right-sided pleurisy and diseases of parts contiguous to the liver, producing inflammation which spreads to it. The affection is not to be distinguished from true cirrhosis, except by the causing elements, particularly by the syphilitic history, and by the absence of the habit of spirit-drinking ; the greater and more persistent pain and tenderness in the hepatic region are of significance ; sometimes there is coexisting heart disease. Red atrophy is a pathological state rather than a recognizable dis- ease. The diminished hepatic dulness is not preceded by alcoholic dyspepsia or valve disease, but is met with in those with a history of dysenteiy or of ulceration of the intestine. It may be also due to obstinate malaria, and the liver is then at first large and red. An inftammation of the portal vein, itith coagula fanning in tf, may occasion the same manifestations of deranged abdominal circulation. the same or greater tumefaction of the spleen and decrease of the liver, as cirrhosis. And what complicates the diagnosis verj- much DISEASES OF THE LIVER. 609 is, that cirrhosis is the chief disease that leads to thrombosis of the portal vein. Indeed, we cannot, under any circumstances, positively discriminate this affection from cirrhosis. Still, we are sometimes enabled to distinguish the venous disorder by laying stress on the sudden development of the symptoms, especially of the violent en- goiigement of the portal system ; and by noting the rapidity with which the ascites returns after paracentesis, the rapid swelling of the spleen, the copious gastric or intestinal hemorrhage, the severe vomiting and diarrhoea, the great enlargement of the abdominal veins, and, when pot too soon fatal, the marked emaciation. Other causes than inflam- mation of the coats of the vein, whether simple or infective, may produce coagulation. We may have thrombosis as the result of dis- ease of the liver structure, in cirrhosis, or cancer, or syphilis ; or of compression by enlarged cancerous or tubercular glands ; or in conse- quence of the perforation of the vein by cancer or by gall-stones, or of sclerotic change of its coats. Compression of the portal vein and of the biliary ducts in the fissures of the liver, from inflammation of the surrounding areolar tissues, may be separated from cirrhosis chiefly by the intense icterus and the complete decoloration of the stools. Of non-hepatic affections, cirrhosis is most liable to be confounded with chronic peritonUis ; a mistake rendered the more likely because chronic congestion or even chronic inflammation of the peritoneum may exist as a complication of cirrhosis. But, even when no such complication is present, the diagnosis may be difficult. It rests chiefly upon the greater and more extended tenderness of the abdomen in peritonitis, the febrile signs, the absence of splenic enlargement and of dilated veins, the usually unchanged, or certainly not jaundiced, hue of the skin, the association with signs of disease in other viscera, especially of the lungs, — for chronic peritonitis is generally tubercular. Under rare circumstances, cancer of the stomach may simulate cirrhosis. I had some years since a case under my charge at the Pennsylvania Hospital, in which, with very slight digestive symptoms, and without discernible epigastric tumor, considerable ascites and effusion into the left pleural cavity existed. Owing to this effusion, the state of the spleen could not be accurately ascertained. There was some fulness of the abdominal veins, and the hepatic percussion dulness did not extend entirely to the margin of the ribs. Bile-pig- ment was present in the urine, the bowels were loose, and progressive emaciation ensued. The man had been very intemperate, and his case might certainly have been selected as an illustration of cirrhosis ; yet . at the autopsy the liver, though small, rather hard, and deeply con- 610 MEDICAL DIAGNOSIS. gested, was not cirrhotic, and a cancer involving the whole stomach, except the pylorus, was found.^ Chronic Atrophy of the Liver. — ^Although cirrhosis is the most frequent it is not the sole cause of dwindling of the liver. We hare just spoken of its diminution in consequence of obstruction of the trunk of the portal vein, as well as of other causes ; but besides these causes we find some, such as a decrease of the oiigan from long-con- tinued closure of the common duct, or its atrophy in old age, or in connection with grave disease of the heart or lungs obstructing the circulation and causing persistent hyperaemia of the liver, or as an accompaniment of chronic disease of the intestine. The first of these morbid states is mainly discriminated by the deep jaundice, without marked ascites and enlarged abdominal veins ; the second, by the ab- sence of any important symptoms referable to the liver and associated with the diminished hepatic dulness ; the third, by the history of the case, the physical signs of cardiac or pulmonary difficulty, and the more general dropsy. The fourth form has been mentioned under red atrophy. We may sometimes suspect the cause of the shrinkage of the organ from the persistent and intractable diarrhoea and dis- turbance of the stomach. But there is no cause of simple atrophy of the liver so common as thrombosis of the portal vein. SECTION IV. ABDOMINAL ENLARGEMENT. In describing the causes of abdominal enlaiigement, I shall new them as they occasion a general and uniform or a more circum- scribed and partial swelling. Oeneral Abdominal Enlargement. Ascites. — The collection of serous fluid in the peritoneal sac, or ascites, may form part of a general dropsy, and be dependent upon an organic disease of the kidneys or of the thoracic viscera ; or the accumulation of liquid may be confined to, or occupy principally, the abdomen. In either case the local signs are much the same. They are : enlargement of the belly ; a dull sound on percussion, due to the presence of liquid ; and the sense of fluctuation imparted to the hand on one side of the abdomen by a wave of fluid put into motion by a tap on the other side. * For a fuller report of this case, see Proceedings of the Pathological Society, Amer. Joum. Med. Sci., vol. Hi., 1866. ABDOMINAL ENLARGEMENT. 611 As regards the former of these signs, it is uniform and progressive, and is generally very evident ; although, of course, when the quantity of liquid is small, enlargement of the abdomen may escape detection. The percussion dulness is most readily perceived at the lower portion of the abdomen, where the fluid gravitates. The bowels float usually to the upper part of the liquid, and at this spot their tympanitic resonance may be distinctly discerned. When the patient is in the erect position, the intestinal percussion note is commonly discover- able in the epigastric and umbilical regions. If he be placed upon his back, the tympanitic sound is found to extend lower than the umbilical region, while dulness will be elicited in the hypogastric region and the flanks. If he be placed upon his side, the flank which is uppermost becomes resonant. This alteration of the level of the fluid with the change of position is thus a significant sign, and always happens except when the effusion is encysted; it is detected without difficulty, save where "great flatulent distention of the bowels or impaction of faeces accompanies the accumulation of liquid. Ordinarily, the fluctuation wave felt by the hand is easUy dis- cerned. It is obscured by thickening of the abdominal walls from oedema, or from the accumulation of fat in the subcutaneous tissues ; it is, moreover, indistinct if adhesions circumscribe the fluid in the peritoneum. The amount of albumin in the fluid rises with the ascites and its duration. For all practical applications the specific gravity determines the proportion of albumin, and the urinometer may be employed for the purpose. There are no means of distinguishing the character of the fluid except by direct observation. Chylous ascites has been not infre- quently found associated with tubercle,^ or cancer of the peritoneum. It has also been met with in filariasis and in rupture of the thoracic duct. A hemorrhagic fluid indicates cancer or tubercle of the perito- neum, though it is occasionally seen in cirrhosis. The other symptoms often found m ascites, such as a pushing upward of the liver, spleen, and stomach, embarrassed breathing compression of the lungs, and digestive disturbances, present nothing characteristic. But we insist on this : that a diagnosis of ascites is only half a diagnosis, and that we should in every instance endeavor to ascertain the cause of the collection of fluid in the peritoneal sac. The morbid states with* which dropsy in the peritoneum is liable to be confounded are chiefly : * Busey, Ainer. Journ. Med. Sci., Dec. 1889. 612 MEDICAL DIAGNOSIB. Ovarian Dropsy ; Chronic Peritonitis ; Distention of the Bladder ; Graved Utervs ; ('HBONic Tympanites. (karian l)rop»y. — It is not until an nvarian cyst rises above the brim of the pelvis that it occasions a swelling marked enough to be mistaken tor abdominal dropsy. Supposiiij< that it has led to consid- erable enlargement of the belly, we are yet able to discriminate be- tween the two disorders by attention to the physical signs of the history of the case. As regards the former, we perceive these differences : the sound on percnssion over an ovarian cyst is dull in the umbilical and hypo- gastric regions, while at tlie sides the tympanitic resonance of tlie in- testines may be obtained. Moreover, the dufness in ovariaji dropsy does not change its position in different postures ; and, like all ovarian tumors, the ovarian dropsy causes a projection in the centre of tlie abdomen, not a flattening there and a bulgin^jr of the flanks, as is common in ascites. Bacelli* states that in ascites there is a deep tympanitic sound during percussion in tlie region of the intestines, while an ovarian cyst preseiils dulness on the side in which the cyst has its origin, and a tympanitic sound on percussion on the other. In ascites, vaginal and rectal touch detect fluctuation at once, and Uie uterus is normal in size and in mobility, sometimes it is prolapsed ; in ovarian dropsy, fluctuation is less distinct, and may not be found at all, and the uterus is generally displaced behind the cyst. The fluctuation from an ovarian cyst is unequal at different parts of the distended abdomen. When the effused fluid is free in the peritoneal ca\ity, fluctuation may be perceived beyond the line of dulness as the fluid is thrown in waves among the intestines ; but when it is confined within a cyst, fluctuation cannot be perceived beyond the cyst avails : hence the outline of the cyst as obtained by percussion, and titat of the area within which tluetuation is perceived, must be the same. It should be remembered, however, that fluctua- tion in an ovarian cyst may escape detection on account of the great thickness of the cyst walls, or of the unusual tenseness of the cyst, or of the great density of the fluid, or of the small amount of fluid in each cyst. In ovarian cyst O^ere is, for tlie most pari, impairment of the general health, and the color of the face is that of cachexia. When there is ascites complicating an ovarian tumor, the diagnosis ABDOMINAL ENLAKGEMENT. 613 is very diflicult. Finding the fluctuation unequal, and an irregular outline of the ovarian growth, may aid us ; but a preliminary tapping, though now mostly condemned by gynaecologists, may be necessary to arrive at an opinion. The specific gravity of the fluid of ovarian cysts is 1020 to 1025, thus considerably higher than of ascitic fluid, which is generally about 1010. Entire reliance cannot be placed on the chem- ical character of the fluid, since the rule that paralbumin is significant of ovarian fluids and fibrin of serous fluids has many exceptions. Spencer Wells ^ accepts the presence of the " granular cell," as shown by Drysdale and W. L. Atlee,* to be characteristic of ovarian fluid. This granular cell is generally round, sometimes oval, varies in diameter from one five-thousandth to one two-thousandth of an inch, is transparent, is much smaller and far less opaque than the compound granular cell of inflammation, and contains a number of fine granules which become more distinct on the addition of acetic acid, and nearly transparent under ether ; there is no nucleus.^ In uncomplicated cases, the history assists us greatly in reaching a correct diagnosis. In ovarian dropsy, we can, as a rule, make out that the distention of the abdomen has begun at its lower portion on one side, and has spread upward. Again, we do not find those signs of disease of the liver, heart, kidneys, or spleen which are so apt to coexist with ascites, or that the swelling is reduced by the use of hydragogue cathartics and diuretics, as in the latter complaint. Attention to the history and progress of the complaint is especially valuable in the class of cases in which the physical signs of ascites are modified by the intestines not being able to float to the surface of the fluid in the peritoneal cavity, in consequence of adhesions to one another, or of a diseased omentum, or in which the fluid has been limited in sacs by inflammatory adhesions. On the other hand, an ovarian cyst may contain air, either fipom a communication with the intestine, or after tapping and decomposition of the contained fluid, and percussion would then give a clear note in iront and a dull note below ; succussion, too, has been noticed. In the diagnosis between encysted dropsy of the peritoneum and an ovarian cyst, if we obtain, by tapping, a spring-water fluid, it points to cyst of the broad ligament. Chronic PeritonUis. — We find chronic peritonitis as the result of an acute attack, or in connection with cirrhosis of the liver, with dila- » Brit. Med. Journ., June, 1878. ' Ovarian Tumors. ' See Transactions of the Pathological Society of Philadelphia, vol. vii., 1877 ; American Journal of Obstetrics, vol. xii., 1879; also Gynaecological Transactions, 1883. 614 MEDICAL DIAGNOSIS. tation of the colon, with chronic dysentery, or with interstitial nephri- tis. But usually the peritonitis is either tubercular or cancerous. Tubercular peritonitis generally occurs in those who have tubercles in the lungs or enlarged caseous glands ; and when such patients com- plain of abdominal pain and uneasiness, of soreness to the touch, of nausea and vomiting, of diarrhoea alternating with constipation, and of losing flesh and strength ; when the tender abdomen is tense, re- sistant, much distended, in part with liquid, but especially with wind, and exhibits on its exterior the tracings of the convolutions of the intestines ; when in addition there is oedema of the lower limbs, with fever, irregular, at times high, at times almost ceasing, and a growing cachexia, — we can hardly be wrong in presuming the signs of chronic peritoneal inflammation to be owing to the presence of tubercle. Even when disease of the lungs is absent, or is not well defined, we shall generally be correct, if the abdominal symptoms mentioned exist, and there are repeated attacks of acute or subacute peritonitis, in determining the peritoneal affection to be tubercular. Signs of great significance are the presence of nodules in the rectum and io the sacro-uterine ligaments, and of inflammation around the Fallo- pian tube. In some instances the disorder develops with rapidity, and has the aspect of an acute complaint. On the other hand it may be latent. The tumefaction of the belly may be so great as to simulate an abdominal tumor.^ The disease is often mistaken for ovarian disease. A cancer of the peritoneum gives rise to many of the same phe- nomena as tuberculous disease. But the affection is far less common, and there is this difference : the malady usually happens consecutively to an external or an internal cancer, and scarcely ever save in persons advanced in years ; there is little or no fever, or, indeed, a subnormal temperature, and neither diarrhoea nor profuse sweats. Pain, on the other hand, or at least attacks of spontaneous pain, are more fre- quent ; the lymphatic glands enlarge ; and, as the omentum is the most common seat of the cancerous growth, we can generally delect a tumor stretching across the upper portion of the abdomen. The morbid mass is unequal, and usually discovered readily, except where separated by fluid from the abdominal parietes. There are often nodules in the neighborhood of the umbilicus and enlarged inguinal glands ; a peritoneal friction-sound is heard. Hemorrhage into the abdominal cavity or the effusion of bloody serum occurs in cancerous as it does in tubercular peritonitis. In cancerous peritonitis the ascitic * See case in Liverpool Hospital Reports, 1868. ABDOMINAL ENLARGEMENT. 615 fluid has a turbid gray look. In the sediment that forms there is a rich cell-growth with many red blood-corpuscles. The cells are for the most part peculiar, large, swollen, nucleated cells ; ^ many are multi- nuclear cells. In primary cancer of the peritoneum, or that following ca^icer of the retroperitoneal glands^ the diagnosis is very obscure, un- less the tumors are marked. The cancerous malady pursues a slowly progressive course, lasting months ; but it may develop as an acute miliary disease. Retroperitoneal timiors may be readily mistaken for diseases of the liver. They may occasion jaundice from pressure on the common duct. The fiact that they do not move with the acts of breathing, as well as that there is often a line of resonance between the dulness they occasion and the liver dulness, is a point of value in diagnosis.^ Distention of the Bladder. — This may give rise to a sense of fluc- tuation and to very marked abdominal enlargement ; so marked, in- deed, that patients have been tapped, under the supposition that they were laboring under dropsy of the abdomen. But when the bladder is so much distended as to simulate ascites, there is more or less tender- ness on pressure over the seat of the obvious swelling ; which, more- over, presents a rounded outline of dulness on percussion. Again, we have the history either of retention or of apparent incontinence of urine.^ But, to avoid all possible chance of error, in any case of doubt a catheter should be introduced into the bladder. This mode of pro- cedure, it may here be mentioned, is the one which leads most speedily and decisively to a true appreciation of the abnormal phenomena in those rare cases of anasarca which are produced by distention of the bladder, and of which Trousseau has recorded several. The Gravid Uterus. — ^A gravid womb is readily distinguished from abdominal dropsy by the peculiar form of the dulness on percussion, its steady and uniform increase corresponding to the enlargement of tlie womb, the absence of fluctuation, the detection of the sounds of the foetal heart, the alteration in the color and appearance of the mammary areola, and the production of movements in the womb on making an examination per vaginam. Chronic Tympanites. — Great prominence of the abdomen, due to flatulent distention of the bowels, is, if at all persistent, very apt to * Runeberg, Deutsches Archiv f. klin. Med., Sept. 1883 ; also Coe, New York Med. Journ., July, 1888. * Vander Veer, Amer. Joum. Med. Sci., Jan. 1892. * In a case recorded by Watson, in his Lectures on the Practice of Physic, although the bladder was enormously distended, large quantities of urine were constantly passing from the patient. S16 MEDICAL DIAGNOSIS. be mistakeD for ascites. But the laiTge abdomen yields not a dull, but everywliere a tympanitic sound, and there is no fluctuation* Then Uie historj^ of the case and the attending symptoms Uirow light upon the nature of the aihnent Many persons suffering from chronic tym- panites have all the signs of weak gastric or intestinal digestion ; in others there is hysteria. Among soldiers this chronic tympanites — owing, perhaps, in many cases to the character of their diet and consequent digestive dis- turl>ances — is far frtmi being an uncommon disorder, and may be m very obstinate one. It gives rise to abdominal enlai^^ement, whicli is constantly mistaken for dropsy, but which does not yield a sense of fluctuation, or return on percussion any otlier tlian a well-marked tympanitic sound. The distention produces, moreover, an inability to take active exercise, sensations of cutting pain under the ribs, and palpitation of the heart; pressure on the abdomen occasions much discomfort ; the soldiers, therefore, walk with their clothes unbuttoned, and find it yery irksome to wear their belts. They are sometimes troubled by indigestion, and feel particularly uncomfortable after meals ; or the symptoms of indigestion, although they may have been present at the beginning of ttie complaint, disappear, but the swelling of the abdomen persists for many months. According to my experience, the ailment is always gradual in its development. Besides the complaints just reviewed, which are those most com- monly confounded ^vith ascites, there are a few very rare disorders which might be mistaken for collections of fluid in the peritoneal sac. They are dropsy of the womb ; dropsy of tlie Fallopian tubes ; dropsy of the omentum ; very large serous cysts in the kidney ; hydatids of the liver, of size so great as to lead to general abdominal distention : and a dUatation of the stomach so extensive that the \iscus occupi almost tlie whole abdomen. With reference to the latter affection may disUtiguish it from ascites by tlie liistory of the case and ttie^ vomiting and oUier marked gastric symptoms, by the extended tym- panitic percussion note, by the mdistinct fluctuation, which is not noticed except over the most dependent part of the organ, by the splashing or the metallic or amphoric sounds which are perceive4| when its contents are agitated, by the lengUi to which the stoma! tube can be introduced, and by the chemical examination of the gastric contents. The other maladies mentioned can be separated only bjj taking into account tlieir history and progress, and by laying si upon the absence of those morbid states which generally cause ascites, and upon the occurrence of special phenomena which point to the structures implicated. ABDOMINAL ENLARGEMENT. 617 Partial Abdominal Enlargement. Abdominal Tumors. — Even at the risk of repetition, it is for clinical purposes a matter of convenience to point out connectedly the relations an abdominal swelling bears to the normal structures of the abdominal cavity, and to consider, moreover, the swelling as consti- tuting the starting-point of our diagnosis. Let us first examine into the meaning of an abdominal tumefac- tion occupying solely or principally one region of the abdomen. • Rigfit Hypochondrium. — ^The most usual cause of a tumor in this region is an enlargement of the liver. Sometimes a tumor which is in the lower part of the right hypochondrium, or proceeds from the ter- mination of this region, is simply a displaced liver, or an affection of the gall-bladder. In the first instance, the recognition of the disorder — such as a pleuritic effusion — which has given rise to the displace- ment ; in the second, the history of the case, the shape of the swell- ing, and the symptoms attending it, — ^will give us an insight into its cause. Again, a tumor in the parts mentioned may be due to an enlarged kidney, cancerous or cystic, or especially hydronephrosis. Careful examinations of the urine and the history of the case furnish the most certain means of discrimination. Then we must also bear in mind that all enlarged kidneys displace the bowel in a particular manner ; they press it forward, and the dulness over the tumor is largely mixed with a tympanitic sound, or the dulness is, indeed, not very appreciable. Left Hypochondrium. — ^The most usual tumors in this region are produced by enlargement of the spleen. An increase in size of ihis viscus, if acute, is generally owing to toxaemias, acute fevers, and bac- terial infection, as pyaemia, puerperal fever, acute tuberculosis, scarlet fever, typhoid fever, relapsing fever, or the malarial fevers. The cause of the swelling is disclosed by the history of the case and by the accompanying symptoms. Inflammaiion of the spleen is an affection very difficult to recognize. The most trustworthy symptoms are : pain in the left hypochondrium, radiating as far as the left shoulder, and augmented by pressure by coughing, and by a deep inspiration ; nausea and vomiting ; fever having irregular fits of exacerbation ; sometimes delirium, dry cough, and a sense of suffocation. The extent of the splenic percussion dulness is decidedly increased, and, when we are sure that the spleen is not displaced, the suddenly widened area of dulness forms an im- portant element in the diagnosis. Splenitis is rarely primary, is gen- erally from pyaemia and from- infarcts. It is often observed to be 618 MEDICAL DIAGNOSIS. connected with emboli from endocarditis, and, these being wafted also to the kidneys, albumin and blood are found in the urine, ^^^len suppuration in the spleen ensues, of which the general cause is infec- tive endocarditis, the fever may assume a hectic character and the patient lose flesh rapidly, while the spleen increases in size. Bui there is no certainty in these signs, nor, indeed, in any of the signs of splenic abscess ; this may be latent and suddenly rupture into the abdominal cavity or the stomach. Then there may be abscesses around the spleen with manifestations similar to those in its substance, or to pyopneumothorax.^ An acute enlargement of the spleen may also be owing to hemorrhage from injury. Chronic enlargement of the spleen may be caused by hypertrophy, by waxy disease, by leukaemia and lymphadenoma, by splenic anaemia, by a malignant growth, by hydatids, by syphilitic tumor, by congenital syphilis, and by structural changes from malaria. There are scarcely any symptoms characteristic of these states, except the alteration the blood undergoes, evinced often by a diminution of the red globules and an increase of the white. But this, as we shall find in studying the blood, depends very much upon the special disease. Waxy hue of the face, dropsy, bleeding from the nose, from the stomach, or from the intestinal canal, and digestive disturbances, though far from infrequent, are also not constant signs. Death even may result, as from rupture of varices of the enlarged viscus, without any other manifestations of a lesion than increased size of the oi^gan.* Wien enlargement of the spleen has reached a certain point, the organ curves into the hypogastric and right iliac regions, and a notch or notches may be felt on its anterior and inner surfaces.^ Tliis sign may be very valuable in distinguishing the enlarged organ from cancer of the kidney, for which it has been mistaken.* In some instances enlargement of the spleen is hereditary.* Having determined the persistent swelling to be due to the abnor- mal size of the spleen, we must next endeavor to ascertain the cause of it. The history of the case and the blood examinations are the main elements in diagnosis. A fulness projecting from the left hypochondrium towards tlie umbilical or lumbar region may be owing to fecal (Accumulations in the colon. Although these fecal accumulations do not occur so often * Zuber, Revue de Medecine, Nov. 1882. * Traube, Virchow's Archiv, 1869. » Fagge, Guy's Hosp. Rep., 1868. * Lancet, July, 1873. 5 Wilson and Stanley, Clin. Soc. Trans., 1893. ABDOMINAL ENLARGEMENT. 619 in or near either hypochondrium as they do in the iliac regions, yet they are not very uncommon, and we should be on our guard against confounding them with organic disease, whether of the stomach, spleen, liver, kidneys, peritoneum, or ovary. Their irregular outline, their doughy consistence and painlessness, and attention to the his- tory of the case and to the accompanying disorder of the digestive functions, will generally enable us to detect the true nature of the swelling. But we must not lay too much stress on the non-existence of constipation, for sometimes great irritability of the bowels or per- sistent diarrhoea is kept up by a large collection of fecal matter in the colon, and an irritative fever superadded gives a strong resemblance to typhoid.^ Repeated attacks of colicky pains and soreness to the touch are not unusual in cases of extensive fecal accumulation, and jaundice and anaemia have been also noticed. Besides looseness and mucus, the stools are apt to show small, hard, fecal masses, of leaden hue. In cases of doubt, laxatives, especially castor oil, should be employed before any opinion is given, and with the voiding of large masses of faeces the tirnior and the attending symptoms may disappear. . As regards swellings of any kind situated in either hypochon- drium, or in fact at any portion of the upper third of the abdomen, we should always observe whether they are affected by the act of res- piration. This is a valuable sign, for if the morbid mass move in con- sequence of the depression of the diaphragm, it is because structures are involved, such as the stomach and transverse colon, the liver or spleen, which admit of some mobility ; whereas a tumor that is unin- fluenced must appertain to a fixed part, — for instance, to the aorta. Epigastrium. — ^The most common cause of an epigastric tumor is cancer of the stomach. The swelling is then associated with the symptoms already described. But a tumor in this region may be also produced by a disease of the pancreas, A swelling occasioned by fatty degeneration^ or by uni- form simple hardening of the gland^ cannot, as a rule, be discerned at the bedside. In pancreatic fat necrosis^ the areas of white necrotic tissue are usually also found in the mesentery and in other seats of abdominal fatty tissue. There are no diagnostic signs. In chronic pancreatitis^ deep-seated epigastric pain and tenderness with colicky attacks, a large quantity of matter like saliva passed by stool, profuse salivation, sugar in the urine, colorless or fatty stools, and jaundice have been observed to attend the appreciable swelling extending across the epigastrium. The association of chronic pancreatitis with ' As in a case seen with Dr. Arthur V. Meigs. 620 MEDICAL DIAaNOHIS. diabetes is close. Suppurative pamv^miitis, as we know from Fitz*s analysis, is much more common in women than in men. Though oilen clironic, it may manifest itself by sharp epigastric pain and vomiting, and is not infrequently attended with chills aJid irregular fever. It may last weeks or months. A deep-seated resistance over the seat of tlie pancreas with circumscribed peritonitis, diarrhoea, and slight jaundice are noticed as the case progresses. As regards ctmcer, which can be recognized ^\ith more certainty, the most trustworthy symptoms are : a tumor in the epigastric region ; pain there or in tlie back, not increased by the taking of food, but usually augmented by the erect posture ; progressive emaciation and debility ; an appetite capricious rather than diminished, and in some instances, indeed, a ravenous desire for food ; conslifjation, and at times, but far from in- variably, fatty stools, or fat-crystals in abundance in^the grayish stools,* and profuse salivation. Besides these indications, we commonly find, as the disease advances, obstinate jaundice and occasional vomiting. Many of these phenomena belong also to cancer of the stomach ; Jn truth, we never can be certain of the existence of the pancreatic iiialady until we have excluded the gastric affection. In a dilTerential diagnosis of this kind, the early presence and habitual occurrence of vomiting after meals, the sour enictations, the ha^malemesis. Uie want of free hydrochloric acid in the stomach-contents with the presence of lactic acid, and the absence of jaundice, assist us in locating the seat of the disease in the stomach. A ci^st of the pancreas is distin- guished by a smooth round tumor in the epigastrium, slightly movable, and separated by tympanitic percussion resonance from the liver and spleen. When the slomacli is inflated, Uie tumor is found to lie behind and below it. If the cyst be aspii*ated, an alkaline fluid is obtained which emulsifies fat, transforms starch into glucose, and may digest albimiiii and fiJ)rin. Cnlmfotti-i tlkaiHe of the pancreas is a very rare affection. There are, in addition to the duli sense of wt*ight at the epigastrium and other symptoms of pancreatic disease, — such as the intermitlent presence of sugar hi the urine, vomiting, the passage of nuuvh undigested muscular tibre, a»ul of fatly stools, — sharp, irregular attacks of colicky pain radiating to the letl, due to the passa^ of calculi ; there is no jaunchce.^ Pancreatic calculi may lead to atrophy of the gltiml and become associated with permanent diabetes.^ ' But col lections of fat*ci7stals, Gerhard I has found, are also deteclsd in the pale stools of ictenis without pancreatic disease ; when the bile reappearis in the stools the crystals are no lon^fer seen. * Fitz, "Diseases of the Panfrens/' Allbutfs System of Medicine. •Lichtheim, Berlin, kliii. Wochensch., 1894, No. B. ABDOMINAL ENLARGEMENT. 621 An epigastric tumor is sometimes simulated by a corUraction of the upper portion of the rectus muscle on palpation ; but the swelling soon subsides, especially if rubbed. Occasionally, however, a tumefaction due to contraction of an abdominal muscle may be of some duration/ I have known a contraction of the rectus muscle in a case of gastric cancer occasion so obvious a resistance and swelling that it was looked upon as due to malignant disease of the intestine or of the peritoneiun. Moreover, the rigid muscle gave rise to dulness on percussion. But, though the phenomena were for a long period a marked feature of the case, it was observable that the muscle was raised and rigid to a de- cided degree only in certain positions ; at all events, that certain posi- tions gave a distinct outline to the swelling, and that the latter then, like the line of dulness, was regular and straight, evidently corre- sponding to the contour of the muscle. And this occurs in all instances of contraction of the rectus, no matter with what associated. The muscular contractions are not always confined to one muscle, or to the whole of one muscle, and when irregular, and particulariy when associated with tympanitic distention of the intestine, give rise • to most of the so-called " phantom tumors" of the abdomen. These swellings are perplexing, and are constantly mistaken for serious ab- dominal tiunors. The history of the case, the absence of grave con- stitutional symptoms, the most frequent occurrence of the tumefaction in women, especially in hysterical women, and the usually coexisting constipation, furnish us with valuable signs of distinction. But I be- lieve the use of anaesthetics to be the most important means of diag- nosis. I was first led to employ them a number of years ago, in a case which had baffled the skill of several eminent surgeons, one of whom had proposed to the patient an operation as the only means of relief from what was considered an ovarian disease. The patient was thirty-one years of age, a widow, and evidently of highly hysterical temperament. She was very subject to constipation ; and the swelling of which she complained was of irregular outline and occupied the centre of the abdomen, extending some distance on each side of the median line. It was hard and resisting to the touch, but, on strong percussion, yielded a tympanitic sound. Whenever it was touched she shrank. Thorough relaxation was produced by the administration of ether ; the hand could be pressed almost against the vertebral column, and all signs of the tumor disappeared. . A complete recovery took place ; and thus terminated a case which had lasted for fully one year. In any instance of phantom tumor I would recommend the use of * Greenhow's cases, Lancet, 1867. 89 622 MEDICAL DIAGNOSIS. anaesthetics for purposes of diagnosis ; nay, they may be most advan- tageously employed, for similar reasons, in all cases of abdominal swelling in which the rigid state of the abdominal walls interferes with accuracy of investigation. Fitz^ regards the chronic phantom tumor as identical with idiopathic dilatation of the colon, and the latter as the constant characteristic. In soldiers we observe at times one or several small movable tumors, yielding a tympanitic sound on percussion, in the epigastric or at the upper part of the umbilical region. They are, probably, small portions of intestine which have been pushed between the fasciculi of a ruptured rectus muscle, similar to umbilical hernia. Umbilical Region, — Tmnors which are found in this region form, as a rule, merely portions of a swelling that is principally seated in the epigastrium or in the hypochondria, such as can«er of the stomach, of the liver, of the pancreas, or of the omentum, and dilatation of the gall-bladder. The only two affections which are apt to occasion a swelling solely, or at least principally, limited to and perceptible in the umbilical, region, are tuberculous disease of the mesenteric glands and a movable kidney. The symptoms of the former malady, or tabes mesefUerica, are much the same as those of tubercular peritonitis. Indeed, unless the enlarged mesenteric glands can be felt through the abdominal parietes, the discrimination is uncertain. The abdomen is prematurely laiige, is slightly tender on pressure, and has often a doughy feel ; the child loses flesh, the digestion is impaired, the evacuations are frequent liquid, and ofifensive. It often presents signs of scrofulous or tuber- cular disease elsewhere ; and under such circumstances we cannot be at a loss in determining the nature of the tume&ction in the umbilical region. The disease is very rare in adults, though it occurs.* Its simulation, especially in young women, by psevdo tabes mestnieriau has been described in reviewing the affections of the stomach. When the kidneys are not firmly held by their attachments, they become displaced, and are apt to give rise to serious errors in diag- nosis. The dislocated oigan is perceived under the maigin of the ribs on the right flank, or in the umbilical region, and sometimes extends across the median line. The mass is easily moved, may be, by careful and methodical pressure, returned to the renal region, and presents, on palpation and on percussion, the outline of the kid- ney. The lumbar region yields a tympanitic sound on percussion. ^ American Journal of the Medical Sciences, Aug. 1899. * See case reported by Grairdner^ Lectures to Practitioners. ABDOMINAL ENLARGEMENT. 623 and we find less resistance and a slight depression over the usual seat of the organ. But the most certain way of detecting a movable kidney is to examine the patient by palpation with both hands, while in the recumbent position with the abdominal walls relaxed, and on deep inspiration the fingers of the right hand will then feel the resistance and the outline of the kidney. There is in some instances sensitive- ness over the displaced oigan, especially after fatigue or strong press- ure ; and this occasions the same sensation as when the renal region of the non-aflfected side is pressed ; but we do not find any disturb- ance of the urinary functions, save, perhaps, firequent urination, nor, in fact, except a disagreeable feeling in walking, does any real incon- venience result from the accident, unless the movable kidney has become painful, or, by compressing the vena cava or portal veins, occasions dropsy. • Yet we meet with exceptions to the rule that tlie disorder gives rise to no decided symptoms. Sometimes dyspepsia, especially nervous dyspepsia, is pronounced, as well as intercostal neuralgia. The stomach is often below the normal level. So-called gastric crises also occur, marked by constipation, a feeling of weight in the abdomen, pain in the sacral region after exertion, throbbing of the abdominal aorta and vomiting, with severe abdominal pain and fever ; or there are attacks simulating renal colic. Further, we may find intermitting hydronephrosis.^ In certain instances the pressure on the bile-ducts from a displaced right kidney gives rise to attacks of hepatic colic followed by jaundice, and leads to the supposition of gall- stones.^ There seems to be a special connection between movable kid- ney and neurasthenic hysteria, gastric dilatation, enteroptosis, chronic appendicitis of the right side,^ and membranous enteritis, but the majority of cases are latent, and are only accidentally detected. The disorder is most apt to occur after violent exertion, or after many pregnancies, or may be due to attacks of congestion of the organ, or to tight lacing. It is rare in meTi. The right kidney is oftener movable than the left, and it may be felt low down as a movable mass floating near the right iliac fossa. Both kidneys may be displaced. The aflfection may be mistaken for any form of abdominal tumor, and if the kidney should have become adherent the diagnosis is un- certain. Generally the disorder can be distinguished by the history of the case, and by the physical phenomena mentioned. To these may be added the comparatively slight dulness or rather the tympanitic- » Knight, Lancet, Oct. 1893. * Maclagan and Treves, Lancet, Jan. 6, 1900. "^Edebohls, Medical Record, March, 1899. 624 MEDICAL DIAGNOSIS. character of sound elicited, except on very strong percussion, over the seat of the tumor. This is an important fact as regards the discrim- ination of a movable and displaced spleen^ in which, as the oi^gan is generally enlarged, there is extended dulness on percussion. More- over, tlie history of the splenic disorder, which not uncommonly can be traced to a malarial affection, the usually great tenderness, the nausea, dyspeptic symptoms, and hemorrhagic tendencies which at- tend the displacement of the spleen, and the notch which can be felt in it, will assist us in our diagnosis. A movable kidney may be simu- lated by malignant disease of the colon} Yet another of the abdominal organs is occasionally displaced and movable, — the liver. Now, a movable liver would be often mistaken for a movable spleen, were it a more common affection. But few well-authenticated cases are on record.^ In these the peritoneal attachment of tlie organ had become lax, usually in consequence d pregnancy ; in the hepatic region there was a tympanitic sound on percussion ; and in tlie mnbilical region and towards the right flani a solid body was discerned, the upper border of which presented a convex outline, the lower border was in the inguinal region. The displaced organ was easily pushed about, and could be replaced in its proper situation. The spleen was found in its usual seat; the symptoms were merely those of weight and uneasiness in the abdo- men. The movable or wandering oiigan may be painful or painless. It has the physical characters of the liver, and the most certain sign is the detection, on palpation, of the notch between the right and tiie left lobe and of a zone of tympanitic resonance between the swelliqg and the lung. Tlie diagnosis is, however, always difficult and doubt- ful. New growths of the kidney, as a case of Leggr's proves, are par- ticularly confusing. In most recorded cases autopsies are wanting: and the whole subject is ven* obscure. The affection is more usual in women tlian in men. and. besides pregnancy, tight lacing and chronic inllanimation of tlie peritoneum are said to lead to it. Lumbar Riyion. — ^Tumors in tliis region, or on either flank, aiv occasioned by some morbid growth of the kidney, or by an abscess in it or its surroundings, or in the psoas muscles. Again, they may be due ^ HeuiT Morris. Lancet, April. lS9o. * See Cantani. Ann. Univeis di Medicina, 1866 : and Mexssner's article in Schnudt*s Jahii).. 1$69. No. 1 : also ibi'i.^ Xo. 2. i$7i : Blet. Le Foie mobile. Thesis de P^tfis, 1S76 : Le|!|r. St Bartholomew's Hospital Reports. 1877 : Arini. Anaiesdd Cbcolo Med. Ai^ntino. ifuoted in Amer. Joum. Med. Sci.. JuIt. i$M : H. W. Sea- rs Brit Med. Jooni.^ London. 1$$5. ii. : L. Landau. Deatsefae Med. Wocfae&sch . , 188ft, it ; Rkbelot L Tnion Medicale, Pfths. Aug. 189^ ABDOMINAL ENLARGEMENT. 625 to fecal accumulations ; or, if on the right side, to very considerable in- crease of the liver ; if on the left, to a greatly enlarged spleen. To dis- criminate between these conditions, we have to determine whether the swelling fluctuates or not ; we must also analyze the urine, and inquire minutely into the circumstances precedmg and attending the tumefaction. It is thus only that we can attain the necessary data for a diagnosis, which has, indeed, often to be reached by the process of exclusion. Tumors behind the peritoneum may give rise to a visible promi- nence in either lumbar region, extending to the upper part of the iliac region. The most common cause of these tumors is cancer of the lymphatic glands lying by the sides or in front of the vertebral column. The disease is very difficult of detection. Still, we may suspect its existence if, in a patient who is evidently cachectic and who is steadily losing flesh and strength, we discover, on deep palpation, on one side of the linea alba or in the flank, a tumor which, owing to its being surrounded by intestine, returns a tympanitic percussion sound. In some cases the swelling communicates the beat of the aorta and sim- ulates an aneurism, or it presses on the vena cava and gives rise to enlargement of the abdominal veins and of those of the lower ex- tremities, and to oedema of the legs. The disease may involve the iliac glands and the tumor extend into the pelvis, or it may reach up- ward to the diaphragm ; and, by the cancer spreading to the posterior mediastinum, it may finally open the aorta, producing hemorrhages precisely like those coming from an aneurismal sac.^ Iliac Regions. — ^Tumors in either of these regions may be due to many different causes. They are, as we have elsewhere discussed, principally owing to ovarian affections; to fecal accumulations; to disease of the large intestine, such as intussusception or cancer ; and to pelvic abscess. Sometimes they are caused by displacement of the kidney, by enlargement of the spleen, and in women by retrouterine haematocele, or by extrauterine pregnancy. The ovarian tumors are, as a rule, distinguished from the other disorders mentioned by their more or less globular form, by their movability from side to side or in an upward direction, by their seem- ing to spring out of the pelvis, and their evident attachment below, by the displacement of the womb, by the comparatively unimpaired general health, and by their indolent and generally painless nature. These remarks do not apply to the very slight swelling occasioned by ovarian inflammation, for here the tumid spot is often the seat of severe pain. The healthy ovary is not sensitive to the touch. To ^ Case reported by Haldane, Edinburgh Medical Journal, Aug. 1868. 626 MEDICAL DIAGNOSIS. examine the ovary with exactness, the abdominal muscles must be completely relaxed ; the patient is placed in the attitude recommended by Marion Sims, — on her back, with the shoulders supported, the legs drawn up so that the heels are a few inches asunder and the thighs fall easily apart. As ovarian tumors grow and spread upward they give rise to diffi- culties in diagnosis, which we have already examined into. We may here again mention the manner in which ovarian may simulate renal gi*owths. Stress may be laid on the renal tumor being first detected between the false ribs and the ilium ; on the signs in the urine, and on the absence of those changes in the quantity and regularity of the menstrual discharge which are common in ovarian disorders. More- over, the ovarian growth usually displaces the intestine backward ; in tlie renal growth it is pressed forward and towards the centre of the abdomen ; and large tumors of the right kidney ordinarily have the ascending colon on their inner border, while tiunors of the left kidney are generally crossed from above downward by the descending colon. Among the causes of a tumor in either iliac fossa, retrouierinf hoemcUocele has been mentioned. The tumor, conmionly of rounded shape, rises above the brim of the pelvis, but is traceable into it It forms quickly, and an examination through the vagina detects a boggy swelling in Douglas's cul-de-sac, and at times the grating of the blood coagula ; faintnd^s and collapse attend its production. Much the same physical phenomena are presented by the swelling due to pelvic ceUv- litis. But the slow way in which the tumor forms, the presence of a hot, pufify, bra\\Ti-like condition of the vaginal wall, the usually greater tenderness of the swelUng felt through the walls of the vagina, and the feverishness and constitutional s3rmptoms attending the grad- ual formation of the abscess, are distinguishing marks, except where tlie contents of the hsematocele suppurate, when for a differential diagnosis we may have to rely on the history of the case. Hypogastric Bcgion. — Distention of the bladder and enlaiigement of tlio uterus, whether produced by air, by liquid, by a morbid growth, or by pregnancy, are the most usual sources of a swelling in this r^ion. If due to any one of these causes, the outline of the tumor is regular and rounded : and by the aid of the catheter, of explorations through the vagina and the rectum, of the history of the case, and of the attending symptoms, we are generally enabled to arrive at a oomx t diagnosis, A tumor in tlie hyp>ogastrium may also have its origin in splenic enlargi^mont, in diseases of tlie peritoneum, or in hematocele. In the latter case it is apt to be uniform and to extend to the iliac fossae. ABDOMINAL ENLARGEMENT. 627 In concluding this sketch of abdominal tumors, we shall briefly glance at those which are likely to occupy more than one region, and sometimes even the whole or greater pari, of the abdomen. In rare instances, a cancer of the liver, or hydatids of that organ, or a fibrous tumor of the uterus, or a solid ovarian growth, or an enlarged spleen,^ or a kidney the pelvis of which has become enormously distended in consequence of obstruction of the ureter, may lead to the formation of a swelling that occupies nearly the entire abdomen. But the most usual cause of so diffuse a tumor is carcinoma of the peritoneum. Here there is an irregular tiunor, pain, ascites, and, in consequence of the peritonitis set up, fever. Much the same symptoms may be produced by hydatid disease of the peritoneum^ though there is less fever or none, the swelling may be uniform or even more irregular, the abdominal enlargement greater and painless, and we may be able to detect the hydatid fremitus, and the booklets in the evacuated fluid.^ Yet as regards the hydatid thrill we must bear in mind that a similar sensa- tion is obtained from large parovarian cysts * or from colloid cancer of the peritoneum; a sensation of peculiar and very superficial fluctua- tion,* associated, however, here with grave symptoms of cachexia, and generally with a rapidly spreading growth. Peritoneal abscesses en- closed by adhesions will also, if large, give rise to several of the signs of a cancer; but the history of an antecedent local or gen- eral peritonitis, the swelling not being influenced by changes in the posture of the patient, the irregular fever, the indistinct fluctuation of the tumefaction, and its acute course, may enable us to distin- guish the non-malignant from the malignant affection. In rare in- stances a tumor may be enormous, increase rapidly, yet be simply fatty. There are no means of positively distinguishing the affec- tion.* Sarcoma cannot be told from carcinoma ; it is more common in advanced age. In some cases the malignant disease is closely simulated by dila- tation of the colon, caused ordmarily by fecal tumors. This, though it may present but a single swelling, generally occasions several, which are . commonly seated at the middle third of the abdomen, are apt to * As in the case reported by Porter, Philadelphia Medical Times, June, 1876, in which the spleen weighed twenty-one pounds. * See the cases of Bright, in Clinical Memoirs on Abdominal Tumors, repub- lished from Guy's Hospital Reports by the New Sydenham Society. ' Bristowe, St. Thomas's Hospital Reports, vol. xi. * As in the instances recorded by Albert Robin, Bull, de la Soc. Anat., 1873, and Vidal, Bull, et Mem. Soc. Med. des H6pit., 1874. 5 See St. George's Hospital Reports, vol. v., 1870, p. 253. 628 MEDICAL DIAGNOSIS. appear on both sides, to be movable and painless and to bear handling without pain, to change their position slightly at intervals, and to be- come occasionally less in size. Then, after the case has been for some time under observation, we may be able to notice lai^ and characteristic discharges; though we must not forget that a mere sluggish state of the bowels, or even diarrhoea, may exist while the colon is dilated and perhaps filled with fecal accumulations. Some- times the mass may be seated above the symphysis and be mistaken for a pelvic tumor. Like a cancerous growth, it may lead to complete intestinal obstruction. The tympanites and the dilatation it occasions, which may be idiopathic, produce at times fetal results.^ The dilata- tion may be enormous. Cancer of the intestine has symptoms similar both to fecal accumu- lation and to cancer of the peritoneum. The marked cachexia and the signs of persistent and increasing narrowing of the bowel, as shown by the flattened faeces, the blood and pus in the stools, the fre- quent attacks of colicky pains, and the vomiting, distinguish it from the former affection. The limitation of the swelling, the absence of dropsy, the character of the stools, the frequent change in the position of the tumor and in its distinctness,* and, if it affect the duodenum, the decided jaundice, separate it from peritoneal cancer. SECTION V. ABDOMINAL PULSATION. Aortic Pulsation. — By far the most frequent cause of a pulsation visible in the abdomen, and especially at the epigastric region, is a throbbing of the abdominal aorta. It is common in neurasthenics and hysterical persons. Some women are liable to it immediately before their menstrual periods or during the earlier months of pregnancy. In men it is seen most often in those who suffer from inveterate dys- pepsia, and is apt to come on in severe paroxysms, which are alarm- ing to the patient, but which generally disappear under brisk puiging. In hypochondriacs whose abdominal walls are thin, the beating at the epigastrium may become a source of continued distress. The in- creased action of the aorta, or, as happens in emaciated persons, the greater distinctness ^vith which the beat of the artery is perceived ^ Gee, St Barthol. Hosp. Rep., vol. xx. ; A. Money and S. P^t, Clin. Soe. Transact., 1888 ; Formad, Trans. Coll. Physicians, Phila., 1892. • Leube. Ziemsseu*s Cyclopaedia. ABDOMINAL PULSATION. 629 without there being abnormal throbbing, may be distinguished from an enlarged and somewhat displaced heart by the circumstances of the case and the absence of the physical signs of cardiac disease ; and from an aneurism by the want of the signs that characterize an aneurism. Abdominal Aneurism. — ^Aneurism of the abdominal aorta is a disease of middle life, and of males especially. Its most frequent cause is excessive muscular exercise ; sometimes it is produced by a blow on the abdomen, or by syphilis. Its duration is very uncertain ; occasionally six or seven years elapse from its earliest indications until the fatal termination ; not unusually the patient lives twenty to thirty months after its occurrence. The chief symptoms are pain, and an absence of dropsy, of fever, or of any considerable constitutional disturbance. The pain is gener- ally felt in the back, or in the right hypochondrium, or shooting down the sciatic nerves to the lower limbs. It may be constant and dull, or occur in protracted and violent paroxysms ; ordinarily there is a per- sistent pain which has periods of fierce exacerbation. The dispropor- tion between its violence and the otherwise almost unimpaired health is a striking feature of the disease, and continues until the aneurism becomes very large and occasions displacement of important organs. Besides pain, vomiting and hiccough are sometimes prominent symp- toms. The physical signs of an abdominal aneurism are : an impulse communicated to the hand when placed over the swelling ; a systolic blowing sound ; a thrill ; and in some instances a distinct prominence and alteration in the form of the abdomen. The impulse corresponds, with rare exceptions, to the beat of the heart, is single, and ordinarily very forcible. Generally it cannot be felt from behind ; it is a beat discerned only anteriorly and on either side of the pulsating sac. With the expansion of the tumor, we hear a short blowing sound, both posteriorly and anteriorly, sometimes perceived in the recum- bent posture only ; or a dull, muffled sound ; rarely are there two sounds. A thrill felt at the same time as the pulsation is noticed ; still, it may be absent, even in large-sized aneurisms. The pulse in the femoral is often retarded. Aneurism of the abdominal aorta may be confounded with—: Rheumatism ; Neuralgia ; Colic ; Disease of the Spine ; Aortic Pulsation ; Lumbar and Psoas Abscess ; NON-AXEURISMAL PuLSATlNG TuMOR. 630 MEDICAL DIAGNOSIS. The first four of these afifections are likely to be mistaken for an abdominal aneurism, on account merely of the pain ; the others, be- cause of the presence of pulsation, or of a swelling, or of both pulsa- tion and swelling. RJmimaiism; Neiiralffia ; Colic. — The pain caused by an aneurism may closely simulate rheumatism of the lumbar muscles, or sciatica, or abdominal neuralgia, or colic. There is nothing in the pain itself which will lead to the detection of its origin : this can be effected only by a recognition of the physical signs of the aneurism. Yet, abdom- inal pain, or abdominal neiu^lgia, especially when obstinate, must always make us very suspicious of an aneurism. In doubtful cases a skiagraph may prove of much value. Disease of the Spine, — Patients who are suffering from aneurism often complain of pain in the spine, and present sometimes an obvious spinal curvature. But a careful examination, by detecting the physical signs of an aneurism, will enable us generally to distinguish the source of the difficulty. The constant boring pain so much complained of in cases of aneurism is usually thought to be due to absorption of the vertebrae, but it has no necessary connection with this lesion. Aortic Pulsation, — Simple abdominal pulsation, such as we observe in neurasthenia, hysteria, in dyspepsia, in pregnancy, and in movable kidney ; or excessive epigastric pulsation due to an enlarged right ven- tricle or to insufficient aortic valves, may be readily mistaken for an aneurism. But in the former case the history will generally lead us to a correct conclusion, especially if taken in connection with the facts tliat the pulsation is not heavy and slow, as in an aneurism, but jerking and sudden ; that there is no thrill ; no tumor with corresponding dulness on percussion, if we except pregnancy ; no systolic murmur audible in front of the abdomen or along the spine ; and no pain. The pulsation due to disease of the heart is discriminated by the physical signs in the thorax. Regurgitation at the aortic orifice, which is the cardiac affection most liable to be confounded with an aneurism, on account of the marked pulsation it may occasion in the left hypo- chondrium or at the anticardium, is distinguished by the single or double blowing sounds, which are heard not only over the thorax, but also over many arteries of the body, and by the character of the pulse. Lumbar and Psoas Abscess. — In some cases, soft, fluctuating, deep- seated tumors, that are really produced by an aneurism, may arise in the lumbar region ; nay, they may seem to point, like a psoas abscess, at Poupart's ligament. But, unlike an abscess, the effusions of blood give rise, with rare exceptions, to impulse and to murmur. ABDOMINAL PULSATION. 631 Non-Aneurimncd Pulsatiiig Tumors. — When a tumor of any kind presses upon the aorta, a distinct pulsation is communicated, and the similarity to an aneurism is heightened by the circumstance that the morbid growth may produce a murmur. The tumors which most usually occasion the phenomena mentioned are : enlargement of the left lobe of the liver, cancer of the pylorus, disease of the pancreas, or of the omentum, or of the mesentery, and, in rarer instances, enlarge- ment of the kidney, fecal accumulations, and cancer of the lumbar glands. To avoid error, we must pay close attention to the history of the disorder and the attending gastric and renal symptoms; we must trace, by percussion, the outline of the solid mass, and see if it correspond with any viscus. Then, in non-aneurismal tumor the patient has almost always been in bad health before the tumor is detected, and the swelling rarely causes pain of such severity as is observed in an aneurism ; moreover, the transmitted aortic impulse is lessened by placing the patient on his hands and knees, thus taking away the pressure from the artery. A varicose state of the epigastric veins and the existence of ascites will also decide against an aneurism; while, on the other hand, the lateral as well as the forward direction of the impulse, violent neuralgic pains in the loins or shooting down the back, and an immovable tumor, are in its favor. Still, there are cases in which a morbid growth lying across the aorta occasions symptoms so nearly like those of an aneurism that the most skilful diagnostician finds himself in doubt ; or cases of aneurism in which the physical signs are absent, and in which the affection affords no indication of its existence, beyond, perhaps, pain. Under these circumstances we can only suspect its occurrence. But supposing that, from the combination of the physical signs and symptoms, we know that we are dealing witli an abdominal aneu- rism, can we be sure that it is aortic ? We cannot ; for, although this is generally its seat, an aneurism of the splenic or the coeliac artery, of the superior mesenteric artery, or of the renal artery, may pro- duce the same phenomena.^ When an aneurism bursts, it gives rise to symptoms which vary with the seat of the rent. The accident is always fatal, but deatU may not follow for several days ; usually great tenderness of the abdomen and changes in the physical signs are at once produced. ^ See Ballard, Physical Diagnosis of Diseases of the Abdomen, p. 217. CHAPTER VII. ON THE URINE, AND ON DISEASES OF THE URINARY ORGANS. URINE. The urine, besides being the most accurate index of the condition of the urinary organs, becomes a fair indication of that of many other important secreting glands in the body. To glean the full benefit from an analysis of the urine, we must explore it not merely quali- tatively, but quantitatively, and examine its deposits with the micro- scope. Modern chemistry is especially endeavoring to find means which will determine, by apt volimaetric processes, the exact propor- tion of the ingredients as accurately and as easily as hitherto we have detected their presence. This is a subject which cannot be more than indicated in these pages : only such of these investigations will be noticed as have furnished results which may be made readily avail- able for the exigencies of professional life. It is customary, in quantitative analyses, to use the French system of measures, and to employ instruments on which cubic centimetres are marked. One thousand cubic centimetres are equal to one litre, or 2.1 pints, or to a thousand grammes of water ; and one gramme is equal to 15.434 grains ; one centigramme to .1543 of a grain. Urine, in its normal state, is an amber-yellow fluid, of acid reac- tion, and specific gravity of 1016 to 1020 as compared with distilled water at 1000. On standing from eight to twelve hours, a slight cloudy deposit takes place, consisting mainly of mucus, epithelial cells from the urinary passages, and a few crystals. Normal urine freshly voided contains no bacteria, and is aseptic. Oidinarily, urine soon undergoes decomposition, which renders the results of analysis valueless. It is advisable, therefore, to exam- ine every specimen promptly, but, as this cannot always be done, the addition of some preservative may be needed. Chloroform seems to be the most suitable ; six or eight drops added to each fluidounce, the mixture to be well shaken, will preserve samples for months, even in hot weather. Chloroform gives a strong reaction similar to sugar with Trommer's test, but does not reduce bismuth subnitrate nor interfere 682 THE URINE, AND DISEASES OF THE URINARY ORGANS. 633 with the phenylhydrazin test. It arrests the fermentation of sugar and of urea. In the examination of sediments great advantage, both as to time and complete collection of the suspended matters, is gained by the use of a centrifugal machine, several forms of which are now procurable. The electric centrifuge is the most convenient. The centrifugal method tends to exaggerate the amount of material, as compared with the old method of sedimentation, but by it we may obtain casts and suspended matter which otherwise would be missed. In addition to its usefulness in urine-examination, a good high-speed centrifugal machine is of much use in other clinical work, especially in examining sputum and blood. Purdy's percentage tubes increase the advantage of the instrument. The manner of obtaining a specimen of urine is not unimportant. We should instruct our patient, as is so strongly recommended by Sir Henry Thompson,^ to pass the first two ounces into one vessel, and the remainder into another. We thus procure a specimen of the renal secretion, in addition to anything in the bladder, separate from any urethral products, and avoid the error of confounding prostatic or urethral with vesical or renal disease. When it is essential to obtain a specimen of urine absolutely pure and unmixed with products of the bladder, the same authority recommends the drawing oflf of the urine by means of a soft gmn catheter, while the patient is standing. The bladder should then be carefully washed out by repeated one-ounce injections of warm water. The urine is now to be permitted to pass, as it will do, drop by drop, into a small glass vessel. The bladder contracts around the catheter, and the urine percolates direct from the ureters, through their virtual prolongation, — the catheter, — into the receptacle. The urine passed in the morning, immediately after rising, will be found to represent with sufficient accuracy the general process of disassimilation ; but, if greater accuracy be desirable, a specimen of the mixed urine of the twenty-four hours should be used. As r^ards the quantity of urine daily voided, the mean average of healthy persons is 1500 cubic centimetres (fifty fluidounces). In sum- mer, when the skin is acting freely, less fluid passes off by the kidneys than in winter. The more liquid that is taken into the systean, the greater is the secretion of urine, unless the other organs that eliminate water, as the skin, the lungs, and the intestines, are excreting with unwonted activity. The quantity is diminished in all cases in which the specific gravity is increased, with the exception of diabetes ; it is diminished in acute ^ Clinical Lectures on Diseases of the Urinary Organs. 634 '^^^ MEDICAi. DIAGNOSIS. diseases, m fevers, in cholera, and in tlio eai'ly stages of dropsies ; in some forms of Brighl's disease, particularly the acute forms, tliroiigh their entire course, and often in the last stage of all forms of that disease. It is, on the other hand, augmented in cardiac hypertro- phy and whenever the specific gravity is diminished ; in Iiysteria ; in contracted kidney, and in polyuria. In ahnost all vesical and renal affections frequent micturition is a marked symptom,— ^not ahvays, however, associated with iniTcased quantity of urine. The imprdumtj^ of urine are numerous. The principal are : urea, sulphates, phosphates, chlorides, uric acid and urates, kreatinin, hip- puric acid, mucus, colorinif-matter, and a lai^e proportion of water. The following data for average normal urine are taken from an article by Charles F^latt;^ the ingredients are given according to a strictly scientilic system. Reaction, acidity in twenty-four hours equivalent to 2-4 graitimes of oxalic acid. Total quantity of liquid in twent}^-foiir hours : man, 1450 cc; woman, 1250 cc, Umiumc* ejtcjeted lu twenty-four boun. Man. Waman. Toliil ^o\iih 60.0 51.0 Urea 34.0 30.0 Uric acid 0.6 0.5 Kreahnin 0.9 0.8 Hippiiric add 0,7 0.6 Xanthin and analaguea 0,006 Minor organic maUers iiit'iuding^ pigment 0.3 Snlphur dioxide derivable froni ethereal sulphates 0.250 rhloriri 7.8 6.0 Phosphoric anhydride 3,0 2.5 Sylpijuric anhydride 2.2 1.9 Pcitassium oxide 3.0 2.8 Sodium oxide 4.»") 4.0 Ctddum oxide 0.3 0.28 MiLgiiesium oxide 0.4 0.35 Ammonia (NH,) 0.7 0.6 In>n 0.007 Besides the elements mentioned, tlie quantities of whieh fluctuate with the food-supply and with the acti\ity of Ussue-metamorphosis, we meet, hi morbid states, with siibstances that do not exist at all in healthy urine, or the firesenre of whieh is douhtful, such as various forms of albumin, sugar, blood, bile, fats, oxalate of lime, and certain pigments. Most of these are dissolved in the urine, and are not to be * Joum. Amer. Chem. Soe., 1897, p. 382. THE URINE, AND DISEASES OF THE URINARY ORGANS. 636 detected except by delicate tests ; others form in sediments after the urine has been discharged, and may be recognized by the microscope. As matters of clinical interest we endeavor to fix these waymarks : the color, the specific gravity, the quantity, the reaction, the presence or absence of such important abnormal ingredients as albumin and sugar, and the character of the deposits. Frequently, too, we extend our examination until we have determined approximately, if not accu- rately, the increase or diminution of the main constituents of the urine, especially of the urea, uric acids, chlorides, phosphates, and sulphates, and the distribution or non-distribution of bile and other unusual con- stituents through the fluid. Color. — The color of the urine is much affected by food and medicine, as well as by various morbid processes. A smoky or a red aspect is apt to be owing to admixture of blood ; a* very light color denotes generally an increase of water, and is commonly found in diabetes, in hysteria, and in kindred nervous affections. In febrile diseases the urine is of dark hue. A greenish-yellow or brownish tint of the discharge is indicative of bile ; but a similar tinge may be present when rhubarb has been taken. A dirty-blue urine happens from an indigo sediment, and is alkaline. Strong coffee darkens the urine ; turpentine darkens and imparts a violet color to it ; carbolic acid, tar, and creosote render it black ; so do disintegrated blood and melanotic cancer. Santonin, logwood, and senna discolor it. The first-named substance gives it a bright yellow color, which on the addition of an alkali becomes crimson. Senna may impart to it a brownish or a deep red color, which, however, like that due to rhubarb, is lightened on the addition of mineral acids, and is thus distinguished from the hue of urine containing blood. The altered appearance is mostly due to the coloring-matter of these articles being excreted with urine. The chemistry of the coloring-matters of the urine is still incom- plete, and the clinical significance of the color-changes still obscure. The principal normal coloring-matter is urobilin^ which is an oxida- tion-product from blood and bile-pigment. In febrile conditions a less oxidized product is excreted, which MacMunn has named patho- logical urobilin and declares to be identical with the coloring-matter of the faeces, stercobUin. He further states that the presence of this body in the urine is to a certain extent an indication of the absorp- tion of fecal matter and ptomaines which have not been destroyed by the liver. Other pigments have been described, among which may be named uroerythrin^ urochrome, and haematin fi-ee from iron, fi^stallized oxalates. Not infrequently traces of albumin are associated with the calcium oxalate. This is the disorder called oxaluria^ and is generally combineil with tissue-changes and increased excretion of urea. Its existence as a separate affection has been denied ; but I believe the clinical THE UKINE, AND DISEASES OF THE URINARY ORGANS. 651 ciation of a considerable number of oxalates with the symptoms mentioned to be undoubted. The presence of uric acid and of oxalates is not uncommon in lithsemia. The origin of the oxalic acid is not certain. It is generally the product of incomplete oxidation of organic matters in the body, as well as of sugar, of starch, and of the salts of the vegetable acids. Probably in the first class of cases alone are the constitutional symptoms described present. In the others we may at times detect evidence of the irritation of a calculus, or of disease of the bladder or the kidneys. Acid fermentation of mucus in the urinary passages also occasions it. Calcium oxalate may be detected in the urine when articles which contain it, such as sorrel and the rhubarb plant, have been eaten, or Fig. 61. Calcium oxalate crystaLs. after the free use of tomatoes or of carbonated drinks. It may be also foimd in the urine of those recovering from severe sfcute maladies, and is encountered, but only in very small quantities, in the urine of healthy persons. But in neither instance is it permanent, nor can the presence of a few crystals be looked upon as of the least importance. The microscope is incomparably the readiest means of detecting the salt. This appears in well-defined octahedra of varying size, and in dumb-bell bodies. The former are the more common and charac- teristic; for the dumb-bells are not frequent, nor is this formation peculiar to calcium oxalate. Occasionally, long or pointed octahedra or prismatic crystals are observed. All forms are unaffected by acetic acid. The oxalates are often mixed \vith deposits of urates or uric acid]; a fact which some use as an argument that oxalic acid is but the MEDICAL DIAGNOSIS, direct Iranslbniiation of uric acid, Sonietinics — Ben eke says con- stantly— the earthy phosphates coexist in large amount wath tiie oxa- lates. Occasionally ttie irritation from tlie passage of the crystals gives rise to tube-casts, A case came under my observation years since in which a patient suflering from a protracted attack of oxaluria voided for weeks, along with the oxalates, hyaline, exudative, or small waxy casts. Neither heat nor nitric acid detected albumin. Under treatment, the crystals disappeared from the urine, and with them the casts. The urine examined ten yeiirs ailerwards showed not the slightest sign of degeneration of the kidneys. Liiiviue ftnd Tifirmne. —Both these substances are the result of the decomposition of highly nitrogenous animal matter, are verj' similar, and are usually associated. Tfiey replace urea, and have been found in the urine only in disease, as in acute yellow atrophy of the liver, in typhoid fever, in smallpox, in phosphorus poisoning, in cancer of the liver, and in other forms of enlargement of the organ.^ Tliey are either spontaneously deposited, or form a deposit if a small quantity of urine be evaporatetl. Tyrosine is readily detected by the micro- scope. It crystallizes in long, very fine, sliining needJes, which may congregate in globular bodies. Hofmann has proposed the following delicate chemical test for tyrosine. A solution of mercuric nitrate, nearly neutral, is to be treated with the solution suspected to contain tjTOsine ; if it be pres- ent, a reddish precipitate is produced, and the supernatant fluid is of , a very dark rose-color. Leucine crystallizes in granular masses, con- sisting of roundish globules, sometimes of concentric form, and for the most pari of yellowish color and resembling oil-drops, but, unlike oil, is not dissolved by etiier. The chemical test for leucine is to place the suspected deposit on platinum foil and then to evaporate it witli nitric acid. The residue is moistened with caustic soda, and this mixture is carefully heated over a spirit-lamp. It is gradually con- densed into oily-looking drops, — a property which Scherer has pointed out as a cliaracteristic of leucine. Tyrosine is the parent substance from which the acid, homogenti- sinic acid, is formed lliat occasions alcaptonuria. In tliis rare disorder the urine when passed rapidly becomes of deep brown color and finally black. The fact that urine containing alcaptone reduces Feb- ling's solution, though only with the aid of heat, causes it to be mis- taken for saccharine urine. But both tlie bismuth test and the fer- * Vaaghan and Beringer, Contributions from the Chemical Laboratory of the University of Michigan, vol i,, 1882. THE URINE, AND DISEASES OF THE URINARY ORGANS. 653 mentation test give negative results. Alkalies greatly intensify the brown color of the urine. The disorder does not markedly affect the general health, and frequently dates from childhood. It is most com- mon in males.^ Bile, — ^The occurrence of bile in the urine imparts to it a very dark color. All the constituents of the bile may appear in the urine, or only the pigment, without the acids or their salts. The pigment is sometimes found transiently, and in small quantities, without yellow- ness of the skin : its more permanent and marked occurrence is, how- ever, always attended with jaundice. It may be discerned before the discoloration of the skin is noticeable, and after it has lost its yellow hue. The bUiary acids are not of necessity present in the urine of icterus. The detection of the coloring-matter of bile is effected by pouring a small quantity of urine on a white plate; a drop of the yellow fuming nitric acid of commerce is then permitted to fall on the thin layer of fluid. Soon a play of color takes place, beginning with green and blue, passing to violet and red, and often finally to yellow or brown ; the green is the predominant and the most characteristic of the colors. According to Frerichs,* this reaction may fail in cases where the other symptoms of jaundice are undoubted, owing to the bile-pigment having already passed through stages of transformation. When this is the case, the urine is at one time of a brown or brown- ish-red color, and becomes red on the addition of nitric acid; at another time it is of a deep red, which is converted by nitric acid into a dark bluish-red. Murchison has made a similar observation * in cases where jaundice has resulted from a blood-poison, and he has frequently found the urine to present these characters where there has been no jaundice, yet obvious derangement of the liver. Heller's test is also very easily performed. In a small beaker glass containing about 6 cc. (1.62 fluidrachms) of pure hydrochloric acid mix enough urine to discolor this, then allow nitric acid to trickle along the sides and form a layer underneath. A beautiful play of colors takes place at the point of contact, and, on stirring up the mixture with a glass rod, throughout it. The following is also a delicate test for bile. Add to the urine some calcium chloride solution, and then solution of sodium carbonate. The precipitate will contain any bile-pigment, and may be collected by agitating the liquid with chloroform. The chloroform solution » Garrod, Med.-Chirur. Trans., 1899. * Diseases of the Liver, Sydenham Soc. TransL, vol. i. p. 100. ' Clinical Lectures on Diseases of the Liver. 41 654 MEDICAL DIAGNOSIS. should be agitated with water and acidulated with acetic acid. Any bilirubin will color the chloroform yellow, which will become green on adding the acid. If the urine contain only altered biliary coloring-matters (bilifusdn), they may, according to Hoftnann and Ultzmann, be recognized as fol- lows. A piece of clean white linen is dipped into the urine, and then allowed to dry ; it is discolored brown. Further confirmatibn is found in a very dark reaction for urophaein (by adding about double the quantity of urine to strong sulphuric acid), the urine appearing not garnet-red, but black. A similar reaction is produced only by the presence of sugar and of blood-coloring matter, both of which can be excluded by the appropriate tests. The biliary adds are sought for by Pesttenkofer^a test. It consists in adding a few drops of a solution of sugar to a small portion of urine contained in a test-tube or in a china dish, placed in cold water. To this mixture an excess of concentrated sulphuric acid is added, drop by drop. The fluid assumes a yellowish-red color, which, if bile be present, passes into a crimson or violet. But it is inconclusive ; for urine containing an excess of indican or oleic acid or albumin ntay display, when thus treated, a reaction similar to that caused by the bile acids. The spectrum, which shows lines by F and near to E, affords, according to Schunck, the most certain test of bile acid ; in- deed, minute distinctions between the diflferent coloring-matters can- not be attained except through spectroscopy. A delicate test vftry generally used for biliary acids is Oliver's UM, The test solution consists of half a drachm of pulverized peptone, four grains of salicylic acid, half a drachm of acetic acid, and dis- tilled water to make eight ounces. The fluid is made transparent by repeated filtering. Twenty minims of urine are added to sixty minims of the test solution ; if bile acids are in excess, a distinct milkiness quickly appears. Indican. — Among the so-called ethereal sulphates occuiring in urine, of special significance is potassium indoxyl sulphate, indican. It exists in mere traces in normal urine. A notable increase in amount is regarded as evidence of increase in intestinal putre&ction. It is also found in all wasting diseases, and in morbid states attended with rapid decomposition of albuminous substances, as in empyema. It has been particularly noticed in obstinate constipation and obstruction of the small intestine. Occasionally the blue color of indican may be observed in urine soon after it is passed. Indican may be detected by the following test : Add to a sample of the urine an equal volume of strong hydro- THE URINE, AND DISEASES OF THE URINARY ORGANS. 655 chloric acid, and then a few drops of a solution of chlorinated soda. A bluish-black cloud is formed just beneath the surfece of the liquid, and on stirring the reaction takes place throughout the mass. If the liquid be shaken with chloroform, the color will pass into the chloro- form and collect at the bottom of the tube. Care must be taken not to use much chlorinated soda. The depth of color gives an approxi- mate idea of the amount of indican present. Sugar. — This substance is not a normal ingredient of urine, or exists only in traces too minute to be detected by the ordinary tests. When met with in normal urine it is probably due to the decomposi- tion of the indican. Sugar may be found occasionally in the urine of those who live exclusively on a starchy diet, or who take large quan- tities of sugar ; but the proportion even then is very small. It may also form from the breaking up of albuminous substances. Sugar ap- pears in the urine after inhalation of carbon monoxide, and, as this is a common ingredient in illuminating gas, cases of light chronic poison- ing giving rise to apparent slight diabetes are probably not uncommon. The urine secreted while under the influence of turpentine, ether, chloroform, chloral, or amyl nitrite is found to respond to the copper tests for sugar. Bordier^ has grouped together many observations which led him to conclude that saccharine urine may be considered as an almost normal occurrence in the stage of recovery from acute dis- eases. Measles, pneumonia, erysipelas, all inflammatory fevers, are likely to exhibit it during convalescence. It may be detected in cer- tain lesions of the brain and spinal cord and in phthisis. But a large and persistent amount occurs only in diabetes. Urine holding sugar in solution is light-colored, of high specific gravity, and of peculiar smell. It rarely deposits sediments, and the excess of water in it may be large. To detect the presence of sugar, several tests have been proposed, nearly all of which are easy of application. When albumin is present, this should be first separated by boiling and filtering. Trommer's Test — ^A few drops of a solution of copper sulphate are dropped into the test-tube holding the urine. Solution of caustic soda is now added in excess. If the fluid be saccharine, the faint green- ish tint is changed to a deep blue, the precipitate which is formed when the alkali is first added being soon redissolved. On heating the blue mixture it becomes brownish, then yellow, and finally a reddish- brown mass of copper suboxide is thrown down, very diflferent from the flocculent or greenish sediment noticed when no sugar exists. A ^ Archives Generales de Medecine, 1868. 656 MEDICAL DIAGN08IB. very small quantity of sugar can be detected by this process; but, good as tlie test is, it has its diuwhacks ; for sugar is not the only sub- stance wliicli possesses ttie power of reducing tlie salLs of copper. Chloral, cellulose, kreatinin, and to some extent uric acid and the urates, share with it this property. Furthermore, Beale lias stiown that the presence of amnioniuni salts will prevent the precipitation of the suboxide in urine containing but little sugar. For the quantitative deterniinaiion of suf^far, F'ehling's sokition is generally employed. This may be njade by the foUowmg formula, in wlilch, in accordance with the recommendation of Allen, the quantity of Rochelle salt is rather greabr than ordinarily given. 34.64 grammes of pure trystallized copper sulphate are dissolved in pure water, and tlie solution is made up to oOO cc. 70 grammes of caustic soda in sticks and 180 grammes of pure Rochelle salt are dissolved in 400 ee. of whaler, and this solution also is made up to 500 cc. The two solutions ^ should be kept in separate well-stoppered b€>ttles. For use equal quan- tities are mixed as required. To determine the proportion of sugar in a sanqjle, five cc. of each solution are mixed, dil uteri with al:»out an equal volume of water, and brought to the boding-point, in a porcelain basin. Tlie porcelain dish with handle, called a casserole, is very convenient for this fiurpose. No precipitate nor loss of color should result from the boiling of the solution. The sample of urine is then added by small portions at a lime, boiling between each addition, and watching Ihe liquid so as to note the point at which all the blue color is removed. The condition is best determined by withdrawing fhe basin from the flame from time to time, uiclining slightly, and allowing the red pre- cipitate to settle. Any trace of blue color is easily seen. Ten cc, of the solution require .05 gramme of glucose to reduce them completely ; the amount of urine used, therefore, contains this amount of glucose, and a calculation of percentage can easily be made. To get accurate resuHs, the urine should be quite dilute, and if llie qualitative tests indicate considerable sugar it will be necessary to dilute the liquid to five or even ten times its bulk. This dilution must, of course, be allowed for when making the tinal calculation, Allen recommends the following test for cases in wdiich there may ^ be doubt as to the presence of sugar. Heat, to boiling, about ten cc^ of Fehlings solution, and add a nearly equal quantity of the urine; heat for a few' minutes, and then set aside to cool. If no turbidity is produced as tlie h(|uifl cools, the urine is free from sugar, or, at most, contains less than ^V V^'^ ^'t'nt. Fehling's test can also be used for peptone and propeptone. It gives at the point of contact in Uie test- tube a rose-pink or purple color. THE URINE, AND DISEASES OF THE URINARY ORGANS. 657 Boettger's Test — Add to the filtered urine about half its volume of sodium hydroxide solution and a pinch of pure bismuth subnitrate, and boil the mixture. Sugar will be indicated by a blaek precipitate. If sugar is not present, the precipitate will be white, or, at most, some- what gray. This test is very delicate and tolerably free from fallacy. Dark-colored urines of high gravity may produce a gray precipitate, but it does not settle so rapidly nor so completely to the bottom of the tube. Only a pure, finely powdered preparation of the bismuth compound should be used for the test. The bismuth test has an additional value, because alcaptone in the urine, which reduces the Fehling test and thus leads to the mistaken idea of the presence of sugar, does not influence it.* Phenylhydrazine Test. — Phenylhydrazine is a coal-tar derivative which possesses the property of forming crystalline compounds not very soluble in water with bodies of aldehydic or ketonic type, to one or the other of which classes the sugars belong. It is generally used in the form of phenylhydrazine hydrochloride. It is said to cause a persistent eczema when much in contact with the skin. The test may easily be conducted without danger. The following method seems, according to some comparative experiments made by Leflfmann on the diflFerent published processes, to be the best. Fifty cc. of the urine are mixed with 0.75 gramme of phenylhydrazine hydrochloride and 1.0 gramme of sodium acetate, and the mixture is heated for one hour at least in a test-tube placed in boiling water. Very small amounts of sugar will produce a marked yellow precipitate — a compound of sugar with tlie reagent — which under moderate magnifying power exhibits either brush-like branchings or more decidedly radiate crystals, some- what like chestnut-burs. A flocculent brownish precipitate or small brown globules should be disregarded, The precipitate is almost char- acteristic of sugar, but cannot by the microscope be distinguished from a similar precipitate by glycuronic acid, a rare substance which is closely allied to dextrose in structure. The distinction can be made only by collecting the precipitate and determining its melting-point. The test, however, is principally of value in distinguishing those cases in which very limited reducing action is exhibited by a sample of urine when tried by the ordinary tests. As a delicate reaction for true sugar it does not seem to possess the great advantage over Boett- ger's test that has been claimed for it. , Further tests, though now not much employed, are Moore'H test — boiling the urine with an equal part of potassium hydroxide — and the fervxerUoiion test. * Fulcher, Alcaptonuria, New York Medical Journal, 1897, ii. 65S MEDICAL DIAGNOSIS. Other fonns of sugar, such as iiv^r or' wuli^ may be found in the urine. Sugar of milk has hitherto been detected only in the urine of lying-in and of niusing women. -irWow^, — ^Ralfe gives the following test About 4 cc (one drachm) of sodium hydroxide scdutkin containing a gramme (fifteen grains) of potassium iodide are placed in a test-tube and boiled. An equal volume of urine is then p^ouned in cautiously, so as to float on the siir&ce of the alkaline liqmd. At the point of contact a ring of phos- phates will be fcvmed. and after a few minutes will be ocdcHred yellow and studded with crystals of iodofonn. Alcc^ol and lacfikr add also give this result On adding a very dilute alkaline solution of sodium nitit^wiisside to a ftuid containing aoetone, a ruby-red color is produced which in a few minutes changes to yellow. r^vyric aWiii a body somewhat simikr to aoetone, is occasionally present in urine. It is n^tx^nnxsed by the red coIot prcduced by solu- tion of ferric chlvvide in i>erfts:ljy Sresh, unboCtJ urine. Etoth avx-tv^ne and diacetic acid are derivadves of betaoxybutyric add. and this itsc-lf results 6\>n: the diaiittCTatian of the tissue albu- mins. Oxybutyric acid is now very ^neially ne^amcled as giving rise to tht a.5d intoxiv';ition that prodacvs diabetk «ffiaL In this it may be four.'ii in Ae urine in vix>rmoL!s aniour.ts;. I*>» ;o 3:«> grammes in twesin-iour houi^ Tht "test fC'P oxybutyria' acod i> with :br i»oiaris«»f«e. In thor- ougtJT :rm:!rnted "jLrat. wtl'. i'jttivd. :hr T^ays of roiarized light an? dvfe::t'.: :: :h- .v?. F:t -.ht :uir.tTi::T. t xir^izii:5oi: ti-jatic»n is aJS;^ r-tvi-ssATv. •-'/••*■ - '.h .■>-" 5> rV'T^v.vA rj -.ht iirfv: .xiii^cr. :•: sTaj*e-?u*ar. Th- :^<: ::■? :: 2? :: r»:c- ::r:v- v^^ih ±L;::t >-^yhur?: £cai: ibe liquid -"'/..v.-r, — Tr.i> i? i 5vJ>s:-rc-: :;:•: ":•:"■: ::ar-:i*: :: ibr s-a^ars. but 1dc>s'.i:^ i? i frni: ■::-*■. ri.::.--r :1:,sj:: k iiSti^..* Tbr rh^rarcerisDv r*- i.cj:- :■: ir.:s5i:r i? txhirt:::'.: Ti-:T:-. t f::.r^.;.- v :bt >:±t=caiK>r is rVi^or^Trvi -^Ti-J: — ::rj- .-.,:•.: -..viry :; .ir. -.--.ss ;-: -.itriiun. ar*d ^-r resii-rr, n:»i>:rc-'i rri'.h iL 1:: -: i:r..r..;i:. .;v. :.>.ir:vj>: ir?i a 5icojti:»r. vv :il:::i:i: /r_ .nc:. 2? i^riiv :^-2.:'. ::£::•: : Arr.-.-ss: i riiArkr-i r:«sr- THE URINB, AND DISEASES OF THE URINARY ORGANS. 659 color appears, — which is not the case when true sugars are treated in the manner described. The presence in the urine of the blood-extractives indicates merely the escape of blood-material, and proves the existence of congestion or inflammation of some part of the urinary surfaces. Rees has pointed out * that in Bright's disease the extractives can be found in the urine before albumia is met with, and also that they exist after the albumin has disappeared, — thus warning us, on the one hand, of the approach of albuminuria, and, on the other, against too early a belief in conva- lescence ; for, as he justly observes, so long as the blood is losing its extractives so long is the patient ia peril. The presence of the extrac- tives also enables us to diagnosticate nephritic irritation fix)m renal calculus before albumin, blood, or pus has appeared. To the delicate test by guaiacum for the crystalloids of the blood, which has been used to detect the prealbuminuric stage of Bright's disease, we shall presently more particularly refer. Albumin and other Proteids. — ^The study of the various proteids occurring in urine is a matter of difficulty ; and much uncertainty and confusion still exist with reference to them. The genito-urinary tract being a mucous area of great extent, abnormal secretions are frequent, and it is in many cases impossible to determine the boundary between health and disease. Thus, much discussion had been held as to the occurrence of albumin in ruyrmal urine, without any clear definition as to what is meant by the term normal. Eflforts have been made to secure tests of extreme delicacy, but, while some of these have value in physiological investigation, they are often too delicate for practical work. By the term albumin, unqualified, clinicians generally mean serum- albimiin, and that meaning will be understood in this work. A pro- teid, derived from the mucous tissue, is generally present in urine. This has been designated mucin, but seems to be identical with a body called nucleo-albumin and also obtained from bile. Fibrin and haemo- globin may appear, and also all the products of the transformation of proteids under the influence of digestive ferments, that is, the various proteoses and peptones ; what is often designated peptone is an inter- mediate product, — an albumose. Albumin appears sometimes for a short period and then for a time is not found. Egg-albumin, it is stated, may show itself in the urine after the free use of eggs as food. The tests for albumin depend on -coagulation. The most important are: * Guy's Hospital Reports, 3d Series, vol. xiv. p. 431. 660 MEDICAL DIAGNOSIS. Heat ; Nitric acid ; Picric acid ; Potassium ferrocyanide ; Trichloracetic acid. Heat Test. — Albumin is coagulated by heat of about 150® F. (60° C). The application of heat to normal urine often causes a precipi- tate of phosphate. To avoid this fallacy a small amount of acid, nitric or acetic, is added. The test is best performed as described by Purdy: Mix a portion of the sample with about one-eighth its volume of a sat- urated solution of common salt, filter, and fill a test-tube nearly full with the mixture. Add two or three drops of acetic acid, and l)ofl the upper stratum of liquid. The contrast between the two layers of liquid ^vill be sufficient to indicate very small amounts of albumin. The salt solution prevents the interference of mucin, which is not pre- cipitated under these conditions. This is a satisfactory method for the detection of minute amounts of albumin. Small quantities may be also found by thorough boiling of urine to which a few drops of acetic acid have been added, A\ithout admixture with the salt solution. Nitric Acid^ Heller^s Te^t. — Fifteen drops of commercial nitric acid are placed in a somewhat narrow test-tube, and some urine poured slowly down upon it, the tube being considerably in- clined. Another method is to put the urine in first and introduce the acid by means of a pipette, so as to form a clear layer at the bottom of the tube. A white ring forms at the point of contact. Urine in which this test does not show albumin may be regarded, for practical purposes, as not containing it. Tests by the so-called underlaying method are con- veniently made by the use of the albumin-test glass de- signed by Kyner. The precipitating substance, e.g.^ nitric acid, is put in proper quantity in the tube, and the liquid to be tested is allowed to flow through a filter folded in the usual way and placed in the funnel-shaped top of the glass. In testing filtered urine it must be borne in mind that many forms of filter-paper will fiimish enough soluble vegetable albumin to give distinct reactions ^viih the more delicate tests for proteids. To avoid this error it will be best to use the centrifugal machine to secure a clear liquid. Urine rich in urea sometimes forms a precipitate of urea nitrate. It may be distinguished from albumin by its crystalline character. Fig. 62. Albumiii U»st- THE URINE, AND DISEASES OF THE URINARY ORGANS. 661 especially after standing a few hours, and by its solubUity when the liquid is warmed. Excess of urates may also produce a precipitate that might be mistaken for albumin, but the ring is irregular and will in a few hours become distinctly crystalline and can be easily determined under the microscope. Resinous bodies administered as medicines are precipitated by the addition of nitric acid. They may generally be recognized and dis- tinguished from albumin by their strong odor and by their solubility in alcohol. In urine containing alkaline carbonates an eflfervescence will occur when any acid is added, but this will soon cease and the coagulum will be formed. Convenient ways of determining the quantity of albumin in urine are by Esbach's albuminometer and Purdy's centrifugal method. The standard reagent for the former is composed of 10 grammes of picric acid, 20 grammes of citric acid, to 1000 cc. of distilled water. After admixture with the reagent, the imne must stand for twenty-four hours. With Purdy's electric centrifuge the test is more accurate, and can be completed in fifteen minutes. Graduated percentage tubes and acetic acid, and a solution of potassium ferrocyanide, are employed.^ Sometimes urine is encountered on which neither the heat nor the acid test yields the customary result. This is owing to its containing modified albumin, albuminose. Such a case was published by Bence Jones.^ No coagulation was produced by heat, and none by nitric acid, unless the urine was subsequently heated and permitted to cool. The solid that formed on cooUng disappeared on heating. The patient was suflfering firom mollities ossium. The test as now mostly prac- tised consists in slowly heating slightly acidulated urine, which be- comes cloudy, but clears on thorough boiling ; on cooling, the cloudi- ness or the deposit reappears. Nitric acid produces in cold urine a deposit, which disappears on boiling, and reappears on cooling. A number of late observations, especially those of Kahler, Rosin, and Ellinger^^ have associated this form of albuminose with multiple tumors of the marrow of the bones. In a case reported by Fitz * there was also myxoedema. Basham recommends the tincture of galls as a test for this modified form of albumin. Picric A,cid Ted. — The saturated solution of this acid may be employed in the manner of the nitric acid contact test. The solu- tion, being lighter than most urines, will form the upper layer. Picric * Piirdy, Joum. Amer. Med. Association, Sept. 23, 1899. * Philosophical Transactions for 1848. » Deutsches Arch. f. klin. Med., Ixii., 3 and 4, 1899. * Transactions of the Assoc, of Amer. Phys., 1898. 662 MEDICAL DIAGNOSIS. acid makes a very delicate test, but shows the same &llacies as the other acid tests. It also forms a slight precipitate with mucus, stains the ^in yellow, and is somewhat explosive. Potassium Ferrocyanide Test — ^Twenty-five drops of strong acetic acid are thoroughly mixed with three times that amount of a solution of potassium ferrocyanide (1 in 20). A considerable volume of the urine is then added. Albumin if present will form a precipitate. The test thus applied is absolute evidence of albumin. Trichloracetic Acid. — ^This is a solid, highly deliquescent body. It is corrosive, and should be handled with care. It is employed in the strongest possible solution, best obtained by allowing the solid to absorb water from the air until a solution is just formed. It is too delicate a test for general clinical work. It reacts with all proteids. Halliburton sums up the reactions for the diflferent proteids as follows : If no precipitate forms on boiling after acidulating, albumin and globulin are absent. A precipitate may indicate both. If no precipitate is produced after neutralizing the original liquid and saturating with magnesium sulphate, globulin and heteroproteose are absent. If the urine gives no precipitate by the boiling test fcff albumin, nor with nitric acid in the cold nor when saturated with ammonium sulphate, peptone is the only proteid that can be present Peptone may be detected by the so-called biuret reaction, which de- pends on the red color produced by adding solution of sodium hydrox- ide to the liquid to be tested and then a small amount of a dilute solution of copper sulphate. Other proteids react with this test, but give a reddish-violet color. The complete removal of all the other proteids from a mixture containing peptone by means of ammonium sulphate is difficult Peptone is met with physiologically only during the puerperal state.^ It occurs pathologically during many varying conditions, especially as the result of incomplete digestion and where there is tissue degenera- tion. It is frequent in general paralysis.^ Globulin very seldom occurs in the urine except in combination with serum albumin. But in advaiiced disease of the kidneys its rela- tive proportion may be much increased. According to Senator it is most increased in waxy kidney. Estelle ^ met with a number of cases * Robltschek, Zeitschr. f. klin. Med., xxiv. • * Arch. Gen. de Med., March, 1894. ^ Quoted by Hills, in a very instructive article on the Proteids of the Urine. Boston Med. and Surg. Joum., Aug. 1899, which may be also advantageoush r^ ferred to for the relative study of the chemical tests. THE URINE, AND DISEASES OF THE URINARY ORGANS. 663 in which globulin was the sole proteid. Globulin is insoluble in water, but soluble in dilute salt solutions. Mucin, Nucleo-ABmmin. — ^The reactions of this substance . have been studied especially by D. D. Stewart.* He found that solutions of citric acid, both dUute and concentrated, used by the underlaying method, as in the cold nitric acid test for albumin, gave distinct contact rings. Picric acid associated with citric acid also gave such precipi- tates, but picric acid alone produced, with solutions containing not more than .02 per cent, of nucleo-albumin, only a tardily appearing haze. If urine be diluted with water and then strongly acidulated with acetic acid, mucin is precipitated, and may be collected, redis- solved in water by the aid of alkali, and again precipitated by acetic acid. Blood. — ^The passage of blood with the urine constitutes haema- turia. The urine is of a red color, or of a smoky hue. If much blood be present, small, irregular masses are seen at the bottom of the vessel. But the only certain diagnosis is by the microscope ; for urine may be red or black, from the admixture of various pigments derived from substances swallowed as food or medicine, or belonging to the economy. Thus, beet-root, some kinds of strawberries, log- wood, and rhubarb impart a deep red color, which may be the cause of groundless s^larm ; or urine deeply tinged with bile, or discolored by fever, may be thought to signify the occurrence of hemorrhage. The chemical tests for blood are much inferior to the microscopic examination. Yet we sometimes may have to resort to them. I have found a rough test in the addition of carboUc acid, which not only coagulates the albumin, but also changes the color of the fluid. It does not produce the same peculiar reddish tinge with bile, or, so far as I have tried, with any other substance. The guaiacum test is verj^ accurate. It is especially valuable in the recognition of the pre- albuminuric stage of Bright's disease, in which haemoglobin appears in the urine before albumin.^ The test, as modified by Stevenson, consists in adding to a few drops of urine in a small test-tube a drop of tincture of guaiacum and then a few drops of ozonic ether. The mixture is agitated, and as the ether collects at the top it carries with it the blue color produced by the haemoglobin, leaving the urine colorless below. If saliva or a salt of iodine be present, the test is fallacious. The spectroscope affords a very delicate test The char- acteristic bands of haemoglobin of yellow and green are seen between * Medical News, July, 1894. ' Mahomed, Medico-Chirurgical Transactions, 1874. 664 MEDICAL DIAGNOSIS. D and E. If the haemoglobin be in a state of destruction or reduction, only one broad band appears. But the microscope, as already stated, is the means most employed and most valuable. The corpuscles we detect are often crenated, or very pale, and sometimes very small, but never collected in rouleaux ; there is often considerable granular pigment After having determined that hsematuria exists, the questions remain to be solved, at what point has the blood been poured out? Is it really from the urinary organs ? and if it be from them, whence ? — from the kidneys, from the bladder, or from some other portion of the tract ? Again, what morbid state lies at the root of the hemorrhage ? Now, the first of these questions must always be answered at the onset. Blood may flow from the vagina or uterus and become mixed with the urinary secretion, or it may have been added for purposes of deception. In the former case, a careful inquiry into the state of these organs, or, if necessary, a digital examination, will eliminate tlie source of error ; in the latter, drawing off the urine by the catheter wUl detet t the imposture. When we have fully satisfied ourselves that the blood is derived from the urinary organs, the next point to be ascertained is whether it proceeds from the kidney or from the bladder. To deter- mine this, we have not only to study the character of the fluid excreted, but also to investigate all the conditions of the accident. If the blood come from the bladder, it is not equally di£Fused through the urine ; the fluid discharged is at first clear or nearly so, but at the end of the act of micturition is much more deeply colored ; or pure blood, in a liquid form or in clots, is voided. Then, too, there is usu- ally pain over the bladder, with a frequent desire to pass water, and a stoppage in doing so ; the urine is generally alkaline. When the blood is derived /ror/i the kidney, we mostly discover pain in the lumbar region, and other symptoms pointing to the affected organ, the existence of albumin in considerable quantities in the urine, or the passage of gravel. Clots are not encountered in renal hemor- rhage, except when the blood coagulates in the infundibulum or the ureter and is gradually forced downward. Such clots are of a whitish color, and generally of cylindrical shape. In their passage towards the bladder and out of the urethra they become often the source of distressing pain. They are very significant, yet they are not absoluteijr pathognomonic of renal hemorrhage ; for C9agula formed in the blad- der may be retained there for some time, and lose their color before they are expelled. Sometimes we meet with little solid or gelatinous fibrinous coagula which bespeak simply localized fibrinous exudation from some part of the urinary passages. THE URINE, AND DISEASES OF THE URINARY ORGANS. 665 Aid in diagnosis may be derived from the study of the shape of the clots, which for this purpose should be floated out in water. According to HUton,^ they will oftentimes be exact moulds or casts of the cavity in which the blood was effused. Thus, coagula formed within the bladder have a somewhat uregular, circular outline, and are flattened in shape, with bevelled and serrated edges. The use of the microscope, furthermore, is very valuable in the differential diag- nosis. The epithelium which is mixed with the blood from the kidney is not flat and in scales, like that from the bladder, but small and more or less round or columnar; nor are there fibrinous shreds. Some- times the blood-corpuscles are observed to be collected on casts that have been moulded within the renal tubes. These blood-casts warrant an absolute conclusion as to the source of the hemorrhage. Renal Hcematuria. — ^When of renal origin, the haematuria is often due to congestion or an acute parenchymatous inflammation of the kidneys in infectious maladies, such as scarlatina, smallpox, malignant measles, and typhus. Here we have the history of the malady, and the presence of tube-casts, of blood-casts, and of a considerable amount of albumin, to explain the meaning of the hemorrhage. The blood is derived from the engorged and ruptured Malpighian corpuscles. It has been stated ^ as a diagnostic sign that in renal haematuria the blood- corpusles show fragmentation, similar to the irregularities of poikilo- cytosis, while this does not happen in vesical hemorrhage. But as regards the large amount of albumin present, we must not lay too much stress on this as indicating marked kidney implication. Irritant medicines, such as turpentine and cantharides, may cause congestion and bloody urine ; and so do strains and blows on the back. In all these varied circumstances, a careful survey of the history and the symptoms will establish the diagnosis. Renal haematuria of chronic character is generally due to cancer of the kidney ; to cystic degeneration ; to ulceration within the pelvis of the organ ; or to irritation, with or without ulceration, set up by a calculus. In the first of these affections there is nothing in the urine to point out the source of the haematuria until the disease is far ad- vanced, when pus, and sometimes disorganized cancerous tissue, may be discerned in the sediment. The manifestations of cystic degenera- tion are uncertain unless we can detect a lai^e tumor ; the signs of a non-calculous pyelitis are not definite, but haematuria is a rare symp- tom. The existence of a calculus — the most common of the causes * Guy's Hospital Reports, 3d Series, vol. xiii. p. 19 et seq. * Gumprecht, Deutsch. Archiv f. klin. Med., liii. 1894. 666 MEDICAL DIAGNOSIS. producing chronic haematuria — is indicated as the source of the hemor- rhage by localized pain, leucocytes in the urine, and by the bleeding having followed active exertion, or a jar of the body from a fell, and by its recurring from time to time under cu-cumstances like those just mentioned, favorable to the disturbance of a calculus lodged in the kidney. We find also haematuria in tubercular disease of the kid- neys ; as in cancer, it is apt to be intermittent. Haematuria is at times met with in interstitial nephritis. Then there is a form of hae- maturia unconnected with any obvious lesion, and apparently of neurotic origin, to which Klemperer and Harris have especially called attention. Hcemoghbinuria^ or paroasysmal hoemoghbinuria^ as it is in its most marked form, differs from ordinary renal hemorrhage: the urine, although coagulable by heat and nitric acid, exhibits very few or no blood-corpuscles, but shows much granular pigment ; there is blood dissolution, and only the blood coloring-matter is found in the urine; with the haemoglobin is generally methaemt^lobin. We may use the guaiacum test to develop the presence of the dissolved blood-oells; the haemin crystals of Teichman can be produced, and with the spec- troscope we find the oxyhaemoglobin bands between D and E, occa- sionally also the methaemoglobin bands in the red. The urine voided is generally of a, deep blood-color, and within an hour or two, per- haps, changes suddenly to a pale straw-color. It shows an increased proportion of urea. According to Greenhow,^ crystals of calcium oxalate are constantly passed during a paroxysm, and are absent at other times. The affection is unattended by any permanent lesion q) .the kidneys. It is paroxysmal in form, but not of malarious origin. It is ushered in by a chill ; in some instances immoderate yawning and stretching of the limbs are the initiatory symptoms, and urticaria, great thirst, and local cyanotic appearances are observed. There is, indeed, a close association with Raynaud's disease. The temperature may be normal or elevated. Transitory albuminuria may precede the attacks ; between them the urine is normal. Pain in the loins is not unusual. In tlie blood during the attack a marked diminution of red corpuscles is observed, as well as masses of granules and spindle- shaped bodies and other products of destructive change ; and it is very likely, as Ponfick maintains, that the blood condition is primar}* and the haemoglobinuria secondary : haemoglobin in the blood-serum always precedes the haemoglobin in the urine. The etiolog}* of the disease is unknown. It often happens in syphilitic subjects. In those * Transactions of the Clinical Society, 1868, vol. i. THE URINE, AND DISEASES OF THE URINARY ORGANS. 667 predisposed, brain-worry brings on attacks ; rest and food may pre- vent them. The influence of cold seems to be a very potent cause.^ Haemc^lobinuria also occurs in a non-paroxysmal form, as after extensive bums, or due to toxic causes, such as poisoning by chlorate of potassium, carbolic acid, naphthol, pyrogallic acid, salol, arseniu- retted hydrogen. The poisons of the infective fevers, such as scarlet fever, typhoid fever, yellow fever, may also occasion it. There is an intermittent hsematuria which is malarial. This malarial Juematiiria may occur in daily paroxysms, or at longer but regular intervals. The bleeding sets in suddenly. The urine is albu- minous, contains casts, haemoglobin, and generally only few blood- disks; it shows a haemoglobinuria rather than a haematuria. The attacks are mostly preceded by coldoess of the extremities ; elevation of temperature follows. When there are distinct fever and yellowness of skin, the hemorrhage from the kidney forms part of the disease known as hemorrhagic malarial fever, which will farther on receive more detailed consideration. Malarial haematuria is more common in men than in women.* It differs from ordinary paroxysmal haematuria above described in the greater regularity of the paroxysms, and in the influence quinine exerts on them, though by some quinine is regarded as the cause of the haematuria. Malarial organisms are especially found in the blood. There is also a form of haematuria which is endemic and depends upon the presence of a parasite^ Bilharzia haematobia. It prevails in the Mauritius, certain parts of Cape Colony, Natal, Egypt, and Brazil. The parasite inhabits mainly the small vessels of the mucous mem- brane of the urinary passages and the kidneys, and it gains access to these parts chiefly during the act of bathing in rivers. Persons aflfected with the Bilharzia haematobia are often observed to pass small renal calculi of calcium oxalate having for theu- nuclei the ova of this parasite ; ^ they may also present chylous urine. A similar para^tic hcemaiuria^ due to the Filaria sanguinis hominis, is met with in India. Further, there is a haematuria peculiar to infants. This has been described by Parrot,* under the name of renal tubal hosmatuiia^ and is * Rosenbach, Berlin, klin. Wochensch., 1880 ; Mackenzie, Lancet, Feb. 1884. * Tyson, System of Pract Med. by Amer. Authors, vol. iv. ; see also Baker, Prize Essay, North Carohna Med. Joum., 1887 ; J. A. Stamps, Therap. Gaz., 1888, 3d Series, iv. ' Geo. Harley, Med.-Chir. Transact, vol. xlvii. p. 66, and vol. Hi. p. 379 ; Handford, Brit Med. Joum., 1887 ; Allen, London Practitioner, April, 1888, and Hill, London Lancet, May, 1888. * Archives de Physiologie, Sept 1873. <68 MEDICAL DIAGNOSIS. characterized by haBmaturia and the a^cumuJation in the itibtilcs of the kidney of the red globules of the blood, and by a bronze diseot^ oration of the skin, and cephalic symptoms. Besides these causes, renal hemorrhage may occur from mpttm of the kidney, of which it is the most prominent sign. It may also result from an altered state of the blood, as in purpura and in scurry or in leukaemia ; or we may find hiemoglobinuria in these states. Vmcal HtEmaiuria, — One source to which this may be owiiig is a congestion of Uie bladder, as witnessed in fevers of a low type ; another is irritant diuretics ; another is blood-effusion from purpura or the hemorrhagic diathesis. Yet another is inflammation, whetJier acute or chronic, and whether of traumatic oiigin or brought on by a stone. In most of these contingencies the history of the case and the load symptoms establish the diagnostic distinctions; in arriving at which we are often materially aided by the introduction of a sound into the bladder. In hemorrhage from the bladder, dependent upon tumor or malignant growths, there is generally also purulent urine ; the appear- ance of blood in the urine may be the first sign of disease.* Vesical hat^maturia» more frequently than renal, occurs as a vica-^- rious discliarge. Persons who are subject to bleeding piles lose bloo^^l occasionally from the bladder instead of from the rectum. But true^^ vesical hemorrhoids are not uocommoiu Blood may be discharged from other parts of the urinarj' appa- ratus ; it may come from the prontak f/ia nrf or from the urethra. Now, in either case the bleeding is usually profuse, and large quantities of blood are passed pure, or unmixed with urine* Besides, the local sij furnish important points of discrimination* Hiematuria itself is very rarely fatal. One of the worst consi <[uences it may entail is tiie retention of a clot which serves as nucleus for the formation of a calculus. Pm. — Urine containing pus deposits an opaque creamy sediment or a glairy mass, is generally alkaline, and always slightly albuminous. If the deposit be agitated with a strong solution of caustic soda becomes gelatinous. This is the chemical test for pus. But it is clumsy one, compared with the rapid and absolute diagnosis by means^ of the microscope. With the leucocytes we find considerable epithe- lium from the bladder or the pelvis of tlie kidney. A deposit of phosphates may be mistaken for pus ; a few drops acetic acid clear it up, but do not influence pus. Sometimes a 1; amount of mucus is mixed with the purulent sediment, or a deposit * See case by Todd, Case XI., Lectures on Urinary Diseases. THE UBINE, AKD DTSEASE6 OF THE URINARY ORGANS, m9 due wholly to the former ingreciieiil is so considerable that it is mis- taken for pus. Yet the mucous deposit shows distinct points of differ- ence : it is less dense, and collects more in clouds at the bottom of the I vessel ; and it does not under any test show alboinin. Again, the microscope is a valuable mc^ans of discrimination. In place of ieuco- cytes, quantilies of epithelium are always seen to be entangled in the transparent mucus, and the action of acetic acid develops the fila- ments of mucin. Sometimes, also, there are thin flakes of cylindrical bodies, unlike any appearance exhibited by pus. Yet, when the urine is strongly ammoniacal, even the microscope does not furnish a certain test ; for the salts of ammonia obliterate the distinctive pus-globules Fio. 63, Leuoocytcs In the uriiio : Dime &( the lower puxt oi the tleh) exhibit the action of acetic aofi on the ct)rt^*tiscle*. and convert pus into a slimy mass, in which nothing but the nuclei may be distuiguishable. As to the exact seat of the formation of the pus, its existence in the urine atfords no clue. When the leucocytes are round and well developed, witli their characteristic imclei readily brougtit out by acetic acid, tliey generally have Oieir origin in a catarrtial inlhunma- tion of the mucous membrane of ttie bladder, and are apt to be asso- iated \^'ith triple phosphates. On the other hand, pus-corpuscles of irregular contour, exhibiting irregular nuclei when treated witli acetic acid, and very granular, partly destroyed cells, indicate tlie probable existence of deep-seated suppuration, ulceration, or tubercular dis- ease ; and in this we find also tubercle bacilli. The sudden appear- ance in the urine of large quantities of pus pomts to Uie bursting of an 42 670 MEDICAL DIAGNOSIS. abscess ; an abundant deposit of pus in acid urine is chiefly noticc^d in pyelitis* In all instances we must be certain tliat the pus in tbe urine is not from a urethritis or a vaginal discharge. To be sure in the latter case the urine must be examined after catheterization. Fat, — Fatty matter may occur in tlie urine in various forms and in different conditions. It may be found in the shape of globules, vrhen oil or milk has been added to the urine for purposes of deception^ or when the former article has been swallowed for some lime in consid- erable quantities, as for instance during the administration of cod-liver oil. Fat is also encountered in globules of varying size, either free, in cells* or in tube-casts, as in fatty degeneration of the kidneys. Fat, , too, may be found in the urine in cases of chronic suppuration, phos- 1 phonis poisoning, and in fat embolism after fractures. The tests for fat are its solubility in ether, and its microscopical characters. Lee and AUee have pointed out ^ an illusor}' detection of fiat. They found, in testing a specimen of urine, that the etiier rose to the top so charged with matter as to resemble a half-liquid pomade. Separated by a pipette and spontaneously evaporated^ it left a dirty- wliite greasy mass. A careful examination of this residue showed that, instead of consisting of fatty acids, it contained nothing but the nonua! constituents of the urine, for it was soluble in water, reap- pearing as normal urine. It was Uien ascertained that almost any urine will form an enmlsion when violently agitated with etlier, espe- cially if the ether contain a small amount of alcohol. When, there- fore, ether appears to dissolve out fatty matter from urine, ttie ethereal solution should be separated, and allowed to evaporate spontaneously* and if Oie residue be soluble in water it cannot be held to contain fat. There is no certainly of the presence of fat unless the sediment be examined chemically and microscopicalJy. The opalescence of urine caused by a sediment of urates has been mistaken for that from oily matter, and so also has been the pellicle which often forms on urine, and which consists not of fat, but of \ibriones, fmigi, and crystals of the triple phosphates. The '' kyestein'^ pellicle observed in the preg- nant state is of similar kind, though some oily matter may enter into its composition. In some cases fat Ls oiet with in a very finely divided state, iiu- parting to tlie urine a milky look, which disappears on its admixture with ether. This condition, to which the name ehylous urim has been given, does not depend upon any permanent morbid change in the * Amer. Joum, MetL Sci., April, 1869, p, 357, THE URINE, AND DISEASES OF THE URINARY ORGANS. 671 kidney ; the chylous character of the urine is intimately connected with the absorption of chyle, but precisely how the urine acquires that character is uncertain. It may be absent in the day urine and very marked in the night urine ; there are at times small quantities of albumin present. The affection may continue for years without im- pairment of the general health, being always perceptibly increased by exercise. In the tropics chylous urine is found often in connection with the Filaria sanguim's hominis. " A urine which spontaneously coagulates soon after being voided, owing to fibrin^ a fibrinuria, is very uncommon except in the Isle of France and in Brazil. A thick urine may be due to pus dissolved in alkalies, as in certain bladder affections. But the thick matter is at once greatly thinned by water, and on the addition of acetic acid a white precipitate of alkaline albuminate falls.^ Sediments. — In connection with the ingredients of the urine, the nature of the urinary sediments has been discussed, and it has been insisted that they cannot be accurately determined save by a micro- scopical examination. I shall here group together only theu- general characteristics : 1. A light and flocculent cloudy deposit is commonly mucus, entangling epithelial cells, bacteria, or spermatozoa. 2. A dense, abundant, white deposit is generally composed of urates or phosphates ; but it may be pus or extraneous matter. 3. A yellow or pink deposit is almost always due to urates. 4. A granular or crystalline deposit, of reddish or dark-brown color and small in quantity, is uric acid. 5. A dark, sooty or dingy-red deposit is blood. 6. A blue deposit is indican. The following table may serve a useful purpose, in showing how both the sediments and the soluble urinary ingredients are affected by the reagents commonly employed : Table exhibiting the Significance of the Main Conditions and the Action of the Main Reagents employed in the Examination of the Urine. i Urine high-col- ( Increase of urea, ^*8>h J Qped 1 uric acid, etc. ^ Urine pale Diabetes. ( Urine high-colored ( Certain forms of Low J or normal ( Bright's disease. ( Urine pale Excess of water. Specific Gravity . * Hofmann and Ultzmaim, op, oit. 672 MEDICAIi DIAGNOSIS. Table exhibitixo the Sigkificakce of the Maiiv Conditions and the Agtioh of the Main Reagents employed in the Examination of the Urine. — CbnHmied, Heat. Nmuc Acid . Throws down de- posit Dissolves deposit . [ Phosphates. Soluble in nitric acid Insoluble in nitric r Senun-albumin. acid I Serum-globulin. Urates. deposit ( Phosphates. Precipitates .... Dissolves Quickly Albumin. i Uric acid. More gradually. . . J Urea^ nitraTc ( (crystalline). Earthy phosphates. • Alkaline phos- phates. Oxalates. ^lor^.^''^ "' } B"«-Pi«n»e"i- Turns black . Melanin. Hydrochloric Acid , Precipitates Uric acid. Transforms | ^^^^ »^^ ^^ ( acid. Change of color to lange oi coior lo ^ violet [ Uroxanthin. il To bluish Admixed chloro form becomes bluish or violet Indicans. SoLPHURic Acid . Changes color of Brown Crimson or violet (if sugar have been added) . . . Violet Urohaematin. Biliary acids. Indican. Acetic Acid . Precipitates de- posit (not solu- ble in excess of the acid) Precipitates with potassium ferro- cyanide Mucin (nucleo- albumin). Albumin and albu- rn oses. THE URINE, AND DISEASES OF THE URINARY ORGANS. 673 Table exhibitino the Significance of the Main 'Conditions and the Action of the Main Reagents employed in the Examination of the Urine. — Continued, Picric Acid. Precipitates Albumin, albu- moses, peptones. Red deposit, — blood. Slowly-developed haze, — mucin. Sodium Hydroxide . ( On boiling, turns ) g^ urine brown . . J Dissolves Fonns gelatinous mass r Uric acid. 1 Deposits of urates. I Pus. Ammonium Hydroxide . ( Precipitates . . I Dissolves .... Earthy phosphates. Cystin. Barium Chloride. . < Precipitates . . . Deposit, soluble in ) „, free acid \ Phosphates. [ Sulphates. Deposit, insoluble in acids Silver Nitrate. Precipitates ' Yellow deposit, soluble in ni- tric acid and ammonia ' White deposit, insoluble in nitric acid, but soluble in am- monia Alkaline phos- phates. ► Sodium chloride. Copper Sulphate AND Sodium Hy- •< droxide Ether Precipitates with heat yellowish- red deposit Turns violet . ' Precipitates . Dissolves . . . Bromine Water Does not dissolve Turns urine yel low, then black. Sugar. ( In cold Peptone. ( With heat Serum-albumin. Albumin. [ Hippuric acid, sol- ^ uble in alcohol. ^ Fat. Uric acid. \ Melanin. 674 MEDICAL DTAGNOHia Toxicifif of the Urine. — The human urine is toxic, and the toxicity varies under diet, and in disease. The substances in tlie urine pro- ducing tlte poisonous etT'ects ai*e llie potassium salts, phenol deriva- tives, unknown products of metabohsm, coloring substances, as well as toxines obtained from various forms of bacteria) infection. Tlie toxicity is reduced by prolonged lasting and by a milk diet, althou^'h Lapicque and Marette ^ found that alter the thu'd day of exclusive milk diet it was again increased. Tlie toxicity of human urine is reduced in amemia ; * the urine is also less toxic than normal in tuberculous k*pers.' On the other hand, the toxicity of the urine is increased in cholera and in other infectious diseases, as well as in ci^ain liver aflfections,* such as in atrophic alcoholic cirrhosis, in tuberculosis, car-^ cinema, some forms of chronic icterus, and in hypeiiropliic cirrhosis. It is normal or diminished in hypertrophic alcoholic cirrhosis, in con- ditions secondary to heart lesions, and in infectious icterus until tlie crisis, when it augments. F*ernmnent increase is of grave prognosis. as it indicates destrnction of liver-substance and function. The process of suppuration also increases the poisonous eflfect of the urine/' The toxicity of the urine is decreased in cases of pueri>enil eclampsia, whereas the toxicity of tlie serum of the blood is increased-, as discovered by Bouchard, and confirmed by Ludwig and Savon* The observation that the urine of epileptics is less toxic immediately preceding and during a fit or series of fits, and hypertoxic after the attack, has been made by Voisin and PeronJ The urine of epilep- tics aftected with mental disorder is ako constantly less toxic. These observers therefore claim that by frecfuent estimation of the urinary toxicity it may be possible to predict the occurrence of a fit, to de- termine whetlier or not a series has terminated, or if mental disturb- ance is likely to follow. The method pursued in order to determine the relative toxicity of the urine is to take a certain f]uantity of the nibced urine of the preceding twenty-four hours, filter it, and render it alkaline, pre- cautions being taken to avoid bacterial contamination. The urine is then slowly injected into a vein in the ear or the leg of a rabbit or > Le Bulletin Medical, July 26, 1894. * Piccini and Conti, Revue des Sciences Med. en France et4 T^trajigvir, PirtSi^ 1894. * ChartJniere, Annales de DermalQlogie et de Syph,, March, 1895. * Surmoiit, La Semaiiie Med., Paris, Jan. 20, 1892, * Nanimti and Baiocchi, Biromia Med,, 1892. ■ Manatshefte ftJr Geburtsh. umi Cijnak., 1896, * Archives de Neurologie, Paris, 1892* THE URINE, AND DISEASES OF THE URINARY ORGANS. 675 guinea-pig. Death of the animal follows after several ounces have been injected. By dividing the entire daily excretion of urine by the amount required to produce the lethal result (in cubic centimetres) and multiplying this by the fraction represented by the weight of the animal (in kilogrammes) as a numerator, and the weight of the patient as the denominator, a number is obtained which is called the toxic coefficient. URINARY ORGANS. Di8ea43es of the Kidney of which Pain is a Prominent Symptom. The group embraces acute inflammation of the kidney, and those painful affections classed under the term nephralgia. Acute Painful Nephritis. — Acute inflammation of this kind is not a frequent disease, indeed, its very existence is not generally ad- mitted ; it is chiefly observed in old persons and in damp climates. It may be occasioned by exposure, by direct violence to the organ, or by the irritation of a calculus. It begins with a chill, soon followed by fever of moderate degree ; there are nausea and vomiting, and at times diarrhoea with tenesmus. The urine is voided drop by drop ; it is red, and may contain blood. The patient complains of pain in the renal region, sometimes dull, at other times sharp and lancinating, and augmented by pressure and by moving. The pain is not limited to the kidney, but radiates to the diaphragm and to the bladder. With it are often associated numb- ness of the thigh of the affected side and retraction of the testicle. The disease rarely affects more than one kidney. It lasts from one to three weeks, and generally terminates in resolution. But it may lead to suppuration. The disorder is recognized by the pain, the fever, the retraction of the testicle, and the appearance of the urine. It differs from an attack of colic by the signs of disturbance of the urinary organs, by the seat of the pain, and by the fever ; from rheumatic pains in the back, by the former of these symptoms. Then, in lumbago, we rarely find much febrile excitement, nor are there nausea and vomiting, or numbness along the course of the anterior crural nerve ; but, on the other hand, the pain is much more influenced by movements, espe- cially by stooping, and such other motions as call the muscles of the back into play. Congestion of the kidneys is distinguished from in- flammation by its affecting both sides, by the absence of protracted or severe pain, and by the comparatively slight derangement of the urinary functions. Further, the congestion is not idiopathic, and we 676 MEDICAL DIAGNOSIB. call ^,'enerally trace it to the swallowing of some irritating substance. or lo the poison of a febrile malady, such as smallpox or typhus. From the passage of a renal calculus acute paintiil nephritis differs by tlie steady, less paroxysmal and less violent pain, wiiich does not, as in renal colic, begin suddenly and end suddenly ; by the fever ; and by the absence of a histor}^ of previous attacks. Still, we must bear in mind that a calculus may be the cause of the painfiil nepliritis. The distinction betw^een this form of nepluitis and that in acute Bright's disease will be presently considered. Nephralgia. — Severe pain in the kidney, unconnected with in- flammation of the organ, is ordinarily caused by tlie passage of a cal- culus. There is no fever, though passing elevations of temperature may occur. Nephralgia exhibits a great similarity to colic ; but tliis has been already discussed ; and in )>articular cases we are often much aided by the knowledge that in '* renal colic'' the patient has on a former occasion passed renal concretions. The amount of jjain varies according to the magnitude of the stone and its character. As a rule, calculi composed of oxakitr of Hmt give rise to most i>ain. We may distinguish them by their roughness and irregularity and their brow^n or dark-gray color: those of uric acidasxd itrf{tfj< are redtlish and nnieh softer, and not jagged, and, unlike calcnii consisting of jhe salts of lime, are combustible on platinum foil, leaving a mere trace of residue, wiiile the oxalate of lime calculus leaves con* siderable residue, and is soluble in mineral acids without effervescence. Calculi of tlie miiril phoH^phatej^ are wliite, ver)^ brittle, soluble in acids, insoluble in alkalies, and fuse in the blow^-pipe flame. The mixed phospliales rarely form a stone entirely, being often only an incrusta- Uon around a blood-coagulnm or a foreign body, or having a kernel of uric acid. Indeed^ tlie majority of phospliatic stones have uric acid centres, while calculi of uric acid or its salts possess, ais a rule, the same composition throughout ; calculi of oxalates have often a nucleus of uric acid and a crust of pliosphates. Xanthine and ct/sthu are the rarer constituents of stones. The former, like uric acid and Uie am- monium and sodium urates, is consumed by lieat, and burns without visible flame, but ttie mnrexide test exhibits an orange-yellow color; cystine bums with a bluish-white flame emitting an odor like that of burning fat, and the powder is soluble in dilute ammonia. The crys-i tallization of tlie ingredients of the urine forming a calculus is very apt to take place around particles of mucus. As already stated, we have in the severity of Uie pain a sign in- dicative of the nature of the case. Still, there are slates in wtuch paroxya^tm of pain referred to the neigld>orhood of the kidney are THK URINE. AND DISEAHES OF THE URINARY ORGANS. f^77 aitribiitable to otlier causes than the passage of a calculus. Leaving out of consideration tliat doubtful disease, pure nt-urakiui of fh kldneif, we find a few afl'eetions — very rare, it is true — which closely sujiulale tlie passage of a renal calculus. The Qrst of these is the pain occasioned by an tnfftttntd ami ul^^t^r- aied urtirr, Todd relates a case of tlie kind.' The patient had severe attacks of lancinating pain, referred to tlie right side, lasting for weeks, and accompanied by constant and intractable vomitin|u^ The orine contained pus in varying quantity, but neither blood nor calculous matter could be detected. At one time he contuiued free from any paroxysm for foor years. After death the most careful search was niade for a calculus, but none could be discovered. The ureter of the right side was tliickened tliroughout tlie greater part of its course, and deposits of lympli adhered to its mucous membrane. A some- what similar train of phenomena may occur from irritation or inflani- niation of the ureter caused by the poison of rheumatism or gout, although ttie paroxysms of pain are apt to be neither so severe nor of so long duration. Another morbid condition closely resembling the passage of a renal calculus may result from mala rial pokon. How close this resemblance may be, Ihe following case wit) show : A soldier, twenty-four years of age, of strong constitution, was seized suddenly with pain over the left kidney. The loin was sensi- tive to the touch, and appeared swollen. The skin was hot ; tlie pulse 100. The urine was reddish, but was not found to be abnor- mal. The pain continued for several days^ becoming more severe, notwithstanding that by direction of Dr. Hilborne West, with w^hora I saw the man, six ounces of blood were drawn from near ttie aftecled part. On the fourth day of the disorder he was assailed witli excru- ciating pain along the course of the ureter, attended with the voiding, at short intervals, of a liigti-colored urine. Tlie attack Ifisted trom six o'clock in the evening until five o'clock the next mornirig, leaving him exhausted : Uie only relief throughout its duration being obtained from Hie inhalation of chloroform. At six o'clock that evening an- other seizure, of equal violence, set in : and, after tlie lapse of twenty- four hoiu*s, again iuiottier. Seeing tlie recurrence of the paroxysms at about the same time of each day, and learmng from ttie patient tijat a few months before he liad had a remittent fever, wliich had letl behind an irregular intermittent, we resolved upon the adminis- tration of large doses of sulphate of quinine in the interval between 678 MEDICAL DIAGNOSIS. the paroxysms. The seizure did not take place that night ; but, the remedy being a day or two afterwards suspended, the fourth night was again a night of anguish. The antiperiodic was resumed, and continued, in lessened doses, for three weeks. The patient remained under observation for about six weeks after the last attack, gradually recovering his health and spirits. When he was lost sight of, there was still a dull pain in the left lumbar region, with inabUity to stand erect ; but no return of the excruciating intermittent pains. In a case of this kind, which was observed before the days of Laveran's discovery, it is evident that nothing but a knowledge of the history of the patient, and the noting of the regularly recurring onsets of the pain, could have led to a correct appreciation of its cause. We sometimes meet with a so-called neuralgia of the bladder, of similar origin, and having much the same symptoms, except that the distress- ing pain is referred to the bladder. As in the case just detailed, the attacks occur at night. These remarks are all based on the assumption that the renal pain is very severe and paroxysmal in its character. Let us now briefly inquire into the significance of a steady and less acute pain, premising that we have excluded from consideration abdominal aneurism, affec- tions of the muscles of the back, of the spine, and of the tissues sur- rounding the kidney, in which diagnosis, of course, we are materially assisted by an examination of the urine. We meet with persistent pain referable to the kidney itself, in in- flammation of the organ, especially in that variety of inflammation affecting the infundibula and pelvis, termed pyelitis. We also en- counter it in malignant disease of the kidney ; sometimes, although it is not then of long duration, from the irritation of concentrated and highly acid urine ; much more generally from the presence of a stone lodged in the kidney. The pain in the latter complaint often extends along the course of the ureter to the testicle, which is retracted and swollen. Not infrequently there is also tenderness on pressure over the affected kidney, and the pain is greatly increased by active exer- cise ; and it is not uncommon to find, associated with these exacer- bations of pain, nausea and vomiting, and the appearance of blood in the urine. There is yet another point in the diagnosis of the passage of ealcuii which we must not overlook, — namely, that the pain may be referred to other parts than the region of the kidney and the course of the ureter. It may be felt near or at the sacrum, and not merely on one side ; it may extend to the bladder and become associated with a painful spasm of this viscus and with the voiding of urine drop by THE URINE, AND DISEASES OF THE URINARY ORGANS. 679 drop ; or to the testicle, which becomes sensitive and swells ; or to the thigh, which feels numb ; or it may be referred to the region of the appendix, or to the right hypochondrium, and extend downward, but not be perceived in the loin. Under the latter circumstances there may be, with pain of great intensity, coexisting distention of the colon, vomiting, and constipated bowels, and the symptoms so closely resemble those of the passage of a biliary calculus that only the detection of blood in the urine prevents error.* Again, as hap- pened in two cases which came under my notice, the pain may be referred to the left hypochondrium or along the course of the colon, may be associated with soreness to the touch and with digestive dis- orders, and may closely simulate an oi^nic lesion of the stomach or intestine. Nothing but careful and repeated examinations of the urine, and observing the irregular and whimsical course the supposed intes- tinal malady pursues, will enable us to arrive at a knowledge of the * truth. Nor must we be unmindful that a calculus may be months in passing, and that as it changes its position the seat of the pain changes. I had a case of the kind under my charge in a lady about fifty years of age. She suffered for weeks at a time from excruci- ating pains, beginning in the left kidney, then felt somewhat below it, and finally localized in the neighborhood of the left ovary. She was occasionally free from pain for five or six days. But it was only after fiilly nine months of recurring suffering that the passage of a calcu- lus the size of a plum-stone, followed by a discharge of large amounts of a gritty substance and a soapy-looking urine, removed her distress. The stone consisted of urates. The symptoms of renal calculus may, after having existed for a longer or shorter time, entirely cease, owing to the calculus becoming encysted and thus remaining innocuous ; or to its obstructing the ureter, causing retention of the urine, and, by pressure, producing gradual atrophy of the cortical and tubular structures, the kidney being finally converted into a mere bag. In concluding the subject, it will be useful to group together the signs by which we may infer the existence of a calculus in the kidney. They are : frequent micturition, often attended with pain at the end of the penis ; pain in the loin on one side, with or without accompa- nying soreness, occasionally passing suddenly into a violent parox- ysm, with a tendency to shoot along the course of the ureter to the testicle and the hip of the aching side ; and in some cases the dis- * Case of Owen Rees, Guy's Hospital Reports, 3d Series, vol. x. 680 MEDICAL. DIAGNOSIS. cliarge of pus due to coincident pyelitis. These symptoms becos positive evidence if the blood-extraclives be present in the patieofs urine, or if this, when examined microscopically, be found to contain blood-corpuscles ; or If we know Uiat attacks of hcematuria have pre- viously happened, and tliat gravel or small urinary concretions have , at any time been discharged. The presence, too, of microscopic cal- culi in the urine, points to the existence of larger concretions in the pelvis or in the structure of the kidney. But all these indications areJ far from being always present. The renaJ stones may be so lai^ that| tliey cannot leave the kidney : we may have notliing but Uie symp- toms of a pyelitis, which w^e suspect to be calculous, and even these! symptoms may be wanting. To determine w^hether botJi kidne}^! are implicated in the calculous disease, which occurs in about fifteen] per cent, of the cases,* we must examine the urine during tlie of a renal calculus. If the luine become perfectly healtliy, wheal previously it has been abnormal, we conclude that it comes from a' healthy kidney, and that the secretion from ttie diseased one is tempo- rarily blocked up. Another method of determining wtiich kidney is diseased is by callieterization of the lu'eters, and the examination the iu*ine thus obtained from each. But tliis is a very diflicull pr cedure, and is only possible in liie hands of a sui^cal or gynaecolc eal experi. Yet another method that has been suggested is by pn^s- ure 00 the pelvis, and the ingenious apparatus invented by Harris.^ But the most certain of all our means is by the X-ray, and I add reproduction of a skiagraph taken by Dr. Leonard from a patient in whom the calculus thus delected was removed by Ur. Keen. I haxi*\ also seen a stone in the ureter brought to light by the same procc^. Irrespective of finding the stone, the Roentgen rays enable us to daj what no otlier process can accomplish, — to detect the presence several stones in the same kidney, and to determine their relative six and position.^ Diseases marked by an Albuminous Condition of the Urine,] associated with more or less Dropsy. The chief of these diseases is Bright's disease. At tlie present day we hold that the disease which bears Bright^s name consists of a group of maladies liaving the common feature of a more or less albu- minous state of the urine. But, though I believe this view to be the ' Henry Morris, AllbuU's System of Medicine, voU iv, ' Journ, Amer, Med. Assoc., Jan. 29, 1898, • Leonard, Phila. Med. Joum., Aug, 20, 189S. THE URINE, AND DISEASES OF THE URINARY ORGANS. 681 correct one, I shall in this sketch prefer to consider the disorder in the main as it is seen separated by broadly drawn lines into an acute and a chronic fomi, and then examine the further dififerences these present. Anatomically speaking, we have a dififuse nephritis which is paren- chymatous or interstitial ; interstitial nephritis, generally seen in a chronic form, and often the result of gradual insidious tissue changes of a degenerative kind ; the waxy or lardaceous kidney, and the fatty kidney, which is mostly an attendant upon other kidney alterations. Acute Blight's Diseajse. — In this form, which is almost always an acute parenchymatous nephritis, the symptoms are of an acute character. Especially so is the dropsy, which is quickly developed Pio. 64. BpithellAl casts and epithelial cells from the kidneys found in a case of acute Bright's disease {acute parenchymaJUmt nephrUU) ; magnified about 460 diameters. and soon becomes the most marked token of the malady. The his- tory of a large number of cases is as follows. After exposure to wet or cold and checked perspiration, a fever sets in, accompanied by nausea, and by a dull pain in the region of both kidneys, extending along the ureters. The eyelids and face become puffy and swollen, and soon a general oedematous condition of the skin is observable, showing itself very plainly in the extremities, scrotum, and abdominal parietes. Subsequently dropsical effusions often take place into the interior cavities. The same symptoms are noticed in the acute parenchymatous nephritis, which so constantly attends scarlatina, except that, following as it does an exhaustive disease, there are from the onset much greater pallor and general debility. Acute parenchymatous nephritis is also met with, though less frequently, and generally in a less violent form, 682 MEDICAL DIAGNOBIB. in other infections diseases, as t[i smallpox, measles^ diphtheria, typhoid fev^er, typhus. It oeciirs also in malaria and yellow fever. It may follow hard drinking, a lightoing'-strokej or sewer-gas poisoning,^ The urine in the acute malady is of high specific gravity, and may be din«ry from its admixture ^vitli blood. There is a frequent desire to void it» although the whole quantity passed i^ rather below the natural average. The urine contains a lai-ge amount of albumin ; a niicroscopical examination brings to light red blood-cells and casts, lined here and there with blood-rori^uscles. As the malady pro- gresses, these ** blood-casts" disappear, and we find casts coated with epithelium, which may be normal or slightly fatty, and with free nuclei ; or we observe granular or hyaline casts ; or we may discern leucocytes and long cylindrical ribbon-like mucous casts. Furthermore, crystals of uric acid, of urates, even of oxalates, and a considerable amount of renal epithelium, are oflen seen in the sediment. The chlorides and phosphates are diminished ; the uric acid is less so, may, indeed, like the pigments, be increased. The amount of urea fluctuates much ; it is generally lessened. There is moderate fever, with a temperature of about 101°; tlie |iulse, tiowever, may be quick^ tense, and full. The skin is generally harsii ami dry ; nausea and vomiting are of common occurrence. The urgent symptoms last ordinarily for several weeks, and the albumin gradually cltsai>pears. But this is not the invariable issue; the disease may gradually lapse into a chronic fonn. Or a certain amount of albumin may remain in the urine ; and after exposure this uicreases, and the dropsy and most of the acute symptoms return. In some instances of the malady, not in many, there are numerous tube- casts and tree epithelium in the urine, but Httle albumin ; and, on tlie other hand, in acute interstitial nephritis, witli scanty, highly albu- minous urine and marked general dropsy, tube-casts may be absent from fii'st to last;' There is a form of acute Bright's disease due to a bacillus. Letz- erich * describes it as " nephritis bacillosa interstitial is primaria.'' It occurs in children, runs its course with a moderate fever in from two to six weeks, and generally ends in recovery. The urine contains red blood-corpuscles, a few leucocjies, only small amounts of albumin, but great numbers of bacilli, shorter and thicker than the tubercle 1 Medical and Surgical Reporter, July 23, 1887. =» Lancet, March, 1894. " Dickinson, All butt's System of Medicine, vol, iv. p, 369, * Neurol. CentralbK, 1887, quoted in Sajous's Annua), 1888, p. 4d^. THE URINE, AND DISEASES OF THE URINARY ORGANS. 683 bacilli, and easily-stained with methyl-violet. An infectious nephritis also has been described due to the bacillus coli communis.^ Whatever the attending circumstances, the risk to life, when an attack of acute Bright 's disease has been prolonged, is greatly in- creased by the supervention of local inflammations, — as of the pleura, lungs, peritoneum, or pericardium ; or by the sudden effusion of fluid into the pulmonary structure ; or by the retention of urea in the blood and consequent uraemic intoxication. The recognition of the disease is readily efifected. The puflfy, pale lEace ; the general dropsy ; the albumin in the urine, associated with tube-casts, — form a combination of signs so remarkable that it is difficult to mistake their meaning. Many of the same phenomena are encountered in the chronic form of the malady; therefore, what is about to be said of the dififerential diagnosis of the acute complaint may be in the main applied with almost equal correctness to the chronic ailment. The chief disorders with which acute Bright's disease is apt to be confounded are : Acute Painful Nephritis ; Suppurative Nephritis ; Purulent Urine ; Hi:maturia ; Simple Albuminuria ; Pulmonary (Edema ; Pleurisy and Pericarditis ; Dropsy ; Coma; Convulsions. Acute Painful Nephritis. — This differs from acute Bright's disease by its affecting generally only one kidney, by the much greater pain and tenderness in the lumbar region, by the retraction of the testicle, and by the higher degree of febrile excitement. Then, too, the deeply colored urine which is voided contains little or no albumin. Suppurative Nephritis ; Purulent Urine. — In rare cases the suppu- rative process may coexist with Bright's disease. But, on the whole, the two disorders are distinct and may be readily discriminated. We find pus of renal origin in the urine, in consequence of pyelitis or of abscess of the kidney. The former is generally linked to the irritation of calculi, or is an infective process ; the latter shows a fever of a remittent type, and often a well-defined swelling is felt in the lumbar region and extending far downward. All this is different from Bright's disease. Then, we detect pus as well as blood in the urine of cases * Fernet et Papillon, Bull, et Mem. de la Soc. Med. des H6p., 1892. 684 MEDICAID DIAONOSI8. of pyelitis or of renal abscess, and any casts that are found are iijil to be covered with leucocytes, which is of verj' rare occurrence m acute Bright*s disease. I Hcofuituria, — In ha&maturia. if we can speak of it as a separate disease, Uiere is albumin in the urine ; and, on the otlier hand, soni#.» blood as well as pus may be present in the urine of Bright 's disease* But, as in purulent urine, the quantity of albumin met with in h^ema- turia is small ; in fact, it is in exact proportion to the amoimt of blood or pus the urine contains ; whereas, on Uie contrary, if the secretion from a Bright's kidney be mixed with pus or blood, the amount of albumin is generally lai^e. The microscopic examination » too, and the casts found, and their predominating cliaracter, are of great value. Simple Albuviinurin, — By this is meant an albuminous urine un- connected with any marked structural lesion, except congestion ♦ — such an albuminuria as is observ'ed as a transient phenomenon in the course of several diseases; as in the exanthejuata, in typhoid, in typhus, in cholera, in hectic fever, in chronic congestion of the liver* in oxaluria, or as a consequence of surgical diseases and operations* and of ether narcosis. An albuminuria of similar kind is met with when the kidneys become congested from interference with Uie circulation, as in disease of tlie heart, or from the pressure of a gravid womb. Albumin in tlie urine may also be encountered in erysipelas, in diphtheria, in pneumonia, in acute rheumatism and in gout, consecutively to very high temperatures, to a burn, to a blister or a laiige mustard-plaster, or to tlic use of salicylic acid or of turpen- tine or of carbolic acid. But in all these conditions the quantity found is small and transitory, very unlike what it Ls in the persistent albu- minuria of Bright's disease, and the urine is usually dense and high- colored. Then the constitntional symptoms and the general clinical features in the morbid states referred to tell us the meanuig of the albuminuria. Moreover, there is really often more than mere conges- tion; tliere is present a parenchymatous inflammation to a limited degree, and of a transitorj^ kind. In all these cases of albuminuria the amount of albumin is apt to be small, and there are few, if any. casts. Wlien found, these are generally of the epithelial or livaHiir variety, and are not highly granular or fatty. In adthtion to these forms of simple albumiiiuria there is lujc t*i great importance to recognize, where the albumin hap[)ens in i)ersons who in ever)^ respect seem healthy, and occurs shortly after pftrtaking plentifully of food, especially of albuminous food, or after severe exer- cise, particularly in young persons at or near the iige of pid^erty. Some of these cases are cyclic, occurring only al certain times of tlie d«) ; THE URINE, AND DISEASES OF THE URINARY ORGANS. iS85 in much fewer, the albuminuria is persistent. In the great majority of cases there is a time in every day in which the urine is free from albu- min. It is normal in quantity, normal or slightly increased in specific gravity, normal in the amount of urea it contains, and no tube-casts are found in its sediment. The amount of albumin in these functional albuminurias is small, and there are no cardio-vascular changes ; in- deed, there is no symptom except the albuminuria to suggest disease. This kind of albuminuria has a strong bearing on life assurance. There is a form of albuminuria that stands in close connection with excessive uric acid formation and oxaluria, to which I have called attention.^ The amount of albumin is generally small ; hyaline and epithelial casts are found, though they are scanty. The specific gravity of the urine is high, and this, as well as urates or the oxalates in the urine, is of much significance. Violent exercise increases this albumi- nuria of uric acid and oxaluria. The cases may be of short or long duration ; recovery is the rule. In elderly people, we meet with a form of albuminuria in which there are traces of albumin in the urine, and hyaline and finely gran- ular casts of small diameter. The specific gravity of the urine is normal, the general health is unimpaired. If this albuminuria be due to beginning senile changes, they are very slow in their development, and my experience leads me to the conclusion reached by the inves- tigations of F. C. Shattuck, that it is of little practical importance. Pulmonary (Edema, — Bright's disease is one of the most frequent causes of dropsical effusion into the air-cells ; oppression in breathing, inability to lie in the recumbent position, cough, frothy expectoration, are the symptoms. And to distinguish this a^dema from that produced by other morbid states we have only to examine the urine carefully. Yet we must not forget that small amounts of albumin may be found .in the urine from any stress of breathing, and from diseases that, like those of the heart, congest the lungs and kidney and are themselves among the causes of pulmonarj' oedema. Pleurisy and Pericarditis, — ^The tendency to inflammations of the serous membranes is a remarkable peculiarity of Bright's disease. We may discriminate pleurisy or pericarditis complicating the malady from either of these affections of other origin, by noting the far greater amount of dropsy that is found in these disorders, and by detecting persisting albumin and tube-casts in the urine. Drop»y, — By an examination of the urine, too, may be distin- guished the dropsy of the complaint under consideration from that > Amer. Journ. Med. Sci., Jan. 1898. 43 686 MEDICAL DIAONOBIB. [produced by otlier causes. And we also see oflen tlie evidences of the true nature of tlie dropsy iu ils beginning with swelling of the face, and in the eharacleristie pliysiognomy wiiicli it has a share in developing. Coma; Conrtdmon^. — A dangerous complication of Bright's disease manifests itself by drowsiness and convulsions. Now, it is very im- portant to distuiguish the cases produced l>y ura^mie poisoning from epileptiform convulsions and kindred states in w^hich there is no appre- ciable cliange of structure in tlie kidneys. Let us see liow they differ. Urcemia, or uneniic intoxication, is commonly preceded by a dimi- nution in the urinary secretion. In some cases the marked phenomena set in witli a eliill. There is headaclte, w'ith indistinct vision, great drowsiness, and vertiginous sensations ; the pupils are sluggish and usually dilated ; the liearing is impaired ; the countenance is dusky ; the skin is cool, with short rises of febrile heat ; and the patient suf- fers trom constipation, nausea, and obstinate vomiting. AmBsthesia and various kinds of cutaneous eruptions may be observed. Tlie dnl- ness of mind is apt to deepen uito stupor or coma, or convulsions .set in as precursors of the coma, which terminates in deatli unless Uie urinary secretion be freely re-establislied. The coma may at one time be so profound that it is impossible to arouse the patient, whilst at another time he rouses himself and acts with intelligence. Tlie con- vulsions generally succeed one another rapidly. As regards the decided lessening, or suppression, of the urinary secretion, though this is the rule, it Is not constant. I have known the symptoms of unemia many a time to receive an erroneous inter- pretation, from sui>posing that nrnemia could not exist, as the quan- tity of urine i>assed w^as about normaL We must test for urea and the other urinary ingredients, which may be profoundly changed in amount, notwithstanding the seemingly hc^althy aspect of the secretion, and notwithstanding, too, tliat it may be found free from albumin. In addition to tlie great decrease in the urea* the uric acid is reduced ; tJie specific gravity is generally lo\v ; casts are mostly found in the urine. Cases of unemic coma differ from ordinary comatose conditions, as witnessed in apoplexy, in fevers of a low type, or following narcotic poisoning, by the dissimilar symptoms ushering them in. The coma is much more suddenly developed than that in fevers : far less sud- denly than lliat of apoplexy or narcotic poisoning.* Then, the stertor- ^ There may tiowever, be excepticuis fco this rule, as in the cjise repiiiKed by Moore in tlin L< union Medical Gazette, 1845, in which a i>ers(ju lR*c«mi» romato^ afler hiking liiudarnmi, yel his df?iith was found to Im? caused by conlnicted kidnep* THE URINE, AND DISEASES OF THE URINARY ORGANS. 687 ous respiration is peculiar : * the loud sounds of the expired air are of much higher key, not like the low, guttural tones of apoplexy. Fur- thermore, we may have in the general dropsy a clue to the nature of the case ; but of course the most certain light is thrown on it by the analysis of the urine. The same remarks apply to the delirium or to the epileptiform convulsions of uraemia. Here the difficulty in diagnosis is increased by the first seizure often happening unexpectedly, — so much, in truth, increased, that, unless we are aware of the history of our patient and have previously examined the urine, the true explanation of the symp- toms is not to be reached. Urcemic delirium is rare, but I have met with it under circumstances in which nothing preceded it to indicate its nature.^ Cases of acute urcemic vuinia may also originate thus sud- denly. Cases of urosmic convulsions may occur in pregnant women ; in them, however, the tendency to disorder of the kidney is so great that we are rarely in error in concluding convulsions to be of urajmic origin. We must, however, here, as in all convulsions, be certain that we do not mistake effect for cause. A slight amount of albumin may follow violent convulsions in epileptic seizures. The temperature in ursemic convulsions is variable. It is generally stated to be low ; but this is denied by Bartels, who notes it as considerably elevated,^ and by McBride,* and by Hughes.* Among the other marked nervous manifestations of uraemia may be persistent headache, anaesthesia, temporary blindness, and palsies of uraemic origin, local or hemiplegic, without gross lesion in the brain. Uraemia is sometimes a chronic state, more particularly in chronic interstitial nephritis. Any of the symptoms already described may be met with; very common are nausea, vomiting, dyspnoea, headache, and eye disturbances. Convulsions, too, epileptic in character, and either general or of Jacksonian type, are found, and in some cases stomatitis, in others a long-continued, though moderate, fever, often with considerable mental torpor. The cause of uraemia is still undetermined : a contamination of the blood by retained poisonous urinary ingredients or poisonous sub- stances that have formed from them always happens, though these toxines may be of different kinds. * Addison, Guy's Hospital Reports, 1859. * Case at the Pennsylvania Hospital, April, 18G5. *' Ziemssen's Cyclopaedia. * American Journal of Neurology, 1883. * Philadelphia Hospital Reports, 1893. 688 MEDICAL DIAGNOSIS. Ohronic Bright*s Disease. — An tu'ute attack of Briglifs disease' may gradually pass into a conOrrnefi malady, or the complaint may come on insidiously and develop itself slowly. The transition from the acute to the chronic disease is indicated by the disLippetiranee of blood from tlie urine, hy its lessened specific gravity and the smaller amount of albumin it contains, by the temper- ature becoming normal, and not uncommonly by a temporary diminu- Oon of the anasarca and an increase in Ihe quantity of urine voided. When the disease runs a more or less chronic course from tlie begin- ning, its initiatory steps are obscure. We generally tind such cases in persons who are poorly fed and half clad, who live in damp, ill-ven- tUated houses, who are intemperate, or who have been subject to great grief or worry, or are saturated with malaria, or whose con- stitutions are ruined by syphilis or by scrofula, or who show signs of arteriosclerosis. The lirst symptoms noticed may be trequent desire to urinate ; swelhng of the extremities or of the face ; increasing pdlor and general debility ; and headache, especially occipital head- ache. An examination of the urine reveals at once the cause of Uie protracted indisposition. Yet the renal disease may lead suddenly to a fatal termination witliout ttie patient having experienced any ill health. And even atler Uie malady has been recognized, it is ditlicult to predii^t its coui^e. We meet in many eases with the same plie- nomena as those of the acute variety, except the fever. But in others ilie signs are dissimilar, — the dropsy, for instance, is slight or is wholly wanting. The only tonslant and etiaracteristic manifesta- tions are the increasing anmmia, and the presence of albumin and tube-casts in the urine. Where chronic nephritis is suspected the urine passed at different times of the day, especially the morning and evening urine, should be separately examined. Generally, the urine is of unchanged spe- cific gravity, though this is lowered as the urinary solids and the lu-ea are lessened. The aibmiiin is variable in amount; its quantity may, indeed, lluctuate Jiiuch in the same patient, and evep change from day to day. It is persisteid ; yet it may disappear for a short time. The tube-casts, too, are not ujiiform, — not nearly so much so as in the acute vai'iety of the affection. We meet with hyaline 'casts, small or lai^e ; with casts besprinkled with shrivelled degenerating epithe- lium; with casts covered with gi*anules or with oil-drops. Fn the progress of a particular case, nearly ail tliese forms may be encoun- tered, although, as we shall hereafter see, the preponderance of any one of them is of significance. There is only one kind we do not find in the chronic disorder; the one covered with well-developed epithelial THE URINE, AND DISEASES OF THE URINARY ORGANS. 689 cells or blood-corpuscles. The apparent absence of casts from albu- minous urine is not absolute proof of the non-existence of renal degeneration. In some cases their absence is only temporary, while in others they are small and few in number and easily escape detec- tion. This is especially the case in the contracted kidney. In this disease methylene-blue is much more slowly excreted by Uie kidneys than in other forms of nephritis, or with normal urine.^ A great diversity of phenomena is thus witnessed in chronic Bright's disease, and the different grouping of the symptoms tells us to a ver>' great extent the form of the chronic malady we are dealing with. But before considering its varieties let us, leaving out of con- sideration those affections for which both the acute and the chronic disease may be mistaken, and which have been already discussed, consider the conditions with which chronic Bright's disease in general may be confounded. They are : AxiCMiA ; Neuralgia ; Chronic Rheumatism ; Chronic Bronchitis ; Asthma ; Disease of the Heart ; Cardiac Dropsy ; Gastro-Intestinal Disorders ; Cancer; Tuberculosis; Cysts of KiDNEy; Chronic Consecutive Nephritis ; Renal Inadequacy. Anceinm. — There are few diseases which alter the blood so com- pletely as chronic Bright's disease, and the gradual impoverishment of the waste-laden blood makes itself manifest by the increasing de- bility, and by the pallor and waxy look of the countenance. We may discriminate this well-marked anaemic condition from that un- connected with renal disease by the existence of albumin and tube- casts in the urine, and often also by the prominence of the dropsical symptoms. But it is essential to know that some of the phenomena — certainly albuminous urine and dropsy — may attend the anaemia following profuse or frequently repeated hemorrhages, without the structure of the kidneys having been impaired. It is difficult to dis- tinguish these cases from true Bright's disease, except by taking into account the diminution of the albumin as the hemorrhagic tendency is lost, and the absence of tube-casts. The dropsy, unless it be con- siderable, can hardly be looked upon as a valuable differential index, ' Bard and Bonnet, Arch. Gen. de Med., Feb. and March, 1898. 6S DIAGNOSIS. for ii slight or moderate amount of dropsy, or even none, may be encountered in either rnorbid stateJ The oplitliahiioseopic appearances presented by the retina afford help in distinguisliing between the ani^mia of Bright's disease and that produced by any other cause. Albnminuric retinitis is not limited to any form of Bright's disease. It generally happens in both eyes, and, thougli in the clironic variety of the malady it may greatly improve, it does not disappear. The sight itself deteriorates ; and we have attacks of blindness^ unemic amaurosis, whicii come on suddenly and pass off suddenly. Neurafgki. — This is not infrequent in Iho chronic form of Bright's disease. Neuralgia of ri*nal origin may afteet the fifUi nerve, or other nerves; sometimes it takes the form of hemierania, and it is oflen associated with disordered vision, or with impairment of other special senses ; or it may coexist with persistent headache or with strange and anomalous nervous symptoms. Headache from Brighl's disease may also be present without neuralgia ; it may be of the nature of megrim, and orcur in paroxysms attended with nausea and vomit- ing. Chroniv h'hvirmafmiL—Fvequi^ntiy patients affected with chronic Bright's disease comi>hnn of muscular pains. The pain is dnlK not increased on pressure ; sonietinies slioolmg, more like that ordinarily termed neuralgic. The pain is oftenest met with in tliose instances in wliich the dropsy is slight or wliolly wanling, and an examination of the urine is then the only means of determining its real signiJicance. Chrmtk' Bronchifis, — This is one of the most connnon complica- tions of Bright's disease, — so common, indeed^ that Rayer obser\'ed it in seven-eighths of his patients, and Wilks* stales it, from an extensive analysis of cases, to have been more ynivei*sal than any other single symptom, albuminous urine alone excepted* It is tiardly necessary to add that the lasl-mentioned sign is the one that distinguishes this sec- ondary pulmonary alTection from all otiter forms of broncliia] disease. Renal Aitihma. — Wliether or not there be coexistmg broncliitis, attat'ks of shortness of breath, like paroxysms of astlmia, occur as tlie result of Bright's disease, Tliis renal asthma is most common in the chronic contracted kidney. It has no features by whicli it can be recognized from ordinary' asthma, except tliat ttie wheeling and the * The occurrence of marked albuminuria afti^r heuiorrhage, to which atieutifHi was here called, h^ l>een since sturlied by Fist-hl, Arch, f, khn. Med., B 0«ii, ilt M^d,, Od. 188G ; Jiiemud, Gaz, des Hop., 1888. * Neumann, Archiv t klin. MimJ,, Bd, \xx,, 1882. f ■" THE URINE, AND DISEASES OF THE URINARY ORGANS. 693 richs in his work on Blight's disease. The tubercular matter is gen- erally derived from the pelvis of the kidneys. With the albumin, pus and other signs of chronic pyelitis are present. The disease may be primary, or the infection take place from the bladder, the prostate, or the ureters. We may be assisted in the diagnosis by finding tubercles in other organs, as in the lungs ; or there may be scrofulous disease of the vertebrae. In tubercle of the kidney, extreme pain, occurring in paroxysms like those of nephritic colic, is a very important sign. This pain, as I have had occasion to observe, is associated with frequent micturition, and is temporarily relieved by the flow of water. The urine is, however, scanty, and generally of low specific gravity. A moderate amount of haematuria may happen; tube-casts are rare; the patient passes at times little fibrinous shreds, has irregular fever, and emaciates steadily. The bacillus of tubercle in the urine serves as a means of diagnosis. In some cases the kidney most diseased en- larges sufficiently to form a tumor discernible through the abdominal walls. In cysts of the kidney — those at least enclosing echinococci — vesi- cles containing the characteristic structures of the yarasites may be perhaps detected. Ordinary cysts, when small, are not to be recog- nized with any certainty during life: nor can they be distinguished from Bright's disease ; they are, indeed, frequent in the chronic varie- ties of this disorder. When the cyst^ attain decided dimensions, they give rise at times io the discharge of highly bloody urine, and to albu- minuria, and to large tumors, which may be detected through the front walls of the abdomen. They may affect one or both kidneys, pro- ducing slow cachexia and enormous abdominal swelling. Cysts of the kidney and liver often coexist.^ Chrome CxynsecxUive Nephntut. — In consequence of affections of tlie bladder, of stone in the bladder, of strictures of tlie urethra, of disease of the ureters and of the prostate, indeed of various surgical affections of the urinary organs, we may have a kidney disease established which is rather a form of slow inflammatory change than Bright's disease. It may affect only one or both kidneys, and the diseased organs are tough and hard, large or small, and show great increase of fibrous tissue. The source of irritation which has led to the secondary inflammation is at times in the kidney itself, in the shape of a large calculus in the pelvis. In another form of this consecutive nephritis suppuration takes place, affecting first especially the pelvis of the kidney, a suppurative * Saliourin, Arch, de Phys., ix., 1882. 694 MEDICAl. DIAGNOSIS. pyelonephritis, — the contliHon alien called Huvfjival kidney. It is difB- nilt lo distin^uisti these consecolive forms of nephritis, especially where pus Is found in the urine, either from tlie condilion last mentioned or from coexisting bladder disease, except by the|history. Ver\' often there is pain aloup: the course of the ureter; and the urine, when passed free from pus, contains Jieither albumin nor casts, or only a small amount of albumin and a few hyaline casts. The urine js apt to be copious and of low specific gravity. When it contains pus from the kidneys, Fig. iio. Futty caRts uid epithelial cetl» hlled with fat, a^* >h.i] iu the dlsdmrgc coming fmm ft htslUf ] fatty kidney* and the bladder is comparatively unatTecti'd, the purulent urine is gen- erally acid. The lieart rarely becomes disturbed, thougti hypertrophy has been occasionally noticed in the non-suppurative form.^ Rt^nal Inmh'tjmivti. — Tliere are patients wlio pass the ordinary amount, or less than the ordinary amount, of urine daily, of low spe- cific gravity, from 1W2 lo 1(X>8. not rontaining more than two per cent, of urea, though tlie uric acid may be normal, and who in conse- quence of this insudlcient action of the kidneys are always ailing and weak, lake cold easily, and suffer from headache and nervousness. Even if they drink water freely, they do not pass more urine ; this does not contain albumin or casts, clitfering in this respect from Brighfs disease. But dropsy, as Sir Andrew Clark, who first described the complaint,-' states, with putTy face and dry, glossy skin, may happen, and a state similar to rnyxoMlema be gradually developed. Having now treated of clironic Bright's disease as one afifection^ 1 * Faj^ge's cases, in Praclic** of M»^(licine, 1886, vol ii. p, 4SS. * Britisb Medical Jounial, vaL i., 1883, THE URINE, AND DISEASES OF THE URINARY ORGANS. 695 shall briefly refer to the distinctions between its forms. In'so doing, I shall follow the classification based on the diversified anatomical aspect of the kidneys. First there is the chronic enlargement of the organ, of which several kinds exist : 1. The enlarged chronically inflamed kidney ^ known also as the large white kidney, or as chronic parenchymatous nephritis. This variety of the malady may or may not be preceded by acute nephritis. It may last for a few years, but generally terminates fatally before Fkj. m. Hyaline or waxy casts, magniiicd about 460 diameters. On some of them are scattered a few shrivelled epithelial cells and oil-drops; the large cells to the left are epithelial cells from the bladder. Thf kind of casts here depicted may be found in any form of Bright's disease, acute as well as chronic. In the waxy kidney, however, they vastly preponderate, and are of large size,— many much larger than those in this figure. that time. The urine is diminished in urea and pigment and in chlo- rides ; it contains large amounts of albumin and granular and epithe- lial casts, with some hyaline casts and a few slightly oily casts. The dropsy occasioned is extensive and persistent, and there is usually little difficulty in tracing it to an acute attack. Sometimes the dropsy lessens materially, then actively recurs. The large kidney rarely contracts ; but it may do. so. The large white kidney may also pass into the fatty kidney. Dilatation of the heart is common in chronic parenchymatous nephritis, more common even than pure hypertrophy, which is more usual in contracted kidney. 2. The fatty kidney. The kidney is very large and fatty. The convoluted tubes are filled with oil, accumulated in their epithelial cells. The fatty disease is recognized by the numerous oily casts, fatty cells, and firee oil-cells which appear in the highly albuminous urine. 696 MEDICAL DIAGNOSIS. It is a fatal complaint, generally very chronic in its course, and attended with persistent dropsy. This morbid condition must not be confounded with a simply fatty kidney, such as is sometimes found in phthisis or oftener in drunkards, and which is not associated with albuminous urine. A certain amount of fatty casts and fatty cells may appear in the urine and not be persistent or indicate the real, dangerous latty kidney. Acute nephritis from cold and exposure is much more apt to be followed by fatty kidney than the acute nephritis attending scariet fever, which is more likely to pass into the lai^e white kidney. A fatty kidney is sometimes combined both with the granular and with the lardaceous kidney. 3. The %mxy or amyloid kidney is the result of a general lardaceous or waxy disease involving the kidneys in common with other organs, and generally following upon protracted suppuration from any cause, either wound or disease. The luine is increased in quantity in the earlier stages, and of low specific gravity ; it contains much albu- min, but not many, casts. Those which are seen are pale, and for tlie most part hyaline, or highly refracting, structureless moulds of the tubules of large diameter ; they may or may not give the characteristic amyloid reaction, the red color when treated with a watery solution of iodine and of potassium iodide. Methyl-green colors amyloid sub- stances an intense green. It is used for staining in the form of a one per cent, aqueous solution. Methyl-green colors hyaline casts in situ ultramarine blue, so that these also can be readily distinguished in sections of the kidney from the green-colored tissues around, in wliich they may lie. Blood is rarely present in the urine of the amyloid kidney, and the urea is but slightly diminished in quantity. Diarrhoea frequently coexists, and the liver and spleen are apt to be enlarged; but the heart is not affected. The dropsy is absent or trifling in amount, yet its persistence while the urine is increased in quantity is peculiar to this form of renal disease, and it may exist markedly as a late symptom ; the patient is sallow-looking and emaciated ; his dis- ease may last for years. In laying stress on the hyaline and waxy casts we must be careful not to confound them with those still larger mucous moulds of the uriniferous tubules, or mucous casts. They are also smooth, but of enormous length, subdividing into smaller ones, and of cylindrical shape. They are met with in acute parenchymatous nephritis, but occur particularly in consequence of transmitted irritation firom the bladder, and are then associated \yith small amounts of albumin and of pus. Yet unless the latter be present there is no albumin, or the merest trace. Further, flask-shaped hyaline bodies and cylinders THE URINE, AND DISEASES OF THE URINARY ORGANS. 697 may be moulds of the vesicles and smaller ducts of diseased pros- tates.^ 4. Then we have the small contraithcliuin and granules. Casts of this char- acter are chietiy found in the chronic inflammator>' forms of Bright's disease, both parenchymatous and interstitial. The granular matter may be coarse and dark. a litfle oil is observed. But though the urine may contain only small amounts of serum-albumin and of globulin, there may be a consider- able quantity of other proteid matter in the shape of albuminose.^ Dropsy is absent in a certain proportion of cases, and when present is generally slight. It often disappears for a while and returns. Tlie urine is increased in quantity, although towards the termination it may become scanty or even suppressed. Dyspepsia, puffy eyelids, chronic bronchitis, increased arterial tension, hypertrophied ventricles, albuminuric retinitis, headache, and disorder of the nervous system are common symptoms. The malady runs a very clironic course. It is chiefly characterized anatomically by an affection of the fibrous tis- sues surrounding the Malpighian corpuscles and lying between the tubes, a slow increase, followed by a slow contraction, of the inter- * Sir Andrew CLark, Ti*ansactions of the Clinical Society of London, vol. xix.. .1886. '^ Rose Bradford in Allbutt's System of Medicine, vol. iv. p. 804. 698 MEDICAL DIAGNOSIS. tubular fibrous tissue and atrophy of the tubules, connective-tissue changes in the renal plexus/ and fibroid changes in the small vessels of the body. The sphygmograph shows marked pulse-tensipn, and this, with altered specific gravity, has been noticed before albumin is present in the urine. In the uric acid or gouty nephritis, uric acid deposits may be found in the straight tubes of the medullar)^ sub- stances. A chronic interstitial nephritis may be also associated with deposits of lime, which take place very generally in the uriniferous tubules in the cortex. These lime deposits may be, as Virchow poinii out, calcareous matter washed into the kidney from diseased bone. In contracted kidney, especially in the earlier stages, albumin, even casts, may be absent from the urine, and we may have to recognize the malady rather by the hypertrophied heart and thickening of the vessels, the high arterial pressure, the accentuation of the second sound of the heart, the headache, vertigo, nausea, breathlessness, retinal changes, and the anaemia. The urine may be of low specific gravity and copious, but there are many exceptions to this ; it is generally de- ficient in urea. A few hyaline or granular casts are at times found : and the albumin may not be entirely absent, but appears every now and then in traces. There may be even chronic general oedema present without albuminous urine,^ and various nervous and mental symptoms. Stewart^ has called attention to cases of chronic granular kidney witii- out albumin, though generally with hyaline or finely granular casts, and with cylindroids, but with habitual diminution in the amount of urine and of the urinary solids, especially the urea, and with symptoms n\ retention of nitrogenous waste. Among these, debility, headaches, and vertigo are very prominent ; there are no cardio-vascular changes. Cases of fibroid kidney following generalized arteriosclerosis can- not be distinguished from primary granular kidney, except by the his- tory of previous organic change in the heart and blood-vessels. Xor is the distinction of any importance. Chronic interstitial nepliritk may bo wholly latent, and nothing- but an attack of endocarditis or pericarditis, or apoplexy, or convulsions call attention to its existem e. The diCferent kinds of albumin have been above mentioned. Of these serum-albumin and serum-globulin are by far the most important, and have much the same clinical significance. Willi reference to llif tube-casts, no special kind is of diagnostic value ; it is the preponderance of the type alone that is. Hyaline casts have the least significance. ^ Da Costa and Longstreth, Amer. Journ. Med. Sci., July, 1880. ^ As in Case 31 of Malioined's paper on Chronic Bright*^ Disease willnMil Albuminuria, Guy's Hospital Reports, 3d Series, vol. xxv. ' Transactions of the Association of American Physicians, vol. xii., 1897. THE URINE, AND DISEASES OF THE URINARY ORGANS. 699 In the following table the clinical differences between the various forms of Bright's disease are set forth : Table exhibiting the Clinical Differences between the Principal Forms of Bright'h Disease. Acute Ccusee in which Droptty occurs quickly and in cxiensive. Acute Bright'8 dis- ease; acute des- quamative or tubal nephritis; acute pa- renchymatous ne- phritis ; acute renal dropsy Caused mostly by ex po- sure, or scarlet fever. Dropsy extensive, gen- erally begins in the eyelids or In the feet ; usually fever; urae- mia may be met with. Disease most common in child- hood and among young adults. Recovery frequent; but disease may ter- minate in chronic parenchymatous ne- phritis. Urine usually scant)', deep-colored , of high specific gravity, con- taining much albu- min, often blood ; also blood-casts; casts, many of large size, covered with epithelium, and a few hyaline and granular casts ; and free epithelial cells, cloudy and granu- lar; urea dimin- ished. Kidneys enlaiged, con- gested or mottled, shedding epithe- lium; cortical sut> stance increased; cones usually redder than cortical 8u1> stance. Dilated con- voluted tubes, dis- tended with swollen, cloudy epithelium ; at ends of tubules also blood or plugs of fibrin. Chronic Ca*ea in which Droj)*y is variable in amount and may be absent. Chronic parenchym- atous nephritis; chronic tubal ne- phritis ; chronic dif- fuse nephritis ; large white kidney Fatty Bright's kidney. Wttxy kidney; larda- ceous or amyloid . doreneration of kid- ney HLstor>' often of ante- cedent acute inflam- matory attack; dropsy a pniminent i sj-mptom. Marked anfiemia ; puffy face. Inflammations of se- rous membranes and unemia not uncom- mon : hypertrophy of heart, e8pe<>ially of the left ventricle, or dilatation. Recover)' possible, but doubtful. Persistent and ofjsti- nate dropsy, coming on gradually; face (wtle and puffed ; hy- ]>ertrophy of heart affecting often lx)th sides. Always fatal. Follows usually wast ing disease8,syphilis. caries, and long-con- tinued suppuration. Rare in very early and in advanced age. Dropsy trifling, except late in disease ; great emaciation ; striking sallowness of face; liver and spleen en- larged; diarrhoea; much thirst: heart not affected; ner- vous symptoms in- frequent. rn favorable prognosis. Urine in normal or in increased quantity ; specific gravity somewhat below normal ; urea dimin- ished ; albumin gen- erally in consider- able amount ; granu- lar casts; at times compound granule- cells and ijartially fatty epithelium ; no blood-castx : leuco- cytes. Urine contains much albumin, fatty casts, fatty epithelial cells, free oil. Spec. grav. variable, usually from 1015 to 10:«. Quantity variable, generally moderate or diminished ; urea diminished. Urine increased, con- tains much albumin, but few casts, which are pale and trans- parent or highly re- fracting. The casts may or may not give the mahogany-red . reaction with a water)' solution of iodine. Spec. grav. low, yet usually above 1010; urea normal or slightly diminished. Kidneys large, [wtle. capsules easily stripped off, cortical substance greatly in- creased; cones may be of natural color ; tubes irregularly dis- tended. and filled with granular epi- thelium and with detritus. Thicken- ing of intertubular matrix. Kidneys enlarged, and very fatty; some- times have a mottled look. The tubes, es- pecially the convo- luted ones, full of highly fatty epithe- lium, and free oil. Kidneys enlargeK AL lH/rEUKNCES RETWKKN THE PBIWCirAL PoJUffi OF BRmHfO I H!^ RA s E.— Coni in uefJ . which rhffptiif i* variQl>le in amotmt ami maf/ tfc abstnL—ChtUinnttl Klrliiey* WHsto »k>w1y, U r \ n V num* ctipioim bf?coine A e ri $ v and tliun hi htiihh. yet extremely sum 11 nimviuit fif an>aioiii, this al tlraeii temfm- rarily nti«ieiit; hya- Vuw am] hinre liiiely griiiuilar ea*^te; al- tered e[»itheliimi ; » liltTe rAL S]M^. ormv* low ; rarely above KHO, miieh often er below : urea diHre^iM^^nvliuiUy ; iiittrked • dtrrraN? later in di«CMijR\ Dropsy sHjchL fre- quetiLly alt^nrjl ; fiw'e sallow : *iiUu \nw{- iuhe Hiid rfleiitlt>ii of un»i4, t4L'n- mta; ei'lstdxl^; rtti- II 1 1 1 s : hyiKTtnjpliy of hettrt ; liver umy iye cirrhowl. Mosit eonimoD bdweeu forty and tilxty yeiirw of a*re. Miiv exist for yuari* uu!^U)(piH.'teti ; i»> a ver>' c'hmnie dise-Aiie. eontmcted ; caii^ule vi»ry iidbcrt*ni; &u^ fn^H^-ofUTi ^Tuiiuljur; thiekncs^ of the cur- tivnl ^ubft&nec dl- mi nii^hed : cy»lf (■nmiiion. , Tltcre is hyiKTtmphy of con- nee live liNsnt? ; erMn- prvKsion and atrnphy of 1^ 1 a n d-4:teinent6 and of I u Lutes. Cnrdlo'^va^ctilJir c hanger. Tl8»n« j trhiinges Ui reiial [ Kuiiirlia, Diseases associated with Purulent Urine* In every f:ase in whicli pus in any (juantity is detected in Uie urine, it beeonies of great irnportaoee to ascertain primarily that it is not derived from llie uretlira, from the vagina, or from an abscess that has opened into the urinary passages. The fii'st point we may decide by examining into llie history of tlio case, and, if necessary, by an exploration of the parts, as well as by an examinalion of the urine procured in the manner recommended in the first part of Uiis chap- ter; the second, by Hie same means, and l>y determining that a dis- ctiargc takes place equally when no urine is voided ; tlie tliird is mort* difficult to make out, but there is generally something in the symp- toms and in the history of the case furnishing a clue to its inter- pretation,^— such, for uistance, as the sudden appearance of a large quafitily of pus in the urine. Having excluded each of these morbid states as ttie source of the purulent urine^ we next turn to see vvWt^li of the maladies that are its most common cause is before us. They are: Acute Oystitia, — Acute inflammation most frequently affects the mucous menil>rane at or near the neck of the bladder. It is much more commonly encourdered in men than in women, and in adults than in diildren. Its main symptoms are a feeling of weight and i>ain in the hypogastric region, augmented by movement and by pressiwe. The pain does not, however, remain contined to the region about the bladder, but is felt also in the iliac and sacro-Jumbar regions. It is attended with considerable febrile disturbance and exti-eme irritability of the ailected viseus. The urine is voided drop by drop, and its passage is accompanied by straining and a scalding sensation at tJie THE URINE, AND DISEASES OF THE URINARY ORGANS. 701 neck of the bladder ; it is high-colored, cloudy from vesical mucus, and contains blood and pus and sometimes shreds of lymph. At first the urine is acid. The acute disease generally terminates within a week, leaving often an irritable bladder or a chronic inflammation. The symptoms of acute cystitis are similar to those of acute painful nephritis^ and the exciting causes may be much the same. But acute inflammation of the bladder diflfers from acute inflammation of the kidney by the far greater severity of the pain, its much lower posi- tion, and by the distress in voiding the urine. Neuralgia, or spasm, of the bladder may be distinguished from acute inflammation by the absence of fever, and by the sharp, lancinating, but paroxysmal pain, each onset of which lasts hardly longer than from two to six hours, and is attended with difficulty in passing water, which disappears as the pain subsides. Meii-itis exhibits several of the traits of cystitis : we find the same hypogastric pain shooting to the thighs or to the anus and loins, the same feeling of weight in the perineum, and the same signs of irri- tation of the bladder and of fever. As it, however, generally occurs in the puerperal state, we have the history, and the character of the discharges from the vagina, to guide us, as well as the knowledge to be gained by a local examination. Chronic Cystitis. — This affection, often called chronic vesical catarrh, is common in advanced age. It generally comes on in an insidious manner, and is excited by some obstacle to the evacuation of urine, such as a stricture, or by the presence of a stone in the blad- der, or by an enlargement of the prostate gland. A paralysis of the viscus leading to retention of its contents, or a serious structural dis- ease of its coats, whether malignant or non-malignant, may, however, also establish the morbid process. The most usual symptoms, indeed in every way the most charac- teristic, are dull pain, a frequent desire to pass water, and the discharge of a large quantity of muco-pus or pus with each act of micturition. The urine, which is alkaline, on standing deposits a glairy, viscid sed- iment, in which, under the microscope, vesical epithelial triple phos- phates, large pus-corpuscles, extremely regular both in contents and in shape, and patliogenic germs, especially the bacillus coli communis and the staphylococcus pyogenes, may be detected. The urine usu- ally contains more albimiin than is found in acute cystitis. The diagnosis of the disease in males is easy. The only affection with which it is liable to be confounded is abscess of the kidney. In females, uterine disorders may so closely simulate it that it may require a local examination to tell the difference. 44 702 MEDICAL DIAGNOSIS. But, lia\ing decided the case to be one of chronic cystitis, it is always more difficult to discover its exciting cause, We have to depend, to a great extent, upon the history of the malady ; its as- sociation with a stone can be determined only by the use of the sound. Abscess of the Kidney. — This dangerous condition is the result of suppurative inflammation of the kidney, or of abscesses forming in connection ^Aith pyaemia, or with embolism. The suppurative inflammation is sometimes traceable to an acute attack of nepliritis brought on by exposure or by external violence, to retention of urine, or to the impaction of a renal calculus; but at otlier times it origi- nates without any assignable cause, and in an insidious way. The association of suppurative nephritis with erysipelas has engaged much attention, and the renal affection is even thought to be erysipelatous in its origin.' Abscess of tiie kidney may also arise from acute inter- stitial nepliritis and in siipjjuration tliat occasions surgical kidney. Abscess of tlie kidney is a rare disease. It has nmcli the same symptoms as pyelitis. There is a fulness on one side of tlie, sj»ine associated with tenderness on deep pressure in the lumbar region, and with more or less constant pain, the pain and tenderness being increfised by lying on the affected side : fliere are also fever and oc- casional rigors, digestive disturbances, and blood and pus in the sc*anty, acid urine, though pus in the urine may be absent. In some cases a marked tumor is foond in the loin, extending towards the iliac fossa. If tile abscess burst into the calyces, there occurs, simultaneously with a subsidence of tiie tumor, a sudden and copious dischaj^a* of pus with Uic urine, or, if it break into the intestine, with the fecal evacuation. The disease almost never affects more than one kidney ; hence so- called urremic symptoms are rarely met with, since the healtliy kid- ney enlarges and becomes capable of performing a double amount of work. Ebstein- has, however, observed that chronic abscess in one kidney may produce amyloid disease af the otlier. The disorder gradually leads in most cases to a fatal issue, from the irritation, (he vomiting, the diarrhoea, the w^asling dischai^ge, and tlie protracted hectic ; sometimes paralysis of one or both legs happens, adding greatly to the distress. There is a possibility of recovery, if the patient have strength enough to withstand the purulent dmin until the abscess empties itselfl It may do this through (he urinar}* pas- ' Goodhad, Guy's Hospital Repaiis^ 3tl Series, vol. xix. • Ziemsseii's Cyclopajdia. THE URINE, AND DISEASES OF THE URINARY ORGANS. 703 sages, through the colon, through the lumbar muscles, through the diaphragm, and be evacuated by coughing, and the cavity of the ab- scess then cicatrizes ; or the abscess may burst into the peritoneal cavity and cause rapid death. The diseases for which the malady is most apt to be mistaken — leaving out those extremely rare cases in which abscesses from dis- eased vertebrae break suddenly into the urinary tract — are chronic cystitis, perinephritis, and pyelitis. From cystUis it may be distin- guished by the dissimilar local signs and the different appearances of the urine. Thus, in the affection of the bladder the quantity of pus constantly discharged is far greater, — for in abscess of the kidney there are times when little or no pus is voided ; on the other hand, the urine of the vesical disorder is less albuminous. In the renal malady we can detect casts and other renal products in the sediment. Perinepfmiis unconnected with inflammation of the kidney is a very rare disease. When primary, it may result from exposure ; but it is more generally due to contusion or strain. I saw an instance of it in a young man who, returning home from a long walk, strained his back in jumping a fence. An abscess gradually formed, giving rise to a slight fulness in the left lumbar region and severe pain, which dis- appeared as matter was discharged through the integuments. The function of the kidney was not afl'ected. But an external opening may be established when the process of inflammation and suppuration has begun in the kidney and thence spread to the loose tissues surrounding it. Under these circum- stances, the appearance in the urine of pus prior to its discharge through the muscles of the back would be the only certain means by which we could judge where the suppuration had primarily taken place. The inflammation may travel upward from the pelvic viscera or from the head of the colon or the appendix; it has been also noticed after irritation of the testicles and of the spermatic cord. The pus is generally situated behind the kidney. Secondary perinephritis has been observed in pyaemia, and after typhoid and typhus fevers, smallpox, and the other exanthemata. The disease is not uncommon in chUdhood.' The prominent symptom in perinephritis is pain, which at times is so severe as to confine the patient to bed with his knees flexed, with a sense of fulness and dragging weight, with tenderness in the region of the kidney, and with lameness owing to the interference with the play of the psoas muscles. The urine is generally unaltered. * Gibney reports twenty-eight cases, Amer. Joum. of Obst., April, 1876. 704 MEDICAL DIAGNOSIS. or only full of urates ; the bowels may be constipated, owing to the pressure of the tumor on the intestine. A rounded, doughy, and generally indolent swelling, uninfluenced by the respiratory move- ments, is usually found in the lumbar region or a little lower. The abscess may cause pulmonary or pleuritic complications, but rarely gives rise to jaundice. As the disease advances, severe chills, with high fever and copious night-sweats, occur, as well as emaciation and marked debility, and the thoracic symptoms may mask the renal; fluctuation may be at times detected, and, before the abscess breaks externally, a phlegmonous appearance of the skin where the abscess points is not unusual. Great relief follows the discharge of the pus. From inflammatiati of the psoas muscle we distinguish perinephritis by the absence of marked sensitiveness over the renal region in the former complaint, and by flexion of the thigh in it producing pain. Pyelitis. — Inflammation of the mucous membrane of the pelvis of the kidney is almost never idiopathic, being commonly caused by a calculus arrested in the ureter ; or by a retention of urine from an obstacle in the ureter, bladder, or urethra ; or by an extension upward from the bladder of an inflammation. Bright's disease and diabetes are not unusually, and typhus and the eruptive fevers, pyaemia, scurvy, diphtheria, carbuncle, puerperal septicaemia are occasionally, compli- cated with some degree of pyelitis. Pyelitis may be also catarrhal or rheumatic. Under these circumstances, and in all the infectious dis- eases, pyelitis is apt to show itself in an acute form. The symptoms of the chronic malady are in part those produced by the morbid states exciting it, especially those denoting a calculus lodged in the kidney or arrested in its transit towards the bladder: partly those directly traceable to the inflammation of the pelvis and infundibula. The manifestations of the latter disorder are a constant dull pain in the loin, felt also in the course of the ureter, and the pas- sage of pus and occasionally of small quantities of blood with the urine ; in cases from retention and decomposition of urine there are recurring chills, sweats, vomiting, headache, delirium, and fever. In If: most cases of pyelitis the urine is acid, albuminous, very abundant, and offensive. It may be acid even if it abound in triple phosphates ; if detained any length of time in the bladder it becomes ammoniatal. Bacteria are a frequent cause of pyelitis, as well as of abscess of the kidney, by migrating from a diseased bladder. 'In some instances of pyelitis an eruption like rubella is noticeably. Pyelitis not infirequently afl'ects only one kidney. The most difficult point connected with the recognition of pyelitis is the ascertaining that the purulent discharge does not proceed from THE URINE, AND DISEASES OF THE URINARY ORGANS. 705 the bladder. And there is no positive sign to guide us, except the existence in the urine of epithelium from the pelvis of the kidney, distinguishable by its oval or fusiform shape, and by the frequent occurrence, in a cell, of clearly-defined, dark-colored, round granules, and of two nuclei. But this epithelium will not be always found, and we have then to fall back upon the history of the case, upon the attacks of renal pain, upon the haematuria caused by a calculus, and upon the combination of signs as pointing more to one disease than to the other. In some cases there is a perceptible swelling in the loin ; at times, too, owing to coexisting degeneration of the cortex of the kidney, the amount of albumin is whblly disproportionate to that con- tained in pus, and this becomes a valuable indication of the affection not being vesical. But if there be a coincident disease of the bladder, the differential distinction may become impossible. Under these cir- cumstances, too, the acid state of the urine, on which in uncompli- cated cases much stress may be laid, is not apt to be a feature to aid us. The crystals of nitrate of urea formed when nitric acid is added to the urine have in pyelitis irregular blades or are in the shape of small feathers.* Supposing the point settled, and the vesical origin of the pus dis- proved, the diagnosis is limited to an inflammation of the ureter, to an abscess in the substance of the kidney, and to pyelitis. Here again the history of the case comes into play. Furthermore, in the former of these affections — a very rare one, unless associated with pyelitis — the amount of pus in the urine is very trifling ; in tlie second, too, it is less than in pyelitis, except when the abscess empties itself. The pus is also, as already indicated", not constant, alternately appearing in and disappearing from the urine ; there is usually more obvious swell- ing, although this is by no means always discernible or even present in abscess, and the abscess is attended with much greater constitu- tional disturbance. Still, here again we must admit that the disorders are sometimes very obscure and difficult to distinguish, and it may be impossible to discriminate between them should the morbid states coexist, or a typhoid condition and uraemic fever be induced by the retention of the urine and its decomposition. Catarrhal or rheumcUic pyelitis is generally a short disease which ends favorably ; so does the idiopathic pyelitis of the puerperal state, which rarely lasts more than from five to eight days. The pyelitis with retention and decomposition of urine is a much more serious complaint, and, although it usually runs a rapid course, not having ^ Pascallucci, II Morgagni, quoted in Lancet, June, 1873. 706 MEDICAL DIAGNOSIS. a duration of more than a week or two, it may become protracted. Pyelitis due to the irritation of calculi is apt to develop into a chronic condition. In tuberadous pyelitis the symptoms are the same as in the ordinary form. The association with tuberculosis in other parts, and the de- tection of tubercle bacilli in the urine, establish the diagnosis. In those cases of pyelitis in which there is a very decided obstruc- tion to the flow of urine through the ureter, caused by a calculus, a clot of blood or viscid pus, or other debris, the discharge of pus is suddenly arrested and the cavity of the pelvis dilates greatly ; grad- ually the gland-tissue is compregf^ed, and a large pus-containing sac is formed, giving rise to a condition known as pyonephrosis^ and to a dis- tinctly limited swelling in the side. Tumors of this kind are ordi- narily not painful to the touch, are indolent, and do not materiail? aflfect the general health, certainly not nearly so much as might be sup- posed. They frequently subside gradually by free dischaiiges of pus, and the patient recovers.^ Sometimes they become much reduced, and then swell up again from time to time. They may occur in both kidneys : but this is of great rarity. The urine generally contains albumin and considerable pus ; it is acid and of low specific gravity. Pyonephrosis cannot be distinguished from suppurative nephritis and ordinary abscess of the kidney^ except it be by the history. Tlie more constant and larger discharge of pus may be also made a point of diagnosis, as well as the obvious variations in the swelling, and the slighter constitutional symptoms. But too much stress must not l)e laid on these points; and the fact should not be overlooked that abscess of the kidney may be latent,* or be present almost without fever, or with very obscure manifestations of pain, irregular attacks of fever, and vomiting, coming on at intervals for months or years. When there is an impediment to the flow of urine the peUis of the kidney dilates from the accumulating urine and we have hytlro- nephrosis; in time the kidney tissue disappears. Hydronephrosis is due to mechanical obstruction from retroflexion or cancer of the womb, or from morbid growths or abscess of the bladder, or to con- genital malformation of the ureter, or to movable kidney or to im- pacted stone in the ureter. Sometimes it is double ; it is much more common in women than in men. The swelling to which it gives rise may subside simultaneously with a sudden and copious dischai;^ «~'f urine. When this symptom is absent, the diagnosis must be based on * S«H», for inslaiuv. Cases XLVIIl. and L. in Todd's Clinical Lectuivson tb^ I'rinar)- Diyans. THE URINE, AND DISEASES OF THE URINARY ORGANS. 707 pain in the back, frequent micturition, and the existence of a fluctu- ating renal tumor, often lobulated, and on the absence of signs of sup- puration. There may be attacks of renal colic due to the passage of clots of blood. The urine is at times copious, at times scant. The disease may lead to temporary, but entire, suppression of urine. Ac- curate percussion enables us to distinguish hydronephrosis from ascites ; in the former the dulness is generally one-sided, and is un- influenced by change of position. Ovarian cysts are more difficult to discriminate. Careful examinations by the rectum and by the vagina, and an investigation of the fluid after an exploratory puncture, are alone of value ; and even the latter may mislead. Urinary constitu- ents, for instance, have been found to be absent in rare cases of hy- dronephrosis. Pyonephrosis is chiefly distinguished by the irregular fever, chills, and the purulent urine. Hydatid tumor of the kidney is of comparatively rare occurrence, and is likely to be confounded with hydronephrosis. When the urine contains no hydatid vesicles or their debris and the hydatid fremitus is absent, the diagnosis is extremely difficult, and must rest chiefly on the history of the case. Ordinary refnal cysts^ when large enough to occasion a tumor, can- not be distinguished from hydronephrosis save by the history, and by the albuminous and decidedly bloody urine which the cysts give rise to, while in hydronephrosis the urine presents nothing peculiar, or occasionally only small amounts of pus and of blood. Then, renal cysts are double-sided, preserve the shape of the kidney, and do not rapidly change their size. There are casts in the urine, and the gen- eral symptoms are those of chronic interstitial nephritis including the cardio-vascular changes. Pyelitis may be connected with fibrinous clots due to repeated hemorrhages from muUipk aneurisms of the renal artery. We may suspect this condition if the other more usual causes of pyelitis seem to be absent, and if the affection happen in an old person having re- peated attacks of haematuria and atheromatous arteries.^ Disorders in which a very large Amount of Urine is dis- charged. Diabetes. — In diabetes mellitus, or glycosuria, the urine is of pale color, decidedly acid, and of high specific gravity, ranging generally from 1030 to 1050. The quantity passed is enormous : seventy pints and upward have been known to be discharged daily. The urea is * Ollivier, Archives de Physiologie, 1873. IV 708 MEDICAL DIAGNOSIS. increased ; so are the sulphates, the chlorides, and the earthy phos- phates, while the alkaline phosphates vary greatly with the food, and uric acid is diminished ; so is the coloring-matter. The urine contains from one to ten per cent, of sugar. In a small proportion of cases the flow of urine is not increased, nor is the specific gravity above nor- mal. In some instances the phosphates are strikingly in excess. The symptoms attending the drain of fluid from the system are great thirst, constipation, a dry, harsh skin, a red tongue, and a feel- ing of constant emptiness and of hunger. To these are added a steadily progressing waste of the body, muscular feebleness, chills, a somewhat hurried breathing, a peculiar mawkish odor of the breath, peevishness of temper, chronic catarrh of the stomach, a tendency to eczema and to boils and carbuncles, and in women pruritus of the vulva. The temperature is subnormal, often not over 96°. The knee- jerk is generally absent. Cataract and other defects of vision are not infrequent. There is a peculiar form of retinitis ; * retinal hemorrhage and palsies of the muscles of the eyeball, diabetic hypermetropia, and atrophy of the optic nerves have also been noticed. Defects in ac- commodation are common. Diabetic endocarditis alsof happens, and is more frequent in women than in men ; * and arteriosclerosis, neu- rites and neuralgias, periostitis,' and arthritic disorders* may have their origin in diabetes. Double sciatica is often of diabetic source : and there are cases presenting symptoms like tliose of tabes, with lightning pains and loss of knee-jerk. Diabetes is generally a fatal disease ; yet it is impossible to foretell its exact mode of termination. Some are cut off rather suddenly: others drag out a long existence, and die w^orn out and dropsical, or of cirrhosis of the liver, or of chronic nephritis, or of broncho-pneu- monia, or of phthisis. For some days, or even for weeks, before death, the sugar may disappear from the urine.* Diabetic gangrene is also a mode, though not a frequent one, of termination of the disease.^ When the disease ends suddenly, it is apt to do so by so-called diabetic coma. The comatose condition is prone to be preceded by * Galezowski, Compte-Rendu du Congr^s Ophlh. de Paris, 1862. * Lecorche, Arch. Gen. de Med., June, 1882 ; Bulletin de TAcad. de Mt^d.. 18S0. » Arch. Gen. de Med., Feb. 1882, and Amer. Journ. Med. Sci., April, 1882. * Dyce Duckworih, St. Barth. Hosp. Rep., vol. xviii., 1882. * In a case for a long time under my charge, in which the diabetes lasted for several years, sugar entirely disappeared from the urine as the signs of phthisis became fully developed, for some months before death. * See cases collected by Hunt, Transact. Phila. Co. Med. Soc., Nov. 1888. THE URINE, AND DISEASES OF THE URINARY ORGANS. 709 vomiting and abdominal pain, rapid pulse, great anxiety and restless- ness, labored breathing, depressed body-heat, headache, and drowsi- ness. These symptoms are attributed to the poisoning of the body by the development of acetone, a derivative of acetic acid, in the blood ; the acetone can be foimd in the urine, and may be readily detected on the breath by its odor resembling that of chloroform. The evidence, however, of the decomposition of the sugar into ace- tone, and of the consequent nervous symptoms called diabetic coma, is not conclusive. Diacetone was believed by. some to be a more probable cause ; but betabutyric acid, from which acetone is derived, is now more generally thought to be the cause of the diabetic coma. Certain it is that this is due to some toxic agent of extreme acidity in the blood. In thuly cases of diabetic coma examined by Naunyn,^ extreme acidity was found ; and in twenty-six in which the examina- tion was made, the proof of the excretion of large amounts of oxy- butyric acid was conclusive. Diabetes is a disease chiefly of the upper classes of society. It is very rare in the colored race, very common among Hebrews. It is especially found in neurotics who lead a sedentary life, and a con- nection between gout and diabetes can be often traced, as also be- tween obesity and diabetes. The disease is vastly more frequent in men than in women, and is often hereditary. Mental emotion, worry, and excessive devotion to business are among its causes. There is evidence of its being contagious. The sugar is derived from the glycogen in the body, and when this forms in excessive quantities and is not fully destroyed in the lungs, it is excreted by the kidneys. But as the sugar-forming function is not a simple one, and various oi^ns and structures, such as liver, pancreas, and nervous system, take part in it, and there may be even direct change of the food products into glycogen, the question of the origin of diabetes in a given case is never an easy one. Clinically speaking, we are apt to find diabetes in this connection : in large feeders, especially large eaters of the carbo- hydrates, with poor assimilative powers; the diabetics among the obese and the dietetic diabetics mostly belong to this group ; in dis- eases of the liver, especially in cirrhosis, and there is a form of cir- rhosis with enlargement of the organs and with pigmentation of the skin which is regarded as peculiarly associated with diabetes ; in diseases of the nervous system, such as tumors, epilepsy, — in fact, in most various structural as well as functional disorders of the brain or spinal cord ; in disease of the fourth ventricle, or of tumors pressing » Diabetes Mellitus, p. 297, Vienna, 1898. 710 MCAL DIAGNOSIS. there, diabet^ has been particularly noted ; in diseases of the creas. The frequent association of pancreatic disease or disorder its function witti dial^etes is very evident, and depends upon the with- drawal of the glycolytic ferment which the normal gland fiirnishes. In the diti^nosis of diabetes the constancy of the excretion of the grape-sugar must be regarded, and not merely its occasional presence* In mild cases the amount of sugar does not exceed two per cent; in severe cases we find from five to ten per cent. In some instances tlie constitutional symptoms are very marked^ and the disease mns an acute course. The sure test for diabetes is furnished by the chemical tests for grape-sugar in the urine, which have been discussed in an early part of this chapter. But blood-tests are also made use of, and are of vahie where sygar exists in doubtful traces, or where it is tem- porarily absent from the urine. Bremer's* lest consists in comparing witli each other slides smeared with normal blood and with tlie sus- pected diabetic blood, afler having been heated in a thermostat to about 135° C,» and cooled and stained in a one per cent, aqueous solution of Congo-red for two minutes. The excess of stahi is washed off, and diabetic blood is ibund to be unstained or orange- stained, while normal blood shows the distinct Congo-red stain. In leukfemie blood, liowever, we may have the same result as in diabetic blood. Diabetic btood will turn weak alkaline solutions of methylene- blue to yellowish green or yellow, and Williamson'' has, in accordance, suggested a blood-test for diabetes of definite proportion, — ^about a six per cent, solution. Starchy and saccharine substances increase the quantity of diabetic sugar. Nay, ttiey may be the cause of a little sugar appearing in the urine of healthy persons. Yet those in whom a saccharine state of the urine is readily induced are in danger of becoming cUabetic, If we are in doubt whether we are dealing with a case of diabetes, we may follow Seegen's advice and let the patieiit eat heartily of saccha- rine and sugar- forming siit)stances, and examine the urine tliree lioiirs ^J after the meal ; if no sugar then be found in the urine, diabetes may^f be excluded. In the aged, sugar may be present in the urine without being attended with distressing symptoms. It is in such cases that we are most apt to meet with the intermitting dial^etes to which attention has been called by Bence Jones.^ When the abnormal ingredient thus * Medical Record, Oct. 1897. ' Brilifih Me^lical Journal, 18J>6, vol. ii. ' Medic4)-Chirurgical Transactions, vol, xxxviii. THE URINE, AND DISEASES OF THE URINARY ORGANS. 711 disappears from the urine, it is replaced by uric acid and by oxalates. There is still another form of intermitting glycosuria. Sugar is found in the urine during the paroxysms of intermittent fever ; but it vanishes during the intervals. Sugar is also found in the urine in small quantities in the obese, or after inhaling chloroform or taking chloral or sulphonal. Among the insane, sugar may be present in the urine without there being other symptoms of diabetes, and without grave significance.* Indeed, this appearance of sugar in the urine from passing causes or without other marked symptoms has given rise to the distinction made by some between glycosuria and diabetes, restricting the latter term to persistent saccharine urine with decided symptoms. The temporary glycosuria gets well ; true diabetes rarely does. In some instances we have diabetes with coexisting albumimiria, and even with other evidences of Bright's disease. In the majority of such instances the degeneration of the kidneys has happened sub- sequently to the diabetes, and in its more advanced stages, from their constant irritation ; but I have met with cases in which the nephritis has preceded the diabetes. A high degree of fatty kidney or amyloid kidney has also been noticed in cranection with diabetes. A small amount of albumin in diabetic urine is common. Chronic Diuresis. — This disease is otherwise known as polyuiia, or diabetes insipidtis. It is characterized by the habitual discharge of a very large quantity of urine of low specific gravity, from 1001 to 1008, containing an excess of water, but no sugar ; urea is increased ; uric acid is very deficient ; inosite is often present ; kreatinin may be ex- creted in increased quantity. The general symptoms are much the same as those of diabetes ; the thirst is generally extreme, and it may happen that more water is passed than is drunk. Most cases recover under treatment, except when dependent upon irremediable lesion. They sometimes die of suppression of urine.^ The cause of this singular malady is obscure. We meet with polyuria after cerebro-spinal fever, or in connection with tumors of the brain, or with disease of the medulla oblongata, or of part of the floor of the fourth ventricle, or with tumors compressing the abdom- inal ganglia. Lancereaux tells us that the disorder is not uncommon in syphilitic affections of the nervous centres ; ' and Bartholow's ex- perience is that syphiloma of the brain is its most usual cause. I have * Lailler, quoted in Journal of Mental Science, May, 1871. ^ Case under my charge at the Philadelphia Hospital. * Sydenham Society's Translation, p. 77. 712 MEDICAL DIAGNOSIS. repeatedly encountered the malady after injuries to the head,^ after sunstroke, or in persons broken down with malaria. At times it is seen in instances simply of great nervous depression without organic disease. It is, indeed, mostly connected with some abnormal state of the nervous system. It has been stated to coexist with marked excess of phosphates, and to be a phosphaturia. Cases of chronic polyuria differ from true diabetes by the low specific gravity of the urine, and the utter absence of a saccharine ingredient. Sometimes a state of diuresis is found to exist temporarily during the removal of dropsical effusions, or when the action of the skin is insufficient. We also meet with apparent cases of diuresis in hysterical women and in persons who suffer from inGOfniinence of urim. In all such we can establish the diagnosis by measuring the amount of urine passed in the twenty-four hours, — which amount may be large, but is not inordinate. In hysteria it may be temporarily very lar^ge after a paroxysm, but is not persistently so. In some instances dia- betes mellitus alternates with diabetes insipidus. The discovery of an hydraemic centre in the cerebellum, as well as the well-known points at the floor of the fourth ventricle, which, according to the exact seat of puncture, produce increased flow of urine with sugar or without sugar, gives us the clue in which direction to look for the ex- planation of such cases. The large flow of urine we sometimes meet with in contracted kidney is known from hydruria by the presence of albumin and tube-casts and the other signs of kidney degeneration. An excessive flow of urine may happen in hydronephrosis. But the antecedent history, the previous existence, as a rule, of a fluctuating tumor, and the character of the urine, either normal or containing at times traces of albumin or of blood, will throw light on the character of the malady. Disorders in which little or no Urine is Discharged. Suppression of Urine. — Suppression of urine, unconnected with degeneration of the kidney, is a rare disorder. Yet it may occur in previously healthy persons, or in the course of fevers of low type, or in alcoholism, and probably associated with no other morbid state than congestion of the kidneys. It is occasionally met with as one of the freaks of hysteria, or is caused seemingly by the irritation reflected to a healthy kidney from a diseased bladder. The symptoms it occasions, independently of the absence of the discharge of urine, are drowsiness, nausea, vomiting, comA, sometimes * Transactions of the College of Physicians of Philadelphia, 1875. THE URINE, AND DISEASES OF THE URINARY ORGANS. 713 convulsions ; in one word, the symptoms of ursemic poisoning. The formidable complaint may give rise to markesd urinous smell of the perspiration and of the breath, and to exceeding and very general cutaneous hypersesthesia.* The temperature may be low, and remain so even if there be coexisting internal inflammation, or be abbve the norm.* ' Concerning the exact cause of the supression we are often kept in the dark until the termination of the malady ; for, unless familiar with the antecedent symptoms, we are unable to detennine, in the absence of the urinary secretion, whether or not a disease of the kid- ney lie at the origin of the mischief. Oppolzer tells us that we may diagnosticate thrombosis of the renal vein if we have diminution of the secretion of urine and its final sup- pression preceded by blood, albumin, and casts in the urine. If there be a history of severe injury to the kidney, these symptoms have a much more positive meaning. Retention of Urine. — ^The urine retained in the bladder distends the viscus and forms a swelling in the hypogastrium, discoverable both by palpation and by percussion. The urine is generally not wholly kept back, for a slight discharge every now and then takes place, or there is a constant dribbling, — a matter which in itself should suggest the introduction of a catheter. Retention of urine, if soon recognized, is not a dangerous com- plaint, as it can be at once relieved by the passage of a catheter ; but if the ailment escape observation, or be inefficiently dealt with, the bladder may burst, — though Sir Henry Thompson tells us that this is a circumstance of exceeding rarity, — or the patient die from the absorption of the noxious urinary ingredients. The causes which lead to retention are various ; prominent among them, at least in a medical point of view, is paralysis of the bladder, especially that form of paralysis which occurs in low fevers ; retention is also one of the symptoms of paraplegia ; then inflammatory swell- ing of the neck of the bladder, organic stricture, or enlarged prostate may give rise to it ; again, retention or incontinence may be due to ' This was the most obvious symptom in a case under my care at the Philadel- phia Hospital, in which no urine was secreted for many days, the catheter being repeatedly introduced into the bladder. The patient recovered. She had, previ- ously and subsequently to the attack, vesical catarrh. In a case reported by Fuller, St George's Hospital Reports, vol. v., the difficulty existed for eight days without occasioning convulsions. It was the same in a case of mine that lasted eleven days and got well. » Boumeville, Gaz. Med. de Paris, 1872. 714 MEDICAL DIAGNOSIS. hysteria. If the urine be long retained in the bladder, it becomes alka- line, and putrefactive ghanges occur, and fission fungi, especially the micrococcus urese, develop in great numbers in the ammoniacal urine. The disorder is readily detected. It may be discriminated from suppression of urine by the existence of the hypogastric tumor, and by the introduction of a catheter, — a means which, in cases of doubt, ought never to be neglected. Sometimes the abdominal swelling is so great as to lead to the belief of the existence of dropsy ; and the error is fostered by learning that the patient has been passing his water, and has a constant desire to discharge it, or by seeing that it dribbles from hun. The retention from paralysis is distinguished from that due to other causes, as obstruction, by observing that the catheter enters readily, and that the urine flows out in a continuous stream, in- creasing and lessening with the respiratory movements, but does not come out in jets. CHAPTER VIII. DROPSY. A COLLECTION of Watery fluid in the areolar tissue or in the serous cavities constitutes dropsy. Now, dropsy is but a symptom, and is associated with various disorders ; yet, though but a symptom, it is one that comprises so often apparently the whole complaint, that it will be useful to investigate connectedly the clinical meaning of its typical forms. I^opsy, according to its Seat and Extent. Dropsies may be external, or be confined to internal parts. To the latter variety belong .hydrothorax, hydrocephalus, and ascites. External dropsies are illustrated by anasarca and oedema ; the first, a universal accumulation of serous fluid in the areolar textures; the second, a localized collection in the same structures. Both exhibit painless swelling of the surface, devoid of redness ; a skin often stretched and shining, pitting upon pressure, and retaining for some time the mark of the finger ; and in both, the tumid part, if punctured, discharges a watery fluid. (Edema is most commonly perceived around the ankles ; the tumefaction of anasarca is found generally not only in the lower extremities, but also in the arms and in the face. Anasarca is usually dependent upon disease of the kidneys, or of the heart. The swelling rarely shows itself at all parts of the body at once ; it ordinarily begins at the feet and ankles in diseases of the heart, in the face in diseases of the kidney. Giklema may be due to the same causes. Yet a limited collection of fluid is often the consequence of a purely local difficulty, of a char- acter interfering with the venous circulation. Thus, the compression or obliteration of a large vein occasions oedema below the point of the disorder. We see oedema happening if swollen glands press upon the main vein of a limb. We also meet with it in the adhesive form of venous inflammation, and in phlegmasia alba dolens. In all of these forms the oedema is one-sided, and there is little difficulty in its recog- nition. A circumscribed oedema also accompanies erysipelatous in- flammations of the skin or subjacent tissues, and is found in limbs the general nutrition of which has been lowered by paralysis. 71/; flfi MEDICAl. DIAGNOSIS. When the oxlcmal dropsical etTusioo is dependent upon a tuinur seated in an internal cavity and interfering witti the passage of the blood, it may be very local and one-sided, as we sometimes find in connection witli abdominal cancer ; but it is most apt to be found on both sides of a portion of the body, although more particularly marked on one side. The ct^dematous extremities exliilMt usually also marked enlargement of the veins. Another source of a double-sided oedema is an^^mia. The serum collects first about the ankles* The absence of any discoverable oi^anic affection, the pallid countenance, and the pearly whiteness of the conjunctiva are very significant. A microscopical examination of the blood and a blood-count establish the diagnosis. A dropsical efiiision in part of similar origin, but much more often cotuiected with infenial f!ropj whether it has caused the change in the arteries or is a mere eoriistiri;^ affection ovii^ to the same ^ceral mort>id process, a nbnjisis. Arth-ir V. 31e^ ~ m^es this Tiew, and I beiiere it is generally the tnie explasadoc It is &se<{ueDce oi the haniening erf' the walls of thr artefy. and Its most osoal kind, the sen£e form, is note*! after the age of i^ as a dc^npcratxre change. Thickenii^ of the indma is the most '^Mr.rr.ogi -iisease of arteries, azid may I^ad to obSteratiTe endarteritis.' The th>:-kenii^ of the intima of the arteries asd arterioles tdaj extend to s»)me degree into the reirks. The symp^onks to whkh chroGi: endarteritis gives ri^e are Ln-jrvase^i K<:<^i-f'ressiire, hea»i- ache. cold ertiemitiesw hneail^sssess on eiertioc. aret^fnia. ej^^staxis. or hem«MTh.a^^ into internal or^ar^s, sr>:h as the brain or ±e lungs : •fdema without re^x^gnizaivle caTsse : atia^^ks of h-ri-Khitas or ^atarr^ pnecmocia : and torpor o( the lirer. An a^<^«rarar>.'e of p*«niijefye of the smaller vessess and their greater resascan-re show the fily deTeli^ped disease, and we :ben Sod r.TrTvi2s symf^oms, sor^h as Tert^gc*. at times with syn->?pe. l«-"«s of memory, and general wan: of power in the Smhs. Hypiertr*:»fiy of ie heart. lbr»i heart. ai>L a: times, dilatation and TalTe-cha:::^^^s m^y als*: be rrese^t. as wel' as a3>amin and casts in the uriDe. and c-tner si:ns •>: kidsey affertj:*:. Bit th-ese do n«A ne?:er5sarny o:\ur. A^rsln. "iere ire .'sses m wri«:h faejeTe "jia: :: 5s ^er?2s.:en:> slii-iy r!rTi:el En^iineri'ii? is i". -in-"-? »Mmj:er55i:ory in s!:Trin£ :: 'Jir i:l'»i-:.irTvn:.' An i.\enr.iin«:c : the sexni s*::inL is -arrll is r^ r^E-inioian'rc is a js-iil :ea:-jz\ .r. ar:erv.>s*:ler:-.•««':-.:,' ."•T'^Tlfw. 2? i Ter^ rare i:fe:n':-c. .mi -s-hrn :: Liz ^ens :: is i .::r. In a :ew mis-tin-es :* rh-rnniinsm we In-i .:.-"> ■*?->> 3ri?ir^. ini -fsce^iaily in^animanoc DISEASES OF TFIE BLOOD-VE88EL8. |\iith pain, increased pulsation, a tlislinct murmor in the course of tlie [vessel, and tujuiiltuous action of tlie heart witliout there being obvious iBigns of disease of that organ present. Still, the diagnosis is never a positive one. We may also meet with arteritis clearly infective^ and general or local, in inOocnza, In pneumonia, in typhoid fever, and in ulcerative endocarditis. The result of tlie inflammation is that the blood may clot, and thrombi or emboli result, and, if infected^ pytemic _fever develop. It is generally impossitile to reecignize the rnalady until "after tlie thrombosis ; ajid then severe pain in the timb supplied by the affected vessel, its sensitiveness and cord-like feel, the absent pulse and the coldness of the skin and lowered local temperature, and tlie swelling of the part are significant of a cr>ndition that often lends in gangrene. Yet all these signs of narrowing of the caliber of a vessel may occur without a thrombus, and be due to proliferating endarteritis, sucli as may exist in obliterative endarfeniifi. Atheromatous Changes.— These are only the more obvious naked eye appearances, esijeeially as they are found in the aorta and larger vessels, due to arteriosclerosis ; calcareous degeneration is often seen. These alterations, happening in internal arteries, are be- yond the accurate discernment of the physician. He may infer that they exist, if a distinct systolic blowing sound be heard in the track of the aorta or its branches^ in a person wtio is not markedly antemic, who is past middle life, — ^and therefore at an age at which these kinds of changes of tissue happen, — or has liad any of the diseases predis- posing to arteriosclerosis, and in whom no cardiac murmurs, or only faint cardiac murmurs, are perceived. But it is chiefly by the age of the patient, the rigid resisting superficial arteries, often irregular to the touch, and the gradual development of cardiac enlargement, that a conclusion as to the nieatiing of the physical signs is arrived at. The atheromatous change may be so great as to cause almost com- plete occlusion, even in arteries as large as the common carotid. Diseases of the Veins. The chief afteclion of the veins in a diagnostic point of view is inOamination, Phlebitis. — This is met witli by the surgeon much oftener than by the physician, who encounters it more especially in af!*ections of internal organs, sucti as Hie liver, and has to study it in association with the formation of thrombi, and melastaiic abscesses to wliich it leads, and witli infective fevers. The most common form in w^hich phlebitis comes under the cognizance of the physician is in connection with milk leg, or phhymamu alba dolem. Here we have 722 MEDICAX DIAGNOSIS. usually plilebilis with an obstruction by a coagnlum of the venotis c trculation in tlic afl'ected limb, and bacilli, those of typhoid fever for instance, have been detected both in the clots and in the walls of the vessels. Yet it Is by no means certain that the tlironibosis is always j secondary and caused by phlebitis. The phlebitis or the tlirombus that forms, when of septic origin, may lead to pyaemia. The disease, except in gouty phlebitis, is mostly one-sided. The pain in the legj may cause it to be mistaken for rheumatism, but the one-sided swell-j ing and Uie (rdema distinguish it. Among its early and significant 1 symptoms is pain on pressing the calf of the leg on the affected side. Diseaaes of the OapiUaries. Some of the organic diseases of the capillaries belong to the arterio-J sclerosis in Bright's disease, or to the waxy degeneration in purpursul It is diflicutt to say what the functional disorders are, for many of them are regarded as forming jmrt of the peripheral diseases of the] nen^ous system, and the affection of the arterioles and of the capil^ laries is a mere vasomotor spasm in connection with the neurosis«| This is supposed to be the case in tlie anomalous localized sensation of cold which some patients have in particular parts of the body^ though their persistency is unlike a spasm. The painful flushings the feet bespeak temporar)* excessive dilatation of Ihe fine vessels. A spasm of the minute vessels of more permanent character majr 1 lead to profound distiu'lmnce of nutrition in a part, even to its de- struction. This is the case in the vasomotor neurosis, called tn^nmd^ riciil ffantp'rne, or ** Raynaud's disease.^" The affection shows itself in three forms, local syncope, Ick-* asphyxia, and symmetrical gangrene, which are in reality but differenl| stages of a condition m which there is recurring contraction of the arterioles and consequent interference with nutrition. The malady is most often seen in the hands affecting corresponding fingers ; it is ' also met with in the feet, on the exterior surface of tlie forearm, and sometimes in the helix of the ear, on tlie nates, the front of Utt thighs, and below the knees. It is nearly always symmetrical. The local syncope shows itself mainly in sudden attacks of pallor, cold-1 ness and numbness of corresponding fingers, and in these **dead fingers'* there is a cramp-like pain and impairment of tactiie s&tse and of sensibility to pain; the surface temperature is lowered, Thej attacks are apt to come on at Uie same hour, often in the momin and may recur daily for some months. They are more common winter than in summer, are readily brought about by expci&iire to^ cold or by putting tlie hands in cold water, and are especially DISEASES OF THE BLOOD-VESSELS. 723 witli in hysterical women and in neurasthenics. Each attack lasts from a few minutes to several hours ; in the reaction the skin be- comes red and sensitive to pressure. In local asphyxia we have the same history, but duskiness is soon noted, and purple or bluish dis- coloration of the symmetrically affected parts. There is much pain in them, and difificulty in executing concerted movements. The paroxysm gradually passes away ; at times there are coexisting tem- porary alterations in the fundus of the eye. In symmetrical gangrene there may have been preceding local syncope or asphyxia, but these have become very frequent, and the altered nutrition shows itself in bullae fonning, and then in limited gangrene, as of the tip of a finger, which slowly sloughs oflF; within ten days, generally, the gangrenous process is over. The local character of the lesions, their intermittency, and their superficiality, are the chief features of Raynaud's disease. We do not find lesions of the vessels as in senile gangrene. The malady is closely allied to paroxysmal haemoglobinuria, which, indeed, has been repeatedly observed in association. Raynaud's disease must not be mistaken for chUbJmns. These do not appear, disappear, and reappear in the manner in which the dis- coloration does in Raynaud's disease. In erythromelalgia, described by Weir Mitchell,* there are vascular changes, acute congestion, or cyanosis. The disorder manifests itself in one or more extremities, usually in the heel or the sole of the foot, and is attended with flushing, local fever, and great pain, which comes on in paroxysms, aggravated by the vertical position and by movement. It is an affection of middle life, of which the pathology is still undetermined. It resembles most closely Raynaud's disease. But contrasting Weir MilchelVs disease with this, we find these striking differences : there is in erythromelalgia no change of color until the part hangs down, when it becomes rose-red. Then, too, the pain becomes worse, as it also does in summer and by heat, whereas neither position nor season affects the local asphyxia of Raynaud's disease, though cold is very apt to produce it. Moreover, in this there is lowered local temperature and anaesthesia to touch and pain, whereas increased heat of the flushed part, undisturbed sensation, and hyper- algesia mostly occur in Weir Mitchell's disease. Further, this is gen- erally symmetrical, and never associated with a local gangrene, such as often follows the local asphyxia of Raynaud's disease. ' Medical News, AuJ^. 1893. CHAPTER X. DISEASES OF THE BLOOD. Prominent among the clinical traits of all diseases of the blood are general debility, a changed aspect of the mucous membranes and of the skin, especially in color, and alterations of nutrition. In the investigation of these diseases, tlie microscope is of the first impor- tance. It informs us with regard to the relative proportions of tlie white and red corpuscles, and exhibits the blood-plates or haemato- blasts. It tells us much as to what part of the blood-making oi^gans the former are derived fix>m, and which are purely pathological; it indicates whether tlie red globules are of the right color, whether their outline is regular, and whether their number is altered. It enables us to study the blood-films and the effects on them of various stains. To count the blood-corpuscles, the forms of apparatus now mostly in use are tlie Iwemocytometer of Thoma-Zeiss and of Gowers. An- other is the graduated moist-chamber globule-counter of Malassez; another the ha^matokrite. The Thoma-Zeiss, or Zeiss, hivmocytometer consists of tliree j>arls : a graduated pipette or mixing-vessel, with rubber tube attached : a counting-cell on an object-slide made of ground glass : a cover-glass witli ground level surfaces. To count tlie red corpuscles of the human blood, the tip of the finger should be thoroughly cleaned, the middle finger of the left hand being generally selected. By rubbing the end of the finger or the lobe of the ear with a coarse towel a slight hyjH^nvmia is induced, so that a cut with a spear-jKiinteil needle will permit of the flow of a drop of blood sufticiently large for examination. The Up of the pipette is placed into this drop, and the blood carefully drawn up to tlie mark 1, — i.r., one cubic niillimetre. After tliis has been accom- plished, the tip should be cleaned by means of a soft clotli and the pi^>ette inserted into a carefully liltertHl ten jht ivnt. solution of sodium sulphate, or Thoma's substitute of a tlmv j>er cent, solution of sodium chloride, or (lowers's solution of 112 gnuns of sulphate of sodium in 5 drachms of acetic acid and 4 ounces of water. This is drawn up Ti4 DISEASES OF THE BLOOD. 725 into the tube until the bulb is filled to the mark lOL The blood and fluid are then mixed by shaking' tlie tube, holding the fmger over the tip of the pipette, that the hquid may not escape. ^Vfter the mixture has been Ihoro uglily efiFected, half of the fluid in the bulb is blown out, and the drop that follows is permitted to flow on to the pre- viously cleajicd floor of the counting-cell. The cover-glass is then immediately placed in position, and tlie apparatus allowed to stand upon a liorizontal surface for two or tliree minutes, tliat tJie corpuscles may settle. For the success of this operation perfect cleanliness must be mahitained. In order to make the examination, tlie slide should be placed in the stand of tlie microscope and held in a horizontal position, that tlie corpuscles may not be displaced. Great care should be taken tliat no liquid flow between the cover-glass and the ring. It is important that the drop of blood mixture shall remain standing in the centre of tlie cell, and that by the spreading of the celt the under surface of the cover-glass shall be in contact with the mixture for several millimetres. Using a one-fourth or a one-fiflh objective glass to bring hito view tlie divisions cut upon the floors of the cell, we find that upon these lie the red blood-corpuscles. The number of corjjuiscles in each space is then noted, counting in the corpusi^les touching the top and right lines, but Ic^avingout those touching the lower and left lines. Through eacli tilUi iiorizontal and vertical row of the lines an additional line is drawn, for the purpose of fixing more readily the position of the squares counted. Each held of the net- work contains a surface of one fourtum- dredth of a square millimetre. The distance of the cell-floor from the undc^r surface of the cover-glass is one-tenth of a millimetre. Each square, therefore, represents the one four-thousandth of a cubic nullimetre. The number of corpusck^s contained in one of these cells multiplied by the number of times tlie blood has been diluted will pve the amount of corpuscles contained in the one four-thousandth »f a cubic milUmetre. Tlie amount contained in a cubic millimetre can, therefore, be found by multiplying by four thousand. The surest method is to count at least thirty-six spaces, as Cabot' does, or forty spaces, to take the average of them all, and proceed as above. It is sometmies difficult to distinguish the white from the red blood-cor- puscles, and this dilliculty is obviated by adding a one-third per cent. solution of acetic acid to the diluted blood. Another method for com- puting tlie wliite corpuscles and their relative number to the red is to ^ Clinical Examination of Uie Blood, 1898. 726 MEDTCAI. DTAGNOBia H>^. use, with {be salt solution, a few drops of a one per cent, solution of gentian violet ; this leaves tlie red blood-corpuscles unaltered and stains the leucocytes a deep violet ; or we may employ Toisson's solution, which consists of methyl violet, 5B, 0.25 gm. ; chloride of sodium lOQO gms,, sulphate of sodium 8(XH> gms., neutral glycerin 30,000 ems., and distilled water 160,000 cms. It takes about ten minutes to fully stain tJie leucocytes. The following method for differential counting of leucocytes in fresh blood is recommended by Elzhok. After drawing blood into the pipette, a solution com- posed of seven grammes of two per cent, eosin solution, forty-five grammes of glycerin, and fifty-five grammes of water is added ; then, a solution composed of four drops of concentrated watery solution of gentian violet with one drop of absolute alcohol and Hfteen grammes of water, by which the polynuclear cells are more deeply stained ; the eosinophile cells are reddish \iolet. The kamionito?fit'ter of Gowers is about the same as that of Zeiss, differing mainly in the number of divisions on the cell, each space being but one-tenth of a milli- metre in length. The method of preparing the blood solution is not so convenient as tliat of Zeiss. A htemic unit of five millions of corpuscles to one cubic milli- metre of blood is assumed. Tlie pipette is best cleaned with an aspirator. In tlie htemocytooieter of Durham' the pipette is self-filling. By the original method of Malassez the blood is diluted with artitkial serum so that it represents j^ or j^ of the original. A small amount is then introduced into a flattened capillary tube of known capacity and, \rith the micrometer eye-piece, tlie globules are counted in the capillary tube of a certain length, say 5(X) micromillimetres. The capacity of tliis length of the tube in parts of a cubic millimetre being already known, tlie entire number of globules in a cubic niOli- metre of the undiluted blood is c^asily determined by calculation. For the purpose of diluting the blood* Potain's capillary pipette (Fig, 6H) IS well adapted. w I'titAln'K pijiette« in pogittoii. To the left \s^ the tulje-hoMer or tmine, with oin' tiiU? removal §i> fts to sJiov Uu Bpring, by which the tube is to bu hebl in place. To thu ri^rht Is » tiiln^ eniitaintn? blcuwl th»l hi»-> bcerfttuhjeettMl toeeutrifugal force^ liKlieatiiig ninety ix*r eeiJt,cif eiinrttsculiir elements, as eom|«m) with normftl blinod. of the scale. A single revolution of the lai^e handle causes one hundred and thirty-four revohitions of the frame. The instrument must be firmly secured to a solid table. The method of employinjj tfi- Iiai'matokrite is simple. To fill tlie glass tube, a rul>ber tube* is slipp "ttle with pijiettc-gtopfjer ; B. capHlary pii»ctU' ; C, grvdu tube ; 1>. tiitK* coutnining stundiml tU\t, fixed in E, ii wtincU-n block ; F, fniarrlcti necdJv. The chief apparatuses for t\^fimttUnf/ ihv hretuoghbin are the hiTemr^j globinometer of Gowers, FleiscliFs hteniometer, Henocque's ha?mato- scope, and Oliver s heemojjlobinometer. Of these, the haemometer at FleischI is the most used, fh^nocque s is especially valuable for specti'oscopic examination. In Oliver's hjemoglobinometer tlie blood tint is compared with definite tints of glass, Gowerss apparatus con- sists [of tw^o glass tubes of exactly the same size. One contains a standard of the tint, of the dilution of twenty cubic millimetres ofj blood with one thousand nine hundred and eighty cubic millimetresj ♦ of ^water. The second tube is graduated to one hundred degreesJ ^ Transactions of the College of Physicians of Philadelphia, IS^S. DISEASES OF THE BLOOD. 731 which equal two cubic centimetres. The twenty cubic millimetres of blood are measured by a capillary pipette. This quantity of the blood to be tested is dropped to the bottom of the graduated tube, a few drops of distilled water being first placed in the latter, and the mix- ture is rapidly agitated, to prevent the coagulation of the blood. The distilled water is then added drop by drop until the tint of the solu- tion is the same as that of the standard, and the amount of the water added indicates the amount of hsemc^lobin. Fleischl's haemometer consists of a stand to which is attached a reflector made of card-board. On the under surface of the plate there are two grooves, into which slides the frame, holding in position a wedge-shaped glass colored red, the intensity of the hue being grad- uated from zero to one hundred and twenty degrees. The frame is moved by means of a thumb-screw so that when it is operated the tinted glass passes beneath one of the compartments of the compar- ing vessel. The horizontal projection of the partition of this vessel should fall directly upon the outer edge of the glass wedge when the instrument is properly adjusted. In operating the instrument, care should be taken to have everything perfectly clean. Accompanying each apparatus are a glass pipette 'for dropping the water into the compartments, and several minute capillary tubes for securing the blood. The compartments — that is, the blood and wedge compartments — are filled almost to the top with distilled water, and the vessel is placed in situ. The instrument should then be so arranged and the reflector so adjusted as to secure the full rays of light from either a candle, a lamp, or.a gas-flame. Before securing the blood, the tip of the middle finger of the lefl; hand should be carefully cleansed and dried. The automatic blood-pipette, with a capacity of six and a half cubic millimetres, and about eight niillimetres long, to which is at- tached a fraD wire for its manipulation, should always be greased, to prevent the blood from adhering to its sides. This is dipped into the blood sideways, to facilitate the flow into the tube : the greatest accu- racy is essential to the correctness of the test. With as little delay as possible the tube is then placed into the blood compartment and its contents allowed to escape, aiding by gently moving the tube back and forth along its own axis. The diluted blood remaining in the tube is then washed out by means of the pipette and allowed to flow into the compartment. This is filled, as is the wedge compartment, with distilled water, care being taken not to allow the fluid in the two chambers to run together, and that the upper surface of the water is perfectly level, neither curved nor concave. 732 MEDICAL DIAGNOSIS. The blood is now ready for examination. In looking at the partment tlie eyes should be sliaded, that the direct rays of light ma not cause error in the observation. The thumb-screw is turned^ which slowly moves the wedge from right to left ; this movement is continued until the eye can perceive no difference in color between the two compartments: should the difference be imperceptible for a considemhle distance, then the poini at whi<'h the color appears lighter and thai at which it appears darker should both be noted and the mean ascertained. The rnuiiber of degi*ees — that is, Uie percent- age of haemoglobin as compared with healthy blood, which is taken as one hundred — ^will be found on the movable slide. Another and easier method of estimating the haemoglobin is by taking the specific gravity of the blood. This is most readily done by Hammerschlag s method. It consists in mixing in an ordinar>" uri- nometer glass such quantities of chloroform and benzol as to mark 1069, the specific gravity of normal blood. A drop of blood in a pipette is blown into this chloroform-benzol mixture, and does not mix, but is seen to float. If it sink, add chloroform, a few drops at a time ; if it rise to the top, add benzol until the drop of blood remains stationary in the body of the liquid, indicating that it has the same specific gravity as that of the whole mixed tluid. The speciJic grra^it is then taken with the nrinometer. From tlie specific gravity of the blood we can deduce the perceE age of hiemoglobin. Here is Ilammerschlag's table: SiJiecirte Gravity. Hicmoglobiii. 1033'-1035 = 25-30 i>er cent. 1035-1038 = 80-15 1038-1040 = 35-40 1040-1045=^40-45 1045-1048 =-45^5 •* Sfjedrtc Gravity. HA^moglobin 1048-1050 =z 55-65 per cent, 1050-1053 = 65-70 1 05*V1 055 = 70-75 1055-1057 --75-85 1057-1060 = 85^95 In computuig the haemoglobin from the specific gravity of the blood, we must bear in mind that it varies considerably in dropsies, and that the weight of the leucocytes causes it always to be relatively higher in leuktvmia. A hajmoglobinometer based on the principle of the .comparison of a thin film of undiluted blood, illuminated by candle-liglit, with a graduated color scale, has been invented by Arthur Dare,* and fur-^ nishes a rapid method of htpmoglobin estimation. More important even than estimating Ihe number of the corpuscJes" DISEA8E8 OF THE BLOOD. 733 or the amount of hsemoglobin is the microscopical study of the blood, both in a fresh and dried state, and especially with the aid of stains. A drop of blood, taken from the tip of the finger or the lobe of the ear, is allowed to fall on a slide, and a cover-glass is placed over it. This answ^ers for the study of the ordinary character of the red cor- puscles, of the leucocytes, and of malarial parasites. But for finer study preserving fluids must be used, which are neutral diluting fluids, unstained or stained. Of the neutral unstained solutions those of Gowers, or Hayem, are mostly used. Gowers's solution consists of sodium sulphate, 104 grains ; acetic acid, 1 drachm ; distilled water, 4 ounces ; Hayem's solution, of perchloride of mercury, 0.5 gramme ; sulphate of sodium, 5 grammes ; chloride of sodium, 1 gramme ; dis- tilled water, 200 grammes. Another diluting solution much employed for clinical purposes is that of Toisson, which, as it is colored, is especially valuable in enabling us to distinguish the leucocytes, which it colors blue, from the red blood-corpuscles, and to determine their relative proportion. It consists of glycerin (neutral), 30 cm. ; sodium sulphate, 8 grammes ; sodium chloride, 1 gramme ; methyl-violet, 0.025 gramme ; distilled water, 160 cm. To obtain permanent preparations, and for purposes of greatest accuracy, the examination of the blood in films, especially in stained blood films, is necessary, — a method which we chiefly owe to Ehrlich. Blood films are usually prepared by allowing a drop of blood to fall on a perfectly clean cover-glass, to cover it with another, and then gently slide one over the other. The film dries in a few seconds, or rapid drying can be insured by swaying it in the air, or heating it over an alcohol lamp or for ten minutes in a dry hedt sterilizer at a tem- perature from 100° to 150°. Immersion for about half an hour in equal parts of ether and absolute alcohol, as advised by Nikiforoff*, is an excellent method for fixing a blood-film. But staining may be essential, and this is done chiefly by aniline dyes. These are classified by Ehrlich as acid, basic, and neutral ; and especially in studying leucocytes we make the greatest use of this division. The chief acid stain is eosin ; methyl-green or methylene- blue represents the basic stains ; neutral stains are a mixture of both ; for instance, acid fuchsin with methylene-blue or green. One of the most generally used stains is Ehrlich's triple stain ; it consists of a saturated watery solution of orange G, 24-27 cc. ; acid fuchsin, 16-33 cc. ; methyl-green, 25 cc. ; then add water, 60 cc. ; ab- solute alcohol, 40 cc. ; glycerin, 20 cc. The mixture should stand for one or two weeks before being used. Preparations ought to be ex- posed to the stain for several hours, having been previously thoroughly 46 7:M MEDICAL DIAGXOb?!^ heated : and to be preserved should be washed, dried, azkd moostcd in Canada balsam. The modification of the Ehrtich stain, known as the Elhrlich'Biondi staia, is also mach employed. Stains are used as a means of classihring the leucocytes. Those containing granules that stain deeply with eosin or other ac»d an£iDr stains. and show as coarse, prominent granules, aie called t^QttiAOfJtUc^, Cells with fine granules which stain with basic aniline dyes, as with methylene-blue, are bcusophiltis. ' Granules which stain with a mixtuiv- of basic and acid stain, as acid fuchsin and methylene-blue. are f^e%- tnjphiU'M. They are also verj' conveniently stained by Ehriich's. t»r Ehrlich-Biondi's, triple stain, and the granules are then violet or lilac, unlike the red or browniish-red coarse granules of the eosinophiles. By Ehrlich's stains the nuclei of the leucocytes are stained grvenisii blue. In the minute study of the blood we pay close attention to its three elements, the red corpuscles, or erythrocytes : the white cor- puscles, or leucocytes ; and the blood-plaques, or blood-plates. Red Corpwsel&f. — ^The red corpuscles are of various sizes. They have, according to Hayem, a mean diameter of 7.5 micromillimetres. the micromillimetre being y^^^th part of a millimetre : their i^lor is due to haemoglobin. Prolonged fatigue and menstruation diminish them. Tlieir size varies much in disease. We may find many dwarf corpuscles or myerocytes^ ha\ing a diameter of from three to six micro- millimetres, or numerous giant-cells, or megalocytes. with a diameter from nine to fourteen micromillimetres. In the latter, the amount of haemoglobin is increased, and, in consequence, where they abound, as in severe anaemias, there is a high-color index. The red corpuscles in disease not only undergo changes in size but in form. They lose their disk shape, and show irregular tliickeninj.'? and projections at their borders, forming the so-called poihilocytt^, common in, but not characteristic of, pernicious anaemia, and to Ix- regarded essentially as a sign of degeneration. So, too, according to Ehrlich, is it a sign of degeneration or of death of the corpuscle, when with stains of eosin and haematoxylin the red corpuscles become ^^olet or purple instead of pink or red. Where the corpuscles are found to be very pale or colorless, it is a proof of a low state. These *' shadow corpuscles'' are especially seen in protracted typhoid fever and when^ the blood is undergoing destruction and its haemoglobin has btn^n lil>- erated from the red blood-cells. A very striking change in the red corpuscles is their nucleation. This is never normal in the adult except in the immature red cor- j)US(les in the bone-marrow, and is best seen in dry films stained ^vitll DESCRIPTION OF PLATE V. RED CORPUSCLES AND LEUCOCYTES. The specimens were prepared by Dr. Boston, Bacteriolo^st to the Clinical Laboratory of the Pennsylvania Hospital, from cases chiefly of anaemia, pernicious ansemia, and leukaemia ; they were drawn by Mr. Louis Schmidt from Queen Micro- scope, Obj. A^^ oil immersion, eye piece 2, tube length 160 mm., and exhibit the effects of different stains. The Bed Blood- Corpuscles. — ^The preparations are stained with eosin and haematoxylin. The 'first group represents normcU blood-celh and shows a slight variation in their size ; next comes a group of microcytes, of which two are deeply stained, the so-called Eichhorst corpuscles. Following^ in the same line, are a number of large red corpuscles, or megalocytes^ the two on the right showing some degree of vacuo- lation. The second line begins with a group of poikilocytes, of various size, shape, and color ; next is a group of pale or shadow corpuscles, followed by nucleated corpuscles of about the normal size, — normoblasts. The number of nuclei varies ; in some the nucleus is partially extruded. The smallest elements shown are mi- croblasts. Next will be found a number of megaloblastSy or large nucleated red corpuscles. Leucocytes. — ^The first group shows three small lymphocytes^ the second two large lymphocytes^ all stained with Ehrlich'a tri-stain. Following is a group of four polymorphonuclear neutrophiles. The first two are stained with Ehrlich's tri-stain ; the other two with Ehrlich-Biondi stain, exhibiting fine neutrophilic granules. In the next line are shown normal eosinophilic cells^ of two or more nuclei. The protoplasm contains lai*ge granules deeply stained with eosin. Next are two mast cells, stained with Ehrlich's stain. A group of myelocytes^ stained with Ehrlich's stain, completes this line. Immediately below, on the last line, is shown a group of the same cells stained with Ehrlich-Biondi ' stain, as is also the group in the lower left-hand corner, showing marrow-cells containing eosinophile gran- ules, or eosinophile myelocytes. Plate V RED BLOOD-CORPUSCLES. # ^ 4 o J .^) \r ■"*^a t • 40 •• LEUCOCYTES. .fVk ^W • ^ 09 ^ ij'"'Jck.iir^ 1 DISEASES OF THE BLOOD. 735 eosin-luDmatoxylin, or methylene-blue ; the stain of the nucleus is especially deep. The nucleated blood-corpuscles are termed, accord- ing to their size, normoblasts, microblasts, and megaloblasts. The normoblasts are of the same size as the ordinary red corpuscle, and usually have a single nucleus which stains deeply ; their outline is often irregular. They are a sign of new formation of blood, of an attempt at regeneration of the blood from the marrow, and may occur in crops, the " blood crisis" of Van Noorden. The normo- blasts are found in marked ansemics. The mieroblusts are nucleated red corpuscles, of smaller size than the normal corpuscles. Their occurrence is comparatively infrequent. The megaloblasts are much larger than the normoblasts, being from ten to twenty micromillimetres in diameter. The nucleus is verj' large, and takes a pale stain ; the protoplasm around it stains deeply with eosin. Megaloblasts are never found in healthy blood; they indicate an abnormal state of the bone-marrow. They are a sign of degeneration, and are of grave import when hi lai^e numbers. Both normoblasts and megaloblasts may become poikiloblasts. The red corpuscles stain especially with eosin; cells that stain with several colors from the same mixture, as with the Ehrlich- Biondi stain, becoming purple or gray or brownish in spots, are called polychromatophiles. They are especially met with in perni- cious anaemia. When blood has been standing for a short time the corpuscles form in roulexixix, and a fine nd-work of fibrin is also seen. Rouleaux and the net-work of fibrin both show generally more markedly and quickly in inflammatory conditions. Decided net-works are also met with in many infectious diseases. Absence oF rouleaux-formation never exists in health. Leucocytes, — The white blood-corpuscles, or leucocytes, are pale, homogeneous or slightly granular, spherical cells, devoid of haemo- globin. They are larger than the red corpuscles, but in number are few compared with these ; ten thousand to the cubic millimetre is the normal limit. They increase after a meal and during pregnancy, and are numerous in the newly-born and in infancy. They contain one or several nuclei, are mostly amoeboid, and some of them possess the power of attacking and digesting bacteria, therefore are *' phagocytic." The leucocytes are variously affected by aniline dyes, as has been already explained, but are stained violet or lilac. Among the stained leucocytes the eosinophile cells are very important. These are ac- tively amoeboid. They are increased in asthma, in lithaemia, in affections of the liver, in trichiniasis, and often in spleno-medullary 736 MEDICAL DIAGN08IS, leiiki^mia; they are dimiiHsheci in influf'nzR, in maligiianl lumors, m The chief forms of leucocytes in normal blood are the sma uninueleated leucocytes, the large uninucieated leocoeytes, and the ninltinucleated leucocytes. The first of these, also called the ffvwfl li^ftiplwe^/ie^, are estimated by Stengel at twenty-five per cent.; the large uninueleated or hyaline cells at three to six per cent. ; the mul- tinucleated neutrophile (ells at sixty-five to seventy-five percent. ; the eosinophile cells not above three per cent, ('al)ot gives similar pro- portions^ but adds *' mast cells/' These are his figures: small lyni- phwyles, tv^^enty to thirty per cent. ; lai^^e lymphocytes (same strticture, only lar^^er), four to eight per cent. ; polymorphonuclefl neatrophiles, sixty-two to seventy per cenL ; eosinophiles, one-half l^ four per cent. : '* mast cells/' one-fortieth to one-half per cent. Som4 observers describe separately, as a irmmfional or infennediatt form,'' tlie large uninueleated leucocytes in which the nucleus is indented or horseshoe-shaped. The small lyniphorytes are about the same size as the rc*d corpus cles ; there is extreniely little protoplasm, and they are not amceboid or phagocytic ; the lai^e multinucleated leucocjies are considerabl| larger: they are both actively ama^boid, phagoc>iic. and neutrophilic and the granules do not stain ttioroughly except with triple stair like Ehrlich*s. The so-called '* mast cells" occur in liealtJi in onlj very small numbers. They are large, having a diameter of twenty' micromillimetres or upward, and are coarsely granular, Tliey stain with basic dyes, with dahlia or methylene-blue, are therefore baso- plulic, but do not show themselves with Khrlich's triple stain. They get into the blood chiedy from tlie connective tissue. There haS| been some doubt as to whether they are not pathological ; there ifl none as regards the mj^rloiyka^ or marrow-cells. They are very la cells with a pale nucleus, which with Ehrlich's stain is seen as pale-stained micleus nearly filling the cell ; the protoplasm contains fine granules. The myelocytes are found in various intoxications, in myxcedema, in syjihilis, but in large Jiumbers only in medullar)* spleno-medullary leubemia. Biood' Plates, — These, discovered by Hayem, and called by him htematoblasts, are small round or oval bothes of faintly yellow color,^ and very adherent. They may be seen in fresh blood, when immc diately examined. Tliey are smaller than the red corpuscles, colar less, and very cotiesive. They are best studied mth*Hayem's solutioiiJ or a one per cent, solution of osmic acid : they stain faintly witlp aniline dyes, and number about two hundred thousand to the eubi» DISEASES OF THE BLOOD. 737 millimetre. They are obsen''ed to be increased in anaemias unac- companied by fever, and after loss of blood ; they are diminished in cachexias, particularly in cancer, protracted typhoid and typhus fevers, in erysipelas, and in all infectious fevers with high temperatures. It is often a matter of great convenience to represent the blood- examinations graphically. An excellent chart for this purpose is in use at the Johns Hopkins Hospital. Fig. 72 shows it, and the manner in which the record is made. 120^ 110^ 90 JC 90% 70% 60% *0% 90% iO% 10 !( i% s% i% 1% Fig 72. L» 'R>L 1 »AV UUNE 1 i j\i>]nUi lT.ltitB:»lii'?ri»i I ? & I V 11 iiii ^ \ii 2] a ^■i-.'J>Al 4 * » * IV u >t 14 11 W' 6,000.000 ■ i \ r ■ \ i ' f ' M M ■ i ; ' : , 1 ^000.000 ' ■ 1 i 1 "^ '* ^ >% 1 -hU ^ ■n 1, IT' '^ h^ ii r - * r f ■ p- 4.000.000 ? / A r^ u ^ ^ ■ih / 3,000.000 1 r^ •■ ■-J J / ^ ' ^ ^ ^ 9,000.000 i^ f^ K .1 1,000.000 1 1 dOO.OOO ~ ii),mo 1 ^i - tUD.lHKt _ i J_ tmjaoQ MlOW to.poo M i. 70,000 ^ _i «ofii» "' 50,000 ^ 40,000 90,000 90,000 18,000 16,000 14.000 1S.O0O 10,000 6,000 ^ =1 ^ '" tfiOO r^ ^ f^ -" ^ ^ 4,000 ^ ~" ■^ 2,000 > J \ 1 1 ml 1103( tost to* *o% sun «* 30* 10* t* 1* BLACK— RED CORPUSCLES RED — HAEMOGLOBIN BLUE-COLORLESS CORPUSCLES Chart showing blood-changes In chlorosis. AnsBmia. — Poverty of blood is met with as a consequence of profuse or frequently recurring hemorrhages, of insufiicient nourish- ment, of afi*ections which prevent the nutriment taken from being properly absorbed or assimilated, of disease of the blood-making oi^ns, and of profuse chronic discharges, which drain the blood of many of its important elements, and especially of its albumin. Be- sides these causes of anaemia, we find it occasioned by particular 738 MEDICAL DIAGNOHIB- poisons, as by malaria; by syphilis; by uterine complaints; by the absori.>tion into or the retention of noxious in^edients in the blood ; by rapid destruction of the red corpuscles, as in fevers ; and as consec- utive to malig[iant growtlis, and organic diseases in general Again, it is sometimes encountered without our being able to trace it to any obvious source. This is the so-calteri primar)^ aniemia, as distin- guished from tlie instances in which the aufemia is symptomatic of some disease, or secondary. But nnder all circumstances, except in the anaemia after hemorrhage, where all the constituents of the blood are dimmished together, we have to deal with a blood deficient in red corpuscles, and the corpuscles are often badly shaped, and shrunken , at their edges* In extreme anflemic conditions, lai*ge and giant corpus- cles are common ; the leucocytes and blood-plates are not altered, or are somew^hat dinunished* In secondary anmmia there is more apt to be an increase of leucocytes, the red corpuscles are dwarfed, and there are normoblasts rather than megaloblasts. The ti^emoglobin may be increased relatively, or it may be diminished, or it may not be ma- terially clianged. Ana-'mia begins with four million corpuscles to Uie cubic millimetre. | Whatever may have given rise to the anaemia, the manifestations of the disorder when well marked are nmch the same* The patient is weak and pale; his lips and tongue have lost their red color; Uie eye is pearly ; his pulse is feeble, and generally accelerated ; Uie appe- tite is deficient or depraved ; the bowels are apt to be costive. Yet persons, who are apparently well nourished and are not pale, may have deficiency of red blood-cells and of luvmoglobin. Exercise induces great fatigue, shortness of breath, and palpitation ; and Uie disturbance of the heart may be associated witli cardiac murmurs or with blowmg sounds in the cervicctl veins, and is at times so per- sistent as to lead to structm*al changes. In some cases, we meet among the symptoms with obstinate headache and with dropsy, and in many with a persistent pain in the left side, in Uie region of the spleen. Anaemia may be owing to Uie presence of parasites, such as intes- tinal w^orms. The very marked form wdiich is common in Egj^jt is that due to anehi/lofifomiasis, Ttie anvhifloistomum duodenale is taken into the body in the muddy water, or by eating earth containing the embryos of this worm, Anchylostomiasis is an insidious, wasting disease, characterized by progressive aniemia and by digestive and nervous deterioraUon, occurring chiefly in earth and brick laborers of warm climates, eauseil by the presence hi the duodedum and jejuniun of a blood -sucking, rhabditic, nematode worm. The blood shows DISEASES OF THE BLOOD. 739 great diminution of red blood-corpuscles, reduction of hsemoglobin,^ megaloblasts, indeed all the signs characteristic of pernicious anaemia ; but, as in bothriocephalus latus, these disappear with the expulsion of the parasite. Chlorosis. — Here the pallid, wax-like countenance, the very pale lips, and the pearly eye afford unmistakable evidence of the deteriora- tion of the blood, consisting chiefly in great deficiency of haemoglobin, which is usually much more marked than the reduction in the red corpuscles; these, indeed, may be of almost normal amount. The corpuscles are pale. The smaller corpuscles, the microcytes, generally abound, and nucleated red cells are not infrequent; the leucocytes are not affected. Lloyd Jones ^ regards the disease as an exaggeration of a change which occurs in the blood of the healthy female at puberty, and which leads to an increase of the amount of blood- plasma associated with a diminution of the amount of haemoglobin. Meinert has noted, in cases of chlorosis, gastroptosis combined with enteroptosis and occasionally movable kidney, and, as these displace- ments are produced by wearing corsets, his deduction is that chlorosis is due to faulty wearing-apparel. Chlorosis may also attend the absorp- tion of ptomaines from the intestines in habitual constipation. Con- siderable stress has been laid on the fact that in chlorosis there is a greater tendency to inflammation of the optic nerve and retina than in pernicious anaemia, while the tendency to retinal hemorrhage is considerably less.^ The complaint is especially encountered in young women, and is, as a rule, associated with amenorrhoea. Indeed, many restrict the term to the obvious anaemia combined with suppression of the menses, so often affecting girls about the age of puberty. In pure chlorosis, organic diseases of the gastro-intestinal apparatus of the spleen and lymphatic glands, or of the lungs and kidneys, are absent ; the tem- perature shows a slight rise ; the nutrition of the body is fairly well kept up ; the urine is pale and abundant, containing but a small amount of phosphates. Forchheimer finds a diminution of urobilin in the urine, which he regards as of considerable diagnostic impor- tance. The nervous system is irritable. Pigmentation about the second joints of the fingers, on their dorsal surface, has been noticed.* Sometimes these symptoms of chlorosis happen before puberty ; or * Sandwith, Proceedings XI. International Med. Congress, Rome, 1894. * Brit. Med. Journ., July, 1894. ' Stephen Mackenzie, Sajous's Annual, 1895, vol. i. L. 10. * Bouchard : also Pouzet. 740 MEDICAL DIAGNOSIS. there are relapses of the malady in middle age. Boys about the age of puberty may also develop the manifestations of chlorosis. Virchow has pointed out the frequent association of chlorosis with narrowing of the aorta and of the great arteries, and such cases are distinguished by obstinate relapses. There is a variety of chlorosis in connection with tubercle, at times preceding it. Chlorosis as well as anaemia may be associated with nasal hyperirophies or adenoid vegeiatiom in the vault of the pharynx/ and be relieved by their removal. Both the corpuscles and the haemoglobin may be decidedly decreased in consequence of surgical shock.* Fever may occur in chlorosis, though to but slight degree. Jac- coud attributes it to anoxcemia^ the deficiency of oxygen in the blood acting as a stimulant to the calorific centres. Fever may be also due to local causes, such as phlegmasia alba dolens. Pemicioiis AnsBmia. — ^This is an extreme anaemia advancing steadily, or with remissions, towards a fatal ending ; yet no certain cause can be detected for the profound and disastrous alteration the blood is undergoing. To pernicious anaemia belong most of the cases of " essential" or ^' idiopathic anaemia." The disorder is most frequent in women, and has been especially observed in childbearing women after several pregnancies ; still, it also often happens in men, especially before the age of forty. It sometimes seems to have its origin in long-continued dyspepsia or diarrhoea, and atrophy of the gastric tubules ; or to arise after pro- tracted hemorrhages or incessant worry, — ^after, indeed, slowly but steadily acting debilitating influences ; and it has been noted to arise after nervous shock, or to be of parasitic origin, and due to worms, sometimes to a tape-worm, — bothriocephalus latus.* But in the ma- jority of instances it originates seemingly without cause, and, although it has periods of deceptive improvement that may last for months, or, as I have known, even for a year, it progresses relentlessly towards a fatal issue.* It is true that some cases of recovery have been re- corded ; but of these it is not quite certain that they presented all the characteristic symptoms. There is an insidious beginning, except at times when the anaemia * F. Oppenheimer, Berl. klin. Wochenschrifl, Oct. 3, 1892 ; Sajous*s Annaal of the Universal Med. Sciences, vol. iv., 1894. Joseph Leidy, Jr., Transactions of the CoUege of Physicians, Phila., 1893, vol. XV. p. 242. » Schmidt's Jahrb., i., 1891 ; also ibid,. No. 10, 1887 ; and Berl. klin. AVoch- ensch.. No. 40, 1886 ; also Deutsches Arch, fdr klin. Med., Bd. xxxix, * See also case with remissions in Schmidt's Jahrb., No. 4, 1882. DISEAEES OF THE BLOOD. 741 develops itself in the pregnant state. Pale tongue, bloodless lips, pearly eye, becoming paler, more bloodless, more pearly, from week to week ; breathlessness ; palpitation of the heart, especially on exer- tion ; weak digestion ; constipation, or constipation alternating with diarrhoea ; loud systolic murmurs in the heart, and venous hum in the jugulars ; vertigo, a marked lemon-colored hue of the skin about the large joints, at times jaundice ; finally extreme exhaustion, sluggish- ness of mind, fainting-fits, and dropsy, without persistent albumin in the urine, or disease of the liver, or enlargement or valvular disease of the heart, to account for it, — are the prominent symptoms. In the later stages, too, hemorrhages from the nose and from the gums are not uncommon ; and hemorrhages from the uterus or from the kid- neys, or into the skin and into the retina, may be also noticed ; the latter especially are very frequent. Yet, notwitlistanding all these grave signs, the body appears well nourished ; there is certainly no decided emaciation, except in instances in which fever is more than commonly marked. Now, fever is a significant feature of progressive pernicious anaemia ; it has been present in every case that I have met with. It is not an early symptom, belonging to the full development or to the latter part of the disease. It is of very irregular type, and not of high intensity, the temperature rarely exceeding 103° F. It is apt to be continued, or to show occasional exacerbations, followed by remis- sions, the febrile state lasting for days, or even for a week or two at a time ; then there are periods of shorter or longer duration when it wholly disappears, to come on again in an outbreak attended with all the usual signs of a febrile paroxysm for which no cause is apparent. Towards the end of the case it is not unusual for the anaemic fever to have entirely ceased, and for the temperature to have fallen below the normal standard. Pernicious anaemia may run an acute course. In this perilous malady the red globules are strikingly diminished in number, — to about a million and a half or less ; the white cor- puscles are not relatively altered, or they may remain normal, and seem to be increased, because the red globules are much fewer. Towards the end there may be, indeed, a true leucocytosis.* The haemoglobin, while, in the whole amount, markedly lessened, is in the individual corpuscles generally increased,^ the leucocytes are normal or diminished, the pale hsematoblasts are diminished and may quickly assume irregular shapes. The red corpuscles are generally increased in size. Eichhorst regards as a characteristic change that the blood * Stengel, Twentieth Century of Medicine. • Hayem, Du Sang. Paris, 1889. 742 MEDICAL DIAGNOSIS. contains also a quantity of ill-developed, small, spherical, highly colored red corpuscles. But these are not pathognomonic ; for they have been found by Cohnheim in medullary leukaemia, and by Green- field in lymphadenoma ; on the other hand, they are frequently ab- sent. Besides this there are giant-cells of irregular shape, on which Hayem * lays great stress, also many very large normal-looking red corpuscles, some of which are, however, nucleated megaloblasts. Nucleated red corpuscles were detected in the blood of all the patients examined by Howard : * the blood seems to revert to a lower type. Fig. 73. Blood ill ptTiiicious aiiffimia, illustrating the irregularly shaped blood-cells (Poikilocytosbt). This has been also insisted upon by Henry. Stengel regards the nucleated red blood-corpuscles as a constant feature. The accom- panying cut (Fig. 73), from a well-marked instance of the disease, shows the irregular shape of the corpuscles and their varied size and appearance ; some are nucleated. Of the real cause of the disease we are in ignorance. No constant lesion of the blood-making glands has been found ; but evenihing points to excessive blood-destruction. The structure of the spleen and of the lymphatic glands is not altered ; the marrow of the bones » Op. cit. * Montreal General Hospital Reports, vol. i., 1880. DISEASES OF THE BLOOD. 743 may or may not be.* Hunter* has brought forward strong proof that the characteristic anatomical change is the presence of an excess of iron in the liver, the seat of disintegration of the corpuscles being chiefly in the portal circulation. The existence of some toxic sub- stance in the circulation is highly probable, and by some this is thought to come from intestinal autointoxication. Diminished or faulty haemogenesis may also exist and contribute to the anaemia, as insisted upon by Van Noorden.^ There is also a close association with structural disease of the brain and cord. Degeneration of the lateral pyramidal and lateral cere- bellar tracts, and especially of the posterior columns of the spinal cord, has been found. But the question of the relatien of these degenerative changes to pernicious anaemia is unsettled. They have been studied by Lichtheim,* by Van Noorden,"^ by Bowman,* and more recently by Burr," who found the gray matter seldom even slightly involved. He favors the view that both the anaemia and the cordal lesions are due to a common cause, — a poison or poisons, as in diphtheria or ergotism, and Lichtheim's opinion is similar. The diagnosis of pernicious anaemia is never an easy one, for it is difficult to be quite certain that no latent organic disease exists which would account for the progressive alteration of the blood. Indeed, without the microscopical features of the blood a diagnosis is impos- sible, and ought not to be attempted. While no one element is char- acteristic of pernicious anaemia, this state of the blood warrants it : red cells extremely low, two million or lower ; some, but not marked, increase of the white cells ; haemoglobin variable, relatively increased ; high color-index ; many large and many verj' irregularly shaped red corpuscles (megalocytes and poikilocytes) ; red corpuscles, whether of irregular shape and size or not, frequently nucleated (poikiloblasts and megaloblasts). With reference to diseases likely to be confounded with pernicious anaemia, I have more than once known obscure organic disease of the stomuch, especially gastric cancer, where the tumor could not be discerned, or eatUracted kidney, with but little albumin in the urine, and where the anaemia was marked, to be regarded as a typical illustration * Pepper, Amer. Joum. Med. Sci., Oct. 1875; see also Cohnheim, Virchow's Archiv, Bd. Ixviii., and Waldslein, Arch. f. Path. Ariat., Berlin, 1883, xci. ^ Lancet, London Practitioner, Aug. 1888. ^ Quoted in Sajous's Annual for 1895, vol. i. L. 8. * Congress fiir Innere Medizin. ^ Charity Annalen, 1891. « Bniin, 1894. ' University Medical Magazine. April, 1895. MEDICAL DIAGNOSIS. of the malady, mitil the autopsy revealed the true cause of the fatal exhaustion. With reference to tlie former affection the error is all tlie more likely to happen because symploms of ^^astric disorder are usual in progressive aniemia ; %vith reference lo disease of tlie kiduey the mis- leading part is tlmt a trace of albumin is occasionally present in pro- gressive antemia. But it is not persistent, is associated with marked evidence of urobilin and with increase of uric acid, and a microscopi- cal examination of tlie urine will tell us the real extent of kidney ailet tion, Tlie caclieetic pallor of subjects *jf maltt/ftatit dwr4t«e may be mistaken for the lemon- or straws-colored appearance of the skin in per- nicious anaemia, and tlie antemia is otlen pronounced, and, poikiloc vies and normoblasts are common. But niegaloblasts are few, and tliis, Cabot states, is a valuable distinguishing mark from pernicious anaemia. lA^&iseji of the henrt may be held to be pernicious anaemia. A fatty heart, in an elderly person, witti or witlioul valvular rlisease, witli lailure of strength, and with tlie peculiar pallid, sickly look occa- sioned by the malady, may mislead. But the long duration of sucJi ca§es,and the absence of fever, are strong points in the case. Indeed, the error is apt to be the otlier w^ay, — tliat, overlooking the symptoms of profound aniemia and general failure, w^e regard the nnimiurs and the otlier cardiac symptoms whicli are associated with the fatty heart of peniicious amemia, a very conmionly coexisting lesion, as pointing to a disease of the heart alone. The physical signs will not always assist : tlie murmurs may be very distinct and loud, A number of trophic and vascular disturbances have follow^ed sur- gical extirpation of the thyroid gland, and have been also noticed alter alrophy of the gland has occurred. To this condition the name of rttrluwhf xtrmmprim has been given. It is distinguished from ana-miii by the occuiTence of signs of myxo'dema, often with cretinism and circulatory disturbances, with local asphyxia and transient or inter* mittent albuminuria. In some cases epilepsy is developed, in others pulmonary plitliisis. From the other diseases of the blood pernicious anaemia is dis- tinguished by the special features of the blood already mentioned, particularly by the large and irregular forms of the blood-cells. Besides, it {lllTers from ordinary anwmia by its relentless progress and the little influence the most nourishing diet and courses of iron have on it. Moreover, the distinctness of the cardiac mummrs, tln^ slight emaciation, and tlie irregular outbreaks of fever are significant. The marked accessions of fever, the presence of dropsy, tliough moderate, tlie retinal extravasations, the other hemorrhagic symptoms, and the unyielding blood-change, separate pernicious amemia from chlo- DISEASES OF THE BLOOD. 745 rosis. The pernicious malady sometimes seems to develop out of a long-standing chlorosis, and then the grave symptoms just spoken of prove its supen'ention. The same grave symptoms happen also, at least the hemorrhages are as frequent, and the fever and dropsy may happen, in leukcemia and in p8eudo'leukon as exceeding the limit of leucocytosis. But it is the character of the elements of the blood, not the mere number of the white cells, that positively determines the diagnosis. The charac- teristic feature is the great preponderance of marrow-cells, Thest- myelocytes are generally large, highly granular, ollen irregular, and, stained with aniline, they show themselves as the so-called eosino- ptiile marrow-cells. Besides this, the eosinophonic cells are in- creased, as w^ell as the lympliocytes ; though this increase is ver>' slight ui proportion to the enormous number of the myelocytes. There are all forms of intermediate, irregular leucocytes. There is only a slight decrease in the number of tlie red cells, notwithstanding the enormous increase of the white cells, and among tlie red cells are many nucleated ones. As contrasted witli leucocytosis, Hayeni and Cabot lay stress on the fact that the large wiiite cells are mostly not anifeboid. These cliaracters of the blood distinguish splenic leukjemia from splenic anaemia, from pseudo-leukaamia, and from malarial en- laiwment of the spleen. In all these, moreover, the leucocytes, even if increased, are not markedly so, are not abnonnal in appearance, and the ditferential enumeration gives a wholly dissimilar result The red corijuscles are ouich more apt to be decreased ; there is, indeiKl, nwi'Q or less antemia. In fi/mphfitlc letftfrmh there is marked swelling; of the lymphatic glands, while the spleen is but slightly, or not at aJl enlaiie^ed. The leucocytes are also markedly increased, but not to the extent found in splenic leukaemia, and they are almost entirely lymphocytes. Polynucleated leucocytes, so common in splenic leuka?mia, are few% only about three per cent. ; myelocytes are mostly absent ; and so are nucleated red corpuscles. In the medullar^f form of leuktemia, raiv except in combination with the splenic, tliere is DISEASES OF THE BLOOD. 749 obvious abnormal condition of the spleen and the lymphatic glands, the blood shows marrow-cells in enormous numbers and in all stages of development, many very granular or undergoing multiplication by indirect nuclear division. In comparatively rare instances leukaemia runs an acute course, varying in duration from one to nine weeks to its termination. It may be of the splenic, splenic medullary, or lymphatic variety. The disease generally sets in with chills, the fever is irregular, the spleen or the lymphatic glands enlarge, and a hemorrhagic tendency mani- fests itself. The blood condition is the same as in the chronic form, especially the lymphatic variety, and the small uninucleated leucocytes are immensely increased. It is almost invariably fatal. Bramwell * has reported a case recovering rapidly under quinine. Lymphadenoma. — As regards the symptoms, the closest similarity to leukaemia is presented by the affection described as lymphadenoma, pseudo-leukaemia, or HodgkirCa disease. It consists in an enlargement of the lymphatic glands of the body, often with lymphoid growths in other parts, which soon becomes complicated with weakness and signs of cachexia, with diarrhoea, with dropsy, with cardiac palpitation, shortness of breath and attacks of suffocation, with tendency to pro- fuse bleedings and to bedsores, and leads usually, in the course of not many months, or, at farthest, of a few years, to death. There is often a sense of fulness in the abdomen, attended with violent pains ; the temperature in advanced cases shows hiostly an evening rise. Some of the superficial lymphatics are first affected, others follow ; the disorder then extends more decidedly, the spleen and the liver increase in size, other organs, too, may become involved, and lymphoid tumors develop in various parts of the body ; but among the internal organs the spleen is the one most constantly disturbed. The disease generally begins in the cervical glands ; far less fre- quently does it show itself first in the inguinal or in the axillarj' glands ; still less fi^quently in the bronchial or in other internal glands. The affection occurs much oftener in men than in women. It mostly happens in males between the ages of ten and thirty-five and of fifty and sixty ; it is not ver>' uncommon in young children. Its cause is unknown ; it certainly has no definite connection with either scrofula or syphilis. In infancy the disease, as von Jaksch shows, occurs as a combination of a grave anaemia with marked leucocytosis. The blood shows some deficiency in red globules, but otherwise no constant alteration. Slight increase of leucocytes has been occa- » AnaRinia, Edinburgh, 1899, p. 164. Too MEDICAL DIAGNOSIS, sioiiaJIy noticed, especially durin^^ the later stages ; the while corpusrles are generally small and uninucleated or multinucleated, Myelocyles are absent. The hemoglobin is reduced. It is this ditference in the state of the blood that makes the chief distinction between pseudo-leukaemia and kukwmia^ in which there may be glandular enlargements. Rare cases of diffused lymphatic cancer closely resemble Hodgkin's disease; so closely Uiat they are undistinguishable, except by the history of the case and by a micro- scopical examination of any of the tumors that may have been re- moved ; the spleen is not involved, wMIe the origans contiguous to the glandular cancer are likely to be more rapidly implicated. In 9€irofma of the li/mphafie glands the disease is at first stricUy local, and then^ if it spread, invades not the lymphatic tissues specially, but any part of the body ; the enlaiged glands do not move freely on each other as they do in lymphadenoma ; and the blood-clianges are tliose of a secondary aneemia. Perhaps tlie fact Cabot regards as of much value — that in cancerous ansBmia the megaloblasts are always fewer in number than the normoblasts — may here prove of decided use, Loetit glaml lymphonian are separated from Hodgkin s disease by their local character^ by their want of extension, and by the absence of marked cachexia. Scrofulous or iuherrvlov^ glands^ unlike lymphadenoma. enlaive rapidly, have tliickened tissue around them, and are apt to undei^go cheesy degeneration, or to soften and suppurate. More- over, they are associated with the presence of tubercle bacillt. aJiii mostly affect tjje submaxillary glands. The anterior cervical glands are the ones cliieOy and primarily affected in Bodgkin's disease. In tjjenic mutmia^ or »ptenic pfteudo-ieukftmia^ as it is less appro}:»riate)y called, we have the same condition of the blood as in Hodgkin'd disease, save that there is mostly a much greateT decrease in the red blood-corpuscles, and nothing absolutely disliiigiiishes it except the absence of enlarged external lyniphalic glands, and the more decided increase of the spleen, wliicb, though greatly enlaifrBd, is tmallered in shape. There may be some enlargement of the retn>*peri(oftefti ; glands, and tliere is variable fever, as hi olher grave ^iMffitj^ b some cases of Hodgkins disease fever is a profoihieiit symplcim, and this may be of intermittent type, gnring rise to tlie belief that we are dealing with a wtatariat ajfedum ; recurring cfaiUs make eiTDr still i more likely. In the eariy stages of hrmphadenoma a dis^gnosts is impossible, and we are at a loss (o account for the increaaiqg s%ns of cadiejaa, tintil the involvement of the lymphatic glands in npid socoessioii, and their quick growtlu or the speedy formation of other lymphoid tnmoff ^ DISEASES OF THE BLOOD. 751 under the skin or in other parts of the body, clear up all doubt. There will also be great uncertainty in all those instances in which the growths happen first in internal glands or structures, — as in the bronchial glands and the mediastinum, producing severe bronchitis, extreme dyspnoea, and signs of venous stagnation in the veins of tjie upper part of the body ; or as in the glands around the biliary ducts, giving rise to jaundice ; or as in growths of the spinal cord leading to paraplegia, — until the external swellings explain the case. The kidney is not an organ that often suffers primarily ; the occurrence of more than a mere trace of albumin shows that it has become implicated from parenchymatous changes or disseminate lymphoid growths. Lymphadenoma may run an aciite course, with fever and marked hemorrhagic tendency. Addison's Disease. — While seeking for the explanation of puz- zling cases of anaemia, Addison discovered that a peculiar anaemia always occurs in connection with a diseased condition of the supra- renal capsules, and is characterized by distressing languor and great general prostration, remarkable feebleness of the heart's action, loss of appetite, obstinate vomiting, and a singular alteration of the skin. This consists in a dingy or smoky hue of the surface ; or the color may be of a deep amber or chestnut brown, or the altered skin may have a bronzed tinge. The change of color begins on exposed parts, such as the face and neck and the back of the hands, and deepens first there ; but we also soon find it marked in parts which are nat- urally the seat of much pigment, such as the axillae, the groins, and the areolae of the nipples. It is also marked around the umbilicus, on the penis, and on the scrotum, and is dependent upon a layer of pigment in the rete mucosum. There are also deposits of pigment on the lips and gums and other mucous membranes. The skin remains soft and smooth, and becomes in large portions uniformly discolored, gradually deepening, and often presenting a hue on the face and hands like that of a mulatto. Any irritation of the skin is followed by dark streaks. Discoloration in patches is both less constant and less significant than extensive alteration of hue; yet the darkening in undoubted cases may occur in ^patches, which are usually most obvious on the face or the superior extremities. The patient may seem at first sight to be jaundiced ; but the pearly whiteness of the conjunctiva soon dispels such an idea. The nails are pale and bluish ; the tongue may have patches of dark color ; the body and breath at times exhale an offensive odor. The blood does not undergo any characteristic alteration. It shows a more or less marked decrease of the red corpuscles, without any change in the white. These are 752 MEDICAL DIAGNOSIS. sometimes found to roiitaiu black pi^'nieiif granules. The haemo- globin is but little, if at all, below the normal average* Willi reference to the other symptoms, tlie most eonclusive of them are reniarkaljle prostration, generally without any marked waste of. the body, feebleness uf heart action and of pulse, and obvious aoEBmia, In most eases, but far trom in all, these symptoms precede the discoloration of the skin ; and they are not infrequently associated with pain in the back and with nausea and vomiting and attacks of diarrho'a, witli brealhlessness upon exertion, witti vertigo, and with dimness of siglit or impaired hearing. A peculiar odor of the body, like that perceived in the colored race, was observed in two cases placed on record by Mr, Hutchinson. In the later stages of the malady the temperature falls below" tlie norm. The pulse, in place of being feeble, may be of strikingly high tension, owing to the absence of the secretion of the suprarenals, and we may recognize disease of these organs from this high tension even when no pigmentation exists, provided we are al)le to exclude other causes for a liigh-tcnsion pulse. Death may take place gradually from the constantly growing asthenia ; or it may occur suddenly, and wiiere the amount of pros- tration does not appear so excessive as to foreshadow^ it. According to the elaborate researches of Wilks, the destruction of the capsuk^s is dependent upon a peculiar scroliilous degeneration ; and this view of the tubercular nature of Addison's disease is now very generally held J Sliould this prove to bo correct, — should it appear, in other words, tliat the nature of the disease of the adrenals influences the symptoms more than the mere fact of ttjeir being diseased, — it would explain wiiy in some ciises of absence of the glands, or of their can- cerous degeneration or suppuration, no signs of Addison^s disease ex- isted. Yet tuberr^ulous disease of the adrenals, with tubercle bacilli in the caseous glands, lias been found without bronzing of the skin." Many of the symptoms of the fully developed malady may be due to the implication of the nervous branches, derived from the sympathetic and tlie pncumogastric, which go to the glands. Indeed, tJie idea of the primary seat of the disease in the abdominal sympatlietic nerve is strongly advocated by some observers, Bramwell calls attention to the frequency of coexisting atrophy of the heart. Now, b) the diagnosis of Addison's disease the alteratii>n of the color of the skin plays so important a part tlial we must inquin* * See, for smajyuis of cas^s, Gil man Ttiompsoi), Transact, of Assoc, of Ame^. Physicians, IS93. * As lit tlje case of Ballengliien, Jourti. des Sci. Mi*atches, but tlie subcutaneous tumors due to neuromata, the tumors of the skin of the nature uf molluscum fibrosum, the pain, the arihralgia, the alteration of sensa- tion, and the impaired mental activity characterize tlie afTeclion. One of the confusing points connected with tlie diagnosis of Addi- son's disease is that cases occur witliout bronzing, or with the dis- coloration of the skin so sligld as to be a matter of doubt. Such cases are generally in persons who die before Itiey have had the dis- ease any length of time. If the altered tme of the skin be wanting, the complaint is undistinguistiable from pernwious anrefma^ except by the characteristic blood-clianges tins presents. Other iUsrancs of the miprarenal vapifulej^s^ sucti as cancer and waxy disease, are also not to be separated from the peculiar affection of the gland occasioning Addison's disease, if bronzing of the skin be not present. The malady, as Greenhow^ proves, is ver}^ rare except in persons employed in manual labor. In some instances it seems to arise from grief or protracted anxiety. The disorder is a chronic one, generally lasting for yeai^ ; but it almost always destroys life. Yet cases have been recorded in which most of the symptoms of Addison's disease existed and which recovered ; and certainly long remissions in the symptoms have been not infrequently obser\ ed, and in these remissions the discolored skin has lightened. The disease is occasionally met with in young persons. Dyson reporis a fatal case in a girl tliirteen years of age.^ Pyssmia, — Purulent contamination of llie blood is an afTeclion much more likely to be met with by the surgeon tlian by the physi- cian ; yet the physician must be familiar with its symptoms. These are, great depression of tlie \ital powei-s, high but irregular tempera- ture, profuse sw^eats, rapid pulse, and tlie formation of purulent de- posits in difl'erent portions of the body* Tlie symptoms may be of gradual development ; but often they set in suddenly with a chill, to which a fever of low type soon succeeds: or the shivering is followed ^ CaiTier, Mediral Xews, Fell. 3, 189'4. p. 127. ' Quar, Med. Journ,, vol. iii., Fiirt L DISEASES OF THE BLOOD. 755 by copious sweating, and the febrile phenomena subsequently appear. A transient erythematous blush on the slcin is not unusual. The pyaemic fever rarely lasts longer than a week, and during its continuance the temperature shows marked variations. Yet the disease is not alw^ays alike in this respect ; for we find not only cases in which the most decided increase of heat is constantly followed by an equally decided decrease, but also cases in which there are febrile attacks followed by intervals during which the temperature is almost normal. Still, in all the maximum temper- ature is apt to be very high, ranging from 105° to 108°. Pyaemia, as the physician meets with it, is seen where sinuses or abscesses exist that have no free vent for the pus ; or in consequence of an infective phlebitis or arteritis ; or in inflammation of the external coat of ar- teries, with suppuration, especially in the periarteritis of the thoracic aorta ; or in ulcerative endocarditis ; or the pyaemia results from the purulent breaking down of coagula in the blood-vessels ; or it may supervene upon diffuse cellular inflammations, or upon puerperal fever : in fact, it will be found under many dissimilar circumstances. Micro-organisms play an important part in its production, especially the several varieties of the streptococcus pyogenes and the staphylo- cocci. They render the pus septic, and, under conditions favorable to their development, diffuse the process. There are several complaints with which pyaemia is likely to be confounded, the chief of which are typhoid fever, rheumatism, acute glanders or farcy, and acute afl'ections of the liver. It is liable to be mistaken for typhoid Jever^ on account of the adynamic character of the fever, and, it may be, the occurrence of diarrhoea and of cerebral symptoms. But the history of the case is very dissimilar : there is no eruption, or, if there be an eruption, it consists, as Bristowe so particularly points out, of sudamina sur- rounded by a zone of congestion, and is therefore not the eruption of the typh-fevers; and, on the other hand, we find in typhoid fever neither the profuse sweating nor secondary deposits of pus, and the thermometry of the disease is very different. The Widal test would, in any instance, be of value. The pain in the joints and their swelling in succession, the fever, and the perspirations, resemble much at times rheumatic fever. But the difference consists in the greater severity of the constitutional phenomena caused by the poisoned blood, in the marked exhaustion, in the rigors, and in the history not being that of acute rheumatism. Moreover, the frequent signs of formation of abscesses in internal organs or around the joints, the development of pustules on the skin, 756 MKDICAL. DIAGX06IB. and the striking redness of the tumid joints assist materially in the diagnosis. Acuif glatidm or ac¥ie farcv is a disease scarcely distinguishable from pyaemia, since it occasions, for the most part, the same manifes- tations. The knowledge that the patient who has a^iparently pyaemic symptoms has been working among horses : the ulceration of the mucous membrane of the nose, and the fetid dischaige proceeding from it which occurs in acute glanders and is apt to be associated with nasal hemorrhages, and with an eryapelatous rash qveadii^ to the cheek and forehead and with enlaigement of the lymphatic glands in the licinity of the affected mucous membrane. — afford us the means of discrimination. Then we find a peculiar tuberrulated or pustular eruption, resembling smallpox, upon the skin : and in iarcy the lymphatic glands and ressels speciaUy suffer. But most significant are the distinct history of the contagion, the detection of the badlius mallei in the dischaige. and the inoculation test in guinea-p^ pro- ducing a characteristic swelling of the testicles followed by suppuratioo. Amte awecii€m* of the iirer resemble pyaemia on account of the jaundice that may attend the latter disorder : the histcoy of the ease, the rigors, the sweats, and the purulent deports distinguish it Yet it must be remembered that suppuratire inflammation (rf* the pc«1a] reins and metastatic abscesses of the tiver happen, giring rise to pyaemia. The secondary deposits, or meiaMatie or rwAolic abmcf*ite$^ take place in the parenchymatous organs, particulariy in the lungs and the liver : in the synovial sacs, in muscles, or in areolar tissue, espe^ ial> in that under the skin. They are mostly due to fragments of seio thrombi that have be»:ome centres of suppurative change. If o:- altered blood coagulate in the arteries, and the infected clot disin- tegrate, occasioning dep^osits in solid organs, as in the liver or ±r spleen, we may liave symptoms arising like those of ordinar}" pya-ciij. Indeed, in the arteritil pu'Tmia, as it has been called, rigors, febrilr symptoms and sweating, and f*ains in the joints are obserrablr. In connection with the obscure febrile c«:>ndition. the liver an«i thr spleen are ojflen observed to increase in size slowly.^ The ht'art niay or may not be affected: ulcerative endocarditis is often pni^e:::. Hayem has |K)Lnted out that there may be capillary emboSsm i:i pyaemia, not to be recogmze»i except by the microscope. It inay be one of the causes of the so-^:^ied i^ioytthic pmrmia in whkh thv source of infection is not apparent. ■ Si:-.;-: W'v' '< Hosp/-kl Rep- r>. \u. \t.. 3d S«->s. DISEASES OF THE BLOOD. 757 There is a form of pyaemia, called by Leube * apontaneous sepiico- pycemia^ which comes on without obvious cause, or is perhaps pre- ceded by a fall or a slight skin wound, in which the symptoms of pyaemia become developed with pain and tenderness in joints and muscles, ecchymgsis of the conjunctiva, vesicles in the skin contain- ing blood, extremely high temperature, swelling of the spleen, albu- minous urine, pleurisy or perhaps signs of endocarditis or pericarditis, stupor, delirium, cramps, and finally involuntary discharges and coma. The disease, resembling the typh-fevers, or ulcerative endocarditis, is to be distinguished only by the association of the symptoms. The description of pyaemia given represents it as an acute affec- tion, and so it almost always is. Yet there are cases much slower in their course, and extending over months. These chronic or re- lapning instances of the disease have been described by Paget.* The symptoms presented are the same as in the acute disorder; but the local evidences of the complaint are more often seated in different parts of the same tissues, and less frequently in internal organs. The malady is not nearly so perilous as is the acute disease. Septicadmia. — This is a poisoned state of the blood, produced especially by animal poisons, such as the bites of venomous serpents, or the absorption of putrid matters that have been generated in the economy, or by their inoculation. It may be seen after injuries and wounds, or in the puerperal state. The continued exposure to the breathing of foul air and of septic gases will also occasion septicaemia. There are no discoverable foci of suppuration, but the bacteria occa- sioning the sepsis are in the main the same as those of pyaemia. Toxines and ptomaines have much to do with the process. The symptoms of the blood-poisoning vary somewhat with the individual poison that has occasioned it. They are, as a rule, the symptoms of pyaemia, except that secondary pus-formations belong to the former rather than to the latter ; and the same may be said of embolism and its results. Rigors are frequently observed. In many instances the altered condition of the blood leads to great prostration, to hemorrhages from internal organs, to petechiae, to delirium and coma, to extreme rapidity of pulse, to rapidly developed fever with high temperature, to enlargement of the spleen, to cough and bron- chial catarrh, and to gastric and intestinal disorders. The blood shows the white corpuscles almost always in marked excess, although not altered in character as they are usually in leukaemia; the red Archiv flir klin. Med., xxii., 1878. ■ St. Bartholomew's Hospital Reports, vol. r58 MEDICAL. DIAGNOfcsIS. globules are diminished.^ The barterial types eharaeteristie of forms of seplicfeniia are generally demonslrabte by microscopic ey ination and by culture experiments. Staphylococcemia has been often recognized, and a number of instances of pyoeyaneus bacilli- aemia have been recorded,^ • Mff/arial Sfpfu^fvmia. — Since the discovery of tlie pUwmodium jmi- larrn^ malaria has entered the list of infectious diseases, and it has become recognized that it may cause a form of septicaemia, Klebs asserts that he has found tlagellate protozoa in the febrile stage of infiueiiza^ but this observation has not been confirmed. Ttfphoid Scptv^amia, — Several observers, especially in Italy,^ have reported cases of typhoid septicaemia without ttio accustomed altera- tions in the intestinal tract. The diagnosis was based upon bacterio- logical examination. Dogliolti also reported a case wliich had fever, entailed spleen, and copious eruption of typhoid roseola extending over the entire body. There was profuse diarrha^a. Cultures of blood from the finger and from a vein in the arm remained sterile; but cultures taken from the blood of the papules developed bacilli having all the characters of the typhoid bacilli. At the post-niorlem exaniination no ulcers or cicatrices were found in the intestine. The conclusion is that, besides the familiar Ibmt of abdominal typhoid, there Lsaiiother, identical in every w^ay except that it has no intestinal or lymphatic localization ; the bacilli select the skin in preference. Septiciemic typhoid then presents the following characters : an irreg- ular fever, not typical as tliat of ileo-typhoid ; tlie absence tlirough the entire illness of visceral complications and of syniptoras pertain- ing to the digestive system ; tlie presence in the circulating blood, and especially in the blood extracted from the rasli, of a bacillus pre- senting the characters of the typhoid bacillus.* Pyfemia and seplica'mia have shifted greatly from their old signifi- cance. We know mucli more of direct infection and how foci of sup- puration are set up in various parts of the body. Another set of symptoms is occasioned w^hen the products of the mlcro-oi^ganisms only, the so-called (o.rinrK are absorbed by the blood ; here feven prostration, and various nervous ]>lienomena are caused. Tliis condi- tion has been termed sapntmUt, to distinguish it from septicemia, in * Beport of Uie ConiniiUee uf the P^liiolo^cjil Society or London, TransMC- lioijs, 1879. ^ " See paper by WtS^"^ Liluii? Joun). Med. Sci., Aug. 1&99. ' See Guido B *a ' ♦Tnmshtinn ' v-i wwi;; ,. 203; ,asu» D<>>fM^ olli, Gazz. M*mL .li DISEASES OF THE BLOOD. 759 which the infective agent is actually present in the blood. Occa- sionally pathogenic micrococci may be present in the body without giving rise to either suppuration or septic disease. The tissue-cells, especially those of the spleen and the kidney, play a very important part in the destruction, and the leucocytes are also active in the warfare. Thrombosis and Embolism. — Although in connection with endocarditis, with obstruction of the cerebral arteries, and with dis- eases of the kidney, the phenomena of embolism have been described, it may serve a useful purpose to view here connectedly, though chiefly in their diagnostic bearing, some of the results of the formation of the clots in lai^ge vessels or in the heart, and of their being carried along with the current of the blood and driven into remote vessels, — the results, therefore, of thrombosis and of embolism. In the veins thrombi may form, which, so long as they do not pro- duce obstruction of the canal, give rise to no marked signs. A slight hardening and pain on pressure if the coagulum be in one of the more superficial veins, their enlargement if the clot be in a deeper vein, are apt to be the only evidences of the disordered condition. But when the occlusion is considerable, and especially when the col- lateral circulation is insufficient, oedema is developed, which may be attended with very great tenderness of the swollen part, arid, if the impediment be of long duration, with changes in the nutrition of the structures sufficient to produce phlegmonous inflammation. These phenomena are encountered in milk-leg, phlegmasia alba dolens^ as we see it in puerperal fever, in typhoid fever, in influenza, and in pneu- monia ; though it is by no means settled whether the thrombosis is primary from the infected blood, or the result of an infective phlebitis. We may have, also, a thrombo-phlebitis as well as a thrombo-arte- ritis, showing itself as an acute infective fever without anatomical localization, except in the blood-vessels. In some cases profuse hemorrhages happen as a consequence of the stoppage in the vein, — as cerebral hemorrhages produced by thrombosis of the sinus^ or, as in a case referred to by Virchow,* as enormous hemorrhagic infiltration of the subperitoneal and subcutaneous tissues, as well as of portions of the muscles of the abdominal walls, the result of a coagulum in the external iliac vein, the epigastric, and the crural vein. Thrombosis may occur in the cerebral sinuses, without causing hemorrhage, but giving rise to pressure symptoms, pain, prominence of the eyes, and oedema ; it may be followed by complete recovery. * Pathologie und Therapie, p. 172. 760 MEDICAL DIAGNOSIS. In thromboifi^ of the me^^nteric resttek. the symptoms are intense ab- dominal pain, great tenderness, vomiting, abdominal distention, and often, if the patient survive the shock, obstruction of the bowels/ There is an instance of recover}-, the result of an operatio^.- In exhauMing and waging duneti^s^ blood may clot in the veins with- out any clearly mari^ed cause. Trousseau called attention to tfar occurrence of milk-leg as a symptom of gastric cancer : and in other kinds of cancer there may be peripheral venous thrombosis: so. too, in Bright*s disease. Gout may cause phlebitis and clotting iii the veins of the t)ody. as Sir James Paget has pointed ooL Un- doubtedly infective phlebitis is a cause of thrombosis that is com- mon. But it may be. in a given case, extremely difficult to determine whether the thrombosis or the phlebitis is primary. Again, we may have chloral give rise to throml>osis in the cavities of the heart and tlie laiger veins, such as the femorals. without phlebitis preceding the morbid condition. The thromt>oses of chlorosis are generally of the lower extremities, and may l>e successive and multiple. Both lower extremities are often involved. They are supposed to be due to the feeble circulation of the impoverished blood. But this is not certain. Welsh ' suggests that the thrombus results from nutritive disturbance of the red corpuscles and their ready disintegration, producing the material leading to a thrombus. The peripheral thiomtM in phthi?i? may l>e of myotic oriigin. Now. portions of the clot, situated in any part of the venous system, may become, by being broken off and driven onwar^i with the circulation, sources of great danger. When coa^a o-xur in :!> venous system and are wholly or in part oarrieil away with the vir di- lating blood, if we exclude those which. a^:»ra their sititatior.. ■ : u^d only reach the liver, the manifestations of disturban.-e arise ir. it.- heart or the lungs. Arriving at the rhht *i*v :/ :.v v»T.-r. the •-t:*::^--' tion, if large, or if it become so by serving: as a nucleus for a Lar-TrT clot, occasions symptoms of exhaustion and t o'.'.apse : a::> intermittir^'. feeble pulse : irregular and confused beatir*ir o^ the h^ar:. ari-.i » ar.iia sounds enfeebled or lost over the right skie of the orpsLr. : ruii } develoj>ed distress in breathing:, reft* rred. by the s:i5ert-r. to the ht-ir.* and signs of asph\-xia. tho^s^h all the tin:e :he r«at:-::t is ":^'t:''^; .ir- ;. inspirations : ^n>E-at agitation : and a swo.'ei: state of the ve-ir.s v"^: th-. - K *<:.:. L^-sL M-il or.. W . h t r- h- f . M^ ii . If^-f ' Ar. .'. -Thr.:.;>:.5:5. ■ A": ::'5 Sy?:^-. ^ X-.^ r;^. t :. ^ . Ify- DISEASES OF THE BLOOD. 761 body. Death may then take place suddenly if a portion of the clot separate and obstruct the pulmonary artery.* But the mode of death, and the symptoms preceding it, in embo- lism of the ^pulmonary artery^ are not always the same, and depend much upon the size of the embolus and where it is arrested. A large- sized clot, whether it be merely part of one occupying the right heart, or be washed at once into the pulmonary artery, will occasion the same signs as those mentioned as indicative of a large clot in the right side of the heart ; the craving for air is particularly intense, and this craving is increased by every movement of the body ; the muscular debility, the lowered temperature, the cyanosed look, the turgid veins of the neck and their undulations, the increased, irregular cardiac impulse, the disturbed respiration and disordered general circulation, are also noticed ; and in some cases a systolic murmur, and, where the case is at all protracted, vertigo, albuminuria, and oedema of the limbs, may be observable. The intellect remains clear. As regards the pulmonary phenomena proper, collapse of the lung, hemorrhagic effusions or so-called infarctions, oedema, or capillary bronchitis are likely to happen, except in those instances in which the principal trunks of the pulmonary artery are blocked up and almost instanta- neously asphyxia ensues. If the fragments be very small, the amount of dyspnoea is not great, nor are the symptoms of asphyxia marked ; and inflammations of the parenchyma of the lungs may take place, occasioning often secondary obstructions and metastatic abscesses in the lungs, especially when caused by infective emboli. Blood coagulates in the arteries in connection with gangrene, as in diabetic gangrene, and ulceration. Again, inflammation, especially infective, or sclerotic or atheromatous disease of the coats of the arte- ries may lead to the local development of thrombi ; so, it is thought, may feeble action of the heart with increased coagulability of the blood. Arterial thrombosis has much the same symptoms as embolism of the artery, but the intierference with the circulation is less sudden and intense, the signs of obstruction change less rapidly, and we often find a cause for the arterial thrombosis in marked arteriosclerosis. Should the case persist, muscular atrophy and trophic disturbance become noticeable. Still, the most important phenomena connected with obstruction of arteries are those of coagula being washed into them ; the phe- nomena of embolism^ therefore, rather than those of thrombosis. The manifestations of embolism are distinguished from those of the mere * As in a case recorded by Druitt, Med. Times and Gazette, July, 1862. 762 .^lEDICAI. DIAGNOSIS. formation of riots by what, is always the most si;?nifieanl sign of embohsrii, — llie siKldemiess of the phenomena. And in point of fact the symptoms arise less often as the result of any of the conditions mentioned that occasion coagulation than in conseqrience of deposits and excrescences which are seated on the valves of the left side of tlie heart, portions of w^hicti deposits are carried aw^ay by the circulating blood into remote parts. When these bodies become impacted in a vessel the caliber of wliich is such that it does not permit them to pass on, WT find rapid changes taking place in Ihe portions of the body supplied by the obstructed artery,— coldness, pallor of tlie parts, a local auiemia, diminished functional acti%ity ; and if the first obstruc- tion be followed by others, and the collateral circulation cannot be established, local death and gangrene ensue. | All these changes are, of course, discernible only in external parts, especially in the extremities; the disturbances of function are tlie most obvious signs where the internal organs are the sufferers. If the emboli be driven to the hrain, we have often softening as the final result, and this may be preceded by disorder of inlefiect, without motor disturbances, and by severe attacks of vertigo in cases in which merely tlie smaller arteries supplying the cerebral cortex are obstructed. But where, as is, indeed, the most common seat of emboli, Uie arteries of the fissure of Sylvius are clogged, the phenomena are those of apo- plectic liemii>legia, and the prflsy afYeets the whole of one side of the body. The brain may also suffer from the seat of the obstruction being in the carotids ; indeed, of all oi^aos the effects of embolism are most plainly perceptible in the brain. Tlie jjresence of emboli in the splenic, renal, hepatic, and mesenteric arteries is generally only to be inferred from tlie liistory of the case, and does not occasion any clearly discernible signs. But tenderness, enlargement of the spleen* and pain in the spleine region in i^pkmc embotimn, or disordered secre- tion of urine and pain in the loins in embolism of the renal arter^^ or jaundice in emholimi of the vemebi of the lirer, may be very marked. The occurrence of pain in these cases of internal embolism must not be overlooked : and in embolism of the arteries of the extremi- ties pain is a sym|)lom of still gi*eater prominence. It may be like a violent neuralgia, or so constant that it is nnstaken for rheumatism ; and, as happened in the case of embolism of the right iliac arterv', under the charge of Dr. James H, Hutchinson,^ which I saw wilh him, it may recur in paroxysms of intense severity, and be referred to the foot, though this be already in a condition of sphacelus. Be- ' AniiH. Journ. Med, Sci., Oct 1863. DISEASES OF THE BLOOD. 763 sides the pain, we find extreme hyperaesthesia in some parts of the affected limb ; and pricking sensations, formication, and loss of tactile sense, followed by complete anaesthesia, in others. Then painful spasms of the muscles, and a more or less perfect paralysis of motion, may occur. If we join to these symptoms an absence of pulsation in the arteries below the occlusion until the collateral cir- culation is decidedly established, a strong beat of the vessel on the cardiac side of the obstruction, the coldness of the limb below this obstruction, and the signs of defective supply of blood, we have a group of phenomena which, taken in connection with the history of the case, render the diagnosis a positive one. In reviewing the his- tory the state of the heart and the cardiac symptoms must be always (•arefully examined into; and a close inquiry often shows that the sudden manifestations of arterial obstruction were preceded by an attack of palpitation and of irregular action of the heart. A change in the physical signs of the diseased organ, as of its murmurs, may not be evident ; but, should it be evident, it is a sign of utmost moment. Indeed, any change in what may be viewed as the centre from which the embolus may be detached is of great signifi- cance. And this holds good quite as much for venous as for arterial emboli. Thus, in a case of coagulum in a vein, a sudden disappearing of swelling and oedema of the affected limb, with the supervention of signs of embarrassed circulation and respiration, would at once tell what had taken place. In regard also to the diagnosis of embolism we must always bear in mind the causes that are likely to give rise to it. Several of the causes of arterial embolism have been already mentioned ; those of venous embolism are the same as of venous thrombosis, or, to speak more explicitly, the breaking up of the clots and their transportation may occur in any of the conditions which have occasioned them. Now, these conditions, too, will produce arterial clots, and indeed- ' some are more apt to lead to coagulation in the arteries than in the veins. Prominent among them are a narrowing of the caliber of the vessel, as by pressure ; dilatation of the vessels and of the heart ; fail- ure of cardiac power, with consequent retardation of the blood-stream, — a state which is more likely to occasion venous than arterial throm- bosis ; a breakage in the continuity of the vessel, as when it is torn or cut ; changes which take place in the coats of the vessels, especially inflammatory changes, the result of infective disease ; and contact of the blood within the vessels with foreign bodies. Then it is very likely that special states of the blood, by altering the cohesion of the globules, or disintegrating them, may cause the clotting. 764 MEDICAL DIAGNOBIB, . Another vuuse of embolism is that due to accitinuhtfio}}^ of ^ in (he bhoff^ the rt'SuU of malarial fevcT. The pigment may obslnicl the capillaries in the brain and thus occasion capillar)^ apoplexies; or be driven to ttie liver and there produce signs of disturbance of ib circulation^ and abscesses. As in all forms of capillary embolisni, the symptoms are obscure : tlie suddenness of their development, gener- ally so characteristic of the other forms of embolism, is wanting: and the diagnosis, as tliroughout in capillary embolia, is nothing more than a matter of conjecture, based on a close study of the lustor}" of thf case and the general phenomena, including ttie microscopic examina- tion of the blood. Similar symptoms occurring atler fractures of bone point to emboli derived from^the marrow, to fat erfibolimti, Aeide endarteniis may be the cause of embolism as well as of pya?mia. Air hi the hhml i)roduces great disturbance of the circula- tion, which may be thought to Ije due to embolism. The air may tw the result of decomposition, and get iido the venous system and thence into the general circulation. Jurgensen ^ has reported a rase in which the air passed into ttie circulation tlirough the splenic vein. Irregular contraction of the heart, ^>aIlor of the face, a peculiar systolir cardiac murmur, faininess and the signs of cerebral anaemia, and slow breathing, are the conunon symptoms. In conclusion, Uie mtbHrquvM ehmu/e^ of fhe tkrmtibu^ roust be adverted to. It may organize? and be converted into connective tissue and yield an impaired passage to the blood; and perhaps the col- lateral drculation may be freely established ; or, wtiat is not so favor- able a result, it may sollen and undei^go a granular and fatty degen- eration. Further, se|)tic or pundent thrombi, as they soften, may produce septiciemia or pyaemia, or particles of tlie thrombus may be wafted into capillaries and there lay the foundation of abscesses* It is thus that in a case of thrombus or embolus we may have the results • of a secondary pyaemia to deal with. Scurvy. — Tliis disease is not otlen met with in civil practice ; but it is one fanuliar to the military and the naval surgeon. It consists in a deterioration of tlie blood, produced by living for a long period upon the same kind oC tbod, especially u|ion salted meats, without the n;*qui- site supply of fresh vegetables. Another cause of scurvy is the want of proper assimilation of food, as in prison scurvy.^ The existence of scurvy in childhood is now recognized as of not uifrequenl occurrence, and it is probably frequently mistaken for » Archiv f. klin. Med., Bd, xxxi., 1882. ' See Mediral Meiiiuirs of Ihe U. S. Sanitary Cammission, p. 2#S. DISEASES OF THE BLOOD. 765 rhachitis, acute rheumatism, or possibly for purpura. The concurreftce of marked anaemia with joint-swellings in a bottle-fed infant, or in older children, should suggest the possibility of scurvy being present. Northrup and CrandalP found, in over sixty-three per cent, of the cases of infantile scurvy they investigated, that the diet consisted of proprietary foods and condensed milk. The evidence also indicates that milk sterilized is capable of causing scurvy when used as an exclusive diet. Babes,* in studying three cases of scurvy bacteriologically, found a thin, long, wavy bacillus, prone to occur in clusters, in the gums, the lungs, and other viscera. There were also streptococci in the gums. The blood shows nothing characteristic. '^ The red corpuscles are only slightly diminished, the haemoglobin more decidedly, giving, as Coles ^ says, a chlorotic type to the anaemia. Scurvy is usually slow in its development. The patient becomes low-spirited, easily fatigued, and is loatli to exert himself. The appe- tite is impaired ; there is a craving for acids and for vegetable food ; the tongue is flabby ; the breath fetid ; the pulse feeble ; the skin dry. The bowels are usually constipated*; but a tendency to diarrhoea may exist, and indeed generally occurs as the disease advances. Neuralgic pains, referred chiefly to the lower extremities, to the bones, and to the back or thorax, are common. The face is pale, or has a yellow- ish tinge; the eyes are surrounded by a dark ring. During the progress of the ailment, or in severe cases almost from the onset, we find swollen, spongy gums, bleeding on the slightest touch ; hurried breathing ; a rapid pulse ; weakened eyesight, sometimes night-blind- ness ; epistaxis ; painful swelling and hardness about the joints of the extremities and in the calves of the legs ; and purple spots and bruise- like stains on the skin. Should the malady remain unchecked, the symptoms heighten in severity, ulcers form which have a fungoid look and a great tendency to bleed, hemorrhages take place from internal oiigans, old sores and wounds reopen, well-knit fractures become dis- united, there is a constant tendency to swoon, and the patient perishes miserably exhausted, and with his blood in a state of dissolution. Scurvy may be the cause of epidemics of pericarditis-.* In some cases death takes place from diarrhoea or dropsy, which may be suddenly developed. Recovery from scurvy is slow. Purpxira. — Scurvy is not a disease ditFicult to recognize ; only one ' Proceedings of New York Academy of Medicine, Feb. 1894. * Quoted in Sajous's Annual, vol. i., 1895. ' Diseases of the Blood. * Von Dusch, Herzkrankheiten. 766 MEDICAL DIAGNOSIS. affi&ction resembles it at all closely, — purpura. In this disorder also red or purple spots or livid blotches, uninfluenced by pressure, and passive hemorrtiages firom the mucous membranes happen. But there is this difference between the two complaints : purpura is com- mon in fruit seasons, and often attacks persons who have not been in any way deprived of vegetable food. The gxuns are not soft and spong}' as in scurv}\ nor do we find the same weakness of mind and body. Then, the stain of the skin in purpura is apt to be more gen- erally diffused, and the purple blotches are smaller, or, at all events, the large patches of discoloration consist clearly of an aggregation of very many small spots. Moreover, the disorder is not controUedL like scurvy, by antiscort)utics, such as fresh vegetables and lemon-juice. From a clinical point of view we find several forms of purpura. In the mildest, the purpurous spots are apt to appear only on the l^s. They come in crops, which fade, and there are no constitutional symptoms, except a little lassitude, and peiiiaps aching of the limbs and pain in the back. In the graver cases, *** purpura hemorrhagica,** we have, in addition to the cutaneous hemorrhage, epistaxis, ha»na- temesis, haematuria, or other internal hemorrhages, and extravasa- tions of blood may happen into the substance of the muscles. The amount of pain attending the malady is very different There may be none, or it may be trifling : or deep-seated pains in the cavities of the body, or extended neuralgic pains, may accompany the purpuroos complaint ; there is at times soreness at the pcHuts of extravasatioD. In some instances the pains are chiefly felt in and around the joints, and the apparently rheumatic aches subside in a few days, and spots of extravasated blood become visible. This "purpura rheumatica'* is usually met with in the strong and healthy. It is, indeed, one of the peculiarities of any kind of purpura, that it may come on in the midst of seemingly excellent health : for while it is true that the dis- order may be preceded by general debility, or occur in the course of t^Usease of the liver, of Bright's disease, or as a sequel to the exan- themata and rheumatic fever, it most oflen happens where we shoulii least expect it. Its production as the result of a sudden shock, such as fright, and its intermittent character, have been repeatedly noticed, it has appeared after the administration of quinine, as observed by Vepau,^ by Gauchet,- and by Woodbur>*.^ The blood shows nothing peculiar, noticing but the form of anaemia common after heniorrhaues. — rt*duction of the corpuscles and luvni- * iia2»-tte Mtrd. dr SlHisU mr^. 1 Sj^5. - Bulletin de Th»rrapeuti.iu»\ vol. cI. DISEASES OF THE BLOOD. 767 globiii, slight increase of the white, occasionally nucleated red cells. Purpura is clearly not merely a disease of the blood ; the capillaries lose their retentiveness and allow the corpuscles to migrate. The duration of the malady is very variable : only a week may elapse, or several months may pass, before the spots disappear. In some cases purpura presents an acute form. It is ushered in by a chill, and by intense pain in the back and limbs, but is unattended with fever or severe constitutional disturbance. The purple spots usually first ap- pear on the legs, and are wholly uninfluenced by pressure. They last five or six days, or somewhat longer, then gradually change their color and fade. Even in marked hemorrhagic cases, the mind remains clear, and cerebral or spinal symptoms are absent. It is thus that we are able to distinguish severe cases of acute purpura, which may indeed prove fatal in forty-eight hours,^ from cerebro-spinal menin- gitis. Some of these acute or fulminating cases occur in young chil- dren, and it is a question whether or not they were in reality subjects of infantile scurvy. The distinction between hcemophilia and purpura is simple. It is true that in the former the bleeding may happen into the skin, or from any of the parts from which it may take place in purpura ; but the family histor>% the congenital proneness to frequent hemorrhages from the slightest cause, their danger and protraction, the functional disorder of the heart, followed perhaps even by cardiac hypertrophy, the attacks of rheumatoid joint-inflammation, especially after exposure to cold and damp, and the hemorrhagic diathesis exhibited, stamp haemophilia with distinctive features. Microscopic examination of the blood of haemophilia shows nothing different from the anaemia found in scurvy or in purpura. Microcytes, and reduction of haemoglobin and of the red blood-corpuscles, were found by Daland.^ Henrj' has directed attention to the wasting of the middle muscular tunic of the arterioles. Vasomotor influences 'undoubtedly play their part in bringing about an attack. This is shown by the flushing of the face which so often precedes it, and also by the fact that the attack may follow emotional excitement. Lexihixmki may be accompanied by subcutaneous extravasation of blood, but it cannot be mistaken for either haemophilia or purpura, if an examination of the blood be made. Haemophilia is almost ex- elusivelv restricted to the male sex. ^ Hanison Allen, Amer. Joum. Med. Sci., Jan. 1865. * College of Physicians of Phila., Jan. 9, 1894. CHAPTER XL RHEUMATISM AND GOUT. Rheumatism and Gout are affections having a strong tendency to change their seat, and are dependent upon the presence in the blood of some poisonous material which probably accumulates there in consequence of malassimilation. The rheumatic poison, concerning which there is a growing but as yet unproved belief that it is a mi- cro-oiTganism, has a singular predilection for the fibrous, serous, and muscular textures. Hence we find it attacking principally the joints, the fascioe, the endocardium and pericardium, and the muscles in various parts of the body. According to its main forms, it is some- times divided into articular and muscular ; but the more usual division into acute and chronic is simpler. Acute Rheumatism. — Here the poison gives rise to the symp- toms of an acute, active disease, and attacks especially the lai^ger joints. These swell, become hot, red, tense, tender, and the seat of pain, aggravated by the slightest movement ; an effusion also takes place into the surrounding structures, or into the synovial mem- branes of the joint itself. The rheumatic inflammation may either remain confined to the joints first affected until the disease is over, or, what is more common, it shirts from joint to joint, implicating most of the large ones in succession, yet often invading firesh joints before the swelling has subsided in the parts first attacked. The articular disorder is ushered in and accompanied by high fever, stwn attende MEDICAL DIAGNOSIS. course of c<"rtiiiri infective diseases, such as scarlet fever, dysentery. cnrebro-spiiial fever, and gonorrhcea, or in septic slates, sucli as in pyanuia, the joints swell, and there may be symptoms like those of rheumatism. In f/miorrittnri rhrmnnttHm Ihe articular pain is not so severe or acute; the integument covering ihe averted joint is apt to reisdn its normal color; there may be but one joint — and tliere are not gener- ally many — imi)licated ; the inflammation is confined lo tJie synovial membrane, and a copious sero-fibrinous exudation occurs ; the joint- afTection, which is found chiefly in the knees or the sacro-iliac or Ih'* slerno-clavicular joints, shows a slight tendency to shift, ajid resembles* rather an acute or a snbacute rheimiatoid arthritis than acute rheuma- tism ; the eye, too, utdike what happens in ordinary acute rheumali«' fever, is often attacked. There is but little fever, no coj>ious sweating. and no disturbance of the heart, though there jnay be, in rare in- stances, a coexisting gonorrha^al endocarditis ; often there has been a discharge from the urethra, which diminishes when the gonorrhceal rheumatism seb in, but which ihws not cease. The disorder doc^s not come on early in a case of gonorrham ; and the joint-affecUon appeal^ really to be of [jyteniic origin, ft disapjiears only very slowly, and h uninlluenced by salicylic acid/ It is rare hi women. In two hun- dred and fifty-two eases analyzed by Northrup there were only twenty-two women, Gonorrtia'al rheumatism may run an acute course.^ I^nrulent etTusions into joints may be mistaken for acute rheu- matism. Tlie historj' of the case, the frequent association with an infectious or septic malady, and the location r»f the swelling, disUngnlsh these pifiimii* joinfH, They are also met with in puerperal fever, hi acute otiteoviycVdm happening in the long bones near the joints there may be misleading symjitonis. But the great severity of the pain, the fact thai the cjnphyses rather than the joints are aft'ected. and tJie grave constitutional symptoms prevent error. The tmits nf an attack of acute rheumatism are frequenUy altr by certain complications in internal organs wliich the contamin^i .. blood occasions. Prominent among them are the cardiac disorders. which are in fact so common that they maybe looked upon as form- ing |mrt of the rheumatic manifestations. Their signs we investigated while examining endocarditis and pericarditis. Certain cardiac phe- nomena, such as extreme pain witJiout evidence of valvular afTection, ' fterman edition of tliis work. * Davies-ColJf»y, Guy's Ho6|))tal HqioHs, \mx RHEUMATISM AND GOUT. 771 pain which may shoot to the neck and shoulder and be associated with signs of great irritability of the heart or of heart-failure, have been by Peter and Letulle ^ attributed either to rheumatic myocarditis, or to an abnormal excitement of the cardiac plexus, of rheumatic origin. Other complications are inflammations of the lung, of the bron- chial tubes, and particularly of the pleura ; an affection of the kidney which is generally a parenchymatous nephritis with some albumin and tube-casts, but which may be due to pyaemic or embolic infarc- tion,^ and — though not often — cerebro-spinal disturbances, exhibiting themselves by headache, violent delirium, convulsions and coma, and occurring either in connection with peri- or endocarditis, or solely in consequence of the action of the vitiated blood on the nervous centres, or of uraemia, or of multiple capillary embolism. In these cerebral cases the temperature is apt to be very high, to reach 107° or more, but the association is not invariable. Indeed, rheumatic delirium is far from always of the same nature. It may develop itself with or without the signs of cardiac complaint. It may come on early in the disorder during the violence of the fever ; or late, and clearly from debility and impoverished blood, yielding to nour- ishment and stimulants. It is rarely the result of meningitis. The delirium wliich attends cei-ebral rheumatism may be marked by great talkativeness, or, on the other hand, the patient may be extremely taciturn.'* Insanity may follow the brain symptoms of acute rheu- matism. In some instances, whether due to rheumatic inflammation or to mere disturbance of the medulla and lower half of the pons, we find in rheumatic hyperpyrexia nervous symptoms that simulate multiple sclerosis, — exaggerated knee-jerks, ankle-clonus, scanning speech, nystagmus, and tremor. Foxwell * has reported such a case in which the temperature reached 111°. The occurrence of nodules in connection with rheumatism, espe- cially among children, has attracted much attention. They are met with chiefly in the neighborhood of joints, especially of the elbow. These fibrous nodules may appear at once in any form of rheu- matism, or come out in crops. They are not tender. They most often occur in cases of rheumatic endocarditis or pericarditis. * Archives Generales de Medecine, June, 1880. ^ Chomel, Recherches sur les Heins dans le Rhumatisme, Paris, 1868 ; also Schmidt's Jahrb., No. 2, 1871. ' Some of these points are more fully detailed in my paper on Cerebral Rheu- matism published in the Amer. Journ. Med. Sci., Jan. 1875. * Lancet, May 1886. 772 MEDICAL DIAGN08I8. In a few instances of rheunialism we find acute arteritis arising, and especially inilaniniation of the fibrous structures of the aorta. This condition may be suspected should we observe intense general uneasiness and distress, witli pain, increased pulsation, a distinct niurniTir in the course of the vessel, and tumultuous action of the head without there being obvious signs of disease of that oi^^n present. Still, the diagnosis is never a positive one. Acute rheumatism rarely ends fatally ; its cardiac consequences are more to be feared than tlie acute athu k. Cases occur not inlK'- quently in wlueh the inflammation in the joints is lingering, and in which tlie febrile symptoms are not intense. These cases form an intermediate grade between acute and chronic rheumatism, and are spoken of as mbcteute. The disorder is more apt than the acute variety to affect the muscles as well as the joints ; nay, the former may be alone attacked. It may be witnessed in the joints of one ex- tremity^ or in one joint, and might then be mistaken for synovitis. But the dissimilar history of the complaint will guard against error: no accident has happened to account for th<' swelling of the joint, and often the patient will tell us tliat tie has had previously an attack of rheumatism. The subacute form of rheumatism is more likely to be confounded witli rheumatic arthritis: we shall presently refer to their distinction. Clironlc Rheumatism. — This may be either a sequel of the acute disease, or the disorder may from the onset assume a lingering form, the constitutional symptoms being slight. The affection may show ibelf in the joints, giving rise to stitTness, dull actiing, pain pro- duced by motion, but without heat or obvious swelling, tenderness, and febrile excitement, or marked sweating ; or it may implicate tlie muscles in various parts of tlie body^ occasioning stiiTiiess, as well as pain when they are moved*; or it may attack both joints and muscles. In any case the occurrence of the pain furnishes ttie starting-point in diagnosis ; and we must ascertain whether it be augmented by motion, whether it be more or less shifting, whether it be not combined with stiffness eitlier of lire nuiscles or of the joints, whether it be influencHl by changes of temperature, whether it be not neuralgic, or associated with a disturbance of some viscus, such as of the Uver or the kidneys, before we conclude that tlie complaint is really rheumatic, Tliis is esperialty necessary in the most common form of clironic rheumatism, — muscuiar rhcumtjiimn. All kinds of pains in the mus- cles or their surroundings, the cause of which is not at once apparent, are apt to be pronounced rheumatic. And indeed it is not always easy to say whetlier they arc or are not of that character. We ir»a} RHEUMATISM ^D GOUT. 773 distinguish them from neuralgia by the pain hi the latter being ordi- narily confined to the distribution of one nerve and not being increased by movement or by pressure, nor is it so steady, or attended with soreness, except over a few spots in the course of the affected nerve, which then, indeed, bespeaks neuritis rather than neuralgia. As regards the pain caused by organic structural disease, we can generally discriminate them from those of rheumatism by close atten- tion to the history of the case, and by a careful exploration of the internal oi^gans. Thus, for instance, we shall find pain radiating from the right hypochondrium to the shoulder to be dependent upon hepatic disease ; or pain shooting down to the groin, thigh, and testicle to be caused by a disturbance of the kidney ; or a bearing down and an aching near the sacrum to be probably due to uterine disorder, prostatic disease, or anal fissure. Muscular rheumatism may affect the neck, the scalp, the muscles of the face, and the parietes of the chest or of the abdomen. It may be not only chronic in any of these situations, but also acute; or what is more firequent, when it occurs with fever and is transient, it is a sudden acute exacerbation in persons who are rheumatic and suffer more or less persistently from rheumatism, though perhaps in a different part of the body from the one in which the acute affection has happened. Muscular rheumatism has been noticed in an epi- demic form.^ One of the most common seats of muscular rheumatism is in the loins. It then constitutes the disease known as lumbago. The patient is unable to stand erect, or, after being seated, to assume the erect posture without suffering much pain, and finds it nearly impossible to stoop forward, on account of the pain occasioned when the mus- cles of the back are called into action. Unless the attack be very severe or acute, there is no constitutional disturbance ; but the dis- order is often obstinate. We distinguish it from pain in the loins due to disease of the kidneys, chiefly by an examination of the urine and by the way in which movement affects the rheumatic pain ; fi-om lumbo-abdominal neuralgia, by the two or three sore spots in the course of the affected nerve ; from rheumatism of the vertebral articu- lations, by the absence of tenderness and swelling around the spi- nous processes ; from lumbar abscess, by the want of local bulging or fulness, of fluctuation, and of fever. Then, we must be careful not to consider as lumbago the pain in the back caused by disease of the spine, or by disorder of the uterus, or by the passage of abnormal » Schmidrs Jahrb., No. 12, 1872. 774 MEDICAL DIAGNOSIS. • urinary constituents, such as oxalate of lime, or consequent upon strains, or blows, or scurvy, or malaria, or anaemia, or a general or local muscular debility. Thus there are many causes of pain in the loins, and where the case is of any duration or of any doubt we must be careful to exclude these causes from consideration before we assume the disease to be really rheumatism of the muscles and fasciae of the back. This cau- tion is very necessary in investigating the cases of " weak back" so prevalent among soldiers, which are, for the most part, due to strains or injuries that have perhaps produced a weakness of the muscles and a persistent cutaneous hyperaesthesia ; or to impoverished blood, to neuralgia, to scurvy ; or to digestive disorders attended with the passage from the kidneys of large amounts of urates or of oxalate of lime. The remarks made with reference to lumbago and the states which simulate it are also applicable to pains apparently muscular affecting other portions of Uie body. We may have pain and sore- ness of tlie muscles developed by strain or overwork and attended both with muscular and with cutaneous hyperaesthesia, — a condition very different from rheumatism, and designated myalgia. This sore- iiess of tlie muscles is always in direct proportion to their debility, and is diiefly caused by long-continued exertion beyond the power of the muscle, or by an ordinary amount of action when the musi le or the individual himself is debilitated. The moii)id state is ven maurked during convalescence from scarlet fever, where it may be looked upon as due to over-exertion of the weakened muscles. Tlie soreness of the muscle is commonly accompanied by heightened sen- sibility of the'' skin over it ; and this coexisting cutaneous tenderness is an important diagnostic sign. Myalgia is chiefly found in the mus- cles of the trunk, and is rarely general. Another form of muscular involvement that we may herv m-L- tion is wry -neck, or toriicoHiif, This depends chiefly upon contractile of the sterno-i^leido-mastoid muscle of one side, and occasions i:: ung;iinly appearance. But everj- case is not of rbeumatk orci... The disorder may be spastic, or may depend upon nervous injcn. and when chronic may lead to alteration in the muscular sInKtur-. The therapeutic test is with injections of atropine, hjrpodermkaLy. which are genenilly useful, not only for their remedial efTecL bo: a-i^? btH*auso, oven in chronic cases, they may show us, by the difficuliy .^ tmpivssibility of relaxing the muscle, bow much of it is neallT citac^i There an^ fonns of pain in muscles and tendons that ape ofiti: mistaken for musiular rheumatism. Achiiiod^ia is one: the sacit RHEUMATISM AND GOUT. 775 swelling about the insertion of the tendo AehiUis, with pain on stand- ing or walking but without much tenderness, marks an aflfection that is frequently not rheumatic. In Morton's disease the pain in the meta- tarsal phalangeal articulation of the fourth toe is due to nerve-com- pression. It is a form of neuralgia, which occurs in seizures, yet only when the foot is moved as in walking; there is neither heat nor swelling. The muscular pains of trichiniusis may be mistaken for muscular rheumatism. But the marked exhaustion, the signs of gastro-intestinal catarrh, and an examination of the blood direct attention to the real cause. A form of chronic rheumatism which also may be briefly men- tioned is that affecting chiefly the fibrous membranes, such as the peiiosieum. This becomes thick, and tender on pressure; its thick- ening may be even perceptible to the touch as well as to the eye. This kind of rheumatism happens especially in those who have syph- ilis ; but it also occurs where no such taint exists. The pains are generally much more severe at night ; and this is sometimes assumed to be a proof of the syphilitic character of .the disease, — but incor- rectly so ; for many varieties of chronic rheumatism are aggravated by the warmth of bed. Indeed, the only really diagnostic signs of syphilitic rheumatism are the obvious evidences of constitutional syphilis, or the history of the infection. Still, to cases in which sev- eral nodes exist, and in which the pains more particularly affect the long and flat bones, and in which iodide of potassium speedily modifies the pains, we shall be rarely wrong in attributing a syphilitic origin. Chronic rheumatism is often feigned, especially by malingerers in the army and the navy, and the deception may be ditficult of detec- tion. They pretend to be scarcely able to walk, or hobble around with a cane, and complain much of the pain and stiffness in their joints. Yet there is not the least sign of deformity or real stiffness ; the pain is always stated to be the same ; and their general health is excellent. Their way of using the stick, too, is characteristic : they move it each time they move the seemingly crippled leg, but, as a rule, not immediately, thus not employing it as a support. Anaes- thetics are of great value in enabling us to decide as to the real amount of immovability of the limb. Gout. — This disease may be, like rheumatism, either acute or . chronic. Instead of describing its phenomena, I shall at once point out the quarks of difference between jthe two kindred maladies. In gout, the small joints are chiefly or [alone affected ; in rheumatism, the large. The gouty inflammation is accompanied by more local pain and redness than the rheumatic, and by oedema, enlargement of 776 MEDICAL DIAGNOSTK the veins, aiid desqimmalion of the ruticle, and implicates, at least at first, only one or a few joints, especially ttie joint of tlie great toe; while rheimiatism attacks Uie joints of ttie upper as well as of the lower extremities* In gont there is a tendency to disease of the kid- neys, with a moderate febrile disturbance, and no profuse sweats ; but we meet rarely witli a cardiac complication, at least a valve affec- tion, as constantly happens in rlieumatism. (loul is more decidedly hereditar}^ than rheumatism ; its early attacks are apt to recur with a certain amount of periodicity, and last about a week, — -therefore a mucti shorter time than those of rheumatic fever. During the parox- ysm of gout the urine is scanty, and both before tlie attacks and during the first days the uric acid is strikingly dimmished. (fout occurs generally in men of middle age wlio live high or who drink large quantities of malt liquor, or in their descendants, jiarticii- larly those who lead inaclive lives ; it also is seen in those whose sys- tems have been inq>regnated with lead ; while rheumatism is usually met with in Uie weak, is excited by cold and damp, is almost as com- mon in females as in males, and is oftener found in the young and before middle age. Gout is frequerdly combined with a deposilion of chalk-stones in the joints; rheumatism never. Ttien, as shown by Garrod,' we possess means of diagnosis in the examination of the blood. Uric acid is always present in large excess in gout, and absent in rheumatism. Nor is the method of detecting tlie uric acid difficult, if w^e make use of Garrod's ingenious plan. It consists in obtaining ttie crystals of uric acid, crystallized on a thread filaced in a mixture of the serum of the blood, or of the fluid from a blister, with acetic acid, in the proportion of six minims of the acid to each fluidraclim of the serum. The mixtm'e of the serum and acid, with the thrt»ad in it, is allowed to stand in a shallow watch-glass from twenty-four to forty-eight hours, |>rotected from the dust. In the blood of gouty patients tliere is otlen a slight increase of the leucocytes. The remarks just made apply more especially to the distinction between acute gout and acute rlieuniatism, Tlie chronic disorders are more difficult to separate. Indeed, unless there be external deposits or chalk-stones, tlieir discrimination may be impossible. In these obscui'e cases, however, the history and an examination of the blood may throw considerable light on the diagnosis. In many sub- jects, too, the exploration of the exterrial ear will assist us in arriving at a correct diagnosis : we find one or several spots of subcutaneous deposit of urate of sodium on the helix. * (iout and Rheumatic Gout, 2d edit., Londt3n, 1863, RHEUMATISM AND GOUT. 777 Grouty persons are subject to indigestion, flatulency, pains and cramps, or palpitation of the heart, — phenomena due to the gouty poison, and generally ameliorated by a fit of gout. The teeth of those of gouty diathesis are remarkably well enamelled, enduring, and free from decay ; biit there is great proneness for tartar to col- lect upon them.^ Violent fits of sneezing may be a most annoying symptom,^ and so are deep-seated pain in the tongue and a sense of burning.^ In chronic gout there are often knotty finger-joints and tophaceous deposits in fingers and toes. Gouty endarteritis is not uncommon ; and the frequent association of contracted kidney with gout is universally recognized. Hay fever, or asthmatic seizures, may be symptomatic of the gouty* diathesis or lithsemia. The gouty inflammation of the joints may retrocede during an attack, and severe epigastric pain, nausea, vomiting, flatulence and acidity, faintness and a feeling of sinking, and a quick, feeble pulse show that the morbid action is transferred to the stomach ; or it flies to the hecul,, and apoplexy or maniacal symptoms occur; or to the heart, and there is violent palpitation, with dyspnoea and intense anxiety ; or it attacks the spinal cord, and a sense of constriction around the thorax and abdomen, and piercing pains in the limbs, like those of locomotor ataxia, are encountered, and the spinal dura mater and the roots of the spinal nerves are found to be incrusted with uric acid and urate of sodium.* Closely connected with gout is lUhceniia. Indeed, the excessive formation of lithates and the dyspeptic symptoms with heart-burn and eructations, the signs of functional derangement of the liver, the vertigo, the mental gloom or the listlessness and indisposition to exertion, the cramps in the legs and muscular twitchings, the neuralgic attacks, the restless nights, the palpitations of the heart and its irregular beat, are in many but the precursors, although, it may be, the long precursors, of a regular outbreak of gout ; while in many more this half-dyspeptic, half-nervous condition, with the faulty assimilation, the imperfect oxidation, the excessive discharge of lith- ates at times and their disappearance at other times, will go on for years without ever developing into an attack of gout.* Still, in time, the same local lesions may follow in internal organs ; we may have ^ Dyce Duckworth, Transact. Odontol. Soc. of Great Britain, 1883. * Schmidrs JahrbUcher, No, 8, 1881. ' Dyce Duckworth on Gout, London, 1889, p. 87. * Ollivier, Archives de Physiologie, 1878. * See paper on Lithaemia, by the author, Amer. Journ. Med. Sci., Oct. 1881 ; and University Medical Magazine, May, 1894. 778 MEDICAL DIAGNOSIS. the same form of coiitradiFig kidney, arteriosclerosis, and the heart- affecUon with hypertrophy, and tiie accentuated second aortic sound of Ihe lithiemic slate. Utliieniia is very common in this country, and may be termed American gout. lathft^mia sometimes nuinifests itself in attacks of pain m the Hlomaeh miff howek. The pain is associated with tenderness, and is most common when the stomach is empty. Among the symptoms of lithiemia that are very liable to be mistaken and mistreated are (fhor- det\H of vlmon. As Risley ' has stated, lithtemia is both a primary and a modifying factor in many of the discomforts and more serious disor- ders of the eye* It stands second only to syphilis in the frequency \vith which it causes iritis, hi adults, ^obstinate conjunclivilis and episcleritis are apt to own lith^emia as a cause, and it oflen gives rise to pain and to photophobia. It may lead to ulceration of the cornea and errors of refraction and attendant eye-strain and headtichei Arthritis Deformans.^ — (iout is rare in this country. But tlie same cannot be said of tliat distressing disorder known as arihHiU fhforrnam, or rlimnntic f/ottf, which is neither rheumatism nor gout, ^though not uncommon in those of gouty histor}', — but a distinct affection. Tlie disorder may be acute or chronic. It is not often the former; many of the acute cases, indeed, being rather subacute than acute. Even in ttiose belonging to the acuh' form there is little febrile disturbance ; and though we observe pain and aching in the joint^s, and some discoloration, we find less redness than in acute rheuma- tism, and certainly Ihe tongue less furred, much less profuse perspira- tion^ no sucli heavy deposits in tlie urine, and aji utter treedom from cardiac complication. Ttie acute arthritic disease has rather inflam- mation of the pleura and of the eye as its attendants, and Is often accompanied by a sallow skin, yellowish conjunctiva, and discolored, costive stools. It implicates the large aujd small joints equally, thus ditfering trom goul, and causes very great swelling, due to an effusloiL not around Oie Joint, but into its capsule. It fastens upon several joints, and, thougli it may pass from joint to joint, it sliows but UlUe nngratory tendency ; the joints first attacked remain ttie seat of dis- ease. Unlike gout, it is apt to affect the smaller joints of the Itands without a previous alTection of the toes, and exhibits no pericxlic paroxysms or exacerbations. Moreover, an acute attack is of very much longer duration. Unlike subacute rheumatism, it does not affect the muscles, and is, both in the snlTeringat the time and in its ultimate results, a much graver malady. ' PrtMjeefliugs of the State Medical Society of Pennsylvania, 1S&6. RHEUMATISM AND GOUT. 779 The great danger in defonning arthritis is from the effects of the inflammation on the joints. The changes there produced are obvious in the chronic form, for each joint attacked is apt to be much damaged. The chronic complaint may follow the acute, or it may begin without any febrile symptoms, with pain and stiffness in the joints. These soon become much distended with fluid, which is gradually absorbed, and the structure of the joint alters, the cartilages become, sooner or later, implicated, and gradually waste, and chronic changes and per- manent deformity are produced. The alterations may go on getting worse and worse in consequence of repeated attacks, until complete immobility ensues, and, the joints becoming permanently affected, the ends of the bones are disloc*:ed and enlarged. But though there is much swelling, no deposits of urate of sodium are found in the joints. The appearance of the joints seen with the X-rays is very character- istic. The enlargement and irregularity of the articulating surfaces and the bony outgrowths at the margins are conclusive evidence of the affection, and unlike anything perceived in either rheumatism or gout. Occasionally, especially in men, the disease is only found on one side of the body, and may show itself only in a large joint, as in the hip or the shoulder, or affect only the spinal column, producing immo- bility. Among its peculiar, though less constant symptoms, are very rapid pulse, sweating, and pigmentation of the skin, like freckles. In one of the forms of the disease, little nodes are found, especially at the sides of Ihe second phalanx of the fingers, and gradually increase in size. These "Heberden nodes" in time become associated with eburnation of the ends of the bones. Charcot has pointed out that in paralysis agitanti^ in addition to rigidity of the muscles, deformities of the fingers result resembling closely those of chronic articular rheumatism. But the likeness to the deformities caused by rheumatic gout is still closer, and to dis- tinguish them we must take into account the whole history of the case, the tremor, the fixed look, the peculiar gait, the indistinct speech, the tremulous handwriting, the sensation of excessive heat. More- over, the disfigured joints are not stiff, and do not crack. The or- thrapathies of hcomotor atcucia may be mistaken for arthritis defor- mans, but, irrespective of the history and of the characteristic pains, the absence of the patellar tendon reflex distinguishes them. All these joint affections following nervous diseases, and sometimes classed together as spurious arthritis, differ from joints attacked by rheuma- tism or by deforming arthritis in the absence of marked swelling and of pain, except on forcible movemient; stiffness is the prominent feature. no MEDICAL DIAGNOBIS; Doforming urihrilis is more comnjoii in women than in men; like rheumatism » it may b<^ excited by cotd and damp, and is very apt to occur in the weak and unhealHiy. It ^^enerally, even in cases that re- cover, persists for months. Nor will it yield to the remedies usually admini.stered in acute rheumatism ; nor tn colchicum and the alkalies, so beneficial in gout. Its causation is still unsettled. In children a form of arthritis deformans has been particularly described by Still, in which with the general enlargement of the joints there is swelling of the lymph-glands and of the spleen. I shall here add a short description of a disease of nutrition of dissimilar character to those described, but having this in common, thai it markedly afferLs tlie organs of locomotion, — rickets. Rickets.^ — In this country rickets is a comparatively rare affection, certainly rare as compared with its prevalence in England, in Holland, in Germany, and in some other Continental States. It is a constitu- tional disease of early childhood connected with impaired nutrition, and is chiefly characterized by increased growth of the epiphyses and I*eriosteum, and imperfect ossification, producing softening of the bones with curvatures and distortions. The changes arc most mani- fest in the long bones; and llie amount of organic matter in them is more than doul>led, while the calcareous salts are greatly diminished. Besides tlie osseous changes there is evident cachexia ; and the liver and spleen become enlarged and indurated from overgTOW*th of the glandular elements and interstitial development of fibroid tissue. A similar process may also happen in the kichieys and in lymphatic glands. Insufficient and ini[jroper food is a poweriut cause of rickels. The malady may show itself as late as the seventh or eighth year; but it generally sets in during the first or second year of life. Wven it leads to death, it does so usually by gradual exhaustion, by impair- ment of Uie digestive functions, by tlioracic complications, such as extensive bronchitis, pleurisy, or collapse of the lungs, by spasm of the glottis, by convulsions, or by chronic hydrocephalus. As a marked disease it does not usually last longer than a year, though the results of the osseous changes may long persist, and, afiiecting the thorax or tlie pelvis, prove eventually very injurious. The beginning of the disease is generally about the period ot dentition, and insidious. The child makes no attempt at walking, or ceases to walk if it have connnenced. It is languid, irritable, its face pale, its tissues tlabby. The appetite fails, there are thirst and ir^}g- ularity of tlie bowels^ or the marked signs of agastro-intestinal calarriu Restlessness at niglil, a disposition to throw off the bedclotlies. pn> RHEUMATISM AND GOUT. 781 fuse perspiration about the head, neck, and chest, while the rest of the body is hot and dry, attend an irregular febrile condition which soon shows itself; while fear of being touched, or general soreness and tenderness of the body or actual pain, bespeaks the local process that is going on in the bones and their covering. The changes in the bones now become more and more distinct. The joints appear swollen, especially at first the wTist-joints, and, when these are examined, the lower extremities of the radius and the ulna are found to be enlarged ; similar changes are perceived in the tibia and fibula, and in the elbow. There is tenderness along the ribs, and, should the affection continue, nodules are felt at the junction of the ribs with their cartilages ; the sternum protrudes, a pigeon-breast results ; then the limbs show contortions, the clavicles are bent, the spine may be curved, the pelvis deformed. The head is large and square, the fore- liead high, the anterior fontanel remains unclosed, the sutures are open and thickened on the sides. A blowing sound is frequently to be perceived over the cranial sutures. Dentition is delayed, or the teeth decay and fall out. The urine is copious, and contains lactic acid and an excess of phosphates. Convulsions, laryngismus stridulus, and tetany are among the complications. In advanced cases the symptoms of cachexia are very marked ; the flabby muscles, the wan, anaemic aspect, the large abdomen contrasting with the small face, the enlarged liver and spleen, the persistent tenderness over the bones, and at times the marked fever, give sad evidence of altered nutrition and of suflFering ; yet even then the little patient may recover, though most likely with part of the osseous system irretrievably damaged. Of course we have all kinds of gradations in the malady, and the general symptoms attending the morbid process may be slight, just as the rickety condition of the bones may be limited. The diagnosis will have been made apparent from the description of the symptoms. In advanced cases there can be no doubt. The changes in the bones, the curvature, the distortions, the appearance of the patient, the evidences of cachexia, clearly stamp the malady. Earlier in the disease it may be confounded with the manifestations of hereditary syphilis. But this affection comes on even sooner than rickets, almost from birth ; there are other signs of the constitutional taint, including early enlargement of the spleen, syphilitic coryza, and, at a later period, the notched teeth ; a distinctive history may perhaps be obtained ; and the enlarged bones not infrequently suppurate, the swollen epiphyses become detached, and osteophytes form, — changes not met with in rickets. MoUiiies ossium produces deformities which may be mistaken for iS2 MEDICAX DIAGNOSIS. those of rickets. But Ihe softening of the bone is the result ot lU disease, and not of its want of proper ossification. There is consid- erable difficulty in locomotion, and the bones bend or break, after having been affected with deep-sealed pains. The malady lasts for years, and is not one of childhood, being most common between the ages of twenty-tive and forty, and attacking chiefly women. The pehic bones are often implicated ; it is doubtful if the phosphates in the urine are increased, but, as in rickets, tlie urine contains lactic acid. Yet there are not the characteristic signs at the cranial bones, the open fontanel and sutures, nor the swelling of the epiphyses. wliich this malady so strikingly presents. There are cases described as acute rickets which are a eombinatioil' of rickets and scurvy^ They are most common in infancy, and gen- erally present the spongy gums only alnjut the teeth that have been cut. They sometimes show, in addition to periosteal hemorrhages, a sudden protrusion of one eyeball. In the early stages rickets may be mistaken for amte or mbaeuie rheuviaiiiffn ; the fever, the pain, the swx*ats, and the swelling near the joints mislead. But the age, the size of the epiphyses, the absence of redness of the joints and of heart-lesion, the ** beading'' of the ribs, the signs of beginning cachexia, the faulty dentition, and the pale urine full of phosphates, tell the true meaning of the sjinptoms. Moreover* the apparent joint-affection is apt to show itself at the wrist-joints, always a suspicious circumstance in delicate young children. Some of the local deformities that result and the diseases with which they may be confounded^ as of the thorax and of the head* have been elsewhere discussed. Besides the alteration of the skaOi in chronic hydrocephalus, the condition described by Elsacsser and] others as craniofabes may be mistaken for ordinarj' rickets. II consislfll in thinning of the bones of the cranium, especially of the ocdpttal bone, ^vhich becomes perforated, allowing the membranes oftlie brain to come in contact wiih the under surface of tlie scalp, and convul- sions may be induced by undue pressure over the points of perforaticin of the bone. The malady, though regarded by some as a separate affection, is by others, by Virchow among them, looked upon as due to a rhacliitic diathesis ; we certainly often find evidences of Uiis in conjunction with the peculiar alteration of the bones of the skull. ^ Barlow, British Medical JnurnaL 1883. i, p. 1029. and ** BrndsliAw Uvtine,** ibid,, 1894 ; also St Louis Courier of Medicine, 1881$, p. 4^. CHAPTER XII. FEVERS. Fever is eitlier a symptom of some strictly local malady or consti- tutes the only obvious affection present. In the latter case the disor- der is called essential or idiopathic fever. The first step, therefore, when fever has been recognized, is to ascertain whether it is sympto- matic or idiopathic ; whether, in other words, it is but a complement to a disease, or, as far as can be ascertained, the disease itself. This is not generally a difficult matter. The history of the case, the course it takes, the absence or presence of the marked peculiarities of seri- ous local disturbances, soon determine whether we are dealing with fever as a symptom, or fever as a disease. Idiopathic fevers, with some striking exceptions, are characterized by the want of definite and invariable anatomical lesions. That in all changes occur in parts of the nervous system, or in the blood, is highly probable. But there is no constant injury perceptible in the organs of the body : some- times one, sometimes another, suffers ; sometimes nearly all ; at times, none, certainly none in an obvious manner. When we contrast this with symptomatic fever, the difference is striking. The visceral lesions, then, of an idiopathic fever are not the starting-point of the fever, but rather secondary and uncertain complications. In idio- pathic fever, the fever controls the lesions ; in symptomatic fever, the lesions control the fever. Idiopathic fevers are mostly infective and of bacillary or^n. Most fevers run a definite course, showing a strong tendency to a spontaneous termination at a given time. At their beginning, too, they are for the most part similar. There is a prodromic state, marked generally by unsound sleep, pain in the back, and lassitude. This is followed by chills, which are succeeded by heightened temperature, arrested secretions, quick pulse, and evident fatigue upon the least exertion. The fever now reaches its full development and its precise character becomes evident. After a while the disturbance declines, or speedily ceases under the influence of critical discharges, and a convalescence, more or less rapid, sets in. An unfavorable termina- tion, on the other hand, may take place at any period after the system has been fairly invaded. 7K3 794 MEDICAI. DlAGXa^K^ Tbr maifced Scatores impressed Gpcc tbe S^r^s- -'ffha- liy ti»e <rc "C^ aZ leiiff£3a&aik€i of ier^fs e as ineL to a ipKot r-x^jFrt, a laatur of s^ jiiiespt is ^suit at a& ^ccaastrre or strk^ sassiv£ic: csasadcatkni. SoBie ^ifeordasw sac^ ^ <2»:t»£»a awi efwkinif dr^ef^^iy. ooesikred by oaanr .»*?g>^w^r pfl^Ksocs!^ to beioQ^ to K&ofnifak fer^ers^ bare do pfive as^^aed ^* ^ken : ^c»e2- OG^vShstukfiD^ 2s nwioGfaied cSaes. bas bees afm^Jr. i? FEflsoos. efeevlKf¥> coiaikivd. T«c ^«]^ a ffn in'fii p»:sct of vicv the anaiip«Dent ado{»ted k orfiT-iKKSfL aai is sQd&desLT acmsrate to be bee "^kxi praxe ob«ie:' sicL* *: 2ij>^n" "tif* mcnras* c SiznpLe Coetrniied Fever. — >c:i;t*r v^-^r^ :r ifoni'^a^ i^r«*s n FEVERS. 785 excited pulse, tliirst, headache, pain in the limbs. Tlie bowels are generally confined, the urine -high-colored. The fever is soon at its height ; it then either gradually declines, or is more suddenly relieved by copious perspiration or by a critical discharge from the bowels. Generally it runs through all these stages in a few days ; but it may be protracted for upward of a w^eek or longer. On the other hand, a day may witness both its beginning and its termination. The con- valescence is almost always rapid. The exciting causes of this form of fever are fatigue, errors in diet, change in mode of life, exposure to cold and damp, or to the sun, and there is no doubt that ptomaines may also act an important part in its production. When brought on by mental overwork or by anxiety or grief, it is not uncommonly attended with increased sensibility of the skin, and with considerable prostration, simulating typhoid fever, but dififering from it by the absence of epistaxis, of the peculiar abdominal symptoms, and of the eruption. More frequently the fever has the appearance of one of high action. At times, in- deed, it is so intense, and the vascular system is so wrought up, that the distemper assumes what is called an inflammatory type. It then exhibits the characteristics of the fever described by the physicians of the last century as synochus. A temperature of 103° or upward, throbbing of the temporal arteries, severe headache, and delirium are among its symptoms. This variety of the fever is not now encoun- tered, save in tropical latitudes, and is a form of the so-called thermic fever of Guiteras. In point of diagnosis, it is most apt to be con- founded with internal inflammations, especially with meningitis. But there is not the vomiting, nor the irregular pulse this presents. In addition to these ordinary forms of simple continued fever, which are of short duration, there is a form, rare it is true, of very long duration, and in which the fever may last for weeks, without internal complication or obvious cause. The absence of eruption, of enteric symptoms, and the negative character of the Widal test distinguish them from typhoid fever.* Catarrhal Fever. — ^This epidemic malady, which belongs to the idiopathic fevers, is sometimes described as a mere variety of bron- chitis, because inflammation of the bronchial mucous membrane con- stitutes one of its most prominent symptoms. But this is not a just view. With as much reason might typhoid fever be omitted from the list of febrile maladies and described as a variety of enteritis. ' See a paper of mine with illustrative cases in Amer. Jouni. Med. Sci., June, 1896 ; also Heubner, Deutsches Archiv fUr klinische Medicin, vol. Ixiv., 1899. 49 786 MHIUCAL DIAUN0SI8, ( atarrlial tev^-r. nv iulluciiza, is I'SSt'iiUally an epidemic tlis, uneasiness about the tliroat, and a tomientiiig cough. But associated with these are great depression of spirits and usually an extraordinary' amount of lassitude and impaimient uf strength,^ — rnucli more than the cold in tlie bead, or tlie lary^ngitis, or tlie bronchitis, will accourU for. The skin is hot, at times covered with perspiration ; tlie tlieniiometric record is peculiar only in its ex- treme in'e;j;ularity. The temperature generally ranges between 1(M}° and 102°, or starts up suddenly to 104*^ or 105^, and in less than a day subsides almost to normal ; the pulse is of moderate volume, the tongue coated ; the patient complains of debility, of headache, of aching pains in his back and limbs, and of constriction at the lower part of the cliesh Otlen tliere Is some dyspna^a, as well as epistaxis, hypenesthesia, especially of the neck and head, and disturbance of the alimentary trait, evinced by toss of appetite, nausea, and vomit- ing, or by diarrlnea, ( Vimmonly after three or four days these sym|> lonis begin to subside, the cough and debility outlasting the other morbid signs. The cough is often dry and harassing, and chiefly laryngeal. But all epidemics do not run precisely this course. In some, the prostration Is not so evident, and the febrile signs are more active and of an uiOamnuitory type; in others, ttie pain and soreness in Uie limbs and in the Joints are the most prominent symptoms ; or vrc may find hemicrania, or torpor and delirium, or parotitis with saliva- tion, or otitis, or epistaxis, or catarrhal jaundice, or bronchitis of tlie finer tubes, or pneumonia, or tendency to heart-failure, or meningitis, basilar or spinal, and irregular rashes, as complications. FiuiJier, as complications or seijuehe of infiuenza have been observed vht' psychoses and neuroses, or neuritis, local or multiple, bulbar p acute ascending paralysis, hemiplegia, diabetes, vascular occlusion* gangrene, angina pectoris, inflammation of the lymphatic glands and * Pteifl'er, Zeilst-brifl flir Hyg^iene and InfeklioiiBkranktieiieii, Miirch 3, 1898. FEVERS. 787 of the antrum, acute nephritis, and painful and inflammatory afifec- tions of tendons, fasciae, joints, periosteum, and bones. The disease also brings out a latent syphilitic taint.* The lung complication of influenza is striking. It is mostly an intense congestion, with bronchitis, here and there with spots of con- solidation, a broncho-pneumonia. True lobar pneumonia is much rarer. The lung aflfection may be of long duration, showing the record of a fever with marked rises and remissions. After declining, the temperature may become subnormal and remain so with occa- sional exacerbations for a long time, as seen in the accompanying chart of a case in my ward at the Pennsylvania Hospital.^ Influenza is not ordinarily in itself a fatal disease. It is only so in the very young or the very old. It is also a grave malady in persons with weak hearts. A source of danger is the indurated lung it may leave behind becoming the seat of tuberculosis. Catarrhal fever is easily discriminated from other maladies. Its peculiar epidemic character and the prostration prevent us from mis- taking it for an ordinary cold or bronchitis. Occasionally the attend- ing debDity makes it look like the onset of a long-continued fever. But brain-symptoms are present only in rare instances in influenza ; and, on the other hand, decided catarrhal symptoms are not common in typhoid and typhus fevers. Before long, too, the eruption of these diseases clears up whatever doubt may have existed ; rashes of any kind are extremely rare in influenza, and are of irregular type when they happen. At times there is a long-continued fever in influenza like that of typhoid fever, but the Widal reaction of this is lacking. Catarrhal fever may be mistaken for hay-fever. But the local symptoms of irritation of the nostrils, the watery eyes, and the red- dened conjunctivae are very striking, and the febrile movement is gen- erally less than in catarrhal fever. Moreover, there are asthmatic symptoms in hay-fever or hay-asthma in a certain proportion of cases ; and the histoiy of the case, the manner in which it comes on as a rose-cold in the latter part of May or early in June, or as autum- nal catarrh after the middle of August ; the hereditary idiosyncrasy so often seen ; the persistence of the attack while exposed to the peculiar vegetable emanations that give rise to it ; its almost abrupt cessation on removal to certain localities, — make up a set of features which are very distinctive. > Howard, Lancet, July, 1899. *-' For a full description of the lun^r complications of influenza, see my pajier on lh»:r subject in the ** International Clinics," Vol. I., Si'cond Series. FEV'ERS. 789 When influenza is prevailing on a large scale, it is often found masked by other diseases, and it may be dillicult then to separate its manifestations from those of the malady it accompanies. Other pecu- liarities of influenza are the long time it takes the patient to regain his strength, and the annoying sweats that attend convalescence. This was striking in the epidemic of the early winter months of 1890 ; as was also the tendency to repeated attacks, to irregular heart action, and to alterations of cutaneous sensibility. Typhoid Fever. — In this country and on the continent of Europe a form of continued fever prevails, especially among young adults, that is marked by great prostration and disturbance of the nervous system, and by constant anatomical lesions. To this disease tlie designations of typhoid fever, enteric fever, and abdominal typhus have been applied. The distemper may set in suddenly, but more generally it has an insidious beginning. For some days preceding the access of the fever the patient feels weak. He is without animation, complains of sore- ness and fatigue, of dull pain in the head, of loss of appetite. His sleep is unsound ; all exertion is wearisome. A fever now appears, preceded mostly by a chill, or by chilly sensations, which alternate with flushes of heat. The muscular prostration accompanying the febrile movement becomes so great that the patient is obliged to keep his bed. His appetite is entirely gone, the tongue is coated, the bowels are loose, the abdomen is somewhat swollen and tender to the touch. The malady has now completed its first week. It enters on the second week with fever unabated, and with the signs of disturbance of the alimentary tract and of the nervous system more and more unmistakable. There is sometimes nausea or epigastric distress, often pain in the right iliac fossa, increased by pressure and tympanites. On close inspection, a few reddish spots, resembling flea-bites, are found on its surface. The tongue dries and becomes reddish or brownish ; it is often glazed and covered with a light coat ; sometimes it has deep fissures ; very frequently I have noticed at the tip a wedge of brownish or reddish surface free from coat, but which begins to bo covered over as the disease declines ; the gums and teeth are lined with dark crusts. The mind is dull and wandering; cough and great restlessness exist ; the debility is extreme. The disease now begins to draw to its close. It has reached the third week, and a change, for better or for worse, may be looked for. Slowly recovery sets in, marked by a brightening of the countenance and by a gradual increase in consciousness and strength ; or deepen- 790 MEDICAL BIA6N08IS. ing insensibility, jerking of tlie lendons, feeble pulse, and cold, clammv svveats indicate that dissolution is fast approaching. Tlius, in one way or the other, the fever itself is apt to terminate by the begiiniing or, more generally, by the middle of the fourth week. Yet such is not always the case. Death may take place at earlier period ; or, on the other hand, the malady, by troublesomi complications, may be lengthened beyond the second month. Under any circumstances, convalescence is protracted. The nervous system rallies but gradually from the shock it has received. Among the symptoms enumerated, some tend clearly to charac- terize the disease. And, first, of the more purely febrile symploms. The skin during the fever is mostly dry. But Uiere may be an arid perspiration, verj' manifest during the whole course of the disease, and also encountered long after convalescence has set in. The pufjie is accelerated, mostly about 120, and is rapid even after the fever has left, though in convalescence it may be much slower than normal ; it is very compressible, and, intercurrent acute inftammations notwith- standing, it seldom loses its compressibility. A jerking, it r beat, or very great rapidity, a rumiing pulse, is an unlavoral* Dicrotism of the pulse is not unusual. Associated with the dimin- ished strength of the pulse is a decided faintness of the first sound of the heart. The tempertUure is peculiar ; in the first five or six days of Ihe disease it pursues an ascending line ; that is to say, starting al the normal i>8.*>° F., there is a daily evening rise of about 2^* mllij a morning remission of about 1^. From the fifth or the sixtli day to the twelfUi or a little later, — roughly speaking, we may say fixiro the end of the first week to the end of tlie second, — the fever is continuous, with a morning remission rarely exceeding I*'. From J that time on, let us say firom the twelfth day, altJiougb the eveiung temperature may remain for a day or two <[uite or nearly as lijglu there is an abatement of from 1° to 2° in the morning. These changes between morning and evening become very evident at thi? end of the week, and are still more evident in the thin! week, when the morning and evenuig temperatures may vary as much as from 4^ to 6°. During this week, too, the evening temperature gradually de- creases ; but in severe cases it remains high, and there are no decided remissions either in the second or the tJiird week. The tiioming temperature is high, 104^ or more, and there may be still greater heal of skin in the evening, or else it differs but little from tlial of Ihe morning. One hundred and six degrees is a high temf)erature, but I have known it 107.5", yet the patient recover. The peripheral teni- FEVEI{.<. 791 perature, as measured, for instance, in the palm of the hand, becomes during the fever as high as the axDlarj^ temperature, but their equali- 3 5 zation ceases prior to defervescence.* In exceptional instances, the temperature may be normal throughout ; ^ in still rarer instances it ' Couty, Archives de Physiologie, No. 2, 1880. * Vallin, Arch. Gen. de Med., Nov. 1873 ; Finlayson, American Journal of the Medical Sciences, March. 1891, p. 225 ; Wendland, Deutsche Medicinische Wochen- schrifl, Aug. 29, 1892; Dreschfeld, Practitioner, No. 298, vol. 1., p. 272; Fisk, 792 ^fEDICAL DIAGNOSIS. is subirornuiL' I have never seen a case of either kiiiih (JeeiLsionally the curve may resemble that of intermittent lever," Again, tlie fever may terrninale by crisis at the end of the third or in the fourth week. This I have met witli more than once. The ujnne is aeid, high-colored, scanty.— the urine of fever. EJu'iich has stated that the urine of t)*phoid fever ^ves a special rt^- at tion, — tlie diazo reaction, Tliis test consists in taking forty parts of a satyrahnl sohitioo of sulphanilic acid in hydrochloric acid, one to twenty T and one part of a one-half per cent, solution of sodium nitrite, and adding them to an equal bulk of. urine rendered alkaline by strong ammonia. Normal urine is colored brownish by tlie test liquid, typhoid-fever urine pink or ruby, with slight frotliing. The reaction has not bc^en found in all cases of typhoid fever, .and has been obtained in a variety of other morbid conditions, such as tuber- culosis, typtms fever, measles, scarlatina, enteritis, malaria* pneu- monia, meningitis, sepUciemia, unemia. The toxicity of I he tirine is greatly increased in typlioid fever. Robin' regards t^K' urine as chaj*acteristir even from the onset ; the chief characteristics bc?ing a peculiar odor, constant presence of albumin in moderate atnounU absence of urohiematin, presence of indican, increase of uric arid, niiuked diminution of tlie earthy phosphates. As regards the albu- min, I do not think it constant, and it is not in lajige amounb. H b most marked in severe cases and those with high lem]jerature, and co- exists with a few tube-casts. In the so-called rennf type of tjrpboiiL In which an acute nephritis for tlie most part happens, we also find red corpuscles, free granular epithelium, and casts of variotts kinds, though not oily ; there is considerable albumin, and oflen at the otisH a scanty bloody urine. Tlie kidney involvement may mamfest itself from the start, and persist throughout. In *very rare mstunrf^ of typhoid fever there is marked hiematuria. Among the abdominal symptoms, diarrhtm t- j r mostly present, except when the disease is imosiialh i i. . ;^ prevalence varies in different epidemics, (lenefally it is a vi^r; early symptom; at limes il is even seen a; 'udrosoes, Tb«f to its cause is found in the state of i'^. . al ^and^ in the largement and ulceration of the glands of Peyer and of the Mediad N^irs, ICof. 3, 1894. p. 479 phis l^Aneet, laly , IB9S, * RaitiKindi. GuHl» ile« H Afnlaiix lUrOiKiisll, Uumel, April IS. I8M ; \m4 \o 1tK4 iVistniMill i^ FEVERS. 793 glands, with the tumefaction of the mesenteric glands. And in these morbid alterations we find an explanation not only of the occur- rence of the diarrhoea, but also of its frequency. The stools are thin, of a yellow or dark-brown color, and of offensive smell. When the affection is at its height, from three to four evacuations occur during the twenty-four hoiy^; but the passages may become much more numerous, and with their number the danger rises. If they take place without the knowledge of the patient, his situation is precari--* ous. Sometimes the stools contain blood. Should this be present Fig. 76. Eberth typhoid-fever bacillus, from a potato culture. The broad ones are really two bacilli lying in juxtaposition. Zeiss ^, homo. im.. Oc. 5. in considerable quantity, it is a very unfavorable circumstance. Yet intestinal hemorrhage is by no means necessarily fatal. In rare in- stances there is haematemesis, in others haemoptysis, and this in the absence of any pulmonary lesion.^ The bacillus giving rise to typhoid fever is the bacillus typhosus described by Eberth and by Gaff ky (Fig. 76). The bacillus is chiefly found in the intestinal lesions and in the stools. But it is very gen- erally diffused, being met with in the gall-bladder, in the bone- marrow, in the blood, in the coats of vessels, and in the urine even in cases in which there are no renal symptoms. It is a rather plump » Dickinson, Lancet, Feb. 17» 1894, p. 421. MEDICAL DIAGN08IH. Lirganism from two to three fi long, with rounded ends, actively motile, and staining with the ordinary aniline eoloi-s. It is very sensi- tive to high temperatures, and does not form spores. Unlike the colon bacillus, the typhoid bacillos does not cause fer- mentation in glucose-containing solutions, nor does it curdle steril- ized niiik ; it grows readily on gelatin plates. Potato cultures of the typlioid bacillus are, as a rule, scarcely visible, w^hile those of the colon bacillus appear as distinct, broad, orange streaks. Finally, the typhoid bacillus does not yield the indol reaction with the ordinary tests, while the colon bacillus does. For diiignostic purposes the most valuable jiroperty connected with the bacillus typhosus is the arrest of motility and the agglutination occasioned when brought in contact with immune serum or a culture of the typhoid bacillus,^ — the Widal test. The clumping that occurs is characteristic* and happens in from one to fifteen minutes with a dilution of 1 to l(K The applicability of the test has been immensely widened by the use of dry blood, as suggested by Wyatt Johnston ; it is thus largely employed for purposes of public sanitation. A drop or two of blood is colletled on glazed paper and can be transmitted to a laboratory by mail, and is for a long period ready for testing by simply dissolving the dried blood in water.^ The Wtdal reaction is the tnost important of all recent additions to the diagnosis of typhoid, or, indeed, of any idiopathic fever, I have used it very extensively at the Pennsylvania Hospital, and believe in its wide applicability. It gives accurate results in fully ninety-two l*er cent, of the trials, if the technique be careful, and many of its supjiosed failures are due to defective technique, (t has, however, its limitations. If a person lias once had typhoid fever the reacUon may show itseH* for years allerwards, and be very misleading stiould a fever attack of doubtful character occur. Then it is of little value in the first week of the disease, rarely being manifest before the fourth day, and often not until the sixth to the eighth day. It may not show itself until very late in the disease. Thus in one of my cases of renal typtioid, repeatedly tested, there was no Widal reaction until in the fifth week. It is sometimes obtahied wdiere there is no clinical eW- dence of typhoid lever, though we must remember, especially in hospital practice, the possitiility of the j>atient having had this years before. I have found most of these erroneous tests to be in instances of acute rheumatism, of acute tuberculosis, and of nephritis. ^ For the exact and fulli*r tochniqup, sflf works on bacleriology, or •*Th«* Diiignosis of Disease/' l>y Cabol, 1899. FEVERS. 795 Enlargement of the spleen is a very constant attendant upon the fever. The tympany that often exists interferes mth the recognition of the enlargement. Another abnormal symptom of significance is pain. It varies much in severity and character, and is, indeed, not always present. It is often a heavy, aching feeling. In some patients it is of a griping kind, preceding the loose discharges ; in others it seems to be called into existence only by pressure. Its most common seat is in the iliac fossae, especially in the right iliac fossa, and the pain corresponds, for the most part, to the seat of thB lesions. In rare instances the pain is really in the muscles, which may, indeed, suppurate.* Often, while the hand is exploring the abdominal regions, a movement of the fluid and gas in the distended bowel, attended with a gurgling noise, becomes appreciable. This sign is best elicited near the ileo- caecal valve. During convalescence, griping pains are not infrequently com- plained of. They are colicky pains, produced generally by errors in diet, and may be followed by a return of the diarrhoea. But pains at almost any stage of the disease may be also due to peritonitis and to perforation. Hardly inferior to the abdominal symptoms in import are the signs of disturbance of the nervous system. The fever is, as its old name implies, pre-eminently a *' nervous" fever: the nervous symptoms are, in truth, never absent ; but, though always present, they are less extensive in some cases than in others, and not the same throughout all the stages of the disease. Thus, early in the disorder, dull head- ache, mental languor, wakefulness, and a perverted state of the senses, such as ringing in the ears and dulness of hearing, are encountered ; while later, great restlessness, delirium, somnolence, or coma, and jerking of the tendons are phenomena more likely to be met with. Occasionally the disease is ushered in by acute mania.^ In some epidemics the nervous symptoms are so pronounced that a cerebro- spinal type of the disorder is recognizable. The delirium sets in generally during the second week, for the most part at night, and terminates with convalescence or ends in coma. It is not a wild delirium, but a confusion of mind associated with rambling thoughts. If the patient's attention be strongly en- gaged, he may be almost always roused, and does for a time as he is * Ebing, Archiv fISr kiln. Med., viii. ^ Hare and Patek, Medical News, June 20, 1891, p. 681 ; MacDougall, Lancet, April 15, 22, 1893. 796 MEDICAL. DIAGN08I8. told ; but after a short interval his in uttering lips indicate thai some curious faney has again taken possession of him. In some cases, not in many, the delu'iuni is attended with great restlessness and agita- tion, and the sick man, if not prevented, attempts to walk about the room. This kind of frenzy ofl^n ends in fatal coma. Equally un- promising is early or unremitting delirium. When contrasted with the mental wandering in other acute disorders, the delirium of typhoid fever exhibits |)eculiar traits. It is ordinarily more active than that of typhus ; far less demonstrative or talkative than the mania of drunken- ness ; as aUnless as, but less continued than, the ravings of inflamma- tion of the brain, Oreat restlessness and tremoi^, associated with a clear mind* and at times with copious perspirations, have a verj* sig- nificant meaning: they point to deep and extending ulceration. Other symptoms of grave disturbance of the nervous system shov%^ themselves in violent general convulmom. These are more common in children than in adults, in whom they may be a late symptom; tliey may or may not be of ursemic origin* The knee-jerks are present, unless peripheral neuritis exists. In severe cases both the reflexes and the muscular irritability are said to be increased.* On the other hand, it has been observed that in children tiie tendon-reflexes are often enfeebled during the acute stage of the disease and exagger- ated during convalescence.- In some cases of typhoid fever symptoms not only cerebral but also of spinal origin appear, and they may, indeed, assume a high degree of intensity. We find extensive cutaneous hyperaesthe^ia, spinal pain and tenderness, with a sense of pricking along the verte- bral column, and, in some instances, cutaneous and muscular anaes- thesia, numbness of the extremities, partial paralysis or convulsive contractions of the respiratory muscles, con^Tilsive cough, paralysis of the sphincters, contractions of the extremities, and even rigidity of the muscles of the neck. These spinal symptoms are more conmion when the disease is epidemic than when it is sporadic, and are always indicative of a very serious form of the disorder. They sometimes persist after the fever has left, or indeed — and this is especially true of paralysis — may not appear until convalescer»a\ The y>r lo imciliiiT trfiicid infec- Tbr aq:«f "rMii is ik:c TLfnyTXfh'iiT ibr fieai nf trpiKid iiiceis. aud Ihey iiAT t:T*-!i kad *o j:»rrfcear McBcrDej's jcar-l. a r«eTi:jc«ia:is 5t»rt«Sap ^con there, lipdity of il>e ri^t rKlias m^is-t-jr, se^isje of resastazK*- cc drfumsimbed iHDsk*n ill iLe ri^t iia<- iossa. azid Tciini±]^ srt tbe mosi s^gxu&aiit sTniptwrtf- I*eaT«T * iays s^trerss oij the ra'asea asd TosnitJng ceasing wfaeii ti>e piixi becomes k^alzzied i!i the light iliac- iossa : there may or may ijc»* be the faisiofy ci a p«^T>i:»:2s anaie^ The syr:4:4cere iras -ie^iie^i jeD^ct^rtosas. Tbe worst of the t'om|:»5cat>:«!is of "nrricod fe-Ter is prrfc»naTi»y%. This ortCTirs in frf>m two to two aryd a half j»er ^^ent. of the tastes, and it fe aseiled to he rather more oc^snmoeL wher. zbr fai'i: treatment has been eEpkjT't^i It is miirh mc-re "zssTsal in rser ^^^air ir^ wc»men, and is Terr ^r.rrsLlJy fetal Tie a:':5ir:L: ijsri^y i^iteis £■ the ^zii :*:' the ^ird week- :t ^ter. ■Lh:*:^^ ;: i? ijc-: ritrenely irirerjen: in •Jjr SK^C'iii week- At diiiies "ir synj-ir.r::? c-f r»rr:M:sLtJoi: are iaten:. and maske-i iy ±v ^i;eral iraTin- •:•: ibe v-iSie. an-i ibe pva: mete-rinsn: : it is 01. -T a: iLe ar^irtsy '±^i thr i»rrfM:k:i:»:: is fz-^nd. Whei: p-erfoia- tic«i. >v-Asd:'r_s sympToiLS. *±ese irv of m-o kir.'ds : ibere is either -.x*'.- iajiise folowe^i by jteritonias, cr i-eiv is i s: reading itersionius wiu:- ou: tie si^T_s >f .o.La^^se. In ih.^ nrs: :ase we meet with sudden ac-:;:e ai-doiiinil piain. referrei :. ^.e ..wrr _r.ar c' ie ai>domer., TOEiung. signs •:■: i-rnstratiMi. lin ned rViinres. npdity of the r>Kn m.is..'.es. a: 'imes lal :f :enii»era:-.:rr. an.i surrs^xjenny !:h£is, e^evate-i ten-p-eralnre. l>-al :endemess, f:C:wei ry siivadiise peritonitis. Ir. the So: end :ase ±e j-^rritcnins al:ne is marke-d. and is attende-i ; r no: w:-± :yn:j:*ciiu': dis:rnn:n :r T:ni:±i^ :r swears, but always wi::. FEVEK8. 801 obviously increasing gravity of the case. Under either set of circum- stances great diminution of the hepatic dulness is a vahiable sign. To this may be added marked leucocytosis, as found by Thayer. The same symptoms as those of intestinal perforation may be due to per- foration of the appendix or of the gall-bladder in typhoid fever, and no distinction is possible, unless the exact seat of the pain and of the early peritonitis and the history of the case enable us to maJce it. Occasionally, unfortunately not often, inflammatory adhesions close the perforation and recovery ensues without an operation ; or a local- ized abscess results. The peritonitis and intestinal adhesions that follow perforation may be attended with symptoms of obstruction of the bowel .^ Sometimes sequelae appear long after the primary disease has come to an end. Orlow^has reported a case in which five and one-half months afterwards typhoid bacilli were detected in a granuloma of the tibia, P^an and Cornil * observed a case in which five months after a typhoid-fever attack typhoid bacDli were found in the lesions of a suppurative periostitis, and Van Dungem * reports an instance of typhoid bacilli met with in the pus fi'om an abscess around the gall-bladder fourteen and a half years after the attack. Sudden death may take place in the course of typhoid fever as a result of disturb- ances in the circulation, fi'om the formation of blood-clots, from inflammatory and degenerative changes in the muscular wall or dis- order of the nervous supply of the heart, or from the poisoning of the system that is an essential part of the disease.^ Death has also resulted from profuse sweating.* The disorders with which typhoid fever may be confounded are not the same at all the stages of the complaint. Early in the affec- tion it is most likely to be mistaken for simple continued fever, for in- fluenza, or for one of the exanthemata. But diarrhoea is not present in these, nor are there marked prodromata; and whatever doubt may exist with reference to the first two is cleared up in a few days, since the temperature-record is different and the acute symptoms generally come to an end at a time at which in typhoid fever they begin to be more and more developed. The exanthematous fevers ' Blaikie Smith, International Clinics, vol. i., 2d Series, 1892, p. 79. * Deutsche Medicin. Wochenschrift, Nov. 27, 1890. ' ' Bull, de TAcademie de Medecine de Paris, April 14, 1891. *Mtinch. Med. Wochenschr., 1897, No. 26. * Dewevre, Archives G^nerales de Medecine, Oct., Dec. 1887 ; Galliard, ilnd., May, June, 1891. * Juhel-Renoy, Archives Generales de Medecine, 1886, vol. i. p. 274. iVO •802 MEDICAL. DIAGNOSIS. cannot before their eruptions appear, be distinguished with abedote certainty ; thou^ we may suspect measles by the cor3rza. scariatina by the sore throat, and smallpox by the lumbar pains and high fever. At a more advanced period, typhoid fever may be confounded with typhus, and with these morbid states : General Debiutt : Typhoid Coxomoxs : ExTERin? : PERrroxms: AppEXDicms : Mexixgitis: Ulcerative Exdocarditis : Acute Ptlmoxart Ajtectioxs. General DMlUy, — It does not seem likely that so acute and dan- gerous a malady as tjrphoid fever could be mistaken for mere debility : yet such an error may occur when the disease is latent or so U^t as not to confine the patient to l>ed. In these so-called ** walking cases** the debility, however, sets in suddenly, and not gradually, as in weak- ness from general constitutional causes. Moreover, the abdominal symptoms are rarely wanting, and there is mc«e or less confoaon of mind. The thermometer is of 4gnal value. But the greatest safe- guard against error is to be aware that the disease assumes at times a latent form, and to examine every case of sudden debility, to see if under its mask are hidden the features of typhoid firver. Typhoid Condition*. — Xo blunder is more commcn than to mis- construe into typhoid fever a typ»hoid o:»:i'i::iori of the system. W- may find this condition in many different ojciplainis. i«h a^jute ani chronic: but more especially are punileGt irJ^:dor.. s«:-:r^-r roms c: pneumonia, dysentery, erysipelas, and absf-ess o: :Le ki-inry attrii':-: with delirium, drowsiness, dry. bn^wn tor;^>ie. aM extrrzit pr:t?:r*- tion. — in one word, with a typhoid state. Yet a typ»ho;d state is not typ«hoid feT»^r; it is si^ip-.y a low .:c-c»i:- tion of the system which may be present in many diiganr.ar irjLa.ifrs. and which is present in its most f^&rfe^:* form in tyih»:*i 5evrr. But in this disease we have other stms than i'>se •>: aciyrami^ : wrj- *^^^i j(Mned to it diarrhoea. tymp»anites. epistaiis, an rr:;r-t>>n- s^^milI niani- teMinoQs Di oisiurDancr oi me Qtiirou^ i¥Coffd,aiid the vm: kacoGvtosfew What exaetlT pcf ' ^kl^^^^^K ^ to say. MUDer Fotimfill ^ I FEVER8. 803 creased renal activity, and with the accumulation in the blood of the products of the tissue-waste. At times we meet wth a fever attended with typhoid symptoms and diarrhoea due to contaminated drinking-w^ater. The septic fever, of which on one occasion I saw a number of instances at the Penn- sylvania Hospital among sailors from drinking bilge-water, is, how- ever, of comparatively short duration, and has not the characteristic temperature record or eruption of typhoid fever. Enteritis. — The great difference between enteritis and typhoid fever consists in this : in enteritis the inflammation of the intestine constitutes the disease; there are no symptoms other than those referable to the inflamed intestine. We find no great prostration ; no mental wandering ; no enlargement of the spleen ; no rose-spots ; no signs of abnormal processes due to a typhoid dyscrasia. The dis- order, too, gives rise to much more abdominal pain, and is of shorter duration. In certain rare cases the follicles of the intestines are in- flamed and swollen, and the attending febrile malady may closely simulate typhoid fever, without, however, its characteristic intestinal lesions, or eruption, though with considerable diarrhoea and swelling of the spleen.'^ Again, I have known fecal accumulations in the in- testine to produce and keep up diarrhoea and continued fever of sev- eral weeks' duration similar to that of typhoid, and ceasing only when the large fecal masses were voided. The absence of eruption, of cerebral symptoms, and of enlargement of the spleen proved the points on which the correct diagnosis of the non-existence of typhoid fever was based. In all such cases the Widal test would be of value. Peritonitis, — The same remarks apply to peritoneal inflammation. Here, moreover, the expression of the face, the constipation, and the great abdominal tenderness serve as marks of discrimination. The low continuous fever in tubercular peritonitis may be very misleading, as well as the gradual development of the disease and the tympanitic distention. But the history of the case, the irregularity of the fever, the supervention of ascites become very significant. On the other hand, we must not forget that acute peritonitis may appear in the course of typhoid fever. Generally this untoward event happens at a late period of the disease, and is connected with intestinal perfora- tion, and, as a general diagnostic rule, we are right in assuming, when peritonitis is found in typhoid fever, that there has been perforation. But in very rare cases there is no such association. Appendicitis, — The diff'erential diagnosis between typhoid fever and * Cazalis and Renaut, Archives de Physiologic, 1873. 804 MEDICAL DIAGNOSIS. appendicitis has been inquired into with the latter affection: their coexistence has been just mentioned with the complications of typhoid fever. Meningitis. — Typhoid fever has some symptoms in common with inflammation of the brain ; but the signs of difference have been dis- cussed in connection with acute meningitis, and need not here br examined. The temperature record is very significant, and Kemig's sign is said to be absent.* But in rare cases we really have meningitis as a complication of typhoid, showing small pupUs, strabismus, vomit- ing, and rigid neck ; in the exudate in the meninges typhoid bacilli have been found. The distinction from epidemic cerebro-spinal mt-n- ingitis we shall presently trace. Ulceraiive Endocarditis. — In some cases the differential diagnosis between this and typhoid fever becomes of great difficulty, especially if the case be not seen until the endocarditis have led to delirium and the symptoms of collapse. Recurring chills, with high temperatmv and sweats, as in malarial fever, great rapidity of pulse, with sudden changes and marked irregularity, a generally diffused roseolous erujh tion, and the signs of the cardiac lesion, form the most trustworth} points of distinction. Acute Pulmonaiy Affections. — In the majority of cases of typhoid fever we find cough, dependent upon an affection of the bronchial tubes. The bronchial affection gives rise to extreme loudness of the rales, with a cough disproportionately slight ; sometimes, too, owing to the blood gravitating to the most dependent portions of the lungs, the resonance over the posterior part of the chest is impaired. Fn»m these phenomena, added to the abdominal and cerebral symptoms of the fever, the eruption, and the vital depression, there is no diflicuity in discriminating between idiopathic bronchitis and typhoid fever. Not infrequenUy we find a dry pleurisy combined with the bn»n- chitis, and in some cases, not in many, the cough is associated with exudation into the pulmonary structure. Now, it may be extremely difficult to distinguish a pneumonia of this kind from inflammation of the lung setting in amid signs of prostration, until the eruption and the abdominal symptoms solve, the difficulty. Generally, however, it is not a matter of much doubt, as the condensation of the lung in typhoid fever does not occur early in the disease, — not, in fact, until the symptoms of the fever are clearly developed. At times, however, typhoid fever sets in acutely with the signs of acute lobar pneumonia ; there is a chill, followed by high fever : there * Keller, Revue des Maladies de TEnfance, Sept. 1898. FEVERS. 805 are no abdominal symptoms. The lung consolidation does not un- dergo resolution, and in the second week or later diarrhoea appears, and the characteristic eruption of typhoid fever may or may not show itself. The general typhoid condition gradually becomes marked. It is very difficult to distinguish these cases of so-called pneumo-typhus — chiefly described by Wagner * and other German observers — from pneumonia of a low type ; they depend upon early and extreme bacil- lary infection of the lungs. The eruption, when present, is very valu- able, as is the Widal reaction. Occasionally a cough remains after the typhoid fever has left. The patient soon loses the strength he may have acquired ; the temperature is again higher, and over both lungs many fine, dry, or moist sounds are heard. The percussion-note is here and there dull ; profuse ex- pectoration, dyspnoea, and excessive sweating are noticed. An exam- ination of the sputum shows that the case has become tubercular. But, as regards the lung symptoms of typhoid fever, we must always bear in mind that acute pulmonary tuberculosis may simulate it ; the high fever, the prostration, the scattered rales in the chest, with here and there spots -of dulness, evert the delirium, the stupor, and the enlargement of the spleen may be present ; but the eruption never is, and the diarrhoea rarely. In general acute miliary tuberculosis the similarity is even greater, and diarrhoea is not uncommon ; the dis- ease is, as a rule, longer. Tubercle bacilli may or may not be present in the sputmn ; they have been detected in the urine and in the blood ; when present they enable us to make a positive diagnosis. In rare instances the two diseases coexist. In concluding the subject of typhoid fever it will be proper to notice those forms of the affection which run their course in a different man- ner from that ordinarily pursued by the malady, — there are especially two, — the mild typhoid and the aboHive typhoid. The former has usu- ally a gradual beginning, and the disease throughout remains mild ; its duration may be, however, the same as, or even longer than, that of ordinary typhoid, or it may be considerably shorter, — in fact, an abortive typhoid, the variety of typhoid to which JUi^ensen especially has directed attention.* Yet the abortive type is not always mild; cases are mentioned* in which the temperature rose to 106°, but in which the duration of the fever was only from seven to twelve days. > Archiv fUr klin. Med., Aug. 1884. ' Sammlung klinischer Vortrige, No. 61, 1873. See also paper by Johnston, Amer. Joum. Med. Sci., Oct. 1875. ' Liebenneister, in Ziemssen's Cyclopaedia. 806 MEDICAIi DIAGNOSIS, Indeed, it is the short duration that is characteristic of iiboi^ive typhoiff. As a rule, il begins suddenly, and the temperature reaches its highest point on the seeond or third day. It ofleri does not exeeed 104°, and it stays at, or near, the height il has so speedily attained for the greater part of the duration of the fever, and then remissions show them- selves» and there is a gradual return to a healthy standard, much in the same way as at the end of ordinarj^ typhoid fever : or the ehaDgi*s are so marked and rapid that the defen^escence is accomplished in a few days. The symptoms of typhoid fever are all met with in the abortive malady, though they are not present with the same con- stancy ; tenderness in ttie right iliac fossa is the most frequent ; en- largement of tlie spleen and the rose-colored spots are ver>' usual; diarrh(Pa is often wanting* Ttie disease terminates in sixteen days or less; but there is great proneness to relapses. It is not apt to be a fatal afleclion. I am certain it is one very rarely seen in this country. Much has been said about mountain fever, especially as it has been obsen^ed m Colorado and other mountainous regions of the Western States, being a separate form of fever. Bui it is not ; it is an Irregular form of typhoid in whicli the erupllbn is often absent. The obsen^a- tions of Woodrutt' and of Raymond, wtio got characteristic reactions with ttie Widal test, remove any doubt as to its nature that may have existed. Bradycardia, or slowness of pulse, is often present,^ Another variety of typhoid fever is occasioned by the eoea-uttmei' tinth malaria. Tlie manifestations of this occur mostly late in the disease, and chills are apt to call our attention to the ctiaracter of (he malady. But dulls olleu happen from other causes in typhoid fever: from ctiolecystitis, from peritonitis, from appendicitis, from pyteDiia, from masturbation, — of which I once saw a striking illustration. — from the decided use of antipyretics, especially the coal-tar prepara- tions, and sometimes without discernible cause. To be sure that the chills in typhoid fever are malarial, wi* must Ond the malarial organ- isms. But we shall, farther un, examine the cissociation of niahirm with typhoid fever more hi detail. In conclusiun, the interesting quesiion arises, In how far can we recognize fifphtAd Jtnr wit hunt intv^tinal trmom f We now know that this tiappens ; the bacillus typJiosus lias been found in the gall-bladder, gall-ducts, hmgs, and elsewhere, and tiiere has been a positive Widal reaction without any other marked sign. As yet we are nut in a con- dition to l>e sure of such a form of typhoid fever. There is ahvajs the possibility of a previous attack of typhoid being the cause ot^ Uir * Amer. Joum, Med. ScJ., Mai^h, 1898, ' Raymond, ibitL FEVERS. 807 Widal reaction. But it is a question whether irregular forms of fever, with persistent slight elevations of temperature and general depres- sion, for which no organic cause can be foimd, or many of the in- stances of afebrile typhoid fever, are not illustrations of this kind of typhoid infection. Typhus Fever. — This is a highly contagious malady, almost always met with in an epidemic form. It prevails in jails and camps, among crowded, underfed populations, or in badly ventilated locali- ties, and has no constant structural lesion. In this country it is a very rare disease ; indeed, it is becoming rarer everywhere. It is either preceded by a brief stage of lassitude and dejection, or is ushered in with a chill and pain in the head and back. The skin soon becomes dry and of pungent heat ; the pulse rises much in fre- quency, and is at first full, sometimes even tense. The patient lies in a state of half-consciousness, dull, drowsy, weak, with evident signs of his nervous and muscular system being overwhelmed by the influence of some fearfully depressing poison. There is headache and giddi- ness ; the face is flushed, the eye injected ; the odor frhm the body extremely unpleasant. • By the fifth day all these symptoms are plainly marked, and about this time a coarse, red eruption makes its appearance. But it occa- sions no change in the graWty of the symptoms. On the contrary, these increase ; the patient wanders, picks at his bedclothes, and ceases to complain of the pain in the head or limbs. The pulse is frequent and feeble ; the tongue drj' and dark ; sordes collect on the gums and teeth. The bowels remain as they were at the onset, — constipated. The urine often comes away drop by drop, or, as the bladder loses the power of contracting, is retained. The case has now reached its height ; the signs of a prostrated nervous system, of deteriorated blood, and of utter loss of muscular strength either begin to pass away, or deepen from hour to hour and clearly show the doom that awaits the fever-stricken patient. From the beginning of the distemper untU the unfortunate issue is rarely over thirteen days. If the sick man can withstand the poison until the third week, he is apt to throw it off and recover ; but it may be so virulent as to over- power him almost at the onset. Micro-organisms have been found hi cases of typhus fever, though it is not certain that they are characteristic. Dubief and Bruhl ^ have found a diplococcus, chiefly in the lungs and bronchial secretions, that they designate "diplococcus exanthematicus." Andrew Balfour and ' Univei*sal Medicul Journal, May, 1893. 808 MEDICAL DIAGNOSIS. Porter* isolated a diplococcus not identical, detected also in the blood which retained the stain by Gram's method, and which they believe to be the specific bacillus. Let us examine some of the symptoms of the pestilential disease : The skin is covered with a characteristic eruption, from which the disease takes its name of "spotted" or "maculated" or "exanthe- matic" typhus. The rash is at first slightly elevated and much like that of measles. It is of a dark tint, a " mulberry rash," and fades but does not vanish on pressure. It makes its appearance from the fifth to the seventh day, and is permanent, consisting not of successive eruptions, but of the same spots, which deepen or lighten with the changes in the disease, and do not pass away before the fourteentli day. Each spot thus lasts until recovery or until death, and no new ones show themselves after the second or third day of the rash. They are numerous on the trunk and the extremities, but are rarely observed upon the face. Some are much lighter than others, and thus a mottled aspect of the skin is produced. Sometimes the spots are of purple color and uninfluenced by pressure. These petechiae are attendants of the worst forms. The skin of a typhus-fever patient is often sensitive, and generally very hot. In some cases the thermometer indicates a temperature of 107°, or more; commonly it ranges above 104°. The heat is sus- tained : it does not show the decided differences between morning and evening that are observed in typhoid fever, the daily variations to the middle of the second week being rarely one degree ; and from that time onward the morning abatement does not amount to more than about 1.5°, until the defervescence is reached. The passing away of the high temperature occurs, however, not, as in enteric fever, by more and more evident remissions, but suddenly. Early in or towards the middle of the third week the temperature falls quickly, and in twenty- four or thirty-six hours a normal standard is reached. In rare instances, the temperature may not rise above the normal, or may be subnormal.^ The cerebral symptoms of typhus fever are never absent. Stupor is frecfuent. The patient lies in a heavy slumber, occasionally mutter- ing some incoherent words ; or he is sleepless, his eyes remain wide open, he has coma-vigil, he takes no notice of anything going on around him. Either of these states may deepen into coma. In other > Edinb. M«'d. Jourii., Wh. 181»9. ■^ Coinheniale. (Jazetto ht»bdoin. d*' Mt'uleciiu* ^'t dp Chirurgie. 1893, No. 30, j». 352. FEVEES. 809 cases delirium is the most conspicuous symptom. This dehrium rarely sets in before the end of the first week. In type it is low and muttering, and unaccompanied by great restlessness; or it may be associated with constant movements and trembling of the limbs, or jerking of the tendons, — in fact, with hysterical symptoms. Some- times the mental wandering is active and very persistent. The patient can hardly be restrained from getting out of bed. He has illusions of hearing and of sight ; his eyes are injected, the pupils often contracted ; there is headache, with intolerance of light. Here we have the true brain typhus, with its formidable cerebral symptoms simulating closely those of acute meningitis^ and differing only by their union with a cutaneous eruption, by the absence of strabismus and of rigidity of the neck, by the dissimilar aspect of the tongue, the great prostration, and by the beat of the pulse, which is rarely full, and never so tense as that of meningitis. Convulsions, should they occur, are generally of anemic origin. The head-symptoms of typhus are, like those of enteric fever, sometimes connected with a noisy, shallow, and irregular respiration. This kind of breathing can be clearly traced to the abnormal state of the nervous system, as no signs of alteration in the lungs coexist. Often, as Flint ^ has pointed out, it is a forerunner of fatal coma. In one case I found the strange phenomenon associated with distention of the bladder, and subsiding after the introduction of a catheter. The remarks with reference to the cerebral phenomena of typhus apply to those mstances in which there is no inflammatory disorder within the cranium. But we must not overlook the fact that this may ensue. Such cases are difficult of recognition. The pulse, as a rule^ is slow and irregular, the pupils are contracted, there is a frown on the forehead, and intense headache, sometimes screaming. Vomiting is not always encountered. The morbid appearances may be con- fined chiefly to the base of the brain.* The pulse^ after the disease is fully developed, is generally rapid, and of moderate volume or feeble. The beat of the heart may be excited and violent, while the pulse is very weak. Often the cardiac impulse undergoes a great diminution, and with its change the first sound becomes enfeebled; in fact, it is sometimes almost lost, and only very gradually regains its natural tone. Occasionally, at the height of the disease, it is replaced by a soft, systolic murmur of blood origin. * Clinical Reports on Continued Fever. '' Kennedy, Dublin Quarterly Journal. Feb. 1867. Titr ♦-.*«* if iitoitsiiLjr inEir-:-:ucr;*c in iiT?r^ anc Ofiiosits an abuD- oau'r t: uTHi^ aiiC TiiiDsxibaittE. T^isrt k an abssit^ of the chlo- ride£- :c uitT* a?e T^dn^'^c ic £ Tmt^^ Tijf ursiu a? as(^ertaiD€Hl bv Pic^*^ h. k 'jasit in viiiii uc na^mcxat wa? ^rreL. is iDcrrease-d : dur- rrtf *'Zimit^'.'^m'.t r, *5TTigs i»ejr»v ih*- uncnia. siaiidai*d. Id eigiii out of rw-i-^rT-:iij*r '.:&sit:^ •>!»• ] 'examiiiec dirdiij: hl twAtimcJ' Ibe urine Komaiiifd albnniEL. i»ii: "ibi? inc^difai: "wa? it^tiseiTt cairy in tb** sexerer 'jase£. Tni#e-iafc5T^ -eiiiier iinejy xsMmiar cc hyaiiaf^ or ejiiQjelial. are aisc' l^mid. Tiiert is usuarr n: Hffon' ">^^f»i. il Tyxiiiii? iertf-. HarrrT Lh- tieviiiiL and Etr irmnc ii cmJT Tvi?^ jl nrt'nty casts, and il was not t^raiL -lOKCiier 'Jbt tvc casts nad no: hai icvncins attach of tyjthoid ierfT." Oi**finant * T«»nri? ibr Widal rtUitiriL as icresenl in ont- cast- fjf TTTinus ierer '.•carEsmf^c ry anioitST. TiH: r{mta*iirat»cM erii-zmmt'T^ dnrinc liir r-cucse of Ibt- fext-r. or dnrrac '.-iiirrajest^nt't, aiv niii'ji. "Ltrt saiiit as tLctsr ciT tyjibcad feTrr. ahiic*iui "in-T dc* ncc it lift- rv: disea-sstrs ci/vcr jktJL eaua: fresijuencT. W^ Ei*^: ^rj- aii=i:-es=4*&. "wxt ian?r sic»ai:iis la. liir irnnt and €-rtreini- "Ses. ■:d I'T'y.i- '.\l Tr^i •Zfi.tj : c :t r r i: 't .< : T-t -r .■.»>■> : •: : : - .:: i^f- . de: »^ i: iiij a:*:-! ■:':u:--?ii:':.. ^nii i- :•!:?; a :i£.":j:«:.. 1^:'^: :•: --tfr :»frir-r--L •:•:: ibr i-'i.- hj-'I-lt} ^ssjt.. Hr-rr is -Tir v ::.- i^:ir?r ;•:■ lL. :rit ■.•:»ii.:d:'&ti.'.:iS. — 2& : V J : -ri- : *i i Cj -uh.- : -Uia- : c t r. : l i! .♦: r«r: »rj . i* :— ; •rj'r-uiij c^rJ . ttt tr , I»*j:rln|: Ht »ii>: siaiTt-s :•:' Tyr-i'jf itv^*. ..r i^tr iTC^^jT-si-riii-r Las set iiiii tsltj'.''^ iLicjfi'dies rrSriiiJCTi^ :'. rc' ii-Or ?: :*.< :»?*■: t as fri»'»:»»*:'- tV--. Tijr ?:!:•■ I'lij^f :ii»;r srj""^s ':*:'.: ir-vr 5:i:iiiirrD--s and ifaeir FEVERS. 811 Typhoid. Age generally from eighteen to thirty- live. Not contagious ; mostly sporadic. Attack generally insidious. Duration fully three weeks ; frequently much longer. Death hardly ever before end of second week ; more generally in, or after, third week. Cerebral symptoms come on gradually ; last longer. Great emaciation. Face pale, or* flush confined to cheeks. Characteristic temperature-record, chiefly influenced by the changes in the in- testinal glandular lesion. Abdominal symptoms, such as diarrhoea, tympanites ; stools contain character- istic bacilli ; intestinal hemorrhage not unusual. Epistaxis common. Bronchitis aud pleurisy ; pulmonary con- gestion. Eruption light red in fine spots, and not on extremities or face. Widal test positive. Typhus. At all ages ; often in persons beyond middle life. Highly contagious ; usually epidemic. Attack generally sudden. Duration somewhat shorter ; often not prolonged beyond second week. Death not infrequently at end of first week, and often before conclusion of second. Delirium or decided stupor comes on soon, sometimes almost from the on- set ; headache has appeared and dis- appeared by about the tenth day. Less emaciation ; greater prostration. Face deeply flushed ; eye injected. Temperature-record more that of a con- tinuous fever ; for the most part sud- den and rapid defervescence. No abdominal symptoms ; bowels con- stipated ; meteorism rare ; intestinal hemorrhage of extreme rarity ; some- times acute dysentery during conva- lescence or as a sequel. No epistaxis. Intense pulmonary congestion ; broncho- pneumonia. Eruption darker in color, coarser, and all over body ; seldom on face. Widal test generally negative. Yet it is occasionally very difficult to come to a conclusion between typhoid and typhus fever, on account of the measly rash that the former exceptionally presents ; or the symptoms of the two diseases are strangely blended or interchanged. Thus, w'e may have consti- pation in typhoid, and diarrhoea in typhus, or the eruption may be curiously mixed. For instance : A boy, sixteen years of age, was received into the Philadelphia Hospital, with evident signs of a beginning fever of a low type. A day or two after his admission, and corresponding, as nearly as c^ould be ascertained, to the fifth day of the disease, an eruption showed itself all over the body. It was dark-colored, petechial in its aspect, and did not disappear on pressure. Associated with it were drowsi- ness and constipation. In a few days more, however, the symptoms changed. The dark eruption faded, and rose-colored spots were per- ceptible on the chest and abdomen ; diarrhoea set in, and the fever 812 MEDICAL DIAGNOSIS. ran its course la a favorable teriniiiayon with the character of typhoid, just as at tlie onsel it had assumed the character of typhus. Besides typtioid fever, typhus may be coufouoded witli meningitis, with inflaiumatiou of the lungs, with measles, with smallpox, and with the plaj^ue. The distmctive marks between the first two and typhus fever have been rendered apparent while discussing the cere- bral and pulmonary complications of the malady, I shall here only dwell again upon ttie great value of tlie ertiption from a diagnoslic point of view. The symptoms that approximate measles, smallpox, yellow fever, cerebro-spinal fever, and the plaice to typhus will be analyzed in runnection with these affections. Oerabro-Spinal Fever.— This disease is also known as cerebro- spinal typhus, as epidenuc meningitis, and as epidemic cerebro-spinal meningitis, and is the affection which has been caJJed in this counlr)* spotted fever. It was formerly very prevalent in portions of the United States, but the present generation of physicians had little knowledge of it until about simultaneously with the severe epidemic in Germany in lHiyl\ and 1864 it invaded this country and committed great ravages^ especially in some of the New-England States, in New York, and in Pennsylvania. Since that time it has become naturalized here, as Ziemssen states to be also the case in Germany.^ There was an epidemic in Boston in 1897 and 1898, and I saw a number of cases in Philadelphia in the early spring of 1899, Cerebro-spinal menmgitis does not always present exactly Uie same symptoms. These vary somewhat accordmg to the structures which bear the brunt of the disease. Usually, however, marked cerebro-spinal phenomena preponderate ; in some instances the evi- dences of pulmonary embarrassment or of blood deterioration are very promineid. Again, the signs of spinal disturbance maj prevail over those of the cerebral, or the reverse. The disease may be gradual in its approach, feelings of chilliness, succeeded by headache, by tenderness at the nape of the neck, by nausea, and by pain in the l>aek and joints, preceding its full devel- opment. Generally its onset is sudden ; a violent chill is quickly followed by intense headache, vomiting, and extreme prostration. However the beginning, the disease usually soon reaches its full devel- opment. The excruciating headat^lie is associated with vertigo, and often with delirium and stupor. The headache may remit, but does not eease during the attack. Another symptom of the fully develo|H*d disease is stiffness of the deep muscles of the neck, so that the patient * Cyclopaedia of the Pmclicc of Medicine, vol. U., IS75. FEVER8. 813 cannot bend the head forward; and the stiffness may pass into marked contraction, and the head be thrown backward and rigidly fixed. The contraction of the muscles may extend along the spine, which frequently is painful, not specially to the touch, but on move- ment of any kind; sometimes, moreover, severe spontaneous pain occurs. There are also pain at the nape of the neck, and in the loins and shooting to the lower extremities, and pain at the epigastrium, and a feeling of contraction of the chest. The Kemig sign of menin- gitis is always present. The face has a fixed or suffering expression ; the patient is extremely restless ; he trembles ; talks incoherently ; when spoken to, does not appear to hear ; his pupils are contracted or dilated and often unequal, and there may be dimness of sight, or double vision and strabismus. The skin is dry, generally very sensi- tive, or in some parts the sensibility is increased, in others diminished, and the cutaneous surface is frequently spotted with a red eruption, erythematous and roseolous, — an eruption which often becomes brownish, and then for the most part rapidly petechial, and is wholly uninfluenced by pressure ; or the purple spots may be seen from the start. Vesicles, too, commonly appear on the lips. They show them- selves from the third to the sixth day of the disease, while the erup- tion is seen on the first day, or may at all events be detected by the third day. The blood rapidly undergoes • changes. I have found marked blood-murmurs in the heart in a case of but two days' duration. The pulse at first is natural or slow ; but it becomes rather fre- quent and irregular, and commonly remains accelerated throughout the disease, showing extraordinary variations in a few hours; the impulse of the heart is at times much augmented. The tongue is moist or dry, and brown ; the breathing often hurried and shallow ; and the urine I have often noticed to contain large quantities of urates and to be slightly albuminous; hyaline and granular tube-casts are also found in severe cases; in the malignant cases there may be haematuria. The bowels are at the outset constipated; but as the malady advances they may become relaxed ; in some cases dysentery has been observed. There are usually persistent irritability of the stomach, with great thirst, and spasmodic contractions or convulsive movements in the muscles of the extremities. The spleen, early in the affection, is apt to enlarge, but does not continue tumefied. With these symptoms, to which those of exhaustion become plainly added, the disorder progresses to its close, presenting now and then strange and delusive remissions, soon followed by distinct exacerbations. In fortunate instances the morbid phenomena gradually lose their vio- MEDICAL DIAGNOSIS, lenco, and the patient, RTeatly emaciated, enters upon convalescence. But though these are the symptoms which frequently recur inf epifleniics, yet as already indicated, they cannot always be taketi the standard expression of the disease. The temperature is most variable ; it may be scarcely above the norm, or may reach between lOB^ and 108*^^ or even higher, without there being a proportionate | rise in the pulse. Irregularity of the temperature is a verj' comnion and significant Teaiiire. High temperature may be interrupted by long-continued normal temperature, and sometimes the type of fever] is like tliat of ik tertian intermittent, but with much longer paroxysms. In an epidemic in a mining centre in the State of Maryland, care- fully investigated by Flexner and Barker,* symptoms referable to the ] franial nerves were especially observed, particularly loss of smell strabismus, nystagmus, inequality of the pupils, photophobia, pio^. impairment of vision, deafness, rigidity of the face, trismus, besides Cheyne-Stokes breathing and disturbances of speech. The stra- bismus was divergent, and in many cases affected especially ttie right eye, . A considerable number presented engorgement of the retinal veins ; some, optic neuritis. The tendon-reflexes were not unifonUt but were in many cases diminished. In addition to herpes and pui^ punl' and [>i4cchial spots, a common form oJ" cutaneous eruption was an iudistinct jjurplisli mottling of tlie surface. Nearly twenty per i cent, of the cases ijreseiitcd articuhu' complications, principally effu- sions into antl around tlie joints, witti redness and swelling. Well- marked leococytosis was a constant feature at the height of the dis- ease; the red blood-corpuscles were little, if at all, changed to number, while the luemoglobin was somewhat diminished. Leuco- cytosis was also observed in every instance of the disease seen by ' Osier -^ in an outbreak in Baltimore in 1898. The duration of tlie malady is very various. Patients may become) rapidly comatose, and die witliin twelve hours, before any distinctly febrile action has bji?gun ; or may sink in a few days ; or, on the other hand, the com|>laint may pursue a clu-onic course, lasting fori many weeks, and during this lime deafness and blindness, convul-( sions, retention of urine, and local palsies — though these are unusualf — may be prominent phenomena. ' American Journal of the Medical Scienoes, Feb, March, 1894. For a of Uie orular finding^, see, also, Randolph, Bulletin of the Johns Hopkitts Hfl pital, 1893, vol iv., No. 32, p. 59. * Cavendish Lecture^ Phila. Med. Joura., July, 1899. FEVERS. 815 The cause of epidemic cerebro-spinal meningitis is the diplo- coccus intracellularis meningitidis of Weichselbaum, also called the meningococcus. It is often found in association with the pneumo- coccus, and, indeed, the frequent clinical combination with pneumonia shows a close connection between the two micro-organisms. A valuable means of diagnosis of cerebro-spinal fever has been found in lumbar puncture introduced by Quincke. The puncture is best made between the second and third, or the third and fourth, lum- bar vertebne ^vith an ordinary exploratory needle, local anaesthesia by Fig. 77. The diplococciu intracellularis. obtained from a lumbar puncture of a ciueof cerebro-spinal menin- gitis at. the Pennsylvania Hospital, by the rjathologist, Dr. Oattell. a freezing mixture having been previously produced. After the needle has been passed to about four centimetres in children, and double this distance in adults, the fluid generally comes out drop by drop, and from five to ten cubic centimetres should be collected in a com- pletely sterilized culture-tube, which is then tightly plugged. The fluid may be clear or turbid ; in severe cases it is usually turbid. Bacteriologically studied, it is found to contain the organisms always detected in cerebro-spinal fever, and the earlier in the case the lumbar puncture is made the greater is the chance of finding the diplococcus intracellularis. No evil effects follow from lumbar purlt- ture. Williams found it even beneficial to the patient, an opinion which Wentworth does not share, believing any relief to be but for a *:^ MEWCAL r»lA03fr HAT itr, Zjie^ ziTxi. sLZ-iEirr z: :bf i^aviarr-sjdrHL synj- t;c«it5-* B"r. :br rj^iD-rcs Cif ibesir 5rT^rs AT^ ctf zTfts: (iiagTJ.riiOc Ti;->r, 4s i? tbr ■e^ATyesn-riL: :' ibr =^'>e-c- kz^z tbrx 5:' sot r-resri:: 'iriij: L^r-ri'r:— sv-iLkil iijriirizris?. Tbr-r. ibr W*":*- rvAior-n in tTrb roi nil?: -ii-zsii^r -rTJi-i::^, OrTr;---:. ini ibr .nl-is ibi: -^f j^.-f j: :nf :*:»nr5K :c ib»r A?€^t>:'!:. En: n-r rrnis^i'i-nf trv '•:•: ?: nu^rkei i:5 m ibi? i»r'Tnir>>:2? znMlkdj, Dcr slt-z zl^ rXii-^rtiLiir.ns :re:vlt*i rj i .:,r^:, T-J:.>rn: rill SIc^v- FEVERS, 817 not begin with congestive symptoms, but the first attack is like that of an ordinary intermittent or remittent : hence we have the history of the case to instruct us. Finally the detection of haematozoa in the blood establishes the diagnosis of the malarial affection. From tetanus cerebro-spinal meningitis may be distinguished by its epidemic prevalence, and by the signs of mental disturbance, which are very slight or wholly wanting in the former disorder. Trismus is common and early in tetanus ; very rare in cerebro-spinal fever. Gen- erally, too, the sudden and painful spasms, aggravating the tetanoid contractions, and the cognizance of. the exciting cause of the tetanic convulsions, such as their following wounds or punctures, aid in interpreting their meaning. How can we discriminate between inflamrifiation of the meninges of the cord and epidemic cerebro-spinal meningitis when protracted? By the history of the case, the mental symptoms of the cerebro- spinal fever, the eruption, and the persistent rigidity of the muscles, rather thaij the clonic spasm so much more common in the former malady. Tubercular meningitis is distinguished by its insidious beginning, the generally much more protracted course, the absence of eruption, and usually of marked stiffness of the neck, the variations in the pulse according to the stage of the malady, the irregular breathing, and the history of a tubercular taint. Idiopatliic or sporadic cerebro-spinal meningitis is a very rare disease. It runs a much slower course than the epidemic malady generally does, and its spinal symptoms are less marked. But it cannot be dis- tinguished with any certainty from sporadic cases of cerebro-spinal fever. . The absence of an eruption and of the striking variations of temperature presented by the latter is of significance. But as the diplococcus intracellularis has been found in the sporadic cases,^ these represent the same disease as epidemic cerebro-spinal fever, only in a somewhat dissimilar form. It is, indeed, a question whether there are not yet other forms due to this, for ih typical anterior poliomyelitis the same organism has been found by lumbar puncture.* As regards the different forms of ordinary meningitis, the distinc- tion, except by laying stress on the epidemic character of the disease, is not easy. The eruption is wanting in these, and the spinal symp- toms are far less pronounced. The history of the case, too, is impor- tant, as pointing to blow or injury, to syphilis, to extension of disease * Still, Journal of Pathology and Bacteriology, vol. v., 1898. ^ Schultze, MUnchener Med. Wochenschr., 1899. 51 '.'Zi—z- n urr "iim-r : -I . J • JT^L-fc-. ■ 1 T— T_t _:! ~.Ir ■t. $W«'.:A, i :rrf- :iir- l.,2-**. . i^-ti* *•> FEVERS. 819 In some instances of cerebro-spinal fever there is great pain, with some swelling of the joints, and the disorder is thought to be acvie rheumatism. But the head-symptoms, the state of the muscles of the neck, and the dissimilar course of the malady soon clear up the diagnosis. The poison may produce so light a case that the stiffness of the neck may be mistaken for rheumaiism of the cervical muscles. There is, however, even in these instances, an unusual amount of headache, and in a case in which I was consulted it became a permanent condi- tion for several years, and then yielded. Urcemia with contracted kidneys may give us most of the same symptoms as cerebro-spinal fever, especially headache, vomiting, and retraction of the head ; the differentiation will depend upon the pre- vious history, the presence or absence of febrile phenomena and of cutaneous eruptions, and an accurate examination of the urine. From the cerebral form of typhus, the dusky countenance of the latter, the ^characteristic eruption, the regularity of the high fever, the violent delirium, and the absence of marked spinal symptoms, distin- guish epidemic cerebro-spinal meningitis. Most of the same symp- toms differentiate it from the cerebral form of typhoid, and, in addition, we have, as the case progresses, the important aid of the Widal test. Cerebro-spinal fever may, during an epidemic, complicate other acute maladies, and mix its symptoms curiously with them. With the attack the difficulty does not pass off, for it may leave want of power and all kinds of local palsies, besides derangement of vision, permanent deafiiess, impaired intelligence, ^ilepsy, persistent head- ache, chronic meningitis, which may be indeed the cause of the headache, and chronic hydrocephalus. In one instance I have known an extraordinary swelling of the whole body to follow ; the skin is hard, tense, and greatly thickened, pits very little on pressure, except around the ankles, and is tightly drawn over the fece ; this swelling and thickening, very much like a general sclerema, has now lasted for upward of twenty years, and has been attended with a feeling of numbness in the skin and a moderate amount of anaemia. There is no palsy or albuminuria ; the patient suffers little inconvenience, except from her size. She has a waxy countenance, and looks like a very fat woman. Relapsing Fever. — ^This is a form of fever characterized by its rapid course and its proneness to relapse. Epidemics of this disease — ^and it occurs only in epidemics — are frequently encountered in Ire- land and in Scotland. There was an epidemic of it in New York and in Philadelphia in 1869. 820 MEDICAL DIAGNOSIS. The disorder is decidedly acute. Its invasion is sudden, and marked by rigors, pain in the back and limbs, vertigo, severe head- ache^ and nausea and vomiting. Fever is soon developed, and rises high, to from 104° to 107°. There are severe muscular pains, partic- ularly in the muscles of the extremities ; the pulse is ver>' rapid ; the temporal ru'teries throb; tlie tongue is covered with a thick white fur* The bowels, as a rule, are constipated. In many cases there is engorgement of the liver, with yellowness of skin ; and in nearly all there are epigastric tenderness and njarked enlargement of the spleen. The matter ejected from the stomach is greenish, or sometimes hlskck and like coffee-grounds. Minute points of extravasated blood are not uncommonly seen upon the integument. The urine is scanty, and contains usually bile-pigment, some albumin, and hyaline casts. On the fifth or the seventh day, though sometimes not until the tenth, tlie symptoms subside as speedily as they set in, a profuse perspiration preceding ttieir decided al>atement, and tlie temperature falls to the norm or even below. Convalescence is now apt to be rapid, and secmiingly complete, the patient being up and going about ; but the apparent return to health does not last long. Ordinarily after a week, therefore on the twelfth or fourteenth day from the beginning,— sometimes sooner, rarely later, — the attack, preceded perhaps by a slight rise in temperature for an evening or two, returns, presenting again the same signs, and again terminating by a critical sweat in con- vafescence. This second attack may be short and mild ; but it maf be both longer and of graver character than the first. It is, at Umc followed by another, and yet anotlier, relapse. ^\Tien the patiei finally throw-s off the disease, he is very weak, and his blood is muc impoverished. He shows a tendency to dropsy of the extremities and blowing nmrmurs, evidently not organic, are perceptible while^ listening to the heart. These murmurs, however, may also be heanl during the paroxysms. The patient is not really well during (lie intermission ; his spleen remains enlarged, the pulse is slow, Uie actioi of the heart is weak, and the muscular and arthritic pains do m entirely disappear. Relapsing fever has an intimate connection with destitution. It ii a contagious but far from a fatal disorder, except, perliaps, in Un negro. In fatal cases death sometimes happens during Uie fi paroxysm as the result of syncope, of hemorrhage into the brain from the lungs; or it may occur suddenly during the tntemiissi^ from paralysis of the heart. But the most common termination the cases having an unfavorable issue is in consequence of compli tions or of states which have been induced by the malady, such m i FEVERS. 821 lobular or lobar inflammation of the lung, hemorrhagic pachymenin- gitis, abscess of the spleen or of the kidney leading to pyaemia, Bright's disease, dropsy, chronic diarrhoea, parotitis, palsies. At times the patient perishes in a condition similar to the collapse of cholera, though the collapse is more protracted and the pulse can be felt, and discharges from the bowels are by no means a constant accompani- ment. The extreme prostration, attended with great coldness of the 3kin, may last for days. It is more particularly met with in the " bil- ious" or " bilious typhoid" form of the malady, — a dangerous variety, in which severe vomiting, jaundice, and delirium are encountered, and the paroxysm is not followed by a distinct intermission or remission, but often by the signs of collapse mentioned, in which uraemic symp- toms have been more particularly noticed.^ The collapse, however, may happen not only at the close of the paroxysm, but in the remis- sion, w^hether this be distinct or not, or in a subsequent paroxysm ; and this may be the case no matter what variety of the disorder we have to deal with, and whether or not the serious symptoms be due to uraemia. Yet the state of the kidneys and of the urinary secretion has com- monly much to do with the graver phenomena of the malady. Actual renal disease with albumin and tube-casts in the mine was discerned by Obermeier^ in two-thirds of his cases. It was also, with or with- out tube-casts, met with in a number of Pepper's cases.^ The urea is increased and may be retained, thus occasioning grave symptoms. Leucine and tyrosine have been also found. There is no constant obvious lesion in relapsing fever, unless it be the lesion in the spleen. This organ is greatly enlarged, and presents numerous roimd or irregularly shaped bodies, of white or yellowish- white color.* But myriads of minute organisms, spirilla, are foimd in the blood just prior to the outbreak of the paroxysms, and at its height. Indeed, since Obermeier's discovery of the spirilla in re- lapsing fever, there is no doubt that they are the cause of the malady, and their detection in the blood makes the diagnosis clear. In a single field of the microscope we may see only a few, or from twenty to thirty spirilla. The diagnosis of the malady cannot be made positively during the primary seizure. Yet, while an epidemic prevails, it may be suspected ' Hermann, Account of St. Petersburg Epidemic, Schmidt's Jahrb., No. 6, 1865. See also further observations in Meissner's article, ibid.. No. 2, 1870. » Virchow's Archiv, 1869, Bd. xlvii. ' American System of Medicine, article ** Relapsing Fever.'' * Pastau, ibid. MEDICAL DIAGNOSIS. FiQ. 78. from the fierce beginning of the attack ; from the fiact of the fever-heal showing itself in less than twenty-four hours, and ei ing either a mornmg remission of to two degrees and the tnaximuni of temperature in the early aflemoon or evening, or but little difference between morning and evening, until the rapid and great fall which takes place at the crisis ; and from the character of gastric symptoms. Then the mici seopical examination of the blood of great importance. Relapsing feve resembles yellow fever in its short du ration and in some of its manifesta- tions. But there is this evident differ^j ence : in yellow fever the paroxysm febrile stage is usually much sborierj the symptoms in the remission do noj subside nearly so completely stage is a brief one as compared witl the decided intermission of relapsingl fever ; Uie black vomit of yellow feves^ does not come on until ttie stage collapse is reached j and this far more fatal malady presents lesion in the liver and heart that are not found in relapsing fever, while it does not sliow the extraordinary enlargement of the spleen. From typhoid and typhim fevers^ relapsing fever may be distin- guished by the shorter prodromata, by Uie presence of jaundice, by the absence of the characteristic eruptions, and by the short period ^ during wiiich tlie symptoms last. Again, critical sweats with Uie rapid cessation of the fever are not likely to bf? seen in these disorders,! certainly not in typhoid fever; and the very high temperature, tbe^ severe muscular and arthritic pains, the tenderness over tlie liver and j the spleen, the vertigo, and in some cases the early collapse wtthoutj apparent cause, are characteristic ; while, on the other band, deliriuml and stupor are rarely encountered in relapsing fever. After Uie re- lapse has taken place, the diagnosis is easy, if the case have been watched during the first attack. But, should it not have been underl notice before, it may be at times very dilhcuU, without an exaim]ia*:i tion of the blood tor spirilla, to say wheUier we are dealit^ wil relapsing fever or with a rchipse of typhoid or typhus fever. And^ this tlilliculty is enhanced by tlie want of uniformity of the svrin*tc i^lrillft of Telmpfilnic fever (ftom Hey- denrdch) : o, siutfk ipirlllum ; b, star- thafKsI liiinrlle ; r, rsldus of ftpiHIlii, v^ith blorid 'CorjiUMiles. FEVERS, 823 in the second onset of the strangely recurring malady. Another diCQ- culty is presented by the fact that relapsing fever may exhaust itself in the first paroxysm. But this is an unusual occurrence, and the abortive cases are light. In them, too, the spirilla may be detected in the blood. Yellow Fever.— This formidable malady takes its familiar appel- lation of yellow fever from the yellow tinge assumed during its course by the skin. It is a distemper met with in hot climates in low and level localities on the sea-coast. Its source is unknown; it is not malaria, nor has a characteristic micro-organism as yet been de- tected.^ All we know certainly of the cause is, that the malady is due to a specific poison which does not exist without a high temper- ature, and that frost is its greatest enemy. Yellow fever is an affection of short duration: it rarely lasts a week ; many die on the third or the fifth day of the disease. It has but one paroxysm, which is never repeated. This paroxysm may be divided into three stages, which are well marked in some epidemics, far less so in others. The first stage is pre-eminently the febrile stage. Its average duration is from thirty-six to forty-eight hours, but it itiay last three days or longer. It usually begins suddenly, and is frequently ushered in by a chUl. In rare instances this is protracted, there is great internal congestion, and death ensues before reaction occurs. But much more generally a short chill is followed by decided fever. The skin is harsh and hot ; the pulse quick and tense, although sometimes it is both easily compressible and not much accelerated ; indeed, as a rule, it falls before the temperature declines, and there is a marked disproportion between the two. On the evening of the third day, and while the patient is still in the paroxysm of the fever, there may be, as Faget has pointed out, a temperature of between 103° and 104°, with a pulse from 70 to 80. The face is flushed ; the eye bril- liantly injected, yet watery. The patient is conscious, restless, anx- ious, and complains much of the torturing pains in his forehead, loins, and legs ; the muscles of the extremities are sore when moved. The breathing is hurried; the stomach irritable, the epigastrium painful on pressure ; there is great thirst. The bowels are constipated ; the stools very dark-colored. The tongue is more or less coated and moist ; sometimes it is red, while at other times it remams natural ^ The bacillus found by Sternberg and called by him bacillus X is most likely the specific agent. It is very similar to the one described by Sanarelli as the bacillus icteroides. But our knowledge is as yet not positive. 824 MEDICAL DIAGNOSIS. throughout the disease. There is albuminuria, which, indeed, as Guit6ras mentions, may be sometimes detected in the evening of the first day, and is almost always foimd by the third. The febrile signs increase towards evening and lessen towards morning, but do not distinctly remit until after from thirty-six to forty-eight hours, or a day or two later, when a remission does occur, or when, to speak more correctly, the whole aspect of the case changes. The disorder now appears in its second stage, that of calm; the fever subsides ; the pulse falls and becomes easDy compressible ; the headache is relieved ; the breathing is no longer oppressed ; the tem- perature declines to a little above the norm. But the gastric irrita- bility does not wholly disappear, and a deep yellow or orange hue, which may have shown itself slightly almost from the beginning, gradu- ally tinges the eye and the whole surface of the body. The patient is cheerful, and wishes to get out of bed. His suflferings may be, indeed, over ; convalescence may have set in : after a few dark, bUiary stools, the yellowness of the skin fades, and he slowly gets well. But it is not often that the disease relaxes its hold so easily : more generally the deceptive improvement does not last a day, and after a brief lull the* struggle for life begins. The patient grows again very uncomfortable and anxious, the fever rises ; this secondary fever may last from one to three days, in favorable cases passing oflf gradually. But in severer cases, during its course, the symptoms of the first stage reappear with increased intensity. New signs, of the gravest import, show tliemselves ; some of which are clearly due to the cor- ruption of the blood that the poison has silently effected. The puke sinks, and becomes slow and extremely irregular and compressible: the skin is cool, dry, dark, and in some cases of a bronze hue, or livid, and spots may be occasionally seen on its surface. The stomach is as irritable as before, but the act of vomiting is easier ; and, with- out much retching, laiige quantities of altered blood, or "* black vomit," are ejected. Blood oozes from the mouth, from the gums: sometimes from the eyes and nostrils, from the bowels, and from tht vagina;^ or hemorrhage takes place into internal cavities^ and the blood is retained.* The phenomena of collapse become now more and more umnis- takable : the black vomit often ceases, because the contractile power ' Cases in the epidemic of 1856-57 at Lisbon, reported upon by Lyotk^ Lc- don, 1858 ; also by Alvarenga, Fievre jaune k Lisbonne, Paris, 1861. * In a case at the Pennsylvania Hospital the pericardium was filled witk hi»: resembling black vomit. FEVERS. 825 of the stomach has ceased ; a low, muttering delirium sets in ; at times uraemic symptoms show themselves. Yet the mind may remain clear almost to the last, and the strength be but Uttle impaired. Should reaction take place, recovery is only very gradual. But yellow fever does not at all times and in all localities present precisely the same degree of intensity or the same group of symp- toms. Sometimes it exhibits frank, active febrile phenomena; at other times there is little febrile excitement, but a disposition to inter- nal congestions and to early prostration. This congestive form is far more dangerous than the inflammatory. Yet both are highly destruc- tive. From 10 up to 75 per cent. * are the figures representing the mortality of this fearftil malady. Omitting the instances of an ex- ceptionally mild type, the aver- age is calculated, in the elabo- rate work of La Roche,^ to be 1 in 2.32. The more rapidly the stages succeed one another, the more dangerous the case. The occurrence of black vomit, of great epigastric tenderness, of hiccough, of suppression of urine, of delirium, of early marked jaundice, of oppression in breathing, of convulsions, of a fiery, glistening eye, and of petechiae, warrants an unfa- vorable prognosis. '' Walking cases," or those in which the patients walk about until they suddenly eject black vomit, al- ways terminate fatally. As regards the temperature in yellow fever, the maximum elevation is attained upon the first, second, and third days of the disease, ranging from 102° to 110° ; it then falls in again Temperature of yellow fever in a case ending in recovery recorded by B^miss. the stage of calm, to rise usually in the stage of secondary fever and of collapse, though it > Yellow Fever. Philadelphia, 1855. 826 rCAl* DIAGNOSIS. never attains the high feinperatore characteristic of the first s' and never rises so rapidly* The elevated temperature of the fii days may, however, continue witli little variation until the sixth day, when the remission becomes marked. A complete remission usually happens on the morning of the third day, but may not occur un^ the fiilli or the ninth. Whenever it lakes place, the speedy deft vescence is very characteristic. Slight rises in temperature are neither uncommon nor grave after the marked fall in the second stage. But when the temperature rises rapidJy in the stage of calm it is of m^ serious meaning. In tliis stage of calm the absence of fever may complete ; but generally the defervescence is only partial : a rem; sion, therefore, rather than an intermission.* Yellow fever has rarely any complications. It may, however^ sei upon those affected mth other diseases. It has been specially notie that it is frequently intercurrent in surgical and obstetrical cases; The recognition of yellow fever is, generally speaking, easy, intense pain in the back, limbs, aiKi forehead ; the look of the fi the appearance of the eye ; the color of the skin ; the short duratii of the high fever; the falling of the pulse while tlie teniperat remains elevated ; the nausea ; the epigastric tenderness ; the early albuminuria. — constitute a group of symptoms whieli unmistakably mark the disease. But lei us look at the points of contrast which yellow fever pi senls to other aflections. It diilers from plague by the absence bilboes and of carbuncles, and by the much more frequent occ rence, on the otlier hand, of jaundice and black vomit. Then, loi the red, suftysed eye and 'the single paroxysm are not witnessed in plague. The lines of demarcation between the ordinary forms of continued fever and yellow fever are broadly drawn. It is distin- guished from relapmng fever by the diflerent countenance, by the su- praorbital pain, by the early remission, and, above {ill, by the extreme rarity of a relapse and the inrtnitely greater mortality. To fever it bears so slight a resemblance that it is scarcely possible confound the two affections; one, a short, severe disease, witli ii dly tier ' See on Uie temperature and other symptoms Fagel, New Orleans Med. Surg. Journ,, 1873-74; Bemisa, Amer. iourn. Med, Sci,, April, 1880, and i ''Yellow Fever'" in Syst. of Pracl» Med, by American Authors; (lie tenipeiata cluirtS of Naegeli^ of Bio Janeiro, as given by Jaccoud, Pathologie inb Guii>*rfis, arliele ''Yellow Fever** in Keating*s **Cyclopsedia of Diseases Children'' aiid elsewhere ; Sternberg, article *♦ Yellow Fever'* in Loomis Thompson's System of Pnidical Medicine, 1897, vol. i, * S. M. Bemiss, Clinical Sludy of Yellow Fever, ^oc. eU. FEVERS. 827 peculiar physi(^omy and gastric symptoms; the other, a long- continued malady, of low type, with its characteristic eruption and enteric signs. It is only when yellow fever is protracted beyond the ninth day that the diagnosis is rendered doubtful ; and then we have generally the history to guide to a correct understanding. The like- ness between yellow fever and typhus is much closer. But one is a short: fever, with distinct stages ; the other is a longer, much more continued fever. One has no marked cerebral symptoms; in the other the cerebral symptoms are the most prominent feature. One has but rarely an eruption, but often hemorrhages; the other has always an eruption, and hardly ever hemorrhages. The disease most likely to be confounded with yellow, fever is remittent fever. In truth, the symptoms are very similar, and many of them differ only in intensity. The diagnosis of the milder forms of yellow fever from remittent fever is, indeed, extremely difiBcult, unless • the epidemic influences prevailing be taken into account. Then, as is well known, the affections may be blended, and yellow fever become obviously periodical in its febrile phenomena. If there be coexisting malaria, we may fmd the malarial parasites in the blood, and we are thus deprived of the most positive means of distinction between the two diseases. Under ordinary circumstances, the detection of these, and they are generally of the eestivo-autumnal form, is of the greatest value in diagnosis. The occurrence of black vomit is not in itself a distinctive sign in yellow fever, for black vomit may be absent in yellow fever, and, on the other hand, it may, although it rarely does, occur in remittent fever, just as it has been known to occur in child- bed fever, in the plague, and even in typhus.^ A valuable sign is derived from an examination of the urine ; there is early and marked albuminuria in yellow fever. When yellow fever is well marked, it differs in this way from bilious remittent : Yellow Fever. Remittent Fever. Of short duration, ending commonly in Lasts nine days or upward. from three to seven days. Period of incubation from five to nine Period of incubation very variable ; may days. extend to months. • * This statement with reference to typhus fever is made on the authority of Stokes. The occasional occurrence of black vomit in remittent fever is admitted by many others. Some winters ago, a physician of this city brought to me, for examination, a specimen of black vomit which had the same microscopical char- acters that I have repeatedly found in the black vomit of yellow fever. The patient undoubtedly had remittent fever, from which he recovered. 828 MEDICAL DIAGNOSIS. Yellow Fbver, A disease of one paroxysm, lerminatiug in recovery or colltipse. Very severe nausea iind vomiting throughout ; early jaundice ; early and dwided epig^astric tenderness j black vomit. Hemorrliages from gums and various parts of the body. Tongue clean, or but slightly coated ; pulse very variable, frequently t>e- oomes s\o\\\ otit of proportion to tem- perature. Hiphly injected, humid eyes ; ollen fierce or anxious expression of face. SupraorbiUl pain, and pain in back and in calves of the legs. Very rarely delirium ; niind usually clear. Urine Bjcul, very generally contains albu- min, also epitlieliaband granular casts and blood-casts ; suppression of urine common ; no micro-or^jaaism in blood ; bfemoglohin in blood-serum. Little muscular prostration ; often rapid convalescence ; no sequelie. Almost certain immunity after one at- tack. Very high mortality ; disease is epidemic. Treatment unsatisfactory. Autopsy shows inflammation or great congestion of stomach, and some soft- ening. Spleen slightly or not at all enlarged. Liver of a yellowish color, its secreting cells filled with oil-glob- ules. Kidneys swollen, inflamed, Heart often exhibits granular or fatty dis integration of muscular fibres. Remittent Fever. A disease of several paroxysms, with intervening remissions. Nausea and vomiting not so severe, and rarely sis marked at tlie onset ; neitJier as early nor as constant ; jaundice and epigastric tenderness ; vomiting of _ bUe. No hemorrhagic tendeiuy. Tongue heavily coaled • pulse varies le is always rapid until convalesc^no sets in. Eye not peculiar ; diflerent physiognomy. Headache ; sense of fulness in bead| ollen no pain in loins or in legs. Delirium frequent ; mind always dull. No albumin in urine ; suppression of urine rare ; malarial parasites in blood. Much greater muscular prostmtion ; flloi convalescence and tedious sequeliB. One attack seems rather to predispose toy others. Slight inortiility ; disease more endemic in its nature. Very amenable b treatment Autopsy shows congestion of stnmach? more rarely inflamraaiion. Markedly enlarged spleen. Liver of an olive or bronze hue, not fatty ; accumulation of animal starch in liver of maliirial| fever» no grape-sugar.' Kidneys un-" changed^ or simply congested. The diagnosis from fkngni\ at times a very difficult one, will bi* coosidored with this disease. Dengue. — ^This is an arthritic fever with a cutaneous eruption* It is prevalent in the form of epidemics eliiefly in India, and in the West Indies, in Virginia, South Carolina, Texas, and other of Ibe Southern States. We owe some of its best descriptions to Dickson* FEVERS. 829 It has a period of incubation of from three to five days. It usu- ally begins with pain, stiflfness, and swelling of some of the smaller joints, or with severe muscular pains, aching in the back, and stiffness of the muscles of the neck. Fever follows, with suffusion of the face, violent headache, hurried breathing, and coated tongue; but, as a rule, without nausea and vomiting. The temperature usually attains its height, which may be 106° or 107°, within the first twenty-four hours, and then shows during defervescence marked remissions and exacerbations. On the third day the fever ceases altogether or sub- sides markedly, though the muscular and arthritic pains do not pass off entirely. The febrile paroxysm may last somewhat longer, indeed, five to seven days, or only six to twelve hours. In any case it is apt to be succeeded by an interval of two to four days free from absolute suffering, though not from great debility. Then, the pain returns, and with it a moderate fever ; nausea and vomiting and a thickly-coated tongue, too, are noticed. This new phase of the com- plaint is generally relieved by the appearance of an eruption, which may be accompanied by a slight rise in temperature. The erup- tion shows itself on the fifth, sixth, or seventh day of the malady, arid, therefore, very much later than the rash of scarlatina, which it resembles in hue and aspect. But not invariably ; for it may occur in patches and be papular, or even vesicular, or like urticaria. The eruption is attended with a sense of burning and of itching, and dis- appears after two or three days' duration, with desquamation. It is much more pronounced than the slight and inconstant erythematous rash of the period of invasion, which disappears without desquamation with the febrile stage. With the occurrence of desquamation following the marked rash of the third period of the disease convalescence sets in, marked by considerable muscular weakness and general depression, and fre- quently with the rheumatic stiffness or soreness persisting for some time. Swellings of the lymphatic glands of the neck, axilla, and groin occur in many instances, and may continue during convalescence, which in any case is apt to be prolonged, and may be interrupted by a relapse. The cause of this singular malady — the breakbone fever of parts of our country— is unknown. McLaughlin^ has found in the blood micrococci in great numbers, about one-twentieth to one-thirtieth the diameter of the red corpuscles, of spherical shape and red or purplish in color. ' Joum. Amer. Med. Assoc., June 19, 1886. 830 MEDICAL DIAGNOSIS. Dengue is generally a harmless disorder, epidemic, and conta^ous. Isolated cases are difficult of diagnosis, but when the disease lai^gely prevails its recognition is easy. It differs from rheumatism or gout by the significant features of the fever and the eruption ; firom 9carU fever by the different character and want of continuity of the fever, by the pains, the arthritic symptoms, and the polymorphous erup- tion towards the close ; from infiuenza by these, and chiefly by the eruption. The remission may cause the disease to be mistaken for a malarial fever ; but the irregularity of the fever in dengue, the joint and muscle pains, the rashes, and the absence of hepatic and splenic enlargement are very imlike. Dengue has a closer resem- blance to yellow fever^ and the difficulty of distinction becomes the greater because epidemics of both may be present side by side, and because we may find most of the same symptoms, even the jaun- dice, the albuminous urine, the hemorrhages, and the slow pulse with elevated temperature. But all these signs are of comparatively infre- quent occurrence, and neither jaundice nor albuminuria is an eariy symptom, as in yellow fever. Moreover, the single paroxysm, the tongue with red edges, the great irritability of the stomach, the grave nervous symptoms are not met with in dengue; and, on the other hand, we miss in yellow fever the rashes, and the pains and swelling of the joints. Dengue is not a serious disease ; yellow fever is a very dangerous one, and the character of the prevailing epidemic is mostly conclusive. But when they coexist, the distinction between a light case of the latter and a severe case of the former may be very difficult. Plague. — The plague, also known as bubonic plague or the pest is an acute infective fever accompanied by inflammatory swelling of the lymphatic glands, and is due to a micro-organism, the bacVbu pestis^ discovered by Kitasato, of Japan. It is a disease that prevailed in frightful epidemics in the Middle Ages, in Eiirope as well as the East, and was popularly called the " black death.^' Now it is unknown in Europe and this country, except for a few sporadic cases that have been imported or have been developed in bacteriological laboratories, and the epidemic at Astrachan, in Russia ; though quite recently there have been some cases in Portugal. In parts of Asia, especially of India and China, it is still prevalent. There are two forms in which plague shows itself, — ^Ihe severe or ordinary plague, pestia major, and a minor or abortive form. TTie ordinary plague is a highly contagious malady, and spreads as an epidemic. It has a short period of incubation, not more than one week. Its early symptoms are headache, vertigo, and staggering gut: FEVERS. 831 the face is pallid and vacant ; the eye is injected ; the patient appears stupefied by the poison. There is from the onset extreme muscular weakness ; soon high fever shows itself, preceded by chilly sensations or a chill. The temperature is high, and may range between 104° and 107° ; in favorable cases it falls gradually. There is great thirst, as well as burning in the throat and stomach. The pulse is rapid, generally weak; the bowels are constipated. There is stupor, or coma. The febrile stage does not generally exceed five days. Before its conclusion, sometimes from the start, buboes appear, often attended with some abatement of the general symptoms. The glands are hard and painful, and frequently surrounded by oedematous skin ; their slow suppuration is looked upon as favorable. Not only the inguinal glands, but the femoral, the axillary, the submaxillary, and other lymph-glands ^ may be attacked. The glandular affection outlasts the febrile stage. Purpuric spots and petechiae, and hemorrhages from various parts, especially from the lungs and bowels, are also at times noticed, as is bilious vomiting. The disease, mostly fatal, is a short one, generally lasting from three to five days, though suppuration in the buboes may keep ill for a long time even the cases that recover from the fever. The short duration of the febrile malady, the absence of a characteristic erup- tion, the presence of buboes, distinguish it from typhus fever. From forms of malignant malarial fever, for which it has been sometimes mistaken, it differs by the signs of the affection of the lymph-glands, the absence of intermissions or decided remissions and of malarial organisms in the blood ; on the other hand, the bacillus of plague can be detected in the lymph-glands. The minor form, pedis minor, has but slight fever, and no violent symptoms. The glandular swellings are its only marked sign. It is rather endemic than epidemic, though it sometimes has been noticed to precede ordinary epidemic plague, which, it is thought, may develop from it. The minor form of plague lasts about two weeks ; it is very rarely fatal, and is supposed not to be contagious. Malta Fever. — Tins is a disease known also as the Mediterra- nean fever, " rock fever," Neapolitan fever, and by many other names. There is reason to believe that it also exists in Porto Rico, and its occurrence has been recently established in the United States.* The disease is an infectious fever of hot climates, due to a micro-organism — — ^— ^^-^— ^-^^-^— ■ — I ^ Case of Musser and Sailer, Pbila. Med. Journal, Dec. 31, 1898. The case reported by A. A. Smith, Trans. Assoc. Amer. Phys., 1897, as Levant fever, and in which a non-malarial parasite was found in the blood, is also, most probably, an illustration of the disease. 832 MEDICAL. DIAGNOSIS. described by Bruce, the microco<:eus Ifelitenms, and is fomid in associa- tion with bad sewerage. It is generally met with in epidemics, in which the mortality is not gl-eat, and which alternate with typhoid fever. It mostly begins gradually, with languor, chilliness, weakness, and muscular pains, but rarely with a chill or %^omiting. Symptoms of gastric and intestinal catarrh appear early and continue tliroughout. Tliere is enlargement of the spleen wdth tenderness, also muscular pain and marked anaemia. The tonsils are often sw^ollen ; the bowels are generally constipated. Palpitation is of common occurrence, and heemic murmurs £ire heard, Epistaxis, bleeding from the gums, and haemoptysis ai*e usual. Bruce has proved that wiiile the red corpus- cles diminish greatly, the white corpuscles, as m typlioid fever, remain in normal amount. The temperature is that of a continued fever, generally between 102° and 104°, but very irregidar. There is pro- fuse perspiration, also great restlessness, weariness, and often in- somnia; orcliitis is not uncommon. After a w^eek, or longer, the symptoms decline, and the patient appears to be convalescing, but in a few days a relapse is apt to happen with recurrence of the marked symptoms. In ttus relapse the fever may assume a remittent rather than a continuous form. These relapses may be ft'equenlly repeated, and thus the disease be a ver}^ protracted one. Late in tlie original attack or in the relapse there are rlieumatic pains in the joints, espe- cially, as found by Notter,' in the ankle and sacro-ileal joints, which become very tender, and at times tlie seat of an eDTusion, Node-like swellings occur on the ribs and on the costal cartilages. It will be seen from this description that the disease simulates dengue, but the peculiar eruptions of this are absent, and the arthritic symptoms occur later, nor is jaundice present. Moreover, the finding of the micro- coccus Melitensis is conclusive. There is a serum test producing agglutination, similar to that obtained in typhoid fever.^ In rare and very protracted cases the swelling of the joints may lead to the supposition of a typhoid fever with arthritic complications and with relapses. In such a case,^ in which Midta fever was sus- pected, that occurred in my w^ard at the Pennsylvania Hospital last winter^ the blood examination made by Doctors Kirkbride and Kneass proved it to be not Malta fever, but typhoid fever with arthritic com- plications. There was a positive reaction with the Widal test, but no cliaracteristic signs of Malta fever witli the special serum test for this. ^ Allbiitt*s System of Medicine, voL ji., article - Wright, The Lancet, March, 1897, " Philadelphia Medical Jounoid, May t», 1899. 'Malta Fever/ • FEVERS. 833 Glandular Fever.— This disease, first described by PfeifFer, is an infectious fever in children associated with marked swelling of the lymphatic glands, especially those of the heck. The fever is generally pronounced, 101° to 103°, but of short duration; the swelling of the glands persists for several weeks. Not only the cervical glands are swollen, but frequently also the axillary and the inguinal glands. Both spleen and liver are mostly enlarged ; there is slight redness of the throat. The fever precedes the tenderness and swelling of the glands by a day or two ; at times there is pufflness of the skin around them, and they may suppurate. Nephritis is an occasional complication. The disease nearly always ends favorably. Periodical Fevers. These fevers are characterized by the distinct periodicity of their phenomena : they exhibit intervals during which the patient is wholly or nearly free from febrile disturbance ; they are all owing to malaria. This noxious agent gives rise to a group of fevers ever betraying their common origin by their strong family resemblance: alike in occurring in low, swampy localities ; alike in most of their symptoms, and in the diflSculty of eradication from the system ; alike in being due to well-recognized micro-organisms; alike in the secondary le- sions, in the enlargement of the spleen and of the liver, and in the altered condition of the blood, which they leave behind them ; and also alike in being under the control, absolute and immediate, of cin- chona and its various preparations. Since the great discovery by Laveran of the malarial parasite our knowledge of all malarial fevers has become much clearer, and in- finitely more exact, and this shows itself as much in diagnosis as in pathological studies. It is, therefore, fitting that a short description of the malarial organisms should precede the description of the indi- vidual fevers, at least in so far as they concern questions of diag- nosis ; for the larger questions of origin, growth,^ and technical study I must refer to the admirable works of Thayer and of Mannaberg,* and to the numerous papers of observers, such as Marchiafava, Celli, Golgi, Grassi, Sternberg, Dock, Hewetson, and Manson, who have done so much to extend our knowledge. The malarial parasite is best studied in fresh blood, care being taken that the cover-glasses and slides have been well cleansed in alcohol or ether ; a drop of blood is readily obtained from the lobe of > Malarial Fevers, 1897. * In NothnagePs Spec. Path. u. Therap., 1899. 62 834 MEDICAL DIAGNOSIS the ear, thoroughly washed* If stains be employed, LoeSler's methy- lene-blue is very serviceable. There are three forms of parasites now recognized, whieli pass through their cycle of development in from twenty-four to seventy-two hours ; at the start tliey are small, color- less bodies within the red coqiuscles and are soon seen to be actively amoeboid. As the bodies increase in size, pigment granules dot tlieir periphery ; gradually the centre or very nearly the entire red corpuscle is taken up ; the pigment in the organism increases, and becomes darker and coarser. After full development has been reached, sporu- lation takes place, and the pigment mostly collects into a small mass at a particular |)oint, generally towards the centre, Tlie red corpus- cle now bursts and the segments or spores are set free, and invade fresh corpuscles ; the pigment graimles float in the blood-serum. But the parasite may escape from the red blood-cell before sporulation. In some instances roundish vacuoles of irregular size, thought to be due to degenerative process, are observed in the parasite ; or thread- like, colorless, actively motile flagella appear from the periphery of tlie origanism. Different forms of malarial parasites produce different types of malarial fever, and there is a close connection between their develop- ment and the clinical features of the fever ; the paroxysms, as pointed out by Golgi, are associated with the segmentation of a group of Uie malaria] parasites. Very often there is evidence of two or more groups, and if these reach maturity on different days and at different times tjTJes of fever are produced entirely different from those when the groups are single. A combination of the main malarial oiiganisms may also occur. There are three distinct varieties of malarial parasites, and some subdivisions ; tht- three distinct and chief varieties are ; 1. The parasite of tertian fever, 2. The parasite of quartan fever. 3. The parasite of festivo-autumnal fever. 1. The krtian parasite, by far the most frequently observed in this country, completes its cycle of development in forty-eight hours. It is lai^er, less refractive, has much more active amoeboid motion than Uie quartan, and has fmer, lighter pigment granules and rods ; the pigment moves very markedly. The red corpuscle containing the parasite swells up, and becomes paler than normah The pigment at maturity is collected into a mass near the centre, and the parasite is absolutely quiescent ; it breaks up into fifteen to twenty segments, and the spores are rounded and smaller tlian those of Uie quartan parasite. DESCRIPTION OF PLATE VI. MALARIAL PARASITEa A number of these micro-organisms were obtained in blood examinations of malarial fevers made at the Pennsylvania Hospital, and drawn from nature by Dr. C. F. M. Leidy. Some of the rarer forms, especially of the sestivo-autumnal variety, are taken from the works of Mannaberg and of Thayer. The engraving is by Mr. Louis Schmidt. In the tertian group, the first is a red corpuscle of normal size. The swelling of the corpuscle by the tertian parasite is seen in the following ones. The second and third show hyaline bodies ; the next four, the gradual growth and development of the parasite and pigmentation in the same ; then follow seg- mentation and discharge of the spores, of which there are from fifteen to twenty. The last body is a large flagellate. In the quartan group are shown different forms of the quartan parasite, their development and segmentation. The parasfte is small and the corpuscle has a tendency to contract around it, the rim having a deep coloration. The pigment is coarser and darker than in the tertian, and there are only from six to twelve sporules in segmentation. The flagellate is smaller than the tertian. In the a'stivo-autumnal form the pigmentation is seen to be more marked to- wards the periphery of the parasite. The figures show the small size of this para- site, which is the smallest of the malarial parasites, but always very distinct. In the fourth of this group the degeneration of the corpuscle is distinctly j>erceived. On the last line various forms of ovals and crescents are seen as well as a flagellale. The flagellate is coarsely pigmented, but smaller than the tertian variety. Plate VI. MALAIMAI, PAUASITES. TERTIAN FORMS. /' \ ■0 l?> @ ^'^^ r K O^ \^ «••• n m '^t-^ I ti^ -v:'^ ^-^ QUARTAN FORMS. r ..A N »> ^'f^ ^ ■*• fi ©-J3^ >eSTIVO-AUTUMNAL FORMS. ^''t^ I I l^-'' FEVER8. 835 2. The parasite of quartan fever has a cycle of development of about seventy-two hours ; sporulation occurs every fourth day. The pigment is coarse and dark and found on one side chiefly ; the para- site and the pigment have slow motions. The young parasite is small, about one-fourth the size of a red blood-corpuscle. As the parasite grows, the red corpuscle contracts around it, and the rim shows deep coloration; there is no irregular breaking up of the organism into sections, of which there are from six to twelve. Before segmentation, the pigment tends to the centre in radial lines, forming a star-like arrangement. When two groups of organisms reach maturity on different days we have paroxysms on successive days and a day of intermission. 3. The (BStivo-aiUumnal parasite is the most irregular of all the malarial parasites ; the cycle of development varies from twenty-four to forty-eight hours, and it does not, like the other forms, occur in great groups which arrive at maturity at the same time. Its most distinctive feature is the production of crescents from the spherical parasite within the red corpuscle. These crescents are very gener- ally pigmented ; but the bodies may be oval or fusiform in place of crescentic. The crescents are not met with unless the fever be at least of a week's duration. In their earliest stages the aestivo- autumnal organisms are like the tertian or quartan forms, except smaller, and they often first show themselves as minute ring-like re- fractive bodies, in which a few dark-brown pigment granules appear, and the red corpuscles soon exhibit degenerative changes. The pig- ment gathers towards the centre, and segmentation takes place as in the tertian parasite. But segmentation is very rarely seen in the blood taken from the peripheral circulation, indeed, only the youngest form of the parasite and the crescents are encoimtered ; the later develop- ment of the organism and the segmented bodies can be studied in blood taken from the spleen. The irregularity of development and maturity accounts for the irregularity of the clinical manifestations in the malarial fevers in which the aestivo-autumnal parasite is found. This is, indeed, pre-eminently the malarial organism of all irregular exhibitions of malarial infection, as well as of the autumnal malarial remittent fever which is so varied in form. The parasite has been further divided into two varieties, the quotidian and malignant tertian organisms, and these have been further subdivided as to whether pig- mented or not. But these distinctions are not generally accepted, €tnd their clinical value has not been determined. We shall now look at the clinical side of malarial fevers, premising that it is the general tendency of malarial paroxysms to anticipate. 836 MEDICAL DIAGNOBI8. Intermittent Fever.^Tlie paroxysm comes on with a chill : the face bocomes pale, llie lips bluish ; the teeth chatter; the skin is cold; there is a feeling of uneasiness and fatigue. After a period varying commonly from half an hour to an hour, this cold stage passes off. Now we find decided beat of tbe surface, with restlessness, thirsty a full, rapid pulse, muscular pains, a scanty secretion of urine ; in other words, active febrile symptoms. These continue for hours, for a period always nuicb longer tban tlie first stage : then a sweat brt*aks out all over tbe body; tbe pulse becomes softer and less frequent; the secretions are fully re-estaljlisbed ; and this sweating stage termi- nates the paroxysm, Tbe patient is now, for the time being, well ; but the disease soon recurs : in from twenty-four to seventy-two horn's the paroxysm re- peats itself. In the former ease we caJl the fever a quotidian; in the latter, a f/imrtaji. The tertian type is before us when the paroxysm sets in again in about forty-eigbt liours ; the double teHi&n, when we find a daily attack, but those of alternate days alone corresponding in time and severity. Even a f/vmhtn ague may happen.* The period between the ending of one attack and the beginning of another is spoken of as the mtermwmon or apifre^a ; wliile tbe time between thf beginning of tlie two |iai*Qxysms, including the first with its suc- ceeding intermission, is called the iniervoL The tertian and the quotidian are the usual types in this country. In the ordinary tertian there is a single group of infection with the tertian malarial organism ; where tbe quartan parasite is present in large numbers and as a single infection that reaches maturity at about the same time, we have the quartan fever; if in two groups, reaching their full development on successive days, with a day of intermissiou, the double quartan. Should either the tertian or the quartan parasitic occur, the first in double, the second in triple infection, — the diflerent sets of parasites reaching maturity on successive days, — we have Uie quotidian type of tbe fever, which .may thus depend on either tlic tertian or quartan parasite ; or, again, there may be a coexistence of these, which is not, liowever, frequent. Even Uie (estivo-auturanal infection may produce quotidian intermittents. Yet this is not com- mon, and the paroxysms are much less regular. The most usual cause of the quotidian in this country is the infection with two groups of tertian parasites that reach maturity on successive days. Tbe varitnl types of tbe fever present marked differences in tlit» character and duration of the several stages. The tertian has geiier* Case of Henry, Brit. Med. Joarn., Feb. 18, 18S8. FEVERS. 837 Fig. 80. ally the longest hot stage, the quartan the longest cold stage. In the quotidian there is a short cold stage, followed by a hot stage which may last for upward of fifteen hours. Occasionally the stages are very irregular and anomalous. Thus, the sweating stage may precede the cold stage, or it may be the only one which shows itself; or, again, the rigor may be altogether wanting. Sometimes, there are no distinct stages, but the patient has a " dumb ague," which manifests itself at definite periods by a feeling of great depression, or of a severe pain at some portion of the body, or by chilly sensations, or by headache, or by nausea and vomiting, or, as I have seen, by excruciating pain over the kidneys, and almost entire sup- pression of urine, or by spasmodic ob- struction of the intestine.* The temperature in intermittent fever shows a record that, in doubtful cases, may be turned to great advantage. Not- withstanding the marked sense of chilli- ness, the thermometer rises suddenly and rapidly to a high degree ; there may be a slight elevation of temperature for an hour before a chill, but the striking rise begins with the chill. Even during the decided chill of the beginning of the paroxysm it indicates 105° or more in the axilla. The temperature remains stationary, or con- tinues to rise, though not much, during the hot stage, and during the sweating stage falls at first slowly, then rapidly, until it comes down to about the normal heat. During the chill the peripheral tem- perature is decidedly lowered ; during the hot stage it is increased. But with the ending of the paroxysm it is found that the fall has been rapid. In the intermis- sion the thermometer in the axilla marks a natural temperature, or one somewhat lower than in health. It rises again quickly with each paroxysm. No other malady presents these varia- tions. In some cases of intermittent fever an intermitting murmur is Temperature-recopd of a tertian termittcnt. ^ Cases of Hoyl, Atlanta Med. and Surg. Journ., Sept. 1876. 838 MEDICAL DIAGNOSIS. heard over the spleen. This is ascribed to the movement of the bloc hi the splenic arleries with the systole, hi consequence of the soft, enlarged, and overfilled condition of the spleen. It is usually detected most distinctly during the febrile period, ceases with the paroxysms,* and is not hi^ard in chronic malaria. To the peculiar appearance of the tongue which those under the malarial influence may show, Osbom has directed pariicular atten- tion.'^ There is a distinct lateral boundary of the organ, an appear- ance of indentation transversely, and the inferior surface appears to have encroached upon the superior and lateral borders. The diagnosis of an ordinary and regular intermittent is easy. Leaving the other malarial fevers out of consideration, only two morbid states are likely to present recurring rigors and febrile excite- ment, and are, therefore, apt to be confounded with it : hectic fever, and cldlls attending upon suppuration in deep-seated parts. Now, hedk fever differs in this trom intermittent: it is smiply a fever of irrita- tion, the cause of which a careli]| scrutiny will generally detect. We find it accompanying many chronic diseases in which destruction of tissue occurs, especially jjlithisis ; aiid the chronic affection has its own signs, which exist at all times, whether the symptomalic fever be present or not. Then its outbreaks are irregular. Several oflen take place within the twenty-four hoiu-s ; their intermissions are incom- plete ; the temperature does not fall as in intermittent fever, for there is not comiilete defervescence; and although the paroxysms may begin with chilliness, they are not usliered in by a well-defined rigor. Further, they are apt to be morning paroxysms, and are not moilified by antiperiodics. Whenever, indeed, we find an intermitting fever not influenced by these agents, it ought to arouse suspicion, and all the internal organs, particularly the kuigs, should be carefully explored. Thus only can serious errors in diagnosis be guarded against. When pm forms, and especially wiien it forms m internal cavities, it betrays its presence by rigors, followed by more or less fever. But these, unlike the chills of ague, do not repeat themselves at definite periods. Moreover, in the midst of the apparent intermission, febrile signs or other manifestations of a seriously disordered system may be discovered ; or we may find the local cause, for instance, a pelvic cellu- litis. The chills of ordinary pyaemia, unlike the malarial malady, are often characterized by the profuse sweating that immediately follows them, rather tlian by an active development of fever. In cases of ^ Maissurianz, St. Pelersburger Mediriu, \VcK!heiigercuIar affections ; a very common error, as Janeway has proved.^ Long-continued, causeless fever in which blood-examinations show no malarial organisms, and where tliere is no distinct evidence of tuberculosis, should always make us very suspicious of syphilis. In the diagnosis of intermittent fever we have also to consider that certain diseases which are non-malarial exhibit at times a decep- tive/^eriWw#y ; they may be worse ever>^ second day* Even mania. as Schroeder van der Kolk has pointed out, may lake this type. In all such instances the microscopic examination of the blood for malarial parasites is of the greatest value. In the puerperal state a malarial outbreak may happen which, as Manson and Fordyce Barker* have shown, may be mistaken for puer- peral fever. Unlike the latter, however, the pu^rpa^al malarial fever is attended with pain in the head, back, and limbs, and does not gen- erally appear so soon after partorilion, — not, therefore, between the first and fifth days after deliverj\ Moreover, it has at the be^ning a great temperature-rise, and marked remissions or intermissions. Puerperal malarial fever may lead, atler the twelfth day, to second hemorrhage. Now, in all these diseases simulating outbreaks there ar^ two t of great value, more important than any mentioned, — one the thera- peutic test of their not yielding to decided doses of quinine ; the other, still more valuable, that careful and repeated examinations of the * Cases of Musser and of Prentiss, Phila, Med* Joum., July» 18^9. ' Wood, Transactions of tlie College of Physicians of Philadelphia, Feb, ISW; also in Medical News, Philadelphia, March, 1881 ; Janowsky, quoted iMd, * Transaclinns of the Association of American PhysicianSi 1898* * Medical Record, Feb. 1880 ; Virginia Med. Monthly, Nov. 1881. I ■ FEVERS. 841 blood fail to detect the malarial organisms. Further, though not so generally applicable in complicated malarial fevers, there is no leuco- cytosis, while decided leucocytosis is among the features of most of the conditions named, and especially of all those with a septic in- fection. Remittent Fever. — ^This is a fever pre-eminently of hot climates and malarial districts, and is now more generally described as sestivo- autumnal fever. It is the fever of Hungary, of the Pontine Marshes, and particularly of AMca and the southern portion of the Norili American continent, and of parts of South America. Occasionally, not often, we meet with it in winter and in early spring ; very gener- ally, during the summer and autumn months. The malarial parasite that occasions it is the aestivo-autumnal parasite, of which, as above stated, a main characteristic is irregularity, and we see this reproduced in the clinical features of the disease. Remittent fever has no well-defined and constant prodromic symptoms, except, perhaps, a singular sense of gastric uneasiness. It is ushered in by a marked chill, soon succeeded by violent fever, which, after a varying period, decreases, and then breaks out again. By this time the symptoms of the disease are very apparent. The patient complains of pain, of fulness and of throbbing in his head. He is restless and distressed ; his limbs ache ; his tongue has become coated ; he suffers firom thirst, and rejects the contents of the stomach. After continuing at their height from six to eighteen hours, these symptoms again subside : a sweat breaks out all over the body ; the irritability of the stomach lessens; the patient is composed, even cheerful ; his headache has nearly ceased, and he falls into a quiet slumber. But this lull is not of long duration, not longer than some hours. Soon the active fever is rekindled : the skin is as hot and dry as before, the pulse as full, frequent, and hard ; the spleen is observed to be swollen ; and the other symptoms return with increased in- tensity, again to abate, again to recur, until either the exacerbations are effaced and the fever assumes a continued type, or else the remis- sions become better and better defined, — ^more, indeed, like intermis- sions than remissions. In the progress of the disease and after its height the pulse is generally quicker and weaker than at first. The temperature rises markedly with the first chill, and continues to rise during the high fever that follows. With the sweating stage it declines by several degrees, to rise to a greater height than previously with the succeeding febrile phenomena ; then again there is a fall in the remission, with another quick rise in the fever, which may attain a very high point, marking firom 105° to 108°. The greatest height ^^H is usually reached in the exacerbation of the tlm*d day. After this ^^H the remissions become less distinct, and may be, indeed, recognizable ^^H only by the thermometer ; the whole fever is more like a continued ^^H fever. Subsequently to the ninth day usually the remissions are very ^^H marked, the difference between the temperature in tliem and the ex- ^^H acerbations being three degrees or more. The exacerbations become ^^1 less and less hi^h, and soon cease, the temperature falling perhaps ^^H previously to below the norm. In cases in which the fever remains ^^B for a long time continuous, irregular remissions occur, especially ^^H towards the end, though the fever may preserve its continued type ^^H until it gradually ceases. ^^M M C M E ^ ^CMtMCMeHCHEMCMEMCME.! h "S \ n v H ^i ^ k t\ A 1 \ V N \i »/ \ ■/ ^ I ~^ \, \ i \ 1 1 u \ 1 1 L ■/ ; \ f I ^ W ts- ■fll- 1 la i iS- T 6 V J9 90 105" n- 120 l« tie ,9 20 ^^■ i'd^ -M- 2 4- 16, it if i^ 1t^ ^^H tions, is fr ^^H or rather, ^^H correspon ^^H symptoms ^^H hours, — a ^H form. T ^^H hours ; in In a case of reiniiuent fever of modcrutc iMiverity. ending in recovery q day. The chart shows also the pulse ftiid tht* respimtioo. verage duration of the fever, unless protracted by om nine to twelve days. Its most common form is < perhaps, double tertian, the exacerbations of aHer ding in severity, in duration, and even in the nati 5, Sometimes there are two exacerbations in tw duplicated quotidian, — or the paroxysms have lie exacerbations may occur any time in the It^ many instances morning exacerbation is noticed, a compUca* quotidian* nate days ire of Uie enty-four a tertian ^enty-four nd 1 have FEVERS. 843 met with more cases in which the paroxysm comes on in the after- noon than in the evening. The urine in remittent fever presents much the same changes, though in a different degree, as those occurring in intennittent fever. During the active stages of the fever there is an increase of urea, not simply above the standard of health, but even above that in inter- mittent fever ; and this increase of urea is attended with a diminution of uric acid — unlike what happens during the paroxysms of ague — and of the coloring and extractive matter ; while, as convalescence sets in, the urea decreases in amount, and the other ingredients men- tioned increase.^ A copious deposit of urates, forming with the phos- phates as it were a critical discharge, is noticed as the fever subsides, and is analogous to what takes place after the paroxysm in intermit- tent fever. At no stage does the urine contain albumin, as it often does in typhus, and as it generally does in yellow fever ; but, as in intermittent, it may contain sugar. Remittent fever is readily recognized : the rise and fall of its febrile signs are too striking to escape observation. Its characteristic traits are closely allied to those of interh^ittent fever. But there are these points of contrast : in intermittent fever each paroxysm begins with a chill, which is not the case in remittent fever ; for after the first paroxysm there is rarely a marked chill, and even the chill ushering in the disease is usually not violent. After each febrile exacerbation comes an abatement, — ^not an intermission, for the thermometer shows that the fever does not leave ; the tongue remains coated, and the gas- tric derangement does not entirely cease; the patient is not well. The symptoms rise and decline ; they do not, as in ague, appear and disappear. In both affections we may have herpes labialis at the decline, but it is more common in remittent than in intermittent. Owing to the jaundice in many cases of bilious remittent fever, the disease is often mistaken for acute congestion of the liver, or acute catarrhal jaundice. Here, again, the exacerbations and remissions in the temperature serve as distinguishing marks ; and so, too, in sepa- rating the gastric complications of bilious remittent fever fi-om acute gastric inflammation. The severe headache is also a distinctive feature of value ; so is the herpes labialis. But of greatest importance and conclusive is the finding of the malarial parasites. Under ordinary circumstances there is very little likelihood of con- founding with each other typhoid and remittent fevers. The lines between the two diseases are too strongly drawn : no marked perio- ^ Joseph Jones, Observations on Malarial Fever. 84 MEDICAL DIAGNOSIS. dicity exists in typhoid fever, nor ai'e vomiting and jaundice often seen ; and, on the other hand, we find no diarrhtra, no enipUon, except at limes herpes and nrticaria, no thoracic symptoms, no deafness, and no very^ great prostration in remittent fever, and tlie snnptoms are strikingly influenred by quinine. Very decided periodicity may be witnessed in tv^jhoid fever as it is approaching a favorable termination; the afternoon or evening rise of temperature is most marked, the morning remission very great. Here a knowledge of the previotis history of the case and the Widal test guard against error. We shall presently again refer to the symptoms of periodicity in exaniiriing into typho-malaiial fever. Further, not infrequeiilly, after an attack of remittent fever has lasted for ten or twelve days, these symptoms are noticed : great mus- cular debility, jerking of the tendons, picking at the bedclothes, dark, dry tongut^^ and Aveak pulse, perhaps diarrha-a. The fever becomes of a continued type. It is tliese cases which have given rise to the opinion that bilious fever oflen changes into typhoid fever^ But in reality it is not the specific ty^jhoid fever, with its enteric lesions, but a typhoid condition, tlial is developed. The Widal test is negative; malarial organisms are found m the blood. During tlie exacerbations qjf remittent fever the cerebral symp- toms are sometimes almost identical with those of an acute brain- aflfection. There is severe headache, with violent beating of the arte- ries of the neck and face, a wild eye, intolerance of light, and even delirium. Were the patient now" seen for the first time, he would be pronounced to be laboring under acute meningitw. Suddenly the pulse loses its throbbing character, a perspiration covers the surface, and, unexpectedly, llie cerebral disturbance ceases until the next paroxysm redevelops it. Cases of this kind are readily enough recognized, if we know something of their histo^}^ If we are not familiar witli it, we have to await the remission for tlieir explanation ; and after the sudden cessation of the signs of disorder of the brain it is hardly possible lo have doubts as to the meaning of the acute nervous symptoms, should they recur. But occasionally these show tliemselves under circura- stances wiiere a malaria! poison is not suspected to be at work : A young gentleman of studious habits, wtiile diligently preparing for a college examination, was seized with violent headache and fever. The sense of fulness in the head was unbearalilc, the fever was liigh, there was nausea with great gastric irritability. These symptoms lasted for nearly twenty-lbiu' hours, and then subsided in the forenoon, to become aggravated in the evening. Delirium followed by great drowsiness was perceived at an early hour of the Uiird dif FEVERS. 845 of the disease. The case now assumed a very alarming aspect. Local bloodletting was resorted to with some relief, and in a few hours the symptoms were, fortunately, favorably modified: the headache was much less, the mind was again quite clear. Although the patient had never suffered from a malarial fever, he had spent part of his summer vacation in the marshy neighborhood of Washington ; but several months had elapsed, and winter was setting in. The time of the year was not in favor of malaria. But the evident remission in the cerebral symptoms, the coated state of the tongue, and the malarial look of the countenance, that became daily more apparent, decided me upon administering quinine. The evening exacerbation came, but was far less severe. The nature of the case was now evident : the quinine treatment was vigorously pursued, and the patient soon recovered. The violent headache and delirium were in this case observed to be in connection with well-defined febrile signs. Occasionally one or both of the symptoms mentioned last during remission, while the fever abates. I have even met with them occurring in paroxysms without fever being present, as in the following case seen a number of years ago : A young lady of delicate constitution was attacked, in September, with remittent fever. The disease ran its course without any unusual symptoms ; a violent headache, but little, if any, wandering of the mind being observed during the daily exacerbations. After the tenth day the fever lessened, and the disease assumed a continued type ; yet soon afterwards, as convalescence seemed to be established, every evening for three days, between five and six o'clock, a boisterous delirium set in, lasting for three or four hours, and once nearly all night. It was followed by a profound sleep, from which she woke up with a clear mind. During the§e fits the pulse was not accelerated, and there was no fever. The third attack was not so very severe, as the patient was already in part under the influence of decided doses of quinine ; another was prevented by this drug. Both these cases were seen before the discovery of the malarial parasite ; the presence of this would have at once determined their true nature. In both the symptoms approached those of the con- gestive type of the disease, and the issue appeared at one time doubt- ftil. Generally speaking, remittent fever, unless it be of the con- gestive variety, has a favorable prognosis. It is difficult for us, living in a century in which the remarkable eflfects of quinine are so well understood, to believe that the complaint was once so fatal, and that so many deaths should have taken place from a disorder over which we now exercise so undoubted a control. But the long list of dis- 846 MEDICAL DIAGNOSIS. tinguished names that liave (Allien victims to it, among them Crom- well, James L, and the Emperor Charles V./ proves the medical skill of former times to have been insnHieient for its cure. In our day, the consequences of remittent fever are more to be dreaded than the dis- ease itself. We often find, as its sequel®, obstinate intermittents, enlargement of the liver and spleen, dropsy, protracted anaemia, head- ache, and impaired activity of mind. In children, a fever of remittent l>i>e is observed, called infanfik remiUeid, which is rarely a miasmatic disorder. It is often a gastro- enteritis connected with verminous irritation or produced by errors in diet ; or a typhoid fever,— an affection which now and then occurs even in very young children. What has given rise to this confusion is, that all febrile diseases in children exhibit a much greater periodicity than in adults, and in all some cerebral symptoms are apt to be present. To distinguish the two maladies mentioned from true remittent fever, we must study particularly their manner of beginrung and tlieir probable origin, and note tlie peculiarities of the abdominal symptoms. Then we may lay stress on tlie irregular mode and the unequal dura- tion of the febrile exacerbations. Sometimes, also, by close scrutiny, the characteiistic eruption of a low continued fever may be found m an apparent remittent. But some of ttiese cases of infantile remittent fever are te^^f of malaria! origin ; even in young children this may be their source. I saw, for instance, some years ago, a little girl, three years of age, who had a distinctly malarial remittent fever, w^hich was checked by antiperiodics. During the violent exacerbations she was very deliri- ous ; her tace had a most anxious, frightened look ; her screams could be heard all over the house. In the remissions she w-as pt^rfecUy sensible, but there was gastric irritability, and the bowels were very constipated. I have met with a similar case in an infant of eighteen months. Pernicious or Congestive Fever* — This is a malignant, malarial fever, w^hich may be either of the intermittent or of the remittent form, and with rare exceptions depends upon infection witli the sestivo- aulunmal parasite Avhieh is present in large numbers, A special form of tlie iBstivo-aulumnal parasite, the malignant tertian parasite, is held to be the cause of the malignancy. But this is not certain. Manna- berg lays stress on individual predisposition and on the anatomical * From the record of tjje Emperor's illness, as given by the historian ICgiiflij (CharleB V au Monasl^re de Yuste), we may Ieam» what fortunately now we hu6% have an opportunity of obsemng, the features of remittent fever when left to" ilaelf. FEVERS. 847 lesions produced, such as occlusion of the finer blood-vessels with the infected blood-corpuscles. If ordinarj'^ aestivo-autumnal fever be not treated, it tends to become pernicious. The pernicious attacks are of the tertian or the quotidian type. While they are at their height, there is intense congestion of one or several internal organs, with a dangerous perversion of the function of innervation. From this state the patient may rally, but only to fall a victim to another paroxysm, unless art intervene. The temperature during the chill and subse- quent fever ranges from 104° to 108°. Sugar is found in the urine much more commonly than in ordinary intermittent fever. The symptoms of this violent malady vary according to the organ more specially disturbed, and to the extent of the derangement of the nervous system. We have, thus, several distinct varieties, of which I shall describe the prominent. The gastro-enteric form is common in our Southwestern States. Its distinctive features are nausea and vomiting, purging of thin dis- charges mixed with blood, intense thirst, and an equally intense desire for air. There is little abdominal pain or tenderness, but a weak, fre- quent pulse, and very great restlessness. The patient complains of a sense of sinking and of weight, and of burning heat in the stomach. His breathing is deep-drawn ; to each expiration succeed two short inspirations. The face, hands, and feet are pale and cold ; the features shrunken. Sometimes these symptoms continue for several days, and gradually increase in intensity, in spite of nature making eflforts at re- action. More frequently reaction does take place j the temperature is very high, the pulse feeble, and the stormy symptoms subside or wholly yield, until another outbreak, which is very apt to be deadly, occurs. The usual length of the fatal paroxysm is stated by Parry ,^ to be from three to six hours. The thoracic variety of the malady is often combined with the one just described. Its most characteristic trait is violent dyspnoea, caused by overwhelming congestion of the lungs. It is perhaps the most rapidly destructive of all the forms of the disastrous affection. In the cerebral variety the temperature-curve is not that of any special type of malarial fever. The abnormal state of the brain mani- fests itself either by coma or by delirium. In the former case there is usually preceding stupor with occasional delirium ; the pulse is slow and full ; the face is dull, and either flushed or livid ; indeed, some of the symptoms which are observed in apoplexy show themselves. When, on the other hand, delirium is marked, we have much the * Amer. Joum. Med. Sci., July, 1843. 848 MEDICAL DIAGNOSIS same morbid phenomena as in acute meningitis ; the patient is wfldr he sings, he cries. He may die in tliis state without coma super- vening ; but a comatose condition generally succeeds rapidly to Uie fierce excitement. Should recovery take place, the delirium gradually ceases. Another variety much dwelt upon is the so-called algid form. This is not often seen in this countr}^ ; but is not uncommon in Cor- sica and Algeria, The disease is more than a mere continuation of the cold stage of a paroxysm : usually tlie characteristic symptoms manifest themselves during the period of reaction. The pulse slackens, and finally ceases; tlie extremities, face, and trunk become in suc- cession rapidly cold. There is no tliirst ; tlie skin feels like marble ; the breath is cold ; the voice broken. The mind is clear ; the expres- sion of the countenance impassive and like that of a dead man- There may be frequent attacks of syncope; or eiccessive sweating; or- vomiting and choleraic discharges occur. These symptoms go on steadily towards death, unless decided reaction be brought about In none of these ftirms of congestive fever is the first paroxysm apt to be of a pernicious character. In the majority of instances the disease begins as ordinary periodic fever, and it is only in the second or third paroxysm that the alarming symptoms appear, Nor is the first pernicious paroxysm likely to prove mortal ; generally it is not until the second or third that a fatal issue is to be apprehended. Proper watchfulness will sometimes detect, even at the onset of the attack,— by the unusual prolongation of the cold stage^ or by tlie irre^- larity of the pulse, or by the great sensitiveness in the splenic region and by the pain wliich pressure there may occasion all over the body, or by an miperfect hot stage^ or by the feeling of internal heat wliile the surface is really cold, — ^the danger that is approaching, and arrest its further steps by tlie bold use of antiperiodics. The cause of this desperate disease is a highly active malarial poison, and very likely some peculiarities of the malarial parasites. Should the patient even weather the first attack completely, he is not wholly out of danger ; he may have a second seb.ure quite as pei'ilous within the same season. Dock* has recorded in detail the study of a case of pernicious malarial fever characterned by an enormous de- velopment of Plasmodia in the blood, with consequent annemia and melanar-mia ; parenchymatous degeneration and inllammaUon in liver, kidneys, and stomach ; thrombosis in various organs ; hyperplasia of the spleen and lympliatic glands. On micro-chemical examination Uie * Ainer. Journ. Med. Sci., April, 1894, p. 379. FEVER8. 849 pigment in the malarial parasites failed to respond to tests for iron, wliile deposits in the tissues themselves yielded such reaction. Hemorrluiffic Malarud Fever. — Closely connected \vith congestive fever, indeed a form of it is that pernicious malady which is known as the yellow disease, icterode pernicious fever, malarial hsematuria, hemorrhagic malarial fever, or black-water fever. It is the same dis- ease as that which some of the French writers have long described as haematuric bilious fever, and is found in intensely malarial places, sometimes in epidemics. It usually occurs in those who have already suffered much from malarial fever, and is almost always ushered in by a marked chill, longer usually and more intense than the patient has had in the preceding seizure of intermittent, — for often the dan- gerous paroxysm is preceded by one of ordinary kind. Soon after the protracted chill, distressing nausea and vomiting are noticed, as well as headache, great restlessness, and quickly developed, deep jaun- dice. The fever which follows the chill is not high, the pulse is rarely extremely rapid, the patient is very thirsty. In a few hours after the chill, pain in the right hypochondrium, in the epigastrium, and over the kidneys is encountered, and a dark-colored, bloody urine is voided. Sometimes hemorrhages occur also from the nose and bowels. The type of the fever is either intermittent or remittent, occasionally it is continuous. The bloody urine — for I know the dark-colored urine, from the specimens I have examined, to be bloody or to contain lai^ge quantities of dissolved haemoglobin — is at times associated with con- siderable albumin and with tube-casts. The parasite is of the «stivo- autumnal form. Baccelli * attributes the haemoglobinuria not to the malarial parasite, but to its toxines. If the case progress unfavorably, the pulse rises, cold sweats occur, purpuric spots appear on the skin, and the signs of uraemic poisoning are not unusual. In the intermission or remission the symptoms abate considerably, jaundice and bloody urine cease to a great extent, per- haps almost entirely, — at least this is true of the latter symptom, — but they recur in the paroxysms, which may happen every day or every ten or twelve hours. The disease may prove fatal in three days ; but generally it lasts longer. Convalescence sets in slowly, and not until the urine has en- tirely and permanently cleared. It is thought by several observers, especially by Tomaselli, Ughetti, and other Italians, that the disease is not due to the malarial infection, but to the toxic influence of quinine. But this view is not adopted in this country. Policlin., Jan. 1897. 53 850 MKlUrAL DlAGNOfSLS. As regards the diagnosis of the disease, there arc ma twu fUscasH that closely resemble il. One is inienmtfenf hamof/hbhntria. Now* undoubtedly some of the recorded cases of this are cases of the malady under discussion ; but in those to whieh the name can be talrly given the absence of malarial elements in the blood, of jaundice, of red blood-disks in the urine, and the want generally of fever, supply the distinguishing traits. From i/ciimr jWrt\ for which hemorrliagic malarial fever may be mistaken, it differs in Hie speedy occurrence of marked jaundice, in the bloody urine, in the extreme rarity of black vomit, in the course of the fever with its recnrring paroxysms, and in the high degree of malarial poisoning whicli the history of the case and the examination of the blood proves. Then, again, the matarial |>oison may affect tlie kidneys, producing allered secretion, transitory albuminuria^ or even nepliritis. Albumi- nuria was found by Thayer^ io nearly half thi* tases of the malariaK fevers of Baltimore, and much more frequently in tlie aeslivo-auluninal infections than in the other forins. In this form, too, acute nepltritis is more common than in tlie other varieties. The malarial infection may lead to chronic renal disease. In all these kidney complications the history of the case and thi' examination of the blood for the malarial parasites are of the greatest importance. The cases of nephritis foJ- lowing htenioglobiniiria are always grave. Before proceeding to the discussion of anolher subject, I shall here devote a few pages to the consideration of some of tlie irregulaj' forms atid modilications of malarial poisoning, and to its share in producing febrile disorders of blurred and uncertain type. Practi- cally, this is of great importance, and specially of importance to American ptiysicians. In the first place, I stiall speak of the chronic tnaktrial poimnwff, or makt rial effrhexia, so oll(*n seen among inhabitaids of malarial dis- tricts. It manifests itself by lassitude, debility, torpor of the liver, and enlargement of the spleen. The stools are often black, tlie diges- tion is impaired, the complexion .sallow. Occasionally attacks of jamidice occur, which ratlier relieve than aggravate the unhealtliy state of the system. Sometimes the noxious inthience shows itself hi another way : the patient is seized with nausea, and with gastric irri- tability so great that almost everytJiiJig he lakes is instantly rejecteih The tongue is coated, the skhi dryish ; but In* has little if any fever The bowels are confined, the urine is turbid. He is restless, and as weak as if lie fiad typhoid fever; but lie has neither an eruption nor ' Amer. Joiini. Med. Si-i., D6«\ 180S. FEVERS. 851 diarrhoea. His sleep is disturbed, and he often suffers with hyperaes- thesia of the scalp, and neuralgic pain shooting over the forehead and causing twitching of the eyelids. After remaining from six to seven days in this condition, his nails, perhaps at a certain hour every day, are noticed to become bluish ; or he feels chilly, and a slight fever im- mediately afterwards sets in. The return of these febrile symptoms is checked by quinine, and the patient enters upon a slow convales- cence, remaining for a long time enfeebled. Again, there may be headache, coming on at a certain hour, associated with rise of temper- ature ; or attacks of diarrhoea or of vomiting ; or a persistent slight febrile state with the temperature from 99° to 100°, with occasional rises. We also encounter malarial diseases of the eye, pulmonary congestion of malarial origin with the parasites in the sputum, malarial aphasias,^ malarial atony of the bladder,^ neuralgias, espe- cfally of the supraorbital and intercostal nerves, and malarial palsies. Fig. 82. A drop of blood taken from the finger of a man the subject of malarial cachexia. The granules of pigment, as well as the larger fragmentH of irregular form, are Heen among the blood-globules. The pigment was for the most part black ; some of the particles were reddish brown. In these, as in a case under my care at the Pennsylvania Hospital in 1889, the detection of the malarial corpuscles in the blood led to the diagnosis of the affection. Indeed, in any of these doubtful and sus- pected cases, in which, too, the periodicity may ultimately be lost, careful and repeated blood examination is essential. The usual form of parasite found is the aestivo-autumnal ; pigmented leucocytes are also not uncommon. But as regards the parasites in all these in- ^ Longayet, Indian Lancet, Jan. 1897. ' Marion, New York Med. Journ., 1897. H52 MEDICAL. DIAGNOtilS. stances of clironit* malarial infection, they may nol be detected excef after several examinations. In the !nalarial cachexia we have not only the ordinarj^ signs of anaemic blood, and witii these fretfuently enlargement of the spleen, dropsy, and hemorrhagic tendejicies, but the blood itself exhibits pecu- liar signs. It will show not only the malarial parasites, but consider- able pigment, the result of the destructive chanjjes in the hi^nio^lobin of the red corpuscles. Besides the black pi^'ment ttiere is also a yel- lowish or rusty-colored pigment, the seat of which, however, is more especially the spleen, liver, and bone-marrow. The pigment granules are found not only within the malarial parasite, but also exist free, and, accumulating in the capillaries, produce clogging, with setrondarj' results of disturbeil circulation, and altered nutrition in the brain* liver, kidney, or of wttatever part the vessels should supply. For the pigment to be of diagnostic value, it must be present in decided amounts; for J. F. Meigs ^ found pigment in Ihe blood of those who had never had malarial fc^ver or had never presented any signs of ] malarial poisoning. In the malarial blood the number of leucocytes is diminislied, with, as Thayer states, a relative increase in the large mononuclear forms. Typho-Malarial Fever. — Following the observations of Wood- ward dining our civil war, Uie thought obtained wide ciurency that there existed a special form of fever, typho-matarial, running a defi- nite course and with characteristic lesions. It was supposed to be a hybrid, generated by the malarial and typjioid poisojis, with, in tjie case of the camp fevers, an admixture of scun^y; and the soK'alled ** Chickahoniiny fever,'' seen among soldiei*s who contracted it in the swamps of tlie CJiickahominy, was its most striking illustration. But the verdict of the firofession now is, that there is no such fever as a distinct disease. Yet with our present means of research it can be proved that ttiere is undoubted coexistence of the malarial and typlioid infections. There Jire malarial cases m which true enteric fever happens, or typhoid-fever c^ses in wtiich the malarial [joison has been held in check by the typhoid infection, and does not show itself until late in the disease; cases beyond doubt clinically, in which the Widal reaction is positive, and malarial organisms are found in the blood. Thompson ' has reported several such instances of con- current disease ; Lyon"* has brought togetlaer otliers ;*and I havt * Pennsylvania Huspilal Reports, vol, u * Amer. Journ. Med. BcL, Au^» 1S94. ' Ibid., Jan. 1899. FEVERS. 853 records of twelve, one of which was separately published ' in a clinical lecture, and ten of which were subsequently analyzed. Patholc^- cally, also, a number have been studied in an interesting communi- cation by Muehleck.^ Now, it is a question whether, irrespective of the Widal test and the microscopic examination of the blood for malarial elements, such oases can be recognized clinically. Not with certainty. Yet they may be suspected from chills occurring late in the disease, and de- cided sweating following; from obvious and apparently causeless temperature-rises, and marked irregularity of temperature without such rises ; and from long duration of the fever. In all such cases repeated examination of the blood for malarial organisms should be made. The parasites I found were tertian or sestivo-autumnal, and frequently decidedly pigmented ; an instance of the quartan type in one of these combined typhoid and malarial fevers has been published by Craig.3 There is, then, such a morbid condition as a typho-malarial fever, but not as a separate disease, and not in the sense in which it has been understood. It is a concurrence rather than a blending, — a typhoid fever, after all ; and, if we are to give it a name, malario- typhoid would be appropriate. Eruptive Fevers. The eruptive or exanthematous fevers form a group having numer- ous features in common. They are characterized by a period of incu- bation, during which the poison lies dormant ; by a fever preceding the eruption ; by an eruption which presents a distinct aspect in each disease, and which pursues a definite, clearly defined course until it, and, with it, the febrile malady, disappears. Moreover, they are all very prone to occasion serious sequelae ; are all, in the main, disorders of childhood ; rarely attack the same person twice ; and are conta- gious. These remarks apply particularly to the three chief exanthem- atous fevers: scarlet fever, measles, and smallpox. In great part, too, they hold good in regard to erysipelas, described here in connec- tion with the eruptive fevers. Scarlet Fever. — Scarlatina affects both children and adults, and is marked by great heat of skin, frequent pulse, sore throat, and an early scarlet eruption. These symptoms are preceded by an uncer- tain, generally a short, period of incubation, but soon exhibit their * Philadelphia Med. Journal, May 6, 1899. « Ibid., May 20, 1899. « Ibid., June 17, 1899. 854 MEDICAL DIAGNOSIS. striking features. The feDrile excitement is characteristic ; the skin is very hot and generally dry, and the rapidity of the pulse so great that often by this sign alone we may, especially in the midst of an epidemic, predict the coming eruption. Vomiting, too, is a frequent symptom at the beginning of the illness. The temperature, which may reach between 105° and 106°, does not fall with the appearance of the eruption. The highest temperature occurs on the second or the third day.^ The temperature continues high until the eruption is completed and at its height. It slowly declines as this fades, and with the occur- rence of desquamation attains the norm ; but it may persist, with marked morning remissions and evening exacerbations, when the eruption has gone and during the first week of desquamation. The rash appears on the second day of the disease. It comes out almost simultaneously all over the body, although, on close scrutiny. it may be soonest perceived on the neck and the breast. At first the surface exhibits an almost uniform red blush, which disappears momentarily on pressure, or rather pressure leaves a white stain on the skin, which quickly again reddens from the periphery to the centre. Soon, however, the eruption presents an unequal aspei t ; it is of more vivid scarlet hue in some parts of the body, as in and around the flexures of the joints, and is not everywhere smooth. Here and there are seen elevated rough points of darker tint, edged by the red integument, and not infrequently vesicles containing a tliin fluid. The skin is very hot and itchy, and tumefied, especially on the hands and feet. The eruption declines on the fourth or the fifth day ; by the seventh or eighth, the cuticle begins to come away in laive flakes. Sometimes the rash, when at its height, recedes and then appears again. In malignant cases it comes out late, and is either pale and indistinct, or dark and Uvid. In some instances it is wanting. Some years ago, I saw this " scarlatina sine exanthemate" in a lady, who, watching over the sick-bed of her daughter, contracted the dis- ease and went regularly through it, even to its sequelae of disorder of the kidneys and swelling of the salivary glands, but in whom not a trace of an eruption could be detected. The 8ore throat of scarlatina is almost as constant and as cliarar- teristic as the scarlet rash. It shows early, sometimes before the eruption, and rarely waits until the third day of the complaint. At first the throat-affection consists in a diffused redness extending over Ui the tonsils, palate, and half-arches, and in a swelling of the tonsils: * Hatfield, article "Scarlet Fever/' in American Text- Book of Dt9ease^ •».' Children, 1894. Hi FEVER8. 855 the patient complains of pain in his throat, augmented by pressure and by swallowing, and of stiffness of the muscles of the neck. After a few days, if the disorder be severe, irritating discharges occur from the inflamed surfaces, and patches of false membrane and superficial ulcerations are seen in the fauces. The glands at the angle of the jaw become much tumefied, and, by pressing on the cervical vessels, produce a tendency to drowsiness and stupor. These are grave symp- toms ; their occurrence, indeed, is indicative of one of the main dangers in these " anginose" cases of the disease. The false membranes which are developed last about five or six days ; they form as well as reform in patches, and are very easily re- moved. Sometimes they extend to the larynx ; but this does not often happen. They contain masses of streptococci, but no diphtheria bacilli, unless there be a true diphtheritic complication. Yet this is a point that is not accepted by all clinicians. The mortality in these mixed cases is much greater.* The acid discharges and the decom- posing membranes often occasion a most fetid breath. The toiigiie has a peculiar look. At first it is thickly coated, and its borders only are red ; but soon the fur is cast off, and the whole organ becomes very red and its papillae prominent. After it has presented this appearance for six or eight days, it returns to its normal condition. In bad cases it is extremely dry and of a browniish hue. There is always marked leucoeytosk in scarlet fever, and it reaches its maximum in the first few days of the disease ; a close relationship exists between the severity of the rash and the number of leuco- cytes ; ^ and the return to normal is always gradual. In children the disease frequently sets in with convulsions. In truth, cerebral symptoms of one kind or another are not uncommon at all stages of the malady. In some cases of malignant character, the vomiting, the screams, the grinding of the teeth, the occurrence of delirium and insomnia, make the attack look, at the onset, like one of acute meningitis ; but the eruption soon sets all doubt at rest, and, even before it is noticed, the great heat of the skin and the extreme rapidity of the pulse point to the source of the mischief. The nervous symptoms in these dangerous instances of the affection do not, how- ever, cease with the eruption ; they may last to the end of the malady. Sometimes they are not noticed until late in the disorder, and after the period of desquamation has fully begun ; but the convulsions and * Chabade-Roussk. ark. patol. klin. med. ibakt, Feb. 1899, quoted in Medical. Mart., July, 1899. 'Sevestre, St. Bartholomew's Hosp. Rep., 1897. 856 MEDK AL DIAGNOSIS. stupor — for iliese are llu' nmrbid manifestations tlic-u more specialtr encountort^d — are owin^ rattier to a diseased state of the kidneys tlial lias been induced, than to the immediate effect of ttie fever poison. Occasionally some of the larger joints swell up, and present the ap- pearance of subacute rheumatism. The Joints are not, liowever, ven^ painful on pressure, and generally only two or lliree are enlarged. Endocarditis and pericarditis may be present as complications, but occur also irrespective of articular involvement, as does chorea. Further complications of the disease aiv dropsies, renal hiernatu- ria, pleurisy, local ^^n^reiie. ledema of the glottis, neuritis, diph- theria, and profound anieniia. These coniplieations do not usually arise until at or soon atler the period of destjuamation ; sometimej^ they lead to long-t-onlinued (tisorder, and become thus the most hazardous of the seejueUe, Ottier consequences of tlie aflfection. lastinjj, it may be, for year's after the febrile attack, are a tendency to boils, swelling of the parotid and of tlie lymphatic glands of the neck, nasal catarrh, diarrtifta, clironic intlanmiation of the eyelids, and deafness from inflammation exlending up the Eustacliian tube to Uie membrane of the tympanuriL or from suppurative destruction in the middle ear. Epilepsy is also a sequel of scarlet fever, more cases being ( onsecutive to it thaji [o all otlier acute diseases eiimbined/ Optic neuritis may follow scarlet fever, without oi^anic cliange in tlie brain. Of all these morbid states, droj/itt^ is the mosl common. The elhLsion of fluid may be caused by the altered state of the blood : but mucli more generally it is owing to the poison producing an acute desi[uamative nephritis : albumin, tube-casts, epithelial cells, and sometimes blood, are found in I he scanty urine ; and we meet with severe headache, great restlessness, and oedema of the face and extremities, as tfie attending symptoms* Still, notwithstanding Uiese grave phenomena, I lie majority of the cases recover, and the kidneys are rarely |K?rmarienfly injured. Ttie dropsy is apt to show itself between the tenth aiid the twen- tieth days of tlie malady. The albuminous condition of Uie urint* may precede it by several days; yet dropsy may happen without albumhmria,- and albumin in the urine is not always associated with dropsy. In most cases of scarlatina albumin is found at some period of tlie disease for a short time and in small quantities. ' Gowers, Diseases of tlie Nervous Sysleiii. * Gee. in Russell Reynnlds's SysU'm of Mi*ili<'iiie ; also Quim-k**, Eferliii- kliii" Wtxh., 1882, No. 27 ; Dyce Duekwurtlx, SL BarllL Kosp. Hep.. IS83, 4 4 FEVERS. 857 The siate of exhaustion noticeable at the close of the fever and while desquamation is still going on is at times great, — so great that, in young persons especially, the case wears the look of typhald fever. And the resemblance is heightened by the occurrence of diarrhoea associated \vith a swelling of the solitary and agminated glands. But the signs of desquamation, the sore throat, the enlargement of the cervical glands, and the history of tlie affection furnish distinctive marks of the utmost value. We must also bear in mind that an erythematous rash like scarlatina occurs at times in typhoid fever preceding the characteristic rose-spots. The statements that have just been made concerning the diverse complications of the malady are mainly of interest on account of their exhibiting the intricate diagnostic questions that may arise. Of the recognition of the disorder during the febrile stage it is not necessarj- to say much, as ordinarily it is not difficult. The distinction between it and the other exanthematous fevers will be seen by glancing at the table, to which a place is elsewhere assigned. I shall only here mention, as bearing upon the differences between scarlet fever and measles^ that cases are occasionally encountered in which the erup- tion alone is too ill defined to become the sole basis of an opinion, and that then we have to lay the greatest stress on the presence or absence of catarrhal symptoms and sore throat, and on the march of the symptoms. So, too, with reference to ainaUpox. The rash pre- ceding the formation of the pustules may so strongly resemble that of scarlet fever that a scrutiny of all the attending circumstances, and a careful watching of the eruption for at least a day, are requisite for the detection of the true nature of the case. An erythematous rash, appearing in blotches everywhere except on the face, has been noticed in laryngeal diphtheria after the opera- tion of tracheotomy.^ But it is very irregular, runs a rapid course, and is not followed by desquamation ; a point, it may be here men- tioned, distinguishing all the forms of irregular rashes happening at times — though very rarely — in diphtheria, from the scarlet fever eruption. As the result of gonorrhoea we may have symptoms of a low fever associated with a cutaneous rash like that of scarlet fever. The history and progress of the case chiefly distinguish this pHeudo'searlatina? The same is true with reference to the so-called surgical scarlet fever. It shows an eruption that may be like that of ' Bericht des k. k. Krankenhauses, Weiden, 1865. ^ Ballot, Arch. Gen. de Med., Sept. 1882. The same author calls attention to a puerperal pseudo- rubeola, a false measles, from blood-infection. 858 MEDICAL DIAGN08IB. soarlot finer, Hiou^^h the throat symptoms and the sequela* are larking. It is most likely of septic Drijdn. Like measles, searlaiina may be mistaken for rubella. But tliis really resembles measles more closely, and in examining it preseriHy tlie differences between it and scarlet fever will become apparent. An alTectioM with several features like scarlatina is breakbone fever, or deiifpu\ The points of dissimilarity may be learned by referrin^r to the description of tlie malady already given. It is well also lo re- member that rertain (intgH, such as quinine may produce a scarlaliai-* form eruption. Scarlet fever may ^n on concurrenHy with other fevers. It lias been observed with typhoid fever, witl^ varicella,^ and with small- pox.^ Measles. — The symptoms [jrecoi-sory io the specific erupUon (*f this alfertioji are fever, water}^ eyes» frecpient sneezing, How from Ihe nose, and cough ; in fact, all the maiiifes tat ions of an acute cor>*za or catarrh. To these diarrhcea is in many instances added, indieathitr a simultaneous irritation of the intestinal nmcous membrane. On the fourth day alter the hej^annin^ of the morbid signs, a rash is perceived on the face and neck ; theiK'e it continues to extend, until, in I lie coui'se of two or iliree days, the whole body is covered. The tem- |)erature during the first day of the disease is generally from 1(»2^ to lOil"^; if hig^her, the attack is likely to be severe. On the second or third day — usually on the second, when it may be but 1)8.6° or 1*!»" — it is markedly lower, and it rises aKain on the evening of tlie tlurd or on the fourth day to decided fever heat. The temperature does nol at once decline with the rash. Indeed, it is apt to go on rising for twenty-four to tlurty-six liours ; the occurrence of the eruption does not alleviate the febrile symptoms ; on the contrary, wtiile it is spread- ing to tlie trunk and the low^er extremities, the constiiulional disturij- ance lasts, or more generally increases. But as soon as tlie rash has fully reacht-d its height, flie defervescence is rapid ; and from the fiftli to the seventh day of the disease the temperature sinks until it is but little above tlie norm. By the ninth day of the disease both fever and nish liave lell. Frequently tlien the euticle comes away in fine scales, and this destpiamation is attended with very annoying itching. Tlie jiatient, now that lie is convalesrent, shows his illness: he is pale and somewhat emanated, fttten lie still coughs, and his eyes are slightly inflamed. These signs are nol unusually the last lo disapp«»ar. ' Chiircti, St. Barthol. Hosp. Bep., 1881 ; LimJ. Med. Record, N'ov. I^cH;; * See the t-ases oF Murson, iMt dico-Cbirurjf. Traiisiict., vol. xxx. FEVERS. 85^ Paralysis, of cerebral, spinal, or peripheral origin, may occur in the sequence of measles.* Of all the symptoms mentioned, two are, in a diagnostic sense, of pre-eminent importance : the catarrh and the eruption. The caiarrh is nearly constant. It is true that a variety of measles is recognized, — " rubeola sine catarrho ;" but this is very rare. Gen- erally speaking, the coryza and catarrh decline with the eruption ; occasionally, however, they remain for some time after the rash has left. The feature which distinguishes these catarrhal symptoms from those of influenza is the eruption : before this happens, the diagnosis is uncertain, though we may often suspect measles by the look of the face, the greater intensity of the febrile signs, and the knowledge that the disease is prevailing in the community. The eruption is peculiar: it consists of slightly raised red spots, which coalesce and fonii blotches of an irregular, crescentic shape ; between these blotches the skin is of natural color. The eruption disappears first from the face ; in other words, it disappears in the same order in which it appears. As it fades, wiiich it does on the third or fourth day of its appearance, it becomes brownish, and sub- sequently of a yellowish tint. In its earliest stages it is similar to the papulte of smallpox ; and this similarity may be heightened by its being mixed, as it sometimes is, with a few miliary vesicles. But after the first day of the rash there is little room for doubt. In the one case the spots remain ; in the other, they change into pustules. A very valuable contribution to the diagnosis of measles, especially to its early diagnosis, has been made by Koplik.^ He has pointed out that from three to five days before the outbreak of the eruption, as well as to be seen afterwards, are found, when the mucous membrane of the cheeks and lips are examined by strong daylight, and limited to them, small, irregular, bright-red spots with a minute bluish-white centre. These spots are most frequent opposite the lower molar teeth, and they are not met with in any other exanthem, or in any disease of the skin. A question may sometimes arise as to whether the eruption be that of typhtis fever or of measles. Both are coarse, both often not unlike in color, and both may be developed about the same time. Generally speaking, however, the eruption of typhus fever shows itself several days later than the rash of measles; and, although ' Allyn, Medical News, Nov. 28, 1891, p. 617 ; Carpenter, Medical News, Feb. 13, 1892, p. 183. « New York Med. Record, April 9, 1898. MEDICAL DIAGN08I8. f*oarst% It is not ert?sccntic, and is found on ttie trunk and extremities and only rarely on llie faee. Moreover, the physiognomy, (he exces- sive prostration of strength, and the marked cerebral s)Tnptonis of the low fever are such as to render a diflerential diagnosis seldom diflicutt. From hemorrliaglc measles the distinction is more difficult ; but here, too, the absence of cerebral symptoms is of niuch importance. Measles is usually met with in children; but it maybe encountered in adnlts» especially among soldiers, and is in adults a much mure severe coniptuini than in children. In the latter it is not an alarming disease. Only occasionally does it occur in epidemics which present a mali^manl character. Us greatest danger commonly consists in ttie eruption disappearing prematurely or appearing but partially, and in the severity of the tlioracic complications. These are either acute bronchitis or acute pneumonia. Amie bmnehUlut may occur at atiy period of the disorder, and involve the finer lubes. But it does not generally set in with severity until the eruption has reached its height or is beginning to fade. In young children, symptoms of inflanimaiion of the larynx, or of croup, are at the same periud a]>t to manifest themselves. Acute pneumonia, loo, either croupous or broncho-pneumonia, the latter much more often, is met with at this stage of the malady, or sometimes even afler convalescence has apparently be^un. Occasionally the thoracic affection leaves a chronic bronchial dis- ease» or a persistent cougli and night-sweats point to tuberculosis. It may be, in individual cases, extremely difficult to decide vvitli which of these morbid states we have to deal, and as ttie physical signs of tubercular consumption are, in children, noloriousiy ill defined and untrustworthy, we may be obliged to depend upon llie presence or absence of tubercle bacilli before coming to a definite conclusion. An affection formerly ver)^ common, raUiary fever ^ would be also a source of much confusion were it in our day often encountered. But epidemics of miliaria are now extremely rare. Yet we know that it is a disorder with a prodromal stage of two or three days, during which great irritation of the skin, debility, and a feeling of suffocation are usual. The marked disease begins with profuse sw^eating and with severe fever, and pni^cordial and epigastric distress. These symptoms last until the ajipearance of the rash, generally on the third or tlie fourth day, thoiagli sometimes not until much later, and then, as a rule, slowly sut^side. Ttie rash appears first upon ttie neck and the breast, anii consists of numerous round or irregular spots, in the centre of wldcli vesicles arise that finally burst and form crusts. The disease ends with desquamation, and generally in a slow* convaU*s- FEVERS. 861 cence. The sweating, the oppression and praecordial pain, and the peculiar eruption distinguish this epidemic disease from measles. Rubella. — The most striking resemblance to measles is furnished by rubella. This, called by the Germans R'diheln^ and often spoken of as " German measles," is not a hybrid of measles and of scarlet fever, but a special exanthem, which occurs in epidemics. It displays a red eruption, ushered in by a chill, followed by slight fever, which is accompanied by coryza, cough, and sore throat. The fever lasts for two or three days prior to the eruption, but this* is far from constant ; indeed, it often does not last more than half a day, or it may be of a week's duration.^ The temperature rarely exceeds 102.5°. The rash may come out all over at once, or spread in a day or two over the body ; it generally appears first on the face and neck. It is most dis- tinct on the face, the scalp, the neck, and the trunk, being more scat- tered on the extremities : it is specially distinct about the mouth. It first resembles measles, but the spots are round or oval, and smaller and paler, and they soon run together in irregular patches, unlike the well-defined crescentic eruption of measles ; they show no tendency, however, to become generally confluent. The patches are of variable size, and, unlike the rash of scarlatina, are surrounded by healthy skin ; small spots range themselves around the large ones. They are of deepest color in the centre, but not bright-colored as in measles, nor of the dark red of severe scarlatina, are elevated, and very much influenced by pressure. The eruption lasts ordinarily four or five days, but in severe cases eight or ten. It gradually fades, but it may happen that it fades on the face before it has fairly come out on the legs, and desquamation may ensue, though the scales are small, and never in size like those of scarlet fever. During the continuance of the rash, which is attended with much itching, the general symptoms are greatly aggravated, except the fever, which indeed may be percep- tible only at the beginning of the affection ; the sore throat and catarrh may be severe, and attended with hoarseness and with ina- bility to swallow ; there are congestion of the conjunctivae and pain in the eyes. Osbom has called attention to enlargement of the small glands at the edge of the hair on the postero-lateral sides of the neck as a pathognomonic sign.^ As the rash fades, the other symptoms subside. Swelling and even suppuration of the cervical glands are not uncommon sequelae. The disease may be very difficult to distinguish from measles, * Edwards, article "Rubella,'' in Keating's Cycl. of Diseases of Children. » Weekly Med. Rev., Dec. 24, 1887. ^62 MEDICAL DIAGNOSIS. except when it is epidemic and affects those who have already had measles. The more sudden onset, often almost feverless, the milder course of the complaint, and the peculiarities of the eruption already spoken of, are guides in separating individual cases. But the appear- ance of the rash may be ill defined and very misleading. The fol- lowing table exhibits the differences between well-marked cases of rubella, measles, and scarlet fever : Rubella. Period of incubation from nine to twenty-one days ; usually eighteen days. Premonitory symptoms often wanting, but fre- quently sore throat. If attack severe, loss of appetite and drowsiness for twenty- four hours before eruption. Eruption is mostly the first symptom ; dots, rosy- red, with well-defined edges, first behind the ears, on scalp and face, around mouth ; extends to neck and chest ; grad- ually covers entire body. Dots coalesce and form patches. P^auces look dr}', with a dark mottled red hue ; little relation of appejir- ance of fauces to extent of rash. Sore throat may disappear, to recur in last sbges of the disease. No diazo-reaction in urine. Eyes pink-red ;md suf- fused. Lymphatic ^'lands ^'emture varies be- tween 102° and lOS**. Infectiveness lasts from ten to fourteen days if disinfection efficient. Sequehe, few and not fre- quent ; glandular en- largements may follow. Usually complete i-ecovery ill twr» weeks, or less. Measles. Catarrhal symptoms and cough constant ; a little flaky shedding of the epithelium, A'arying ac- cording to the intensity of the rash. Kidneys not affected. Diarrhoea frequent. Usually feels illness much. Tongue slightly furred. Pulse usually accelerated ; maintains ratio to tem- perature. Temperature usually from 101 *» to 108°. Infectiveness does not last for more than from four- teen to twenty days, if disinfection efficient. Sequelae, bronchitis, pneu- monia, pleurisy, oph- thalmia, otitis. Usually complete recovery in two weeks ; is some- times followed by pro- longed period of ill health. Scarlet Fever. Catarrhal symptoms and cough absent, or slight throat cough. Desqua- mation in proportion to the extent of the erup- tion ; begins as this fades, and continues for weeks ; marked about hands and feet. Kidneys often implicated ; albuminuria ; acute ne- phritis common. Diarrhaea not uncommon. In slight cases light ill- ness ; in severe cases grave illness. Tongue coated with a thick, white fur, peeling from the tip and edges on the fourth day, leav- ing the * * stra wlierry ' ' tongue. Pulse greatly accelerated, and rapid out of pro- portion to temperature. Ranges from 103° to 106° ; proportionate to rash, but not to pulse. At onset only slightly in- fective ; is very infective after first forty-eight hours; infectiveness may continue for six or eight weeks or longer. Sequelae, nephritis ; en- largement or suppura- tion of submaxillary and lymphatic -glands ; otitis ; arthritis ; endo- carditis ; epilepsy. Usually complete recovery ; sometii»es prolongeti convalescence from se- quela* ; mortality high in the very young. 7)jplius fevet% at least as regards the eruption, has some similarity to (Jerman measles. But the severe fever, the far greater gravity of the constitutional symptoms, the rash not appearing on the face, and 864 iMEDICAL DIAGNOSIS. the absejjce of catarrhal symptotiis, render it strikingly unlike lh».- lalter alTectiotL Rubella is contagious, and afleeLs especially children ; it is ex- tremely luieominon afler forty yr^ars of age. Second attacks are also very rare. It does not protrrl from cillier scarlet fcvrr nr mt'aslt-^. nor do they from it. Smallpox, — Smallpox, or variola, attacks boLli cluhlreii ami adults. U is a highly contagious malady, spreading rapidly among those who are unprotected by vaccination. The period of ineubalioi) is generally at^out twelve days. The chief symptoms of (lie stage of hwimon are chUls, fevef, vom- iting, (lain in the back, and, in children, convulsions. The fever runs high, and exacerbates markedly towards evening; the temperature may reach lOO^ or more. The pfiin in the back is severe, particularly in grave cases ; it may be attended by pain hi the limbs like those of rheumatism ; there are also intense headache and restlessness. All these symptoms subside witli great relief at the end of the tlurd or oti the fourth day, when an eruption shows itself on the lips and fore- head and wrist, soon extends to the Iriuik, and from the trunk all over the body ; with the appearance and the spread of the erupUoii there is a gradual but very decided fall in tenijjeralure, often to 1(X».^ At fu'st tlie i'rupdoH has the appearance of pajmlje; but on Uie second and third days the coarse spots undergo a decided change. At the lop of each papule appears a vesicle, which gradually becomes larger, and fills up with a thick, milky fluid; in sliort, becomes a pustule. By the fifth or sixth day, the change has been fully accom- plished, and the pustules are splieroidal and lose the umbilicated look wliich they had wliile forming. During all ttiis lime the temperature does not again rise ; tlie tongue is coated and swollen. On the eighth day pus begins to ooze from the edges of the pustules, and a secon- dary fever sets in, lasting for three or four days,— until, indeed, all the pustules are broken ; tliis secondary fever is sometimes ushered in by a cliill ; it is of remittent type, and tlie evening temperature marks between 103^ and 105°. There is gradual and protmeted deferves- cence; crusts form wiiere prtiviously tlierc had been pustules: and as these crusts dry and fall off, the skin beneatli is seen to be of a red color, that only slowly fades, and here and there are noticed those sc:u? and pits which the patient carries during the remainder of his life. Preceding the chfu*acteristic eruption in sniallpox a red rash likif that of scarlatina may he noticed in the pubic and Uie inguinal or lateral thoracic regions ; and at times a very imsleading rash of meai^lv form. FEVERS. 865 When the pustules are in great abundance, they run together, constituting confluent smallpox. The eruption may be discovered a day earlier than in the discrete form, and the rough, red blotches are often so thickly clustered as to give a uniformly red aspect to the whole surface. When the pustules completely fill up, whole por- tions of the face or of the trunk seem to be covered by one extensive Fig. K\. Temperature in the severe form of variola ; death during tlie .«iee<)iKlar>* fever (After Wunderlieh.) pustule, which gradually dries into a continuous brownish and most disfiguring crust. While the process of maturation is going on, the features are observed to be greatly swollen ; the eyes may be hidden from view; the nose and lips are tumid; conjunctivitis is not un- common. The patient complains of the tension of the skin, and not infrequently of sore throat and of a steady flow of saliva from the mouth, — a symptom that may be also met \vith in measles. The sec- 54 866 MEDICAL DIAGNOSIS. ondary fever is violent » Far more so tlian in diserelf variola^ It mar not appear until a day or two later, but lasls longer, shows a Iiigher temperature, and is the period of danger, since it is at this time that death is most apt to happen. Before death the temperature is some- times extraordinarily higli, 108*^ or upward, A fatal issue is often [irereded by a dry tongue, by delirium, and by great restlessness ; by what, in fact, are called typhoid symptoms. Sometimes death is occasioned by aUaeks of dysentery or of diar- rhoea, by inflammation, redema or necrosis of the larynx, extensive pharyngitis, by acute endocarditis, or by plugging of a vessel in the brain. A case of varioUi has been reported complicated, during con- valescence, by convulsions, followed by left hemiplegia, in wiiiclt alWr death an area of softening was found in the motor area of the right cerebral hemisi>heTe, due to vascular occlusion.^ Cases of variola have also been observ^ed presenting peripheral neuritis or purulent peritonitis.^ Other complications, not infrequently fatal, are pleurisy and broncho-pneumoma. Sometimes the patient sinks at the onset of the disease. In these muHgmmf cases, mostly met witli at tlie beginning of an epidemic*, he dies from the virulence of the poison. He is stupid, delirious ; the eniplion seems, as it were, to struggle to reach the surface, is ill dehned and of a livid hue, and nmy fail to appear until after death. Many of the malignant ciLsos, too, are of the hemorrhagic ty]ie. marked by petechial blotches and ecchymoses, and jirofuse hemorriiages from mucous membranes. The speoifir micro- organism of smallpox is still undiscovered. The sequelae of smallpox are chronic diarrhoea, glandular enlarge- ments, boils, various diseases of the eyelids and eyeballs, otitis niedia« and suppurative arlhrilis. Smallpox is occasionally met with during the progress of other disorders, blending its symptoms witli those of the complaint to whicli it becomes superadded. It is thus found as an intercurrent ai!'ection in typhoid fever, in lyphus, in scarlet fever, and in measles ; yet even then there is r»o dilTiculty in recognizing its peculiar trails, — its lumbar [>aiu and characteristic eruption. Ordi- narily the detection of variola is extremely easy, except at its onset But ttie points of similarity it may present, in its early stages. In typhus fever, and to several other diseases, have been already dis- cussed, and need not be repeated ; we have often to wait the caurst^ of the eruption before framing a positive diagnosis from the symptoms alone, and wittiout taking into account ttie epidemic influences f»re- ^ Davezac and Detmas, Joiimal de MMechie de Rrirdenux. lS9fi. No. 38, p, 421, * Auche, Bulletin MeiJicaL J:m. 25, 18^3. FEVERS. 867 Fig. 84. vailing. When the disease is fully developed, all difficulty in its diag- nosis ceases. In the period of invasion the pain in the loins is the most significant differential sign. It is by this alone that we may be enabled to tell the scarlatiniform rash or the measly rash that is some- times found to precede the papules of smallpox ; though these initial rashes are generally much more localized and not so widely diffused as those of real scarlet fever or measles, and the bastard scarlatina has not the vivid hue of the true dis- ease, nor the measly rash the coarse ness and hardness of the papule of smallpox. The contagion of smallpox does not always manifest itself by an attack of variola. Sometimes it is modified by happening in a person who is partially protected by vaccination. This vario- loid disease is mild and very rarely fatal ; it protects against smallpox. It is distinguished from variola by the pustules passing more quickly through all their stages, and, above all, by an absence of secondary fever. . Soon after the eruption — within thirty-six hours — the thermometer shows freedom from fever, and, unless serious complications happen, the temperature remains nearly normal. The suppuration is far less deep; and the resulting cicatrices are often scarcely discernible. Varicelkt. — A specific disorder simi- lar to but not identical with variola or varioloid is chicken-pox, or varicella. It differs, as regards its symptoms, from smallpox in the leniency of the intro- ductory fever ; in the eruption beginning generally first on the trunk, occurring often on the second day, though it may not show itself until the end of the third, and continuing to appear and disappear in crops, the mass of the eruption, however, having become evident within twenty-four hours ; in the vesicles being surrounded by little or no inflammatory redness ; in their remaining vesicles and not becoming pustules ; in their attaining their height on the third or fourth day of the eruption, TeTiiiHTatiire-rooord in varioloid oiul- iiig ill ru(!oven- : tlio abuence of second- ar>- fever h* clearly seen. (After Wun- derlich.) 870 MEDICAL DIAGNOBIB, of febrile invasion; in all, ton, alllioiigh the onipUon takt-s its origin al one spul, and i^enerally on the face, it is not lijiiited tliere. The Ihickly-efiistered blotches of beginning conjiuent mnaUpox give at times lo the face the look of erysipelas. Yet here, also, evidences rati be fonnd of a rash atmni to appear ail over the body: and doubt is soon dispelled by the prog^ress of the eruption. Sometimes vesicles and even irregular i>uslules form in erysipelas, and the malady may be looked upon as a etironie disease of the skin, such as eczema, pem- phigus, or impetigo : hut these affections lack the liistory of a recent acute disease, and in reality the likeness is not a striking one. The dosest similarity is to herpes zoster of the foreliead and face. But tlie eruption in this does not pass tlie middle line,' The red color of the skin, the fever, and Uie absence of colic and of gastro-intestinal attacks, distinguisli erysipelas from the transient but recurring swell- ings of tiitgiht-nfurofic (rsdeina. Erysipelas may break out in one part of tlie body after another and the disease be thus kept op for a tong period. This er^mipfUiM imgram runs its course more rajiidly and completely in one part than in anotlier, and in accordance with a general law wtiicti it obeys,* Erysipelas may be confounded witli mumps. The error is mainly caused by stress being laid on the redness wliich is frequently found beneath one or both ears in parotitis, but which, unlike erysipelas, is attended with much pain on moving the jaw, and with decided glan- flular luniefaclion. The redness, moreover, shows no tendency to spread, and rarely continues for the four or live days during wliich mumps lasts. In very young children, however, tliere may be some dilliculty in diagnosis. I have seen the glands at the angle of the jaw swollen for one or two days prior to the discoloration over them taking on an erysipelatous blush, which then spread rapidly, and became associated with swelling of the glands of the other side. The glandular complaint was the complication of erysipelas. A fever with a cUstinct pharyngitis as a local manifestation, the so- called phanfugen! fevet\ is probably an epidemic erysipelatous fever of liglit ty[>e. It has been particularly described by Austin Flird, Roches- ter,^ and HiU'vey E. Brown/ The fever lasts froiii three to six days, and, besides the marked pharyngitis, is attended with swelling of the lymphatic glands of the neck, accompanied by pain. The disease shows a proportion of cases with erj^sipelas of the tace. ' Ftigge, Practice of Medidne, vol, i. p. 271. * Traced biy Pllfiger in 70 cases \ qnated in Sclimidt's Jahrb., No. 7, 187JI. » BufTalo Medical .IrmniaK 1857. * FJiid's Principles aiul Priictic*.' of Medicine, i CHAPTER XIII. DISEASES OF THE SKIN. To facilitate the discrimination of diseases of the skin, they have been grouped into classes. An extensively used system of classifi- cation takes for its basis the anatomical seat and arrangement of the healthy. The distressing disonter may bt* purely jooai. oivurri::.- anMHul the anus, or on the scrotum and the root of the |"fni5, or i*. tlu- pudenda. Some of Uiest* rast*s. however, though lalled prurip-. pnsint no papuhv, and the disonler, is dut- to jvrverled sen>ibi:ity o!' the outanei^us ner^'es alone, and is rt-ally a pruritus. Pniri^r** is otit n attendeil with eizema. Many suppostnl instances an* not really pruriiro, but phtlieiriasis. dur to tlie irritation of botty-liic. that produce papuJes, whose aj»h-- an^ si rati heti olT and show little |^K>inls of dried blocni. True prurir is triMjuently found to be ronneiteil witli deterioration of Iht hea :: . an«i is t hietly met with among the pix^r and tlie mrsrk^-led. 1: r..u\ last a liletinio. Ix^nning in ehihlhiXHl. Its lixal forms art- as^s^vb*--: with irritation of the bladder, the nxtum. or the utenis. Papiiles and tulx-roK^. or large jmpules. ivourin thv iatttT sca.>-s •: DISEASES OF THE SKIN. 877 syphilis; they are often preceded by the pigmented erythematous syphiloderm. Gumma is a tertiary manifestation, mostly appearing in the subcutaneous or submucous connective tissue without inflamma- tion, irritation, or itching, the lesions ultimately attaining a considera- ble size. At first the color of the skin is not changed, but finally it becomes deeply congested and glazed, and as the contents of the lesion soften, the overlying skin breaks down, and the purulent ma- terial is discharged. Vesicular Diseajses. — ^These are characterized by an effusion of a clear or a sero-purulent fluid beneath the epidermis, which is gener- ally raised in small elevations. To the class of vesicular diseases belong especially eczema and herpes. Eczema. — ^The malady consists of minute vesicles collected together in irregular patches. The vesicles are often confluent, and it then aji- pears as if the whole surface were secreting fluid. This may harden, from exposure to the air, in scabs of various thickness and color. The skin itself is often of a vividly red hue ; indeed, it is inflamed, and a new cell-growth takes place both in the rete mucosum and in the papillary layer of the derm. It is there that the effusion of serum begins. In chronic cases the inflammatory infiltration extends deeper. Eczema is the most common of all the cutaneous maladies ; but it is not contagious. It may affect the whole body, yet is ordinarily limited to some portion of it. It is acute or chronic. The former is generally seen as the effect of local irritants, and may be met with in young and healthy persons. Chronic eczema is more usual, is often the. consequence of constitutional disturbance, and is fi-equently found to be associated with some disorder of the digestive system. It has as a frequent seat the flexor surfaces of the limbs. Dentition and un- healthy milk are common sources of the affection in very young chil- dren. In them the disease is extremely apt to attack the scalp and face, forming the complaint often described as " crusta lactea ;" or if the secretion be partly purulent, or early become so, and dry into laige, dark scabs, the malady is designated as eczema impetiginodes. This is most often met with in scrofulous subjects. There is less heat and itching than in other forms of eczema. Eichhoff holds many cases of eczema to be of parasitic origin. In some of the forms of eczema, especially in its chronic varieties, the vesicles supposed to characterize the disorder can often not be found. This and other reasons have caused several dermatologists, especially Hebra and Anderson, to deny that eczema need be vesicular at all. Infiltration of the skin, exudation on its surface, the formation of crusts, and itching, are held to be its distinctive signs while the (78 MKDICAL DIAGNOBIS. iTH|*tiori is iil ils 1 1 eight ; but Ilit* tTUption may roiisist o! clusters of [japult^s, vesicles, or pustules, or there may not be a vestige of any of these, the skin being thickened, red and smooth, and secreting a slicky tluiih or eovered witli K^een or gummy crusts, or fissured wiUi dee|j (Tacks ; yet there are no ulcerations. Not infrequently the disorder Ijt/gins as an erj'theniu. A scdy form of eczema, eeztnua nfptamofuui^ is a[A to be confnied to iliv lumds and feet. In all the foniis of ec* zema there is severe itchiJig. Tliis itching is especially violent in the foniJ witli the deep-red and weeping smface, the rezema ruhrum^ often seen in gouty or in dyspeptic subjects, and having a predilection for the Hexures of the joints. Eczema, when it aflfects the scalp and face, must not l>e confounded with the morbid secrt*Uon from the sebaceous follicles that gives rise to 5oil crusts, Sehorrha'it by preference attacks the parts mentioned ; bul its iTusts, Jis Hardy has shown, are unlike tliose of eczema in ihc readiness witli which they are detached and are susceptible of being moulded between tlie fingers. The surface beneath Uie crusls, too, is 'dissimilar. It has an oily, glistening look; there is no discharge. Uiiiia' has dislinguished a seborrhteic form of eczema, which, begin* ning usually on tlie scalp, sipreads to other portions of tlie cutaneous Burface; but he aHribuies tlie source of the fatty scales and crusts lo disorder of the sudoriparous, rather than to the sebaceous glands. Patdies of seborrha?ic eczema are also found in the sternal regionJ which, atler the scalp* is the locality most frequently affected, the] imtches spreading by small papules at the border, leaving the centr less scaly and even smooth, w^hile Ihe margin is a red, scale-covereer, and lymphangitis. The tumefaction may be m swell-! ings separated by deep furrows, giving somewhat of a tuberculated look to the part, or it may be uniform ; it chiefly attacks males, and occasions great deformities. It is a disease of the tropics. Cases. especially of elephantiasis of the scrotum, have been frequently traivd to filariie, or to repeated attacks of erj^sipelas. There is a form of enlargement of the leg to which we may here briefly refer, — one in which the overgrowth of the affected Umb is associated with tlineaM in the Ipnphatir si/siem. Vesicles form, which are connected by ridge-like elevations, and which from time to time dischai-ge a chylous fluid.^ The subcutaneous lymphatics near Hie groin are usually found to be distended. Sclej'oder^ina, — Scleroderma, or sclerema, is an induration of Ihe^ skin and areolar texture^ which may be partial or general, affecling nearly the whole body. The skin is dense and hard, and iJi Uie tnl<^, skin and the subcutaneous tissue the fibrous elements are much in- creased. The true skin shrinks and binds down and is bound to Hie parts beneath. If the malady seize upon the Jingers, it renders them rigid. The disease is generally symmetrical, and much more connnuu 4 ' See Gould's Year-Book of Merlicine jind Surgery, 1H97, p. 860. ' W. H. Day, TrarisuuU t-'liii. 8oc\ Lf)«d.. vol. il., 1869. DISEA8E8 OF THE 8KIN. 887 ill women than in men ; it may appear after unusual exposure to cold and resulting frost-bite.* It frequently coexists with feeble health; and in time the internal organs become affected, or these are from the first implicated.- Yet the general health may remain good. In generalized scleroderma the plaques may appear on any portion and extend over almost the whole surface of the body, as in the case described by Leredde and Thomas.^ I had some years since a marked case of this strange affection under my charge at the Pennsylvania Hospital, in a woman, forty-two years of- age, who, admitted with oedema of the feet, was at the same time noticed to have a swelling of both wrists and forearms as well as of the cheeks. The swelling was firm and resistant, and did not pit on pressure. The skin covering it was ver>^ smooth, and of redder hue than at other portions of the body ; there was well-preserved sen- sibility. The oedema disappeared from the feet, but the signs of the indurated cellular tissue did not leave the afi'ected parts. On the contrary, the condition of these parts became worse, though the gen- eral health was excellent, all the internal viscera being in a normal state. Gradually the hands, particularly the fingers, were found to be more and more resisting and immovable, and she could scarcely bend them ; occasionally they were the seat of pain. The skin lost all suppleness, and could not be raised up. At no time while under observation was albumin present in the urine. She left the hospital unimproved by the sulphur baths, the bichloride of mercury, and the various other alteratives she took ; and I afterwards learned that she died of an acute pleurisy succeeding an attack of acute meningitis. Prior to her death, so great was the pressure exerted by the dense and contracting areolar tissue that dry gangrene of a finger ensued, as well as of a toe, the disease having been also noticed in the lower extremities. She died about one year from the beginning of the dis- ease. Examined after death, the skin of the affected parts was found firmly united to the muscles by the dense areolar textures. Scleroderma is very similar in many of its features to myxwdenut. But the marked anaemia of this, the decided nervous symptoms, and the fact that we do not find the stiff*, hard skin compressing the parts beneath causing in time marked atrophies, distinguish the two mala- dies. The successful treatment of layxcedema by thyroid extract sug- gests a means of diagnosis between the two aff'ections. Goldzieher* * Goldzieher, BeitrSge der Berlin. Dermatolog. Gesellsch., March, 1893. * Hiirley, Med.-Chir. Transact., 1877. =» Archives de Med. Exp. et d'Anal. Path., Sept. 1898. * Beitnij^e der Berlin. Dermatolog. Gesellsch., March 12, 189^^. 888 tEDICAL DIAUNOSIf considers scleroderma a |jrogressive rhrouic dermatitis arcompatiied by jjernjaneut (x*d*»ina. Repealed attacks of erympela>t Uiicken tlie skin, but we do uot find atropldes from com|jression. Scleroderma is closely related to morpluea. This occurs over tlie course of nen^e-lracts, tlie Ihiekeninf,^ being in circumscribed patches and lacking the peenliar hardness of sclerema ; then changes in the stmelure of the skin, hypenemic appearances at first, pigmentation and cicalrization afterwards, oeenr in niurplnea, witli pain and tinglinff in the aflected paHs, Tlie color of the patch of morpliui^a is charac- teiistir, Tlie central part is usually of a yellowisla-white or ivory I'olor, whicli is suronnded by a zone of lilac, due to enlarged capiJ- laries. By some, niorphrum, inhabits the seba- ceous and hair-folhcles, but does not cause disease. The complaints associated with (he vegetable parasites, the rpi^ phifii'H, — c)r, as those on the skin are called, the flenrnttophi^m, — also known by the generic name of fhiea, are eliiefly favus, mentagra, pity- riasis versicolor, and some of the forms of ringworm. finf:n cireimita, and Hncu ton^funuui. Pellagra^ supposed., too, to be due to a vegetable parasitic growth, is not an aflection met witli in this country. Xor does the presumed parasitic fungus lodge in the skin. It is said tn be found in diseased Indian corn i>r maixe, which, when eaten, causes the digestive disorders, the general cachexia, and the erythematous cuta- neous eruptio!! that characterize the malady. In the chronic eases melancholia, suicidal mania, and paraplegia are met with. Belmondo fonnd lesions of the spinal cord in a number of instances. I DISEASES OF THE SKIN. 889 Fig. m. Scabies. — Scabies, or the itch, is owing to the acarus scabiei. This burrows in the skin, particularly between the fingers and between the toes, about the wrists, on the buttocks and abdomen, and the upper part of the penis. The channels produced are curved, and may be traced as whitish or more generally black streaks several lines in length, in the situations just indicated. The disease is attended with excessive itching, which is increased at night, and with the eruption of conicle vesicles, or even of a marked eczema and of papules and pustules ; most of the rash is due to the irritation of scratching. At the close of our civil war we had a form of itch prevalent in this eountrj', spread far and wide, as is presumed, by contact with the troops, — the so-rnlled army itch. It was a chronic and distressing affec- tion, and no age or social state was exempt from it. The itching was intense ; the eruption was like pru- rigo, but vesicles, or even an ec- zematous condition of the skin, or pustules, attended the intolerable itching ; and in cases of long dura- tion the appearance of the skin was altered, and all trace of a dis- tinctive eruption was gone. The eruption was seen on the arms, chest, abdomen, and lower ex- tremities, particularly on the ulnar side of the forearm and the inner aspect of the thigh. It was sometimes found on the scalp, but sel- dom in the groins, in the axilloB, on the hands, or between the fingers. It was benefitecl by sulphur ; for almost all the preparations recom- mended for it contained sulphur. To what it was due I am unable to say. Itnea Favosa. — Tinea favosa, or favus, is a chronic disease that gives rise to bright-yellow umbilicated crusts, of circular shape, which often form yellow rings around the hair-follicles. There is no dis- charge. The disease rarely affects any other part of the body than the scalp, and produces baldness ; when the nails are attacked, they become brittle and yellow. The microscope furnishes us with a cer- tain means of diagnosis, by exhibiting the cryptogamic plants. Tinea Sycosis. — Tinea sycosis, or barber's itch, is to be distin- guished from a non-parasitic form. The distinctive marks of the disease consist in the development of yellowish pustules, having a A female acarus, taken from a photograph from nature: magnified 220 diameters. The ventral surface is shown. }i90 MEDICAL DIAGNOSIS, bright-red base, around the roots of the hair of the beard : the hair.- portion of the neck may be also affected. The crusts may run !•- gether. and more or less inflammatory thickening of the skin T3ds". This is especially seen in the parasitic form of the disease, in whi h. however, less suppuration happens, and less pain or itching, but Iri which the hairs become brittle. The upper lip is rarely impiicat^i In tinea sycosis, \on-parasitic sycosis consists chiefly in an intlamma- tion around the follicles, which always starts in these parts.^ Tinea Cirnnata and Tinea Tonmirans. — ^The tricophyton tonsurai.s is the parasite met with in tinea circinaia. the ringworm of the b«>iy. and in (ineo tonsurans, the ringworm of the scalp. This is commo!i \n children, and spreads by contagion. It exists in circuiar scaly patche?. on which are drj* broken hairs. In ringworm of the body the pat'-h-s are also circular and scaly : but they are red and very itchy, and mu' h paler in the centre than at the edge. Examining the scurf, we nnd the fungous. growth. Tinea Versicolor. — ^This parasitic affection, also known as pityriasis versicolor, occasions those yellow or yellowish-brown disodorations which may be not infrequently seen on various parts of the l»iy. The microsporon furfur of Eichstadt is the parasite present : and it is found abundantly in the scales which can be Si-raped from the raist^i. itching patches. In pit>Tiasis affecting the scalp we may also niid parasitic growths of a vegetable nature : they are often the caus- ••f baldness, as in tinea decaltans. Pityriasis capitis, or dandmif. is rea.i- ily distinguished frt)m ordinary seborrbpa, in which the oily eleiivnt predominates in the scales, that are aggregated in masses. This is ii- marked contrast to the fine pearly scales of pityriasis, which arv:- -i :-- to epithelial exfoliation. This condition often leads also to baldn-L-s.-. The diagnosis of artinomift-osi^ of the skin depends upon the i is- ton-, and the distribution of the tumors in necklaee-Iike series, eiti. r in lines or in cin.les. or in groups. The disease pursues a rapid co':r>-. with fevef, sometimes septic<^mic in character. Majocci* re*>Dtrrii:-.-s two fonns, the anthracoid and the ulcero-fungous. In thv foniit-r :i.- lesions are rtat-toppe77. - Aim.iles i]^ Derm, et de Syph.. Paris. lSi*2. p. 31»>. DISEASES OF THE SKIN. 891 Altered Gland-Secretions. — One of these, seborrhcea, or in- creased secretion from the sebaceous glands mixed with epidermic scales, has been already mentioned. It is especially found on the scalp, nose, and genitals, and is often seen among those who have menstrual disorders. It is unattended by itching; the crusts are readily removed by strong alkaline soaps, and the skin beneath is healthy, or pale and glistening, or slightly reddened. Where the sebum is retained in the follicle, giving rise to little prominences dis- colored by dirt, and without, as happens in acne, inflammation around the gland and its duct, the disorder is called comedo. The plug of sebum can be easily squeezed out. The disorder is most common on the face and shoulders of young persons of lymphatic temperament. The sweat-glands are often altered in their activity, and excessive persi)iration results. This may be general, or confined to particular localities, as to the hands and feet. This local sweating is often offen- sive, and makes the parts very tender. The disease formerly known as licken tropicus is now regarded as due to congestion or inflammation of the sweat-glands, and is termed more correctly viiliaria papiihsa. The strophulus or "red gum" of infants is miliaria vesiculosa. At times there is sweating of blood from tbe skin. This condition, known as hcemidrosis, is due to some alteration in innervation, and may be preceded or accompanied by a localized erythema or eczema ; or the bleeding may comp from the follicles of the skin ; it is not a secretion of the sweat-glands, but is a hemorrhage, or an exudation. MoUuscum epitheliale presents numerous globular or flattish nodules, sometimes seated on a broad base or attached to a pedicle. They are due to a psorosperm in the deep layers of the skin and in the seba- ceous glands. The lesions occur in groups on the face or neck, or on the trunk ; they have a doughy feel, vary in size from that of a pea to that of a pigeon's egg, show no tendency to inflame, and are not attended with increased sensibility of surface. They are of the color of the skin or of brownish hue. They may last during life without affecting the general health. There is a variety met with especially in children, which has at the top or the side of each tubercle a small orifice, from which a creamy, fatty fluid can be pressed. This variety is by many regarded as contagious. The little tumors are distin- guished from so-called moUuscum fibroma by the central aperture, and by the substance resembling sebum that can be squeezed out of them. Although plica polonica is of rare occurrence in this country, yet among immigrants it is occasionally met with, and may be recognized by the mass of felted, matted hair, and the inflammation of the scalp from which serous oozing occurs. The mass of hair affords refuge for ^92 MEDICAL DIAGNOSIS. vermin, and the s^rcretions from the scalp pro^iu-Te^ a prr»!:iliar coi-r. which has led to the supposition that the disease is eaose*! s»xeJT bj dirt. Dnmesnil considers it a neoroas and the dirt oqIt iinier::^. Under thi.- microscope the hairs show decided change, affectiz]^ rr^'j the medulla. Jarochevski has pronounced the disease a dktiiTi3az:«>^ of nutrition of neurotic origin. Nervous Affections. — Several of these, such as herp^es los^rT. have been already considered. The large group of itching a£e.t>:-r:5 in which no obvious local affection exists, find here their piaieir. S^kl are. for instance, the various forms of pmrihts, either local or g»=^krral. which are specially apt to affect elderiy persons. Sometimes the itching is violent and obstinate, and we cannot even trace it to re- flected irritation, though this is often its cause. Again. r-.^ to ♦rarly syphilis. Syphilitic licht-n has better-define! ^^apul^rr? th^. simple Iich»^n. The ulcerations in the pustular affe«;tions are d-Trp-rr : whii*^ in the squamous disorders the scabs are smaller and the {.lapul-e:? larger tlian iii the non-syphilitic eruptions. A luruneuioid eruptior; is met with in hereditar}* syphilis. Syphilitic afftf«:tions of tlie skin ar. apt to h*s mixed, and light is thrown on th^rm by ttus fact, as wei- as by the histor>' of th^ case, tht- sore throat, the fallin;^ of the hair. ar;'i the mrve- and bon»-pains. CHAPTER XIV. POISONS AND PARASITES. Toxic symptoms from causes arising within the body, either from fermentative or putrefactive changes of the food within the intestinal tract, or from micro-organisms causing infectious diseases, septicaemia, saprsemia, and the like, have been referred to in other chapters, espe- cially those on Diseases of the Blood, the Acute Infectious Diseases, and Gastro-Intestinal Affections and Fevers. In this section vnW be considered only those disorders due to poisons or parasites, the morbid phenomena of which are clearly occasioned by causes intro- duced into the system from without. POISONS. Cases of poisoning may arise from accident, attempt at suicide, or criminal intent. It is only intended here to set forth the main signs by which the most common poisons may be recognized and distin- guished. For this purpose it vn\l be convenient to consider the cases as divided into acute and chronic, subdividing these classes according to the character and effects of the different substances. Acute Poisoning. The attack comes on suddenly, the patient, previously in good health, having taken some food, drink, or medicine which has been followed by the severe symptoms. It is always, in a case of sus- pected poisoning, of the utmost importance to be able to make out these points. Irritant Poisons. — The chief articles which give rise to acute poisoning belong to the class of irritant poisons. The symptoms are generally those of acute gastritis, attended often with more or less inflammation of the mouth, the fauces, and the oesophagus. Some- times the air-passages may be involved, either directly or by sympathy, and we find hoarseness and cough. Convulsions are occasionally observed, and collapse is apt to occur sooner or later. The acute pain, the tenderness, and the vomiting come on shortly after a meal, or at least after something has been swallowed. This 893 894 MEDICAL DIAGNOSIS. disliiinfuishos the acute gastritis caused by poisonin^\ associated with cramps or convulsions. Chofrrai morbus is separated by tlie Instory of the case, by the absence ofl epigastric tenderness, and by the purging and vomiting often comingj on simultaneously. Cholera resembles poisoning in the suddennessj and the violence of the attack, but is distinguished by the rice-water| discliarges and by its epidemic character Bacteriological examina- tion of the stools also atlords a means of diagnosis. In sb-auf/filaiMi furnia, the comparatively gradual onset, the pain, the tumor, and the' coostipation wilt be significant. As regards the separation of eases of poisoning in which blood is ejected, from ordinary heimrrhage /rami ihr stomach, we find ftiat pain and purging are both absent in tlie latter, while in irritanl poisoning' they are well-marked symptoms. Let us now exanune some special poisons. Strong acids sometimes used in self-destruction. Nifrie acid colors the lips andl mouUi orange-yellow wlierever it touches them. Sulpknric acid stainsj the skin or mucous membrane white or even dark gray ; the pain is , excessive, and nervous symptoms are not infrequent. If the vomited! matter be mixed witli a solution of t>arium nitrate, a dense white pne^- ci|)itate of barium sulphate is thrown down. Hydrovhioric arid is less irritant and corrosive than sulphuric acid ; in the ejected matter - silver jutrate produces a copious white precijjitate insoluble in nitric acid. Oxalic acid, when concentrated, is rapidly fatal. The irritant effects are those of the mineral acids : but we also meet with dyspnoea and with nervous phenomena, sucli as anaesthesia, parsesthesia, palsies, and convulsions. The strong aikalu*s, when taken into the stomach, cause inOamina- tion of the organ and of Hie fauces and the oesophagus. Should the, case end in recovery, tliickening of the o^sopliagus is apt to ocear. Ammoitia may also induce severe nervous symptoms, similar lo those i of tetanus ; its vapor sometimes acts powerfully on the air-passages, , l>rodncing harassing cough. Fotassinm and sodium hi/droTuh» — com- monly known as caustic potash and caustic soda — give rise to violent local intlammalion in the mouth, tpsophagus, and stomacii. TIj*!* vomited matter has an alkaline reaction. Potassium nitmle is a strong cardiac sedative. POISONS AND PARASITES. 895 Potassium iodide^ iodine, bromine, aiid cMorine are all capable of destroying life by their intensely irritant effect. Phosphorus, which is not infrequently taken as a poison, imparts to the breath, to the fteces, and even to the urine an alliaceous smell, and may make them luminous in the dark. It acts as an irritant, causmg obstinate vomiting and purging, pain at the epigastrium, rapid, weak pulse, jaundice, and unquenchable thirst. The local pain and hiflammation are usually extreme, and collapse, with or without con- vulsions, comes on early. In some cases painful cramps in the limbs occur, and various disturbances of sensibility, and, later, violent de- lirium and convulsions, eventuating in coma and in death. In other cases hemorrhage is a striking feature, the blood is very fluid, and issues from all the passages, and petechiae form beneath the skin. The temperature remains normal until near death. The pulse be- comes feeble and small ; the first sound of the' heart almost disap- pt^ars. Jaundice is a constant symptom ; it seldom, however, comes on before the third day, and is rarely intense ; it may be associated with urticaria. The spleen increases in size simultaneously with the Jiver. The urine becomes ver>' scanty. Albumin, blood, and casts are occasionally present ; biliary coloring-matter is usually met \vith ; urea is defective; peptonuria is observed. In cases of phosphorus poisoning, acute and extreme fatty degeneration of the tissues hap- pens. It occurs with astonishing rapidity. It has been seen, in the bodies of persons poisoned by phosphorus, within forty-eight hours, and has been found to afl'ect the heart, the smaller blood-vessels and capillaries, the liver, the kidneys, the glands of the stomach, and the voluntary muscles ; * the liver is principally implicated. Various compounds of pofassium, copper, zinc, snlver, lead, and iron occasionally cause death. They act, for the most part, as irritants merely ; but some of them are powerfully astringent, and even caustic, as, for instance, zinc chloride or silver nitrate. If the toxical phe- nomena are due to the nitrate of silver, the staining of the lips may afford a clue to the nature of the case. There are no really distinc- tive symptorfis produced by large doses of arsenic, of antimony, of mercury, or of their compounds, which are among the best known of irritant poisons : the peculiar effects of each of these substances, when insidiously introduced into the economy, will be presently mentioned. In acute arsenicxil poisoning, besides the pain and the gastro-enteric symptoms, convulsions, delirium, palsies, and bloody or albuminous urine have been specially noticed. Arsenical poisoning is a verj' com- * Tardieu, l5tude inedico-legale sur rEmpoisonnement, 1867, p. 445. MEDICAL DIAGNOSIS. moil form of self-di^structioii. It is also observed among those whtt accitleiitally lako Srheele's {^reen^ or amon|f eliifdreTi who swallmv arsenkal paints. There is in the internal orfTcins a fatty degeneralioii similar to that hi phosphorus poisoninfj. In the recognition of the cause of the symptoms, Reinsch's test, applied to the vomited math^. is very convenient and satisfaeiory. In poisonin*: by corrosive subli- mnf(\ epigastric pain, vomiting, diarrhoea, bloody stools, and linallr collapse, are met with. Among animal substances, ctodharifJes has sometimes been pn>- ductive of poisonous effects ; strangury, bloody urine, albumintiria, more permanent titan that (iroduced by turpentine, priapism, and simsm of the glottis, are the most marked symptoms ; while the shining green particles of the drug, if taken in substance, have been detected in the vomited matters. Saumii/e, miil\ vhetm\ t^ffffs, especially in articles of confectioner)', such as (^reum pufi<, frequently produce violent symptoms suggesting some of the more powerful irritaids, although chemical exanunation fails to reveal any mineral poison. The main cause of these actions is that mjder the influence of certain niii"ro-oi*ganisms the albuminous matters undei^^o rapid decomposition, producing nitrogenous bodies, among which one has been idrvntified as a dktzobenzene compound. Vaughan originally called this body tyrotoxicon, — cheese poiison. II is liighly poisonous, but also very unstable. It is produced early in the decay of tlie albuminous articles, and is decomposed subsequently. We can, therefore, understand wliy articles of food may be less irri- tating, w^hen decidedly decomposed than when decomposition has just set in. Besides the signs of gastro-intestinal irrilation, vertigo, head- ache, marked anxiety, and muscular weakness have been nolired among the effects of these ptomaines. The vegetable irritants are mainly articles commonly used as pur- gtitives. Thus, ekiferhnn^ aioe^, eohei/nth^ and PohhUmm liave all proved fatal when taken too freely. The symptoms do not differ materially from those caused by other poisons of this class. 7b- bcwvo and lobelia arc powerful local excitants, occasioning emesis and purging, with a speedy collapse of the system. Tlie former, when the nicotine produces acute symptoms of poisoning, gives rise also lo salivation, cold sweats, slow pulse, colicky pains, and at times convul- sions. Savin not only produces inflammation of the alimentary ciinaL but is apt also to give rise to strangury ; it is most frequently resorted to with the view of bringing on abortion. Ergot is also used for ttw same purpose ; the most striking symptoms of acute ergot poiscuiinjz are colic, vonuting, diarrhoea, increased salivation, retardation and POISONS AND PARASITES. 89T weakening of pulse, musculai* weakness, and, in severe instances, stupor. The poisoninp* rarely ends fatally, Poimnmm fungi, such as tlie fh^ fungus, which are eaten by mistake for mushrooms, produre violent symptoms of irritaTii poisoning at- tended with otlier phenomena. The jioisonous agent in the fly fungus ^ is imi^eunm\ and it gives rise to vomitmg, violent colic, and diarrlia^a, besides slowing of the pulse and Uie breathing, and violent excitement followed by stupor and somnolency. The case generally lasts two or ttiree days, and may then end in recovery or in collapse ; but it may terminate fatally in six or seven hours, hoemoglobinoria being among the symptoms. Finding the fungi in the vomited matter or in the stools gi'oatly facilitates the diagnosis. Other poisonous fungi produce much the same syinptoms ; and even the usually eaten and innocuous kinds of mushrooms may, if at all spoiled, or in certain individuals, or wlien eaten raw, occasion similar symptoms. Narcotic Poisoning.— The syinptoms of narcotic poisoning vary more, according to the special article taken, than those caused by irritants. Narcotic poisons affect chiefly the nervous system and the circulation. Many of them produce phenomena like apoplexy and intoxication, from which they need to be carefully distinguished. Narcotic poisoning is, for the most part, of the acute form. Opinm is by far the most important of narcotic poisons. Jt in- duces giddiness, stupor, and lethargic sleep, from wtiich, however, the patient can at first be roused, if sharply spoken to. Subsequently this sleep deepens into coma and cannot be broken ; the skin is relaxed aiul perspiring; the lace is usually pale; ttie pupils are contracted and insensible to light ; erections of the penis are com- mon. A more or less evident odor of opium may often be perceived about the person or on the breath* No distinction can be drawn be- tween the eflects of dilTerent forms of this poison: tlie stronger the preparation, however, the more marked and the more rapid will be the progress of the case. Morphine, codeine, narcoUne, and the other alkaloids give rise to similar sj^nptoms, but the smell of opium is absent ; convulsions are most likely to occur from narcotine, papav- erine, and tliebaine. The diagnosis of opium poisoning from apoptea-y and from the coma of unemia has been discussed in a former chapter. We may merely recall that the contracted pupil caused by opium is of very great significance, and does not, witli ttie exceplions there referred to, exist in the other states. Moreover, the coma in apoplexy is at once developed ; while in narcotic poisoning it is not sudden, but is pre- ceded liv drowsiness or stupor, whicti gradually passes into coma. 66 898 MEDICAL DTAGNOS These phenomena occur also in the same sequence in ura?mia ; bnf they are even slower in their progress, and are frequently associati^nl j with convulsions and with markedly Vilbuminous urine and dropsy. From aintff aleoholmti we discriminale opium poisoning chiefly by the aljsence of the alcoholic odor, the slow respiration, and Itiu presence ol" morphine in the m'ine. Tlie characteristic smell of chlo- rqform^ the great pallor of the countenance, the complete and speedy] collapse, and the absence of contracted pupils distinguish chloroform poisoning from opium poisoning. It is the same with dhei\ Potsoii- ing by chloroform or by ether is mostly encountered during surgical] operations. Chhml\ in excessive doses, produces heavy sleep, with contracted' pujnls, but they dilate on awaking.^ There is some reduction of ten*- peralure, with rapid pulse, giddiness, inability to walk straight, double vision, and headache, in cases in which consciousness, sensibility, and inusculai' power have not been entirely suspended by tiie drug. Weak action of the heart is another of the dangers of chloral poison-j ing, and I have known a dilated heart almost paralyzed even by small^ doses. In some instances a stage of excitement like alcoholic intoii-^ cation precedes the narcotism. The urine may or may not contaim sugar.^ Chloral itself simulates sugar in the results of the copper and) bismuth tests. It is occasionally used for drugging liquor for purposes] of robbery or rape. Benzin^ when taken internally, occasions noises in the liead, mus* cular tremor and twitchings, and deep sleep ; but the narcotic depres- sion ends in recovery. Airohol^ if taken in large cpiantities and not much diluted, gives! rise to symptoms like those caused by opium. The eye is injedeitj and the seat of eechymosis ; the pupils are, as a rule, cUlated andj very sluggish ; the breathing is irregular and stertorous ; the temper- ature lowered ; the insensibility may alternate with convulsions : tlie breath has a strong smell of alcohol or may be quite free from spirit- uous odor. This absence of odor of the breath, although not usual, may give rise to a confusion between alcoholic poisoning and apoplexyj and the discrimination of these condihons nnisl then depend in somel measure upon evidence furnished by the history of the occurrence oC the insensibility, and by the presence or absence of palsy. Alcohol may readily be detected in the urine. Woodbury *s* mod- * Taylor on Poisons, 3d edit, 1875. ' See a case of tniiie recorded in & Clinical Lecluri? on Chloml Poisonifii'.j Phila. Med. Times. March, 1883. ^ PUilaJelphia M*jdlmi Times, Mtirch, 1883. POISONS AND PARASITES. 899 ification of Ainstie's test is very convenient. Into a tube containing a gramme of sulphuric acid, which should be coloriess or neariy so, twice as much of the urine to be tested is poured. A small crystal of bichromate of potassium is then dropped in, and the liquid slowly mixed by rotating the test-tube. If alcohol be present in proportion^ as large as two or three parts per thousand, a permanent green dis- coloration will result ; if there be less than this, the liquid will remain of ruby color. Chloral in the urine does not produce the peculiar reaction. Belladonna^ or its active principle, atropine, and hyoscyamus pro- duce more marked excitement of the brain than opium does, causing delirium of active kind, perhaps with convulsions. The pupils are greatly dilated^ and vision is singularly deranged; there is intense thirst, with great dryness, redness, spasm, and burning in the throat ; the breathing is rapid, thus differing from apoplectic conditions. The temperature is always lowered; the pulse becomes quick and com- pressible; a scarlet efflorescence may happen. The surest test of poisoning by atropine is to take some of the urine passed, and with it to dilate the pupil in the eye of a cat. Conium occasions stupor, paralyzes the muscular system, and dilates the pupils ; there is dyspnoea, while the heart, though rendered slower, is not much affected. Convulsions may come on. These help to distinguish conium poisoning from curare poisoning, which it much resembles. In the latter, however, the palsy is greater. Carbolic add, if taken in poisonous doses, produces rapidly dan- gerous symptoms, which may terminate in death in a few hours. Vomiting, slow pulse, noisy breathing, loss of consciousness, deepen- ing into profound coma, abolition of reflex movements, cool skin, suppression of urine, are the main symptoms. When the urine is obtained, it is of dark-green or black color ; this and the odor of car- bolic acid about the patient are significant features. The discolored urine contains blood-corpuscles, epithelium, and tube-casts. Aniline poisoning is met with among the workers in factories in which the aniline colors are made. It is the breathing of the aniline vapor, especially, which occasions the toxic effect. Vertigo, headache, a sense of suffocation, vomiting, anaesthesia, pain in the extremities, somnolency, and a dark cyanotic discoloration of the ears, the nails, and the mucous membrane of the nose, have been especially noticed. Hydrocyanic ov pruasic axAd usually leads to convulsive contrac- tions of the muscles of the limbs and trunk, and destroys life by stopping the circulation and the respiration. Sometimes the odor of the acid, resembling that of bitter almonds, is perceptible in the 900 M£DICAL DLA.GN06I8. breath; but too much reliance must not be placed upon this point. Unfortunately, the diagnosis of this poison has generally to be made after death, for medico-l^fal purposes. The gases arising firom burning coal and charcoal may cause death by asphyxia ; and a knowledge of this (act has. particularly in France, led to many suicides. In those cases in which the asphyxia has not a fatal termination, yet has been decided* disorders in the peripheral nerves may manifest themselves, either by the signs of neuritis, or by pain and swelling simulating a phlegmon, or by vesicular eruptions in the course of an affected nerve. The peripheral disturbances may appear at once or not until after some days. The signs of disorder of the vasomotor nerves do not lasl long : those of the motor or sensi- tive nerves have a longer duration: the complaint induced may be incurable, extending firom the centre to the periphery, or in the re- verse direction ; or, lastly, the aiSection may cause an acute ascending paralysis.* The poisonous action in these cases is due laigely to carbonic oxide, carbon monoxide, a gas which has a strong affinity for haemo- globin, and suspends the oxygen-«d)sort)ing function of the blood, thus establishing a chemical asphyxia. The gas, being non-irritating, may be inhaled without exciting immediate suspicion. The so-called water- gas contains laiige amounts of carbon monoxide. Experiment lias shown that such gas is much more dangerous when inhaled than the ordinary illuminating gas, which consists almost entirely of compounds of carbon and hydrogen. In poisoning by carbonic acid, carbon dioxide, there is much greater distiu-bance of breathing than in riir- bonic oxide poisoning, Aiitipyrin given in largt> dieses may produce extreme lowering: of the temperature and collapse. Cyanosis, frequency of respiration and of pulse, dyspna\i, a feeling of extreme heat over the body, and an enthematous, iirtiearial, or nie;isly eniption, have also been noticoi. In one instance reporttni. tlie use of the drug led to the formation •■: membranes in the mouth, and to symptoms of laryngeal spasm, whirl. wiis not the lase when phenaeetin, antifebrin, or exalgin was substi- tuted." Ptt\»kuiyt tiiken in exit*ssive quan:itifs produces giddiness, £air;!- nt-ss, and palpitation, with tonio and iionio convulsions, contraLt^-^i pupils, hot skin, and slow pu'se ; it does not occasion either stu^xT -t vomiting : tlu- urine has ar; arc'matie odr-r. Recovery is the ruK*. I • >..:;.-•:. A:.>t. .* .:rr.. Mv.v >v... M«v. ISW. POISONS AND PABASITE8. 901 Nitroglycerin occasions a throbbing headache increased by motion, mental confusion, flushing of the face, pulsations all over the body, arterial relaxation, and collapse. Following these poisons, which are in the main narcotic poisons or belong to the group of poisonous carbon compounds, we shall ex- amine some forms of acute poisoning produced by certain powerful vegetable poisons. Aconite has a strongly sedative influence upon the action of the heart, brain, and spinal cord, as well as an irritant action upon the alimentary canal ; slow pulse, giddiness, delirium, numbness, and tingling of the skin, loss of power in the legs, with formication, tingling of the tongue, vomiting, and purging, are followed by sjincope and death. Digitalis causes dilatation of the pupil, generally with vomiting, often with pui^ging and with headache, giddiness, and suppression of urine ; its chief effect, however, is upon the pulse, which is strikingly lessened both in frequency and in force, and becomes irregular ; the action of the heart, too, becomes weak, and blood-pressure is dimin- ished. The skin is cold, pale, and covered with sweat ; the mind is generally clear, though there are great lassitude, with muscular debil- ity, a tendency to sleep, and at times convulsions. The action of the poison generally extends over days. VercUrum viride resembles digi- talis in its action. It markedly reduces the pulse, and gives rise to vomiting, to great prostration, and to irregular breathing. The tem- perature is much lowered. Poisoning by jaborandi or pilocarpine produces profuse sweating and salivation, vomiting, diarrhoea, respira- tory and cardiac distress, dimness of vision, and contracted pupils. Calabar bean acts as a direct sedative to the spinal marrow, par- ticularly to the medulla, and produces great muscular debility or re- laxation, or even paralysis, extending to the heart and respiratory muscles. The mental faculties remain unaffected, and in this its Action differs from that of the cerebral sedatives. It is, however, irritant to the alimentary canal, causing vomiting or purging, a pecu- liar epigastric sensation is generally experienced, and increased saliva- tion is met with. Calabar bean contracts the pupil and also the ciliary muscle, thus making the eye myopic. The condition of the eye is the main diagnostic sign that distinguishes poisoning by calabar bean from poisoning by curare or by conium. Strychnine and brudne^ the active principles of nux vomica and of allied plants, give rise to phenomena strongly resembling those of tetanus. A very short time, however, — from a few minutes to an hour or two, — will determine the issue of a case of poisoning ; while teta- 902 MEDICAL DIAGNOSIS. nus may run a course of several weeks. The first symptom of strj'ch- nine poisoning is a sense of suffocation and dyspnoea, followed by s(>asms of the respirator)' muscles, by starting and twitching and rigidity of Uie arms and legs, espeiially of the extensor muscles, but not by loi'k-jaw ; tetanus, on the other hand, comes on with setting or locking of the jaws, and the limbs are not at first affected ^vith spasms ; indeed, the arms remain throughout nearly firee firom them, and Uie paroxysms of spasm do not follow one another so rapidly as in stn'chnine poisoning, and are of shorter duration. Again, idio- paUiic tetaiuis is extremely rare : almost always there has been some womid or injury as a proximate cause of tlie malady. But we need not pursue these points of diagnosis farther : they hare been men- tioned in connection with tetanus. From epUepit^ strychnine poison- ing differs by tlie unimpaired consciousness ; from hydroj^obut^ by the absence of spasm of the oesopliagus and of the terrible dysphagia. I^crotarin also produces convulsions which may be mistaken for those loused by strychnine. But they arv not of a leflex nature, and reflex s^vasms are not induced. The breathing is rapid : the contrac- tion of the heart is letarded : there axv often somnolence and muscular debility. A scarlatinal eruption has been noticed. Chronic Poisoning. \\Tien the patient has been subjected to the continuous action of a noxious substance, the case is said to be one of chronic or slow poi- soning. Any of the irritant jx>isons. given in small and repeated dose? will kot^p up a morbid condition of Uio stomach and bowels mui h likt- oniimin* ohn^nio inflammation. The narcotics, taken in \hc Siime manner, act upon the vasomotor ner\t^ and the i-orebn>-spina! system, and through this ujx^n the ali- mentar>- canal, so donu^pn*: liiptstion aiM nutrition as even indirei tiy to cause dt-ath. Ophrr; is tht- iratst imiH«rtant of the articles thi:s nsod : it is of^cn administortii :o infants for the purpose of quielinj their cries, aiid the ftvn^uent i\-r-. titior. o: the dost- induces a st-ries ••: I'henonui'ja i.i^t^y ;il":itHi :v> :hits-: obst-ntv. in the adult. Wiui ti.r t'ffects. on the mind, of oj-iur.: Mkt n ii-rsistt y.t.y for :he sake of intoxi- cation, the r^adin^ wor.d is :;ir..:.i.\r '.hrx;*::. the ;':ir'Iished rxpt-rienvr-s of 1\- 0--"^^T A'"ii^ *>• iV.triiVC. Tht i:aiv: is ht ri anii :n Kur;;*: ^ntrAliy 5. quirt-ii oniy by j^r^.-: s who hav; Kr*::;n :ht j-ra^rcv :. r ::.* riliv* ;•: s^Tiniv ikainfu^ a^t-vti ■ : in :hc K;;s:, oviun; is nse.i ::;::. h ::;. rt ■. n;r:^;»nA. aiici. in njaiiv « Ti- cn:a^ I onntrii-s. :o sniokv i: is a :.;> .riit ;.:... :sv:nt:n:. Thost wh:- . :..- POISONS AND PARASITES. 903 a dull eye. They lose their power of will and their energy, and are troubled by loss of appetite, giddiness, anomalous neuralgic pains, sleeplessness, and low spirits, which they relieve by resorting to the opiate. Though, in spite of the pernicious custom, the general health may remain for many years good, yet sooner or later it gives way, and the opium-eater dies worn out ; or death may be the consequence of disease of the liver, of palsy, or of inveterate diarrhoea, produced by long addiction to the vice. Persons who consume large quantities of opium are apt to have, from time to time, attacks of extreme nervous prostration, attended, perhaps, with violent headache, and requiring free stimulation for their relief. The employment of morphine hypo- dermically has become an alarmingly frequent form of the opium habit, especially among members of the medical profession. Besides the general symptoms of chronic opium poisoning, we may have ex- tensive ulcers and other local signs of skin irritation to deal with. Ether and chloroform^ habitually made use of, also cause serious disturbance of the nervous system ; and so does alcohol. The abuse of spirituous liquors gives rise to a disorder of the mental, motor, and sensory functions, producing sleeplessness, headache, giddiness, hallu- cinations, imbecility, anaesthesia, disordered vision, and palsies. There results a fine irregular tremor, affecting particularly the hands, lips, and tongue, and occurring only on attempted movement. Multiple neuritis is also a common sequel. Chronic alcoholism also occasions a sensation of choking, a diminished vitality, a persistent catarrh of the gastro-intestinal membrane, a tendency to fatty degeneration, espe- cially of the liver and kidneys ; in short, the symptoms met with in drunkards and constituting the state described as chronic alcoholism. Chronic alcoholism in the parent may produce epilepsy in the child. ChUyral has proved, like opium and like chloroform, a very fasci- nating drug to many. The chief symptoms of chronic chloral poi- soning are digestive disorders, irregular breathing, impairment of intelligence and of memory, persistent drowsiness, almost stupor, striking enfeeblement of will, want of power in the legs amounting at times to paralysis, and occasional tremor. Defective co-ordination with marked ataxic symptoms, similar to those of locomotor ataxia, and loss of knee-jerk, occur from the habit of taking chloral.* I have known delirium tremens to follow its use, when large quantities of it had been taken and the medicine stopped. Feeble, irregular action of the heart, and sweating, I have also found among the symptoms of * J. C. Wilson, article *' Opium Habit and Kindred Affections, '' System of Practical Medicine by American Authors, vol. v. 904 MEDICAL DIAGNOSIS. cliloral poisoning. An erj'tliematous inflammation of the skin of the fingers, with desquamation and ulceration around the borders of the nails, has been pointed out as a result ; ^ and various forms of erup- tion, such as urticaria, lichen, and purpurous spots, as well as bed- sores, have been obsen'ed after its. prolonged use. Pamhiehjfde is abused like chloral and morphine. It occasions, when taken liabitually, gastric disorder, diarrhoea, sleeplessness, feeble cin*ulation, sweating, and delirium tremens. ToboixH) used in excess gives rise to tremors, to giddiness, to ema- ciation, to im))aired digestion, and to intermittence in the pulse, with irregular cardiac action and palpitations, which may become very an- noying and originate the belief of an organic disease of the heart. Like the persistent abuse of alcoholic drinks, tobacco may occasion amaurosis ; an insidious, obstinate form of otitis is developed in in- veterate smokers, and is* attended with very minute granulations of the pharynx, nasal fossae, tubes, and middle ear,^ When taken in laige quantities by those prenously unaccustomed to it, tobacco produces colic, diarrhoea, weakness, sleeplessness, dull hearing, vomiting, diffi- culty in brtHithing, cold sweats, feeble action of the heart, and will even cause collapse and death. The peculiar odor of tobacco may assist us in the diagnosis of tobacco poisoning : but it must be remembered that this may attend other moihid states in those who use tobaci-o laivv^ly. Krpoi^ long continued, particularly when taken contained in im- pure flour, gives rise to the well-characteriied dis^ease, chronic eivot- isnu This ap|>ear? mainly in two fc>rms : the first is marked by con- vulsions with disturt>anoe of sensation : the second by gan^^ne : l»th ary^ apt to show themselves in epidemics, in the convulsive fc-n:. thon^ is at first formication, which lasts, whether attended with an^vs- thesia or not, throughout the whole illness. Soon muscuiar twi:chir^ and cramps foUoweil by jxainful contractions haj^pen. and the iv:-- vulsions may Ivoome genera]. These si^asnis especisLl> afe-:: •J> flexors oi the arm, and unlike tl.i>se of stryvh:u!>e, :bey arv r^:-: rrfir i sfxasn^s. Thert^ is no fever: the i ircu'.atior. :> slow and fe^b!-: ::• apivtito is ir.Siitiabie : we find naus^-a. vonudn*:. iiKi diirrtiia. Tr.r disoast^ ^^nerally lasts otic v>r two ir.or.ths. h: sus rr^.cisc: :h- >ir..r syn:^:o:r.s hainv:: : but in avixiitior. we n.tv: w::! *njL?y:Tvrjr wlii yr fevor or si^rtis of inSa:v.n:a:io::- The ^v::;^::: r/jty >•; .7. :h- tXTTtr.:- tit'^ . r :r. the f:ivx\ POISONS AND PARASITES. 905 Let us now examine some of the features of slow poisoning by the metals. Mercury^ in any of its preparations, may lead to chronic poisoning. The mouth is inflamed, the gums are sore and swollen, the salivarj- glands act inordinately, and the- breath is very oflfensive. Colicky pains, diarrhoea or bloody discharges, as well as acute nephritis, may occur. Tremors of the limbs when any motion is attempted are par- ticularly frequent in cases where the poison has been inhaled in the form of vapor ; they come on by degrees, and are associated with loss of power of locomotion. The tremors may be incessant and the movements involuntary, like those of chorea, and so rapid as to pre- vent the patient from obtaining rest at night.* In some cases an eczematous affection is observed. Poisoning by mercury is generally the result of the exposure to its action incidental to certain occupa- tions, such as glass-plating, gilding, and working in quicksilver-mines ; but it may be also noticed as following antiseptic injections of corrosive sublimate. Lead poisoning is by no means uncommon among painters, plumb- ers, type-setters, and other workers in lead. Sometimes it may be caused by accidental circumstances, as when the patient has drunk water passed through leaden pipes, or taken snuff which has been impregnated ^ith lead for the purpose of coloring it. Poisonous properties are also acquired by snuff wrapped in lead-foil ; and lead poisoning has been observed after the use of cosmetics, and among those engaged in the manufacture of lucifer matches, of brushes, of lace, or working in glass enamel or glass powder;* and in conse- quence of food adulteration, especially of the use of lead chromate to colof cakes.^ In such cases, the physician may have to depend entirely upon a correct appreciation of the symptoms for the diagnosis. Pain and un- easiness in the course of the colon, constipation, loss of appetite, anaemia, weakness, mental depression, and emaciation are the earlier signs. A metallic taste is perceived ; the breath is fetid, the tongue pale and furred ; the gums are edged with a narrow blue line of sul- phide of lead, deposited mainly outside loops of blood-vessels. Colicky pains occur from time to time, and a severe and long-con- * As in a case reported by Taylor, in which the patient died from the effects of the poison, without, liowever, having presented salivation or mercurial fetor of the breath, or a blue line on the gums. Guy's Hospital Reports, 3d Series, vol. x. * Lacharriere, Arch. Gen. de Med., Dec. 1869. * Stewart, Clinical Analysis of Sixty-four Cases of Poisoning by Lead Chro- mate, Medical News, Dec. 31, 1887, and ibid,, Jan. 26, 1889. 906 MEDICAL DIAGNOSIS. tinued attack of colic may form the culmination of the disease. The muscles atrophy ; electro-muscular contractility to the faradic current is greatly diminished, to the galvanic current it is frequently unaltered or increased ; the sensibility of the skin is but' little affected. Occa- sionally wrist-drop or paralysis of the extensor muscles of the fore- arms, the well-known phenomenon of lead poisoning, happens among the first symptoms ; but it is more generally preceded by one or more attacks of colic. The right arm mostly suffers first. We also find at times lesions of the tendons in saturnine palsy. Yet a paralysis of the extensors occurs which is not due to lead, as in alcoholic multiple neuritis. Another manifestation of lead poisoning is found in the severe pains in the joints and the neighboring muscles. These pains have violent exacerbations, and may be associated with cramps of the painful muscles. They are most common in the lower extremity, especially over and near the knee-joints. There are no signs of in- flammation of the affected joints and muscles ; pressure tends to re- lieve the pains. Sometimes, in cases of saturnine poisoning, there is evidence of grave cerebral disorder : epileptiform convulsions, attacks resembling apoplexy, or general tremors and extended paralysis of the muscles, with acute delirium, inequality of the pupil, optic neuritis, retinal hemorrhages, loss of sight, and other signs of nervous disturbance, are noticed. Of course the diagnosis, under these circumstances, will be materially assisted by an accurate knowledge of the previous his- tory of the patient as regards exposure to the action of the poison. The tremors are, like those caused by mercury, peculiar in ceasing when the limbs are supported or at rest ; they are increased by nfove- ment. There may be tremor in the muscles of the face, which, how- ever, are not affected by paralysis. Another result of lead poisoning is that it leads to granular degeneration of the kidneys. This is apt, again, to coexist with a gouty condition, which, as Garrod has shown, is one of the results of the absorption of lead. But the kidney affec- tion may be found whether or not the joints are markedly affecttHl and may exist without albuminous urine.* In instances in which the symptoms of lead poisoning are obscure or conflicting, we may search for lead in the urine. But the detection of small amounts of lead cannot be undertaken except by a profes- sional chemist. A considerable proportion of the lead is eliminal»«i by the bowels. ^ Liliu-ereaux, Arch. Geu. ile Mtnl., Dec. 1881. POISONS AND PARASITES. 907 Copper-powpning gives rise to dyspeptic symptoms, to diuresis, to loss of flesh, to lassitude and giddiness, to a peculiar greenish-blue perspiration, and to a green line on the gums and teeth. It is said that workmen in copper are singularly insusceptible to cholera or choleraic diarrhoea,* and that wounds in them heal with extraordinary rapidity. Copper appears to be somewhat less liable than mercury, lead, arsenic, or antimony to cause serious chronic poisoning, possibly because it is less cumulative. Small amounts of copper are frequently present in the liver and brain of man and some of the lower animals, also in some articles of food. Dr. Lefifmann informs me that, in the examination of viscera from cases of lead poisoning which occurred in Philadelphia, copper in minute amounts was frequently encountered, and in one instance, that of a child four years of age, an appreciable quantity was obtained from a portion of the liver. Arsenic^ administered in small doses for a lengthened period, produces a state of chronic inflammation of the alimentary canal. Conjunctivitis, oedema of the face and the limbs, in some instances associated with albuminous urine, irritability of the stomach, diarrhoea, sleeplessness, increasing weakness, numbness, formicatfon, alterations of sensation, and even paralysis, mark the progress of these cases ; the hair and the nails occasionally fall out, and there is much frontal headache. Similar effects are noticed to follow the pernicious habit of arsenic-eating, and will be also encountered among persons em- ployed in making artificial flowers and toys, in dyeing cloths, in man- ufacturing and hanging green wall-papers, or in the sublimation of arsenical ores ; those, too, who live in rooms hung with papers con- taining much arsenic have exhibited the influences of the poison.^ Besides the phenomena of internal, poisoning, cutaneous eruptions occur from arsenic. The extensors of the hands and feet are espe- cially aflfected. In some instances, said to be not uncommon in Russia,^ paralysis of the extremities, with muscular atrophy, happens. Arsenical paralysis may have mainly the symptoms of poliomyelitis, as I have had occasion to observe.* In other cases there are severe darting pains in the arms and legs, defective cutaneous sensibility, loss of knee-jerk, and the appearances of locomotor ataxia.'^ The palsies * Clapton, Clinical Society's Transactions, vol. iii. * James Putnam, Analysis of Twenty-six Cases, Bost. Med. and Surg. Journ., March, 1889. ' Scolosuboff, Arch, de Phys., Sept. 1875. * Phila. Med. Times, March and July, 1881. * Dana, Brain, vol. ix. 908 MEDICAL DIAGNOSIS. of arsenical poisoning are now generally thought to be due to periph- eral neuritis. The inhalation of the fumes of zinc gives rise to a peculiar form of poisoning, characterized by a sense of weariness, by a feeling of tight- ness in the chest, and by attacks of shivering, followed by heat of skin and a profuse sweating-stage. This irr^ular form of ague is common among brass-founders.* Carbon diauiphide produces toxical effects of a singular character, conspicuous among which are gastric disturbances, inordinate appe- tite, loss of muscular strength, a cachectic condition, a feeling of icy coldness in the lower limbs, severe cramps in the calves of the legs, impotence, and, in severe cases, amaurosis, impaired hearing, hallu- cinations, loss of memory, and complete perversion of the intellect* These phenomena are met with among workers in india-rubber. Phosphorus is often seen, particularly among those who woric in lucifer-match factories, to give rise to serious lesions. When the poisoning is caused by inhaling the vapor, it may occasion, as acute phosphorus poisoning does, aJteration of the composition of the blood, a hemorrhagic diathesis, a fatty d^eneration of several organs, as well as of the voluntary muscles,* and peptonuria. It also pro- duces chronic bronchial catarrh, but especially necrosis of the jaw, for which the whole lower jaw has been removed.* The disease begins in carious teeth, and may extend to the cranial bones. Osteophjrtes form freely in the afifected bones. Phosphorus taken internally in doses that gradually exert a poisonous effect leads to chronic inflam- mation and thickening of the stomach, colicky pains, diarrhoea, hectic fever, general emaciation, falling out of tlie hair, and to palsies, which are generally the precursors of a fatal termination. Animal Poisons. — These may give rise to chronic as well as to acute poisoning. We find, for instance, syphilis, gonorrhoea, hydro- phobia, dissecting wounds, snake-bites, acute glanders, and farcy,— all disorders exhibiting the effect of an animal Aims. But we have already discussed some of these as far as is admissible in a work of tliis kind ; and of the others it need only be said that the antecedent circumstances generally place the diagnosis beyond a doubt. ^ Greenhow, Med.-Chir. Transact., 1802. - Delf>ecli, Meinoires de I'Academiede Medecine, 1856 ; and Heuiiaux, Reiut*il de la Sooit^te Medic-ile d'Ohso nation, 1860. * I^iDooivaux. L' Union Medicale, 1863. * Casi»? uf Hunt and Boker, Anier. Jouni. Meil. Soi., April, 1865 : Wells. \Vw York Med. Jouni.. Jan. 1S66 : Werner, Virehow's Anhiv. Bd. xl. POISONS AND PABASITE8. 909 Yet there are a few illustrations of animal poisons and their effects which must be here, however briefly, mentioned. One of these is the malignant pustule or anthrax^ a terrible mal- ady, wliich is the cause of many deaths on the Continent of Europe, and which is identical with the charbon of animals. The disorder is also prevalent in New Mexico.^ It is communicated to man by direct inoculation ; or by means of the skin or hair of the diseased beast, or by eating its flesh ; or by insects which, sucking the poison from the sick animal, implant it in the skin of man. . The poison produces a red speck, which develops into a vesicle, under and around which an extremely hard spot forms that becomes gangrenous. The surround- ing skin inflames, new vesicles or pustules spring up, and the gan- grene spreads rapidly, the patient speedily sinking ; or the death of the parts is arrested, and separation takes place between the living and the gangrenous textures. In some cases it is attended with extended oedematpus swelling and infiltration of the areolar tissue spreading from the anthrax pimple. It is remarkable how little local pain attends the grave constitutional disturbance, and the signs of low, irritative fever. The disease is found on the exposed portions of the body, as on the neck and hands. It has been traced by Davaine to the presence of filiform bacteria, bacillus anthracis. The blood swarms with these bacilli. Closely connected vrith malignant pustule is the so-called " wool- sorter's diseasey The wool from sheep is not neariy so dangerous as the hair from the goat, the alpaca, and the camel. The symptoms may be those of malignant pustule with secondary splenic fever, or there often is an utter absence of either external or internal pustule.^ The manifestations of the disease are a low fever with secondary ab- scesses, pyaemic symptoms, and pleuro-pneumonia. The complaint is a dangerous one ; when ending in recovery, convalescence is slow. Another disease transmitted from infected animals, and popularly known as the "lumpy jaw," is the so-called actinomycosis hominis^ described chiefly by Israel^ and by Ponfick.* The malady first appears in the lower part of the face, in the shape of little abscesses containing yellowish granules, which consist of ray fungi. These vegetations are readily detected by the microscope. The dis- ease spreads to the ribs and vertebrae, and produces great destruc- ' A. H. Smith, Amer. Journ. Med. Sci., April, 1867. * Bell, Lancet, June 12, 1880. ' Virchow's Archiv, Bde. Ixxxv., Ixxviii. * Die Actinomykose des Menschen, Berlin, 1882. 910 MEDICAL DIAGNOSIS. lion of tissue: it is also found in the liver and the lungs, in the brain, in the intestines, and in the skin : there are the symptoms of chronic pyaemia. The affection may be mistaken for tubercle, stroma, or malignant tumor. Various forms of iL as of the liver and of the lungs, have been already described in connection with thos«r organs. The foot and mouth disea^ is an affection finom which €^speciaUy children suffer who have drunk the milk finom infected cows. The poison produces an aphthous stomatitis with digestive disorder, and fhequently also a vesicular eruption on the face and on the fingers and hands, which gradually dries into brownish scales, and at times a similar eruption between the toes. The disorder is not a serious one. It is due to a micro-organism, the streptocytus of Schottelios. Ther« is another form of animal poisoning which may be in this connection briefly considered. — namely, milt-^ietmem^ It prevails id some of the new settlements of the southern and southwestcra ports of the United States, and is brought on by drinkiDg the milk or eatiz^ the flesh of cattle which have been exposed to certain infloeoces the nature of which is unknown. Gastrit^ and enteritis are more or ies blended in the eariy stage of the disorder, which at a later per>>i resembles typhoid or typhus fever. The sympioizis are Iftsatxxir. nausea and vomiting, with a sense of bomiz^ at the ep^ftstzicm. grvai o|]^ression. intense thirst fever, swollen toDuue. ofastxmre cooscia- tion. fetid breath, and envious abdomidal p-ilsitk-ei. If a: al^ recovery takes place tardily, the tone of the scoc:*:h i*tirj^ c^-f-n inii^airei.i for life. Tr.riv arv rorcis of arimal p-iis'jrs c nrl:.>i::rv i:i I'h'u -^ ^z.kt^'.-i durlri: d^.ay. The v<'\soz:1i^'lj 's.r^s^ u'~n*i»^:^ fr.ci ' "^ iz.»i ^-.^5 and o±--r sui>?:di:vTr:s has already r-ee:: :i.rc~»:c.-L Frf-riTC-j -_i- j:oi:iaii:r r-j^s^r-rir.;^ rrtjenir-les •±d: of th- v*-^-^:^ jLi-L-.6i?. s-.-ih i? of ci'.n. hiz^r. ..'--i-rin-r, and Trnrrln-r. B*r<:iT< :hr. ti.*. Thry JLT: v^rv -i-rv rfssint: in •i-rir ijcon. n:*!; jrnti :o j:^ vTrr?. :r * i^cnjLtnJi jLi.i in :h- :i5*r :: ihr -x^ .•zn-i-r-L :: ii«::scui. y -;r^ ->- nirnlv .'ba^r^r-i in ih-r^Sr: "^ho .rvathr :':cnni«:c25iT vrn ur in»:»rr — r i:ir':n:'_>:jLn-.'r< iL.i'i-z*! *::. — «is ji hrscrj-.^. iz*i m irs?crL& s: vnj- vl-innn-scs j> :..: TZJiin^i md i:- r^^piri -s noc lUxC v T-cnian«.c. POISONS AND PARASITES. 911 In some persons deleterious emanations from the human body give rise to a form of toxaemia, one of the chief features of which is the marked anorexia which attends the great debility.^ The exposure to animal effluvia may also excite violent diarrhoea, or even symptoms like those of cholera, certainly like those of severe attacks of cholera morbus. Of the occurrence of the former we have an illustration in the diMecting-rooni diarrhoea^ which is usually attended with very fetid discharges, and may be accompanied by colicky pains, by nausea and vomiting, and by headache. The same kind of diarrhoea also happens in those who clean privies, or who are exposed to the emanations arising from sewers ; or dysentery or chol- eraic attacks may follow the exposure. Nay, as in instances recorded by Becquerel, the instant disengagement of large quantities of putrid gases, arising from bodies far advanced in decomposition, where coffins have been opened, has caused sudden deaths, or has resulted in so serious a state of poisoning as to give rise to grave illnesses, having mostly a fatal termination.* In individuals who, in consequence of their vocation, are habitually brought in contact with animal effluvia and inhale noxious ga§es, besides the attacks of diarrhoea referred to, chronic disturbances of the stomach and liver, with marked impair- ment of the general health, may happen. Cases occur, too, of self- infection from ptomaines resulting from decomposition of fecal matter lodged in the caecum, or by perforations taking place from the intestine into abscesses near by, into which the contents of the bowel find their way. PARASITES. Parasites are organisms which become secondarily implanted within or upon the body. Some parasites give rise to no symp- toms at all ; many occasion phenomena closely resembling those of other irritations. In any case, the only absolutely convincing evidence of the presence of a parasite is obtained by seeing it. Vegetable Parasites. — The chief vegetable parasites have been mentioned in connection with diseases of the skin ; the oldium albi- cans, present in thrush, and the sarcinae ventriculi, have also been described. All these vegetable growths can be detected only by the microscope ; and, particularly in those involving the skin or the hair, it is of the utmost use to employ liquor potassae, under the action of which the structures become transparent. * See Hunt's case, described by himself, in Pennsylvania Hospital Reports, vol. i. « Traite d' Hygiene, 3d edit., p. 218. 912 MEDICAL DIAGNOSIS. Aspei^lous infection of the lung, with haemoptysis and cavity-for- mation, in persons engaged in carding hair obtained finom rag-pickers, has been observed by Renon.* A similar fungus that penetrates the internal tissues, the chionyphe Carteri, gives rise to that terrible disease known as poddcoma^ or the fundus foot of India, — a complaint found among the natives of India who go about with naked feet. The fungus, introduced either through a scratch or passing through the pores of the skin, soon spreads, eating its way into the bones of the tarsus and metatarsus, and into Ihe lower end of the tibia and fibula, producing a breaking up and absorption of the osseous tissues. The fungous particles or masses are generally of deep-black color, firm and globular, though they may be white or pinkish. The foot is enlarged about the ankle and over the instep ; and on each side of the ankle-joint, and on the dorsum as well as on the sole of the foot are small, soft swellings, having pouting openings that lead to fistulous canals communicating with the bones, which they perforate in every direction. The fungous mass is for the most part situated in the cavities in the bones, and finom the canals passing to them transudes a discolored, ^air)% or purulent and fetid fluid. The toes are distorted, and the muscles of the leg atrophied : but the fungus does not spread up the leg. The tendency of the disease is to cause death by exhaustion ; the only remedy is amputa- tion.* The affection has also been observed in this country.* A similar disease, leading to local destruction, is the perfomthii/ ulcer of the foot. It is very uncommon in this countrj', although 1 have known of cases ; in France it is not uncommon. It is supposeii to be due to defective vitality of the parts from altereil nerve-supply and the presence of pathc^enic micro-organisms. Local anaesthesia, lowered temperature, and a tendency to profuse perspiration exist. The ulcer leads down to diseased bone. It is generally situated on the first or the last toe, over the articulation of the metatarsal bone >vith the phalanx. The toes sometimes drop off from a disease which constricts them and enlarges them beyond the point of constriction. The affection is ^ Monograph, Vienna, 1896, Comples-Rendus de la Soc. de Biol., Nov. 1. l>i*'> ^ See Carter, in Transact. Bombay Med. and Phys. Soc. ; and on Mycetoni.i. : the Fungus Disease of India, London, 1874. ' Kemper, American Practitioner, Sept. 1876. Cases reported by Adami ;ii.i Kirkpatrick in Montreal Medical Journal, Jan. 1896 : by Hyde and Senn, Jouniai ■* Cutaneous and Genito-Urinary Diseases, Jan. 1896 ; by Pope and Lamb, New Yoik Medical Journal, vol. Ixiv., 1896 ; by Wrip>'* '■^ns. of Apoc. of Aroer. Phys.. 1SV*S . and bv Anvine and Lamb. Amer. Journ Oct 1899. POISONS AND PARASITES. 913 not unusual in Brazil, and seems to be peculiar to the negro. It is known as ainhum} Infectious, multiple gangrene of the skin may be caused by diflfer- ent varieties of micro-organisms. It has been found due to them in tuberculosis and in typhoid fever. Animal Parasites. — When speaking of the aflfections of particu- lar structures, some of these intruders have been mentioned, — those found in the skin or in the liver, for instance. It remains to consider chiefly such of the more important ones as inhabit the hollow viscera, certain solid organs, and the muscles. Intestinal worms are the most common of all parasites. The gen- eral symptoms induced by them are those of intestinal irritation with disordered digestion. The appetite is capricious; the bowels are irregular, sometimes constipated, sometimes relaxed ; the abdomen is frequently swollen and hard, and the seat of uneasiness or of colicky pains ; the tongue is furred ; the breath is fetid ; and there is constant itching about the nostrils and anus. The patient, furthermore, grits his teeth during sleep, and is often annoyed by nightmare. Nervous disturbances are ako met with ; they may range from mere fretfulness to delirium, convulsions, chorea, epilepsy, or insanity. Strabismus and amaurosis may be also due to worms.^ There are many kinds of worms known to infest the alimentary canal of man, and they belong to the order of nematoda^ or round worms, or to that of cestoda^ or tape-worms. The round worms are parasites of an attenuated or cylindrical form, and present these varieties : 1. The ascaris lumbricoides, or I'ound worm^ bears a considerable resemblance to the common earth-worm. It inhabits the small intes- tine, sometimes finding its way into the stomach, or even into the oesophagus, or being discharged through the abdominal parietes.* When it ascends to the stomach and oesophagus it causes sudden attacks of fever and gastric derangement, with nausea and vomiting ; and even, at times, marked delirium.* The worms have been known to be so numerous as to obstruct the intestine. 2. The oxyuris vennieularis^ thread-woinn or seat-worm^ is very small, the male being about two lines, the female about five lines in length. The parasite is white, slender, and extremely active ; it is ^ Da Silva Lima, Arch, of Dermatol., Oct. 1880 ; Duhring, Amer. Joum. Med. Sci., Jan. 1884. » Hogg, Brit. Med. Joum., July, 1888. » Garnier, L'Union Medicale, Oct. 1861. * Schmidt's JahrbUcher, No. 10, 1868. 67 914 MEDICAL DIAGNOSIS, founil in the anus, and causes intense itching of this part. The an- noyance is sometimes such as to excite a suspicion of the existence ot piles. It may creep into tiie vagina, giving rise there to profuse dis-l charge ; or into the uretlira. It affects cluldren frequently, but is not uncommon in adults. 3. The uiimri^ mt/Mai\ a parasite which inhabits the eat, may infest the human body. It is a moderate-sized nematode, from two three inches long, though the female may reach about four inclie Its head end is spear-shaped, 4. Tlie frichocephulus di^par^ or lonff thread-worni^ is detected nj very large numbers in the ileum near ils termination, or in the cole particularly at its head. It is from an inch and an half to Mo inct in length, and is cluiraclerized by the hair-like appearance of the head which is generally buried Ln tlie nmcous membrane of the intestine It is not a connnun pai-asite, and it is doubtful whether its presei gives rise to any marked derangement. It has been found in the typli fevers, and in persons d)ing from cholera or diarrhoea. The tape'Wormj< are jointed entozoa, of a ribbon-like form, The| embrace the true tai)e-worms, or Ueniadte, and the bothriocephall Of the former there are eight varieties, all of which have been fouT in man, though only tw^o — the solium and the mediocancllala — ure < atl common ; the taenia saginata, however, has spread over t -^* Western Europe,^ The bothriocephalus latus is the usual s| bothriocephalus met with in the human intestine ; it, too, is iner greatly in Europe, and, it is said, in Texas, particularly in the portions.' The tfEiiia solium^ or pork t(ipe-ivoft)i^ consists of an immetis number of joints in connection with a single head. It inhabits i.'hiefl^ the small intestines. The researches of Kiichenmeister,* von Sieboldj and others have shown that its eggs become developed into the cerem eeUuloftw discerned in the muscles of the pig, rabbit, and othe^ animals whose flesh is used as food. Being once introduced into Ihl alimentary canal, they find there a nidus in which to underigo devt4 opment into the tape-worm. Cysticeni have also been detected the muscles, the cellular tissue, the brain, the spinal cord, tlie he and the liver of man, and are most commonly met with in middle i * Vun Z*'ht^nder, Parasitical Diseases of the Eye. Bovntian Lectures, Deutach. ] Med. Wocliejischrifl, No. 50, 1887, * Cohnan, quoted in Sajous's Annuiil, vol. J., 1890. •See Manual of Animal and Vegeliible Parasites, Syd. Soc. tmns),. 1857^ * Origin of Intestinal Worms* ibiti,, 1857. POISONS AND PABASITES. 915 and in the destitute ; they are the most frequent parasite in the eye.^ They cannot, as a rule, be diagnosticated, except they be in positions in which they can be seen or felt, or the little tumors they occasion in the subcutaneous tissue be extirpated and examined* In the brain their chief symptom is violent and Fig. 87. rapidly increasing ^epilepsy. In a case reported by Lloyd,* in which cysts developed in the right lateral ventricle and fourth ventricle, the symptoms were severe and constant headache, loss of memory, and a Fig. 88. Segments of taenia solium. Drawn from a specimen. Heads of taenise, magnified, except the small central figure, which represents the head and neck of tenia solium, natural size. The figure to the left is the taenia solium, that to the right the mediocanellata. sensation as if a ball were loose in the head and rolled about from the front to the back. There was left hemiparesis with ataxia, exaggerated knee-jerks, involuntary evacuations of the bowels, and failing vision, but no •epileptic attacks. The tape-worm is nourished from its head, the newly created flat segments pushing those already formed before them, so that the caudal Berenger-Feraud, Lemons de Clinique sur les Taenias de T Homme, Paris, 1888. ' Transaction College of Physicians, vol. xx. p. 32, 1899. 916 MEWCAL DIAGNOSIS. extremity is the oldest portion of the anknal. Each segment contains both a male and a female organ, the orifices of which are joined at the apex of a lateral papilla. In the tcenia solium^ the papillae are ar- ranged alternately at one side and the other. The size of the seg- ments increases gradually towards the caudal extremity, the largest being three or four lines in breadth. There may be upward of eight hundnni segments, and the worm may measure above thirty feet Upon the head, wliich is about as large as that of a pin, is a double circle of hooks contained in sacks ; the slender neck exhibits no segmentation. The sucking-disks in the tcenia itiediocaneUata are larger than in the hrnia solium, but the head, which is of blackish appearance and obtuse, has no hooks. The tape-worm most frequently seen in this country is the taenia mediooanellata, or saginata, which is usually found in beef. Leidy stateil, as tlie result of a large experience, that he had rardy encoun- tonxl the pork tape-worm, hmia mlium^ as a parasite in the human intestines in this country* The habit of eating raw or paitiaUj cooked beof is the cause of much of the infecticm with tape-worm. Taenia occasions disordered digestioa. colic, cnonps, a feefing of uneasiness in the abdomen, irritation of the mouth* nose, and anos, aiuemia, headache, dizxiness« disturbed sleep, mental depressioa enuioiation, cough, binting-fits, cutaneous emptioiis. and varioos ceivbm-spinal affections, such as conTuIsions and epflepsr : ret tbefe an^ no absolute data for the diagnosis of the paiasge exceiit the wp- pesuranoe ctf the links, segments, or progloltides in the dfedm^pes. hi orvior that ivlief he permanent, the head must be exj^^ed. The NvAn\.w^i.vs*W i\2h»«. ur^w Ickz^ or ^>3«f krfie-wi^rn, -xfiers frv^m the cx^mmon tape-worm in haTtc^ no !a:rfal rapCiie alirrraiiieJT arrsi:^\i. but a sit^Ie one at the centre of e^cfi se^ss^eit : tie 5*e^ meats tht^m^exves arv miKrh brcuoer : the be^ ^ oc* t*»?Qcii=*i 5jrz. hxs i\o hvx^ks u^va it. ar.d s>c> a r^ir :l Ss55c:r*fs iscif^ :c "iyr :':cr Uiv^uths of the t^nsi sccuni. ino we Ind re tr^.'^es re xcnts tziil about thjve iixhtrs 3vci the h^eifeL T::»f tar^^^ is re j-tL^Tf :c i:wk>^.^ white ccs\>r. *.out^oAvi\ or Vji'xx^ik bt'Ioc:*: 4j?c :: :2.»r iom.7 -^" '^3>* iBCiiitit. tv\-ii > ::i th»t Iiv:: r. inc jltt th»f jiiz:ii:i2« ~rr:cc :c x sct?i2ts :t zbzjl ycn,*;^" .v* :t5 fli'U-^ jl ii^.-it. ^t»:c •v-:i« :: ir*: sm i«-%:is:i;«Sw utt'Lult'' JLTT^ V^'i . >-:: :c irr, v:;^ r ^s r^r?;. :;:-:» jl-. tit: -tnihfr^: * sc^ ."3 XX'rK«i'.<^ .u'i^-iS^^ £r*:ii"-l7 ^ 5^1':. i£L»t :♦:•*: ai»^S :Va'"*~»tETli*X Jin: I ~r:i- P0I80N8 AND PARASITES. 917 cle, around which a granular layer forms which afterwards becomes fibrous, constituting its capsule. The cysts develop in their interior a number of scolices, the larval form of the taenia echinococcus. The saline, non-albuminous fluid, contained in the tumor in large quan- tity, upon microscopical examination will usually show booklets as well as scolices, thus absolutely establishing the diagnosis. A hydatid cyst may fail to develop any scolices, and is then termed an acephalocyst The whole animal is surrounded by an investing membrane, which may burst and allow it to escape; the term hydatid designates the enveloping cyst and contents. When the echinococci are arrested in their normal development and are barren, not attaining to the pro- duction of scolices, they give rise to cysts with walls consisting of distinctly developed, concehtric layers. When pressed tightly by the hand, they cause a peculiar gelatinous trembling or purring sensation. The family of the distortiata is not at all uncommon in man. A species of distoma, measuring from eight to fourteen lines in length, called the didoma hepcUicum^ usual in the liver and gall-bladder of the sheep, has been seen in the human liver and gall-duct, and also, it is said, in abscesses of the scalp. Other species of distoma have been found in the portal vein, ureters, kidneys, and bladder, and upon the intestinal mucous membrane ; yet in the portal vein and . its larger branches — ^a common seat of the distoma — the parasite pro- duces little or no appreciable derangement ; but when in the intestine it may give rise to congestion of the membrane, extravasation of blood, and the symptoms of dysentery. This has been specially noticed of the distoma haematobium, or Bilharzia hsematobia, a worm common in Egypt, and the cause of the haematuria prevalent at the Cape of Grood Hope and at the Mauritius. The entrance into the body is miainly through the urethra in persons bathing. FUarice have been met with in the blood and in the urine. The Filaria sanguinis hominis^ according to Bancroft and Mason, gets into the system chiefly through the use of drinking-water in which the ova of this parasite have been deposited by mosquitoes, or by entering the skin of bathers. It gives rise to considerable pain in the loins, and leads to both bloody and chylous urine, and, according to Manson, to lyoiph-scrotum, the elephantiasis of the tropics. Thus far, I believe, only the filaria noctuma has been found in North America, and ex- aminations for it must be made in the evening. Saussure* has re- ported twenty cases met with in Charleston, South Carolina. Mastin * proves that the filaria in the United States may be the cause of chylo- 1 Medical News, June, 1890. » Medical Record, Sept. 1888. 918 MEDICAL DIAGN06I8. cele of the tunica vaginalis testis. Hemy ^ reports a case of chyluria, appearing after a normal labor in a woman twenty-nine years of age, in which he discovered filaria noctoma in the blood. Dunn found active embryonic filaria in a case in which the symptoms were severe headache, fever, nausea, pain in the back, marked stomach pain and soreness, slight swelling of hands and feet, and puffiness of the &ce. The urine was suppressed for forty-eight hours, then chylous urine was passed, containing blood-cells, albumin, also leucocytes. oQ- globules, and m§ny embryonic filariae.' Osier has placed on record a case of chyluria persisting for thirteen years in which no filaria was found. There is thought to be a non-parasitic as well as a parasitic chyluria. A worm called the drongylus ffigas has 'been observed in the kid- neys. It produces hsematuria, continuous pain, and an abdominal tumor,' and may lead to dropsy and death.^ The dochmiu^ duodenalis is a worm producing a peculiar anaemia by sucking blood firom the walls of the duodenum. It has been found especially among brickmakers, miners, and men working in tunnels, and the disorder has been identified by Leichenstem^ with the so- called Egyptian chlorosis, tropical chlorosis, and brickmaker*s anaemia. It has spread largely throu^ Italian and Polish laborers employed in building tunnels, in mining, and in brickmaking. Anchwl€}«iomMjnj^. as the disease is called, is characterized by marked anaemia, by digestive disorder, abdominal pains, and bleeding from the bowels. There ts a greater tendency to retinal hemorrhage than in simple ana-mia.* Sandwith speaks of the marked sleepiness and dense stupidity.' Fiij parables may be found in the dejections from the i>jwrl and in tlie urine, producing loi^al irritation of the intestine or the bladder. The parasites wliieh chiefly occupy the areolar tissues or the muscles remain to be described. Of these there arv two of sj-l^ iai importance. One is the riiaria medinefu^is, dracuticuiujt, or f^»fi*wf7-«tr>rR*. TrJs is a ver>- slender, flat, finely ringed worm, which introduces itsrrif ir::o ' Medical Xews, May 2. 1S96. and Trans. Assoc. Amer. Phys.. l> l,t*u('karl. Unlersudiungt'i] aber Trirliiiia Spiralis* Leipiic, IM^, POISONS AND PARASITES. 921 suit is accomplished. Nay, as we know from two cases recorded by Virchow, neither the encapsuling nor the calcareous transformation kills the worms of necessity at all speedily ; for in the one case they had remained alive for eight, in the other for thirteen and a half years after the infection, and in one instance mentioned by Turner^ they were alive and active after twenty-six years. The number of trichinae in the muscles may be from several hundreds to many millions. Now, in accordance with their number in the muscles, with the character of the changes which there take Fig. 90. Trichiiia spimlib. Magiiified .100 times. (After Virchow. ) place,! and with the quantity in the intestines, will vary the extent of constitutional derangement and the signs of local irritation. Thus the symptoms and the dangers of trichiniams are not always the same. When merely a few thousand trichinae occupy the muscles, there are chiefly muscular pains with stiffness and general debility ; signs which gradually ease as the worms become encapsuled and cretaceous altera- tions occur. When the muscles are occupied by millions of the flesh- worms, the local phenomena are much more severe ; there may be almost complete immobility of the whole body, the muscles of respira- tion and of deglutition are implicated, irritative fever and general ca- ' Lancet, London, May, 1889. 922 MEDICAL DIAGNOSIS. Fig. 91. calcareous dcr>o«iis. {Atler Leuck- chexia are marked, and the paliont is apt to perish by gradual exha tion, or in consequence of the disordered respiratory function^ or of some pulmonary complication. The presence of large numbers ol Irichinte in the intestine produces diairhcFa, vomiting, abdominal pain aiid tenderness; or the worms may shortly after being swal- lowed give rise to a kind of cholera mor- bus. Should the signs of the affection not appear until from twenty-one to twenty- five days after the use of the infected meat, and take the form similar to acute rhea- matism of the joinls^ there are not as many trichjnse present as in the choleroid or the typlioid variety of the malady, each of which RupprecJil* has told ui shows from rivi^ to ten millions. Speaking generally, we may recognize in trichiniasis three stages: the first, lasting about a week, during which the trichina? are being generated in the intestines and in wtiich we tind only signs of gastro- intestinal irritation ; the second, ttie pas- sage of the brood Into the muscular textures, and the disturbances it there occasions ; the third, the retrogressive formation, which fairly sets in about three or four weeks after the beginning of the second. Now, it is the last two stages which yield the most striking manifes- tations of the malady : loss of appetite ; pasty taste in the mouth ; nausea or vomiting; dry,. somewhat coated tongue ; diarrhcea; abdominal pain and melcMr- ism ; prostration ; fever, with a quit k pulse and copious sweating; a-dema- tous sw^elling of the face, follow^ed in grave cases by almost general anasarca ; sensitiveness of the skin and the muscles to the touch, or piiinfulness when the latter are moved, and their contraction and difficult motion ; dyspticS sleepless nights ; nocturnal attacks of aljdominal neuralgia; and ei ation. There is also decided leucocytosis. The /erer is a marked symptom. It sets in early, owing to Fig. l»2, i-!i# i Encftp^utod chalky coticfvUnm tn muscle> due to deiul trlchin-T- •« - fled about thirty dmef, ( a i art.) Vierteljahrsschrift mr Ges. Med., Oct. 18S0. POISONS AND PARASITES. 923 intestinal irritation, though it is not until the end of, or after, the first week, after therefore the migration of the young trichinae has fairly begun, that it is strikingly developed. The temperature is about 101°, though it may pass to 104° and 105° ; yet it does not, as a rule, reach the high heat which is observable in other continuous fevers. But it is especially in the attending profuse perspirations, the absence of enlargement of the spleen and of an eruption, the swelling of the face, the muscular symptoms, and in a very red color of the visible mucous membranes, that the points of difference lie between the febrile excitement of trichiniasis and typhoid fevei-^ — a malady which, on account of the continuous fever, the prostration, the diarrhoea, and the sudamina, it resembles. In light cases of trichiniasis there may be no fever, or there may be a fever more of intermittent or remittent character. The appearance of the face may be like that of typhus fever ; here, however, the muscular pains are wanting.* The (edema marks the beginning of the second stage of the affec- tion. It manifests itself first in the eyelids, about the seventh day of the disease, and is attended with a catarrhal state of the conjunctiva, with dilated pupils, great susceptibility to light, diminished power of accommodation, and pain in moving the eye. The swelling may ex- tend over the whole face, and is sometimes associated with flushing. It is uninfluenced either by the sweats or by the diarrhoea, but lessens generally very much, or even disappears, after lasting eight or nine days. But instead of the oedema subsiding, it may extend to the chin, to the arms and legs, and to the back. It is probably due to pressure upon the arteries, exerted by the parasites and the exuda- tion. The dropsical swelling of trichiniasis is not associated with albumin in the urine. Still, we find occasionally a slight amount of albumin, as well as polyuria, though generally the quantity of urine is diminished. The trichinae may at times be detected in the passages from the bowels. The muscular symptoms begin in the second stage, at about the tenth day, with pain and stiffness in the limbs. The muscles are ex- tremely painful when touched or moved ; and the patient lies in con- sequence as quietly as possible. The immobility is also due partially to the retracted state of the muscles which occurs, manifest for in- stance in the semiflexed position of the extremities, and in the rigid, trismus-like setting of the jaws. The disturbance of function of certain muscles becomes particularly evident. The disorder of the * See Clinical Lectures on Acute Trichiniasis, by J. M. Da Costa, reported in Medical News and Abstract, March, 1881. 924 MEDICAIi DIAGNOSia muscles of the eye has been sdready spoken of; we encounter, besides, impaired hearing, difficulty of deglutition, and loss of voice, flpom the muscles of the ear, of the pharynx, and of the larynx being filled with trichinae. The respiratory muscles are commonly much affected, and we find hurried and shallow breathing. The muscles of the heart usually, and the unstriped muscles of organic life constantly, escape infection ; and, as the trichinae wander to the fixmt of the body rather than to the back, the muscles anteriorly are more infested than those posteriorly. An interesting observation, which may lead us to sus- pect the true cause of the muscular pains, is the great increase of the eosinophiles in the blood, to which Brown ^ has called attention. In a case mentioned by Osier* they reached sixty-eigfat per cent of the total number of leucocjrtes. Laige numbers of eo6inhiI]c cells may be found in the muscles without there being an increase of these cells in the blood.* The marked muscular pain« the stiffness, the fever, the profuse sweats, the acid urine, simulate the signs of acvie rhemmuMiism ; but we find in trichiniasis diarrhoea, no articular swelling, and no heart- complications. Error is more likely to happen with reference to acute muscular rheumatism. But the signs of prostration and of gastro-intestinal irritation are here wholly wanting. The condition of the respiratory muscles gives rise, as already stated, to the embarrassed res{HFation, but it is not the only cause of the pubnonary ^jmip/otiw. Congestion of the lung« bronchitis, and pleuritis are usual. They are not uncommonly comlnned with pneu- monia, which appears suddenly, selects the lower portion of the left lung by preference, occurs about the twenty-sirth day of the dis- ease, and generally proves fatal. The sputa consist of dark, unmixed blooil : and the pneumonia is thought to l>e due to a trichinous em^ holism, the dots being derived from thrx>mbL which form in the venous system.^ Limited catarrlial pneumonia may be also met with. If the i^tient escape a serious pulmonary complication* if he have strength enough to withstand the weeks of irritative fever and exhaus- tion, he enters at the end of a month or of five or six weeks of suf- fering u|K»n a gradual oonralescence. His appetite becomes insatiible, and he mores his limbs with more and more fre^edom. But it i? a long time before he regains his full muscular power. Iijdeesl this • ;-h::> Hopt:ii< H.^^pi'^O Bulletin. April. ISv?. jlsc M^^-akl X^vs. ;a=l l?y:? • Rupprwk:. Tr-hinen-Krinkhri*.. :!s>4. POISONS AND PARASITES. 925 may be always somewhat impaired. In some cases convalescence is greatly retarded by boils, by inflammation of the lymphatic glands, and by dropsy. Children convalesce more quickly than adults. They suffer, in truth, less from the disease, and are not very subject to it. The diagnosis of the malady' has been made evident while dis- cussing the symptoms. At first the signs of gastro-intestinal catarrh, the vomiting, the slight fever, the perspiration, the muscular feeble- ness, are the most significant, and these early manifestations might be mistaken for irritant poisoning ; we can tell their meaning prior to the marked development of the phenomena in the muscles only by the detection of trichinae in the stools. The same may be said of cholera morbus. Again, it must be borne in mind that in some cases of trichi- niasis the first symptoms of the complaint do not happen for two or three weeks after the infected meat has been eaten ; and that in others it runs a chronic course and the whole disease is very protracted. The so-called " sausage poisoning^'' not dependent on trichinae, differs from trichiniasis in its rapid course and in the quick appearance of the choleraic symptoms after the spoiled sausages have been partaken of. In periarteritis nodosa the severe muscular pains are associated with thickening of the vessels, muscular atrophy, palsies, and great dis- proportion between the rapidity of the pulse and the temperature,^ and an examination of the muscles will show the absence of the trichinous affection. Indeed, in any instance, no matter what be the complaint trichiniasis may simulate, there is, though we may suspect it from the eosinophilia, but one means of determining the presence of the flesh-worms positively, — to examine a piece of muscle. This may be effected by cutting down upon a muscle and removing suf- ficient of its structure for a microscopical examination, or by using Middeldorpff 's harpoon or Duchenne's or Hart's trocar. Owing to the oedema, and particularly the oedema of the eye- lids and face, the malady may be confounded with BrighCs disease. But the absence of albumin and tube-casts in the urine distinguishes it. The physical signs separate the dyspnoea it occasions from that of cardiac disease; and the sweats and the muscular symptoms of trichiniasis tell us what we are dealing with. 1 SchrStter, Wien. Med. Wochenschr., No. 15, 1899. INDEX. Abdomen, abscess in walls of. 529,538 aneurism of 519 auscultation of 470 diseases of 462 attended with pain 512, 520 simulated by hysteria 530 dropsy of 604, 610 enlargement of, general .... 463, 610 partial 617 examination of 462 inflammation of muscles of 527 distinguished from peritonitis 527 inspection of 462 movements of 463 palpation of 464 percussion of 465 pulsation in 520, 628 retraction of parietes of 463 rheumatism of walls of 530 swelling of 528 tumors of 519, 617 Abscess, biliary 589 embolic 756 hepatic 586, 601 lumbar 630 of abdominal walls 529, 538 distinguished from peritonitis 529 of brain distinguished from soft- ening 209 from tumor 211 metastatic 308, 340, 756 rupture of 209 of kidney 702 distinguished from cystitis . . . 703 from pyonephrosis 706 of larynx. 248 of liver 639, 573, 686 of mediastinum 434 of thoracic walls confounded with chronic pleurisy 362 perinephritic 703 peritoneal 627 peritonsillar 248 perityphlitic 535 post-c»cal 634 psoas, confotmded with aneu- rism 630 with appendicitis 538 Abscess, pulmonary 327 distinguished from bronchial dilatation 327 from phthisis 327 pysemic 591 retrolar3mgeal 247 retropharyngeal 115, 247, 458 subphrenic 589 tonsillar 248 tropical 573, 591 Acanthosis nigricans 753 Acarus 889 Acephalocysts 917 Acetone 658, 709 Achillodynia 774 Achylia gastrica 499 Acidity of stomach as a sympton. 476 Acne 880 rosacea 880 Acromegalia 219 Acroparesthesia 70 Actinomycosis, hominis 909 . laryngeal 248 of the liver 588 of the skin 890 pulmonary 329 Addison's disease 751 confounded with acanthosis ni- gricans 753 with discoloration of lacta- tion and pregnancy 753 with disorders of liver 753 with fever-hues 753 with hereditary hue 763 with pernicious ansemia 764 with phthisis 753 with pityriasis versicolor . . 753 with Kecklinghausen's dis- ease 764 with sun-bronzing 763 with syphilis 753 * with vagrants' disease 763 Adenoid vegetations 740 Adhesions, pericardial 399, 405 Adiposa dolorosa 718 iEgophony 284 vEsthesiometer 67, 68, 69 Agraphia 63, 178 Ague, dumb 837 Ainhum 913 927 928 INDEX. Air in the blood 764 Air-passages, diseases of 228 Akaptaphasia 178 Albumin in the urine 659 different kinds of 698 diseases marked by 680 tests for 669 Albuminose 661, 697 Albuminuria, cyclic 684 following epilepsy 186 in laryngeal diphtheria 454 in malarial fever 850 of old people 685 of uric acid and oxaluria 685 simple 684 Albuminuric retinitis 83, 690 ulceration of bowel 555 Alcaptonuria 652, 657 Alcoholism, acute, distinguished from apoplexy 173 from opiimi poisoning 898 from sunstroke 181 chronic 110,903 Alexia 178, 179 Algesimeter 470 Allochiria 69 Alopecia 507, 882, 907 Alvine discharges 510 examination of 510, 511 Amaurosis 119, 904 from gastric hemorrhage 484 Amblyopia 54, 84 Amenorrhoea 495, 739 Ametropia 84 Amoeba coli 510, 558 dysenterise 558 Amphoric voice 284 sound 268 Amygdalitis, follicular 242 Ansemia 82, 737, 744 as a cause of dropsy 716 cerebral 162,208 in Bright's disease 689 essential 740 from parasites 738, 740 idiopathic 740 of amoebic dysentery 558 pernicious 82, 257, 740 distinguished from Addison's disease 754 spinal 113 splenic 750 Anaesthesia 65, 238 crossed 66 dolorosa 67 extended 66 from reflex action 67 hysterical 65 in affections of nervous centres. 66 localized 66 muscular 69 of spinal origin 66, 100 one-sided 66 reflex 67 tests for 67 Anesthesia) trigeminal 67 Analgesia 68 Anasarca 29,715 Anchylostomiasis 738, 918 Anchylostomum duodenale 738 Aneurism, abdominal. . . . 519, 601, 629 intracranial 214 miliary 167,169 of abdominal aorta confounded with aortic pulsation 630 with colic 519,630 with disease of the spine. . . 630 with lumbar and psoas ab- scess 630 with neuralgia 630 with non-aneurismal pul- sating tumors 630 with rheumatism. 630 of ascending aorta 434, 442 of descending aorta 441 of heart 441 of hepatic artery 601 of innominate artery 442 of pulmonary artery 442 of renal artery, multiple 707 phantom 442 rupture of 631 thoracic 432 confounded with abaoess of the mediastinum 434 with chronic laryngitis 250,439 with intrathoracic morbid growths 433 with malformation of chest. 438 with pulsation of pulmo- nary artery 437 eructation as a symptom of... 478 tracheal tugging a sign of 435 Angina Ludovici 456 pectoris 383 distinguished from brachial neuritis 227 from cardiac epilepsy 386 from gastralgia 486 from intercostal neuralgia. 386 from irritability of heart,. . 386 from pain in region of heart 386 rheumatic 242 simple acute. 446 ulcero-membranous 452 Animal parasites 913 Ankle clonus 89, 120, 141 Ano, fistula in 314 Anorexia 148. 475 Anoxaemia 740 Anthracosis 604 Anthrax 909 Antrum Highmorianum, affections of 228 Aorta, aneurism of abdominal. See Aneurismy abdominal. aneurism of thoracic. See An- eurism, thoracic. atheroma of 3S7 coarctation or constriction of.. 436 INDEX. 929 Aorta, inflammation of 397, 434 malposition of 438 pulsation of 397, 628 valves of 424 insufficiency of 436 Aortitis 397 Apepsia, hysterical 476 Aphasia 177 auditory : 179 distinguished from apoplexy 177 in pneumonia 180 in syphilitic fever 840 motor 52, 178 sensory 178 visual 179 Aphonia, feigned 253 from defective breathing 250 nervous 250 of hysteria 250 Aphthae 444, 452 distinguished from diphtheria.. 452 Apoplexy 167 attended with paralysis 168 confounded with acute softening of brain 176 with asphyxia 176 with catalepsy 182 with cerebral hysteria 176 with diabetic coma 175 with epilepsy 187 with insensibility from drink.. 173 with insensibility from nar- cotics 173, 897 with 'obstruction of the cere- bral arteries 172 with protracted sleep 176 with sudden extensive paraly- sis 175 with sun-stroke 180 with syncope 176 with uraemic coma 174 hemorrhage the cause of 169 cerebral 170 seat of 169 pulmonary 339 mistaken for acute pneumonia 339 serous 169 - spinal 107 temperature in 168 Appendicitis 532, 550 acute hemorrhagic 550 associated with typhoid 800 bacterium coli commune in 533 chronic 534 confounded with abscess of liver 539 with acute intussusception . . . 537 with colic 515, 536 with diseases of gall-bladder . . 538 with distention of cacum 539 with extra-uterine pregnancy. 537 with kidney disease 537 with obstruction of bowels . . . 537 with ovarian disease 537 with pelvic haematocele 538 with pneumonia 539 Appendicitis confounded with ty- phoid fever 536, 803 with ulceration of ileum 536 forms of 531 perforative 634, 550 presence of pus in 534 recurring 540 Appetite, exaggerated 476 loss of, as a symptom 476 perverted 507 Arcus senilis 79, 414 Areolar tissue, irritation of 717 Argyll-Robertson pupil 81, 138 Army itch 889 Arteries, atheromatous changes in. 721 cerebral, obstructions of, oon- fotmded with apoplexy 172 coagulation in 761 diseases of 432, 719 aphasia in 179 embolism of 761, 762 inflammation of coats of 719 mesenteric, occlusion of 550 pulmonary, aneurism of 442 pulsation of 437 renal, multiple aneurisms of 707 Arteriosclerosis 720 Arteritis 749, 772 Arthritis deformans 778 distinguished from locomotor ataxia 779 from paralysis agitans 779 spurious 779 Ascaris lumbricoides 913 mystax 914 Ascites 610, 716 chylous 611 , confounded with cancer of peri- toneimi 614 with chronic peritonitis 613 with chronic tympanites 616 with distention of the bladder 615 with gravid uterus 615 with ovarian dropsy 612 with tubercular peritonitis... 614 Asiatic cholera 563 Asphyxia distinguished from apo- plexy 176 from coal and charcoal gases. . . 900 local 888 Astasia-abasia 76 Asthenia, cardiac 392 Asthma 288 cardiac 290 causes of 289 diagnosticated from croup 289 from dyspnoea of disease of the heart 290 from enlarged glands 290 from goitre 290 from nasal polypi 232 from oedema and spasm of the glottis 289 from paralysis of vocal appa- ratus 290 58 930 INDEX. Asthma diagnosticated from press- ure of ancurismal tumor 290 dyspnoea in 290 hay 307 distinguished from chronic bronchitis 307 renal 290,690 spasmodic 288 thymic 290 Astigmatism 71, 77 Ataxia 138 Friedreich's 141, 161 hereditary 141 locomotor 138,141 See Locomotor atojcia, progressive 141 Atiieromatous changes in vessels. . 721 Athetosis 136, 191 Atrophy from overuse of muscles. . 131 idiopathic 133 in joint-inflammation 131 of brain 209 of gastric tubules 499 of liver, acute yellow 677, 582 chronic 610 reil 608 of optic nerve 83, 139 pn>gros8ivo muscular 129, 134 unilateral progressive, of the faw 131 Aura opiloptica 185 Auricle, dilatation of 437 Auscultation 271 of abdominal viscera 470 of children 286 of the voice 2S4 lUoiUus aorogvm** capsulaius ivU iVUiinunis fHsoiou'rtius tvHuui in j:H:4trie carcinoma of anthrax of vvrobiv->jnr.al tovor of oholoi a of vho'era :r,orbu> ol thv--'-*^-^'* of or\ siiv'as of j:*,ar.v;or> of *.or:a o: Ma": A :V\er . of v'a^v.e. S?iV of r:;cu:::o!;:a :^:i>. o44. of :-x'*ap>*.r.i: :\'\or - of >vur\v ^ . of <<••.:: v,y*v.:a. 407 510 4oi» l>0;» Sl.^ 447 7,~>«» Bacteria a cause of disease of the kidneys 682, 704 action upon, by leucocytes 73.3 in fecal discharges 51U Barbadoes leg 886 Barber's itch 889 Bedsores 151 Bell's palsy 105, 124 Beriberi 132,184 Betabutyric acid 709 Bile, inspissated 580 in the stools 609, 562. 582 in the urine 653 vomiting of 481 Bile-duct, obstruction of 579 Bile-pigment 609 Bilharzia hsematobia 667, 917 Biliary abscesses 589 acids 569, 654 tests for 654 calculi 516, 579 passages, inflammation of 579 coniounded with acute hepa- titis 579 Bilious atUck 4VH) pneumonia 346 relapsing fever *. . . . S21 tvphoid ^^21 Black death 8^^ Bladder, disease of. associated with parapt^a US distended, confounded with ad- cites 615 with peritonitis T . . . . 527 fistula into b^ hemorrhage from 6o4 inflammation of 7w confounded with periioniii-i . . 527 neuralgia of, distinguished from aoute i::!la!iiir.aixon 7'>.» paralysis of 115. r4'. >j>a>ni »'f. v-onfounded wiiii vv-lic -^17 Blindness 7-*. >o- l^^ ' Blisters 151 BKx-y;. air in 7-'4 cvNaiTulai;-- n of 17,^ ir» art«::r^. . T* ". in hear: :- • vv^^;:>^.■*e< ^f 7o-4. * >' crisis 7 ^* dis .! ... 7-^ eye in . >i !:'.Ar;A -Niz^^i-is i:z:::L:s iz. >"" h JE niv-.:* : -r vn : n. «■>--. n.* t v^ o: yv . » :; . .r :v>: > m-. :y''tr'.f:^rcv^-i.3j. rs :n ..*-,-,-, .. jj_;^--w :n ."- A «■: .-^ .n Ci->"~ ..iZ.«,r' INDEX. 931 Blood in Hodgkin's disease 749 in leuksemia 746 in malarial fevers 833, 834, 851 in Malta fever 832 in pernicious anaemia 741 in pernicious lever 847, 848 in phthisis. 314 in pseudo-leukepmia 745 •in purpura 766 in relapsing fever 821 in scarlet fever 855 in scurvy 765 in septicaemia 757 in syphilis 840 in trichiniasis 924 in typhoid fever 798 in typho-malarial fever 853 in typhus fever 808 in the urine 663, 849 in yellow fever 827 microscopic examination of.... 724 pigment in 764, 851, 853 Plasmodia in 758 solutions for staining /33 specific gravity of 732 sweating of 152, 892 toxines in 758 vomiting of 482, 495, 583 Blood-casts 665, 682 Blood-corpuscles 724 normal proportions of 727, 731 rouleaux- formation of 735 shadow 734 staining of 735 Blood-extractives 659 Blood-plates 730 Blood- tests, in diabetes 710 Blood-ves.sel8, diseases of 719 Bloody stools in mercurial poison- ing 905 in typhoid fever 793 Body, extraordinary swelling of 819,887 position of, as a symptom 27 Borborygmi 470, 479, 549 Bothriocephalus latus. . . 740, 914, 916 Bowels, albuminuric ulceration of 555 atony of 552 cancer of 555 hemorrhage from 545 inflammation ol 520 intussusception of 537, 544, 547 invagination of 544 lithsemic pain in 778 morbid discharges from 553 obstruction of 537, 544 from internal strangulation.. 546 paralysis of 552 stenosis of 470 strictures in 647 ulceration of 552, 555 Bradycardia 387 Brain, abscess of 209 distinguished from tumor 211 in cardiac malformation 419 Brain, abscess of, metastatic 308, 340, 756 amemia of 208 and spinal cord, table of disor- ders of 153 aneurism of 214 atrophy of 209 centres in 50, 52, 54, 56 concussion of, causing jaundice. 571 congestion of 208 cysts in 214 diseases of 50, 153 vomiting in 496 dropsy of 161 emboli in 172, 762 hypertrophy of 218 inHammauon of 157 confounded with pericarditis. 404 meningitis of base of 156, 161 softening of 207, 210 acute 158, 175 chronic 207 syphilis of • . . 122, 840 thrombosis of sinuses of... 211,759 tumor of 158, 210 distinguished from aoscess... 211 f rom- chronic meningitis. .. . 211 from softening 210 gliomatous 214 seat of 212 tuberculous 214 Brain-power exhaustion of 205 15 rea thing. See Respiration. Breath-sound, metamorphosing. . . . 280 Bright's disease, acute 681 distinguished from acute pain- ful nephritis 683 from coma and convulsions. 686 from dropsy 685 from haematuria 684 from pericarditis 685 from pleurisy 685 from pulmonary oedema... 685 from purulent urine 683 from simple albuminuria. . . 684 from suppurative nephritis 083 chronic 688 confounded with ansemia 689 with cancer of kidney 692 with cardiac dropsy 691 with chronic bronchitis.... 690 with chronic consecutive ne- phritis 693 with chronic rheumatism.. 690 • with cysts of kidney 692 with diseases of the heart. . 691 witli gastro-intestinal dis- orders 691 with neuralgia 690 with renal inadequacy 694 with trichiniasis 925 with tubercle of kidney .... 692 different forms of 695 contracting form of 697 prealbuininuric stage of 663 932 INDEX. Bright's disease, retinitis in. . . 82, 690 table of clinical differences in . . 699 Bronchial dilaUtion 327, 329 glands, tuberculization of 293 phthisis, distinguished from whooping-cough 293 Bronchiolitis exudativa 308 Bronchitis, acute 302, 331, 341 associated with measles 860 diagnosticated from capillary bronchitis 304 from pneumonia 304 from tuberculosis 304. 332 from whooping-cough 293 of large and middle-sized tubes 302 physical signs of 303 sputa in 303 capillary 248.304 confounded with acute lobar pneumonia 304 with acute miliary tubercu- losis 332 with broncho-pneumonia . . . 305 with catarrhal pneumonia.. 305 with phthisis. 305 chronic •. . 306, 319 confounded with Bright's dis- ease 690 with nasal catarrh 307 with phthisis 319 idiopathic, distinguished from typhoid fever 804 of the finer tubes 332 of the large and middle-sized tubes 302 plastic 296,307 sputa in 308 putrid 30S. 329 Bronchophony 284 Bronoho-pneuiuonia . . 305. 312, 332. 341 distingiiishtni from tuberculosis. 332 mistaken for i.'ollapse 312 Bronchorrhcea 306 Bruit de glouglou 50S do moulin 407 Buboes of plairiie S31 Bulbar crises. 122 paralysis 127 asthenic 12S Bulimia 3tH>. 476 Bulk ot Uxiy 29 Bullous diseases S70 C. Cachexia sirumipriva 744 C*vum. apivrulix of. diseases of. . 532 i*aiKvr of 53l> distention oi 53^ intlauimation of 535 solitary u\vr of 555 Calcium o\.iIate t»50, 6<>»> Calculi, biliary 51»». 57*J Calculi of the pancreas 620 renal 505, 517, 675, 679 passage of 678 distinguished from malaria. 677 from nephralgia 676, 678 Cancer, colloid 627 of brain 214 of ccciun 539 of colon 624 of gall-bladder 598 of intestine 628 of kidney confounded with Bright *s disease. 692 of larynx 256 of liver 588, 593 confoimded with acute conges- tion 596 with acute hepatitis 596 with cancer of omentum 599 with cancer of stomach 599 with catarrhal jaui^ce 596 with chronic congestion . . . 595 with disease of gall-Uadder 597 with enlarged kidney 599 with fatty liver 595 with syphilitic liver 597 with waxy liver 595 of lungs 324. 380. 37- .V>i confounded with cancer of liver Sa'j with chronic gastritis. . 4^S. 5«.'i with cirrhosis of liver. . •^^ with gastric ulcer 49S. 5«.^1 situation of 5«>2 super\"ening on ulcer .V«5 of tongue. 445 of tonsils i5> primary 5s>:? Cancrum oris 444 Capillaries, diseases of 722 Capillary pulsation 5> Capsules, suprarenal, disease of. . 754 Carcimmia. gastric 4*.*"^ of peritoneum 614. 627 Cardiac asthenia 3**2 epilepsy $>»» nerve storms. :friT Cardio-pulnK>nary sounds. 317 Carpopedal spasm 2»w Casts in plastic bronchitis 3»^ Catalepsy accompanyiii^ hysteria.. 152 as.-*.viated with Bane^eptsy 17»^ INDEX. 933 Catalepsy confounded with apo- plexy 182 with ecstasy 183 daymare form of 183 feigned 183 partial 183 Cataract 78, 708 Catarrh, acute 229 gastric 490, 894 in measles 859 intestinal 520 nasal 186,230,307 post-nasal 231 vesical 701 Catarrhal fever 785, 830 distinguished from hay-fever... 787 lung complications in 787 nasal catarrh in 230 seqXielse of 786 Cavity in lungs 318, 327 Cellulitis, pelvic 626 Cerebellum, diseases of 143 gait in 143, 586 tumor of 158, 210, 586 Cerebral affections, forms of 153 pain in, distinguished from disease of frontal sinus .... 228 localization 50, 101 neurasthenia 205, 206, 210 thermometry 40 tumors 158, 210, 586 Cerebritis 157, 209 Cerebro-spinal fever 812 blood in 814 confounded with acute rheu- matism 819 with congestive fever 816 with inflammation of cord. . 817 with malignant measles. ... 818 with pneumonia 818 with rheumatism of cervical muscles 819 with scarlatina 818 with sporadic cerebro-spinal meningitis 817 with tetanus 199, 817 with tubercular meningitis. 817 with typhoid fever 816 with typhus fever 819 with uraemia 819 epidemic 814 lumbar puncture in 815 subsequent swelling of body. . 819 urticaria in 875 meningitis 163,812,816,817 sclerosis, multiple 145 distinguished from general pa- ralysis 217 typhus 812 Cestoda 913 Charbon 909 Charcot's disease 146 Charcot-Leyden crystals 289, 296 Chest, alterations of form, size, etc., of, in disease 261 Chest, barrel-shaped 309 contusions of, followed by pneu- monia 344 dilatation of, diseases presenting 352 diseases of 259 physical signs of 285, 357 girth of 264 inspection of, in diagnosis 260 malformation of 438 measurer 264 mensuration of 264 motions of, in diseases of 261 palpation of 266 percussion of 266 retraction of, diseases attended with 363 sounds of, on percussion 267 tumor in 360 Cheyne-Stokes respiration 168, 384 Chicken-pox 867 See Varicella. Chilblains 723 Chloasma , 884 Chloral poisoning 174, 898, 903 Chlorides in the urine 648 Chlorosis 30,38,739,744,760 blood-changes in 739, 740 confounded with pernicious anse- mia 744 Choked disk 83, 210, 213 Cholangitis 577 Cholecystitis 577 acute 580 phlegmonous 581 Cholera 563, 894 Asiatic, distinguished from chol- era morbus 666 associated with ursemia 566 infantum 561 morbus 562, 566 distinguished from irritant poisoning 563, 894 from trichiniasis 925 nostras 562 reaction 565 subnormal temperature in 565 toxine 565 with typhoid symptoms 566 Cholerine 566 Chorea 188 attended with salaam convul- sions 193 caused by eye-strain 77,190 distinguished from athetosis. . . . 191 from cerebro-spinal sclerosis. . 191 from convulsive tremor 191 from epilepsy 191 from facial spasm 192 from hysteria 194 from paralysis agitans 191 from spasms of acute cerebral disease 191 from tetany 193 from writer's cramp 192 electrical 190 934 INDEX, Chorea habit Huntington's hysterical paralytic post-henuplegic post-paralytic relations of, to rheumatism Choroid coat, inflammation of tubercles of Chorstek's symptom •. Chyluria G70, Circulation, derangements of, in cardiac disease 382, paralysis from interference with . phenomena of portal, disturbance of Cirrhosis of liver confounded with cancer of stomach with chronic peritonitis. . . . with inflammation of portal vein distinguished from cancer of liver from cancer of stomach .... from hydatids from other hepatic affec- tions from red atrophy from simple induration .... from syphilitic hepatitis... from malarial infection hypertrophic of children of lung confounded with chronic pleurisy Clergyman^s sore throat Clots, fibrinous, in the heart Club-foot Coagula, fibrinous Cofi*ee-groiind vomit 483, Coldness, sensation of Colic as a symptom bilious 513, confounded with abdominal an- eurism 519, with abdominal neuralgia . . . . with abdominal tumors with angioneurotic cedema... with appendicitis 515, with enteritis with gall-stones with gastralgia with hepatic neuralgia with nephralgia with neuralgia of dorsal and lumbar nerves with perforation of the intes- tine with peritonitis 519, with spasm of the bladder. . . . with spinal disease 'with strangulated hernia with uterine colie copper 190 190 190 190 192 104 189 83 83 200 917 393 91 58 567 604 609 609 608 608 609 607 607 608 608 608 607 606 606 365 457 396 133 290 499 415 512 530 631 518 519 519 536 519 515 514 516 510 518 ri7 i 515 531 51 519 515 518 513 Colic, flatulent .' from disease of the bowel. lead malarial metallic . ; nervous renal 536, 676, simple spasmodic uterine Colitis, croupous entero- ulcerative Collapse, delirium in in acute poisoning in appendicitis in cholera 565, in relapsing fever in yellow fever of the lung 311. confound^ with chr<^ic pleu- risy Colon, artificial dilatation of 548, disease of, associated with heart disease malignant disease of percussion of solitary ulcer of Color-blindness Coma 62, 606, diabetic 63, 175, from narcotic poisoning. .63, 174. in typhoid of apoplexy 63, of Bright's disease 63, uraemic 63, 174, 686, Coma-vigil Comedo . Comma-bacillus of Koch Concretion, intrahepatic Congestion of brain discriminated from softening of features, as a symptom passive pulmonary Congestive fever See Peniicioua fever. Conjunctiva, tuberculosis of Conjunctivitis from lithsemia Consciousness, derangement of . . . . diseases marked by sudden loss of Constipation as a symptom causing chlorosis from mechanical changes habitual 550, ulcers from Consumption. See Phthisis. galloping 331. Continued fever, simple Contractility, electro-muscular 95, Contraction, front tap. of log Contracture 120, Convulsions See also Spasms. 513 514 513 513 513 513 707 512 512 518 336 562 555 61 894 535 567 821 824 366 366 469 627 555 624 460 555 84 686 708 807 796 173 6S6 897 808 891 564 S30 10^ 30 4S3 846 7.S 62 167 540 73'» 730 334 7S4 146 151 149 INDEX. 935 Convulsions, diseases marked by 184 distinguished from epilepsy 187 epileptic 121, 130 from cerebral disorder 186 from irritant poisoning 893 from purulent otitis 187 from syphilitic disease 187 hysterical 118, 130 in apoplexy 167 in Bright*8 disease 686 in scarlet fever 855 in typhoid 796 of eccentric origin 186 salaam 193 unilateral 174 urjBmic 687 Convulsive seizures, limited 187 tic 193 Cord. See Spinal cord. Corpuscles, blood- 724 Coryza , 229 distinguished from nasal hydror- rhcea 230 Cough 291 dry and moist 292 from nasal affections 307 in laryngeal affections 234, 292 in phthisis 313 whooping- 248, 292 Countenance, expression of, as a symptom 29 Crackling in tubercle of lungs 282, 326 Cramp of stomach 484 writer's 192 Cramps ... * 150 caused by various occupations.. 192 Cranial reflexes 87 Craniotabes 782 Crepitation 282, 341 Crises, blood 735 bulbar 122 gastric 490 larjTigeal 140 Croup 243,289 catarrhr.l 243 false 243,246 membranous, or true 245, 454 diseases confounded with .... 246 distinguished from abscess of larynx 248 from acute laryngitis 246 from diphtheria 249, 454 from false croup 246 from oedema of tne lar3mx. . 247 from retrolaryngeal ab- scesses 247 from retropharyngeal ab- scesses 247 from scarlet fever 855 from secondary laryngitis of the exanthemata 246 non-diphtheritic membranous . . . 249 spasm of glottis in 244 spasmodic 244 Crural neuritis, general 226 Crus cerebri, lesions of 110 Ci-usta lactea 877 Crystals, Charcot-Leyden 289,296 Curschmann's sign 289 Cyanosis 30, 338 Cysticercus cellulosa 914 Cystine 676 Cystitis, acute 700 I confounded with abscess of I kidney 702 i with acute painful nephritis 701 with metritis 701 with neuralgia of bladder . . 701 with peritonitis 527 chronic 701 Cysts of brain 214 of kidneys 692, 706 confounded with hydronephro- sis 706 of nose ' 232 of pancreas 620 of vocal cords 267 ovarian 638, 612 fluid of 613 parovarian 627 D. Day-blindness 84 Daymare 183 Dead fingers 722 Deafness 85, 86, 231, 4^2 Debility confounded with typhoid fever 802 Deep reflexes 87 Delirium 60, 156 confounded with delirium tre- mens 166 . fierce 60 hysterical 62 in chorea 189 in diseases of stomach 61 in typhoid 795 mistaken for insanity 61 of cerebral rheumatism 771 of inanition 61 of pneumonia 60, 334 prominent as a symptom, acute affections with 155 quiet 60 simulated 61 tremens 164, 334 confounded with acute mania. 167 with acute meningitis 166 uraemic 60, 687 Dementia paralytica 215 senile 217 Dengue 828 distinguished from influenza . . . 830 from malarial fever 830 from rheumatism or gout. . .". 830 from scarlet fever 830, 858 from yellow fever 830 936 INDEX. Dermatitis herpetiformis 881 medicamentosa 884 Dermatophytes. See Tinea, Deutero-albumoses 746 Diabetes 666,707,711 coma in 176, 708 distinguished from carbon mon- oxide poisoning 665 from chronic polyuria 711 from glycosuria 711 fatty diarrhoea in 661 from pancreatic calculi 620 insipidus 711 intermitting 711 phos^hatic 647 retinitis in 82 test for 710 with coexisting albuminuria 711 Diacetic acid 658 Diacetone 709 Diagnosis by exclusion 22 differential 22 methods of arriving at 20 ophthalmoscope in 82 physical 260 sources of error in 23 Diaphragm, fatty degeneration of. 291 hernia of 356 paralysis of 290 phenomenon 261 rheumatism of 291 Diarrhoea 553, 558 acute 553 bilious 553 choleraic 563 chronic 554 fatty 560 in pulmonary consumption 314 in typhoid fever 792 intermittent 556 membmnous 556 of dissi^cting-room 911 of soldiers 554 strumous, of children 555 tubercular 554 Diathesis, rheumatic 241 Dij^'st ion as a symptom 48 dis<^rviers of, in liver disease. , . . 567 Dilatation, bronchial, confounded with phthisis 325, 329 with pu.monary abs^vss.... 327 with pulmonary gangrene.. 3-S of iv'.on 54S. 6-7 of ht>art 4lf iVr.tVunded with fatty degen- eration 414 with pericardial effusion... 416 of a^s^^phAiTvis of >tor.:.ioh Diphther:.^ K*v*.:'u> of cor.:ou.::v:i\i with iphth* .... with i::en:brAr.ou> orv^up . . with t*rvs:tv-as of the fauces w:tr. gar tne ^-:out^. 460 ^47 447 4oe 4^M 4^"-.> 4of Diphtheria confounded with phar- yngitis and tonsillitis 451 with scarlatina 454 with thrush 452 with ulcerative stomatitis 452 with ulcero-membranous an- gina 452 croupous 449 faucial 229 intercurrent 455 laryngeal 249, 454 confounded with scarlet fever 857 nasal 229,455 paralysis in 121, 142, 450 sequelie of 450 Diplegia 90 Diplococcus exanthematicus 807 in mumps 455 intracellularis 815, 817 pneumoniie 344 Diplopia 80 Discharges, alvine, as a symptom. 509 Displacements of heart. ..... 352, 431 Distoma haematobium. 917 hepaticum 917 Dittrich plugs. 30S Diuresis, chronic 711 distinguished from hydroneplino- sis 712 in hysterical women 712 Dochm'ius duodenalis 91S Dracunculus 91S Drink, insensibility from 173 Dropsv 715 abdominal *. . . 603.610 cardiac 3S±. 716 causes of 716 dependent upon a tumor 716 diseases marked by 6S1 from aniemia 716 from malarial poisoning 716 from scarlet fever v* general 716 from irritation of areolar tis- sue frv»m peripheral ziultiple ritis hepatic in Bright 's disease in disease of liver internal , of brain ovarian pericardia! cv^a founded witii eaniiac « tation peritoneal rer«il Dmnkjinls, gastritis of D^ct. cystic. oHstnxtacB d. stone* Duhri tig's disease Du'Xien^ir!!. casarrii o« u'cer of . r>vTLA=>^z:«er 6!s?, &*: 161. i:: 4».-4 716 4.!*. >->^ INDEX. 937 Dysentery 666 acute 556 amcebic 558 catarrhal 558 chronic 669 confounded with piles 558 with proctitis 658 diphtheritic 558 distinguished from diarrhoea . . . 558 epidemic 557 tropical 510 Dyspepsia as a symptom 488, 492, 551 atonic 489 nervous 488 with aortic pulsation 628 Dysphagia 247, 461 r^spnoea 287, 439 caused by aneurismal tumor 290, 439 by goitre 290 diseases presenting 353 from disease of the diaphragm. . 290 from enlarged glands of neck. . . 290 in asthma 291 in plastic bronchitis 307 laryngeal 234 Dystrophy, progressive muscular.. 133 facio-scapulo-humeral 133 hereditary 133 idiopathic 133 infantile 133 juvenile 133 pseudo-hypertrophic 133 scapulo-humeral 133 Ear, disease of 168 causing abscess of brain 209 Ecchymoses 671 Echinococci 600, 602, 916 Ecstasy 183 distinguished from catalepsy.. ... 183 Ecthyma '. 882 Eczema 161, 877 distinguished from pityriasis rubra 878 from scabies 879 from seborrhoea 878 impetiginodes 877 papular 876 rubrum 878 squamosum 878, 883 Effusions, pericardial 362, 400, 416 diagnostic sign of 401 peritoneal 523 pleuritic. . 310, 312, 323, 349, 358, 689 distinguished from hydatids . . 601 Ehrlich-Biondi stain 734 Electricity in paralysis 94 faradaic 94, 96 galvanic 94, 96 in examination of stomach 471 static or Franklinic 97 Electro-muscular contractility. 96, 123 sensibility 97 Elephantiasis of the Arabs 886 of the Greeks 885 Emaciation as a symptom 29 Embarras gastrique 490 Embolism 397, 759, 761 abscess from 591 cerebral 172, 762 with hysterical symptoms. . . . 197 diagnosis of 763 fat 764 from accumulations of pigment in the blood 764 from acute endarteritis 764 of arteries of the extremities. . . 762 of cerebral arteries 762 of pulmonary artery 761 of renal artery 762 of vessels of liver 762 splenic 762 Embryocardia 387 Emphysema 309, 360 coexisting with tubercle 320 compensatory 311 distinguished from aneurismal tumor 310 from chronic pleurisy 360 from pleuritic effusions 310 from pneumothorax 310 interlobular 311 Emprosthotonos 198 Empyema, pulsating, confounded with aneurism 436 Encephalitis 167 acute focal 167, 158 acute hemorrhagic 168 diffuse 167 Endarteritis 719, 764 gouty 777 obliterative 721 Endocarditis, acute 394 confounded with pericarditis. 402 associated with chorea 189 diabetic 708 ulcerative 398, 766 associated with pneumonia . . . 342 head-symptoms of, confounded with acute meningitis . . 160 with tjrphoid fever.. 399,804 Engorgements, pulmonary, in fe- vers 338 Enlargement of body 219 renal 602 Enteralgia 614 Enteritis, acute 620 confounded with colic 519 with peritonitis 526 with typhoid fever 621, 803 croupous or diphtheritic 522 membranous 566 muco- 621, 563 Enteroptosis ..* 463, 507 Eosinophiles 734, 746, 924 Epigastrium, pain and soreness in 489 938 INDEX Epigastrium, Htnsitiveness of 470, 491 tumors of 619 Epiglottis, disease of 238, 242 Epilepsy 184, 191 abortive 185, 188 associated with vertigo 185 aura preceding 185 cardiac 386 consecutive to scarlet fever 856 distinguished from apoplexy. . . . 187 from chorea 191 from convulsions 187 from hysteria 194 from strychnine poisoning. . . . 902 eccentric 186 feigned 188 idiopathic 187 Jacksonian 187 masked 187 nocturnal 185 post-hemiplegic 186 sequelfp of 185 syphilitic 187 Epiphytes 888 Epistaxis 300, 786, 797 Epstein's stomach test 469 Eructation as a symptom 477 Eruption in typhoid 797 of smallpox 864 produced by drugs 858 Erysipelas . .' 230. 453, 868 associated with nasal catarrh. . . 230 with phar}'ngeal fever 870 distinguished from angeio-neu- rotic oedema 870 from confluent smallpox 870 from erythema 869 from exanthematous fevers.. 869 from mumps 870 from si'urlatina 869 from scleroderma 888 in aortitis 398 migrans 870 of the fauces confounded with diphtheria 453 phlegmonous 868 Erythema lol. 3iH>. 869, 874, 880 desquamative 874 distinguished from erysipelas. . . 869 nourt-Jtic vesicular 879 Erythn>melalgia 723, Kti.or narv>^sis 6S4 Kx.'unination of |vatient.*. methods of 25 K\;uuho!j>atoii< fevers S53, 869 Excitation of ir.U'ii\e'i, direct and ir.direot 94 Exha^ition-*. ]-'i'»i^r.*v.i«i 910 Exophih;\lmic ir^Mtro. . . 32. 7S. 3S9, 438 Ex|xv4iire to ci^Ki 221 Eye, abnormal ohanires in fundus of 81 abnormalities of. external 78 of pupi's * SI appearance of. in disease 77 conjugate lateral deTiation of. . . 79 Eye, derangements of mechanism of 77. 7S embolism of 82 hypersemia of 82 in hay fever 7d lithsemic disorder of 778 paralysis of accommodation of 81.84 paresis of 84 ptosis of 80 reflex neuroses of 84 refraction, errors of 778 sixth nerve of, affections of SO subjective visual derangements of 83 third nerve of, affections of 80 Eyeball, protrusion of 78. 390 Evelids, drooping of 140 Eye-strain 77, 83, 190. 778 as a cause of chorea 77. 190 of epilepsy 77 of gastric derangements 77 of hysteria 77 of melancholia. 77 Eye-symptoms in oerebro-spinal sclerosis 146 in meningitis. 1^ in paralysis 1 15* F. Face, moon-shaped 218 spasm of 192, 222 unilateral progressive atrophy of 131 Facial palsy 124. 17f double 12S Faeces, accumulation of 61^ impacted, simulating gall-stones 51^ vomiting of 481 Faradaic excitability '-^ Farcy, acute, confounded with py- aemia 75^ Fat in intestinal discharges '^^ in urine. 5*»>. *'-'^ necrosis ** j^ Fatty degeneration of heart. . 3vi. 4l4 confounded with diilU 412 with dilatation 41^ with he:irt starvation 41; of pancreas €1* of tissues in poisoning ^'^ liver y^i^K Fauces, diseases of 44| erysipelas of 4^ inflammation of 44i ulcers of, syphilitic 45^ Favus ." >^ Fecal discharges ^ examinatiofi of 510. iV' vomiting 4*1 Feet, blueness and ooldness of . . . . 1^^ Feigned aphonia 2S epilepsy 3^ hysteria Vf. rheumatism INDEX. 939 Feigned sciatica 225 Fever, bilious typhoid 821 breakbone, or dengue 828 catarrhal 785 cerebro-spinal 81^ Chickahoniiny 852 congestive 846 enteric 789 erysipelatous 870 • from contaminated drinking- water 803 gastro-enteric 847 glandular 833 hectic 838 hemorrhagic malarial 849 hepatic 579, 839 icterode pernicious 849 infantile remittent 846 in phthisis 314 intermittent 836 malarial 833 malario-typhoid 853 Malta 831 measles 858 miliary 860 mountain 806 nervous 795 pernicious 846 pharyngeal 870 puerperal malarial 840 relapsing 819 remittent 8*1 scarlet 853 simple continued 784 spotted 808 syphilitic • 839 thermic 785 typhoid 780 typho-malarial 852 tvphus 807 urethral 839 yellow 823 Fevers 783 classification of 784 continued 784 eruptive or exanthematous. 853,869 periodical 833 type of 784 Fibrin, clots of, in the heart 396 network of, in blood 735 Fibroma, nasal 231 Fifth nerve, painful ansesthesia of. 222 Filaria medinensis 918 sanguinis hominis. 184.667,671,917 Fingers, dead 722 Fistula, gastro-pulmonary 493 Flatulency as a symptom 477 Fluoroscope 262 Flushing in myelitis 115 Fly parasites 918 Foot clonus 146 drop 110 perforating ulcer of . . . 140, 152, 912 Foot-and-mouth disease 910 Foreign body in bronchial tube. . . . 327 Foreign body in windpipe 248 FraenkeFs symptom 139 Fraenum linguse, ulceration of 293 Fremitus, bronchial 285 cavernous 285 friction 266 pleural 285 rhonchal 266 vocal 266, 284 absence of 285 Friction, pericardial 380 pleural 283, 403 pleuro-pericardial 403 Friedreich 8 ataxia 141, 146, 151 Frontal sinus, diseases of 228 neuralgia in 228 Fungi 295, 459 poisonous 897 yeast 480, 610 Fungus foot of India 912 Gait as a symptom 28 in cerebro-spinal sclerosis 145 in diseases of cerebellum 143 in general paralysis 215 in hysterical hemiplegia 119 in locomotor ataxia 138, 139 waddling 133 Gall-bladder, cancer of 598 diseases of 538, 588 , confounded with appendicitis. 538 with cancer of liver 597 distention of 598,601 distinguished from hydatids of liver 601 inflammation of 516, 577 tumor of, in cholecystitis 581 Gall-ducts, inflammation of.. 516,577 occlusion of 578 Gall-stones 506, 515, 598 associated with gastralgia 487 impacted, confounded with can- cer of the liver 598 passage of 515, 598 confounded with catarrhal ic- terus 579 with colic 515 with fffical accumulations.. 516 with intermittent fever .... 839 simulated by movable kidney. 623 Gallop rhythm 387 Galvanic excitability 96 Ganglia, central gray, lesions of . . . 102 Gangrene, diabetic 708 of ergot poisoning 904 of mouth 444 pulmonary 295, 308, 328 senile 723 symmetrical 722 Gastralgia 485, 496 confounded with colic 514 Gastric cancer 497 940 INDEX. Gastric catarrh, chronic 491 crises 140, 496 irritation 404 juice, acidity of 474 examination of 472 motormeter 471 tubules, atrophy of 492, 499 ulcer 470, 493 perforating 496 Gastritis, acute 489 from poisoning 489, 894 chronic 491 distinguished from gastric can- cer 601 from gastric ulcer 501 from hepatic congestion. . . . 585 from peritonitis 525 membranous 490 of young children 491 phlegmonous 490 Gastrodiaphane 471 Gastrodynia 485 Gastrograph 471 Gastromalacia 491 Gastroptosis 507, 739 Gastroscope 471 Gastroxynsis 477 German measles 861 Gigantism 219 Gingival line 314 Girdle pain 115, 146 sense 139 Gland, thymus 290 thyroid 219,390,438 Glanders 231,756 Glands, lymphatic, cancer of 625 sarcoma of 750 swelling of, in dengue 829 in plague 831 of axilla, enlarged 434 of neck, enlarged. . 241, 250, 290, 434 retroperitoneal, cancer of 615 retropharyngeal . 458 scrofulous 556, 750 tuberculous 750 Gland-secretions, altered 891 Glandular fever 833 Glenard's disease 507 Globulin 662 Glossitis, acute 445 Glossopletria 106 Glottis, oedema of 290 spasm of 244, 290 Glycosuria 655, 707 Glycuronic acid 658 Goitre 78, 290, 438 exophtlialmic 78, 389, 438 Gonococcus 230 Gonorrhneal infection of nose 230 rheumatism 770 Gout 397,411,775 associated with lithssmia 777 blood examination in 776 distinguished from dengue 830 from rheuma* 776 Gout, rheumatic 778 Gram's tests for micro-organisms. 299 Gravel 517,644 Graves's disease 389, 390 Guinea- worm 918 Gummata 132 Gums, red line of 314 swollen 443 Gyromele 471 H. Habit-chorea 190 Habit-spasm 190 Hamatemesis 301. 482, 793 alcoholic 605 Hsematoblasts 741 Hematocele, pelvic 538 retrouterine 626 Hsematokrite 727 Hsematoma 171 Haematopoi-phyrin 635 Hematoscope 730 Hsematuria 665 confounded with acute Bright's disease 684 intermittent 666 malarial 667 neurotic 666 parasitic 667 • renal tubal 665, 667 diagnostic sign of 666 vesical 668 Hsmidrosis 891 Haemocytometer, forms of 726 Haemoglobin 666, 730, 740 apparatuses for estimating 730 Hammerschlag's table for 732 Hsemoglobinometer 730, 732 Hcemoglobinuria 666, 897 intermittent 850 paroxysmal 666 Htemometer 730 Hffimophilia distinguished from leukaemia 767 from purpura 767 Haemoptysis 299 in typhoid 793 Hair, 'falling of 507, 882, 907 grayness of 65 Handwriting, alteration of 216 Hay-asthma 230 Hay-fever 79. 230 distinguished from catarrhal fever 787 Head, enlargement of, diseases characterized by 217 gouty inflammation in 777 rhythmic movements of 150 shapes of, in disease 218 Headache '. 71 congestive 71 from astigmatism 71 from Bright's disease 690 INDEX. 941 Headache from eye-strain 77 from lithsmia 778 from occlusion of frontal sinus. . 228 from poisoning 72 in diseases of the brain 71 nervous and neuralgic 72 sick 72 sympathetic 72 Hearing, derangement of 85 Heart, anatomy and physiology of 367 aneurism of 408 atrophy of 416, 752 auricle of, dilated 437 auscultation of «. 373 chronic diseases of, with in- creased percussion dulness . . . 409 clots of fibrin in 396 coagula in right side of 760 dilatation of 412,413. diseases of 367 associated with asthma 289 with diseases of colon 555 confounded with intermittent fever 839 with pernicious ansemia .... 744 with trichiniasis 925 presenting pain '6\)'S symptoms of 381 displacements of, diseases pre- senting 352, 431 dropsy caused by disease of 382,691,716 enlargement of, symptoms of . . . 417 mistaken for aneurism 435 without pain 383 examination of 369 fatty accumulation on 416 fatty degeneration of 385, 414 functional disorders of.... 388,419 gallop rhythm of 387 gouty 411,777 associated with contracting kidney 411 hemisystole of 389 hypertrophy of 409, 691 impulse of 371, 391 inflammation of 407 inspection of 370 irregularity of action of 388 irritable 386, 391 malformations of 418 causing abscess of brain. ... 419 mitral disease of 417, 424 murmurs 376 endocardial 376 pericardial 380 seat of 378 musical tone in 421 organic diseases of 393 overaction of 392 pain in region of 383 palpation of 370 palpitation of 386, 388 paralysis of, in relapsing fever . . 820 Heart, percussion dulness of, in- creased 409 percussion of 371 rhythm of 387, 388 rupture of 416 sounds of 373, 375 starvation 415 strain 392 topography of 368 valvular afifections of 417, 426 Heart-bum 477 Heart-clot, in pneumonia 338 Heat exhaustion 182 Heberden's nodes 779 Hectic fever distinguished from intermittent fever 838 Hemianesthesia 66 Hemianopsia 53, 81, 84, 103, 106 Hemiatrophy, facial 131 Hericrania 72, 223 distinguished from pain of or- ganic cerebral affections 223 from periostitis 224 from rheumatism of the scalp. 223 Hemiparaplegia 100 Hemiplegia 98 alternating 99 anatomical diagnosis of 100 appearance of muscles in 104 cerebral 129 corpus striatum in 100 cortical 102 electricity as a test of 100, 104 feigned 104 following epilepsy 185 lesions of internal capsule... 102 of crus cerebri 101 of gray central ganglia 102 of motor zone 102 of optic tract. 103 of pons Varolii 100 of prefrontal lobes 103 hysterical 118 in diphtheria 451 in the course of typhoid fever . . 797 nature of lesions in 103 optic thalamus in 100 pain in 104 pathological diagnosis of 103 rigidity in 104 spinal 100 Hemorrhage, a cause of apoplexy.. 167 cerebellar 170 cerebral 167, 172 cortical 171 from aneurism 301 from bladder 664, 668 from intestines 559 from kidneys 064 from larynx and trachea 300 from lungs 299, 301 from nose 230, 300 from oesophagus 300 from oral cavity 300 from prostate gland 668 942 INDEX. Hemorrhage from stomach 300,482, 495 distinguished from irritant poisoning 804 from urethra 668 from uterus in myxajdema 718 from ventricles of the brain 170 gastric 483 in apoplexy, seat of 169 in yellow fever 824 into cerebrum ovale 171 into corpora quadrigemina 170 into internal capsule 170 into lung texture 339 into medulla 171 into pons 170 into thalamus 170 limited to arachnoid 171 to one crus cerebri 171 of bowels 559 punctiform 158 renal, clots in 664 retinal 82 spinal 107 ventricular 170 vicarious 300, 483, 494 Hemorrhagic diathesis 908 malarial fever 849 confounded with intermittent hipmoglobinuria 850 with yellow fever 850 pachymeningitis 171 Hemorrhoids 550, 558. 550 Hepatic abscess 539, 573, 586 diseases as complications in ty- phoid 799 chronic and acute, confounded 575 droi)sy 717 fever 579 confounded with intermittent fever 839 neuralgia 516 Hepatitis, acute 572 confounded with acute infec- tious jaundice 576 with acute non-hepatic dis- eases vriih jaundice 575 with cancer of liver 596 with chronic hepatic disease with acute symptoms. . . . 575 with diaphragmatic pleurisy 575 with inflammation of the ))iliary passages 579 with intlammation of the portal veins 574 with perihepatitis 573 with pigment liver 574 \^ith jiylephlebitis 574 chronic 586 interstitial 597,607 siihanito infectiou-i 606 su])j)iirative 574 syphilitic 608 Hernia, diaphragmatic, confounded with pneumothorax 356 omental, dislocating stonuich . . . 506 Hernia, strangulated, confounded with colic 515 with intestinal obstructions 542 with irritant poisoning 894 through the recti muscles 5i>l Herpes 814, 87S. Ssl labialis s7y zoster 151, S7i* distinguished from erysipelas. 870 from scabies 8711 ophthalmicus 7S pain in, mistaken for pleurisy 879 Hiccough 203 in diaphragmatic pleurisy. . 204.575 Hip- joint affections 225. 53!' confounded with sciatica 225 History of patient 26 Hodgkin's disease. See Lymphade- fwrna ^. 749 Hour-glass stomach 508 Hutchinson's teeth 123, 781 Hydatid cysts 505, 917 thrill 627 tumor of kidney 707 Hydatids of the liver 587, 600,916 distinctive character of fluid in 602,017 I multilocular 002 of peritoneum 627 Hydrarthrosis 152 I Hydroa S'^) I Hydrocephaloid disease lt»2 I Hydrocephalus, acute 162 chronic 161. 217 , Hvdrochloric acid in gastric juice 473,486.492.4!HJ I Hydronephrosis 602, 706. 712 I confounded with hydatid tumor of kidney 707 with renal cysts 707 with diuresis 712 Hydrophobia 201. 460 distinguished from hysteria 202 I from strychnine poisoning 902 from tetanus I . . . . 201 I Hydrorrhcea, nasal 230 Hydrothorax confounded with ' chronic pleurisy 363 ^ • Hyperemia of stomach, active 4S2 I Hyperesthesia 64. 93 general 65 * hysteria as a cause of 65 I one-sided C5 Hyperalgesia 65 Hypertrophy of brain 218 I of heart.". 4at» of skin 886 I Hypochondriasis 145, 488 Hypochondrium, tumors of 617 Hypogastric region, tumors of . . . . 626* Hypoleukeemia, false 746 Hypotonia 139 Hysteria 142. IM abdominal, confounded with peri- tonitis 530, 540 INDEX. 943 Hysteria after railway accidents. . 196 i "associated with chronic diuresis. 712 with membranous diarrlioea . . 556 > with muscular atrophy 130 j cerebral, distinguished from apo- I plexy 176 I from chorea 194 from epilepsy 187, 194 | confounded with tubercular , meningitis 163 ' feigned 197 resembling hydrophobia 202 locomotor ataxia 142 toxic 196 traumatic 120 visceral 479 Hysterical complaints, local 195 fever 196 headache ^ 196 laughter 195 locomotor ataxia 142 paralysis 118 pseudo-maladies 196 tetanus 198 Hystero-epilepsy 195 I. Ichthyosis 151, 883 Icterus 567 catarrhalis 577 distinguished from abscess of liver 579 from biliary calculi 579 from cancer of liver 579 from cirrhosis 579 from congestion of liver... 578 from hepatic fever 579 Ileum, catarrh of 522 ulceration of 6^6 Iliac fossa, disease in 532 pain and tenderness in 532 region, tumor of 625 Impetigo 881 contagiosa 881 Incontinence of urine 615, 712 India-rubber poisoning 908 Indican in urine 654 Indigestion, functional 489 ■ Infantile paralysis 133 | scurvy 765, 782 ! Infarct, hemorrhagic 340 I Influenza 786 | See also Catarrhal fever. Innominate, aneurism of 442 , Inosite 658 ! Insanity 59 1 • chronic 157 | confounded with delirium 61 following acute rheumatism. ... 771 hysterical 196 , Insensibility from drink distin- ! guished from apoplexy 173 • Insensibility from narcotics dis- tinguished from apoplexy 173 Insolatio. See Sunstroke. Insomnia 63 Inspiration, jerking 277 Insufficiency of aortic valves con- founded with aneurism 436 Intellection, deranged 59 Intermittent fever 836 apyrexia or intermission in . . 836 distinguished from chills of pus formation 838 from diseases of the heart. . 839 from hectic fever 838 from hepatic fever 839 from passage of gall-stones 839 from puerperal malarial fever 840 from remittent fever 843 from syphilitic fever 839 from urethral fever 839 periodicity in 840 types of 836 double tertian 836 quartan 836 quintan 836 quotidian 836 tertian 836 Intestinal sand 509 Intestine, cancer of 628 constriction of 548 dilatation of 507 confounded with dilatation of stomach 507 diseases of 508 hemorrhage of 545, 559, 793 distinguished from hemor- rhoids 559 inflammation of 520 internal strangulation of 546 intussusception of 537, 544, 547 invagination of 544 mechanical changes in 552 morbid discharges from 553 obstruction of 540 causes of .' . . . 544 confounded with peritonitis.. 541 with strangulated hernia. . . 542 frequency of 548 from fecal accumulations 547, 548 from large gall-stone 547 from stricture 547 from volvulus 546 location of lesion in 549 percussion of 467 perforation of 524 associated with typhoid 800 distinguished from colic 515 from irritant poisoning. . . . 894 sloughing of 545 small 469 stricture of 547 tubercular disease of 555 worms in 913 Intoxication 63 944 INDEX. Intracranial tumor 158 Intrahepatic concretion 839 Intrathoracic morbid growth 433 Iris-contraction 87 Iritis 778 Irritant poisoning. 893, 925 Itch 876,889 army 889 J. Jaundice 567 acholuric 568 acute infections 576 catarrhal 577 distinguished from cancer of liver 596 from congestion of liver... 578 from remittent fever 843 deep, diseases marked by 582 diagnosis of 568 fatal forms of 571 from blood poison 570 from mental emotion 570 green or black 571 in acute non-hepatic diseases . . . 575 in cancer of liver 594 in hepatic disease 603 in phosphorus poisoning 895 Jaw, lumpy 909 Jaw- jerk 88 Joint, pyaemic 770 Joint-intiammations 131 Justus's sign 255 K. Kakkc 132 Keratitis 79 Kernig's Mign 155, 813 Kidney, abscess around 537 abscess of 537, 702, 706 distinguished from cystitis... 703 affections of, with swelling 505 in lead poisoning 906 calculus in. symptoms of 079 cancer of 692 distinguished from enlarged spleen 618 conp^stion of 675 contracted 697, 712 associated with albuminuric ulceration of bowel 555 with gout 777 confounded with myxoedema.. 718 with pernicious amemia. . . . 743 diuresis in 712 cysts of 692, 693 dis]ilacenient of 506. 622 distinguisheil from epigastric tumor 622 simulating gall-stones 623 enlargtHl, chronically inflamed... 695 Kidney, enlarged, confounded with cancer of liver 599 with hydatids of liver 600 with ovarian tumor 625 fatty, enlarged 695 fibroid 698 floating 537 hemorrhage from 665 hydatids of 707 confounded with hydronephro- sis 707 inflammation of, painful 675 of pelvis of 706 irritation, distinguished from sciatica % 225 movable or displaced 623 simulated by displaced spleen 624 by malignant disease of colon 624 mucous casts of tubules of ... . 696 neuralgia of 677 pain in 676 confounded with colic... 516,676 paroxysmal 676 persistent 678 percussion of 467 sarcoma of 692 suppurative inflammation of 702 surgical 694 syphilomata of 692 tubercular disease of 666, 692 confounded with Bright's disease 693 tumors of 537 waxy or amyloid, enlarged 696 Klebs-Loeffler bacillus 230, 245, 447 Knee-jerk 87 Kreatin and kreatinin 650 L. Lab-ferment 474 Lachrymation 152 Lactation, discoloration during, distinguished from Addison's disease 753 Lactic acid 472, 499 Ijandry's paralysis 108 Laryngeal affections, acute 240 cough 234 crises 140 diphtheria 249, 454 image 237 paralysis 251 phthisis 255 rheumatism 241 spasm 244 from use of antipyrin 900 stenosis 256 stridor 233. 245 vertigo 76, 24o laryngismus stridulus 244 laryngitis, acute. 240. 246 distinguished from acute pul- monarv affections 240 INDEX. 945 Laryngitis, acute, distinguished from pharyngitis 241 from tonsillitis 241 chronic 249 aneurism of aorta confounded with 260, 439 confounded with nervous apho- nia 250 of epiglottis 253 diffuse cellular 241 diseases confounded with 250 erysipelatous 241 feigned 263 hemorrhagic 241 hiemalis 241 membranous 249 cedematous 242 secondary, of the exanthemata . . 246 sicca 241 spasmodic 251 syphilitic or tubercular 256 Laryngoscopy 234 Larynx, abscess of 248 actinomycosis of 248 affections of nerves of 251 cancer of 256- cartilages and perichondrium of, diseases of 254 changes in breathing in diseases of 233 in voice in diseases of 233 diseases of, acute 239, 240 chronic 239, 249 organic 239 examination of 238 extirpation of 254 growths in 256 inflammation of 243 myxomata of 257 neuroses of, sensory 253 cedema of 242, 247 pachydermia of 266 pain in diseases of 234 papilloma of 257 paralysis of muscles of 251 polypi in 257 sarcoma of 257 stenosis of 256 tubercle of 255 tumors of 256 ulcer of 242,256 venous congestion of 263 ventricular banus of, hypertro- phy of 254 Lathyrus sativus 107 Lead poisoning 513,895,905 paralysis from 92, 121, 906 Lentigo 884 Leontiasis 219 Lepra, or leprosy 885 Leptomeningitis, acute 166 Leptothrix 459 Lethargv 183 African 184 Leucine 583, 639, 652 Leucocytes, classification of 736 counting of 726, 746 decrease in number of 746 in gout 776 in the urine 669 intermediate or transitional 736 phagocytic 735 staining of 734 Leucocytosis 535, 741, 745, 839, 841 in scarlet fever .' 855 in trichiniasis 922 Leucopenia 746 Leuksmia 82, 746 acute 749 distinguished from haemophilia and purpura 767 from pernicious ansmia 746 false hypo- 746 lymphatic 747,748 medullary 742, 748 myelogenous 747 of liver 593 pseudo- leukaemia distinguished from 745,750 retinitis in 82 splenic 747, 748 Lichen 875 planus 876 ruber 875 scrofulosorum 876 syphilitic 892 Lipoma of intestine 546 Lithsemia 777 associated with disorders of vision 778 with gout 777 with pain in stomach and bowels 778 vertigo in 74 Liver, abscess of 539, 573, 586 discharging externally 690 distinguished from appendici- tis 539 from hydatids 601 pyaemic 573 tropical 573 actinomycosis of 588 acute affections of 572 confounded with pyaemia . . . 756 congestion of . . . 572, 593, 596, 843 confounded with cancer of liver 596 with remittent fever 843 inflammation of 572 distinguiBhed from catar- rhal icterus 579,696 yellow atrophy of 577, 579 confounded with typhoid fever 583 with yellow fever 583 from phosphorus poisoning. 584 nervous symptoms in 582 cancer of 579, 588, 593 distinguished from other dis- 595, 601 59 946 INDEX. Liver, chronic affections of 684 with acute symptoms 575 atrophy of 610 congestion of 578,584,593 confoundea with cancer of liver 595 witn catarrhal icterus 578 with chronic gastritis... 585 with hypertrophy of liver 585 with torpor of liver 585 nervous symptoms in 585 cirrhosis of 579, 604 from malarial infection 607 hypertrophic 606, 608 decrease in size of 582, 604 diseases of 567, 571 associated with bronzing of skin 753 dropsy in 605, 717 fever in 579 from spirit drinking 604 jaundice in 567, 572 pain in 567, 603 with absence of jaundice. 584,603 displacement of, diseases pre- senting 352 from tight lacing 585 enlargement of 362, 572, 584 coiSounded with chronic pleu- risy 362 fatty 592,593 confounded with cancer 595 fibro-fatty 607 hobnail 604 hydatids of 587, 600, 607 hypertrophy of 585 inflammation of 573, 586 subacute infectious 606 leuksemic 593 movable 624 percussion of 465 pigment, confounded with acute hepatitis 574 pyemic abscess of 591 red atrophy of 608 simple induration of 608 syphilitic 593, 597 confounded with cancer of liver 597 table of diseases of 571 torpor of 685 tropical abscess of 673, 591 vessels of, embolism of 762 waxy 692, 595 confounded with cancer 595 diseases confounded with 593 Lock-jaw. See Tetanus. Locomotor ataxia 110, 138 artliropathies of, distinguished from arthritis deformans.. 779 diminution or loss of muscu- lar sense in 142 distinguished from diphtheri- tic paralysis 142 Locomotor ataxia distinguished from diseases of the spinal cord 14; from disseminated cerebro- spinal sclerosis. 14 from general paralysis of the insane 140, 21i gait in 28,139,14 gastric crises in 140, 49< of syphilitic origin 14 resembling hysteria 14 station in 2 . Lumbago 77 Lumbar puncture 81 region, tumors of 62 Lungs, abscess of 32 actinomycosis of 3*2 acute affections of 3^ confounded with tubercular meningitis U in typhoid fever 8( cancer of 324, 360, 3« cirrhosis of 3< collapse of 31 1. 3( congestion of 3i • diseases of 260, 2J physical signs of 2>. principal symptoms of 2^ engorgement of, in fevers 3: fistulous opening into 3< gangrene of 295, 308, 3: hydatids of 3i hypostatic congestion of 5< inflammation of 3 oedema of 338. 6i scrofulous disease of 3 syphilitic disease of 3 tuberculosis of 313. 3 See also Phthisis. Lupus 884, S Lymphadenoma 118. 361, 434. 7 distinguished from lymphatic cancer 7 from malarial affection 7 Lymphatic glands, cancer of . . 625. 7 system, disease of S Lymphocytes, small T Lymphomas, local gland 7 distinguished from Hodgkin's disease 7 of mediastinum 4 M. Maculffi ! Malaria ', associated with hepatic fever... I with pulmonary cirrhosis I with typhoid fever i blood in \ chronic 83,716,5 Plasmodium of simulating passage of renal cal- culus I INDEX. 947 Malarial cachexia 850 cirrhosis from 607 changes in kidneys 850 corpuscles in blood 833 fever, distinguished from dengue 830 followed by skin bronzing 753 puerperal 840 hsematuria 667 neuralgia 851 palsy 55 1 parasite 347, i833 poisoning, chronic 716, 850 symptoms in pneumonia 346 Malignant disease mistaken for pernicious anaemia 744 pustule 909 Malta fever 831, 832 Mania, acute 166,456,795 alcoholic 164, 167 confounded with acute meningi- tis 166 with delirium tremens 166 ursmic 687 Mania a potu 164, 167 Marasmus 212 Marrow cells 748 Mast cells 736 McBumey's point 533 Measles 858, 862 among soldiers 860 associated with acute bronchitis and pneumonia 341, 860 catarrh in 230, 859 complications of 342, 860 distinguished from miliary fever 860 from rubella 861 from scarlet fever 857 from smallpox 859, 867 from typhus fever 859, 863 eruption in 859 German 861 Koplik's sign in 859 malignant, confounded with cere- bro-spinal fever 818 Mediastinum, abscess of 434 inflammatory thickening of 435 tumor of 361 Megaloblasts 735,742,743,744 . Megalocytcs 734, 743 Megalogastria 507 Megrim. See Migraine^ Meliena 559 Melancholia, acute 167 Melanin 635 Melasma 884 Membranous croup 245 Memory, disordered 59, 1 86 M6ni^re'a disease 73,74.86,586 Meningitis, acute 155, 326 confounded with acute mania. 166 with acute softening 158 with apoplexy 171 with cerebritis 157, 158 with delirium tremens 165 Meningitis, acute, confounded with head-symptoms of acute rheumatism 159 of acute ulcerative endo- carditis 160 of conti^'ued fevers 159 of pericarditis 160 of pneumonia 160 of remittent tever 844 of typhus tever 809 with tetanus 199 with typhoid fever 804 cerebro-spinal 163, 812 diseases confounded with 816 distinguished from purpura . . 767 epidemic 812, 814 sporadic 164, 817 chronic, distinguished from tu- mor 211 epidemic 812 idiopathic 817 of the base of the brain 156 of the convexity of the brain 156 ordinary 161 pneumococcus 818 serous 162 spinal 113 tubercular 160, 817 distinguished from acute af- fections of the lungs. 163, 334 from acute hydrocephalus. . 162 from cerebro-spinal fever.. 817 from chronic hydrocephalus. l6l from hysteria 163 from ordinary meningitis. . . 161 from pneumonia 162 from typhoid fever 162 rose-spots in 163 suppurative 399 Meningococcus 815 Meningo-cncephalitis 187 Mensuration of chest 264 Mental faculties, diseases charac- terized by gradual impairment of 207 Mercurial salivation 445 tremor 905 Merycism 484 Mosi'nteric vessels, thrombosis of . 760 Meteorism 523 Metritis confounded with acute cystitis 701 with peritonitis 527 Microblasts 735 Micrococcus Melitensis 832 Mipraine 72. 84, 223, 690 distinguished from frontal sinus disease 228 Miliaria papulosa 891 vesiculosa 891 Miliary fever 860 Milk-leg. See Phlegmasia alba do- lens 721 Milk-sickness 910 Mind-blindness 85, 179 948 INDEX. Mitral constriction 417 Mollities ossinm 781 distinguished from rickets . . . 781 Molluscnm epitheliale 891 fibroma 891 Monoplegia 90, 104 brachio-facial 106 crural 105 facial 106 facio-lingual 106 oculomotor 106 Morphine habit 003 Morphoea 888 Morton's disease 776 Morvan's disease 132, 162 Motion, deranged 00 voluntary, diseases marked by sudden loss of 167 Motor path of Gowers 66 Mountain fever 806 Mouth, curd-like exudation of 443 diseases of 443 gangrene of 462 inflammation of 443 morbid appearances of 443 sore, of pregnancy 444 tuberculous ulceration of 444 Mucin 663 Muco-enteritis 621 Mucus in stools 600 vomiting of 481 Multiple neuritis. . . 109, 130, 142, 461,717,906 peripheral 717 See also Neuritis. Mumps 446, 466 See also Parotitis. confounded with erysipelas 870 Murmur respiratory 276 vesicular 274 absence of 276 changes in 275 Murmurs, cardiac 37C cardio-pulmonary 317 endocardial 376, 395 from lung changes 420 from misdirection of current... 419 functional valvular 419 in the course of fevers 396 musical 421 over thyroid gland 438 pericardial 380 without valvular lesion 380 Muscae volitantes 76 Muscle, rectus, contraction of . . . . 621 Muscle-jerk 89 Muscles, appearance of, in paraly- sis 93 morbid states of, paralysis from 91 spasm of 202 wasting of 128 Muscular contraction 90 confounded with epigastric tumor 621 rheumatism 199 Muscular rigidity 104, 199 sense 55, 69 diminution or loss of 142 symptoms in trichiniasis 923 Myalgia 221,774 Myasthenia gravis pseudo-para- lytica 91,128 Myelitis 111,114 acute, contrasted with acute as- cending paralysis Ill contrasted with multiple neu- ritis Ill central 116 disseminated 1 16 from compression 115 hemorrhagic 115, 116 transverse 115 Mycrocytes 734 Myelocytes 786, 748 Myocarditis, acute 407 associated with gonorrhoea 408 chronic 408, 416 rheumatic 771 Myoclonus multiplex 191 Myopia 84 Myotone, congenital 203 transient 203 Myxoedema 219, 717,887 distinguished from acute nephri- tis 718 from contracted kidney 718 from scleroderma 887 Myxoma, nasal 230, 231 N. Nails, state of, in disease. . 314, 358, 367, 882, 907 in typhoid fever relapses 779 Narcolepsy distinguished from sleeping sickness 176 from trance 176, 184 of hysterical origin 176 Narcotics, insensibility from 173 poisoning by 897 Nasal catarrh 229 cysts 232 hemorrhage 230 hydrorfhoea 230 papilloma 232 polypi 232 sarcoma 232 Nausea as a symptom 47S Neck, cellulitis of 241 Nematoda 913 Nephralgia 676 confounded ^vith renal colic 516. 67(j from passage of calculi 676 Nephritis 675. 905 acute painful 675 distinguished from acute Bright's disease 683 from acute cystitis 701 acute parenchymatous ^l INDEX. 949 Nephritis, bacillosa interstitialis primaria 682 chronic consecutive 693 interstitial 697 in Weil's disease 577 suppurative 683 Nerve-storm 223 cardiac 387 Nerves, diseases of 50 paralysis from affections of 91 wounds of 151 Nervous affections, classification of 153 deranged nutrition and secre- tion in 151 centres, diseases of, ansesthesia a symptom of 66 paralysis from 90 exhaustion 162 prostration 207 system, diseases of 59 disturbance of, in typhoid. . . . 795 syphilitic affections of 122 Nettle-rash. See Urticaria. Neuralgia 220 abdominal 518, 630 due to aneurism 630 affecting urinary passages 221 as a cause of headache 71 cerebral 223 confounded with aneurism 630 with pain of rheumatism 220, 773 dorso-intercostal 151, 518 epileptiform . . . • 222 facial 221 distinguished from painful anaesthesia of fifth nerve. 222 from spasm of face 222 from decayed teeth 222 hepatic 616 in Bright's disease 690 intercostal 352, 386 distinguished from acute pleu- risy 352 from angina pectoris 386 from gastralgia 487 lumbo-abdominal 518 of bladder 701 of dorsal and liunbar nerves. ... 518 of frontal sinus disease 228 of kidney 677 of mesenteric or solar plexus.. 519 of spinal nerves confounded with colic 518 of stomach 485 ovarian 518 reflex 221 sciatic 151 supra-orbital 228 trigeminal 152 Neurasthenia 204 cerebral 206,206,210 sexual 206 spinal 206 Neuritis 213,220 acute progressive 109 Neuritis, brachial 226 due to diphtheria 112 general crural 226 multiple 109, 130, 142, 461, 717, 906 distinguished from acute as- cending paralysis Ill from acute myelitis Ill from locomotor ataxia 110 from rheiunatism 110 of diabetes 112 optic 83,158,209,213 Neuromyositis 227 Neurosis, cardiac 386 cutaneous 881 occupation 192 reflex 78, 84 vasomotor 385, 722 Night-blindness 84 Night-terrors 61, 231 Nodes, Heberden 779 Nodules connected with rheuma- tism 771 in leprosy 886 subcutaneous fibrous 395 syphilitic, of lung 324 Normoblasts 736, 744 Nose, diphtheria of 229 diseases of 228 foreign body in 229 gonorrhoeal infection of 230 hemorrhage from 230, 607 Nucleo-albumin 663 Numbness of extremities 70, 142 Nutrition, deranged 151 Nutritional disease of spinal cord. 206 Nystagmus 141, 160, 191 Occupation neuroses 192 Ocular mechanism, derangement of 77 Odor of body, in Addison's disease 752 (Edema 716 angioneurotic 162, 619, 870 distinguished from colic 519 from erysipelas 870 in trichiniasis 923 of ankles 600, 715 of forehead and eyelids 212 of larynx 240, 242 diagnosticated from croup. . . . 247 pulmonary 338, 685 mistaken for pneumonia 338 occurring in Bright's disease 685 CEsophagitis 469 CEsophagus, auscultation of 461 cancerous narrowing of 460 cicatrices of 460 compression of 460 dilatation of 460 diseases of 443, 468 use of sound in 461 diverticula of 471 inflammation of 459 rupture of 460 950 INDEX. (Kriop}iagu8, stricture of 459, 502 Hpasmodic 460 thickening of, from poisoning. . 894 Oidium albicans 444 Omentum, cancer of 506, 699 distinguished from cancer of liver 599 Ophthalmia, gonorrhoea! 79 neonatorum 79 Ophthalmoplegia 81 Ophthalmoscope in diseases of the nervous system 78, 81 Opisthotonus 198 Opium poisoning 897, 902 Optic nerve, atrophy of 83, 139 neuritis 83, 158, 209 tract, diseases of the 103 Orthopnoea 28, 288 Orthotonos 198 Osteitis deformans 219 Osteomvelitis, acute 770 Otitis from inveterate smoking. . . 904 Ovarian cysts 538, 602, 707 dropsy confounded with ascites. 612 fluid, chemical character of 613 inflammation 518, 537 neuralgia 518 tumors 625 simulating renal growths.... 626 Oxaluria 650, 676, 685 Oxybutyric acid 658 Oxyuria vermicularis 913 Oza^na 231 P. Pachymeningitis homorrhagic 114, spinalis interna Paj»tn*s diso»iso Pain as a symptom alH>vt» tho oyo cardiac crises diseasi»s charactcrireti by pistric, as a symptom in chr\n\ic rheumatism in di'ieases of the liver.... 567. in eniK^Hsm of arterit^ in laryngeal atTev^tions in rejrion of ht\irt in typhoid fever lijrhtniujT jvaroxysm.^l, dis**as<*s character- i.-t\i by in rcijion oi kidney l\ilaie. jviralysis of Pal|v»tion of the chest Palpitaiion. cardiac, diseases at- tendtxi with oSt». l\iisy. S^^ al^o Pontiff fijt. ass^vi.'itevi with t\-phoid fever. . . iv:rs ' 105. bu*ilv»r 156 171 114 219 48 228 38a 140 220 4v^4 :::? tU>3 762 234 3Si? 7i>o 141 220 070 450 205 . 1*0 124 127 Palsy by compression 126 cerebral 135 facial 124,172 double 125,127 hysterical 118 lead 121 limited 118 local 124 of the arm 126 pseudo-bulbar 127 rheumatic 130 shaking 144, 217 wasting 128 Pancreas, calculous diseases of 620 cancer of 620 cyst of 620 disease of 619 fat necrosis of 526 fatty degeneration of 619 diarrhoea in 561 ulcerating 484 uniform simple hardening of . . . 619 Pancreatic fat necrosis 619 Pancreatitis, acute 526 confounded with peritonitis.. 526 chronic .* 619 hemorrhagic 526, 550 suppurative 526. 620 Papillitis 83.213 Papilloma 232, 257 Papular diseases 875 Paracentesis 363 Panesthesia 70 Paralysis 90 See also PaUif, acute ascending 108 contrasted with acute myelitis 111 with multiple neuritis Ill agitans 144.146.217.779 distinguished from chorea. ... 191 from general paralysis 217 from rheumatism 77i* alternate V*0 asthenic bulbar 12S bulbar 127. 12S clinical investigation of i*3 complete iM> cn^ssed 90. ^;* diphtheritic 121. 142, 45<> due to multiple neuritis. . 122 electro-muscular contract! : ity and sensibility in y5, 1*7 essential, of children I^ facial 124 following measles S.^9 friMu atTe^nion of nerves at tb«r extremities v»l of nftdiai nerve 121 fn>m apoplexy I •^7 fr\^m chronic softeniag 207 frv^iK cv>2jpres*ion 12^^ fr\>ni exposure to cvvc ?I frv^Ri inierter^EvV with i^ cir«i- .a:;o!a fr\ :r. eixi {x>:?<^a:isir ie.121.*^ INDEX. 951 Paralysis from lesion in the course of a nerve 90 from lesion of crus cerebri 101 from lesion of nervous centres. . . 90 from lesion of spinal cord 56 from morbid state of the muscles 91 from poisoning 92 from progressive muscular atro- phy 128 functional 90 general 215 of insane 140, 215 glosso-labio-laryngeal 127 hereditary 91 hysterical 118, 130, 196 infantile 133 infectious 112 intermittent 92 involuntary movements in 93 local 130 malarial 92, 851 motor, from exposure to cold. . . 91 of arms 105 of leg only 105 of median nerve 126 of musculo-spiral nerve 126 of nerves of arm 126 of radial 126 of sixth nerve 80, 122 of third nerve 80, 122 of ulnar nerve 126 of vocal apparatus 251, 290 periodic 92 pseudo-hypertrophic muscular, 29, 133, 408 rapid or universal 123 reflex 118 rheumatic 120 simulated 91 spastic spinal 116 spinal, general 129 strabismus from 79 sudden, extensive, without coma 175 distinguished from apoplexy. . 175 syphilitic 122 from inherited taint 123 tabular view of 136 tremor in 144 vasomotor 100 with muscular wasting 128 without coma 175 Paramyoclonus multiplex 150 Paramyotone 203 Paraplegia 90, 106 ataxic 141 cervical 115 following accidents 120 from hypnotic suggestion 120 from spinal hemorrhage 107 from tumor of cord 117 functional 120 gradual 112 hysterical 66 reflex 118 from disease of the bladder. . . 118 Paraplegia, reflex, from intestinal worms 118 simple senile 145 sudden 107 Parasites 893, 911 sBstivo-autumnal. . . 835, 841, 846, 849 ansemia due to 740 animal 510, 913 diseases caused by 833, 888 fly 918 in intestines 913 in sputum ^ . . . 297 malarial 347, 833 vegetable 888, 911 Parenchyma, hepatic, diseases of . . 571 Paresis, general 215 spastic 132 Parotitis 446, 455 associated with pneumonia 336 secondary 446 See also Mumps. Pectoriloquy 284 Pellagra 888 Pelvic cellulitis 626 hsemotocele 538 peritonitis 539 Pemphigus 879 Peptone in leuksemia 746 in puerperal state 662 Peptonuria in phosphorus poison- ing 895, 908 Percussion 266 auscultatory ^ 269 clearness of, as a diagnostic sign 302 dulness of, diseases accompanied by 313,362 . of abdominal viscera 465 of chest 266 pitch in 269 respiratory 269 Percussion-hammer 267 Perforation, intestinal, confounded with colic 515 Periarteritis 719 nodosa 719, 925 Pericardial adhesions 399, 405 effusion 362, 399, 416 mistaken for dilatation of heart 416 murmurs 380 Pericarditis, acute 399 cancerous 405 caused by scurvy 765 diagnosticated from endocarditis 402 from gastric irritation....... 404 from inflammation of brain . . 404 from pleurisy 403 friction sounds of 403 head-symptoms of, confounded with meningitis 160 hemorrhagic 405 in Bright's disease 685 indurated mediastino- 406 plastic 404 tubercular 405 952 INDEX. Pericardium, adhesions of 405 dropsy of 404 effusion of, confounded with chronic pleurisy 362 ulcerative perforation of 407 Perihepatitis 573 Perinephritis 703 distinguished from inflamma- tion of psoas muscle 704 Perineuritis 226 Periodicity in non-malarial dis- eases ^ 840 Periosteum, rheumatism of 775 thickening of 151 Periostitis 224 Peristaltic imrest 479 Peritoneum, abscess of 627 carcinoma of 614, 627 colloid cancer of 627 diseases of 508^ 613, 627 dropsy in 610 fatty tumor of ;. 627 hydatid disease of 627 perforation of 515 sarcoma of 627 Peritonitis, acute 522 associated with acute pancre- atitis 526 confounded with abdominal hysteria 630 with acute enteritis 526 with acute gastritis 525 ^with colic 519, 531 with constipation 541 with cystitis 527 with distention of bladder. 527 with inflammation and ab- scess of abdominal mus- cles 527 with intestinal obstruction. 541 with metritis 527 with rheumatism of abdomi- nal walls 530 with typhoid fever 803 chronic 631, 613 cancer in 532 distinguished from cirrhosis . . 609 from dropsical effusion 613 from collection of pus in the cavity 528 local or partial 525 pelvic 539 perforative 524, 541 puerperal 524 subphrenic 589 tuberculous .. 504,532,539,614,763 Perityphlitis 535 Pernicious ansemia 740 confounded with Addison's dis- ease 754 with contracted kidney 743 with disease of heart 744 with malignant disease 744 with organic disease of stom- ach 743 Pernicious ansemia distinguished from chlorosis 744 from leuksemia 745 from ordinary ansemia 744 from pseudo-leukaemia 745 retinitis in 82 state of blood in 741 Pernicious fever 846 algid 848 cause of 848 cerebral 847 confounded with cerebro-spinal fever 816 gastro-enteric 847 thoracic 847 Pestis major 830 minor 831 Petit mal 185 Pettenkofer's test 654 Phantom tumors 621 Pharyngeal fever 870 tonsil 231 Pharyngitis 241, 451 confounded with diphtheria 451 sicca 241 Pharjmgo-mycosis 459 Pharynx and oesophagus, diseases of 443,458 adenoid vegetations in 740 Phenylhydrazine test 657 Phlebitis 408,721.759 gouty 722 Phlegmasia alba dolens. . 721, 740, 759, 769 associated with gastric can- cer 760 con founded with rheumatism 769 Phonendoscope of Bianchi 272, 372, 465 Phosphates in the urine 645, 676 alkaline and earthy 645 calculi composed of 676 Phosphatic diabetes 647 diathesis 647 Phosphorus poisoning 895 Photophobia ; 293 Phtheiriasis 875, 876, 888 Phthisis 313 See also Tuberculosis of lungs, acute 305, 332, 805 associated with typhus 810 distinguished from meningitis 334 from typhoid fever 333, 805 acute pneumonic 333 bronchial 293 cavity from, distinguished from pulmonary abscess 327 chronic 313 confounded with actinomycosis. 329 with bronchial dilatation.... 325 with chronic bronchitis 319 with chronic pleurisy 323, 360 with chronic pneumonic con- solidation 320 with pulmonary abscess 327 with pulmonary cancer 324 INDEX. 953 Phthisis confounded with pulmo- nary gangrene 328 with syphilitic disease of the lungs 324 cough in 313 fibroid 366 laryngeal 255 of old people 320 physical signs of 316 pneumonic 322, 333 retrogression of 330 skin bronzing in, distinguished from Addison's disease 753 Physical diagnosis, methods of 260 Pigeon breast 781 Pigment in the blood 764, 861, 853 in the skin 709, 751, 884 liver 674 Piles 651, 558 Pityriasis capitis 890 maculata et circinata 882 rosea 882 rubra 878, 882 versicolor 890 distinguished from Addison's disease 763 Plague 830 distinguished from typhus fever 831 from yellow fever 826 Plasmodium malarise 758 Pleura, cancer of 361 effusion into 310,312,323, 349, 358, 363, 589 fistula of 366 friction sound in 403 liquid in 403 Pleurisy, acute 340, 348 confounded with acute Bright's disease 685 with acute pneumonia 351 with intercostal neuralgia. 352 with pleurodynia 352 bilious 346 chronic 323, 357, 363 confounded with abscess in thoracic walls 362 with cancer 361, 364 with chronic interstitial pneumonia 364 with cirrhosis of lung 365 with collapse of lung.. 311,366 with emphysema 360 with enlargement of liver.. 362 with enlargement of spleen 362 with fistula of pleura 366 with hydatid cysts 362 with hydrothorax 363 with intrathoracic tumor . . 360 with pericardial effusion . . . 362 with phthisis 323 with pneumothorax. 360 with tubercle 364 diseases confounded with 360 circumscribed 361 diaphragmatic 675 Pleurisy, different forms of 359 double 324 dry stage of 348, 366 associated with typhoid fever 804 effusion, stage of 349 encysted 361 fluid of, microscopical and bac- teriological examination of . . . 359 idiopathic 350 . plastic 366 tubercular 323, 363 Pleuritic effusion... 310,312,323, 349, 358, 363, 689 Pleurodynia 352 confounded with acute pleurisy 352 Pleurothotonos 198 Pleximeter 372 Plica polonica 891 Pneumatometry 265 Pneumococcus of Fraenkel . . . 298, 342 of Friedlaender... 232,299,342,815 Pneumo-hydropericardium 406 Pneumonia, acute 334 confounded with acute bron- chitis .'. 341 with acute phthisis 340 with acute pleurisy 351 with appendicitis 54Q with cerebro-spinal fever. . . 818 with hypostatic congestion. 339 with pulmonary apoplexy . . 339 with pulmonary engorge- ment in fevers 338 with pulmonary oedema .... 338 head-symptoms of, confounded with meningitis 160, 163 apex 338, 344 aphasia in 180 aspiration 342 associated with measles 860 with typhoid fever 804 with typhus fever 810 with ulcerative endocarditis.. 342 bilious 346 broncho- 304, 312. 332, 341 following hemorrhage from cavities 342 temperature chart of 343 catarrhal 304 chronic, confounded with phthi- sis 320 chronic catarrhal 322 croupous 334, 342 deglutition 341 diplococcus of 342, 347 dissecting 328 double 344 from embolism 340 gangrenous 257 hypostatic 339 interstitial 364 latent 344 lobar 304,312 distinguished from collapse of lung 311 954 INDEX. Pneumonia, malarial 346 massive 351 migratory 344 physical signs of 336 pneumococcus of 298, 342, 345 tuberculous aspiration broncho- 342 typhoid 346 articular symptoms of 346 Pneumonic consolidation, chronic. 320 Pneumo-pericardium 406 Pneumothorax 353, 360, 407 chest sounds in 354 diagnosticated from chronic pleurisy 360 from diaphragmatic hernia . . 356 from emphysema 310 from pneumo-pericardium .... 407 physical signs in 354 subphrenic 496, 690 without perforation 366 Pneumo-typhus 805 Podelcoma 912 Poikiloblasts 735, 743 Poikilocytes 734, 743 Poisoning 173, 893 aconite 901 acute 893 alcohol 173,898,903 alkaline 894 aloes 896 ammonium 670, 894 aniline 899 antimony 895 antipyrin 900 arsenic 110,622,895,907 atropine 899 belladonna 899 benzin 898 bromine 895 brucine 901 by poisonous exhalations 910 by ptomaines 910 Calabar bean 901 cantharides 896 carbolic acid 899 carbon dioxide 900 disulphide 908 monoxide 655, 900 carlK)nic acid 900 oxide 900 charcoal fumes 900 cheese, egg, milk 896 chloral 174,898,903 chlorine 895 chloroform 174. 898, 903 chronic 902 coal gas 900 colchicum 896 colocynth 890 conium 809 copper .513, 570, 805, 907 corrosive sublimate 806, 905 cream puff 896 diazobcnzene 896 digitalis 901 Poisoning, elaterium 896 ergot 896,904 ether 684, 898,903 from alkalies 894 from alkaloids 910 from animal effluvia 910 from ptomaines 910 fungi 897 hydrochloric acid 894 hydrocyanic acid 174, 899 hyoscyamus 899 iodine 895 iron 895 irritant 563,893 jaborandi 901 lead 121,250,895,905 lobelia 896 malarial 716, 850 mercurial 522, 895, 905 muscarine 897 mushroom 897 narcotic 173,250,686,897 insensibility from, distin- guished from alcohol- ism , . . . 898 from apoplexy 173,897 from uramia 686, 897 nitric acid 459, 894 nitrobenzole 174 nitroglycerin 901 opium 174,897.902 oxalic acid 894 paraldehyde 904 petroleum 900 phosphorus 584, 895, 908 picrotoxin 902 pilocarpine 901 potassium hydroxide. 894 iodide and nitrate 894, 895 producing coma 63 headache 72 paralysis 92 prussic acid 174. 899 sausage 896, 925 savin t 896 sewer -gas 682 silver 895 slow, by metals 90.5 sodium hydroxide 894 strychnine 901 confounded with epilepsy .... 902 with hydrophobia 902 with tetanus 201,901 sulphuric acid 459, 894 tobacco 896, 904 tyrotoxicon 896 veratrum viride 901 zinc 895, 908 Poisons 893 animal, diseases caused by 008 irritant 803 vegetable 901 Poliomyelitis 116. 151 acute anterior 133. 135 Polyaesthesia 69 INDEX. 955 Polyarthritis 242 ; Polychromatophiles 735 I Polypi, nasal 230, 232, 289 of larynx 257 I Polyuria 711 chronic, distinguished from true diabetes 712 Porencephalus 218 Porrigo larvalis 881 Portal circulation, disturbance of 567 veins^ inflammation of, con- founded with acute hepatitis 574 with cirrhosis of liver... 608 inflammation of, with coagula 608 thrombosis of 609 Position as a symptom 27 Posterior sclerosis 138 Pregnancy, discoloration of skin in 753 extra-uterine, mistaken for ap- pendicitis 537 sore mouth of 444 Pressure-points 202 Proctitis 558 Progressive muscular atrophy 128, 134 distinguished from bulbar paral- ysis 130 from cerebral hemiplegia 129 from general spinal paralysis 129 from hysteria 130 from infantile paralysis 134 from joint inflammations 131 from local paralysis 130 from multiple neuritis 130 from progressive muscular dystrophy 133 • from syringomyelia 131 from unilateral progressive atrophy of the face 131 of peroneal type 132 Prostiate gland, hemorrhage from. 668 Prostatorrhoea 206 Prurigo 876 Pruritus 876, 892 hiemalis 892 in diabetes 708 Pseudo-disseminated sclerosis 146 Pseudo-leukaemia 748, 750 splenic 750 Pseudo-scarlatina 857 Pseudo tabes mesenterica . . . . 476, 622 Psoas abscess 538 muscle, inflammation of 704 Psoriasis 876. 882, 883 distinguished from eczema squa- I mosum 883 from lichen 876, 883 syphilitic 883 Ptomaines 73, 551 Ptosis 80 Ptyalism 443 Puerperal malarial fever 840 Pulmonary afl'ectiona, confounded with laryngitis 240 with typhoid fever ........ 804 Pulmonary apople.vy 339 cancer 324 disease, physical signs of 259 engorgement in levers 338 symptoms in trichiniasis 924 Pulsation, abdominal 628 aortic 628 confounded with aneurism of abdominal aorta 630 of tumors 630 Pulse, condition of, in disease 31 dicrotic 34, 790 frequency and rhythm of 31, 32 gaseous 33 in typhoid fever 790 resistance of 33 respiration-ratio, perverted 334 strength and volume of 33 Pulsus alternans 32 paradoxus 400 Pupil, Argyll-Robertson 81 contraction and dilatation of . . . 81 Purging, diseases attended by. . . . 561 Purpura 765 acute, distinguished from hsemo- philia 767 from scurvy 765 associated with colic 519 hsemorrhagica and rheumatica.. 766 Purulent urine 668, 683 diseases associated with 700 Pus formation, distinguished from intermittent fever 838 in peritoneal cavity 528 in stools 509 in urine 668, 700, 704 in vomit 481 presence of, in appendicitis 534 Pustular diseases 880 Pustule, malignant 909 Py»mia ....*. 754 abscess of 591 arterial 756 associated with myocarditis.... 408 chronic or relapsing 757 confounded with acute affections of liver 756 with acute glanders or acute farcy 756 with intermittent fever 838 with rheumatic fever 755 * with typhoid lever 755 idiopathic 756 joint-aflTection of 770 metastatic or embolic abscesses of 756 spontaneous septico- 757 Pyelitis 704 catarrhal or rheumatic 705 from irritation of calculi 706 tuberculous 706 Pylephlebitis 574 Pylorus, cancer of 502 fibroid thickening of 504 Pyonephrosis 706 956 INDEX. Pyonephrosis confounded with ab- j scess of the kidney 706 ' with suppurative nephritis... 706 | Pyopneumothorax subphrenicus 496,590 I Pyrosis 481 \ Q. Quinsy, distinguished from tonsil- litis 446 Rachitis 193, 218 Rales 280, 336 crepitant, in pneumonia 336 varieties of 280, 281 Rash, mulberry, of typhus 808 Ray fungus 330 | Raynaud' s disease 666, 722 mistaken for chilblains 723 for scleroderma 888 for Weir Mitchell's disease. . . 723 Recklinghausen's disease 764 Records of cases, plans for 26 Red gum of infants 891 Reflex, abdominal 87 arc 86 aural 87 biceps 88 binaural 86 cranial 87 cremaster 86 crossed 89 deep 87 derangements of 86 epigastric 87 erector spins 87 excitability 97 gluteal ^ 87 in hysteria 196 jaw 88 laryngeal and pharyngeal 87, 238 nasal 87 palatal 87 palmar 86 patella tendon 87 periosteal 88 plantar 86 platysma 87 reinforcement of 89 scapular 87 superficial 86 tendo Achillis 88, 216 j toe 88 triceps 88 Regurgitation, aortic 404 mitral 42^ of fluid or food 48< tricuspid 42^ Relapsing fever 8^^ bilious typhoid form of 8^x Relapsing fever distinguished from typhoid and typhus fever . .* St from Weirs disease 57 from yellow fever 822, 83 renal disease in 82 spirilla of 821.82 Remittent fever 84 distinguished from acute conges- tion of the liver 84 from acute meningitis 84 from intermittent fever 84 from typhoid fever 84 from yellow fever 82 infantile 84 sequelae of 84 Renal artery, embolism of 7C multiple aneurisms of 7C calculi 676, 679. 7( irritation of 7( colic 517, 676, 679, 7( concretions, forms of 6'i passage of. See Renal colic. cysts 7( dropsy 71 enlargements 6< gro^'ths simulated by ovarian tumors tti hematuria ^ inadequacy 6! vein, thrombosis of 7 Respiration, amphoric. . . 268, 279. * bronchial 274. 2 broncho-cavernous 2 cavernous 2 Cheyne-Stokes 62, 291, S disturbance of feeble 2 harsh 2 in children, peculiarities of 2 in laryngeal disease 2 jerking 2 metallic 2 metamorphosing breath-sound... 2 prolonged 2 puerile 2 ratio 3; rhythm of 2 sounds of, in health 21 supplementary 21 vesiculo-bronchial 2< vesiculo-cavemous 28 Respiratory movements 20 Retina, embolism of. ^ Retinal hemorrhage ^ Retinitis, albuminuric 83,JJfl diabetic 83. 708 leuksemic ^ Retroperitoneal glands, cancer of. 615 tumors JJJ Retro-uterine hnmatocele *; Rheumatic fever distinguished from pyaciax*. gout \i paralysis , 7U INDEX. 957 Rheumatism, acute.' 768 distinguished from acute syno- vitis 769 from cerebrospinal fever. . . 819 from dengua 830 from milk-leg 769 from rickets 782 from trichiniasis 924 head-symptoms of, confounded with meningitis 159, 771 heart-symptoms in . . : 770 as a cause of chorea 189 associated with nodules 771 with torticollis 774 cerebral 771 chronic 772 confounded witn neuralgia 220, 773 with pain of organic struc- tural disease 773 with paralysis agitans 779 in Bright's disease 690 distinguished from gout 776 feigned 776 gonorrhteal 408, 770 hyperpyrexia in 771 laryngeal 241 muscular '. 772, 773 distinguished from achillo- dynia 774 from Morton's disease 775 from myalgia 774 from neuralgia 773 from organic structural dis- ease 773 from sciatica 225 from tetanus 199 from trichiniasis 775, 924 of abdominal walls 530 confounded with peritonitis 530 of cervical muscles 819 of lumbar muscles, simulating abdominal aneurism 630 of scalp 223 periosteal 775 subacute 772 associated with scarlet fever . . 856 confounded with neuralgia. . . 220 syphilitic 775 Bhinitis 229, 231 atrophic 231, 241 caseosa and fibrinosa 229 hypersesthetic 230 membranous 455 oedematosa 229 Rhinoliths 229 Rhinorrhcea, cerebvo-spinal 230 Khinoscleroma 232 Bhinoscopy 231, 239 Bibs, beading of, in rickets 782 caries of 528 ^tickets 193,218,438,780 combined with scurvy 782 confounded with cranio tabes ... 782 with hereditary syphilis 781 Rickets confounded with mollities ossium 781 with rheumatism 782 diagnosis of 781 Ringworm of the scalp 890 Risus sardonicus 198 Romberg symptom 139 Rontgen light 262 See also X-rays. Rose-cold 230, 307 Roseola 874 Rotheln 861 Rubella 861 associated with pyelitis 704 distinguished from measles 861 from scarlet lever 862 from typhus fever 863 Rubeola sine catarrho 859 Rumination : . 484 Rupia 882 S. Salaam convulsions 193 Salivation 443 Salpingitis 637 Sand in intestines 609 Saprspmia 758 Sarcins ventriculi 480, 506 Sarcoma, mediastinal 361, 434 of hypogastric region 627 of kidney 692 of larynx 257 of lymphatic glands 750 of nose 232 Sarcomata of brain 214 Sausage poisoning 896, 925 Scabies 879, 889 Scalp, loss of sensibility in 67 oedema of, in cerebral thrombosis 173 rheumatism of, confounded with hemicrania 223 Scarlatina 853 anginose 855 associated with rheumatism .... 856 complications and sequelae of... 856 distinguished from cerebro-spi- nal meningitis 818 from dengue 830, 858 from erysipelas 869 from laryngeal diphtheria 454, 857 from measles 857 from rubella 862 from smallpox 857 from typhoid fever 857 followed by dropsy 856 by . epilepsy 866 leucocytosis in 855 nervous symptoms in 865 pseudo- 857 rash of 854 sine exanthemate 854 sore throat of 854 surgical 857 tongue in 856 I i^i [ f ^ ' ^ ^mi 958 INDEX. Scarlet fever. See Scarlatina. Sciatica 224 distinguislied from hip-joint af- fections 225 from irritation of the kidney. 226 from rheumatism 226 feigned 226 of diabetic source 708 Scleroderma or sclerema 819, 886 Sclerosis, cerebro-spinal 146, 217 chronic, of posterior and lateral columns 141 disseminated 141 distinguished from chorea 191 lateral, amyotrophic 116, 117 multiple 145 posterior 116, 138 pseudo-disseminated 146 spinal 116 Scrofula 31, 638, 876 associated with disease of intes- tines 666 pulmonary 330 Scrofulous glands distinguished from lymphadenoma 750 Scurvy 554, 764 combined with rickets 782 confounded with purpura 7tt6 infantile 764 sore mouth of 443 Seborrhoea 878,891 Secretion, deranged 161 Senile dementia 217 Sensation, deranged 64 gnawing, in vertebrse 441 Sensations of patients 48 tests of 67 Sensibility, electrical 65 perverted 70 Sensory centres of brain 55 impressions 56 nerves 64 Septicremia 757 from absorption of toxines 758 malarial 758 puerperal 757, 759 typhoid 758 Septum of nose, deviation of 229 Shock . : 33 Shoulder. stifTness of, in chronic pleurisy 358 Sinus, frontal, diseases of 228 Skiagraph '. 202 Skiameter 263 Skin, actinomycosis of 890 condition of, as a symptom 31 diirin;; typhoid fever * . . 790 discoloration of, following fe- vers 753 from lactation and pregnancy 753 hereditary 753 in Addison's disease % . . . 752 dist'iifij'H , •»■ * • ^"^ bullous . .^^|J^|. g7!> Skin diseai from a • from i nervou papula parasit pustuli squami syphili table vesicul dryness i hypertro] maculae < new gro pigmenta trophic < Skoda's so Sleep, pr< from ap4 Sleeping 8i< Smallpox confluent disting from from fronn eruption invasion maligna! sequel oe < Sneezing, a Snoring .. Softening < chronic discrin fron fron fron fron pc fron fron paraly relatio Somnolence Sopor .... Sore throai chroni( rheu clergyi follicu syphili Sound, adv amphori< bronchia cracked-j elicited 1 Hippocra oesophagi sibilant i splashinj; tracheal, tympanil INDEX. 959 Spasm, carpopedal 200 facial, distinguished from chorea 192 masticatory, of the face, distin- guished from tetanus 199 of arterioles 722 of bladder confounded with colic 517 of glottis 244 Spasmodic dorsal tabea 116 Spasms 149 See also Convulsions, centric and eccentric 150 clonic and tonic 149 diseases marked by 184 facial 192 functional 202 mobile 192 of acute cerebral disease 191 rhythmic, of the head 150 saltatory 150 tetanic, symptomatic 199 Spastic spinal paralysis 116 Speech, defective 131, 141 Spermatorrhoea 206 Sphincters, loss of control of 115 Sphygmochronograph 38 Sphygmogram 36 of aortic insufficiency 425 of contracted kidney 698 of gouty heart 411 of mitral regurgitation 425 of thoracic aneurism 435 Sphygmographs 34, 35, 411 Spinal cord, ansmia of 113 congestion of 112 diseases of 50 gout of 777 hemorrhage into 107 inflammation of 113 distinguished from epidemic cerebro-spinal meningitis. 817 lesions of 56 morbid conditions of, as a cause of paraplegia 107 nutritional disease of 206 sclerosis of 116 syphilis of 123 table of diseases of 153 tumors of 117 Spinal curvature 219 in chronic pleurisy 358 hemorrhage 107 irritation 113 localization 56 meningitis 108, 113 myelitis 114 sclerosis 116 disseminated 145 lateral 116 amyotrophic 117 Spine, concussion of 115 deviation of 132 in chronic pleurisy 358 disease of, confounded with an- eurism 630 with colic 519 Spine, irritable 113 Spirometer 265 Splanchnoptosis 463, 507 Spleen, affections of 617 displacement of 624 embolism in artery of 762 enlargement of 362,618,795 chronic 618 distinguished from cancer of kidney 618 from chronic pleurisy 362 from fecal accumulations.. 618 hereditary 618 in typhoid fever 795 gastric hemorrhage in 483 infarct in 399 inflammation of 617 lesion of, in relapsing fever. ... 821 percussion of 466 size of 467 Spotted fever 812 Sputum 294 albuminous 363 constituents of 295 crystals in 296, 308 elastic fibres in 296 fibrinous coagula in 296 nummular 313 parasites in 297 resembling currant-jelly 324 prune-juice 324, 334 rusty 334 spirals in 296, 308 Squamous diseases 882 Starvation of heart 415 Station 29, 94, 139 Status epilepticus 185 Stenosis, bronchial 258 laryngeal 256 of bowel 470 of pylorus 504 Stereognosis 70 Stethogoniometer 265 Stethometer 264 Stethoscope 271 Stitch in the side 350 Stokes's sign 52rf Stomach, acidity of, excessive 476, 499 activity of, absorptive 475, 504 acute diseases of 489 cancer of 497, 599 contrasted with cancer of liver 599 with chronic gastritis 501 with cirrhosis of liver 609 with gastric ulcer 501 catarrh of 491 chrpnic affections of 491 cramp of 484 dilatation of 480, 505 - confounded with dilatation of large intestine 507 connected with tetany . . .. 200, 506 diseases of 470 dislocation of 506, 507 electricity to 471 960 INDEX. Stom&ch, examination of 470 of contenteof... 471, 492,.499, 606 fibroid thickening of 504 gout in 777 hemorrhage from 482,495,894 hour-glasB constriction of 508 inflammation of .* 489 inspection of interior of 471 insufflation of 469 lithemic pain in 778 motility of 500 motor activity of 475 neuralgia of 487 organic disease of, confounded with pernicious ansmia 743 pain in, as a symptom 484, 489 percussion of 467, 469 perforation of 525 distinguished from irritant poisoning 894 peristaltic disturbance of 515 physical examination of, instru- ments for 571 rupture of 149 softening of 491 tests in diseases of 471,492,499,506 ulcer of 493,505 perforating 496 Stomatitis, aphthous 444,910 gangrenous 444, 452 mercurial 443 ulcerative, confounded with diph- theria 452 Stools as symptoms 509 bilious 509 black 510 dry and watery 509 examinations of 510 fat in 560 shape of 510 Strabismus 79, 177,561 streptococcus 399, 451 ery*»ipelatis 869 pyogenes 342, 755 Streptocytus of Schottelius 910 ^Stricture from nasal polypi 232 of the oesophagus 459 Stridor, laryngeal 245 Strongj'lus gigas 918 Strychnine poisoning 001 confounded with tetanus. 201,901 Stupor 62 in ur-.i'mia 686 St. Vitus's dance. See Chorea. Suffocation 307 Susrar in the urine 655, 707 tests for 655, 710 Su*rar of niilR 658 • Sulphates in urine, pathology of.. 649 Sun -bronzing confounded with Ad- dison's disease 753 Sun-stroke 180 distinpiished trom apoplexy.... 180 Suprarenal capsules, disease of... 7.>4 Swayinj: 20, 94, 130 Sweat-glands 891 Sweating, acid 769, 790 bloody 152, 801 excessive 152, 908 fatal 801 Sycosis 882, 889 Symptoms, pathognomonic 21 Syncope 63 distinguished from apoplexy 175 from epilepsy 187 Synovitis, acute, confounded with acute rheumatism 769 Syphilis, congenital 12S constitutional . .• 883 distinguished from Addison's dis- ease 753 from rhinoscleroma 232 hereditary 123 of spinal cord 123 Syphilitic disease of bowels 548 of brain 214,711,840 of kidney 692 of liver 593,606 of lungs 324 distinguished from phthisis 324 of mouth 444 of oesophagus 460 of skin . 753, 877, 879, 882, 883, 892 of spinal cord 123 of throat 457 fever confounded with intermit- tent fever 839 paralysis 122 rheumatism 775 stenosis 460 teeth 123,781 ulcers of fauces. 457 Syphiloderm 877 Syphiloma of brain causing poly- uria .'. 711 Syringomyelia 131, 152 T. Tabes dorsalis 138, 142 See Locomotor atajria. mesenterica 622 pseudo- 476, 622 spasmodic dorsal 116, 147 tremor in 147 Tachycardia 32. 3S7 Tactile sense, impairment of 68 Tsenia echinococci 916 lata 916 niediocanellata 915. 916 solium 914,915.016 Tape-worms 914. 916 of pork 914.016 Teeth, loss of 140 Hutchinson's or notched... 123, 7S1 Temperature as a symptom 3S cerebral 40 extraordinary 44. 4-1 in apoplexy 16S INDEX. 961 Temperature in appendicitis 636 in cancerous affections 46 in catarrhal fever 786 in cerebro-spinal fever 814 in children 43 in cholera 566 in dengue 829 in gastric ulcer 496 in hepatic fever 579 in intermittent fever 837 in Malta fever 832 in measles 858 in pernicious ansemia 741 in pernicious fever 847 in phthisis 316 in plague 831 in pneumonia 44, 334 in puerperai peritonitis 524 in pyaemia 765 in relapsing fever, 820, 822 in remittent fever 841 in rheumatism 44, 771 in scarlatina 44, 854 in smallpox 864,866 in spinal injury 44 in tetanus 44,198 in trichiniasis 923 in typhoid fever 44,790 in typhus fever 808 in yellow fever 44,823,825 of abdomen 40 of head 40 of surface 38 epigastric 496 subnormal 45 variations 68 Temperature sensibility 69, 145 altered 68 tests for 69 Tenderness as a symptom 49 epigastric 491 Tendo-Achillis jerk 88 Tenesmus 545, 549 Tetanus 108, 191, 197 confounded with hydrophobia. . . 201 with local rigidity 199 with spasms in scarlet fever. . 199 with strychnine poisoning 201, 901 distinguished from cerebro-spinal fever 199,817 from chorea 191 from masticatory spasm 199 from meningitis 199 from muscular rheumatism. . . 199 from tetany 200 hysterical 198 idiopathic 197 traumatic 197 Tetany 193, 200, 506 associated with laryngismus . . . 244 Chorstek's symptom in 200 distinguished from carpopedal spasm 200 Trousseau's symptom in 200 Thermal impressions, paths of ... . 56 Thermal sense 69, 145 Thermometer, clinical use of 40 See also Temperature. Thermometry, cerebral 40 general 40 surface 38 Thirst as a symptom 476 Thomsen's disease 203 Thoracic aneurism 432 confounded with abscess of the mediastinum 434 with chronic laryngitis 439 with dilated auricle 437 with insufficient aortic valves 436 with intrathoracic morbid growth 433 with malformation of the chest 438 with malposition of the aorta 438 with pulsating empyema 436 with pulsation of pulmonary artery 437 eructations in 478 Throat, follicular disease of 457 -inflammation of 466 soreness of, chronic 466 in scarlet fever 457, 864 rheumatic 457 ulcers of, syphilitic 457 Thrombosis 759 cerebral 169, 172 from chlorosis 760 from enfeebled nutritibn 179 from exhausting diseases 760 of brain sinuses 211, 769 of cerebral arteries 172 of mesenteric vessels 760 of renal vein 713 Thrombus, changes in 764 Thrush 443 Thymus gland 219 Thyroid g:land 219, 389, 438 extirpation of 744 swelling of 389 Tic douloureux 64, 222 Tinea 888, 889 circinata 888, 890* decalvans 890 favosa 889 svcosis 889 tonsurans 888, 890 versicolor 884, 890 Tinnitus aurium 86 Tongue, cancer of 445 coating and color of 47 condition of, in disease. .... 45, 444 dryness or humidity of 46, 47 inflammation of 445 in intermittent fever 838 movements of 46 one-sided furring of 152 slips of 178 syphilis of 445 Tonsil, iibscess of 248 cancer of 446, 458 chancre of 458 60 !!l Si yt. St rid. :-::i£:^ "^ 7uiK!r;'i.^r diarrhoea 554 ■^^ Tit^ T r.::? ItJO. S17 _2I iis-.:.c.::* o39 .«•,.»« -^ Ti'-Lr>ji 323. 363 :...'?■ .? of kidney . . . . 092 i-»rj«. 313 .332 ::it 304 .331 >?r ft ISO Phthisis, t ::::.: 'iary 332 .803 zl.':-[t ed with laryngitis. . . . . 2.55 «:::. pyloric obstruction . . . 504 w ;i;. typhoid fever .... . . . . SU5 w.th t}i>hu8 fever SIO aspiration broncho- : :r-^- . r.iA 34:! L.ZL . r> A':>doniiual 51*J, 017 .- hvjxvhondria 017 ^=-r:*:::d! 290,310 .-rrtc*: 210 i.s:in^i$hod from abscess. ... 211 :roni chronic meningitis 211 from softening 210 from thrombotjtis of sinuses. 211 ZAiure of 214 se*: of 212 *y-jhilltic 214 :inV.dteral symptoms of 213 ec„c»*trie Ulw •i»::y 627 JT- v-:AUni* 2M Syiitid, of kidney 7u7 :^ vvnex of brain 212 -.1 episT&strium 610 ,...^131 hypojrastric region 62i» [*• ,r :^ i»iac and lumimr regions 024.62.1 '" ■«• "^^ ^r *w:i left and right hypochoudrium 617 ''' ^r '^.s umbilical region 622 V^ .<: ^ji i-:raoranial 210 '; ' . -^ 'i :r.:rathoracic. ctmfounded with . '■■ * . •. 'i chronic pleurisy^ 30n •*^*\''' ^^^ ^ .^. uiedidstinal .' 301. r.i'.i ^^^'*'\ .. - ' ,v ^ rioa-ani'urisiiuil. ctmfoundoil with *'•>■ ^ •i'. abdominal aneurism 0.'?n I'>*' ^"""^ .i> with thoracic aneurism.... 43."» ^^';;i' ^3^^ .i . of wrebi^llum 212 •^**"V' ;■ ^ '^>* •• > ^^ epigastrium Olt' 'V '^ ''■■ . " **' -. .v.fc of larynx 25iJ «i> of liver OuO Stn»ii;;\ 1 ,. ...,,^ "^^ *■ 1^*;; of pons or crus 212 Siiyrlnim. ^J^ -^^ *i3 of spinal cord 117 "^ ' ii*:j of spleen Ol^ i'ont< HI ui.i-iiiia. St. Viru^'^ dan»' Sullnralimi . . ^^JM»'»' ■ _^ ^^ 1^3 ovarian 62:» «^ ii:?^ phantom fVJl iitt4 pulsating ti3»^ ^14 retroperitoneal 61.^ Su-ar in tho uri*.. ^S^Pb l^^Sl? umbilical '. . 022 *''"^: ^'y . . l»I Tympanites .V^O. fil.i Suu'^a r nf niilic ^^ 'chronic, confounded with a-- Sulpliai,- in in-ill. eites Oi:>. 016 Sun l.n.n/inir «-nfo -^ ^^^ of soldiers lUt*. .li>ca isn TJrphlitis .M.T SniiMn^k.' W> ' " " lid conditions confoundtnl (li-iin-ni-lif.l :>■..; •* ^^ ►• typhoid fever >02 Supiarrnal Laj- 4yer -<..i Swavin-j .177. S0.>. Si»«i INDEX. 963 Typhoid fever, absence of intes- tinal lesions in 806 affections resembling 521,522 appendicitis in. — 800 bacillus of 793, SCfl blood in 798 bloody stools in 793 cerebral 819 coexisting with malaria ...;.... 806 complications of. 799 confounded with acute atrophy of liver 683 with appendicitis 636, 803 with cerebro-spinal fever 816 with enteritis 803 with general debility 802 with meningitis 162, 804 with peritonitis 803 with pulmonary affections 334, 804 with pyemia 766 with relapsing fever 822 with scarlet fever 867 with trichiniasis 923 with typhoid conditions 802 with typhus fever 810 with ulcerative endocarditis 399, 804 convulsions in 796 delirium in 795 diarrhoea in 792 diazo-reaction in 792 discoloration of hands and feet in 798 distinguished from Malta fever. 832 from remittent fever 843 from yellow fever 826 enlargement of the spleen in. . . 795 epistaxis in 797 eruption in 797 febrile symptoms of 790 mania in 795 mild form of 805 nervous symptoms in 796 pain a symptom in 796 palsy in 796 perforation in 800 pulse in 790 relapses in 798,806 renal type of 792 septicemic 758 sequels of 799, 801 spinal symptoms in 796 temperature in 790 walking 802 Widal test in 794 Typhoid septicsemia 758 I^ho-malarial fever 862 T^hus fever 807 acute tuberculosis in 810 bapillus of 807 cerebral symptoms in 808 cerebro-spinal 812 coma- vigil of 808 compart with typhoid fever... 810 complications in 810 Typhms fever confounded with measles 859 with yellow fever 827 distinguished from acute menin- gitis 809 from cerebro-spinal fever 819 from plague 831 from relapsing fever 822 from rubella 863 from trichiniasis 923 eruption in 808 maculated or spotted 808 pulse in 809 temperature in 808 Tyrosine 683, 652 U. Ulcer, gastric 493, 505 confounded with chronic gas- tritis 492,601 with gastric cancer. . . . 497, 501 with ulcer of duodenum. . . . 497 followed by cancer 506 perforating 496 laryngeal 266 of bowel, albuminuric 655 follicular and solitary 566 syphilitic 648 of duodenum 497 of ileum •, 636 of mouth 444 of typhoid, unhealed 665 of ureter 677 peptic 497 perforating, of foot... 140,162,912 of stomach 496 stercoral 662 tubercular, of bowel 666 of mouth 444 typhoid 800 Umbilical region, pain and tender- ness in 520 tumors of 622 Uraemia 686, 897 convulsions in 687 delirium in 60, 687 distinguished from cerebro-spi- nal fever 819 mania in, acute 687 Uremic coma distinguished from apoplexy 174, 686 from narcotic poisoning 686, 897 in Bright's disease 686 Urates as calculi 676 pathology of 644 tests for 646 Urea, pathology of 638 tests for 639 instruments for 640 Ureometer 640 Ureter, inflammation and ulcera- tion of 677 Urethra, hemorrhage from 668 964 INDEX. Urethral fever confounded ¥rith intermittent fever 839 Uric acid 641 calculi 644, 676 detection of 642 in gout 776 in lithsemia 644 murexide test for 641 quantitative estimation of . . . 642 Urinary organs, diseases of . . 632, 675 Urine 632 abnormal substances in 650 acetone in 658, 709 acidity of 637 albumin and other proteids in 659, 662 principal tests for 659 albuminose in 661 albuminous condition of, diseases marked by 680,698 alcaptone in 652, 657 alkalinity of 638, 646, 701 analysis of 632 bile in 653 biliary acids in 654 blood in 663,849 guaiacum test for 663 bl^Ki-eztractives in 659 calcium oxalate in 492,650,666,676 casts in, blood 682 mucous 696 tube 682,698,792,821 chlorides in 336, 505, 648 tests for 648 chylous 670 color of, changes in 635 constituents of, changes in quan- tity of 638 cystine in 676 decreased discharge of 712 diacetic acid in 658 diazo-reaction of 792 estimate of solids in 636 fat in 670 fibrin in 671 globulin in 662 glycuronie acid in 658 haematoporphyrin in 635 haBmoglobin in 570,663,666 in acute yellow atrophy 583 in alcohol poisoning 898 in apoplexy 168, 174 in Bright's disease 681, 688 in carbolic acid poisoning 899 in chlorosis 739 in cirrhosis 605 incontinence of 615, 712 increased discharge of 707 in diabetes 707,710,712 in Duhring's disease 881 indican in 533, 549, 654 in gastric disease 500, 505 ingredients of 634 in haemoglobinuria 666 in hemorrhagic d>' fever.. 849 Urine in jaundice 560, 653 inosite in 658 in phosphorus poisoning 895 in pneumonia 335 in relapsing fever 820, 821 in remittent fever 843 in typhoid fever 792 in typhus fever 810 in Weirs disease 576 in yellow fever 827 kreatin and kreatinin in 650 kyestein pellicle on 670 lactic acid in 782 leucine in 583, 639, 652 leucocytes in 669 melanin in 635 mucin or nucleo-albumin in 659, 663 normal 632, 634, 659 of the insane 711 oxalate of lime in 492, 650, 676 oxybutyric acid in 658 peptones in 659, 662 phosphates in 492, 645, 676 alkaline and earthy 645, 647 mixed 676 phosphoric acid in 648 pigment in 635 purulent, confounded witli acute Bright's disease 683 diseases associated with 700 pus in 668,700,704 quantitative examination of 638 reaction of 637 retention of 713 sediments in 633, 671 specific gravity of 636 specimens, manner of obtaining 633 sugar in 293,655,708,710,898 sulphates in 649 suppression of 707, 712 table showing action of tests upon 671 toxicity of 674 tyrosine in 584, 639, 652 urates in 644, 676, 843 urea in 638, 810, 843 uric acid in 641, 676 urobilin in 635 xanthine in 676 Urinometer 636 Urobilin 6U6, 635, 739 Urochrome 635 Uroerythrin 635 Urticaria 875 Uterus, colic of 518 gravid, confoimded with ascites 615 hemorrhage from, in myxcedema 718 U^'^lla, enlarged 245 Vagrant's disease 753 Valve, aortic, disease of 424, 427 insufficiency of 436 INDEX. 965 Valve, mitral, disease of.... 424,426 pulmonary artery 428 tricuspid, affections of 423, 427 Valvular affections of the heart 417, 426 confounded with functional car- diac disorder 419 with ijittl formations of heart. 418 with misdirection of current. . 419 diagnoais of before development of murmur 431 from rupture of a valvulet or of a papillary muscle 430 table of.,.; 426 Varicella 867 followed by gangrene 868 Variola. See Smallpox 864 Varioloid 867 Veins, diseases of 721 enJ argument of. . . S82, 441, 605, 720 portal^ inflaminatioit of 608 thromboai* of 609, 759 associated with cancer 760 in €xhauBttiig and wasting diseases 760 renal, thrombosis of 713 thrombi in 769 Vena cava, "bcclusion of 441 Venous hum 294 pulsation 38 Ventricles, hemorrhage from 170 Vertigo 73 aural 74, 85 cerebral 73, 210 essential 76 from overwork of brain 76 laryngeal 76, 245 lithsemic 74 of malassimilation 74 paroxysmal or paralyzing 75 precursor of epilepsy 76 stomachal 74 syphilitic 122 Vessels, amyloid d4.^eeBeration of. 506 mesenteric, thrombosis ot 760 Vibrio proteu» 562 Viscera* abdominal percussion and auscultation of 465, 470 Viaian. d