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CLINICAL  DIAGNOSIS 

CASE  EXAMINATION  AND  THE 
ANALYSIS  OF  SYMPTOMS 


BY  ' 

ALFRED   MARTINET,   M.D. 

PARIS.  PRANCE 

With  thb  Collaboration  of 

Drs.  Desfosses,  G.  Laurens,  LioN  Meunier,  Lutier, 
Saint-C^ne,  and  Terson 


AUTHORIZED  ENGLISH  TRANSLATION  FROM  THE  THIRD, 
REVISED  AND   ENLARGED  EDITION 

BT 

LOUIS  T.  deM.  SAJOUS,  B.S.,  M.D. 

PHILADELPHIA 


WITH    895   TEXT   ENGRAVINGS   AND   SEVERAL 
FULL-PAGE   COLOR    PLATES 


COMPLETE    IN   TWO  ROYAL  OCTAVO    VOLUMES 

VOLUME   II 
Analysis  of  Symptoms 


JS^ 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY.  Pubushers 
1922 


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COPYRIGHT.  1922 

BY 

F.  A.  DAVIS  COMPANY 

CoprriKbt,  Great  Britain.    AH  Rights  ReierTcd 


PRESS  OP 

F.    A.    DAVIS    COMPANY 

PHILADELPHIA.  U.S.A. 


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CONTENTS. 


PART  III. 
SYMPTOMS. 

PAQB 

Albuminuria    649 

Alopecia  661 

Anemia    675 

Aphonia  and  Hoarseness   680 

Arhythmia  693 

The  normal  heart  rhythm   694 

Extra-systoles   (premature  beats)    700 

Paroxysmal  tachycardia   707 

Respiratory    (sinus)   arhythmia    710 

Auriculoventricular  dissociation    (heart-block)    714 

Alternation  of  the  pulse   726 

Perpetual  arhythmia   (auricular  fibrillation)    728 

Ascites   737 

Asthenia  and  Fatigue   751 

Chills 757 

Coma 759 

Constipation   766 

Convulsions   770 

Cough    777 

Delirium  and  Delusions  785 

Diarrhea    790 

Dyspepsia    796 

Dyspnea   809 

Edema   825 

Epigastric  Pain    833 

Epistaxis 843 

Exanthemata  847 

Elementary  and  essential  facts  in  dermatology 847 

Main  symptomatic  features  and  course  of  syphilis  855 

Main  symptomatic  features  and  course  of  the  eruptive  fevers 858 

Expectoration  865 

Eyes,  Disorders  of  the  876 

Examination  of  the  eye  and  its  adnexa  880 

The  principal  ophthalmologic  disorders  894 

The  principal  eye  conditions  met  with  in  general  diseases  913 

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IV  CONTENTS. 

PAOB 

Fainting  925 

Fe\^r   929 

Frequent  Pulse ' 942 

Genital  Ulcerations   951 

Glandular  Enlargements   956 

Glycosuria  969 

Headache 976 

Hematemesis    993 

Hematuria  1003 

Hemiplegia  1014 

Hemoptysis   1029 

Hiccough   1039 

High  Blood-pressure 1043 

Hypochondrium,  Left,  Pain  in  1058 

Hypochondrium,  Right,  Pain  in 1068 

Iliac  Fossa,  Left,  Pain  in  1085 

Iliac  Fossa,  Right,  Pain  in  1089 

Insomnia   1101 

Itching  1106 

Jaundice 1119 

Joint  Pains.    Arthralgia.    Rheumatism   1128 

Loss  OF  Weight  1137 

Low  Blood-pressure 1 145 

Lower  Extremities,  Pain  in   1153 

Lumbar  Pain.     Backache  1170 

Neck,  Swellings  in  the  1182 

Nervousness   1193 

Obesity  1206 

Oliguria  1218 

Pain  in  the  Side 1225 

Plethora    1236 

Polyuria   1240 

Precordial  Pain  1245 

Sleep,  Morbid 1271 

Slow  Pulse.     Bradycardia  1285 

Sore  Throat  1290 

Tinnitus  Aurium  1294 

Tongue,  Diagnostic  Features  Relating  to  the 1297 

Tremor 1308 

Upper  Extremities,  Pain   in    1313 

Vertigo   1323 

Vomiting    1332 

Index  of  the  Principal  Clinical  Signs  1343 

Index  to  Volumes  I  and  II 1353 


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ILLUSTRATIONS. 


WIQ.  PAGB 

498.  Hairs  in  alopecia  areata 602 

499.  Alopecia  areata  in  a  child 662 

500.  Microsporia  663 

501.  Hairs  affected  with  microsporia 663 

502.  Tinea  tonsurans  due  to  the  small-spored  fungus.    Microscopic  aspect  of  a  hair  664 

503.  Pieces  of  diseased  hair 665 

504.  Diseased  hair  in  tinea  tonsurans  of  the  large-spored  variety  in  childhood 666 

505.  A  hair  in  tinea  favosa  666 

506.  Celsus's  keiion 667 

507.  Congenital  temporal  alopecia  668 

508.  Alopecia  due  to  x-ray  exposure  669 

509.  Seborrhea  decalvans  of  the  vertex  670 

510.  Alopecia  following  erysipelas  671 

511.  Syphilitic  alopecia   672 

512.  Tinea  decalvans  causing  almost  complete  baldness  673 

513.  Brocq's  pseudopelade  variety  of  folliculitis  decalvans  674 

614.  Paralysis  of  right  recurrent  laryngeal  nerve.    View  during  respiration  682 

515.  Paralysis  of  right  recurrent  laryngeal  nerve.    View  during  phonatlon  j.  682 

516.  Paralysis  of  both  recurrent  nerves  r 682 

517.  Indei>endeut  paralysis  of  the  laryngeal  muscles,  with  the  cords  relaxed 683 

518.  Independent  paralysis  of  the  laryngeal  muscles,  with  "button-hole"  glottis  ..  683 

519.  Partial  paralysis  of  the  posterior  muscles  of  the  larynx  683 

520.  Paralysis  of  the  tensor  muscles  of  the  vocal  cords  683 

521.  Diagram  showing  the  course  of  the  recurrent  nerves 684 

522.  Horizontal  section  of  the  neck  showing  the  position  cf  the  recurrent  nerves  ..  685 

523.  Roseate  vocal  cords  in  acute  catarrhal  laryngitis  686 

524.  Button-hole  glottis  686 

525.  Edema  of  the  arytenoids  686 

526.  Broadened  vocal  cords  In  chronic  laryngitis  686 

527.  Thickening  of  the  Interarytenold  tissues 686 

528.  The  larynx  In  beginning  tuberculosis  687 

529.  Tuberculous  vegetations  in  the  Interarytenold  region  687 

530.  Thickening  of  a  single  cord  in  tuberculosis  687 

531.  Infiltration  of  the  arytenoids  in  established  tuberculosis  087 

532.  Infiltration  of  the  epiglottis  and  ulcerations  of  the  cords  687 

533.  Ulcerations  of  the  vocal  cords  (glottic  variety)  687 

534.  Gumma  of  the  larynx  688 

535.  Ulcerated  gumma  of  the  larynx  688 

536.  Sessile  nodule  on  the  free  margin  of  the  vocal  cord  688 

537.  Pedunculated  polyp  of  the  larynx  688 

538.  Papillomas  of  the  larynx  688 

539.  Nodules  on  cords  688 

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vi  ILLUSTRATIONS. 

FIO.  PAOB 

540.  MaHfenaDt  inflltratlon  and  Teseutlons  immobilisiDg  the  vocal  cord  689 

541.  Papillary  Tegetatlons  in  cancer  of  the  larynx  689 

542.  Extensive  cancerous  Inflltratlon  of  the  larynx 689 

543.  Recurrent  laryngeal  paralysis,  during  respiration.     During  phonation  689 

544.  Paralysis  of  both  recurrent  nerves  in  goiter  690 

545.  The  three  causes  of  paralysis  of  the  laryngeal  muscles 691 

546.  Diagram  of  the  bundle  of  His  695 

547.  548.  Jugular  and  radial  pulse  tracings  696 

549.  Normal  electrocardiogram  697 

550.  Diagram  showing  the  succession  of  motor  events  in  the  normal  heart 697 

551.  The  pneumogastric  nerves  698 

552.  The  nerves  of  the  heart  699 

553.  Diagram  of  the  nervous  system  as  related  to  the  circulation  700 

554.  Premature  contractions  during  an  attack  of  gout  701 

555.  Diagram  of  ventricular  extra-systole  or  premature  beat  702 

556.  Diagram  of  auricular  extra-systole  703 

557.  Diagram  of  aurlculoventricular  extra-systole  703 

558.  559.  Tracings  of  ventricular  extra-systole  704,  705 

560.  Tracing  of  auricular  and  aurlculoventricular  extra-systole 705 

561.  Tracing  of  aurlculoventricular  extra-systole  706 

562.  Diagram  representing  a  brief  attack  of  fxaroxysmal  tachycardia  70S 

563.  Tracing  of  paroxysmal  tachycardia  709 

564.  Tracing  of  respiratory  (sinus)  arhythmia  711 

565.  566,  567.  Tracings  of  sinus  arhythmia  711,  712 

568.  Diagram  illustrating  respiratory   (sinus)   arhythmia  713 

569,  570.  Tracings  of  Cheyne-Stokee  rhythm  713,  714 

571.  Normal  heart  tracing  715 

572.  Tracing  showing  a  tendency  to  aurlculoventricular  dissociation  715 

573.  Diagram  of  partial  heart-block  716 

574.  Diagram  of  complete  aurlculoventricular  dissociation  717 

575.  Tracing  of  extra-systole  718 

576.  Tracing  of  partial  heart-block  719 

577.  Tracing  of  delayed  conduction  719 

578.  Tracing  of  partial  heart-block  720 

579.  Tracing  of  complete  dissociation  720 

580.  Tracing  of  total  bradycardia 720 

581.  Electrocardiogram  of  complete  dissociation  721 

582.  Bradysphygmia  counteracted  by  belladonna.    Marked  dilatation  of  aorta.    Car- 

diac-hypertrophy     722  -. 

583.  Cardiogram  and  sphygmogram  from  preceding  case  723 

584.  Diagram  of  the  alternating  pulse  727 

585.  Diagram  of  auricular  fibrillation  729 

5S6.  Electrocardiogram  illustrating  the  3  leads  in  a  case  of  mitral  stenosis  with 

auricular  fibrillation  730 

587,  588.  Tracings  of  auricular  fibrillation  731 

589.  Diagram  of  the  normal  heart  rhythm 732 

590.  Diagram  of  extrasystoles   732 

591.  Diagram  of  paroxysmal  tachycardia  733 

592.  Diagram  of  sinus  (respiratory)  arhythmia  733 

593.  Diagram  of  aurlculoventricular  dissociation  733 

694.  Diagram  of  the  alternating  pulse  734 

595.  Diagram  of  auricular  fibrillation  734 

596.  Abdominal  areas  of  flatness  in  ascites  and  various  other  abdominal  disorders..  741 


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ILLUSTRATIONS,  vii 

FIO.  PAGE 

597.  The  causes  of  ascites  743 

598.  The  syndrome  of  Increased  porta)  pressure 744 

599.  Normal  rhythm  of  urinary  elimination,  and  opsiuria  746 

600.  Tributaries  of  the  porUl  vein  747 

601.  Diagram  showing  the  nerve  paths  concerned  in   reflexes  of  the  respiratory 

tract  778 

602.  Diagram  of  fluoroscopic  picture  In  localized  cancer  of  the  stomach  807 

603.  Diagram  of  fluoroscopic  picture  In  cancer  of  the  pylorus  807 

604.  Diagram  of  fluoroscopic  picture  In  ulcer  on  the  lesser  curvature  807 

605.  Diagram  of  fluoroscopic  picture  In  callous  ulcer  807 

60<S.  Diagram  showing   the  nerve  paths  concerned   In   reflexes  of   the   respiratory 

tract    809 

607.  Diagram  of  a  terminal  bronchus  under  normal  conditions  and  during  a  par- 

oxysm of  asthma  811 

608.  Cheyne-Stokes  breathing  as  observed  during  quiet  and  profound  sleep  813 

600.  Chart  from  a  case  of  auricular  fibrillation  and  mitral  stenosis  818 

010.  Cheyne-Stokes  breathing 819 

Gil.  Dyspnea  of  myocardial  fatigue  and  general  exhaustion  ^...  819 

612.  General  topographic  anatomy  of  the  abdomen  » ^ 833 

613.  Sagittal  section  of  the  abdomen  834 

014.  Surface  projection  of  involved  area  in  appendicitis,  pancreatitis  and  chole- 

cystlUs    835 

615.  The  artery  of  eplstazls 843 

616.  Primary  chancre  of  the  vulva 852 

617.  Florid  syphilitic  roseola  852 

618.  Hypertrophic  mucous  patches  of  the  vulva 852 

619.  Ulcerated  syphilomas  of  the  nose  852 

020.  Chicken-pox    864 

621.  Small-pox 864 

022.  Scarlet  fever 864 

023.  German  measles  864 

624.  Measles -v 864 

62.5.  Flortd  measles  eruption   864 

026.  Smear  of  sputum  In  "hemorrhagic  bronchitis"  866 

627.  Vartous  forms  of  the  splrochaeta  bronchlalis  866 

628,  629.  The  sputum  in  chronic  serous  bronchitis  868 

630.  Mucoid  sputum  in  acute  bronchitis  869 

631.  Mucoid  sputum  in  an  asthmatic  attack  869 

0.32.  Mucopurulent  sputum  in  chronic  pulmonary  tuberculosis  869 

633.  Mucopurulent  sputum  in  acute  pulmonary  tuberculosis  869 

634.  Purulent  sputum  In  gray  hepatisatlon  809 

035.  Purulent  sputum  In  abscess  of  the  lung 869 

636.  Fetid  sputum  in  gangrene  of  the  lung  872 

637.  Fetid  sputum  In  fetid  bronchitis  872 

638.  Rusty  sputum  in  pulmonary  Infarction  872 

639.  Rusty  sputum  in  acute  lobar  pneumonia  872 

640.  Bloody  sputum  In  gangrene  of  the  lung  873 

641.  Bloody  sputum  in  pulmonary  tuberculosis  873 

642.  Bronchial  false  membrane  873 

643.  Alveolar  cells  containing  pigment  or  dust  particles  in  pneumonokoniosis 873 

644.  Lid  elevator  870 

645.  Terson's  eye  speculum   (blepharostat)    876 

646.  Ophthalmoscopic  mirror  877 


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viii  ILLUSTRATIONS, 

FIQ.  PAGE 

047.  Ophthalmoscopic  lens  877 

G48.  Disc  with  stenopeic  opening  877 

649.  Electric  pocket-lamp  with  speculum  878 

G50.  Armaignac's  test  chart*  with  a  special  chart  for  illiterates  and  the  clock-dial 

for  astigmatism  879 

651.  Examining  a  child 882 

652.  Bent  hairpin  to  be  substituted  for  the  lid  elevator  in  an  emergency  882 

653.  Inspection  of  the  inner  surface  of  the  lower  lid  883 

654.  Seizure  and  eversdon  of  the  upper  lid  883 

655.  Fixation  of  the  everted  lid  884 

656.  Eversion  of  the  lid  with  the  aid  of  a  probe 884 

657.  Outward  traction  of  the  already  everted  upper  lid  885 

658.  Rolling  the  lid  about  dressing  forceps  885 

659.  Complete  eversion  of  the  upper  cul-de-nac  885 

660.  Expressing  the  lacrymal  sac 880 

661.  Lateral  illumination  with  a  lens  886 

662.  Lateral  Illumination  (examination  with  two  lenses)   , 887 

663.  Palpation  of  the  eye  to  estimate  the  extent  of  fluctuation  888 

664.  Illumination  of  the  eye  with  the  mirror  889 

665.  Partial  cataract,  seen  by  transmitted  light  889 

666.  Letters  which  a  normal  eye  should  be  able  to  recognise  at  5  meters  890 

667.  Examination  of  the  field  of  vision  with  the  perimeter  891 

668.  Normal  visual  fields 802 

669.  Pustular  (phlyctenular)   kerato-conjunctlvitis  897 

670.  Corneal   ulcer   897 

671.  Corneal  pannus  and  the  upper  lid  in  granular  conjunctivitis 897 

672.  Hyphema   898 

673.  Hypopyon    898 

674.  Iritis  with  cellular  exudation  In  the  anterior  chamber  898 

675.  Syphilitic  iritis  with  granulomatous  node  899 

676.  Profapse  of  the  Iris  899 

677.  Synechiae  in  irlUs  , 901 

678.  Complete  umbillcoid  occlusion  of  the  pupil  902 

679.  Opacities  in  ttfe  lens  a 902 

680.  Muscles  of  the  left  eye 905 

681.  Course  of  the  optic  nerve-paths  from  the  eye  to  the  brain  910 

682.  Right  homonymous  hemianopia  ^ 911 

683.  Bi-temporal  heteronymous  hemianopia  912 

684.  Central  scotoma  in  an  alcoholic  subject  912 

685.  Temperature  chart  in  the  respiratory  type  of  influenza 930 

686.  Temperature  chart  in  frank  pneumonia  in  an  adult  931 

687.  Temperature  chart  In  a  case  of  acute  miliary  tuberculosis 933 

688.  Infectious  pericarditis   933 

689.  Typhoid  fever,  with  recovery 934 

690.  Malaria.    Intermittent  fever  of  quotidian  type  935 

691.  Malaria.    Intermittent  fever,  finally  quartan  935 

692.  Intermittent  fever  of  hepatic  origin.    Bllio-sepUc  fever.    Reversed  type  of  in- 

termittent hepatic  fever.    Fever  in  relapsing  Jaundice  937 

693.  Diagram  representing  a  brief  attack  of  paroxysmal  tachycardia 943 

694.  Diagram  of  experimentally  induced  tachycardia  944 

695.  Pulse  chart  in  tachycardic  neurosis  945 

696.  Paroxysmal  tachycardia   94O 

697.  Tracings  from  an  attack  of  paroxysmal  tachycardia  947 


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ILLUSTRATIONS.  ix 

FIO.  PAGE 

e&a.  Chart  from  a  case  of  post-infectious  pericarditis  with  extensive  effusion 948 

(S99.  Diagram  of  experimental  tachycardia,  after  exercises  949 

700.  Axillary  lymph-nodes  951 

701.  Hard  chancre  of  the  penis  962 

702.  Chancroidal  pus,  stained  with  methylene  blue  952 

703.  Scrapings  from  hard  chancre  952 

704.  705.  Unusual  papulohypertrophlc  chancroids  of  the  balanopreputial  region  . . .  952 

706.  A  burrow  in  scabies 954 

707.  Deep-seated  vulTar  herpes  954 

708.  709.  Vegetations  on  penis  964 

710.  Superficial  lymph-nodes  and  the  related  anatomic  regions  957 

711.  The  blood  in  Hodgkins  disease  963 

712.  The  blood  In  tuberculous  or  other  Infectious  glandular  enlargement  964 

713.  Lymphatic  leukemia   905 

714.  Myeloid  leukemia 965 

715.  Acute  leukemia  966 

716.  Lymphosarcoma 966 

717.  Cut   showing  the   relationship   between  -the   frontal,    ethmoid,   and   sphenoid 

sinuses    976 

718.  Cut  showing  the  relationship  between  the  ethmoid  sinuses  and  covering  mem- 

branes of  the  braJn  976 

719.  Head's  cranial  zones  977 

720.  Elective  areas  of  fibrous  thickening  over  of  the  skull,  nucha,  and  neck  987 

721.  Posterior  branches  of  the  cervical  nerves  988 

722.  Diagram  of  fluoroscopic  picture  in  localized  cancer  of  the  stomach  995 

723.  Diagram  of  fluoroscopic  picture  In  cancer  of  the  pylorus  995 

724.  Diagram  of  fluoroscopic  picture  in  ulcer  on  the  lesser  curvature  995 

725.  Diagram  of  fluoroscopic  picture  in  callous  ulcer 905 

726.  The  arteries  of  the  stomach  996 

727.  Blood-vessels  of  the  gastric  mucous  membrane  997 

728.  SecUon  of  gastric  ulcer .^ 998 

729.  The  syndrome  of  high  portal  pressure  999 

730.  Section  through  the  region  of  the  bladder  and  membranous  urethra 1004 

731.  Sources  of  the  internal  pudlc  vein  1005 

732.  The  three-glass  test  1007 

733.  Diagram  of  the  structure  of  the  kidney  1009 

734.  Bllharzia  ova  1010 

735.  Areas  of  paralysis  In  hemiplegia  of  cerebral  origin  1015 

736.  The  striate  arteries  and  capsular  hemprrhage  1016 

737.  Branches  of  the  middle  cerebral  artery  1017 

738.  Diagram  of  the  motor  and  sensory  paths  in  the  brain  and  spinal  cord  1018 

739.  Areas  of  paralysis  in  peduncular  hemorrhage 1019 

740.  Areas  of  paralysis  in  inferior  pontine  hemorrhage  1019 

741.  Anatomic  relations  In  the  medulla  and  pons  1020 

742.  Areas  of  paralysis  In  bulbar  lesions  1021 

743.  Areas  of  paralysis  In  section  of  the  cervical  cord  1021 

744.  The  medulla  and  pons 1022 

745-  Diagram  of  pulmonary  infarction  1032 

746.  747.  Diagram  of  pulmonary  Infarction   1033 

748.  Aneurysm  of  the  pulmonary  artery  1034 

749.  Diagram  of  a  pulmonary  lobule  1035 

750.  Diagram  Illustrating  the  pathogenesis  of  hiccough  1040 

751.  The  phrenic  nerves  1041 


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X  ILLUSTRATIONS. 

Fia.  PAGE 

752.  Pulse  tracing  showing  the  successive  variations  of  pressure  In  an  artery  ....  1043 

753.  Diagram  Illustrating  the  systolic,  diastolic,  and  pulse  blood-pressures 1044 

754.  Blood-pressure  determinations  made  a  few  days  apart  1044 

755.  Diagram  of  vlscortty,  pulse  pressure,  and  urinary  output  In  a  normal  subject  1048 
750.  Diagram  of  viscosity,   pulse  pressure,   and   urinary   output  in   a  plethoric    . 

subject    1050 

757.  Diagram  of  viscosity,  pulse  pressure,  and  urinary  output  in  a  subject  with 

sclerotic  disease  , 1054 

758.  Succeeslve  stages  In  the  development  of  cardlorenal  sclerosis  1055 

750.  The  splenic  fossa  1058 

700.  Topographic  features  of  the  spleen  1059 

701.  Sagittal  section  through  the  left  hypochondrium  1060 

702.  Deep-lying  structures  In  the  right  and  left  hypochondria  1061 

7«.'J.  Arab  children  with  malarial  enlargement  of  the  spleen  1063 

764.  Left-sided  abscess  between  the  liver  and  diaphragm  1064 

705.  Perisplenic  abscess  1064 

766.  Post-gastric  abscess 1064 

767.  Abscess  between  the  liver  and  stomach  1064 

768.  Orthodiagrams  from  a  case  of  gaseous  gastric  distention  1065 

769.  Anatomic  relations  of  the  liver  with  the  chest  and  abdomen  1069 

770.  Alcoholic  hypertrophic  cirrhosis  with  ascites  1071 

771.  Alcoholic  atrophic  cirrhosis  with  ascites  1071 

772.  Bantl's  disease  IO71 

773.  Hepatoptosls    IO71 

774.  Biliary  cirrhosis  with  greatly  enlarged  spleen  1071 

775.  Bdliary  drrhosU  with  enlarged  liver  and  spleen  1071 

776.  Hydatid  cyst  of  the  liver  IO71 

777.  Nodular  cancer  of  the  liver IO71 

778.  Cancer  of  head  of  pancreas  IO71 

779.  Relations  of  the  abdominal  organs,  viewed  anteriorly  10T2 

780.  Kink  at  the  first  flexure  of  the  duodenum  1073 

781.  Normal  relaUons  of  the  right  kidney  with  the  hepatic  flexure  and  duodenum  1073 

782.  Anteroposterior  section  of  the  liver  1074 

783.  Vertlcotransverse  diagrammatic  section  through  the  gall-bladder  1075 

784.  Right-sided  abscess  between  the  diaphragm  and  liver  1075 

785.  786.  Points  of  tenderness  In  the  right  hypochondrium  1076 

787.  Evacuation  of  a  subdiaphragmatic  abscess IO77 

788.  Indslon  of  a  subdiaphragmatic  abscess  1078 

789.  Cavities  that  may  be  occupied  by  pus  in  peritonitis  1079 

790.  Normal  relations  of  the  sigmoid  flexure  and  rectum  io85 

791.  Radiographic  view  of  the  large  intestine  1086 

792.  General  topographic  features  of  the  abdomen  IO90 

793.  Topography  of  the  abdomen  IO91 

794.  Topographic  features  of  abscesses  of  appendiceal  origin  1092 

795.  Combined  appendicitis  and  adnexitis  IO93 

796.  Radiographic  picture  of  the  cecun^  and  appendix  1095 

797.  Vessels  and  nerves  of  the  anterior  abdomJnal  wall  1097 

798.  Scabies.    Places  of  election  for  burrows  HH 

799.  Burrow  containing  a  female  itch-mite  and  her  ova  1112 

800.  Sarcoptes  scablei,  female,  dorsal  aspect  III3 

801.  Sarcoptes  scabiet.  female,  ventral  aspect  1113 

802.  Pedlculus  capitis,  male  m^ 

803.  Ovum  of  pedlculus  capitis  attached  to  a  hair  III4 


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ILLUSTRATIONS.  xi 

no.  PAQB 

804.  Phthlrtus  pubis   1114 

806.  Pemculotfis  or  pbtWrtaels.    Areas  of  election  1115 

806.  Chart  of  a  case  with  loss  of  weight  and  lowered  hlood-pressure  1137 

807.  Gradual  retrogression  In  a  cardlorenal  case  with  good  compensation  1138 

806.  Chart  from  a  case  of  cardlo-arterlo- renal  sclerosis  1139 

809.  Bilateral  tabetic  knee-joints  1156 

810.  Lumbosacral  and  hypogastric  plexuses  In  the  male  1158 

811.  Lumbosacral  and  hypogastric  plexuses  In  the  female  1150 

812.  The  greater  sciatic  nerve  1161 

813.  Vallelx's  points  on  the  posterior  aspect  of  the  lower  extremity  1162 

814.  Roussy's  algn  in  left-sided  sciatica  1163 

815.  816.  Roussy's  sign  In  right-aided  scIaUca   1164.  1165 

817.  The  lumbar  plexus  • 1166 

818.  Relations  of  the  Intervertebral  foramina  with  the  lumbar  spinal  ganglia  ....  1167 

819.  The  nerve  paths  from  the  spinal  cord  to  the  periphery  1168 

820.  Lumbar  musculature  1170 

821.  The  spinal  muscles  H'l 

822.  Transverse  section  through  the  lumbar  region  1172 

823.  Posterior  relations  of  the  kidneys  11'7«'^ 

824.  825.  Osteospondylltis  of  the  vertebr»  11^4 

826.  827.  Intraspinal  venous  plexuses   ^^'^'^ 

828-  Diploic  veins  in  the  body  of  a  vertebra  ^^'^ 

829.  Anterior  surface  of  the  neck  ^^^'^ 

830.  Lymphatics  of  the  head  and  neck  ^^^^ 

831.  Adenollpomatoais  ^^^^ 

832.  Deep  structures  of  the  neck  ^^^'^ 

833.  Exophthalmic  goiter  ^^^^ 

834-  Diagram  of  the  symptoms  and  pathogenesis  of  exophthalmic  goiter  1190 

835.  Longillnear  subject  1210 

836.  Mediollnear  subject  ^211 

837.  BreviUnear  subject   1211 

838  to  841.  Anterior,  posterior,  and  lateral  topographic  features  of  the  chest  —  1226 

842.  Anatomic  relations  of  the  heart  1227 

843.  Anatomic  relations  of  the  Intercostal  nerves  1228 

844  to  847.  Head's  sones  1229,  1230 

848.  Segmental  cutaneous  distributions  of  the  nerves  of  the  trunk  1231 

849.  Cutaneous  branches  of  the  intercostal  nerves  1232 

850.  Horizontal  cross-section  of  the  chest  of  a  new-bom  infant  1246 

851.  Orthodiagram  of  a  case  of  a^rophagia  with  dyspnea  on  exertion  and  precor- 

dlalgla 1251 

852.  The  nerves  of  the  heart 1257 

853.  Diagram  of  the  nervous  system  as  related  to  the  circulation  1258 

854.  Tracings  showing  premature  contractions  1262 

855.  Blood-pressure  chart  of  a  normal  Individual  1262 

856.  Normal  subject  as  regards  the  circulation  1263 

857.  Heart  weakness  1263 

858.  859.  Cardiac  neurosis  1263 

860.  Aortic  aneurysm  with  elevated  pulsating  tumor  1267 

861.  Aortic  aneurysm  with  pulsating  tumor  1268 

862.  Diagram  of  the  normal  heart-rhythm 1285 

863.  Diagram  of  delayed  conduction   1285 

864.  Diagram  of  partial  heart-block  1280 

865.  Diagram  of  complete  aurtculoventricular  dissociation  1286 


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xii  ILLUSTRATIONS. 

PIO.  PAQB 

866.  Tracing  of  delayed  conduction  1288 

867.  Tracing  of  partial  heart-block  1288 

868.  Tracing  of  complete  dlssodaUon  1288 

869.  Tracing  of  total  bradycardia  1288 

870.  Tracing  of  bradycardia  due  to  a  gumma  of  the  bundle  of  His  1289 

^71.  Tracing  of  total  bradycardia  due  to  depressive  psychoneurosis  1289 

872.  Mode  of  production  of  tinnitus  aurlum  1295 

873.  Dorsal  surface  of  the  relaxed  tongue  1298 

874.  Extensive  gummatous  ulceration  of  the  tongue  1302 

875.  Tertiary  syphilitic  sclerosis  of  the  tongue  1302 

876.  Actinomycosis 1305 

877.  Macroglossla  1306 

878.  Tuberculosis  of  the  tongue- 1307 

879.  Diagram  concerning  the  innervation  of  the  upper  extremity  1313 

880.  Peripheral  sensory  distribution  in  the  upper  extremity  (posterior  adpect)   ..  1314 

881.  Peripheral  sensory  distribution  in  the  upper  extremity  (lateral  aspect)   1314 

882.  883.  Common  types  of  distribution  of  the  sensory  disturbances  in  section  of 

the  radial  nerve 1315 

884.  Peripheral  sensory  distribution  in  the  upper  extremity  (anterior  aspect)  —  1316 

885,  886.  Palmar  and  dorsal  disturbances  of  sensation  in  severe  injuries  of  the 

median   nerve   1317 

887.  Nerve-supply  of  the  muscles  of  the  upper  extremity  1319 

888.  Distrtbution   of   pain    and    hyperalgesia   after   repeated    attacks   of   angina 

pectoris    1320 

889.  Pathogenesis  of  vertigo  1324 

890.  Diagram  illustrating  aural  vertigo  1328 

891.  The  causes  of  aural  vertigo  1329 

892.  Pathogenesis  of  vomiting  1333 


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^^  Felix  qui  potuit  rerum 
cognoscere  causas.^^ 

PART  III. 
SYMPTOMS. 

In  the  practice  of  medicine  the  PROBLEM  OF  DIAGNOSIS  is 
often  put  before  the  physician  in  the  folloiving  manner:  A  pa- 
tient comes  to  consult  him  because  of  some  concrete  abnormal 
condition;  he  is  coughing,  he  is  losing  weight,  he  is  sleepless,  he 
has  spat  up  blood,  his  skin  is  yellow,  he  has  **kidney"  pains,  his 
skin  itches,  he  has  attacks  of  fever,  he  suffers  from  headache, 
he  feels  tired,  etc.  This  presenting  symptom  must  be  traced 
bcKk  to  its  underlying  cause.  This  is  done  by  means  of  a  verbal 
and  physical  examination  which  enables  the  practitioner  to  group 
about  the  principal  symptom — principal  at  least  in  the  patient's 
estimation — the  remaining  necessary  data,  signs,  and  symptoms; 
— in  short,  by  a  mental  correlation  of  these  data. 

In  the  succeeding  presentation  of  the  subject  a  plan  closely  following 
the  observations  of  ordinary  practice  has  been  adopted.  In  it 
have  been  collected  the  most  frequently  encountered  symptoms, 
and  in  relation  to  each  of  these  symptoms,  after  a  brief  review 
of  the  related  anatomical  and  physiological  features,  the  author 
has  endeavored  to  explain  how,  with  the  assistance  of  the  previa 
oiis  or  concomitant  accessory  symptoms,  and  in  the  light  of 
these  data,  a  concrete  diagnosis  may  be  arrived  at. 

Wherever  it  has  seemed  possible,  each  section  has  been  summarised 
in  the  form  of  a  diagrammatic,  mnemotechnic  table. 


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ALBUMINURIA. 


Albumin,  white  of  egg^^^vpelv^  to 

urinate.     Presence  of  albumin  in 

the  urine. 


Albuminuria  is  a  sign  which  should  never  be  allowed  to 
pass  unnoticed.  The  test  for  albumin  in  the  urine  should  be 
carried  out  as  regulariy  and  routinely  as  auscultation  of  the 
chest  or  palpation  of  the  abdomen.  Two  observations  will  give 
an  idea  as  to  its  frequency  of  occurrence.  Out  of  1000  subjects 
of  both  sexes  and  of  all  ages,  the  great  majority  suffering  from 
chronic  conditions,  examined  in  the  author's  office,  204,  i.e., 
about  one-fifth  of  the  cases,  showed  albtunin.  In  over  half  of 
these  persons  albuminuria  had  not  previously  been  known  to 
be  present.  Out  of  1000  soldiers  from  twenty  to  forty-eight 
years  of  age  under  observation  in  a  hospital,  the  great  majority 
suffering  from  acute  or  subacute  conditions,  the  author  found 
128  instances  of  transient  or  permanent  albuminuria,  constitut- 
ing about  one-eighth  of  the  entire  number. 

Thus,  albuminuria  occurs  with  extraordinary  frequency  and 
under  the  most  varied  clinical  conditions.  Its  symptomatic 
value,  while  sometimes  practically  nil,  may  be  very  great.  In 
finding  our  way  through  the  etiologic  and  pathogenetic  maze 
of  the  various  forms  of  albuminuria,  the  didactic  presentation 
of  the  subject  by  Castaigne  in  his  work  entitled  "Livre  du  mede- 
cin"  (section  on  diseases  of  the  kidneys)  will  be  extensively 
availed  of. 

Clinically,  albuminuria  occurs  in  the  form  of  : 

I.  Acute  albuminuria,  always  symptomatic  of  an  acute  or  sub- 
acute, infectious  or  toxic,  nephritis  which  is  comparatively  easily 
diagnosed. 

II.  Chronic  albuminuria,  which,  on  the  contrary,  as  we  shall 
presently  see,  arises  from  a  great  variety  of  causes  and  the 
etiologic  diagnosis  of  which  is  often  a  matter  of  considerable 
difficulty. 

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650  SYMPTOMS, 

ACUTE  FORMS  OF  ALBUMINURIA. 

Acute  albuminuria  is  met  with  almost  exclusively  in  the 
following  four  groups  of  cases :  (a)  Superficial  and  transitory  acute 
nephritis;  (i?)  typical  acute  nephritis;  (c)  hyperacute  nephritis; 
{d)   acute  exacerbation  in.  the  course  of  a  chronic  nephritis. 

(a)  Superficial  and  transitory  acute  nephritis  is  a  clinical 
type  which  is  mild  and  very  common  and  the  presence  of  which 
should  he  ascertained  through  systematic  examination  of  the 
urine  in  all  infectious  or  toxic  diseases  (sore  throat,  grippe,  pneu- 
monia, acute  gastric  indigestion,  enterocolitis,  etc.). 

The  albuminuria  is  the  constant  sign  of  such  a  nephritis;  in 
degree  it  generally  ranges  between  0.1  and  0.5  gram  of  albumin 
per  liter  of  urine,  but  it  may  become  more  pronounced.  It 
persists  throughout  the  fastigium  of  the  infectious  or  toxic  dis- 
order, but  as  a  rule  passes  off  shortly  before  the  beginning  of 
convalescence.  It  is  clinically  limited  to  a  moderate  and  transi- 
tory albuminuria,  accompanied  by  very "  slight,  temporary  dis- 
turbance of  the  renal  functions,  erythrocytes,  leucocytes,  and 
granular  casts  appearing  for  a  time  in  the  sediment.  Complete 
and  permanent  recovery  from  it  is  the  rule,  though  the  physi- 
cian should  be  somewhat  guarded*  concerning  the  passage  of 
these  cases  of  nephritis  into  a  chronic  involvement,  which  is, 
however,  exceptional. 

(&)  T3^ical  acute  nephritis  is  met  with  under  the  same  con- 
ditions as  the  preceding  group,  i.e.,  generally  in  connection  with 
and  during  the  course  of  an  acute  infection,  definite  or  obscure. 
It  is  characterized  by  three  cardinal  groups  of  signs  by  which  it 
may  easily  be  recc^ized,  and  the  following  summary  of  which 
is  adapted  from  Castaigne. 

1.  The  urinary  syndrome,  which  may  be  summarized  as 
follows:  The  urine  is  scanty,  highly  colored,  comparable  to 
turbid  bouillon,  sometimes  reddish,  and  even  occasionally  ex- 
hibiting hematuria.  The  specific  gravity  is  high,  and  the  re- 
action distinctly  acid ;  chernical  examination  generally  reveals 
a  marked  diminution  of  the  urea  and  chlorides,  together  with 
a  large  amount  of  albumin.  Histologic  examination  of  the 
urinary  sediment  shows  the  presence  of  red  blood  cells,  leuco- 


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ALBUMINURIA.  651 

cytes,  and  casts  of  all  kinds,  among  which  the  granular  type  is 
always  present.  The  various  clinical  procedures  recently  recog- 
nized (blood-pressure,  methylene  blue  test,  and  determination 
of  the  blood  urea)  point  to  a  manifest  impermeability  of  the 
kidneys. 

2.  Edema  is  seldom  wanting  in  the  typical  forms.  It  is 
sometimes  localized  in  distribution,  as  in  the  lower  extremities, 
the  eyelids,  and  even  the  glottis,  but  more  often  it  assumes  the 
type  of  a  generalized  anasarca  with  effusion  in  the  serous  cavi- 
ties— pleura,  pericardium,  and  peritoneum — and  even  in  the  vis- 
cera, particularly  the  brain,  liver,  and  kidneys. 

3.  S3niiptonis  due  tb  impermeability  of  the  kidneys  are 
almost  regularly  present,  but  are,  as  a  rule,  limited  to  relatively 
mild  manifestations  such  as  headache,  cramps,  tinnitus,  ocular 
disturbances,  dyspnea,  vomiting,  etc.;  in  some  instances,  how- 
ever, all  the  signs  of  a  major  attack  of  uremia  may  be  witnessed, 
ttz,,  eclamptic  seizures,  acute  delirium,  and  coma. 

4.  Evidences  of  an  infectious  process  may  be  superimposed 
upon  the  foregoing  symptoms,  involving  either  the  kidneys 
alone  or  the  organism  as  a  whole. 

The  lumbar  pain,  sometimes  very  pronounced,  and  which 
may  be  the  initial  symptom,  is  due  to  an  infectious  process 
localized  in  the  kidneys;  again,  palpation  will  reveal  enlarge- 
ment of  both  kidneys  in  these  cases. 

Infection  of  the  entire  organism  is  manifested  in  more  or  less 
pronounced  fever,  an  enlarged  liver  and  spleen,  and  leucocytosis 
— all  showing  that  the  infection  has  not  been  exclusively  local- 
ized in  the  kidneys. 

This  is  the  type  of  albuminuria  met  with  in  typhoid  fever,  pneu- 
monia, acute  sore  throat,  scarlet  fever,  influenza,  etc. 

(c)  Hyperacute  nephritis  is  usually  a  result  of  the  condition 
of  intoxication  following  exhibition  of  agents  highly  destructive 
to  the  kidneys,  such  as  corrosive  sublimate,  phosphorus,  cantharides, 
etc.  The  patients  are  previously  healthy  persons  who  have  ingested 
one  of  these  poisons  in  considerable  amount  and  develop  almost 
complete  anuria  on  the  same  (fey ;  the  few  drops  of  urine  collected 
by  catheterization  are  found  to  contain  much  albumin  and  many 
casts. 


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652  SYMPTOMS. 

In  the  majority  o£  cases,  anuria  remains  complete  in  spite 
of  all  attempts  at  treatment  and  the  patient  dies  in  coma  five 
to  ten  days  after  the  beginning  of  symptoms,  generally  without 
having  shown  edema  or  convulsive  manifestations. 

Thus,  anuria,  coma,  and  death  may  be  said  to  summarize  the 
clinical  picture,  the  entire  illness  being  gone  through  without  the 
patient  developing  any  edema  or. signs  of  advanced  uremia.  The 
ratio  of  blood  urea  may  rise  very  high.  In  one  such  case  the 
author  found  5.60  grams  of  urea  per  liter. 

This  applies  not  only  to  the  hyperacute  nephritis  following  acute 
intoxication  in  a  previously  healthy  person,  but  likewise  in  the  much 
more  uncommon  cases  of  hyperacute  nephritis  appearing  during 
the  fastigium  in  acute  diseases  such  as  typhoid  fever,  scarlet  fever, 
pneumonia,  etc. 

Recovery  is  altogether  exceptional.  Passing-  mention  may 
be  made  of  the  marked  therapeutic  utility  of  isotonic  or  hyper- 
tonic glucose  or  lactose  solution  in  these  cases. 

(d)  Acute  exacerbations  in  chronic  nephritis. — "These  might, 
by  the  uninitiated,  be  mistaken  for  acute  nephritis.  The  prog- 
nosis in  these  cases  is  that  of  the  form  of  chronic  nephritis  upon 
which  the  acute  congestive  exacerbation  has  been  superim- 
posed." (Castaigne). 

CHRONIC  FORMS  OF  ALBUMINURIA. 

"The  etiologic  circumstances  under  which  chronic  albumin- 
uria may  be  encountered  are  complex  and  should  be  divided 
into  several  main  classes,  which  the  physician  may  call  to  mind 
when  confronted  with  a  case  of  chronic  albuminuria,  He,  1. 
Chronic  nephritis.  2.  Chronic  infections.  3.  Chronic  toxic  and 
autotoxic  states.    4.  Circulatory  disturbances.''  (Castaigne). 

I.  Albuminuria  of  chronic  nephritis. — Albuminuria  having 
been  found  to  exist,  it  is  necessary  to  know  what  variety  of 
chronic  nephritis  is  present  and  to  what  extent  the  renal  func- 
tions are  impaired.  A  systematic  investigation  should,  there- 
fore, be  made  of: 

(a)  The  elimination  of  chlorides,  by  examining  for  edema 
and,  if  need  be,  estimation  of  the  chloride  balance. 


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ALBUMINURIA,  653 

(b)  The  elimination  of  nitrogen,  by  examining  for  the  cus- 
tomary signs  of  nitrogen  retention  and,  in  particular,  by  deter- 
mination of  the  blood  urea  and,  if  need  be,  by  calculation  of 
Ambard's  coefficient 

(c)  The  elimination  of  water,  by  determination  of  the  systolic 
and  diastolic  blood  pressure  and  comparison  of  the  24-hour  out- 
put of  water  with  the  pulse  pressure,  as  well  as,  if  need  be,  by 
calculation  of  Martinet's  coefficient: 

24-hour  output 

pulse  pressure 

Systematic  study  of  these  three  forms  of  elimination  leads 
rationally  to  the  following  classification  of  the  chronic  nephri- 
tides : 

1.  Simple  chronic  albuminous  nephritis,  exhibiting,  apart 
from  the  chronic  albuminuria,  no  indication  of  chloridemia,  azo- 
temia (nitrogenemia),  or  hydremia;  no  edema,  no  azotemic  man- 
ifestations, and  no  elevation  of  blood-pressure. 

2.  Chronic  chloridemic  nephritis  of  Widal,  or  hydropigen- 
ous  nephritis  of  Castaigne,  characterized  chiefly  by  a  retention  of 
chlorides  which  is  clinically  manifested  in  edema,  without  appre- 
ciable high  blood-pressure  or  nitrogen  retention. 

3.  Chronic  azotemic  nephritis — or  uremigenous  nephritis,  as 
formerly  designated  by  Castaigne — characterized  mainly  by 
a  nitrogen  retention  which  is  manifested  in  a  rise  in  the  blood 
urea  and  a  large  number  of  the  classical  symptoms  of  the  uremic 
syndrome,  znz,,  headache  and  even  rigidity  of  the  neck,  neuralgic 
pains,  vertigo,  dyspnea,  general  torpor,  myasthenia,  coma,  con- 
vulsions, delirium,  anorexia,  nausea,  vomiting,  diarrhea,  etc. 

4.  Chronic  hydremic  nephritis  (of  Martinet),  or  hyperten^ 
sive  nephritis  (of  Potain  and  Widal),  characterized  by  a  reten- 
tion of  water  which  is  manifested  in  high  Wood-pressure, 
hydremia  (anemia  and  lowered  blood  viscosity),  and  consequently, 
by  predominant  cardiovascular  manifestations,  such  as  accentuation 
of  the  second  aortic  sound,  sometimes  gallop  rhythm,  various 
forms  of  hemorrhage  due  to  rupture  of  vessels  (epistaxis;  retinal, 
meningeal,  and  cerebral  hemorrhages,  etc.)  followed  eventually 
by  cardiac  impairment  and  dilatation,  tachycardia,  arhythmia. 


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654  SYMPTOMS, 

loss  of  compensation,  etc.  The  condition  begins  with  cardio- 
renal  sclerosis  and  leads  ultimately  to  heart  failure  and  uremia. 
In  contrast  with  the  simple  albuminous  and  chloridemic  va- 
rieties of  nephritis,  the  last  two  forms,  the  azotemic  and  the  hy- 
dremic, frequently  coalesce,  so  that,  the  azotemic  and  hydremic 
syndromes  being  in  combination,  the  clinical  picture  comprises 
both  the  cl^ssfe  uremic  symptom-complex  already  referred  to  and 
the  equally  wdl-known  cardioarterial  symptom-complex  at- 
tending cardiorenal  fibrosis.  By  combined  use  of  the  three  pro- 
cedures now  available:  1.  Determination  of  blood  urea.  2.  Of 
the  blood-pressures,  systolic  and  diastolic.  3.  Of  the  extent  of 
hydremia  and  anoxemia  (as  estimated  through  the  blood  viscos- 
ity, by  refractometry,  by  estimation  of  proteins  in  the  blood 
serum,  etc.),  it  is  at  present  possible  for  us  to  differentiate,  in 
these  ultimate  complex  processes,  that  which  specially  apper- 
tains to  nitrogen  retention  from  that  which  refers  to  retention 
of  water,  to  anoxemia,  to  impaired  cardiopulmonary  function- 
ing, and  to  cardiorenal  insufficiency. 

II.  Albuminuria  of  Chronic  Infections. — Albuminuria  is  very 
often  met  with  in  the  presence  of  chronic  infections,  such  as 
tuberculosis,  syphilis,  malaria,  etc.,  and  it  is  of  advantage  from 
the  standpoint  of  therapeutic  indications  to  establish  the  con- 
currence of  a  chronic  albuminuria  with  one  of  the  chronic  in- 
fections referred  to.  As  in  the  chronic  nephritides,  however, 
the  prognosis  is  largely  based,  it  would  seem,  on  the  functional 
variety  of  nephritis  present — simple  albuminous  nephritis,  or 
hydremic,  chloridemic,  or  azotemic  nephritis. 

III.  Albuminuria  of  the  Intoxications. — **In  this  connection," 
states  Castaigne,  **three  sorts  of  toxic  actions  may  be  distin- 
guished : 

**The  strong  toxics  (cantharides,  corrosive  sublimate,  and 
arsenic  in  large  amount)  which  induce  acute,  and  in  particular 
hyperacute,  nephritis. 

**The  weak  toxics  acting  rapidly  and  not  taken  repeatedly 
(taken  in  a  single  dose)  which  induce  a  temporary  albuminuria. 

''The  toxics  taken  in  small  but  repeated  amounts,  and  acting 
slowly  (lead) :  these  give  rise  to  all  the  varieties  mentioned  in 
respect  of  the  albuminurias  of  chronfc  nephritis;  thus,  it  may 


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ALBUMINURIA,  655 

be  said  that,  in  the  case  of  intoxications  as  in  that  of  infections, 
etiologic  data  do  not  suffice  to  illuminate  the  prognosis/* 

IV.  Albuminuria  of  Autointoxications. — This  comprises  in  par- 
ticular the  albuminurias  of  pregnancy,  of  diabetes,  and  of  gout. 

(a)  Albuminuria  of  pregnancy. — With  Castaigne,  we  shall 
recognize  a  number  of  different  varieties,  which  differ  widely 
in  significance  and  seriousness. 

1.  Albuminuria  of  pregnant  zvonten  who  already  had  albumin- 
uria before  pregnancy. 

2.  True  albuminuria  of  pregnancy,  in  which  the  autointoxi- 
cations of  the  latter  condition  are  responsible  for  the  albuminuria. 
The  prognosis  in  these  cases  is  based  upon  a  study  of  the  renal 
functions. 

3.  Albuminuria  attending  the  pyelonephritis  of  pregnancy, 
with  pyuria,  and  the  seriousness  of  which  is  dependent  upon  the 
intensity  of  the  phenomena  of  retention  and  infection. 

4.  The  transient  and  mild  albuminuria  of  labor. 

5.  Postptierperal  albuminuria,  dependent,  on  the  whole,  upon 
infection,  and  the  prognosis  of  which  is  that  of  the  acute  infectious 
nephritides. 

(b)  Gouty  albuminuria. — Measures  should  be  taken  to  find 
out  whether  the  condition  is: 

1.  A  simple  albuminous  chronic  nephritis.  2.  A  hydremic  ne- 
phritis with  hypertension,  secondary  to  spasm  of  the  vessels  or 
to  cardiorenal  sclerosis.    3.  A  calculous  pyelonephritis. 

(c)  Diabetic  albuminuria. — The  significance  of  this  form  is 
closely  analogous  to  that  of  gouty  albuminuria. 

V.  Chronic  Albuminuria  of  Circulatory  Origin, — This  type 
is  found  dependent  upon  two  main  series  of  causes,  inc.,  cardiac 
and  neuromotor  disturbances  (Castaigne). 

(a)  Cardiac  albuminuria. — This  is  the  albuminuria  which 
appears  at  the  time  of  attacks  of  acute  heart  dilatation  or  failure 
and  seems  to  be  dependent  upon  the  disturbance  in  the  return 
circulation,  i.e.,  venous  stasis.  It  generally  disappears  when  the 
process  of  cardiac  weakening  ceases.  Where  it  persists,  it  should 
be  studied  along  the  same  lines  as  were  advised  in  the  case  of 
chronic  nephritis. 


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656 


SYMPTOMS. 


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ALBUMINURIA. 


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658  SYMPTOMS. 

(b)  Neuromotor  albuminuria. — ^This  is  the  form  which  ap- 
pears following  vascular  disturbances  after  nervous  conditions 
such  as  epileptic  seizures,  cerebral  hemorrhage,  trauma  to  the 
skull,  etc. 

"Cases  of  this  kind  may  be  hard  to  interpret,  and  the  physi- 
cian should  not  be  in  a  hurry  to  make  a  diagnosis  of  uremia 
because  the  patients  show  albuminuria  consentaneously  with 
the  cerebral  manifestations ;  only  the  classic  tests  will  permit  of  an 
accurate  prognosis  of  these  combined  disturbances.'*    (Castaigne). 

CRYPTOGENIC  OR  "FUNCTIONAL" 
ALBUMINURIA. 

Aside  from  the  above  mentioned  groups  of  acute  and  chronic 
albuminuria  which  may  be  more  or  less  readily  referred  to  a 
known  cause,  there  occurs  also  a  relatively  large  number  of 
cases  of  albuminuria  which  have  not  yet  been  completely  worked 
out,  and  for  which  tradition  has  preserved  the  term,  very  prob- 
ably inaccurate,  of  functional  albuminuria;  the  term  cryptogenic 
albuminuria,  which  mentions  our  ignorance  of  its  cause  without 
making  any  premature  assertion  as  to  its  nature,  seems  to  the 
author  more  rational. 

The  most  frequent  of  these  cryptogenic  albuminurias  are 
those  known  as  the  fatigue,  digestive,  cyclic,  orthostatic,  and 
intermittent  and  minimal  albuminurias. 

The  albuminuria  of  fatigue,  which  occurs  intermittently  and 
is  slight  in  amount,  appears  only  after  prolonged,  fatiguing  ex- 
ercise, such  as  hiking,  running,  horseback  riding,  etc.,  and  gen- 
erally disappears  with  rest. 

The  digestive  albuminurias  are  those  which  arise  or  become 
accentuated  during  the  process  of  digestion,  whether  the  sub- 
jects be  dyspeptic,  enteritic,  or  normal.  The  relationship  of 
cause  to  effect  can  be  established  only  by  repeated,  fractional 
analysis  of  samples  of  gastric  juice  withdrawn  at  various  stages 
of  digestion,  every  precaution  being  taken,  moreover,  to  eliminate 
orthostatic  albuminuria. 

The  cyclic  albuminurias  are  those  appearing  in  a  cyclic  man- 
ner, at  certain  periods  of  the  day,  generally  between  1  and  3 


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ALBUMINURIA,  659 

o'clock  P.M.  Described  more  particulariy  by  J.  Teissier  and 
Pavy,  they  seem  to  be  dependent  upon  some  degree  of  insuffi- 
ciency (or  debility)  of  the  liver  and  kidneys. 

In  orthostatic  albuminuria,  the  standing  posture  is  the  sole 
necessary  and  sufficient  factor  of  the  albuminuria,  which  passes 
off  when  the  subject  reclines.  It  is  especially  frequent  in  child- 
hood. 

The  intermittent  and  minimal  type  of  albuminuria,  well  de- 
scribed by  its  name,  is  a  slight  (0.1  to  0.2)  and  intermittent 
albuminuria,  which  appears  and  disappears  without  any  sort  of 
periodicity,  independently  of  all  fatigue,  digestive  process,  or 
body  posture;  this  constitutes  the  most  cryptogenic  of  all  the 
forms  of  albuminuria. 

Long  considered  to  be  of  a  "functional"  nature — sine  materia 
— as  well  as  mild,  this  form  of  albuminuria  has  been  the  subject 
of  a  long  series  of  discussions,  which  have  led  to  the  conclusion 
that,  like  all  the  other  forms  of  albuminuria,  this  clinical  group 
may  be  symptomatic  of  a  large  variety  of  morbid  states,  from 
the  mildest  and  most  evanescent  functional  disturbance  to  the 
most  definite  chronic  nephritis,  and  that  the  accurate  functional 
diagnosis  necessary  for  the  institution  of  an  appropriate,  rational 
and  effectual  plan  of  treatment  can  be  secured  only  by  a  syste- 
matic study  of  the  renal  functions  (hydruria,  chloruria,  and 
azoturia)  by  the  required  methods:  1.  Hydruric  balance:  Blood- 
pressure,  daily  output  of  urine,  and  blood  viscosity.  2.  Chloride 
balance:  Chloride  test  and  examination  for  edema.  3.  Nitrogen 
balance:  Determination  of  the  blood  urea. 

Mention  may  also  be  made  of  artificial  or  simulated  albu- 
minuria, of  which  some  instances  were  observed  during  the  war. 
Albuminuria  is  simulated  by  mixing  some  white  of  egg  with 
the  urine,  either  before  or  after  urination,  or  even  by  intraureth- 
ral  or  intravesical  injection  of  a  solution  of  egg  albumin.  Strict 
isolation  of  the  suspected  individual,  careful  watching,  and  col- 
lection of  the  specimens  of  urine  for  examination  under  direct 
supervision  will  readily  lead  to  detection  of  the  artifice.  (See 
Examination  of  the  Urine.) 

In  this  connection  a  final  word  may  be  said  regarding  the 
relationship  of  albuminuria  to  fitness  for  military  service.    The 


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660  SYMPTOMS, 

main  conclusion  from  the  foregoing  facts  is  that,  on  the  whole, 
albuminuria  is  of  relatively  slight,  and  renal  functioning  of  para- 
mount, importance  in  relation  to  the  prognosis,  and  hence  also 
in  relation  to  military  fitness.  The  essential  point,  therefore, 
is  to  ascertain  the  condition  of  renal  functioning  in  each  case. 
The  author  is  entirely  prepared  to  subscribe,  with  a  few  slight 
modifications,  to  the  conclusions  stated  by  Gilbert  (RSunion  midico- 
chirurgicale  de  la  Ve  armie,  Oct.  28,  1916)  :  An  albuminuric  sub- 
ject, to  be  kept  in  the  armed  service,  must  answer  the  following 
requisites:  1.  A  fixed  amount  of  albumin,  uninfluenced  by  exposure 
to  cold,  the  standing  posture,  food  conditions,  and  fatigue.  2. 
Absence  of  casts.  3.  Blood  urea  normal,  and  urinary  urea  paral- 
lel to  the  nitrogenous  food  in  the  diet  4.  Absence  of  edema, 
with  a  normal  chloride  balance.  5.  No  pronounced  elevation 
of  blood-pressure  (below  180),  and  no  gallop  rhythm.  A  de- 
cision can  be  reached  in  such  cases,  therefore,  only  after  pro- 
longed and  careful  study. 


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ALOPECIA  (COMPLETE 
OR  PARTIAL  LOSS  OF 
THE  HAIRY  APPEND- 
AGES). 


Lat.  alopecia; 

from  the  Greek  n  dXa>7f€;(^ta, 

derived  from  ^  d^nrj^y 

the  fox. 


"Comme  il  advient  au  regnart  que  son  poil 
chiet  une  fois  ran,  aussi  est  appeli  le  choir  des 
cheveux  allopice"^ 

Lanfranc,  folio  38,  verse  XIV 
in  LiTTRi,  article  Renard, 


Even  the  general  practitioner  is  frequently  consulted  by  pa- 
tients on  account  of  loss  of  hair.  While  not  a  few  uncommon 
varieties  of  alopecia  are  very  difficult  to  diagnosticate,  even — 
and  perhaps,  especially — for  the  specialists,  in  9  cases  out  of  10 
the  general  practitioner  may  rapidly  make  such  distinctions  as 
are  necessary  for  the  application  of  suitable  treatment. 

According  as  the  patient  is  a  nursling,  a  child,  an  adult,  or 
an  elderly  person,  the  diagnosis  should  be  oriented,  a  priori,  to  the 
most  frequent  forms  of  alopecia  at  the  patient's  age. 

In  the  Nursling. — In  this  group  the  condition  is  practically 
limited  to: 

1.  Occipital  alopecia,  the  result  simply  of  wearing  away  of 
the  hair  on  the  pillow;  the  occiput  is  the  area  affected,  and  the 
area  is  ovoid  in  shape  with  its  long  axis  directed  transversely. 

2.  Congenital  alopecia. — As  a  matter  of  fact,  it  is  more  par- 
ticularly as  the  patient  grows  older  that  this  form  of  alopecia 
begins  to  attract  attention. 

In  the  Ohild. — Special  thought  should  be  given  to  the  possi- 
bility of  alopecia  areata,  ringworm,  and  cicatricial  alopecia  in 
this  group  of  cases. 

1.  Alopecia  areata. — ^The  following  lines  are  reproduced  from 
Sabouraud's  description  of  this  condition:  "This  is  a  primary 


» "As  it  happens  to  the  fox  that  his  hair  falls  out  once  a  year,  even  so 
is  loss  of  the  hair  termed  allopicia." 

(661) 


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662 


SYMPTOMS. 


form  of  alopecia,  which  is  not  preceded  by  any  functional  mani- 
festation .    .    .     The  hair  is  lost  either  diffusely  over  a  limited 


Fig.  498. — Hairs  in  alopecia  areata,  viewed  with  a  magni- 
fying lens  (Sabouraud). 

region,  or  as  a  patch  which  becomes  completely  bald  from  the 
start  .    •    .     The  bald  surface  is  irregular  in  outline,  of  varying 


Fig.  499. — Alopecia  areata  in  a  child  (Sabouraud) . 

shape,  smooth,  and  devoid  of  any  abnormal  feature.     It  may 
become  definitely  limited  or  arrested,  or  even  undergo  recession. 


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ALOPECIA.  663 

at  any  time;  on  the  other  hand,  it  may  extend  until  the  entire 
scalp  and  the  body  surface  as  a  whole  has  lost  its  hairy  cover- 
ing. Upon  the  scalp,  extending  areas  of  the  disease  are  marked 
by  the  presence  of  the  typical  club-shaped  hair  stumps,  either 
singly  or  in  groups  or  streaks  .  .  .  Such  a  hair,  which  is 
suggestive  of  the  exclamation  point  in  ordinary  printing  type, 


Fig.  500.— Microsporia  (Sabouraud),  Fig.    SOL— Hairs    af- 

fected with  microsporia, 
seen  with  a  magnifying 
lens  (Sabouraud). 

is  one  in  process  of  atrophy ;  it  is  like  a  portion  of  a  needle  with 
its  point  embedded  in  the  skin,  etc." 

Alopecia  areata  generally  sets  in  in  children  between  four 
and  seven  years  of  age  and,  aside  from  the  severe  and  recurring 
forms,  is  spontaneously  recovered  from  in  from  six  months  to 
two  years. 

2.  Ringworm. — (a)  Tinea  tonsurans  due  to  the  small-spored 
fungus  (microsporia)  is  the  commonest  form  among  the  tineas, 
i,e.,  diseases  of  the  epidermis  and  hair  caused  by  a  cryptogamic 


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664  SYMPTOMS. 

microparasite.  "It  is  characterized  by  dry,  scaly,  grayish  patches 
2  to  5  centimeters  in  diameter,  nearly  round  and  with  rather 
well  circumscribed  margins.  The  very  first  glance  at  the  af- 
fected area  reveals  that  the  hairs  at  the  surface  of  these  patches 
are  less  numerous  than  normally.  Of  these  hairs,  a  very  few 
have  retained  their  normal  features.  The  others,  the  ringworm 
hairs,  are  short,  broken  off  at  a  distance  of  3  or  4  millimeters 
above  the  skin  surface,  decolorized,  and  apparently  covered  with 


Fig.  502. — Tinea  tonsurans  due  to  the  small-spored  fungus.  Micro- 
scopic aspect  of  a  hair  (Magnified  3(X)X).  Some  of  the  spores  are  seen 
by  transmitted  light  (R,  Sabouraud). 

a  grayish  shell.  The  hairs  thus  affected  break  off  flush  with 
the  skin  when  depilated.  Ten  or  twelve  grayish  pieces  of  hair 
may  thus  be  pulled  out  at  once  between  the  fingers.  The  possi- 
bility of  thus  depilating  the  surface  with  the  fingers  distinguishes 
this  form  of  tinea  from  all  others."     (Sabouraud). 

Microscopic  examination  of  the  hair  will  confirm  the  diag- 
nosis. 

"When  heated  between  2  slides  in  a  drop  of  caustic  potash 
solution  and  examined  at  a  magnification  of  100  to  300  diameters, 
such  a  hair  reveals  a  cortex  of  very  small  and  refractile  spores, 
arranged  in  irregular  apposition  and  forming  a  kind  of  shell 


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ALOPECIA.  665 

about  the  hair.  .  .  .  The  hair  appears  like  a  little  rod  covered 
^vith  glue  and  then  rolled  in  sand/' 

This  condition  is  less  frequently  met  with  in  Paris  than  the 
succeeding  one,  and  is  rare  in  children  of  less  than  three  or 
more  than  thirteen  years  of  age. 

(b)  Tinea  tonsurans  due  to  the  large-spored  fungus  (tricho- 
phyton or  school  type). — This  is,  in  general,  less  frequent  than 
the  preceding  condition.  When  left  untreated,  it  is  characterized 
by  numerous  small  areas  of  involvement,  each  of  which  might 
easily  be  covered  by  the  fihger-tip,  and  which  are  marked  by  a 


^^ 


Ck  y^ 


Fig.  503. — Pieces  of  diseased  hair  viewed  with  a  magnifying  lens,  being 
seen  as  they  appear  beneath  the  scale  (Sabouraud). 

small  aggregation  of  adherent  scales,  presenting  the  appearance 
of  a  dry  scab.  The  diseased  hair  is  gummed  over  and  sur- 
rounded by  the  scale.  In  order  to  see  it,  the  latter  must  be  re- 
moved and  its  deep  surface  examined ;  there  are  then  seen  pro- 
jecting from  it  little  white  rootlets,  short  and  curved  over.  Mic- 
roscopic examination  of  these  rootlets  will  remove  all  doubt. 
Upon  preparation  by  the  technic  above  described,  the  parasite 
is  found  to  consist  of  spores  much  larger  than  those  of  the  pre- 
ceding variety  and  disposed  in  regular  series  or  chains  and  in 
groups  of  parallel,  slightly  wavy  filaments. 

This  variety  of  ringworm  of  the  scalp,  which  is  at  present  the 
commonest  among  the  school  children  in  Paris,  generally  occurs 
in  girls  four  to  fifteen  years  of  age,  though  occasionally  persist- 
ing to  the  age  of  sixteen  or  eighteen  years. 


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666  SYMPTOMS. 

(c)  Tinea  favosa. — In  contrast  with  ringworm  of  the  scalp, 
which  is  more  particularly  a  disease  of  urban  populations,  favus 
is  a  rural  variety  of  tinea. 


Fig.  504. — Diseased  hair  in  tinea  tonsurans  of  the  large-spored 
variety  in  childhood  (Sabouraud). 

"It  invades  the  scalp  only  in  individuals  of  school  age,  but 
as  it  is  never  spontaneously  recovered  from,  it  may  be  encount- 


Fig.  505. — A  hair  in  tinea  favosa  (Sabouraud). 

ered  at  any  period  of  life.    In  its  ordinary  form  (favus  scutulum) 
the  disease  is  characterized  by  one  or  more  irregular  but  sharply 


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ALOPECIA,  667 

circumscribed  patches,  covered  with  sulphur  yellow  crusts, 
aiul  of  the  color  as  well  as  the  consistency  of  clay.  The  in- 
dividual, separate  crusts  are  rounded,  annular,  and  of  all  differ- 
ent sizes,  the  largest,  which  measure  1  to  2  centimeters  in  diam- 
eter, showing  a  series  of  wave-like  circular  elevations. 

"Of  these  cup-like  formations,  the  smallest  form  simply  a 
ring  about  the  hairs.     The  cups  are  pierced  by  the  hairs  and 


•  Fig.  506. — Celsus's  kerion  (Sabouraud) . 

partly  embedded  in  the  skin.  They  may  be  detached  without 
great  difficulty,  in  pieces ;  in  their  stead  is  left  a  bleeding  wound 
which  appears  to  extend  rather  deeply  in  the  tissues. 

"A  hair  affected  with  favus  exhibits  a  mycelial  parasitic 
growth  composed  of  a  few  irregular,  wavy,  and  frequently  dead 
filaments;  in  the  latter  condition  their  course  is  shown  by  a 
clearly  distinct  air  bubble  of  similar  shape.  The  living  mycelial 
filaments  consist  of  segments  of  rather  variable  size  and  shape, 
with  some  spore-bearing  portions." 

(d)  In  connection  with  the  above  disorders  may  be  men- 
tioned certain   trichophyton  invasions   of   animal   source,   e.g., 


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668  SYMPTOMS. 

from  the  horse,  dog,  cat,  or  sheep,  tending  toward  suppuration 
and  leaving  behind  a  permanent  cicatricial  alopecia.  Among 
this  group  is  the  so-called  kerion  of  Celsus. 

(e)  Under  the  general  term  cicatricial  alopecias  may  be  in- 
cluded the  patches  of  alopecia,  generally  circumscribed  in  more 
or  less  well-defined  islets,  which  follow  impetigo,  furuncle,  or 
trauma.  The  scar-like  fibrous  condition  of  the  skin  in  the  affected 
area,  in  conjunction  with  the  history,  inevitably  lead  to  the 
proper  diagnosis  if  the  case  is  carefully  investigated. 

(/)  Congenital  temporal  alopecia  is  of  importance  only  by 
reason  of  the  mistakes  in  diagnosis  (alopecia  areata)  to  which 


Fig.  507. — Congenital  temporal  alopecia  (Sabouraud), 

it  may  lead.  The  condition  occurs  on  either  one  or  both  sides 
of  the  head — in  the  latter  case  symmetritally — and  is  marked 
by  an  oval  bald  area  2  centimeters  long  and  lyi  centimeters 
broad  situated  on  the  temple  and  directed  obliquely  upward 
and  backward. 

(g)  The  diffuse  alopecias  of  childhood  comprise  particularly 
the  infectious  and  post-infectious  alopecias  (typhoid  fever,  oste- 
omyelitis, eruptive  fevers,  etc.),  but  are  generally  much  less  pro- 
nounced in  children  than  in  the  adult. 

(h)  Lastly,  mention  may  be  made  of  the  alopecia  following 
application  of  the  x-rays.  The  hair  falls  out  twenty  to  thirty 
days  after  depilation  with  the  rays,  and  begins  to  grow  out 
again  two  and  a  half  months  after  the  exposure — unless  there 
results  an  actual  radiodermatitis  causing,  even  when  slight,  a 


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ALOPECIA.  669 

permanent  alopecia,  A  mistake  in  diagnosis  in  this  connection 
cannot  possibly  be  made.  The  regular,  romided  shape  of  the 
bald  area,  suggesting  a  tonsure,  is  in  itself  sufficient  evidence 
for  a  positive  diagnosis.  The  ritual  alopecia  of  the  clergy  alone 
exhibits  such  a  circular  shape  of  the  bald  area  and  the  same 
relatively  large  size. 

4t      4t      4t 

In  the  Adult. — In  this  group  there  are  more  particularly  en- 
countered: Seborrhea  decalvans,  the  ordinary  baldness  of  male 


Fig.  508. — Alopecia  due  to- x-ray  exposure  (Sabouraud) . 

neuro-arthritic  subjects;  the  scaly  alopecia  pityrodes  of  women, 
and  the  various  infectious  and  post-infectious  alopecias,  a  sepa- 
rate place  being  reserved  for  syphilitic  alopecia  and  various  con- 
ditions suggesting  alopecia  areata  but  as  yet  of  uncertain  origin. 

(a)  Seborrhea  decalvans  (the  ordinary  baldness  of  men). — 
"This  presents  as  its  objective  sign  and  fundamental  lesion  a 
cylindrical  plug  of  fat  contained  in  the  sebaceous  duct  and  which 
is  caused  by  pressing  on  the  skin  to  emerge  from  the  duct  in 
the  form  of  a  small  vermicular  mass  or  rudimentary  comedo. 
This  plug  of  fat  is  the  seat  of  a  bacterial  colony  consisting  ex- 
clusively of  the  microbacillus  of  seborrhea. 

"The  alopecia  attending  seborrhea  is  much  less  diffuse  than 
that  of  pityriasis ;  it  is  located  at  the  vertex,  over  the  very  area 
at  which  baldness  is  later  to  result  ...     As  a  rule,  the  earlier 


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670  SYMPTOMS. 

in  life  seborrhea  of  the  scalp  sets  in  the  more  rapid  its  course. 
When  it  begins  at  the  age  of  18  it  results  in  complete  baldness 
at  25  years,  some  200  to  400  hairs  falling  out  each  day.  When 
it  sets  in  at  the  age  of  25,  it  results  in  partial  baldness  only  at 
55  to  60  years ;  from  50  to  60  hairs  are  lost  a  day,  the  number 
varying  according  to  the  season  of  the  year." 

Sometimes  this  local  condition  appears  to  be  associated  with 


Fig.  509. — Seborrhea  decalvans  of  the  vertex.    Common  baldness  in 
process  of  development  (Sabouraud), 

or  secondary  to  that  rather  indefinite,   though   frequently  en- 
countered diathesis:  neuro-arthritism. 

(b)  Alopecia  pityrodes. — In  women  this  plays  a  role  as  im- 
portant as  seborrhea  does  in  man.  One  half  of  all  women  show 
some  evidence  of  this  disturbance,  which  should  be  thought 
of  a  priori  by  the  physician  whenever  a  young  woman  consults 
him  on  account  of  loss  of  hair.  From  the  age  of  10  years  to  20 
years  the  affected  scalp  is  found  to  be  scaly  and  covered  with 
dandruff.  Later  there  results  an  elimination,  not  of  scales  and 
dandruff,  but  of  the  hairs  themselves,  which  fall  out  whole  with 
their  bulb-like  follicles  and  are  replaced  by  other  shorter  and 


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ALOPECIA,  671 

weaker  hairs  until  finally  alopecia  is  established — never  amount- 
ing,  however,  to  complete  baldness.  The  hair  becomes  more 
sparse,  shorter,  less  abundant  and  luxuriant,  with  open  spaces 
interspersed,  but  never  with  anything  actually  suggestive  of 
the  seborrheic  baldness  of  males,  with  its  large,  regular,  elliptical, 
smooth  and  polished  areas  of  involvement. 

(r)  Infectious  and  post-infectious  alopecia  is  of  great  practi- 
cal interest.     Influenza,  the  eruptive  fevers,  mumps,  erysipelas, 


Fig.  510. — Alopecia  following  erysipelas  (Sabouraud), 

and  in  particular  typhoid  fever,  cause  a  more  or  less  pronounced 
loss  of  hair.  "Slight  alopecia  may  follow  these  conditions  as 
soon  as  they  have  terminated,  particularly  those  which,  like  ery- 
sipelas, are  attended  with  intense  local  inflammation,  but  all  of 
them  have  a  definite  period  for  the  production  of  alopecia.  The 
latter  follozvs  its  cause  after  an  interval  of  eighty- five  days.  In 
different  cases  there  may  be  five  days'  discrepancy,  one  way  or 
the  other,  from  this  time  interval."  (Sabouraud).  The  hair  con- 
tinues to  fall  out  for  about  six  weeks ;  this  occurs  in  a  diffuse, 
irregular  manner,  without  ever  terminating  in  true  alopecia. 
Restoration  of  the  hair  is  constant  in  these  <:ases. 

A  separate  place  in  the  classification  may  be  set  apart  for 
the  alopecia?  of  chronic   tuberculous  subjects,  suggesting  alopecia 


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672  SYMPTOMS. 

areata;  this  form  is  occipital  in  situation  and  circumferential  in 
arrangement. 

{d)  Syphilitic  alopecia  is  separated  from  the  preceding  group, 
of  which  it  constitutes  merely  a  single  type,  because  of  its  great 
clinical  importance.  It  appears  about  six  months  after  the  onset 
of  the  disease — in  the  course  of  the  second  six  months'  period, 
never   later.     "This   lesion   is   temporoparietal   and   irregularly 


Fig.  511. — Syphilitic  alopecia,  rather  more  pronounced 
than  usual  (Sabouraud) . 

diffuse,  so  that  when  the  patient's  hair  is  cut  short  the  hairy- 
covering  over  these  surfaces  appears  as  though  chopped  up 
with  poorly  directed  scissor  cuts.  At  each  of  these  points  a  tuft 
of  some  12  to  15  hairs  will  have  disappeared,  leaving  behind 
an  open  space;  even  in  women  with  long  hair  these  open  spaces  can 
still  be  recognized.  Upon  examination  of  the  eyebrows  these 
are  found  to  show  parallel  streaks;  the  cervical  glands  are  en- 
larged; upon  looking  into  the  mouth  mucous  patches  are  to  be 
found.  Or,  general  examination  of  the  patient  may  reveal  the 
indurated  remnant  of  the  chancre,  the  inguinal  lymphatic  en- 
largements, sometimes  a  still  visible  roseola,  etc."     (Sabouraud.) 


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ALOPECIA.  673 

Mention  should  here  be  made  of  the  alopecia  of  old  syphilitic^ 
and  of  congenital  syphilitics,  which  resembles  alopecia  areata. 
In  the  congenital  cases,  it  is  accompanied  by  the  classical  stig- 
mata— dental  dystrophies,  facial  dystrophies,  interstitial  kera- 
titis, etc.  (see  Syphilis),  of  the  condition  and  will  assume  the 
form  of  an  indefinitely  protracted,  recurring  alopecia  areata. 

(e)  Brocq's  pseudopelade  variety  of  folliculitis  decalvans,  on 
the  whole  rather  rare,  is  met  with  almost!  exclusively  in  males 
20  to  45  years  of  age  and  leads  ultimately  to  the  formation  of 


Fig.  512. — ^Tinea  decalvans  causing  almost  complete  baldness  in  a  dwarf 
presenting  all  the  stigmata  of  inherited  specific  infection  (Sabouraud). 

patches  of  alopecia  measuring  1  or  2  centimeters  on  either  side, 
polycyclic,  serpiginous,  and  separated  by  spaces  surrounded  by 
normal  hair.  It  exposes  irretrievably  more  or  less  extensive  sur- 
faces, later  coming  to  an  end  spontaneously.  Its  onset,  course, 
and  termination  remain  wholly  obscure. 

In  the  Elderly. — ^At  this  period  of  life  the  conditions  most 
frequently  met  with  are: 

The  advanced  forms  ofl  seborrheic  baldness  of  the  adult; 

A  form  of  alopecia  due  to  sclerosis  of  the  follicles  and  repre- 
senting, properly  speaking,  senile  alopecia. 

The  alopecia  areata  of  the  fifties. 

Cicatricial  alopecia  of  varying  origin. 

43 


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674  SYMPTOMS. 

Of  the  first  of  these  forms,  nothing  in  particular  need  be  said. 
Regarding  the  second,   only  slight  qualifications  are  required. 
The  process  of  sclerosis  or  fibrosis  leads  to  connective  tissue  re- 
placement and  disappearance  of  the  hair  follicle.    The  scalp,  de- 
prived of  its  follicles,  assumes  a  smooth,  scar-like  appearance. 

In  the  period  of  the  menopause,  or  the  process  of  involution 
taking  place  in  women  in  the  forties,  there  occurs  a  rather  uncom- 


Fig.  513. — Brocq's  pseudopelade  variety  of  folliculitis 
decalvans  {Sabouraud), 

mon  parietal  and  frontal  form  of  alopecia  areata  consisting  of 
more  or  less  extensive  irregular  patches,  which  are  spontaneously 
recovered  from  after  one  or  two  years. 

In  this  period  of  life,  finally,  the  scalp  may  exhibit,  in  the  form 
of  cicatricial  patches  of  alopecia  of  varying  shape  and  extent,  the 
end-results  of  all  of  the  foregoing  possible  causes  of  destruction 
of  the  scalp :  Traumatism,  furunculous  eruptions,  necrotic  acne, 
cold  abscesses,  bone  suppurations,  burns,  gummas,  syphilitic  se- 
•questra,  etc. 


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AMPmrT  A  r^>  ^"»  from  di^d,  privative;  alfia^  blood  J 


As  a  general  rule,  abnormal  pallor,  if  associated  with  a  pale- 
appearance  of  the  mucous  membranes  of  the  lips,  gums,  and 
conjunctivae,  is  due  to  anemia.  It  is  a  fact,  however,  that  simple, 
essential,  or  primary  anemia  is  very  uncommon,  whereas  morbid 
pallor  is  of  very  frequent  occurrence.  The  reason  for  this  is 
that  in  by  far  the  greater  proportion  of  cases,  if  not  invariably, 
the  anemia  is  secondary  to  or  symptomatic  of  some  other  dis- 
turbance, and  that  actually  the  diagnostic  problem  set  before 
the  practitioner  confronted  with  a  pale  individual  is  that  of  in- 
'^estigating  the  condition  which  underlies  the  anemia. 

Despite  the  recommendations  made   in  current  text-books, 
confusion  of  the  customary  pallor  of  anemia  with  the  yellowish 
discoloration  of  incipient  jaundice  or  the  evanescent  pallor  of 
nenous  angiospasm  could  occur  only  as  a  result  of  gross  care^ 
lessness  on  the  part  of  the  clinician.    What  is  more  to  the  point, 
in  the  author's  view,  is  that  both  in  hyposphyxic  cases  and  in 
many  tuberculous  patients,  actual  anemia  may  be  masked  by  a 
certain  amount  of  lividity,  cyanosis,  or  even  jaundice,  particu- 
larly in  hemolytic  icterus.     Hence,  exatmination  of  the  blood  is, 
as  a  rule,  indicated  in  cases  exhibiting  pallor.    This  examination 
should  relate  more  especially  to  the  cell  count  and  the  estimation 
of  hemoglobin    (see  Blood  examination),     Hayem's  classification 
is  generally  followed:  A^  (tmntber  of  red  cells);  R   (hemoglobin 
value) ;  C=-^  (cell  value). 

Normally, ^  N=5,000,000;  /?=5,0(X),000;  G=l. 

ANEMIC  STATES. 

1st  degree:    N  and  R,  and  hence  also  G,  are  very  slightly  reduced. 

2d  degree:  N  =  5,000,000  to  3,000,000:  R  =  3,000,000  to  2,000,000;  G  = 
0.80  to  0.30  (extreme  figures). 

3d  degree:  N  =  3,000,000  to  1,000,000;  R  =  2,000,000  to  800,000;  G  = 
0.84  to  1.00. 

4th  degree:    N  =   1,000,000  to  300,000;  R  =  800,000  to  300,000;  G  = 


0.88  to  1.70. 


(675) 


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676  SYMPTOMS. 

In  the  4th  degree  is  comprised  the  group  of  the  so-called  "per- 
nicious anemias,"  the  confines  of  which  have  not  as  yet  been  thor- 
oughly d^emiined,  and  which  certainly  occur  in  more  than  one 
form  or  variety.  Determination  of  the  differential  leucocyte  count 
is  always  necessary  in  these  cases.  The  total  white  cell  coiuit  is 
seldom  increased ;  much  more  frequently  the  number  of  white  cells 
remains  normal  or  is  diminished,  in  which  eveiTt  leucopenia  is 
present.  In  a  general  way,  a  plastic  anemia  may  be  said  to  exist 
where  blood  repair  is  manifested  in  the  appearance  of  young  or 
immature  cells;  there  may  be  present  a  leucocytosis,  with  granular 
myelocytes;  nucleated  red  cells  may  be  found  in  variable  numbers, 
vis,,  erythroblasts  with  mitotic  nuclei  or  with  nuclei  in  a  state  of 
pyknosis,  many  reds  exhibiting  multiple  and  manifest  deformations, 
microcytes  or  megalocytes,  etc. 

In  the  much  less  common  condition  known  as  aplastic  anemia, 
there  is  an  absence  of  defensive  reaction  in  the  bone  marrow  and 
hence  also  in  the  blood.  There  is  a  leucopenia  with  preponderance 
of  the  mononuclear  cells.  Nucleated  reds  and  myelocytes  are 
absent. 

Anemia  having  been  observed  to  be  present,  the  next  step 
is  to  ascertain  its  cause,  since — it  cannot  be  too  often  repeated — 
primary,  idiopathic  anemia  is  exceedingly  rare. 

The  classification  of  A.  Jousset  appears  to  the  author  par- 
ticularly serviceable  because  it  possesses  all  of  the  three  cardinal 
virtues  of  clinical  classifications,  being  both  practical,  etiologic, 
and  pathogenetic.  It  combines  at  once  the  causal  diagnosis  and 
the  (capitally  important)  diagnosis  that  affords  rational  thera- 
peutic indications. 

I.  Anemias  by  spoliation  may  follow  any  traumatic,  surgical, 
or  spontaneous  hemorrhage.  Included  in  this  group,  in  particular, 
are  all  the  secondary  anemias  attending  the  hemorrhagic  affections; 
Hemophilia,  purpura,  scurTTy,  epistaxis,  metrorrhagia,  hemoptysis, 
hematemesis,  cmkylostomiasis,  etc. 

The  causal  diagnosis  is  often  self-evident  in  these  cases.  Special 
mention  should,  however,  be  made  of  the  occult  gastrointestinal 
hemorrhages  attending  ulcer  and  cancer  cases,  which  require  for 
their  detection  a  systematic  examination  of  the  feces  (see  Exami- 


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ANEMIA, 
THE  ANEMIAS. 


677 


I. — Spoliatory  Type. 


1.  Traumatic  or  operative  hemorrhage. 

2.  Spontaneous   hemorrhage   in    disorders    attended    with   bleeding 

(hemophilia,  purpura,  metrorrhagia,  etc.). 

3.  Gastro-intestinal  hemorrhage,  manifest  or  occult  (ulcers  or  neo- 

plasms of  the  digestive  organs). 


II. — Toxic-infectious  Tjrpe. 


A.  Infectious. 
Chronic: 

1.  Malaria. 

2.  Syphilis 

3.  Tuberculosis. 

Acute : 

1.  Acute  rheumatism. 

2.  Typhoid  fever. 

3.  Suppurative  disorders. 


B.  Toxic. 

1.  Carbon  monoxide. 

2.  Lead. 

3.  Mercury  (?) 


III.— Autotoxic  Type. 


1.  Bright's  disease. 

2.  Hepatic  disorders. 

IV.— Insufficiency  of  the  Hematopoietic  Functions. 

Disorders  of  the  blood-forming  organs. 

V. — Crjrptogenic  Type. 


1.  So-called  "primary," 

2.  Chlorosis. 


essential,  or  idiopathic  anemias. 


nation  of  feces;  Tests  for  blood).  Hookworm  ova  are  likewise 
detected  only  by  examination  of  the  stools;  the  patient's  environ- 
ment will  generally  aflFord  a  serviceable  indication,  as  in  miners 
[and  in  the  endemic  foci  of  the  disease  in  the  Southern  U.  S. — 
Translator] . 

II.  Anemias  due  to  Toxic  Action  on  the  Erythrocytes. — In- 
fectious and  Post-infectious  Anemias. 

In  the  first  sub-group  are  placed  the  three  major  chronic 
infections :  Malaria,  tuberculosis,  and  syphilis.  These  are  three  of 
the  most  frequent  causes  of  chronic  anemia;  if  the  practitioner  will 
constantly  bear  them  in  mind  he  will  never  err  when  seeking  the 
source  of  many  chronic  anemias  apparently  cryptogenic  to  a  su|>er- 
ficial  observer.  Should  cancerous  anemia  logically  be  classed  with 
the  preceding  forms?     At  any  rate  it  should  and  can  be  classed 


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678  SYMPTOMS. 

with  them  clinically,  whether  the  anemia  be  due  to  manifest  or 
occult  hemorrhage,  to  toxic  action  on  the  red  cells,  or  to  both  of 
these  factors  combined. 

In  the  second  sub-group  are  the  three  major  acute  infections: 
Typhoid  fever,  acute  rheumatism,  and  the  various  suppurative  dis- 
orders. In  these  cases  the  relationship  of  cause  to  effect  is  gen- 
erally obvious. 

Toxic  Anemias  Proper. — The  three  common  forms  of  intox- 
icaticTn  are  those  due  to  carbon  monoxide,  lead,  and  mercury. 

The  first  of  these  is  by  far  the  most  common.  It  may  be  said 
to  be  practically  endemic  in  our  cities  throughout  the  cold 
season,  when  houses  are  artificially  heated.  The  imperfect 
draught  through  most  chimneys,  the  frequent  use  of  heating 
devices  under  conditions  of  slow  or  restricted  combustion,  and 
the  insufficient  ventilation  of  living  rooms  are  the  effective  fac- 
tors in  this  form  of  poisoning.  There  results  the  well-known 
carbon  monoxide  winter  anemia  with  its  customary  clinical  mani- 
festations consisting  of  dizziness,  headache,  and  tinnitus,  all 
refractory  to  any  form  of  treatment. 

Lead  anemia  comes  next  in  frequency.  The  occupation  of  the 
patient  (painter,  plumber,  etc.),  the  examination  for  other  signs 
of  lead  poisoning  (blue  line  on  the  gums,  tremor,  and  high  blood 
pressure),  and  sometimes  the  history  of  former  attacks  of  lead 
colic,  readily  afford  a  positive  diagnosis. 

Mercurial  anemia  appears  to  the  author  much  more  uncommon, 
at  least  in  his  own  district,  if  indeed  it  exists  at  all. 

III.  Autotoxic  Anemias. — In  this  group  Bright's  disease  takes 
first  place  and  hepatic  disorder  comes  second. 

Brighfs  disease  induces  anemia  both  by  causing  hydremia  and 
through  an  autotoxic  factor.  To  it  may  be  ascribed  the  pallor 
of  persons  with  arteriosclerosis  (the  aged)  and  of  cases  of  acute 
and  chronic  nephritis  with  or  without  edema.  It  constitutes, 
with  cancer,  by  far  the  most  frequent  cause  of  abnormal,  lasting, 
and  progressive  pallor  coming  on  after  the  age  of  45.  In  pale 
subjects  an  examination  should  always  be  made  for  albumin, 
edema,  and  high  blood-pressure. 


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ANEMIA,  679 

Hepatic  disorder  (hepatism)  is,  as  is  well  known,  attended 
with  particular  risk  to  the  red  blood  cells;  one  need  merely 
recall  the  time-honored  and  of  late  thoroughly  illuminated  con- 
ceptions as  to  hematic  and  hemolytic  icterus,  to  realize  the 
frequency  of  occurrence  of  such  cholemic  anemias  (see  Jaundice), 

lY.  Anemias  due  to  Insufficient  Regeneration  of  Erjrthro- 
cytes. — Perhaps  it  may  be  justifiable  to  place  in  this  group  the 
anemias  secondary  to  affections  of  the  blood-forming  organs: 
Splenomegaly,  multiple  adenopathies,  leukemias,  and  bone  mar- 
row disturbances;  impairment  of  the  nervous  and  digestive  or- 
gans with  consequent  poor  nutrition ;  and  polyglandular  insuffi- 
ciencies. 

V.  Cryptogenic  Anemias  of  obscure  or  as  yet  unknown  ori- 
gin. These  are  the  anemias  that  do  not  fall  into  any  of  the 
preceding  groups.  It  is  more  rational  to  confess  frankly  our 
lack  of  knowledge  by  the  term  "cryptogenic"  than  to  disguise  it 
with  the  word  "essential."  Chlorosis,  an  anemia  of  development, 
appearing  at  puberty  and  disappearing  at  its  termination,  may 
perhaps  be  appropriately  classed  in  this  group  until  further  light 
is  thrown  upon  it.  In  this  form  of  anemia  hemoglobin  reduction 
is  more  pronounced  than  red  cell  reduction,  the  latter  often 
being  very  slight. 


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APHONIA  AND  Fa,  privative;  ^hjttJ,  sound;'] 

HOARSENESS.  [         deprived  of  voice.        J 


Aphonia  seldom  entails  complete  suppression  of  the  act  of 
phonation,  such  suppression  being  observed  almost  exclusively 
among  the  deaf  and  dumb  and  in  hysterical  mutism ;  it  is  char- 
acterized rather  by  dysphonia,  hoarseness,  and  a  muffled,  raucous, 
discordant  quality  of  the  voice. 

For  practical  purposes  aphonia  may  be  divided  into: 

Acute  aphonia,  evanescent  and  generally  of  slight  import. 

Chronic  aphonia,  lasting  and  generally  of  serious  import. 

Acute  Aphonia. — Acute  laryngitis, — This  may  be  roughly 
divided  into: 

(a)  Acute  post- vocal  laryngitis,  practically  a  traumatic  condi- 
tion, occurring  among  speakers,  actors,  lawyers,  "criers,"  vocal 
professionals,  etc.  This  represents  practically  a  "sprain"  of  the 
vocal  cords. 

(h)  Acute  catarrhal  laryngitis  of  infections:  Acute  colds,  erup- 
tive fevers,  measles,  scarlet  fever,  grippe,  etc. 

(c)  Acute  congestive  or  irritative  laryngitis,  that  of  smokers 
and  alcoholic  subjects. 

Chronic  Aphonia. — Three  main  groups  of  causes  are  opera- 
tive : 

1.  Chronic  laryngitis.  2.  Organic  diseases  of  the  larynx.  3. 
Paralytic  disturbances  due  to  pressure  upon  the  nerves  to  the  larynx, 

1.  Chronic  laryngitis,  the  commonest  causes  of  which  are 
chronic  fatigue  of  the  larynx,  as  in  criers,  vendors,  orators,  etc., 
and  chronic  descending  infections  of  the  nasopharynx,  which 
Laurens  has  aptly  designated  as  the  "morning  drop  of  the 
larynx." 

2.  Organic  diseases  of  the  larynx,  chiefly  represented  by 
tuberculosis,  syphilis,  and  benign  or  malignant  tumors.    The  cHni- 

(680) 


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APHONIA  AND  HOARSENESS.  681 

cal  and  laryngoscopic  features  of  these  several  affections  will  be 
found  in  condensed  form  in  the  tables  on  pages  686  to  690.  As 
for  their  distinguishing  features,  the  following  resume  is  borrowed 
from  Georges  Laurens  (Oto-rhino-laryngologie  du  medecin  prati- 
cien,  p.  380)  : 

'^Unquestionably,  for  the  well-trained  physician,  the  results  ob- 
tained by  a4iscultation  of  the  lungs,  bacteriologic  examination  of 
the  sputum,  specific  treatment,  and  histologic  examination  of  a 
piece  of  tissue  from  the  interior  of  the  larynx  may  facilitate  the 
differentiation  of  these  laryngeal  disorders,  vis.,  syphilis,  cancer, 
and  tuberculosis ;  the  laryngoscopic  picture,  however,  affords  singu- 
larly accurate  supplementary  information. 

"The  three  affections  are  characterized  by  excrescences,  a  tumor, 
or  ulcerations. 

**(a)  Tumor  or  excrescences  in  the  larynx, 

"The  syphilitic  gumma  is  recognized  by  its  location,  being  situ- 
ated in  the  anterior  portion  of  the  larynx,  including  the  epiglottis 
and  the  true  vocal  cords;  by  its  red,  smooth,  and  circumscribed 
aspect,  and  by  its  rapid  course. 

'* Tuberculous  vegetations  are  multiple,  irregular,  and  associated 
with  other  lesions  in  the  vicinity. 

''Cancer  results  in  the  formation  of  a  single,  non-pedunculated 
tumor  involving  the  vocal  cord  or  the  epiglottis,  without  any  lesion 
of  the  adjoining  mucous  membrane,  and  immobilising  the  vocal 
cord. 

"(b)  Laryngeal  ulcerations, 

"An  ulcerated  gumma  exhibits  a  sanious  base,  punched  out 
red  margins,  and  infiltration  of  the  surrounding  tissues. 

''Tuberculous  ulcerations  exhibit  dentate,  irregular,  and  torn 
margins,  and  are  multiple. 

"Ulcerated  cancer  exhibits  granulations  and  fungous  outgrowths, 
and  is  sanious,  bloody,  painful,  and  unilateral." 

3.  Paralyses  of  the  Larynx. — ^The  following  excellent  didactic 
article  on  paralytic  conditions  of  the  larynx  is  likewise  borrowed 
from  Laurens's  work. 


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682 


SYMPTOMS. 


PARALYSES  OF  THE  LARYNX. 

By  Dr.  G.  Laurens. 

Let  the  reader  recall  the  two  functions  of  the  larynx :  Respiratory 
and  phonatory.  During  respiration  the  vocal  cords  move  apart 
and  the  glottis  is  partly  opened;  during  phonation  the  cords  are 


Fig.  514. — Paralysis  of  right  re- 
current laryngeal  nerve.  During 
respiration  the  left  vocal  cord  is 
seen  to  move  while  the  right  re- 
mains motionless. 


Fig.  515. — Paralysis  of  right  re- 
current laryngeal  nerve.  During 
phonation  the  cords  are  seen  in  ap- 
proximation, presenting  a  normal 
laryngoscopic  picture. 


approximated  and  vibrate,  and  the  glottis  is  closed  down.  All  these 
movements  are  carried  out  by  the  muscles  of  the  larynx,  some  of 
which  are  constrictors  (closing  the  glottis)  and  others  dilators 
(partially  opening  it). 


Fig.  516. — Paralysis  of  both  recurrent  nerves. 

Within  the  tissue  of  the  cords  themselves  are  muscles  (the 
tensor  muscles  of  the  vocal  cords),  the  functioning  of  which  insures 
phonation  and  relaxation,  of  which  causes  hoarseness. 

All  the  muscles  of  the  larynx  but  one  are  supplied  by  the  recur- 
rent nerves.  Paralyses  of  central,  myopathic,  or  recurrent  origin 
are  encountered'  (Fig.  523).  The  last-named  variety  is  that  occur- 
ring most  frequently. 


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APHONIA  AND  HOARSENESS. 


683 


I.  Paralyses  of  the  Recurrent  Nerves. — These  may  be  either 
uni'  or  bi-  lateral, 

(a)  Unilateral  paralysis,  an  aortic  aneurysm,  for  example, 
exerting  pressure  on  the  left  recurrent  laryngeal  nerve.  In  this 
instance,  the  corresponding  vocal  cord  will  remain  motionless. 
The  outstanding  symptom  is  hoarseness. 


Fig.    517. — Independent   paralysis   of      Fig.   Sl8. — Independent   paralysis   of 
the  laryngeal  muscles.  the  laryngeal  muscles. 

The  tensor  muscles  of  the  cords  (the  thyroarytenoids)  are  paralyzed,  the 
cords  relaxed,  and  the  glottis  presents  a  "button-hole"  appearance. 

(b)  Bilateral  paralysis,  resulting  from  compression  of  the 
recurrent  by  a  tumor  of  the  esophagus  or  of  the  thyroid  gland. 
This  condition  is  rare.  When  it  occurs,  the  cords  cannot  be 
separated,  but  remain  in  absolute  contact. 

The  symptoms  are  hoarseness  and  dyspnea. 


Fig.  519. — Partial  paralysis  of  the 
posterior  muscles  of  the  larynx  (ary- 
tenoids). An  isosceles  triangle  is 
formed  behind  the  glottis. 


Fig.  520. — Paralysis  of  the  tensor 
muscles  of  the  vocal  cords  (crico- 
thyroids). The  vocal  cords  exhibit 
a  wavy  outline. 


II.  Independent  Paralyses  of  Laryngeal  Muscles. — These  are 
frequently  of  myopathic  origin,  following  an  attack  of  lar>'ngitis, 
or  hysterical.     Their  presence  is  manifested  by  hoarseness. 

Figures  517  to  520  show  the  condition  of  the  glottis  in  these 
varieties  of  paralysis. 


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684  SYMPTOMS. 

Interpretation  of  a  Case  of  Laryngeal  Paralysis. — Given  a 
patient  who  has  consulted  the  physician  on  account  of  hoarse- 
ness or  dyspnea,  and  in  whom  the  laryngoscopic  picture  has 
revealed   laryngeal  paralysis. 

What  data  should  he  thereupon  secure  for  diagnostic,  prog- 
nostic, and  therapeutic  purposes? 

He  should  proceed  by  exclusion,  proceeding  from  the  simple 
to  the  more  complex. 


'--  .2 


.•3 
4... 


-o 


Fig.  521. — Diagram  showing  the  course  of  the  recurrent  nerves,  which 
supply  the  muscles  of  the  larynx.  /.  Right  recurrent  nerve.  ^.  Left  re- 
current nerve.  3.  Cancer  of  the  esophagus.  4.  Thyroid  enlargement.  5. 
Aortic  aneurysm.    6.  Tracheobronchial  adenopathy.    7.  Bifurcation. 

First  Possibility, — If  the  condition  is  a  unilateral  paralysis  in- 
volving the  entire  cord,  with  the  larynx  otherwise  normal  and 
not  in  a  state  of  hyperemia,  the  paralysis  is  one  of  the  recurrent 
nerve.  Let  the  practitioner  recall  his  anatomy  and  ascertain  by 
examination  of  the  neck  and  chest  which  organ  is  causing  the 
pressure.  He  should  auscult,  use  the  x-rays,  the  esophagoscope, 
etc.,  and  will  come  to  suspect  some  particular  organ  of  causing 
the  trouble. 


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APHONIA  AND  HOARSENESS.  685 

Following  are  the  possible  causes  of  pressure  on  these  nerves, 
and  hence,  of  paralytic  conditions  of  the  larynx: 

1.  Cancer  of  the  esophagus. — The  left  recurrent  nerve  is  situ- 
ated behind  the  trachea,  in  the  angle  between  the  latter  and 
the  esophagus.  Consequently  any  growth  in  this  organ  will  exert 
pressure  on  the  nerve  and  cause  paralysis  of  the  larynx. 

2.  Thyroid  gland. — Enlargement  of  the  thyroid  gland,  or  of  a 
goiter,  whether  developing  in  the  left  or  the  right  lobe  of  the  organ, 
exerts  pressure  on  the  recurrent  nerve  and  paralyzes  it.  Such 
a  condition  may  also  be  the  result  of  thyroidectomy,  in  the  course 
of  which  the  nerve  may  be  injured. 

3.  Aortic  aneurysm. — The  arch  of  the  aorta  is  in  close  anatomic 


--2 


Fig.  522. — Horizontal  section  of  the  neck  showing  diagrammatically 
the  position  of  the  recurrent  nerves  and  the  structures  that  may  exert 
pressure  on  them.  /.  Trachea.  2.  Left  recurrent  nerve.  J.  Right  recur- 
rent nerve.  4.  Esophagus.  5.  Cancer  of  the  esophagus.  6,  Goiter.  The 
left  recurrent  nerve  is  thus  seen  to  be  particularly  exposed  to  pressure 
from  two  directions. 

relationship  wth  the  recurrent  nerve.  When  dilated,  it  may 
cause  paralysis  of  the  nerve. 

4.  Tracheobronchial  adenopathy,  developing  at  the  bifurcation 
of  the  trachea,  frequently  causes  pressure  on  the  laryngeal 
nerves. 

For  clinical  purposes,  the  greater  frequency  of  left  sided  recur- 
rent paralyses  on  account  of  their  esophagoaortic  origin  should 
be  kept  in  mind. 

Great  significance  attaches  to  this  type  of  paralysis  from  the 
standpoints  of  diagnosis,  pathogenesis,  and  treatment.  Hoarse- 
ness will  thus  have  led  the  physician  to  discover  an  aneurysm 
of  the  aortic  arch  or  of  the  right  subclavian  artery.  The  treat- 
ment, however,  is  ineffectual. 


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686 


SYMPTOMS, 


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APHONIA  AND  HOARSENESS.  691 

Second  Possibility. — If  the  examination  of  the  nedc  and  chest 
has  given  negative  results,  the  points  of  origin  of  the  recurrent 
nerve  in  the  brain  must  be  at  fault.  Hence,  the  physician  should 
make  an  examination  of  the  nervous  system  for  tabes  dorsalis, 
disseminated  sclerosis,  etc.  The  neuropathologist  will  be  able 
to  put  his  finger  on  the  exact  origin  of  the  paralysis. — ^The  prog- 
nosis will  depend  upon  the  cause  found. 

Third  Possibility. — If  the  hoarseness  has  appeared  in  the  course 
of  an  attack  of  influenza  or  acute  laryngitis;  if  it  is  an  expres- 


Y 

Fig.  545. — ^The  three  causes  of  paralysis  of  the  laryngeal  muscles. 

1.  Paralysis  of  the  recurrent  nerves  is  by  far  the  most  frequent ;  any  form 
of  pressure  at  any  point  on  the  course  of  the  nerve  is  sufficient.  The  course 
of  the  left  recurrent  nerve  below,  in  front  of,  and  above  the  aorta  is  shown 
in  Fig.  545. 

2.  Myopathic  paralysis  is  rather  frequently  observed.     It  is  produced  as 
follows:    Following  an  ordinary  catarrhal  laryngitis  the  patient  is  seized 
with  hoarseness.    This  occurs  from  the  fact  that  the  inflammation  of  the 
mucosa  has  extended  to  the  underlying  tissues  and  set  up  a  species  of  myo-  ; 
sitis.    The  prognosis  in  this  form  of  paralysis  is  favorable. 

3-  Paralysis  of  central  origin,  following  disease  of  the  brain  and  spinal 
cord,  is  much  rarer. 

sion  of  isolated  paralysis  of  one  or  both  vocal  cords,  and  if  the 
mucous  membrane  of  the  larynx  is  still  inflamed,  the  paralysis 
is  unquestionably  of  myopathic  origin.  The  prognosis  is  favorable. 
Treatment. — This  is  unavailing  in  paralysis  of  central. origin 
and  very  often,  too,  in  pressure  paralysis  of  the  recurrent 
nerve. 


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692  SYMPTOMS. 

It  IS  useful  in  the  myopathic  disturbances,  i.e.,  in  the  paraly- 
sis following  acute  laryngitis;  also  in  hysteria,  in  intoxications, 
and  in  syphilis. 

The  measures  then  to  be  recommended  should  comprise  vocal 
rest,  inhalation  treatment  (if  there  are  still  evidences  of  catarrh 
and  laryngeal  hyperemia),  strychnine,  electricity,  bromides 
with  suggestion  treatment  (in  hysteria),  and  if  need  be,  external 
vibratory  massage.  In  cases  of  cord  paralysis  in  which  the  cause 
cannot  be  found  the  physician  should  not  hesitate  to  prescribe 
antisyphilitic  treatment ;  pleasant  surprises  for  the  patients  can- 
not but  thus  sometimes  result 

Recurrent  paralyses  are  by  far  the  commonest,  constituting 
perhaps  95  per  cent,  of  all  cases  of  laryngoplegia. 

The  remaining  5  per  cent,  are  represented  by: 

Peripheral  neuritis,  as  in  diphtheria,  alcoholism,  syphilis,  and 
diabetes. 

Spinal  lesions,  as  in  tabes  dorsalis. 

Bulbar  lesions,  as  in  syphilis,  tumors,  softening,  pachymenin- 
gitis, labio-glosso-laryngeal  paralysis,  disseminated  sclerosis, 
tabes  dorsalis,  etc. 

Cerebral  lesions  at  the  foot  of  the  third  frontal  convolution 
and  of  the  subjacent  fibers. 

Lastly,  a  word  concerning  hysteria  and  malingering. 

Aphonia  is  one  of  the  easiest  symptoms  to  simulate,  but  is 
also  one  of  the  easiest  artificial  symptoms  to  detect,  thanks  to 
Zuber's  sign.  When  the  aphonic  malingerer  is  ordered  to 
whistle,  he  insists  he  cannot  do  it;  the  true,  non-malingering 
aphonic  subject  is  generally  able  to  whistle  without  any  trouble, 
since  the  facial  nerve  is  involved  in  this  act,  and  is  unaffected 
by  the  disorders  causing  hoarseness. 


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ARHYTHMIA 

{Irregularities  of 
heart  action,) 


a,  from  a,  privative^  I>v6(i6^^  measure. 
Irregularities  of  heart  action. 


Cardiac  arhythmias,  manifested,  in  cursory  clinical  examina- 
tion, by  more  or  less  distinct  and  pronounced  irregularities  of 
the  pulse,  constitute  a  very  common  condition.  Their  semeio- 
logic  significance  is  always  pronounced  and  sometimes  exceedingly 
great.  The  study  of  the  arhythmias  has  undergone  a  complete 
renaissance  in  recent  years,  and  marked  clinical  benefit  has  re- 
sulted. While  certain  of  the  arhythmias,  as  yet  incompletely  in- 
vestigated, remain  very  difficult  to  interpret,  the  majority,  on 
the  contrary,  are  now  well  understood  from  the  standpoint  of 
pathologic  physiology.  Little  mention  need  here  be  made  of 
the  as  yet  insoluble  problems  relating  to  these  disturbances, 
attention  being  paid,  as  seems  fitting  in  such  a  work,  only  to 
the  facts  that  may  yield  useful  practical  deductions,  i.e.,  con- 
clusions of  actual  therapeutic  service. 

Careful  and  judicious  digital  palpation  of  the  pulse,  combined 
with  correct  auscultation  and  a  critical  study  of  the  associated 
clinical  manifestations,  proves  sufficient  in  90  per  cent,  of  cases 
for  proper  interpretation  of  the  more  commonly  encountered 
arhythmias.  The  graphic  method  (see  the  section  on  technic), 
always  to  be  recommended  where  it  can  readily  be  applied,  is 
sometimes  indispensable.  It  is  the  procedure  of  choice  for  the 
study  of  the  arhythmias.  In  the  subjoined  brief  presentation 
of  the  subject,  extensive  and  legitimate  use  will  be  made  of  the 
results  secured  by  this  procedure. 

In  this  section  only  a  few  typical  examples  of  the  cases  of 
arhythmia  most  often  met  with  in  practice  will  be  given — cases 
which  every  physician  will  certainly  have  occasion  to  observe, 
which  he  may  rather  easily  discover,  and  with  which,  therefore, 
he  should  be  familiar. 

(693) 


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694  SYMPTOMS. 

In  practice,  the  most  frequently  encountered  forms  of  arhythmia 
are: 

1.  Extrasystoles  or  premature  contractions. 

2.  Paroxysmal  tachycardia. 

3.  Respiratory  (sinus)  arhythmia. 

4.  Auriculoventricular  dissociation  or  heart-block. 

5.  Alternating  pulse. 

6.  Perpetual  arhythmia  or  auricular  fibrillation. 

THE  NORMAL  HEART  RHYTHM. 

In  order  to  interpret  most  of  th^e  arhythmias  with  some 
■degree  of  accuracy,  a  short  resume  of  the  facts  now  established 
regarding  the  contraction  of  the  normal  Heart  may  appropriately 
be  given. 

The  cardiac  cycle  consists,  as  is  well  known,  of  a  series  of 
rhythmic  movements,  of  contractions  or  systoles  alternating 
with  periods  of  rest  or  diastoles.  The  several  movements  con- 
stituting the  cardiac  cycle  take  place  in  regular  succession  in 
the  following  order:  Auricular  systole,  ventricular  systole,  gen- 
eral diastole,  auricular  systole,  ventricular  systole,  general  dias- 
tole, etc. 

All  recent  anatomic,  physiologic,  and  physiopathologic  inves- 
tigations have  tended  toward  the  conclusion  that  this  rhythmic 
succession  of  movements  of  the  heart  is  caused  by  a  stimulus 
of  as  yet  unknown. nature  which,  starting  in  the  upper  part  of 
the  right  auricle  in  the  neighborhood  of  the  sinus  of  the  su- 
perior vena  cava,  is  transmitted  from  this  point  through  the 
auriculoventricular  septum  to  the  bundles  of  muscle  fibers  con- 
stituting the  myocardium.  This  apparatus  for  transmission  of 
the  excitomuscular  impulse,  or  neuromyocardial  propagating 
bundle,  has  been  termed  the  bundle  of  His,  after  the  anatomist  who 
first  described  it. 

The  bundle  may  diagrammatically  be  conceived  of  as  follows 
(Fig.  546) :  It  originates  in  the  sinoauricular  node,  a  little  mass 
of  specialized  tissue  consisting  of  muscle  cells  interspersed  with 
a  rich  network  of  nerve  terminals  of  the  cardiac  nerves,  and 
located  in  the  upper  part  of  the  right  auricle,  near  the  opening 
of  the  superior  vena  cava. 


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ARHYTHMIA.  695 

The  rhythmic  stimulus  of  unknown  nature  elaborated  in  this 
center  is  transmitted  along  a  thin  neuromuscular  tract,  the  auric- 
uloventricular  btmdle,  to  a  secondary  center,  the  auriculoventricular 
node,  whence  it  is  further  distributed  to  the  myocardial  bundles  of 
each  ventricle  by  two  main  branches  and  their  subdivisions. 

For  practical  purposes  it  may  be  said  that  the  systolic  stimulus 
originates  at  regular  intervals  of  about  one  second  in  the  sinoauricu- 
lar  node  (the  node  of  Keith  and  Flack) ;  that  it  brings  about  con- 
traction of  the  auricles  at  this  moment ;  that  it  is  transmitted  along 


V,C.,  vena  cava, 
V,P.,  pulmonary  vein. 
P.,  pulmonary  artery. 
A.,  aorta. 

A.D.,  right  auricle. 
A.G.,  left  auricle. 
V.D.,  right  ventricle. 
F.C,  left  ventricle. 
/.  Sinoauricular  node. 

2.  Auriculoventricular  bundle. 

3.  Auriculoventricular  nucleus. 

4^  4'.  Terminal  neuromyocardial  rami- 
fications of  the  bundle. 


Fig.  546. — Diagram  of  the  bundle  which  transmits  the  neuro-myo- 
cardial  stimuli  (bundle  of  His). 

the  auriculoventricular  bundle  to  the  auriculoventricular  node  (the 
node  of  Tawara),  such  transmission  normally  taking  about  one- 
fifth  of  a  second ;  that  it  then  brings  about  ventricular  systole  through 
transmission  of  the  excito-contractile  impulse  to  the  myocardial 
muscle  fibers  along  the  branches  of  the  above  mentioned  auriculo- 
ventricular bundle.  Both  auricles  and  ventricles  then  lapse  into  a 
condition  of  rest  and  lose  their  irritability  for  a  period  of  two-  to 
three-fifths  of  a  second,  after  which  the  cycle  of  contraction  above 
described  is  again  reproduced. 

Objective  representation  of  this  cycle  is  well  afforded  either 
in  polygrams  showing  simultaneously  arterial  contractions  such 
as  those  of  the  radial,  which  accurately  register  the  ventricular 
systole  with  a  delay  of  approximately  one-tenth  of  a  second 


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696 


SYMPTOMS. 


(time  of  transmission  of  the  pulse  wave  to  the  radial  artery), 
and  the  pulsations  of  the  right  jugular  vein,  which  represent 
for  practical  purposes  the  pulsations  of  the  superior  vena  cava 
and  the  right  auricle;  or,  in  a  good  cardiogram  taken  with  the 
patient  in  left  lateral  decubitus  (Pachon). 


»   »  1  <  ■   «    »   »'■■»  '»  w  ■  <   »    I    I   ■   I  !■    i|*|»|    ■•    i»««'«^w     "••'••fi    »•    Ilia* 


Ri^ 


^  er 


s  e 


Fig.  547. — Case  157.    Normal  pulse.    Rj,  right  jugular. 
Rr,  right  radial. 

A  few  samples  of  polygrams  showing  a  normal  rhythm  and 
typical  from  the  standpoint  just  referred  to  are  herewith  pre- 
sented. 

On  a  polygram  the  beginning  of  the  systolic  expansion  of 


Rj. 


9    e     r 


Rr. 


Fig.  548. — Case  504.    Normal  pulse.    Rj,  right  jugular. 
Rr,  right  radial. 

the  radial  artery  is  very  easily  located,  being  at  start  of  the 
ascending  line;  if,  taking  into  account  the  time  required  for 
transmission  of  the  ventricular  systolic  contraction  to  the  radial 
artery  (about  Y^o  second),  one  turns  from  the  radial  tracing  to 
the  jugular  tracing  at  a  point  preceding  the  above-mentioned 


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ARHYTHMIA.  697 

point  by  Y\o  second,  the  point  corresponding  in  time  to  the  ven- 
tricular systolic  contraction  is  obtained.  The  jugular  tracing 
then  becomes  very  easy  to  interpret  (Figs.  547  and  548).  Each 
cardiac  cycle  is  reflected  in  the  jugular  tracing  by  three  eleva- 
tions : 


Fig.  549.— Normal  electrocardiogram  {Daniel  Rvutier) . 

1.  A  presystolic  wave,  a,  corresponding  to  auricular  systole,  and 
presystolic  in  respect  of  the  ventricular  contraction.  This  is  gen- 
erally represented  by  the  letter  a  (auricular). 

2.  A  systolic  wave,  c,  immediately  following  the  preceding,  from 
which  it  is  separated,  as  a  rule,  only  by  a  very  slight  depression ; 


V," 


y.  normal 


Fig.  550. — Diagram  showing  the  succession  of  motor  events  in  the 
normal  heart.  The  auricle  A  contracts  first  and  sends  its  impulse  to  the 
ventricle  F  along  the  bundle  F.  The  ventricle  at  once  begins  to  contract. 
The  time  of  transmission,  which  is  approximately  the  same  as  the  dura- 
tion of  auricular  systole,  is  about  %  second.  R,  radial  tracing;  /,  jugu- 
lar tracing.    Marks  at  the  top :  Time  in  fifths  of.  a  second. 

it  corresponds  to  ventricular  systole.  It  is  generally  represented 
by  the  letter  c  (carotid)  because  the  earlier  observers,  Mackenzie 
among  others,  ascribed  it  to  the  carotid  pulsation,  which,  how- 


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698  SYMPTOMS. 

ever,  does  not  seem  always  to  be  the  case.    At  all  events  this 
notation  will  here  be  preserved. 


Fig.  551. — The  pneumogastrics  (Landois). 

3.  A  post-systolic  wave,  v,  distinctly  separated  from  the  wave 
preceding  it,  c,  and  from  that  which  follows  it,  a,  in  the  next 
cardiac  cycle  by  2  definite  depressions,  x  and  y.     This  wave  is 


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ARHYTHMIA.  699 

generally  represented,  in  accordance  with  Mackenzie's  notation,  by 
the  letter  v  (ventricular),  Mackenzie  ascribing  it,  or  at  least  its 
terminal  portion,  to  relaxation  of  the  right  ventricle  and  opening 
of  the  tricuspid  orifice.  The  exact  significance  of  this  wave  has 
been  the  subject  of  prolonged  discussion  and  is  still  being  discussed ; 
as  a  matter  of  fact  it  is  one  of  the  most  fixed  and  constant  and 
often  one  of  the  most  pronounced  features  of  the  venous  pulse 


Pneumog. 

nerve. 

pve. 


)Qll. 

Recurrent  nerve. 

Middle  ai 
cardiac  z  rve. 

LIB. 

Phrenic  nei 


plexus, 
rdiac 


Fig.  552.--The  nerves  of  the  heart  (Hirschfeld). 

tracing;  it  corresponds  practically  to  the  diastolic  rebound  of  the 
radial  pulse,  to  the  opening  of  the  tricuspid  valve  and  the  closure 
of  the  sigmoid  valves.  The  notation  7',  is  thus  highly  appropriate 
for  it,  provided  there  be  attached  to  it  the  meaning  valvular, 
which  is  more  comprehensive.  Actually  it  marks  the  termination 
of  ventricular  systole  and  the  beginning  of  general  diastole  of  the 
heart. 

The  normal  electrocardiogram  lends  itself  to  the  same  con- 
siderations (Fig.  549). 

The  successive  movements  of  the  normal  heart  and  the  trans- 
mission of  the  neuromyocardial  impulse  of  contraction  may  be 


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700 


SYMPTOMS. 


represented  in  a  diagram  which  will  greatly  facilitate  presenta- 
tion of  the  subject  of  the  arhythmias  (Fig.  550). 

The  apparatus  having  to  do  with  intracardiac  conduction 
may  be  and  unquestionably  is  influenced  and  partly  controlled 
by  the  vagus  and  the  sympathetic.  Some  of  the  cardiac  arhyth- 
mias are  known  to  originate  in  the  extracardiac  nervous  mechan- 
ism, consisting  chiefly  of  the  bulb,  the  vagus,  and  the  sympa- 
thetic; it  seems  desirable,  therefore,  to  reproduce  and  show  in 
a  diagram  the  distribution  of  these  nerves  (Figs.  551  to  5S3). 
These  illustrations  will  doubtless  facilitate  comprehension  of 
certain  forms  of  arhythmia. 


Mf^uMat 


Ihtebra/ yanfff/a 


toikinknd 


Heart 


Fig.  553. — The  nervous  system  as  related  to 
the  circulation.  Connections  of  the  vagus  and 
sympathetic  nerves. 


DISTURBANCES  OF  RHYTHM. 
EXTRA-SYSTOLES  (PREMATURE  BEATS). 

The  normal  cardiac  rhythm  is  produced,  we  have  seen,  by 
an  impulse  which,  starting  at  regular  intervals  from  the  sinoau- 
ricular  node,  or  node  of  Keith  and  Flack,  passes  down  along  the 
conducting  system  previously  described,  awakening  in  succes- 
sion a  contraction  of  the  auricle  and  then  of  the  ventricle.  The 
process  goes  on  as  if  the  entire  cardiac  rhythm  were  governed 
by  the  primary  contractions  of  the  auricle,  these  in  turn  regu- 
larly setting  off  secondary  contractions  of  the  ventricle. 

An  extra-systole  or  premature  contraction  is  an  extraordinary, 
premature  systole  occurring  independently  of  the  above-men- 


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ARHYTHMIA. 


701 


(a) 


ib) 


November  20,  1911 


16 


November  29,  tqtt 


'  v^^xp-N^XI^^^^xT^^ 


VSs5.8 


IS  Nov,  29,  191  J,  5  minutes  after  the  preceding 


86 


\! 


VS«S.8 


15 

December  8,  19^ 

jW- 

vy-v-.^ 

V5.5.6        * 

/w-./^.W->/\ 

IS 

December  16,  191  r 

»"»VA 

nTK/^-vP- 

VS«<k2 

.r-sT-jvp^JX, 

Fig.  554. — Premature  contractions    (extrasystoles)    during  an  attack  of 
gout,    (a)  Bigeminal  and  (b)  trigeminal  pulse. 


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702 


SYMPTOMS, 


^  tioned  regular  succession  of  contractions.  Everything  takes 
place  as  if  the  initial  stimulus  arose  at  an  abnormal  point — inde- 
pendently of  the  sinoauricular  node — either  in  the  auricle,  in  the 
ventricle,  or  in  the  intermediate  auriculoventricular  node.  Hence 
there  are  3  kinds  of  extra-systoles:  Auricular,  ventricular,  and 
auriculoventricular.  These  are  sometimes  rather  hard  to  differ- 
entiate. 

An  extra-systole*  is  generally  felt  by  the  patient  as  a  precordial 
thump  accompanied  by  slight  discomfort  and  an  evanescent 
tendency  to  fainting. 

tiiiiiiiiiiiiiiliiiiiiiiiiiiiltl 


Fig.  555. — ^Ventricular  extra-systole  or  premature  beat.  The  third 
ventricular  contraction  takes  place  too  soon.  The  third  auricular  con- 
traction, taking  place  during  the  period  of  lost  ventricular  irritability 
(refractory  period),  fails  to  induce  a  contraction  of  the  ventricle.  /, 
jugular;  R,  radial;  A,  auscultation. 

It  is  detected  by  the  physician  upon  palpation  of  the  pulse  in 
the  form  of  an  intermittence  in  the  latter,  a  pause  of  unusual 
length,  suppression  of  one  pulse  wave,  a  "misstep  of  the  heart." 
Sometimes  an  ordinary  beat  is  very  closely  followed  by  a  very 
small  beat  succeeded  by  a  long  pause ;  at  other  times  there  is  felt 
but  one  ordinary  pulsation,  followed  by  a  long  pause. 

Auscultation  yields  significant  results  (Figs.  555  and  556)* 
If  the  extra-systole  is  strong  enough  (and  sufficiently  late  in 
respect  of  the  preceding  contraction)  to  open  the  sigmoid  valves, 


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ARHYTHMIA, 


703 


the  double  sound  of  the  preceding  systole  is  at  once  followed 
by  a  double  echo  sound  due  to  the  extra-systole,  and  then  by 

I  I  I  I  I  I  I  I  t  I  I  f  I  I  I  I  I  I  I  I  I  I   I  I  I  I  I  I  I 


f^\^^J^\/r^r^A->^\^>V 


II    1 1  1 1 II    I  I  1 1 


Fig.  556.— Auricular  extra-systole.    /,  jugular;  R,  radial; 
A,  auscultation. 

a  prolonged  pause.    The  rhythm  has  been  reduplicated  and  now 
includes  four  sounds.     If  the  extra-systole   is  too  weak   (and 

I  I  I  I   I   I  I  I  t  I  I  I  I  I  I  I  I  f  I  I  I  I  I  I  I  I  I  I  f 


II     II     I  III         I    I    I  i 

Fig.  557. — Auriculoventricular  extra-systole. 

comes  too  soon  after  the  preceding  contraction)   to  open  the 
sigmoid  valve,  the  double  sound  of  the  preceding  systole  is  fol- 


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704  SYMPTOMS. 

low^d  by  a  single  souml  due  to  the  ventricular  contraction  in  the 
extra-systole  (the  rhythm  now  entailing  3  sounds),  and  then  by 
a  long  pause. 

These  extra-systoles  may  recur  at  quite  irregular  intervals,  de- 
void of  any  regular  rhythm.  If,  on  the  other  hand,  they  occur  in 
series  at  regular  intervals  they  constitute  allorhythmias.  If  each 
regular  systole  is  followed  by  an  extra-systole,  the  pulse  assumes 
a  bigeminal  character;  if  the  extra-systole  recurs  regularly  after 
2  regular  systoles,  the  pulse  is  trigeminal;  after  3  regular  sys- 
toles, quadrigeminal,  etc.     (Fig.  554). 

Such  are  the  simplest  and  most  fundamental  clinical  observa- 
tions that  can  be  made  without  the  help  of  any  form  of  instru- 
ment. 


9 

Fig.  558. — Case  205.    Ventricular  extra-systole.    Pulse, 
74;  pressure,  2i%q. 

The  foregoing  diagrams  will  have  afforded  a  good  demonstra- 
tion of  the  nature  of  the  phenomenon  (Figs.  555,  556,  and  557). 

Differentiation  of  the  several  varieties  of  extra-systoles  is 
attended  with  greater  difficulty,  requiring  the  application  of  the 
graphic  method ;  it  may  even  prove  difficult  when  this  procedure 
is  availed  of. 

Ventricular  extra-systoles  are  distinguished  from  auricular 
extra-systoles  by  the  3  following  features: 

1.  The  total  duration  of  the  cycle  consisting  of  an  ordinary  systole 
and  a  ventricular  extra^systole  is  equal  to  that  of  a  cycle  formed 
of  two  ordinary  systoles;  this  duration  is  appreciably  less,  however, 
in  the  case  of  a  cycle  consisting  of  an  ordinary  systole  and  an  auric- 
ular extra^systole.  This  sign  is  the  simplest,  most  constant,  and 
most  readily  observed  of  the  signs  differentiating  these  2  varie- 
ties of  extra-systoles.  It  can  be  recognized  even  in  a  simple 
radial  tracing  (Fig.  558). 

2.  On  polygrams,  if  the  extra-systole  has  forced  open  the  sig- 
moid valves,  it  is  shown  in  the  tracing  by  a  premature  contraction 


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ARHYTHMIA,  705 

followed  by  a  more  or  less  prolonged  pause,  which  is  always 
definitely  more  prolonged  than  the  normal  diastolic  pause  (Figs.  558 
and  559).  If  the  extra-systole  has  not  opened  the  sigmoid  valves, 
the  radial  tracing  shows  no  evidence  of  any  premature  inter- 
polated elevation;  one  merely  notes  the  absence  of  one  beat, 
and  a  diastolic  pause  of  manifestly  abnormal  duration.  The 
jugular  tracing,  when  distinct,  is  rather  characteristic  of  one  or 


Fig.  559.— Ventricular  extra-systole  {Daniel  Routier). 

the  othes  variety  of  extra-systole.  In  ventricular  extra-systole 
a  rise  synchronous  with  the  extra-systolic  elevation  at  the  radial 
artery  is  observed  during  the  abnormal  pause;  in  auriculoven- 
tricular  extra-systole,  the  extra-systolic  jugular  pulse  wave  often 
occupies  exactly  the  place  which  should  have  been  occupied  by 
the  auricular  elevation,  and  since  it  brings  together  simultane- 
ously the  auricular  and  ventricular  systoles,  it  is  single  and  is 
frequently  definitely  higher  than  the  normal  systoles  that  pre- 


Fig.  560. — Auricular  and  auriculoventricular  extra-systolci 
(Daniel  Routier). 

cede  and  follow  it;  in  auricular  extra-systole,  the  interpolated 
extra-systolic  jugular  tracing  represents  in  miniature  the  events 
occurring  in  an  ordinary  cardiac  cycle  with  its  three  waves:  a, 
presystolic  or  auricular;  c,  systolic  or  ventricular,  and  v,  post-sys- 
tolic or  valvular  (Figs.  558,  559,  560,*  561). 

It  should  not  be  overlooked  that  in  some  instances  the  trac- 
ing's are  rather  hard  to  interpret;  under  these  circumstances 
electrocardiography  may  be  of  service. 

46 


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706  SYMPTOMS. 

3.  Again,  whereas  in  ventricular  extra-systoles  the  normal 
rhythm  of  the  heart,  aside  from  the  premature  contraction  itself, 
is  not  disturbed,  this  is  not  true  of  the  auricular  extra-systoles, 
in  which,  even  apart  from  the  extra-systole,  the  heart  rhythm 
may  exhibit  more  or  less  irregularity. 

The  extra-systole  or  premature  contraction  is  by  far  the  most 
common  form  of  arhythmia  encountered  in  cardiologic  practice. 
We  have  already  seen  the  high  degree  of  accuracy  with  which 
the  physiopathologic  diagnosis  may  be  established  in  these  cases. 
On  the  other  hand,  much  discussion  is  still  going  on  regarding 
the  prognosis ;  the  extra-systole,  indeed,  is  a  common  reactive  mani- 


+-¥4- 


Fig.  561. — Case  72,    Auriculoventricular  extra-systole. 

festation  on  the  part  of  the  myocardium  which  m<iy  be  observed 
under  the  most  varied  circumstances.  Dyspepsia  and  aerophagia 
frequently  induce  extra-systoles  of  reflex  origin,  practically  devoid 
of  significance  from  the  cardiac  standpoint;  yet  these  same  ex- 
tra-systoles may  be  expressions  of  more  or  less  marked  degen- 
eration of  the  myocardium. 

In  short,  the  extra-systole  per  se  is  of  no  prognostic  significance ; 
all  depends  upon  the  circulatory  symptoms  and  signs  which 
accompany  it. 

For  practical  purposes,  there  may  be  differentiated: 
1.  Fimctional,  reflex  extra-systoles  (aerophagia,  dyspepsia, 
or  nervousness)  or  toxic  extra-systoles  (gout) — intermittent, 
temporary  extra-systoles  generally  unaccompanied  by  any  dis- 
turbance of  the  circulation  save  occasionally  a  temporary  eleva- 
tion of  blood-pressure  (neurocardiac  erethism),  and  devoid  o£ 
any  prognostic  significance  as  regards  the  heart  and  circulation. 


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ARHYTHMIA,  707 

2.  Lesional  extra-systoles,  as  a  rule  practically  permanent, 
occurring  in  conjunction  with  some  myocardial  lesion  and  ac- 
companied by  the  ordinary  signs  of  myocardial  and  vascular 
degeneration  which  will  be  repeatedly  mentioned  hereinafter — 
changes  of  blood-pressure,  stasic  phenomena,  dyspnea  on  ex- 
ertion, signs  of  aortic  degeneration,  etc.  In  this  event  the  extra- 
systole  is  a  sign  of  myocardial  degeneration  which,  taken  in 
conjunction  with  the  others,  leads  to  the  usual  guarded  prog- 
nosis of  myocarditis. 

In  brief,  detection  of  extra-systoles  should  lead  the  practi- 
tioner to  make  a  complete,  systematic  examination  of  the  cir- 
culatory system.  If  the  examination  proves  negative,  the  prog- 
nosis will  be  definitely  favorable,  viz,,  that  of  aerophagia,  dys- 
pepsia, or  gout;  if,  on  the  contrary,  it  leads  to  detection  of  the 
customar}*^  signs  of  myocarditis,  the  prognosis  rendered  should 
be  that  of  myocarditis.  There  is  no  doubt  but  that  the  extra- 
systole  may  be,  in  the  eyes  of  the  patient,  the  first,  significant 
sign  showing  the  presence  of  degenerative  myocarditis — it  is 
from  this  viewpoint  that  its  detection  is  of  such  interest  to  the 
cardiologist. 

PAROXYSMAL  TACHYCARDIA. 

Consideration  of  paroxysmal  tachycardia  is  here  taken  up  di- 
rectly following  that  of  extra-systoles  because  recent  cardiologic 
investigations  have  led  to  considering  paroxysmal  tachycardia  as 
consisting  of  extrc^sy stoles,  generally  of  the  auricular  type,  occur- 
ring in  uninterrupted  succession  for  a  period  or  paroxysm  which 
may  last  from  a  few  sevonds  to  several  weeks. 

The  subjoined  diagram  will  satisfactorily  illustrate  the  process 
and  may  take  the  place  of  a  definition  (Fig.  562). 

The  diagnosis  of  paroxysmal  tachycardia  is  relatively  easy: 
It  may  be  put  down  as  an  axiom  that  any  tachycardia  exceeding 
110  beats  per  minute,  sudden  in  onset,  unaccompanied  by  exoph- 
thalmic goiter,  not  appearing  in  the  presence  of  a  febrile  disorder, 
and  the  rate  of  which  is  not  appreciably  modified  by  shifting  from 
the  recumbent  to  the  vertical  posture,  is  paroxysmal  tachycardia. 
Difficulty  of  recognition  arises  only  in  individuals  seen  for  the 
first  time,  whose  history  is  not  known,  and  who,  in  conjunction 


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708 


SYMPTOMS, 


with  more  or  less  pronounced  tachycardia  or  tachyarhythmia, 
exhibit  evident  manifestations  of  cardiac  impairment,'  such  as 
dilatation  of  the  heart,  edema  of  the  lungs,  congestion  of  the 
liver  and  spleen,  reduced  urinary  output,  edema,  etc.  It  may 
be  hard  to  find  out  whether  the  paroxysmal  tachycardia  was  the 
initial  manifestation  of  the  trouble  or  whether,  on  the  other 
hand,  the  tachyarhythmia  observed  is  merely  an  evidence  of 
heart  failure.  The  sudden  onset,  accurate  graphic  studies,  and 
the  therapeutic  test  will  settle  the  question  of  diagnosis  under 
such  circumstances. 

The  onset  is  always  abrupt — and  is  frequently  perceived  by 


••••«iiiii^»rist 


I   I   I   I   I   I   I   I  |.  fi  I  9  • 


Fig.  562. — Diagram  representing  a  brief  attack  of  paroxysmal  tachy- 
cardia consisting  of  eight  successive  auricular  extra-systoles  (premature 
contractions).  A  ventricular  contraction  takes  place  in  conjunction  with 
each  of  these  extra-systoles.  Note  the  abrupt  onset  and  termination  of 
the  attack  and  the  unusual  prolongation  of  the  final  pause. 

the  patient  as  a  kind  of  sudden  thump  in  the  precordium,  a  sen- 
sation of  unleashing  of  the  heart,  or  a  pronounced  palpitation 
coupled  with  general  malaise; — at  times,  however,  no  subjective 
sensation  is  awakened. 

The  duration  may  be  extremely  short — ^the  attack  consisting 
merely  of  a  series  of  premature  beats  varying  from  a  few  to 
several  dozens  in  number.  The  attack  generally  continues  from 
a  few  hours  to  a  few  days,  more  rarely  a  few  weeks. 

Sometimes  the  paroxysm  is  unaccompanied  by  any  appre- 
ciable subjective  sensation.  Usually,  however,  there  are  ob- 
served digestive  disturbances,  such  as  flatulence,  regurgitation,  nau- 


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^  ARHYTHMIA.  709 

sea,  and  vomiting,  and  cardiac  manifestations,  some  of  the  anginose 
type,  e.g.,  distressing  dyspnea  or  a  sensation  as  of  constriction, 
gripping,  pressure  by  a  tight  band,  or  squeezing,  others  of  the 
type  of  inadequate  heart  action,  e,g,,  congestion  of  the  liver  and 
lungs,  cyanosis,  venous  engorgement,  etc. 

Usually  the  attack  ends  abruptly,  as  it  began.  Very  exception- 
ally sudden  death  has  been  witnessed;  sometimes,  though  very  in- 
frequently, the  heart-muscle  is  observed  gradually  to  give  out, 
death  taking  place  from  asphyxia. 

As  in  the  case  of  extra-systoles,  the  prognosis' ol  paroxysmal 
tachycardia  is  much  less  dependent  upon  the  tachycardia  per  se 
than  upon  other  attendant  factors,  particularly  the  pre-existing 
state  of  the  myocardium. 

'Tkhjc)>snxjs26.ity,"  *h^ 

J 


Fig.  563. — Paroxysmal  tachycardia  {Daniel  Routier). 

For  practical  purposes  one  may,  as  with  extra-systoles,  dis- 
tinguish : 

The  functional  paroxysmal  tachycardia  of  the  neurotic,  the 
abnormally  impressionable,  and  the  sphygmolabile,  unassociated 
with  any  appreciable  pathological  changes  and  exhibiting,  in 
the  intervals  between  attacks,  a  perfect  circulatory  balance,  with 
absence  of  any  permanent  symptom.  This  form  of  paroxysmal 
tachycardia  is  not,  as  a  rule,  of  serious  import. 

The  organic  paroxysmal  tachycardia  associated  with  or  even 
dependent  upon  manifest  lesions  of  the  myocardium  or  endo- 
cardium, consisting  most  frequently  of  cardioarteriorenal  scler- 
osis or  of  mitral  stenosis.  The  prognosis  in  these  cases  is  that 
of  the  underlying  disease,  aggravated  by  a  paroxysm  which,  by 
its  prolonged  duration,  may  in  itself  constitute  a  cause  of  rapid 
exhaustion  of  the  heart-muscle. 

Thus,  under  such  circumstances  the  author  witnessed  death 
in  seven  days  from  progressive  cardiac  failure  in  a  patient  80 
years  old,  suffering  from  well  compensated  cardiovascular-renal 


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710  SYMPTOMS. 

sclerosis,  who  was  seized  with  paroxysmal  tachycardia  (heart- 
rate  170  to  180)  one  evening.  Dyspnea  was  rather  pronounced, 
the  respiratory  rate  ranging  from  22  to  48;  the  heart-sounds 
were  muffled  and  unequal;  no  cough,  no  fever,  no  expectoration, 
no  edema,  and  no  congestion  of  the  liver  or  lungs;  there  were 
marked  borborygmi  and  meteorism,  and  dyspnea  and  arhythmia 
recurred  upon  the  slightest  attempt  to  take  food;  the  least  ex- 
ertion brought  on  a  feeling  of  constriction,  pressure,  and  op- 
pression, with  anginose  manifestations. 

Although  not  a  complete  failure,  treatment  by  mustard  packs, 
digalen,  camphor  in  oil,  sparteine,  oxygen  injections,  etc.,  proved 
insufficient.  Progressive  weakening  of  the  heart  action  was 
witnessed,  with  associated  congestion  of  the  bases  of  the  lungs, 
paroxysmal  seizures  of  cardiac  dyspnea,  reduced  urinary  output, 
and  polypnea.     Death  supervened  on  the  seventh  day. 

The  author's  other  cases  of  the  same  disorder  recovered  after 
paroxysms  lasting  from  a  few  hours  to  a  few  weeks. 

In  short,  the  pathological  lesions  present  along  with  the 
syndrome,  and  the  duration  of  the  tachycardial  attack,  are  the 
main  factors  governing  the  prognosis.  Generally  the  prognosis 
as  regards  continuance  of  life  is  favorable,  even  in  the  presence 
of  advanced  sclerotic  lesions. 

RESPIRATORY  (SINUS)  ARHYTHMIA. 

Respiratory  or  sinus  arhythmia  is,  next  to  extra-systolic 
arhythmia,  the  form  of  heart  irregularity  most  frequently  en- 
countered in  practice.  It  is  definitely  known  to  be  the  mildest 
of  the  several  forms  of  arhythmia. 

The  description  of  the  normal  heart  rhythm  already  given 
will  greatly  facilitate  comprehension  of  this  form  of  arhythmia. 
In  accordance  with  the  physiopathologic  observations  already 
recalled,  the  normal  rhythm  of  the  heart  is  dependent  upon  a 
stream  of  regular  stimuli  starting  rhythmically  in  the  sinoau- 
ricular  node  (node  of  Keith  and  Flack)  and  transmitted  thence 
in  succession  to  the  auricular  myocardium  and  the  ventricular 
myocardium  by  the  conducting  system  previously  referred  to. 
This  sinoauricular  node,  however,  is  itself  manifestly  under 
the  control  of  the  vagus  or  pneumogastric  nerve,  which  exerts 


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ARHYTHMIA. 


711 


an  inhibitory  effect  upon  it.  Destruction  of  the  pneumogastric, 
more  especially  of  the  trunk  on  the  right  side,  or  its  physiologic 
suppression   by   the   administration    of    atropine,    which   paralyzes 


1HW1»>||I|'|IH||IIII   III 


I  i  ■  1 1  I  I  1 1  I 


Respiration. 


Right  radial. 


Fig.  564. — Case  236.    Respiratory  (sinus)  arhythmia. 

it,  consequently  accelerates  the  heart-rate;  stimulation  of  it,  on 
the  other  hand,  slows  the  heart. 

As  a  rule,  in  man,  this  brake-like  or  inhibitory  action  of  the 
vagus  is  not  noticeable.     In  certain  individuals,  however,  par- 


Respiration 


Fig.  565. — Case  236.    Sinus  arhythmia. 

ticularly  in  the  majority  of  children,  as  well  as  in  a  few  adults 
(and  always  in  dogs),  this  action  is  plainly  present  and  is  mani- 
fested in  a  pronounced  arhythmia,  affecting  both  the  frequency 


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712 


SYMPTOMS. 


and  the  amplitude  of  the  heart-beats,  and  distinctly  subordinate 
to  the  respiration.  Even  a  cursory  examination,  with  simulta- 
neous palpation  of  the  radial  pulse  and  the  respiratory  rhythm 
(inspiration  and  expiration),  reveals  a  manifest  relationship  be- 


■ 11  I'H^ I  M 


111!  »  mil  nil  II I  I  II   I  II I  llnTI  ijll 


^ 


/.^..>gwi^H'^Jhl4-^»^^ 


.t{J^^,^ 


Fig.  566. — Case  236.    Sinus  arhythmia. 

tween  the  arhythmia  and  the  time  of  the  respiratory  movements, 
the  circulatory  irregularity  being  observed  to  consist  of  an  ac- 
celeration of  the  pulse  occurring  with  inspiration  and  a  slowing 
of  the  pulse  with  expiration. 


]1^.f..lf,.\f?f.^'!\f'.\.''!t.\ 


Fig.  567. — Case  263.    Sinus  arh)rthmia.    Cardiogram. 
E,  expiration ;  /,  inspiration. 

The  tracings  herewith  reproduced  (Figs.  564  to  567)  clearly 
illustrate  this  close  interdependence  between  the  circulation  and 
respiration.  As  a  matter  of  fact,  the  phenomenon  is  merely  the 
expression  of  a  normal  condition  to  an  exaggerated  degree,  and 
may  almost  always  be  recorded  if,  while  a  tracing  is  made,  the 


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ARHYTHMIA,  713 

respiratory  movements  are  purposely  amplified  to  the  point  of 
deep  inspiration  and  forced  expiration. 


a  c 


AaXV-^'A^^W^ 


Fig.  568. — ^Diagrram  illustrating  respiratory  (sinus)  arhythmia.  A  and 
V  stand,  respectively,  for  the  auricular  and  ventricular  contractions,  taking 
place  in  normal  succession.  The  arhythmia  here  consists  of  an  alter- 
nate acceleration  and  slowing  of  the  auriculoventricular  cycles,  due  to 
actual  arhythmia  of  the  initial  stimulus  originating  at  the  sinus. 

This  form  of  arhythmio.,  representing  at  most  the  exagger- 
ated expression  of  a  normal  process,  perhaps  points  to  an  in- 


VV  V  VVVV'VVnivS 


Fig.  569. — Case  36  ter,    Cheyne-Stokes  rhythm.    H.,  61  years;  Feb.  28, 
1913;  sitting  position;  pulse,  100  (?)  ;  pressures,  ®*9i8o;  viscosity,  6.4. 

creased   irritability   of  the   sinoauricular   node.     At   all   events 
it  is  certainly  devoid  of  all  prognostic  significance,  and  yields 


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714  SYMPTOMS. 

but  a  single  therapeutic  indication,  vis.,  that  of  allaying  all 
apprehension  on  the  part  of  the  patient  and  his  family,  and 
therefore  of  ordering  no  treatment,  which  might  simply  lead 
the  patient  to  fear  and  believe  that  some  abnormal  condition 
was  really  present  in  his  case. 

The  above  diagram  will  s^sist  the  reader  in  understanding 
the  probable  mechanism  of  this  form  of  arhythmia  (Fig.  568). 

As  a  matter  of  interest  there  is  also  reproduced  herewith 
a  tracing  from  a  case  of  respiratory  arhythmia  in  which  condi- 
tions were  manifestly  far  different  from  the  group  previously 
referred  to;  the  tracing  was  obtained  in  an  azotemic  patient 
during  an  attack  of  cardiorespiratory  dyspnea  of  the  so-called 
'*Cheyne-Stokes  type"  (Figs.  569  and  570). 


Fig.  570. — Case  36  ter.    Cheyne-Stokes  rhythm  (continued), 
(To  be  read  from  right  to  left). 

AURICULOVENTRICULAR  DISSOCIATION. 

The  diagrams  already  presented  in  illustration  of  the  normal 
heart  rhythm,  extra-systoles,  and  paroxysmal  tachycardia  are  of 
further  marked  utility  in  defining  and  describing  auriculoventricular 
dissociation  or  heart-block. 

The  normal  rhythm  of  the  heart  is  dependent  upon  regular 
transmission  of  a  stimulus  to  contraction  from  the  sinoauricular 
node  (of  Keith  and  Flack)  from  the  auricle  to  the  ventricle  along 
the  bundle  of  His  (Fig.  571). 

If  this  process  of  transmission  is  protracted  or  delayed  owing 
to  some  hindrance  to  conduction,  as  shown  in  Fig.  572,  a  tend- 
ency to  heart-block  will  occur  which  will  be  shown  in  tracings 
by  increased  length  of  the  a-c  interval  and  by  the  appearance 
of  a  short  pause  between  the  end  of  auricular  systole  and  the 
beginning  of  ventricular  systole.    This  constitutes  auriculoven- 


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ARHYTHMIA,  715 

tricular  dissociation  of  the  first  degree,  or  better,  a  tendency  to- 
ward heart-block  (Fig.  572). 

If  transmission  is  interrupted  from  time  to  time,  if  some 

«^ 

A 

r 


^  normal 

Fig.  571. — Normal  tracing. 

obstacle  to  conduction  results  in  its  being  occasionally  broken 
oflF,  some  of  the  auricular  systoles  will  fail  to  send  their  con- 
tractile impulses  to  the  ventricle. 


M/M>*^A/''^Ay^ 


Fig.  572. — ^Tracing  showing  a  tendency  to  auriculoventricular  dissociation. 
Delayed  conduction.    Prolongation  of  the  o-r  interval. 

Suppression  of  some  of  the  ventricular  contractions  will  oc- 
cur under  these  conditions.  This  constitutes  auriculoventricu- 
lar dissociation  of  the  second  degree  or  incomplete   (partial) 


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716 


SYMPTOMS. 


heart-block  (Fig.  573).  If  the  interruption,  at  first  accidental 
and  irregular,  increases  and  becomes  regular  and  rhythmic,  the 
degree  of  dissociation  may  be  expressed  in  some  definite  ratio. 
Thus,  if  the  ventricle  responds  once  out  of  twice  to  the  auricu- 
lar stimulus,  the  heart-block  is  stated  to  be  of  the  2:1  variety; 
if  it  responds  only  once  out  of  three  times,  of  the  3:1  variety, 
and  so  on. 

The  ultimate  degree  of  aiuiculoventricular  dissociation,  or 
complete  heart-block,  is  produced  when  all  conduction  between 

I9IIIIIIIIIII   Itlltlllllllfl 


II  II 


I       I  I     I 


Fig.  573. — Partial  heart-block.    Incomplete  auriculo- 
ventricular  dissociation. 

the  auricle  and  ventricle  is  arrested,  as  illustrated  in  Fig.  574; 
the  auricles  and  the  ventricles  contract  independently;  their 
respective  rhythms  are  completely  dissociated  and  unrelated. 
The  auricular  rate  is  about  72  to  the  minute,  while  the  ventricu- 
lar is  30.  There  is  said  to  be  present  a  bradycardia  through 
auriculo-ventricular  dissociation. 

The  foregoing  statements  constitute  the  simplest  descrip- 
tion that  can  be  given  of  auriculoventricular  dissociation  or 
heart-block  (Figs.  571  to  574). 

The  seat  of  this  form  of  arhythmia  is  plainly  the  bundle  of 
His.  This  bundle  has  been  found  diseased  in  most  of  the  cases 
of  auriculctventricular  dissociation  coming  to  autopsy;  yet  this 
systematic  investigation  has  given  absolutely  negative  results 


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ARHYTHMIA. 


717 


in  a  certain  number  of  instances.  One  is  therefore  led  to  the 
conclusion  that,  as  in  the  case  of  extra-systoles  or  tachycardia, 
there  may  occur,  aside  from  the  organic,  permanent  auriculo- 
ventricular  dissociation  due  to  disease  of  the  bundle  of  His 
(gumma,  fibrosis,  post-infectious  or  post-rheumatic  degenera- 
tions), cases  of  functional,  transitory  auriculo-ventricular  disso- 
ciation (digitalis  block,  temporary  block  in  rheumatism  and  in- 
fectious diseases,  stimulation  of  the  vagus,  etc.). 

For  practical  purposes,  syphilis,  rheumatism,  and  connective 

•  I  f  I  I  I  I  t  I  I  I  t  I  f  I  I  I  I  t  I  I  I  I  I  I  I  I  1  f  1 

\  \  \  \  \  \  \ 
\   \   \    \ 


Fig.  574. — Complete  auriculoventricular  dissociation.     The  auricles  and 
ventricles  contract  inco-ordinately  and  independently. 

tissue  degenerations  are  dominant  in  the  etiology  of  auriculo- 
ventricular dissociation. 

Finally,  it  may  be  added  that,  in  regard  to  the  semeiology  of 
bradycardia,  it  is  necessary  to  distinguish  instances  of  bradycardia 
which  might  be  termed  fascicular,  being  due  to  disease  or  defective 
functioning  of  the  bundle  of  His  and  auriculoventricular  disso- 
ciation, and  the  nodal  or  total  forms  of  bradycardia,  the  result 
of  deficiency  in  the  process  of  stimulus  production  in  the  sino- 
auricular  node,  and  imaccompanied  by  auriculoventricular  disso- 
ciation. 

Diagnosis. — ^The  problem  of  diagnosis  of  auriculoventricular 
dissociation,  as  it  is  placed  before  the  unspecialized  practitioner, 
may  seemingly  be  presented  as  follows: 


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718  SYMPTOMS. 

The  diagnosis  of  incomplete  auriculoventricular  dissociation 
is  practically  limited  to  a  differentiation  of  this  condition  from 
extra-systole.  Radial  palpation  and  simultaneous  auscultation  of 
the  heart  permit  of  easily  and  almpst  positively  settling  the 
question.  In  auriculoventricular  dissociation,  the  pause  noted 
at  the  radial  artery  is  coupled  with  complete  absence  of  heart- 
sounds,  since  no  ventricular  contraction  takes  place  (Fig.  573)  ; 
in  extra-systole,  on  the  other  hand,  the  pause  at  the  radial  is 
coupled  with  one  or  two  heart-sounds  due  to  the  superadded 

I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  I  •  I  I  I 
R. 


All  I     III  I      I         I     I        I      I 

Fig.  575.— Extra-systole  (premature  contraction). 

extra-systolic  contraction  of  the  ventricles  (Fig.  575).  In  the 
first  instance  there  is  present  the  ordinary  rhythm  merely  slowed 
down  in  two  phases,  or  rather,  consisting  of  the  two  sounds, 
systolic  and  diastolic;  in  the  second  instance  there  is  a  three- 
phase  rhythm  comprising  the  two  normal  systolic  and  diastolic 
sounds  followed  by  the  systolic  sound  of  the  extra-systole,  or 
a  four-phase  rhythm  (echo  rhythm)  if  the  extra-systole,  having 
forced  open  the  sigmoid  valves,  is  accompanied  by  a  second, 
diastolic  sound  (Figs.  575  and  576). 

The  diagnosis  of  complete  auriculoventricular  dissociation 
which  is  ohjectizfely  manifested  in  a  very  pronounced  bradycardia 
(30  to  40),  iy  made  as  follozvs: 

1.  Is  there  present  bradycardia  or  bradysphygmia? 


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ARHYTHMIA. 


719 


2.  Is  the  dissociation  functional  in  type  (usually  of  extra-cardiac 
origin  and  due  to  abnormal  excitation  and  defective  functioning 
of  the  pneumogastric  nerve) — or  is  it  organic  (of  intracardiac  origin 
and  due  to  a  syphilitic  or  rheumatic  fibrotic  disease  of  the  bundle 
of  His)  ? 


•  I  ••  I  I  I  I  I  I  I 


•  I  I  I  I  I  f  I  I  I  i 


II      II  I    I     I  I 

Fig.  576. — Partial  heart-block. 

Auscultation  will  promptly  answer  the  first  question,  as  it 
did  in  the  case  of  extra-systoles.  Combined  palpation  of  the 
radial  artery  and  auscultation  will  show  that  for  every  radial 
pulsation  noted  there  are  two  contractions  of  the  heart — one 
a  systole  and  the  other  an  extra-systole. 


Fig.  577. — Delayed  conduction  (^Daniel  Routier), 

In  answering  the  second  question  the  following  clinical  feat- 
ures should  be  availed  of: 

1.  Functional  bradycardia  (of  extracardiac  origin)  is,  as  a 
rule,  transitory,  terminating  upon  cessation  of  its  original  cause ; 
organic  bradycardia  (of  intracardiac  origin),  however,  is  perma- 
nent 


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720 


SYMPTOMS. 


2.  Administration  of  2  milligrams  of  atropine,  by  paralyzing 
the  cardiac  terminals  of  the  vagus,  will  generally  cause  func- 
tional bradycardia  to  disappear  for  a  time ;  organic  bradycardia, 
on  the  other  hand,  is  not  perceptibly  influenced  by  it. 


Fig.  578.— Partial  heart-block  (Daniel  Routier), 

3.  Change  of  posture  {e.g.,  passing  from  recambency  to  the 
erect  posture  and  ince  versa),  exertion,  deep  or  forced  inspiration, 
fever,  and  locomotion  cause  a  distinct  change  in  the  rate  in 


4.5J3.D/5SOC  complete 

Fig.  579. — Complete  dissociation  {Daniel  Routier) . 

functional   bradycardia;  in  organic   bradycardia,  on  the  other 
hand,  they  exert  no  appreciable  effect. 

Many  recent  investigations  have  seemed  to  show  that  these 
indications  are  not  of  absolutely  positive  significance. 


Fig.  580.— Total  bradycardia  (Daniel  Routier). 

For  the  practitioner  specializing  in  cardiology,  the  problem 
of  diagnosis  is  often  markedly  facilitated  and  illuminated  by 
the  employment  of  graphic  procedures,  whereby  auriculoven- 
tricular  dissociation  may  be  recorded  in  the  jugular,  radial,  and 
cardiac  tracings,  as  shown  in  the  annexed  diagrams  for  which 
the  author  is  indebted  to  his  colleague,  Daniel  Routier  (Figs. 


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ARHYTHMIA.  721 

577,  578,  579,  580).^  Electrocardiography  will  almost  certainly 
settle  the  question  when  availed  of  as  a  last  resort  in  doubtful 
cases  (Fig.  581).  The  most  characteristic  indications  in  the 
tracing  are: 

1.  Abnormal  prolongation  of  the  a-c  period. 

2.  A  pause — ^which  may  be  very  brief — between  the  end  of  a 
and  the  beginning 'of  c  in  cases  of  incomplete  dissociation. 

3.  Dissociation  of  the  auricular  rhythm  a  in  the  jugular  trac- 
ing from  the  ventricular  rhythm  (radial  pulsations  and  apex- 
beat)  in  cases  of- complete  dissociation. 

It  should  be  noted  that  in  the  complete  form  of  dissociation 
there  is  often  perfect  adaptation  of  the  system  to  the  new  circula- 
tory rigime,  the  slowing  of  the  systolic  contractions  being  com- 


Fig.  581. — Complete  dissociation.    Electrocardiogram  (Daniel  Routier). 

52.  11.  12.  Aur.  =  62;  ventr.  =  17.    Lead  I,  ord.  1  cm.  =  1  millivolt; 
absc.  2H^  cm.  =  1  meter. 

pensated  for  by  their  increased  power,  objectively  manifested 
in  the  resulting  full,  large  pulse — very  striking  upon  palpation 
and  in  the  tracings — and  in  an  increase  of  both  the  systolic  and 
diastolic  blood  pressures.  The  ventricle,  well  filled  in  the  course 
of  a  prolonged  diastole,  empties  itself  completely  as  the  result 
of  a  powerful  contraction. 

Proper  diagnosis  of  auriculoventricular  dissociation  is  a  mat- 
ter of  great  prognostic  and  therapeutic  importance.  When  func- 
tional, it  is  unattended  with  risk,  as  a  rule,  and  terminates  as 
soon  as  its  original  cause  is  removed.  When  organic,  it  points 
either  to  serious  myocardial  degeneration,  of  which  it  constitutes 
in  Itself  an  especially  dangerous  local  manifestation,  or  to  the 
localization  of  some  destructive  or  degenerative  process,  such  as 


1  For  further  details  the  reader  is  referred  to  Routier^s  thesis  entitled 
"Etude  critique  sur  les  dissociations  auriculo-ventriculaires/'  Paris,  J.  B. 
Bailliere,  1915. 

46 


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SYMPTOMS, 


syphilis,  rheumatism,  or  some  infectious  disorder,  in  the  bundle 
of  His. 

The  study  of  auriculoventricular  dissociation,  and  more  particu- 
larly of  bradycardia,  is  intimately  related  to  that  of  Stokes-Adams' 
disease.  The  features  presented  in  this  condition  are  well 
known.     The  patient  suffering  from  it  is  subject  to  syncopal, 


^-*^  ^ 

./r^ 


Marked  basal 
^syetolic  murmur 

Short 


Fig.  582.— Oct  16,  1911.  Case  263  his.  H.,  59  years.  Bradysphyg- 
mia  counteracted  by  belladonna.  Marked  dilatation  of  aorta.  Cardiac 
h)rpertrophy.    Elevation  of  the  subclavians. 

epileptiform,  or  syncopo-epileptiform  attacks.  The  attack  is 
heralded  by  a  kind  of  aura,  characterized  by  general  malaise, 
tinnitus  aurium  pallor  of  the  face,  etc.;  it  is  associated  with  a 
paroxysmal  slowing  of  the  pulse,  with  pauses — actual  periods  of 
asystole  in  the  literal  sense  of  the  word — which  may  continue 
for  ten  or  more  seconds.  The  disorder  may  be  present  to  any 
extent  and  with  any  degree  of  frequency,  varying  from  the 
transient  mental  confusion  similar  to  that  which  an  extra-sys- 


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ARHYTHMIA. 


723 


tole  causes  in  some  subjects  to  the  serious  syncopal  attack  with 
prolonged  cardiac  arrest  which  may  result  in  death. 

Before  Charcot's  time  such  a  condition  was  ascribed  mainly 
to  the  myocardium,  which  had  sometimes  been  found  in  a  state 
of  degeneration ;  in  accord  with  Charcot's  view,  it  was  attributed 
chiefly  to  the  extracardiac  nervous  system   (medulla  or  vagus 


11.  16. 1911 


4.  10.  1912 


■  ■  M'l^ri^i'i^ 


2.  12.  1913,  8 

Fig.  583. — Case  263  bis.    Cardiogn^m  and  sphygmogram  taken  at  differ- 
ent stages  in  the  course  of  the  case  referred  to  in  Fig.  582. 

nerve) ;  after  the  discovery  of  heartrblock,  however,  it  came  to 
be  ascribed  wholly  to  auriculoventricular  dissociation,  due,  in 
turn,  to  disease  of  the  bundle  of  His.  At  the  present  time  there 
exists  a  tendency  to  revert  toward  a  much  more  eclectic  con- 
ception of  the  condition,  according  to  which  the  Stokes- Adams 
syndrome — slow  pulse  with  syncopal  or  epileptiform  attacks — 
may  be  caused  by  any  functional  disturbance  or  any  organic 


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724  SYMPTOMS, 

change  capable  of  inducing^  a  pronounced  slowing  of  the  pulse- 
rate: 

1.  Organic  disease  or  functional  disorder  of  the  medulla  or  of 
the  pneumogastric, 

2.  Organic  disease  of  the  bundle  of  His  and  at  times  more 
particularly  of  the  node  of  Keith. 

3.  Or  even  extensive  and  severe  disease  of  the  myocardium  with- 
out any  special  localisation  in  the  organ. 

At  all  events,  the  author  has  encountered  Stokes-Adams' 
disease  in  two  cases  in  which  auriculoventricular  dissociation 
seemingly  could  with  justification  be  excluded. 

In  the  first  of  these  cases  (Figs.  582  and  583),  the  patient 
was  a  man  aged  59  years,  suffering  chronically  from  rheumatism 
and  with  a  past  history  of  jaundice,  exhibiting  an  extensive 
aortic  lesion  and  a  marked  systolic  murmur  at  the  base  of  the 
heart,  succeeded  by  a  rolling  sound  which  continued  throughout 
the  short  pause,  and  who  for  several  years  previously  had 
noticed  a  slow  pulse  (55)  in  the  morning  on  awakening.  For 
the  preceding  seven  or  eight  months  this  patient  had  been  sub- 
ject to  periods  of  dizziness  and  confusion  consentaneous  with 
a  slowing  of  the  pulse  to  48;  for  the  last  six  months  he  had 
been  subject  to  sudden,  alarming,  quasi-syn copal  attacks  with 
sudden  pallor  and  transient  amnesia  which  had  compelled  him 
to  give  up  completely  his  ordinary  occupation.  Having  been 
obliged  at  the  time  to  stay  abed  for  seven  weeks  because  of 
complete  inability  to  rise  without  syncope,  he  had  found  that 
when  recumbent  he  felt  very  well  and  was  in  complete  posses- 
sion of  his  mental  faculties,  whereas  if  he  sat  up  he  felt  faint 
and  was  completely  amnesic.  A  strict  diet  and  treatment  with 
a  combination  of  adonis  and  theobromine  had  made  him,  if  any- 
thing, worse;  a  more  generous  diet  had  enabled  him  to  leave 
his  bed,  and  a  stay  in  Savoy  brought  about  some  general  better- 
ment. Bradycardia  (?)  and  syncopal  attacks  continued,  how- 
ever, and  it  was  under  these  circumstances  that  the  patient  came 
to  consult  the  author.  The  man  showed  an  extensive  and  mani- 
fest aortic  lesion  (pronounced  systolic  murmur  continued  as  a 
rolling  sound  during  the  short  pause,  and  a  clanging  sound  in 
diastole).     The  pulse  rate  was  remarkably  low   (33),  but  the 


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ARHYTHMIA.  725 

heart-beats  were  double  as  compared  to  the  pulse  (66).  Aus- 
cultation elicited  the  characteristic  "echo  rhythm" — ^Toc  Toe, 
toe  toe.  The  radial  tracing  was  typical,  showing  a  bigeminal 
pulse  the  result  of  extrasystoles,  with  the  second  pulsation  im- 
palpable, producing  the  condition  termed  bradysphygmia.  The 
systolic  blood  pressure  was  165  mm.,  the  diastolic,  85  mm.,  and 
the  blood  viscosity,  4.    No  albumin. 

In  short,  there  were  present  aortitis  and  myocardial  degenera- 
tion, bradysphygmia  due  to  bigeminal  extrasystoles,  and  syncopal 
attacks. 

The  author  merely  prescribed,  along  with  a  liberal  diet,  the 
following  pills: 

Extract  of  belladonna 0.01  gram. 

Extract  of  adonis 0.10  gram. 

To  make  one  pill. — Five  pills  a  day. 

Almost  immediately  the  dizziness  and  malaise  passed  off, 
and  the  pulse  rate  rose  to  60  through  disappearance  of  the  extra- 
systoles. The  blood  pressure  rose  slightly  to  175  to  180  mm., 
systolic,  and  85  or  80  mm.,  diastolic.  The  patient  gradually  re- 
sumed his  former  occupations.  His  restored  condition  has  now 
been  maintained  for  six  years. 

In  a  second  case  (No.  I64bis),  encountered'  in  a  patient  54  years 
of  age,  likewise  having  an  aortic  lesion  and  suffering  from  at- 
tacks sometimes  of  a  syncopal  and  at  others  of  an  epileptoid 
type,  with  marked  slowing  of  the  pulse,  tracings  made  in  the 
intervals  between  attacks  showed  no  abnormality  of  heart 
rhythm  save  a  slight  tendency  to  slowing  of  the  rate  (58),  with 
practically  normal  blood  pressure  (145  and  95  mm.)  and  a 
slightly  increased  viscosity  (4.5). 

Prognosis. — The  prognosis  depends: 

1.  On  the  nature  of  the  dissociation:  If  functional,  it  is  gen- 
erally not  of  serious  import  and  terminates  when  its  toxic,  dia- 
thetic, or  infectious  (rheumatism,  pneumonia,  or  typhoid)  cause 
is  removed. 

2.  On  the  grade  of  the  heart-block:  Manifestly  the  slight, 
partial,  and  temporary  grades  of  block  are  less  serious  than  the 
pronounced,  complete,  and  permanent  forms. 


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726  SYMPTOMS. 

3.  On  the  other  myocardial  or  endocardial  lesions  simultane- 
ously present:  The  prognosis  in  complete,  permanent  auriculo- 
ventricular  dissociation  is  grave,  in  the  first  place  because  it  is 
an  expression  of  a  particularly  serious  localization  of  the  myo- 
carditis, and  secondly  and  more  especially,  because  it  is  usually 
accompanied  by  deep-seated  and  extensive  myocardial  degenera- 
tion. 

4.  On  the  syncopal  and  epileptiform  attacks  which  may  ac- 
company the  condition. 

(a)  In  the  milder  form,  there  are  noted  brief  fainting  spells 
with  transitory  unconsciousness,  facial  pallor,  and  a  very  short 
period  of  pulselessness. 

(b)  In  a  more  advanced  form,  the  unconsciousness  is  supple- 
mented by  convulsive  movements  of  the  face  and  upper  extrem- 
ities. It  should  be  noted  that  incontinence  of  urine  and  biting 
of  the  tongue  are,  as  a  rule,  absent.  The  condition  of  the  cir- 
culation at  the  time  is  characterized  by  absence  of  the  ventricu- 
lar contractions,  resulting,  in  turn,  in  pulselessness,  and  by  per- 
sistence of  the  auricular  contractions,  manifested  in  rapid  wave- 
like movements  along  the  veins  of  the  neck. 

(f)  Death  may  be  observed — ^though  exceptionally — in  the 
course  of  an  attack  or  a  series  of  attacks  of  the  type  above  de- 
scribed. 

ALTERNATION  OF  THE  PULSE. 

None  of  the  forms  of  arhythmia  previously  referred  to,  vis.^ 
extra-systoles,  paroxysmal  tachycardia,  sinus  arhythmia,  and 
bradycardia,  in  itself  supplies  any  definite  prognostic  indication. 
The  fact  was  sufficiently  stressed  that  these  disorders  do  not, 
taken  alone,  constitute  accurate  prognostic  factors,  and  that  each 
of  these  varieties  of  arhythmia  is  of  markedly  variable  sig^ifi- 
cartce  according  as  it  is  of  a  functional  or  organic  tiature,  and 
that,  on  the  whole,  the  condition  is  of  clinical  value  and  sig- 
nificance only  as  a  factor  taken  in  conjunction  with  the  other 
existing  disturbances.  This  is  by  no  means  the  case,  however, 
with  the  two  forms  of  arhythmia  still  to  be  described,  vis., 
the  alternating  pulse  and  perpetual  arhythmia,  to  both  of  which 
attaches  a  definite  and  serious  clinical  signification.     The  former. 


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ARHYTHMIA,  727 

being  an  expression  of  deep-seated  myocardial  degeneration,  is 
considered  by  Gallavardin  as  **a  highly  important  sign — ^perhaps 
tlie  best  sign — of  inadequacy  of  the  left  ventricle,"  while  the 
latter  points  to  auricular  fibrillation. 

The  alternating  pulse  consists  essentially  in  the  alternate 
occurrence,  at  practically  normal,  regular,  and  equal  intervals, 
of  a  large  beat  and  a  small  beat.  There  is  strictly  speaking,  no 
arhythmia,  but  simply  a  regular  alternation  of  two  unequal 
beats.  At  the  most,  the  small  beat  may  be  slightly  delayed  due 
to  a  slight  retardation  of  cardio-peripheral  conduction. 

1    I    I    I    I    I    i    I    I    I    I    1    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I 


Fig.  584. — Diagram  of  the  alternating  pulse.     Strong  and  weak 
contractions  take  place  in  alternation. 

A  bigeminal  pulse  the  result  of  extrasystoles  might  possibly 
be  confused  with  the  alternating  pulse,  being  likewise  attended 
with  an  alternation  of  large  and  small  pulse  beats.  In  contrast 
with  the  alternating  pulse,  however,  the  extrasystole  or  small 
systole  comes  closer  to  the  preceding  than  to  the  following  beat ; 
in  the  alternating  pulse,  the  small  beat  is  closer  to  the  succeeding 
than  to  the  preceding  beat.  If  careful  palpation  and  ausculta- 
tion fail  to  settle  the  question,  an  ordinary  sphygmographic 
tracing  will  promptly  do  so. 

True  alternation  of  the  pulse  is  of  the  gravest  prognostic 
import,  and  Lewis  does  not  hesitate  to  compare  it  with  sub- 
sultus  tendinum,  optic  neuritis,  and  risus  sardonicus  as  a  sign 
of  the  most  unfavorable  portent     Frequently  it  is  associated 


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728  SYMPTOMS. 

with  cardiac  dyspnea,  anginal  attacks,  and  Cheyne-Stokes  breath- 
ing. But  even  when  present  alone,  its  sombre  prognostic  im- 
port is  retained:  It  is  a  certain  indication  of  deep-seated  myo- 
cardial degeneration  and  of  advanced  exhaustion  of  the  heart- 
muscle. 

A  few  recent  observations,  those  of  Gallavardin  among  others, 
have  seemingly  tended  toward  reduction  of  the  gravity  of  the 
prognosis  in  these  cases.  The  author  has  personally  o"bserved 
three  distinct  cases  of  alternating  pulse  with  respective  survival 
periods  of  six,  seven  and  a  half,  and  fifteen  months. 

PERPETUAL  ARHYTHMIA  (AURICULAR  FIBRILLATION). 

Perpetual  arhythmia,  the  delirium  cordis  of  olden  times,  was 
for  a  long  period  a  puzzle  to  cardiologists.  To  electrocardiog- 
raphy we  owe,  if  not  an  absolute,  complete  elucidation  of  the 
condition,  at  least  an  explanation  which  accotmts  for  the  great 
majority  of  cases  and  affords  the  best  view  into  its  mode  of 
production. 

Perpetual  arhythmia  consists,  as  the  term  implies,  of  a  per- 
manent arhythmia  characterized  by  extreme  irregularity  and 
baffling  all  description.  The  succeeding  systolic  contractions 
are  irregular  both  as  to  duration  and  intensity. 

Prolonged  discussions  as  to  the  exact  pathogenesis  have  been 
indulged  in; — electrocardiography  seems  to  have  definitely 
shown  that  this  type  of  arhythmia  is  dependent  upon  a  special 
condition  of  auricular  activity  which  is  well  expressed  by  the 
term  auricular  fibrillation. 

The  following  description  of  this  condition  is  borrowed  from 
Thomas  Lewis:  "When  we  inspect  the  normally  beating  heart 
of  an  animal,  the  systoles  of  both  auricle  and  ventricle  are  readily 
discerned.  The  movement  of  the  auricle  is  a  sharp  flick,  most 
clearly  perceptible  in  the  length  of  the  auricular  appendix,  for 
in  this  line  the  shortening  is  greatest.  When  the  auricle  is 
forced  into  fibrillation  or  delirium,  the  appearances  are  quite 
distinctive ;  the  muscular  walls  are  maintained  in  a  position  of 
diastole;  systole,  either  complete  or  partial,  is  never  accomp- 
lished; the  structure  as  a  whole  rests  immobile;  but  close  ob- 


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ARHYTHMIA. 


729 


servation  of  the  muscle  surface  reveals  its  extreme  and  incessant 
activity,  rapid  and  minute  twitchings  and  undulatory  movements 
are  visibk  over  the  whole.  It  is  believed  that  the  tissue  mass 
has  suffered  functional  fragmentation  and  that  a  number  of  small 
areas  give  independent  birth  to  new  impulses.  .  .  .  The  effect 
of  the  auricular  confusion  upon  the  ventricle  is  two-fold.  The 
normal,  regular  and  co-ordinate  contractions  in  the  auricle  are  in 
abeyance  and  consequently  the  ventricle  is  robbed  of  the  regular 
impulses  which  form  its  accustomed  supply.  These  are  replaced 
by  numerous  and  haphazard  impulses,  escaping  to  the  ventricle 


-^ 


Fig.  585. — The  auricular  muscle  fibers  fail  to  contract  in  co-ordinate 
and  rhythmic  fashion.  The  auricular  tissue  is  dissociated  into  a  large 
nimiber  of  small  areas  contracting  independently.  Some  of  the  auricular 
impulses  reach  the  ventricle  at  wholly  irregular  intervals,  awakening 
there  contractions  which  are  both  frequent  and  irregular.  /,  jugular;  R, 
radial. 

from  the  turmoil  which  prevails  in  the  upper  chamber;  the 
change  in  the  action  of  the  ventricle,  when  the  auricle  fibrillates, 
is  consequently  profound.  Its  rate  of  beating  rises  considerably 
and  the  contractions  follow  each  other  in  a  completely  irregular 
fashion." 

.  The  above  diagram  will  give  an  approximate  idea  of  the  me- 
chanism involved  (Fig.  585). 

Electrocardiography  plainly  demonstrates  the  fact  that  the  me- 
chanism above  described  is  actually  operative.  The  P  wave  char- 
acteristic of  auricular  systole  is  suppressed  and  is  replaced  by  a 


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730  SYMPTOMS. 

series  of  rapid,  irregular  oscillations  of  slight  amplitude,  ffff 
(Fig.  586).    ^ 

Sometimes  the  fibrillary  twitchings  of  the  auricle  may  even 
be  discerned  rather  clearly  on  a  good  polygraphic  tracing  (Figs. 
587  and  588). 

Electrocardiography  alone  yields  an  objective  observation 
and  reliable  record  of  auricular  fibrillation. 

For  clinical  and  practical  purposes  the  diagnosis  may,  how- 
ever, be  made  either  with  or  without  the  help  of  graphic  pro- 
cedures. 


Fig.  586. — Electrocardiograms  illustrating  the  3  leads  in  a  case  of 
mitral  stenosis  with  auricular  fibrillation.  The  R  wave  is  very  small 
with  Lead  /,  whereas  5  is  pronounced;  with  Lead  ///,  R  appears  the 
highest.  There  are  evidences  of  hypertrophy  of  the  right  ventricle.  The 
ventricle  is  beating  very  irregularly.  There  is  no  P  wave,  but  on  the 
other  hand  there  are  found  a  number  of  rapid  oscillations,  /,  /,  resulting 
from  the  fibrillation  of  the  auricles  {Cambridge  Association), 

The  following  3  practical  rules  may  be  given  in  this  connec- 
tion : 

1.  Any  case  of  tacJty-arhythmia  unth  a  heart-rate  exceeding  130 
is  nearly  always  associated  with  auricular  fibrillation  and  per- 
petual arhythmia  (the  factor  of  irregularity  comprised  in  the 
arhythmia  excludes  instances  of  increased  heart-rate  due  to  fever 
or  emotion,  as  well  as  tachycardia  of  the  nervous  or  paroxysmal 
types,  etc.). 


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ARHYTHMIA.  731 

2.  Any  persistent  arhythmia  coupled  with  signs  of  advanced 
cardiac  impairment  is  almost  always  dependent  upon  auricular 
fibrillation.  The  probability  becomes  practically  a  certainty  if 
the  arhythmia  is  associated  with  tachycardia. 

3.  Any  case  of  arhythmia,  even  if  unaccompanied  by  manifest 
signs  of  existing  cardiac  impairment,  any  arhythmia  which  is  in- 
creased by  acceleration  of  the  pulse,  such  as  might  be  induced 
by  moderate  exercise,  is  likely  to  be  a  perpetual  arhythmia.    The 


Fig.  587. — Auricular  fibrillation  {Daniel  Routier). 

other  types  of  arhythmia,  on  the  other  hand,  and  in  particular 
extrasystolic  arhythmia,  are  reduced  or  even  disappear  under 
the  influjMice  of  pulse  acceleration. 

The  polygraphic  method  records  an  extreme  and  permanent 
arhythmia  in  these  cases.  The  radial  tracing  consists  of  unequal 
and  irregular  systoles,  constantly  varying  in  duration  and  power ; 
the  jugular  tracing  generally  assumes  the  so-called  "ventricular 
type,"   showing  a  series  of  oscillations  synchronous   with  the 


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Fig.  588.— Case  248.    H.,  56  years;  169  cm.;  64.8  kilograms.    Auricu- 
lar fibrillation  (perpetual  arhythmia). 

6.  23.  1913;  pulse,  72  (?) ;  pressures,  i3%oo  (?) ;  viscosity  = 
4.3.     H  =  1200.    Albumin  absent. 

ventricular  contractions,  but  with  absence  of  the  a  wave  charac- 
teristic of  auricular  systole.  Sometimes,  on  the  most  successful 
tracings,  there  is  noted  a  series  of  minute  and  rapid  presystolic 
undulations,  an  aictual  expression  of  auricular  fibrillation  (Figs. 
587  and  588). 

Electrocardiography    records    auricular   fibrillation    more   or 
less  clearly  (Fig.  586). 


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732 


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ARHYTHMIA,  735 

Is  tricuspid  insufficiency  always  present  in  perpetual  arhyth- 
mia,  and  does  recognition  of  the  presence  of  perpetual  arhythmia 
necessarily  mean  recognition  of  the  presence  of  tricuspid  insuffi- 
ciency? Some  observers  have  thought  themselves  justified  in 
giving  a  positive  answer  to  this  question.  The  author,  however, 
has  met  with  many  cases  of  perpetual  arhythmia  in  which  there 
were  no  apparent  signs  permitting  of  recognition  of  the  presence 
of  tricuspid  insufficiency.  This  latter  condition  has  seemed  to 
him  relatively  frequent  in  these  cases,  but  not  constant. 

Auricular  fibrillation  and  perpetual  arhythmia  are  always  as- 
sociated with  and  probably  dependent  upon  a  deep-seated  degen^ 
eration  of  the  myocardium  and  advanced  cardiac  insufficiency. 
Their  signs  are  therefore  likely  to  be  observed  in  association 
with  those  of  myocardial  degeneration  and  heart  weakness, 
znc,  dyspnea  on  exertion,  cyanosis,  venous  stasis,  passive  con- 
gestions, hepatic  engorgement,  edema,  reduced  output  of  urine, 
etc. ;  and  it  is  very  hard  to  say  whether  any  one  of  these  symp- 
toms is  dependent  upon  them  or  even  whether  they  are  exagger- 
ated through  the  presence  of  fibrillation  and  arhythmia — which, 
however,  is  very  probably  the  case. 

Attacks  of  paroxysmal  fibrillation  with  manifest  recrudes- 
cence of  both  the  arhythmia  and  the  associated  symptoms — 
dyspnea,  cyanosis,  edema,  etc. — may  be  witnessed.  Other  pa- 
tients, however,  seem  hardly  influenced  by  the  condition.  The 
same  is  true,  indeed,  of  paroxysmal  tachycardia ;  probably  these 
reactions,  seemingly  so  diflFerent,  are  both  actually  dependent 
upon  the  state  of  the  myocardium ;  if  it  is  but  slightly  impaired, 
the  general  circulation  is  comparatively  little  influenced  by  recru- 
descence of  the  arhythmia;  if,  on  the  other  hand,  it  is  profoundly 
degenerated,  the  usual  signs  of  cardiac  insufficiency  will  rapidly 
appear. 

Mitral  stenosis,  myocardial  degeneration,  and  arterio-renal 
sclerosis  are  the  conditions  nearly*  always  associated  with  per- 
petual arhythmia. 

The  prognosis  of  perpetual  arhythmia  must  therefore  always 
be  guarded,  since  auricular  fibrillation  in  itself  constitutes  a 
positive  sign  of  more  or  less  advanced  degeneration  of  the  myo- 
cardium   and    a    probable    sign    of    widespread    degeneration. 


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736  SYMPTOMS, 

Nevertheless — and  in  this  condition  the  therapeutic  test  is  often 
conclusive — certain  instances  of  perpetual  arhythmia  are  mark- 
edly reduced  by  well-directed  drug  treatment,  while  others  are 
completely  refractory.  The  prognosis  is  obviously  profoundly 
influenced  by  these  factors.  On  the  whole,  the  same  conclusion 
always  follows,  vis,,  that  the  prognosis  is  governed  much  more 
by  a  study  of  the  contractility  of  the  heart  muscle  than  by  a 
study  of  its  conductivity. 


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ASCITES. 


[dax^Sy  a  water-bag;  an  abdomen  havingX 
the  shape  of  a  water-bag.  J 


Ascites^  derived  from  the  word  d(T;^6$,  a  water-bag,  on  ac- 
count of  the  resemblance  of  the  abdomen  distended  with  serous 
fluid  to  such  a  vessel,  consists  of  an  intraperitoneal  serous  effu- 
sion (hydroperitony,  dropsy  of  the  peritoneum,  dropsy,  etc.). 

Becognition  of  Ascites.— Accumulation  of  fluid  in  the  peri- 
toneal cavity  is  generally  a  slow,  gradual  process ;  in  the  excep- 
tional cases  of  ascites  spoken  of  as  a  frigore,  due  to  sudden  ob- 
struction of  the  portal  vein,  effusion  may  take  place  rapidly. 

Though  sometimes  obvious^  especially  when  it  has  attained 
a  certain  size,  when  the  abdominal  parietes  are  relatively  thin, 
and  when  the  fluid  is  freely  movable,  its  recognition  may  in 
other  instances  be  attended  with  considerable  difficulty  when, 
as  is  frequently  the  case,  the  parietes  are  thick  and  infiltrated, 
when  the  effusion  is  of  slight  or  moderate  extent,  when  its 
mobility  is  limited  owing  to  adhesions,  etc. 

Clinically,  its  recognition  is  to  be  based  on  a  systematic  ex- 
amination of  the  case: 

Inspection. 

(a)  Shape  of  the  Abdomen. — 1.  Vertical  position:  Abnormal 
prominence  of  the  hypogastrium  and  the  iliac  fossa. 

2.  Recumbent  position:  The  flanks  broaden  and  flatten  out, 
like  the  abdomen  of  an  amphibian;  the  fluid  moves  about,  on 
the  whole,  according  to  gravity,  therefore  passing  to  the  de- 
pendent side  when  the  patient  is  in  lateral  decubitus. 

3.  Occasionally  the  umbilicus,  turned  out  like  a  glove  finger, 
forms  a  small,  soft,  fluctuating,  depressible,  translucent  tumor. 

(6)  Condition  of  the  Skin. — The  skin  is  frequently  smooth, 
white,  even,  polished,  and  shining;  sometimes  thickened,  infil- 
trated, and  edematous;  at  times  erythematous.  Striae  compar- 
able to  tttose  of  pregnancy  may  be  noticed  upon  it. 

47  {7i7) 


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738  SYMPTOMS. 

(f)  Superficial  Venous  Circulation. — ^The  accessory  portal 
veins,  normally  only  slightly  developed,  enlarge,  sometimes  to 
a  considerable  size,  in  the  event  of  obstruction  to  the  blood- 
current  through  the  portal  vein.  The  circulation  is  in  part  re- 
established through  these  vessels,  whence  there  occurs  dilata- 
tion of  the  subcutaneous  veins  of  the  abdomen,  with  the  pro- 
duction of  a  prominent  network  of  veins  between  the  pubis  and 
the  xiphoid  appendix,  especially  on  the  right  side,  in  the  form 
of  a  peri-umbilical  venous  plexus. 

(d)  Sometimes  there  is  concomitant  hydrocele,  owing  to  per- 
sistence of  the  vagino-peritoneal  duct 

Palpation. — ^The  abdomen  exhibits  an  even,  tense,  sometimes 
elastic^  and  firm  enlargement 

The  fluid  present  masks  the  intestinal  mass  and  forms  an 
obstacle  to  detailed  examination  of  the  abdominal  viscera, 
whence  the  necessity  of  puncture  in  cases  where  such  examina- 
tion is  imperative. 

Percussion. — Flatness  manifestly  varies  in  extent  according 
to  the  amoimt  of  effused  fluid. 

1.  Its  primary  localization  is  over  the  iliac  fossae  and  the  hy- 
pogastrium  (fluid)  ;  the  umbilical  and  epigastric  regions  are  gen- 
erally the  seat  of  tympanitic  resonance  (intestines),  the  transi- 
tion from  flatness  to  tympany  being,  however,  gradual. 

2.  A  small  effusion  may  be  unrecognizable  on  percussion ; 
but  if  the  patient  is  turned  on  the  side,  the  fluid  will  collect  on 
that  side  and  flatness  be  detectable. 

3.  The  flatness  exhibits  movable  margins,  which  vary  accord- 
ing to  the  patient's  position  if  the  ascites  is  movable  and  free; 
it  is  fixed,  however,  if  the  effusion  is  encysted  or  walled  off  (Fig. 
596). 

Combined  Palpation  and  Percussion. — ^This  procedure  yields 
one  of  the  most  important  indications  of  ascites,  viz.,  fluctuation. 

With  one  hand  applied  flat  over  one  side  of  the  abdomen, 
the  physician  taps  lightly  with  the  other  on  the  opposite  side, 
either  by  light  percussion  or  by  flipping  a  finger;  the  former 
hand  notes  a  sensation  as  of  a  blow  or  wave.  It  is  often  useful 
to  have  some  one  else  apply  the  ulnar  border  of  one  hand  along 
the  linea  alba,  in  order  to  prevent  transmission  of* wave-like 


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ASCITES.  739 

movements  of  the  abdominal  parietes,  which  would  constitute 
a  source  of  error. 

At  all  events,  fluctuation  is  almost  pathognomonic  of  ascites, 
as  it  occurs  in  the  absence  of  ascites  only  in  a  few  exceptional 
cases  of  ovarian  cyst  with  thin  walls. 

Vaginal  Palpation. — ^With  this  procedure,  a  doughy,  firm  con- 
dition in  the  culs-de-sac  is  occasionally  found. 

Sometimes  vaginal  palpation  may  prove  of  service  in  aflford- 
ing  an  early  diagnosis  of  ascites  (descent  and  reduced  weight 
of  the  uterus,  and  extreme  mobility  of  the  cervix). 

Functional  Evidences. 

(a)  Chiefly  manifestations  due  to  distention  and  pressure. 

1.  Increased  size  of  the  abdomen:  The  patient  can  no  longer 
button  up  his  trousers. 

2.  Digestive  disturbances:  Constipation  due  to  pressure  on  the 
intestines,  resulting  in  paralysis  (Chopart's  law:  Any  muscle 
underlying  an  inflamed  serous  membrane  is  paralyzed).  Indi- 
gestion and  tympanites. 

3.  Urinary  disturbances:  Dysuria,  diminished  secretion  of  urine, 
oliguria,  and  opsiuria,  chiefly  on  account  of  the  loss  of  fluid 
resulting  from  the  ascitic  accumulation. 

4.  Cardiopulmonary  dyspnea  due  to  pressure  on  the  diaphragm, 
causing  reduced  lung  expansion  and  displacement  of  the  heart. 

5.  Edema  of  the  lower  extremities,  due  either  to  the  same  cause 
as  the  ascites  or  to  pressure  exerted  on  the  inferior  venae  cavae. 

{b)  Functional  disturbances  attending  the  primary  disorder 
(cirrhosis,  peritonitis,  etc.). 

With  What  Oonditions  Might  Ascites  be  Oonfounded?— (a) 
Abdominal  Meteorism. — Here,  resonance  and  tympany  are  in- 
creased ;  yet,  in  truth,  ascites  is  frequently  accompanied  by  mete- 
orism; in  fact,  meteorism  may  conceal  an  ascites.  The  best 
differential  sign  in  these  cases,  in  the  author's  estimation,  is  the 
displacement  of  the  dullness  upon  assumption  of  lateral  decu- 
bitus, the  dullness  appearing  in  the  most  dependent  area,  at  a 
point  previously  resonant. 

(&)  Edema  of  the  Abdominal  Wall. — ^The  finger  leaves  a 
depression  in  the  parietal  tissues;  dullness  is  uniformly  distrib- 


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740  SYMPTOMS, 

uttd,  knd  fluctuation  is  absent.  Abdominal  edema  and  ascites, 
however,  frequently  coexist 

(f)  Retention  of  Urine. — The  bulging  and  dullness  are  dis- 
tinctly located  in  the  hypogastrium,  with  their  convex  aspect 
directed  upward — the  opposite  of  the  condition  in  ascites.  Urine 
is  passed  by  overflow;  palpation  of  the  hypogastrium  is  more 
or  less  painful. 

In  the  event  of  doubt,  which  is  seldom  excusable,  catheteriza- 
tion of  the  bladder  will  dispel  both  the  doubt  and  the  abdominal 
enlargement. 

(d)  Pregnancy. — ^The  enlargement  is  hard,  in  the  median 
line,  rounded,  pyriform,  and  hypogastric  in  situation.  Palpation 
reveals  that  the  uterus  is  the  cause  of  the  bulging.  The  convex 
aspect  is  directed  upward — the  opposite  of  the  condition  in  as- 
cites. On  the  whole,  the  mere  thought  of  the  possibility  of 
pregnancy  is  enough  to  eliminate  this  source  of  error.  If  doubt 
should  nevertheless  exist,  the  other  signs  of  pregnancy  should 
be  examined  for,  vis.,  cessation  of  menstruation,  secretion  of 
colostrum  and  other  mammary  changes,  progressive  enlarge- 
ment, and  after  four  and  a  half  months,  the  diagnostic  fetal 
signs. 

{e)  Ovarian  Cysts. — ^The  following  distinguishing  features 
may  with  advantage  be  recalled: 

1.  Shape  of  the  abdomen. — Globular,  and  with  umbilicus  nor- 
mal, in  ovarian  cyst. 

Flattened  out  and  with  prominent  umbilicus  in  ascites. 

2.  Flatness. — In  ascites :  Flatness  in  the  lumbar  regions ;  umbili- 
cal region  resonant;  flanks  flat;  the  .flat  area  is,  in  a  general 
way,  convex  below ;  the  areas  of  flatness  are  movable  and  vary 
with  the  position  of  the  patient. 

In  ovarian  cyst:  Resonance  in  the  lumbar,  iliac,  and  epigas- 
tric regions ;  flatness  rather  median  and  hypogastric  in  location, 
and  sometimes  umbilical,  with  convexity  directed  upward;  flat- 
ness is  not  changed  by  altered  position  of  the  patient. 

3.  Fluctuation. — Practically  constant  in  ascites;  exceptional  in 
ovarian  cyst. 

4.  History  of  case. — Often  negative  in  ovarian  cyst. 


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ASCITES. 


741 


Dorsal  decubitus. 


Lateral  decubitus. 


Fig.  596. — Abdominal  areas  of  flatness  in  ascites  and  various 
other  abdominal  disorders. 

1.  Frank  ascites  of  hepatic  origin.    2.  Encysted  ascites  of  the  peritoneal 
type.    3.  Ovarian  cyst.    4.  Pregnancy;  retention  of  urine. 


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742  SYMPTOMS. 

Always  positive  in  ascites,  comprising  such  features  as  he- 
patic disorder  (cirrhosis),  cardiac  affections,  general  impairment 
of  health  (tuberculous  peritonitis),  some  serious  organic  affec- 
tion (cachexia),  etc. 

Notwithstanding  all  these  distinguishing  features,  many  mis- 
takes are  made;  the  possibility  of  coexisting  ascites  and  cyst 
further  complicates  matters. 

Oaases  of  Ascites. — In  the  presence  of  ascites,  attention 
should  be  particularly  directed  to  the  liver,  peritonetim,  and  heart. 

The  diagnosis  is  based  largely  on  the  history  of  the  case, 
the  existing  physical  signs,  the  course  of  the  ascites,  and  the 
nature  of  the  fluid  withdrawn  by  puncture. 

(a)  Ascites  of  Hepatic  Origin  (General  Type:  Atrophic  Cir- 
rhosis; Typical  Ascites). — ^The. onset  is  slow,  gradual,  more 
rarely  abrupt,  rapid  after  exposure  to  cold;  the  fluid  is  free  in 
the  abdomen,  movable,  and  fluctuation  is  readily  elicited. 

The  history  includes  a  more  or  less  well-defined  precirrhotic 
stage,  characterized  by  manifestations  of  increased  portal  pres- 
sure (hemorrhoids,  collateral  circulation),  indigestion  and  gas- 
tro-intestinal  disturbances,  catarrhal  disorders,  meteorism,  diar- 
rhea, hepatic  congestion  and  incipient  jaundice,  reduced  output 
of  urine,  etc. 

1.  The  course  of  the  disease  is  progressive. 

2.  The  liver  is  always  found  diseased,  generally  reduced  in 
size  (Laennec's  atrophic  cirrhosis),  sometimes  enlarged  (hyper- 
trophic or  alcoholic  cirrhosis  of  Hanot  and  Gilbert)  ;  the  spleen 
shows  enlargement;  there  are  manifest  evidences  of  portal  hy- 
pertension, together  with  distinct  impairment  of  nutrition.  As- 
cites may  be  encountered  in  syphilis  of  the  liver  or  in  primary 
or  secondary  nodular  cancer. 

3.  The  fluid  obtained  by  puncture  is  serous  and  poor  in  fibrin, 
cellular  elements,  and  protein  material. 

4.  Nevertheless,  it  is  well  to  bear  in  mind  that  peritonitis 
may  and  frequently  does  accompany  many  forms  of  cirrhosis, 
and  that  cases  of  fibrous,  alcoholic,  tuberculous,  and  syphilitic 
hepatitis  are  quite  often  associated  with  localized  peritonitis 
(perihepatitis)  or  generalized  peritonitis  of  a  similar. or  hybrid 


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ASCITES,  743 

type  (e.g.,  alcoholism  with  tuberculosis,  alcoholism  with  syphilis, 
syphilis  with  tuberculosis,  or  even  alcoholism  with  tuberculosis 
and  syphilis). 

(b)  Ascites  of  Peritoneal  Origin  (General  Type :  Tuberculous 
Peritonitis). — 1.  The  ascites  is  of  moderate  extent,  often  but 
slightly  fluctuating,  and  advancing  by  alternate  exacerbations 
and  recessions. 

The  fluid  is  but  slightly  movable,  and  frequently  encysted. 


Cardiac  obstrui  Dyscrasias 

hezia,  Bright's 
disease) 

Hepatic  obstruct 


blebitis 


Inflammation 
of  the  peritoneuzE 


Fig.  597. — ^The  causes  of  ascites. 
Cardiac. — Hepatic. — Peritoneal. — Pylephlebitic. — Dyscrasic. 

Sometimes  there  are  coexisting  dull  and  hard  infiltrations,  best 
palpated  after  puncture. 

2.  The  concomitant  signs  should  be  looked  for,  vis.,  peritoneal 
and  pleural  friction  rubs,  pleural  effusion,  ganglia,  signs  of  pleu- 
ropulmonary,  genital,  or  articular  tuberculous  disease  or  typho- 
bacillosis,  fever,  vomiting,  etc. 

3.  The  ascitic  fluid  is  serofibrinous,  containing  a  much  larger 
amount  of  fibrin,  protein,  or  cells  than  that  of  mechanically 
produced  ascites.  In  short,  it  presents  the  typical  features  of 
inflammatory  exudates.  Guinea-pig  inoculation  will  give  posi- 
tive results  in  the  presence  of  tuberculosis.    Certain  laboratory 


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744  SYMPTOMS, 

procedures  are  available  for  examining  ascitic  fluid  for  the  tu- 
bercle bacillus  (Jousset's  inoscopy). 

4.  It  is  well  to  note  that  tuberculosis  of  the  peritoneum  com- 
prises by  far  the  greatest  number  of  the  cases  of  peritonitic  ascites, 
but  that  one  should  also  think  of  the  possibility  of  cancer  of  the 

Low  blood-pressure 


Pre 
the 

AS 

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P 

hemorrhage 


Hen 


Fig.  596. — The  syndrome  of  increased  portal  pressure. 

peritoneum  in  an  old,  cachectic  individual.  The  reactions  involving 
the  lymph-glands;  examination  of  the  fluid,  which  generally 
contains  red  blood  cells;  the  history  of  the  case,  and  the  sub- 
.sequent  course  of  the  disease,  will  soon  confirm  the  latter  diag- 
nosis if  the  possibility  of  the  condition  is  merely  recollected. 
Nor  should  it  be  forgotten  that  tuberculous  peritonitis  with 
ascitic  effusion  may  occur  in  any  grade  of  severity,  from  the  mild- 


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ASCITES.  745 

est  forms,  such  as  the  long  standing  idiopathic  ascites  of  young 
girls,  running  a  slow  course,  without  fever  or  constitutional 
disturbances,  and  nearly  always  ending  in  spontaneous  recovery 
(dropsy  of  the  peritoneum),  to  the  most  serious  varieties,  such 
as  the  ulcero-caseous  forms  which  lead  so  quickly  and  inevitably 
to  the  hectic  state. 

Finally,  reference  should  be  made  to  the  frequent,  not  to 
say  constant,  participation  of  the  pleura  in  the  process  of  peri- 
toneal tuberculous  involvement,  almost  always  constituting 
more  properly  a  pleuro-peritoneal  tuberculosis.  At  all  events  and 
for  practical  purposes,  in  the  presence  of  a  suspicious  peritoneal 
disorder  the  physician  should  systematically  examine  the  pleurae 
and  always  perform  an  exploratory  puncture  of  the  pleura;  this 
procedure  will  supply  a  solution  of  the  problem  in  the  majority 
of  cases. 

(c)  Ascites  of  Cardiac  Origin  (General  T3rpe:  Heart  Failure). 

1.  One  of  the  most  specific  features  of  these  cases  is  that  here 
the  ascites  clearly  follows  other  manifestations  of  edema,  as  in 
the  lower  extremities,  scrotum,  and  lumbar  regions — in  contrast 
with  what  occurs  in  cirrhotic  and  peritonitic  ascites, — and  that 
it  is  frequently  combined  with  hydrothorax. 

2.  The  diagnosis  is  clear  from  observation  of  the  attending 
circumstances,  the  coexisting  heart  failure,  and  the  physical 
sig^s  of  cardiac  disease.  At  the  most,  doubt  might  occur  in  the 
very  advanced  cases  in  which — ^the  primary  hepatic  cirrhosis 
having  led  to  secondary  cardiac  insufficiency,  or,  on  the  other 
hand,  primary  heart  disease  having  resulted  in  cirrhosis  of  car- 
diac origin — a  combined  cardio-hepatic  inadequacy,  manifested 
in  both  heart  failure  and  hepatic  cirrhosis,  has  been  produced. 
A  careful  inquiry  into  the  past  medical  history  as  regards  the 
heart  and  liver,  along  with  observation  of  the  course  of  the 
edema  and  the  heart  sounds,  will  nearly  always  settle  the  ques- 
tion of  priority,  even  though  such  an  aim  is  of  academic  rather 
than  practical  interest,  since  the  therapeutic  indications,  like  the 
disturbances  of  function,  are  in  close  combination  in  these  cases. 

Other  Oauses. — Apart  from  the  above  three  cardinal  sources 
of  ascites,  mention  should  be  made  of : 


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746 


SYMPTOMS. 


1.  The  Ascites  of  Nephritis. — This  is,  on  the  whole,  rather 
uncommon  and  is  associated  with  the  usual  signs  of  Bright's 
disease  (see  Albuminuria  and  Edema).  The  high  urea  content 
in  the  ascitic  fluid  of  azotemic  cases  should  be  borne  in  mind. 

This  diagnosis  should  not  be  accepted  unless  one  has  become 
convinced  from  careful  examination  of  the  absence  of  hepatic 
cirrhosis,  peritoneal  inflammation,  or  heart  weakness. 

The  differential  features  include,  more  particularly:  Albu- 
minuria and,  in  the  absence  of  all  cardiac  inadequacy,  precession 
of  the  edematous  manifestations  (lids,  extremities,  and  scrotum). 

2.  The  Ascites  of  Cachexia. — ^This  is  likewise  an  exceptional 


^2  4  8    "    U 

Meal  Meal 

Fig.  599. — Normal  rhythm  of  urinary  elimination   (above). 
Opsiuria  (below). 

form,  and  one  which,  upon  thorough  investigation,  can  nearly 
always  be  relegated  to  one  of  the  three  above-mentioned  groups, 
7n2.,  hepatic,  peritoneal  (tuberculous  or  neoplastic),  or  cardiac 
ascites. 

3.  Chylous  Ascites. — Also  a  rare  form,  at  least  in  our  own 
countries,  and  doubtless  of  varied  and  complex  causation. 

The  fluid  withdrawn  is  whitish,  opalescent,  milky  in  appear- 
ance, containing  little  protein  but  much  fat,  which  is  dissolved 
by  ether,  thereby  clearing  up  the  fluid.  Its  composition  is  some- 
what similar  to  that  of  pus  (hyperleucocytosis). 

In  the  presence  of  this  form  of  ascites  there  have  been  de- 
tected filariasis  (Lancereaux),  tuberculosis  (Courtois-Sufiit), 
chronic  inflammation  of  the  peritoneum  (Letulle),  and  pressure 
on  the  thoracic  duct  by  enlarged  mediastinal  glands  (Strauss). 


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ASCITES.  747 


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Fig.  600. — ^Tributaries  of  the  portal  vein  (after  Birard  and  Vignard). 
X.  Internal  mammary  vein.  2.  Superior  vena  cava.  S-  Inferior  vena  cava. 
4,  Suprahepatic  vein.  5.  Liver.  6.  Trunk  of  the  portal  vein.  7.  Gastro- 
duodenal  veins.  8.  Pancreas.  9.  Duodenum.  10.  Mesentery.  ;/.  Ileo- 
colic vein.  12.  Ileocecal  angle.  13.  Appendicular  veins.  14.  Appendix. 
75.  Spleen.  16.  Stomach  (opened).  77.  Intrahepatic  tributaries  of  portal 
vein.  j8.  Celiac  axis.  19.  Tail  of  the  pancreas.  20.  Pancreatic  veins. 
^i.  Inferior  mesenteric  vein.  22.  Mesocolon.  23.  Descending  colon.  24. 
Colosigmoid  vein.    2).  Sigmoid  flexure. 


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750  SYMPTOMS, 

4.  The  Ascites  of  Pylephlebitis. — An  altogether  exceptional 
form  characterized  by  its  sudden  onset,  its  exceedingly  prompt 
recurrence  after  puncture,  the  attendant  pain,  diarrhea,  vomit- 
ing, and  hemorrhage  in  the  digestive  tract,  the  splenic  enlarge- 
ment, and  the  pronounced  development  of  collateral  circulation 
in  the  abdominal  wall. 


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ASTHENIA  AND    [from  a,  privative;  aOevogj  strength^ 
FATIGUE.  L  Deprived  of  strength.  J 


The  term  fatigue  relates  to  a  sensation  too  commonly  experi- 
enced and  well  characterized  to  require  definition.  At  most 
need  it  be  said  that  all  grades  of  fatigue  may  be  encountered, 
from  the  mild,  temporary,  almost  pleasant  sensation  of  fatigue, 
manifested  in  a  desire  to  rest,  to- deep,  persistent,  and  lasting 
exhaustion,  almost  completely  depriving  the  individual  of  will 
power  and  of  the  ability  to  act.  Lastly,  it  is  necessary  to  make 
a  distinction  between  "paralysis,"  or  abolition  of  voluntary 
movements  of  some  portion  of  the  body,  and  "fatigue,"  which 
merely  renders  motion  distressing  or  actually  painful ;  as  a  mat- 
ter of  fact,  however,  "paresis"  is  in  some  respects  closely  allied 
to  "fatigue." 

Fatigue  as  a  symptom  is  too  common  and  ordinary  a  mani- 
festation of  most  infectious,  toxic,  or  depressive  states  to  lend 
interest  even  to  an  attempt  at  a  complete  semeiologic  descrip- 
tion in  this  connection.  The  scope  of  this  chapter  will  there- 
fore be  restricted: 

1.  To  recalling  the  commoner  clinical  states  in  which  fatigue 
occurs  as  a  symptom. 

2.  To  recalling  under  what  circumstances  fatigue,  by  virtue 
of  its  unusual  persistency,  intensity,  or  variety,  assumes  definite 
clinical  significance  and  is  sometimes  practically  pathognomonic. 

The  feeling  of  fatigue  may  be  physiological,  i,e,,  normal,  after 
prolonged  physical  or  mental  exertion,  after  some  form  of  shock 
to  the  system,  violent  emotion,  or  prolonged  test.  In  this  in- 
stance it  is  merely  accidental  and  temporary.  It  yields  readily 
to  rest,  sleep,  and  removal  of  the  cause. 

Fatigue  may  assume  an  abnormal,  pathologic  type  by  virtue 
of: 

Its  intensity   (exhaustion,  profound  asthenia). 

(751) 


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752  SYMPTOMS, 

Its  duration  (yielding  neither  to  rest  nor  to  removal  of  the 
cause). 

Its  special  modalities,  being  frequently  periodic  in  type. 

Its  location,  often  in  the  lumbar  regions. 

It  may  be  succinctly  recalled  that  the  more  usual  causes  of 
pathologic  fatigue  may  be: 

I.  Nervous. — Nervous  fatigue  results  naturally  from  over- 
work, repeated  emotion,  and  in  particular  from  insomnia  of  what- 
ever cause. 

It  is  met  with  almost  constantly,  either  as  a  subsidiary  or 
principal  manifestation,  in  the  majority  of  organic  diseases  of  the 
nervous  system,  and  in  particular  in  all  paralytic  states,  to  which 
no  further  reference  will  be  made. 

Its  diagnostic  significance  may  be  very  great  in  all  forms 
of  depressive  psychoneuroses,  zH:!,,  neurasthenic  and  neurastheni- 
form  states,  anxiety  neurosis,  cerebrocardiac  neuropathy,  psy- 
chasthenia,  general  asthenia  with  gastrointestinal  atony,  ptosis, 
and  impaired  nutrition,  sympatheticotonia,  etc.  It  is  constant  in 
all  these  conditions  and  sometimes  predominant  and  overmastering; 
it  is  nearly  always  associated  with  insomnia.  The  cause  will 
always  be  found  to  be  overstrain,  physical  or  mental;  sexual 
excesses,  or  some  emotional  shock,  the  patient  himself  not  gen- 
erally connecting,  however,  the  two  groups  of  phenomena.  Once 
this  cycle  has  been  established,  vis.,  excessive  excitability  ("emo- 
tionalism,** suggestibility)  and  asthenia  (insomnia),  it  tends,  as 
an  actual  vicious  circle,  to  persist,  the  "emotionalism"  and  sug- 
gestibility engendering  or  accentuating  the  asthenia  and  insom- 
nia, and  the  asthenia  and  insomnia,  in  turn,  engendering  or  ac- 
centuating the  "emotionalism"  and  suggestibility. 

The  diagnosis  is  generally  easy,  an  inquiry  into  the  patient's 
mental  state  yielding  conclusive  results.  It  is  to  be  borne  in 
mind,  however,  that  a  diagnosis  of  primary  psychoneurosis 
should  never  be  made  except  after  a  process  of  exclusion,  and 
that  the  practitioner  should  always  make  certain  that  it  is  not 
symptomatic  of  some  somatic  disorder  such  as  tuberculosis, 
arteriosclerosis,  syphilis,  azotemia,  etc. 


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ASTHENIA  AND  FATIGUE. 


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754  SYMPTOMS. 

n.  The  humoral  caases  of  fatigue  are  legion.  Any  form 
of  intoxication,  whether  endogenous  or  exogenous  and  toxic  or 
toxinic,  may  cause  asthenia.  However  defective  the  following 
classification  may  be — and  it  must  be  confessed  that  many  of 
the  groups  overlap— it  may  be  adopted,  even  if  merely  for  mnemo- 
technic  purposes. 

(a)  Anemias. — In  this  group  fatigue  is  continuous  and  is 
associated  with  the  customary  indications  of  anemia,  viz.,  pallor 
of  the  mucous  membranes,  reduction  of  red  cells,  reduction  of 
hemoglobin,  etc.,  together  with  anorexia,  indigestion,  etc.  The 
main  object,  however,  should  be,  trace  the  cause  of  the  anemia 
(see  Anemias). 

(b)  Hyposph3rxic  States. — ^These  involve  a  special  circulatory 
syndrome  characterized  essentially  by  low  blood-pressure  and 
relatively  high  blood  viscosity,  these  causing  all  the  usual  mani- 
festations of  impaired  circulation,  vis,,  cyanosis,  lowered  super- 
ficial temperature,  dyspnea,  and  undue  fatigability  (see  Low  blood- 
pressure). 

(c)  Conditions  of  Glandular  Insufficiency. — Particular  atten- 
tion will  here  be  paid  to  Addison's  disease  and  myxedema. 

1.  Addison's  disease  (adrenal  insufficiency). — Addison's  disease 
constitutes  simply  a  very  serious,  but  exceptional,  form  of  adrenal 
insufficiency,  which  recent  observations,  particularly  those  of  Ser- 
gent,  have  shown  to  be  so  common  in,  all  infectious  and  post-infec- 
tious states  (typhoid  fever,  scarlet  fever,  dysentery,  malaria,  chol- 
era, tuberculosis,  etc.).  During  the  course  of  these  disorders  the 
3  cardinal  signs  should  be  systematically  looked  for:  Asthenia, 
low  blood-pressure,  and  Sergenfs  white  line. 

2.  Myxedema. — ^The  characteristic  doughy  infiltration  of  the 
tissues  (myxedema),  the  repeated  intermissions  in  the  progress 
of  the  disease,  and  the  permanent  asthenia  lead  to  the  diagnosis. 

(rf)  Diathetic  States  (Metabolic  Disorders). 

1.  Obesity. — This  in  itself  is  often  dependent  upon  insufficiency 
of  several  of  the  ductless  glands,  and  particularly  of  the  thyroid, 
which  allies  it  in  some  respects  to  myxedema.  Asthenia  should 
lead  to  a  suspicion  of  the  latter  condition  (see  Obesity). 

2.  Diabetes. — Ordinarily  the  diabetic  is  a  supernormal,  over- 
active, indefatigable  individual.    Asthenia  of  unknown  origin  may. 


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ASTHENIA  AND  FATIGUE,  755 

however,  at  times  lead  to  the  detection  of  an  incipient  diabetes  in 
a  previously  healthy  subject;  acetonemia  or  azotemia  will  do  the 
same  in  a  subject  with  glycosuria  of  long  standing  (see  Glycosuria), 
(e)  Autotoxic  States. 

1.  Uremia  (and  especially  azotemia). — ^A  persistent,  overpow- 
ering asthenia  in  conjunction  with  general  torpor  occurs  almost 
constantly  in  azotemia. 

2.  Arteriosclerosis  (senile  degeneration). — The  same  state- 
ment 2q)plie&  to  arteriosclerosis. 

III.  The  infectious  causes  of  "fatigue"  and  asthenia  mani- 
festly induce  them  through  poisoning  of  the  nervous  and  mus- 
cular tissues  by  toxins  and  through  adrenal  insufficiency. 
Strictly  speaking,  they  should  therefore  be  included  in  the  groups 
already  given.  Let  it  be  again  repeated  that  in  the  classification 
herein  adopted  *'dogmatic  logic"  is  deliberately  sacrificed  in  the 
interests  of  "practical  pragmatism." 

The  infectious  forms  of  fatigue  are  often  plainly  evident ;  this 
applies  to  most  of  the  asthenic  conditions  witnessed  in  conjunc- 
tion with  acute  infections,  e.g.,  typhoid  and  post-typhoid  asthenia, 
influenzal  and  post-influenzal  asthenia,  diphtheritic  and  post- 
diphtheritic asthenia,  etc.  In  any  case  careful  inquiry  should 
be  made  to  determine  (1)  whether  this  post-infectious  asthenia 
is  not  concealing  incipient  tuberculous  disease,  and  (2)  whether 
It  is  accompanied  by  pronounced  signs  of  adrenal  insufficiency 
(low  blood-pressure,  asthenia,  Sergent's  white  line). 

Particular  attention  should  be  paid  to  the  chronic,  sluggish, 
cryptogenic  forms  of  asthenia.  In  this  connection  especially 
should  the  physician  refuse  to  be  satisfied  with  such  "easy" 
diagnoses  as  "anemia"  or  "neurasthenia,"  but  should,  on  the 
contrary,  make  a  deliberate  search  for  the  three  great  chronic 
infections  (tuberculosis,  syphilis,  and  malaria)  and  the  three 
main  varieties  of  intoxication  already  referred  to  (uremia,  gly- 
cosuria, and  hyposphyxia). 

No  detailed  reference  need  be  made  to  the  well-known  signs 
of  these  disorders.  Yet  it  may  be  recalled  in  conclusion  that 
any  case  of  persistent,  unaccountable  asthenia  should  lead  one 
to  the  particular  thought  of  the  possibility  of  incipient  tubercu- 


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756 


SYMPTOMS. 


losis,  evidences  of  which  should  be  sought  with  great  care, 
vis.,  (1)  Functional:  weakness,  lassitude,  dyspnea  on  exertion, 
anorexia,  loss  of  weight,  slight  vesperal  fever,  night  sweats,  cough, 
frequent  heart  rate,  and  hemoptysis.  (2)  Physical:  reduced  breath- 
ing capacity,  slight  impairment  of  resonance  at  one  apex,  in- 
creased vocal  resonance,  and  persistent  abnormalities  of  respira- 
tion at  one  apex  (rough,  jerky  breathing;  rough,  prolonged,  and 
blowing  expiration;  friction  rubs,  etc.). 

Fluoroscopy,  while  of  very  great  value,  has  in  no  wise  de- 
tracted from  the  significance  of  the  above  time-honored  physical 
signs. 

Systematic  clinical  examination  will  automatically  yield  a 
solution  to  these  problems,  provided  it  is,  or  attempts  to  be, 
thorough  and  comprehensive. 


Systematic  Clinical  Examination  of  Asthenic  Subjects. 


I.  Determination  of  blood- 
pressure,  systolic  and 
diastolic 

High  blood-pressure. 

Low  blood-pressure. 

Arteriosclerosis,  nephritis,  azotemia. 
Hyposphyxia,  tuberculosis,  adrenal  in- 
sufficiency. 

2.  Blood  examination. 
Low  red  cell  count. 
Hyperviscosity. 

Hyperazotemia. 
Wassermann  reaction. 

Anemia. 

Hyposphyxia,     azotemia,     tuberculosis, 

adrenal  insufficiency,  acetonemia. 
Azotemia. 
Positive:    Syphilis. 

3.  Temperature. 
Hyperthermia. 

Infectious  states  (tuberculosis,  malaria, 
etc.). 

4.  Auscultation. 

Lungs. 

Heart 

Tuberculosis. 

(Accentuation  of  second  sound,  gallop 
rhythm:  Nephritis,  arteriosclerosis). 

5.  Urine  examination. 
Sugar,  acetone. 
Albumin. 

Diabetes,  acetonemia. 
Albuminuria  (azotemia). 

6.  Examination  of  reflexes 
and  nervous  reactions. 

1.  Psychoneuroses. 

2.  Sergent's  white  line:   Adrenal  insuffi- 
ciency. 

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r%xjjT  T  c  {French:  Frissons,  from  frigere,] 


A  chill  consists  essentially  of  a  sudden  tremor  of  varying  ex- 
tent and  varying  duration,  usually  accompanied  by  a  sensation 
of  cold  and  followed  by  a  sensation  of  warmth. 
At  least  three  grades  of  chills  may  be  recognized : 
Cryesthesia  or  chilliness^:  An  unpleasant  sensation  of  cold,  with 
very  slight  tremor. 
Shivering, 

An  actual  major  chill,  involving  the  entire  body  and  attended 
with  chattering  of  the  teeth,  diffuse  and  violent  trembling,  and  an 
intense  feeling  of  cold. 

All  true  chills,  except  the  nervous  or  emotional  chills,  are 
followed  by  fever.  As  a  general  rule,  a  definite  chill  accom- 
panied by  an  abrupt  rise  of  temperature  is  symptomatic  of  the 
onset  of  an  infectious  disease,  by  far  the  most  frequent  of  such 
disorders  being  pneumonia,  grippe,  malaria,  tonsillitis,  and  sep- 
ticemia. 

The  commonest  causes  of  chills  may  be  enumerated  as  fol- 
lows : 

Pyogenic  and  septicemic  infections : 
Pneumonia,  tuberculosis,  appendicitis. 
Septic  wounds. 
Suppurative  disorders  of  the  liver  and  kidneys;  biliary  and 

urinary  infections. 
Tonsillitis. 

Vegetative  endocarditis. 
Phlebitis, 
Empyema. 
Erysipelas, 
Malaria. 

Renal  and  hepatic  colic. 
Nothing  special  need  be  said  concerning: 

(757) 


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758 


SYMPTOMS, 


The  chill  from  exposure  or  "a  frigore," 

The  emotional  chill,  or  shivering  "with  fright"  or  "with  horror/' 
or  simply  the  psychoneuropathic  chill.  Some  nervous  degen- 
erates, apparently  "constitutional  shiverers,"  are  always  ready 
to  shiver  on  the  slightest  provocation. 


Causes. 

Fbykb. 

BLOOD  Ex- 

Clinical 

MEANS  or 

amination. 

SIGNS. 

lUCOYKBT. 

Nervousness. 

None. 

Negative. 

Neuropathic 
stigmata. 

Suggestion. 
Discipline. 

Septic  states. 

Remittent 

Polymor- 

Local or  deep- 

Dressings, 

phonuclear 

seated  vis- 

operation, and 

leucocy- 

ceral  infec- 

drainage. 

tosis. 

tion. 

Infectious  en- 
docarditis. 

Collargol  in- 
jections. 

Phthisis. 

Remittent. 

Frequently 

Stethoscopic 

General    and 

leucocy- 

and  fluoro- 

local treat- 

tosis. 

scopic  pulmon- 
ary evidences. 

Tubercle  bac- 
illi in  sputum. 

ment.      Hy- 
gienic  meas- 
ures. 

Spontaneous 
recovery. 

Pneumonia. 

Continued. 

Frequently 

Stethoscopic 

Hygienic  treat- 

• 

leucocy- 

evidences. 

ment.    Gen- 

tosis. 

Characteristic 
sputum. 

eral  measures. 
Spontaneous 
recovery. 

Hepatic  colic. 

Remittent 

Not  char- 

Hepatic colie 

Morphine. 

or  inter- 

acteristic. 

or  gastralgia. 

Operation. 
Diet 

mittent 

Frequently 

jaundice. 

Pain  in  right 

hypochon- 

drium. 

Malaria. 

Intermit- 

Leucopenia. 

Splenic  enlarge- 

Quinine. 

tent  (at- 

Malarial 

ment 

Arsenic. 

tacks  at 

parasites. 

definite  in- 

tervals). 

Tsrphoid  fever. 

Continued. 

Leucopenia. 

Typhoid  state. 

General  treat- 

Agglutina- 

Rose spots. 

ment 

tion  test 

Splenic  enlarge- 

Diet. 

Blood  cul- 

ment, etc. 

Cold  baths. 

ture. 

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nnuiA  \X(i(ia.     Drowsiness  J  suspension] 

i^UMA.  1^       ^y  ^^^  mental  fv/nctions.      J 


Coma  consists  of  a  state  of  profound  somnolence  with  more 
or  less  complete  loss  of  consciousness,  sensibility,  and  motility. 
While  it  is  the  most  striking  feature  of  the  syndrome  resulting 
from  apoplexy,  it  may  be  and  frequently  is  met  with  under  other 
circumstances. 

It  could  hardly  be  confused  with  the  deep  sleep  of  convales- 
cents or  hysterical  cases,  or  with  syncope  or  asphyxia. 

The  deep  sleep  of  convalescents  is  a  quiet  sleep,  with  the 
pulse  regular  and  respiration  normal.  It  is  seldom  so  profound 
that  the  patient  cannot  be  awakened  by  some  sharp  stimulus, 
and  the  history  of  the  case  will  generally  exclude  the  idea  of 
coma. 

The  sleep  of  hysterical  patients  might  more  readily  lead  to 
confusion.  Only  rarely,  however,  will  the  previous  history  and 
the  features  of  the  onset  of  the  attack  fail  to  point  the  way  to 
a  proper  diagnosis,  which  will  be  thoroughly  illuminated,  fur- 
thermore, by  systematic  investigation  of  the  hysterogenous 
zones. 

Systematic  diagnosis  of  hysterical  pseudo-coma  may  be  said 
to  be  based  on  the  following  clinical  findings: 

1.  If  the  onset  was  sudden,  the  patient  falling,  this  fall  oc- 
curred without  the  patient  receiving  any  severe  blow  or  any 
wound  or  traumatism;  no  biting  of  the  tongue,  and  no  relaxa- 
tion of  the  sphincters.  • 

2.  Frequently  there  are  noted  contracture,  winking  of  the 
lids,  and  various  movements  of  the  eyeballs,  which  are  absent 
in  true  coma. 

3.  The  patient,  while  apparently  insensitive  to  pain,  noise, 
and  light,  reacts  to  an  exaggerated  degree,  on  the  other  hand, 
to  pressure  upon  a  hysterogenous  zone,  to  a  cold  affusion,  or 
to  appropriate  suggestion  in  a  loud  voice.    The  author  has  wit- 

(759) 


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760  SYMPTOMS. 

nessed  many  seizures  of  this  type,  sufficiently  striking  to  alarm 
an  experienced  hospital  staff,  suddenly  cease  upon  suggestion 
that  the  patient  was  to  be  "immediately  placed  in  isolation  in 
the  special  quarters"  or  to  be  "subjected  to  cauterization  with 
the  hot  iron."  Much  oftener,  indeed,  it  yielded  to  brief  occlusion 
of  the  nose  and  mouth. 

4.  Lastly,  these  hysterical  pseudo-comatose  states  are  fre- 
quently associated  with  postures  apparently  unconsciously  as- 
sumed, but  plainly  semi-voluntary  to  the  close  observer;  the 
same  applies  to  the  pseudo-delirium  encountered  in  these  sub- 
jects. 

S3mcope  is  ordinarily  of  short  duration.  The  sudden  loss 
of  consciousness,  pallor,  weakness,  and  even  almost  complete 
arrest  of  the  heart-beats,  the  rapidly  beneficial  effect  of  the  hori- 
zontal posture,  elevation  of  the  legs,  and  stimulating  injections, 
will  preclude  any  prolonged  hesitation. 

In  asphyxia,  the  history  of  the  case,  the  cyanosis,  the  livid  ap- 
pearance, and  the  reduced  temperature  of  the  lower  extremities 
will  obviate  any  mistake. 

The  ordinary  causes  of  coma  may,  for  practical  purposes, 
be  enumerated  as  follows: 

Toxic  causes:  Exogenous:  Alcohol,  opium. 

Endogenous:      Uremia,    acetonemia,    acidosis 
(diabetes). 

Cerebral  causes:   Vascular:   Apoplexy,  hemorrhage,  throm- 
bosis, or  epilepsy. 

Inflammatory :    Meningoencephalitis. 
Neoplastic :    Brain  tumors. 
Traumatic:    Skull  fractures. 

Infectious  causes:  Malaria,  rheumatism,  typhoid  fever,  or  in- 
fectious jaunSice. 

Circulatory  causes:    Stokes- Adams'  disease. 

Coma  having  been  clinically  encountered,  the  causal  diag- 
nosis, which  is  of  prime  importance  both  because  of  the  prog- 
nosis it  affords  and  the  indications  it  gives  for  treatment,  is 
based  chiefly  upon  the  history  of  the  illness  and,  in  particular,  on 
the  results  of  clinical  examination.  The  history  and  clinical  findings 
must  be  systematically  collated. 


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COMA.  761 

The  history  is  of  prime  imfrortance, 

1.  Has  there  been  some  traumatic  injury,  fall,  or  contusion 
preceding  the  coma?    If  so,  fracture  of  the  skull. 

2.  Does  the  patient  give  a  history  of  similar  seizures  before, 
and  is  he  subject  to  convulsive  attacks?  Epilepsy,  eclampsia, 
uremia. 

3.  Has  the  patient  been  intemperate?  Had  he  been  on  an 
alcoholic  spree  before  the  coma  came  on?    Alcoholism. 

4.  Has  the  patient  had  syphilis?  Has  he  previously  had  treat- 
ment for  this  disease?  Was  he  under  treatment  at  the  time? 
Brain  syphilis. 

5.  Did  the  patient  have  nycturia,  vertigo,  albuminuria,  etc.? 
Interstitial  nephritis,  arteriosclerosis,  uremia,  etc. 

6.  Was  the  patient  in  a  rundown  state;  did  he  pass  very 
much  water;  had  he  had  itching  and  digestive  disturbances  for 
a  few  days,  etc?    Diabetes. 

And  so  on  .    .    . 

In  short,  the  practitioner  should  <:arefully  take  note  of  all 
information  supplied  by  the  relatives  as  to  the  patient's  previous 
medical  history ;  such  information  will  often  yield  highly  service- 
able clinical  indications. 

The  direct  clinical  examination  is  of  much  greater  importance 
stUL 

As  in  other  conditions,  it  should  be  conducted  systematically 
and  comprehensively.  The  following  lines  of  inquiry  are,  how- 
ever, particularly  essential: 

1.  Is  hemiplegia  present?  (See  Hemiplegia),  With  decrease  of 
muscle  tone  on  one  side  of  the  body ;  sometimes  conjugate  devi- 
ation of  the  head  and  eyes,  an  exaggerated  patellar  reflex  on  one 
side,  and  the  Babinski  ^  sign  or  plantar  reflex.  Hemiplegia,  if 
present,  will  usually  constitute  a  clinical  expression  of  brain 
hemorrhage  or  softening;  it  may  be  met  with  in  uremia,  and 
in  some  forms  of  meningitis  in  childhood. 

2.  Is  fever  present?  And  if  so,  was  it  present  before  the 
coma  (typhoid  fever,  cerebral  rheumatism,  tuberculous  menin- 
gitis, cerebrospinal  meningitis)  ?  Or  was  it  present  along  with 
the  coma  (pernicious  malarial  fever)  ?  Or  did  it  come  on  after 
the  coma  (certain  forms  of  cerebral  hemorrhage)  ? 


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762 


SYMPTOMS. 


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COMA. 


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764  SYMPTOMS. 

3.  Is  sugar  or  albumin  present  in  the  urine?  The  presence 
of  sug^r  would  suggest  diabetic  coma;  in' this  case  the  exami- 
nation should  be  supplemented  by  tests  for  acetone  and  diacetic 
acid  and  by  a  determination  of  urinary  acidity  (see  Technical 
Procedures),  thus  confirming  the  diagnosis.  The  presence  of 
albumin  would  suggest  uremic  coma,  which  is  confirmed  or  ex- 
cluded by  determination  of  the  blood  urea.  Where  the  latter 
exceeds  1  gram  (it  exceeded  5  grams  in  one  of  the  author's 
cases),,  the  diagnosis  of  uremic  coma  is  assured 

4.  Is  there  high  blood-pressure?  A  systolic  pressure  exceed- 
ing 220  millimeters  (Pachon  instrument);  especially  if  asso- 
ciated with  manifest  cardiac  hypertrophy,  gullop  rhythm,  and 
albuminuria,  certainly  justifies  a  diagnosis  of  uremia  with  or 
without  -cerebral  hemorrhage,  arteriosclerosis,  interstitial  neph- 
ritis, etc.  The  finding  of  the  **blue  line"  on  the  gums  of  a  worker 
in  lead  will  lead,  on  the  whole,  to  the  same  inferences. 

5.  Is  there  some  manifest  evidence  of  syphilis?  The  finding 
of  osteoperiostitis,  glandular  swellings,  a  typical  eruption,  sus- 
picious pigmented  scars,  etc.,  may  bring  to  mind  the  possibility 
of  a  specific  cerebral  arteritis. 

6.  A  marked  reduction  in  the  pulse  rate  would  suggest  Stokes- 
Adams*  disease,  brain  tumor,  or  opium  intoxication. 

7.  Examination  of  the  blood  (urea  content  and  Wassermann 
reaction)  and,  in  difficult  cases,  examination  of  the  cerebrospinal 
fluid  (cytologic  study  and  Wassermann  reaction),  should,  if  pos- 
sible, be  systematically  carried  out.  They  will  often  enable  the 
practitioner  to  decide  at  once  upon  a  diasrnosis  of  uremia  (where 
the  blood  urea  exceeds  1  g^am),.  of  brain  syphilis  (positive 
Wassermann),  of  cerebromeningeal  hemorrhage  (many  red  cells 
in  the  cerebrospinal  fluid),  of  tuberculous  meningitis  (lymphocy- 
tosis), of  cerebrospinal  meningitis,  etc. 

The  more  usual  causes  of  coma  in  private  practice  are,  in 
the  order  of  their  frequency: 

Apoplectic   coma    (hemorrhage   and   softening  of   the  brain). 
Uremic  coma. 
Alcoholic  coma. 
Post-epileptic  coma. 
Diabetic  coma. 


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COMA.  765 

Combinations  of  these  forms  may,  of  course,  occur,  the  com- 
binations, alcoholism  with  uremia,  alcoholism  with  apoplexy, 
alcoholism  with  ajcetonemia  (diabetes),  and  uremia  with  apo- 
plexy being  the  most  frequent. 

These  forms  undoubtedly  make  up  over  95  per  cent,  of  the 
cases  of  coma  seen  in  general  practice. 

The  remaining  5  per  cent,  consist  chiefly  of: 

Infectious  and  post-infectious  coma  (lobar  pneumonia,  ty- 
phoid fever,  infectious  jaundice,  malaria,  and  puerperal  infec- 
tion). 

Post-traumatic  coma  (fracture  of  skull). 

Inflammatory,  meningo-encephalitic  coma. 

Toxic  coma  (opium,  morphine). 

Neoplastic  coma  (brain  tumors). 

Demential  coma  (paretic  dementia). 

According  to  Pierre  Marie,  brain  compression  plays  an  impor- 
tant role  in  the  productfon  of  post-hemorrhagic  coma,  and  complete 
coma  is  actually  dependent  upon  brain  hemorrhage  (Presse  med., 
June  6,  1914).  It  may  be  of  service  to  reproduce  here  the  follow- 
ing practical  conclusions,  which  Marie  deems  may  be  formulated 
in  this  connection: 

In  a  patient  presenting  the  signs  of  cerebral  hemorrhage  who, 
three  hours  after  the  attack,  is  in  profound  coma,  the  question 
of  performing  a  decompression  operation  may  be  considered 
(an  extensive  extravasation  of  blood  is  in  all  likelihood  present). 

In  any  patient  suffering  from  cerebral  hemorrhage  who,  after 
having  at  first  presented  only  a  partial  coma,  falls  progressively 
into  a  deep  coma  a  few  hours  or  days  later,  the  performance 
of  a  decompression  operation  should  be  seriously  thought  of 
and  the  decompression  carried  out  as  soon  as  possible  (in  this 
instance  the  condition  present  is  rather  a  secondary  edema). 

At  this  operation  a  large  decompression  opening  should  be  made 
over  the  hemisphere  on  the  sound  side  and  not  over  that  into  which 
the  cerebral  hemorrhage  has  occurred. 


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CONSTIPATION  fConstipatio,  fnym  constipare,! 

[         to  squeeze  together.         J 


Constipation  is  characterized  by  infrequency  of  the  intestinal 
evacuations  and  an  abnormally  hard  consistency  of  the  feces.  What 
are  the  actual  extremes  of  constipation  ?  No  one,  to  the  author's 
knowledge,  has  as  yet  supplied  a  satisfactory  definition  in  this 
direction,  and  none  will  be  rashly  attempted  here,  nor  will  a 
complete  semeiologic  account  of  constipation  be  presented.  The 
subject  matter  will,  in  fact,  be  limited  to  a  succinct  resume  of 
the  more  important  clinical  forms  of  the  condition. 

Constipation  appears  to  depend,  in  general: 

Either  upon  a  decrease  of  the  peristaltic  contractions  (hypo- 
tonia) or,  on  the  other  hand,  upon  spasm. 

Or  upon  a  decrease  of  the  intestinal  secretions  (hypocrinia). 

Or  upon  an  increase  of  absorption  of  the  intestinal  contents. 

Little  space  will  be  devoted  to  accidental  constipation^  the 
cause  of  which  is,  as  a  rule,  easily  ascertained 

The  latter  is  not  true,  however,  of  habitual  constipation,  a 
"menace  to  society"  much  more  certainly  than  is  purgation,  de- 
nounced, not  without  justification,  by  Moliere  and  Burlureaux. 
Much  care  should  be  paid  to  the  detection  of  the  cause  of  this 
type  of  constipation,  and  especially  to  finding  out  whether,  in 
the  individual  case,  it  is  of  atonic  or  spastic  origin. 

Accidental  Oonstipation. 

(a)  Intestinal  obstruction:  Strangulated  hernia;  peritoneal 
bands. 

(fe)  Acute  abdominal  disorders. 

1.  Appendicitis. 

2.  Peritonitis. 

3.  Hepatic  or  renal  colic,  etc. 
(f)  Lead  poisoning  (lead  colic). 

(d)  Certain  acute  disorders  of  the  nervous  system:  Menin- 
gitis, etc. 

(766) 


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CONSTIPATION.  7^7 

Habitaal  Constipation. 

1.  This  may  be  dependent  upon  some  local  abdominal  cause 
capable  of  inducing  habitual  constipation,  either  mechanical 
(pressure  or  kink)  or  reflex. 

2.  It  may  be  due  to  some  more  general  cause. 

1.  Local  Causes. — ^These  comprise  all  abdominal  disorders 
capable  of  producing  pressure  on  the  intestine,  kinking,  or  re- 
flex spasm. 

(a)  Pressure. — Pregnancy,  retroversion  of  the  uterus,  fibro- 
myoma,  or  ovarian  cyst  in  women;  prostatic  hypertrophy  in 
men,  and  a  tumor  of  the  kidney,  spleen,  or  mesentery,  or  a 
stricture,  cicatricial  band,  or  peritoneal  adhesion  in  either  sex, 
may  so  obviously  be  the  cause  of  obstinate  constipation  as  to 
require  no  further  mention. 

(b)  Kinks. — The  causal  influence  of  enteroptosis,  whether 
due  to  loss  of  fatty  support,  pregnancy,  obesity,  perineal  im- 
pairment, peritoneal  bands,  or  congenital  malformations,  has 
always  been  in  some  degree  realized.  Systematic  fluoroscopy 
of  the  abdomen  has,  however,  demonstrated  for  it  a  paramount 
role  in  the  production  of  habitual  constipation.  Relaxation  of 
tissues,  lack  of  tonicity,  and  atony  of  the  abdominal  wall  gener- 
ally act  in  conjunction  with  the  actual  kink. 

(c)  Reflex  Spasm. — This  is  the  obvious  mode  of  production 
of  constipation  dependent  upon  painful  affections  of  the  bowel 
or  of  neighboring  organs — anal  fissure,  hemorrhoids,  chronic 
appendicitis,  cystitis,  salpingo-oophoritis,  pyelonephritis,  prosta- 
titis, etc. 

2.  General  Causes. 

(a)  The  most  frequent  general  causes  are,  perhaps,  simply 
habit  and  sedentary  life.  Education  rapidly  accustoms  the  civ- 
ilized human  subject  to  inhibit  on  various  occasions  the  impulse 
to  defecate.  Propriety,  occupation,  professional  necessities,  and 
likewise  the  low  and  repulsive  conception  attaching  to  the  act 
of  defecation,  exert  an  inhibiting  influence,  consciously  or  un- 
consciously, which  leads  to  gradual  suppression  of  the  function, 
constipation  being  thus  established.  To  these  may  be  added  a 
number  of  auxiliary  factors  such  as  the  disgusting  foulness  of 
some  civil  or  military  privies ;  the  false  prudishness— doubtless 


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768  SYMPTOMS. 

to  be  deplored,  but  quite  justified— of  young  girls;  the  sedentary 
life  imposed  by  various  occupations;  the  wearing  of  corsets; 
lack  of  physical  exercise,  gradually  leading  to  more  or  less 
marked  atony  of  the  muscles  of  the  abdominal  wall,  and,  ulti- 
mately, in  women,  pregnancy  and  the  impairment  of  the  ab- 
dominal wall  frequently  resulting,  at  least  among  civilized  popu- 
lations; all  these  factors  account  for  the  fact  that  constipation, 
which  is  exceptional  in  animals  and  savages,  and  but  moderately 
frequent  in  men,  is  practically  constant  in  women,  particularly 
those  living  in  cities. 

(b)  The  diet  of  city  dwellers,  nearly  always  defective,  is 
another  factor,  consisting  as  it  does  of  white  bread,  meat,  fowl, 
fish,  eggs,  potatoes,  rice,  pastes,  pastry,  confections,  cheese,  alco- 
holic beverages,  and  water — articles  which  leave  too  little  resi- 
due: "Where  there  is  nothing  left  the  bowel-,  like  the  king,  is 
bereft  of  his  prerogatives."  The  same  is  true,  indeed,  of  a  diet 
insufficient  in  amount. 

(c)  Various  metabolic  and  otiier  chronic  disorders  may  like- 
wise induce  constipation  in  one  way  or  another: 

1.  Constipation  is  rather  frequent  in  neuro-arthritic  cases, 
comprising  those  with  gout,  diabetes,  etc. 

2.  It  is  regularly  present  in  diseases  leading  to  asthenia  and 
cachexia,  such  as  chlorosis,  anemia,  senility,  various  cachectic 
disorders,  and  infectious  diseases.  Prolonged  recumbency  is, 
furthermore,  not  a  negligible  factor  in  these  cases. 

3.  The  atonic,  asthenic  type  of  gastrointestinal  dyspepsia,  so 
frequent  in  women  and  nearly  always  associated  with  ptosis 
and  dilatation  of  the  organs  concerned,  is  another  of  the  commonest 
causes  of  constipation,  acting  through  the  three  combined  fac- 
tors, reduced  secretion,  lack  of  tone,  and  kinks,  with  the  forma- 
tion of  "dead  areas"  in  the  digestive  tract. 

In  this  connection  the  term  gastrointestinal  dyspepsia  is  to  be 
taken  in  its  broadest  sense,  comprising  motor,  secretory,  or 
secretomotor  insufficiency  of  the  digestive  tract — stomach,  duo- 
denum, and  bowel — and  of  the  related  glandular  organs — the 
liver  and  pancreas.  The  marked  importance  attached,  for  ex^ 
ample,  to  duodenal  dyspepsia  as  a  result  of  modem  investiga- 
tions is  well-known. 


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CONSTIPATION.  769 

4.  Lastly,  various  nervous  afiFections,  functional  (hysteria, 
neurasthenia,  overwork)  or  organic  (tabes,  myelitis,  etc.),  are 
accompanied  by  habitual  constipation. 

The  etiologic  and  pathogenetic  diagnosis  of  constipation  is 
of  paramount  importance,  since  by  elucidating  the  causes  of  the 
disorder  it  often  supplies  direct  indications  for  treatment,  as,  e.g,, 
by  psychotherapy,  massage,  mechanotherapy,  electric  proced- 
ures, diet,  etc.  Whatever  be  the  cause,  however,  one  should 
always  endeavor  to  distinguish  the  atonic  from  the  spastic  type  of 
constipation.  This  distinction  is  sometimes  self-evident,  but  in  other 
instances  it  is  difficult  or  even  impossible  to  make,  the  two  forms 
coexisting,  both  as  regards  time  and  space,  i.e,,  either  following 
upon  one  another  or  being  actually  present  simultaneously  at 
separate  points  of  the  digestive  tract.  Fluoroscopy  is  of  the 
greatest  assistance  imder  these  circumstances. 


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CONVULSIONS 

(CONVULSIVE 

SEIZURES). 


Convulsio, /rom  convellere,  to  shake; 

sudden  and  involuntary  contractions 

of  the  muscles. 


The  term  convulsions  is  applied  to  sudden,  involuntary  con- 
tractions of  the  muscles.  Tonic  convulsions  consist  of  contrac- 
tions of  relatively  long  duration,  causing  a  condition  of  almost 
continuous  rigidity,  combined  with  shaking  movements  result- 
ing in  only  slight  displacements  of  the  parts.  Clonic  convul- 
sions are  made  up,  on  the  other  hand,  of  more  or  less  regular, 
rapidly  alternating  contractions,  resulting  in  more  or  less  ex- 
tensive involuntary  movements. 

Some  types  of  convulsions,  e,g,,  those  of  chorea,  athetosis,  tics, 
and  tremors  present  such  highly  characteristic  features  that  their 
diagnostic  recognition  is  an  easy  matter.  These  forms  will  not 
be  considered  in  this  chapter,  nor  will  reference  *  be  made  to 
partial  convulsions  such  as  blepharospasm,  spasmodic  torticollis, 
writer's  cramp  and  occupational  spasms  in  general.  Actual,  more  or 
less  diffuse  comnilsions  need  here  alone  be  considered. 

The  only  serious  mistake  in  actual  observation  that  can  be 
made  is  that  entailed  by  malingering.  Only  exceptionally  does 
such  an  imposition  escape  detection  by  an  experienced  and  well- 
posted  observer;  the  convulsions  are  always  defective  in  the 
sense  of  being  pushed  to  excess — the  subject  attempting  too 
"dramatic"  a  representation — or  in  being  unnatural — the  subject 
being  a  "novice."  Yet  the  author  has  met  with  some  "accom- 
plished artists"  in  this  connection  whose  duplicity  was  exposed  only 
with  great  difficulty. 

The  observation  of  an  actual,  not  an  artificial,  convulsive 
state  having  been  made,  the  second  and  highly  important  step 
is  next  to  be  taken,  zns.,  that  of  finding  out  its  cause. 

In  most  instances  the  clinical  history  obtained  from  the  patient 
himself  or  his  relatives  will  enable  the  physician  to  place  the  case 
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CONVULSIONS.  771 

in  one  of  two  groups:  (a)  The  convulsions  appear  in  an  acute 
manner,  (b)  They  are  chronic,  i.e.,  habitual,  occurring  repeatedly 
at  intervals  of  varying  length. 

I.— ACUTE  CONVULSIONS. 

A.  If  the  patient  is  a  child,  special  thought  should  be  given 
— and,  as  a  rule,  the  circumstances  under  which  the  convulsions 
appeared  will  afford  a  pointer  as  to  the  diagnosis — to: 

(a)  Convulsions  of  Reflex  Origin. — Usually  unattended  with 
fever : 

Dental. 

Digestive,  particularly  due  to  colic  and  intestinal  parasites. 

Auricular,  due  to  foreign  bodies  in  the  ear  or  to  otitis  media. 

Acute  otitis  media  is  one  of  the  most  frequent  causes  of  reflex 
convulsions  in  children;  further,  as  is  generally  realized,  it  is  one 
of  the  commonest  and  most  often  overlooked  disorders.  One 
should  never  forget  to  palpate  the  mastoids  and  examine  the  ears 
in  a  child  with  eclamptic  manifestations. 

(b)  Convulsions  of  Febrile  Origin. — Such  convulsions  are  a 
frequent  accompaniment  of  the  eruptive  fevers  and  are  generally 
not  of  serious  import. 

(c)  Convulsions  of  Meningoencephalic  Origin. — These  are 
associated  not  only  with  fever,  but  also  with  evidences  of  meningo- 
encephalic disorder  such  as  Kemig's  sign,  headache,  vomiting, 
disturbances  of  respiration,  etc.  The  marked  diagnostic  value  of 
lumbar  puncture  in  these  cases  is  familiar  to  all. 

(d)  Convulsions  of  Neuropathic  Origin. 

1.  Infantile  eclampsia,  a  very  common  disorder,  is  met  with 
in  children  as  a  symptom  of  various  diseases,  or  as  a  neurosis 
in  which  it  constitutes  in  itself  the  entire  disturbance. 

2.  In  the  latter  form,  or  idiopathic  eclampsia,  there  is  always 
present  an  underlying  neuropathic  condition,  or  spasmophilia, 
consisting  of  abnormal  irritability  of  the  nervous  system. 

3.  Spasmophilia  is  often  due  to  an  acid  intoxication  of  the 
blood  following  one  of  a  variety  of  digestive  disturbances  which 
gradually  induce  poisoning  of  the  system. 


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772  SYMPTOMS. 

4^  The  acidosis  disturbs  the  metabolism  of  the  lime  salts, 
which  may  be  said  to  be  essential  for  normal  functioning  of  the 
nerve  cells. 

5.  In  the  pathogenesis  of  eclampsia  are  also  involved  changes 
in  certain  of  the  endocrin  glands,  especially  the  parathyroids, 
which  lead  to  insufficiency  of  these  glands. 

6.  This  insufficiency  results  in  eclampsia  because  the  para- 
thyroids are  no  longer  carrying  on  their  antitoxic  role  in  the 
system,  while  at  the  same  time  there  is  disturbed  assimilation 
of  lime  salts. 

It  is  certainly  a  fact  that,  whatever  may  be  the  exciting  cause 
of  infantile  eclampsia,  some  individuals  are  particularly  predisposed 
to  it,  i.e.,  that  there  does  occur  a  true  spasmophilic  tendency  based 
upon  nervous  disorder  with  exaggerated  irritability  of  the  nerv- 
ous system  and  often  accompanied  by  an  abnormally  acid  con- 
dition of  the  body  fluids,  or  acidosis,  probably  favored  by  con- 
genital insufficiency  of  the  endocrin  glands. 

B.  The  patient  is  an  adult. 

(a)  The  convulsive  syndrome  results  from  some  pre-existing 
febrile  disorder,  such  as  typhoid  fever  (of  the  ataxo-adynamic 
variety),  cholera,  or  malaria  (convulsive  form  of  pernicious  mal- 
aria). 

(b)  There  may  or  may  not  be  fever,  but  such  fever  as  exists 
is  manifestly  accidental  and  the  history  of  the  case  supplies  the 
diagnosis: 

(a)  The  convulsions  may  follow  some  injury  to  the  skull  asso- 
ciated with  fracture,  extravasation,  meningeal  hematoma,  etc. 

(b)  They  may  follow: 

1.  A  dog  bite:  Rabies  (so-called  "hydrophobic"  seizures,  visceral 
spasms,  etc.). 

2.  A  contaminated  wound:  Tetanus  (trismus;  consciousness 
completely  preserved). 

(c)  They  may  follow  an  acute  intoxication,  premeditated  or 
accidental: 

1.  Strychnine,  the  type  of  convulsive  poisoning. 

2.  Opium,  cocaine,  or  theobromine,  in  which  they  constitute  a 
much  more  exceptional  event. 


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CONVULSIONS,  77i 

(d)  They  may  develop  at  labor  in  an  albuminuric  woman: 
Puerperal  eclampsia. 

(c)  The  acute  convukive  seizures  may  occur  m  the  course 
of  some  chronic  disorder  unattended  with  fever.  These  are  al- 
vrays  cases  of  chronic  systemic  intoxication. 

(a)  Uremia. — This  is  shown  to  exist  by  the  albuminuria,  high 
blood-pressure,  and  enlarged  heart,  sometimes  attended  with 
gallop  rhythm;  the  edema,  which,  however,  is  frequently  lack- 
ing; the  practically  pathognomonic  increase  of  the  blood  urea, 
and  the  history   (headache,  vertigo,  vomiting,  and  insomnia). 

(b)  Lead  Poisoning. — This  is  suggested  by  the  subject's  occu- 
pation (painter,  etc.),  the  characteristic  blue  line  on  the  gums, 
sometimes  by  paralysis  of  the  extensor  muscles  of  the  forearm, 
by  the  high  blood-pressure,  and  frequently  by  the  history  (head- 
ache, insomnia,  and  lead  colic). 

(c)  Diabetes. — Here,  indeed,  the  acute  manifestations  are  gen- 
erally of  the  comatose  variety;  in  any  event,  the  urine  exami- 
nation, always  indispensable,  though  perhaps  more  particularly 
so  in  the  comatose  and  convulsive  cases  than  in  others,  including 
tests  for  sugar,  albumin,  and  acetone,  and  a  determination  of  the 
urinary  acidity,  will  point  to  the  proper  diagnosis. 

(d)  Alcoholism. — This  tends  toward  many  different  forms  of 
convulsions,  and  from  various  causes:  Convulsive  attacks  in  the 
course  of  delirium  tremens;  convulsive  uremic  attacks  super- 
imposed on  the  alcoholism  (cirrhosis  of  the  liver  or  interstitial 
nephritis),  and  hystero-epileptiform  seizures  in  neurotic  alco- 
holics. 

This  is  a  matter  of  great  practical  importance  to  resident 
physicians  in  hospitals,  asylums,  homes,  dispensaries,  and  to 
police  surgeons. 

1.  Absence  of  albumin  from  the  urine  and  a  moderately  tense 
pulse  will,  in  all  likelihood,  exclude  uremia;  subsequent  determina- 
tion of  the  blood  urea  will,  if  necessary,  set  the  diagnosis  straight. 

2.  An  alcoholic  spree  is  obviously  capable  of  bringing  on  an 
epileptic  attack  in  a  person  predisposed  to  such  seizures.  Biting 
of  the  tongue  during  the  attack,  with  resulting  drivelling  of 
blood-stained  fluid,  the  incontinence  of  urine,  the  violence  of 
the  convulsive  movements,  the  initial  cry,  and  the  abruptness 


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774  SYMPTOMS, 

of  the  attack,  frequently  with  bruising  due  to  a  sudden  fall; 
observation  of  inherited  dystrophic  stigmata,  and  the  profound 
coma  which  follows  the  convulsive  attack,  are  as  many  presump- 
tive indications  of  alcoholic  convulsions. 

3.  A  hysterical  seizure  may,  be  started  by  an  alcoholic  debauch. 
The  absence  of  profound  coma  after  the  attack ;  the  semi-volun- 
tary, semi-conscious  character  of  the  movements,  during  which 
the  patient  neither  wounds  himself  nor  receives  any  hard  blows ; 
sometimes  the  incoherence  of  speech,  the  resistance  offered  to 
passive  opening  of  the  lids,  the  absence  of  aura,  of  the  initial 
cry,  of  tongue-biting,  and  of  relaxation  of  the  sphincters,  to- 
gether with  the  "artificial,"  "overdone,"  "exaggerated,"  "theatri- 
cal" quality  of  the  proceedings  which  strikes  the  experienced 
onlooker — all  these  features  are  in  favor  of  an  hysterical  origin 
of  the  seizure. 

4.  Uremia,  hysteria,  and  epilepsy  having  all  been  excluded, 
simple  alcoholic  toxic  convulsive  attack  constitutes  the  remaining 
diagnostic  alternative. 

IL— CHRONIC  CONVULSIONS. 

Convulsions  may  occur  in  a  chronic  or  at  least  a  recurring 
form.  The  preceding  section  (on  acute  convulsive  seizures  oc- 
curring in  the  course  of  some  chronic  disorder  unattended  with 
fever)  should  properly  be  included  in  the  present  group,  from  which 
it  was  separated  simply  because,  in  practice,  the  clinical  problem  is 
put  before  the  physician  under  far  different  conditions.  In  the 
cases  considered  in  the  preceding  section  the  practitioner  is  wit- 
nessing an  acute  convulsive  attack  concerning  which  he  has  little 
or  no  definite  information,  whether  the  patient  has  been  picked 
up  on  the  street  or  has  been  seized  for  the  first  time  with  an 
attack  which  took  his  family  unawares  and  unprepared.  In  the 
group  of  cases  now  to  be  considered,  on  the  other  hand,  similar 
attacks  have  already  occurred.  A  diagnosis  has  been  rendered, 
which  may  have  been  either  correct,  wrong,  or  misleading;  in 
any  case,  much  useful  information  can  be  obtained,  either  from 
the  patient  himself  or  his  relatives,  concerning  his  pre-existing 
condition.  In  these  cases  the  stumbling-block  does  not  lie  in 
the  paucity  of  information,  but  very  often  instead  in  an  excess 


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CONVULSIONS,  77i 

of  contradictory  or  even  incorrect  information  which  may  or 
may  not  be  intentionally  misleading. 

The  majority  of  cases  of  chronic  or  recurring  convulsions  are 
due  either  to  uremia,  epilepsy,  hysteria,  diabetes,  alcoholism,  pro- 
gressive general  paralysis,  or  Stokes-Adams^  disease  (paroxysmal 
slow  pulse). 

Uremia  of  the  convulsive  type  is  a  very  common  disorder, 
which  should  always  be  thought  of  in  the  case  of  a  middle-aged 
or  elderly  patient  or  of  a  syphilitic.  Presence  of  albumin  in  the 
urine,  repeated  finding  of  a  high  blood-pressure,  and  the  coex- 
istence of  usual  signs  of  chronic  uremia  (headache,  vomiting, 
pruritus,  insomnia  or  abnormal  somnolence,  etc.)  will  serve  to 
orient  the  diagnosis ;  blood  urea  determination  will  confirm  it. 

Epilepsy  should  be  suspected  in  the  presence  of  inherited 
stigmata  of  the  disorder  (malformations  of  the  skull,  teeth,  etc.), 
unfavorable  family  antecedents  (epilepsy,  alcoholism,  dementia, 
or  syphilis),  and  a  history  of  certain  disturbances  during  child- 
hood (arrested  development  in  certain  parts,  convulsive  attacks 
in  childhood,  night  terrors,  or  enuresis),  and  its  existence  is 
confirmed  by  the  features  of  the  attack  already  specified. 

Hysteria. — As  is  well  known,  the  problem  of  hysteria  has 
been  thoroughly  gone  over  in  recent  years,  and  but  little  remains 
of  our  former  conceptions  of  the  disease.  A  diagnosis  of  hysteri- 
cal convulsions  is  justified  only  by  careful  study  of  the  patient's 
psychoneuropathic  reactions,  his  suggestibility,  and  the  obser- 
vation of  an  inveterate  mythomania,  together  with  the  special 
features  of  the  convulsions  themselves,  previously  referred  to. 

Diabetes. — In  this  disorder  the  uranalysis,  which  should  be  a 
routine  procedure,  will  supply  the  diagnosis.  Yet  it  should  be 
borne  in  mind  that  uncomplicated  diabetes  never  causes  convulsive 
attacks,  and  that  such  attacks  occurring  in  the  presence  of  diabetes 
constitute  almost  certain  evidence  of  either  hyperacidosis  or  uremia 
as  a  complication  of  the  disease.  Routine  estimation  of  the  urinary 
acidity  and  performance  of  the  tests  for  acetone  and  diacetic  acid 
(see  Uranalysis)  will  settle  the  question  of  acidosis  and  enable  the 
physician  to  expect  and  sometimes  to  prevent  the  threatening  and 
so  often   fatal  coma.     Examination   for  albumin  and  casts  and 


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776  SYMPTOMS. 

determinations  of  the  blood-pressure  and  blood  urea  will,  on  the 
other  hand,  settle  the  question  of  uremia. 

Chronic  alcoholism  is  revealed  by  the  usual  evidences,  rns,, 
tremor  of  the  extremities,  exaggerated  reflexes,  gastrohepatic 
and  cardiorenal  disturbances,  and  an  abnormal  "satiny"  softness 
of  the  skin,  particularly  over  the  abdomen.  The  latter  sign, 
mentioned  by  Cabot,  is  actually  a  very  frequent  indication  of 
alcoholism;  it  seems  to  be  especially  characteristic  in  persons 
engaged  in  manual  labor,  whose  epidermis  is  normally  thick 
and  rough.  Chronic  alcoholism  gives  rise  to  convulsive  attacks 
only  in  the  event  of  an  acute  alcoholic  excess  or  in  a  hysterical, 
epileptic,  or  uremic  individual  (see  above). 

Progressive  general  paralysis  is  detected  by  a  careful  inquiry 
into  the  changes  occurring  in  the  patient's  mentality  and  affec- 
tive faculties,  which  the  relatives  will  nearly  always  describe: 
Changed  handwriting,  which  is  sometimes  illegible;  inability  to 
carry  out  correctly  certain  elementary  mental  tasks  such  as 
adding  or  multiplying  figures;  peculiar  optimism  not  justified 
by  attendant  facts;  inability  to  keep  the  attention  fixed  any 
length  of  time  on  one  subject;  singular  absent-mindedness,  bi- 
zarre and  strange  actions,  and  impairment  of  memory.  Later, 
unconsciousness,  megalomania,  and  paralytic  phenomena.  A 
specific  history  is  nearly  always  present. 

The  period  of  general  torpor  or  coma  nearly  always  follow- 
ing a  severe  convulsive  attack  is  usually  attended  with  a  more 
or  less  pronounced  slowing  of  the  pulse  rate,  which  may  descend 
to  60,  56,  or  54,  without  any  special  morbid  significance.  Where, 
however,  a  convulsive  and  comatose  attack  is  associated  with 
bradycardia  falling  below  40,  a  diagnosis  of  Stokes-Adams*  dis- 
ease may  be  almost  certainly  made.  This  appellation  should, 
in  the  author's  estimation,  be  temporarily  retained,  as  it  desig- 
nates precisely  the  clinical  syndrome,  paroxysmal  bradycardia  with 
convulsive  and  syncopal  attacks,  without  stating  definitely  its  nature, 
which  appears  to  differ  in  the  individual  cases  (see  Arhythmia  and 
Slow  pulse). 


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CX)UGH. 


Cough  is  so  common  a  symptom  in  disorders  of  the  respira- 
tory tract  that  these  two  conditions  are  naturally  conceived  of 
as  bearing  an  almost  necessary  relationship  the  one  to  the  other 
and  the  equation,  cough=respiratory  disease,  is  almost  inevi- 
tably accredited. 

Cough  of  respiratory  origin,  i.e.,  dependent  upon  some  dis- 
turbance in  the  respiratory  tract,  is,  indeed,  the  commonest  type, 
representing  about  nine-tenths  of  all  cases  of  cough  that  come 
under  the  physician's  care.  Little  space  need  here  be  devoted 
to  this  form,  as  the  practitioner's  attention  in  these  cases  is  al- 
ways strongly  drawn  toward  the  respiratory  tract  and  syste- 
matic investigation  is  thereupon  alone  required  to  ascertain  the 
cause. 

This  does  not  apply,  however,  in  cough  of  extra-respiratory 
origin. 

Occasionally  a  patient  presents  himself  complaining  of  cough, 
in  whom  most  careful  examination  reveals  nothing  wrong  in 
the  laryngotracheobronchial  tree.  Usually  it  is  a  fatiguing,  par- 
oxysmal sort  of  cough — a  cough  which  is  disheartening  alike  to 
the  patient  and  the  physician,  as  the  ordinary  measures  of  treat- 
ment for  cough  prove  a  complete  failure. 

For  this  form  the  term  "reflex  cough"  has  been  coined — 
certainly  an  improper  designation  since  cough  is  always  reflex, 
being  a  defensive  reaction  of  the  system  to  a  peripheral  stimulus 
starting  nearly  always  in  one  of  the  sensory  terminations  of  the 
pneumogastric  distributed  to  the  mucous  membrane  from  the 
vocal  cords  to  the  terminal  bronchial  ramifications,  but  which 
may  originate  very  differently  in  different  cases. 

Such  "reflex"  coughs,  or  better,  coughs  of  extra-respiratory 
origin,  can  be  mastered  only  by  being  familiar  with  their  mode  of 
production,  by  tracing  out  their  cause,  and  by  instituting  a 
strictly  causal  line  of  treatment. 

(777) 


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778  SYMPTOMS. 

Clinical  Features. — ^There  are  a  number  of  special  features 
which  impart  to  cough  of  extra-respiratory  origin  a  special  clinical 
aspect. 

It  is  a  dry  cough,  a  "useless"  cough — meaning  by  this  that 
it  is  purposeless,  avails  nothing,  and  that  it  cannot  result,  unless 
bronchitis  is  simultaneously  present,  in  the  expulsion  of  actual 
sputum;  at  the  most  it  may  sometimes  be  ifollowed  by  the  ejec- 
tion of  a  little  mucus  or  saliva. 

It  isf  often  a  paroxysmal  type  of  cough,  i,e,,  one  ordinarily  con- 
sisting of  a  long  series  of  expiratory  jerks,  brief,  occurring  at 

Efferent  motor  f^espk-atoiy  center  in  meduKa  Afferent  sensory 


Btfm 


/^ 


Fig.  601. — Diagram  showing  the  afferent  and  efferent  nerve  paths  con- 
cerned in  the  reflexes  of  the  respiratory  tract. 

short  intervals  and  .separated  by  relatively  few  inspiratory  move- 
ments. It  is  particularly  distressing  on  account  of  the  long  dura- 
tion of  the  paroxysms  and  their  frequent  recurrence. 

Lastly,  it  is  a  type  of  cough  which  is  produced,  ordinarily, 
under  certain  very  special  circumstances.  In  cases  of  pleurisy 
(pleuritic  cough  being,  indeed,  comprised  in  this  group  as  the 
pleura  or  lung  covering  is  physiologically  an  extra-respiratory 
structure),  the  existing  cause' is  some  change  in  the  position  of 
the  patient;  in  some  dyspeptics  it  is  brought  on  by  food  stasis 
(gastric  cough) ;  worm  cough  of  intestinal  origin  is  a  well-known 
form  in  children ;  laryngologists  describe,  further,  a  nasal  cough 
and  a  pharyngeal  cough.  In  one  of  the  author's  patients,  ap- 
parently  free  of  all   neuropathic  taint,  endless   paroxysms  of 


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COUGH,  779 

cough  were  started  by  rather  strong  odors,  such  as  those  of 
violets  and  of  musk. 

Mode  of  Production  of  Cough. — Physiologic,  clinical,  and  ex- 
perimental studies  of  cough  lead  to  a  rather  definite  conception  of 
its  manner  of  production.  This  consists  of  a  peripheral  stimulus 
transmitted  to  one  or  more  nervous  centers  and  then  sent  back 
along  centrifugal  trunks  to  the  muscles  of  expiration. 

The  nervous  center  of  coughing  is  probably  closely  allied  to  the 
respiratory  center  in  the  medulla  at  the  nucleus  of  origin  of  the 
pneumogastric,  to  the  floor  of  the  third  ventricle  and  the  corpora 
quadrigemina,  and  to  a  few  auxiliary  centers. 

The  centripetal  nerve  paths  are  probably  represented  by  the 
pneumogastric;  hence,  the  almost  constant  cough  noted  in  affec- 
tions of  the  mucous  membranes  of  the  respiratory  tract  supplied 
by  this  nerve.  The  exciting  impulse  may,  however,  originate 
instead  in  the  pleural,  pharyngeal,  esophageal,  gastric,  or  intes- 
tinal branches  of  this  nerve;  hence  the  possibility  of  having  a 
cough  symptomatic  of  disturbances  of  these  various  structures 
(pleural,  pharyngeal,  esophageal,  gastric,  worm  cough,  etc.). 

On  the  one  hand,  as  with  other  reflexes,  all  sensory  nerves, 
including  the  cranial  sensory  nerves,  may  be  conceived  of  as  act- 
ing like  the  pneumogastric  on  the  expiratory  center,  stimulation 
of  these  nerves  thus  being  the  starting-point  of  expiratory  re- 
flex effects.  For  practical  purposes,  the  trigeminal  nerve  is,  after 
the  pneumogastric,  in  most  intimate  relationship  with  the  re- 
spiratory center;  this  is  the  nerve  which  presides  over  sensory 
impressions  from  the  face  and  the  nasal  portion  of  the  respira- 
tory passages;  in  its  sphere  of  action  are  generally  to  be  sought 
the  exciting  causes  of  cough  where  examination  of  the  pneu- 
mogastric has  proven  negative.  An  important  role  in  the  path- 
ogenesis of  the  cough  reflex  may  also  attach  to  the  glossopharyn- 
geal. Participation  of  this  nerve  in  respiratory  phenomena  had 
been  overlooked  and  unsuspected  until  it  was  demonstrated  by 
Laborde  in  his  experiments  on  rhythmic  tractions  on  the  tongue. 
These  experiments  showed  that  the  part  played  by  this  nerve 
as  an  exciting  factor  of  cough,  whatever  the  underlying  cause 
may  be,  must  be  duly  taken  into  account,  since  its  sensory  fibers 


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780  SYMPTOMS. 

bear  an  immediate  relationship  to  causes  of  local  irritation  that 
may  arise  anywhere  in  the  region  of  the  pharyngolaryngeal  vesti- 
bule. 

Sneezing  is  the  most  frequently  occurring  reflex  that  involves 
the  nasal  mucous  membrane.  Clinically,  however,  sneezing  often 
precedes  cough.  The  physiologic  mechanism  of  the  two  reflexes 
is  practically  the  same;  most  physiologists  believe  in  the  exist- 
ence of  a  nerve  center  common  to  both  these  acts,  and  nasal 
cough  is  a  condition  recognized  by  all  clinicians. 

The  centrifugal  pathways  are  many,  and  need  not  be  enumerated 
here.  Particular  reference  may,  however,  be  made,  as  expiratory 
nerve  routes,  to  the  pneumogastric  (motor  nerve  to  the  smooth 
muscle  tissue  in  the  bronchi)  and  to  the  intercostal  nerves;  and  as 
inspiratory  centrifugal  routes,  to  the  phrenic  nerve  (motor  nerve 
to  the  diaphragm),  the  spinal  accessory  supplying  the  sterno- 
cleidomastoid, and  the  cervical  and  brachial  plexuses  supplying 
the  trapezius,  scaleni,  and  intercostals. 

Lastly,  the  manifest  inhibitory  influence  of  the  will  or  emotions 
on  cough  leads  us  to  the  belief  that  the  stimuli  emanating  from 
the  cerebral  centers  are  conducted,  along  pathways  as  yet  unknown, 
to  the  reflex,  automatic  centers  in  the  medulla  oblongata.  This 
central  cu:tion  may,  indeed,  be  provocative  as  in  hysterical  cough, 
as  well  as  inhibitory,  as  in  the  checking  of  the  "useless"  cough  of 
consumptives  as  a  result  of  a  peremptory  command 

Therapentic  Indications. — The  complexity  of  the  mechanism 
concerned  in  the  act  of  coughing  and  the  multiplicity  of  centripe- 
tal routes  along  which  the  exciting  stimulus  may  be  conducted  sug- 
gest, a  priori,  the  thought  that  there  is  not  and  cannot  be  any 
"specific"  treatment  for  the  symptom,  cough. 

Again,  cough  which  leads  to  expectoration  and  to  evacuation 
of  the  bronchi  is  a  useful  cough,  which  must  be  spared  or,  at  most, 
somewhat  reduced.  This  applies  to  the  majority  of  coughs  of 
respiratory  origin.  On  the  other  hand,  reflex  cough  is  generally 
a  useless  or  even  harmful  manifestation,  which  must  be  ener- 
getically combatted. 

Rational  treatment  should  aim:  1.  To  reduce  the  sensitiveness 
of  the  mucous  membrane  from  which  the  reflex  starts.    2.  To 


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COUGH.  781 

reduce  the  irritability  of  the  nerve  center  concerned  in  the  reflex. 
3.  To  act  if  possible  on  the  centrifugal  pathways.  4.  To  inhibit 
cough  through  the  influence  of  the  higher  brain  on  the  bulbar 
center,  eg.,  by  suggestion. 

The  first  indication,  which  consists  in  influencing  the  mucous  or 
serous  membrane  from  which  the  reflex  starts,  is  generally  merged 
with  the  causal  treatment.  This  is  the  problem  requiring  the 
greatest  amount  of  clinical  good  sense;  it  can  be  solved  only 
after  an  accurate  diagnosis  has  been  attained.  In  a  worm-in- 
fested individual,  a  vermifuge  remedy  will  clear  up  the  whole 
disturbance ;  in  a  dyspeptic,  proper  dieting  proves  the  best  rem- 
edial measure.  Where  the  disordered  mucous  membrane  is  ac- 
cessible to  external  applications,  a  local  anesthetic  will  often  give 
excellent  results;  thus,  in  two  particularly  rebellious  cases  that 
had  proven  refractory  to  most  active  internal  drug  treatment, 
almost  immediate  results  were  obtained  by  placing  temporarily 
in  the  nasal  cavities  a  wad  of  absorbent  cotton  moistened  with 
1  per  cent,  cocaine  hydrochloride  solution.  In  cough  of  gastric 
origin,  internal  use  of  a  preparation  containing  chloroform  and 
cocaine  answers  the  same  indication. 

The  indication  which  consists  in  reducing  the  reflex  irritability 
of  the  medullary  center  is  generally  fulfilled  by  opium  and  its 
derivatives.  Upon  opium  are  based  the  many  official  prepara- 
tions intended  for  use  in  controlling  cough.  It  is  often  power- 
less, if  not  indeed  directly  injurious,  in  the  so-called  "reflex 
coughs,"  except  pleural  cough.  The  author  has  had  under  ob- 
servation a  patient  suffering  from  paroxysmal  cough  of  naso- 
pharyngeal origin  in  whom  a  few  centigrams  of  extract  of  opium 
brought  on  paroxysms  with  such  regularity  as  to  exclude  the 
idea  of  a  mere  coincidence.  The  value  of  bromides  in  these 
cases  has  already  been  amply  stressed.  The  so^alled  "Meglin's 
pills"  have  also  frequently  proven  successful  in  the  author's 
hands : 

I^  Extract  of  hyoscyamus  seeds ^ 

Extract  of  valerian  r    of  each,  0.05  gram. 

Zinc  oxide    J 

To  make  one  pill.    Three  pills  to  be  taken  daily,  morning,  noon 
and  evening. 


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782  SYMPTOMS. 

The  third  indication,  viz.,  that  of  acting  on  the  centrifugal  nerve 
paths,  is  on  a  more  doubtful  physiologic  plane;  yet  experience 
shows  that  often  two  fly  blisters  placed  over  the  course  of  the 
phrenic  nerve,  one  in  the  cervical  region,  above  the  clavicle  and 
between  the  two  heads  of  sternocleidomastoid,  and  the  other 
at  the  lower  costal  margin  over  the  "phrenic  point,"  act  most 
favorably  on  certain  forms  of  paroxysmal  cough,  particularly 
those — and  they  are  frequent — associated  with  hyperesthesia 
over  the  course  of  the  phrenic  nerve. 

Finally,  a  central  inhibitory  effect  is  induced  by  suggestion  dur- 
ing waking  hours,  the  physician  asserting  before  the  patient  that 
his  cough  is  purposeless  and  convincing  him  of  the  possibility 
and  necessity  of  his  arresting  his  cough  by  a  mere  effort  of  the 
will.  The  following  anecdote,  related  by  Troisier,  is  quite  typi- 
cal in  this  connection:  "During  my  visit  at  Falkenstein,  I  was 
seated  at  the  dinner  table ;  I  had  been  given  the  place  of  honor, 
next  to  the  master;  a  consumptive  physician  was  sitting  not 
far  from  us.  He  was  coughing  and  coughing  without  cessation. 
Dettweiler  whispered  to  me:  *You  see  that  physician  who  is 
coughing;  well,  I  shall  tell  him  after  dinner  that  he  must  either 
cease  coughing  or  take  his  meals  alone  in  his  room,  because  his 
cough  is  unnecessary.'  That  very  evening,  at  supper,  our  unfor- 
tunate colleague  was  in  his  usual  place,  but  he  did  not  cough 
a  single  time  throughout  the  entire  meal." 

On  the  whole,  and  by  reason  of  its  very  commonness,  cough 
is  a  symptom  which,  taken  alone,  is  of  no  great  semeiologic  sig- 
nificance. It  is  clinically  serviceable,  as  a  rule,  only  by  virtue 
of  the  associated  symptoms  and  signs,  viz.,  expectoration,  stetho- 
scopic  findings,  fever,  etc. 

Yet  a  few  varieties  or  modalities  of  cough  are  deserving  of 
brief  mention.  From  the  start,  a  distinction  can  and  should  be 
made  between: 

1.  The  easily  executed,  expulsive,  expectorating  cough  of  re- 
spiratory affections  in  the  productive  stage,  and 

2.  The  distressing,  "useless,"  dry  cough  of  beginning  broncho- 
pulmonary infections  (before  the  productive  stage)  and  of  extra- 
respiratory  infections  (typically  pleuritis,  pleurisy,  or  worm 
cough).    The  following  should  also  be  mentioned: 


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COUGH.  783 

3.  A  form  of  cough  which  is  both  mufHed  (low-pitched)  and 
well-transmitted,  ''brassy,"  metallic,  usually  accompanied  by 
harsh  breathing  and  occurring  in  the  presence  of  tracheobron- 
chial con:^)ression  (as  in  aneurysm,  deep-seated  goiter,  and  medi- 
astinal tumors). 

4.  The  nervous  cough,  habit  cough,  or  "tic  cough"  of  psycho- 
paths. 

This  occurs  mainly  under  two  sets  of  conditions: 

(a)  As  a  "defensive"  or  "disguising"  cough,  occurring  con- 
sciously or  unconsciously  when  tbe  patient  is  embarrassed  and 
desires  a  momentary  interruption  in  his  speech. 

(fc)  As  a  "suggested"  cough,  after  the  physician,  in  questioning 
the  patient,  has  asked  him  whether  he  coughs. 

In  this  connection  two  equally  unfortunate  suggested  inter- 
pretations, personal  or  familial,  are  to  be  guarded  against: 

(a)  A  patient  with  incipient  tuberculosis,  desirous  of  giving 
the  impression  that  he  is  not  ill,  ascribes  his  cough  to  habit  (a 
pseudo-psychopath) . 

{b)  A  psychopathic,  obsessed  patient,  ascribing  his  cough  to 
tuberculosis,  exaggerates  the  cough  (a  pseudo-consumptive). 

5.  The  well-known  "stridulous,"  barking,  "croupy"  cough  of 
croup  (diphtheria)  or  of  false  croup  (laryngismus  stridulus). 

6.  The  chronic,  habitual,  common  cough  of  bronchopulmonary 
disorders,  viz.,  tuberculosis,  emphysema,  chronic  bronchitis, 
bronchiectasis,  chronic  pulmonary  congestion,  impaired  heart- 
action,  etc. 

7.  The  so-called  "effort  cough,"  generally  dependent  upon 
some  cardiac  disorder  and  brought  on,  seemingly,  by  dilatation 
of  the  heart,  more  particularly  of  the  right  auricle.  As  a  matter 
of  fact,  in  old  persons  it  is  often  hard  to  set  apart  that  which, 
in  cough,  is  due  to  the  heart  and  that  which  is  due  to  the  lungs, 
i.e.,  to  distinguish  "heart  cough"  from  "lung  cough."  Heart 
weakness,  indeed,  favors  stasis  and  infection  of  the  lungs;  on 
the  other  hand,  any  bronchopulmonary  disorder  tends  to  accen- 
tuate the  cardiac  inadequacy  and  the  dilatation  of  the  right 
heart:  The  cough  is  then  actually  and  literally  of  "cardiopul- 
monary" origin. 


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784  SYMPTOMS. 

8.  Postural  cough  with  corresponding  expectoration.     The 

patient  coughs  especially  if  he  lies  on  one  side,  right  or  left, 
and  the  cough  is  accompanied  by  copious  expectoration.  This 
combination  is  rather  pathognomonic  of  a  bronchial  cavity 
(bronchiectasis  or  actual  cavity)  evacuation  of  which  is  favored 
by  some  definite  posture. 

9.  The  "pharyngeal"  cough  of  smokers  and  drinkers  is  ac- 
companied by  hawking  and  scraping  and  sometimes  by  nasal 
discharge,  and  is  more  marked  in  the  morning  owing  to  accumu- 
lation of  secretions  in  the  nasopharynx  during  the  night. 


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DEXrIRIUM  AND        [from  de,  out  of  lira,  groove^  oiU\ 
DELUSIONS.  L       of  the  groove^  to  wander.       J 


Obviously  the  aim  here  sought  can  merely  be  to  recall  the 
fundamental  clinical  facts  relating  to  delirium  and  delusions,  Le., 
those  facts  with  which  any  practitioner  not  specializing  in  psy- 
chiatry should  be  familiar. 

To  supply  a  good  definition  of  delirium  is  not  easy.  Grasset's 
definition  may  here  be  accepted:  "Such  conditions  may  be 
termed  delirium  as  are  characterized  by  disturbances  of  reason- 
ing power  and  of  judgment,  with  the  reaching  of  conclusions 
which  the  subject  believes  to  be  correct  and  exact/'  Seglas, 
quoted  by  the  same  author,  refers  to  the  fact  that  delirious  con- 
cepts may,  in  different  cases,  be  either  vague,  indeterminate,  or 
precise  and  distinct;  fixed  or  changing,  polymorphous  or  uniform; 
diflFuse,  monotonous,  or  systematized  (even  to  the  point  of  "crys- 
tallization'* or  stereotypy) ;  plausible,  impossible,  silly,  fantastic, 
absurd,  incoherent,  contradictory,  contrasting,  antagonistic,  etc., 
and  he  studies  them  in  succession  in  such  varying  forms  as 
deliriums  (delusions)  of  self-accusation,  persecution,  self-defense, 
grandeur,  hypochondria,  negation,  enormity,  mysticism,  eroti- 
cism,  metabolism,   body  transformation,   etc. 

For  clinical  purposes,  the  large  aggregate  of  different  types  of 
delirium  may  be  divided  into  the  three  following  subgroups,  vis,, 
oniric  delirium,  partial  or  systematized  delirium,  and  delirium  of 
interpretation. 

1.  Oniric  or  dream-like  delirium  is  by  far  the  commonest  form 
the  non-specialized  practitioner  has  occasion  to  witness.  The 
patient  is  then  constantly  in  a  condition  resembling  sleep — he  is 
dreaming.  The  typical  delirium  of  this  subgroup  is  delirium  tre- 
mens. Lasegiie's  celebrated  definition  may  be  recalled  in  this 
connection:  "Delirium  tremens  is  a  dream  which  is  being  lived;" 
this  is  the  essence  of  the  so-called  oniric  delirium.    The  following 

50  (785) 


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786  SYMPTOMS, 

description  of  its  essential  features  is  from  Reg^s :  "Oniric  delir- 
ium is  an  actual  somnambulistic  state,  a  second  state.  Like  any 
other  second  state,  it  is  brought  into  play  through  subconscious 
or  unconscious  activity;  it  dominates  the  subject  to  the  point  of 
making  him  live  through  and  act  his  subconscious  or  unconscious 
life  .  .  .  lastly,  like  a  second  state,  it  is  always  susceptible  to 
hypnotic  influence.  This  form  of  delirium  is,  literally,  a  dream 
delirium.  Indeed,  it  originates  and  runs  its  course  in  sleep;  it  is 
made  up  of  extemporaneous  associations  of  ideas,  of  hallucinatory 
reproductions  of  former  images  and  recollections,  of  scenes  of 
family  or  occupational  life,  of  visions  u^ally  impleasant,  and 
of  strange,  impossible  combinations  which  are  eminently  mobile 
and  changeable  or,  on  the  other  hand,  to  some  extent  fixed,  and 
which  impose  themselves  more  or  less  completely  upon  the 
patient's  belief.  In  its  mildest  form,  such  delirium  is  exclusively 
nocturnal  and  evanescent;  it  ceases  upon  awakening  and  reap- 
pears only  in  the  evening,  either  at  twilight  or  not  until  later 
when  slight  somnolence  comes  on.  In  a  more  pronounced  form, 
it  again  ceases  upon  awakening,  but  only  incompletely,  and 
recurs  during  the  daytime  as  soon  as  the  patient  shuts  his  eyes 
and  dozes.  Lastly,  in  its  most  pronounced  form,  delirium  fails 
to  disappear  in  the  morning  and  continues  as  such  throughout 
the  day,  like  a  prolonged  dream." 

This  is  the  typical  delirium  of  intoxications  and  of  acute  or 
subacute  infections.  It  is  th(*^  delirium  of  the  toxic  and  infectious 
psychoses  in  general,  of  gastrointestinal  autointoxications,  of  alco- 
holism, of  drug  intoxications  {opium,  salicylates,  belladonna,  etc.), 
of  pneumonia,  of  typhoid  fever,  of  malaria,  of  ^uremia,  of  eclamp- 
sia, etc. 

This,  it  should  be  repeated,  is  the  common,  ordinary  type  of 
delirium  which  the  practitioner  sees  by  far  the  most  frequently. 

Its  extraordinary  frequency  in  children  is  particularly  well- 
known;  the  "dream  delirium"  is  one  of  the  commonest  features 
of  children's  diseases ;  it  goes  hand  in  hand  with  fever  and  accel- 
erated pulse  rate  in  these  cases. 

2.  Systematized  or  partial  forms  of  delirium  (paranoia),  gen- 
erally chronic  and  quite  distinct  from  the  preceding  types,  are 
made  up  of  ''functional  psychopathic  states  characterised  by  perma- 


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DELIRIUM  AND  DELUSIONS,  7%7 

nent,  fixed,  and  systematically  interconnected  ideas,  developing  in 
a  certain  direction  and  following  a  logical  course"  (Amaud). 
Amaud  presents  the  following  classification  of  these  forms: 

1.  Acute  Systematized  Delirium  :  Acute  paranoia. 

2.  Chronic  Systematized  Delirium:  Chronic  paranoia. 

(a)  Depressed, — Delusion  of  persecution  running  a  systema- 
tized course. 

Self-accusatory  and  melancholic  delusion  of  persecution. 
Primary  systematized  self-accusatory  delusion. 
Systematized  hypochondriac  delusion. 

(b)  Expansive. — Ambitious  (megalomania). 
Religious. 

Erotic. 

The  clinical  course,  now  established,  of  chronic  systematized 
delirium  is  as  follows,  according  to  Grasset: 

A.  Period  of  anxiety  or  subjective  analysis  (hypochondriac 
insanity),  characterized  by  strange,  anesthetic  disturbances;  the 
patient  is  very  introspective,  and  discovers  in  these  disturbances 
some  concealed  motive,  some  allusion  to  his  person  or  circum- 
stances. 

B.  Period  of  delirious  (delusive)  explanation  (delusion  of  per- 
secution, religious  delusion,  erotic  delusion,  political  delusion,  de- 
lusion of  jealousy,  etc.)  ;  the  subject  imagines  an  explanation  for  his 
sufferings,  for  his  anxiety,  and  for  the  surprising  amount  of  atten- 
tion which  he  believes  is  being  paid  to  him.  He  discovers  the 
**formula  for  his  delusion" ;  it  is  his  hallucination  which  he  is  inter- 
preting; hence  the  term  "period  of  delusive  explanation." 

C.  Period  of  transformation  of  personality  (delusion  of  ambi- 
tion) ;  from  being  persecuted,  the  subject  becomes  ambitious 
or  megalomaniac ;  his  entire  personality  is  transformed ;  he  be- 
comes a  prince,  a  king,  a  prophet,  or  the  Deity. 

D.  Magnan  recognizes  a  fourth  period  of  dementia,  which  is  a 
common  mode  of  termination  in  this  kind  of  psychosis  as  well 
as  in  many  others. 

This  is  the  typical  delirium  of  chronic  infections  with  second- 
ary degenerative  changes  in  the  nerve  centers. 

Progressive  general  paralysis,  though  much  less  systematized 
and  coherent  than  the  chronic  systematized   delirium   above   de- 


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788  SYMPTOMS. 

« 

scribed,  nevertheless  presents  some  of  its  rather  characteristic  stages, 
especially  the  third  and  fourth.  Two  clinical  signs  point  to  it 
particularly,  vis.,  a  very  special  "euphoric  mental  puerility"  with 
amnesia  and  loss  of  the  autocritical  sense  (Sicard  and'  Roger),  and 
the  characteristic  dysarthria  with  jerky,  tremulous,  drawling  speech, 
which  is  unmistakable. 

3.  Delirium  of  interpretation,  a  chronic  systematized  psy- 
chosis, founded  on  delusional  interpretations,  separated  in  1902 
by  Serieux  and  Capgras  from  the  group  of  the  systematized  de- 
lusions, is  defined  and  described  by  these  authors  as  follows : 

"Delirium  of  interpretation  is  a  chronic  psychosis  in  which 
the  proliferation  of  manifold  interpretations  and  progressive  radi- 
ation of  a  predominant  concept  result  in  the  organization  of  a 
complex  delusive  romance  which  may  lead  to  variable  reactions. 
Delirium  of  interpretation  is  a  constitutional  psychosis,  the  origin 
of  which  is  to  be  sought,  not  in  the  action  of  some  toxic  agent, 
but  in  a  psychopathic  predisposition,  in  developmental  anomalies 
of  the  cerebral  centers  which  hold  in  dependency  perversions  of 
judgment,  gaps  in  the  critical  sense,  and  disturbances  of  affectivity; 
they  are  essentially  the  result  of  a  congenital  malformation. 

"Whereas  some  systematized  psychoses  are  based  upon  pre- 
dominant and  practically  permanent  sense  disturbances,  delirium 
of  interpretation  consists  of  a  delusional  system  in  which  the 
hallucinations  always  remain  an  incidental  occurrence  and  are 
even,  as  a  rule,  entirely  wanting.  Lucidity  and  mental  activity 
are  retained  throughout  the  disease;  weakening  of  the  intellect 
appears  only  after  a  lapse  of  time,  from  the  effects  of  senile 
evolution;  some  subjects  are  seen  retaining  their  mental  alert- 
ness thirty  years  after  the  beginning  of  the  mental  disturbances. 
The  disorder,  while  incurable,  is  thus  not  one  attended  with 
progressive  dementia. 

"When  in  the  presence  of  a  subject  suffering  from  delirium 
of  interpretation,  one  is  first  of  all  struck  by  his  correct  deport- 
ment ;  the  observer  is  sometimes  deceived  by  the  brilliancy  of 
his  conversation  and  the  accurate  logic  of  his  reasoning  pro- 
cesses, and  is  rather  disposed  to  consider  him  at  most  as  a 
thinker  along  fallacious  lines,  with  a  tendency  to  look  upon 
all  events  from  a  peculiar  angle,  and  to  systematize  all  exter- 


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DELIRIUM  AND  DELUSIONS.  789 

nal    or  internal  phenomena  upon  the  basis  of  a  questionable 
preconcept 

'*The  imperative  need  of  referring  all   to  his  own  person 
and    of  interpreting  everything  in  a  certain   direction,  and  of 
emitting,  on  the  whole,  only   affective   judgments   marred   by 
errors  appears  as  the  sole  morbid  condition  in  such  a  subject 
"The  mistaken  interpretation,  the  delusion  of  personal  sig- 
nificance is,  indeed,  the  fundamental  manifestation  of  this  psy- 
chosis.   The  autonomy  of  a  morbid  entity  cannot,  however,  be 
based  merely  upon  a  single  sign.    Delusional  interpretation  plays 
an  important  role  in  a  number  of  other  psychoses  and  even  in 
simple  passional  states.    To  warrant  a  diagnosis  of  delirium  of 
interpretation,  a  whole  group  of  characteristics  must  be  present, 
zns.,  (1)  multiplicity  and  organization  of  delusional  interpretations; 
(2)  absence  (or  paucity)  of  hallucinations,  and  their  casual  occur- 
rence; (3)  retention  of  lucidity  and  mental  activity;  (4)  progres- 
sion through  gradual  expansion  of  the  interpretations;  (5)  incura- 
bility, without  terminal  dementia." 

*  *  * 
The  reason  that  the  author  has — with  Grasset — deemed  it 
proper  to  recall  the  main  clinical  features  relating  to  the  various 
forms  of  delirium  (or  delusion)  considered  very  broadly  as  "dis- 
turbances of  the  reasoning  power  and  of  judgment"  is  that 
definition  and  delimitation  of  the  various  forms  of  delirium  is  a 
difficult*  matter;  that  the  types  above  recalled  and  described 
condense  into  a  small  compass  a  number  of  psychiatric  facts 
indispensable  for  everyday  practice,  and  that  they  will  bring 
to  mind  various  fundamental  and  necessary  acts  of  psychologic 
discrimination. 

As  a  matter  of  fact,  in  general  practice  the  term  "delirium"  is 
applied  particularly  to  the  common,  ordinary  form  of  the  disturb- 
ance, i.e.,  to  confusion  of  ideas  and  the  presence  of  mental  images 
associated  with  mistaken  interpretations  and  often  hallucinations — 
in  a  word,  to  oniric  delirium,  for  which  careful  clinical  study 
will  always  detect  some  cause,  either: 

1.  Toxic  (alcohol,  opium,  belladonna,  salicylates). 

2.  Autotoxic  (uremia). 

3.  Or  infectious  (typhoid  fever,  pneumonia,  malaria,  etc.). 


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DIARRHEA.  [Suappelv,  to /low  through.} 


Diarrhea  is  characterized  by  the  passage  of  liquid  stools. 

Only  the  most  practical,  fundamental,  and  essential  facts  re- 
quired in  the  interpretation  of  this  very  common  symptom  can 
here  be  presented. 

In  diarrhea,  liquid  stools  are  passed  with  variable  frequency. 
In  general,  diarrhea  seems  to  depend  upon: 

Either  an  exaggeration  of  the  persistaltic  contractions  (hy- 
perperistalsis,  intestinal  hypersthenia). 

Or  an  exaggeration  of  the  intestinal  secretions  (hypercrinia). 

Or  diminished  absorption  of  the  intestinal  contents. 

Clinically,  diarrhea  may  be  met  with  under  the  following  cir- 
cumstances : 

I.  Lesions  of  the  intestinal  walls,  whether  there  be  irrita- 
tion or  pathologic  changes  in  the  mucous  membrane,  as  is  the 
case  in  all  instances  of  toxic,  infectious  enterocolitis, 

A.  Infectious  or  parasitic  enterocolitis. 

(a)  In  this  group  are  included  ordinary  acute  enterocolitis, 
typhoid  fever,  and  cliolera,  of  which  mere  mention  is  here  sufficient. 
It  should  be  particularly  borne  in  mind,  however,  that  the  greater 
number  of  instances  of  common  acute  enterocolitis  are  as  yet  not 
accounted  for ;  the  characteristic  clinical  complex  may  be  summar- 
ized as  comprising  diarrhea,  fever,  leucocytosis,  and  albuminuria. 

(fc)  Chronic  parasitic  dysenteriform  diarrhea  with  paroxysmal 
recurrences  requires  more  thorough  consideration.  As  matters  now 
stand,  these  dysenteriform  types  of  diarrhea  may  seemingly  be 
classified,  for  practical  purposes,  as  follows: 

Ordinary  colon  bacillus  dysenteriform  diarrhea,  acute  or  chronic. 
These  cases  yield  to  interruption  of  feeding,  with  restriction  of  the 
patient  to  water  by  the  mouth ;  to  castor  oil,  and  to  lactose. 

Amebic  dysenteriform  diarrhea,  acute  or  chronic.     Ravaut  and 
Maute  have  plainly  demonstrated  the  selective  action  of  emetine 
and  of  arsphenamine  in  these  cases. 
(790) 


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DIARRHEA.  791 

BacUlary  dysenteriform  diarrhea  (acute  or  chronic  dysentery), 
amenable  to  irrigations  with  silver  salts  and  to  antidysenteric  serum. 

Dysenteriform  diarrhea  due  to  trichomonas  (flagellates). 

Tuberculous  dysenteriform^  diarrhea,  with  presence  of  tubercle 
bacilli. 

These  causal  distinctions,  now  absolutely  necessary  as  evidenced 
by  the  specificity  of  the  methods  of  curative  treatment,  can  be 
established  only  by  bacteriologic  examination  of  the  stools  (see 
Examination  of  the  Stools). 

(c)  By  way  of  a  reminder  there  may  also  be  mentioned  here 
intestinal  cancer  which,  however,  causes  obstruction  much  more 
frequently  than  diarrhea,  except  where  the  lesion  is  situated  low 
down. 

B.  Toxic  enterocolitis. — In  this  group  are  met  the  actually 
toxic  and  drug  forms  of  enterocolitis  (enterocolitis  due  to  mercury, 
arsenic,  digitalis,  colchicum,  etc.),  and  the  alimentary  forms  (botul- 
ism, etc.). 

There  is  also  the  autotoxic  or  diathetic  enterocolitis  of  uremia, 
gout,  and  diabetes. 

Some  forms  of  hyperacute  gastroenterocolitis  result  in  a  clin- 
ical picture  well  described  by  Lesieur  (choleroid  state,  reduced 
output  of  urine,  and  uremia),  which  may  be  accounted  for  by 
intense  but  diflfuse  and  superficial  inflammatory  lesions  of  the 
digestive  tract,  particularly  the  small  intestine  (congestion  with 
hemorrhage,  prominence  of  the  follicles). 

The  bacteriologic  basis  of  enteritis  seems  to  be  variable, 
different  combinations  of  bacteria  being  found;  a  constant  fea- 
ture, however,  is  weakness  and  insufficiency  of  the  liver  and 
kidneys.  This  constitutional  or  acquired  weakness  sometimes 
transforms  the  clinical  picture  of  gastrointestinal  infection  into 
that  of  auto-intoxication  and  azotemia.  Hence  the  appropriate 
designation  "uremigenous  gastroenteritis"  proposed  by  Lesieur. 

In  all  such  cases  the  history  or  the  coexisting  diathesic  mani- 
festations will  clear  up  the  diagnosis. 

II.  Diarrhea  of  Nervous  and  Vasomotor  Origin.— Enteric 
neuroses  are  very  frequent. 


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792  SYMPTOMS. 

Diarrhea  upon  emotion  and  the  enter orrhea  of  exophthalmic 
goiter  constitute,  as  it  were,  an  experimental  verification  of  the 
neuropathic  diarrheal  flux  that  may  be  met  with,  frequently  in 
alternation  with  constipation,  in  the  course  of  the  majority  of 
neuroses.  Many  instances  of  paroxysmal  diarrhea  ascribed  to 
dietary  indiscretions  are  really  due  to  this  cause. 

In  most  of  these  cases  the  cause  of  the  diarrhea  remains 
wholly  obscure.  The  physician  finds  neither  infection  (no  fever 
nor  leucocytosis),  nor  ulceration  (no  blood  in  the  stools),  nor 
food  poisoning  (no  dietary  indiscretion).  The  diarrheal  flux 
may  supervene  even  while  a  most  stringent  diet  is  being  ad- 
hered to,  but  nearly  always  appears  in  conjunction  with  over- 
work, insomnia,  nervous  shocks,  or  prolonged  stress.  It  is  hard 
for  the  uninitiated  to  avoid  the  conclusion  that  an  intestinal 
neurosis  exists  and  to  suspect  as  cause  a  diminution  of  vaso- 
motor tone  due  to  abnormal  excitation  of  the  sympathetic,  seem- 
ingly evidenced  by  the  low  blood-pressure,  high  pulse  rate,  ex- 
cessive emotional  susceptibility,  general  asthenia,  tendency  to 
fainting,  and  vasomotor  disturbances  (showing  a  curious  simi- 
larity to  Graves's  disease!)  There  appears  to  be  some  physio- 
pathologic  relationship  between  hyperperistalsis  and  low  periph- 
eral blood-pressure,  occurring  in  conjunction  with  vasodilata- 
tion in  the  splanchnic  area. 

It  seems  not  unlikely  that  the  so-called  "mucous  enteritis"  is 
not  a  true  colitis,  but  rather  a  spastic  enteroneurosis  with  alter- 
nating diarrhea  and  constipation  and  excessive  mucous  secretion. 

Diarrhea  of  circulatory  origin  is  equally  well-known,  e.g., 
the  diarrhea  of  atrophic  cirrhosis,  to  which  Portal  referred  when 
he  said:  *'Wind  precedes  the  rain,"  alluding  to  the  sequence  of 
tympanites  and  diarrhea  met  with  in  cirrhosis.  The  same  con- 
dition may  occur  in  cardiac,  renal,  cardiorenal,  and  cardiohepatic 
disorders,  although  constipation  is  rather  frequently  observed 
under  these  circumstances. 

Mention  should  also  be  made  of  the  diarrhea,  at  times  pro- 
fuse, which  may  follow  reabsorption  of  edemas,  hydrothorax, 
and  ascites,  a  feature  affording  a  definite  indication  for  purgation 
in  the  presence  of  these  disorders. 


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DIARRHEA.  793 

rn.  Diarrhea  of  Digestive  Origin. — The  causes  in  this  group 
are  complex  and  varied. 

Any  condition  of  gastrointestinal  dyspepsia,  especially  if 
associated  with  intolerance  of  fats  ("hyposthenic  dyspepsia/* 
insufficiency  of  the  liver  and  pancreas),  is  almost  necessarily 
accompanied  by  diarrhea  with  passage  of  an  excess  of  fats  in 
the  stools  (hypersteatorrhea) . 

Diarrhea  of  gastrointestinal  digestive  origin  is  thus,  on  the 
whole,  a  manifestation  of  actual  indigestion,  subdivision  of 
which  may  be  attempted  as  follows: 

1.  Botulism,  food  intoxication,  ptomain  poisoning, — The  many 
undoubted  cases  of  collective  intoxication,  as  by  cream  puffs, 
game,  etc.,  are  manifestly  produced  in  this  way. 

2.  Overeating, — In  these  cases  the  digestive  limit  or  capacity 
is  exceeded;  this  is  the  well-known  indigestion  of  released 
schoolboys  and  soldiers  on  leave. 

3.  Fat  intolerance. — An  expression  of  insufficiency  of  the  liver 
and  pancreas. 

4.  Achylia  gastrica. 

5.  Pronounced,  abrupt  discharge  of  bile  occurring  in  overactivity 
of  the  liver  and  resulting  in  sharp  diarrhea  in  the  morning  after 
eating. 

According  to  Cabot,  the  relative  frequency  of  the  various 
causes  of  diarrhea  is  as  follows : 

1.  AciUe  enteritis: 

(a)  Cryptogenic,  five-sixths  of  all  cases. 
{b)  Specific    (typhoid,    dysentery,    cholera,    toxic    disturb- 
ances), one-sixth  of  the  cases. 

2.  Chronic  enteritis: 

(a)  Cryptogenic,  nine-tenths  of  all  cases. 
(&)  Of  known  causation  (digestive  insufficiency),  one-tenth 
of  the  cases. 

3.  Cancer  of  the  intestine, 

4.  Pernicious  anemia, 

5.  Mucous  colitis. 

6.  Intestinal  neuroses  and  exophthalmic  goiter. 

7.  Tuberculosis. 

8.  Fat  intolerance. 


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794  SYMPTOMS, 

Certain  signs  and  symptoms  occurring  in  conjunction  with 
diarrhea  sometimes  permit  of  rather  accurate  localization  of  the 
causal  disturbance. 

The  presence  of  blood  and  pus  in  the  stools  (bloody,  glairy 
stools)  is  characteristic  of  ulceration. in  the  large  bowel,  of  varying 
origin  (infection  or  neoplasm). 

The  presence  of  mucus  and  false  membrane  is  often  charac- 
teristic of  an  intestinal  neurosis. 

The  customary  significance  of  fat-laden  stools  is  well-known ; 
steatorrhea  points  to  insufficiency  of  the  liver  and  pancreas. 

Fluoroscopy  after  a  bismuth  meal  and  proctoscopy,  moreover, 
permit  of  a  most  valuable  direct  examination  of  the  bowel  (see  Tech- 
nical procedures,  in  Part  II). 

Frequently,  indeed,  direct,  gross,  macroscopic  examination 
of  the  feces  affords  highly  serviceable  information.  This  ele- 
mentary clinical  procedure  is  just  cts  essential  as  uranalysis,  taking 
the  temperature,  or  examining  the  pulse.  The  '^offending  body" 
must  always  be  sought,  or  at  least  the  "evidence"  or  "witness" 
of  it. 

The  patient,  then,  should  always  be  ordered  to  collect  and  keep 
the  feces  for  examination. 

The  following  features  of  the  stools  should  be  noted: 

Frequency :  Four,  6,  up  to  100  a  day — the  latter  in  the  pres- 
ence of  rectal  tenesmus,  as  in  dysentery. 

Amount:  From  a  few  hundred  grams  to  several  liters,  as  in 
cholera  and  choleroid  forms  of  diarrhea,  whence  the  enormous 
loss  of  water  from  the  tissues. 

Consistency:  Serous,  albuminoid  (glairy),  mushy,  pasty. 

Color:    Brown,  as  in  normal  stools. 

Dark  green:  Excessive  bile  content  in  certain  cases  of  jaun- 
dice; in  infantile  diarrhea,  or  after  administration  of  calomel. 

Decolorized,  gray,  clayey:    Obstructive  jaundice. 

Red  or  rust-colored:  Dysentery. 

Black,  "coffee-ground":  Melena,  bismuth,  or  krameria  (rhat- 
any). 

Colorless,  serous,  "rice  water":  Cholera  and  choleroid  diar- 
rhea. 

Odor:  This  is  always  more  or  less  unpleasant 


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DIARRHEA.  795 

Exceedingly  malodorous :  Putrid  diarrhea  in  botulism,  putre- 
factive gastrointestinal  indigestion,  and  in  street  cleaners,  anato- 
mists, and  workers  in  sewage. 

Distinctly  acid:  In  gastrointestinal  indigestion  with  fermen- 
tation. 

No  odor  in  serous  stools. 

Kind:  Ordinary  fecaloid  type 

Bilious. 

Serous. 

Watery. 

**Stony":    Intestinal  concretions  and  coproliths;  gall-stones. 

The  macroscopic  examination  referred  to  will  frequently  re- 
veal abnormal  constituents  of  the  stools: 

Intestinal  parasites:  Tenia,  ascaris,  oxyuris. 

Undigested  food  (li enteric  diarrhea)  :  Acute  indigestion,  ex- 
cessive peristalsis. 

Fats  {fatty  stools) :  Fats  present  in  oily  droplets,  spherules, 
or  larger  fatty  masses  (affections  of  the  liver  and  pancreas) 

Blood:     Red:     Hemorrhoids. 

Black:  Melena. 

Intestinal  shreds:  Dysentery. 

Blood-stained,  glairy  material:  Neoplasm. 

Pus:    Infectious  or  neoplastic  enterocolitis. 

Mucus  and  membranous  formations:  Mucomembranous  entero- 
colitis, intestinal  neuroses. 

Intestinal  sand:  Mucous  enterocolitis. 

Rice-bodies:  Flakes  of  epithelial  cells:  Cholera  and  choleroid 
diarrhea. 

The  above  brief  review  suffices  to  illustrate  the  very  great 
semeiologic  value  of  a  mere  macroscopic  examination  of  the 
stools.  Correlated  with  the  medical  history,  other  clinical  mani- 
festations (temperature,  general  condition,  coexisting  digestive 
disturbances,  urinary  evidences,  etc.),  and  examination  of  indi- 
vidual organs  (liver,  stomach,  intestinal  canal,  etc.),  it  will  generally 
lead  promptly  to  a  correct  diagnosis. 

In  puzzling  cases  it  should  be  supplemented  by  chemical,  micro- 
scopic, and  bacteriologic  examination  of  the  stools  (see  Examina- 
tion of  the  Feces),  which  is  frequently  indicated. 


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DYSPEPSIA     \^^'  *''*'  ni^ti,  coction,  digestion;  disturb-'] 
'    [   ance  of  digestion^  particularly  gastric.  J 


The  term  dyspepsia  is  here  employed  in  its  semeiologic  sense, 
and  is  applied  in  a  general  way  to  any  disturbance  of  gastric 
digestion  complained  of  by  the  patient  or  observed  by  the  phy- 
sician. The  author  would  not  have  attempted  to  deal  with  this 
extensive  and  complex  subject — at  least  under  the  above  com- 
prehensive term — had  he  not  found  certain  features  of  it  already 
partly  considered  in  a  section  of  Cabot's  **DifIerential  Diag- 
nosis," upon  which  some  of  the  material  which  follows  is  based, 
and  had  not  his  colleague  Leon  Meunier  consented  to  draw  up 
an  authoritative  plan  of  diagnosis  for  ulcer  and  cancer  of  the 
stomach. 

The  author's  aim  will  have  been  fulfilled  if,  upon  reading 
this  section,  the  practitioner  becomes  convinced  that  dyspeptic 
manifestations,  indigestion,  and  vomiting  are  in  most  instances 
of  extragastric  origin;  that  painstaking  and  complete  investiga- 
tion of  all  the  organs  is  necessary,  particularly  in  all  cases  of 
chronic  indigestion,  and  that  in  a  patient  complaining  of  such 
disturbances,  merely  applying  the  term  "dyspepsia'*  and  ordering 
some  indefinite  antidyspeptic  treatment  amount  to  nothing,  or 
are  even  worse  than  nothing. 

The  very  great  majority  of  the  causes  of  indigestion  are  unre- 
lated to  the  stomach,  or  at  least  to  any  particular  disease  of  the 
stomach.  On  the  other  hand,  there  is  not  a  single  organ  in  the 
human  body  which  may  not  be  a  source  of  gastric  symptoms. 
Nausea,  dyspeptic  disturbances,  the  vomiting  of  pregnancy, 
uremia,  and  brain  tumor  are  familiar  illustrations  of  this  clinical 
aphorism.  As  a  matter  of  fact,  the  heart  and  the  stomach  may 
with  equal  frequency  and  in  an  equal  degree  be  disturbed  by 
remote  and  slight  organic  causes.  The  stomach  is,  moreover, 
as  frequently  free  of  any  pathologic  changes  in  subjects  com- 
(796) 


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DYSPEPSIA,  797 

plaining  of  dyspepsia  as  is  the  heart  in  subjects  complaining  of 
palpitations  or  in  whom  tachycardia  is  observed. 

The  truly  "gastric"  causes  of  indigestion  or  dyspepsia  may 
practically  be  reduced  to  two,  vis,,  cancer  and  tdcer.  Nervous  dys- 
pepsia, the  gastric  neurosis,  is  of  extraordinary  frequency ;  but  only 
exceptionally  does  it  originate  in  the  stomach.  The  same  is 
true  of  many  other  varieties,  such  as  dyspepsia  with  hyperchlor- 
hydria;  dyspepsia  dependent  upon  constipation  or  symptomatic 
of  appendicitis;  gastroptosis,  ordinarily  the  result  of  general 
atony  with  multiple  visceroptosis,  alcoholic  gastritis,  etc.  In 
short,  most  varieties  of  dyspepsia  are  not,  strictly  speaking,  of 
gastric  origin,  and  do  not  constitute  gastric  disorders. 

What  clinical  possibilities,  then,  should  come  into  our  minds 
when  a  patient  complains  of  gastric  symptoms,  and  of  gastric 
symptoms  alone? 

1.  In  the  presence  of  a  pregnant  woman  who  has  not  yet  reached 
the  menopause,  one  should  always  think  first  of  all  of  a  possible 
pregnancy.  As  is  well  known,  under  these  circumstances  any 
symptoms  may  be  observed,  from  a  simple  condition  of  nausea 
in  the  morning  to  the  uncontrollable  vomiting  of  pregnancy— 
as  is  true,  moreover,  in  many  toxic  states  of  the  blood,  such 
as  alcoholism,  uremia,  lead  poisoning,  etc.  These  digestive 
symptoms  occur  with  such  frequency  that  they  may  properly 
be  included  among  the  minor  evidences  of  pregnancy.  The 
classic  indications  of  this  state  should  under  these  conditions 
be  sought,  vis,,  cessation  of  menstruation,  increased  size  of  the 
uterus,  secretion  of  colostrum,  etc. 

2.  Uremia,  manifest  or  latent,  is  also  a  very  frequent  condi- 
tion, and  one  present  far  oftener  than  it  is  diagnosticated.  Many 
obstinate  dyspeptic  disturbances,  either  mild  (nausea,  anorexia, 
aversion  to  food)  or  severe  (vomiting,  hematemesis),  originate 
in  this  way.  Uremia  should  always  be  thought  of  in  the  pres- 
ence of  chronic  dyspepsia  coexisting  with  albuminuria,  edema, 
and  a  definite  elevation  of  blood-pressure,  and  particularly  if 
blood  examination  discloses  a  high  content  of  urea.  Especially 
should  it  be  thought  of,  a  priori,  in  any  individual  who  after  pass- 
ing the  fortieth  year,  and  having  had  a  "good  digestion"  up  to 
that  time,  loses  his  appetite,  experiences  nausea  or  even  vomit- 


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798  SYMPTOMS. 

ing,  becomes  sallow  and  loses  weight,  and  in  whom  examina- 
tion of  the  stomach  gives  practically  negative  results.  The  above 
mentioned  evidences — albumin,  high  blood-pressure,  edema,  and 
hyperazotemia — should  be  carefully  searched  for,  and  the  appro- 
priate antinephritic  treatment  will  remove  all  doubt  as  to  the 
renal  origin  of  the  dyspeptic  disturbances. 

3.  Tuberculosis,  pulmonary  or  elsewhere  situated,  may  like- 
wise be  a  cause  of  many  instances  of  indigestion  in  the  absence 
of  any  internal  (cancer  or  ulcer)  or  external  (food  or  drug 
poisoning)  gastric  cause.  As  is  well  known,  incipient  tubercu- 
losis often  takes  on  the  appearances  of  anemia  and  dyspepsia; 
anorexia  and  loss  of  weight  are  common  in  this  stage  of  the 
disease.  In  these  cases  of  '^cryptogenic"  dyspepsia  one  should 
proceed,  therefore,  to  a  careful  investigation  in  this  direction, 
the  temperature  being  taken  morning  and  evening,  careful  aus- 
cultation carried  out  in  a  quiet  room,  and  an  x-ray  examination 
practised. 

As  a  matter  of  fact,  the  opposite  mistake  is  also  made,  and 
an  attack  of  nervous  dyspepsia  with  anemia  and  loss  of  weight 
too  often  labelled  pulmonary  tuberculosis  without  any  adequate 
reason.  The  fact  cannot  too  often  be  repeated :  One  should  be 
a  "realist"  in  clinical  work,  and  like  St.  Thomas,  one  must  be 
desirous  to  come  into  actual  touch,  i,e.,  to  establish  by  contact 
with  our  senses,  the  sufferings  of  our  patients  and  the  theories 
evolved  in  our  minds. 

Furthermore,  tuberculous  patients — apart  from  the  ordinary 
causes  of  dyspepsia  to  be  mentioned  later  (rapid  eating,  poor 
teeth,  excessive  intake  of  fluid,  etc.),  and  to  which  they  are  sub- 
ject like  other  patients — are  very  often  and  very  particularly  the 
victims  of  two  serious  sources  of  error  regarding  the  stomach, 
vie,  drug  intoxication  (opium,  morphine  and  its  substitutes  caus- 
ing hypopepsia  and  apepsia;  creosote  and  its  derivatives,  anti- 
pyrin,  pyramidon,  etc.,  inducing  ar  "gastritis  medicamentosa"), 
and  alimentary  overwork  the  result  of  ill-considered  overfeeding. 

4.  Numerous  cases  of  indigestioit  in  women  are  the  result 
of  inanition.  In  this  connection  the- author  cannot  do  better  than 
to  quote  literally  from  Cabot,  having  nowhere  found  a  better 
or  more  judicious  critical  exposition  of  the  abuse  of  dietetic 


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DYSPEPSIA.  799 

measures  among  dyspeptics.  "This  [inanition]  comes  about  as 
follows:  Something,  we  need  not  now  inquire  what,  produces 
an  upset  of  digestion.  The  patient  attributes  it  to  certain  food, 
probably  what  she  took  last,  just  before  the  attack  occurred. 
Accordingly,  in  future  she  omits  this  article  of  diet  from  her 
bill  of  fare.  The  indigestion  recurs,  an  article  of  diet  is  ag^n 
blamed,  and  something  else  is  cut  out  of  the  diet  because  she 
thinks  it  hurts  her.  So  in  this  way  food  after  food  is  given  up, 
until  the  patient  gets  down  to  a  regimen  of  slops  or  their  equiva- 
lent. We  have  now  a  typical  vicious  circle.  The  patient  is  ill- 
nourished  because  she  is  dyspeptic,  and  she  is  dyspeptic  because 
she  is  ill-nourished.  We  can  break  this  circle  by  forcing  her  to 
eat  despite  grievous  suffering.  An  ill-nourished  stomach  will 
complain,  yet  it  must  be  nourished  nevertheless.  If  we  can  per- 
suade the  patient  to  undergo  such  suffering,  we  can  honestly 
hold  out  the  hope  that  at  the  end  of  it  she  will  break  her  chain, 
will  get  back  her  nutrition,  and  lose  her  symptoms.  The  trouble 
is  that  ordinarily  the  physician  does  not  believe  this  himself. 
He  has  not  seen  enough  cases  in  which  forcing  the  patient  to  eat 
achieves  this  happy  result;  but  anyone  with  extensive  hospital 
experience  knows  that  what  is  called  "dieting" — that  is,  cutting 
out  of  one's  diet  most  of  the  foods  that  ordinary  people  live  on 
— is  usually  a  most  pernicious  process,  and  leads  to  a  great 
deal  of  long  and  unnecessary  suffering.  Most  cases  of  this 
type  can  be  cured  by  nothing  in  the  world  but  forced  feeding. 

"The  greatest  improvement  that  I  have  seen  in  the  manage- 
ment of  stomach  cases  in  the  last  twenty  years  has  been  the  recog- 
nition of  causes  outside  the  stomach  and  the  successful  attack 
upon  these*causes.  Next  to  this,  the  greatest  improvement  has 
been  through  giving  up  our  habits  of  making  strict,  narrow  diet 
lists  which  result  in  more  or  less  chronic  starvation.  Whatever 
we  do  for  a  gastric  patient,  we  must  not  starve  him.  We  must 
get  in  food  enough  to  maintain  the  caloric  needs  of  the  body, 
and  the  greatest  error  in  the  treatment  of  the  past  has  been  the 
failure  to  recognize  this  necessity." 

5.  Cholelithiasis  is  a  very  common  cause  of  paroxysmal  pains, 
very  often  ascribed  to  the  stomach.  After  cancer  and  ulcer  have 
been  correctly  excluded,  one  may  state  that  it  is  almost  always 


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800  SYMPTOMS. 

a  mistake  to  attribute  really  severe  pain  to  the  stomach.  In 
other  words,  the  only  disorders  of  the  stomach  causing  severe 
pain  are  cancer  and  ulcer.  All  the  other  varieties  of  dyspepsia 
run  their  course  with  their  usual  assortment  of  symptoms  and  vary- 
ing combinations  of  flatulence,  heart-bum,  discomfort,  nausea,  sen- 
sations of  constriction  or  oppression,  and  vomiting,  but  without 
violent  pain. 

Gall-stones  often  induce  attacks  of  pain  situated  in  the  epi- 
gastrium and  not  in  the  gall-bladder  region.  Overlooking  of 
this  fundamental  fact  leads  to  many  mistakes.  If  the  patient 
has  repeated  attacks,  some  will  sooner  or  later  become  localized 
in  or  be  referred  to  the  right  hypochondrium,  but  in  the 
earlier  stages  of  the  disease  such  localization  is  very  frequently 
lacking. 

Allied  to  the  gastralgia  of  cholelithiasis  are  the  obstinate  dyspep- 
tic phenomena,  with  delayed  pain  and  eructations,  dependent  upon 
adhesions  between  the  gdl-bladder  and  the  neighboring  viscera 
(stomach,  liver,  transverse  colon,  etc.)  the  result  of  a  former  chole- 
cystitis with  pericholecystitis.  These  may  assume  the  extremely 
grave  form  of  pyloroduodenal  stenosis,  with  vomiting  and  absolute 
intolerance  of  food. 

6.  Angina  pectoris  may  be  overlooked  and  treated  as  a  form 
of  dyspepsia  when  the  pain  is  felt  in  the  epigastrium,  is  preceded 
and  accompanied  by  flatulence  and  eructations,  as  is  frequently 
the  case,  and  comes  on  after  meals.  These  three  observations  of  a 
digestive  character,  especially  when  made  in  combination,  lead 
to  many  mistaken  diagnoses  of  various  gastric  aflfections.  De- 
termination of  the  blood-pressure,  careful  auscultation,  and 
painstaking  inquiry  relative  to  the  patient's  medical  history  and 
the  factors/  which  brought  on  the  attack  will  usually  reveal  in 
definite  fashion  the  existence  of  angina  pectoris.  One  of  the 
most  constant  features  of  angina  pectoris  is  its  almost  inevitable 
occurrence  under  the  influence  of  bodily  fatigue  and  emotion, 
and  its  subsidence  under  rest  and  quiet.  Disturbances  of  gas- 
tric origin  do  not  have  this  feature.  In  the  majority  of  cases 
of  angina  pectoris  the  pain,  even  if  it  starts  and  culminates  in 
the  epigastrium,  radiates  to  the  precordial  region  and  sometimes 
even  into  the  left  arm. 


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DYSPEPSIA,  801 

Yet,  in  truth,  the  diagnosis  is  frequently  a  nice  matter,  at  least 
when  based  merely  on  cursory  clinical  examination.  This  is  due 
to  the  facts  that:  1.  Many  discomforts  manifestly  referable  to  the 
stomach,  particularly  aerophagia  and  the  gastric  neuroses,  are  fre- 
quently accompanied  by  anginose  symptoms.  2.  The  anginose 
S)mdrome  (see  Precordial  pain)  is  of  very  variable  origin  and 
gravity,  but  if  it  be  recognized  that  true  angina  pectoris  always 
constitutes  an  outward  manifestation  of  myocardial  weakness  or 
an  aortic  or  periaortic  lesion  or  the — very  frequent — combination 
of  these  two  conditions,  the  clinical  examination  should  be  directed 
definitely  along  these  lines.  The  objective  evidences  of  myocardial 
impairment  and  aortic  lesions  should  be  sought,  and  if  such  exami- 
nation proves  negative,  the  angina  theory  resolutely  discarded. 

7.  Gastralgic  crises  of  tabetic  origin. — ^The  possibility  of 
tabes  as  the  cause  of  violent,  paroxysmal,  uncontrollable  "crises" 
of  sudden  onset  and  disappearance  should  always  be  thought  of. 
Indeed,  if,  in  accordance  with  the  precepts  presented  in  the  sec- 
tion on  systematic  organization  of  clinical  examinations,  testing 
of  the  patellar  reflex  and  for  the  Argyll-Robertson  pupil  is  never 
omitted,  many  unrecognized  cases  of  tabes  will  be  detected  and, 
iir  consequence,  many  gastralgias  treated  as  ulcer  of  the  stomach 
referred  to  their  true,  tabetic  origin;  even  more  particularly 
should  these  procedures  be  remembered  in  gastralgia  occurring 
in  known  cases  of  tabes.  Gastric  ulcer  or  cancer  may,  however, 
be  present  in  combination  with  tabes.  The  fact  of  having  de- 
tected tabes  does  not  warrant  the  practitioner's  dispensing  with 
an  investigation  for  the  signs  of  ulcer  or  cancer. 

As  an  exceptional  condition,  brief  mention  may  be  made  of 
the  possible  presence  of  gastralgia  of  syphilitic  origin  resulting 
cither  from  the  so-called  "hourglass"  shape  of  the  stomach, 
probably  due  to  a  cicatricial  band  remaining  after  cure  of  a 
specific  lesion,  and  which  fluoroscopy  after  a  bismuth  meal  will 
reveal  de  visu,  or  to  specific  ulcerations,  which  appear  to  be  un- 
common. 

*8.  Dyspepsia  and  gastralgia  due  to  lead  occur  much  oftener 
than  they  are  diagnosticated.  Painters,  printers,  and  workers 
in  rubber  are  particularly  subject  to  them ;  on  the  other  hand,  they 
need  hardly  be  thought  of  in  persons  who  are  not  manual  work- 
si 


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802  SYMPTOMS, 

ers.  Any  una«ccountable  dyspepsia  or  loss  of  appetite  coming 
on  in  an  individual  who  handles  lead  should  be  presumed  to  be 
of  saturnine  origin.  If  to  the  dyspepsia  are  added  colic  and 
marked  anemia,  and  if  the  gum  margins  exhibit  the  character- 
istic bluish-gray  lead  line,  a  mistake  in  diagnosis  is  inexcusable. 
In  the  premonitory  stages,  however,  one  cannot  do  more  than 
presume  the  existence  of  lead  poisoning;  in  any  case,  application 
of  the  classical  precept  *'sublata  causa,  tollitur  effectus"  is  in 
order;  abstention  from  all  contact  with  lead,  proper  diet,  and 
the  exhibition  of  diuretics  and  laxatives  will  bring  about  rapid 
improvement  if  lead  poisoning  exists.  The  patient,  thus  fore- 
warned, should  thereafter  take  whatever  precautions  or  carry 
out  whatever  procedures  he  may  deem  appropriate. 

9.  Cancer  oi  the  large  intestine  deceives  many  clinicians,  even 
when  very  well  posted,  when  it  is  manifested,  as  is  often  the 
case,  in  irregular  periods  of  nausea,  pain,  and  even  vomiting,  in 
the  absence  of  any  notable  or  appreciable  intestinal  symptoms. 
A  bismuth  meal  or  enema  followed  by  systematic  fluoroscopic 
examination  will  sometimes  alone  settle  the  diagnosis. 

Simple  fecal  obstruction  of  atonic  and  aged  patients  may, 
indeed,  give  rise  to  wholly  similar  manifestations.  The  author 
will  always  retain  a  recollection  of  a  patient  seen  in  the  late 
Dr.  Landrieux's  service,  in  which  he  was  an  intern  at  the  time. 
This  patient,  about  60  years  of  age,  cachectic,  anemic,  of  a  straw- 
yellow  color,  presented  upon  palpation  a  tumor  of  the  size  of 
the  fist  between  the  umbilicus  and  the  right  hypochondrium ; 
digestive  disturbances  were  very  marked,  consisting  of  anorexia, 
aversion  to  meats,  frequent  vomiting,  constipation,  etc.  Dieula- 
foy,  from  whose  service  the  patient  had  recently  issued,  had  made 
a  diagnosis  of  cancer  of  the  stomach,  which  seemed  to  the  author 
plainly  warranted. 

Months  elapsed  without  any  notable  change  in  the  situation, 
when  one  day,  a  large  dose  of  castor  oil  resulted  in  the  evacuation 
of  several  chamberfuls  of  stercoral  masses,  together  with  disap- 
pearance of  the  abdominal  tumor  and  rapid  betterment  in  the  diges- 
tive disturbances. 

The  subject  was  seen  again  in  subsequent  years,  and  the  im- 
provement thus  initiated  was  observed  to  have  been  maintained. 


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DYSPEPSIA.  803 

10.  Organic  affections  of  the  nervous  system,  as  well  as 
arteriosclerosis,  are  very  often  causes  of  indigestion;  the  head- 
aches and  vertigo  which  frequently  accompany  indigestion  in 
these  cases  should  draw  the  practitioner's  attention  to  the  arter- 
ies, kidneys,  and  brain.  It  should  be  recollected  that  sclerous, 
specific,  or  neoplastic  lesions  of  the  brain  may  induce  for  weeks 
or  even  months  headaches  of  the  so-called  "bilious''  type  ascribed 
to  indigestion  or,  if  unilateral,  decorated  with  the  term  "migraine." 
These  mistakes  are  obviated  by  careful  anamnesis,  determina- 
tion of  the  blood-pressure,  uranalysis,  inspection  of  the  ocular 
fundi,  and  a  search  for  the  indications  so  often  overlooked  by 
the  patient  or  masked,  vu:,,  paresthesias  of  the  extremities,  slight 
evanescent  attacks  of  paresis,  aphasia,  mental  confusion,  con- 
vulsive twitches,  etc. 

11.  Alcoholic  gastritis,  a  common  disorder  in  some  classes 
of  society,  and  not  exclusively  in  the  lower  strata,  is  easily  diag- 
nosticated if  merely  kept  in  mind:  (a)  By  observation  of  the 
ordinary  signs  of  chronic  alcoholism,  vi::.,  tremor  of  the  extremities, 
abnormal  excitability,  various  evidences  relating  to  the  mucous 
membranes,  etc.  (fe)  By  eliciting  a  history  of  habitual  intemper- 
ance, which  should  be  carefully  inquired  into  in  any  class  of  society 
by  minute  questioning  regarding  the  use  of  spirituous  beverages, 
(r)  By  the  nature  of  the  dyspeptic  disturbances,  taz,,  anorexia, 
aversion  to  food,  and  especially  the  vomiting  of  mucoid  material 
in  the  morning — a  frequent  and  characteristic  finding,  (rf)  At 
times  by  the  simultaneous  presence  of  other  visceral  manifesta- 
tions directly  or  indirectly  related  to  alcoholism,  vis.,  hepatic  cir- 
rhosis, arteriosclerosis,  progressive  mental  deterioration,  etc. 

12.  A  most  frequent  clinical  type,  particularly  in  women,  is 
that  aflforded  in  the  following  syndrome  of  gastrointestinal  dys- 
pepsia: 

Poor  or  capricious  appetite;  a  sensation  of  discomfort, 
weight,  or  tension  in  the  stomach  during  the  digestive  period, 
continuing  for  a  varying  period  of  time;  stasis  of  food  in  the 
stomach,  manifested  clinically,  apart  from  the  unpleasant  sen- 
sations already  mentioned,  by  regurgitation  of  food  several 
hours  after  meals  and  by  succussion  splash  in  the  empty  stomach 
in  the  morning;  gastrointestinal  fermentation,  distention  after 


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804  SYMPTOMS, 

meals,  and  eructations.  These  patients  state  that  they  are 
greatly  relieved  by  belching,  and  lay  much  stress  on  this  fact. 
Generally  there  is  manifest  sluggishness  of  the  bowel,  with  hab- 
itual constipation,  sometimes  interrupted  by  attacks  of  diarrhea; 
mucomembranous  enterocolitis  is  frequently  present,  as  are  also 
disturbances  due  to  reaction  on  the  liver  (slight  jaundice,  painful 
congestion  of  the  liver,  etc.)  ;  frequently  the  patient  appeals  to 
the  physician  on  account  of  disturbed  heart  action  (palpitations, 
tachycardia:,  etc.),  or  for  more  or  less  definite  nervous  disturb- 
ances, such  as  migraine,  general  malaise,  vertigo,  headache,  gen- 
eral weakness,  and  psychasthenia. 

Upon  examination  there  is  found  almost  invariably  a  relaxa- 
tion of  the  abdominal  wall,  with  lessening  of  the  normal  ten- 
sion of  the  abdomen;  palpation  gives  a  particular  impression 
of  softness  and  atony;  it  excites  no  defensive  reaction  or  reflex 
tension.  Needless  to  state,  ptosis  of  the  viscera  is  constant,  con- 
sisting of  descensus  of  the  kidney,  liver,  stomach,  or  even  the 
uterus. 

Low  blood-pressure  is  an  almost  constant  finding;  the  hypo- 
sphyxic  syndrome  is  frequently  present,  and  respiratory  insuffi- 
ciency is  the  rule. 

From  the  purely  clinical  standpoint,  this  condition  may  seem- 
ingly be  designated  as  a  h3rposthenic  gastrointestinal  dyspepsia 
(hypomotor  and  hyposecretory),  with  stasis,  fermentation,  ptosis 
of  organs,  and  various  reactions  elsewhere,  e.g.,  upon  the  liver, 
heart,  kidneys,  and  nervous  system. 

It  should  be  repeated  that  few  clinical  types  occur  as  fre- 
quently in  women  as  this  one.  This  is  sufficiently  shown  by 
the  large  number  of  investigations  that  have  been  made  on  the 
subjects  of  visceroptosis,  dilatation  of  the  stomach,  movable  kid- 
ney, flatulent  dyspepsia,  etc.,  all  of  which  are  simply  particular 
modalities  of  the  foregoing  major  type. 

In  truth,  these  are  cases  of  inadequate  circulation,  respiration, 
or  neuromuscular  action  as  plainly  as  they  are  cases  of  digestive  in- 
sufficiency. They  are  general  hyposthenics,  the  functions  of  all 
their  organs  being  below  normal   (see  Hyposphyxid). 

13.  Lastly,  one  should  not  forget  the  reflex  dyspepsia  of  ap- 
pendiceal origin,  with  or  without  nausea  and  vomiting. 


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DYSPEPSIA.  805 

Having  concluded  this  lengthy,  albeit  incomplete,  enumera- 
tion of  the  possible  causes  of  indigestion  and  gastralgia,  there 
remain  to  be  mentioned  the  commonest  and  most  important 
causes  of  these  conditions,  in  the  author's  estimation. 

The  first  four  are  functional: 

1.  Bad  teeth. 

2.  Rapid  eating. 

3.  Aerophagia. 

4.  Psychoneuroses  and  mental  depression;  overwork. 
The  last  two  are  organic: 

1.  Gastric  ulcer. 

2.  Cancer  of  the  stomach. 

Bad  teeth,  so  exceedingly  frequent  a  condition,  particularly 
among  the  poorer  classes,  is  a  common,  manifest,  and  unfortu- 
nately too  often  overlooked  cause  of  dyspepsia.  Patients  will 
come  to  the  physician  already  provided  with  strict  dietetic  regu- 
lations and  most  expertly  written  prescriptions,  in  whom  but 
one  point  in  the  examination  has  been  omitted,  viz,,  that  of  look- 
ing at  the  patient's  teeth — an  initial  and  necessary  step  in  any 
examination  of  the  digestive  tract. 

Rapid  eating  goes  hand  in  hand  with  bad  dentition;  the 
profound  and  patient;  studies  of  Fletcher  should  be  recollected 
in  this  connection.  Ke-education  of  mastication  is  sufficient 
treatment  for  curing  a  very  large  number  of  dyspeptic  cases. 

The  most  elementary  clinical  investigation,  indeed,  will  afford 
conclusive  evidence  in  support  of  the  two  following  axioms : 

A  person  zvho  masticates  his  food  correctly  is  almost  never  a 
dyspeptic  (apart  from  obvious  dietary  indiscretions). 

A  person  who  masticates  his  food  insufficiently  is  always  a 
dyspeptic. 

Practical  conclusion:  In  all  dyspeptics,  whatever  be  the  type 
of  dyspepsia,  the  prescription  should  begin  with  the  time-honored 
but  often  neglected  warning:  Eat  slowly,  masticate  the  food  thor- 
oughly, and  moisten  it  well  with  saliva, 

Aerophagia  is  very  frequently  combined  with  rapid  eating, 
and  gives  rise  to  similar  dyspeptic  symptoms  consisting  of  a 
feeling  of  weight  and  distention,  meteorism,  sometimes  with 
cardiac  manifestations,  dyspnea,  palpitation,  or  even  premature 


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806  SYMPTOMS, 

beats,  all  very  easily  accounted  for  by  the  anatomic  relationship 
between  the  fundus  of  the  stomach  and  the  diaphragm.  Obser- 
vation of  the  unconscious  aerophagic  reflex  and  percussion  of 
Traube's  space  insure  a  prompt  diagnosis. 

Psychoneuroses,  mental  depression,  and  overwork  induce  or- 
dinary manifestations  of  dyspepsia,  either  chronic  or  oscillating 
like  patient's  ''humor*'  itself.  That  mental  factors  powerfully 
influence  gastric  digestion  and,  conversely,  that  disturbances  of 
gastric  digestion  powerfully  influence  the  patient's  "morale" 
or  "humor"  is  a  clinical  fact  which  is  well  expressed  in  the 
old-fashioned  word  "hypochondria"  and  the  truth  of  which  or- 
dinary observation  will  easily  prove. 

The  older  authors,  e,g.,  Chomel  and  Grisolle,  considered  dys- 
pepsia a  neurosis  of  the  stomach.  Subsequent  organicist,  path- 
ologic, and  chemical  investigations  for  a  long  time  eliminated 
this  conception  which,  however,  has  never  been  completely 
abandoned.  The  most  recent  investigations  point  back'  in  its 
direction ;  unquestionably  the  nervous  system  in  the  widest  meas- 
ure regulates  the  secretion  and  motility  of  the  stomach,  and  the 
latter  is  one  of  the  most  sensitive  organs  in  the  body,  upon 
which  react  most  frequently,  through  the  solar  plexus,  all  causes 
of  nervous  disturbance,  whether  depressive  or  stimulating. 

As  a  matter  of  fact  the  majority  of  dyspeptics  are  psychopaths. 
Bourget  estimated  that  the  "dyspeptics  through  psychic  dis- 
turbances" made  up  three-fourths  of  the  practice  of  physicians 
specializing  in  the  digestive  tract.  Mathieu  and  Roux  write  that 
nervous  dyspepsias  are  frequent.  Dubois,  of  Bern,  asserts  that 
"90  per  cent,  of  dyspeptics  are  cases  of  psychoneurosis."  The 
latter  estimate  appears  to  the  author  too  high,  and  is  probably 
accounted  for  by  the  fact  that  Dubois  is  a  neurologist.  The 
author's  experience  leads  him  to  conclude,  with  Bourget,  that 
psychopathic  dyspepsias  make  up  about  three-fourths  of  all  dys- 
pepsias. 

Disappointments  and  constant  worry  exert  a  marked  influ- 
ence. How  many  "hypochondriac"  employes  show  restoration 
of  spirits  and  digestive  capacity  through  mere  promotion  to  a 
position  sought  for  a  long  period!  How  many  ladies,  terribly 
dyspeptic,  with  a  daughter  to  be  married  off,  find  their  digestive 


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DYSPEPSIA, 
Ulcer  and  Cancer  of  the  Stomach. 


807 


Catheterization  of  the  Fasting  Stomach. 

(a)  Food  stasis  Pyloric  stenosis  and,  if  true 

stasis,  cancer  of  the  py- 
lorus. 
Wash   water  contains  jReichmann 
free  HCl. 

Wash  water,  with  1 
per  cent,  acetic  solu- 
tion, contains  chem- 
ically demonstrable 
blood. 


(b)  No  food 
stasis. 


(probably    py- 
loric ulcer). 
Ulcer   of  the  body  of   the 
stomach   (simple  or  can- 
cerous). 


Examination  of  the  Stomach  after  a  Test  MeaL 


(a)  Free  HCl 
in  excess. 

(b)  Free  HCl 
reduced  to- 
ward 0. 


Ether  capsule  dis- 
solved in  less  than 
one  hour. 

Ether  capsule  not  dis- 
solved. 


Probable  ulcer. 
Probable  cancer. 


Examination  of  Feces  after  a  Milk  and  Vegetarian  Diet 


Presence   of 
blood  chem- 
ically demon- 
strable. 


Blood  disappears  after 
a  few  days  rest. 

Blood  still  present. 

Blood  is  present  in 
feces  but  not  in  acid- 
ulated wash  water 
^  from  stomach. 


Probable  ulcer. 

Probable  cancer. 

Duodenal  ulcer  or  ulcer  on 
duodenal  aspect  of  py- 
lorus. 


Fluoroscopic  Examination  (Principal  types). 


Small,  con- 
tracted stom- 
ach with  les- 
sening  of 
peristaltic 
contractions. 


Filling-defect 
in  stomach 
(apparent  ab- 
sence of  a 
portion  of  the 
gastric  shad- 
ow). 


Diffuse 
cancer. 


Localised 
cancer. 


"Amputation" 
of  the  py- 
loric region 
and  delayed 
evacuation 
of  bismuth 
meal. 


Stomach 
presenting 
bilocular  ap- 
p  ea  ranee 
(due       to 
spasm). 


Cancer  of 
pylorus. 


[Diverticular 
a   aspect  (ap- 
parent ad- 
dition to  gas- 
tric shadow). 


Ulcer  on 

lesser 
curvature. 


Callous 
ulcer. 


Blood  Examination. 
Increased  antitryptic  power  of  the  serum   Cancer. 

Cytologic  Examination. 

Microscopic  examination  of  the  wash  water  after  gastric 

lavage. 
Study  of  centrifugation  sediment 
Presence  of  neoplastic  cells Cancer. 


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808  SYMPTOMS. 

power  suddenly  improved  at  the  wedding  feast!  Unfortunately, 
in  these  patients,  except  in  the  case  of  single  persons,  the  physi- 
cian's role  is  necessarily  a  rather  restricted  one. 

Ulcer  and  Cancer  of  the  Stomach. — ^The  importance  of  such 
diagnoses  as  those  of  ulcer  or  cancer  of  the  stomach  is  obvious. 
At  the  author's  request,  Dr.  Leon  Meunier  consented  to  formu- 
late a  vade  mecum  of  the  laboratory  procedures  indispensable  in 
the  diagnosis  of  ulcero-cancerous  affections  (see  the  preceding 
page). 

Aside  from  the  classical  symptoms  of  ulcer  and  cancer  of 
the  stomach,  viz.,  late  pains,  vomiting,  hematemesis,  cachexia, 
etc.,  it  is  important  to  be  able  to  make  a  diagnosis  in  the  earliest 
stage  of  these  lesions,  since  often  the  only  effectual  treatment, 
prompt  operation,  depends  for  its  practicability  upon  such  early 
diagnosis. 

In  the  annexed  synopsis  are  presented  the  various  methods 
of  examination  which  should  be  availed  of  when  ulcer  or  cancer 
of  the  stomach  is  clinically  suspected,  together  with  the  results 
obtainable  therefrom. 

It  should  be  noted  that  any  one  of  these  procedures  is  rarely 
sufficient  to  afford  a  positive  diagnosis,  but  that  their  combined 
results  often  lead  to  a  strong  probability. 


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DYSPNEA.  [8vg,  ill;  nvelv,  to  breatJie.] 


Dyspnea  is  characterized  by  a  difficulty  in  breathing;  it  is  usvially 
associated  with  increased  frequency  of  respiration  (polypnea) 
and  sometimes,  as  will  be  seen  later,  by  changes  in  the  ampli- 
tude of  the  respirations.  In  brief,  the  essential  feature  of  dysp- 
nea is  distress,  or  even  at  times  pain,  attending  the  respiratory 
exertion. 

EfTarentirwtor  n^spirdtorf  center  inmedalla  MTerent  sensory 


£)pirc 


"^ 


Fig.  606. — Diagram  showing  the  afferent  and  efferent  nerve  paths  con- 
cerned in  the  reflexes  of  the  respiratory  tract   (cough,  asthma,  etc.). 
Pathogenesis  of  dyspneic  and  asthmatic  attacks. 

All  grades  of  dyspnea  are  met  with,  from  the  dyspnea  on  exer- 
tion, appearing  only  u|x>n  more  or  less  marked  or  prolonged  motor 
activity,  to  orthopnea,  in  which  extreme  dyspnea  compels  the 
patient  to  brace  himself  against  furniture  or  a  window  in  order 
to  breathe. 

Some  attacks  of  paroxysmal  dyspnea  are  known  as  asthma. 

It  is  not  within  our  plan  to  discuss  the  physiology  of  regula- 
tion of  the  respiratory  rhythm  and  the  pathologic  physiology  of 
dyspnea.  It  should  be  noted,  however,  that  the  automatic  reg- 
ulation of  the  respiratory  function  is  effected  both  by  a  chemical 
and  a  nervous  process. 

(809) 


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810  SYMPTOMS, 

1.  Chemical. — The  concentration  of  carbon  dioxide  in  the  blood. 

2.  Nervous. — Through  the  pneumogastrics,  which  embody  two 
kinds  of  fibers:  (a)  The  fibers  inhibitory  to  inspiration  and  acceler- 
ator to  expiration  which  are  excited  by  the  expansion  or  dilatation 
of  the  lungs,  (b)  The  fibers  inhibitory  to  expiration  and  acceler- 
ator to  inspiration,  which  are  excited  by  deep  expirations,  as  in 
the  majority  of  instances  of  dyspnea;  these  are  inoperative  dur- 
ing ordinary  breathing.  Any  morbid  state  which  leads  to  an 
excessive  concentration  of  carbon  dioxide  in  the  blood  or  which 
by  any  route  directly  excites  the  respiratory  center  in  the  me- 
dulla, or  indirectly  through  the  pneumogastric  nerves,  is  capable 
of  inducing  dyspnea  in  the  physiopathologic  sense. 

The  number  and  variety  of  the  causes  of  dyspnea  are  such 
that  the  semeiologic  value  of  this  condition  is  rather  limited. 
In  general,  however,  one  may  state  that  there  is  present: 

1.  Either  a  manifest  or  latent  lesion  of  the  respiratory  system. 
Or  a  manifest  or  latent  lesion  of  the  circulatory  system. 
Or  some  grave  toxic-infectious  state  (uremia,  acetonemia). 
As  with  most  other  symptoms,  one  must  likewise  reckon  with 

the  possibility  of  neurotic  dyspnea  (due  to  nervous  inhibition). 

2.  The  clinical  significance  of  dyspnea  varies  in  importance  and 
precision  according  to  the  degree  to  which  the  symptom  is  independ- 
ent of  other  manifestations,  i.e.,  is  observed  in  the  absence  of 
fever,  changes  in  the  lungs  or  heart,  acceleration  of  the  pulse  rate, 
and  neurotic  stigmata.  One  may  almost  make  the  assertion  that 
any  dyspnea  sine  materia,  in  the  accepted  sense  of  this  term,  is 
either  a  toxic  dyspnea,  usually  uremic  or  acetonemic,  or  a  neurotic 
dyspnea. 

3.  Some  forms  of  dyspnea  possess  per  se  a  more  or  less  char- 
acteristic significance  : 

A.  Thus,  sometimes  dyspnea  affects  more  particularly  the 
act  of  inspiration,  or,  on  the  contrary,  the  act  of  expiration: 

(a)  Inspiratory  dyspnea  is  characteristic  of  obstruction  of  the 
upper  respiratory  passages ;  thus,  it  is  met  with  in  edema  of  the 
glottis,  croup,  diphtheria,  laryngeal  spasm,  tumors  of  the  larynx, 
foreign  bodies  of  the  larynx,  trachea,  or  bronchi,  retropharyn- 
geal abscess,  Ludwig's  angina,  or  pressure  on  the  trachea  (as  by 
intrathoracic  goiter,  aortic  aneurysm,  etc.).    Particularly  difficult 


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DYSPNEA. 


811 


inspiration  may  be  noisy  and  assume  a  stridulous  quality  which 
is  practically  pathognomonic  of  pressure  on  the  larynx  or 
trachea. 

(fe)  Expiratory  dyspnea  is  frequently  accompanied  by  whistling 
sounds;  as  is  well  known,  it  is  one  of  the  most  characteristic 
features  of  emphysema  and  of  asthma.  It  is  met  with  exception- 
ally in  edema  of  the  lungs. 

(c)  Mixed  dyspnea  affecting  both  inspiration  and  expiration  is 
by  far  the  most  frequent  form  and  likewise  the  least  character- 
istic. 


Fig.  607. — Diagram  of  a  terminal  bronchus  under  normal  conditions 

(A)  and  during  a  paroxysm  of  asthma    (B)    (Abrams).     During  the 
asthmatic  attack,  the  spasm  of  the  circular  fibers  in  the  bronchial  wall 

(B)  causes  retention  of  air  in  the  air-vesicles,  difficulty  of  expiration, 
and  dilatation. 

B.  Kinetic  and  Static  Dyspnea. — One  should  also  carefully 
distinguish : 

(a)  Kinetic  dyspnea,  or  dyspnea  on  exertion,  motion,  and  ex- 
ercise, which  is  merely  an  exaggeration  of  a  nonnal  event  and  which 
appears  only  upon  exertion,  such  as  walking,  ascending  stairs, 
exercising,  etc.  The  clinical  signification  of  such  dyspnea  is 
quite  distinct  and  of  great  value.  Any  exercise,  exertion,  or 
muscular  contraction  demands  increased  function  on  the  part  of 
the  cardiopulmonary  system,  which  is  normally  manifested  by 
a  temporary  acceleration  of  the  heart  rate,  a  rise  in  blood  pres- 


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812  SYMPTOMS, 

sure,  an  increase  in  the  frequency  and  amplitude  of  the  respira- 
tory movements,  and  an  increased  elimination  of  carbon  dioxide 
from  the  lungs.  The  tachycardia  and  polypnea  induced  by  ex- 
ercise are  thus  absolutely  normal  phenomena  and  being  such, 
are  not  accompanied  by  cardialgia,  palpitation,  or  dyspnea  and 
subside  rapidly  after  cessation  of  the  exercise.  If  the  exercise 
taken  is  too  violent  or  too  prolonged,  or  the  reserve  cardio- 
pulmonary power  of  the  individual  in  question  is  slight,  there 
will  occur  an  excessive,  prolonged  dyspnea,  palpitation,  or  tachy- 
cardia. 

Kinetic  dyspnea  on  exertion  is  one  of  the  first  and  most  valuable 
indications  of  insufficient  cardiopulmonary  function.  The  sub- 
ject notices  that  he  can  no  longer  take  a  rather  prolonged  walk 
or  ascend  the  stairs — ^as  he  could  previously  do  without  the  least 
difficulty — without  experiencing  dyspnea.  The  dyspnea  on  exer- 
tion, at  first  accidental  (after  a  copious  meal)  or  slight  (occur- 
ring only  after  relatively  violent  exercise),  gradually  becomes 
habitual  and  pronounced,  requiring  for  its  production  only  a 
very  moderate  amount  of  exercise. 

If  sought,  it  will  be  found  present  in  all  cases  of  chronic 
cardiopulmonary  insufficiency,  including  weakened  heart  action, 
anoxemia,  inadequately  compensated  heart  aflfections,  and 
chronic  bronchopulmonary  disorders  such  as  emphysema,  chronic 
bronchitis,  and  fibrosis  of  the  lungs. 

(fc)  Static  dyspnea  continuing  while  the  individual  is  at  rest 
either  represents  the  final  stage  of  the  preceding  type  of  dyspnea 
or  is  the  expression  of  a  toxemia. 

Brief  mention  may  here  be  made  of  the  influence  of  posture 
and  of  rest  at  night. 

Dyspnea,  of  whatever  source,  is  almost  invariably  increased 
by  the  horizontal  position,  and  diminished  or  relieved  by  the 
sitting  posture.  In  extreme  cases,  indeed,  the  patients  lean  for- 
ward, with  their  elbows  on  their  knees,  or  sit  at  the  edge  of 
the  bed  or  are  able  to  rest  only  when  seated  in  an  armchair. 
Various  factors  are  doubtless  operative  in  this  phenomenon,  the 
most  important  being  the  pressure  on  the  mass  of  abdominal 
viscera  and  on  the  diaphragm. 


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DYSPNEA, 


813 


As  for  the  influence  of  rest  at  night,  it  may  be  stated  that, 
with  the  exception  of  "dyspnea  on  exertion"  which,  as  the  term 
implies,  passes  oflf  after  rest,  the  majority  of  instances  of  dysp- 
nea, whether  of  cardiopulmonary  or  of  toxic-infectious  origin, 
become  worse  at  night.  In  a  certain  proportion  of  cases  this 
may  be  ascribed  to  an  unfavorable  influence  of  the  horizontal 
position  customarily  assumed  at  night;  yet  this  recrudescence 
of  dyspnea  is  the  rule  even  in  subjects  who  remain  in  the  sit- 
ting position  at  night.  Many  plausible  explanations  have  been 
vouchsafed  to  account  for  this  fact,  e,g,,  the  disturbing  influence 

Uremic  Coma.    Chejme-Stokes  Breathing. 


15"       •         15**       I     1Q*»   [    lO"    '         1j5"      i        15" 

/Ip/iea    \4/kfjDiMim  llRe^tations  ^fRe^iSMfon^,    ^finea 
•  '  1  I 


J L- 


frequency 

Fig.  608. — Cheyne-Stokes  breathing  observed  during  quiet  and  pro- 
found sleep.  Systematic  observation  for  eighteen  minutes  showed  ten 
stereotyped  respiratory  "cycles"  absolutely  like  that  represented  above  in 
duration,  rhythm,  amplitude,  and  auditory  manifestations. 

Case  613.  Albuminuria,  6  grams  to  the  liter ;  blood  urea,  2.10  grams ; 
blood-pressure,  269ieo ;  no  edema.  Other  evidences  of  uremia :  Headache, 
vomiting,  flow  of  viscid  saliva,  convulsive  seizures,  etc. 

of  the  night  and  darkness  on  the  patient's  imaginative  processes, 
the  period  of  maximal  organic  intoxication,  a  tendency  to  inhibi- 
tion of  the  respiratory  center  during  sleep,  etc. 

C.  Che3me-Stokes  Bireathing. — Special  mention  should  be 
made  of  a  particular  type  of  respiration  known  as  the  Cheyne- 
Stokes  rhythm,  so  called  after  the  names  of  two  observers 
(Cheyne,  1816,  and  Stokes,  1854)  who  made  a  special  study  of 
it.  Tt  consists  of  a  series  of  respirations  of  progressively  in- 
creasing frequency,  amplitude,  and  noise  production  (ascending 
phase),  followed  by  respirations  occurring  at  increasing  in- 
tervals and  becoming  smaller  and  more  quiet  (descending  phase), 


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814  SYMPTOMS. 

after  which  there  appears  a  stage  of  complete  apnea  with  cessa- 
tion of  all  breathing  (period  of  apnea),  the  cycle  thereafter 
beginning  anew. 

This  sort  of  breathing  is  observed  in  its  pure  form  only  if 
the  subject,  completely  relaxed  and  unconscious,  is  in  a  deep 
sleep.  In  the  waking  state  it  is  always  more  or  less  interfered 
with  by  mental  reactions  arising  from  anxiety,  pain,  etc.;  in  the 
presence  of  coma,  on  the  other  hand,  the  rhythm  is  disturbed 
by  the  complications  attending  this  stage,  vis.,  congestion  of 
the  bases  of.  the  lungs,  partial  obstruction  of  the  pharynx  and 
larynx,  paralytic  phenomena,  etc.  Yet  it  is,  as  a  rule,  readily 
detected  if  the  least  attention  is  paid  to  the  respiratory  rhythm. 
The  stages  of  apnea  are  particularly  characteristic.    " 

When  the  condition  is  observed  in  its  pure  form  during  sleep 
one  is  always  impressed  with  the  accurate  control  character- 
izing the  phenomenon,  which  recurs  with  mathematical  regu- 
larity, as  in  the  case  herewith  illustrated. 

Sometimes,  though  exceptionally,  the  foregoing  rhythm  of 
respiration  is  present,  but  without  any  stage  of  apnea  (Biot's 
breathing).  Such  respiration  possesses  the  same  clinical  signifi- 
cance. 

Cheyne-Stokes  breathing  is  almost  universally  looked  upon  as 
an  indication  of  serious  impairment  of  the  bulbar  centers,  which 
have  a  tendency  to  *'go  to  sleep"  and  the  activity  of  which  is  ex- 
cited only  by  such  a  carbon  dioxide  stimulation  as  attends  be- 
ginning asphyxia. 

By  far  the  most  frequent  cause  of  it  is  uremia,  and  the  prog- 
nosis is  usually  very  unfavorable. 

From  the  standpoint  of  semeiology  alone,  the  various  kinds 
of  dyspnea  may  be  grouped  as  follows: 


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DYSPNEA.  815 


Dyspnea  of  Respiratory  Origin. 


Type  case:    Pneumonia. 


Foreign  bodies  in  the  respiratory  passages. 

Pressure  (pharyngeal,  cervical,  or  medias- 
tinal); acute  and  chronic  pleuropulmon- 
ary  disorders. 


Dyspnea  of  Circulatory  Origin. 


(a)  Cardiac 

Type  case:  Heart  failure. 

(b)  Dyscrasic. 
Type  case:   Uremia. 


Cardiac  insufficiency,  hyposystoly,  hypo- 
sphyxia,  inadequately  compensated  heart 
affections  (cardiac  pseudo-asthma). 

Anemia  or  anoxemia. 

Uremia  or  acetonemia. 

Intoxications  (certain  asphyxiating  gases). 

Febrile  disorders. 


Dyspnea  of  Nenrons  Origin. 


Type  case:   Hysteria. 


Neuroses.    Neurocardiac  erethism. 
Asthma,  certain  forms  of. 
Bulbar  affections. 


L— DYSPNEA  OF  RESPIRATORY  ORIGIN. 

This  IS  usually  obvious,  the  relationship  of  cause  to  eflfect 
being  in  most  instances  readily  demonstrable. 

Such  is  the  case  in  foreign  bodies  in  the  respiratory  passages ; 
in  pressure  and  obstruction  of  the  pharynx,  larynx,  or  trachea 
(as  in  nasopharyngitis,  adenoid  vegetations,  laryngeal  diphtheria, 
tumors  of  the  larynx,  and  tumors  or  glandular  enlargements  in 
the  neck)  ;  in  bronchitis — especially  capillary  bronchitis;  in  bron- 
chopneumonia, congestion  of  the  lungs,  lobar  pneumonia,  pleu- 
risy, pleuropneumonia,  etc.,  further  discussion  of  which  would 
seem  superfluous. 

These  instances  of  dypsnea  of  pleurobronchopulmonary  origin 
are  produced,  on  the  whole,  in  the  same  way,  vie,  through  suppres- 
sion of  a  more  or  less  extensive  portion  of  the  functionating  lung 
surface,  owing  either  to  compression,  as  in  pleurisy  or  pneumo- 
thorax; to  encroachment  upon  the  bronchi,  as  in  bronchitis;  to 
encroachment  upon  the  air  vesicles,  as  in  pneumonia  and  bron- 
chopneumonia, or  to  inadequate  motion  of  the  ribs  and  dia- 
phragm, as  in  emphysema,  etc. 

The  paroxysmal  attacks  of  dyspnea  commonly  known  as 
asthmatic  seizures,  which  may,  as  will  be  seen,  be  of  very  vari- 
able origin,  hardly  exhibit  any  special  differential  features  ac- 


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816  SYMPTOMS, 

cording  to  their  varying  cause ;  the  two  essential  and  characteristic 
factors  are:  A  pneumospasmodic  disturbance  (the  paroxysmal 
dyspnea)  and  a  secretory  disturbance  (the  catarrhal  condition). 
No  lengthy  description  of  these  features  need  here  be  given. 
Their  essential  characteristic  is  paroxysmal  dyspnea,  together 
with  bradypnea  or  slow  breathing.  It  is  in  tracing  the  under- 
lying cause  of  the  asthmatic  state  that  the  therapeutist  is  called 
upon  to  display  the  highest  degree  of  clinical  common  sense  and 
carry  out  the  most  painstaking  inquiry,  for  upon  this  investigation 
curative  treatment  mainly  depends.  No  form  of  clinical  investi- 
gation is  more  difficult,  and  while  at  times  the  physician  may 
succeed  in  detecting  the  exciting  factor  at  once,  more  often  a 
prolonged  and  painstaking  search  is  required,  since  "anything 
may  happen  in  asthma,  and  even,  in  the  presence  of  certain 
bizarre  manifestations,  to  be  skeptical  would  be  a  mistake" 
(Brissaud). 

In  practice,  the  following  6  groups  of  causes,  which  are  by 
far  the  commonest  (Moncorge),  should  be  examined  for:  1.  Neu- 
roarthritism.  2.  Causes  relating  to  the  lungs.  3.  Cardio-arterio- 
renal  causes.  4.  Gastro-hepato-intestinal  causes.  5.  Toxic-infec- 
tious causes.  6.  Nasal  hyperexcitability.  As  may  be  noted, 
according  to  this  almost  the  entire  field  of  internal  medicine  will 
have  to  be  gone  over. 

Mention  should  be  made  again  of  the  fact  that  chronic  bron- 
chopulmonary affections — particularly  emphysema,  asthma,  and 
chronic  bronchitis — necessarily  react  upon  the  right  heart,  and 
that  at  a  more  or  less  advanced  stage  of  the  disorder  dyspnea 
is  as  much  of  cardiac  as  it  is  of  pulmonary  origin. 

It  should  be  recalled,  furthermore,  that  many  lung  manifesta- 
tions are  merely  a  symptomatic  expression  of  some  general  morbid 
condition,  such  as  uremia  or  cardiac  inadequacy;  this  is  true,  e.g., 
of  passive  congestion  of  the  bases  of  the  lungs,  of  acute  and  sub- 
acute edema  of  the  lungs,  of  many  instances  of  chronic  bronchitis, 
and  of  many  asthmatoid  conditions.  Cardiorenal  insufficiency  is 
at  the  bottom  of  a  very  large  number  of  acute  and  chronic  respira- 
tory manifestations. 

For  these  various  reasons,  the  semeiologic  study  of  dyspnea 
associated  with  some  definite  localized  disorder  in  the  respiratory 


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DYSPNEA.  817 

tract  necessarily  indicates  a  careful  examination  of  the  heart 
and  kidneys,  both  for  diagnostic  and  for  prognostic  purposes. 

IL— CARDIAC  DYSPNEA. 

As  for  so-called  "cardiac  dyspnea"  one  cannot  do  better  than 
quote  the  succinct,  profound,  and  clinically  excellent  presenta- 
tion of  the  subject  by  Ribierre: 

"From  the  start,  dyspnea  on  exertion  (appearing  upon  climb- 
ing stairs,  steeply  inclined  streets,  etc.)  is  accompanied  by  painful 
sensations  behind  the  sternum  and  in  the  epigastrium,  and  to  these 
painful  sensations  is  attached  from  the  outset  an  element  of  angor, 
although  they  are  evanescent  and  quickly  disappear  at  rest. 

"Next  there  is  decubital  dyspnea,  coming  on  suddenly  just  be- 
fore or  during  sleep  and  likewise  accompanied  by  precordial  angi- 
nose  pains,  frequently  radiating  to  the  back,  shoulders,  and  arms. 
Sometimes  the  dyspneic  element  clearly  predominates  over  the 
painful  element ;  there  exists  then  an  asthmatoid  dyspnea  or,  in 
accordance  with  the  rather  questionable  term  sanctioned  by  us- 
age, a  cardiac  pseudo-asthma. 

"When  one  takes  into  consideration  the  special  features  attend- 
ing these  painful  manifestations,  angina  pectoris  at  once  comes  to 
mind.  Is  It  wise,  on  account  of  slight  symptomatic  differences 
relating  to  the  duration  and  severity  of  a  symptom,  to  perpetuate 
former  misconceptions  and  establish  a  definite  distinction  between 
these  anginose  pains,  constituting  a  supposed  angina  minor  (which 
ought  not  to  be  fatal!),  from  the  true  angina,  which  ends  fatally? 
Here  again,  the  subsequent  course  of  the  case  will  bring  out  the 
true  state  of  affairs.  Not  infrequently,  indeed,  there  are  seen  to 
appear,  in  subjects  who  had  previously  exhibited  only  this  rela- 
tively mild  syndrome,  the  major  phenomena  of  insufficiency  of 
the  left  ventricle,  vis.,  a  most  typical  angina  pectoris,  and  also 
edema  of  the  lungs,  of  which  no  detailed  description  is  here  re- 
quired. Since  the  investigations  of  Merklen,  it  is  no  longer  possible 
to  ignore  the  close  relationship  existing*  between  the  painful  dyspnea 
of  high  pressure  cases  and  angina  pectoris  and  edema  of  the  lungs, 
nor  the  relationship  of  these  syndromes  with  left  ventricular  insuffi- 
ciency." 

52 


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818  SYMPTOMS. 

The  above  word  picture  is  particularly  applicable  to  the  cardiac 
dyspnea  of  high  pressure,  aortic,  cardiorenal,  and  nephritic  cases. 

In  insufficiency  of  the  right  ventricle,  dyspnea  on  exertion  sets 
in  gradually,  without  concomitant  precordial  pains.  Then  the 
dyspnea  becomes  continuous,  making  it  impossible  for  the  patient 
to  remain  in  dorsal  decubitus  and  being  progressively  supplemented 


Fig.  609. — Case  826.     Heart  failure,  auricular  fibrillation,  and  mitral 
stenosis.    H.,  1888 ;  164  cm. ;  57  kilogr. 

by  the  classical  symptoms  of  impaired  heart  action,  viz.,  painful 
enlargement  of  the  liver,  jugular  stasis,  increasing  cyanosis,  re- 
duced output  of  urine,  edema,  albuminuria,  etc.,  heart  failure  fin- 
ally occurring  after  a  varying  period.  This  clinical  picture  is  more 
particularly  that  of  the  dyspnea  of  mitral  stenosis  and  of  chronic 
lung  disorders,  such  as  pulmonary  fibrosis,  adhesive  pleuritis,  bron- 
chiectasis,  emphysema,  etc. 

In  the  later  stages  of  cardiac  disorders,  there  is  combined  in- 
sufficiency of  the  right  and  left  sides  of  the  heart,  the  result  being 


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DYSPNEA.  819 

the  .classical  picture  of  complete  cardiac  insufficiency,  involving 
both  the  right  and  left  auricles  and  ventricles. 

Lastly,  it  should  be  mentioned  that  in  simple  fatigue  of  the 
myocardium  there  may  be  observed  in  a  very  'mild  form  a  kind 
of  dyspnea  suggesting  Cheyne-Stokes  breathing  (Fig.  611). 

Cardiac  asthma. — Cardiac  asthma  consists,  according  to 
Merklen's  definition,  of  a  paroxysmal  dyspnea  complicating  dis- 
turbances  of  pulmonary  circulation  and  of  the-  cardiac  function. 


xvAVffll^^ 


a 

Fig.  610. — Cheyne-Stokes  breathing,    a,  apnea;  b,  ascending 
phase;  c,  descending  phase. 

Cardiac  asthma  generally  occurs  in  subjects  presenting  un- 
mistakable evidences  of  insufficiency  of  the  heart,  such  as  diffi- 
culty in  walking,  dyspnea  on  exertion,  dyspnea  in  recumbency, 
habitual  breathlessness,  and  attacks  of  threatened  pulmonary 
edema  manifested  by  slightly  reddish  albuminous  expectora- 
tion, gallop  rhythm  on  auscultation,  reduced  blood-pressure,  etc.. 

At  times  there  are  mild,  incipient  seizures  occurring  occasion- 
ally, either  at  the  moment  of  retiring,  or  during  sleep,  or  even 


.AfM  ...jJi 


d      b  a 

Fig.  611. — Dyspnea  of  myocardial   fatigue  and  general  exhaustion. 
a,  apnea;  b,  ascending  phase;  descending  phase  absent. 

several  times  in  a  single  night  These  are  the  result  of  a  weak- 
ness of  the  myocardium  which  is  favored  by  the  reduction  of 
circulation  that  naturally  occurs  during  sleep  and  which  passes 
off  on  awakening.  Sometimes  these  attacks  recur  as  soon  as  the 
patient  attempts  to  fall  asleep  again.  Occasionally,  after  taking 
cold,  or  a  heavy  meal,  or  some  emotional  impression,  there  is 
a  severe,  dramatic  attack  with  anginose  manifestations. 

Oppression  is  greater  in  cardiac  asthma  than  in  nervous  as- 
thma; this  is  because  of  an  interference  with  pulmonary  circu- 


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820  SYMPTOMS, 

lation,  which,  however,  is  not  always  readily  detected.  Fre- 
quently, indeed,  there  is  elicited  on  auscultation  merely  an  ex- 
aggeration of  resonance,  due  to  a  species  of  acute  emphysema 
of  the  lung  brought  on  by  spasm  of  the  muscles  of  respiration. 
In  other  instances,  there  develops  a  more  or  less  extensive  pul- 
monary edema,  generally  confined  to  the  bases  of  the  lungs. 
Serous  transudation  may  be  sufficiently  free  to  lead  to  the  ex- 
pectoration of  albumin-laden  sputum  stained  with  blood — a  proc- 
ess which  brings  some  relief  to  the  patient.  In  such  instances, 
cardiac  asthma  and  acute  edema  of  the  lungs  coexist.  Finally, 
the  tracheal  rale  may  be  noted  in  the  absence  of  rales  in  the 
lungs. 

Cardiac  asthma  may  be  complicated  with  angina  pectoris,  and 
this  complication  is  met  with  particularly  in  subjects  poisoned 
by  tobacco,  suffering  from  sclerosis  and  atheroma  of  the  coron- 
aries,  or  subjected  to  a  severe  degree  of  overwork.  The  left 
heart  reacts  to  the  distention  in  common  with  all  reservoir-like 
organs  with  muscle  tissue  in  their  walls,  eg,,  the  bladder;  hence 
the  pains  felt  by  the  patient.  These  pains  cease  when  the  heart 
is  dilated. 

During  an  attack,  auscultation  of  the  heart  is  frequently  im- 
practicable. Sometimes  one  may  note  gallop  rhythm,  which  is 
an  expression  either  of  cardiac  insufficiency  in  general  or  a  mitral 
insufficiency  from  dilatation,  which  disappears  a^  soon  as  the 
heart  has  become  restored  to  its  normal  dimensions. 

Cardiac  asthma  may  eventually  terminate  in  fatal  syncope. 
In  such  instances,  the  extremities  become  cold,  there  is  incon- 
tinence of  urine  and  feces,  the  patient  is  covered  with  sweat, 
his  sight  becomes  dim,  and  death  supervenes  very  quickly.  In 
many  instances  the  fatal  termination  occurs  only  after  the  lapse  of 
one  or  two  hours.  Some  patients  pass  into  a  comatose  state. 
As  a  rule,  however,  the  case  does  not  die  if  the  necessary  meas- 
ures are  taken  in  due  time,  and  the  physician  always  has  reason 
to  hope  for  termination  of  the  attack,  even  under  what  appear 
to  be  most  unfavorable  circumstances. 

Cardiac  asthma  is  the  result  of  sudden  insufficiency  of  the 
left  ventricle;  it  is  due  to  an  abrupt  turn  for  the  worse  in  a 
latent  heart  disorder. 


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DYSPNEA.  821 

The  attacks  of  asthma  are,  as  Merklen  puts  it,  prepared  for 
by  pathologic  changes  or  functional  disturbances  of  the  myo- 
cardium, the  chief  causes  of  which  are  tobacco  abuse,  alcoholism, 
overwork,  and  impaired  coronary  circulation.  They  are  directly 
brought  on  by  any  factors  tending  to  produce  or  increase  the 
dilatation  of  the  heart.  The  most  important  of  these  causes  are 
those  which  induce  peripheral  vaso-constriction — exposure  to 
cold,  emotional  impressions,  indiscretions  of  diet,  excessively 
long  tramps  or  prolonged  work,  sexual  excesses,  intercurrent 
diseases,  influenza,  and  pneumonia. 

Thus,  the  subject  of  cardiac  dyspnea  would  be  a  fairly  lucid 
one  were  it  not  rendered  obscure  by  the  cardiac  neuroses,  i.e., 
those  individuals  who,  apart  from  any  acute  or  dironic  organic 
lesion  of  the  heart  or  its  separate  layers  (endocarditis,  pericar- 
ditis, myocarditis),  and  even  in  the  absence  of  any  true — e.g., 
congenital  or  constitutional — myocardial  weakness,  or  of  any 
known  disease  of  the  nervous  system,  suffer  from  some  symp- 
tom-complex preeminently  involving  the  heart.  As  a  matter  of 
fact,  it  is  these  cardiac  neuroses  which  are  accompanied  by  the 
most  numerous  and  distressing  cardiac  or  pseudo-cardiac  symp- 
toms, the  most  important  of  which  are  dyspnea,  choking  sensa- 
tions, or  angor  with  radiation  of  pain  to  the  arm  and  neck  (nerv- 
ous angina,  etc.). 

Differentiation  of  cardiac  neurosis  and  organic  disease  is  not 
always  an  easy  matter.  Auscultation  may  be  difficult  and 
misleading;  various  types  of  arhythmia — extrasystoles,  nodal 
rhythm,  etc. — may  be  observed  in  either  condition ;  the  same  is  true 
of  the  customary  hypertrophy  of  the  left  ventricle  and  even 
in  greater  degree  of  the  subjective  manifestations,  such  as  dysp- 
nea on  exertion,  sensations  of  constriction,  or  even  an  anginose 
syndrome,  palpitations,  phrenocardia,  etc.  Nevertheless  there 
are  some  differential  points. 

(a)  The  first  and  most  important  is,  perhaps,  the  neuropathic 
substrate  over  which  cardiac  neurosis  always  runs  its  course.  The 
cardiac  symptom-complex  above  referred  to  is  but  a  portion  of 
the  neuropathic  picture,  always  more  or  less  distinct  and  gener- 
ally supported  by  heredity  and  the  extracardiac  neuropathic 
manifestations,  particularly  digestive  and  mental. 


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822  SYMPTOMS. 

(6)  The  second  is  the  frequency  and  severity  of  the  symptoms 
occurring  at  night,  viz.,  insomnia,  anxiety,  dyspnea,  and  even  angor 
and  cardiac  pseudo-asthma,  incomparably  more  frequent,  im- 
pressive and  seemingly  more  "dramatic,"  as  a  rule,  than  in  cases 
of  organic  heart  disease.  These  nocturnal  psychosomatic  dis- 
turbances are  very  definite  in  neuro-cardiac  cases. 

(c)  N euro-cardiovascular  instability  and  mobility  constitute  the 
external  evidences  of  excessive  nervousness,  the  pulse  frequency 
and  blood-pressure  being  affected  to  a  surprising  extent  by  the 
slightest  disturbing  causes.  The  same  is  often  true  of  the  aus- 
cultatory signs,  which  are  far  from  being  as  relatively  fixed  and 
constant  as  those  present  in  organic  disease. 

{d)  Absence  of  the  customary  etiologic  factors  of  organic  heart 
disease  is,  as  a  rule,  noted,  vis.,  rheimiatic,  typhoid,  s)rphilitic, 
diphtheritic,  or  other  infections,  plethora  and  auto-intoxication, 
gout,  uricemia,  etc. 

(e)  Lastly,  the  circulatory  functional  test  (see  the  Circulatory 
system)  clearly  demonstrates  the  heightened  vasomotor  reactions 
and  the  usually  considerable  margin  of  safety  in  the  reserve 
power  of  the  myocardium. 

III.— DYSCRASIC  DYSPNEA. 

One  of  the  most  salient  features  of  this  type  of  dyspnea  is 
that  of  being  for  a  long  period  sine  materia,  and  the  fact  that 
neither  the  time-honored  and  already  somewhat  obsolescent 
routine  examination  of  the  circulation,  nor  an  examination  of  the 
respiratory  system,  reveal  any  disorder  or  organic  disease  which 
might  plausibly  account  for  it. 

Whereas,  however,  the  objective  cardiopulmonary  evidences 
and  the  classic  symptoms  already  mentioned  are  ordinarily  lacking, 
and  while  such  dyspnea,  considered  from  this  already  antiquated 
standpoint  alone,  are  sine  materia,  such  is  far  from  being  the  case 
if  they  are  studied  and  listed  with  the  assistance  of  the  modem 
methods  of  examination. 

Actually,  most  cases  of  this  type  of  dyspnea  may,  clinically, 
be  placed  in  one  of  the  three  following  groups : 

1.  Anoxemia. — ^At  bottom,  in  these  cases,  there  is  a  func- 
tional cardiopulmonary  insufficiency  unattended  by  any  recog- 


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DYSPNEA,  823 

nized  disease,  but  in  which  modem  means  of  investigation  gen- 
erally elicit:  (1)  Insufficiency  of  respiration  (the  spirometer 
showing  a  breathing  capacity  below  2  litres  in  an  average  sub- 
ject). (2)  Low  blood-pressure,  with  the  systolic  at  120  milli- 
meters or  less  and  the  pulse  pressure  at  15  to  35  millimeters.  (3) 
Increased  blood  viscosity,  4.5  and  upwards,  or  at  least  a  relatively 
high  viscosity,  4.2  and  upwards.  Fluoroscopy  and  orthoradiography 
demonstrate  this  lowered  functional  and  nutritive  state  of  the  heart 
and  lungs  even  more  rapidly,  showing  microcardia  (the  small  *'drop" 
heart),  insufficient  breathing  particularly  manifested  in  a  rela- 
tive reduction  of  the  excursions  of  the  diaphragm,  reduced  clear- 
ing of  the  lung  margins  during  inspiration,  and  the  presence 
in  these  parts,  especially  at  the  bases  of  the  lungs,  of  zones 
which  hardly  exhibit  any  clearing  at  all  during  inspiration. 
These  are  cases  of  hyposphyxia   (see  Low  blood-pressure), 

2.  Uremia. — Whether  manifest  or  latent,  uremia  is  perhaps, 
after  hyposphyxia,  the  commonest  cause  of  dyscrasic  dyspnea. 
Apart  from  the  customary  but  often  misleading  evidences  of 
uremia,  vis,,  headache,  nausea,  itching,  cramps,  numb  fingers, 
sleeplessness,  albuminuria,  etc.,  there  are  now  available  certain 
practically  pathognomonic  signs,  one  of  which  in  particular,  viz., 
hyperazotemia,  or  an  excessive  amount  of  urea  in  the  blood — 
0.60  or  more — should  be  examined  for  by  determination  of  the 
blood  urea  in  all  suspected  cases.  High  blood-pressure,  exceed- 
ing 200  millimeters,  the  presence  of  traces  of  albumin,  and  the  pas- 
sage of  an  excess  of  urine  of  low  specific  gravity  at  night,  in  a  dysp- 
neic  subject,  are  in  themselves  almost  pathognomonic  of  azot- 
emia, especially  if  the  dyspnea  assumes  at  times  the  so-called 
Cheyne-Stokes  character.  In  uremic  poisoning  the  azotemia  is 
much  more  active  in  causing  dyspnea  than  the  chloridemia, 
which  appears  to  act  rather  in  a  mechanical  manner  (through 
hydremic  plethora  and  edema  of  the  lungs). 

3.  Acetonemia. — As  is  well  known,  some  cases  of  dyspnea, 
in  which  indeed  the  prognosis  is  highly  unfavorable,  are  asso- 
ciated with  the  presence  of  acetone  in  the  urine  and  with  urinary 
hyperacidity  (see  Uranalysis),  This  is  the  case  in  the  dyspnea, 
sometimes  fatal,  witnessed  in  the  final  stages  of  some  cases  of  dia- 
betes.   The  precise  mode  of  production  of  this  kind  of  dyspnea  is 


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824  SYMPTOMS, 

still  being  widely  discussed.  One  need  here  merely  recall  that  such 
dyspnea  is  always  accompanied  by  acidosis,  which  is  expressed, 
among  other  manifestations,  in  urinary  hyperacidity,  and  by  cu:e- 
tonemia  (test  for  acetone),  and  that  it  is  met  with  chiefly  in  the 
terminal  stage  of  diabetes  (diabetic  coma). 

From  the  above  the  reader  will  have  gained  an  idea  of  the 
importance  of  chemical  studies  of  the  urine  and  blood  in  the 
presence  of  dyspnea  unattended  with  definite  cardiopulmonary 
pathology. 

As  possible  causes  of  dyscrasic  dyspnea  may  be  mentioned : 

1.  Some  forms  of  intoxication:  Asphyxiating  gases. 

2.  Certain  febrile  conditions, 

IV.— DYSPNEA  OF  NEUROPATHIC  ORIGIN. 

This  type  of  dyspnea  is  mainly  represented  by  hysterical 
polypnea,  which  can,  as  a  rule,  be  readily  differentiated  by  means 
of  the  following  features: 

1.  There  is  very  marked  polypnea,  the  rate  of  respiration  reach- 
ing or  exceeding  that  noted  in  the  final  stages  of  cardiopulmonary 
diseases. 

2.  It  occurs  in  the  absence  of  any  marked  or  even  appreciable 
lesion  of  the  heart  or  lungs;  cough  is  practically  absent  and 
expectoration  nil. 

3.  Such  polypnea  may  be  greatly  reduced  or  even  completely 
removed  by  distraction  of  the  patient's  attention,  as  by  an  in- 
teresting conversation ;  it  may  cease  while  the  patient  is  answer- 
ing questions ;  in  any  event,  it  is  never  continuous,  but  is  paroxys- 
mal, coming  on  in  distinct  attacks. 

4.  This  syndrome  is  present  in  conjunction  with  the  psycho- 
pathic state  characteristic  in  these  subjects,  evidenced  by  sug- 
gestibility, distortion  of  the  truth,  mythomania,  etc. 

5.  There  is  absence  of  the  other  signs  of  true  dyspnea:  No 
cyanosis,  little  or  no  acceleration  of  the  heart  rate,  no  reduction 
of  urinary  output,  no  edema,  no  azotemia,  etc. 


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KDEMA.  lol^fM,  from  oiSelv^  to  swell] 


Edema  consists  of  a  serous  infiltration  of  the  subcutaneous 
cellular  tissues  or  of  visceral  tissues,  as  in  edema  of  the  meninges 
— involving-  the  pia  mater, — of  the  lungs,  etc.  The  ordinary 
edema  of  the  subcutaneous  cellular  tissues  will  here  alone  be 
considered.  Its  characteristic  feature  is  the  lasting*  depression 
in  the  edematous  region  made  by  any  form  of  pressure  (depres- 
sion from  pressure  with  the  finger,  grooves  from  folds  of  the 
clothing  or  pillow,  depression  with  central  groove  upon  pinch- 
ing, depression  en  masse  by  lying  on  an  edematous  region,  etc.). 

While  sometimes  obvious  where  the  swelling  has  caused  a 
marked  change  in  the  shape  of  an  affected  part,  careful  exami- 
nation is  frequently  necessary  for  the  detection  of  edema:  In 
the  lower  extremity  it  appears  more  particularly  in  anterior 
pretibial  tissues,  in  the  region  of  the  malleoli,  and  on  the  pos- 
terointernal aspect  of  the  thigh.  In  some  subjects  the  lower 
lids  constitute  a  seat  of  election,  exhibiting  a  characteristic 
prominence.  In  patients  confined  to  bed  one  should  not  forget 
to  examine  the  sacral  region  and  the  posterointernal  aspect  of 
the  thighs.  In  persons  who  still  leave  their  beds  and  walk 
about,  it  often  appears  only  after  they  have  been  standing  for 
a  more  or  less  prolonged  period,  so  that,  while  absent  in  the 
morning,  it  reaches  its  maximal  degree  in  the  evening  before 
retiring.  At  the  very  beginning  it  may  sometimes  be  elicited 
only  by  noting  an  unusual  sensitiveness  of  the  cellular  tissue  to 
palpation,  constituting  a  species  of  pre-edematous  hyperesthesia. 

In  established  edema,  the  skin  is,  as  a  rule,  tense,  shining,  and 
pale  (white  edema  of  kidney  cases)  ;  in  heart  cases,  with  impaired 
heart  action  and  hyposphyxia,  the  skin  may  assume  a  livid,  purplish 
tint  (blue  edema  of  heart  cases)  ;  in  inflammatory  edema,  as  in 
suppurative  lesions  and  lymphangitis,  the  color  ranges  from  pink 
to  red  (red  edema  of  infection) ;  in  hard,  chronic  edema  the  color 

(825) 


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826  SYMPTOMS, 

may  become  darker,  a  bronze  shade  appear,  and  pigmentation  of 
the  skin  occur  {bronzed  edema  of -chronic  cc^es). 

The  usual  consistency  of  edematous  tissues  is  soft ;  the  finger 
sinks  into  them  as  though  into  butter ;  if  the  illness  is  prolonged, 
and  the  edema  becomes  chronic,  the  cellular  tissue  undergoes 
sclerosis  and  the  condition  becomes  a  hard  edema.  This  is  the 
case,  in  particular,  in  the  chronic  edema  of  cases  of  varicose  veins, 
of  lymphangitis,  of  myxedema,  and  of  elephantiasis. 


The  cause  of  edema  is  often  plainly  apparent,  the  case  being 
either  one  of  heart  disease,  with  cyanosis,  dyspnea,  oliguria,  an 
overburdened  disordered  heart,  and  arhythmia;  or  one  of  chronic 
nephritis,  with  pallid  skin,  gallop  rhythm,  and  more  or  less 
pronounced  albuminuria;  or  one  of  malignant  disease  of  the 
stomach,  greatly  emaciated,  cachectic,  and  with  the  lower  ex- 
tremities enormously  swollen;  or  one  of  puerperal  phlebitis, 
with  fever,  leucorrhea,  etc. 

Sometimes,  and  even  frequently,  more  than  a  single  cursory 
examination  is  required.  While  an  experienced  clinician  will 
almost  always  be  able  to  get  right  to  the  point  by  virtue  of 
practical  knowledge  previously  acquired,  a  less  experienced 
practitioner  would  do  well  to  carry  out  the  following  funda- 
mental steps  in  the  process  of  diagnostic  analysis: 

Edema  may  be  due  to  either  a  local  or  a  general  cause. 

The  local  causes  of  edema  should  be  examined  for: 
(a)  Skin  and  cellular  tissues. — Infections  and  toxic  infections 
of  these  tissues, — Furuncle,  carbuncle,  lymphangitis,  abscesses,  and 
erysipelas  are  always  accompanied  by  local  edema.  Are  not 
the  three  cardinal  signs  of  infection,  known  since  the  early  his- 
torical ages,  swelling,  redness,  and  pain?  Mere  recollection  of 
the  fact  is  sufficient.  Allied  to  these  conditions  are  certain  dis- 
orders, rare  in  the  Western  countries,  involving  the  lymphatic 
tissues  (pressure  or  obliteration,  of  bacterial  or  parasitic,  e,g., 
filarial,  origin)  and  causing  edema  of  the  type  of  elephantiasis. 
Certain  poisonous  bites,  mosquito  or  snake  bites,  etc. — ^pro- 
duce a  similar  effect. 


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EDEMA,  827 

Axrute  eczema  may  be  attended  with  edema. 

For  the  sake  of  completeness  the  post-traumatic  form  of 
edema,  particularly  following  fractures,  may  be  referred  to. 

(b)  Veins. — Phlebitis,  whether  primary  or  secondary,  and 
whether  infectious  (as  is  the  rule)  or  dyscrasic  (as  is  much 
less  common)  or  neoplastic  (as  is  much  rarer  still),  is  nearly 
always  attended  with  edema  confined  to  the  affected  limb.  It 
is  seldom  wanting,  even  during  the  pre-obliterative  stage. 

Pain  more  or  less  limited  to  the  course  of  a  vein,  sometimes 
the  feeling  of  the  vein  as  a  characteristic  cord,  the  observation  of 
more  or  less  extensive  edema,  the  knowledge  of  some  previous 
infectious  disorder  (puerperal  infection,  typhoid  fever,  rheumatic 
fever,  etc.)  or  of  a  gouty  tendency  or  a  tuberculous  or  neoplastic 
affection  causing  cachexia  (phlegmasia  alba  dolens)  are  the  very 
features  required  for  a  diagnosis  of  phlebitis. 

General  cau8e8.-^The  above  causes  being,  as  will  have  been 
noticed,  easy  to  exclude,  the  various  possible  general  causes 
remain  to  be  considered. 

In  the  presence  of  a  definite,  manifest  edema,  one  should  think 
mainly  of  the  three  commonest  causes,  viz.,  cardiac,  renal,  and  hemic 
(dyscrasic),  and  secondarily,  the  former  having  been  excluded,  of 
the  three  exceptional  causes,  viz.,  hepatic,  nervous,  and  dystrophic. 

I.  Cardiac  edema. — ^This  is  a  characteristic  feature  of  cardiac 
insufficiency  or  hyposystoly.  The  diagnosis  is  obvious  in  the  stage 
of  asystoly  or  complete  decompensation:  Marked  edema,  constant 
dyspnea,  tachy-arhythmia,  oliguria,  edema  of  the  bases  of  the  lungs, 
passivq  congestion  of  the  liver,  cardiac  dilatation,  and  frequently, 
the  observation  of  a  definite  heart  lesion. 

At  the  outset  of  heart  disease  one  should  look  carefully  for 
the  minor  evidences  of  impaired  heart  action,  viz.,  dyspnea  on 
exertion,  nycturia,  orthostatic  oliguria,  vesperal  edema  of  the  lower 
extremities,  and  persistent  pulse  acceleration  after  exertion  (see 
Functional  tests  of  the  circulation). 

In  these  cases  water  retention  and  chloride  retention  are 
often  closely  parallel. 

II.  Renal  edema. — ^This  is  perhaps  the  most  frequently  en- 
countered of  all  the  varieties  of  edema;  often  it  is  present  in 
association  with  the  preceding  variety. 


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828  SYMPTOMS, 

Here  again,  the  diagnosis  is  sometimes  obvious,  as  in  acute 
nephritis  where  it  develops  suddenly,  accompanied  by  fever,  pro- 
nounced albuminuria,  and  even  hematuria,  and  in  long-standing, 
established  chronic  nephritis. 

In  early  cases  a  special  examination  for  it  is  frequently  neces- 
sary, edema  being  looked  for  in  the  lids,  the  cheeks  (as  shown 
by  map-like  formations  on  the  face,  found  in  the  morning  and 
due  to  pressure  by  folds  of  the  pillow),  and  the  malleoli.  Its 
appearance  is  generally  preceded  by  a  stage  of  pre-edema,  or  better, 
of  internal,  invisible  edema,  demonstrated  by  periodic  weighing 
of  the  patient  and  by  determination  of  the  chlorides,  which  will 
indicate  in  a  parallel  and  synchronous  manner  any  increase  of  weight 
and  retention  of  chlorides. 

In  all  instances  the  physician  should  carry  out  a  systematic, 
complete  investigation  of  the  renal  functions  (see  Examination  of 
the  urinary  system),  including  examination  for  albumin  and  casts, 
and  determination  of  the  amount  and  rhythm  of  urinary  excretion, 
the  systolic  and  diastolic  blood-pressure,  elimination  through  the 
kidneys,  chlorides  in  the  urine,  and  blood  urea.  Such  an  investi- 
gation is  particularly  necessary  in  the  course  and  during  the  after- 
math of  infectious  diseases,  especially  scarlet  fever. 

Renal  edema  is,  as  is  well-known,  related  mainly  to  retention 
of  the  chlorides. 

III.  Hemic  or  dyscrasic  edema. — This  form,  the  mode  of 
production  of  which  is  as  yet  quite  uncertain,  is  the  one  met  with 
in  anemias  of  the  pernicious  type  and  particularly  in  the  final  stage 
of  cachectic  disorders  (tuberculosis  and  malignant  growths). 
Whether  it  be  true  or  fiction,  it  is  related  that  Trousseau,  who 
had  been  suffering*  for  a  long  time  from  digestive  disturbances 
resulting  in  loss  of  strength  and  pain,  declared  to  Dieulafoy, 
his  pupil,  that  he  was  afflicted  with  a  growth  of  the  stomach 
and  forecast  an  early,  unfavorable  termination  because  of  the 
presence  of  edema  of  the  lower  limbs  which  could  not  be  ac- 
counted for  by  the  condition  of  the  heart  or  kidneys.  His  diag- 
nosis and  prognosis  unfortunately  proved  to  have  been  well 
founded.  In  old  subjects  one  should  always  look  with  suspicion 
upon  such  insidious  edemas  that  cannot  be  shown  to  be  either 
of  cardiac  or  renal  origin. 


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EDEMA,  829 

Much  less  commonly,  one  of  the  following  types  of  edema 
may  be  encountered: 

1.  Edema  of  hepatic  origin,  nearly  always  of  mechanical  caus- 
ation, vis.,  pressure  upon  the  inferior  vena  cava  in  advanced  cir- 
rhosis of  the  liver.  Gilbert  has,  furthermore,  described  a  preascitic 
edema  met  with  early  in  the  course  of  hepatic  cirrhosis. 

The  supposedly  established  theory  of  an  hepatic  form  of  edema 
was  seriously  discredited  by  a  few  clinicians.  In  1893  Hanot  wrote : 
"Changes  in  the  liver  cells  account  for  the  cases  of  localized 
edema  either  about  the  malleoli  or  in  the  face  in  the  absence 
of  albuminuria.  There  exists  an  hepatic  form  of  edema  just  as 
there  is  a  renal  edema  and  the  former  may  be  an  early  sign  of 
disease."  Le  Damany,  in  a  later  contribution  on  the  subject  {"Les 
hepatites  hydro pigenes,"  1914),  concluded  that  there  may  be  a 
defective  elaboration  of  protein  material  in  the  liver,  by  virtue 
of  which,  such  material  being  retained  in  the  tissues,  it  may 
secondarily  induce  retention  of  water  and  chlorides.  Certain 
puzzling  clinical  combinations,  e.g.,  pronounced  edema  with  but 
little  ascites,  preascitic  edema,  and  extreme  ascites  without 
edema,  occur,  indeed,  which  argue  against  the  purely  mechanical 
causation  of  edema  of  hepatic  origin. 

2.  Edema  of  nervous  origin. — Edema  may  be  witnessed  in 
the  presence  of  peripheral  neuritis,  of  spinal  affections  such  as 
tabes  and  syringomyelia,  of  hemiplegia,  of  epilepsy,  of  paralysis 
agitans,  and  of  exophthalmic  goiter.  Generally,  however,  if 
one  carefully  eliminates  the  edemas  of  cardiorenal  origin  which 
may  occur  in  the  presence  of  these  disorders,  one  finds  that,  as 
a  rule,  the  condition  present  is  merely  a  dystrophic  pseudo- 
edema  in  which  the  characteristic  sign  of  pitting  on  pressure 
cannot  be  elicited. 

3.  Dystrophic  edema. — This  is  the  so-called  "trophedema"  of 
Henry  Meige:  "The  term  trophedema,  without  further  qualification, 
may  be  applied  generally  to  the  dystrophic  edemas  of  as  yet  un- 
known cause,  but  seemingly  of  nervous  origin. 

"Chronic  trophedema  is  characterized  by  a  white,  firm,  pain- 
less edema  affecting  one  or  more  segments  of  one  or  several 
limbs  and  persisting  throughout  life  without  notable  prejudice 
to  the  health  of  the  individual.    Sometimes  the  condition  occurs 


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830  SYMPTOMS, 

singly.    In  other  instances  it  is  an  inherited  and  family  disorder. 
It  may  also  be  congenital. 

"One  may  describe  as  acute  trophedema  the  so-called  neuro- 
pathic, circumscribed,  angioneurotic,  neurovascular,  and  inter- 
mittent edemas,  etc. — transitory  edematous  involvements  some- 
times accompanied  by  thermic  manifestations,  by  disturbances 
of  sensation,  by  pain,  by  changed  color  of  the  skin,  and  fre- 
quently also  by  trophic  skin  disturbances,  eruptions,  or  ulcera- 
tions. This  group  of  conditions  make  up  what  is  known  as 
Quincke's  disease."  (Henry  Meige). 

Special  Localized  Edema. — Lastly,  certain  local  forms  of 
edema  require  mention,  znc,  edema  of  the  lower  extremities,  edema 
of  the  upper  extremities,  and  edema  of  the  face  and  lids. 

(a)  PulHn^ss  of  the  face  and  lids. 

1.  Puffiness  of  the  face  and  slight  edema  of  the  eyelids  are 
normal  conditions  upon  awakening  in  some  individuals.  This  is 
due  to  an  unusual  relaxed,  flaccid  state  of  the  tissues  in  these 
persons.  Such  a  quasi-normal  edema  is  seen  most  frequently 
in  women  and  obese  subjects. 

2.  Puffiness  of  the  face  is  a  well-known  feature  upon  awakening 
after  alcoholic  sprees. 

3.  It  is  likewise  of  frequent  occurrence  in  pregnancy,  and  seems 
to  be  one  of  the  component  features  of  the  facies  of  pregnancy.  As 
in  the  preceding  forms,  however,  it  is  well  none  the  less  to  test 
the  urine  for  albumin. 

4.  It  is  met  with  in  eczema,  erysipelas,  and  sunburn, 

5.  BlepharO'Conjunctivitis  is  also  attended  with  puffiness  of  the 
eyelids. 

6.  Edema  of  the  surrounding  tissues  in  dental  abscess  is  char- 
acteristic. 

7.  Furuncles  in  the  nostrils  frequently  induce  a  marked  edema 
of  the  infrapalpebral  or  even  the  palpebral  portions  of  the  face. 

8.  Tumors  of  the  neck  and  mediastinum — aortic  aneurysm, 
posterior  forms  of  pericarditis,  Hodgkin's  disease,  Ludwig's  angina, 
and  much  more  exceptionally,  thrombosis  of  the  superior  vena  cava, 
cause  edema  of  the  face  and  neck,  sometimes  very  widespread, 
extending  at  times  to  the  upper  portion  of  the  thorax  and  to 


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EDEMA,  831 

the  root  of  the  upper  extremities.    Of  all  these  causes,  aortic 
aneurysm  and  pericarditis  are  the  commonest 

9.  The  doughy  facies  of  myxedema  should  likewise  be  borne 
in  mind. 

10.  Certain  druff  intoxications  (iodine,  bromine,  antipyrin)  in- 
duce congestion  of  the  mucous  membranes  with  facial  edema. 

11.  Finally,  mention  may  be  made  of  angioneurotic  edema  or 
Quincke's  disease,  characterized  by  the  sudden  appearance  of 
edema  of  the  extremities,  accompanied  by  edema  of  the  mucous 
membranes.  Often  this  condition  is  restricted  to  the  lids  (idio- 
pathic edema  of  the  lids). 

(b)  Edema  of  the  upper  extremities. — ^This   is  met  with: 

1.  In  septic  disorders  involving  the  upper  extremities  and  the 
axilla. 

2.  In  phlebitis,  much  less  commonly,  however,  than  iu  the  lower 
limbs. 

3.  In  gout,  likewise  much  less  commonly  than  in  the  lower  limbs. 

4.  In  cervical  and  mediastinal  pressure: 

(a)   Lymphatic  enlargements,  cervical  and  mediastinal, 
(fr)  Malignant  growths  of  the  breast  and  mediastinum, 
(c)  Aortic  aneurysm, 
(rf)  Hodgkin's  disease  (mediastinal  lymphoblastema). 

5.  In  malignant  metastases  in  the  mediastinum  or  axilla. 
It  should  be  noted  that : 

1.  Renal  edema  is  rare  in  the  upper  extremities,  and  is  seen 
only  in  a  late  stage,  in  the  period  of  anasarca. 

2.  The  same  is  true  of  edema  of  cardiac  origin,  which  is  only 
exceptionally  observed  in  recumbent  subjects  who  have  been  lying 
on  one  of  their  arms,  causing  venous  obstruction  and  hindrance  to 
the  return  circulation.  It  should  be  carefully  remembered  that 
cardiac  edema  is  a  dependent  or  ^'gravity"  edema. 

(c)  Ekiema  of  the  lower  extremities. — In  contrast  with  the 
assertions  made  above  concerning  the  upper  extremities,  the  fol- 
lowing kinds  of  edema  nearly  always  appear  first  in  the  lower 
limbs : 

1.  Edema  of  cardiac  origin. 

2.  Edema  of  renal  origin. 


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832  SYMPTOMS. 

As  in  the  case  of  the  upper  extremities,  edema  is  here  met 
with  in  the  presence  of: 

1.  Septic  affections  of  the  lower  extremities,  and  particularly 
of  the  feet. 

2.  Phlebitis,  relatively  common  in  this  region,  particularly  as 
puerperal  phlebitis,  phlegmasia  alba  dolens,  post-operative  phle- 
bitis, etc. 

Much  commoner  still  is  varicose  edema,  due  to  phlebosclerosis, 
almost  always  absent  on  arising  from  recumbency,  but  reaching 
its  height  before  retiring,  after  having  been  in  the  vertical  posture 
all  day. 

3.  Gout,  the  seat  of  election  of  which,  as  is  well  known,  is  in  the 
great  toe. 

4.  Abdomino-pelvic  pressure: 

{a)  Utero-ovarian  tumors  and  cysts  (cysts,  fibromas,  malignant 
or  inflammatory  swellings). 

(fr)   Rectovesical  malignant  growths. 

(c)  Primary  or  secondary  enlargements  of  pelvic  and  abdominal 
lymphatics. 

(rf)  Various  abdominal  tumors  and  cysts  (hydatid  cysts,  various 
new  growths). 

5.  Malignant  metastases. 

6.  Lastly,  the  lower  limbs  are  the  seat  of  election  of  the  so- 
called  ''cachectic"  edemas,  of  varying  and  complex  causation. 

The  pathogenesis  of  edema  and  its  significance  in  pathologic 
physiology  have  been  the  subject  of  very  many  investigations  in 
the  course  of  the  last  ten  or  fifteen  years.  To  present  an  outline 
of  this  subject,  however  important  it  is  and  tempting  the  occasion, 
does  not  come  within  the  scope  of  this  work.  The  reader  desirous 
of  obtaining  an  idea  of  some  of  the  later  studies  on  the  causation 
of  edema  is  referred  to  current  medical  periodicals. 


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EMOASTRIC  PAIN.  [*^'  X; CI&aT^] 


The  pit  of  the  stomach  or  epigastrium,  a  region  bounded 
above  by  the  xiphoid  appendix  and  the  lower  costal  margins, 

lb. 

Diaphragm. 

m. 

5. 
Xiphoid 
append. 
Lesser 
curvature. 

Liver. 

Pleura. 

Gall-bladder. 

Pylorus. 

Liver.  !oloii. 

colon. 
Ascend,  colcm.  *' 


Cecum. 


Sigmoid  flex. 


Fig.  612. — General  topographic  anatomy  of  the  abdomen   (Poirier). 

and  below  by  a  line  passing  midway  between  the  umbilicus  and 
the  xiphoid,  overlies,  from  before  backward,  the  anterior  aspect 
of  the  liver,  the  anterior  surface,  upper  border,  and  posterior 
surface  of  the  stomach,  the  pancreas,  the  celiac  axis,  and  the 

53  (833) 


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834 


SYMPTOMS. 


solar  plexus;  still  farther  posteriorly  is  the  lesser  peritoneal 
cavity,  and  lastly,  the  aorta,  which  can  often  be  seen  or  felt 
pulsating  in  the  epigastrium  in  thin  individuals  with  atonic 
musculatures. 

Pain  is  frequently  referred  to  the  epigastrium,  either  as  a 


Diaphragi 

Live 
Oastrohepadc  li 

Stomac 


Traniver 
mesocolo 


Tranrverae  colo 


Spigelian  lobe. 

Pancreas. 

Spinal  column. 
Duodenum. 


Great  omentui 


Mesentery. 


Small   intestine 
its  mesentei 


Bladd4 
Symphysis  pub 


Rectum. 

Seminal   vesicle. 
Prostate. 


Tunica  vaginal 
TesUe 

Fig.  613. — Sagittal  section  of  the  abdomen. 

dull,  heavy  sensation,  especially  after  meals  as  in  many  dyspep- 
tics— or  as  an  acute  and  almost  lancinating  or  even  a  piercing 
pain,  coming  on  a  few  hours  after  or  independently  of  the  meals, 
as  in  gastric  ulcer,  the  gastralgic  form  of  calculous  attacks,  or 
the  gastric  crises  of  tabes — or  brought  on  exclusively  by  pres- 
sure or  percussion,  as  in  many  instances  of  congestion  of  the 
liver  or  gastric  neuroses  (hyperesthesia  of  the  solar  plexus). 


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EPIGASTRIC  PAIN.  835 

Epigastric  pain  is  generally  an  expression  of  some  gastro- 
hepatic  disorder,  such  as  gastrohepatic  congestion,  hyperchlor- 
hydria  and  its  attendant  manifestations,  gastric  neurosis,  ulcer 
or  cancer  of  the  stomach,  or  cholelithiasis  of  the  gastralgic 
type. 

Much  more  exceptionally  it  is  an  expression  of  disease  of 
some  adjoining  organ,  e,g,,  pancreatitis,  pericarditis,  or  abdom- 
inal aneurysm,  or  of  disease  of  some  remote  structure,  e.g., 
appendicitis. 

Among  the  possible  causes  mention  should  also  be  made  of 
tabes  dorsalis,  with  its  frequently  dramatic  attacks  of  pain  in 


Fig.  614. — A,  Surface   projection  of   involved  area  in  appendicitis;  P, 
of  involved  area  in  pancreatitis ;  V,  of  involved  area  in  cholecystitis. 

the  epigastrium  (gastric  crises),  the  pathogenesis  of  which  is 
still  rather  obscure,  and  to  which  the  term  abdominal  angina 
has  been  applied. 

Hepatic  Syndromes. — The  pain  of  active  or  passive  congestion 
of  the  liver  is  generally  latent,  being  elicited  only  by  palpation  or 
percussion.  It. is  most  constant  in  the  epigastrium  in  these  cases. 
From  the  semeiologic  standpoint,  it  is  equivalent  to  congestive  ten- 
derness of  the  liver.  Whenever  it  is  met  with,  further  investigation 
to  ascertain  its  origin  is  indicated. 

1.  Disorders  of  the  biliary  passages— cholelithiasis  (hepatic  colic, 
sensitiveness  of  the  gall-bladder,  jaundice,  and  the  evidences  of 
hype  rchlorhyd  ria  ) . 


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836  SYMPTOMS. 

2.  Disorders  of  the  liver— <iyspeptic  congestion  due  to  excessive 
intake  of  alcoholic  beverages  and  meats,  precirrhotic  hyperemia, 
abscesses,  infectious  jaundice,  syphilis,  or  malaria. 

3.  Disorders  of  the  heart  in  particular,  passive  congestion  of 
the  liver  with  tenderness  being  one  of  the  most  patent  and  con- 
stant signs  of  cardiac  insufficiency  (reduced  function  or  actual 
heart  failure). 

Gastric  Syndromes. — Pain  thus  caused  exhibits  very  different 
features  in  two  practically  opposite  conditions  affecting  the  stomach, 
zfis.,  the  syndrome  of  hyperchlorhydria,  and  gastric  neurosis  with 
ptosis  and  gastrointestinal  atony.  Indeed,  the  combinations  of 
gastric  symptoms  are  so  protean  that  almost  anything  may  occur, 
even  an  apparent  coexistence  of  the  two  syndromes  referred  to. 

Little  space  need  be  devoted  to  the  well-known  "hyperchlorhy- 
dric  syndrome" — pain  oh  gastric  evacuation,  "hunger  pain" — the 
main  feature  of  which  is  a  combination  of  tardy  stomach  pains, 
sometimes  quite  severe  and  of  the  "burning,"  boring  type,  coming 
on  periodically  several  hours  after  meals,  and  generally  allayed  by 
alkalies  or  bland  foods,  and  a  more  or  less  pronounced  hyperchlor- 
hydria or  even  sometimes  a  gastroduodenal  ulcer. 

The  pain  in  these  cases  had  formerly  been  ascribed  to  irritation 
of  the  sensory  nerves  of  the  stomach,  when  exposed  by  an  ulcer, 
by  the  unduly  acid  gastric  contents.  As  with  any  other  careful 
clinical  observation,  the  observed  fact  remains  unimpeachable,  and 
its  interpretation  alone  has  been  subject  to  revision.  The  finding 
of  the  symptoms  of  "hyperchlorhydria"  in  persons  with  normal 
gastric  acidity,  physiological  experimentation,  and  x-ray  observa- 
tions tend  to  show  that  gastric  hypertonicity,  pylorospasm,  and 
exaggerated  peristaltic  movements  play  an  important,  if  not  pre- 
dominant, role  in  the  causation  of  this  pain.  That  the  oncoming 
of  the  pain  is  delayed  is  because  it  appears  particularly  during  the 
period  of  evacuation  of  the  stomach,  consentaneously  with  especially 
forcible  contractions  of  the  pylorus.  There  is  thus  likewise  ex- 
plained the  observation  of  the  syndrome  referred  to  in  many  chronic 
disorders  of  the  intestine  and  biliary  passages  causing  excessive 
peristalsis  in  these  structures.  Examination  of  the  very  large  ag- 
gregate of  clinical  and  experimental  data  available  leads,  at  any  rate, 
to  the  conclusion  that  hypertonicity  of  the  stomach  and  intestines 


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EPIGASTRIC  PAIN.  837 

and  gastric  hyperacidity,  generally  in  combination,  are  the  fnain 
factors  of  the  syndrome  of  hyperchlorhydria. 

These  "theoretic"  considerations  have  here  been  referred  to  at 
some  length  because  they  afford  important  therapeutic  indications: 
Excessive  peristalsis  indicates  administration  of  belladonna,  and 
hyperacidity,  of  alkalies — ^both  often  remarkably  efficient  measures. 

These  considerations  are  completely  applicable  to  the  diagnosis 
and  treatment  of  gastric  ulcer.  The  s)rmptoms  of  hyperchlor- 
hydria,  x-ray  examination,  and  systematic  testing  of  the  stools  for 
blood  after  the  institution  of  a  special  diet  are  the  main  factors 
leading  to  a  diagnosis,  an  obvious,  outward  demonstration  of  which 
may,  however,  in  some  cases  be  supplied  in  the  form  of  actual  hema- 
temesis.  In  addition  to  the  remedial  measures  already  mentioned 
a  protective  "dressing"  of  bismuth  in  the  stomach  should  be  applied 
in  these  cases. 

As  for  gastric  neurosis  with  gastroptosis  (dilatation  of  the 
stomach),  gastrointestinal  atony,  frequently  hyperacidity,  in  short, 
hyposthemc  dyspepsia,  the  pain  manifestations  attending  it  are  far 
different.  These  are  dull  pains  coming  on  immediately  after  inges- 
tion of  food,  with  marked  hyperesthesia  of  the  solar  plexus  (per- 
manent induced  epigastralgia),  sensations  of  weight  or  puffing, 
various  local  discomforts,  vasomotor  disturbances,  etc. — ^all  super- 
imposed upon  an  asthenic  and  neuro-  and  psychopathic  make-up 
which  is  frequently  characteristic.  It  should  be  borne  in  mind, 
however,  that  occasionally,  accidentally  the  pains  may,  in  a  few 
of  these  cases,  assume  the  type  met  with  in  the  "syndrome  of  hy- 
perchlorhydria ;"  one  of  the  surprises  sometimes  encountered  in 
fluoroscopy  is  the  observation  of  such  a  ptotic  and  habitually  atonic 
stomach  contracting  with  very  great  vigor,  at  the  time  of  evacuation. 
Observations  of  this  sort  are,  in  this  connection  at  least,  in  favor 
of  the  hyperperistaltic  theory  of  the  causation  of  pain  in  these 
cases,  the  pain  thus  representing  an  actual  "colic  of  the  stomach.*' 

The  pain  in  cancer  of  the  stomach  is  of  very  variable  descrip- 
tion, being  sometimes  almost  nil,  and  only  slightly  elicited  by  palpa- 
tion; at  other  times,  a  dull  pain,  with  sensations  of  weight  in  the 
epigastrium  and  distention  in  the  same  r^on;  more  rarely  it  pre- 
sents the  delayed  and  "boringf'  attributes  of  the  ulcer  upon  which 
the  cancer  has  been  superimposed  (degenerated  ulcer).    Thus,  in 


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838  SYMPTOMS, 

these  cases  study  of  the  pain  may  be  misleading.  The  diagnosis 
should  be  based  especially  on  the  finding  of  blood  in  the  feces  (on 
a  meat-free  diet),  the  frequently  pathognomonic  results  of  fluoro- 
scopic examination,  the  age  of  the  patient,  the  degree  of  impair- 
ment of  ntttrition,  and  later  on,  the  direct  detection  of  a  gastric 
tumor  (see  Dyspepsia), 

Cholelithiasis  is  frequently  attended,  as  already  pointed  out, 
with  the  syndrome  of  hyperchlorhydria,  and  differentiation  from 
duodenal  ulcer  and  hypersthenic  dyspepsia  is  frequently  a  dif- 
ficult task.  A  positive  diagnosis  in  some  instances  may  be 
reached  only  by  careful  examination  for  gall-bladder  signs,  such 
as  gall-bladder  pain  and  tenderness,  radiation  of  the  pain  to  the 
right  shoulder,  slight  or*  distinct  jaundice,  definite  attacks  of 
hepatic  colic,  and  a  history  of  former  infections  (typhoid  fever, 
etc.). 

All  of  the  preceding  conditions  giving  rise  to  epigastralgia 
are  very  common.  The  following  are  much  less  common,  or  in- 
deed, strictly  speaking,  are  exceptional : 

The  epigastralgia  of  pericarditis  presents  absolutely  no  dis- 
tinctive feature ;  it  is  a  dull,  or  even  latent,  pain,  readily  awakened 
by  pressure.  When  one  has  had  the  opportunity  to  see  and 
follow  up  cases  of  "already  diagnosticated"  pericarditis,  the  pain 
will  regularly  be  thought  of ;  in  the  opposite  event,  it  will  always 
be  overlooked.  Dyspnea,  cardiac  acceleration,  and  sometimes 
precordial  pain  will  attract  the  observer's  attention.  Systematic 
examination  of  the  case,  including  fluoroscopy,  will  afford  a 
positive  diagnosis. 

The  epigastric  pain  of  pancreatic  origin  is  met  with  under 
two  quite  different  clinical  conditions: 

1.  In  the  chronic  form. — This  is  often  the  pancreaftco- 
biliary  syndrome  of  Dieulafoy  (former  gallstone  disease,  obstruc- 
tive jaundice,  loss  of  weight,  pain,  and  sometimes  a  pancreatic  mass 
in  the  right  intercostoumbilical  region).  Yet,  as  Dieulafoy  so  cor- 
rectly said,  "even  supposing  that  the  maximum  of  pain  is  observed 
at  the  pancreatic  point,  that  is,  a  point  4  or  5  centimeters  to  the 
right  of,  above,  and  laterally  from  the  umbilicus  (pancreaticochole- 
dochian  region),  it  is  not  always  easy  to  find  out  whether  the  pain 
is  to  be  attributed  to  pancreatitis  or  to  stones  in  the  bile-duct" 


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EPIGASTRIC  PAIN,  839 

Doubt  may  persist  even  after  operation.  Twenty-five  years  ago 
the  author  had  under  observation,  with  the  late  Dr.  Guinard,  a  case 
of  chronic  obstructive  jaundice  with  marked  loss  of  weight  in  a 
patient  manifestly  suffering  from  gall-stones;  the  operation  showed 
a  large  stone  blocking  the  bile-duct,  which  was  removed,  and  also 
a  scirrhous  growth  of  the  head  of  the  pancreas.  De  visu,  the  diag- 
nosis of  cancer  of  the  head  of  the  pancreas  was  decided  upon  and 
the  prognosis  corresponding  to  this  condition  issued.  The  patient 
not  only  recovered,  but  **bloomed  out"  again,  and  lived  fifteen  years 
longer.  The  condition  present  was  an  interstitial  pancreatitis  second- 
ary to  calculus  in  the  bile-duct — s,  condition  of  which  little  or 
nothing  was  known  at  the  time,  and  which  Dieulafo/s  work  was 
instnxmental  in  bringing  to  general  notice. 

2.  Hyperacute  epigastric  pain,  7vith  pancreatic operitoneal 
hemorrhage. — ^Dieulafoy's  account  of  the  "pancreatic  tragedy' 
should  be  read  over  in  this  connection.  "Terrific  and  generally  fatal 
symptoms  suddenly  develop  at  a  time  when  little  apprehension  ex- 
isted and  in  persons  not  exhibiting  jaundice  at  the  time.  The 
patient  is  seized  with  violent  pain  in  the  umbilical  region,  in  the 
epigastrium,  and  in  the  hypochondriac  regions.  The  highly  distress- 
ing and  excruciating  pain  is  accompanied  by  vomiting,  prostration, 
and  a  tendency  to  syncope;  there  is  general  abdominal  hyperes- 
thesia, constipation  is  absolute,  and  there  is  not  the  least  passage 
of  gas.  In  the  presence  of  such  a  condition  one  thinks  of  an  acute 
peritonitis,  an  attack  of  poisoning  of  some  sort,  or  perforation  of 
the  stomach,  duodenum,  or  gall-bladder ;  one  thinks  of  appendicitis, 
or  of  intestinal  obstniction,  but  none  of  these  conditions  exist,  and 
I  have  applied  to  the  attack  the  term  'pancreatic  tragedy'  in  order 
to  establish  a  clear  distinction  between  it  and  all  other  conditions 
that  may  resemble  it.  At  the  operation  or  the  autopsy,  indeed, 
there  is  found,  not  a  peritonitis,  not  a  perforation  of  some  organ, 
not  an  appendicitis,  not  an  intestinal  obstruction,  but  the  major 
pathologic  witnesses  of  the  tragedy,  vis,,  the  white  foci  (candle- 
grease  spots)  of  fat  necrosis,  with  which  are  frequently  associated 
pancreaticoperitoneal  hemorrhages — lesions  consecutive  to  an  at- 
tack of  c^ute  pancreatitis,  nearly  always  superimposed,  in  turn, 
upon  a  chronic  pancreatitis."  The  diagnosis,  rarely  correctly  made, 
is  based,  on  the  whole,  upon  the  history  of  pancreaticobiliary  trouble, 


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840 


SYMPTOMS. 


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EPIGASTRIC  PAIN, 


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842  SYMPTOMS, 

the  **tragic"  syndrome  above  described,  and  particularly  upon 
actual  inspection  of  the  lesions  found  upon  laparotomy,  which  is 
indicated  whatever  condition  may  be  thought  present. 

Aneurysm  of  the  abdominal  aorta  may  be  suspected — at  least 
at  first — only  in  the  presence  of  the  following  combination  of 
clinical  indications:  Pain  in  the  epigastrium  and  diffuse,  deep- 
seated  pulsations  in  the  same  region.  Careful  fluoroscopic  ex- 
amination with  the  patient  in  an  oblique  position  can  alone  afford 
a  positive  diagnosis. 

Appendicitis,  whether  acute  or  chronic,  may  be  attended  with 
epigastric  pain  and  even  nausea  and  vomiting — epiphenomena  of  a 
syndrome  of  peritonitis  or  "peritonism"  or  hyperperistalsis,  the  fre- 
quency of  which  has  already  been  referred  to.  Only  very  excep- 
tionally, however,  will  careful  clinical  examination  not  reveal  the 
right  iliac  fossa  as  the  probable  source  of  the  disturbance.  For 
the  required  further  discussion  of  these  cases  the  reader  is  referred 
to  the  section  on  Vomiting. 

Concerning  gastralgia  in  tabes  the  same  may  be  said  as  of 
epigastralgia  in  pericarditis,  vis.,  whoever  has  seen  and  followed 
one  such  case  will  always  have  the  condition  in  mind^  while 
whoever  has  not  will  never  think  of  it.  The  onset  is  generally 
sudden,  with  extremely  severe  pain  in  all  respects  suggesting 
that  of  gastric  ulcer  or  of  hepatic  colic ;  with  unusual  obstinacy, 
so  that  even  morphine  brings  only  partial  relief ;  with  vomiting, 
often  uncontrollable ;  the  duration  of  pain  a  few  hours  to  a  few 
days,  and  the  cessation  of  pain  sudden  like  the  onset  These 
features  will  put  the  well-posted  observer  on  the  right  track. 
Furthermore,  systematic  examination  of  the  patient  (which 
should  never  be  omitted)  will  often  discover  a  number  of  char- 
acteristic evidences,  vis.,  a  history  of  syphilitic  symptoms,  loss 
of  knee-jerks,  Argyll-Robertson  pupil,  impaired  equilibration, 
ataxia,  etc.  The  attacks  are  often  exactly  similar  as  to  onset, 
course,  and  duration,  and  the  patient,  having  in  mind  an  earlier 
diagnosis  of  his  case,  may  even  supply  the  diagnosis  himself. 


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EPISTAXIS.  1^        Naaalhemorrhage.        J 


Epistaxis  may  be  defined  as  a  hemorrhage  in  the  nasal  cavities. 

This  symptom,   when   present,   is   obvious,   and   cannot  be 

mistaken  for  any  other  unless,  in  posterior  epi^t^is — which, 


Fig.  615. — ^The  artery  of  epistaxis.  Terminal  distribution  of  the 
sphenopalatine  artery.  Upon  raising  the  tip  of  the  nose  with  the  fore- 
finger and  inserting  a  speculum,  the  observer  will  notice  in  many  per- 
sons, at  the  lower  anterior  portion  of  the  septum,  a  small  group  of 
diverging  arterial  branches.  If  ulceration  occurs  at  this  point — usually 
on  account  of  insertion  of  the  finger — copious  hemorrhage  from  one 
of  these  vessels  will  occur.  This  is  the  source  of  the  majority  of  • 
cases  of  epistaxis  {Laurens), 

however,  is  uncommon — the  blood,  unwittingly  swallowed,  is 
later  discharged  by  vomiting  (suggesting  hematemesis)  or 
passes  out  with  the  stools  (suggesting  melena).  The  mere 
recollection  of  the  possibility  of  these  altogether  exceptional 
mistakes  is  sufficient  completely  to  guard  against  their  occur- 
rence; in  the  event  of  doubt,  rhinoscopic  examination,  advan- 
tageous in  any  case,  and  often  essential,  will  settle  the  question. 
There  are  many  possible  causes  of  epistaxis, 

(843) 


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844  SYMPTOMS. 

Locally,  epistaxis  may  be  of  traumatic  (blow  on  the  nose)  or 
operative  origin  (the  latter  following,  for  example,  removal  of  one 
of  the  turbinates,  etc.)  ;  further  reference  to  these  obvious  causes 
would  be  superfluous.  In  90  per  cent,  of  cases,  according  to  G. 
Laurens,  epistaxis  is  due  to  a  localized,  varicose  erosion  of  the 
anterior  inferior  portion  of  the  nasal  septum.  This  is  a  clinical 
feature  to  be  carefully  remembered,  since  all  local  treatment  (caut- 
ery, packing,  pressure,  etc.)   is  necessarily  based  on  it. 

General  causes  of  epistaxis  may  be  divided  into  2  groups, 
vis,,  the  mechanical  or  circulatory  and  the  dyscrasic  or  hemic. 
Like  all  other  attempts  at  a  simple,  easily  remembered  classi- 
fication, this  division  is  in  some  respects  questionable,  most 
causes  of  epistaxis  acting  in  a  *'mixed"  manner,  i,e,,  both  mechan- 
ically (through  low  blood-pressure  and  reduced  resistance  of 
the  vascular  walls)  and  dyscrasically  (through  hydremia,  low- 
ered viscosity,  disturbances  of  coagulation  of  the  blood,  etc.),  as  in 
chronic  nephritis  or  arteriosclerosis.  The  division  above  made  is 
merely  of  didactic  value — which  is  the  essential  point  herein. 

The  mechanical  causes  comprise  all  factors  resulting  in  con- 
gestion of  the  nasal  mucosa,  which  is  an  exceedingly  vascular 
and  erectile  tissue. 

(a)  Passive,  venous  congestion  of  the  nasal  mucosa,  due  to 
increased  venous  blood  pressure  in  the  superior  vena  cava.  Un- 
der this  heading  belong  mitral  and  tricuspid  lesions  with  loss 
of  compensation,  heart  failure  in  general,  and  pressure  upon  the 
veins  of  the  neck  or  mediastinum;  these  are,  on  the  whole, 
relatively  uncommon  causes  of  epistaxis,  which  are  readily  de- 
tected by  virtue  of  the  accompanying  cyanosis,  turgescence  of 
the  veins,  dyspnea,  frequent  and  irregular  heart  action,  and  even 
a  cursory  examination  of  the  chest. 

(&)  Active,  arterial  h)rpcrcmia  of  the  nasal  mucosa,  due  to 
high  blood-pressure,  is  by  far  the  most  frequent  cause  of  epistaxis. 
All  disorders  attended  with  high  blood-pressure,  including 
plethora,  gout,  and  in  a  greater  degree,  arteriosclerosis,  aortic  insuffi- 
ciency, and  Bright's  disease  are,  par  excellence,  conditions  favoring 
epistaxis  of  the  recurrent  type  and  sometimes  of  alarming  extent. 
In  the  same  group  are,  the  epistaxis  of  vicarious  menstruation,  those 
of  hemorrhoids  and  of  the  menopause,  and  in  some  degree,  that 


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EPISTAXIS,  845 

of  puberty,  Epistaxis  is  the  most  frequent  type  of  hemorrhage  wit- 
nessed in  these  conditions  of  high  pressure  with  hemorrhagic  tend- 
encies, apparently  because,  most  fortunately,  the  vessels  of  the  nasal 
mucous  membrane  constitute  a  vascular  locus  minoris  resistentiae 
or  actual  safety-valve  affording,  in  the  presence  of  dangerously  high 
blood-pressure,  a  "providential  bleeding"'  and  a  warning  often  of 
marked  service  when  its  significance  is  duly  appreciated  by  the 
physician  and  patient  It  may,  however,  in  a  given  person  occur 
in  alternation  with  most  varied  types  of  hemorrhage,  as  in  an  arterio- 
sclerotic patient  with  high  blood-pressure,  under  the  author's  ob- 
servation for  over  ten  years,  who  developed  every  spring  either 
epistaxis,  hemoptysis,  or  hemorrhoidal  bleeding  and  was  finally 
rendered  hemiplegic  by  cerebral  hemorrhage.  In  all  these  cases  sys- 
tematic blood-pressure  estimations  will  supply  the  diagnosis  as  well 
as  the  prognosis,  and  bring  out  the  various  indications  as  to  treat- 
ment Systematic  uranalysis,  determination  of  the  blood  viscosity, 
and  also,  of  course,  general  clinical  examination,  are  essential  in 
all  instances. 

The  dyscrasic  causes  or  blood  changes,  such  as  lowered  coag- 
ulability, hydremia,  etc.,  very  frequently  co-operate  with  the  pre- 
ceding causes  in  the  production  of  the  severe  forms  of  epistaxis. 

As  is  well-known,  certain  blood  disorders,  including  anemias 
and  leukemias,  frequently  tend  toward  hemorrhage  production. 
Cell  counts,  hemoglobin  estimations,  and  the  differential  leucocytic 
count  are  the  main  diagnostic  factors  in  these  cases. 

Other  disorders,  vis,,  the  purpuras  and  hemophilic  conditions 
are  as  yet  only  rather  imperfectly  defined  from  the  hematologic 
standpoint.  Marked  delay  in  coagulation  is  always  noted.  These 
states  are  frequently  related  to  more  or  less  obvious  deficiencies  of 
the  hepatic,  renal,  and  polyglandular  functions.  Indeed,  clinically, 
the  concept  of  inherited  deficiency  and  the  frequent,  identical  repe- 
tition of  the  hemorrhagic  manifestations  will  compel  the  practi- 
tioner to  make  a  provisional  diagnosis  of  this  nature — since  these 
are  clinical  cases  of  a  complex  and  probably  dissimilar  nature. 

Ever  since  remote  ages  there  have  been  noted  cases  of  epistaxis 
symptomatic  of  z^arious  liver  conditions.  As  a  matter  of  fact  this 
form  of  epistaxis  is  of  very  variable  origin: 

1.  Dyscrasic  infectious  epistaxis  in  infectious  "grave"  icterus. 


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846 


SYMPTOMS, 


2.  Dyscrasic  non-infectious  epistaxis  of  hepatic  secretory  insuffi- 
ciency. 

3.  Dyscrasic  and  mechanical  epistaxis  in  cirrhosis,  particularly 
of  the  atrophic  variety. 

4.  Mechanical  epistaxis  in  congestion  of  the  liver — either  passive 
congestion,  as  in  increased  venous  pressure  in  the  liver  and  cirrhosis 
of  cardiac  origin,  or  active  hyperemia,  as  in  the  increased  arterial 
blood-pressure  of  plethoric  or  gouty  enlargement  of  the  liver,  etc. 

Infections. — Lastly,  many  infections  are  either  especially  and 
primarily  producers  of  hemorrhage,  or  may  occur  in  a  hemorrhagic 
form.    This  applies  particularly  to: 

1.  Typhoid  fever, — Epistaxis  is,  as  is  well-known,  frequently 
a  preliminary  symptom  in  typhoid.  In  the  hemorrhagic  form,  epis- 
taxis may  go  hand  in  hand  with  hemorrhage  from  the  bowel. 

2.  Eruptive  fevers,  particularly  measles,  chicken-pox,  varioloid, 
and  scarlet  fever. 

3.  "Rheumatism"  and  "infectious  pseudo-rheumatism"  in  some 
of  their  "purpuric"  forms. 

EPISTAXIS. 


1.  Traumatism  . . 

2.  Operation  — 

3.  Inflammation 


(a)  Passive  venous 
congestion. 


(b)  Active  hyptt- 
emia  (far  more 
common). 


(c)  Dyscrasias. 


Local  Causes. 

(Obvious). 
(Obvious). 

(Erosion  of  the  anterior  inferior  portion  of  the 
septum;  rhinoscopic  examination). 

General  Causes. 

1.  Heart  disease  with  loss  of  compensation,  im- 
paired heart  action  (cyanosis,  auscultatory 
evidences,  and  often  low  blood-pressure). 

2.  Pressure  in  the  region  of  the  superior  vena 
cava,  as  by  a  tumor  of  the  neck  or  medias- 
tinum (cyanosis,  sometimes  edema,  collateral 
circulation,  and  signs  of  tumor). 

1.  All  disorders  attended  with  hipjh  blood- 
pressure:  Plethora,  gout,  arteriosclerosis, 
B right's  disease. 

2.  Certain  physiologic  states:  Menopause  and 
puberty. 

3.  Vicarious  menstruation  or  hemorrhoidal 
flux. 

1.  Anemias,  leukemias,  purpura,  and  hemo- 
philic states. 

2.  Liver  disturbances:  Infectious  jaundice,  cir- 
rhosis, or  hepatic  congestion. 

3.  Infections  promoting  hemorrhage:  Typhoid 
fever,  the  eruptive  fevers,  infectious  rheuma- 
tism, etc. 


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EXANTHEMATA. 


if 6>,  out  of;  ivdog^  flower;  i^dvOefia^ 

from  i^dvdetVy  to  bloom.     A  skin 

eruption. 


Skin  eruptions  are  of  such  frequent  occurrence  that  it  has 
seemed  absolutely  necessary  to  devote  a  semeiologic  section  to 
a  brief  presentation  of  the  various  types  of  eruption.  These 
various  types,  however,  by  virtue  of  their  actual  frequency  and 
number,  do  not  lend  themselves  well  to  condensation  into  a 
short,  yet  comprehensive  article.  After  prolonged  hesitation  the 
author  decided  to  employ  the  following  plan : 

1.  To  give  a  didactic  account  of  certain  elementary  facts  in 
dermatology,  based  on  the  writings  of  an  authority  on  the  sub- 
j  ect — Sabouraud. 

2.  To  recall,  in  a  short  synopsis,  the  main  clinical  features 
of  the  great  chronic  infectious  skin  disorder  of  temperate 
climates,  vis.,  syphilis. 

3.  To  recall,  in  condensed,  tabular  form,  the  more  essential  facts 
concerning  the  eruptive  fevers. 

4.  To  request  the  reader  to  refer  to  special  works  on  derma- 
tology for  further  details. 

L  ELEMENTARY  AND  ESSENTIAL  FACTS  IN 
DERMATOLOGY. 

(After  Sabouraud)*. 

There  are  some  eruptive  diseases  that  involve  the  entire  surface 
of  the  body  or  the  greater  portion  of  it.  Such  are  the  exanthematic 
{eruptive)  fevers. 

On  the  other  hand,  there  are  skin  disorders  which,  without  ever 
extending  to  involve  the  entire  cutaneous  surface,  have  no  definite 
seat  of  election  and  may  be  noted  in  any  portion  of  the  body.  Such 
are  the  epitheliomas. 


*  See  Sabouraud's  Dermatologie  topographique,  p.  581. 

(847) 


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848 


SYMPTOMS. 
EXANTHEMATA. 


Primary  Charactkb- 

Dermatolooic 

o  ■•  K  V I  n  L.na  T 

ISTIC    FEATDRB. 

Appellation. 

DCiHBIVwvU  X. 

1.  Some  skin  disorders 

Simple  squam- 

Ichthyosis  (congenital). 

are   characterized 

ous    skin   af- 

Desquamation in  febrile  states 

solely  by  dry  scales 

fections. 

and  eruptive  fevers  (scarlet 

and  exfoliation  of  the 

fever). 
Pityriasis  in  various  forms: 

homy   layer,   without 

redness  or  oozing  of 
fluid. 

—  simplex. 

—  (tinea)  versicolor  (mycotic). 

—  rosea  of  Gibert. 

—  rubra  pilaris. 

Dry  eczema. 

Psoriasis. 

2.  Flat  elevations,  with 

Urticarial  af- 

Nettle  rash. 

itching,    exactly    re- 

fections. 

Dermographism  (vasomotor 

sembling  nettle  rash. 

neurosis). 

Toxic  urticarias. 

Food  poisoning. 

Drug  poisoning. 

Idiopathic    urticarias    of    un- 
known cause. 

3.  Parasitic  lesions,  les- 

Parasitic skin 

See  Pruritus. 

ions  due  to  scratching, 

affections. 

Scabies.     Pediculosis.     Fleas. 

attended  with  itching 

Bedbugs.    Mosquitoes. 

and    easily    confused 

with  prurigo. 

4.  Papules,  widi  itching, 

Papular  and 

Papular  syphilides. 

smaH   dry,  elevated, 

lichenoid  skin 

Lichen  planus. 

flat,    discrete,    circu- 

affections. 

Papulonecrotic  tuberculides. 

lar,  tablet-like  lesions 

Prurigo  (with 

Prurigo  in  various  forms: 

or  lesions  grouped  in 

itching,  pap- 

symptomatic; 

thick,    cross-lined 

ules  and  Uch- 

senile; 

patches. 

enification). 

diathetic,  and 

regional  or  circumscribed. 

5.  Vesicles,  small,  clear 

Vesicular  and 

Eczema  (initial  eczematous  ves- 

collections   of    fluid 

exudative  skin 

icle,    patch    of    eczema,    with 

slightly    raising    the 

affections. 

itching,   oozing,   crust    forma- 

superficial epidermis; 
like  "small  pearls" 

tion,  desiccation,  and  licheni- 

fication). 

embedded  in  the  epi- 

Miliaria sudoralis. 

dermal  layer.    When 

Chicken-pox. 

broken,    the    vesicles 

Vesicular  urticaria. 

discharge  fluid. 

Diffuse  impetigo. 
Pemphigus  foliaceus. 

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EXANTHEMATA. 
EXANTHEMATA  (conHnued). 


849 


Pbimabt  character- 

Dermatologic 

Semeioloot. 

istic  FBATUBE. 

Appellation. 

6.    Pustules,   or   puru- 

Pustular and 

Staphylococcic  pustules. 

lent   vesicles.     Rup- 

ulcerative 

Furuncle.     Carbuncle. 

tured     pustules     be- 

skin affec- 

Acne pustules. 

come   more   or   less 

tions. 

Phlyctenosis  strcptogenes. 

superficial  ulcera- 

Ecthyma. 

tions. 

Small-pox.     Varioloid.     Chic- 
ken-pox. 

Bullous  and 

Urticaria  bullosa. 

icles,    "balloon-like" 

pemphigoid 

Erythema  multiforme  bullosa. 

and  constituting  the 

eruptions. 

Bullous  drug  eruptions. 

so-called  pemphigoid 

Acute  infectious  pemphigus. 
Various  forms  of  pemphigus 

eruptions. 

(vegetating,  foliaceous, 

traumatic,  or  hysterical). 

Painful,  multiform  dermatitis 

(Duhring,  Brocq). 

8.  Purpura,  consisting 

Purpura  and 

Hemophilia. 

of  blood  macules. 

purpuric 

Rheumatic    purpura    (peliosis 

ecchymotic  spots,  or 

eruptions. 

rheumatica). 

extravasations     into 

Werlhoff's  disease. 

the  skin  which  pres- 

Acute febrile  purpura. 

sure  with  the  finger 

Cachectic  purpura. 

cannot  dissipate. 

Toxic  purpura. 

Purpuric  eruptions  in  eruptive 
fevers  (exanthemata  with  pur- 
pura). 

9.  Erjrthematous  mac- 

Measles and 

Measles. 

ules,  hyperemic  spots. 

rubeoliform 

Rubella. 

temporarily  dissipated 

eruptions. 

Febrile  roseolae  (typhoid 

by  pressure  with  the 

fever,    small-pox,    puerperal 

finger. 

fever,  etc.). 
Syphilitic  roseolae. 
Drug  roseolae. 
Roseola  due  to  serum  disease. 

10.  Diffuse  erythema, 

Scaxiet  fever 

Scarlet  fever. 

,     scarlet  red,  more  or 

and  scarla- 

Scarlatinoid rash  in  small-pox. 

less  extensively  dis- 

tinoid erup- 

Recurrent   exfoliative    scarla- 

tributed. 

tions. 

tinoid  erythema. 
Toxic  scarlatinoid  erythemas. 
Mercurial  rash. 

11.  Erythrodermias  con- 

Enrsipelas and 

Febrile  erysipelas. 

sisting  mainly  of  ery- 

erythroder- 

Exfoliative  erythrodermias. 

thematous  lesions 

1.  Generalized,  afebrile,  and 

with  edematous  infil- 

primary. 

tration  of  the  dermal 

2.  Secondary  (traumatic. 

layer. 

mercurial,  and  arsenical 
eruptions). 

54 


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850 


SYMPTOMS, 
EXANTHEMATA  (continued). 


PRIMARY    CHARACTBR. 
I8TIC    PBATURB. 

DERMATOLOOIC 

Appellation. 

Sbmeioloqt. 

12.  Dyschromia,  melan- 
odermia,  vitiligo, 
scleroderma,  and 
morphea. 

Dyschromia. 
Sderodermm. 

Symptomatic  dyschromias,  as 
in  albinism,  pigmented  nevi, 
lentigo,  ephelides*,  xero- 
derma pigmentosum,  and 
neurofibromatosis. 

Nervous  dyschromias,  as  in 
Addison's  disease,  tubercu- 
lous melanodermia,  pig- 
mented syphilis,  leprous  dis- 
colorations,  and  vitiligo. 

Hematic  dyschromias,  as  in 
lymphadenosis,  leukemias, 
mycosis  fungoides,  malarial 
cachexia,  and  bronzed  dia- 
betes. 

Toxic  dyschromias,  as  in  pois- 
oning by  arsenic,  antipyrin, 
silver,  or  lead. 

Dyschromias  of  local  causa- 
tion, as  by  heat,  counter- 
irritation,  or  pediculosis. 

Scleroderma. 

13.  Tumors  of  the  skin; 
cutaneous  neo- 
plasms. 

Skin  tumors. 

Retention  cysts  and  the  like 
benign  tumors:  Milium,  se- 
baceous cysts,  wens,  hygro- 
mas, etc. 

Small,  transmissible  benign 
tumors:  Molluscum  contag- 
iosum,  warts,  and  papillomas. 

Parasitic    tumors :      Blastomy- 
cosis, bothriomycosis,  and 
keloids. 

Circumscribed  congenital  skin 
deformities    or    nevi:     Pig- 
mented nevi,  vascular  nevi, 
and   verrucose   or   fibroma- 
tous  lymphangiomas. 

Dermatomyomas. 

Dermoid  cysts. 

Fibroraas.                                     ^ 

Lipomas. 

Xanthomas. 

Sarcomas. 

Mycosis  fungoides,  cutaneous 
lymphadenosis;  papillary  or 
pearl-like  epitheliomas,  rod- 
ent ulcer,  etc. 

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EXANTHEMATA.  851 

Again,  there  are  some  which  have  elective  locaHzations,  yet 
spread  over  the  entire  body  surface  and  therefore  require  a  gen- 
eral description.    Such  is  scabies. 

These  disorders  are  in  themselves  very  many,  and  necessitate 
a  classification  for  the  practitioner.  Such  a  classification  should 
be  planned  on  lines  sufficiently  simple  so  that  the  physician  will  be 
able,  without  any  previous  dermatologic  study,  to  ascertain  easily 
the  dermatologic  type  to  which  any  disorder  under  observation 
belongs. 

Condensed  in  the  tables  presented  on  the  succeeding  pages 
will  be  found: 

The  main  symptomatic  features  and  course  of  syphilis. 

The  main  symptomatic  features  and  course  of  the  eruptive 
fevers. 

4c      4t      ♦ 

The  following  statistical  matter,  collected  by  Halperin  at 
Camp  Lee,  Petersburg,  Va.,  gives  a  good  idea  of  the  ^proxi- 
mate and  respective  frequency  of  the  various  skin  disorders  in 
young  recruits  upon  their  arrival  in  camp.  Among  8000  sub- 
jects examined  during  the  week  following  their  incorporation 
Halperin  found: 

Skin  Conditions  in  8000  Recruits. 

Syphilis  (open  lesions)   125                    Brought  forward 443 

Tinea  versicolor  109      Sebaceous  cysts   3 

Pustular  acne 75      Ringworm   3 

Psoriasis   40      Erythrasma    2 

Scabies    20      Herpes  zoster   2 

Seborrheic   eczema    18      Varicose  ulcers   2 

Chronic  eczema 16      Purpura  2 

Folliculitis   11      Pediculosis  pubis   3 

Alopecia  areata  8      Pediculosis  Corporis   1 

Ichthyosis    8      Parapsoriasis  1 

Urticaria 5      Lupus  vulgaris   1 

Erythema  multiforme  4      Acne  rosacea  1 . 

Lipoma  4      Keloid  acne 1 

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Again,  the  war  resulted  in  a  renaissance  of  artificial  or  simu- 
lated eruptions.  Such  eruptions  may  be  of  an  eczematoid  aspect, 
or  pustular,  or  pemphigoid,  or  may  suggest  mucous  patches, 
sloughs,  etc. 


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Explanation  of  the  Annexed  Plate. 
Tjrpical  Manifestations  of  Ssrphilb  in  its  Several  Stages. 

1.  A  primary  chancre  of  the  vulva,  fully  developed.  The  appearance  is 
quite  characteristic.  If  it  be  further  recollected  that  the  chancre  is  indurated 
and  accompanied  by  multiple,  painless,  inguinal  glandular  enlargement,  with 
the  central  node  particularly  enlarged,  an  accurate  mental  conception  of  the 
ordinary  syphilitic  chancre  and  its  accompaniments  will  be  had.  (Photo  by 
Dr.  Ravaut). 

2.  A  florid  roseola  of  the  "peach-bloom"  variety,  distinguished  from  the 
non-specific  "roseolai^*  eruptions  only  by  the  history  of  a  chancre  and  the 
subsequent  secondary  manifestations  on  the  skin  and  mucous  membranes, 
together  with  the  Wassermann  reaction,  which  is  always  positive  in  this 
stage.     (Photo  by  Dr.  Ravaut). 

3.  Hypertrophied  mucous  patches  of  the  vulva,  which,  when  so  typical 
as  those  presented,  could  hardly  be  confounded  with  any  other  condition 
involving  the  genitals.  One  should  get  accustomed  to  looking  for  smaller 
and  more  discrete  patches  than  these.    (Photo  by  Dr.  Brocq). 

4.  Ulcerated  syphilomas  of  the  nose,  which  increasingly  accurate  diagnosis 
and  energetic  treatment  are  rendering  daily  more  uncommon.  Note  the  regu- 
lar, "cyclic"  appearance  of  the  ulcers,  with  their  indurated  margins  and 
necrotic  bases;  these  lesions  are  attended  with  surprisingly  little  pain.  The 
most  striking  advantage  of  arsphenamine  and  mixed  (iodide  and  mercury) 
treatments  is  that  they  will  heal  and  "dissipate"  such  ulcers  as  these  within 
a  few  days.     (Photo  by  Dr.  Brocq). 

The  author's  thanks  are  due  to  Drs.  P.  Teissier,  Brocq,  and  Ravaut,  who 
kindly  consented  to  select  from  among  their  valuable  collections  some  excel- 
lent autochrome  reproductions  of  skin  conditions,  thus  enabling  him  to  place 
before  his  readers  a  few  of  the  types  of  cutaneous  disturbance  most  com- 
monly met  with. 


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EXANTHEMATA.  853 

The  diagnosis  in  these  cases  of  malingering  is  always  diffi- 
cult, the  patient  obstinately  refusing  to  confess  his  own  re- 
sponsibility in  the  matter.  As  in  other  forms  of  malingering,  the 
suspicious  appearance  of  the  patient,  the  unusual  sort  of  erup- 
tion, the  lack  of  harmony  between  different  symptoms  and  signs,, 
the  durajtion  of  the  disease  and  its  unaccountable  recurrence,  in 
short,  the  incoordinate  or,  on  the  other  hand,  repeatedly  co- 
ordinate course  of  the  disorder  will  eventually  lead  to  a  pre- 
sumption and  probable  diagnosis  of  the  condition. 


On  succeeding  pages  will  be  found  a  few  chromo-typographic 
typical  illustrations  of  the  chief  infectious  eruptive  disorders. 
These  will  assist  in  making  one  familiar  with  the  characteristic 
eruptions  of  rubella,  measles,  chicken-pox,  small-pox,  and  scarlet 
fever,  and  ipso  facto  with  the  typical  features  of  vesicular  (chicken- 
pox),  morbilliform  (rubella  and  measles),  scarlatinoid  (scarlet 
fever),  and  pustular  (small-pox)  skin  disorders. 

GENERAL  REMARKS  CONCERNING  THE  DIAG- 
NOSIS OF  SYPHILIS. 

Syphilis,  tuberculosis,  and  alcoholism  are  unquestionably 
three  of  the  greatest  scourges  with  which  the  human  race  is 
compelled  to  contend.  No  more  imperative  task  devolves  upon 
the  practitioner  than  that  of  detecting  them  in  whatever  form 
they  may  appear. 

As  for  syphilis  in  particular,  such  endeavor  is  all  the  more 
necessary  in  that:  1.  The  earlier  the  diagnosis  is  made,  the 
greater  the  chances  of  radically  effective  treatment.  2.  We  are 
possessed  of  antisyphilitic  remedies  which  are  extremely  power- 
ful if  administered  early  and  with  due  energy  and  wisdom. 

The  succeeding  tables,  together  with  the  annexed  illustra- 
tions, will  give  a  general  idea  of  the  clinical  manifestations  of 
syphilis  and,  properly  comprehended  and  availed  of,  will  greatly 
facilitate  its  diagnosis.  Let  it  be  particularly  borne  in  mind  that 
the  skin  and  mucous  membrane  eruptions  of  syphilis  are  merely 
the  outward  manifestations  of  a  deep-seated  septicemia;  that 
the  entire  system  is  impregnated  with  the  syphilitic  virus,  and 


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854  SYMPTOMS. 

that  especially  the  cardiovascular  and  nervous  systems  are 
always,  or  nearly  always,  more  or  less  attacked  by  the  infection. 
Hence,  let  it  not  be  thought  that  a  syphilitic  has  been  cured 
simply  because  he  has  been  freed  of  all  manifestations  of  the 
disease  aflfecting  the  skin  and  mucous  membranes;  and  let  it 
not  be  asserted  that  an  individual  never  had  syphilis  before 
because  he  has  retained  no  obvious  stigmata  of  the  disease. 

The  diagnosis  of  syphilis,  to-day  as  in  the  past,  remains,  as 
was  happily  stated  by  Foumier,  one  of  a  series  of  morbid  states 
based  on  a  definite  diagnostic  triad,  ids.,  the  history,  the  existing 
signs  of  syphilis  (in  the  skin,  mucous  membranes,  and  internal 
organs),  and  a  practically  specific  serum  test  (the  Wassermann 
reaction).  This  statement  must  be  adhered  to  with  precision, 
judicious  consideration,  and  common  sense,  if  the  practitioner 
is  to  avoid  making  one  of  two  almost  equally  fearsome  mistakes, 
vis.,  either  of  overlooking  syphilitic  infection  which  is  still  a 
source  of  danger,  or  of  burdening  an  individual  free  of  syphilis 
with  an  obsessive  and  depressing  idea  that  he  is  syphilitic.  Few 
problems  in  diagnosis  bring  so  actively  into  play  the  moral 
responsibility  of  the  practitioner. 

The  three  classic  laws  relating  to  congenital  syphilis  may 
here  be  recalled: 

Law  of  Colics  (1837)  :  A  child  born  syphilitic  of  a  syphilitic 
father  generally  does  not  infect  the  mother  if  she  shows  no  signs 
of  the  disease,  and  she  may  nurse  it  without  risk.  To  this  we 
may  add,  with  Carle  (of  Lyons) :  But  she  should  be  placed  un- 
der treatment  at  once,  as  she  harbors  specific  infection. 

Law  of  Profeta  (1865) :  The  healthy  child  of  a  syphilitic 
mother  cannot  contract  syphilis  during  lactation  nor  through  any 
form  of  contact.  To  this  we  may  add,  with  Carle:  But  the 
child  should  be  kept  under  observation,  and  even  given  treatment 
if  indicated,  as  he  is  often  syphilitic  himself.  Most  cases  of  late 
inherited  syphilis  are  merely  exhibiting  delayed  symptoms  of  an 
unrecognized  congenital  syphilitic  infection. 

Law  of  conceptional  syphilis  (Diday;  Fournier) :  A  syphi- 
litic fetus  in  utero  may  infect  its  mother  through  the  placental 
vessels,  with  resulting  appearance  of  secondary  symptoms  in  the 
pregnant  mother  without  any  primary  stage. 


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Explanation  op  the  Adjoining  Plate. 
The  commoner  types  of  infectious  exanthemata. 

1.  Chicken-pox  (varicella),  the  type  of  the  vesicular  exanthemata. 

2.  Small-pox  (variola),  the  type  of  the  pustular  exanthemata,  illus- 
trating clearly  the  essential  eruptive  lesion  (the  pustule). 

3.  Scarlet  fever  (scarlatina),  the  type  of  the  scarlatinoid  exanthemata, 
affording  a  good  illustration  of  the  maximal  degree  of  eruption  at  the  natural 
skin  folds. 

4.  Rubella  (Grerman  measles),  a  rare,  seasonal,  epidemic,  contagious 
disorder  characterized  ''by  a  general  glandular  enlargement,  itching,  and 
a  rash"  (Sabouraud). 

5.  Measles  (rubeola),  the  type  of  the  "morbilliform"  rashes. 

6.  Florid  measles,  almost  purpuric  in  appearance,  constituting,  from 
the  eruptive  standpoint  alone,  a  manifest  transitional  form  between  the 
morbilliform  rash  (hyperemic)  and  the  purpuric  eruption  (hemorrhagic). 

The  author  is  indebted  to  Prof.  Pierre  Teissier  for  the  six  original 
pictures  comprised  in  this  plate. 


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[6^,  out  ofy  pectus,  chest;  expulsmi] 
of  ahnormal  secretions  from  the  J 
respiratory  tract 


Expectoration  is,  together  with  cough,  the  commonest  mani- 
festation of  affections  of  the  respiratory  tract.  While  sometimes 
devoid  of  any  great  diagnostic  importance,  under  certain  other  cir- 
cumstances it  assumes  an  exceedingly  characteristic  significance, 
as  in  hemoptysis,  putrid  sputum,  sputum  containing  false  membrane, 
etc.  It  may  even  be  practically  pathognomonic,  as  in  the  case  of 
"rusty  sputum." 

Macroscopic  examination  of  the  sputum  is  very  often  sufficient, 
when  taken  in  conjunction  with  the  other  clinical  evidences,  to 
indicate  the  correct  diagnosis. 

Microscopic,  cytologic  examination  yields  useful  information, 
but  is  seldom  indispensable. 

Microscopic,  bacteriologic  examination,  including  particularly  a 
search  for  the  tubercle  bacillus,  is,  on  the  other  hand,  ordinarily  a 
very  necessary  adjunct  to  the  clinical  examination  of  the  patient. 
Presence  of  the  tubercle  bacillus  in  the  sputum  is  an  indication  of 
an  already  advanced  tuberculous  infection  of  the  lung,  and  all  the 
physician's  endeavors  and  procedures  (stethoscopic,  fluoroscopic, 
hematic,  etc.)  should  aim  toward  the  making  of  a  much  earlier 
diagnosis.  None  the  less,  the  sputum  should  be  examined  for 
tubercle  bacilli  almost  routinely,  even  in  many  instances  of  ordinary 
acute  bronchitis,  and  in  all  cases  of  chronic  bronchitis. 

The  tables  hereinafter  presented  will  show  in  a  condensed  form 
the  various  possible  types  of  expectoration,  their  macroscopic  and 
microscopic  features,  and  their  semeiologic  value. 

Mention  should  be  made  of  a  very  simple  chemical  method  of 
examining  the  sputum  (the  albumin  test),  the  exact  semeiologic 
significance  of  which  has  not  as  yet  been  definitely  ascertained 
(see  page  196). 

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866  SYMPTOMS. 

Lastly,  reference  must  be  made  to  a  peculiar  affection  known 
as  Castellani's  hemorrhagic  bronchospirochetosis,  apparently  car- 
ried into  France  by  Asiatic  laborers  and  soldiers,  and  studied  anew 


Spiroch<£ta  hrofi" 
chialis. 

Red  corpuscle. 
Mononuclear  cell. 
Polymorphonu- 
clear leucocyte. 
Pharyngeal  cell. 
Lung  cell. 
Heart  cell. 

Various  micro- 
organisms. 

Fig.  626. — Smear  of  sputum  in  "hemorrhagic  bronchitis." 
Immers.  object.  Mb  Stiassnie,  ocul.  1.  Fresh  specimen  (yiolle), 

during  the  war  by  Violle,  Dalimier  and  others  (Presse  medicale, 
July  5,  1917;  July  18,  1918,  and  Mar.  10,  1919).     The  condition 


Fig.  627. — ^Various  forms  of  the  Spirochata  bronchialis, 

Immers.  object  %5  Stiassnie,  ocul.  L  Stained  by  the  Fontana- 

Tribondeau  method  {Violle) . 

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EXPECTORATION.  875 

soon  the  patient  begins  to  complain  of  slight  pain  in  the  tracheo- 
bronchial region,  is  seized  with  harsh,  annoying  cough — almost 
exclusively  at  night,  and  expectorates  a  certain  amount  of  mucus 
and  blood.  The  sputum  presents  a  characteristic  appearance,  being 
homogeneous,  rose-colored,  and  comparable  to  currant  jelly;  it  is 
copious  and  soon  becomes  mucopurulent  and  greenish.  After  a 
few  days'  intermission  a  fresh  exacerbation  occurs  with  elimination 
of  the  same  kind  of  sputum.  The  latter  contains  enormous  numbers 
of  the  Spiroch(£ta  bronchialis,  which  are  characteristically  variable 
in  their  morphologic  features.  This  germ  is  met  with  only  in  the 
discharge  from  the  lungs. 

Where  the  possibility  of  this  disorder  has  not  been  kept  in  mind 
and  bacteriologic  examination  of  the  sputum  has  been  omitted,  a 
mistaken  diagnosis  of  tuberculosis  is  almost  sure  to  be  made. 


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EYES,  DISORDERS  OF  THE. 

EXAMINATION  AND  SYMPTOMATOLOGY  OF 
THE  EYES. 

By  a.  Terson,  M.D. 

In  his  daily  practice  the  non-specialized  physician  will  neces- 
sarily be  compelled,  sooner  or  later,  to  see,  first  and  alone,  diseased 
eyes  and  cases  of  poor  vision. 

The  occasions  of  this  sort  vary.i 


Fig.  644. — Lid  elevator. 

Sometimes  it  is  an  emergency,  medical  or  surgical,  because  of 
traumatism,  relating  to  the  eye  or  the  rest  of  the  body  (with  secon- 
dary visual  disturbance),  or  because  of  a  rapidly  progressive  spon- 
taneous  disorder  (suppurative  conjunctivitis,  corneal  ulcer,  glau- 


Fig.  645.— Terson's  eye  speculum  (blepharostat). 

coma,  detachment  of  the  retina,  etc.),  which  compels  him  to  make 
a  provisional  diagnosis  and  institute  provisional  treatment — without 
postponing  too  long  a  special,  thorough  consultation,  at  which 
the  necessary  accurate  conclusions  may  be  reached. 

Occasionally    some   eye   complication   will   develop   in   the 
course  of  another  disease  which  is  already  under  treatment. 


1  For  further  details  the  reader  is  referred  to  Terson's  "Ophtalmologie 
du  medecin  praiicicn,"  2d  Ed.,  Masson  et  Cie.,  1921. 

(876) 


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EYES,  DISORDERS  OF  THE.  877 

Finally,  the  physician  will  often  be  called  upon  to  state  ''what  he 
thinks"  of  some  eye  condition  or  other  before  the  services  of  an 
ophthalmologist  are  sought 

It  will  therefore  not  be  without  utility  here  to  devote  a  few 
pages  to  describing  for  the  practitioner  a  line  of  conduct  to  be  fol- 
lowed by  him  when  confronted  with  a  manifest  lesion  of  the  eye 


Fig.  646. — Ophthalmoscopic  mirror. 

and  its  adnexa,  or  with  some  visual  disturbance  unattended  with 
any  apparent  lesion.  Furthermore,  examination  of  the  eyes  is 
sometimes  of  assistance  in  the  rendering  of  a  diagnosis  and  a 
prognosis  as  to  zision,  and  even  as  to  life,  in  the  presence  of  a 
general  disease. 

In  any  event,  after  the  first  visit,  or  even  after  a  mere  conver- 


Fig.  647.— Ophthalmoscopic  lens.  Fig.  648. — Disc  with  stenopeic 

opening. 

sation,  the  physician  must  be  able  to  judge  in  due  time  whether  he 
should  seek  the  help  of  a  specialist.  Putting  himself  in  the  patient's 
place,  he  will  have  to  make  up  his  mind  whether  he  can  conscien- 
tiously continue  to  treat  thd  patient  alone  in  a  satisfactory  manner, 
"A  good  physician,"  said  La  Bruyere,  "is  one  who  has  specific 
remedies,  or  who,  if  he  has  none,  allows  others  who  have  them  to 
treat  his  patient."     It  seems  doubtful  if  any  better  fundamental 


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878  SYMPTOMS. 

rule  of  professional  behavior  could  be  found,  even  in  text-books  on 
medicine. 

The  practitioner  will,  of  course,  undertake  only  a  brief,  ex- 
oscopic  examination,  covering  mainly  that  which  is  visible  to 
the  unaided  eye.  Examination  of  the  eye-grounds,  endoscopy  of 
the  countless  "hidden"  disorders  of  the  inner  membranes  of  the 
eye,  and  a  host  of  other  procedures  of  mensuration  and  func- 
tional determination  are  not  within  his  province  and  can  be 
learned  only  by  prolonged  training  in  the  living  human  subject. 
Among  the  elementary  instruments  in  the  following  list  are, 
however,  to  be  found  included  an  ophthalmoscope  and  its  lens, 


Fig.  649.— Electric  pocket-lamp  with  speculum* 

the  mirror  being  used  solely  to  obtain  pupillary  reflection, 
without  any  attempt  to  examine  the  posterior  segment  of  the 
eyeball. 

Minimum  Instrumental  Requirements. — ^Two  lid  elevators 
(Fig.  644) ;  one  blepharostat  (Fig.  645)  ;  a  simple  ophthalmo- 
scope, with  lens  (Figs.  646  and  647)  ;  a  decimal  test  chart  (Fig. 
650)  for  the  purpose  of  quickly  distinguishing  normal  from  de- 
fective vision;  three  concave  lenses  of  — 1,  — 2,  and  — 3  diopters, 
respectively;  three  convex  lenses,  of  +1,  +2,  and  +3  diopters, 
and  a  disc  with  central  stenopeic  opening  (Fig.  648)  (for  which 
a  visiting  card  with  a  hole  put  through  it  may  be  substituted). 

An  electric  pocket  lamp  is  always  serviceable.  When  com- 
bined (Fig.  649)  with  an  ear  speculum  (A.  Terson),  it  supplies 
a  sharp  beam  of  light  for  pupillary  examination.  It  may  also  be 
used  in  diaphanoscopy. 


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EYES,  DISORDERS  OF  THE. 


879 


Obviously,  it  would  be  advantageous  for  the  practitioner  to 
measure  the  field  of  vision  and  record  it  on.  special  sheets,  and  like- 
wise, to  probe  the  lacrymal  passages,  etc.  Much  experience  with 
these  procedures  is  required,  however,  if  they  are  to  yield  conclu- 
sive results  and  be  carried  out  without  serious  mishaps  (injections 
and  catheterization). 


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Fig.  650. — Armaignac's  test  chart,  with  a  special  chart  for  illiterates  and 
the  clock-dial  chart  for  the  detection  of  astigmatism. 

One  should  have  on  hand  ampoules  of  2  per  cent,  and  1  per 
cent,  solutions  of  cocaine  hydrochloride ;  of  1 :  1000  adrenalin  solu- 
tion ;  of  1  per  cent,  pilocarpine  nitrate  solution,  and  of  0.5  per  cent, 
atropine  sulphate  solution.  Such  ampoules,  which  do  not  deteriorate 
and  are  convenient  for  carrying  about,  are  frequently  just  as  use- 
ful for  diagnostic  purposes  as  for  the  prompt  institution  of 
treatment. 


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880  SYMPTOMS. 

I.  EXAMINATION  OF  THE  EYE  AND  ITS 
ADNEXA. 

Even  if  it  is  only  superficial,  an  ophthalmologic  examination 
should  be  carried  out  patiently  and  systematically  if  any  conclusion 
is  to  be  reached  from  it.  Examinationr  from  a  point  some  distance 
from  the  eye  is  insufficient.  Countless  foreign  bodies  in  the  con- 
junctiva and  even  on  the  cornea,  pupils  occluded  because  of  iritis, 
and  cases  of  chronic  glaucoma,  granulations,  dacryocystitis  (even 
purulent)  have  been  overlooked,  sometimes  for  months,  because  the 
examiner  failed  to  get  close  enough  to  the  eye,  used  neither  a  lens 
nor  a  lamp,  and  neglected  to  ez^ert  the  eyelids  and  to  make  a  direct' 
examination  of  the  eye  or  the  lacrymal  sac.  And  yet  innumerable 
eye  washes,  useless  or  actually  prejudicial,  have  been  prescribed 
during  these  wasted  periods. 

The  observer  must  see  the  tissues  properly  with  the  necessary 
lens  and  illumination ;  he  must  also  adopt  means  for  examining  by 
direct  contact  the  eyeball,  the  lids,  the  lacrymal  sac,  and  the  region 
of  the  orbit,  and  must  check  up  the  functions  of  both  eyes,  whether 
the  patient  is  seen  at  his  home  or  in  the  office.  Mere  impressions 
and  suppositions  are  not  sufficient;  the  physician  must  be  actually 
certain  of  anything  that  conditions  permit  him  to  be  certain  of. 

In  the  patient's  home,  he  should  have  with  him  the  few  articles 
already  mentioned  for  the  clinical  examination  (including  a  folding 
pocket  test  chart,  mounted  on  muslin).  Two  alternative  conditions 
may  present  themselves :  Either  the  patient  is  unable  to  get  out  of 
bed  or  he  is  able  to  sit  on  a  chair. 

If  the  patient  is  in  bed,  the  observer  should  try  to  have  him  sit 
up,  and  should  himself  sit  on  the  edge  of  the  bed  or  on  a  chair  drawn 
close  to  it.  If  the  patient  cannot  be  moved  at  all,  lateral  illumination 
of  the  eyes  can  always  be  obtained  by  having  some  one  hold  a  lamp 
for  the  purpose.  If  the  patient  is  sitting  in  a  chair,  opposite  the 
physician's,  he  should  be  examined  first  in  daylight  and  then  with 
artificial  illumination.  The  daylight  should  never  stream  directly 
into  the  patient's  eyes,  but  should  reach  them  from  the  side. 

In  the  physician's  office,  which  can  be  turned  into  a  dark  room 
at  the  appropriate  time  by  means  of  shades,  the  test  chart  should 
be  hung  at  a  distance  of  5  meters  from  the  chair  on  which  the  pa- 


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EYES,  DISORDERS  OF  THE,  881 

tient  sits,  with  his  back  turned  toward  the  light.  The  source  of 
artificial  light  may  be  a  common  lamp,  a  gas  burner  (not  an  incan- 
descent mantle),  or  a  frosted  electric  bulb.  Candle  light  is  gen- 
erally quite  inadequate. 

ELEMENTARY  OFFICE  EXAMINATION  OF  THE  EYE. 

PreUminary  Verbal  Examination. — After  having  rapidly 
made  note  of  the  general  deportment,  position  of  the  head 
(photophobia),  and  facies  of  the  patient,  the  physician  inquires 
of  him  or  of  his  associates  (if  an  infant  or  child)  what  caused 
them  to  seek  medical  advice — e.g.,  impairment  of  vision,  ocular 
or  periocular  pain,  annoying  secretions,  a  structural  defect,  etc. 

Care  should  be  taken  to  bri^g  out  how  long  the  morbid  con- 
dition of  one  or  of  both  eyes  has  been  present ;  what  the  patient 
is  still  capable  of  in  the  way  of  near  and  distant  vision ;  whether 
the  eyes  water  and  the  lids  are  stuck  together  in  the  morning  on 
awakening;  whether  the  pain  is  constant,  intermittent,  and  spon- 
taneous or  induced  by  certain  activities  or  labors ;  whether  the 
morbid  condition  began  suddenly,  rapidly  or  ran  a  slow  course ; 
whether  both  eyes  began  to  be  affected  at  the  same  time,,  and 
lastly,  whether  the  disorder  is  ascribed  to  some  definite  cause, 
local  or  general  and  old  or  recent. 

The  above  verbal  examination,  brief  but  concise,  should  be  fol- 
lowed by  the  local  examination,  which  is  concluded,  in  turn,  by  a 
supplementary  verbal  inquiry  dealing,  in  addition  to  any  points  that 
may  have  been  overlooked  or  suggested  by  the  local  examination 
itself,  with  the  present  and  past  medical  history  and  the  family 
history,  the  latter  extending  two  generations  back.  The  last  step 
consists,  where  indicated,  of  a  complete  examination  of  the  patient, 
including  a  review  of  his  general  health,  his  habits  as  regards 
hygiene,  and  his  mode  of  life  and'  occupation. 

Local  Examination. — The  physician  first  washes  his  hands 
thoroughly  with  soap — in  full  view  of  the  patient — and  then  be- 
gins with  the  direct  examination,  which  comprises,  as  in  the 
case  of  any  other  structure,  two  objective  procedures,  exoscopy 
and  endoscopy,  and  thereafter  a  third,  no  less  indispensable  pro- 
se 


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882  SYMPTOMS. 

cedure,  vis,,  examination  of  the  functions  of  the  eye  and  its 
adnexa. 

The  external  examination  (exoscopy)  should  be  made,  first  in 
daylight,  then  by  artificial  light.  For  the  specialist,  the  latter 
method  is  frequently  sufficient. 


Fig.  651. — Examining  a  child. 

The  older  children  and  adults  should  be  seated  in  front  of  the 
physician;  small  children  and  unruly  patients  in  general  should  be 
placed  with  the  head  low  and  the  extremities  held  by  other  per- 
sons  (Fig.  651). 


Fig.  652. — Bent  hairpin  which  may  be  substituted  for  the  lid 
elevator  in  an  emergency. 

In  examining  the  cornea  and  pupil — points  of  major  importance 
in  the  external  examination — no  direct  contact  with  the  eyelids  is 
required  in  docile  patients  and  where  the  eyes  give  little  or  no  pain. 
In  the  case  of  painful  and  watery  eyes,  the  lids  should  be  carefully 
dried  with  absorbent  cotton,  the  observer's  index  fingers  covered 
with  a  thin  layer  of  cotton,  and  these  fingers,  slightly  bent,  then  ap- 
plied at  the  ciliary  margin.  If  the  fingers  are  placed  farther  in, 
the  lids  come  together  and  prevent  inspection  of  the  cornea. 


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EYES,  DISORDERS  OF  THE. 


883 


In  cases  where  the  fingers  do  not  suffice,  lid  elevators  (Fig.  644) 
or  the  adjustable  blepharostat  (Fig.  645)  should  be  used.  A  hair 
pin  bent  over  at  the  curved  end  (Fig.  652)  may,  with  due  care,  be 
availed  of  where  no  other  instrument  is  at  hand. 

In  rare  instances,  instillation  of  a  1  per  cent,  solution  of  cocaine 
hydrochloride  (stronger  solutions  are  useless  except  under  certain 
special  conditions)  five  minutes  before  the  examination  is  required. 
The  specialist  also  uses  adrenalin  under  certain  definite  circum- 
stances. The  examination  of  the  eye,  one  region  after  the  other,  is 
then  promptly  proceeded  with. 

Eyelids. — The  size  and  shape  of  the  palpebral  fissures  of  the 
two  sides  should  be  compared,  the  patient  opening  and  closing  the 


Fig.    653. — Inspection    of    the    inner      Fig.   654. — Seizure    and   eversion   of 
surface  of  the  lower  lid.  the  upper  lid  (1st  step). 

eyes.  Altered  direction  of  the  lashes  should  be  looked  for  with  a 
hand  lens. 

The  lids  are  palpated  for  nodular  masses,  which  may  or  may 
not  be  tender. 

The  lids  should  be  everted  in  any  disorder  causing  pain.  The 
lower  lid  is  merely  pulled  well  down,  the  patient  being  meanwhile 
asked  to  look  strongly  upward  (Fig.  653). 

Turning  the  upper  lid  requires  more  dexterity.  It  must  be 
turned  without  causing  pain  and  ivithout  exerting  pressure  on  the 
eye. 

It  is  absolutely  essential  that  the  patient  should  look  down. 
He  should  be  instructed  to  look  at  his  knees.  The  lashes  are  next 
seized  between  the  thumb  and  forefinger  of  the  left  hand  (Fig.  654)  ; 
the  tip  of  the  forefinger  of  the  right  hand  then  tilts  back  the  tarsus 
and  holds  the  lid  in  the  everted  position  (Fig.  655). 


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SYMPTOMS, 


If  the  physician's  fingers  are(  not  small  enough  for  the  purpose, 
the  forefinger  may  be  replaced  by  a  probe,  a  grooved  director,  a 
bodkin,  or  some  other  thin,  smooth  object  (Fig.  656).  If  eyelashes 
are  few  or  wanting,  the  margin  of  the  lid  itself  is  pinched  up. 

It  is  very  necessary  that  the  patient  should  continue  to  look 
STEADILY  downward  during  all  these  manq>ulations. 

When  performed  gently  and  methodically,  such  an  instantaneous 
turning  back  of  the  lids  causes  no  pain  in  a  docile  patient  who  does 
not  insist  upon  looking  upward,  which  hinders  the  procedure. 

It  is  quite  useless  to  attempt  to  turn  the  lid  with  one  hand,  be- 
tween two  fingers;  the  procedure  already  described  is  preferable 
and  less  unpleasant  to  the  patient. 


Fig.  655. — Fixation  of  the  everted  lid 
(2d  step). 


Fig.  656. — Eversion  of  the  lid  with 
the  aid  of  a  probe. 


In  some  cases  it  may  be  necessary  to  investigate,  in  addition,  the 
upper  cul-de-sac,  which  forms  a  deep  pocket  beneath  the  lid  that 
has  already  been  turned  back. 

Among  several  procedures  available  for  the  purpose,  the  fol- 
lowing are  the  most  effective : 

The  first  consists,  after  having  turned  the  lid  back,  in  introduc- 
ing the  elevator  into  the  cutaneous  recess  of  the  lid,  which  is  thus 
drawn  forward,  allowing  the  observer  to  glance  into  the  cul-de-sac 
(Fig.  657).  The  second,  or  thorough,  procedure,  which  exposes 
the  entire  cul-de-sac,  consists,  after  instillation  of  cocaine  followed 
by  subcutaneous  injection  of  the  local  anesthetic  and  a  ten  minutes' 
wait,  in  having  the  patient  lie  down  and  seizing  the  lid  horizontally 
with  forceps  and  rolling  it  about  the  latter  (Fig.  658).  With  this 
procedure,  no  foreign  body,  tumor,  granulations,  etc.,  may  be  over- 


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885 


looked,  as  may,  on  the  other  hand,  be  the  case  if  one  merely  turns 
the  lid  or  passes  a  smooth  curet  blindly  into  the  cul-de-sac,  as  text- 
books invariably  recommend. 


Fig.  657. — Outward  traction  of  the  already  everted  upper  lid  with  an 
elevator  inserted  into  the  fold  of  skin  for  the  purpose  of  inspecting  the 
upper  conjunctival  cul-de-sac. 

Lacrymal  Duct. — The  physician  should  ascertain  whether  the 
lower  lacrymal  punctum  is  not  everted  and  therefore  useless;  he 
should  make  firm  pressure  on  the  lacrymal  sac  to  see  if  any  secre- 


Fig.  658.— Rolling  the  lid  about  dress-     Fig.  659. — Complete  eversion  of  the 
ing  forceps  (1st  step).  upper  cul-de-sac  (2d  step). 

tion  will  exude  from  it  (Fig.  660).  The  procedure  of  making  sure 
of  the  permeability  by  injection  into  the  lacrymal  passages  and 
catheterization  with  an  olive-tipped  probe  belongs  to  the  field  of  the 
eye  specialist.    One  may,  in  any  case,  instil  a  colored  solution  such 


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SYMPTOMS, 


as  argyrol  or  coUargol  and  have  the  patient  blow  his  nose  fifteen 
minutes  later  to  see  if  the  solution  has  passed  into  the  nasal  cavity, 
but  this  gives  no  information  as  to  the  degree  and  number  of  the 
stenoses  that  may  exist. 


Fig.  660. — Expressing  the  lacrymal  sac. 

Examination    of    the    Eyeball. — (a)  Cornea. — The    cornea 
should  always  be  examined  in  a  darkened  room]  with  lateral  illumi- 


.".1  z  r  rl~I-I"-W.'vC<"-."-.T».-v>» 


D 


Fig.  661. — Lateral  illumination  with  a  lens. 

nation,  concentrated  on  the  eye  with  a  lens  (Fig.  661)  ;  if  need  be, 
an  additional  hand  lens  may  be  used  (Fig.  662). 

(6)  Conjunctiva  and  Sclera. — Color,  vessels,  deformations, 
etc. 

(c)  Iris  and  Pupil. — The  surface  of  the  iris  should  be  care- 
fully examined  for  fissures,  spots,  prominence  or  retraction,  abnor- 


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EYES,  DISORDERS  OF  THE,  887 

mal  shape,  etc.,  and  likewise,  the  contents  of  the  anterior  chamber 
(aqueous  humor,  blood,  pus,  cellular  exudate,  etc.),  the  outline  of 
the  pupil,  the  si::e  of  the  pupil,  and  its  motor  responses,  all  in  the 
darkened  room. 

A  comparison  of  the  two  eyes  should  always  be  made. 
If  the  least  irregularity  of  the  pupil  is  noted,  two  drops  of  2 
per  cent,  cocaine  should  be  instilled;  at  the  end  of  half  an  hour  this 
will  accentuate  the  peculiarities  of  shape  (from  synechiae,  etc.). 

Complete  examination  of  the  motor  functions  of  the  pupil — 
response  to  light  and  convergence,  or  to  convergence  alone  {Argyll- 
Robertson  pupil) — ^has  already  been  mentioned  in  this  work  (see 


Fig.  662. — Lateral  illumination  (examination  with  two  lenses). 

p.  481),  and  likewise  the  manner  of  eliciting  the  pupillary  reflexes. 
The  significance  of  these  tests  will  be  referred  to  later. 

One  cannot  insist  too  strongly  upon  the  necessity  on  the  part  of 
the  practitioner  of  informing  himself  de  visu  as  to  the  actual  condi- 
tion of  the  cornea  and  pupil  (adhesion  or  its  absence,  and  normal 
or  abnormal  reflexes)  if  he  wishes  to  avoid  overlooking  certain  par- 
ticularly serious  disorders  (corneal  opacity  and  ulcer,  occlusion  of 
the  pupil,  etc.)  which  prompt  recognition  and  treatment  would  have 
checked  before  damage  hard  to  undo  had  resulted. 

Palpation. — Note  should  always  be  made  of  the  comparative 
tension  of  the  two  eyes.  The  practitioner  should  confine  himself  to 
digital  palpation.  He  should  never  press  one  finger  against  the  eye. 
Both  forefingers  must  be  used  (Fig.  663),  and  employed  in  exactly 
the  same  way  as  for  eliciting  fluctuation  in  an  abscess,  and  after 
having  requested  the  patient  to  look  down.    One  may  then  note  the 


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SYMPTOMS. 

firmness  or  hardness  of  increased  tension,  which  is  sometimes  stone- 
like {glaucoma),  or  the  lowered  tension  and  flaccid  condition  in  cer- 
tain other  disorders. 

Pressure  may  be  exerted,  if  need  be,  to  elicit  the  oculocardiac 
reflex  (see  p.  482).  In  some  forms  of  keratitis,  the  sensibility  of 
the  eye  to  contact  should  be  tested  with  horsehair,  a  fine  probe,  or 
a  wire  previously  passed  through  an  open  flame. 

Endoscopy. — ^The  specialist  examines  the  fundus  of  the  eye 
with  his  perforated  mirror  and  lens.    This  form  of  examination. 


Fig.  663. — Palpation  of  the  eye  for  the  purpose  of  estimating 
the  extent  of  fluctuation. 

which  requires  prolonged  training  and  an  ability  to  distinguish  the 
numerous  varieties  of  intraocular  disease,  is  not  available  to  the 
practitioner  who  has  not  gone  through  the  course  of  studies  required 
for  the  purpose. 

Nonetheless,  the  practitioner  incapable  ot  examining  the  fundus 
of  the  eye  may,  by  illuminating  the  pupillary  region,  obtain  some 
information  concerning  the  degree  of  transparency  of  the  crystal- 
line lens  and  vitreous  body.  The  pupil  should  preferably  be  first 
dilated  by  instilling  2  per  cent,  cocaine  solution,  and  after  waiting 
half  an  hour,  light  is  thrown  on  the  eye  with  the  mirror  (Fig.  664), 
the  patient  meanwhile  rotating  the  eye  in  various  directions.  There 
will  thus  appear,  when  present,  conditions  of  partial  opacity  of  the 


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EYES,  DISORDERS  OF  THE. 


889 


lens  (Fig.  665),  cellular  deposits,  synechice  of  the  iris,  and  floating 
bodies  in  the  vitreous  humor.  All  these  abnormalities  appear  black, 
contrasting  with  the  red  of  the  illuminated  fundus.  At  the  least 
movement  of  the  eye,  the  corpuscles  in  the  vitreous  body,  will  be 
observed  in  motion  and  thereby  distinguished  from  fixed  opacities. 


Fig.  664. — Illumination  of  the  eye  with  the  mirror. 

The  pupillary  field  may  exhibit  several  colors  (partial  cataract, 
dislocation  of  the  lens,  swellings,  or  detachment  of  the  retina). 

When  a  patient  states  that  his  vision  became  impaired  suddenly, 
and  the  pupil  appears  alternately  dark  grayish  and  reddish  under 
simple  illumination  with  the  mirror,  without  a  lens,  and  with  the 
eye  in  motion,  one  should  think  of  the  possibility  of  detachment  of 


Fig.  665. — Partial  cataract,  seen  by  transmitted  light. 

the  retina,  and  find  out  whether^  the  patient  sees  a  hand  better  in 
one  portion  of  the  visual  field  than  elsewhere. 

Diaphanoscopy. — The  specialist  may  likewise  be  led  to  practice 
diaphanoscopy,  with  a  lamp  (Fig.  649)  held  over  the  cocainized 
eye;  such  an  examination  is  sometimes  conclusive  (growths,  foreign 
bodies  in  the  lens,  etc.). 

Movements  of  the  Eyes. — ^With  his  head  held  steadily  in  one 
position,  the  patient  should  be  required  to  move  each  eye  in  all 


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890  SYMPTOMS. 

directions,  the  eye  not  under  test  being  meanwhile  covered;  one 
finds  out  thus  whether  there  is  free  ocular  motion  or  motor  in- 
capacity. The  physician  notes  whether  diplopia  is  present,  and  if 
so,  whether  it  disappears  (binocular  diplopia)  or  persists  (monoc- 
ular diplopia)  when  one  eye  is  covered. 

Orbitoscopy. — The  condition  of  the  walls  and  accessible  con- 
tents of  the  orbit  should  be  summarily  ascertained  by  palpation.  If 
exophthalmus  exists,  diaphanoscopy,  examination  of  the  sinuses, 
and  fluoroscopy — the  latter  also  very  useful  in  the  detection  of  in- 
traocular foreign  bodies — should  be  availed  of. 

Examination  of  the  Ocular  Functions.— In  many  instances 
this  may  come  before  any  other  procedure,  even  endoscopy. 

(a)  Visual  Acuity. — ^Testing  visual  acuity  requires  the  use 
of  a  special  test  chart  (Fig.  650),  placed  at  a  distance  of  5  meters 

T  c  N  D  z  p 

Fig.  666. — A  normal  eye  should  be  able  to  recognize  these  letters  at  a 
distance  of  5  meters  (16%  feet). 

from  the  patient,  in  a  good  light.  If  no  such  chart  is  available, 
the  practitioner  may  nevertheless  eliminate  instances  of  normal 
visual  acuity  if  the  above  line  (Fig.  666)  can  be  read  off  with 
each  eye  at  a  distance  of  5  meters,  in  a  good  light,  the  other  eye 
being  meanwhile  covered. 

By  means  of  the  test  chart,  the  visual  capacity  (acuity)  of  each 
eye  is  ascertained  in  turn ;  it  is  also  necessary,  however,  if  vision  is 
insufficient,  to  find  out  whether  this  condition  is  due  to  a  defect  of 
refraction  (myopia,  hyperopia,  or  astigmatism)  alone  or  in  com- 
bination with  some  disease  of  the  eye. 

Looking  through  a  perforated  disc  (the  stenopeic  opening  in 
Fig.  648)  or  through  a  pinhole  in  a  card  is  in  itself  sufficient  to  im- 
prove vision  in  persons  with  defective  refraction.  The  remaining 
procedures  (testing  with  lenses,  optometry,  skiascopy,  etc.)  are  the 
particular  concern  of  the  eye  specialist.  The  visual  power  of  an 
illiterate  subject  or  of  one  with  word  blindness  can  be  tested  by 
having  him  hold  in  his  hand  a  card  cut  in  the  shape  of  a  fork  and 


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EYES,  DISORDERS  OF  THE.  891 

turn  it  in  the  directions  in  which  he  sees  the  prongs  of  the  letter  E 
pointing  on  the  special  test  card  (Fig.  650). 

In  some  patients  vision  is  so  poor  that  it  can  be  estimated  only 
by  the  distance  at  which  fingers  can  be  distinguished  or  a  candle 
seen,  etc. 

(b)  Field  of  Vision. — Defects  in  the  field  of  vision  show  exactly 
the  situation  and  extent  of  existing  intraocular  lesions;  testing  the 
visual  field  yields  valuable  information  regarding  various  conditions 


Fig.  667. — Examination  of  the  field  of  vision  with  the  perimeter. 

of  the  brain,  especially  through  detection  of  the  presence  of  hemi- 
anopia.  The  results  obtained  localise  the  lesions  in  the  eye  without 
or  before  their  observation  by  ophthalmoscopy. 

Study  of  the  visual  field  likewise  localizes  them  in  the  cranial 
cavity  and  in  the  brain. 

The  field  of  vision  is  tested  with  the  light  coming  from  behind. 
The  campimeter  or  better  the  perimeter  (Fig.  667)  are  the  usual 
instruments  employed  for  the  purpose.  One  of  the  patient's  eyes 
is  closed  or  blindfolded  and  the  examiner  moves  a  white  or  colored 
pointer  over  various  points  in  the  field,  at  first  working  in  from  the 
regions  inaccessible  to  the  eye.  The  patient  says  "I  see  it"  as  soon 
as  the  test  object  passes  into  his  visual  field.  His  head  must  be  held 
still  throughout  the  test  and  the  eye  must  fix  the  central  mark 


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892  SYMPTOMS. 

directly  in  front  of  him.  The  examiner  records  on  the  chart,  with 
a  line,  the  limits  obtained  in  the  test  and  then  compares  them  with 
the  normal  field  (Fig.  668). 

An  approximate  idea  of  the  visual  field  may  be  secured  without 
the  special  apparatus.  The  patient  keeps  his  head  motionless,  covers 
one  eye  with  his  hand,  and  looks  steadily  at  the  forehead  of  the  ob- 
server, who  moves  about  in  front  of  the  eye  thus  fixed  a  finger  or  a 
piece  of  white  paper  held  in,  forceps.  He  is  thus  enabled  to  ascer- 
tain whether  there  exist  any  extensive  scotomata  (defects) — lateral, 
superior,  or  inferior, — or  any  concentric  contraction  (retinitis  pig- 
mentosa, neuritis,  or  neurosis)  of  the  field  of  vision. 


Fig.  668. — Ndrmal  visual  fields. 

The  white  area  represents  the  field  of  vision  for  white.     The  con- 
tinuous line  indicates  the  limit  of  the  field  of  vision  for  blue.    The  line 

indicates  the  limit  of  the  field  of  vision  for  red.    The  line 

indicates  the  limit  of  the  field  of  vision  for  green. 

The  peripheral  defects  having  first  been  investigated,  there  re- 
main to  be  detected  central  and  paracentral  defects,  positive  scoto- 
mata (black  spots)  or  negative  scotomata  (gaps).  The  central 
scotoma  is  the  most  peculiar  type,  and  is  met  with  in  the  presence 
of  ambly<^ia  (due  to  alcohol  or  tobacco)  and  disease  of  the  macula 
lutea. 

To  make  a  rough  test  for  central  scotoma  the  patient  may  be 
asked  to  distinguish  the  color  of  discs  of  red  or  green  paper  of  the 
size  of  a  ten  cent  piece  or  less. 

Accurate  examination  of  the  field  of  vision  is  nearly  always 
referred  to  the  eye  specialist 


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EYES,  DISORDERS  OF  THE.  893 

After  any  examination  of  the  eye  and  its  adnexa,  the  question  of 
possible  simulation,  a  frequent  occurrence  in  industrial  accidents, 
hystero-pithiatism,  etc.,  should,  if  it  arises,  be  put  up  to  the  specialist 
for  solution. 

Following  is  the  outline  of  a  complete  examination  of  the  eye 
and  its  adnexa.  From  among  the  procedures  enumerated  the  prac- 
titioner will  select  those  which  he  is  able  satisfactorily  to  carry  out. 


Plan  of  Examination  for  an  Eye  Disorder. 

General  appearances:    Brief  verbal  inquiry. 
Examination  (always  compare  the  two  eyes). 

1.  Eyelids,  on  both  their  external  and  internal  surfaces.    The  con- 

junctival culs-de-sac. 

2.  Lacrymal  passages. 

3.  Conjunctiva  and  sclera. 

4.  Cornea  (lateral  illumination). 

5.  Surface  of  iris  and  anterior  chamber. 

6.  Pupils:    Reflexes  and  size. 

7.  Crystalline  lens,  with  or  without  artificial  dilatation  of  the  pupil 

(cocaine). 

8.  Test  of  visual  acuity  (distant  vision)  and  for  refractive  defects 

(myopia-hypometropia,  hyperopia,  and  astigmatism). 

9.  Test  of  the  accommodation  and  of  near  vision. 

10.  Test  of  the  field  of  vision. 

11.  Test  of  ocular  motility. 

12.  Test  of  binocular  vision. 

13.  Test  of  color  vision. 

14.  Test  of  intraocular  tension  and  sensitiveness  (palpation).    The 

oculocardiac  reflex. 

15.  Endoscopy  of  the  eye  (ophdialmoscopy),  relating  to  the  lens, 

vitreous  body,  choroid  and  retinal  layers,  and  the  optic  nerve. 

16.  Illumination  by  transmitted  light  (diaphanoscopy).    Fluoroscopy 

and  radiography. 

17.  Examination  of  the  orbit  (orbitoscopy)   and  of  the  periorbital 

sinuses. 

18.  Special  examinations  (prospective  railway  employees,  soldiers,  or 

emigrants;  industrial  accidents,  etc.):  Detection  of  malin- 
gering. 

19.  Examination  of  the  face  and  cranium  (nose,  ears,  teeth,  lymph- 

nodes,  etc.)  and  of  the  neck  (thyroid  gland,  etc.).  A  more  or 
less  exhaustive  examination,  as  in  a  patient  with  some  inter- 
nal disorder  (organs  in  general,  heart,  liver,  urine,  blood,  com- 
prehensive examination  by  the  latest  methods,  various  tests, 
blood-pressure,  bacterioscopy,  biopsy,  etc.).  History.  In- 
herited disorders.    Supplementary  verbal  examination. 

20.  Name,  age,  occupation,  address,  diagnosis,  treatment,  date,  case 

number,  prescription,  and  certificate  if  required. 


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894  SYMPTOMS. 

In  short,  after  thorough  examination  of  the  eyes  a  complete 
examination  of  the  patient  is  generally  necessary  in  order  to  con- 
firm the  results  of  the  eye  examination:  After  the  ophthalmopathy 
comes  the  ophthalmopath  himself.  It  is  unnecessary  here  to  empha- 
size how  much  of  added  accuracy  may  be  contributed  by  examina- 
tion of  the  cranium,  nose,  heart  and  vessels,  kidneys,  urine,  blood 
and  its  reactions,  etc. — of  all  the  bodily  functions  and  the  physical 
and  mental  circumstances  of  life — ^to  the  diagnosis,  the  prognosis, 
the  intelligent  and  causal  direction  of  local  and  general  treatment, 
and  hygiene  after  recovery. 

The  local  examination,  however  well  conducted,  becomes  of  con- 
clusive significance  only  when  supplemented  by  a  complete  general 
examination,  and  a  satisfactory  general  examination,  in  turn,  must 
include  an  inquiry  into  all  organs  and  functions,  apart  from  cer- 
tain exceptional  cases. 

II.  THE  PRINCIPAL  OPHTHALMOLOGIC 
DISORDERS. 

Eye  disorders  may  be  divided,  for  the  purposes  of  the  un- 
specialized  practitioner,  into  two  main  groups.  In  the  first  group, 
there  exists  an  obvious  morbid  condition,  visible  to  the  naked  eye, 
in  the  ocular  and  periocular  region.  In  the  second,  the  patient  com- 
plains of  pain  or  disturbed  vision,  but  the  eye  shows  no  externally 
manifest  lesion,  or  no  lesion  discernible  without  some  special,  com- 
plicated technical  procedure. 

The  following  facts  will  lead  to  definite  recognition  or  to  pre- 
sumption of  certain  morbid  conditions,  while  awaiting  more  en- 
lightened inquiry. 

A.  Disorders  Attended  with  Externally  Obvious  Lesions. — 
Discharges. — (a)  Lacrymation. — Using  a  lamp  and  hand  lens,  the 
physician  should  make  a  very  careful  examination  of  the  cornea 
(erosion,  foreign  body,  slight  keratitis,  etc.),  the  iris,  tlie  con- 
junctiva (cul-de-sac  and  deep  aspect  of  the  lids,  which  should 
always  be  everted),  the  ciliary  margin  (intumed  lashes),  and  the 
lacrymal  apparatus — in  conformity  with  the  directions  outlined 
under  Examination  of  the  eye — in  order  to  ascertain  whether  the 
lacrymation  results  from  some  lesion  of  the  eye  or  from  a  disorder 


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EVES,  DISORDERS  OF  THE.  895 

of  the  lacrymal  apparatus.  In  the  newborn,  congenital  dacryo- 
cystitis, nearly  always  unilateral,  is  readily  mistaken  for  conjunc- 
tivitis if  one  n^lects  to  compress  and  empty  the  lacrymal  sac. 

(b)  Catarrhal,  pseudomembranous,  and  purulent  excretions. — 
These  result  from  the  presence  of  catarrhal,  pseudomembranous,  or 
purulent  conjunctivitis.    Bacterioscopy  is  indicated. 

Conditions  Affecting  the  Lids. — Aside  from  congenital  defects 
(coloboma,  etc.),  there  may  occur:  (a)  Edema:  1.  Passive  and 
chronic,  in  heart  disorders,  nephritis,  etc.,  or  disorders  in  the  vicinity 
(tumors  of  the  orbit,  etc).  2.  Acute:  Urticaria  and  transient 
edema. 

(b)  Infectious  edema:  Local  disorders  (furuncles  and  styes, 
malignant  pustule,  erysipelas,  subcutaneous  abscess,  herpes  zoster, 
etc.)  or  neighborhood  disorders  [lacrymal  sac,  orbit,  sinuses,  or  eye 
(conjunctivitis,  keratitis,  iritis,  etc.)]. 

(c)  Emphysema:  Comes  on  abruptly,  nearly  always  upon 
blowing  the  nose  violently  (involvenfent  of  the  lacrymal  passages, 
nose,  and  sinuses). 

(d)  Ulcerations  and  tumors,  identical  with  those  affecting  the 
skin  in  other  regions. 

(e)  Skin  disorders  of  all  kinds,  similar  to  those  of  the  hairy  sur- 
faces (blepharitis  ciliaris  marginalis)  or  of  various  regions  of  the 
body. 

(f)  Abnormal  position  of  tissues. — Eversion  (ectropion),  cica- 
tricial or  non-cicatricial.  Inversion  (entropion),  with  or  without 
ingrowing  lashes  (trichiasis).  Adhesion  to  the  eyeball  (symbleph- 
aron).  Tics,  spasms,  and  contractures;  one  should  carefully  ascer- 
tain whether  the  condition  is  one  of  purely  nervous  disease  or 
whether  the  eye  is  itself  affected  (photophobia  and  blepharospasm 
in  keratoconjunctivitis,  folliculo-adenoid  conjunctivitis,  etc.). 
Lagophthalmos  (the  eye  unable  to  close  in  facial  paralysis).  Ble- 
pharoptosis,  which  may  be  either  complete  through  paralysis  of  the 
levator  muscle  (3d  pair),  with  or  without  paralysis  of  the  extrinsic 
muscles;  or  incomplete,  through  paralysis  of  the  cervical  sympa- 
thetic (Claude  Bernard's  syndrome,  with  myosis,  enophthalmus,  and 
slight  ptosis).  Ptosis  of  conjunctival  origin  {granular  conjunc- 
tivitis, etc.).    Ptosis  merely  of  cutaneous  nature,  through  dermato- 


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896  SYMPTOMS. 

lysis  of  the  lids.     One  should  always  examine  the  pupils,  ocular 
motility,  and  the  condition  of  the  conjunctiva  in  ptosis. 

Abnormal  Conditions  and  Appearances  of  the  EyebalL — 1. 
Congenital  anomalies  (anophthalmia,  cyclops,  microphthalmia,  albin- 
ism, etc.). 

2.  Megalophthalmia  (glaucomatous  buphthalmia,  extreme  my- 
opia, or  intraocular  tumor). 

3.  Hypotonic  atrophy  of  the  globe. 

4.  Disturbances  of  motility  with  various  types  of  abnormal  posi- 
tions, with  or  without  oculomotor  paralysis,  and  with  or  without 
characteristic  diplopia  (see  the  table  on  Diplopia,  p.  908). 

5.  Retraction  of  the  eyeball  (enophthalmus). — Due  to  cachexia 
and  general  disorders.  Unilateral  in  Claude  Bernard's  syndrome 
and  certain  cases  of  trauma  to  the  face  and  orbit.  Sometimes  alter- 
nates with  exophthalmus. 

6.  Prominence  of  the  eye  (exophthalmus). — May  result  from 
direct  traumatism  (foreign  body,  hematoma,  fracture,  etc.)  or  in- 
direct traumatism  (pulsating  exophthalmus,  sometimes  spontane- 
ous) ;  from  inflammation,  as  in  rheumatic  tenonitis  (a  species  of 
post  ocular  synovitis)  ;  orbital  abscess ;  osteoperiostitis  in  syphilis, 
tuberculosis,  mycoses,  or  sinusitis ;  orbitocranial  phlebitis  or  thrombo- 
phlebitis (exophthalmus  often  bilateral) ;  from  tumor,  benign  (con- 
genital or  hydatid  cysts,  etc.)  or  malignant;  or  from  exophthalmic 
goiter  (the  incomplete,  unilateral  cases  should  be  watched  for). 

Examination  of  a  case  of  exophthalmus  necessitates  painstaking 
investigation  of  both  eyes  and  of  all  their  functions,  of  the  adjoin- 
ing cavities  (nose  and  sinuses,  ear,  cranium,  and  mouth),  radiog- 
raphy, and  a  general  examination  of  the  patient. 

Diseases  of  the  Conjunctiva. — Varipus  tumors  (benign,  as  in 
papilloma,  pinguicula,  etc.,  or  malignant,  as  epithelioma  and  sar- 
coma, the  latter  frequently  melanotic).  Special  dystrophies  such  as 
pterygium  (fan-like  fold  of  the  conjunctiva  between  the  caruncle 
and  cornea).    Lithiasis,  manifested  in  small  yellowish  concretions. 

Conjunctivitis. — Secreting:  Pseudomembranous,  catarrhal,  or 
purulent.  Vegetating:  Granulations,  follicles,  etc.  Eruptive:  Pus- 
tules, vesicles,  and  various  skin  disorders  (erythema  multiforme, 
pemphigus,  psoriasis,  etc.). 


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EYES,  DISORDERS  OF  THE, 


897 


One  should  avoid  confusing  conjunctivitis  with  keratitis,  scle- 
ritis,  iritis,  or  glaucoma,  these  being  much  more  serious  diseases 
which  require  prompt  treatment  of  a  different  kind. 

These  last  disorders  are  eliminated  only  by  exclusion.  Close  ex- 
amination can  alone  reveal,  indeed,  whether  the  cornea,  pupil,  intra- 


Fig.  669.— Pustular    (phlyctenular) 
kerato-con  j  uncti  vitis. 


Fig.  670.— Corneal 
ulcer. 


ocular  tension,  and  vision  are  normal.  Only  after  '.having  made 
certain  of  the  integrity  of  the  other  portions  of  the  eye  should  the 
observer  look  for  thel  distinguishing  features  of  the  several  forms 
of  conjunctivitis.    At  the  same  time  he  should  find  out  whether  the 


Fig.  671. — Corneal  pannus  and  the  upper  lid  in  granular  conjunctivitis. 

conjunctivitis  is  not  complicated  with  keratitis  (Fig.  669)  or  some 
other  affection  of  the  eye. 

The  physician  should  never  allow  himself  to  be  led  into  error  by 
faint  resemblances  to  certain  disorders. 

The  most  important  thing  in.  the  diagnosis  of  conjunctivitis  is 
to  make  sure  of  the  precise  condition  of  the  other  portions  of  the 

67 


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898  SYMPTOMS. 

eye  and  its  adnexa,  and  actually  to  see  that  they  are  in  a  normal 
condition. 

Diseases  of  the  Sclera. — General  inflammation  (diffuse  scleritis) 
or  superficial  (episcleritis)  or  deep  (parench)rmatous  scleritis)  focal 
inflammation. 

There  is  less  of  a  bright  red  color  (violet)  than  in  conjunc- 
tivitis, and  the  conjunctiva  is  smooth,  with  vegetations  or  secretions. 

Congenital  brown  spots  (not  to  be  confused  with  supra-and  intra- 
ocular tumors). 

Cornea. — (a)  Opacity  and  keratitis:  Without  ulceration 
(superficial,  parenchymatous,  or  deep-seated)  or  with  ulceration 
(Fig.  670).  There  should  be  a  detailed  examination  with  the  lamp 
and  hand  lens.    The  observer  should  ascertain  if  there  is  not  some 


Fig.  672.— Hyphema  Fig.  673.— Hypopyon  Fig.  674.— Iritis  with 
(blood  in  the  anterior  (pus  in  the  anterior  cellular  exudation  in 
chamber).  chamber).  the  anterior  chamber. 

lesion  in  the  vicinity — dacryocystitis,  blepharitis,  or  conjunctivitis — 
or  a  foreign  body;  if  the  eye  is  not  hard  (glaucoma),  and  whether 
the  opacity  is  of  long  standing  (cicatricial  leucoma)  or  recent  Sen- 
sation  of  the  cornea  should  be  tested  with  a  piece  of  wire,  being 
sometimes  abolished  (neuroparalytic  keratitis). 

(b)  Vascularization,  a  frequent  condition  during  repair  of 
ulcers,  congenital  syphilitic  interstitial  keratitis,  etc.  Vasculariza- 
tion (Fig.  671)  of  the  upper  portion  of  the  cornea  (pannus)  often 
points  to  granular  conjunctivitis  (in  such  a  case  the  upper  lid,  seat 
of  the  disease,  should  always  be  everted). 

(c)  Ectasia,  transparent  (keratoglobus,  keratoconus)  or  opaque 
(staphyloma). 

(d)  Tumors  about  or  in  the  cornea,  sometimes  melanotic.  Con- 
fusion with  an  extravasated  intraocular  tumor  is  to  be  avoided. 

Anterior  Chamber. — Contents  normal  or  abnormal:  Hyphema 
(Fig.  672),  hypopyon  (Fig.  673),  cell  deposits  (Fig.  674),  foreign 


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EYES,  DISORDERS  OF  THE. 


899 


bodies,  dislocated  lens,  etc.  The  depth  of  the  anterior  chamber 
may  be  reduced  or  increased;  sometimes  it  is  entirely  emptied  (the 
iris  being  then  glued  to  the  cornea). 

Glaucoma  (characterized  by  intraocular  hypertension). — 1. 
Acute:  Intense  congestion  of  the  eye,  paroxsymal  pains,  pupil 
dilated,  eye  very  hard  on  well-conducted  palpation  (see  Examinor- 
tion  of  the  eye),  but  only  slightly  sensitive  to  pressure;  vision 
markedly  impaired. 

It  should  not  be  confounded  with  acute  iritis.  Signs  of  the  lat- 
ter: Eye  red,  pupil  contracted  and  irregular,  intraocular  tension 
normal  or  subnormal,  palpation  very  painful,  vision  interfered  with. 

2.  Chronic :  But  little  redness,  intraocular  tension  more  or  less 
excessive,  field  of  vision  contracted  (on  the  nasal  side),  pupil  free 


Fig.  675. — Syphilitic  iritis  with  granulo- 
matous node. 


Fig.  676. — Prolapse  of  the  iris. 


of  adhesions.  Iridescent  vision  about  lights,  such  as  that  of  a 
candle. 

Instillation  of  atropine  is  to  be  avoided  where  a  precise  diag- 
nosis has  not  been  made,  for  atropine  markedly  aggravates  glau- 
coma— 2L  mistake  too  often  made. 

Ophthalmomalacia. — ^Transient  or  permanent  hypotonia  (with 
atrophy  of  the  eye). 

Iris. — Anomalies.  Inflammatory  conditions  (iritis)  and  nodular 
formations  (granulomata  in  syphilis,  tuberculosis,  leprosy,  the 
mycoses,  etc.). 

The  DIAGNOSIS  of  acute  iritis  is  based:  1.  On  the  special  type 
of  redness  of  the  eyeball,  such  redness  being  especially  pericorneal, 
like  a  radiating  areola,  with  distorted  outline  of  the  narrowed  pupil, 
some  parts  of  the  iris  becoming  adherent  to  the  lens  (synechia) ; 


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900  SYMPTOMS, 

the  pupil  appears  ragged  and  fringed  (Fig.  675).  2.  On  the  sub- 
jective disturbances:  Spontaneous  pain,  increased  on  palpation, 
interference  with  vision,  and  photophobia.  The  upper  lid  is  some- 
times swollen.  Detailed  examination  of  the  cornea  excludes  the 
existence,  or  demonstrates  the  coexistence,  of  keratitis,  which  causes 
redness  of  the  same  order  as  that  of  iritis. 

Some  cases  of  chronic  iritis  are  not  attended  with  redness  nor 
pain,  being  featured  by  the  disturbance  of  vision  combined  with 
observation  of  pupillary  cohesions. 

Iritis  is  distinguished  from  acute  glaucoma,  first  of  all,  by  pal- 
pating the  eyeball,  which  is  hard  in  glaucoma;  next,  by  noting  that 
glaucoma  exhibits  a  dilated,  mydriatic  pupil  instead  of  .the  myotic 
pupil  of  iritis.  Some  cases  of  chronic  iritis  may  be  complicated 
with  increased  intraocular  tension  {secondary  glaucoma),  but  ex- 
amination of  the  pupil  shows  the  iritic  synechias 

Iritis  should  not  be  mistaken  for  conjunctizntis,  in  which  the 
redness  is  diffuse,  not  merely  pericorneal,  and  the  pupil  free,  with 
vision  but  slightly  or  not  at  all  interfered  with.  The  secretions, 
eruptions,  and  swelling  (chemosis)  complete  the  diagnosis  of  con- 
junctivitis in  the  absence  of  any  iritic  corneal  complication. 

Tumors:    Cyst,  sarcoma,  etc. 

Prolapse  of  the  iris  (in  ulcerous  or  traumatic  perforation), 
forming  a  small,  black,  projecting  mass. 

Displacements:  Prominence  or  retraction  in  certain  disorders 
'of  the  lens  and  vitreous  body.  Tremulousness  (iridonesis)  in  dis- 
location of  the  lens,  etc. 

Abnormal  Conditions  of  the  Pupils. — A  comparison  of  the  two 
pupils  as  to  shape,  size,  and  spontaneous  or  induced  mobility  should 
always  be  made. 

One  should  note  the  outline  of  the  pupil,  which  is  sometimes 
notched  (congenital  coloboma),  wavy  or  angular  te^V/toM/  adhesion 
(glaucoma,  tabes,  etc.),  or  irregular  and  adherent  to  the  lens  or  cor- 
nea {synechicE),  It  is  of  capital  importance  to  detect  these  adhe- 
sions (iritis)  of  the  "fringed**  pupil.  In  doubtful  cases,  dilatation 
with  cocaine  (2  per  cent.)  will  reveal  the  smallest  synechiae  (Fig. 
677)  after  waiting  twenty  minutes,  thus  obviating  the  unpleasant 
features  (visual  disturbance  persisting  for  about  ten  days  and  inter- 
fering with  reading)  of  atropine,  which  may  be  reserved  for  the 


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EYES,  DISORDERS  OF  THE.  901 

treatment  of  iritis  after  it  has  been  duly  diagnosed.  The  adhesions 
of  iritis  should  not  be  confounded  with  the  threads  of  a  congenitally 
persisting  pupillary  membrane ;  the  latter  do  not  start  from  the  mar- 
gin of  the  pupil,  but  from  the  anterior  surface  of  the  iris. 

Mydriasis  and  Myosis. — Where  uni-  or  bi-lateral  myosis  is  pres- 
ent, one  must  exclude :  The  use  of  a  myotic,  some  disease  of  the 
nervous  system  (tabes,  etc.),  paralysis  of  the  cervical  sympathetic 
[disease  in  the  cervical  region  (enlarged  glands)  or  in  the  medias- 
tinum should  be  looked  for]  with  slight  ptosis,  and  intoxication  by 
opium,  morphine,  etc. 

Where  there  is  mydriasis,  one  must  exclude:  The  use  of  a 
mydriatic  (sometimes  surreptitious),  oculomotor  paralysis,  paral- 
ysis of  the  iris  and  ciliary  muscle  (diphtheria,  syphilis,  etc.),  cere- 
brospinal diseases,  lesions  of  the  orbit,  and  certain  intoxications 


Fig.  677. — Synechiae  in  iritis. 

(belladonna,  spoiled  meat,  etc.).  The  physician  should  think  of 
incipient  general  paralysis  where  the  pupils  are  markedly  unequal 
and  insensitive  to  light. 

An  indispensable  proceeding  is  to  ascertain  the  mobility  or 
IMMOBILITY  of  the  pupil  to  light  and  accommodation,  and  then  to 
test  the  consensual  reflex. 

The  Argyll-Robertson  pupil  {lack  of  response  to  light  coupled 
with  response  to  fixation  and  convergence)  is  a  sign  of  nervous 
syphilis  (tabes,  general  paralysis,  etc.),  hut  very  many  syphilitics  do 
not  show  it. 

Finally,  there  are  cases  in  which : 

1.  When  light  is  thrown  into  one  eye,  its  pupil  fails  to  contract, 
but  the  opposite  pupil  responds,  through  the  consensual  reflex;  the 
condition  then  present  is  a  paralytic  mydriasis  with  peripheral  in- 
volvement of  the  ciliary  and  pupillary  nerves  due,  e.g.,  to  syphilis. 
If  light  is  thrown  in  the  opposite  eye,  the  pupil  responds,  but  the 
pupil  of  the  first  eye  remains  motionless. 


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902  SYMPTOMS. 

2.  Light  is  thrown  in  a  single  eye  and  both  pupils  remain 
motionless.  If  now  light  is  thrown  in  the  other  eye  alone,  both 
pupils  respond.  This  condition  is  the  result  of  a  complete  blindness 
of  the  first  eye  due  to  local  (peripheral)  disease  of  the  retina  and 
optic  nerve. 

In  so-called  "hysteric"  blindness  and  in  blindness  of  cortical 
origin  the  reflexes  are  retained,  as  a  general  rule. 

Pupillary  Area. — ^The  pupillary  opening  overlies  the  anterior 
surface  of  the  lens.  The  observer  should  ascertain  whether  there 
is  not  some  exudate,  with  partial  or  total  occlusion  of  the  pupil 
(Fig.  678)  and  pigment  deposits  (former  iritis). 


Fig.  678.--Complete,  urn-  Fig.  679.— Opacities  in  the  lens  (partial 

hilicoid  occlusion  of  the  cataract),  contrasting  as  black  spots  in  the 

Qupil.  pupil  illuminated  with  the  ophthalmoscopic 

mirror. 

The  condition  of  the  lens  should  be  investigated — ^whether  it  is 
clear  or  opaque  (cataract,  partial  or  total,  acquired  or  congenital, 
and  of  many  possible  varieties). 

The  observation  of  a  grayish  hue  of  the  pupil,  very  commonly 
present  in  old  persons,  yet  unaccompanied  by  opacity,  should  not 
lead  to  the  conclusion  that  cataract  exists.  The  pupil  does  not  seem 
to  be  of  a  clear  black  when  looked  at  by  daylight;  yet  the  lens  is 
found  to  be  clear  on  closer  examination. 

Aside  from  the  cases  in  which  there  is  advanced,  intense,  and 
unquestionable  opacity,  as  seen  on  lateral  illumination  with  a  lamp 
and  by  use  of  the  hand  lens,  the  physician  should  not  commit  him- 
self until  after  he  has  illuminated  the  interior  of  the  eye  with  the 
ophthalmoscopic  mirror,  which,  after  dilatation  of  the  pupil  with  2 
per  cent,  cocaine  (and  waiting  20  minutes),  will  reveal,  contrasting 
in  black  against  the  red  background  of  the  eye,  the  slightest  lens 


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EYES,  DISORDERS  OF  THE.  903 

opacities  (Fig.  679)  of  incipient  cataract — ^not  yet  sufficiently 
marked  to  prevent  reading  and  writing. 

Without  being  trained  in  examining  the  retina  and  optic  nerve, 
the  practitioner  may  employ  for  this  purpose  the  mirror  and  any 
available  source  of  light,  the  patient  being  meanwhile  shaded  by  a 
screen  (Fig.  664). 

The  patient  should  be  requested  to  move  his  eye  about  while 
the  light  is  being  directed  at  him  with  the  mirror;  very  often  the 
pupillary  area  will  appear  filled  with  moving  objects,  floating 
particles,  detached  retina  bobbing  about  a  dislocated  and  mov- 
able lens,  crystals,  etc. 

Som«  eyes  that  prove  unilluminable,  the  pupil  continuing  to 
exhibit  an  ebony  black  appearance,  are  the  seat  of  tumor,  hemor- 
rhage, black  cataract,  etc. 

Limiinous  Pupil. — Where,  in  a  child,  the  pupil  presents  a 
glowing,  illuminated  (cat's  eye)  appearance,  there  is  frequently 
present  a  glioma  of  the  retina,  a  tumor  which  destroys  the  eye 
and  is  generally  fated  in  spite  of  enucleation. 

B.  Disorders  Unattended  with  External  Lesions,  thoagh  some- 
times Attended  with  Internal  Lesions,  Visible  only  by  Endoscopy. 
— Pain. — Pain  in  or  near  the  eye,  without  any  visible  pathologic 
condition,  must  be  differentiated  from  headache  and  migraine — 
though  these  are  often  present  in  addition. 

After  having  carefully  investigated  (by  palpation,  etc.)  whether 
the  pain  is  not  the  result  of  some  inflammatory  condition  which  is 
not  yet  superficially  manifest  (beginning  stye,  keratitis,  iritis^  over- 
looked foreign  body  beneath  the  lid  or  in  the  cornea)  or  of  increased 
intraocular  tension  {glaucoma),  the  physician  should  proceed  to 
eliminate  simple  migraine  and  especially  ophthalmic  migraine  with 
scintillating  scotoma  and  images  of  luminous  bands,  sometimes  with 
transient  hemianopia. 

He  should  next  think  of  facial  neuralgia  (making  pressure  over 
the  points  of  emergence  of  the  trifacial  branches  about  the  orbit) 
and  tic  douloureux ;  a  prospective  eruption  {herpes  zoster)  should 
be  kept  in  mind.  Neurasthenic  and  hypochondriac  patients  some- 
times experience  for  years  paroxysms  of  ocular  neuralgia  (delayed 
recurrent  keratalgia)  in  eyes  that  have  previously  been  subjected 


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904  SYMPTOMS, 

to  some  form  of  traumatism,  often  of  trifling  degree  (erosion  from 
contact  with  the  finger  nail  or  with  a  house  plant,  etc.).  Very  care- 
ful examination  is  necessary  in  such  cases. 

Pain  after  Close  Work. — Refractive  disorders  {astigmatism, 
hyperopia,  presbyopia,  and  sometimes  marked  myopia)  should  be 
excluded.  Headache  of  this  type,  which  is  very  common,  demands 
the  wearing  of  glasses,  in  conjunction  with  general  treatment  of 
coexisting  disturbances  (neurosis,  anemia,  intoxication,  etc.). 
Latent  strabismus  and  insufficiency  of  and  excessive  strain  in  con- 
vergence, as  well  as  slight  forms  of  diplopia,  may  likewise  be  the 
cause  of  the  pain. 

Miscellaneous  Visual  Disturbances. — ^Impaired  Vision  on  One 
or  Both  Sides. — The  patient  complains  of  blurred  vision  with 
one  or  both  eyes ;  or  he  may  be  unable  to  see  anything,  not  even 
light ;  yet  the  eyes  seem  normal. 

Where  the  patient  is  still  able  to  see  a  few  objects  he  should  be 
placed  5  meters  away  from  the  test  card  (Fig.  650),  with  the  latter 
well  illuminated  and  the  patient's  back  to  the  light,  and  his  ability 
to  distinguish  some  of  the  letters  ascertained. 

The  observer  may  hold  the  perforated  disc  (stenopeic  open- 
ing) in  front  of  each  eye  in  turn,  the  other  eye  being  meanwhile 
covered;  or  a  card  with  a  pinhole  may  be  substituted.  If  vision 
is  improved  thereby,  some  error  of  refraction  (myopia,  hyper- 
opia, or  astigmatism)  is  present,  with  or  without  disease  of  the 
fundus,  and  the  patient  will  derive  more  or  less  benefit  from  the 
use  of  concave,  convex,  or  cylindric  lenses,  which  the  practi- 
tioner may  try  to  select  if  they  are  available,  but  accurate  pre- 
scription of  which  requires  the  intervention  of  the  eye  specialist. 

Where,  on  the  other  hand,  the  stenopeic  opening  reduces 
vision,  some  disease  of  the  fundus  exists,  or  an  amblyopia  due  to 
a  post-ocular  cerebral  or  neuropathic  disorder. 

Here  again  an  examination  by  the  specialist  is  necessary  to 
settle  the  question  and  determine  which,  among  the  numerous 
possible  disorders,  has  been  the  cause  of  the  blindness  or  visual 
impairment  in  one  or  both  eyes. 

Nyctalopia. — Improvement  of  vision  as  the  light  of  day  dimin- 
ishes, occurring  in  subjects  who  are  dazzled  in  broad  daylight  (alco- 


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EYES,  DISORDERS  OF  THE,  905 

holic  amblyopia,  some  cases  of  cataract,  certain  diseases  of  the  fun- 
dus, etc.). 

Hesperanopia. — This  term,  proposed  by  the  writer,  and  more 
accurate  than  the  old  term  hemeralopia  (which  is  etymologic- 
ally  nonsensical),  refers  to  a  sudden  reduction  of  vision  as  the 
light  of  day  declines.  The  subject  then  becomes  nearly  blind.  There 
are  cases  of  transitory  hesperanopijsi  (in  overworked  or  poisoned  in- 
dividuals and  disorders  of  the  liver  and  kidneys)  and  cases  of  per- 
manent hesperanopia,  already  present  in  childhood  (retinitis  pig- 
mentosa chronica).  It  is  essential  to  have  the  eye-grounds  ex- 
amined in  such  cases,  particularly  where  the  subject  is  a  child  who 
seems  helpless  and  has  difficulty  in  getting  about  towards  evening 
(crepuscular  amblyopia). 

Phosphenes. — This  symptom  is  an  evidence  of  retinal  irrita- 
tion, which  is  sometimes  of  serious  degree  in  myopic  subjects;  it 
may  be  a  forerunner  of  detachment  of  the  retina.  It  is  also 
present  in  a  variety  of  affections  of  the  retina  and  choroid.  There 
are  even  blind  subjects  who  continue  to  be  inconvenienced  by 
luminous  visions.  The  condition  should  not  be  confounded  with 
the  paroxysm  of  ophthalmic  migraine  with  scintillating  scotoma. 

Muscae  volitantes. — These  are  most  commonly  present  in 
myopia,  in  overworked  individuals,  and  in  neurasthenia.  They 
may  sometimes  be  present  for  years,  or  even  indefinitely,  irre- 
spective of  normal  vision.  Examination  of  the  fundus  will  show 
whether  the  lens,  vitreous  body,  and  internal  membranes  remain 
in  a  normal  condition  and  will  permit  of  making  a  more  accurate 
prognosis. 

Disturbances  of  Color  Vision. — These  may  be  temporary,  as  in 
alcoholic  and  tobacco  amblyopia,  affections  of  the  retina  and  choroid, 
diabetes,  etc.,  or  congenital,  as  in  Daltonism  (color  blindness;  to 
be  excluded  by  special  tests). 

Colored  Vision. — Erythropsia  (red  vision)  in  neuroses,  after 
cataract  extraction,  etc.    Various  phenomena  of  colored  audition. 

Iridescent  Vision. — When  a  patient  sees  the  colors  of  the  rain- 
bow when  looking  at  an  open  flame  (candle),  the  intraocular  ten- 
sion should  always  be  tested,  this  symptom  being  often  an  accom- 
paniment of  glaucoma. 


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906  SYMPTOMS. 

Photophobia. — Where,  in  the  presence  of  photophobia,  the  cor- 
nea and  iris  are  both  found  normal,  a  disorder  of  the  retina  or  of 
the  lens  (cataract)  is  to  be  feared.  Some  neurasthenics,  however, 
are  subject  to  paroxysms  of  photophobia  although  vision  and  the 
eye  are  and  remain  normal. 

Vertigo. — One  should  first  of  all  determine  whether  the  patient 
is  not  suffering  from  double  vision;  the  writer's  advice  has  fre- 
quently been  sought  on  account  of  vertigo  attributed  to  the  stomach, 
previously  treated  by  diet  and  antidyspeptic  remedies,  where  the 
actual  cause  was  paralysb  of  a  nerve  or  muscle  of  the  eye. 

JVhen  a  patient  complains  of  vertigo,  the  physician  should  close 
one  of  the  patient's  eyes,  which  will  cause  the  vertigo  to  disappear 
at  once  if  some  form  of  ocular  paralysis  is  responsible. 

Vertigo  also  occurs  in  connection  with  deep-seated  disorders  of 
the  eye,  with  unsuitable  glasses,  with  overstrong  lenses,  and  with 
general  disorders. 

Diplopia  and  Polyopia. — One  should  at  once  ascertain,  by 
having  the  patient  close  one  eye,  whether  he  is  not  seeing  double 
with  a  single  eye;  in  some  neuroses,  indeed,  and  especially  in  in- 
cipient cataract,  there  occurs  a  monocular  diplopia  or  polyopia,  the 
patient  seeing,  e.g.,  seven  or  eight  gas  jets  where  there  is  but  one, 
with  one  of  his  eyes. 

Where  the  subject  has  to  use  both  eyes  to  see  double,  paralysis 
or  contracture  of  some  muscle  exists,  or  there  may  be  a  mechanical 
deviation  of  the  eye  on  account  of  orbital  disease  (tumor  or 
abscess). 

A  person  suffering  with  diplopia  generally  shows  a  faulty  posi- 
tion of  the  eye,  due  to  loss  of  power  of  one  muscle  and  attraction 
of  the  eye  by  the  normally  antagonistic  muscle.  Ordinary  strabis- 
mus, or  squint,  does  not  cause  diplopia,  and  in  spite  of  the  faulty 
position,  each  eye,  when  examined  independently,  is  capable  of 
rotating  in  all  directions;  paralysis  is  not  present  under  these  cir- 
cumstances. Faulty  position  and  diplopia  are  the  result  of  the 
physiologic  peculiarities  of  the  nerves  and  muscles  of  the  eye  (Fig. 
680).  In  paresis  with  but  slight  muscular  weakness,  however,  or 
where  a  single  muscle,  such  as  the  inferior  oblique  or  inferior  rec- 
tus, is  weak,  the  faulty  position  is  almost  imperceptible,  and  the 
localizing  diagnosis  is  based  on  the  diplopia  alone. 


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EYES,  DISORDERS  OF  THE.  907 

It  is  well  to  place  a  red  glass  before  an  eye  in  order  to  find  out 
with  which  eye  the  fed  image  is  seen  (crossed  diplopia— or  hotnony- 
mous  when  on  the  same  side),  and  to  hold  a  lighted  candle  2  meters 
in  front  of  the  patient. 

Objective  and  Subjective  Signs  of  Paralyses. — Complete 
paralysis  of  the  oculomotor  nerve  (3d  pair)  which  supplies  both 
the  superior,  inferior,  and  internal  recti,  the  inferior  oblique,  and 
the  constrictor  of  the  pupil  and  levator  palpebral  superioris, 
results  in : 

Ptosis,  mydriasis,  paralysis  of  accommodation  {reading  being 
impossible  except  with  a  strong  convex  lens),  divergent  strabismus, 
and  horizontal  crossed  diplopia,  i.e.,  a  condition  in  which  the 
false  image  is  projected  to  the  side  opposite  that  of  the  paralyzed 
eye. 

]  Sup.  rectus 
Sup.  oblique 


Int.  recttiil^.   ^'  ■■^iw  Ext.  rectni 

Inf.  oblique 

Inf.  rectus 

Fig.  680.— Muscles  of  the  Ufi  eye,  with  their  respective  distances 
from  the  cornea  and  functions. 

Internal  rectus,  adductor ;  external  rectus,  abductor ;  inferior  rec- 
tus, depressor,  inward  rotator,  and  adductor;  superior  rectus,  elevator, 
inward  rotator,  and  adductor;  superior  oblique,  with  its  pulley,  depres- 
sor, inward  rotator,  and  abductor;  inferior  obuque,  elevator,  outward 
rotator,  and  abductcM*. 

Paraljrsis  of  the  abducens  (6th  pair),  which  supplies  the  ex- 
ternal rectus  or  abductor  muscle,  results  in  convergent  strabismus, 
with  the  false  image  on  the  same  side  (horizontal  homonymous 
diplopia). 

Paralysis  of  the  patfaeticus  (4th  pair),  which  supplies  the 
superior  obUque  or  inward  rotator,  depressor,  and  abductor 
muscle,  results  in  vertical  homonymous  diplopia,  with  deviation 
upward  and  toward  the  unaffected  side. 


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908 


SYMPTOMS, 


Lastly,  there  occur  instances  of  independent  paralysis  of  a 
nerve-branch  supplying  but  one  of  the  muscles  innervated  by  the 
oculomotor,  either  in  one  eye  or  in  both,  and  in  which  determina- 
tion of  the  exact  type  of  involvement  is  a  complex  matter.  There 
being  no  distinct  defect  of  position,  the  diagn'osis  is  gradually  elab- 
orated through  analysis  of  the  existing  diplopia.  By  moving  the 
candle  about  before  the  eyes,  at  first  horizontally  and  then  vertically, 
the  head  meanwhile  being  kept  motionless,  a  progressive  widening 
of  the  distance  between  the  images  is  noted  (in  the  direction  of  the 
paralyzed  muscle). 

Puech  and  Fromaget  clearly  summarize  the  significance  of  dip- 
lopia in  the  table  reproduced  below.    Examination  shows,  indeed : 

1.  In  //i^  direction  in  which  the  function. o/  the  affected  muscle 
is  normally  exerted: 

False  image,  increase  of  the  diplopia  and  progressive  increase 
of  the  distance  between  the  images,  limitation  of  movement,  an 
altered  direction,  of  the  face  and  the  inclination  of  the  head, 

2.  In  the  direction  opposite  to  the  physiologic  function  of 
the  affected  muscle: 

Faulty  position  of  the  eye  and  diminution  of  the  diplopia. 
Later,  after  having  precisely  determined  whether  the  diplopia  is 
of  the  HOMONYMOUS  or  CROSSED  variety,  the  following: 


A. — Homonjrmous  Diplopia.                                     | 

Paralyzed 
Muscle. 

Affected  Eye. 

1.  In  the  horizontal  direc- 

External 

The    distance    between    the 

tion  : 

rectus. 

images   steadily  increases 
on  the  paralyzed  side. 

f  above: 

Inferior 

The    upper    image    corre- 

2. In  the  vertical    1 

oblique. 

sponds  to  the  affected 

direction: 

eye. 

I  below: 

Superior 

The    lower    image    corre- 

oblique. 

sponds  to  the  affected  eye. 

B. 

—Crossed  Dip 

miopia. 

1.  In  the  horizontal  direc- 

Internal 

The    distance    between    the 

tion: 

rectus. 

images    increases    in    the 
direction     of    the    motor 
action    of    the    paralyzed 
muscle,  and,  hence  toward 
the  normal  eye. 

2.  In  the  vertical    f  ^^^^^• 
direction:                (  below: 

Inferior 
rectus. 

The  upper  image  is  that  of 
the  affected  eye. 

Superior 

The  lower  image  is  that  of 

rectus. 

the  affected  eye. 

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EYES,  DISORDERS  OF  THE.  909 

The  general  practitioner  scarcely  needs  to  undertake  such  in- 
vestigations:  He  may  Hmit  himself  to  the  immediate  diagnosis  of 
the  more  easily  recognizable  forms  of  paralysis  with  obvious  devia- 
tion and  muscular  weakness — those  involving  the  oculomotor  and 
abducens — and  to  blind-folding  one  eye  to  abolish  diplopia  and  ver- 
tigo ;  in  any  kind  of  paralysis  he  should  then,  without  further  ado, 
proceed  with  an  investigation  of  the  cause  and  with  causal 
treatment. 

A  consultation  with  the  specialfst  later  will  determine  the  fur- 
ther details  of  the  condition,  and  will  also,  if  the  occasion  exists, 
differentiate  paralysis  from  contracture,  which  is  much  less 
common. 

Ophthalmoplegia. — Diffuse  forms  of  paralysis,  congenital  or 
acquired,  inherited  and  familial,  oi  the  neri'es  and  muscles  of  the 
eye.  " 

Where  all  the  centers  (progressive  nuclear  ophthalmoplegia) 
of  the  motor  nerves  to  the  eye  fail\in  succession,  the  patient, 
with  his  drooped  lids,  with  difficulty  raised  by  wrinkling  the 
forehead,  and  his  eyeballs  fixed  in  their  orbits,  is  said  to  present 
the  ophthalmoplegic  Hutchinson's  facies. 

Ophthalmoplegic  migraine  (with  sudden  and  recurrent  failure 
of  all  the  muscles)  is  frequently  a  benign  condition,  from  which 
recovery  occurs  withifi  a  fe%v  days-;  in  some  instances,  however,  it 
is  attended  with  dangerous  intracranial  disturbances,  infectious  or 
neoplastic. 

Paralysis  of  Associated  Movements. — Cases  occur  in  which, 
in  both  eyes,  whereas  other  movements  of  the  eyes  can  still  be  made, 
there  exists  a  paralysis  of  the  associated  movements,  vertical 
(paralysis  of  ele7'ation  or  of  depression  of  the  eyeball)  or  lateral, 
owing  to  disease  of  the  association  fibers  connecting  the  centers  and 
convolutions.  An  ophthalmo-neurologic  consultation  should  be  held, 
as  in  any  other  form  of  paralysis,  to  determine  the  cause  and  seat 
of  the  lesion.  A  complete  examination  of  the  patient  should  be 
made,  with  determination  of  any  co-existing  syndromes,  such  as 
that  of  Millard-Gubler  (pontine  lesion  with  paralysis  of  the  ab- 
ducens and.  facial  on  the  same  side  and  hemiplegia  on  the  opposite 
side)  and  that  of  Weber  (peduncular  lesion  with  oculomotor  paral- 


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910  SYMPTOMS. 

ysis  and  opposite  paralyses  of  the  face  and  extremities) — syndromes 
to  be  referred  to  again  later  in  this  work. 

Abnormalities  of  the  Visual  Field. — (a)  Peripheral  con- 
traction.— ^This  may  be  concentric  or  excentric  and  monocular  or 
binocular. 

In  glaucoma,  the  patient  presents,  if  the  disease  is  of  long 
standing,  an  excentric  and  internal  contraction  of  the  visual  field. 


Fig.  681. — Course  of  the  optic  nerve-paths  (with  their  direct  and 
crossed  fasciculi)  from  the  eye  to  the  brain;  c,  c',  cuneus;  a,  b,  decussa- 
tion of  the  optic  tracts  (chiasm). 

He  is  unable  to  see  an  object  placed  in  front  of  his  eye,  and  sees  it 
only  when  it  is  moved  toward  the  temporal  region. 

An  extreme  degree  of  concentric  contraction  (some  fieMs 
are  only  of  the  size  of  a  dime)  may  be  observed  in  retinitis 
pigmentosa,  in  optic  atrophy — e.g.,  in  tabes — and  in  various  in- 
stances of  amblyopia  unattended  with  ophthalmoscopic  lesions 
(hystero-pithiatism,  etc.). 


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EYES,  DISORDERS  OF  THE,  911 

(ft)  Bilateral  contraction  with  obscuration  of  one-half 
OF  THE  VISUAL  FIELD:  Hemianopia.^ — In  hemianopia  there  is 
complete  normalcy  of  the  eye-grounds  and  inspection  of  Fig.  681 
will  show  what  the  homonymous  or  homolateral  (on  the  same  side) 
and  the  heteronymous  varieties  of  hemianopia  consist  of. 

Central  vision  is  retained  and  the  patient  is  able  to  read. 

Where  hemianopia  is  suspected  on  account  of  the  position  of 
the  patient,  who  turns  his  head  in  such  a  manner  as  to  direct  toward 
external  objects  that  portion  of  the  eye  which  is  still  functionally 
available,  and  ot\  account  of  the  absence  of  lateral  vision  of  per- 
sons, o£  dishes  on  the  table  (the  patient  sees  his  glass,  but  nothing 


Fig.  682. — Right  homonymous  hemianopia  the  result  of  disease  of  the 
left  optic  tract  at  d  (Fig.  681)  or  of  its  cerebral  origin,  c. 

which  adjoins  it),  or  of  the  word  following  that  which  he  is  read- 
ing, it  is  easy  to  localize  the  intracranial  situation  of  the  lesion 
responsible.  This  can  be  done  by  copying  the  accompanying  dia- 
gram and  by  interrupting  the  optic  fibers,  either  between  the  brain 
and  the  optic  chiasm,  at  d,  for  example,  showing  that  there  is 
homolateral  homonjrmous  hemianopia,  right-  or  left-  sided  (Fig. 
682),  or  in  the  region  of  the  chiasm,  at  the  crossed  or  non-crossed 
fasciculi,  heteronymous  or  heterolateral,  binasal  or  bitemporal 
hemianopia  (Fig.  683).  There  also  occur  complicated  cases,  with 
patch-like  defects,  atypical  forms,  double  hemianopia,  etc. 


1  This  condition  has  often  been  termed  hemio^io  or  hemianopsia;  the 
writer  prefers  to  substitute  for  these  the  term  hemianopia,  which  expresses 
the  gap  in  the  field  of  vision  and  conforms  in  its  termination  to  the  cus- 
tomary, general  nomenclature,  as  in  diplopia,  hy per mtir a pia,  nyctalopia. 
etc 


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912  SYMPTOMS. 

For  practical  purposes,  homonymous  hemianopia  (Fig.  682)  is 
nearly  always  the  result  of  a  cortical  lesion  in  the  occipital  region 
and  cuneus  (softening,  syphilitic  arteritis,  hemorrhage,  etc.).  It  is 
generally  accompanied  by  apoplectic  strokes,  hemiplegia,  aphasia,  or 


Fig.  683. — Bi-temporal  heteronymous  hemianopia    (in  acromegaly) ,  due 
to  pressure  on  the  optic  chiasm  (crossed  fasciculi). 

psychic  blindness.     Consultation  with  the  ophthalmologist  and  the 
neurologist  is  quite  indispensable. 

Cro.y.y^rf  hemianopia  of  the  bitemporal  type  (Fig.  683)  is  fre- 
quently  the   result   of  acromegaly,   the   enlarged   pituitary   body 


Fig.  684. — Central  scotoma  in  an  alcoholic  subject. 

exerting  pressure  on  the  optic  chiasm  (a,  b) ;  whence  a  characteris- 
tic form  of  visual  field  (see  Eye  conditions  met  with  in  general 
diseases), 

(c)  ScoTOMATA. — The  patient  complains  of  spots  or  gaps  in  the 
CENTRAL  or  PARACENTRAL  PORTIONS  of  the  visual  field,  and  not  at 


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EYES,  DISORDERS  OF  THE,  913 

its  periphery.  Central  scotomata  (Fig.  684)  indicate  defective  func- 
tioning of  the  macular  region  of  the  retina  and  are  the  most  annoy- 
ing to  the  patient.  In  some  cases  they  are  due  to  disorders  of  the 
fundus,  in  others  to  special  disturbances,  among  others  alcoholic 
and  tobacco  amblyopia.  They  impart  the  sensation  of  a  spot  or 
hole,  a  gap  (the  patient  failing  to  see  certain  words  in  a  printed 
line),  or  of  poor  color  perception.  They  should  not  be  confused 
with  hemianopic  defects. 

In  all  visual  disturbances,  with  or  without  obvious  pathologic 
change,  one  should  keep  in  mind  the  possibility  of  simulation, 
which  the  specialist  may  be  called  upon  to  settle,  in  conjmon  with 
artificially  induced  disorders  of  the  eye. 


III.  THE  PRINCIPAL  EYE  CONDITIONS  MET  WITH 
IN  GENERAL  DISEASES. 

The  majority  of  diseases,  whether  acute  or  chronic,  may  be  at- 
tended at  some  time  in  their  course,  sometimes  even  before  their 
manifest  onset,  and  sometimes  during  or  even  after  convalescence, 
by  some  organic  or  functional  disturbance  of  the  eye. 

It  may  happen,  indeed,  that  an  ocular  disturbance  appears  a  long 
period  ahead,  as  the  initial  manifestation  of  a  disorder  that  is  to  be- 
come obvious  and  generalized  only  a  long  time  after.  Iritis  may  be 
the  initial  localization  of  a  gouty  or  rheumatic  state  which  will  sub- 
sequently involve  other  regions ;  retinal  hemorrhages  sometimes  pre- 
cede albuminuria,  etc.  The  eye  condition  is  thus  the  harbinger  of  a 
latent  general  disease.  In  these  cases  a  complete  examination  of  the 
eye  patient  and  inquiry  into  his  family  history,  together  with  a 
thoroughgoing  plan  of  treatment,  calculated  to  improve  all  bodily 
functions  and  all  conditions  that  might  be  considered  subnormal, 
constitute  "the  best  thing  to  do"  while  awaiting  the  conclusive  evi- 
dence to  be  afforded  by  the  subsequent  course  of  events. 

Again,  while  several  general  diseases  are  attended  by  well- 
known  and  customary  eye  complications,  these  do  not  always  occur; 
or  there  may  occur  others,  of  very  varied  type  and  much  more  un- 
expected. To  cite  one  example:  Diabetic  cataract  is  familiar  to 
all,  but  many  diabetics  do  not  show  it  or  suffer  exclusively  from 

58 


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914  SYMPTOMS, 

iritis,  amblyopia,  and  less  ordinary  eye  affections;  yet  these  are 
characteristic  to  an  ophthalmologist. 

Finally,  assuming  a  loftier  view,  one  may  recall  how  the  assimi- 
lation and  sometimes  the  identification,  in  general  and  compara- 
tive MEDICINE,  of  the  ocular  disturbances — regional  states  com- 
parable to  those  observed  in  other  portions  of  the  body  and  in  other 
organs — is  a  matter  of  compelling  interest  and  affords  a  solution 
for  many  ophthalmologic  or  general  problems  which  could  not  be 
solved  by  men  restricted  to  their  own  special  field,  medical  or  sur- 
gical. As  far  as  the  writer  is  concerned,  he  has  always  believed 
and  taught,  through  the  last  twenty-five  years,  that  an  eye  condi- 
tion is,  as  a  rule,  in  all  respects,  even  as  regards  treatment,  an  oculo- 
general  syndrome.  There  is  no  doubt  but  that  the  other  specialties 
would  derive  benefit  from  a  similar,  daily  confrontation  of  observa- 
tions, as  well  as  from  a  like  joint  conclusion  as  regards  the  etiology 
and  treatment. 

Diseases  of  the  Kidneys. — Many  cases  of  Bright's  disease  re- 
main free  of  ocular  disturbances  throughout  One  should  be  wary 
as  regards  coincident  disorders  (hyperopia,  myopia,  etc.),  non- 
pathognomonic  complications  such  as  iritis,  cataract,  paralyses  of 
eye  muscles,  etc.,  and  those  due  to  a  concomitant  disease,  and 
should  have  a  complete  examination  of  the  eyes  made  in  these  cases. 

Edema  of  the  lids,  bilateral  and  of  varying  degree  (less  common 
than  is  generally  believed),  retinitis  with  hemorrhages  and  white 
spots,  accompanied  by  edema  of  the  optic  nerve,  are  more  character- 
istic. The  patient  has  difficulty  in  reading  or  cannot  read  at  all,  but 
can  still  get  about.  ^  Blindness  is  rare,  unless  some  complication 
occurs  such  as  detachment  of  the  retina,  glaucoma,  etc.  The  eye 
disease  is  recovered  from,  however,  only  if  the  nephritis  is  likewise 
cured. 

Retinitis  sometimes  precedes  the  appearance  of  albuminuria 
{prealbuminuric  retinitis)  in  patients  with  arteriosclerosis  and  high 
blood-pressure. 

It  occurs  frequently  in  combined  glycosuria  and  albuminuria. 

Retinitis  with  white  spots  is  rather  the  result  of  the  azotemic 
condition ;  edematous  neuro-retinitis,  of  chloridemia,  and  the  retinal 
hemorrhages,  of  high  blood-pressure.  These  several  types,  while 
sometimes  present  independently,  are  rather  usually  combined. 


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EYES,  DISORDERS  OF  THE.  915 

Thus,  the  patient  almost  never  becomes  blind,  but  in  the  many- 
cases  of  incurable  nephritis  the  appearance  of  retinitis  is  an  un- 
favorable omen.  Statistical  records  show  that  "ocular"  nephritics, 
with  few  exceptions,  die  sooner,  generally  not  surznving  longer  than 
two  years. 

Some  patients  with  albuminuria  and  high  blood-pressure  suffer 
attacks  of  transitory  amaurosis,  unaccompanied  by  disease  of  the 
eye-grounds  and  followed  by  return  of  vision. 

Diabetes. — Aside  from  retinal  hemorrhage  and  mixed  forms 
of  retinitis  (diabetes  with  albuminuria),  diabetic  patients  may 
suffer  from  cataract  of  different  varieties  (soft,  white,  and  bi- 
lateral in  young  subjects)  and  more  or  less  operable  under  local 
and  general  precautions;  acute  or  chronic  iritis;  hemorrhagic 
glaucoma;  amblyopia  with  central  scotoma  (of  the  toxic  type, 
similar  to  that  in  alcoholic  amblyopia) ;  optic  atrophy ;  paralysis 
of  the  motor  nerves  of  the  eye ;  rapidly  progressive  myopia,  etc. 
The  urine  should  always  be  examined  in  eye  disease,  especially 
when  deep-seated. 

Gout. — Iritis,  sometimes  hemorrhagic;  scleritis  or  sclero- 
tenonitis. 

Arthritis  Deformans. — Iritis,  iridochoroiditis,  scleritis,  or 
anterior  sclerochoroiditis. 

Diseases  of  the  Heart  and  Vessels. — (a)  Heart  Disorders. — 
In  the  last  stage,  edema  of  the  lids,  the  optic  nerve,  and  the  orbit ; 
sometimes  retinal  hemorrhages,  glaucoma,  and  hemorrhagic  glau- 
coma. Embolism  and  thrombosis  of  the  retina  in  chronic  endocar- 
ditis, causing  sudden  blindness  on  one  side,  which  is  often  per- 
manent 

Pulsation  of  the  retinal  vessels  is  frequently  present  in  aortic 
insufficiency  and  at  times  in  mitral  insufficiency. 

Spontaneous  subconjunctival  ecchymoses,  sometimes  preceding 
cerebral  hemorrhage,  occur  in  arteriosclerosis  and  high  blood- 
pressure. 

Inequality  of  the  pupils  is  observed  in  aortic  aneurysm  (pressure 
on  the  sympathetic). 

(b)  Major  hemorrhages. — Certain  profuse  hemorrhages,  as 
in  hematemesis,  intestinal  hemorrhage,  metrorrhagia,  epistaxis, 
wounds,  etc.,  lead  either  at  once  or  later,  severed  days  after  the  loss 


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916  SYMPTOMS. 

of  blood,  to  bilateral  disturbances  of  vision  which  may  go  on  to 
blindness,  partial  or  complete,  curable  or  incurable  (complete  or 
partial  optic  atrophy). 

(c)  Blood  disturbances. — A  thorough  examination  of  the  blood 
by  the  latest  methods  is  of  exceedingly  great  importance  in  the 
majority  of  diseases  of  the  eyes  and  their  adnexa,  both  as  regards 
diagnosis,  prognosis,  and  treatment.  One  should  not  be  too  positive 
in  concluding  that  syphilis  is  absent  where  thej  Bordet-Wassermann 
reaction  is  negative;  in  the  writer's  experience,  intensive  antisyph- 
ilitic  treatment  has  often  brought  about  a  recovery  undeii  these  cir- 
cumstances in  a  wide  variety  of  eye  disorders.  An  investigation  for 
syphilis  should  always  be  made,  even  in  the  presence  of  manifest 
tuberculous  disease,  which  is  often  combined  with  syphilis. 

A  study  of  the  blood  should  be  made  in  chlorotic  anemia,  leu- 
kemia, Hodgkin's  disease,  hemophilia,  etc.,  where  localized  ocular 
involvement  exists. 

Various  Infectious  Diseases. — Eruptive  fevers. — Measles. — 
Conjunctival  hyperemia,  chiefly  in  type  (like  pterygium)  ;  styes,  ab- 
scess of  fhe  lid,  pustular  keratoconjunctivitis,  blepharitisi  or  dacryo- 
cystitis. 

Small-pox  and  Chicken-pox. — Pustular  formations  in  or  about 
the  eye ;  seriou§  corneal  ulcers  and  abscesses;  iritis,  iridochoroiditis, 
or  optic  neuritis ;  orbital  abscess ;  chronic  ulcerative  blepharitis  with 
misplaced  lashes.  Persons  in  whom  a  vaccinal  eruption  is  at  its 
height  should.be  cautioned  not  to  touch  their  eyes  with  their  fingers 
(vaccine  blepharitis  and  keratitis). 

Scarlet  fever. — Conjunctivitis,  sometimes  with  false  mem- 
branes; dacryocystitis;  albuminuric  retinitis. 

Note. — In  all  eruptive  fevers  with  eye  or  lid  involvement  the 
physician  should  ascertain  daily,  with  the  lamp  and  hand  lens, 
the  exact  condition  of  the  cornea  and  pupillary  margin. 

Diphtheria. — Paralysis  of  accommodation  with  mydriasis;  the 
patient  is  unable  to  read,  unless  a  strong  convex  lens  of  +3  or  +4 
diopters  is  used,  or  a  1  per  cent,  solution  of  pilocarpine  nitrate  is 
instilled  and  he  waits  half  an  hour  for  its  effect.  Paralysis  of  eye 
muscles;  pseudomembranous  conjunctivitis. 

The  pupils  and  vision  should  always  be  examined  in  the  presence 
of  any  kind  of  sore  throat. 


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EYES,  DISORDERS  OF  THE.  917 

Grip. — ^Herpes  of  the  cornea,  transient  or  lasting;  iritis,  etc. 
Grip  initiates,  relights,  or  aggravates  the  majority  of  eye  disorders. 

Mumps. — Inflammation  of  the  lacrymal  glands  (dacryoadenitis)  ; 
conjunctivitis,  iritis,  or  optic  neuritis. 

Typhoid  fever. — Optic  neuritis,  paralysis  of  ocular  muscles,  etc. 

Malaria. — Obstinate  herpes  comeae,  iritis,  retinitis,  floating  par- 
ticles in  the  vitreous  humor,  optic  neuritis. 

Acute  and  recurrent  rheumatism. — Iritis,  scleritis,  or  sclero- 
tenonitis;  causal  role  in  other  eye  affections  more  doubtful. 

Erysipelas. — Abscess  of  the  lid;  dacryocystitis,  conjunctivitis, 
corneal  ulcer,  iritis,  optic  neuritis ;  phlebitic  orbital  infections.  Some- 
times a  (**curative")  erysipelas  causes  improvement  in  a  rebellious 
eye  affection  (granular  conjunctivitis,  leprosy,  etc.). 

Anthrax. — Malignant  pustule  and  edema  of  the  lids. 

Leprosy. — Leprous  nodules  of  the  lids,  conjunctiva,  or  cornea; 
iritis ;  paralysis  of  the  orbicularis  muscle. 

Tuberculosis. — Almost  any  of  the  syndromes — whether  inflam- 
matory or  in  nodular  foci — affecting  the  eye  and  its  adnexa  may  be 
of  tuberculous  origin.  One  should  exclude  or  detect  syphilis,  ac- 
quired or  congenital,  and  the  other  affections  frequently  present  in 
combination. 

Syphilis. — Chancre  of  the  lids  or  conjunctiva.  Pustules,  papules 
or  patches.  Gummas  and  syphilomas  of  the  lids,  conjunctiva,  lacry- 
mal sac,  lacrymal  gland,  orbit,  cornea,  sclera,  or  interior  of  the  eye 
(perforating  gumma  of  the  iris  and  ciliary  body).  Intraocular  in- 
flammatory states,  acute  or  chronic  (iritis,  choroiditis,  retinitis,  optic 
neuritis,  etc.).  Optic  atrophy,  with  or  without  tabes.  Paralysis  of 
oculomotor  muscles.  Frequent  anachronisms  in  the  various  mani- 
festations (early  tertiary  or  delayed  secondary  manifestations). 

Syphilis  in  its  acquired  or  congenital  forms  should  always  be 
looked  for  in  the  presence  of  ocular  disorders.  Any  of  the  afore- 
mentioned eye  conditions  may  be  met  with  in  congenital  syphilis, 
with  a  special  predilection,  however,  for  interstitial  keratitis,  chorio- 
retinitis, congenital  cataract,  buphthalmus  (infantile  glaucoma), 
strabismus,  and  nystagmus.  Tuberculosis  is  frequently  present  in 
association.  The  therapeutic  test  by  means  of  antisyphilitii  treat- 
ment— which  should  not  be  neglected  in  spite  of  the  results  of  the 


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918  SYMPTOMS. 

blood  or  other  tests,  whether  positive  or  negative— of tentimes  yields 
unexpected  benefit.. 

Mycoses. — A  definite  differentiation  of  these  disorders  from 
syphilis,  tuberculosis,  and  the  other  infections  of  the  eye  and  its 
adnexa  should  be  made. 

Diseases  of  the  Respiratory  Tract — (a)  Nose. — Dacryo- 
cystitis, lacrymal  stenosis  in  the  presence  of  rhinitis  and  ozena,  with 
or  without  serious  corneal  ulcers.  Adenoid  growths  are  often  pres- 
ent in  combination  with  follicular  conjunctivitis  (likewise  an 
adenoid  condition)  and  with  pustuloscrofulous  (or  phlyctenular  or 
impetiginous)  conjunctivitis.  Exophthalmus  may  be  produced  by 
extension  of  nasal  tumors. 

(fc)  Sinuses. — Many  ocular  and  periocular  conditions  develop 
in  sinusitis  (optic  neuritis,  iritis,  detachment  of  the  retina,  orbital 
abscess  and  orbitocranial  phlebitis,  paralysis  of  ocular  muscles,  etc.). 

Examination  of  the  nose  and  sinuses  is  imperative  in  most 
affections  of  the  eyes  and  especially  in  affections  of  the  lacrymal 
passages  and  orbit,  just  as  examination  of  the  eyes  is  necessary  in 
disorders  of  the  nasopharynx  and  sinuses. 

(c)  Larynx,  trachea,  bronchi,  and  lungs. — Pupillary  dis- 
turbances (mydriasis  or  myosis)  may  occur  in  cases  of  tumor  or 
enlarged  glands  through  paralysis  or  irritation  of  the  sympathetic 
(slight  ptosis,  enophthalmus,  and  myosis  in  Claude  Bernard's  syn- 
drome). Mydriasis  on  the  side  of  a  diseased  lung  (pleurisy,  pleu- 
ral pneumonia,  tuberculosis,  etc.)  is  rather  common.  Consumption 
generally  runs  its  course,  however,  without  any  special  eye  dis- 
turbances. 

Herpes  comeae,  iritis,  and  optic  neuritis  occur  in  influenza  and 
pneumonia. 

An  extensive  subconjunctival  ecchymosis  sometimes  occurs  in 
whooping-cough,  but  is  unattended  with  risk,  no  hemorrhage  in  the 
fundus  of  the  eye  taking  place. 

Diseases  of  the  Ears. — Iritis,  choroiditis,  optic  neuritis,  orbito- 
cranial phlebitis,  paralyses  of  ocular  muscles — especially  the  abdu- 
cens  distribution — are  met  with  in  otitis  and  mastoiditis ;  nystagmus, 
spontaneous  or  induced,  may  be  encountered. 

Diseases  of  the  Digestive  Tract. — (a)  Teeth  and  Mouth. — 
Infections,  such  as  orbital  abscess  and  phlebitis,  iridochoroiditis. 


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EYES,  DISORDERS  OF  THE.  g\g 

optic  neuritis  and  keratitis.  Mixed  or  reflex  complications  (neur- 
algia, amaurosis,  blepharospasm,  glaucoma,  paralyses  of  ocular 
muscles,  etc.).  Coexisting  disorders  may  be  exemplified  in  the 
oculodental  stigmata  of  congenital  syphilis,  rickets,  etc.  Mikulicz's 
syndrome,  involving  the  lacrymal  and  salivary  glands. 

(ft)  Esophagus. — Tumors,  resulting  in  Claude  Bemam's  syn- 
drome. 

(c)  Stomach  and  Intestine. — Enterogenous  autointoxication 
and  intestinal  infection  take  part  in  very  many  eye  disorders. 
Blindness,  transient  or  permanent  (optic  atrophy),  may  follow 
hematemesis  or  intestinal  hemorrhage.  Intraocular  metastases  of 
visceral  cancers.    Ocular  parasites  of  intestinal  origin. 

(d)  Liver. — Choroiditis,  chorioretinitis,  retinal  cirrhosis  (retin- 
itis pigmentosa  with  hesperanopia) ,  or  retinal  hemorrhages.  Xan- 
thoma of  the  lids,  conjunctival  icterus,  or  lithiasis  conjunctivae. 

Metastases  in  the  liver  are  frequent  in  melanosarcoma  of  the 
eye. 

Diseases  of  the  Skin. — ^Any  skin  disorder  may  occur  primarily 
or  secondarily  on  the  eyelids;  many  occur  likewise  on  the  conjunc- 
tiva and  even  on  the  cornea.  Similarly,  diseases  of  the  hair  may 
occur  in  the  eyebrows  and  eye-lashes. 

Blepharitis  ciliaris  or  marginalis  corresponds  to  the  various 
types  of  skin  disorder,  viz.,  eczema,  seborrhea,  folliculitis,  sycosis, 
etc.,  the  exact  nature  of  which  should  be  inquired  into  in  each  in- 
dividual case. 

Among  the  most  noteworthy  general  pathologic  conditions, 
special  mention  should  be  made  of  erythema  multiforme,  with  its 
huge  conjunctival  papules  directly  on  the  eyeball;  of  acute  cutaneous 
edema,  sometimes  alternating  with  acute  glaucoma — further  prov- 
ing that  acute  glaucoma  is  a  condition  of  acute  edema  occurring  in 
the  eye  and  associated  with  increased  intraocular  pressure  (A.  Ter- 
son),  and  of  pemphigus,  which  gradually  results  in  complete  fusion 
of  the  eyelids  with  the  immobilized  ocular  globe  (symblepharon). 

Diseases  of  the  Ductless  Glands. — (a)  Thyroid  gland, — ^Ex- 
ophthalmic goiter,  complete  or  fruste  (incomplete  or  truncated;  uni- 
lateral, dissociated,  etc.),  with  exophthalmus,  Graefe's  sign  (de- 
layed motion  of  the  upper  lid  when  the  patient  looks  down),  tachy- 
cardia and  tremor.    Sometimes  there  are  inequality  of  the  pupils, 


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920  SYMPTOMS. 

paralyses  of  ocular  muscles,  etc.  Reduction  of  pulse-rate  on  testing 
the  oculocardiac  refle?^. 

The  condition  of  the  cornea  should  be  watched  in  marked  exoph- 
thalntus  (the  cornea  being  examined  with  a  lamp  and  hand  lens)  in 
order  to  detect  any  incipient  ulceration  and  to  be  able  to  apply  the 
emergency  treatment  (tarsorrhaphy,  etc.). 

(&)  Adrenal  glands, — Asthenia  of  the  eyes,  etc. 

(c)  Pituitary  body. — Exophthalmus,  nystagmus,  and  paralyses 
of  ocular  muscles  in  conjunction  with  the  acromegalic  facies.  Pro- 
gressive optic  atrophy. 

The  fields  of  vision  should  always  be  tested — bitemporal  hemi- 
anopia  with  loss  of  the  two  outer  halves  of  the  visual  fields  on 
account  of  pressure*  on  the  two  crossed  fasciculi  of  the  optic  nerve 
at  the  optic  chiasm  (see  Fig.  683). 

(rf)  Testicles  and  ovaries. — Effects  on  the  eyes  may  be  of  the 
asthenic,  hypersthenic,  or  toxic  types, — ^to  be  determined  with  a 
varying  degree  of  probability  in  the  individual  case. 

Diseases  of  the  Reproductive  System. — (a)  Male. — Gonor- 
rheal ophthalmia,  direct  or  metastatic,  with  scleritis,  iritis,  optic 
neuritis,  or  dacryoadenitis. 

(fc)  Female. — Iridochoroiditis  and  deep-seated  infections  of 
metritic  origin,  following  the  menopause,  etc.  Menstrual  asthen- 
opia.   Optic  atrophy  following  profuse  metrorrhagia. 

Retinal  hemorrhages  and  neuroretinitis  during  pregnancy,  the 
nephritis  of  pregnancy  (sometimes  necessitating  induction  of  labor), 
or  lactation.  Pulsating  exophthalmus.  Metastatic  intraocular  sup- 
puration (puerperal  sepsis). 

Purulent  conjunctivitis  of  the  newborn.  Serious  accidents  to 
the  eyes  (exophthalmus  or  orbital  fracture)  due  to  use  of  the  for- 
ceps or  various  other  obstetrical  procedures. 

Diseases  of  the  Nervousi  System. — Hysteropithiatism. — Am- 
blyopia and  amaurosis,  with  sudden  blindness,  total  or  partial.  The 
eye-grounds  are  normal  and  the  pupillary  reflexes  are  preserved. — 
Concentric  contraction  of  the  visual  field  with  inversion  of  the  color 
fields.  In  some  instances,  anesthesia  of  the  conjunctiva,  blepharo- 
spasm, facial  hemispasm,  strabismus,  or  spasm  of  accommodation 
(special,  transient  myopia). 


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EVES,  DISORDERS  OF  THE.  921 

Examination  of  the  eyes  is  imperative,  to  obviate  confusion  (or- 
ganic disturbance  or  simulation).  , 

Neurasthenia. — Ocular  asthenia  (asthenopia)  while  at  work; 
muscae  volitantes,  ophthalmic  migraine,  or  periocular  neuralgia; 
transitory  contraction  of  the  visual  field  due  to  fatigue. 

Epilepsy. — Frequency  of  refractive  defects  and  eye  disorders, 
stigmata  of  inherited  syphilis,  alcohol  and  tobacco  amblyopia,  etc. 

iNsANiTY.-r-Attacks  of  ocular  hyperemia.  Auto-mutilation  of 
the  eye,  in  several  instances  extending  to  the  rapid  tearing  out  of 
both  eyes,  the  preliminary  incision  about  them  being  made  with  the 
sharp  finger  nails. 

Idiocy. — Stigmata  of  inherited  syphilis;  congenital  anomalies. 

Meningitis. — Mydriasis  or  myosis.  Optic  neuritis.  Irido- 
chorioretinitis.  Tubercles  of  the  choroid.  Paralyses  of  ocular 
muscles.    Total  or  partial  optic  atrophy.    Nystagmus.    Strabismus. 

Intracranial  thrombophlebitis. — Exophthalmus,  generally 
bilateral.    Paralyses  of  ocular  muscles.    Optic  neuritis. 

Encephalitis  of  various  types. — ^Lethargic  encephalitis,  among 
others,  exhibits  paralyses  of  the  ocular  muscles  in  successive  groups 
or  "waves;"  paralysis  of  associated  movements  (convergence); 
ptosis;  nystagmus. 

Hydrocephalus. — Optic  neuritis  and  atrophy;  paralyses  of 
ocular  muscles;  nystagmus  and  strabismus.  Coexisting  signs  of 
congenital  syphilis  or  tuberculosis. 

Brain  softening,  cerebral  hemorrhage,  etc. — Amblyopia; 
word  blindness;  hemianopia,  usually  homonymous,  permitting  of 
localization  of  the  disease  in  the  hemisphere  opposite  to  that  of  the 
field  defects  (see  Fig.  682). 

Tumors. — Edema  and  venous  congestion  of  the  optic  nerve 
owing  to  increased  intracranial  pressure.  Paralyses  of  ocular 
muscles.  Hemianopia.  These  signs,  while  frequently  present,  may 
be  lacking  or  present  with  conditions  other  than  tumor.  They  con- 
firm the  diagnosis  of  endocranial  tumor,  but  seldom  suffice  in  them- 
selves to  localise  it. 

Involvement  of  the  cerebellum,  peduncles,  or  pons. — Syn- 
dromes of  Millard-Gubler  or  of  Weber  (p.  909),  in  conjunction  with 
other  localizing  neurologic  syndromes ;  optic  neuritis. 


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922  SYMPTOMS. 

Myelitis. — Optic  neuritis  (optic  neuromyelitis),  sometimes  pre- 
ceding the  myelitis. 

Tabes  dorsalis. — ^Argyll-Robertson  pupil;  pupillary  inequality; 
frequently  myosis.  Irregularity  of  the  pupillary  outline  (oblique- 
ovaloid  pupil  of  A.  Terson).  Sclerous  atrophy  of  the  optic  nerve, 
as  yet  incurable  and  becoming  bilateral  in  spite  of  the  latest  forms 
of  treatment.  Highly  intensive  treatment  further  accelerates  the 
reduction  of  vision,  notwithstanding  the  fact  that  these  patients  are 
known  to  be  syphilitic.  Paralyses  of  ocular  muscles,  transient  or 
persistent. 

General  paralysis. — Inequality  and  irregularity  of  the  pupils 
with  mydriasis  and  paralysis  of  the  iris.  Toward  the  final  stage, 
optic  neuritis  and  atrophy,  and  motor  paralyses. 

Friedreich's  ataxia. — Nystagmus;  sometimes  optic  atrophy. 

Little's  disease. — Strabismus;  nystagmus;  stigmata  of  in- 
herited syphilis. 

Disseminated  sclerosis. — Nystagmus;  paralyses  of  ocular  mus- 
cles ;  rarely,  sclerosis  of  the  optic  nerve. 

Intoxications. — Alcohol  and  tobacco. — Amblyopia,  bilateral 
from  the  start,  with  central  scotoma. 

Far  vision  is  impaired,  but  the  subject,  while  dasded  by  bright 
light  and  nearly  blind  in  broad  daylight,  has  much  better  vision  in 
the  evening  (crepuscular  improvement). 

Near  vision  is  greatly  interfered  with ;  the  patient  is  unable  to 
read,  and  distinguishes  certain  colors  poorly  (green  and  red),  espe- 
cially over  a  small  area,  on  account  of  the  central  scotoma.  While 
he  recognizes  the  color  of  a  sheet  of  red  paper,  he  is  unable  to  state 
the  color  of  disc  of  red  paper  o£  the  size  of  a  dime.  When  the 
disease  is  sufficiently  advanced,  he  mistakes  a  dime  for  a  silver 
dollar. 

This  condition,  if  taken  at  the  start  and  treated  by  a  strict  diet 
and  suitable  remedies,  may  be  completely  recovered  from  if  the  sub- 
ject does  not  resume  his  harmful  habits. 

The  practitioner  should  always  have  an  examination  of  the  eyes 
made  in  order  to  exclude  certain  very  serious  mistakes  (diabetic 
amblyopia,  macular  chorioretinitis,  retrobulbar  neuritis,  optic 
atrophy,  etc.)  and  diagnose  coexisting  disorders. 


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EYES,  DISORDERS  OF  THE.  923 

Many  other  forms  of  poisoning  (lead,  male  fern,  pelletierine, 
iodoform,  etc.)  may  give  rise  to  toxic  neuritis  and  a  variety  of 
ocular  and  oculomotor  disorders  of  a  lasting  or  transient  nature. 

Ingestion  of  large  amounts  of  quinine  at  a  single  dofse  sometimes 
induces  temporary  blindness,  which  terminates  either  in  recovery 
or  in  partial  and  lasting  sclerosis  of  the  optic  nerves. 

Atoxyl  has  been  the  cause  of  many  cases  of  optic  atrophy  and 
incurable  blindness. 

Naphthalene,  when  ingested,  yields  an  experimental  form  of 
cataract  (in  animals). 

Botulism  may  bring  about  optic  neuritis  and  paralyses  of  the 
ocular  muscles,  including  those  of  accommodation. 

Ophthalmic  Signs  and  Reagents  Indicating  Death. — Exami- 
nation of  the  eye  is  of  assistance  in  distinguishing  actual  from  ap- 
parent death  and  in  obviating  premature  burial,  whether  under  ordi- 
nary or  unusual  circumstances  (wars,  epidemics,  or  catastrophes). 

Loss  of  the  winking  reflex,  loss  of  corneal  sensibility,  dilatation 
of  the  pupil  following  myosis  (frequent  in  the  agonal  state),  a  dull 
appearance  of  the  eyes,  and  complete  opening  or  closure  of  the  lids 
(a  very  variable  condition  in  different  subjects  and  according  to  the 
manner  of  death)  constitute  merely  presumptive  evidence.  The 
pupils  of  a  corpse  will  often  react  for  several  hours,  especially  to 
myotics  (eserine  and  pilocarpine)  and  electric  stimulation.  Palpa- 
tion of  the  eyes  may  be  practised;  they  become  particularly  flaccid 
at  the  end  of  several  hours. 

In  S.  Icard's  procedure  (subcutaneous  staining  injection  of  fluo- 
rescin,  which  fails  to  diffuse  in  a  dead  body ) ,  the  eye  may  assume  a 
greenish  tint  in  a  living  subject;  but  this  phenomenon  is  very  in- 
constant. 

Lecha  Marzo  has  made  an  investigation  such  as  had  already 
been  made  in  other  regions  of  the  body,  of  the  existence  of  a  post- 
mortem acid  reaction  of  the  tears,  which  are  neutral  or  alkaline  in 
the  living  subject,  by  placing  a  piece  of  litmus  paper  beneath  the 
eyelid.  Unfortunately  the  time  of  appearance  of  the  acidity,  as 
well  as  its  intensity,  are  highly  variable  after  actual  death.  Dis- 
tinct acidity,  it  is  claimed,  is  never  present,  however,  in  a  living 
subject  in  a  condition  of  apparent  death. 


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924  SYMPTOMS. 

Instillations  of  irritants  and  mechanical  stimuli  (scraping  or 
chemical  or  actual  cauterization  of  the  conjunctiva  or  of  the  up- 
turned lids,  etc.)  may  be  tried,  and  will  induce  redness  and  hyper- 
emia in  an  inert  living  subject.  Instillation  of  ether  (d'Halluin) 
may,  however,  not  be  without  risk  to  the  cornea.  The  writer  pre- 
fers the  introduction  of  a  wheat-grain-sized  amount  of  powdered 
ethyl-morphine  hydrochloride  (dionin),  a  substance  used  in  daily 
practice  without  harmful  results,  and  which  induces  redness  and 
swelling,  often  of  considerable  extent,  of  the  conjunctiva  in  the  eye 
of  a  living  subject. 

One  need  not  limit  himself  to  the  ocular  tests  of  death,  but  they 
should  be  utilized  among  the  routine  measures  for  the  determina- 
tion of  death. 

The  foregoing  summary  considerations  on  the  subject  of  com- 
bined ophthalmology  and  general  medicine  may  have  served  at  least 
to  suggest  to  the  practitioner  the  marked  importance  of  an  objective 
and  functional  examination,  whether  positive  or  negative,  of  the 
eyes  and  their  adnexa  in  the  diagnosis  and  prognosis  of  almost  any 
disorder  affecting  the  human  body — not  to  mention  the  cases  in 
which  such  an  examination,  as  yet  so  frequently  neglected  or  inade- 
quately performed,  actually  permits  of  apprehending,  arresting,  or 
curing  a  disease  of  the  eye  itself. 


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FAINTING  [From  aiv,  with,  and  x&JVtBiv,  to  cvi.^ 

[  Faintneas,  fainting  spell.  J 


(SYNCOPE). 


True  S3mcopc  consists  of  a  sudden,  temporary  cessation  of 
the  heart's  action.  It  is  exceedingly  uncommon.  On  the  other 
hand,  faintness,  semifainting,  or  lipothymia  (from  ^htislv,  to 
relinquish,  dvfzdg,  spirit)  is  met  with  rather  often,  and  is  char- 
acterized by  a  more  or  less  complete  loss  of  consciousness  ap- 
parently dependent  upon  a  reduction  of  varying  degree  in  the 
blood  flow  (ischemia)  through  the  brain.  The  nervous  and 
circulatory  systems  are  so  intimately  interdependent  that  psy- 
chic and  circulatory  manifestations  are  in  close  association,  and 
the  most  reliable  sign  of  syncope  and  of  lipothymia,  which  sign, 
moreover,  allows  of  their  immediate  differentiation  from  coma, 
asphyxia,  etc.,  is  the  combined  observation  of  a  more  or  less 
complete  loss  of  consciousness  with  weakened  and  sometimes 
slowed  heart  action,  the  latter  sometimes  passing  into  actual 
cessation  of  the  heart  beats  for  a  varying  period  of  time.  Syn- 
copal states,  then,  are  characterized: 

1.  By  a  more  or  less  profound  state  of  fainting  and  uncon- 
sciousness, with  more  or  less  complete  muscular  relaxation. 

2.  By  a  marked  weakening  of  the  pulse  (small,  feeble  pulse) 
and  of  the  heart  beats. 

3.  By  certain   associated   vasomotor  and   secretory   disturb- 
ances, ins,,  pallor  of  the  face   and  lips,   cold   sweat,   cold   ex- ' 
tremities,   etc.,  which   impart  in   some  degree   to   syncope  the  ^ 
appearances  of  death. 

It  should  be  noted  that  frequently,  just  before  the  termina- 
tion of  syncope,  a  short  general  convulsive  seizure  is  observed, 
independently  of  any  epileptic  tendency. 

Thorough  realization  of  the  three  above  mentioned  characteris- 
tic features  will  suffice  to  eliminate,  usually  at  the  first  glance, 
artificial  fainting  spells,  "theatrical  faints,"  and  "suggestive  syn- 

(925) 


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926  SYMPTOMS. 

copal  states"  so  prevalent  in  certain  quarters,  and  seemingly 
in  all  historical  periods,  judging  from  the  high  percentage  of 
**swoons"  referred  to  in  the  romantic  literature  of  all  ages  and 
all  climes.  '*Clarisse  Manson,"  wrote  Lenotre  (the  celebrated 
witness  of  the  Fualdes  episode),  "succeeded  in  holding  in 
anxious  suspense  the  attention  of  the  entire  world  for  two  whole 
years  merely  by  swooning,  a  proceeding  which  she  carried  out 
to  perfection  and  repeated  indefinitely  without  becoming  fa- 
tigued." 

Syncope  and  syncopal  states  are  met  with  chiefly  under  the 
following  conditions: 

1.  Ordinary  fainting,  probably  due  to  acute  anemia  of  the  brain 
(by  vaso-constriction  or  nervous  cardiovascular  inhibition)  acting 
upon  predisposed  individuals  when  in  a  confined  or  poorly  venti- 
lated room,  in  the  presence  of  a  crowd,  or  unexpectedly  witnessing 
some  accident  or  a  hemorrhage.  The  sight  of  blood-shed  regularly 
causes  faintness  in  some  persons  who  may  properly  be  said  to  be 
hemophobic,  and  in  these  individuals  personally  experienced  pain 
or  hemorrhage  has,  of  course,  an  even  more  certain  eflFect  in  this 
direction.  The  wearing  of  a. corset  or  other  tight  garment,  and 
either  the  period  of  digestion  or  that  of  fast,  plainly  predispose  to 
fainting  in  some  persons.  In  short,  at  the  bottom  of  the  condition 
there  are  always  found:  1.  Some  emotional  impression  (anxiety, 
apprehension,  pain,  fear,  terror,  etc.).  2.  An  emotional  neuro- 
cardiovascular  predisposition,  finding  its  ultimate  expression  in  an 
exaggeration  of  the  nervous  vasomotor  and  inhibitory  reflexes. 

Allied  to  ordinary  fainting  are  the  faintness  and  lipothymic 
attacks  of  patients  with  low  blood-pressure,  of  convalescents,  of 
septic  cases,  and  of  cases  of  visceroptosis,  accounted  for  in  each 
case  by  a  manifest  state  of  neurovascular  weakening. 

2.  Certain  minor  forms  of  epilepsy  are  commonly  considered 
related  to  ordinary  fainting,  but  in  these  cases  the  vasomotor 
manifestations  characteristic  of  syncopal  states,  zns,,  small  pulse, 
coolness  of  the  extremities,  etc.,  are,  as  a  rule,  absent.  Yet 
it  must  be  admitted  that  some  of  these  conditions  are  very  simi- 
lar to  syncope.  They  should  always  be  thought  of  in  the  pres- 
ence of  recurring  pseudolipothymic  attacks  or  repeated  faints 
ot  obscure  causation. 


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FAINTING.  927 

3.  Certain  cerebrocardiac  forms  of  arteriosclerosis,  especially 
if  accompanied,  as  is  the  rule,  by  aortitis,  may  lead  to  particu- 
larly dangerous  syncopal  states.  The  fatal  syncope  of  the  major 
forms  of  angina  pectoris  belongs  in  this  group.  It  is  mainly 
the  possibility  of  such  an  occurrence  that  furthers  an  unfavor- 
able prognosis  in  the  latter  disorder.  Yet  it  should  be  mentioned 
and  repeated  that  even  in  the  major  forms  of  angina  pectoris, 
even  in  the  presence  of  definite  and  extensive  aortk  lesions, 
such  as  dilatation  or  actual  aneurysm,  and  even  wijth  a  rather 
marked  elevation  of  blood-pressure,  fatal  syncope  is  exceptional 
and,  in  any  case,  perhaps,  is  generally  long  delayed.  The  author 
has  had,  and  still  has,  under  observation  such  subjects  for  peri- 
ods of  ten  or  twtlve  y^ars  or  over. 

For  practical  pmrposes  the  following  general  rule  may  be 
adopted : 

Syncope  is  ordinarily  a  mild  condition  in  young  individuals; 
on  the  other  hand,  it  is  always  a  serious,  at  times  a  dangerous,  and 
sometimes  even  a  fatal,  occurrence  in  old  persons, 

4.  The  fainting  of  paroxysmal  bradycardia  (Stokes- Adams' 
disease)  is  easily  diagnosticated  if  one  merely  takes  care  to  count 
the  pulse  (see  Arhythmia:  Auriculoventricular  Dissociation).  A 
subsequent  thorough  general  examination  and,  if  need  be,  a  good 
polygraphic  tracing  will  eliminate  all  doubt. 

5.  Chloroformic  syncope  is,  as  is  well  known,  a  dangerous 
manifestation.  Following  are  the  warning  signs  of  this  condition, 
as  recalled  by  Desfosses: 

(a)  Respiration:  Arrest  of  respiration  occurring  together  with 
pallor  of  the  face. 

(&)  Facial  appearance:  "If  the  face  is  seen  suddenly  to  become 
blanched  or  dusky,  and  the  pupil  to  dilate,  this  means  that  the 
respiration,  or  perhaps  the  pulse,  has  just  stopped;  the  result  is 
'white  syncope.'    The  patient  is  in  extreme  danger." 

(c)  Condition  of  the  pulse:  "If  the  pulse  stops,  there  is  present 
cardiac,  syncope,  a  very  serious  or  'white  syncope' ;  but  as  a  rule 
the  arrest  of  respiration  will  already  have  served  to  warn  the  care- 
ful anesthetist." 

(d)  Examination  of  the  eye:  "If  the  pupil,  after  having  been 
contracted,  suddenly  dilates,  the  corneal  reflex  should  be  tested  at 


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928  SYMPTOMS. 

once;  if  present,  vomiting  and  return  to  consciousness  are  to  be 
apprehended;  if  not  present,  a  severe  syncopal  attack  is  to  be 
feared." 

6.  All  weakening,  exhausting,  debilitating  illnesses  lead  to  a  mani- 
fest predisposition  to  faintness,  which  may  pass  into  actual  syncope. 
The  mere  change  from  the  horizontal  to  the  vertical  position  is 
sufficient,  in  many  convalescents,  to  bring  on  a  lipothymic  attack. 
Sphygmomanometric  study  of  these  cases  reveals  in  this  connec- 
tion a  considerable  d^free  of  tachycardia  with  markedly  low  blood 
pressure.  As  is  well  known,  in  such  cases  a  post-infectious 
adrenal  insufficiency,  with  low  pressure,  asthenia,  and  Sergent's 
white  line,  is  nearly  always  found.  This  seems  to  be  the  case,  in 
particular,  in  attacks  of  pernicious  malarial  fever  (of  the  syncopal 
type). 

7.  Cases  of  syncope  in  the  presence  of  extensive  pleural  effu- 
sion, with  large  areas  of  flatness,  have  been  reported.  "Do  not 
wait  till  the  patient  faints  to  tap,"  wrote  Trousseau.  Doubtless 
it  is  through  having  followed  this  rule  that  the  author  has  never 
witnessed  syncope  in  these  cases,  neither  spontaneously  nor 
during  the  process  of  tapping. 

8.  Any  extensive  hemorrhage,  e.g.,  the  intestinal  hemorrhage 
of  typhoid  fever,  the  intraperitoneal  hemorrhage  of  extra-uterine 
pregnancy,  postpartum  hemorrhage,  internal  hemorrhage  follow- 
ing wounds  of  the  chest  or  abdomen,  or  an  uncontrolled  ex- 
ternal hemorrhage,  bring  on  a  syncopal  condition  which  may 
pass  into  fatal  syncope. 

Syncopal  states  are,  as  a  rule,  easily  distinguished,  as  was 
previously  pointed  out,  from  "s3mcopomorphic"  hysterical  seiz- 
ures by  their  shorter  duration  (hysterical  coma  persists  for  min- 
utes or  hours;  syncope  only  for  seconds),  the  existence  of  an 
actual  provocative  cause,  and  especially,  the  observation  of 
actual  cardiac  and  vasomotor  disturbances,  such  as  slowing,  or 
suppression  of  the  pulse,  pallor,  cold  sweat,  cooling  of  the  tis- 
sues, etc. 


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FEVER.  [Febris,  from  ^eSofiai,  to  tremble.] 


In  practice,  the  words  "fever,"  "pyrexia,"  and  "hyperthermia" 
are  often  used  indiscriminately,  without  marked  disadvantage. 

A  patient  is  spoken  of  as  having  "fever"  when  his  temperature 
is  continuously  above  the  normal. 

The  rectum  and  the  floor  of  the  mouth  are  the  points  of  election 
for  taking  the  so-called  ''central"  or  "internal"  temperature.  In 
adults  the  normal  internal  temperature  ranges  between  37°  and 
37.6°  C.  (98.6°  and  99.68°  F.),  the  physiologic  oscillations  of  tem- 
perature during  the  24  hours,  and  the  difference  between  the  mini- 
mal or  morning  and  the  maximal  or  evening  temperature  being 
sometimes  as  great  as  0.5  to  0.6°  C. 

The  axilla  and  the  inguinal  fold  are  the  points  of  election  for 
taking  the  so-called  ''peripheral"  or  "superficial"  temperature.  In 
adults  the  normal  superficial  temperature  ranges  between  36.4®  and 
37°  C  (97.52°  and  98.6°  F.),  with  diurnal  oscillations  of  0.5  to 
0.6°  C.  There  is  thus  a  mean  interval  of  0:5°  C.  between  the  in- 
ternal and  superficial  temperatures.  The  sources  of  error,  how- 
ever, vis.,  sweating,  cooling  of  the  surface,  and  faulty  mode  of 
application  of  the  thermometer,  are  much  more  pronounced  over 
the  surface. 

Preference  should,  therefore,  be  given  wherever  possible  to  the 
internal  temperature.  Ordinarily  the  internal,  rectal,  and  oral  tem- 
peratures are  the  same ;  but  sometimes  they  are  markedly  different ; 
it  should  be  borne  in  mind  that  a  local  inflammation  or  hyperemia, 
as  in  proctitis,  hemorrhoids,  high  portal  pressure,  etc,,  may  result 
in  a  localized  h)rperthermia  unaccompanied  by  true  fever  {i.e,, 
there  is  no  actual  pyrexia).  The  author  has  seen  patients  considered 
febrile  and  kept  in  bed  for  weeks  or  even  months  because  of  a 
rectal  temperature  persisting  in  the  neighborhood  of  38°  C. 
(100.4°  F.),  but  having  no  true  fever,  as  was  later  proved  by  regu- 
lar and  careful  notation  of  an  absolutely  normal  buccal  temperature 

59  (929) 


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930  SYMPTOMS. 

(37°  to  37.4°  C— 98.6°  to  99.32°  R),  a  pulse  rate  of  60  to  72, 
and  the  absence  of  all  symptoms,  in  spite  of  persistence  of  the 
rectal  temperature  in  the  vicinity  of  38°  C.  All  these  were  cases 
of  proctitis,  hemorrhoids,  portal  hypertension,  or  congestion  of  the 
liver.  Sometimes .  repeated  introduction  of  the  thermometer,  two 
or  more  times  a  day,  or  the  local  use  of  irritant  antiseptics  seem 
to  be  the  exciting  cause  of  the  local  irritation. 

In  a  general  way,  as  is  well  known,  fever  is  an  indication  of  the 


Fig.  685. — Respiratory  type  of  influenza. 

presence  of  infection.  Clinically,  the  equation,  fever  =  infection, 
is  justified  in  19  cases  out  of  20.  There  remains,  however,  a  small 
percentage  of  non-infectious  fevers,  to  be  briefly  discussed  later. 
To  review  all  the  causes  of  fever  would  thus  entail  a  tiresome  enum- 
eration of  all  the  infections,  with  the  further  addition  of  a  few  non- 
infectious forms  of  pyrexia. 

As  a  matter  of  fact,  the  solution  of  the  clinical  problem  of  fever 
is  sometimes  immediately  manifest;  erysipelas,  herpes,  the  eruptive 
fevers,  etc.,  become  plainly  apparent  sooner  or  later. 

In  other  instances  the  cause  remains  for  a  long  time,  if  not 
permanently,  obscure,  and  for  a  solution  of  the  problem  application 
of  the  most  recent  technical  procedures  is  required. 


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FEVER.  931 

From  the  exclusive  standpoint  of  practical  diagnosis,  a  useful 
clinical  division  of  fever  is  that  into: 

Fevers  of  short  duration,  lasting  altogether  not  over  two 
weeks. 

Fevers  of  long  duration,  persisting  over  two  weeks  without 
descending  to  normal. 

Intermittent  fevers,  or  recurring  fevers,  made  up  of  variable 
periods  of  pyrexia  separated  by  intervals  of  apyrexia. 

Little  need  be  said  concerning  the  fevers  of  short  duration, 
since  in  these  cases  either  the  diagnosis  becomes  more  or  less 


Fig.  686.^Frank  pneumonia  in  an  adult 

plain  sooner  or  lat^,  or,  if  the  cause  remains  obscure  (as  is 
often  the  case) ,  more  or  less  prompt  recovery  occurs  in  any  case, 
thus  settling  the  main  practical  question  of  import  to  the  patient 
as  well  as  to  the  physician. 

In  this  group  of  fevers  are  encountered: 

The  eruptive  fevers  or  exanthemata:  Measles,  scarlet  fever, 
rubella,  etc.,  and  diphtheria.    . 

Common  or  specific  infections  of  the  respiratory  tract:  Catarrhal 
conditions,  acute  bronchitis,  sore  throat,  pharyngitis,  pneumonia, 
bronchopneumonia,  etc. ;  also  influenza,  etc. 

The  ordinary  gastro-intestinal  infections:  Febrile  gastric  up- 
sets, acute  gastro-enteritis,  appendicitis,  etc. 

Acute  infections  of  the  various  other  systems  and  structures: 
Acute  arthritis,  lymphangitis,  pelvic  infections,  sinusitis,  erysipelas, 
poliomyelitis,  etc. 


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932  SYMPTOMS. 

In  truth,  most  of  these  fevers  of  short  duration  are  actually 
of  unknown  etiology  and  origin,  or  at  least  are  "non-specific,"  and 
many  of  the  terms  applied  to  them,  such  as  cold,  grippe,  influenza, 
febrile  pains  in  the  limbs,  ephemeral  fever,  rheumatoid  fever,  etc., 
are  none  other  than  makeshift  "clinical  labels"  applied  to  "cryp- 
togenic fevers,"  generally  mild  and  of  brief  duration. 

Further,  some  of  these  conditions,  persisting  for  unduly  long 
periods,  may  pass  into  the  group  of  the  fevers  of  long  duration, 
to  be  next  considered,  and  conversely,  a  few  of  the  clinical  states 
ordinarily  attended  with  fever  of  long  duration  may  be  cut  short 
in  some  unusual  way  and  fall  into  the  present  group.  The  possible 
occurrence  of  such  exceptional  cases  should  be  kept  in  mind.  For 
practical  purposes  the  general  division  given  above  nonetheless  re- 
mains of  marked  clinical  service. 

The  fevers  of  long  duration  are  attended  with  a  more  urgent 
need  of  proper  diagnosis  because  in  them  prompt  recovery, 
which  would  quickly  solve  the  clinical  problem  in  spite  of  the 
physician's  doubt,  fails  to  occur. 

In  90  per  cent,  of  cases  the  underlying  condition  is  either 
tuberculosis,  typhoid  fever,  septicemia,  or  deep-seated  suppura- 
tion. 

The  remaining  10  per  cent,  of  cases  refer  to  a  wide  variety 
of  conditions,  including  rheumatic  feVer,  influenza,  meningitis, 
chronic  appendicitis,  leukemia,  syphilis,  cancer,  etc. 

Cabot's  statistics,  referring  to  784  febrile  cases  recorded  at 
the  Massachusetts  General  Hospital,  are  as  follows: 

Typhoid  fever   586 

Sepsis  70 

Tuberculosis   54 

710  (90  per  cent). 

Meningitis  27 

Influenza 10 

Acute  rheumatism  9 

Leukemia 5 

Cancer   2 

Syphilis    2 

Trichiniasis   2 

Cirrhosis    2 

Gonorrhea    2 

Scattering 11 

74  (10  per  cent). 


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FEVER,  933 

These  statistical  results  manifestly  do  not  in  the  least  represent 
those  of  private  practice;  the  disproportionately  great  number  of 
typhoid  cases  is  accounted  for  by  the  special  concentration  of  these 


Fig.  687. — Temperature  chart  in  a  case  of  acute  miliary  tuberculosis  with 
onset  suggesting  typhoid  fever  (Letulle  and  Debri), 

cases  in  the  Massachusetts  General  Hospital.     In  private  practice 
tuberculosis,  deep-seated  sepsis,  and  the  indefinite  infections  labelled 


Fig.  688. — Infectious  pericarditis. 

influenza  and  rheumatism  greatly  exceed  typhoid  fever.  Yet,  on 
the  whole,  in  private  practice  as  in  the  statistics  above  presented, 
it  may  be  said  that  98  per  cent,  of  the  cases  of  prolonged  fever 
fall,  in  the  order  of  frequency,  under  the  five  following  headings: 


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934  SYMPTOMS. 

Tuberculosis,  sepsis  of  visceral  origin,  influenza,  rheumatism,  and 
typhoid  fever. 

In  tuberculosis,  certain  localizations  of  the  infection  are  practi- 
cally obvious,  e.g.,  tuberculosis  of  the  bones  and  joints,  lymphatics, 
peritoneum,  meninges,  reproductive  organs,  and  pleura.  It  is  par- 
ticularly the  pulmonary  and  the  renal  forms  that  may  remain  latent 
for  a  rather  long  period.  The  diagnostic  means  at  the  physician's 
disposal  in  modern  special  procedures  are  known  to  all:  Ausculta- 
tion, fluoroscopy,  inoscopy,  inoculation,  etc. 

Among  the  septic  conditions  one  should  think: 


Fig.  689.-— Typhoid  fever,  with  recovery  (IVidal  and  Sicard). 

1.  Of  infectious  vegetative  endocarditis,  malignant  and  septic, 
very  insidious,  but  revealed  to  a  certainty  by  careful  auscultation, 
by  the  characteristic  temperature  curve  (the  large  oscillations  of 
septicemia),  and  sometimes  by  complications   (embolism). 

2.  Of  puerperal  and  post-puerperal  infections,  generally  obvious. 

3.  Of  visceral  infections,  viz.,  in  the  order  of  frequency: 
Appendicular  and  peri-appendicular  infections. 

Cystic   (gall-bladder),  pericystic,  and  hepatic  infections. 
Urinary  infections,  renal  and  perirenal. 
Genital  infections,  pelvic,  prostatic,  etc. 
Gastrointestinal  infections. 

4.  Of  pleural  infections. 

5.  Of  lymphatic  infections,  lymphangitis,  erysipelas,  or  abscesses. 
Deep-seated  visceral  abscesses,  particularly  those  of  the  kidney 

and  liver,  are  at  times  the  hardest  to  detect  because  local  symptoms 


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FEVER,  935 

are  often  absent.  All  the  resources  of  modem  clinical  investigation 
are  to  be  availed  of  in  such  cases.  It  is  in  respect  of  these  cases 
that  the  author  has  committed  and  seen  committed  the  greatest 


Fig.  690. — Malaria.    Intermittent  fever  of  quotidian  type  (Laveran). 

mistakes  in  diagnosis.     The  possibility  of  these  conditions  should 
always  be  thought  of  in  prolonged  "cryptogenic"  fever. 

In  influenza  with  protracted  fever,  the  chief  problem,  on  the 


Fig,  691. — Malaria.    Intermittent  fever  of  quotidian  t)rpc,  then 
tertian,  and  finally  quartan  {Laveran), 

whole,  is  to  ascertain  whether  a  threatening  tuberculous  infection 
is  not  concealed  behind  the  screen  of  the  acute  infection,  and  if 
some  deep-seated  complication  (liver,  kidney,  etc.)  has  not  stepped 
in  and  changed  the  usual  course  of  the  disease.  The  diagnostic 
problem  merges  with  that  above  referred  to. 


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936  SYMPTOMS. 

In  acute  articular  rheumatism  and  the  post-infectious  rheumatic 
states,  the  joint  involvement  and  the  history  generally  render  the 
diagnosis  obvious. 

The  diagnosis  of  typhoid  fever,  the  paratyphoid  fevers,  and 
typhobacillosis  is  founded  on  the  frequently  typical  temperature 
curve,  the  sometimes  very  definite  clinical  picture,  and  especially 
on  the  modem  methods  of  blood  examination — serum  diagnosis, 
blood  cultures,  and  inoscopy. 

Many  cases  of  prolonged,  obstinate  febricula  in  childhood  and 
even  in  adults,  with  temperatures  of  36"*  to  37**  C.  (96.8''  to 
98.6^  F.)  in  the  morning  and  37.5^  to  38.2^  (99.5''  to  100.76°  F.) 
in  the  evening — accompanied  at  the  latter  period*  by  slight  malaise — 
wrongly  ascribed  to  tuberculosis,  are  undoubtedly  of  pharyngeal 
origin, 

♦     ♦    ♦ 

The  above  mentioned  febrile  affections  make  up,  as  already 
pointed  out,  98  per  cent,  of  all  cases  of  prolonged  fever.  The 
remaining  2  per  cent,  comprise  a  great  variety  of  disorders,  such 
as  secondary  syphilis  (always  to  be  kept  in  mind),  meningitis  (soon 
revealed  by  headache,  Kernig's  sign,  etc.)  and  meningococcal  con- 
ditions (often  associated  with  herpes),  the  leukemias,  rapidly  grow- 
ing malignant  tumors  (particularly  cancer  of  the  liver),  Hodgkin's 
disease,  Malta  fever,  etc. 

Mention  should  also  be  made  of  certain  exceptional  and  gener- 
ally obvious  conditions,  such  as  wounds  and  diseases  of  the  brain 
(cerebral  hemorrhage,  acute  delirium,  tumors,  and  skull  fracture), 
belladonna  poisoning,  and  toxic  gas  poisoning. 

The  majority  of  these  clinical  conditions  are,  as  may  be  noticed, 
non-infectious. 

Along  with  tliis  group  may  be  cited  the  highly  characteristic 
pyrexia  of  exophthalmic  goiter,  always  of  moderate  degree,  vis,, 
38"*  C.  (99.5**  F.)  or  below,  accompanied  by  a  frequent  pulse,  gen- 
erally reaching  its  maximum  in  the  morning — as  does  likewise  the 
pulse  rate — and  its  minimum  in  the  evening.  With  this  form  of 
pyrexia  may,  with  Leopold-Levi,  be  contrasted  the  customary 
hypothermia  of  cases  of  thyroid  insufficiency,  both  these  condi- 
tions being  associated,  moreover,  with  the  usual  concomitant  dis- 


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FEVER.  937 

turbances  of  disordered  thyroid  function,  vis.,  circulatory  disturb- 
ances (vasomotor  or  congestive),  secretory  disorders  (hyper- 
idrosis),  and  sensory  symptoms  (itching,  burning  sensations,  etc.). 

December  Januaiy 


Intennltteiit  feff«r  ct  hepttio  orlsln  (euppttrattve  aagloctioUUs). 
Hay  AsrU 


Blllo-feptlo  fei?«r.  Berersed  type  of  intermittent  hepatic  ferer. 

Aaguit 


Fever  in  relapilng  Jaundice  (Weil-Matlileu's  disease). 
Fig.  692.— Intermittent  types  of  fever  of  hepatic  origin  (Lereboullet) , 

This  type  of  hyperthermia  may  occur  in  nervous,  neuroarthritic 
patients,  during  rapid  growth,  in  persistent  juvenility,  in  the  vari- 
ous Basedow  disorders,  in  thyro-testicular  cases,  at  all  periods  of 
the  reproductive  life  in  the  female,  and  in  some  high  pressure 
cases. 


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938 


SYMPTOMS. 


o 

M 

H 

Q 
O 

z 
o 

O 

> 


^ 

Intradermal 

test 
Examination 

for  tubercle 

bacilli. 

o 

9  < 

< 

Polymorphonuclear    leu- 
cocytosis.      Sometimes 
pathogenic     germs     in 
blood  culture. 

J 

(O 

ll 

Leucopenia. 
Agglutination  test. 
Blood  culture. 

*Jo 
O 

8 

3 

.22 

2 

JV 

■*•» 

u 

o 

s 

si 

P 

Large   temperature  os- 
cillations.   Septic  state. 
Local  evidences. 

Irregular,  erratic  fever. 
Local  evidences.    Aus- 
iuoro- 
s. 

Continuous  fever.  Rose 
spots.  Enlarged  spleen. 
Typhoid  state,  etc. 

Headache,  backache,  in- 
fluenzal tongue,  respir- 
atory catarrh. 

Signs  of  arthritis,  some- 
times   with    secondary 
involvements  of  endo- 
cardium and  pleurae. 

o 

1 

Infective 
focus. 
Heart. 

Lungs. 
Pleura;. 
Bones. 
Lymph-nodes. 

CO   V 

t 

2 

(0 
CO  (9 

Joints  (some- 
times pleurae 
and  endocar- 
dium). 

GO 

as 

O 

1 

1 

1 

CO 

1 

1 

2 

Poverty. 
Overwork. 
Poor  nutrition. 
Contagion. 

August.    Septem- 
ber.    October. 

Contaminated 
water  or  milk. 

Typhoid  bacillus 
carriers. 

s 

5. 

w 

Cold  and  damp- 
ness. 

: 

BO 

•< 

II 

Tuber- 
culosis. 

^*** 

id 

Infectious 
arthritis 
(rheuma- 
tism). 

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FEVER. 


939 


15-8*1  s-s 

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-,  ^  ^ 

V  o  ^ 
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940  SYMPTOMS. 

This  fever  of  neuropathic  origin  may  be  compared  with  the 
so-called  purely  "nervous,"  "hysterical,"  or  "psychic"  fevers,  our 
knowledge  of  which  is  as  yet  very  deficient.  How  shall  one  ac- 
count for  the  "admission  fever"  noticed  when  a  patient  enters  a 
hospital,  apparently  a  very  real  pyrexia,  and  the  "Sunday  fever," 
observed  when  visitors  are  admitted?  In  truth,  many  different 
factors  may  be  operative  under  these  circumstances. 

Intermittent  Fevers. — In  practice  this  group  of  fevers  is  repre- 
sented in  our  climes  by  malaria,  detected  from  the  history  (fonner 
residence  in  a  malarial  district),  the  intermittent  type  of  the  fever, 
the  enlarged  spleen,  and  examination  of  the  blood  for  the  causal 
parasite. 

Relapsing  fever  is  very  exceptional  in  temperate  climates. 

It  should  not  be  overlooked,  however,  that  this  intermittent  or 
recurrent  form  of  fever  may  be  caused  by  non-specific,  non-exotic 
infections,  foremost  among  which  are: 

Hepatic  intermittent  fever  (bilio-septic  fever),  especially  fre- 
quent in  angiocholitis  and  quite  precisely  reproducing  the  appear- 
ances of  malarial  intermittent  fever,  sometimes  even  to  the  extent 
of  showing  a  maximum  of  temperature  in  the  morning,  constitut- 
ing a  "reversed"  type  of  fever  (Gilbert  and  Lereboullet).  The 
fever  may  be  remittent  or  even  at  times  continuous  in  type  (see 
page  937). 

Urinary  intermittent  fever  (uroseptic  fever),  especially  com- 
mon in  pyelonephritis,  involves  precisely  the  same  considera- 
tions. 

Yet,  while  these  infections  may  present  the  appearances  of  an 
attack  of  sudden  onset,  running  a  more  or  less  rapid  course,  well 
maintained  and  with  typical  recurrences,  they  never  exhibit 
the  characteristic  feature  of  regular  intermittence  shown  in  the 
true  malarial  paroxysms. 

♦    ♦    ♦ 

In  conclusion,  it  may  be  well  to  recall,  with  Edmond  Lesne, 
the  following  point  of  practical  importance,  viz,,  that  "the  in- 
ternal TEMPERATURE  OF  THE  BODY  MAY  BE  CAUSED  TO  RISE  BY  ONE 

OF  A  NUMBER  OF  DIFFERENT  FACTORS,"  which  may  be  enumerated 
thus:  • 


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FEVER.  941 

(1)  Elevation  of  the  external  temperature;  (2)  tetanic  muscu- 
lar contractums;  (3)  lesions  of  the  nerve  centers;  (4)  infections. 

When  present  in  combination,  these  several  factors  bring 
about  the  so-called  ** hyperthermic  fevers,"  e-g.,  in  meningitis  at- 
tended with  convulsions. 


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FREQUENT  PULSE. 


Tachycardia,  or  frequent  pulse,  is  marked  by  a  more  or  less 
pronounced  and  persistent  acceleration  of  the  heart  beats.  Nor- 
mally, in  sitting  or  recumbent  subjects,  the  pulse  frequency 
ranges  from  60  to  80  in  different  individuals,  at  different  times 
of  the  day,  in  accordance  with  the  intervals  before  or  after  a 
meal,  etc.  For  practical  purposes,  tachycardia  or  frequent  pulse 
can  hardly  be  said  to  exist  unless  the  rate  exceeds  90;  it  may 
attain  and  even  exceed  200. 

Accelerated  heart  action  is  a  ccwiimonly  and  easily  observed 
condition.  Its  clinical  meaning  is  sometimes  obvious  and  of  slight 
import ;  under  other  circumstances,  however,  its  significance  is  so 
great  as  to  make  of  it  a  separate  morbid  entity,  viz.,  paroxysmal 
tachycardia,  a  condition  which  has  excited  wide  interest  among 
modem  clinicians.  Rather  frequently  the  proper  interpretation  of 
a  frequent  pulse  proves  a  matter  of  considerable  difficulty. 

For  practical  purposes,  the  frequent  pulse  may  be  said  to  occur 
in  three  separate  modalities  which  lend  themselves  to  rapid  differen- 
tiation: 1.  More  or  less  permanent  tachycardia.  2.  Attacks  of 
paroxysmal  tachycardia.  3.  Temporary,  accidental  attacks  of  tachy- 
cardia. 

I.  More  or  Less  Permanent  Tachycardia. — This  is  met  with 
under  two  groups  of  circumstances,  sometimes  clearly  defined 
and  separate,  at  others  in  combination. 

(a)  In  the  presence  of  a  recognized  heart  lesion,  such  as  myo- 
carditis,  pericarditis,   and   valvular  disorders,  especially  aortic. 

{h)  In  the  absence  of  any  recognised  heart  lesion: 

(1)  Graves's  disease  (exophthalmic  goiter). 

(2)  Tachy cardie  neuroses. 

(a)  The  frequent  pulse  occurring  as  a  symptom  of  organic 
heart  lesions  should  generally  be  attributed  to  a  more  or  less 
pronounced  weakness  of  the  myocardium.    The  reduction  in  the 
(942) 


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FREQUENT  PULSE. 


943 


tachycardia  following  rest,  good  hygiene,  and  digitalis  when 
properly  administered  constitutes  evidence  of  the  truth  of  this 
supposition.  The  results  of  the  static  and  dynamic  tests  of  the 
circulation  may  be  said  to  afford  also  an  experimental  demon- 
stration. This  type  of  frequent  pulse  is  met  with  in  associa- 
tion with  myocarditis  (particularly  post-infectious),  pericarditis, 
and  endocarditis,  especially  aortic.  The  diagnosis  should  be 
based  on:  1.  The  presence  of  the  characteristic  clinical  signs 
of  these  conditions.  2.  The  results  of  the  special  test  of  the 
circulation  already  referred  to.  3.  The  effects  of  treatment,  as 
by  rest,  diet,  and  digitalis.     What  remains  in  the  way   of  a 

I  I  I  I  I  4  I  I 


•  I«|4I|I||1|| 


•   I  I   I   I  I   I 


Fig.  693.— Diagram  representing  a  brief  attack  of  paroxysmal  tachy- 
cardia consisting  of  8  auricular  extra-systoles.  With  each  auricular  im- 
pulse there  corresponds  a  ventricular  contraction.  Note  the  abrupt  onset 
and  termination  of  the  attack  and  the  abnormal  prolongation  of  the 
terminal  pause. 

tachycardia  under  these  circumstances  constitutes  an  index 
either  of  irreducible  myocardial  weakness  or  of  a  concomitant 
tachycardic  neurosis. 

Tt  should  be  borne  in  mind,  moreover,  that  in  some  individ- 
uals the  most  varied  forms  of  tachycardia  may  be  observed 
occurring  in  succession,  viz.,  tachy-arhythmia,  paroxysmal  tachy- 
cardia, persistent  tachycardia  of  the  Graves's  disease  type,  pre- 
mature contractions,  etc.  These  cases  are  exceptional,  but  many 
instances  of  them  have  nevertheless  been  recorded. 

{b)  "Yet,"  as  Gallavardin  correctly  writes,  "it  must  be  con- 
fessed that  bordering  on  these  sinus  tachycardias  of  known  origin 
there  occurs  a  vast  group  of  tachycardias  of  poorly  determined 


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944  SYMPTOMS, 

origin,  generally  appearing  in  young  or  adult  subjects,  and  concern- 
ing which  comparatively  little  is  known.  Some  of  these  cases  are 
unquestionably  to  be  ascribed  to  a  fruste  Graves's  disease,  for,  in 
spite  of  the  absence  of  any  ocular  sign  of  this  disorder,  careful 
examination  often  elicits  a  small  nodular  goiter  or  merely  a  neck 
slightly  broadened  at  its  base,  with  slight  diffuse  enlargement  of 
the  thyroid  lobe  (usually  the  right).  In  other  instances,  however, 
nothing  is  found  upon  examination  of  the  thyroid.  These  cases 
are  well  known,  and  no  physician  exists  who  has  not  seen  some 
of  them;  it  would  seem  well  to  group  them  provisionally  under 
the   generic   term    tachycardic    neuroses.     The   accelerated    heart 


Fig.  694.— Heart  weakness.     (H.,  1893;  165  cm.;  60  kilogr.) 
Experimentally  induced  tachycardia. 

action,  an  aggregate  of  symptoms  of  disturbed  function,  some- 
times highly  distressing  (palpitations,  breathlessness  on  exertion, 
and  various  painful  reactions),  and  lastly,  the  absence  of  any  notice- 
able cardiac  lesion  constitute  the  basic  symptomatic  triad  which 
may  serve  as  a  foundation  for  all  the  cases  of  this  kind." 

The  frequent  pulse  of  Graves's  disease  origin  is  obvious  from 
the  recognized  symptomatic  accompaniments  of  this  condition, 
vis,,  tachycardia,  exophthalmos,  hyperthyroidism,  and  second- 
arily, tremor  and  vasomotor  disturbances. 

The  tachycardias  of  cryptogenic  origin  (tachycardic  neu- 
roses) already  mentioned  are,  aside  from  the  absence  of  exoph- 
thalmus  and  of  hyperthyroidism,  identical  with  the  tachycardia 
of  Graves's  disease.^ 


iSee  Martinet:    "War  and  the  Cardiac  Neuroses"  (Presse  mid,,  Nov. 
5,  1915). 


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FREQUENT  PULSE,  945 

Both  forms  are  enhanced  by  exercise,  are  only  rarely  accom- 
panied by  dyspnea  or  premature  contractions,  and  are  but 
slightly  or  not  at  all  influenced  by  compression  of  the  eyeballs 
or  treatment  with  digitalis ;  a  moderate  elevation  blood-pressure 
is  nearly  constant  in  these  cases.  A  very  common,  if  not  con- 
stant, phenomenon  should  also  be  referred  to,  viz.,  inversion  of 
the  temperature  and  pulse  rate,  the  pulse  frequency  diminishing 
while  the  body  temperature  ascends.  Gallavardin  has  made  a 
special  study  of  this  phenomenon,  and  the  author  of  this  work 
has  frequently  had  occasion  to  see  it.    Tachycardia  of  this  type 


Fig.  695. — ^Tachycardic  neurosis  (Case  V,  458,  H., 
1896,  178cm.;65kilogr.). 

Note  the  rise  in  heart-rate  each  morning. 

is  at  its  maximum  in  the  morning  and  its  minimum  in  the 
evening. 

The  author  freely  agrees  with  the  conclusions  expressed  by 
Gallavardin : 

"In  the  two  instances  (fruste  Graves's  disease  and  tachycardic 
neuroses),  the  clinical  syndrome  is  really  the  same.  There  is  the 
same  variability  in  the  heart  acceleration,  the  same  morning  type 
of  tachycardia,  the  same  change  in  the  temperature  and  pulse  rate 
cycle,  and  the  same  clinical  features,  with  continuous  or  temporary 
tachycardia.  The  condition  may  always  be  summarized  as  an  in- 
tense excitation  of  the  sympathetic,  with  not  only  a  cardio-acceler- 
ator,  but  also  a  vasoconstrictor  and  blood-pressure-raising  and  even 

00 


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946  SYMPTOMS. 

a  thermic  action.  One  must  actually  make  bold  to  state  that  these 
two  varieties  of  patients  differ  only  as  regards  the  neck  enlarge- 
ment, 

"Hence  two  modes  of  interpretation  are  allowable.  Is  one  deal- 
ing with  two  thyroid  disorders,  the  one  with  a  manifest  goiter,  the 
other  with  some  concealed  change  in  the  thyroid  (small  adenomas, 
defects  in  the  internal  secretion),  or  merely  with  two  pathogeneti- 
cally  distinct  syndromes  of  sympathetic  excitation,  the  one  of  thy- 
roid origin  and  the  other  of  unknown  causation?  While  the  first  of 
these  two  theories  seems  the  most  likely  and  many  authors  have 
already  spoken  of  cases  of  fruste  Basedow's  disease,  without  goiter, 
and  with  tachycardia  alone  present,  it  will  be  wise,  before  reaching 
a  conclusion,  to  await  positive  proof.'* 

Tachyc  parojys  26.2 13,     *- 


Fig.  696. — Paroxysmal  tachycardia  {Routier). 

In  this  group  of  casts  belongs  the  continuous  post-emotional 
form  of  frequent  pulse. 

II.  Attacks  of  paroxysmal  tachycardia,  coming  on,  as  the  term 
implies,  in  paroxysmal  outbursts,  starting  and  ending  abruptly. 
The  very  nature  of  the  attacks  of  tachycardia,  their  marked  clinical 
autonomy,  and  their  rather  clearly  elucidated  pathogenesis,  as  de- 
veloped in  late  years,  which  makes  of  them  actual  extra-systolic 
seizures  brought  on  by  the  coming  into  play  of  an  abnormal  center 
of  cardiac  motor  excitation — ^all  these  facts  contribute  to  their  for- 
mation into  a  special  group  of  tachycardias  which  are  really  abnor- 
mal, arhythmic,  and,  as  a  rule,  readily  distinguished. 

The  diagnosis  of  this  disorder  is  rather  easy.  It  may  be  put 
down  as  a  definite  rule  that  any  tachycardia  exceeding  110,  of 
abrupt  onset,  unaccompanied  by  exophthalmic  goiter,  not  coming 
on  in  association  with  some  febrile  disorder,  and  the  rate  of  zvhich 
is  not  greatly  altered  by  passage  from  the  recumbent  to  the  up- 
right posture,  is  a  paroxysmal  tachycardia.  The  only  difficulty 
arises  in  subjects  seen   for  the  first  time,  whose  history  is  not 


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FREQUENT  PULSE. 


947 


known,  and  who,  in  conjunction  with  tachycardia  of  varying  de- 
gree, present  obvious  signs  of  heart  failure,  such  as  dilatation  of 
the  heart,  edema  of  the  lungs,  congestion  of  the  liver  and  enlarged 
spleen,  reduced  urinary  output,  and  edema.     In  such  cases  it  may 


Right  jugular. 

1 

Right  radial. 


vv      wv      tf     www 


¥        ¥      '¥      W 


^^'-NAA^^y^^ KJI^^^jKj^^^ 


Fig.  697.— Case  1219,  Mar.  18,  1915  (F.,  1867;  158  cm.;  48  kilogr.). 

Attack  of  paroxysmal  tachycardia  of  a  few  minutes'  duration  (/,  be- 
ginning; ^,  middle;  j,  end  of  attack)  in  an  improved  case  of  exophthal- 
mic goiter  at  the  menc^ause.  Note  the  abrupt  onset,  abrupt  termination, 
and  clearly  extrasystolic  terminal  period. 

be  difficult  to  ascertain  whether  the  paroxysmal  tachycardia  was 
the  initial  morbid  manifestation  or,  on  the  other  hand,  the  tachy- 
arhythmia  witnessed  is  not  a  secondary  result  of  the  impaired  heart 
action.  The  sudden  onset,  accurate  graphic  records,  and  the  thera- 
peutic test  with  digitalis  will  settle  the  question. 


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948  SYMPTOMS. 

III.  Temporary,  accidental  attacks  of  tachycardia  are  those 
in  which  there  is  simply  acceleration  of  a  heart  beating  in  normal 
rhythm.  The  most  common  and  manifest  causes  of  such  attacks 
may  be  briefly  recalled  as  follows: 

(a)  Fever. — Pulse  acceleration  and  hyperthermia  are  the  two 
characteristic,  clinical,  and  essential  features  of  fever.  As  is  well 
known,  in  some  kinds  of  fever,  as  in  meningitis,  peritonitis,  etc., 
there  may  be  noted  a  discrepancy  between  the  degree  of  hyper- 
thermia and  the  increased  pulse  rate,  and  such  a  discrepancy  is 
in  itself  a  clinical  indication  of  by  no  means  negligible  value. 


Fig.  698.— Case  V,  750  (H.,  1897;  168  cm.).    Post-infectious 
pericarditis  with  extensive  effusion. 

It  should  also  be  remembered,  as  will  be  mentioned  again  later, 
that  hyperthermia  may  exert  a  sedative,  slowing  action  on  certain 
forms  of  continuous  tachycardia  (Graves's  disease,  tachycardic  at- 
tacks). In  one  case  of  pericarditis  with  extensive  effusion  (in 
which  puncture  was  carried  out)  which  the  author  had  occasion 
to  observe  closely  for  a  long  period,  two  successive  attacks  of  acute 
suppurative  otitis  media  caused,  in  addition  to  marked  fever  (39°- 
40°  C),  an  equally  pronounced  slowing  of  the  pulse,  which  was 
reduced  in  the  two  attacks  from  124  to  104  during  the  period  of 
fever,  rising  again  to  120  or  above  in  the  interval  and  after  the 
second  attack.  Herein  lies  a  rather  odd  application  of  the  well- 
known  aphorism:  similia  similibus  curantur. 


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FREQUENT  PULSE,  949 

(&)  Exertion. — That  the  pulse  rate  rises  during  exertion,  and 
ascends  to  a  degree  varying  with  the  extent  of  the  exertion  and 
its  duration,  is  a  matter  of  common  observation.  Upon  the  basis 
of  this  fact  the  author  has  devised  a  test  of  induced  tachycardia 
brought  on  by  a  standard  amount  of  exertion,  which  affords  some 
measure  of  information  concerning  the  reserve  power  of  any  given 
heart.  In  a  general  way  it  may  be  asserted  that  after  a  medium 
amount  of  exertion  the  acceleration  of  the  pulse  as  compared  to 
the  rate  while  at  rest  is  less,  and  the  return  to  the  status  quo  ante 
after  cessation  of  exertion  more  rapid,  according  to  the  amount 
of  reserve  power  possessed  by  the  heart. 

^   ^  SltUng 

mmtrnn^  Recumbent 

I    I  I  StandiDg 

L  L  L  Dipping  exercises 

1*2*3*  Time  in  minutes 

it,, 

^PSfi  ^1  Blood-pressures 


Ma" 

!•••••  Pulse  frequency 

Fig.  699.— Normal  individual  (H.,  1884;  149  cm.;  46.5  kilogr.). 
Experimental  tachycardia,  after  exercises. 

(c)  Posture. — Acceleration  of  the  pulse  due  to  passage  from  the 
recumbent  to  the  upright  posture,  or  orthostatic  tachycardia,  is 
likewise  a  well-known  event.  Prevel  seems  to  have  found  out  an 
essential  factor  in  this,  form  of  tachycardia,  ascribing  it  largely  to 
visceroptosis,  making  of  it  an  abdominocardiac  reflex,  and  demon- 
strating that  it  can  be  reduced  or  eliminated  by  the  wearing  of 
an  abdominal  support. 

{d)  Emotion. — The  well-known  ''doctor's  pulse,"  an  emo- 
tional tachycardia  which  the  physician  regularly  observes,  es- 
pecially at  his  earlier  visits,  should  not  lead  him  into  error;  it 
generally  subsides  after  he  has  been  talking  with  the  patient 
for  a  few  minutes.  Pulse  acceleration  is  one  of  the  most  con- 
stant somatic  signs  of  the  emotional  syndrome.  There  actually 
exists  an  emotional  tachycardic  constitution — a  true  tachycardic 
neurosis. 


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950 


SYMPTOMS. 


(e)  Pain. — Many  forms  of  visceralgia  bring  on  an  evanescent 
reflex  tachycardia,  the  source  of  which  may  be  as  likely  fotmd  in 
the  uterus  as  in  the  pleura. 

(/)  Certain  kinds  of  intoxication,  among  the  foremost  of  which 
should  be  placed  coffeeism  and  teaism,  caffeinism  (caffeine)  and 
theobrominism  (theobromine).  At  first  the  heart  acceleration  is 
transitory  and  present  only  during  the  period  of  intoxication ;  later, 
however,  there  may  be  seen  to  develop  an  actual  tachycardic  neu- 
rosis. Hence  the  rule,  which  is,  on  the  whole,  frequently  justified, 
of  forbidding  the  use  of  tea  and  coffee  in  persons  with  "excited" 
hearts. 

Lastly,  it  may  be  noted  that  while  the  heart-rate  is  in  normal 
subjects  entirely  independent  of  cerebral  volition,  15  authentic  cases 
have  been  recorded  in  medical  literature  of  individuals  who  could 
at  will  markedly  increase  the  frequency  of  their  heart  beats. 


TACHYCARDIA. 


I.  ParoxjrsmaL 

II.  Temporary.    AccidentaL     Easily  referred  to  the  follow- 
ing causes: 

1.  Fever:    Febrile  pulse  acceleration. 

2.  Exertion:  Pulse  acceleration  on  exertion. 

{Experimental  pulse  ac- 
celeration (cardiac 
functional  test). 

4.  Emotion:   Emotional  pulse  acceleration. 

5.  Pain:  Algic  pulse  acceleration. 

6.  Intoxications:  Toxic  pulse  acceleration  (tea,  coffee,  caffeine,  kola, 

theobromine). 

III.  Continuous. 

A.  In  the  presence  of  a  recognized  heart  lesion:    Frequently  a  re- 

active effect  of  heart  weakness  or  failure. 

B.  In  the  absence  of  any  recognized  heart  lesion. 
B^.  Graves's  disease: 

(a)  Cardinal  symptoms:  Accelerated  pulse,  exophthalmos,  hyper- 
thyroidia  (goiter). 

(&)  Accessory  symptoms:  Tremor,  vasomotor  disturbances,  exces- 
sive nervousness. 

B*.  Tachycardic  neuroses.  Features  same  as  those  of  Graves's 
disease,  with  the  exception  of  the  goiter  and  sometimes  the 
exophthalmos.  "These  two  kinds  of  disorder  differ  only  in 
the  appearance  of  the  neck."  (Gallavardin). 


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GENITAL  ULCERATIONS. 


Recognition  of  the  cause  of  ulcers  on  the  genitals  is,  on  ac- 
count of  the  frequent  presence  of  syphilis,  of  great  clinical  im- 
portance. A  condensed  tabular  presentation  of  the  main  facts 
in  this  connection  seems,  therefore,  appropriate. 


Fig.  700. — Axillary  lymph-nodes,  with  the  afferent  and  efferent 
lymphatic  vessels  {Sappey). 

1,  1.  The  two  most  dependeDt  nodes  of  the  inguinal  chain,  alike  remarkable 
because  of  their  size.  £.  Inferior  lateral  inguinal  node.  S,  S.  Mesial  inguinal 
nodes,  receiving  lymphatic  vessels  from  the  scrotum,  perineum,  anal  region,  and 
upper  and  inner  portion  of  the  skin  of  the  thigh.  4.  Superior  mesial  inguinal 
node,  receiving  vessels  from  the  urethral  canal,  the  surface  of  the  glans,  and  the 
skin  of  the  penis.  5,  5.  Superior  medial  and  lateral  inguinal  nodes.  3  or  4  in  num- 
ber, receiving  lymphatic  vessels,  from  the  abdomen  below  the  umbilicus.  6,  6. 
Lymphatic  vessels  of  the  anterior  and  inner  portion  of  the  thigh.  7.  7.  Vessels 
from  the  outer  aspect  of  the  thigh.  8,  8.  Vessels  from  the  buttocks.  9,  9.  Ves- 
sels of  the  lumbar  region.  10,  10,  10.  Vessels  of  the  anterior  abdominal  wall  be- 
low the  umbilicus.  11,  11.  Lymphatic  vessels  of  the  scrotum.  If.  Lymphatic  ves- 
sels of  the  prepuce.  IS,  IS.  Lymphatic  vessels  of  the  skin  of  the  penis.  H. 
Lymphatic  trunk  coursing  about  the  corona  of  the  glans.  15.  Mesial  trunk  con- 
nected with  the  preceding.    16.  Umbilicus. 

(951) 


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952 


SYMPTOMS. 


Fig.  701.— ^Hard  chancre  of  the  penis  (Sabouraud), 


Fig.   702. — Chancroidal    pus,    stained 
with  methylene  blue. 


Fig.  703. — Scrapings  from  hard 
chancre.    (Giemsa  stain). 


Figs.  704  and  70S. — Unusual  papulohjrpertrophic  chancroids  of  the 
balanopreputial  region  (Marcel  F errand). 


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GENITAL  ULCERATIONS. 
GENITAL  ULCERATIONS. 


953 


Macroscopic 
Appbabanci. 
Incubation 

PERIOD. 


Glandulab 
Bnlabgbmbnts. 


ASSOCIATED 

CLINICAL 

EVIDENCES. 

CODBSE. 


Vabious  Tests, 
micboscopic 
Examination. 


Hard  Chancre. 


1.  Flat    ulcer, 
non-suppura- 
tive,  generally 
single. 

2.  Resting  on 
a  plate  of  car- 
tilaginous in- 
duration (see 
Fig.  701). 

Fourteen  to 
twenty-eight 

days     after 

coitus. 


Later  on,  rose- 
olar  eruption, 
mucous 
patches, 
patchy  alo- 
pecia, etc. 


In  contrast  to  chan- 
croidal glandular 
enlargement,  the 
non  -  inflammatory 
nature  of  the 
glandular  enlarge- 
ments attending 
chancre  is  to  be 
noted. 

1.  Ricord's  Plei- 
ades. 

Secondary  syphilitic 
multiple  glandular 
enlargement. 

Multiple,  elastic, 
movable,  and  pain- 
less glands. 

2.  Indicating  (pri- 
marily enlarged) 
gland,  or  satellite 
of  the  chancre, 
somewhat  larger. 

Apart  from  the  initial  specific  lesion,  ssrphilis  may  be  manifested 
on  the  glans  penis  in  several  other  ways: 

1.  Papules:  Secondary  papular  syphilides,  varying  in  number. 
(Recognized  from  the  history,  absence  of  lymphatic  reaction,  and 
the  effects  of  specific  treatment). 

2.  Gummas:  Rather  rare;  gummatous  nodules  undergoing  absorp- 
tion under  treatment  or  terminating  in  vicious  and  deforming  scars. 

3.  Chancriform  gummas:  Similar  to  the  initial  lesion  (false  rein- 
fection, false  S3rphilis  redux,  etc.);  no  roseolar  eruption  and  no 
glandular  enlargement 


Later  on,  the  sec- 
ondary stage. 

Positive  Wasscr- 
mann  test. 

Negative  reinocu- 
lation  in  the  same 
subject  upon  in- 
sertion by  punc- 
ture of  material 
from  the  initial 
lesion. 

Ultra-microscopic 
examination. 
Giemsa  stain. 
Schaudinn's  pale 
spirochete  (see 
Fig.  703). 


Chancroid. 


\.  Vesiculo-ul- 
cerations. 

2.  Then  suppu- 
rating ulcers. 

3.  Then  mul- 
tiple punched- 
out  ulcers, 
suppurating 
freely,  with- 
out induration 
(see  Figs.  704 
and  70S). 

Appear  four  to 
eight  days 
after  coitus. 


1.  Single    bubo, 
soft,    painful,    ter 
minating  in  suppu 
ration  and   ulcera 
tion. 

2.  Ganglionic  soft 
chancre,  ulcerated 
and  suppurating. 


In  some  in- 
stances :  pha- 
gedenic tend- 
ency. 

Ordinarily, 
rather    quick 
recovery  with- 
out sequelae. 


Positive  reinocula- 
tion  in  the  same 
subject  upon  in- 
sertion by  punc- 
ture of  pus  from 
the  original 
lesion. 

Bacillus  of  Ducrey 
(see  Fig.  702). 


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954  SYMPTOMS. 


ed 
ita. 


)enlng 
to  the 
irrow. 


Fig.  706. — A  burrow  in  scabies  Fig.  707. — Deep-seated  vulvar  he)i>es 

(Darier).  (Darter), 


Figs.  708  and  709. — Vegetations  on  penis  (Musee  de  Saint-Louis), 


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GENITAL  ULCERATIONS. 


955 


GENITAL  ULCERATIONS  {continued). 

Macroscopic             I 

ASSOCIATED  Clinical 

Appearanci. 

Glandular 

Evidences. 

Incubation  period. 

ENLARQBMBNTS. 

Course. 
Various  Tests. 

. ,              ... 

Herpes. 

1.  Vesico-pustules 

Glandular  reaction 

Sometimes  recurrence 

grouped  together,  then, 

very    slight     or 

in  situ  with  discour- 

2.   Superficial,    circinate, 

wanting. 

aging  obstinacy. 

polycyclic  ulcerations. 

One  or  two  days  after 

irritation    or    without 

appreciable  cause. 

Scabies. 

1.    Round,   red,    flat,    al- 

Glandular reaction 

1.  Itching  in  nocturnal 

most  papular  spots. 

very    slight     or 

paroxysms. 

2.    Sometimes    distinct 

wanting. 

2.  Lesions  due  to  scratch- 

burrows. 

ing. 

3.  Similar  lesions  on  the 

3.  Lesions  at  the  points 
of    election :      Groins, 

prepuces,  in  the  groins 

and  axillae,  etc. 

armpits,  forearms,  etc. 

Characteristic  feature  of 

4.    Characteristic     bur- 

the  acquisition    of    an 

rows. 

itching    affection    by 

Itch     parasites     in     the 

contact 

burrows.     (See  Para- 
sitology and  Itching.) 

Cauliflower  or  coxcomb  genital  vegetations. 

1.  More  or  less  promi- 

Glandular reaction 

Persistent,   rebellious. 

nent  papules   ulti- 

very   slight     or 

and    recurrent    owing 

mately      forming,     by 
proliferation : 

wanting. 

to   a   manifest   predis- 

position   to    epithelial 

2.  Excrescences,  tumor- 

proliferation. 

like  masses,  or  vege- 

tations, attended  with 

a    varying    degree    of 

suppuration. 

Perhaps    of    gonorrheal 

origin. 

Genital  diabetides.                                               | 

Nothing  characteristic: 

Glandular  reaction 

Refractory  to  all  meas- 

Oozing erosions  and 

very    slight     or 

ures  other  than  anti- 

eczematoid balanitis. 

wanting. 

diabetic  treatment. 

Glycosuria. 

Balanitis.                                                       | 

More    or    less    copious 

To  be  examined  for: 

and  rebellious  suppu- 

Diabetes (see  above). 

ration,    most    pro- 

Mercurial poisoning. 

nounced  over  the  glans 

Potassium  iodide  pois- 

and prepuce. 

oning. 

Erosive  circinate  bal- 
anitis. 

Vegetations,  herpes, 
chancre,  etc. 

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GLANDULAR 
ENLARGEMENTS. 


Adenitis  or  adenopathy  [dbyiP  gland]  consists  generally  of  a 
morbid  enlargement  of  one  or  more  lymphatic  ganglia. 

It  is  rather  hard  to  define  exactly  at  what  degree  of  enlarge- 
ment ^'adenopathy"  begins. 

Indeed,'  in  stout  individuals  none  of  the  lymph  glands,  even 
those  superficially  situated,  are  normally  palpable;  in  very  thin 
persons,  on  the  contrary,  they  are  easily  palpable  at  certain 
points,  vis,,  in  the  inguinal  and  axillary  regions;  in  no  indi- 
viduals are  they  normally  distinguishable  in  regions  other  than 
those  just  mentioned. 

The  diagnosis  of  glandular  enlargements  is  hardly  open  to 
error.  Lipomas  are  of  an  altogether  different,  soft  and  lobulated 
consistency;  sebaceous  cysts  (wens)  are  embedded  in  the  skin 
proper,  and  their  localization  is  usually  quite  different  from  that 
of  glandular  enlargements ;  actinomycotic  skin  infiltrations  are  intra- 
dermal in  situation. 

Morbid  enlargements  of  these  lymphatic  ganglia  generally  corre- 
spond to  certain  definite  areas  or  anatomic  regions. 

Considering  for  a  moment  only  the  readUy  and  actually  access- 
ible glandular  regions,  it  may  be  considered  a  general  rule  that 
swollen  glandular  masses  correspond  to  the  several  anatomic  divi- 
sions of  the  body  as  follows: 

Inguinal  glands. — These  drain  the  reproductive  organs,  the 
lower  extremity,  and  very  exceptionally  react  to  pelvic  or  ab- 
dominal affections. 

Axillary  glands. — These  are  related  to  the  thoracic  wall,  in- 
cluding the  breast,  and  the  upper  extremity,  and  very  exception- 
ally react  to  thoracic  tumors. 

Post-cervical  glands. — These  drain  the  mouth,  throat,  face, 
and  cranium. 

Submaxillary  glands. — Related  to  the  lower  jaw. 
(956) 


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GLANDULAR  ENLARGEMENTS.  957 

Supraclavicular  glands. — These  exceptionally  exhibit  metas- 
tasis from  cancer  of  the  stomach. 

It  should  be  remembered,  however,  that  the  majority  of  lym- 
phatic enlargements  completely  escape  our  examinations  by 
reason  of  their  depp  situation  in  the  body. 

Thus,  abdominopelvic  tumors  and  infections  almost  inevitably 
give  rise  to  inaccessible  deep  mesenteric  and  prevertebral  glandular 


Si: 
Su]  cla 


xlll 


Bi)  Bpil 

chl< 


Fig.  710. — Superficial  lymph-nodes  and  the  related  anatomic  regions. 

swellings  in  the  abdomen,  and  only  in  exceptional  instances  to 
enlargement  of  the  inguinal  glands.  Tumors  and  infections  in  the 
chest  almost  inevitably  give  rise  to  inaccessible  tracheobronchial 
glandular  enlargements,  and  only  exceptionally  to  enlargement  of 
the  cervical  and  axillary  lymphatics. 

Such  a  condition  is,  on  the  whole,  the  rule ;  thus,  cancer  of  the 
stomach,  tuberculous  peritonitis,  infections  of  the  biliary  tract,  gas- 
tric and  duodenal  ulcers,  in  fact,  the  great  majority  of  abdominal 
disorders  that  are  hard  to  diagnose  are  unaccompanied  by  any  ap- 


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958  SYMPTOMS, 

preciable  enlargement  of  superficial  lymphatic  glands.  Only  ex- 
ceptionally and  in  the  terminal  stage,  and  only  in  certain  forms, 
are  enlarged  supraclavicular  glands  found  in  cancer  of  the  stomach. 

The  tonsils,  as  is  well  known,  like  the  follicles  of  the  intestine, 
may  and  should  be  looked  upon  as  actual  submucous,  pharyngeal 
and  intestinal,  lymphatic  ganglia.  The  frequency  with  which  they 
become  diseased  and  the  common  occurrence  of  sore  throat  and  of 
intestinal  folliculitis,  specific  or  non-specific,  is  also  a  matter  of 
common  observation.  Do  these  infections  take  place  usually  through 
the  blood  stream  or  through  the  alimentary  tract?  Do  they  con- 
stitute oftener  a  portal  of  entry  or  a  focus  of  secondary  involve- 
ment? An  answer  to  this  question  is  of  marked  theoretical  as 
well  as  practical  (therapeutic)  importance;  from  our  present  ex- 
clusive standpoint  of  semeiology,  however,  it  is  of'  much  less  sig- 
nificance. 

Finally,  mention  may  be  made  of  the  lymphadenomas^  or  neo- 
plastic enlargements  of  lymphatic  foci  normally  not  palpable. 

In  this  work  space  will  not  permit  of  more  than  a  review  of 
certain  common  clinical  observations  susceptible  to  everyday  appli- 
cation in  the  causal  diagnosis  of  glandular  enlargements. 

In  whatever  region  a  glandular  enlargement  be  situated,  it 
may  present  itself  to  the  examiner  in  one  of  the  four  following 
forms  : 

(a)  Simple  glandular  hypertrophy  or  painless  adenopathy 
of  intermediate  extent  and  generally  involving  several  lymph  nodes. 
This  includes  the  syphilitic  adenomas,  lymphatic  hypertrophies  with 
or  without  accompanying  leukemia,  cold  tuberculous  glandular 
swellings,  and  lymphatic  enlargements  which  one  is  compelled  to 
qualify  as  cryptogenic,  since  in  last  analysis  their  exact  nature  is 
beyond  our  ken,  e,g.,  the  lymphatic  enlargements  of  convales- 
cence, of  the  **lymphatic  temperament"  ('iymphatism'*),  etc. 

The  syphilitic  gland  enlargements  deserv^e  especial  mention 
both  on  account  of  their  frequent  occurrence  and  their  diagnostic 
signification,  sometimes  practically  pathognomonic. 

Glandular  swelling  is  a  constant  appurtenance  of  the  syphilitic 
chancre.  It  involves  either  a  single,  large,  hard,  sluggish  node, 
which  never  suppurates ;  or  a  group  of  nodes  in  the  center  of  which 
is  one  larger  than  the  rest. 


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GLANDULAR  ENLARGEMENTS.  959 

In  the  secondary  stage,  the  lymph-glands  become  enlarged  in  all 
parts  of  the  body,  including  not  only  the  glands  corresponding  to 
the  lesions  on  the  skin  and  mucous  membranes  in  the  secondary 
stage,  but  also  those  of  other  regions;  the  epitrochlear  and  post- 
cervical  glands  are  of  prime  diagnostic  import  in  this  connection. 

(b)  Inflammatory  glandular  hypertrophy  or  painful  adeno- 
pathy, involving  one  or  more  glands,  with  or  >vithout  suppura- 
tion. This  is  the  ordinary  type  of  septic  adenitis  following  local 
infection:  Cervical  and  submaxillary  lymphatic  enlargements, 
etc.,  in  sore  throat  and  infective  disorders  of  the  mouth  or 
pharynx;  enlarged  inguinal  and  femoral  glands  in  wounds  and 
infections  of  the  lower  extremities  and  infective  disorders  of  the 
genital  organs  (gonorrhea,  balanoposthitis,  and  chancroid) ;  en- 
largement of  the  axillary  glands  in  infections  of  the  upper  ex- 
tremities, and  secondary  lymphadenitis  in  boils  or  carbuncles  in 
any  portion  of  the  body.  These 'disturbances  may  result  in  the 
production  of  glandular  abscesses  or,  as  is  more  common,  un- 
dergo absorption. 

General  infections  of  the  type  of  "grippe"  may  cause  tem- 
porary painful  enlargement  of  "glands"  that  have  been  latent 
for  a  number  of  years. 

(r)  Caseous  glandular  enlargement,  or  gland  softening.  This 
is  generally  the  result  of  tuberculous  lymphadenitis,  the  usual  pre- 
cursor of  the  so-called  "cold  abscesses,"  which,  if  improperly  treated, 
become  adherent  to  and  break  through  the  skin,  leaving  the  per- 
manent, highly  characteristic  scars  still  rather  frequently  noticed 
in  the  cervical  region. 

Adhesion  of  lymph-glands  to  the  skin  is  met  with  particularly 
in  the  septic  and  tuberculous  varieties  of  lymphadenitis. 

(d)  Hard,  nodular,  scirrhous  glandular  enlargements. — ^These 
are  usually  the  result  of  neoplastic  metastqsis  from  cancer,  either 
manifest  or  latent;  on  the  whole,  they  are  generally  secondary 
malignant  glandular  enlargements.  Some  varieties  are  of  great 
clinical  import,  e.g.,  the  secondary  enlargement  of  the  axillary 
lymphatics  in  cancer  of  the  breast  and  the  rather  exceptional 
supraclavicular  enlargements  in  malignant  growths  of  the 
stomach. 


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960  SYMPTOMS. 

Cervical  lympjiadenitifly  a  very  common  disorder,  and  one 
readily  observed  in  the  exposed  neck  region,  deserves  especial 
mention.  Of  all  gland  swellings  these  are  the  most  accessible, 
and  they  should  be  examined  for  as  a  routine. 

Submaxillary  and  post-maxillary  lymphadenitis  is  almost 
constant  in  children,  being  dependent  upon  one  of  the  ordinary 
infections  of  the  mouth  or  pharynx  (sore  throat,  dental  infection, 
etc.),  which  few  individuals  escape. 

Lateral  cervical  adenitis  is  also  extremely  common.  The  naso- 
pharynx is  the  usual  portal  of  entry  to  the  infecting  germ  in  these 
cases,  and  the  tubercle  bacillus  is  the  commonest  of  the  infecting 
germs.  The  submaxillary  and  stemomastoid  series  of  glands  gen- 
erally become  involved  at  practically  the  same  time.  All  different 
varieties  may  be  observed,  from  the  multiple  slight  enlargement 
of  several  nodes  (micropolyadenitis)  to  the  caseous  lymphadenitis 
terminating  in  cold  abscess.  Scrofula  and  tuberculous  infection 
appear  to  be  the  commonest  causes  of  these  glandular  affections. 

Occipital  adenitis,  manifest  about  the  margins  of  the  hairy 
scalp,  on  either  side  of  the  occiput,  is  encountered  chiefly  in  the 
presence  of  scalp  infections  (as  in  phthiriasis  or  impetigo) ;  ac- 
cordingly, it  is  seen  more  especially  in  children  in  the  form  of 
tender  gland  swellings  which  never  undergo  suppuration. 

Syphilitic  glandular  enlargements  occur  in  the  cervical  region 
in  two  equally  characteristic  forms : 

(a)    SxERNOMASTOro  ADENOPATHY  IN  CHANCRE  OF  THE  TONSIL. — 

This  occurs  as  an  initial  indication  of  primary  general  syphilitic 
glandular  enlargement,  represented  by  a  single  large  node  (ganglion 
indicateur) ,  beneath  and  at  the  middle  of  the  stemomastoid  mus- 
cle, of  the  size  of  a  walnut  or  hazelnut,  and  rendering  the  muscle 
tissue  prominent  above  the  surrounding  surface,  and  a  conjoint 
group  or  "pleiad"  of  smaller  nodes  underlying  the  whole  neck 
region  on  the  same  side,  hard,  painless,  and  rolling  beneath  the 
finger.  Careful  inspection  of  the  patient's  throat  will  reveal  a 
chancre  of  the  tonsil  on  the  same  side,  or,  if  it  has  already  been 
absorbed,  the  patient  will  recall  having  had  a  tonsillitis  on  one 
side  lasting  a  few  weeks. 

Chancre  of  the  tip  of  the  tongue  or  of  the  lips  gives  rise  to 
enlargement  of  a  suprahyoid  node,  "single,  movable,  and  rolling 


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GLANDULAR  ENLARGEMENTS.  961 

beneath  the  finger  like  a  little  rubber  ball,  the  feel  of  which  it 
exactly  reproduces.*'  (Sabouraud.) 

(&)  Secondary  syphilitic  adenopathy  is  chiefly  post-cervical, 
the  nodes  extending  along  the  neck  like  a  string  of  beads,  mov- 
able, elastic,  and  practically  insensitive.  These  should  always 
be  systematically  examined  for,  and  if  they  are  found,  the  other 
signs,  stigmata,  and  the  history  of  the  disease  should  likewise 
be  sought. 

Neoplastic  glandular  enlargements  are  secondary  to  cancer 
of  the  tongue  or  lips. 

Cancer  of  the  base  or  lateral  portions  of  the  tongue  reacts  on 
the  submaxillary  and  postmaxillary  glands,  and  later  on  the 
stemomastoid  group. 

Cancer  of  the  lips  or  of  the  tip  of  the  tongue  gives  rise  at 
first  to  suprahyoid  glandular  enlargement  Later,  it  extends  to 
all  the  other  lymph  nodes  in  the  region. 

Thefee  glandular  enlargements  are  hard,  nodular,  and  scir- 
rhous, tending  to  become  adherent  and  to  infiltrate  the  surround- 
ing tissues. 

The  lymphadenosis  of  Hodgkin's  disease  generally  appears 
first  in  the  cervical  region  and  is  predominant  in  this  location 
for  a  long  time  in  the  form  of  multiple,  sometimes  very  large 
masses  (varying  in  size  from  an  almond  to  an  orange),  hard, 
insensitive,  freely  movable,  not  adherent  to  the  skin,  and  never 
undergoing  suppuration.  Examination  of  the  blood  shows  a 
moderate  leucocytosis  with  lymphocytosis  (see  below). 

♦    ♦     ♦ 

Special  reference  should  be  made  to  the  apparently  primary 
tumor  growths  of  the  lymphatic  and  adenoid  tissues.  These  com- 
prise the  large  group  of  the  lymphomas,  lymphadenomas,  and 
lymphosarcomas,  with  or  without  leukemia. 

The  glandular  enlargements  are  generally  made  up  of  hyper- 
trophied  nodes  exhibiting  structurally  one  of  several  different 
types : 

1.  The  first  and  commonest  type  is  characterized  by  hyper- 
plasia of  lymphoid  tissue  similar  to  the  normal  tissue  of  the 

61 


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962  SYMPTOMS, 

lymph-nodes,    i.e.,    by    proliferation    of    the    lymphocytic    cells 
(lymphocytomatosis) . 

2.  A  second,  less  common  type  is  that  which  reproduces  mye- 
loid tissue,  or  the  tissue  of  which  bone  marrow  is  composed,  and 
is  characterized  by  the  presence  of  myelocytes  and  nucleated 
red  cells  (myelomatosis). 

3.  More  rarely,  the  growths  are  made  up  of  large  mononu- 
clear cells  with  basophilic  non-granular  protoplasm  and  clear 
nuclei  (macrolymphocytes  or  primitive  cells),  like  those  seen 
in  acute  leukemia. 

4.  The  last  group  brings  together  a  number  of  very  different 
kinds  of  tumors,  all  characterized  by  a  special  malignancy  of 
growth  (malignant  or  atypical  lymphadenosis).    It  includes: 

(a)  Lymphosarcoma,  consisting  of  sarcoma  cells. 

(fe)  Granulomas,  the  hybrid  structure  of  which  is  character- 
ized by  a  combination  of  lymphoid  and  myeloid  hyperplasia  with 
neoplastic  and  inflammatory  proclivities. 

The  condition  of  the  blood  reflects,  as  a  rule,  that  of  the 
blood-forming  organs;  hence  the  need  of  blood  examination  in 
the  diagnosis  of  lymphatic  adenopathies. 

The  ease  with  which  this  mode  of  examination  may  be  carried 
out  renders  it  accessible  to  the  practitioner,- 

A  mere  leucocyte  count  will  show  whether  the  case  is  one  of 
leukemia. 

Qualitative  examination  is,  however,  equally  indispensable 
for  revealing  a  lymphocytemia  or  a  myelemia,  which,  even  in 
the  absence  of  leukemia,  then  becomes  the  main  clinical  feature. 

A  few  stained,  dry  blood  preparations  will  readily  permit  of 
ascertaining  the  leucocytic  formula. 

Yet  the  typical  blood  reaction  may  be  lacking  (though  un- 
commonly), especially  at  first;  in  this  event,  removal  of  a  bit 
of  the  glandular  tissue  for  histologic  study  may  be  of  great 
assistance. 

Clinically,  with  the  aid  of  the  blood  examination,  one  will  be 
able  to  distinguish : 

(a)  Hodgkin's  disease  (lymphadenoma,  aleukemic  lymph- 
adenosis. Trousseau's  adenosis). 


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GLANDULAR  ENLARGEMENTS.  963 

In  this  condition  the  glandular  enlargement  develops  slowly, 
at  the  angle  of  the  jaw,  in  the  submaxillary  region,  or  along  the 
carotid  chain  of  glands,  often  symmetrically ;  other  glands  then 
appear  and  fuse  with  the  primary  group,  thus  forming  a  mass 
which  is  sometimes  of  considerable  size  (up  to  that  of  a  man- 
darin orange).  This  development  takes  place  in  the  course  of 
several  months  or  even  years.  The  enlarged  nodes  are  freely 
movable  beneath  the  skin,  and  never  undergo  ulceration  or  sup- 
puration. 

Similar  ganglionic  masses  occur  in  the  axillae  and  groins. 


Fig.  711. — Blood  in  Hodgkin's  disease.     /.  Lymphocjrte. 
^.  Red  cell.    j.  Polymorphonuclear  leucocyte. 

Hypertrophy  of  the  spleen,  liver,  tonsils,  testicles,  etc.,  may 
likewise  be  observed. 

Blood  Examination. — Cell  Count. — The  red  cells  show  a 
slight  decrease,  numbering  4  to  5  millions. 

The  white  cells  do  not  show  a  leucocytosis,  numbering  3000 
to  5000.' 

Or,  there  may  be  a  moderate  increase  of  the  white  cells — ^to 
about  25,000 — constituting  a  subleukemia. 

Differential  Count. — Generally  there  is  a  lymphocythemia : 

True  lymphocytes:  60  to  90  per  cent. 

Polymorphonuclear  leucocytes:  less  than  IQ  per  cent. 

Rarely,  myelemia  (presence  of  myelocytes  or  granular  mono- 
nuclears and  of  nucleated  red  cells). 

Rarely,  an  ordinary  pol)rmorphonuclear  increase. 


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964  SYMPTOMS. 

Rarely,  again,  the  differential  count  may  be  normal. 
The  DIFFERENTIAL  DIAGNOSIS  of  Hodgkin's  disease  involves  espe- 
cially the  elimination  of: 

1.  Infectious  glandular  enlargements. 

In  these  there  are  either  no  blood  changes  or  there  is  pol)rmor- 
phonuclear  leucocytosis. 

2.  Tuberculous  lymphadenitis. 

In  these  cases  either  the  blood  formula  remains  practically  nor- 
mal or  there  may  be  a  polymorphonuclear  leucocytosis. 

(b)  Lymphatic  leukemia,  the  ordinary  form  of  which  is  the 
splenogang^lionic  form,  is  characterized  by  gland  enlargements, 


_./-..3 


Fig.  712. — Blood  in  tuberculous  or  other  infectious  glandular  en- 
largement. /.  Large  mononuclear.  ^.  Polymorphonuclear  leucocyte.  3. 
Lymphocyte. 

either  slowly  or  rapidly  progressive,  in  the  neck,  the  submaxil- 
lary and  nuchal  regions,  the  axillae,  and  later  in  the  inguinal 
regions. 

Enlargement  of  the  spleen  is  neither  constant  nor  pronounced 
in  these  cases. 

Blood  Examination. — Cell  Count. — The  red  cells  show  a 
decrease,  frequently  slight. 

The  white  cells  show  a  leucocytosis,  often  less  marked  than 
in  myeloid  leukemja — 100,000  to  250,000,  occasionally  up  to 
900,000. 

Differential  Count. — True  lymphocytes:  90  to  99  per  cent. 

Polymorphonuclear  leucocytes:  barely  10  per  cent. 


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GLANDULAR  ENLARGEMENTS. 


%5 


Eosinophiles :  none. 

(r)  Myeloid  leukemia,  uncommonly. 

Enlargement  of  the  lymph-glands  is  uncommon  in  myeloid 
(spleno-myelogenous)  leukemia,  which  is  characterized  mainly 
by  enlarged  spleen  and  liver,  etc. 


Fig.  713. — L)rmphatic  leukemia.    /.  Large  lymphocyte.    2.  Small 
lymphocyte.    3.  Polymorphonuclear  leucocyte. 

Blood  Examination. — Cell  Count. — The  red  cells  show  a 
marked  reduction,  to  about  3  millions. 


Fig.  714. — Myeloid  leukemia,  /.  Neutrophilic  myelocyte.  2.  Eosino- 
philic myelocyte.  3.  Small  lymphocyte.  4.  Large  lymphocyte.  5. 
Nucleated  red  cell.    6.  Polymorphonuclear  neutrophilic  leucocyte. 

The  white  cells  are  increased  to  about  300,000,  up  to  1  million. 
Differential  Count. — The  myelocytes  or  granular  mononu- 
clears predominate. 


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966 


SYMPTOMS, 


Nucleated  red  cells  are  present  in  varying  numbers. 
(d)  Acute  leukemia. — The  various  groups  of  lymph-nodes, 
particularly   the   cervical   and   submaxillary,   are   involved,   but 


Fig.  715. — Acute  leukemia.    /.  Macrolymphocyte.    ^.  True  lymphocyte. 
3.  Polymorphonuclear  leucocyte. 

hardly  reach  the  size  of  an  almond.    Enlargement  of  the  spleen 
is  slight. 

There  is  tonsillar  hypertrophy,  suggesting  an  acute  tonsillitis.. 


^/— Ji 


Fig.  716. — Lymphosarcoma.    /.  Eosinophile.    ^.  Polymorpho- 
nuclear neutrophile. 

Hemorrhages,  pronounced  anemia,  and  fever. 
Blood  Examination. — Cell  Count. — The   red  cells  show   a 
marked  decrease. 


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GLANDULAR  ENLARGEMENTS,  967 

The  white  cells  are  increased  to  50,000  or  100,000;  sometimes 
200,000,  or  even  900,000. 

Differential  Count. — Polymorphonuclears:  below  10  per  cent. 

Eosinophiles :  none. 

Macrolymphocytes  or  primitive  cells:  80  to  90  per  cent. 

(Non-granular  mononuclear  cells  with  voluminous  proto- 
plasm, basophilic,  and  with  clear  nuclei.) 

{e)  Lymphosarcoma. — In  this  condition  the  lymphatic  tumor, 
generally  located  in  the  neck,  shows  rapid  progression,  attains 
a  considerable  size  within  a  few  months,  and  produces  a  rounded 
prominence  covered  with  a  pronounced  network  of  veins,  some- 
times ulcerated,  and  capable  of  leading  to  copious  hemorrhage. 

Blood  Examination. — The  blood  shows  little  change.  There 
is  a  moderate  degree  of  leucocytosis  with  excess  of  polymorpho- 
nuclears, with  or  without  eosinophilia. 

(/)  Lymphatic  granulomatosis. — Enlarged  glands  form  masses 
of  varying  size,  running  a  rather  rapid,  malignant  course. 

Blood  Examination. — Generally  there  is  a  leucocytosis  of 
30,000  to  50,000. 

Differential  Count. — Polymorphonuclear  leucocytes  increased. 

Eosinophilic  polymorphonuclears  increased. 

Myelocytes  sometimes  present. 


Before  concluding  this  section  a  word  or  two  must  be  said 
concerning  the  moot  question  of  the  lymphatic  temperament  or 
diathesis,  now  needlessly  obscured  by  discussions  as  to  termin- 
ology and  pathogenesis  (inter-relationship — as  yet  uncertain — of 
scrofula,  the  lymphatic  diathesis,  tuberculosis,  and  "arthritism"). 

Clinically  there  is  no  doubt  of  the  existence  of  a  lymphatic 
diathesis.  Children  in  general,  and  certain  children  in  particular, 
exhibit  a  marked  tendency  to  excessive  reactions  on  the  part  of 
the  lymphatic  channels  and  nodes,  and  in  some  of  them,  this  tend- 
ency is  expressed  in  a  variety  of  clinical  manifestations,  chiefly 
involving  the  skin  and  mucous  membranes,  which,  in  the  aggre- 
gate, justify  us  in  speaking  of  a  lymphatic  temperament — ^an  actual 
diathesis,  constitution,  or  special  morbid  predisposition — some- 
times called  lymphatism. 


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968 


SYMPTOMS. 


With  exclusive  reference  to  the  actual  clinical  evidences,  these 
manifestations  may  be  grouped  as  shown  in  the  subjoined  table: 

Clinical  Manifestations  of  the  Ljrmphatic  Constitution. 


pbimabt. 

SECONDARY,    WITH    A    TBND- 
BNCT    TO    RBCUBBSNCB. 

Skip        

Scaly  eruptions.  Intertrigo. 
Prurigo. 

Eczema.    Impetigo. 
Multiple  abscesses. 

Mucous  mem- 
branes   

Desquamative  processes 
and  various  evanescent 
catarrhal  states. 

Sore  throat. 

Pharyngitis. 

(Gastro-enteritis). 

Coryza  (hay  fever). 

Laryngitis  (false  croup). 

Bronchitis  (asthma). 

Conjunctivitis. 

Blepharitis. 

Balanitis. 

Vulvo-vaginitis. 

Lsrmphatic 
structures  ... 

Hypertrophied  palatal  and  pharyngeal  tonsils.     En- 
larged cervical,  inguinal,  axillary,  or  other  glands. 

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pj  Yco^TTRTA     Fy'^^^^^  sweet  substance;  ovpelv,  to  wri-1 
•    [  nate.   Pi'esence  of  sugar  in  the  urine.  J 


Since  uranalysis  should  be  carried  out  as  a  routine  in  the  process 
of  examining  a  patient,  glycosuria  is  a  condition  which  ought 
not  to  be  overlooked.  Even  accidental  or  alimentary  glycosuria  is 
almost  certain  to  be  detected  if  the  test  for  sugar  is  repeated  at 
each  examination,  as  it  should  be. 

In  the  event  of  doubt,  glycosuria  may  be  clinically  considered 
to  exist  whenever  there  is  distinct  reduction  of  Fehlingf  s  solu- 
tion (see  Technical  procedures). 

The  following  figures  will  give  an  idea  of  the  frequency  with 
which  glycosuria  clinically  occurs: 

Out  of  2000  subjects  of  both  sexes  suffering  from  various 
chronic  disorders  examined  in  the  author's  office,  106,  or  approxi- 
mately 5  per  cent.,  showed  glycosuria;  in  two-thirds  of  these  pa- 
tients the  condition  had  previously  been  overlooked. 

Out  of  1000  military  subjects,  suffering  for  the  most  part  from 
acute  disorders,  examined  in  a  hospital,  6,  or  approximately  0.5 
per  cent,  showed  glycosuria;  the  condition  had  previously  been 
overlooked  in  4,  i,e,,  two-thirds  of  the  cases. 


Diabetes  mellitus  is  a  clinical  symptom-complex  characterized 
by  permanent,  or  at  least  lasting,  glycosuria,  usually  associated  with 
polyuria,  polydipsia,  polyphagia,  and  autophagia,  none  of  these 
symptoms  being,  however,  necessarily  present  in  all  stages  of  the 
disease,  while  the  essential,  characteristic  manifestation  is  habitual 
glycosuria  with  hyperglycemia. 

Diabetes  is  put  down  as  a  clinical  symptom-complex  and  not 
a  disease,  because  the  diabetes  or  permanent  glycosuria  is  not 
always  due  to  the  same  cause  nor  attended  with  constant  patho- 
logic evidences — ^as  is  also  true,  indeed,  of  the  accidental,  tempo- 
rary forms  of  glycosuria, 

(969) 


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970  SYMPTOMS. 

Clinical  observation  and  experimental  work  have  shown  that 
a  temporary  or  a  permanent  (diabetic)  glycosuria  may  be  produced 
either : 

1.  By  hyperglycophagia  (so-called  "alimentary  glycosuria"), 
including  muscular  hypoglycolysis  (due  to  insufficient  exercise). 

2.  By  disease  of  one  of  various  organs. 

(a)  The  liver. — Hepati<:  diabetes,  occurring  in  two  forms  (Gil- 
bert and  Camot)  :  Excessive  hepatic  actiznty  (hypertrophy,  conges- 
tive states,  etc.),  and  insufficient  hepatic  activity  (cirrhosis,  oblitera- 
tion of  the  portal  vein,  etc.). 

(b)  The  pancreas  (pancreatic  insufficiency). — Pancreatic  dia- 
betes, a  well-known  condition  clinically,  and  one  also  experimentally 
reproduced  (von  Mehring  and  Minkowski). 

(c)  The  kidneys  (renal  insufficiency). — Renal  diabetes,  experi- 
mentally demonstrated  through  the  production  of  phloridzin  gly- 
cosuria. 

(d)  The  adrenals  (hyperepinephria). — Adrenal  diabetes,  ex- 
perimentally demonstrated  through  epinephrin  glycosuria. 

(e)  The  thyroid  (hyperthyroidia). — Thyroid  diabetes  (hyper- 
thyroidia,  Graves's  disease). 

3.  By  lesions  of  the  nervous  system. — The  manner  in  which 
this  form  of  glycosuria  is  produced  was  demonstrated  experi- 
mentally by  Claude  Bernard  in  1849,  sugar  appearing  in  the  urine 
upon  production  of  a  lesion  of  the  medulla. 

(a)  Organic  disease,  especially  bulbospinal:  Brain  tumors,  gen- 
eral paralysis,  disseminated  sclerosis,  tabes  dorsalis,  etc. 

(b)  Neuroses  and  psychoses:    Chorea,  Graves's  disease,  etc. 

(c)  Traumatic  lesions. 

4.  By  disturbed  general  nutrition. 

(a)  Neuroarthritic  glycosuria,  dependent  upon  a  chronic  dis- 
turbance of  general  nutrition,  usually  inherited  and  variously  asso- 
ciated or  combined  with  the  various  so-called  "arthritic"  disorders, 
vis,,  gout,  obesity,  lithiasis,  etc. 

(b)  Toxic  states,  acute  or  chronic.  Those  clinically  most  famil- 
iar, though  generally  evanescent,  are  caused  by  chloroform  or 
chloral  hydrate;  the  most  important,  however,  because  frequently 
overlooked,  are  the^nore  or  less  lasting  forms  of  glycosuria  brought 


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GLYCOSURIA,  971 

on  by  the  insidious  intoxications  by  illufninating  gas  and  carbon 
monoxide. 

The  foregoing  simple  etiologic  classification  gives  a  sufficient 
understanding  of  the  various  well-known  theories  as  to  the  causa- 
tion of  glycosuria,  vis.,  the  hepatic  theory,  the  pancreatic  theory, 
the  nervous  theory,  and  tlie  glycolytic  theory.  These  theories  hold 
good  in  certain  individual  cases  and  explain  certain  clinical  forms 
of  glycosuria,  but  are  not  sufficiently  comprehensive.  They  apply 
in  some  forms  of  the  condition,  but  not  in  all. 

As  matters  now  stand,  if  one  takes  into  account  all  known 
clinical  and  experimental  data,  it  becomes  necessary  either  to  limit 
one's  efforts  to  special  studies  of  each  of  the  innumerable  varieties 
of  glycosuria  or,  adc^ting  broader  conceptions  of  the  pathogenesis, 
to  put  it  down  as  a  fact  that  the  diabetic  symptom-complex  is  the 
obvious  organic  expression  of  a  lesion  or  disturbance  of  function 
at  some  point  of  the  glycotrophic  nutritive  system. 

This  glycotrophic  nutritive  system,  which  is  highly  complex, 
is  governed  and  coordinated  by  the  organic  cerebrospinal  nervous 
system,  which  insures  functional  cooperation  in  this  system,  thus 
rendering  it  possible  to  have  a  glycosuria  of  nervous  origin  through 
glycotrophic  incoordination. 

The  glycotrophic  system  consists  essentially  of  a  group  of  gland- 
ular organs,  vis,,  the  liver,  pancreas,  and  in  fact  the  entire  digestive 
tract,  the  adrenals,  the  thyroid,  etc.,  charged  with  the  task  of  elab- 
orating sugars,  presiding  over  their  conservation  (glycogenesis) 
and  destruction  (glycolysis),  and  whose  overactivity  or  insuffi- 
ciency, inducing  disturbance  of  sugar  nutrition,  brings  on  a  diabetes 
of  glandular  origin. 

Yet  this  glycolytic  property,  while  more  especially  possessed  by 
certain  individual  organs,  ap^pears  to  be  a  functional  attribute  of 
cell  nuclei  in  general,  so  that  any  general  disturbance  of  cell  nutri- 
tion— usually  combined,  indeed,  with  the  glandular  disturbances 
above  mentioned — may  bring  on  a  form  of  glycosuria  that  may 
properly  be  described  as  a  dystrophic  diabetes  of  arthritic  or  toxic 
origin. 

Brief  reference  may  here  be  made  to  the  ingenious  theory  in- 
volving the  role  of  the  endocrine  glands  (thyroid,  adrenals,  and, 
in  part,  the  pancreas).    This  theory  presupposes  that  the  glycolytic 


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972  SYMPTOMS, 

reaction  in  the  cell  nuclei  can  occur  only  in  the  presence  of  catalyz- 
ing reagents  or  complements  set  free  in  the  system  by  the  endocrine 
glands;  in  the  absence  of  these  indispensable  complementary  fer- 
ments, the  glycolytic  reaction  is  held  not  to  occur,  glycosuria  there- 
fore resulting.  In  truth,  this  theory,  while  opposed  by  the  actual 
known  instances  of  diabetes  induced  by  hyperepinephria  and  hyper- 
thyroidia,  is  based  upon  the  definite  observations  well  described  by 
Minkowski  and  leading  to  the  conclusion  that  glycosuria  may  be 
brought  on  by  suppression  of  the  internal  secretion  of  the  pancreas, 
which  in  the  normal  animal  proceeds  to  exert  its  action  upon  the 
other  glycotrophic  organs  through  the  medium  of  the  circulation. 

At  all  events,  the  brief  causal  and  pathogenetic  review  just  pre- 
sented will  have  imparted  some  conceptions  as  to  the  occurrence  of 
the  syndrome  of  diabetes,  accounted  for  by  one  of  a  variety  of 
causes,  and  the  causal  treatment  of  which — ^the  only  rational  means 
of  therapy — should  be  adapted  to  each  clinical  form. 

However  limited  our  knowledge  may  as  yet  be  in  this  con- 
nection, it  is  thus  nevertheless  indispensable  to  make  a  systematic 
study  of  each  case  and  try  to  trace  back  the  initial  cause  of  the 
nutritional  disorder. 

"Before  undertaking  to  treat  a  diabetic  subject,  one  should  study 
the  case  with  care  not  only  as  regards  the  existing  symptoms  but 
also  as  regards  the  patient's  habits  and  character.  The  results 
obtained  depend,  indeed,  upon  a  host  of  circumstances  apart  from 
the  nature  of  the  diabetic  disorder  per  se:  The  patient's  occupa- 
tion and  tastes  and  the  general  type  of  his  associates  frequently 
offer  hindrance  to  successful  results  from  the  physician's  advice."^ 
(Le  Gendre). 

This  careful  preliminary  investigation  will  sometimes  enable  the 
physician  very  readily  to  dispel  incipient  diabetes.  "My  advice  was 
sought  a  few  years  ago,"  wrote  Lepine,  "by  a  manufacturer  about 
fifty  years  of  age,  free  of  inherited  morbid  taints.  He  was  leading 
a  normal  life  and  was  not  subject  to  worry;  his  diabetic  condition 
had  set  in  about  two  years  before. 

"After  prolonged  questioning  I  finally  learned  that  during  the 
preceding  three  years  he  had  made  a  change  in  his  daily  routine 


1  Diabete  in  "Traiti  de  midecine"  vol.  i,  Masson  et  Cie. 


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GLYCOSURIA.  973 

which  he  wrongly  deemed  of  little  consequence;  he  had  taken  up 
his  abode  directly  at  the  factory,  whereas  previously  he  had  walked 
to  and  from  the  factory  twice  daily,  thus  covering  a  distance  of 
8  kilometers.  Upon  finding  out  this  fact,  I  recommended  that  he 
take  a  walk  for  two  hours  each  day.  I  also  adjusted  his  diet. 
The  glycosuria  disappeared." 

Such  easy  cases  as  this  are  exceptional ;  yet  they  are  sometimes 
met  with  in  practice.  The  above  example  shows  how  intelligent 
and  painstaking  an  inquiry  is  required  before  prescribing  treatment. 

A  clinical  classification  of  cases  of  diabetes,  however  imperfect 
it  may  be  with  our  present  restricted  knowledge,  is  of  marked 
service  in  defining  the  general  lines  of  antidiabetic  treatment  in 
the  various  cases. 

For  want  of  a  better  one,  the  following  least  defective,  oldest, 
and  most  practical  classification  will  here  be  adopted: 

Stout  Diabetics,  without  Impairment  of  Nutrition. — These 
are  usually  cases  of  "neuro-arthritic"  diabetes,  or  hepatic  dia- 
betes through  overactivity  of  the  liver;  this  is  the  diabetes  of 
plethoric  or  of  florid  gouty  persons  with  enlarged  and  congested 
liver,  a  sluggish  intestine,  and  taking  but  little  exercise.  Such 
diabetics  generally  appear  very  well  nourished,  stout,  red  com- 
plexioned,  and  show  marked  endurance;  they  eat  and  drink 
heartily  and  are  in  a  general  sense  high  livers. 

In  these  patients  the  body  weight  is  definitely  above  the  average, 
and  the  same  is  true  of  tlie  daily  output  of  urea,  which  exceeds 
0.40  gram  per  kilogram  of  weight ;  the  glycosuria  is  of  intermediate 
degree,  ranging  from  0  to  60  grams.  If  the  urine  is  systematically 
collected  at  fairly  regular  intervals  after  and  between  meals,  the 
sugar  elimination  will  be  found  to  be  intermittent,  or,  if  it  is  con- 
stant, a  marked  recrudescence  after  meals  will  be  noted. 

This  is  the  commonest  type  of  case,  and  these  are  also  the  most 
favorable  cases  from  the  standpoint  of  treatment,  proper  and  well 
planned  general  hygiene  and  diet  being  suflicient  for  successful 
results.  Marked  benefit  accrues  from  restriction  of  the  total  intake 
of  food,  special  reduction  of  carbohydrates,  and  systematic  exercise. 

Thin  Diabetics,  with  Impaired  Nutrition. — ^This  is  the  dia- 
betes of  young  subjects  and  of  those  with  serious  disease  of  the 
pancreas  or  certain  lesions  of  the  liver. 


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974  SYMPTOMS, 

The  disease  in  these  cases  is  attended  with  rapid  loss  of  weight, 
progressive  asthenia,  and  a  tendency  to  cachexia.  The  general  ap- 
pearance is  one  of  physical  debility,  and  resistance  to  fatigue  is 
slight. 

The  body  weight  is  distinctly  below  the  average;  polyuria  and 
glycosuria  are  very  marked,  the  former  amounting  to  3  liters  a  day 
and  the  latter  to  over  100  grams.  The  amount  of  sugar  excreted 
may  exceed  the  intake  of  carbohydrates.  Examination  of  the  urine 
collected  at  regular  intervals  shows  that  glycosuria  is  constantly 
present  and  that  the  influence  of  the  meals  on  it,  though  present, 
is  much  less  marked  than  in  the  preceding  group  of  cases. 

These  are  the  worst  cases  from  the  standpoint  of  treatment. 
Often  it  is  impossible  to  arrest  denutrition  and  prevent  cachexia. 
The  prognosis  is  most  unfavorable. 

Nervous  Diabetes. — This  group  includes,  indeed,  several  very 
diflFerent  forms  of  the  disorder;  but,  if  one  excludes  the  cases 
manifestly  dependent  upon  some  obvious  lesion  of  the  nervous 
system  and  in  which  the  glycosuria  is  to  be  considered  only  as 
a  bulbar  manifestation  of  the  organic  disorder  present,  there  re- 
mains a  rather  clear-cut  clinical  type,  vis,,  the  diabetes  of  city 
dwellers,  business  men  and  others  overburdened  with  mental 
work  or  continually  subjected  to  emotional  impressions  and  oc- 
cupational stress  and  worry.  The  predominating  clinical  feature 
in  these  cases  is  nervousness  and  irritability.  The  urinary  evi- 
dences are  likewise  very  changeable ;  the  polyuria  and  glycosuria 
vary  markedly  from  one  week  to  another  or  from  one  day  to  the 
next,  without  apparent  relationship  to  the  diet,  and  an  obvious, 
direct  connection  can  be  made  out  between  the  degree  of  over- 
work and  worry  and  the  glycosuria  and  general  condition  of 
the  patient.  Oxaluria  and  phosphaturia  are  frequently  present 
in  these  cases. 

Obviously,  in  these  subjects,  general  hygiene,  mental  rest  if 
possible,  country  life,  a  regular  mode  of  living,  and  nervine 
medication  are  the  chief  therapeutic  indications. 

The  above  varieties  having  been  enumerated,  there  remain  cer- 
tain indefinite  cases,  of  varying  etiology  and  symptomatology,  such  as 
post-infectious  diabetes,  toxic  diabetes,  traumatic  diabetes,  etc.. 


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GLYCOSURIA.  975 

complex  in  their  pathogenesis  and  not  precisely  compatible  with 
the  groupings  already  referred  to.  In  these  cases  clinical  inves- 
tigation should  be  especially  painstaking  and  intelligent,  since  a 
rational  and  sometimes  effectual  causal  treatment  may  be 
worked  out  upon  discovery  of  the  exciting  cause  of  the  condition. 
The  author  is  well  aware  that  the  above  mentioned  groupings 
are  arbitrary  and  are  not  adequately  supported  by  clinical  or  patho- 
logic data ;  yet  they  are,  for  the  present  at  least,  worthy  of  adoption 
from  the  practical  standpoint,  i.e.,  for  prognostic  and  therapeutic 
purposes. 


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HEADACHE 
(CEPHALALGIA). 


[xe^Hxki^^  head;  d>lyo$,  ^in,l 
headache.  J 


Headache  is  one  of  the  commonest  of  clinical  symptoms.  A 
definition  of  the  term  cephalalgia  is  scarcely  necessary ;  in  a  gen- 
eral way,  it  refers  to  pain,  generally  diffuse  in  character,  experi- 
enced in  any  portion  of  the  cranial  region. 


Fig.  717. — Cut  showing  the  close  ana- 


tomic relationship  existing  between  the 
frontal,  ethmoid,  and  sphenoid  sinuses 
and  the  covering  membranes  of  the  brain. 
The  ethmoid  sinuses  are  diagrammatic- 
ally  represented. 


Fig.  718.--Cut  showing  the 
close  anatomic  relationship  exist- 
ing between  the  ethmoid  sinuses 
and  the  covering  membranes  of 
the  brain. 


This  region  includes : 

1.  The  cranial  contents:  Cerebrum,  cerebellum,  the  brain  mem- 
branes, and  the  intracranial  vessels  and  nerves. 

2.  The  cranicU  cavity  with  its  annexes:  Frontal,  maxillary,  and 
ethmoid  sinuses,  and  the  auricular  and  orbital  cavities. 

3.  The  pericranial  tissues:  Pericranial  muscles,  insertions,  and 
fasciae  (frontal,  occipital,  and  temporal),  and  in  particular  the 
occipital  (nuchal  muscles)  and  temporal  muscular  masses;  also 
the  skin  and  cellular  tissue  of  the  frontal  and  temporal  regions  and 
of  the  scalp. 

(976) 


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HEADACHE  (CEPHALALGIA),  977 

All  these  tissues,  with  the  exception  of  the  brain  itself,  are 
provided  with  sensory  nerves;  furthermore,  while  the  brain  itself 
is  actually  insensitive,  the  brain  arteries  are  provided  with  sym- 
pathetic plexuses,  and  the  dura  mater  and  pia  mater  and  their 
extensions  are  abundantly  innervated ;  thus,  many  deep-seated  brain 
disorders,  e.g.,  tumors,  may  give  rise  to  inveterate  headache,  pos- 
sibly through  meningeal  or  vascular  irritation. 

This  structural  complexity  accounts,  at  least  in  part,  for  the 
exceeding  frequency  of  cephalalgic  reactions,  of  which  even  the 
subjoined  enumeration  will  give  only  an  incomplete  idea: 


Fig.  719. — Head's  cranial  zones.  NF,  nasofrontal :  6th  upper  thoracic 
segment :  Disorders  of  the  pulmonary  apexes  and  of  the  base  of  the  heari. 
T,  temporal :  7th  thoracic  segment :  Disorders  of  the  bases  of  the  lungs, 
the  left  ventricle,  and  the  upper  gastric  region.  AP,  anterior  parietal : 
8th  thoracic  segment.  PP,  posterior  parietal :  9th  thoracic  segment.  O, 
occipital :    10th  thoracic  segment. 

1.  The  scalp  itself  may  be  the  source  of  the  morbid  impulses, 
as  from  parasites,  wigs,  hats,  or  dyes. 

2.  The  muscle  mass  and  fasciae  of  the  nuchal  region  may  be 
the  seat  of  fibrous  deposition,  of  inflammation,  or  of  painful  infil- 
trations the  importance  of  which  will  later  appear. 

3.  The  cranial  sinuses,  frontal,  ethmoid,  and  auricular  (middle 
ears),  by  virtue  of  their  contiguity  to  the  nasopharyngeal  mucous 
membrane,  are  particularly  exposed  to  the  catarrhal  states  and  in- 
fections which  so  often  affect  the  latter  surface. 

4.  The  intracranial  membranes  (meningeal  and  vascular)  are 
likewise  frequently  subject  to  congestive  or  inflammatory  painful 
conditions. 


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978  SYMPTOMS, 

5.  The  trigeminal  region,  rendered  hypersensitive,  it  seems,  by 
the  refinements  of  civihzation,  is  subjected  to  the  abnormal  irrita- 
tion of  affections  of  the  eyes,  nose,  and  teeth.  It  might  further 
be  stated,  apparently  with  sufficient  justification,  that  the  chief  cen- 
ter of  cephalic  sensation,  "the  headache  center,"  if  one  may  use 
such  an  expression,  is  principally  made  up  of  the  "trigeminal  cen- 
ters." 

6.  Many  clinical  observations  compel  recognition  of  the  occur- 
rence of  reflex  headaches  brought  on  through  morbid  excitation 
of  extracranial  regions,  sometimes  very  remote,  probably  owing 
to  more  or  less  intimate  connections  between  the  pneumogastric 
centers  and  the  fifth  pair.  Thus,  Head  has  described  certain  cephalic 
zones  which  he  considers  particularly  "exposed"  and  painful  in 
the  presence  of  disorders  of  the  thoracic  or  abdominal  viscera. 
Diseases  of  these  viscera  are  well-known  to  cause  hyperesthesia 
and  reflex  pain  in  certain  definite  zones  of  the  thoracic  and  ab- 
dominal walls.  If  this  pain  exceeds,  however,  a  certain  degree  of 
intensity,  a  similar  hyperesthesia  and  pain  tend  to  set  in  in  a  corre- 
sponding cranial  zone.  The  general  law  of  pain  distribution,  as 
conceived  by  Head,  is  as  follows :  The  higher  up  the  affected  por- 
tion of  the  trunk,  the  more  anterior  the  affected  zone  of  the  encepha- 
lon.  Thus,  according  to  Head,  the  relationships  existing  between 
the  trunk  and  head  may  be  given  as  follows: 

Six  upper  thoracic  segments,  naso-frontal  area. 

7th  thoracic  segment,  temporal  area  (held  to  be  one  of  the  most  frequent 
types). 

8th  thoracic  segment,  vertical  (anteroparietal)  area. 
9th  thoracic  segment,  parietal  area. 
10th  thoracic  segment,  occipital  area. 

The  hyperesthetic  zone  of  the  seventh  thoracic  segment,  which 
corresponds  to  a  visceral  disorder  at  the  base  of  the  lungs,  the 
upper  portion  of  the  stomach  or  the  left  heart,  including  more  par- 
ticularly the  mitral  region,  is,  indeed,  often  attended  with  tem- 
poral headache. 

Reflex  headaches  of  more  remote  source,  e.g.,  from  the  uterus 
or  ovaries,  have  also  been  reported. 

7.  Lastly,  the  close  connections  existing  between  the  cortical  and 
subcortical  centers  of  head  sensation  and  the  special  sense  centers 
(visual,  auditory,  gustatory,  and  olfactory  in  particular),  as  well 


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HEADACHE  (CEPHALALGIA),  979 

as  the  general  and  special  hyperesthesia  of  hypercivilized  subjects, 
account  for  the  headaches  of  special  sense  origin  induced  in  algic- 
hyperesthetic  persons  by  marked  or  prolonged  special  sense  excita- 
tion, e,g.,  too  much  light  (as  illustrated  in  the  headache  and  neu- 
ralgia met  with  on  the  Cote  d'  Azur,  or  Southern  Coast  of  France), 
sharp,  discordant  sounds,  strong  or  nauseous  odors,  unpleasant 
tastes,  etc. 

If  one  considers,  furthermore,  that  all  of  the  foregoing  head- 
ache-producing stimuli  may  be  direct  or  indirect,  circulatory,  in- 
flammatory, toxic,  etc.,  a  conception  will  be  had  of  the  very  great 
frequency  of  the  syniptom  headache,  the  multiplicity  of  its  causes, 
and  the  practical  impossibility  of  supplying  a  complete,  practical, 
and  logical  classification. 

For  want  of  a  better  classification  and  in  full  knowledge  of  the 
attendant  shortcomings  and  of  the  frequently  artificial  nature  of 
distinctions  thus  made  between  different  groups  of  headaches,  the 
following  classification,  which  is  the  least  inconvenient,  will  be 
adopted  herein: 

Headaches  of  toxic  and  toxinic  (infectious  toxins)   origin. 

Headaches  of  neuralgic  and  neuropathic  origin. 

Headaches  due  to  pressure  (inflammatory,  meningoencephalitic, 
or  neoplastic). 

Headaches  of  reflex  origin. 

Headaches  of  muscular  origin. 

Headaches  of  toxic  origin  are  very  common  and  often  diffi- 
cult to  diagnosticate,  being  highly  variable  as  to  type,  severity, 
localization,  and  duration. 

In  this  group  may  be  mentioned  the  prodromal  headache  of 
infectious  diseases.  In  general  these  are  poorly  localized  and  of 
intermediate  severity;  they  usually  diminish  in  the  morning  and 
show  exacerbation  in  the  afternoon  and  evening;  they  are  often 
associated  with  a  gradual  rise  in  the  temperature;  after  the  pro- 
dromal period  they  generally  subside  or  diminish.  This  prodromal 
type  of  headache  is  particularly  marked  in  typhoid  fever,  malaria, 
and  influenza.  The  first  of  these  disorders  may  be  suspected  upon 
careful  examination  of  the  temperature  curve  and  search  for  the 
other  prodromal  signs   (epistaxis,  dizziness,  diarrhea,  appearance 


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980  SYMPTOMS, 

of  the  tongue,  enlarged  spleen,  etc.),  and  its  existence  may  be  later 
confirmed  by  the  Widal  test  and  blood  culture.  Malaria  is  recog- 
nized from  the  periodicity  of  its  febrile  paroxysms  and  their  cfiar- 
acteristic  successive  stages;  examination  of  the  blood  for  malarial 
parasites  may  definitely  settle  the  question.  Influenza  is  generally- 
recognized  from  the  existence  of  an  epidemic  at  the  time,  the  sudden 
onset,  the  respiratory  catarrh,  and  the  rapid  course  of  the 
disease. 

Headache  of  uremic  orig^  seems  to  be  most  pronounced  in 
the  presence  of  azotemia.  Often  a  comparative  remission  in  the 
mornings  will  be  noted.  Frequently  attending  the  digestive  form, 
it  is  accompanied  by  nausea,  vertigo,  mental  confusion,  and  some- 
times vomiting;  it  frequently  presents  the  appearance  of  migraine; 
high  blood-pressure  is  almost  constantly  present;  determination 
of  the  blood  urea  will  definitely  settle  the  matter.  In  the  high 
pressure  forms  without  marked  azotemia,  which  seem  to  occur 
rather  frequently  in  interstitial  cases  with  excessive  output  of  urine 
of  low  specific  gravity,  without  albuminuria,  but  with  markedly 
high  blood-pressure,  the  toxemia  is  often  less  pronounced,  and 
the  headache  is  perhaps  less  dependent  upon  this  factor  than  upon 
the  lack  of  elasticity  of  the  arteries  with  increase  of  the  blood-pres- 
sure in  the  cranial  cavity.  Such  conditions  induce  headache  which 
varies  with  every  change  in  the  circulation  and  frequently  assumes 
a  pulsating  character.  Renon  has  called  attention  to  a  special  form 
of  morning  headache  occurring  in  high  pressure  cases  and  accom- 
panied by  polyuria,  excessive  output  of  urine  at  night,  acute  albu- 
minuria, and  hypertrophy  of  the  left  ventricle. 

The  headache  of  stercoremia  or  constipation  is  generally  of 
the  toxic  type,  and  the  frequent  association  of  the  cause  with  the 
eflfect  is  usually  known  to  the  patient  himself. 

A  much  more  severe  variety  is  the  bilious  headache  which, 
in  some  individuals,  recurs  at  irregular  intervals  and  ranges  from 
a  simple  persistent  feeling  of  frontal  weight  to  a  lancinating, 
throbbing,  boring  pain.  It  is  commonly  associated  with  nausea  and 
vomiting;  the  vomitus  first  brought  up  consists  of  more  or  less 
digested  food,  and  that  appearing  later,  of  mucus  and  bile.  This 
type  of  headache  is  due  partly  to  the  presence  of  toxic  sub- 
stances in  the  blood,  but  mainly  to  the  brain  congestion  resulting 


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HEADACHE  (CEPHALALGIA),  981 

from  repeated  vomiting.  Very  common  and  annoying  concomi- 
tant symptoms  are  palpitations  and  vertigo. 

A  form  of  headache  recurring  regularly  in  the  morning,  gener- 
ally of  slight  intensity,  and  passing  off  after  breakfast  and  a  walk 
in  the  open  air,  is  that  due  to  insufficient  ventilation  of  the  bedroom. 
In  such  cases  the  gas  pipes  and  chimneys  should  be  examined 
with  great  care  since,  aside  from  the  fatal  risks  which  an  intoxica- 
tion of  this  sort  may  entail  (as  exemplified  in  the  death  of  Zola 
and  of  Tarbe  des  Sablons),  a  mild  but  continuous  intoxication  may 
in  the  course  of  time  induce  a  very  obstinate  type  of  headache 
together  with  marked  alterations  of  the  blood.  Apparently  also 
belonging  in  this  category  is  the  inveterate  winter  headache  of  city 
dwellers,  coextensive  with  the  cold  season  of  the  year  and  artificial 
heating  of  the  houses,  and  absent  throughout  the  warmer  period 
and  during  life  in  the  country. 

Toxic  headache  du£  to  tobacco  or  alcohol  is,  as  a  rule,  easily 
recognized. 

Lastly,  mention  may  be  made  of  the  headache,  sometimes  very 
characteristic,  of  cases  of  lozv  blood-pressure  or  hyposphyxia  (see 
Low  blood-pressure) — an  occipital  variety  of  headache  which  is  en- 
hanced by  recumbency,  obstinate,  resistant  to  all  the  usual  treat- 
ments for  headache,  not  influenced  by  seasonal  or  digestive  factors, 
and  always  associated  with  low  pressure  and  a  relatively  high  blood 
viscosity. 

The  term  headache  of  nervous  origin  is  manifestly  only  a 
makeshift  used  to  designate  headaches  the  cause  of  which  ap- 
pears to  reside  in  a  functional  disturbance  of  the  nervous  system 
per  se,  although  as  a  matter  of  fact  careful  clinical  analysis 
nearly  always  leads  to  the  detection  of  some  proximate  cause, 
reflex,  congestive,  anemic,  or  toxic. 

The  most  characteristic  form  is  migraine,  a  unilateral  type  of 
headache  recurring  at  regular  or  irregular  intervals  in  plainly 
neurotic  patients  whose  family  history  reveals  the  frequency  of 
migraine  among  their  forebears  and  collateral  relatives,  espe- 
cially women.  Migraine  is  a  very  severe  type  of  headache  of  the 
boring,  throbbing  type,  generally  accompanied  by  very  distinct 
ocular  symptoms.     Sometimes  the  pain  begins  in  one  eye  and 


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982  SYMPTOMS. 

extends  over  the  whole  of  the  same  side  of  the  head;  at  other 
times,  the  converse  condition  occurs.  The  patient  often  experi- 
ences an  impression  as  of  luminous  particles  in  the  affected  eye ; 
the  skin  vessels  are  engorged,  and  there  iscommonly  nausea  and 
vomiting. 

These  attacks  may  last  several  days  and  are  regarded  by 
neurologists  as  representing  "nervous  discharges"  for  the  pro- 
duction of  which  an  inherited  predisposition  as  well  as  an  ex- 
citing cause  are  required.  In  very  many  cases  there  are  present  re- 
fractive errors  and  disturbances  of  ocular  motility  which  demand 
careful  examination,  since  much  may  be  done  in  this  direction  to 
reduce  the  frequency  of  the  attacks.  While  migraine  may,  like 
epilepsy,  be  looked  upon  as  the  result  of  an  inherited  nervous 
instability,  it  is  none  the  less  worthy  of  note  that,  in  a  given 
subject,  the  attack  is  often  brought  on  by  tbe  same  cause.  The 
treatment  is  very  difficult,  and  it  is  a  source  of  great  consolation 
for  the  patient  to  know  that  his  attacks  will  become  much  less 
frequent  during  the  second  half  of  his  life. 

Recognition  must  be  given  to  the  occurrence  of  a  headache 
of  the  migraine  type  of  pituitary  origin,  detection  of  which  is 
facilitated  by  observation  of  the  ordinary  signs  of  disturbed  pituitary 
function,  vis.,  increasing  coarseness  of  the  features,  thick  lips, 
prognathism,  thick  eyebrows,  mustache  in  women,  hairiness  of 
the  body  and  extremities,  tendency  to  acromegaly,  hig^  blood- 
pressure,  etc. 

Administration  of  preparations  of  the  whole  pituitary  gland 
generally  causes  this  type  of  headache  and  the  other  attendant 
symptoms  to  disappear.  ' 

Facial  neuralgia  is  often  attended  with  pain  which  may  sug- 
gest cephalalgia.  The  pain  may  be  severe,  lancinating,  of  sud- 
den onset,  and  be  accompanied  by  tender  points  along  the  course 
of  the  affected  nerve.  In  bad  cases,  pronounced  local  edema  may 
be  superadded.  One  should  always  bear  in  mind  the  fact  that 
the  neuralgias  and,  in  a  general  way,  all  the  headaches  of  nerv- 
ous origin  may  be  purely  toxic  or  anemic. 

Neurasthenia  and  hysteria  are  often  attended  with  headache, 
the  distinguishing  feature  of  which  is  a  feeling  of  pressure  or 
numbness  at  the  vertex,  or  of  compression  or  constriction  over 


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HEADACHE  (CEPHALALGIA).  983 

the  lateral  regions  ("en  casque")*  One  may  here  recall,  more- 
over, the  variety  of  neurasthenia  so  well  described  by  Krishaber 
under  the  name  cerebrocardiac  neuropathy,  owing  to  the  predomi- 
nance of  cerebral  (headache,  insomnia,  and  depression)  and  car- 
diac (palpitations,  tachycardia,  angor,  etc.)  manifestations. 

Usually  there  are  found  in  combination  with  the  headache 
neuropathic  symptoms  such  as  exhaustion  on  slight  effort,  alter- 
nating periods  of  exaltation  and  depression  and,  in  a  general 
way,  nervous  irritability.  One  should  not  forget,  as  already 
pointed  out,  that  these  headaches  of  so-called  "nervous"  origin  and 
their  proximate  causes  themselves  are  often  the  expression  of 
some  form  of  reflex  irritation  of  a  weakened  nervous  system,  and 
that  both  headache  and  neurasthenia  may  actually  be  the  result 
of  a  latent  hyperesthesia  of  the  eyes,  nasal  mucosae,  or  stomach. 

Pressure  headaches  may  be  the  result  of 

Inflammation:    Meningo-encephalitis,  syphilis. 

Tumor. 

Endocranial  abscess. 

Glaucoma. 

The  differential  diagnosis  in  these  forms  is  often  a  matter  of 
great  difficulty  and  sometimes  requires  the  assistance  of  a  neuro- 
logist. As  a.  rule,  they  are  characterized  by  their  constancy, 
increasing  severity,  and  nocturnal  exacerbations;  they  are  ac- 
companied by  fever  in  the  acute  diseases,  such  as  meningitis; 
exceptionally,  however,  even  in  the  case  of  brain  abscess,  they 
may  be  attended  with  subnormal  body  temperature.  Examina- 
tion of  the  cerebrospinal  fluid  and  testing  for  Kemig's  sign  are 
indicated  in  all  instances.  Marked  assistance  may  be  had,  both 
as  regards  causal  diagnosis  and  localization  of  the  disease  focus, 
from  examination  of  the  fundus  of  the  eye  or  observation  of  a 
localized  paralysis. 

A  very  severe  form  of  headache,  often  mistaken  for  neur- 
algia, is  that  due  to  acute  glaucoma.  The  possibility  of  this 
diagnostic  error  is  enhanced  from  the  fact  that  there  is  fre- 
quently edema  with  points  of  hyperesthesia  around  the  orbit  and 
the  patient  thinks  he  sees  luminous  particles.  Such  a  mistake 
is  attended  with  serious  consequences,  for  glaucoma,  even  when 


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984  SYMPTOMS. 

properly  treated,  may  lead  to  deep-seated  visual  disturbances, 
and  an  overlooked  and  consequently  untreated  glaucoma  may 
induce  complete  blindness  in  a  few  hours.  In  glaucoma  the  eye 
is  red  and  lachrymal  secretion  profuse,  but  the  cardinal  factors 
in  the  diagnosis  are  painful  tension  of  the  eyeball,  a  turbid  and 
insensitive  condition  of  the  cornea,  and  wide  dilatation  of  the 
pupil,  which  reacts  poorly  to  light  and  to  myotics. 

Special  reference  should  be  made  to  syphilitic  headache, 
which  is  of  great  diagnostic  importance.  In  this  connection  the 
two  commonest  types  of  this  kind  of  headache  should  be  re- 
called: 1.  Secondary  syphilitic  headache,  deep-seated,  with  a 
feeling  of  weight,  continuous,  with  vesperal  exacerbations,  ap- 
parently dependent,  on  the  whole,  upon  an  actual  process  of 
secondary  syphilitic  congestive  meningo-encephalitis  with  cere- 
brospinal hypertension,  as  shown  by  lumbar  puncture.  2.  Ter- 
tiary SYPHILITIC  HEADACHE,  circumscribcd,  boring,  persistent,  with 
nocturnal  exacerbations,  and  dependent  upon  a  gumma.  The 
Wassermann  reaction  and  the  efficacy  of  antisyphilitic  treatment 
bring  convincing  proof  to  the  diagnosis. 

The  headache  of  brain  tumor  is  often  localized,  increased  by 
percussion,  and  sufficiently  severe  to  cause  the  patient  to  cry 
out;  it  appears  in  paroxysmal  attacks  and  is  generally  accom- 
panied by  vomiting,  dizziness,  and  pupillary  disturbances. 

^Headache  of  reflex  origin. — This  form,  as  already  implied, 
is  steadily  increasing  in  frequency,  apparently  because  of  the 
gradual  heightening  of  civilization  which,  by  increasing  sensory 
acuity  and  developing  specialized  functions,  is  bringing  about 
the  formation  of  a  series  of  normal  or  morbid  reflexes  which  are 
absent  among  savages.  Prolonged,  patient  study  of  his  case  will 
enable  the  physician  to  find  out  whether  a  headache  is  reflexly 
dependent  upon  some  ocular,  digestive,  genital,  or  other  source 
of  irritation. 

This  type  of  headache  is  among  the  most  frequent  symptoms 
of  ocular  disorders,  and  such  a  cause  may  be  suspected  where 
the  pain  is  particularly  localized  in  the  superciliary,  frontal,  or 
temporal  region,  and  where,  being  absent  on  rising  in  the  morn- 
ing, it  thereafter  gradually  increases  with  increasing  use  of  the 


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HEADACHE  (CEPHALALGIA).  985 

eyes  and  becomes  very  marked  upon  constant  use  of  the  eyes  for 
some  task  requiring  minute  ocular  adjustment.  The  severity  of 
such  headache  bears  no  relationship  to  the  extent  of  the  ocular 
disorder;  slight  refractive  defects  often  cause  much  more  severe 
headaches  than  marked  defects.  Patients  frequently  have  ob- 
vious refractive  errors  without  experiencing  any  symptom  of 
eye-strain,  owing  to  an  instinctive  compensatory  reaction.  Thus, 
many  persons  with  hypermetropia  are  able  to  see  objects  dis- 
tinctly, without  apparent  ocular  fatigue,  by  continuous  contrac- 
tion of  the  ciliary  muscles.  If,  however,  they  overwork  or  lose 
the  hypertrophy  of  their  ciliary  muscles  either  by  reason  of 
abuse  or  through  disease,  vision  becomes  difficult  and  close  work 
impossible. 

<  Myopic  persons,  whose  distant  vision  is  improved  when  the 
ciliary  muscles  are  completely  relaxed  and  consequently  almost 
atrophied,  similarly  suffer  from  frequent  headaches  whenever 
they  undertake  any  continuous  work  requiring  some  accommo- 
dative effort.  The  same  result  is  often  brought  about  by  over- 
correction of  myopia,  when  the  latter  is  estimated  solely  with 
the  objective  procedures  employed  by  opticians. 

Very  distressing  headaches  are  also  induced  by  even  a  slight 
degree  of  astigmatism. 

Under  normal  conditions  the  ocular  muscles  maintain  the 
eyeball  in  such  a  position  that  the  rays  of  light  from  a  distant 
object  fall  directly  upon  the  macula  lutea  without  requiring  any 
exertion  on  the  part  of  the  individual.  Frequently  one  group  of 
muscles  is  too  strong  or  too  weak,  so  that  a  parallel  position  of 
the  two  eyeballs  is  obtained  only  by  dint  of  overcontraction  of  the 
weaker  muscles.  Generally  the  muscle  is  able  to  carry  out  its 
task  and  the  tendency  to  deviation  can  be  detected  only  by 
special  tests;  the  constant  exertion  entailed  by  binocular  vision 
may,  however,  lead  to  a  number  of  distressing  nervous  symp- 
toms, particularly  headache.  Sometimes  the  weaker  muscles 
become  momentarily  insufficient  and  temporary  strabismus  is 
then  noticed;  in  other  instances,  the  strabismus  is  permanent. 
Where  there  is  continuous,  permanent  strabismus,  the  patient 
gets  in  the  habit  of  disregarding  completely  the  image  from  one 
of  his  eyes,  and  great  patience  is  then  required  to  convince  him 


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986 


SYMPTOMS, 


that  he  "sees  double";  he  is  not  making  any  effort  to  combine 
the  two  images  and  hence  does  not  suffer  from  asthenopia  and 
generally  has  no  headache. 

Headache  of  nasal  origin  is  less  common  than  that  due  to 
eye-strain.  It  is  generally  localized  in  the  frontal  region  and 
associated  with  some  obvious  nasal  disorder.  It  is  the  result  of 
irritation  of  the  terminals  of  the  fifth  pair  in  the  nasal  mucous 
membrane.  For  example,  swelling  of  the  mucous  covering  of 
the  turbinates  in  acute  rhinitis  is  accompanied  by  a  dull  headache, 
particularly  if  the  nasal  cavities  are  too  small  to  permit  of  this 
mucous  swelling  without  morbid  pressure ;  this  sort  of  headache 
is  very  often  relieved  by  the  use  of  vasoconstrictor  astringents, 
such  as  cocaine  or  adrenalin.  Headache  recurring  regularly  at 
certain  seasons  or  when  the  wind  blows  from  a  certain  direction 
is  often  of  reflex  nasal  origin.  In  subacute  rhinitis  the  headache 
is  more  marked  in  the  morning  owing  to  the  accumulation  of 
mucous  secretions  in  the  nasal  cavities  during  the  night.  An 
ulceration  of  the  nasal  mucosa  exposing  the  nerve  terminals  may 
be  the  cause  of  a  reflex  headache.  This  is  also,  as  is  well  known,  an 
important  symptom  in  sinus  inflammations. 

Head,  as  already  mentioned,  made  a  special  study  of  the 
zones  of  cutaneous  hyperesthesia  and  the  corresponding  cranial 
headache  zones  as  they  occur  in  disorders  of  the  thoracic  and 
abdominal  viscera  governed  by  the  vagus  nerve.  The  following 
table  epitomizes  his  conclusions : 

Head's  Zones. 


Zones  of  cutaneous 

CORBESPONDINO 

DEEP  Viscera  Associated 

HYPEBE8TUE8IA. 

CRANIAL  Zones. 

With  These  Zones. 

3d  and  4th  cervical. 

Naso-frontal. 

Apex  of  lung,  liver,  stom- 
ach, aortic  orifice. 

2d,  3d,  and  4th 

Pretemporal. 

Lung,  heart,  aortic  arch. 

dorsal. 

5th  and  6th  dorsal. 

Fronto-temporal. 

Intermediate  portion  and 
base  of  lung,  left  ven- 
tricle, upper  gastric 
region. 

8th  and  9th  dorsal. 

Antero-parietal  and 

Stomach,  liver,  upper  por- 

parietal. 

tion  of  small  intestine. 

10th  dorsal. 

Occipital. 

Liver,  intestine,  ovaries, 
testicles. 

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HEADACHE  (CEPHALALGIA),  987 

Utero-ovarian  disorders  are  a  frequent  cause  of  reflex  head- 
ache, whether  the  condition  present  be  ulceration  or  dis- 
placement. This  type  of  headache  is  often  localized  in  the  occip- 
ital region  and  becomes  accentuated  during  the  menstrual 
periods.  Indeed,  headache  is  so  frequently  present  at  these 
periods  that  it  seems  almost  a  normal  accompaniment  of  the 
menstrual  process. 


Fig.  720. — Elective  areas  of  fibrous  thickening  over  of  the 
skull,  nucha,  and  neck. 

Lastly,  many  persons  are  subject  from  time  to  time  to  slight 
headaches,  perhaps  partly  reflex,  as  a  result  of  exposure  to  cold 
or  of  an  emotional  impression  or  dietary  indiscretion. 

The  foregoing  list,  in  spite  of  its  already  tiresome  length,  is 
far  from  exhausting  the  possible  causes  of  headache.  There  is 
one  group,  not  yet  referred  to,  which  has  been  the  subject  of  numer- 
ous investigations  in  late  years,  7t;?.,  that  of  the  headaches  of 
muscular  origin,  seemingly  dependent  upon  connective  tissue  in- 
filtration of  the  muscles  of  the  neck,  particularly  of  the  nuchal 
region,  and  of  the  head,  nearly  always  accompanied  by  excessive 
muscular  tone  with  a  tendency  to  rigidity  and  frequently  an  arthritis 


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988  SYMPTOMS. 

sicca  of  the  vertebral  articulations.  Palpation  of  the  back  of  the 
neck  and  particularly  of  the  skull  over  the  fascial  insertions  en- 
ables one  directly  to  observe  the  presence  of  such  fibrous  thicken- 
ings. The  headache  in  these  cases  may  assume  one  of  three  types 
(Hartenberg)  : 


Trapezius, 

Splenius, 

Small  occipital  nerve. 

Great  occipital  nerve. 
Sd  cervical  nerve. 

4th  cervical  nerve. 


Fig.  721. — Posterior  branches  of  the  cervical  nerves  {Soulii). 

1.  Frank  migraine  with  unilateral  pain,  arterial  throbbing, 
scotomas,  and  vomiting. 

2.  Neuralgia,  definitely  localized  and  associated  with  the 
presence  of  tender  points. 

3.  Indefinite  headache  with  a  feeling  of  weight  or  a  crushing 
or  dragging  sensation. 

Hartenberg,  who  has  made  a  special  study  of  this  variety  of 
headache,  ascribes  these  infiltrations  to  a  cervical  myocellulitis.  **I 
feel  justified  in  incriminating,"  he  states,  "as  the  chief  exciting  cause 


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HEADACHE  (CEPHALALGIA).  989 

of  these  infiltrations,  an  insufficiency  of  arterial,  venous,  and  lym- 
phatic circulation,  due,  in  turn,  to  insufficient  muscular  activity. 
Indeed,  local  exposure  to  cold  and  reduction  of  temperature, 
which  reduce  both  tissue  metabolism  and  circulation,  distinctly 
favor  the  production  of  these  lesions.  Again,  I  have  observed 
them  particularly  in  subjects  leading  a  sedentary  life^  and  those 
who  take  physical  exercise  are  free  of  them. 

"Cellulitis  thus  appears  to  us  as  a  species  of  tissue  rust  due 
to  insufficient  physical  activity.  It  constitutes  a  stigma  of  pre- 
mature senility  in  overcivilized.  subjects  who  have  replaced 
muscular  labor  by  brain  work."^ 

The  series  of  causes  above  enumerated  shows  how  difficult 
the  differential  diagnosis  sometimes  is.  In  truth,  often  it  is 
obvious  and  does  not  require  any  very  prolonged  examination, 
e.g.,  in  the  headache  of  infectious  diseases,  of  acute  meningitis, 
of  migraine,  etc.  In  other  instances,  again,  a  painstaking  clinical 
study  is  required.  On  the  whole,  there  are  a  certain  number  of 
points  which  should  never  be  forgotten  during  such  studies,  and 
which,  correctly  illuminated,  will  yield  a  positive  diagnosis  in 
95  per  cent  of  cases  of  obstinate  chronic  headache : 

History  of  the  Illness. 

1.  Are  there  paroxysms,  sometimes  at  regular  intervals 
(monthly),  or  with  ocular  disturbances,  nausea,  etc.  (migraine)? 

2.  Is  the  headache  periodic,  and  accompanied  by  attacks  of 
fever  (malaria)  ? 

3.  Are  there  clear-cut  past  evidences  of  specific  infection 
(syphilis)  ? 

4.  Have  there  ever  been  manifestations  of  a  psychoneurosis 
(neurasthenia)  ? 

Etc. 

Daring  the  clinical  examination,  one  should  always  examine: 

1.  The  eyes,  including  the  retina  (albuminuric  retinitis,  vas- 
cular disturbances,  evidences  of  intracranial  disease). 

The  pupils  (reaction  to  light,  Argyll-Robertson  pupil,  showing 
a  specific  meningo-encephalitis). 

The  intraocular  tension  (glaucoma). 


iHartenberg:  Presse  mid.,  Feb.  14,  1912,  p.  134. 


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990 


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HEADACHE  (CEPHALALGIA). 


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992  SYMPTOMS, 

2.  The  ears,  middle  and  internal  (otitis,  brain  abscess). 

3.  The  nose  and  its  annexes  (maxillary  and  frontal  sinuses). 

4.  The  temperature  (toxic-infectious  headache). 

5.  The  blood-pressure  (headache  of  high-pressure  cases,  of 
uremia,  of  hyposphyxia). 

6.  The  urine  (albuminuric,  indicanuric,  or  acetonemic  headache). 

7.  The  blood  (determination  of  the  blood  urea  for  uremia,  Was- 
sermann  reaction  for  syphiUs). 

8.  If  need  be,  the  cerebrospinal  fluid  (high  pressure  and  the 
white  cell  formula,  e.g,,  lymphocytosis  in  tuberculous  meningitis 
and  polynucleosis  in  ordinary  meningitis,  etc.). 

9.  The  muscle  insertions  on  the  cranium  and  nuchal  region 
(headache  of  muscular  origin). 


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HEMATEMESIS.  [-^^l^^l/^'iST""] 


Hematemesis  consists  of  the  vomiting  of  blood.  The  pres- 
ence of  blood  in  vomited  material  is  frequently  obvious;  if  it  is 
doubtful,  blood  should  be  tested  for  by  the  usual  procedures  em- 
ployed for  the  purpose  [See  Blood  examination:  Microscopic  ex- 
amination (red  cells,  hematin  crystals)  ;  spectroscopic  examination 
(hemoglobin  spectrum);  chemical  examination  (Meyer's  test)]. 

The  diagnostic  problem  is  put  before  the  practitioner  in  the 
following  terms : 

A.  Is  hematemesis  taking  place? 

I.  And  first  of  all,  is  it  blood  that  has  been  brought  up? 

(a)  If  the  vomited  material  is  bright  red  blood,  there  is  no  dif- 
ficulty in  recognizing  it,  and  all  that  is  necessary  is  to  exclude  the 
possibility  of  hysterical  simulation. 

(&)  If  it  is  coffee  ground  vomit,  it  may  be  confused  (in  rare 
instances)  with  the  black  vomitus  of  a  patient  who  has  taken  in 
succession  a  preparation  of  ergotin  and  gallic  acid  and  one  of  ferric 
chloride  (ink  formed  in  the  stomach)  ;  also  with  biliary  black  vomit. 

1.  Microscopic  examination  shows  more  or  less  distorted  red 
corpuscles  and  crystals  of  hematoidin  or  hematin. 

2.  Spectroscopic  examination  permits  of  easy  diflFerentiation. 

3.  Frequently  the  coexistence  of  intestinal  hemorrhage  obviates 
the  need  of  these  procedures. 

4.  Sometimes  there  are  only  traces  of  blood. 

In  the  latter  event,  the  most  serviceable  procedure  for  clinical 
purposes  consists  in  mixing  in  a  test-tube  some  tincture  of  guaiac, 
ozonized  oil  of  turpentine,  and  gastric  juice.  If  blood  is  present, 
even  in  small  amount,  a  characteristic  blue  color  will  appear  (see 
Blood  examination:    Weber's  test). 

II.  It  is  blood.    Where  is  the  seat  of  the  hemorrhage? 

(a)  It  is  from  the  pharynx,  the  nose,  or  the  mouth;  inspection 
of  these  cavities  will  settle  the  matter. 

«3  (993) 


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994  SYMPTOMS. 

{b)  It  is  from  the  esophagus: 

Former  indications  of  disease  of  this  canal  (dysphagia,  post- 
sternal  pain,  fluoroscopy  after  ingestion  of  bismuth)  alone  permit  of 
establishing  such  a  diagnosis. 

The  above  causes  having  been  excluded  the  following  question, 
which  is  that  of  greatest  clinical  importance,  arises : 

(c)  Did  the  blood  issue  from  the  stomach  or  the  respiratory 
tract?    Isi  there  hematemesis  or  hemoptysisf 

1.  Particular  import  attaches  to  this  question  in  view  of  the  fact 
that  entrance  of  a  few  drops  of  blood  into  the  larynx  in  the  course 
of  hematemesis*  is  sufficient  to  induce  cough,  and  conversely,  that 
in  hemoptysis  blood  may  be  swallowed  and  then  expelled  in  the  act 
of  vomiting.  Accordingly,  although  the  blood  in  hemoptysis  is  gen- 
erally red,  foamy,  and  mixed  with  air-laden  mucous  discharges, 
this  sign  is  absolutely  unreliable, 

2.  Consequently,  the  diagnosis  is  based  on  the  concomitant 
signs.  In  hemoptysis  the  physician  will  note  the  customary  evi- 
dences of  disorders  attended  with  this  condition  (tuberculosis,  hy- 
peremia, or  apoplexy  of  the  lung,  or  valvular  heart  disease) ;  in 
hematemesis,  gastric  manifestations  predominate  (dyspepsia,  epi- 
gastric pain,  dilatation  of  the  stomach,  etc.). 

3.  The  practitioner  may  be  greatly  puzzled  in  the  event  of  simul- 
taneous presence  of  gastric  and  pulmonary  disease  {gastric  ulcer  and 
pulmonary  tuberculosis), 

4.,  In  theory,  the  differential  signs  of  hematemesis  and  hemo- 
ptysis may  be  summarized  thus : 


Hemoptysis. 

Hematemesis. 

History  of  lung  disturbance. 

The  blood  is  expectorated. 
It  is  red,  foamy,  and  frothy. 

It  may  be  mixed  with  sputum. 

The  onset  of  hemoptysis  is  often 

heralded  by  a  pricking  sensation 

in  the  larynx. 
It  may  be  accompanied  by  nausea 

and  pain  in  the  chest. 
It  is  rarely  followed  by  discharge 

of  blood  from  the  bowel. 

History  of  a  gastric,  hepatic,  or 

splenic  disorder. 
The  blood  is  vomited  up. 
It  is  black,  compact,  and  free  of 

air  admixture. 
It  may  be  mixed  with  bile  or  food 

debris. 
The     onset     of     hematemesis     is 

often   heralded  by  a  feeling  of 

dizziness  or  faintness. 
It  may  be  accompanied  by  nausea 

and  pain  in  the  epigastrium. 
It  may  be  followed  by  discharge 

of  blood  from  the  bowel. 

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HEMATEMESIS, 
Ulcer  and  Cancer  of  the  Stomach. 


995 


Catheterization  of  the  Fasting  Stomach. 

(a)  Food  stasis  Pyloric  stenosis  and,  if  true 

stasis,  cancer  of  the  py- 
lorus. 
'Wash  water  contains  Reichmann     (probably    py- 


(b)  No  food 
stasis. 


free  HCL 
Wash  water,  with  1 
per  cent,  acetic  solu- 
tion, contains  chem- 
ically demonstrable 
blood. 


loric  ulcer). 
Ulcer   of  the  body  of  the 
stomach   (simple  or  can- 
cerous). 


Examination  of  the  Stomach  after  a  Test  MeaL 


(a)  Free  HCl 
in  excess. 

(b)  Free  HCl 
reduced  to- 
ward 0. 


Ether  capsule  dis- 
solved in  less  than 
one  hour. 

Ether  capsule  not  dis- 
solved. 


Probable  ulcer. 
Probable  cancer. 


Examinajdon  of  Feces  after  a  Milk  and  Vegetarian  Diet 


Presence   of 
blood  chem- 
ically demon- 
strable. 


Blood  disappears  after 
a  few  days'  rest. 

Blood  still  present 

Blood  is  present  in 
fe.ces  but  not  in  acid- 
ulated    wash     water 

.  from  stomach. 


Probable  ulcer. 

Probable  cancer. 

Duodenal  ulcer  or  ulcer  on 
duodenal  aspect  of  py- 
lorus. 


Small,  con- 
tracted stom- 
ach with  les- 
sening  of 
peristaltic 
contractions. 


Fluoroscopic  Examination  (Principal  types) 
'Amputation"  Stomach 


Filling-defect 
in  stomach 
(apparent  ab- 
sence of  a 
portion  of  the 
gastric  shad- 
ow). 


of  the  py- 
loric region 
and  delayed 
evacuation 
of  bismuth 
meal. 


presentmg  a 
bilocular  ap- 
p  ea  ranc  e 
(due  to 
spasm). 


Diverticular 
aspect  (ap- 
parent ad- 
dition to  gas- 
tric shadow). 


Callous 
ulcer. 


Ulcer  on 
Diffuse  Localized         Cancer  of  lesser 

cancer.  cancer.  pylorus.         curvature. 

Blood  Examination. 
Increased  antitryptic  power  of  the  serum   Cancer. 

Cytologic  Examination. 

Microscopic  examination  of  the  wash  water  after  gastric 

lavage. 
Study  of  centrifugation  sediment 
Presence  of  neoplastic  cells Cancer. 


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996  SYMPTOMS, 

B.  Hematemesis  has  occurred.    What  is  its  cause? 

I.  The  hematemesis  occurs  under  certain  special  circum- 
stances, independently  of  any  local  disorder  which  might  facili- 
tate discovery  of  the  causes  of  the  bleeding*. 

(a)  It  occurs  in  the  course  of  an  infectious  disease:  Hemor- 
rhage-producing disorders  such  as  scurvy,  purpura,  hemorrhagic 
smallpox,  infectious  endocarditis,  typhus  fever,  plague,  perni- 
cious malarial  fevers,  grave  icterus,  and  yellow  fever. 


en 


gastric  branch 

istroepl- 
artery 

Gai 

Hepatic 

Gastrohepatic 

Pyloric 


Right  gi 
epiploic 


Fig.  726. — The  arteries  of  the  stomach. 


{b)  It  may  follow  phosphorus  or  arsenic  intoxication. 
Ic)  It  may  be  substituted  for  hemorrhoidal  or  menstrual 
bleeding. 

(d)  In  predisposed  subjects,  especially  hysterical  persons,  it 
may  come  on  following  some  pronounced  emotional  impression, 
slight  traumatism  to  the  epigastrium,  or  exposure  to  cold.  The  diag- 
nosis in  these  cases  is  based  on: 

1.  Persistence  of  the  disorder  in  spite  of  all  treatment. 

2.  Relatively  slight  impairment  of  the  general  condition  in  spite 
of  copious  hematemesis. 

3.  The  presence  of  permanent  stigmata  of  hysteria,  such  as 
anesthesia,  and  contraction  of  the  visual  fields. 


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HEMATEMESIS.  997 

The  fact  should  be  borne  in  mind,  however,  that  gastric  ulcer 
is  not  uncommon  in  neuropathic  subjects. 

(e)  Again,  attention  should  be  called  to  the  possibility  of 
hematemesis  where  persons  are  exposed  to  a  sudden  reduction  of 
atmospheric  pressure,  as  exemplified  in  the  "Zenith"  balloon  disaster. 

(/)  Lastly,  mention  may  be  made  of  the  hematemesis  of  uremia 
and  of  unrecognized  strangulated  hernia  in  old  persons  (Robin). 

II.  In  cases  of  exactly  opposite  type,  the  hematemesis  is  recog- 
nized as  being  of  local  origin,  and  the  seat  of  the  hemorrhage  is 
localized  in  the  stomach,  its  annexa,  and  other  organs. 


Capillary  network 
about  oriflcea  of  glands 


Periglandular 
capillary  network 


Vertical  yein 

Small  artery 

Submucous  vein 

Fig.  727. — Blood-vessels  of  the  gastric  mucous  membrane  (Brinton). 

(a)  Stomach:  1.  M^y  he  mentioned  sls  occasional  causes:  In- 
ternal or  external  traumatic  injuries,  miliary  aneurysms,  thrombo- 
sis, embolism,  amyloid  infiltration,  and  venous  stasis  of  cardiac 
origin. 

2.  As  common  causes:    Cancer  and  ulcer  (see  p.  995). 

3.  Some  difficulty  attends  the  differentiation  of  hematemesis  due 
to  ulcerations  of  the  stomach  in  the  presence  of  chronic  gastritis, 
particularly  of  uremic  origin.  All  the  symptoms  combine  to  mis- 
lead the  clinician ;  under  these  circumstances  Robin's  predept  should 
be  called  to  mind:  "You  should  make  a  diagnosis  of  cancer  only 
when  you  cannot  do  otherwise." 

(b)  Auxiliary  digestive  organs. 


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998  SYMPTOMS, 

1.  Diseases  of  the  liver. 

In  cirrhosis  of  the  liver,  especially  atrophic  cirrhosis,  hemateme- 
sis  sets  in  rather  early,  in  the  pre-ascitic  period,  and  is  then  associated 
with  the  usual  clinical  signs  of  the  pre-cirrhotic  stage;  sometimes 
it  is  very  copious,  and  in  some  instances  it  has  been  known  to  cause 
death.  It  seems  to  be  dependent  both  upon  varicose  vessels  of  the 
esophagus  and  upon  altered  nutrition.  Undoubtedly  it  occurs  very 
often.  Like  the  succeeding  forms,  it  is  largely  secondary  to  the 
syndrome  of  high  portal  pressure  (see  Fig.  729). 

Hypertrophic  cirrhosis  and  cancer  of  the  liver;  mention  should 


Fig.  728. — Section  of  gastric  ulcer  (Dieulafoy).  U,  ulcer  farmed  at 
the  expense  of  the  mucosa  M  and  the  muscularis  mucosae  mm ;  a,  a  sub- 
mucous arteriole  destroyed  at  the  point  /»,  where  a  large  number  of  red 
cells  are  collected;  the  fatal  hemorrhage  has  taken  place  at  this  point; 
.  t\th,  a  thrombosed  vein;  sm,  submucous  layer;  mtr  and  ml,  muscular 
layer;  s,  serous  coat;  /,  ^,  3,  miliary  abscesses  in  the  depths  of  the  mucous 
layer. 

also  be  made  of  grave  icterus,  which  is  attended  with  hematemesis 
for  various  reasons,  some  local  and  others  general. 

2.  Pressure  on  the  portal  vein  by  tumors  of  the  hilum  or  of 
neighboring  structures  (pancreas,  etc.). 

3.  Embolism  of  the  mesenteric,  hepatic,  or  splenic  ar- 
teries, e.g.,  in  the  course  of  infectious  endocarditis. 

(c)  Disorders  of  neighboring  organs. 
1.  Duodenum:    See  Dyspepsia. 

Ulcer  of  the  duodenum  may  be  attended  with  hemorrhage,  in 
which  the  blood  travels  back  toward  the  stomach.    The  diagnosis 


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HEMATEMESIS.  999 

is  based  on  the  frequency  of  intestinal  hemorrhage,  the  different 
seat  of  pain,  and  the  result  of  clinical  examination  according  to 
Meunier's  procedure  (see  p.  75). 

Varicose  conditions  of  the  duodenum  occur  under  the  same  cir- 
cumstances as  varicose  conditions  of  the  esophagus  or  stomach  (syn- 

Low  blood-presBure 


hemorrhage 


Fig.  729. — The  syndrome  of  high  portal  pressure  (portal  hypertension). 

drome  of  portal  hypertension).  Ulcers  may  also  follow  extensive 
bums  of  the  body  surface. 

2.  Esophagus: 

Varicose  vessels  of  the  esophagus  are  met  with  particularly  in 
cirrhosis  of  the  liver  or  cancer.  The  customary  evidences  of  eso- 
phageal tumor  are  present  under  these  circumstances,  vis,,  dys- 
phagia, pain,  regurgitation  of  food,  results  of  examination  with  the 
sound,  etc. 


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1000 


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HEMATEMESIS. 


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1002  SYMPTOMS, 

3.  Circulatory  system. 

Heart  failure ;  aneurysm  of  the  aorta  or  celiac  axis.  The  diag- 
nosis is  based  on  the  usual  symptoms  of  these  disorders.  Hemor- 
rhage from  ruptured  aortic  aneurysm  is  generally  of  the  fulminating 
type. 


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HEMATURIA.  [,„"i!SXfc.] 


Hematuria  is  jone  of  the  commonest  and  most  important  mani- 
festations of  disease  of  the  urinary  tract.  For  clinical  purposes  the 
term  hematuria  will  be  held  to  refer  to  cases  in  which  blood  in  the 
urine  is  visible  to  the  naked  eye.^ 

The  physician  should,  in  the  first  place,  make  certain  that 
hematuria  actually  exists  by  himself  directly  examining,  if  possible, 
the  suspected  specimen  of  urine  obtained  from  the  patient. 

He  should  exclude,  then,  either  by  direct  inspection  of  the 
urine  or  by  microscopic  or  spectroscopic  examination,  pseudo-hema- 
turia  due  to  ingestion  of  drugs  (see  below)  and  hemoglobinuria, 
and  should,  furthermore,  guard  against  making  a  serious  error 
where  blood  from  the  female  genital  tract  is  mixed  with  the  urine, 
as  in  menstruation  or  metrorrhagia. 

The  actual  existence  of  hematuria  having  been  positively  estab- 
lished, he  should  next  endeavor  to  ascertain  the  source  of  the 
hemorrhage  and  its  cause,  without  waiting  for  further  symptoms  to 
appear. 

Hematuria  often  occurs  abruptly,  during  apparent  good  health, 
in  a  subject  previously  free  of  any  symptoms  referable  to  the 
urinary  tract.  Under  these  circumstances  it  constitutes  an  alarm 
signal,  practically  a  useful  manifestation  of  a  disorder  as  yet  latent 
or  circumscribed,  early  recognition  and  treatment  of  which  may 
result  in  complete  cure — which  is  all  the  more  advantageous  in  that 
the  more  distressing  phases  of  the  disease  will  thus  have  been 
forestalled. 


1  It  should  be  borne  in  mind,  however,  that  there  may  occur  a  micro- 
scopic hematuria,  which  sometimes  plays  an  important  part  in  the  diag- 
nosis of  renal  calculus,  according  as  microscopic  examination  of  the  cen- 
trifugated  urine,  before  or  after  walking,  shows  the  presence  of  red  blood 
cells  in  greater  numbers  in  the  urine  collected  after  exertion  or  fatigue. 

(1003) 


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1004  SVMPTOMS. 

Too  often,  however,  it  happens  that  the  physician,  reassured  by 
the  absence  of  other  clinical  signs,  rests  content  with  the  mere  ob- 
servation of  the  presence  of  hematuria;  only  much  later,  when  the 
hematuria  recurs,  when  it  alarms  the  patient,  and  when  other  symp- 
toms appear  such  as  a  local  swelling,  fever,  and  pain,  does  he  think 
of  carrying  out  a  complete  examination  of  the  patient. 


die 


Bulb  of  urethra 
Fig.  730. 

This  mode  of  procedure  is  all  the  more  to  be  deplored  in  that, 
thanks  to  systematic  clinical  study  and  especially  to  the  modem 
means  of  examination,  one  is  able  very  early,  and  even  in  the  ab- 
sence of  any  other  symptom,  to  detect  the  cause  of  the  bleeding. 

In  the  presence  of  hematuria  two  questions  arise:  Where 
does  the  blood  come  from?  and  What  is  the  cause  of  the  hemor- 
rhage? 

It  will  be  well  to  consider  the  special  features  presented  by 
the  hemorrhage  according  as  it  comes  from  one  or  another  por- 
tion of  the  urinary  tract,  as  well  as  the  attributes  afforded  to 
it  by  its  various  possible  causes. 


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HEMATURIA.  1005 

I.  The  blood  comes  from  the  urethra  or  the  prostate. — The 

blood  appears  at  the  start  of  micturition.  It  is  an  initial  hemor- 
rhage, the  blood  in  the  urethral  canal,  washed  down  by  the  urine, 
appearing  with  the  first  drops  of  urine  that  pass  out. 


Fig.  731. — Sources  of  the  internal  pudic  vein,  H,  and  the  vesical  vein, 
V  (Farabeuf).  The  pin  passing  through  the  lower  and  outer  surface 
of  the  bladder  represents  the  dividing  line  between  the  two  venous  cur- 
rents, pelviovesical,  F,  and  perineopudic,  H. 

This  initial  type  of  hematuria  is  of  small  amount,  and  follows 
either  a  traumatized  state  of  the  urethral  canal  (acute  urethritis, 
injury  during  coitus,  rupture  of  the  urethra,  or  false  passage  dur- 
ing catheterization)  or  a  lesion  of  the  prostatic  urethra  (varicose 


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1006  SYMPTOMS. 

vessels  of  the  prostatic  region,  cancer  of  the  prostate).  The  diag- 
nosis is  based  particularly  on  the  history. 

Where  initial  hemorrhage  is  more  pronounced,  blood  appears 
at  the  meatus  independently  of  micturition.  The  condition  is 
then  an  actual  urcthrorrhagia,  the  amount  of  which  bears  a  re- 
lationship to  the  seriousness  of  its  cause.  Such  urethrorrhagia 
is  met  with  chiefly  as  a  result  of  rupture  of  the  urethra,  either 
from  external  traumatism  (fall  or  blow  on  the  perineum)  or 
internal  traumatism  (serious  false  passage). 

Sometimes  blood  coming  from  the  posterior  urethra  or  pros- 
tate independently  of  micturition  passes  back  into  the  bladder, 
and  if  the  bleeding  is  of  considerable  degree,  the  entire  amount 
of  urine  may  be  discolored  by  it;  upon  inserting  a  catheter  and 
washing  out  the  bladder,  however,  the  urine  in  the  latter  will 
rapidly  become  clear. 

II.  The  blood  comes  from  the  bladder. — Vesical  hematuria 
may  be  terminal  or  total.  Terminal  hematuria,  characterized  by 
the  appearance  of  blood,  generally  in  moderate  amount,  at  the 
end  of  micturition,  at  the  moment  when  the  bladder  is  complet- 
ing its  evacuation  by  means  of  a  few  forcible  contractions,  is  in- 
dicative of  a  lesion  of  the  neck  of  the  organ,  as  in  gonorrheal 
cystitis. 

Disorders  involving  the  body  of  the  bladder  produce  more 
abundant  hemorrhage;  the  blood  may  in  these  cases  be  com- 
pletely mixed  with  the  urine,  which  issues  red  from  the  beginning 
to  the  end  of  micturition  and  may  be  deeply  colored. 

The  vesical  origin  of  total  hematuria  may  be  established  as 
follows : 

When  the  blood  is  derived  from  the  bladder,  the  depth  of  dis- 
coloration of  the  urine  increases  as  the  close  of  micturition  is 
approached.  If  the  patient  is  caused  to  urinate  into  three  glasses, 
the  first  two  glasses  show  less  discoloration  than  the  third ;  lastly — 
an  important  indication — a  bleeding  bladder  is  hard  to  wash  out. 

Thus,  given  a  patient  with  hematuria.  A  catheter  is  inserted 
and,  upon  slow  injection  of  fluid  into  the  bladder  several  times, 
the  wash  water  tends  to  come  back  clear  at  the  beginning  of 
its  expulsion,  but  as  the  bladder  is  further  emptied,  the  later 
wash  water  shows  increasing  discoloration,  which  is  the  more 


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HEMATURIA.  1007 

marked  according  as  the  bladder  is  allowed  to  empty  itself  more 
completely.  If,  furthermore,  one  waits  until  the  bladder  is  thor- 
oughly empty,  the  bleeding  at  once  recurs,  sometimes  in  the 
form  of  an  outflow  of  almost  pure  blood. 

Vesical  hematuria  is  met  with: 

(o)  In  trauma  of  the  bladder;  here  the  circumstances  under 
which  the  hematuria  arose  point  definitely  to  the  source  of  the 
bleeding. 

(h)  In  cystitis — ^tuberculous,  calculous,  or  neoplastic  cystitis, 
or  simple  hemorrhagic  cystitis. 


R.K.  L.K. 


-Iff 


111 


-111 


Three  glasseB  equally  henuituric. 
Total   hematuria  =   Renal. 


Last  glass  colored  or  more  deeply 

colored. 
Terminal  hematuria  =  Vesical. 


First  glass  colored. 

IniUal  hematuria  =  Urethral. 


Fig.  732. 

(r)  In  the  absence  of  all  signs  of  cystitis,  in  certain  tumor 
formations — papilloma,  angioma,  and  beginning  cancer. 

(rf)  In  some  forms  of  congestive  prostatic  enlargement  in 
which  hemorrhage  occurs  into  the  bladder. 

As  a  general  rule,  the  practitioner  should  not  be  satisfied  with 
a  diagnosis  of  hematuria  of  vesical  origin  based  on  the  observa- 
tion of  other  bladder  signs  such  as  pain,  tenesmus,  pyuria,  etc.; 
bladder  manifestations  may  occur  in  the  presence  of  hematuria 
of  renal  origin,  and  to  depend  upon  such  evidences  may  lead  to 
serious  mistakes. 

The  only  absolute  rule,  which  must  be  remembered  as  a  defi- 
nite axiom,  is  that  any  total  hematuria  believed  to  be  of  vesical 
origin  points  to  the  necessity  of  cystoscopic  examination  of  the 
bladder. 

III.  The  blood  comes  from  the  kidney  or  ureter. — Hematuria 
of  renal  origin  is  a  form  of  total  hematuria  in  which  the  urine 


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1008  SYMPTOMS. 

shows  a  uniform  discoloration  from  the  beginning  to  the  end  of 
the  act  of  micturition.  In  contrast  to  that  which  occurs  in  vesi- 
cal total  hematuria,  the  wash  water  finally  becomes  quite  clear 
or,  if  there  is  continuous  oozing  in  the  kidney,  the  results  of  irri- 
gation will  always  be  sufficiently  marked  to  permit  of  immediate 
cystoscopy. 

There  are  three  great  causes  of  renal  hematuria  which  should  at 
once  come  to  the  practitioner's  mind,  viz.,  tuberculosis,  stone,  and 
cancer. 

In  each  of  these  three  disorders,  bleeding  may  appear  abruptly, 
without  any  previous  or  coexisting  symptom.  It  is  essential  that 
the  physician  be  familiar  with  this  fact,  since  it  is  in  these  cases 
that  early  hematuria  constitutes  an  actual  benefit,  enabling  him 
to  act  early  in  the  disease  and  under  the  best  possible  conditions. 

Usually  certain  other  signs  assisting  in  the  diagnosis  are  pres- 
ent in  conjunction  with  the  hematuria. 

In  incipicjit  tuberculosis  of  the  kidney,  there  are  present  certain 
mild  vesical  symptoms,  such  as  frequent  urination,  a  light  pul- 
verulent deposit  at  the  bottom  of  the  chamber,  and  slight  pain 
in  the  bladder,  and  sometimes  enlargement  and  sensitiveness  of 
the  kidney  are  also  present  (see  Examination  of  the  Kidney:  Renal 
points  of  tenderness,  p.  335). 

In  more  advanced  tuberculosis  of  the  kidney,  there  are  present 
polyuria,  pyuria,  a  more  or  less  remote  history  of  cystitis,  and 
enlargement  of  the  kidney. 

In  renal  calculus,  hematuria  often  appears  abruptly,  without  any 
previous  attack  of  pain.  Some  kidney  stones  induce  absolutely 
no  pain.  In  other  instances,  however,  pain  is  a  prominent  feat- 
ure (dull  pain  in  the  kidney  region,  renal  colic,  and  expulsion  of 
stones).  Finally,  renal  hematuria  of  calculous  origin  is  often 
(but  not  always)  brought  on  by  fatigue,  walking,  horseback 
riding,  etc. 

In  cancer  of  the  kidney,  hematuria  may  appear  very  early  and 
be  the  only  symptom.  At  a  later  stage,  however,  it  occurs  in  con- 
junction with  pain,  enlargement  of  the  kidney,  and  cachexia. 

Apart  from  these  three  main  causes  of  renal  hematuria,  there  is 
one  other  which  is  of  relatively  frequent  occurrence,  zns.,  hema- 
turic  nephritis,  with  or  without  pain.     This  form  of  nephritis  is 


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HEMATURIA.  1009 

sometimes  associated  with  only  trifling  general  manifestations, 
and  the  diagnosis  is  made  chiefly  by  ureteral  catheterization; 
upon  examination  of  the  separated  urines,  the  hemorrhage  is  found 
to  be  often  bilateral  (either  concomitantly  or  alternately  on  the 
right  and  left),  the  kidneys  exhibit  impaired  functional  power, 
and  casts  are  observed.  The  pain  in  this  forni  of  nephritis  often 
disappears  after  renal  decapsulation. 


Fig.  733. — Diagram  of  the  structure  of  the  kidney.  Shaded  gray,  a 
renal  pyramid,  with  its  apex  dipping  into  a  calyx,  and  its  base  sending 
several  processes  (the  pyramids  of  Ferrein)  into  the  cortical  substance 
(white).  In  relief,  the  arterial  vessels  (interlobar  artery,  arterial  arcade, 
and  interlobular  and  glomerular  arteries).  In  black,  a  few  uriniferous 
tubules,  the  course  of  which  is  from  glomeruli  to  the  apex  of  the  renal 
pyramid  (Laederich), 

IV.  The  hematuria  is  of  hemic  origin. — The  appearance  of 
the  urine  in  this  event  is  naturally  the  same  as  in  hematuria  of 
renal  origin,  but  the  cause  of  the  condition  has  less  to  do  with 
changes  in  the  kidneys,  which  are  nearly  always  present,  than 
with  a  blood  dyscrasia  of  infectious  or  toxic  origin,  such  as : 

1.  Hemorrhage- provoking  disorders  of  the  type  of  purpura,  hem- 
ophilia,  scurvy,  and  the  leukemias.     Recently  there  have  been  re- 

64 


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1010  SYMPTOMS, 

ported  instances  of  actual  '^vesical  purpura,"  either  in  conjunc- 
tion with  purpura  of  the  skin  or  even  occurring  independently. 

2.  Hemorrhagic  forms  of  various  infectious  diseases,  such  as 
typhoid  fever,  malaria,  small-pox,  typhus  fever,  yellozv  fever,  septi- 
cemia, and  icterohemorrhagic  spirochetosis. 

3.  Certain  forms  of  poisoning  associated  ivith  hemorrhage,  such 
as  cantharis  poisoning  (blistering)  and  phosphorus  poisoning 
(an  exceptional  condition  aside  from  speciaHzed  industrial  occu- 
pations). 

Separate  recognition  must  also  be  given  to  hematuria  of  para- 
sitic origin  of  the  type  of  bUharziasis,  a  condition  met  with  ex- 
clusively in  tropical  countries  or  in  individuals  coming  from  such 


Fig.  734. — Bilharzia  ova. 

countries.    The  finding  of  the  parasitic  oya  in  the  urine  will  alone 
suffice  for  diagnostic  purposes. 

Finally  there  remain  the  crjrptogenic  hematurias  of  unknown 
origin,  including  vicarious  hematuria,  occurring  in  place  of  the 
menstrual   flow;   the   diathetic   hematurias,   renal   "epistaxis,"   etc. 


In  any  case  of  total  hematuria,  the  physician  must  strenuously 
endeavor  to  find  out  the  source  and  the  cause  of  the  bleeding. 

Cystoscopy  will  of  itself  generally  permit  of  establishing  the 
origin  of  a  vesical  hematuria. 

Catheterization  of  the  ureters,  by  enabling  the  practitioner  to 
collect  separately  the  urine  from  the  two  kidneys,  will  give  an  idea 
of  the  actual  functional  capacity  of  each  kidney,  permit  of  cyto- 
logic and  bacteriologic  studies  of  the  individual  urines,  and  lead 
accurately  to  discovery  of  the  cause  of  the  bleeding. 

Radiography  is  likewise  of  considerable  service. 


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HEMATURIA. 


1011 


FALSE  HEMATURIA. 

Mention  should  also  be  made  of  the  false  or  pseudo-hematurias, 
in  which  the  urine  is  colored  red  by  one  of  a  number  of  different 
drugs. 

Red  discoloration  of  the  urine  by  various  drugs 
{pseudo-bloody  urine). ^ 


Antipyrin: 

Pyramidon: 

Sulphonmetfaanum : 

Phenol  and  its  Salts: 

Cryogenin: 

Cascara: 

Senna: 

Rhubarb: 


Blood-red  color. 

Cherry-red  or  salmon  color. 

Brownish  red  color. 

Reddish  brown  color. 

Reddish  dark  yellow  with  a  species  of  iridescence. 

Reddish  yellow  or  brown  (red  if  urine  is  alkaline). 

Reddish  yellow  or  brown  (red  if  urine  is  alkaline). 

Reddish  yellow  or  brown  (red  if  urine  is  alkaline). 


*     * 


For  clinical  purposes,  the  commonest  causes  of  hematuria  ap- 
pear to  be  those  given  in  the  following  table : 


After  Jacquot,  Union  pharmaceutique,  1916. 


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1012 


SYMPTOMS. 


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HEMIPLEGIA. 


iffiuyvg^  half;  nXrc/uv^  to  strike;  more 

or  less  complete  loss  of  motion  in 

one  side  of  the  body. 


The  term  hemiplegia  refers  to  a  paralytic  condition  restricted  to 
one  lateral  half  of  the  body,  right  or  left.  Hemiplegia  may  be  com- 
plete or  incomplete  according  to  the  degree  of  paralysis.  As  a  rule 
its  presence  is  very  readily  observed. 

For  practical  purposes  the  diagnosis  of  hemiplegia  necessarily 
entails  an  answer  to  each  of  the  two  following  questions: 

1.  Where  is  the  lesion  located? 

2.  What  is  its  nature? 

I.  Location  of  the  lesion. — The  site  of  disease,  usually  located 
at  some  point  along  the  pyramidal  tract,  may  be  either  cerebral 
(cortical  or  capsular),  mesocephalic  (peduncular  or  pontine),  bul- 
bar, or  spinal.  Clinically,  hemiplegia  of  cerebral  origin  is  far 
more  frequent  than  all  other  varieties  combined.  These  various 
types  of  hemiplegia  are  rather  easily  distinguished  by  virtue  of 
the  following  features : 

A.  Paralysis  of  cerebral  origin  is  of  the  hemiplegic  type,  in- 
volving more  or  less  completely  the  face  and  the  upper  and  lower 
extremities.  It  usually  sets  in  with  an  apoplectic  attack;  is  some- 
times associated  with  conjugate  deviation  of  the  head  and  eye- 
balls, and  spares  the  muscles  having  synergistic  bilateral  motor 
functions. 

The  sensory  functions  are  seldom  affected ;  the  tendon-reflexes 
are,  as  a  rule,  exaggerated ;  there  is  inversion  of  the  plantar  reflex 
( see  Reflexes:  Babinskis  sign).  Muscular  atrophy  is  never  present 
at  the  outset  and  seldom  later.  On  the  contrary,  secondary  con- 
tracture frequently  occurs  at  the  end  of  two  or  three  months. 

Cortical  hemiplegia,  usually  induced  by  cerebral  softening  as  a 
result  of  embolism  or  thrombosis,  is  distinguished  from  capsular 
hemiplegia,  the  result  of  cerebral  hemorrhage,  by  the  following 
features : 

(1014) 


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HEMIPLEGIA.  1015 

Hemiplegia  of  cortical  vrigin  {cerebral  softening): 
Hemiplegia  complete  or  incomplete. 
Aphasia  frequently  present. 

Tendency  to  recession  of  paralysis  in  the  days  following  the 
stroke. 

Hemiplegia  of  Cerebral  Origin. 

Paraljmis  of  the  lower  branch  of  the  facial  and  of  the  extremities 
on  the  side  opposite  the  lesion. 

Gsion. 


Paralyi  iralysls 


Fig.  735. 

Hemiplegia  of  capsular  origin  (cerebral  hemorrhage)  : 
Hemiplegia  complete  and  permanent. 
No  aphasia. 

Tendency  to  extension  in  the  days  following  the  stroke. 
Initial  reduction  of  body  temperature. 
Early  contractures. 

Conjugate  deviation  of  the  head  and  eyeballs. 
More  frequent  involvement  of  the  right  side. 
(These  diflferential  features,  however,  are  not  absolutely  reliable). 
B.  Paralysis  of  mesocephalic  origin,  relatively  uncommon,  oc- 
curs in  the  form  of  an  alternate  (crossed)  hemiplegia,  the  extremi- 


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1016  SYMPTOMS. 

ties  being  paralyzed  on  one  side  and  the  face  or  eyeball  on  the 
other. 

1.  Alternate  hemiplegia  of  peduncular  (upper  pontine)  origin 
results  in  the  so-called  syndrome  of  Weber,  with  paralysis  of  the 
face  and  limbs  on  the  side  opposite  to  that  of  the  brain  lesion, 
and  oculomotor  paralysis  on  the  same  side.  As  shown  in  the 
annexed  illustration : 

Anatomic  Features. 


Fig.  736. — Striate  arteries — capsular  hemorrhage.  /.  Internal  carotid. 
2,  Anterior  cerebral  artery,  j.  Middle  cerebral  artery  coursing  through 
the  Sylvian  fissure.  4.  Internal  striate  arteries.  5.  External  striate 
arteries.  6.  The  artery  of  cerebral  hemorrhage,  with  a  miliary  aneurysm 
in  its  course.  7.  Cerebral  hemorrhage.  8.  Caudate  nucleus.  9.  Optic  thal- 
amus. 10,  Internal  capsule.  //.  Claustrum.  12.  External  capsule.  13. 
Lobule  of  the  insula.  14,  Lenticular  nucleus  or  extraventricular  nucleus 
of  the  corpus  striatum. 

(a)  The  lesion  of  the  pyramidal  tract  and  geniculate  fibers 
before  their  decussation  results  in  paralysis  of  the  face  and  ex- 
tremities on  the  side  opposite  to  that  of  the  lesion. 

(fc)  The  lesion  of  the  oculomotor  or  3d  cranial  nerve  at  its 
origin  causes,  on  the  same  side  as  the  brain  lesion,  paralysis  of 
the  superior  rectus,  inferior  rectus,  internal  rectus,  inferior  ob- 
lique, pupillo-constrictor,  and  levator  palpebrae  muscles,  such 
paralyses,  in  turn,  resulting  clinically  in  blepharoptosis,  mydriasis, 
divergent  strabismus,  paralysis  of  accommodation,  and  crossed 
horizontal  diplopia. 


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HEMIPLEGIA.  1017 

2.  Alternate  hemiplegia  of  pontine  {lower  pontine)  origin  re- 
sults in  the  so-called  syndrome  of  Millard-Gubler,  .with  paralysis  of 
the  limbs  on  the  side  opposite  to  that  of  the  brain  lesion  and 
paralysis  of  the  face  and  internal  oculomotor  on  the  same  side. 
As  shown  in  the  annexed  illustration : 

(a)  The  lesion  of  the  pyramidal  tract  before  its  decussation 
results  in  paralysis  of  the  extremities  on  the  side  opposite  to  that 
of  the  lesion. 

(fc)  The  lesion  of  the  facial  or  7th  cranial  nerve  at  its  origin 
results  in  paralysis  of  the  face  on  the  same  side  as  the  brain  lesion. 


Fig.  727. — Branches  of  the  middle  cerebral  artery.  Cerebral  softening. 
J.  Middle  cerebral  artery.  2,  External  orbital  artery.  3.  Inferior  frontal 
artery.  4.  Ascending  frontal  artery,  5.  Ascending  parietal  artery.  6, 
Inferior  parietal  artery.  7.  Artery  to  angular  gyrus.  8.  Temporal  arteries, 
p.  Near  the  origin  of  the  Sylvian  artery  are  to  be  seen  the  perforating 
(anterolateral)  arteries. 

It  should  be  noted  that  in  embolism  (as  by  a  piece  of  valve,  vegetation, 
or  clot),  the  occluding  foreign  body  rarely  enters  the  innominate  artery, 
which  opens  obliquely  into  the  arch  of  the  aorta,  but  nearly  always  passes 
into  the  left  carotid,  which  forms  an  almost  direct  prolongation  of  the  aortic 
arch.  Thus,  hemiplegia  due  to  embolism  is  almost  always  a  right-sided 
hemiplegia,  due  to  a  lesion  of  the  left  cerebral  hemisphere. 

(c)  The  lesion  of  the  external  oculomotor  (abducens)  or  6th 
cranial  nerve  at  its  origin  results  in  paralysis  of  the  external 
rectus  muscle  on  the  side  of  the  brain  lesion,  i.e.,  clinically  in  con- 
vergent strabismus  with  homonymous  diplopia  (displaced  image 
on  the  same  side). 

The  aphasia  bundle  passes  down  from  Broca's  convolution  to 
the  anterior  portion  of  the  internal  capsule  and  from  there  to  the 
bulbopontine  centers  of  articulate  speech  production. 


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1018  SYMPTOMS. 


The  geniculate  bundle  passes  down  from  the  foot  of  the  ascend- 
ing frontal  convolution,  passes  through  the  internal  capsule  at 
the  genu,  decussates  at  the  pons  (see  below),  and  terminates  in 
the  centers  of  the  facial  and  hypoglossal  nerves. 


■  Geniculate  flbera 
(facial). 

■  Tmo'i?).'  ''•"'        ^      Eil  Apha-la  bundle. 
B  Sensory  tract.  ^  Gray  matter. 

Fig.  738. — Diagram  of  the  motor  and  sensory  paths  in  the 
brain  and  spinal  cord. 

The  pyramidal  tract  passes  down  from  the  central  convolutions, 
passes  through  the  internal  capsule  in  its  posterior  and  middle 
portion,  behind  the  geniculate  ganglion,  and  decussktes  with  the 
pyramidal  tract  of  the  opposite  side  at  the  bulbar  pyramids,  after 
giving  off  a  direct  bundle  which  remains  in  the  corresponding 
half  of  the  cord. 


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HEMIPLEGIA.  1019 

Peduncular  hemarrhage. 
Weber's  syndrome  or  superior  alternate  hemifrfegia. 


> 


A 


sLfion^* 


^^ 


Fig.  739. — /'.  Paralysis  of  the  extremities  on  the  side  opposite  the  brain 
lesion.  2.  Oculomotor  paralysis  on  the  same  side  as  the  lesion,  (a) 
Ptosis.  (6)  Outward  deviation  of  the  eye  owing  to  persistence  of  func- 
tion of  the  fourth  and  sixth  cranial  nerves. 

Inferior  pontine  hemorrhage. 
Syndrome  of  Millard-Gtibler.    Inferior  alternate  hemiplegia. 


2 


Fig.  740. — /.  Paralysis  of  the  extremities  on  the  side  opposite  the  brain 
lesion.  2.  Paralysis  of  the  face  on  the  same  side  as  the  lesion,  j.  Paral- 
ysis of  the  sixth  cranial  nerve  on  the  side  of  the  lesion,  causing  conver- 
gent strabismus  through  deviation  of  the  eye  inward  and  downward. 


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Anatomic  Relations. 

Cerebral  peduncles 

Left  genicula  nlculate  fibers 

Left  pyramidal  rramldal   tract 

Right  oculo- 
motor Den  ft  oculomotor  nerve 


Right 
geniculate  fibers-  ns 

ft  geniculate  fibers 

Right  oculo-  .    «      .    ^ 

motor  nerve-  Left  sixth  cranial 

nerve 
Right  facial  nen  ''t  facial  nerve 


ive 
Hypoglossal  nen 


Right  pyramidal  tra<  ramidal  tract 


Fig.  741. 

1.  High  lesion  involving  peduncle  and  pons. 
Superior  alternate  hemiplegia. 

1.  Involvement  of  the  pyramidal  tract  above  its  decussation :  Paralysis  of 
the  extremities  on  the  side  opposite  the  lesion. 

2.  Involvement  of  the  facial  above  its  decussation :  Facial  paralysis  on  the 
side  opposite  the  lesion. 

3L  Involvement  of  the  oculomotor  on  the  side  of  the  lesion :  Oculomotor 
paralysis  on  the  side  of  the  lesion  (superior  rectus,  inferior  rectus,  internal 
rectus,  inferior  oblique,  constrictor  of  the  pupil,  and  levator  palpebrse  super- 
ioris),  whence: 

Blepharoptosis,  mydriasis,  paralysis  of  accommodation,  divergent  stra- 
bismus, and  crossed  horizontal  diplopia. 

2.  Inferior  pontine  lesion. 

Inferior  alternate  hemiplegia. 

1.  Involvement  of  the  pyramidal  tract  above  its  decussation :  Paralysis  of 
the  extremities  on  the  side  opposite  the  lesion. 

2.  Involvement  of  the  facial  below  its  decussation :  Facial  paralysis  on  the 
side  of  the  lesion. 

3.  Involvement  of  the  abducens  at  its  point  of  origin:  Paralysis  of  the 
external  rectus  on  the  side  of  the  lesion,  whence : 

Convergent  squint  with  homonymous  diplopia   (false  image  on  same 
side). 

3.  Bulbar  lesion  (very  rare). 

1.  Involvement  in  the  vicinity  of  the  olive,  affecting  the  hypoglossal  and  the 
pyramidal  tract  above  its  decussation. 

2.  Involvement  of  the  pyramidal  tract  above  its  decussation :  Paralysis  of 
the  extremities  on  the  side  opposite  the  lesion. 

3.  Involvement  of  the  hypoglossal  at  its  point  of  origin :  Paralysis  of  the 
tongue  on  the  side  of  the  lesion. 

(1020) 


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HEMIPLEGIA, 
Bulbar  lesion. 

Lesion 


1021 


Fig.  742.—/.  Paralysis  of  the  extremities  on  one  side.   2.  Paralysis 
of  the  tongue  on  the  opposite  side. 

Section  of  the  cervical  cord  (extremely  rare). 

Spinal  hemiplegia. 

Brown-S6quard'8  ssmdrome. 


S 
8      / 


Fig.  743. — I.  Paralysis  of  the  extremities  on  the  side  of  the  lesion.    2, 
Hemianesthesia  on  the  side  opposite  the  lesion,    s.  Face  unaffected. 


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1022  SYMPTOMS, 

The  sensory  tract  originating  from  the  posterior  columns  of  the 
spinal  cord  ascends  to  the  bulb,  where  it  decussates  at  the  pos- 
terior portion  of  the  cerebral  pedvmcles,  passes  through  the  in- 
ternal capsule  in  its  posterior  part,  and  terminates  in  the  occipital 
convolutions. 

C.  Hemiplegia  of  bulbar  origin  is  exceedingly  uncommon. 

I.  Olfactory 
II.   OpUc 


III.  Oculoi 

IV.  Pathetic  ne 

V.  Trifacial  ne 

te  of 

VI.  Abducens  ne  ^ 

VIII.  Auditory  ne 

VII.   Facial  nerve 

IX.   Glossopharyngeal 

X.   Pneumogasti 

XII.  Hypoglosi 

XI.  Spinal  accessory  n( 

I.  Cervical  n< 


Fig.  744. — The  medulla  and  pons. 

The  commonest  example  of  superior  bulbar  paralysis  is  that  at- 
tending polioencephalomyelitis,  the  cardinal  syndrome  of  which  is 
external  ophthalmoplegia,  i,e,,  paralysis  of  all  the  muscles  of  the 
eye  except  the  pupillary  muscles. 

The  commonest  example  of  inferior  bulbar  paralysis  is  that  of 
labioglossolaryngeal  paralysis,  attended  with  paralysis  and  atrophy 
of  the  lips,  tongue,  muscles  of  mastication,  soft  palate,  and  laryn- 
geal muscles,  resulting  in  progressive  disturbances  of  deglutition, 
respiration,  and  circulation. 


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HEMIPLEGIA. 


1023 


'  (a)  The  lesion  of  the  pyramidal  tract  before  its  decussation 
(see  p.  1020)  results  in  paralysis  of  the  extremities  of  the  opposite 
side. 

(fc)  The  lesion  of  the  hypoglossal  nerve  at  its  origin  causes 
paralysis  of  the  tongue  on  the  same  side  as  the  lesion. 

D;  Hemiplegia  of  spinal  origin,  a  condition  wholly  exceptional 
in  the  absence  of  traumatic  injury  of  the  cervical  cord,  results  in 
the  so-called  syndrome  of  Brown-Sequard,  in  which  there  is  paralysis 
of  the  limbs  on  the  side  opposite  to  that  of  the  lesion,  anesthesia 
likewise  of  the  opposite  side,  and  the  face  and  eyes  uninvolved, 

E.  Finally,  one  should  not  overlook  the  possibility  of  a  purely 
functional  hemiplegia,  independent  of  any  nervous  lesion. 

Hysterical  hemiplegia  is  diflferentiated  from  the  organic  hemi- 
plegias already  described  by  the  following  features : 


Differential  Diagnosis. 


Obganic  Hsmiplboia. 

Hysterical  Hemiplboia. 

The  tendon  and  skin  reflexes  are 
affected: 

There     is     exaggeration     of     the 
patellar  reflex,  abolition  or  dimi- 
nution of  the  skin  reflexes,  and 
inversion   of  the  plantar   reflex 
(toe    phenomenon    or    Babinski 
sign). 

The  tendon  and  skin  reflexes  are 
unchanged.  The  toe  phenom- 
enon (Babinski  sign)  is  absent. 

The  disturbances  of  sensation  de- 
crease as  one  ascends  from  the 
distal  to  the  proximal  portions 
of  the  extremities. 

The  anesthesia  or  hypoesthesia 
present  is  of  the  hemianesthetic 
type. 

There  is  usually  no  facial  paral- 
ysis, although  there  is  some- 
times glossolabial  spasm  on  the 
opposite  side. 

The     patient    is    suffering     from 
heart    disease,    arteriosclerosis, 
syphilis,  uremia,  or  other  con- 
dition. 

The  patient  is  generally  young, 
most  often  of  the  female  sex, 
and  exhibits  stigmata  of  hys- 
teria and  neuropathic  evidences. 

The  syndrome  appears  abruptly, 
frequently  after  some  emotional 
impression. 

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1024  SYMPTOMS. 

II.  What  is  the  cause  of  the  hemiplegia? 

Certain  general  features  of  nervous  disease  may,  in  the  first 
place,  be  referred  to. 

The  brain  is  more  frequently  affected  by  disorders  of  vas- 
cular origin  (thrombosis  or  hemorrhage)  than  by  inflammatory 
disorders  (meningo-iencephalitis) . 

The  spinal  cord  is  more  frequently  involved  in  inflammatory 
degenerative  processes,  acute  (myelitis)  or  chronic  (systema- 
tized sclerotic  processes),  than  in  vascular  lesions. 

The  peripheral  nerves  are  oftenest  affected  by  intoxications 
(alcoholism,  lead  poisoning,  etc.),  infections  (diphtheria,  typhoid 
fever,  etc.),  and  traumatic  injuries. 

It  is  impracticable  and  would  be  tiresome  to  review  all  the 
possible  causes  of  hemiplegia. 

Let  it  be  borne  in  mind  that  practically  ps  per  cent,  of  all  hemi- 
plegias are  dependent  upon  arteriosclerosis,  Bright's  disease,  syph- 
ilis, alcoholism,  or  rheumatism  (endocarditis),  and  that  these  several 
causes  can  be  almost  always  discovered  by  the  following  plan  of 
examination : 

1.  History:  Age,  vertigo,  mental  impairment  (arterio- 
sclerosis). 

Polyuria,  nycturia,  albuminuria,  etc.  (Bright's  disease). 

Specific  history  (syphilis). 

Intemperate  habits  (alcoholism). 

Acute  rheumatism  or  other  acute  infection. 

2.  Auscultation:  Aortic  evidences  (arteriosclerosis,  specific 
aortitis). 

Aortic  evidences  with  gallop  rhythm  (Bright's  disease). 
Mitral  or  mitro-aortic  evidences  (rheumatism). 

3.  Examination  of  the  urine:  Albuminuria  and  casts 
(Bright's  disease,  arteriosclerosis). 

4.  Blood-pressure  determination:  Pressure  particularly  high 
in  arteriosclerosis  and  Bright's  disease. 

5.  Special  features  of  the  hemiplegia  per  se, 

(a)  A  right-sided  hemiplegia  without  apparent  cause,  after  a 
short  period  of  dizziness,  with  or  without  an  apoplectic  stroke,  and 
without  temperature  changes,  generally  points  to  softening  of  the 
brain  due  to  thrombosis  in  an  arteriosclerotic  subject. 


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HEMIPLEGIA, 


1025 


(8)  A  right-  or  left-  sided  hemiplegia,  appearing  after  an  apo- 
plectic stroke  in  a  middle-aged  or  old  subject  is  generally  dependent 
upon  cerebral  hemorrhage,  the  commonest  causes  of  which  are 
Bright' s  disease  ^nd  arteriosclerosis. 

The  predisposing  influence"  of  plethora  in  males  and  of  the 
menopause  in  women  may  here  be  noted. 

(c)  An  incomplete  right-sided  hemiplegia,  appearing  abruptly, 
without  a  stroke,  in  a  young  or  adult  subject  suffering  from  mitral 
or  mitro-aortic  endocarditis  is  induced  by  cerebral  embolism  occur- 
ring as  a  complication  of  endocarditis, 

(rf)  A  right-sided,  progressive  hemiplegia,  appearing  without 
an  apoplectic  stroke  in  a  young  or  adult  subject  who  is  syphilitic  is 
generally  due  to  syphilitic  arteritis. 

{e)  A  hemiplegia  appearing  more  or  less  abruptly  in  a  young 
or  adult  subject  addicted  to  alcoholism,  and  soon  accompanied  by 
contractures  or  even  convulsive  attacks  of  the  Jacksonian  type 
should  direct  the  observer  toward  the  thought  of  a  hemorrhagic 
pachymeningitis  in  an  alcoholic  individual, 

(/)  The  following  brief  tabular  statement  of  the  diagnostic 
featuresi  of  facial  paralysis  should  be  kept  constantly  in  mind : 

Facial  Paralysis. 


Medical 
causes 


(fl)  Peripheral 


I  (b)  Central 


Both  branches  are  involved;  in- 
fluenzal neuritis,  and  the  ordi- 
nary so-called  "rheumatic" 
facial  paralysis. 

C  Lower  branch  alone  involved; 
\  cerebral  hemorrhage  or  soften- 
L     ing,  or  tumor  of  the  cortex. 


Traumatic 
causes  . .. 


(a)  Intratemporal 


{b)  Extratemporal 


{Fractured  skull,  foreign  body  in 
the  mastoid,  or  mastoid  opera- 
tion. 

Wound  of  the  face  by  a  missile 
or  by  an  operation  in  the  paro- 
tid region. 

(After  Pauchet). 


6.  Blood  examination   (blood  obtained  by  cupping  or  vein 
puncture). 


65 


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1026 


SYMPTOMS. 


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HEMIPLEGIA. 


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1028  SYMPTOMS. 

(a)  The  W.assermann  reaction,  if  positive,  will  confirm  the 
diagnosis  of  syphilis  if  it  has  already  been  rendered,  or  will  draw 
the  observer's  attention  in  that  direction  in  doubtful  cases. 

(fc)  Determination  of  the  blood  urea:  Blood  urea  exceeding 
0.80  gram  indicates  the  presence  of  uremia. 

Much  might  be  written  concerning  the  relationship  of  uremia  to 
hemiplegia.  Formerly  it  was  practically  an  established  custom  to 
consider  the  terms  relatively  antagonistic.  At  the  present  time  one 
cannot  help  noting  that  these  two  conditions  bear  most  intimate 
clinical  interrelationships,  and  that  hemorrhages  (including  cerebral 
hemorrhage),  high  blood-pressure,  azotemia,  and  albuminuria  are 
practically  common  accompaniments  of  arteriosclerosis  and  nephr- 
itis. Concomitance  of  the  two  conditions  is,  indeed,  the  clinical 
rule.  Most  of  the  author's  cases  of  sclerosis  with  hemiplegia  have 
been  azotemic,  and  many  of  his  uremic  subjects  have  shown  a 
terminal  hemipl^ia.    Such  are  the  actual  facts  in  this  connection. 

7.  Examination  of  the  cerebrospinal  fluid. — ^This  is  of  espe- 
cial service  for  the  detection  of  : 

1.  Hemorrhagic  states :  Cerebral  and  meningeal  hemorrhage 
(red  blood  cells  in  the  cerebrospinal  fluid). 

2.  Inflammatory  states:  Meningitis  (leucocytosis;  presence 
of  pathogenic  bacteria). 

The  annexed  clinical  table  summarizes  the  iacts  already  re- 
called. 


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«i7iurrki>T»vcTC      faW*  hlood;  nrvCLg,  spitting.    Spitting'] 
inii.MUi'l  Yblb.     1^      of  blood.  (See  Expectoration.)      J 


Hemoptysis,  defined  as  the  expectoration  of  blood  set  free  in 
the  air  passages,  is  very  often  an  obvious  occurrence ;  yet  rather 
frequently  the  fact  that  the  blood  expectorated  has  come  from 
the  broncho-pulmonary  tract  requires  to  be  investigated,  verified, 
and  proven.  Hemoptysis  and  hematemesis  are  often  confused, 
and  even  more  frequently,  more  or  less  deeply  blood-stained  dis- 
charges of  nasal,  lingual,  gingival,  or  laryngeal  origin  are  put 
down  as  constituting  hemoptysis. 

Epistaxis. — Production  of  bloody  expectoration  by  epistaxis, 
especially  of  the  posterior  variety,  is  a  very  commonly  observed 
occurrence.  Where  expectoration  of  blood  attends  an  anterior 
"external"  epistaxis,  the  source  of  the  blood  is  obvious;  where, 
however,  it  is  not  accompanied  by  "nosebleed,"  examination  of 
the  pharynx  and  even  the  nasopharynx  is  indicated.  Naso- 
pharyngeal hemorrhage  is  generally  of  dyscrasic  origin  (hemo- 
philia or  high  blood-pressure)  or  the  result  of  ulceration,  rupture 
of  a  varicose  vessel,  or  ani  adenoid  inflamrtiation  which  careful 
examination  cannot  fail  to  detect. 

The  only  real,  though  slight,  diagnostic  difficulty  arises  from 
the  fact  that  blood  shed  in  the  nose  or  pharynx  may  actually  be 
swallowed  or  coagulate  in  the  nasopharynx  itself  and  be  dis- 
charged only  by  a  spell  of  coughing.  Under  these  conditions 
the  blood  is  more  or  less  mixed  with  mucus  from  the  stomach 
or  nasopharynx  and  may,  upon  hasty  examination,  be  deemed  to 
have  issued  from  the  lung  or  stomach.  The  opposite  mistake, 
which  consists  in  carelessly  ascribing  to  the  nasopharynx  a 
hemorrhage  actually  occurring  in  the  stomach  or  lung,  is  much 
more  serious. 

Let  it  be  repeated  once  again  that  a  careful  general  examina- 
tion— including    that    of    the    nasopharynx — will    inevitably    and 

(1029) 


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1030  SYMPTOMS. 

promptly  lead  to  a  correct  determination  of  the  source  of  expec- 
torated blood. 

The  lingual  origin  of  blood  expelled  from  the  mouth  may  be 
noted  in  the  event  of  a  bite  of  the  tongue,  traumatic  or  "epi- 
leptic," or  of  a  tuberculous  or  neoplastic  ulceration.  Mention  of 
this  cause  of  blood  spitting,  which  could  confuse  only  a  very 
careless  or  inexperienced  practitioner,  is  required  merely  for 
the  sake  of  completeness  and  because  it  is  customary  to  do  so. 

Bleeding  from  the  gums  is  extremely  common,  even  inde- 
dendently  of  scurvy  and  hemophilia,  which  are  themselves  ex- 
ceptional disorders.  The  ubiquitous  pyorrhea  alveolaris,  various 
diathetic  disturbances,  and  even  abuse  of  the  tooth  brush  may 
induce  swelling  and  "inflammation"  of  the  g^ms  and  render 
them  both  sensitive  and  prone  to  bleed.  Under  these  circum- 
stances the  least  contact  with  the  gums  results  in  oozing  which 
stains  all  sputum  with  blood  and  gives  rise  to  "pseudo-hemo- 
ptysis." A  most  casual  examination  of  the  gums  will  discover  the 
actual  source  of  the  bleeding  to  be  in  these  structures. 

Hemorrhage  in  the  larynx  may  result  either  from  traumatism 
or  from  ulceration.  The  former  is  readily  excluded.  Ulcerations 
are  always  either  syphilitic,  tuberculous,  or  cancerous ;  they  are 
always  attended  with  hoarseness  and  local  pain ;  they  are  always 
preceded  by  a  period  during  which  the  attention  was  drawn  to 
and  fixed  upon  the  larynx.  Examination  of  the  larynx  with  the 
mirror  will  always  demonstrate  the  laryngeal  source  of  the 
bleeding. 

The  only  real  difficulty  in  diagnosis  is  that  sometimes  met 
with  in  the  differentiation  of  hemoptysifl  from  hematemesis,  which 
may  constitute  a  most  puzzling  problem  (see  Hemat  erne  sis). 

As  a  rule,  there  is  little  trouble  in  this  connection : 

The  preliminary  symptoms  are  different,  being 

Digestive  in  hematemesis  and  respiratory  in  hemoptysis. 

The  manner  in  which  the  blood  is  expelled  is  likewise  different. 

In  hemoptysis  there  are  attempts  at  coughing  and  the  blood 
is  liquid,  red,  and  foamy. 

In  hematemesis  there  is  retching  and  the  blood  is  clotted, 
dark  colored,  without  admixture  of  air,  but  mixed  with  food 
material;  sometimes  intestinal  hemorrhage  coexists. 


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HEMOPTYSIS.  1031 

All  these  signs,  however,  are  unreliable. 

In  hemoptysis  there  may  be  dark  colored  blood  (pulmonary 
hemorrhage)  and  in  hematemesis  red  blood  (gastric  ulcer). 

In  hemoptysis  the  preliminary  cough  may  be  wanting,  while 
on  the  other  hand  there  may  be  concomitant  vomiting  and  con- 
sequently admixture  of  blood  with  food  material. 

In  hematemesis  the  blood  may  or  may  not  be  mixed  with  bile 
or  food  material. 

After  careful  deliberation  and  thorough  examination  the  con- 
clusion may  eventually  be  reached  that  hemoptysis  has  occurred. 

♦    ♦    ♦ 

The  diagnosis  of  "true  hemoptysis"  having  been  correctly  made 
— ^and  definitely  established,  i.e.,  on  the  whole,  the  presence  of 
blood  in  the  sputum  either  being  obvious  or  having  been  demon- 
strated by  suitable  hematologic  procedures;  the  supposition  of 
hematemesis  having  been  excluded,  sometimes  a  difficult  matter, 
as  the  author  has  seen  mistakes  in  this  ccmnection  made  (and  later 
proven)  by  experienced  observers;  and  the  oropharynx,  gums, 
tongue,  and  nasopharynx  being  readily  eliminated  as  sources  of 
bleeding  by  a  mere  citrsory  examination,  provided  it  is  actually 
carried  out, — ^the  cause  of  the  hemoptysis  is  generally^  very  easily 
found  if  the  following  fundamental  propositions  are  kept  in  mind : 

1.  Eleven-twelfths  of  all  instances  of  true  hemoptysis  are  of 
cardiopulmonary  origin  and  are  due  to  one  of  two  following 
causes : 

(a)  Pulmonary  tuberculosis  in  any  one  of  its  stages,  from  the 
pretuberculous  congestive  stage  to  the  stage  of  cavity  pro- 
duction. 

(b)  Infarction  of  the  lung,  generally  secondary  either  to  a 
mitral  disorder,  particularly  mitral  stenosis;  to  some  cardio-arterial 
disorder  which  has  advanced  to  the  stage  of  decompensation  with 
stasis,  or  to  phlebitis  in  any  of  its  stages,  from  the  pre-obstructive 
stage  to  the  stage  of  disintegration  of  the  intravascular  clot. 

Pulmonary  tuberculosis  is  a  far  more  frequent  cause  than  in- 
farct of  the  lung.  As  for  the  latter,  its  cause  is  nearly  always 
obvious  upon  any  sort  of  careful  examination  (mitral  stenosis, 
heart  failure,  puerperal,  infectious,  or  post-operative  phlebitis,  etc.)  ; 


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1032  SYMPTOMS, 

frequently,  moreover,  infarction  is  marked  by  a  sudden  pain  in  the 
side  with  cough,  dyspnea,  and  even  orthopnea,  an  area  of  fine 
rales,  etc. 

Thus,  any  case  of  hemoptysis  unattended  with  cardiovascular 
disease  (heart  disease  or  phlebitis)  may  be  considered  to  be  in 
all  likelihood  tuberculous.  Furthermore,  the  hemoptysis  of  ad- 
vanced tuberculosis,  in  the  stages  of  softening  or  cavity  forma- 
tion, cannot  fail  to  be  recognized,  as  its  source  is  quite  obvious. 

Doubt  may  arise  only  in  connection  with  the  premonitory 


Fig.  745. — Diagram  of  pulmonary  infarction.  The  embolus,  having 
become  detached  at  some  point  in  the  inferior  vena  cava  {v,  c.  i.)  or  its 
tributaries,  or  in  the  superior  vena  cava  {v.  c.  s.)  or  its  tributaries,  passes 
through  the  right  auricle  {o.  rf.),  is  discharged  into  the  pulmonary  artery 
(a.  />.),  and  lodges  in  one  of  the  lobes  of  the  lung,  giving  rise  to  an  infarct 
which  finds  its  clinical  expression  in :  1.  A  sudden  sharp  pain  in  the  side. 
2.  Blood-spitting  (hemoptysis).  3.  The  physical  signs  shown  in  Figs.  746 
and  747. 

hemoptysis  at  the  very  beginning  of  tuberculosis,  accompanied 
by  little  in  the  way  of  general  or  auscultatory  evidences,  or  even 
occurring  at  a  time  when  the  disease  is  as  yt^t  entirely  latent. 
Any  true  hemoptysis  of  obscure,  cryptogenic  origin  should  be 
considered  of  tuberculous  nature  imtil  proof  to  the  contrary  is 
obtained,  and  the  patient  kept  under  careful  observation  as  re- 
gards body  weight,  temperature,  general  health,  and  examina- 
tion of  the  lungs ;  this  is  a  clinical  axiom  from  which  the  practi- 
tioner should  never  depart,  lest  he  take  upon  himself  a  most 


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HEMOPTYSIS, 


1033 


serious  responsibility  and  meet  with  egregious  disappoint- 
ment 

The  only  real  difficulty  in  these  cases  lies  in  the  possibility  of 
simultaneous  mitral  stenosis  and  pulmonary  tuberculosis;  only 
rarely,  however,  will  careful  observation  of  the  patient's  general 
condition  and  temperature  and  systematic,  repeated  ausculta- 
tion of  the  lungs  fail  sooner  or  later  to  afford  a  distinction  be- 
tween the  manifestations  appertaining  to  one  or  the  other  of 
these  disorders. 

Certain  instances  of  hemoptysis,  due  exclusively  to  mitral 
stenosis  and  associated  with  marked  and  persistent  hyperemia  of 

Phjrsical  signs. 


■^  Weakened  or  muffled  breathing. 
Ck^    Surrounding  area  of  crepitant  rales. 

Figs.  746  and  747. — Pulmonary  infarction. 

a  pulmonary  apex,  may,  however,  hold  the  diagnosis  in  suspense 
for  a  time. 

2.  One  twelfth  of  all  instances  of  true  hemoptysis  may  be 
referable  to  exceptional  or  obvious  or,  on  the  other  hand,  with 
difficulty  detected  causes. 

Among  the  obzious  causes,  traumatism  is  the  most  important; 
thus,  a  chest  wound  or  contusion,  a  fractured  rib,  or  gas  poisoning 
are  obvious  conditions. 

The  majority  of  acute  and,  particularly,  chronic  affections  of 
the  lungs  may  ultimately  be  associated  with  hemoptysis.  Ac- 
cordingly, hemoptysis  may  be  met  with  in  pneumonia,  chronic 
bronchitis  with  dilated  bronchi,  abscess  of  the  lung,  broncho- 


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1034  SYMPTOMS. 

pulmonary  gangrene,  and  syphilitic  or  cancerous  involvement. 
Frequently  the  clinical  evidences  present  in  conjunction  with  the 
hemoptysis  are  such,  especially  in  bronchiectasis  and  pulmonary 
abscess  or  gangrene,  as  to  make  the  diagnosis  perfectly  plain ; 
syphilis  and  cancer,  however,  require  a  painstaking  examination 
for  their  detection,  and  especially,  the  actual  thought  of  their 
possible  presence  on  the  part  of  the  physician. 


Fig.  748. — Aneurysm  of  the  pulmonary  artery  {Letulle  and  Natlan- 
Larrier.  Microphotogr.  by  E.  Normand.  X5).  n,  ruptured  wall  of  the 
affected  artery;  c,  tuberculous  cavity  bounded  by  a  layer  of  caseous 
material;  x,  a  diverticulum  of  the  aforesaid  cavity;  />,  pulmonary  vein, 
occluded  and  included  in  the  caseous  layer  about  the  cavity. 

Hemorrhagic  disorders,  including  the  infectious  purpuras,  in- 
fectious jaundice,  hemophilia,  leukemic  conditions,  etc.,  as  well 
as  some  severe  forms  of  typhoid  fever  and  malaria,  may  likewise 
lead  to  hemoptysis,  but  in  these  disorders  the  hemorrhage  takes 
place  in  the  presence  of  a  clinical  picture  so  definite  as  to  leave 
little  chance  of  any  actual  difficulty  in  diagnosis.  One  of  the 
author's  patients  with  arteriosclerosis  and  high  blood-pressure 


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HEMOPTYSIS,  1035 

developed  every  spring,  in  April  and  May,  for  over  ten  years,  a 
varied  assortment  of  hemorrhages,  usually  in  the  form  of  epi- 
staxis,  sometimes  as  hemoptysis  and  less  frequently  as  hemor- 
rhoidal hemorrhages  of  almost  alarming  extent ;  the  tenth  year, 
he  developed  a  severe  cerebral  hemorrhage  resulting  in  perma- 
nent hemiplegia. 

In  addition  to  these  hemorrhagic  disorders  mention  should  be 
made  of  the  congestive  hemoptysic  attacks  of  gouty  patients;  the 
author  has  seen  several  instances  of  this  condition.  The  history  of 
gout,  the  congestive  nature  of  the  pulmonary  attack — ^which  gen- 


Fig.  749. — Diagram  of  a  pulmonary  lobule  {Miller).  B,  terminal  bron- 
chus; y,  vestibule;  At,  atrium;  S,  air-sac  (infundibulum)  ;  C,  air-cell 
(alveolus)  ;  Ar,  artery;  V  (at  the  right),  vein. 

erally  involves  the  bases  of  the  lungs  and  sometimes  assumes  the 
appearances  of  acute  edema — and  the  ovemourished  aspect  of  the 
patient  directly  suggest  the  diagnosis  in  such  cases.  Uremia  may 
give  rise  to  a  similar  condition,  the  source  of  which  is  ascertained 
by  blood-pressure  estimation  and  determination  of  the  blood  urea. 

Aortic  aneurysm  may  likewise  lead  to  hemoptysis,  under  two 
very  different  groups  of  circumstances.  There  may  occur  either 
slight,  intermittent  hemoptysis,  due  to  the  presence  of  a  slight 
fissure  at  an  area  of  adhesion  of  the  aneurysm  to  the  trachea  and 
sometimes  compatible  with  life  for  a  more  or  less  prolonged 
period,  or  else  rupture  of  the  aneurysm  into  a  bronchus  or  the 
trachea  with  fatal  hemorrhage.  From  the  diagnostic  standpoint, 
either  the  presence  of  aneurysm  will  already  have  long  been 


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1036  SYMPTOMS. 

known  at  the  time  of  the  hemoptysis,  the  significance  of  which 
will  therefore  be  obvious,  or  the  aneurysm  will  have  up  to  that 
time  remained  latent,  either  because  of  insufficient  clinical  ex- 
amination or  on  account  of  a  remarkable  degree  of  tolerance  of 
the  disease  by  the  patient,  who  has  not  as  yet  consulted  a  physi- 
cian. In  no  case  of  this  type,  to  the  author's  knowledge,  has 
careful  clinical  examination  failed  to  elicit  some  sign  or  other 
of  a  mediastinal  mass  (bronchial  murmur,  collateral  circulation 
over  the  upper  part  of  the  thorax,  pressure  manifestations,  pupil- 
lary inequality,  elevation  or  broadening  of  the  arch  of  the  aorta, 
inequality  of  the  right  and  left  pulse,  etc.). 

Few  symptoms,  the  reader  will  note,  are  of  such  definite 
semeiologic  significance  as  hemoptysis.  Almost  constantly  it 
constitutes  an  external  expression  of  some  pulmonary  or  cardiac 
disorder,  hemorrhagic  diathesis,  or  manifest  or  latent  congestive 
state. 

Does  Vicarious  Menstruation  in  the  Form  of  Hemoptysis  Act- 
ually Occur? — Before  concluding  this  section,  mention  may  be 
made  of  a  very  exceptional  form  of  hemoptysis  which  has  been  the 
subject  of  prolonged  discussion  and  the  diagnostic  and  prognostic 
significance  of  which  may  be  altogether  different,  vis.,  vicarious 
menstruation  through  the  lungs. 

The  reader's  indulgence  is  requested  by  the  author  for  de- 
voting a  disproportionate  amount  of  space  to  this  subject,  but 
the  condition  is  a  very  peculiar  and  as  yet  variously  regarded 
one,  and  the  following  brief  contribution  to  its  study  seems  war- 
ranted on  condition  that  the  reader  makes  good  note  of  the  fact 
that  this  constitutes  only  a  very  exceptional  form  of  hemoptysis. 

According  to  many  observers,  particularly  phthisiologists, 
vicarious  menstruation  through  the  lungs  is  almost  invariably 
evidence  of  a  manifest  or  threatening  tuberculosis  of  the  lungs. 

The  condition  is,  as  a  matter  of  fact,  met  with  either  singly 
or  repeatedly  in  not  a  few  cases  of  pulmonary  tuberculosis  in 
women.  But  the  writer  has  also  seen  it  in  cases  in  which  all 
idea  of  an  organic  disease  could  be  clinically  excluded  and  in 
which  very  prolonged  later  observation  failed  to  show  the  exist- 
ence of  any  morbid  manifestation. 


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HEMOPTYSIS,  1037 

One  case,  among  others,  may  be  here  referred  to  because  the 
period  of  observation  was  sufficiently  prolonged  to  carry  con- 
viction. The  patient  was  a  young  lady  about  twenty  years  of 
age,  free  of  any  history  of  general  disease,  apparently  in  robust 
health,  having  one  child  eighteen  months  old  and  another  three 
months  old  which  she  was  nursing,  and  who,  in  November,  1901, 
saw  her  menstruation  stop  suddenly  on  the  second  day  and  a 
copious  hemoptysis  set  in  which  continued  for  two  days  and 
then  ceased  as  it  had  come  on,  without  apparent  cause.  The 
patient,  with  whom  the  author  had  been  acquainted  for  three 
years,  had  had  no  discomforts  during  that  time;  her  pregnancies 
had  been  normal  and  unattended  with  any  noteworthy  difficul- 
ties. The  attack  of  hemoptysis  referred  to,  aside  from  some 
justifiable  but  temporary  anxiety,  was  not  associated  with  any 
marked  disturbance ;  there  was  no  rise  of  temperature  nor  of  the 
pulse  rate,  nor  any  dyspnea.  Very  careful  auscultation  gave 
negative  results. 

Lactation  was  not  discontinued  and  no  special  treatment  was 
instituted.  Although  kept  under  careful  observation  for  a  long 
period,  the  patient  showed  no  further  untoward  symptom.  The 
author  has  been  seeing  her  at  somewhat  irregular  intervals  for 
almost  eighteen  years,  on  account  of  illnesses  of  her  husband  or 
children,  and  has  not  seen  her  health  in  the  least  impaired  at 
any  time.  No  recurrence  of  the  hemoptysis  ever  took  place. 
It  would  seem  difficult  to  supply  any  more  positive  clinical  evi- 
dence than  this. 

An  almost  similar  clinical  picture  was  seen  by  the  author  in 
a  lady  of  thirty-five  years;  the  ophthalmic  test  was  negative. 
From  the  ISth  to  17th  of  May,  1908,  he  had  occasion  to  observe 
6  spontaneous  hemorrhages,  including  2  of  copious  epistaxis  in 
arteriosclerotic  subjects,  1  of  cerebral  hemorrhage,  1  of  hemop- 
tysis in  a  consumptive,  the  case  of  vicarious  hemorrhage  already 
referred  to,  and  a  case  of  vicarious  epistaxis.  In  this  more  than 
a  mere  coincidence  was  unquestionably  involved;  the  subject 
will  be  taken  up  again  in  a  later  publication. 

Were  the  physician  still  to  harbor  any  doubts  as  to  the  actual 
occurrence  of  idiopathic  hemoptysis  vicariously  substituted  for 
the  menstrual  flow,  Ventura's  case  would  certainly  remove  them 


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1038  SYMPTOMS.       . 

(Gas.  degli  osped,.  No.  129,  1907).  This  author  gave  the  history 
of  a  family  in  which  substitution  of  periodic  hemoptysis  for 
menstruation  took  place  in  three  successive  generations.  The  first 
generation  comprised  three  sisters;  in  one  of  them  menstruation 
was  replaced  by  hemoptysis  at  monthly  intervals.  One  of  the  un- 
aflfected  sisters  had  five  female  children,  two  of  whom  presented 
the  same  clinical  phenomenon  as  their  aunt.  Again,  one  of  the 
latter  had  four  female  children,  two  of  whom  showed  the  same 
inversion  of  function.  In  none  of  these  subjects  was  either 
tuberculosis,  syphilis,  hemophilia,  or  cardiac  disease  discovered. 

Finally,  as  an  interesting  clinical  case,  reference  may  be 
made,  although  unrelated  to  hemoptysis,  to  a  quite  typical  and 
remarkable  instance  of  menstrual  substitution  recorded  by  the 
author  at  the  Maison  municipale  de  sante  while  in  Danlos's 
service. 

The  patient  was  a  woman  about  forty  years  of  age,  short  and 
stout,  who  had  had  ten  years  before  a  child  which  she  had  nursed 
for  a  long  time  (up  to  about  two  years)  and  who  had  had  no  men- 
strual periods  since  that  time  but,  on  the  other  hand,  had  kept 
on  secreting  milk  continually,  with  periodic  recrudescences,  as 
the  author  had  occasion  personally  to  observe.  This  woman 
died  of  a  brain  tumor.  At  the  autopsy  a  normal  uterus  but 
atrophied  uterine  adnexa  were  found. 

Thus,  due  recognition  should  be  given  to  the  actual  occur- 
rence of  idiopathic  hemoptysis,  vicariously  substituted  for  the 
menstrual  periods,  in  the  absence  of  any  organic  disease  in  the 
lungs  or  heart  and  of  any  hemorrhagic  disorder  of  the  blood. 
The  prognostic  importance  of  this  fact  is  self-evident. 

4c       4c       4c 

Bronchial  Spirochetosis. — Castellani  in  1905  described  a  special  form  of 
bronchial  infection  observed  in  Ceylon  and  caused  by  spirochetes.  In  1908, 
American  observers  reported  it  from  the  Philippines,  and  others,  in  various 
tropical  lands.  Experience  during  the  great  war  led  to  the  detection  of  a 
considerable  number  of  cases  along  the  shores  of  the  Adriatic  and  in  Serbia, 
Switzerland,  Egypt,  and  France.  The  disorder  is  commonly  mistaken  for 
tuberculosis,  whether  acute  or  chronic  in  form.  The  patients  generally  com- 
plain of  an  obstinate!  cough  which  gets  worse  at  night  and  in  the  morning 
and  is  associated  with  blood-stained  expectoration.  In  the  common,  chronic 
form  of  the  disease,  the  patient  is  usually  free  of  fever  and  the  general 
health  may  be  slightly  impaired.  The  diagnosis  of  the  disease  is  based  ex- 
clusively on  examination  of  the  sputum  for  the  organism  termed  by  Castel- 
lani Sptrochcpta  hronchialis.  It  stains  easily  with  the  basic  anilin  stains,  but 
is  negative  to  Gram's  method  (see  p.  527). 


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HICCOUGH. 


Hiccough  or  hiccup  consists  of  a  clonic  contraction  of  the 
diaphragm.  Its  essential  feature  is  a  sudden  inspiratory  con- 
traction of  the  diaphragm  occurring  in  conjunction  with  a  rapid 
closure  of  the  glottis;  there  result  an  abdominal  spasm,  inspira- 
tion and  sudden  expulsion  of  air,  consequent  vibration  of  the 
completely  or  partly  closed  glottis,  and  a  hiccup  sound  which 
may  at  times  assume  the  characteristics  of  a  bark. 

A  diagrammatic  representation  of  the  usually  reflex  patho- 
genesis of  hiccough  is  presented  below. 

The  medullary  center  concerned  adjoins  that  of  the  pneumo- 
gastric  and  consequently  the  vomiting  and  respiratory  (cough) 
centers. 

It  appears  to  undergo  direct  stimulation,  possibly  through 
the  circulation,  in  the  course  of  "grave  infections'*  and  "agonic 
states,"  the  resulting  condition  constituting  a  terminal  form  of 
hiccough. 

The  centripetal  (afferent)  routes  of  stimulation  consist  chiefly 
of  the  pneumogastric  nerve  and  secondarily  ofJ  the  sympathetic  and 
certain  cortico-bulbar  fibers. 

Through  the  pneumogastric  (an  appropriately  named  nerve)  : 

The  center  may  be  brought  into  activity  by  stimuli  starting : 

(a)  From  the  abdomen  (subdiaphragmatic  region)  : 

1.  From  the  stomach:  This  is  the  starting-point  of  hiccough  in 
4  out  of  5  cases,  e.g.,  very  commonly  in  infants  after  nursing,  in 
dyspepsia  (especially  of  the  neurotic  type),  in  dilatation  of  the 
stomach,  aerophagia,  tachycardia,  the  ingestion  of  unduly  hot  or 
cold  food,  and  much  less  frequently  in  ulcer  and  cancer  of  the 
stomach.  In  these  cases  the  hiccough  may  be  either  continuous  or 
intermittent,  appearing  and  disappearing  for  no  evident  reason  or 
when  the  subject  takes  food  or  a  little  fluid. 

2.  From  the  intestine :   Helminthiasis. 

3.  From  the  peritoneum:  Peritonitis,  especially  when  situated 
below  the  liver. 

(1039) 


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1040  SYMPTOMS. 

4.  From  the  female  reproductive  organs:  Genitourinary  and 
uterine  disorders. 

(b)  From  the  thorax  (supradiaphragmatic  region). 

1.  In  diaphragmatic  pleurisy:  Actually  a  rare  cause,  the  stimu- 
lus being  ordinarily  inhibited  by  pain.  The  same  is  true  in  pneu- 
monia. 

2.  In  car dio pericardial  disturbances :  Hiccough  is  observed  espe- 
cially in  pericarditis,  particularly  at  the  beginning,  when  the  phe- 

Medullanr  center.  ^^SSdS  °' 

1^6&r     th©      "v**"™ '*'•*"■     ««»Ti*oi»"      anil      thfl      "i>oaf\li>atm>tr 

center."  This  c 
—possibly  throu 
tioDS  and  In  age 


Diaphragm 


The  stomach 
ordinary  blccouf 
cold,    etc..   or  t 

Fig.  750. — Diagram  illustrating  the  pathogenesis  of  hiccough. 

nomena  of  irritation  are  still  predominant.  Exceptionally  the 
author  has  seen  it  in  lesions  of  the  aortic  arch,  aortitis,  and  aneurysm. 
The  same  is  true  of  heart  disorders,  such  as  acute  or  chronic  endo- 
carditis, myocarditis,  etc. 

The  SYMPATHETIC  ROUTE  may  in  all  likelihood  be  one  of  the 
afferent  routes  of  stimulation  of  the  phrenic  nerve,  chiefly  in  the 
presence  of  heart  disturbances. 

Finally,  the  corticobulbar  routes  of  stimulation  are  those  involved 
in  psychoneurotic  states  (tic-hiccough),  in  hysteria  (barking  hic- 
cough), and  in  meningitis. 

The  centrifugal  (efferent)  routes  of  transmission  are  chiefly 
represented  by  the  phrenic  nerve  which  is  the  motor  nerve  to  the 


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HICCOUGH.  1041 

diaphragm  and  the  gross  anatomic  relationships  of  which  should 
always  be  kept  in  mind.  Issuing  from  the  cervical  plexus,  it 
passes  down,  crosses  the  anterior  aspect  of  the  scalenus  anticus 
muscle,  runs  down  along  the  internal  border  of  this  muscle, 
enters  the  thorax,  and  passes,  on  the  right  side,  between  the  sub- 
clavian artery  and  vein,  on  the  lateral  aspect  of  the  pneumo- 


ScalenuB  an 

Phrenic  d 
Subclavian  ai 

Superior  Tena  cai 


Phrenic  nerve. 


Fig.  751.— The  phrenic  nerves  {Hirschfeld), 

gastric,  and  along  the  superior  vena  cava,  and  on  the  left  side,  be- 
hind the  innominate  artery,  crossing  the  arch  of  the  aorta.  It 
then  courses  on  either  side  between  the  pleura  and  the  pericar- 
dium and  ends  in  ramifications  over  the  upper  surface  of  the 
diaphragm. 

It  receives  the  stimuli  issuing  from  the  pneumogastric : 

1.  Through  the  intermediation  of  the  medullary  center  of 
this  nerve  and  through  the  anterior  gray  horns. 

2.  Through  the  cervical  plexus   (whence  the  phrenic  nerve 
originates  from  three  roots),  being  connected  with  the  pneu- 

G6 


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1042  SYMPTOMS. 

mogastric  through  the  gangliform  plexus  by  means  of  one  or 
two  nerve  filaments. 

It  is  enabled  to  receive  the  stimuli  from  the  sympathetic  by 
reason  of  the  many  anastomotic  connections  between  the  cer- 
vical plexus  and  the  sympathetic. 

The  actual  cortico-bulbar  pathways  are  not  as  yet  satisfac- 
torily known. 

Recoftnition  of  the  cause  of  hiccough  is  based  chiefly  upon  the 
associated  symptoms  or  physical  signs,  which  may  indicate  gastric 
disturbance,  peritoneal  or  meningeal  involvement,  psychoneu- 
rosis,  etc. 


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HIGH  BLCX)D-PRESSURE. 


Inspection  of  a  sphygmographic  tracing  of  the  pulse,  such  as 
that  presented  herewith  (Fig.  752),  in  which  variations  of  blood- 
pressure  within  the  artery  under  examination  are  elicited  and 
recorded,  is  sufficient  to  show  that  this  pressure  is  a  variable 
quantity  and  that  it  exhibits  both  a  high  point  corresponding  to 
cardiac  systole  (the  maximal  or  systolic  pressure)  and  a  low 
point  corresponding  to  diastole  (the  minimal  or  diastolic  pres- 
sure).   There  is  thus  not  one  single  blood-pressure,  but  several 


TVT^^TU 


.  Systolic 


Diastolic 


Fig.  752. — Pulse  tracing  showing  the  successive  variations  of  pressure 
within  the  lumen  of  an  artery. 

blood-pressures.  The  maximal  pressure  corresponds  to  but  a 
very  brief  portion  of  the  cardiac  cycle,  the  point  of  culmination 
of  the  systole.  The  minimal  pressure,  on  the  other  hand,  consti- 
tutes the  permanent,  basic  pressure  below  which  the  pressure 
never  descends;  it  will  be  seen  at  once  that  this  latter  pressure 
is  at  least  as  important  to  know,  and  perhaps  even  more  impor- 
tant, than  the  maximal  pressure.  The  difference  between  the 
maximal  or  systolic  and  the  minimal  or  diastolic  pressures,  the 
differential  or  pulse  pressure,  bears  a  manifest  relationship  to 
the  force  of  the  pulse  and  consequently  to  the  cardiac  contrac- 
tion. The  diagram  herewith  presented  will  demonstrate  at  once 
the  main  features  and  mutual  relationships  of  these  several 
grades  of  pressure  (Fig.  753). 

All  of  these  three  grades  must  be  taken  into  account  if  an 
approximate  idea  of  the  general  circulatory  condition  in  a  given 
subject  is  to  be  obtained. 

(1043) 


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1044 


SYMPTOMS. 


The  maximal  or  systolic  pressure  has  long  been,  and  still  is,  the 
kind  of  blood-pressure  investigated  by  the  majority  of  cardiologists. 
Yet  it  is  certainly  insufficient  to  afford  an  exact  idea  of  the  cir- 
culatory balance  in  a  given  case.  Convincing  evidence  of  this  is 
relatively  easily  given.  Following  are  two  sphygmomanometric 
tracings  (Fig.  754)  taken  from  the  same  patient,  the  one  directly 


It 


160 

I 


Pulse  pressure 


Diastolic  pressure 


ryy/V/V/VI 


(90) 


I. 

Fig.  753. — Diagram  illustrating  the  systolic,  diastolic,  and  pulse 
(differential)  blood-pressures. 

during  an  attack  of  heart  failure,  and  the  other  during  convales- 
cence with  a  normal  condition  of  circulatory  equilibrium.  The 
systolic  and  differential  pressures  are  the  same,  vis,,  200  milli- 
meters Hg,  in  the  two  cases,  but  the  minimal  and  differential 
pressures  show,  on  the  contrary,  pronounced  changes.  This 
single  example,  taken  from  among  many  others,  is  sufficient  to 


200 


200 


^VTV 


Fig.  754. — Blood-pressure  determinations  made  in  a  single  individual, 
a  few  days  apart,  the  patient  having  heart  failure  in  A,  but  restored 
compensation  in  B, 

show  that  henceforth  it  will  be  necessary  to  be  able  to  determine 
both  the  systolic  and  the  diastolic  pressures ;  this  is  one  reason, 
and  perhaps  the  most  important  one,  which  led  the  author  to 
adopt  the  Pachon  oscillometer  in  his  blood-pressure  studies. 

The  normal  systolic  pressure  ranges  from  140  to  160  milli- 
meters Hg  (Pachon)  in  different  individuals;  exceptionally,  the 
writer  has  found  it  130  or  170. 


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HIGH  BLOOD-PRESSURE,  1045 

This  observation  is  in  itself  of  considerable  practical  impor- 
tance, showing  that  the  concept  of  high  blood-pressure  is  act- 
ually a  relative  or  individual  quantity.  A  person  whose  normal 
systolic  blood-pressure  was  130  would  already  be  suffering  from 
a  marked  increase  in  blood-pressure  at  190  millimeters  Hg;  on 
the  other  hand,  190  would,  constitute  but  a  moderate  degree  of 
hypertension  in  a  patient  whose  normal  pressure  was  170. 

High  systolic  blood-pressure  starts  then,  in  the  writer's 
opinion,  at  180  millimeters  Hg. 

For  practical  purposes  three  grades  of  high  blood-pressure 
may  be  recognized: 

Slight  hypertension,  from  180  to  200,  generally  observed  in 
plethoric  or  full-blooded  subjects  and  in  the  obese,  gouty,  or  dia- 
betic; generally  a  result  of  overeating. 

Intermediate  hypertension,  from  210  to  250,  likewise  observed 
in  many  of  the  plethoric  subjects  already  enumerated,  but  also  in 
certain  number  of  cases  of  arterial  and  renal  sclerosis. 

Marked  hypertension,  from  260  to  350,  almost  exclusively  met 
with  in  arteriosclerosis  and  interstitial  nephritis. 

This  rough,  simple  nomenclature  shows  that  the  equation,  high 
blood-pressure  =  arteriosclerosis,  is  to  a  large  extent  in  error,  and 
that,  aside  from  organic  (vasculorenal)  hypertension,  there  occurs 
also  a  functional  (neurohemic)  hypertension.  This  distinction  is  of 
decided  importance,  for  the  treatment  to  be  instituted  is  quite  dif- 
ferent in  the  two  instances. 

It  should  be  borne  in  mind,  moreover,  that:  (1)  The  sys- 
tolic arterial  pressure,  like  all  other  systemic  coefficients  (pulse 
rate,  temperature,  urinary  output,  etc.),  exhibits  normal  varia- 
tions of  20  to  30  millimeters  Hg  in  the  course  of  the  day,  rising 
from  morning  to  evening,  after  meals,  after  exercise,  etc.  (2) 
In  some  sphygmolabile,  angiospastic  subjects  sudden,  tem- 
porary, and  pronounced  changes  of  pressure  amounting  to  40  or 
50  millimeters,  or  even  more,  may  be  witnessed. 

Whence  2  practical  deductions:  (1)  In  any  g^ven  subject 
the  blood-pressure  should  be  taken,  as  much  as  possible,  at  the 
same  hour  of  the  day,  midway  between  meals,  in  order  to  obtain 
comparable  readings.  (2)  True,  continuous  high  blood-pressure 
should  be  considered  present  only  after  several  pressure  deter- 


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1046  SYMPTOMS. 

minations,  made  at  intervals  of  several  days,  have  actually 
shown  it  to  exist. 

The  minimal  or  diastolic  pressure,  or  constant  pressure, 
varies  within  limits  much  more  restricted  than  does  the  systolic 
pressure. 

In  the  normal  subject,  it  commonly  ranges  between  80  and  100 
millimeters  Hg;  80  corresponding  to  the  normally  low  systolic 
pressures  of  130  to  140  millimeters  (Pachon  instrument),  and  100 
to  the  normally  high  systolic  pressures  of  150  to  170  millimeters. 
It  is  thus  seen  to  be  relatively  stable  as  compared  to  the  systolic 
pressure. 

Increased  diastolic  pressure  is  met  with  under  the  following  four 
circumstances : 

1.  In  cases  of  markedly  high  systolic  pressure  with  good  com- 
pensation (260  millimeters  or  higher),  in  which  the  sustained 
diastolic  pressure  may  reach  120  millimeters  or  even  exception- 
ally 130  millimeters. 

2.  In  cases  of  heart  failure,  heart  failure  being  associated  much 
oftener  with  an  increase  of  diastolic  pressure  than  with  a  reduction 
of  systolic  pressure ;  these  two  pressure  indications  may,  indeed, 
coexist;  in  fact,  they  are  usually  present  together. 

3.  In  cases  of  uremia, 

4.  In  cases  of  plethora  with  venous  congestion,  especially  in  in- 
dividuals exhibiting;  the  syndrome  of  increased  portal  pressure. 

In  short,  high  diastolic  pressure  is  generally  associated — if, 
indeed,  it  is  not  actually  its  true  sphygmomanometric  expres- 
sion— with  high  venous  pressure,  loss  of  cardiovascular  balance, 
heart  weakness,  or  heat  failure. 

The  highest  diastolic  reading  the  author  has  recorded  was 
190  millimeters,  in  a  case  of  uremia  with  heart  failure. 

Thus,  the  diastolic  pressure  is  seen  to  be  of  at  least  as  great 
diagnostic  and  prognostic  significance  as  the  systolic  pressure. 

Were  it  necessary  to  summarize  the  relative  portent  of  high 
systolic  and  high  diastolic  pressure  in  one  brief,  epigrammatic, 
almost  crude  phrase,  the  matter  might  be  expressed  as  follows: 

High  systolic  pressure  is  the  balistic  high-pressure  having  to  do 
with  rupture,  hemorrhage,  and  apoplexy. 


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HIGH  BLOOD-PRESSURE.  1047 

High  diastolic  pressure  is  the  static  high-pressure  having  to  do 
with  loss  of  cardiovascular  balance,  venous  congestion,  and  heart 
failure. 

The  differential  or  pulse  pressure,  consisting  of  the  difference 
between  the  systolic  and  the  diastolic  pressures,  commonly 
varies  in  the  same  direction  and  almost  to  the  same  extent  as 
the  systolic  pressure  in  persons  in  a  state  of  satisfactory  cardio- 
vascular balance ;  thus,  •/  absolutely  necessary,  the  curve  of  varia- 
tions in  the  systolic  pressure,  practically  parallel  to  that  of  the 
variations  in  the  differential  pressure,  may  be  sufficient  in  fol- 
lowing up  the  circulatory  function  in  a  subject  with  good  cir- 
culatory balance. 

In  a  subject  on  the  road  to  heart  failure,  on  the  other  hand, 
the  differential  or  pulse  pressure  decreases  much  more  quickly 
or  rises  much  more  slowly  than  the  systolic  pressure.  Discrep- 
ancy is  shown  between  the  courses  followed  by  these  two  kinds  of 
pressure.  To  estimate  the  progression  of  heart  failure,  the  pulse 
pressure  seems  to  the  writer  to  be  essential. 

Thus,  one  is  led  to  consider  the  pulse  pressure  as  a  reflection 
or  sphygmomanometric  expression  of  cardiac  power.  Indeed, 
constitutionally  weak  individuals  with  congenitally  small  hearts 
show  a  low  pulse  pressure  (20  to  40  millimeters  Hg) ;  well  com- 
pensated cases  of  arteriosclerosis  with  **ox  hearts"  show  an 
enormously  high  pulse  pressure  (100  to  250  millimeters)  ;  cases 
of  heart  failure  with  low  pulse  pressure  generally  show  a  grad- 
ual gain  in  the  pulse  pressure  as  the  heart  recovers  its  func- 
tional power  and  the  output  of  urine  undergoes  a  corresponding 
increase,  etc. 

A  rather  absurd  objection  is  sometimes  made  to  this  rela- 
tionship of  the  pulse  pressure  to  cardiac  power,  which  at  least 
has  the  advantage  of  bringing  out  in  striking  fashion  the  impor- 
tance of  the  diastolic  pressure;  and,  strangely  enough,  this  objec- 
tion has  been  raised  by  the  very  persons  who  have  overlooked 
the  latter  variety  of  pressure.  Thus,  it  has  been  said  that  it  is 
absurd  to  believe  that  any  relationship  exists  between  the  pulse 
pressure  and  cardiac  power.  Take  two  individuals,  for  example : 
The  first  shows  160  millimeters  as  systolic,  90  as  diastolic,  and 
70  as  pulse  pressure,  and  is  in  a  satisfactory  state  of  circulatory 


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1048 


SYMPTOMS. 


balance;  the  second  shows  260  millimeters  as  systolic,  190  as 
diastolic,  and  again  70  as  pulse  pressure,  but  is  already  in  a  state 
of  complete  decompensation,  although  the  pulse  pressure  is  the 
same  in  the  two  cases.  Quite  so.  The  above  remark  is  of  exactly 
the  same  order  as  would  be  one  to  the  effect  that,  strangely 
enough,  a  mover  carried  a  trunk  from  the  ground  floor  to  the 
second  story  without  any  trouble  but  gave  out  in  going  from 


Blood  of  normal  viscosity 


Pulse  pressure  (p)  normal 
6 


Normal  daily  output  of 
urine,  H  =  1500  c.c. 
Hydruric  coefficient: 
H      1500 

—  = =  250<i.c. 

P  6 


Kidneys 


Urine  normal  =  1500  c.c. 
Fig.  755.— Normal  subject  (pulse  pressure  in  centimeters  of  mercury). 

the  sixth  to  the  seventh;  yet  he  was  carrying  the  same  trunk 
and  the  number  of  steps  to  be  climbed  was  the  same  in  both 
instances.  Precisely  so ;  but  the  man  had  been  exhausted  owing 
to  the  five  stories  already  climbed.  The  same  applies  to  the 
heart ;  in  order  to  climb  the  70  steps  from  190  to  260,  the  heart 
had  already  to  climb  the  190  steps  represented  by  the  diastolic 
pressure  and  was  exhausted;  on  the  other  hand,  the  heart  was 
quite  fresh  in  climbing  the  70  steps  from  90  to  160,  having  as 
yet  ascended  only  90.  Nothing,  it  would  seem,  could  show  more 
definitely  than  this  the  importance  of  the  diastolic  pressure. 


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HIGH  BLOOD-PRESSURE.  1049 

As  a  matter  of  fact — in  general  clinical  work — cases  of  high 
arterial  pressure  may  be  roughly  divided  into  the  four  following 
groups. 

1.  Plethoric  cases. 

2.  Nervous  (angiospastic)  cases. 

3.  Renal  (infected  and  poisoned)  cases. 

The  natural  ultimate  ending  in  these  three  groups  is  repre- 
sented in  the  last  group. 

4.  Arteriosclerotic  cases. 

The  first  three  categories  correspond  to  perfectly  distinct 
clinical  conditions,  of  different  pathogenesis,  and  consequently 
yield  definite  therapeutic  indications.  This  classification,  there- 
fore, serves  some  practical  purpose.  Yet,  in  truth,  these  several 
conditions  may  perfectly  well  occur  in  combination:  A  ple- 
thoric subject  (e.g.,  weighing  100  kilograms)  may,  in  addition, 
be  angiospastic  (abnormally  emotional)  and  harbor  infection 
(syphilis).  Under  these  circumstances  he  is  very  likely  to  travel 
a  precipitate  journey  along  the  road  leading  to  arteriorenal 
sclerosis  (arteriosclerosis),  this  constituting  the  natural  penulti- 
mate stage  in  chronic  high  arterial  pressure.  A  diagram  illus- 
trating the  course  followed  by  these  instances  of  cardiorenal 
sclerosis  is  presented  herewith.  It  will  be  noticed,  however,  that 
this  next  to  last,  almost  incurable  stage,  that  of  arteriosclerosis, 
is  preceded  by  a  long  period  of  functional  hypertension  (ple- 
thoric, angiospastic,  and  renal),  in  respect  of  which  we  are  pos- 
sessed, on  the  contrary,  of  very  efficient  remedial  means.  The 
differential  diagnosis  of  the  several  varieties  of  high  arterial 
tension  is  thus  by  no  means  merely  an  academic  procedure. 

I.— PLETHORA. 

The  term  plethora  actually  applies  to  a  very  clear-cut  and 
frequent  clinical  state.  It  is  not  employed  in  current  text-books 
on  internal  medicine  because  the  time-honored  list  of  diseases 
includes  scarcely  more  than  the  disorders  accompanied  by 
known  organic  lesions,  definite  humoral  disturbances,  or  dis- 
tinct symptom-groups. 

The  plethoric  subject,  indeed,  is  by  no  means  an  ill  person  in 
the  accepted  sense  of  the  word.     Apart  from  slight,  occasional 


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1050  SYMPTOMS. 

disturbances  such  as  skin  eruptions,  hemorrhoids,  etc.,  he  is  in 
a  flourishing  state  of  health  and  apparently  normal;  in  fact  he 
displays  an  excess  of  functional  activity  betokening  unusually 
intense  vitality.  He  consumes  large  amounts  of  food  and  his 
digestive  functions  are  admirably  performed — as,  indeed,  is  like- 
wise the  case  in  diabetic,  gouty,  or  obese  cases.  He  takes  in 
large  quantities  of  fluid  and  is  polyuric,  as  are  diabetic  and  gouty 

^         T^iooH  ftf  ^i^h  viscosity 
6 

ressure  (/>)  high 
10 

Increased  daily  out(>ut  of 
urine,  H  =  2300  c.c. 
Hydruric  coefficient: 
H      2300 

—  = =  230c.c. 

P         10 


^8 


\ 


Urine  increased :    2300  c.c. 
Fig.  756. — Plethoric  subject  (pulse  pressure  in  centimeters  of  mercury). 

patients.  His  complexion  is  ruddy  and  his  appearance  that  of 
robust  health.  Without  his  being,  properly  speaking,  an  obese 
individual,  his  weight  is  nevertheless  distinctly  above  normal, 
e.g.,  96  kilograms  (212  pounds)  as  against  a  height  of  187  centim- 
eters (6  feet  lyi  inches);  74  kilograms  (163  pounds)  as  against 
a  height  of  166  centimeters  (5  feet  5  inches),  etc.  He  has 
marked  endurance,  is  very  active,  and  the  aggregate  of  work  he 
performs  may  be  much  above  the  normal — as  in  many  gouty 
and  diabetic  cases. 


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HIGH  BLOOD'PRESSURE,  1051 

In  short,  without  being  at  all  ill,  one  might  almost  say  that 
the  plethoric  subject  is  a  supernormal  individual,  a  *'superman" 
from  the  physiological  standpoint.  The  heart,  unusually  power- 
ful, hypertrophied,  contracts  with  unusual  vigor,  this  being  re- 
flected in  a  heightened  pulse  pressure.  The  blood,  richer  and 
less  watery,  exhibits  a  higher  degree  of  viscosity.  The  kidneys, 
adapted  to  an  unusually  abundant  circulation  and  nutritive 
process,  eliminate  abnormally  large  amounts  of  water,  salt,  urea, 
uric  acid,  etc.  The  digestive  glands,  richly  supplied  with  blood, 
are  overactive  in  their  secretion,  with  resulting  polyphagia,  poly- 
dipsia, polyuria,  plethora,  etc. 

The  plethoric  is  thus  an  individual  who  is  not,  properly 
speaking,  abnormal,  but  supernormal,  featured  by  his  appear- 
ance of  flourishing  health,  his  body  weight  which  exceeds  the 
normal,  and  his  high  blood-pressure  and  viscosity. 

He  is,  however,  a  candidate  for  obesity,  diabetes,  or  gout,  of 
which  he  already  presents  many^  anatomical  and  functional 
manifestations.  He  is  a  candidate  for  sclerotic  vasculorenal  dis- 
orders. To  the  author's  mind,  it  is  precisely  a  great  feature  of 
superiority  of  the  sphygmo-visco-hydrurimetric  methods  that 
they  are  sufficiently  searching  to  disclose  the  morbid  tendencies 
long  before  any  established  and  recognized  pathological  change 
exists,  hence  enabling  the  physician  to  rectify  them  with  much 
greater  certainty. 

II.— NERVOUS  ANGIOSPASTIC  CASES. 

Everything  tends  to  show  that  this  condition  frequently  con- 
stitutes the  intermediate  stage  between  simple  plethora  and  car- 
diorenal  sclerosis — that  it  represents  in  part  what  Huchard  so 
appropriately  termed  the  stage  of  presclerosis. 

In  the  course  of  the  development  of  sclerosis,  starting  from 
the  simple  plethoric  subject,  the  present  stage,  that  of  prescle- 
rosis, might  be  said  to  come  5  years  after  the  onset,  and  that  of 
established,  irremediable  sclerosis  10  to  15  years  after  the  onset. 

At  times,  indeed,  one  is  enabled  to  contrast  the  two  clinical 
types  in  an  almost  perfect  manner.  Thus,  the  case  is  recalled  of 
a  man  of  31  years,  obese  and  suffering  from  lithiasis,  171  centim- 
eters (5  feet  7  inches)   tall  and  weighing  123  kilograms   (271 


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1052  SYMPTOMS. 

pounds),  florid  and  well  compensated,  with  a  pulse  rate  of  98, 
systolic  pressure  250,  diastolic  pressure  120,  and  viscosity  4.8; 
and  the  case  of  his  mother,  51  years  of  age,  of  the  degenerated 
obese  type,  160  centimeters  (5  feet  3  inches)  tall  and  weighing 
87  kilograms  (192  pounds),  an  established  case  of  sclerosis,  with 
nycturia,  albuminuria,  a  pulse  rate  of  120,  systolic  pressure  of 
280,  diastolic  pressure  160,  and  viscosity  4.1. 

One  of  the  characteristic  features  of  this  condition,  whether  as 
regards  the  pulse  rate,  the  systolio  and  pulse  pressures,  the  blood 
viscosity,  or  the  output  of  urine,  is  an  altogether  abnormal  instabil- 
ity or  variability  which  is  met  with  neither  in  the  preceding  stage — 
practically  normal  from  the  circulatory  standpoint — nor  in  the 
subsequent  stage  in  which  permanent  pathological  changes  have 
occurred. 

In  the  first  stage  balance  is  maintained  by  virtue  of  a  gen- 
eral, harmonious,  and  regular  functional  hypertrophy;  in  the 
third  stage,  the  system  has  adapted  itself,  either  well  or  badly, 
to  permanent  lesions  constituting  a  permanent  infirmity ;  it  con- 
tinues on  its  course,  limping  along  in  a  continuous,  even  man- 
ner, as  it  were. 

In  the  stage  of  the  disease  here  especially  under  discussion, 
however,  the  organism,  not  yet  permanently  altered,  is  not  re- 
signed to  its  fate  and  will  not  admit  itself  conquered.  It  strug- 
gles against  the  approaching  collapse  by  processes  of  compen- 
satory hypertrophy ;  but  at  times  the  functional  adaptation  be- 
comes insufficient,  there  is  functional  disorganization,  disordered 
reactions,  angiospasms,  and  various  forms  of  insufficiency  mani- 
fested in  the  form  of  paroxysmal  attacks  of  hydremia,  angina, 
myocardial  weakness,  etc.  Ordinarily,  under  the  mere  influence 
of  a  diet  instinctively  imposed  upon  himself  by  the  patient, 
everything  returns  to  normal.  But  the  transitory  attacks  of 
hydremia  with  diminished  *urinary  output,  high  blood-pressure, 
and  increased  blood  viscosity,  expressed  in  a  sudden,  marked 
rise  of  the  sphygmoviscosimetric  index  and  betokening  a  forcible 
reaction  on  the  part  of  the  heart  against  an  abrupt  vasculorenal 
block  due  to  angiospasm,  are  quite  significant  and  characteristic. 
They  constitute  the  last  cry  of  warning  at  the  entrance  to  the 
blind  defile  of  sclerotic  infiltration. 


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HIGH  BLOOD-PRESSURE,  1053 

The  outstanding  feature  of  this  stage  is  nervous  erethism, 
emotivity,  and  exaggerated  tendency  to  angiospasm  which,  in  pre- 
disposed subjects,  plays  an  important  role  in  the  pathogenesis  of 
arteriosclerosis,  as  Lancereaux,  Bouveret,  Potain,  and  Huchard 
clearly  saw  and  taught.  Some  cases  may  even  reach  ultimate  scle- 
rosis solely  by  the  angiospastic  route.  The  majority  reach  it,  how- 
ever, by  the  plethoric  route;  degeneration  is  promoted  by  angio- 
spasm and  infections. 

III.— RENAL  CASES.    NEPHRITIS. 

The  marked  influence  of  nephritis  (excepting  certain  rare  forms 
of  excessive  renal  permeability)  in  causing  high  blood-pressure 
is  an  obvious  clinical  fact,  whatever  explanation  of  it  be 
adopted.  Whether  the  nephritis  be  acute  or  chronic,  of  infec- 
tious or  toxic  origin,  it  is  nearly  always  associated  with  high 
blood-pressure,  which  is  slight  or  wanting  in  simple  albuminous 
nephritis,  moderate  in  chloridemic  forms,  constant  and  some- 
times very  marked  in  the  azotemic  and  hydremic  forms.  The 
last-mentioned  form,  indeed,  as  is  well  known,  was  long  termed 
hypertensive  nephritis,  high  blood-pressure  constituting  one 
of  the  cardinal  features  of  this  type  of  the  disease  (see 
Albuminuria). 

Whether  the  nephritis  be  the  result  of  a  metabolic  disorder 
such  as  gout,  or  of  some  form  of  poisoning  such  as  lead  poisoning, 
or  of  an  infectious  disease  such  as  scarlet  fever  or  typhoid  fever, 
high  blood-pressure  is  one  of  its  most  constant  symptomatic 
manifestations,  and  frequently,  indeed,  it  exhibits  distinct 
features  in  accordance  with  the  clinical  courses  of  these  several 
disorders. 

A  rational  classification  of  these  cases  is  afforded  by  system- 
atic study  of  the  renal  functions  (output  of  water,  chlorides, 
urea,  albumin,  etc.),  in  conjunction  with  blood-pressure  deter- 
minations. 

IV.— ARTERIOSCLEROSIS. 

Plethora,  angiospasm,  and  infection,  whether  they  do  or  do  not 
cause  preliminary  renal  changes,  and  whether  they  are  or  are  not 
present  in  combination,  in  the  long  run  induce  degeneration  of  the 


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1054 


SYMPTOMS. 


arteries  and  arteriorenal  sclerosis  or  arteriosclerosis.  In  the  pres- 
ence of  this  common  disorder,  continuous  elevation  of  blood-pres- 
sure being  the  rule,  the  equation  high  blood-pressure  =  arterio- 
sclerosis was  long  accredited,  though  this  is  manifestly  an  error, 
as  already  noted. 

The  practitioner  should  make  a  methodical  search  for: 

*  Blood  of  normal  or  low  viscosity 
3.8 
\  Pulse  pressure  (/>)  very  high 
18 

Daily  output  of  urine 
rather  highly  H  =  1800  c.c. 
Hydruric  coefficient: 
H      1800 

—  = =100  ex. 

p         18 


Kidneys 


Urine  output  rather  high :    1800  c.c. 
Fig.  757. — Subject  with  sclerotic  disease. 

Evidences  of  peripheral  fibrosis :  Tortuous  temporal  vessels,  in- 
duration of  the  radial,  brachial,  and  temporal  arteries,  intermittent 
claudication,  etc. 

Evidences  of  chronic  aortitis  and  cardiac  hypertrophy:  Accen- 
tuation of  the  second  aortic  sound,  gallop  rhythm,  and  enlargement 
of  the  area  of  heart  dulness. 

Ezndences  of  interstitial  nephritis:  Increased  output  of  urine  of 
low  specific  gravity,  low  urea  output  in  the  urine,  high  blood-pres- 
sure, slight  albuminuria,  reduction  of  the  hydruric  coefficient,  and 
hydremia  (lowered  blood  viscosity). 


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HIGH  BLOOD-PRESSURE,  1055 

One  should  bear  in  mind  the  frequent  occurrence  of  hemor- 
rhagic complications  such  as  epistaxis,  hemoptysis,  and  hema- 
temesis. 


^^■^•^^ 


Heart 

Fig.  758. — Successive  stages  in  the  development  of 
cardiorenal  sclerosis. 
/.  Normal. 

2,  Eusystoly. — Simple  plethora. — Good  cardiorenal  compensation. 
J.  Hypersphyxia. — Hydremia. — Renal  insufficiency. 

4.  Heart  weakness. — Hydremia  and  anoxemia. — Cardiorenal  insufficiency. 
Mx,  Systolic  blood -pressure. 
Mn.  Diastolic  blood-pressure. 
V.  Blood  Viscosity. 
H.  Daily  output  of  urine. 
— .  Hydruric  coefficient. 

The   main   diagnostic    features   of   these    disorders   will   be 
found  in  the  accompanying  table. 


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1056 


SYMPTOMS. 


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HIGH  BLOOD-PRESSURE. 


1057 


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HYPOCHONDRIUM,      \vn6,  below;  x^^^pog,  cartilage;^ 
LEFT,  PAIN  IN.  L  below  the  ribs.  J 


For  clinical  purposes  the  left  hypochondrium  consists,  as  its 
etymological  derivation  shows  and  without  any  need  of  further 
definition,  of  that  region  of  the  abdomen  which  is  situated  be- 
neath the  lower  and  anterior  margin  of  the  thoracic  cage  on  the 
left  side.     Painful  affections  of  the  fundus  of  the  stomach,  the 

5" 


P 
D 

9 
R 

Ipc 
cd 

e 

ac 


Fig.  759. — The  splenic  fossa. 

FS,  Splenic  fossa.  E.  Stomach  retracted  to  the  right.  R,  Upper  end 
of  right  kidney,  with  the  adrenal  gland  within.  P.  Section  of  tail  of  pan- 
creas, or.  Splenic  flexure  drawn  down.  cd.  First  part,  e.  Omentum  of 
descending  colon.  Ipc.  Phrenocolic  ligament,  g.  Sulcus  formed  between 
the  kidney  and  costal  wall.  D.  Diaphragm,  p.  Thoraco-abdominal  wall. 
S.  Sternum  (Picon,  after  Constantinesco,  in  Poirier  and  Charpy), 

spleen,  the  left  kidney,  and  the  splenic  flexure  of  the  colon  are 
the  chief  disorders  which  find  clinical  expression  in  this  region. 

Clinical  Description. — Nine-tenths  of  all  instances  of  pain  in 
the  left  hypochondriac  region,  coincidently  with  pains  in  the  lower 
(infracardiac)  thoracic  region  on  the  left  side,  are  of  gastric  origin 
and  are  symptomatic  of  gaseous  distention  of  the  fundus  of  the 
stomach,  i.e.,  of  flatulence,  meteorism,  and  aerophagia.  Percussion 
leads  to  the  discovery  of  a  pronounced  extension  of  Traube's  space, 
(1058) 


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HYPOCHONDRIUM,  LEFT,  PAIN  IN.  1059 

frequently  coupled  with  a  tympanitic  note.  The  patient,  in  addition 
to  experiencing  pain  in  the  hypochondrium  and  left  side  of  the  chest, 
generally  complains  of  heart  disturbances,  such  as  palpitations, 
dyspnea,  and  even  "missed  beats"  or  extrasystoles,  especially  when 
lying  on  the  left  side;  he  states  that  he  is  frequently  relieved  by 
eructations ;  not  rarely,  while  he  is  talking,  he  may  be  caught  in  the 
very  act  of  swallowing  air ;  conscious  or  unconscious  sialorrhea  is  an 
almost  constant  accompaniment.     These  patients  actually  consult 


8th  rib 

Spleen 

Adren 

PlBsure  of  lung 

Lower    border 
Qaatric  of  lung 

SplenI 


Colon 


Pleural    cul-de- 
sac 


Fig.  760. — Topographic  features  of  the  spleen.    Projection  of  the  spleen 
on  the  costal  wall  (Picou,  in  Poirier  and  Charpy). 

the  physician  on  account  of  heart  disturbances  such  as  palpitations, 
precordial  pains,,  "missed  beats,"  angor,  dyspnea,  etc.,  much  oftener 
than  they  do  on  account  of  the  hypochondriac  discomfort,  thus 
justifying  the  old  clinical  aphorism:  "When  a  patient  complains  of 
his  heart,  there  are*  9  chances  out  of  10  of  his  being  a  neurotic  dys- 
peptic." Many  instances  of  pseudoangina  pectoris  arise  solely  from 
this  cause.  Gaseous  distention  of  the  stomach,  having  once  been 
detected,  its  cause  remains  to  be  discovered,  whether  it  be  a  gastric 
neurosis,  gastric  hyperacthnty,  chronic  intestinal  disease,  or  even 
cholelithiasis  or  appendicitis,  without  forgetting  the  most  frequent 
cause  of  all,  vis,,  aerophagia. 


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1060  SYMPTOMS. 

Frequency. — In  the  order  of  frequency,  surgical  affections  of 
the  left  kidney — nephrolithiasis,  pyo-  and  hydro-  nephrosis,  peri- 
nephric abscess,  tuberculosis  of  the  kidney,  or  neoplasm— come 
next  to  the  gastric  disturbances.  Certain  details  concerning  the 
pain  of  renal  involvement  are  presented  in  the  section  on  the 


Ti 


Fig.  761. — Sagittal  section  through  the  left  hypochondrium,  passing  in 
the  middle  of  the  space  between  the  parasternal  and  nipple  lines,  in  a 
subject  with  marked  dilatation  of  the  stomach  (Luschka), 

right  hypochondrium  (q.v.).  Pain  on  pressure  is  usually  most 
marked  in  the  lumbaf  region;  it  radiates  along  the  left  ureter, 
over  the  iliac  fossa,  and  even  to  the  testicle.  Bimanual  palpation 
may  sometimes  reveal  the  presence  of  a)  tumor  of  the  kidney; 
finally,  examination  of  the  urine  in  some  instances  leads  directly 


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HVPOCHONDRIUM,  LEFT,  PAIN  IN.  1061 

to  the  diagnosis.  Detection  of  perinephric  abscess  frequently 
demands  considerable  clinical  sagacity,  and  the  author  cannot 
escape  the  recollection  of  a  disastrous  case  of  perinephric  abscess 
coming  on  insidiously  in  a  pregnant  woman  and  gradually  mani- 
fested in  persistent  pain  in  the  left  hypochondrium  and  lower 
intercostal  spaces,  with  fever  and  tenderness  in  the  left  lumbar 


Spleen 
Right  adr«  Left  adrenal 

Tail  of 
pancreas 
Duodenum*' 


TrauBTerse 

colon** 


Deacendlng 


Descending 
colon 


Right  \ 


E  artery 

artery 


Fig.  762. — Deep-lying  structures  in  the  right  and  left  hypochondria. 

region,  then  in  an  alarming  symptom-group  of  peritonitis,  with- 
out renal  evidences  being  apparent  at  the  time,  and  which,  al- 
though suspected  to  be  of  renal  or  perirenal  origin  by  the  first 
three  physicians  called,  was  wholly  overlooked  by  two  eminent 
consultants,  who  diagnosticated*  a|>pendicitis  and  subsequently 
failed  to  be  enlightened,  after  a  fruitless  appendectomy,  by  a 
pyemic  state  of  daily  increasing  gravity  and  even  a  copious  dis- 
charge of  pus  from  the  urinary  tract.  This  was  one  of  the  most 
trying  episodes  of  the  author's  entire  medical  career,  and  one 
which  he  is  unable  to  recall  without  a  feeling  of  bitterness. 


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1062  SYMPTOMS, 

Pride,  conceit,  and  absurd  pretentions  to  a  species  of  infallibility 
may  lead  physicians  to  really  criminal  acts. 

Although  relatively  common,  the  disorders  most  specifically 
attaching  to  the  left  hypochondrium  are  the  affections  of  the 
spleen.  All  splenic  enlargements,  whether  due  to  leukemia, 
anemia,  malaria,  syphilis,  or  polycythemia,  and  whether  or  not 
associated  with  hepatic  cirrhosis  or  heart  weakness,  are  accom- 
panied by  a  varying  degree  of  painful  tension  in  the  left  hypo- 
chondrium. Enlargement  of  the  spleen  having  been  noted,  there 
remains  to  be  made,  by  means  of  the  customary  methods  of 
examination  (history,  blood  examination,  liver  examination, 
uranalysis,  Wassermann  reaction,  etc.),  a  diagnosis  of  leukemia, 
malaria,  syphilis,  cirrhosis,  heart  failure,  etc. 

Subdiaphragmatic  abscess  on  the  left  side  appears  to  warrant 
a  somewhat  extensive  consideration  in  view  of  the  fact  that  little 
attention  is  generally  paid  to  it  and  because,  although  uncom- 
mon, it  is  much  less  rare  than  one  might  suppose,  the  author 
having  personally  observed  a  dozen  cases,  aside  from  others  that 
may  have  been  overlooked.* 

There  are  two  anatomic  varieties  of  subdiaphragmatic  abscess 
which  may  give  rise  to  signs  and,  in  particular,  to  pain  in  the  left 
hypochondrium.    These  are : 

1.  More  often,  abscesses  of  the  perisplenic  fossa  (or  gastro- 
splenic  fossa  of  Dieulafoy),  bounded  above  by  the  diaphragm 
and  the  left  extremity  of  the  left  lobe  of  the  liver,  within  by  the 
fundus  of  the  stomach  and  the  pancreas,  posteriorly  by  the  dia- 
phragm and  kidney,  anteriorly  by  the  diaphragm  and  the  omen- 
tum, externally  by  the  diaphragm  and  ribs,  and  below  by  the 
splenic  flexure  and  the  left  mesocolic  fold. 

Abscesses  collecting  in  this  locality  are  secondary  either  to 
abscesses  of  the  spleen  (infarct,  malaria)  or  to  a  perforation  of  the 
stomach  situated  -near  the  cardia  or  on  the  posterior  wall  of  the 
fundus. 

In  these  cases  the  pain  is  located  deeply  in  the  left  hypochon- 
drium, the  mass  formed  shows  little  tendency  to  encroach  on 
the  epigastrium,  pronounced  enlargement  of  splenic  dulness  is 


1  See  also  Martinet :    "Des  varietes  anatomiques  d'abces  sous-phr6niques," 
Paris,  1898. 


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HVPOCHONDRIUM,  LEFT,  PAIN  IN.  1063 

noted  and  left-sided  pleurisy  is  almost  constantly  present;  fre- 
quently, beneath  the  false  ribs  of  the  left  side,  there  is  an  actual 
cake-like  condition  about  the  spleen. 

2.  Less  commonly,  there  occur  abscesses  of  the  left  inter- 
hepato-diaphragmatic  fossa,  bounded  on  the  right  by  the  sus- 
pensory ligament,  posteriorly  by  the  triangular  ligament,  below  by 
the  upper  surface  of  the  left  lobe  of  the  liver  and  part  of  the 
anterior  aspect  of  the  stomach,  above  and  to  the  left  by  the  dia- 
phragm, anteriorly  by  adventitious  adhesions  between  the  dia- 
phragm and  the  anterior  root  of  the  left  lobe  and  by  a  varying 
portion  of  the  anterior  abdominal  wall. 


Fig.  763.-.-Arab  children  of  Algeria  with  malarial  enlargement  of  the 
spleen.    The  cross  +  shows  the  position  of  the  umbilicus   (Brumpt). 

The  cause  of  this  type  of  abscess  is  invariably  a  perforation 
of  the  anterior  wall  of  the  stomach. 

In  this  variety  the  initial  pain  is  predominantly  situated  on 
the  left  and  sometimes  radiates  toward  the  left  shoulder;  con- 
vexity is  especially  pronounced  on  the  left;  Traube's  space  is 
always  modified ;  frequently  there  are  signs  of  left-sided  pleurisy, 
displacement  of  the  heart-apex  upward  and  inward,  formation 
of  a  mass  below  the  ribs  on  the  left  side,  and  immobilization  of 
the  left  side  of  the  chest. 

The  splenic  flexure  of  the  colon,  forming,  as  is  well  known, 
an  extremely  acute  angle,  is  one  of  the  "critical"  points  of  the 
intestine,  and  is  one  of  the  commonest  sites  of  intestinal  tumors. 
Indeed,  a  neoplasm  of  the  splenic  flexure  frequently  causes  no 
local  pain;  careful  deep  palpation  of  the  left  hypochondrium 


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1064  SYMPTOMS. 

may,  however,  yield  significant  information  which,  when  corre- 
lated with  a  more  or  less  pronounced  symptom-group  of  obstruc- 
tion, may  lead  to  the  diagnosis  of  tumor,  to  be  subsequently  con- 


Fig.  764. — Left-sided   abscess  be-  Fig.  765. — Perisplenic  abscess.  Ab- 

tween  the  liver  and  diaphragm.    Per-      scess  of  the  spleen :    Infarction,  raal- 
f orated  stomach,  due  to  gastric  ulcer,      aria,  gastric  perforation. 


Fig.  766. — Post-gastric  abscess.  Fig.  767. — Abscess  between  the  liver 

and  stomach. 

firmed  by  testing  of  the  stools  for  blood  and  fluoroscopy  follow- 
ing a  bismuth  meal. 

There  is  one  symptom-group,  however,  which  has  not  yet 
been  adequately  described:  Chronic  pain  in  the  left  hypochon- 
drium  with  periodic  exacerbations,  apparently  the  result  of 
gaseous  accumulation  at  the  splenic  flexure  and  of  defective 


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HVPOCHONDRIUM,  LEFT,  PAIN  IN. 


1065 


transit  through  the  large  intestine  owing  to  excessive  angula- 
tion of  the  splenic  colon — a  condition  admirably  demonstrated 
by  fluoroscopic  examination. 

The  possible  occurrence  of  pain  in  the  left  hypochondrium  in 
cases  of  pneumonia  involving  the  left  lobe  or  of  pleurisy  lends  itself 
to  the  same  observations  as  are  made  in  the  section  on  the  right 
h)rpochondrium  (q^v.). 

♦    ♦     ♦ 

As  a  suggestive  instance  of  the  disturbances — sometimes  ap- 
parently very  serious — that  may  be  brought  on  by  the  accumula- 
tion of  air  and  gases  in  the  fundus  of  the  stomach,  with  the  re- 
sulting pressure  on  the  left  side  of  the  diaphragm  and  displace- 
ment and  distortion  of  the  heart  and  aorta,  the  follgwing  data  per- 
taining to  a  case  of  this  type  may  be  here  presented : 


Case  3596. 


Fig.  768. 


Man,  1862, 


171  < 


— ;  76  kilograms. 


Pressures : 


Pulse  press.,  100. 


27  cm. 

230 

125- 

Marked  anginoid  syndrome,  espe- 
cially pronounced  on  walking  and 
after  meals.  During  attacks,  the 
patient  is  "rooted  to  the  spot"  and 
unable  to  move.  The  stomach  shows 
a  very  large  air  bubble  and  there  is 
meteorism  with  marked  pressure  dis- 
placement of  the  heart  and  distor- 
tion of  the  aorta. 


Case  3596. 


Same  patient  three  weeks  later, 
after  treatment.  Weight,  74.8  kilo- 
grams. 

IGO 

Pressures :    j^  .    Pulse  press.,  60. 

All  anginoid  manifestations  have 
disappeared.  Locomotion  and  mod- 
erate outdoor  sports  resumed.  Met- 
eorism has  disappeared  and  the  gas- 
tric air  bubble  is  markedly  reduced. 
The  heart  and  aorta  are  restored  to 
their  normal  shape  and  position. 


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1066 


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HYPOCHONDRIUM,  LEFT,  PAIN  IN. 


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HYPOCHONDRIUM,  RIGHT,  PAIN  IN. 


The  right  hypochondrium  normally  corresponds  to  the  lower 
border  and  anterior  surface  of  the  liver  in  its  entire  extent.  As  a 
matter  of  fact,  four-fifths  of  all  pain  disturbances  in  this  region 
originate  in  the  liver  or  gall-bladder;  yet  by  no  means  all  pains  in 
the  hypochondrium  originate  in  these  structures. 


A  brief  review  of  the  regional  anatomy  will  suggest  the  various 
possibilities  in  the  interpretation  of  pain  in  this  area. 

The  right  hypochondrium  is  in  its  entirety  in  relationship  with 
the  anterior  surface  and  lower  border  of  the  liver,  including,  in  its 
middle  portion,  the  fundus  of  the  gall-bladder.  Disorders  of  the 
liver  and  other  biliary  structures  constitute  the  chief  pain-producing 
agencies  in  the  right  hypochondriac  region.  Acute,  paroxysmal 
pains  of  the  type  of  colic  are  especially  characteristic  of  cholelithir- 
asis,  simple  or  with  complications.  It  should  not  be  overlooked, 
however,  that  frequently  this  disorder  is — like  chronic  appendicitis 
— spontaneously  manifested  only  in  what  appear  to  be  ordinary 
dyspeptic  disturbances  or  in  a  pyloric  symptom-group  with  tend- 
ency to  stasis  and  dilatation  in  the  presence  of  adhesions  uniting 
the  gall-bladder  and  duodenum.  Jaundice  occurs  in  about  one: 
fourth  of  all  cases  of  cholelithiasis.  Only  in  exceptional  instances 
(1  out  of  20)  will  palpation!  not  induce  a  characteristic  pain  at  the 
fundus  of  the  gall-bladder  for  a  more  or  less  prolonged  period  of 
time  during  the  intervals  between  the  acute  attacks. 

Pain  of  hepatic  origin  is  generally  of  a  duller  type,  and  is  some- 
times only  brought  out  by  palpation  or  percussion.  Pain  has  to 
be  actually  examined  for  in  these  cases.  Sometimes  it  is  latent; 
active  or  passive  congestion  of  the  liver  is  by  far  the  commonest  of 
the  disorders  of  this  organ  inducing  sensitiveness;  it  accompanies, 
precedes,  or  heralds  the  oncoming  of  the  majority  of  instances  of 
(1068) 


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HYPOCHONDRIUM,  RIGHT,  PAIN  IN.  1069 

hepatic  cirrhosis.    As  is  well  known,  it  is  one  of  the  most  constant 
symptoms  of  heart  weakness  or  heart  failure. 

Lastly,  one  should  always  bear  in  mind  the  possibility  of  syph- 
ilis of  the  liver,  a  fairly  common  but  generally  rather  painless  con- 
dition  (enlarged  syphilitic  liver,  pseudocancerous  form,  syphilitic 


a  — . 


^/.-.. 


Fig.  769. — Anatomic  relations  of  the  liver  with  the  walls  of  the  chest 
and  abdomen  (Laederich),  a.  Projected  outline  of  the  upper  border  of 
the  liver,  b.  Lower  border  of  the  lung.  c.  Pleural  cul-de-sac.  d.  Gall- 
bladder. 

lobulated  liver,  lobed  liver,  or  syphilitic  cirrhosis)  ;  of  hepatic  abscess 
(history  of  malaria,  fever,  jaundice,  pain,  etc.),  and  of  cancer,  for- 
tunately much  more  uncommon  ("galloping"  enlargement  of  the 
liver  with  marked  emaciation  and  rapid  cachexia).  In  all  these 
cases,  it  is  not  the  character  of  the  pain  but  the  associated  signs  and 
symptoms  and  the  clinical  course  which  constitute  the  basis  of  the 


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1070  SYMPTOMS, 

diagnostic  conclusion — as  will  be  seen  in  the  tabular  summary  at  the 
end  of  this  section. 

Immediately  behind  the  liver  are  situated  the  angle  formed  by 
the  ascending  and  the  transverse  colon  (hepatic  flexure)  and  the 
first  flexure  of  the  duodenum,  to  which,  furthermore,  the  gall-blad- 
der so  frequently  becomes  adherent  in  the  event  of  pericholecystitis. 
A  corollary  of  this  is  that  pain  in  the  right  hypochondrium  may 
be  symptomatic  of  a  precolic  or  retrocolic  high  appendicitis,  and 
the  incipient  jaundice  frequently  present  in  these  cases  may  still 
further  augment  the  difficulty  of  diagnosis.  Indeed,  the  author  has 
seen  the  two  following  mistakes  committed,  viz,,  a  cholecystitis  with 
prolapse  mistaken  for  an  appendicitis  and  a  high  appendicitis 
mistaken  for  cholecystitis.  ,  Appendicitis  may,  as  a  matter  of  fact, 
be  the  starting-point  of  subhepatic  abscess.  Ordinarily,  and  apart 
from  the  particularly  acute  emergencies  in  which  incipient  or  estab- 
lished peritonitis  prevents  all  precise  localization,  palpation  will  en- 
able the  practitioner  to  elicit  an  especial  localization  of  the  disturb- 
ance in  the  right  iliac  fossa. 

As  for  duodenal  ulcer  (see  Dyspepsia)  the  particular  type  of 
the  pain,  coming  on  spontaneously  and  periodically  with  a  uniform 
relationship  to  meals,  the  symptom-group  of  hyperchlorhydric  in- 
digestion which  usually  accompanies  it,  and  the  lower  position  of 
the  tenderness  elicited  by  palpation  between  the  right  hypochon- 
drium and  the  umbilicus  will  frequently  permit  of  an  easy  diagnosis, 
sometimes  definitely  confirmed  by  the  advent  of  hematemesis.  The 
chief  condition  to  be  differentiated  from  duodenal  ulcer  is  chole- 
lithiasis. 

Behind  the  lower  surface  of  the  liver,  the  hepatic  flexure  and 
the  duodenum  is  the  right  kidney,  many  disorders  of  which  may  be 
manifested  in  pain  in  the  right  hypochondrium.  Especial  mention 
should  be  made  of  nephrolithiasis  and  of  kidney  suppurations  (pyo- 
nephrosis) or  perirenal  abscess.  Aside  from  the  paroxysmal  attacks 
of  renal  colic,  in  the  presence  of  which  brief  hesitation  may  occur 
in  the  diflFerentiation  from  hepatic  colic  by  reason  of  the  practical 
impossibility  of  making  an,  examination  on  account  of  the  severe 
pain,  cholelithiasis  is  readily  differentiated  by  the  fact  that  the  pain 
or  tenderness  is  most  marked  in  the  lumbar  region,  by  the  radiation 
of  the  pain  along  the  ureters  and  to  the  testicles,  by  the  urinary 


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FMg.  770.— Alcoholic  hyper-       Pig.  771.— Alcoholic  atrophic  Fig.  772.— Bantl's  disease: 

trophic    cirrhosis    with    as-  cirrhosis  with  ascites.  Greatly      enlarged      spleen, 

cites.  atrophic   cirrhosis,   and   as- 

cites. 


Pig.    773.— Hepatoptosis.  Fig.      774.— Biliary      clr-  Pig.      775.— Biliary      cir- 

Movable  lobe.  rhosis  with  greatly  enlarged       rhosis    with    enlarged    liver 

spleen.  and  spleen. 


Pig.    776.— Hydatid    cyst    of  Fig.  777.— Nodular  cancer  Fig.  778.— Cancer  of  head 

the  liver  (left  lobe).  of  the  liver.  of    pancreas.     Dilated   gall- 

bladder. 

(1071) 


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1072  SYMPTOMS. 


manifestations,  and  sometimes  by  the  detection  of  gravel  in  the 
urine.  Similar  considerations  apply  in  thd  case  of  pyonephrosis  or 
perirenal  abscess,  although  in  the  latter  instance,  if  the  abscess 
points — as  is  seldom  the  case — below  the  liver,  the  diagnosis  may  be 
very  difficult;  differentiation  is,  however,  of  capital  importance, 
since  the  institution  of  proper  operative  treatment,  viz,,  lumbar  in- 


Fig.  7^9. — Relations  of  the  abdominal  organs,  viewed  anteriorly. 

cision  or  subhepatic  celiotomy,  depends  upon  the  decision  reached. 
To  be  particularly  borne  in  mind,  in  order  that  they  may  be  excluded, 
if  possible,  by  careful  clinical  study,  are  pericholecystitis,  subhepatic 
abscess  of  appendicular  origin,  and  subdiaphragmatic  abscess. 

All  the  above  mentioned  disorders,  capable  of  causing  pain  in 
the  right  hypochondrium  as  an  important  or  predominant  clinical 
manifestation  are  of  abdominal  origin,  being  hepaticobiliary,  colo- 
duodenal,  or  renal.  Two  thoracic  disorders,  right-sided  pleurisy  and 
right-sided  pneumonia,  may  also  give  rise  to  pain  in  this  locality. 


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HYPOCHONDRIUM,  RIGHT,  PAIN  IN.  1073 


Fig.  780. — Kink  at  the  first  flexure  of  the  duodenum  due  to  a  nephro- 
ptosis of  the  third  degree.  Pronounced  dilatation  of  the  first  part  of  the 
duodenum. ,  Hydronephrosis  has  been  produced  owing  to  multiple  kinks 
of  the  ureter.  The  patient  had  been  admitted  to  Prof.  Terrier's  service 
with  symptoms  suggesting  intestinal  obstruction.  She  died  in  a  few  days 
without  having  been  operated,  and  at  the  autopsy  the  only  lesions  found 
were  those  here  illustrated :  /  p.d.,  first  portion  of  the  duodenum,  greatly 
dilated  above  its  flexure,  r.    Note  the  adhesions  ad,  c,d. 


Fig.  781. — Diagram  showing  the  normal  relations  of  the  right  kidney 
with  the  hepatic  flexure  and  duodenum.  The  lower  pole  of  the  kidney 
is  generally  situated  behind  the  hepatic  flexure.  Exceptionally,  this 
flexure  lies  below  the  kidney  (Alglave). 


68 


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1074  SYMPTOMS. 

In  pneumonia,  such  a  location  of  the  pain  is  the  rule  in  involvement 
of  the  lower  lobe,  and  at  times  of  the  middle  lobe  of  the  right  lung, 
particularly  in  children.  In  these  cases,  indeed,  pain  in  the  right 
hypochondrium  is  actually  of  threefold  origin : 

Cutaneous,  or  pain  attending  a  superficial  hyperesthesia  (Head's 
hyperesthetic  projection  zone). 

Hepatic,  or  a  deep  seated  pain  due  to  the  active  congestion  of  the 
liver  attending  infection. 

Diaphragmatic,  or  pain  due  to  an  inflammatory  pleural  reaction. 

Lung 

Pleural  cul-de-sac 
P*®"'**^  Coronary  ligament 

ht  kldpey 


Trans' 


Fig.  782. — Anteroposterior  section  of  the  liver  (Charpy).    The 
section  passes  through  the  right  hypochondrium. 

Excepting  in  children,  the  diagnosis  is  very  seldom  held  in  sus- 
pense for  a  long  time  in  pneumonia.  The  same  is  true  of  pleurisy, 
except  in  diaphragmatic  pleurisy,  in  which  the  diagnosis  is  often 
difficult. 

Lastly,  mention  should  be  made  of  a  variety  of  subdiaphragmatic 
abscess  located  in  the  right  hypochondrium,  in  the  right  interhepato- 
diaphragmatic  fossa,  and  bounded  above  by  the  diaphragm,  to 
the  left  by  the  falciform  ligament  and  gastrohepatic  omentum, 
and  below  by  the  right  half  of  the  transverse  colon  and  a  double 
transverse  fold  of  peritoneum  extending  from  the  lower  portion  of 
the  ascending  colon  to  the  abdominal  wall  slightly  below  the  tip 
of  the  eleventh  rib.    This  is  one  of  the  commonest  varieties  of 


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HYPOCHONDRIUM,  RIGHT,  PAIN  IN,  1075 

subdiaphragmatic   abscess.     In   the   course  of   a   study   of  the 
several    varieties   of    subdiaphragmatic    abscess,    made   by    the 


Fig.  783. — Verticotransverse  diagrammatic  section  passing  through  the 
gall-bladder.  The  fundus  of  the  latter  exhibits  a  perforation.  Below, 
adhesions  are  shutting  off  the  peritoneal  cavity.  An  outpouring  of  bile 
has  occurred  and  the  resulting  abscess  developed  between  the  diaphragm 
and  the  liver,  which  is  pushed  downward.  (Right-sided  inter-hepato- 
diaphragmatic  abscess). 


Fig.  784. — Right-sided  abscess  between  the  diaphragm  and  liver. 

author  a  number*  of  years  ago,  this  variety  was  found  to  have 
existed  in  60  out  of  146  cases.     Such  abscesses  are  sometimes 


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rdera  of  the  liTer 
gall-bladder 


( Pleurtsy 
( Pneumonia 

al  diaordera 


PneumonI 

PleurlB  ,„ 

j  Hyperemia 
Subdiaphra«m(  IverK  Syphilia 

abscera  I  Cancer 

all-bladder.  Stone 

:omach     f  rjice- 
Stone)  uodenuml*^ 

Abscess  >l 
Pyonephrosis) 

ppendiclUa 


Figs.  785  and  786. — Points  of  tenderness  in  the  right  hypochondrium,  with 
their  respective  causes  and  modes  of  radiation. 
(1076) 


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HYPOCHONDRIUM,  RIGHT,  PAIN  IN.  1077 

secondary  to  a  disturbance  of  the  liver,  such  as  cholelithiasis  or 
abscess  or  suppurative  hydatid  cystic  disease  of  the  right  lobe, 
or  may  follow  perforation  of  a  duodenal  ulcer. 

The  diagnosis  is  based  on  the  initial  pain,  most  marked  in 
the    right    hypochondrium    and    frequently    radiating   toward    the 


Fig;.  787. — Evacuation  of  a  subdiaphragmatic  abscess  (i)  of  appendic- 
eal origin  through  the  chest  wall  below  the  pleura.  /.  Colon.  2.  Liver, 
displaced  downward  and  inward    4.  Right  lung  (Kelly). 

right  shoulder;  on  the  epigastric  prominence,  extending  mainly 
toward  the  right  side ;  on  the  enlarged  area  of  hepatic  dulness, 
or,  on  the  other  hand,  in  tlie  case  of  gaseous  abscesses,  on  the 
percussion  note  over  the  liver  and  the  lowered  position  of  this 
organ,  the  complete  or  incomplete  immobilization  of  the  right 
half  of  the  thorax,  and  the  frequent  association  with  a  right- 
sided  pleurisy  or  even  a  phrenic  neuralgia  on  that  side.     The 


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1078  SYMPTOMS. 

causal  diagnosis  should  be  based  mainly  on  the  history  of  the 

case. 

Finally,  three  rarer  conditions  may  be  referred  to: 

(a)  An  exceptional  localization  of  herpes  zoster,  revealed  by 


Fig.  788. — Incision  of  a  subdiaphragmatic  abscess  of  appendiceal  origin 
in  the  9th  right  costal  interspace  (Berard). 

direct  inspection  of  the  painful  area — a  procedure  indicated  in  all 
regions  of  the  body. 

(fc)  A  special  localization  of  the  "girdle  pain"  of  tabetic  origin, 
mere  recollection  of  the  possibility  of  which  is  sufficient,  but  which 
should  always  be  thought  of  in  the  presence  of  pain  in  the  right 
or  left  hypochondrium  or  the  epigastrium,  and  which  systematic 
examination  of  the  reflexes  and  station — always  a  necessary  pro- 
cedu/re — is  sufficient  to  establish. 


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HYPOCHONDRIUM,  RIGHT,  PAIN  IN.  1079 

(c)  Hydatid  cyst  of  the  liver  is  usually  painless,  even  where  it 
reaches  a  considerable  size.  In  exceptional  instances  it  may,  how- 
ever, give  rise  to  attacks  of  pain  suggesting  gall-stones.  The  cause 
of  these  attacks  is  by  no  means  clear ;  possibly  a  reflex  contraction 


Fig.  789. — Cavities  that  may  be  occupied  by  pus  in  peritonitis :  /.  In- 
framesenteric  space.  2.  Pelvic  cavity.  3.  Supramesenteric  space.  4- 
Right  paracolic  space.  5.  Interhepatocolic  space.  6.  Right  and  8,  left 
subdiaphragmatic  spaces,  the  latter  separated  from  the  preceding  by  the 
falciform  ligament  (7).    9.  Left  paracolic  space. 

of  the  biliary  passages  occurs,  constituting  a  species  of  painful 
biliospasm  (ChauflFard)  ;  or,  more  probably,  there  is  obstruction  of 
the  common  bile  duct  by  vesicles  or  membranes  set  free  from  an 
hydatid  cystic  disease  of  the  liver  that  has  opened  into  the  bile 
passages  (Dene). 


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1080  SYMPTOMS. 

Diagnosis  of  hydatid  cyst  simulating  gall-stones  (hydatid 
hepatic  colic)  is  a  matter  of  great  difficulty  and  sometimes  quite 
impossible  where  the  clinical  signs  of  cyst  are  wanting. 


Courvoisier,  in  1890,  in  his  monograph  on  "The  Pathology  and 
Surgery  of  the  Biliary  Passages,"  enunciated  the  following  law: 
'7n  obstruction  of  the  common  bile  duct  by  a  stone,  dilatation  of  the 
gall-bladder  is  exceptional;  under  these  circumstances  the  gall-blad- 
der is  t^ually  contracted.  In  obstruction  of  the  duct  due  to  any 
other  cause,  dilatation  of  the  gall-bladder  is  the  rule."  This  law 
was  confirmed  but  slightly  modified  by  Terrier,  who  wrote:  '7n 
cases  of  occlusion  of  the  common  bile  duct  of  internal  causation, 
the  gall-bladder  is  ordinarily  shrunken,  whereas  dilatation  of  the 
gall-bladder  is  the  rule  when  occlusion  of  the  biliary  passages  is  of 
external  causation." 

Krahenbiihl,  of  Bale,  in  turn,  corrects  the  law  in  the  following 
manner:  "In  cases  of  gall-bladder  enlargement  of  long  standing, 
the  occlusion  of  the  common  bile  duct  is  ordinarily  of  neoplastic 
nature;  where  gall-bladder  enlargement  is  wanting  or  but  temporary, 
occlusion  of  the  duct  is  usually  due  to  stone." 

Statistical  records  confirm  the  frequency  of  stones  in  cancer 
OF  THE  GALL-BLADDER.  Out  of  41  cases  of  cancer  of  the  gall-blad- 
der the  presence  of  stones  was  found  mentioned  in  36  instances,  or 
89  per  cent. ;  in  4  other  cases,  stones  were  not  referred  to,  and  in  a 
fifth  case,  the  patient  is  said  to  have  previously  passed  calculi  with 
his  stools. 

The  relatively  frequent  coexistence  of  lithiasis  and  cancer  of  the 
gall-bladder  naturally  suggests,  as  J.  Dumont  states,  the  thought  of 
a  possible  etiologic  relationship  between  the  two  diseases.  Is  chole- 
lithiasis the  cause  of  cancer  or  merely  a  consequence  of  it  ?  A  fact 
justifying  the  belief  that  cholelithiasis  precedes  the  cancer  and  con- 
stitutes one  of  its  predisposing  causes  (irritation  theory)  is  that  in 
the  overwhelming  majority  of  cases  (37  out  of  41),  the  patients  had 
been  suflFering  for  a  long  time,  in  some  instances  for  decades,  from 
hepatic  colic.  (It  may  be  added,  to  complement  the  above  data  re- 
lating to  cancer  of  the  gall-bladder,  that  jaundice  was  present  in  63 
per  cent,  of  the  cases  and  that  cancer  occurred  oftenest  between  the 


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HYFOCHONDRIUM,  RIGHT,  PAIN  IN.  IQgl 

ages  of  sixty  and  sixty-five  and  5  times  oftener  in  women  than  in 
men).  The  pathogenetic  role  of  cholelithiasis  in  cancer  of  the  gall- 
bladder is  supported  by  the  fact  that  the  latter  seems  to  be  getting 
more  uncommon  since  operations  for  cholelithiasis  have  been  per- 
formed oftener  and  earlier  in  the  disease.  Thus,  between  1890  and 
1900,  140  operations  for  gall-stones  revealed  17  instances  of  cancer 
of  the  gall-bladder  (12  per  cent.);  from  1901  to  1910,  ;197  opera- 
tions brought  to  light  16  cancers  (8  per  cent.),  and  from  1911  to 
1919,  151  cases  yielded  only  9  cancers  (6  per  cent). 


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1082 


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IIVPOCHONDRIUM,   RIGHT,   PAIN   IN. 


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ILIAC  FOSSA,  LEFT,     [Ilia,  the  flanks;  appertaining'} 
PAIN  IN.  L  to  the  flanks.  J 


Practically  the  same  considerations  apply  to  pains  in  the  left 
iliac  fossa  as  to  those  in  the  right  iliac  fossa  (to  be  discussed  in 


Am 

loid 
Dd  vein 

>ermatic 

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Fig.  790. — Normal  position  and  relations  of  the  sigmoid  flexure  and 
rectum  in  the  adult.  The  pelvis  has  been  freely  opened  anteriorly  by  a 
frontal  section  passing  through  the  centers  of  the  acetabular  fossae 
(Poirier) . 

the  succeeding  section),  the  only  important  differences  being 
those  attendant  upon  the  presence  of  the  appendix  and  cecum  on 
the  right  side  in  lieu  of  the  iliac  colon  on  the  left. 

(1085) 


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1086  SYMPTOMS, 

The  annexed  anatomical  illustration  of  the  region  and  the 
diagnostic  tabulation  will  give  data  serviceable  in  the  clinical 
study  of  this  region. 

Abdominal  palpation,  palpation  from  the  rectum  (and  the 
vagina  in  women),  fluoroscopic  examination  after  a  bismuth 
meal,  and  gross  and  microscopic  examination  of  the  stools  are 


s 


Fig.  791. — Radiographic  view  of  the  large  intestine   (Tuffier,  Aubourg). 

the  mam  clinical  procedures  employed  in  investigating  the  left 
iliac  fossa, 

Muco-membranotis  enterocolitis  (or  mucous  colitis),  a  very 
common  disorder,  gives  rise  to  pain  localized  in  the  left  iliac  fossa; 
it  is  oftenest  situated  in  the  cecum  and  transverse  colon.  Again, 
palpation  of  the  left  iliac  fossa  frequently  reveals  the  descending 
colon  and  sigmoid  in  a  contracted  condition,  with  reduced  size,  im- 
parting the  sensation  of  an  elastic  "sausage'*  rolling  beneath  the 


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ILIAC  FOSSA,  LEFT,  PAIN   IN.  1087 

finger.  This  condition,  when  correlated  with  alternating  diarrhea 
and  constipation  and  the  discharge  of  mucus  and  false  membrane, 
generally  affords  an  easy  diagnosis.  Pain  is  not  constant  in  these 
cases. 

It  should  be  borne  in  mind  that  tumors  of  the  descending  colon 
and  sigmoid  may  be  particularly  silent  from  the  symptomatic  stand- 
point and  be  associated  with  very  little  local  or  general  disturbance ; 
even  the  degenerative  process  itself,  similar  to  a  small  ring  of  metal, 
is  often  hard  to  detect.  In  general,  in  any  subject  over  fifty  years 
of  age  exhibiting  irregularity  of  bowel  action  which  had  previously 
been  regular,  or  losing  weight,  the  stools  should  be  examined  for 
blood  and  x-ray  studies  carried  out. 


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1088 


SYMPTOMS. 


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ILIAC  FOSSA,  RIGHT,  PAIN  IN. 


The  semeiology  of  the  right  iliac  fossa  revolves  chiefly  about 
the  diagnosis  of  acute  and  chronic  appendicitis. 

Yet,  appendicitis  is  not  the  only  pain-producing  disorder  met 
with  in  this  region. 

It  would  seem  of  interest  in  this  connection  to  reproduce  the 
highly  suggestive  statistics  recorded  by  Cabot  in  "Dijferential 
Diagnosis/^ 

Relative  frequency  of  the  disorders  causing  pain  in  the  right 
iliac  fossa  (Cabot,  1747  cases). 

Appendicitis  1169  cases  66%  per  cent 

Pus-tube  (and  pelvic  adhesions)   427  "  24  "  " 

Dysmenorrhea   81  "  4%  "  " 

Extra-uterine  pregnancy   23  "  1%  **  " 

Ovarian  cyst  with  twisted  pedicle 21  "  1%  "  " 

Psychoneurosis  and  the  fear  of  appendicitis  .     17  "  1%  **  " 

Colica  mucosa   5  "  %  "  " 

Ureteral  stone   , 4  "  %  -  " 

1747  cases. 

To  the  above  might  well  be  added  a  few  exceptional  cases 
of  inguinal  hernia  with  pain  radiating  to  the  iliac  region  and  the 
more  frequent  cases  of  obstruction  in  the  ileocecal  region  due  to 
neoplasm,  tuberculous  disease,  morbid  or  post-operative  adhe- 
sions, abnormal  position  of  the  cecum  (ptosis,  congenital  dilata- 
tion, etc.)  ;  in  these  cases,  however,  the  pain  is  generally  slight 
and  rarely  localized  in  the  iliac  fossa. 

Examination  of  this  region  of  the  abdomen  is  of  such  out- 
standing importance  as  to  warrant  a  description  here  of  the  sys- 
tematic procedure  to  be  followed. 

The  patient  being  relaxed  and  recumbent,  and  the  abdomen 
exposed  : 

The  abdomen  should  first  be  examined  as  a  whole,  attention 
being  paid  to  any  visible  prominence  of  one  abdominal  region, 

«»  (1089) 


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1090  SYMPTOMS, 

due  to  meteorism,  pus  accumulation,  or  a  tumor,  and  noting 
whether  the  two  sides  of  the  abdomen  show  different  motion  in 
respiration,  as  might  occur  through  inhibition  of  one  side  of  the 
diaphragm  because  of  an  underlying  process  of  peritonitis.    One 


Anterior  aspect 


Diaphragm 


4th  rih 

Diaphragm 
Left   lung 


Xiphoid  LlTer 

append. 

Stomach 


curyature 

Liver 

Spleen 
Pleura 

Spleen 

Gall-bladder 

Pylorui  Stomach 

H^^  TransT.   colon 

Descend,   colon 
TJmbllieus 
Small  intestine 


Sigmoid 
flssurs 
Cecum 


Sigmoid 
Hezure 


Fig.  792. — General  topographic  features  of  the  abdomen 
(T.  Jonnesco,  in  Poirier  and  Charpy). 

should  also  note  whether  respiration  or  coughing  awaken  any- 
localized  pain,  and  if  so,  at  what  point. 

Skin  sensation  should  be  tested  on  the  two  sides  by  drawing  the 
finger  over  the  skin,  pinching,  and  the  application  of  heat  and 
cold.  Any  existing  anesthesia,  dysesthesia,  or  hyperesthesia 
should  be  noted.    Where  such  sensory  disturbances  are  found  to 


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ILIAC  FOSSA,  RIGHT,  PAIN  IN. 


1091 


be  unilateral — hemianesthesia  or  hemidysesthesia — an  examina- 
tion should  be  made  for  the  customary  stigmata  of  the  neuroses 
(hysteria).  If  the  disturbances  show  a  metameric  distribution 
corresponding  to  one  .of  the  zones  of  Head,  the  condition  may  be 
regarded  as  a  cutaneous  expression  of  some  deep-seated  visceral 
inflammatory  process. 


Fig.  793. — ^Topography  of  the  abdomen,    pp.  The  pancreatic  point. 
App.  The  appendiceal  point. 

Palpation  is  the  chief  factor  in  the  examination  of  this  region, 
and  too  much  care  and  attention  cannot  be  given  to  its  execution. 
Both  superficial  and  deep  palpation  should  be  practised.  In  the 
acute,  febrile,  peritoneal  stages  the  palpation  should  be  particu- 
larly light  and  cautious.  It  should  be  carried  out  with  the  tips 
of  the  fingers,  in  a  gradual  manner.  Sudden,  forcible  palpation 
always  excites  a  defensive  reaction  of  the  abdominal  wall,  even 
in  the  normal  subject  and  in  the  absence  of  all  pain;  the  ab- 
dominal muscles  contract,  form  a  barrier,  and  resist  depression 
by  the  palpating  hand — a  condition  particularly  to  be  avoided. 


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1092  SYMPTOMS. 

The  patient  being  well  extended  in  recumbency  and  eased  in 
mind,  with  his  legs,  if  possible,  slightly  flexed,  palpation  is  be- 
gun and  the  various  regions  of  the  abdomen  (right  and  left  iliac 


8 


Fig.  794. — Topographic  features  of  abscesses  of  appendiceal  origin  in 
the  order  of  their  frequency :  /.  The  commonest  type  of  abscess,  in  the 
right  iliac  fossa.  2.  Pelvic  abscess,  s.  Retrocecal  and  prerenal  abscesses. 
4.  Abscess  in  the  left  iliac  fossa.  5.  Mesoceliac  and  infraumbilical  ab- 
scesses. 6.  Right  subphrenic  abscess.  7.  Portal  and  intrahepatic  suppura- 
tion. 8.  Right-sided  suppurative  pleurisy,  p.  Left-sided  prerenal  abscess. 
70.  Infrasplenic  abscess     //.  Left-sided  suppurative  pleurisy  (Kelly), 

fossae  and  hypochondriac  regions,  hypogastrium,  and  umbilical 
region)    lightly    and   gradually   depressed,   beginning  with    the 


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ILIAC  FOSSA,  RIGHT,  PAIN  IN.  1093 

regions  manifestly  free  of  pain  at  the  time.  If  the  subject  is  well 
relaxed,  the  several  abdominal  regions  can  be  depressed  more 
or  less  deeply  without  meeting  with  too  much  resistance,  often 
with  the  result  that,  by  slow,  "coaxing,"  gradual  pressure  the 
deep-lying  organs  may  be  palpated.  In  the  presence  of  some 
inflammatory  visceral  disturbance,  and  particularly  in  appen- 
dicitis, the  palpating  finger  encounters  over  the  site  of  pain  a 
firm  resistance  or  insuperable  reflex  muscular  contraction,  con- 
stituting the  so-called  **board-like  rigidity."     This  sign,  which 


Fig.  795. — Combined  appendicitis  and  adnexitis.  The  appendix  (A)  is 
adherent  to  the  ampulla  (P)  of  the  Fallopian  tube,  which  is  closed  and 
distended  with  pus.  The  inflammatory  cyst  (K)  is  partly  covered  over  by 
the  omentum  (E)  (Berard). 

is  never  absent,  is  the  earliest  and  perhaps  the  most  reliable  indi- 
cation of  appendicitis. 

Its  exact  features  must,  however,  be  carefully  noted;  in  some 
nervous,  pusillanimous  subjects  there  may  occur  a  general  abdom- 
inal rigidity  preventing  palpation  of  any  of  the  regions  of  the 
abdomen,  and  under  these  circumstances  the  rigidity  is  devoid  of  all 
diagnostic  value.  The  same  is  true  of  the  muscular  contraction  in- 
duced by  unduly  rough  palpajtion.  But  whenei'er  a  correctly  con- 
ducted palpation,  after  noting  the  absence  of  undue  resistance  in 
other  regions  of  the  abdomen,  meets  with  rigid  contracture  in  some 


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1094  SYMPTOMS. 

definite  area,  the  result  is  to  be  considered  pathognomonic  evidence 
of  a  subjacent  inflammatory  insceral  disorder. 

By  the  same  proceeding  of  palpation  with  one  finger  one  should 
endeavor  to  ascertain  the  point  of  maximum  pain.  The  diagnostic 
significance  of  the  so-called  McBurney's  point  is  well  known. 

Palpation  sometimes  leads,  moreover,  to  the  detection  of  a 
mass  of  varying  size,  sensitiveness,  and  evenness  of  outline, 
such  as  an  accumulation  of  feces,  an  abscess,  or  a  tumor, 
thorough  examination  of  which  will  reveal  its  actual  nature. 

**On  the  second,  third,  or  fourth  day  of  acute  appendicitis, 
palpation  over  the  right  iliac  fossa  reveals  a  doughy  condition 
or  broad  area  of  induration  which  spreads  out  laterally,  is  ap- 
parently connected  with  the  abdominal  wall,  and  forms  a  species 
of  thick,  hard  shield.  This  condition,  if  it  possesses  and  retains 
the  characteristics  just  referred  to,  is  an  outward  expression  of 
the  Vailing  off'  process  which  has  set  in  and  gradually  ex- 
tended about  the  diseased  area;  such  being  the  case,  its  pres- 
ence is  actually  of  favorable  import. 

"About  the  fifth  or  sixth  day  the  temperature  recedes  and 
drops  more  or  less  rapidly  to  normal,  and  the  pulse  rate  de- 
creases in  parallel  fashion;  the  hard  *shield,'  which  has  by  this 
time  frequently  extended  over  a  broad  surface,  now  ceases  to 
enlarge  and  becomes  still  harder  in  its  central  portion,  while 
softening  and  yielding  at  its  periphery,  and  appears  less  and  less 
tender  on  palpation."  (Lejars,  Chirurgie  d'urgence,  p.  496). 

Finally,  it  is  of  advantag^e,  though  not  absolutely  indispens- 
able, to  practise  ''decompressive"  palpation,  which  consists, 
after  more  or  less  deep  pressure  at  some  region  of  the  abdomen, 
in  suddenly  removing  the  compressing  finger,  so  that  abrupt 
release  of  pressure  results.  Sometimes  it  is  noted  that,  whereas 
pressure  has  been  relatively  painless,  decompression  causes 
much  pain.  This  seems,  to  all  appearances,  to  be  a  reliable  in- 
dication of  inflammation  of  the  peritoneum  beneath  the  palpated 
area. 

Percussion  may  prove  of  great  service  in  the  detection  of  an 
abnormal,  flat  area  in  certain  cases  in  which  satisfactory  palpa- 
tion is  practically  impossible.  It  may,  furthermore,  be  availed 
of  as  a  gentle  method  of  palpation. 


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ILIAC  FOSSA,  RIGHT,  PAIN  IN,  1095 

The  foregoing  examination  of  the  right  iliac  fossa  should  be 
supplemented  with  the  three  following  procedures : 

(a)  Manual  and  bimanual  palpation  of  the  right  lumbar 
region  for  the  detection  of  any  existing  pus  tracks  in  retrocecal 
disease,  to  exclude  the  possibility  of  renal  disorder,  etc. 

(fc)  Vaginal  palpation  in  women  for  the  detection  of  diseased 


2- 

1- 


Fig.  796. — Radiographic  picture  of  the  cecum  and  appendix  twelve 
hours  after  ingestion  of  bismuth  magma.  The  cecum  (/)  and  the  ascend- 
ing colon  (2)  appear  dilated  and  segmented  by  the  constricting  bands 
due  to  pericolitis.  The  appendix  (3)  is  seen  occupying  a  latero-intemal 
position  (Berard). 

adnexa  and  pelvic  infiltration  of  appendiceal  origin,  and  rectal 
palpation  in  males  for  prostatitis,  ureteral  involvement,  and  ex- 
tensions of  appendiceal  suppurative  foci  into  the  pelvis. 

(c)  Gentle  examination  of  the  psoas  muscles  by  flexion,  exten- 
sion, abduction,  and  adduction  of  the  lower  limbs  against  a  slight 
d^ree  of  resistance.    Where  the  psoas  is  involved,  e.g.,  if  there  is 


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1096  SYMPTOMS. 

appendiceal  inflammation  adjoining  this  muscle,  such  an  examina- 
tion of  the  latter  is  a  painful  procedure. 

In  conclusion  it  may  be  added  that  it  is  always  well  to  examine 
the  right  iliac  fossa  under  anesthesia  just  before  the  operation. 

"Before  operating,  one  should  never  neglect  to  conduct  a  final 
examination  upon  the  well  anesthetized  patient  in  a  state  of  com- 
plete muscular  relaxation.  Frequently  the  yielding  of  the  abdom- 
inal wall,  which  is  no  longer  rigid,  will  lead  to  the  detection  of  a 
more  or  less  distinct  prominence  in  the  right  iliac  fossa,  or  upon 
oblique  inspection,  a  marked  lack  of  symmetry  of  the  two  lateral 
halves  of  the  abdomen  may  become  apparent. 

"Examination  by  palpation  will  afford  more  exact  information ; 
generally  the  examiner  will  find  one  of  the  following  conditions: 
Either  a  definitely  fluctuating  pocket,  tense,  circumscribed,  and 
sharply  defined  at  its  mesial  border ;  a  thick  sausage-like  mass,  com- 
pact, indistinctly  or  partially  fluctuating,  or  with  nodular  surface 
and  poorly  defined  borders  below  and  toward  the  median  line,  or  a 
small,  hard  mass,  rounded  or  nodular,  non-adherent  and  readily 
mistaken  for  the  appendix  itself. 

"Sometimes  the  tumor  noticed  in  the  waking  state  will  seem 
to  have  almost  completely  disappeared.  It  may  be  added  that  if, 
when  the  patient  has  been  anesthetized,  iliac  palpation  continues  to 
give  the  impression  of  a  diffuse  doughy  condition,  while  the  ab- 
domen fails  to  recede  and  remains  prominent  and  tense,  the  pre- 
vious apprehensions,  of  generalized  peritonitis  are  to  a  singular  de- 
gree confirmed."  (Lejars.) 

The  following  summary  reflections,  of  general  application  in  the 
diagnosis  of  abdominal  disorders,  are  borrowed  from  Cabot 
C Differential  Diagnosis"), 

Though  it  seems  judicious  and  is  in  accord  with  current  prac- 
tice to  differentiate  the  exciting  causes  of  the  various  localized 
and  diffuse  abdominal  pains,  as  a  matter  of  fact  such  distinctions 
do  not  always  hold  good.  Disorders  such  as  appendicitis,  theo- 
retically attended  with  pain  in  the  right  iliac  fossa,  may  very 
readily  cause  pain  localized  even  above  the  waist  line.  Again, 
lead  poisoning,  which  ordinarily  gives  rise  to  distinctly  diffuse 
pains  in  the  last-named  region,  may  instead  readily  cause  a  much 
more  circumscribed  pain. 


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ILIAC  FOSSA,  RIGHT,  PAIN  IN.  1097 

Thus,  the  reader  looking  up  in  a  certain  chapter  a  variety  of 
pain  commonly  described  as  being  localized  in  a  certain  region 
may  wonder  at  its  absence  from  that  point  and  at  finding  it  else- 
where.   Again,  some  causes  of  pain  may  be  found  referred  to  in 


Fig.  797. — Vessels  and  nerves  of  the  anterior  abdominal  wall  projected 
upon  the  ceco-appendicular  region.  MB.  McBurney's  point.  M.  Morris's 
point.  L.  Lanz's  point.  The  dotted  line  pointing  to  MB  shows  the  line 
of  the  McBurney  incision.  The  dotted  line  ML  shows  the  Jalaguier  in- 
cision   (Berard), 

two  different  chapters  (ovarian  cyst  with  twisted  pedicle,  ectopic 
pregnancy,  etc.)  because  they  are  equally  common  on  the  right 
and.  the  left  sides  of  the  body. 


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1098 


SYMPTOMS. 


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ILIAC  FOSSA,  RIGHT.  PAIN  IN. 


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1100  SYMPTOMS. 

In  a  general  way,  when  the  practitioner  is  seeking  to  find  out  the 
probable  cause  of  a  pain  in  the  abdomen,  he  should  be  guided  by 
the  folloTving  rules: 

1.  First  of  all  he  should  suspect  the  gastrointestinal  tract,  and 
if  the  most  commonplace  disorders,  such  as  constipation  and  colitis, 
can  be  excluded,  he  should  think  especially  of  appendicitis,  peptic 
ulcer,  neoplasm  of  the  stomach  or  large  bowel,  and  the  ultimate 
consequences  of  these  conditions,  such  as  peritonitis  and  intestinal 
obstruction. 

2.  Next  he  should  suspect  (in  women)  the  generative  tract — 
salpingitis,  ovarian  cyst,  uterine  fibroids,  and  ectopic  pregnancy. 

3.  The  gall-bladder  and  bile-ducts  should  be  particularly  in- 
vestigated in  persons  over  middle  age. 

4.  The  urinary  tract,  especially  in  old  men  and  young  girls, 
comes  next  in  the  list  of  causes  of  abdominal  pain. 

Clinical  examination,  the  history,  palpation,  blood  examination, 
uranalysis,  fluoroscopy,  and  cystoscopy  are  the  most  serviceable  aids 
in  reaching  a  diagnosis. 


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INSOMNIA. 


I  In,  negative;  somnum,  8leep;'l 
I        deprivation  of  sleep.        J 


Insomnia  or  agrypnia  consists  in  a  more  or  less  complete  and 
lasting  inability  to  sleep.  It  occurs  in  all  grades,  from  simple 
hyposomnia,  characterized  by  shorter,  lighter,  more  restless,  and 
less  refreshing  sleep  than  usual,  to  the  obstinate  and  inveterate 
complete  insomnia,  sometimes  attended  with  a  very  unfavorable 
prognosis. 

The  causes  of  sleeplessness  are  many.  For  practical  purposes 
they  may  be  divided  into  the  three  following  groups : 

Insomnia  due  to  pain. 

Insomnia  due  to  excessive  nervous  excitability. 

Insomnia  due  to  circulatory  or  respiratory  disturbances. 

Insomnia  due  to  pain  may  be  the  result  of  any  kind  of  pain,  of 
whatever  situation  and  nature,  including  the  most  varied  forms  of 
neuralgia,  arthralgia,  and  visceralgia.  To  attempt  to  enumerate  all 
these  causes  would  be  tiresome  to  the  reader  and  plainly  superfluous. 
At  the  most  it  will  be  well  to  call  attention  to  the  fact  that  some 
"pain  insomnias,"  when  carefully  traced,  lead  to  the  discovery  of 
certain  "algias"  which  recur  at  night  and  are  of  special  clinical 
significance,  such  as  the  osteocopic  pains  of  syphilis,  sometimes  the 
neuralgias  of  tabes,  and  more  frequently  the  myalgias  and  arthral- 
gias of  gouty  subjects. 

Again,  it  should  be  noted  that  itching  or  pruritus  (see  Itching) 
of  whatever  cause  (parasitic  or  toxic)  may  be  the  source  of  highly 
obstinate  insomnia.  When  correctly  traced,  this  symptom  leads  to 
the  detection  of  numerous  "incomplete"  cases  of  diabetes,  uremia, 
and  cholemia. 

Lastly,  it  may  be  pointed  out  that  the  insomnias  due  to 
special  sense  hyperesthesia  and  the  psychosplanchnic  neurosis 
merge  insensibly  with  the  next  succeeding  group,  affording  a 
good  illustration  of  the  fact  that  clinical  conditions,  with  their 
infinitely  numerous  variations,  always  tend  to  pass  beyond  the 

(1101) 


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1102  SYMPTOMS, 

group  limitations  within  which  the  physician,  for  his  conveni- 
ence, endeavors  to  confine  them. 

Insomnia  due  to  abnormal  excitability  of  the  nervous  system. 
— Such  nervous  overexcitability  may  be  the  result: 

1.  Of  some  organic  change  in  the  nervous  system  (type  condi- 
tion:   meningitis). 

2.  Of  an  overexcitation  of  functional  origin  (type  condition: 
psychoneuroses ) . 

3.  Of  an  intoxication  or  infection  (type  conditions:  caffeinism 
and  t3rphoid  fever). 

In  the  first  group  are  included  the  insomnias  of  meningitis,  brain 
tumor,  general  paralysis,  and  cerebral  syphilis.  In  all  these  cases 
the  symptomatic  combination  of  headache  and  insomnia  exists. 

The  second  group,  that  of  the  psychoneuroses,  is  much  more  fre- 
quent. In  it  are  comprised  the  so-called  "nervous**  insomnias  de- 
pendent upon  overwork,  excessive  ideation,  worry,  mental  excite- 
ment (irritable  weakness,  emotivity,  emotional  impressions),  mania, 
psychoneuroses,  hysteria,  neurasthenia,  obsession,  phobia,  and  anx- 
ious states.  "In  acute  attacks  of  psychosis,"  states  Regis,  "insom- 
nia is  one  of  the  first  symptoms  to  appear;  it  is  manifested  particu- 
larly in  restlessness,  dreaming,  and  nightmares.  On  the  other  hand, 
restoration  of  the  ability  to  sleep  towards  the  close  of  a  period  of 
mania  or  melancholia  is  of  excellent  prognostic  import."  In  chronic 
mental  diseases  insomnia  is  uncommon,  except  among  insane  subjects 
harboring  hallucinations  or  cenesthetic  illusions.  Insomnia  as  a 
symptom  should  receive  careful  treatment  in  all  psychoneurotic 
states:  A  patient  able  to  sleep  is  already  half-cured  under  these 
circumstances. 

The  third  group,  the  insomnia  of  toxic  and  infectious  states,  is 
more  complex. 

In  this  group  some  forms  of  sleeplessness  seem  to  be  instances 
of  true  toxic  insomnia  due  to  direct  stimulation  of  the  cerebral  cells ; 
among  these  are  the  insomnias  due  to  abuse  of  tea,  coffee,  alcohol, 
tobacco,  morphine,  cocaine,  etc. 

As  for  the  infectious  and  post-infectious  insomnias,  their  mode 
of  production  is  unquestionably  much  less  simple.  Some  appear  to 
be  algic  insomnias  dependent  upon  some  predominant  painful  dis- 
turbance (headache,  joint  pain,  or  pain  in  the  side),  as  in  meningitis, 


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INSOMNIA.  1103 

acute  rheumatism  and  pneumonia.  Others  seem  to  be  true  toxic- 
infectious  insomnias,  of  dyscrasic  origin,  due  to  the  action  of  the 
toxins  of  infection  on  the  nerve  centers,  as  in  the  early  insomnia  of 
typhoid  fever,  of  grippe,  and  of  erysipelas.  Lastly,  an  additional 
g^oup,  especially  related  to  convalescence,  appears  to  be  dependent 
upon  neurovascular  weakness,  e.g.,  the  insomnias  of  anemic  and  (w- 
thenic  cases  (starvation,  convalescence,  sequelae  to  infections,  etc.). 
Insomnia  due  to  circulatory  or  respiratory  disturbances. — 
Insomnia  dependent  upon  some  cardiopulmonary  affection, — This  is 
the  insomnia  of  heart  failure,  of  lost  compensation,  of  cardiopulmon- 
ary disorders  causing  cough  and  dyspnea,  of  asthma,  of  chronic 
bronchitis,  etc.  The  causes  are  many  and  outstanding,  z/is,,  cough, 
dyspnea,  and  toxic  influences. 

Thus,  insomnia  is  a  very  common  symptom  and  consequently  one 
of  very  restricted  diagnostic  value,  except  possibly  in  the  psycho- 
neuroses.  This  does  not  apply,  however  to  its  causal  diagnosis, 
for  it  is  from  such  a  study  of  its  cause  that  the  basis  for  rational 
and  effectual  treatment  can  be  found.  A  patient  with  heart  weak- 
ness is  made  to  sleep  by  restoring  circulatory  balance;  a  coffee 
fiend  by  withdrawing  the  drug,  and  a  syphilitic  subject  by  specific 
treatment. 

Even  with  reference  to  much  less  definite  groups  of  cases, 
however,  rational  use  of  special  hypnotic  remedies  depends  upon 
a  partial  knowledge  of  the  pathologic  physiology  of  insomnia, 
and  as  an  illustration  of  this  fact  it  seems  of  interest  to  consider 
summarily  the  respective  indications  of  chloral  hydrate  and  of 
morphine  in  this  class  of  cases. 

INDICATIONS    AND     CONTRAINDICATIONS    TO     CHLORAL 
HYDRATE  AND  MORPHINE  FOR  HYPNOTIC  PURPOSES. 

Chloral  hydrate  and  morphine  are  probably — ^and  with  reason — 
the  two  most  commonly  employed  hypnotics.  They  should  not, 
however,  be  thought  of  as  being  interchangeable.  While  they 
may  sometimes  be  administered  with  advantag'e  in  combination, 
they  actually  meet  wholly  different  indications  and  should  be  pre- 
scribed only  for  definite  reasons. 

Chloral  hydrate  and  morphine  appear  to  be  directly  acting  hyp- 
notics, i.e.,  drugs  inducing  sleep  by  a  selective,  direct  action  upon 


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1104  SYMPTOMS, 

the  nerve  cell.    This  constitutes,  however,  about  the  only  property 
they  have  in  common.    Indeed, 

L  Opium  and  its  derivative,  morphine,  exert,  in  moderate  dosage, 
— as  Sydenham  had  plainly  noted — ^a  tonic  action  on  the  heart;  under 
their  influence  the  heart  beats  develop  increased  amplitude  and 
power,  the  blood-pressure  rises,  and  circulation  through  the  viscera 
becomes  more  active. 

Chloral,  on  the  other  hand,  is  a  cardiovascular  depressant;  un- 
der its  influence  the  heart  beats  become  weaker  and  less  frequent, 
the  blood-pressure  is  reduced,  and  visceral  circulation  is  less 
Active. 

2.  In  the  first  stage,  at  least,  opium  and  morphine  produce  evi- 
dences of  cerebral  stimulation  (a  property  availed  of  by  morphin- 
ists), in  all  likelihood  through  hyperemia  of  the  brain  and  meninges 
and  direct  nervous  action.  The  sleep  induced  is  frequently  associ- 
ated with  dreaming;  sometimes  it  presents  features  suggesting  the 
so-called  "coma  vigil.*' 

Chloral  sleep,  on  the  other  hand,  is  not  preceded  by  any  stage 
of  stimulation;  it  is  in  all  respects  comparable  to  normal  sleep  as 
to  general  features  and  duration. 

.  3.  Finally,  morphine  is  an  analgesic  agent  of  the  first  order, 
being  the  type  of  the  pain-relieving  drugs. 

Chloral,  on  the  other  hand,  is  neither  analgesic  nor  anesthetic; 
pain  prevents  chloral  sleep  from  coming  on,  while  loud  noises 
awaken  the  sleeping  patient. 

Such  are  the  more  salient  diflFerences  between  chloral  hydrate 
and  morphine.  Their  respective  indications  and  contraindica- 
tions are  logically  based  on  these  differences  in  action. 

Morphine,  a  cardiac  and  vascular  stimulant,  at  least  temporarily 
a  sPimulant  of  the  brain  functions,  and  an  analgesic  agent  of  the 
first  order,  is  especially  indicated  in  insomnia  dependent  upon  or  as- 
sociated with  neurovascular  zveakness  or  some  painful  disorder. 

Such  being  the  case,  it  is  serviceable  in  pain  insomnia,  generally 
due  to  neuralgia  or  visceral  pain,  as  well  as  tabes  dorsalis,  cancer, 
etc.  In  these  cases,  however,  in  order  to  obviate  or  postpone  as 
much  as  possible  the  risk  of  morphine  habit,  it  is  well  not  to 
resort  to  it  until  after  the  entire  list  of  pure  analgesics,  such  as 
acetphenetidin,  antipyrin,  exalgin,  salipyrin,  etc.,  has  been  exhausted. 


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INSOMNIA.  1105 

In  the  insomnia  of  anemic  or  asthenic  subjects  (inanition,  con- 
valescence, typhoid  fever,  pneumonia,  etc.)  or  of  persons  with  weak 
heart  action  or  low  blood-pressure,  morphine,  with  or  without  the 
addition  of  heart  tonics,  remains  the  hypnotic  remedy  of  choice. 

In  these  cases,  on  the  other  hand,  chloral  hydrate  proves  ineffec- 
tual or  even  usually  does  harm. 

In  the  so-called  nervous  insomnia,  however,  dependent  upon 
overwork,  excessive  ideation,  worry,  mental  excitement,  mania, 
alcoholism,  meningeal  congestion,  and  high  blood-pressure,  mor- 
phine not  only  proves  ineffectual,  but  is  frequently  even  dangerous. 
Chloral  hydrate  is  the  hypnotic  of  choice,  in  these  cases. 

Lastly,  there  occur  a  large  number  of  hybrid  clinical  species, 
and  various  "mixed"  insomnias,  which  warrant  combined  use  of 
the  two  drugs  to  some  extent. 

Such,  for  example,  is  the  insomnia  of  overworked  anemic  sub- 
jects, the  painful  insomnia  present  in  high  blood-pressure  (neu- 
ralgia in  a  case  of  arteriosclerosis),  etc.  Under  these  circum- 
stances the  combination  of  chloral  with  morphine,  while  it  doubt- 
less fails  to  afford  an  ideal  pharmacodynamic  procedure,  consti- 
tutes a  logical  solution  of  the  problem  of  sleep  induction. 

Were  it  necessary  to  summarize  in  one  concise  sentence  the 
above  considerations,  it  might  be  stated  that: 

Opium  and  morphine  are  indicated  in  insomnia  associated  with 
neurovascular  weakness  or  pain;  chloral  hydrate,  in  insomnia  re- 
lated to  neurovascular  overactivity,  without  pain. 


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ITCHING. 


The  least  inaccurate  definition  of  itching  or  pruritus  would 
appear  to  be  that  of  Jaccoud,  vk.,  pruritus  is  the  sum  of  the  sub- 
jective sensations  which  awaken  the  desire  and  need  of  scratching. 

The  frequent  association  of  pruritus  with  vasomotor  disturb- 
ances, as  in  dermographia,  has  led  to  the  view  that  its  cause  may 
be  an  organic  or  functional  disturbance  of  the  sympathetic  nerves. 

Many  diflferent  classifications  of  pruritus,  based  on  its  patho- 
genesis and  clinical  features,  have  been  formulated.  The  best, 
for  practical  purposes,  appears  to  be  the  following : 

Toxic  (and  metabolic)  pruritus. 

Derma tosic  pruritus  (due  to  skin  lesions). 

Parasitic  pruritus. 

Keurotic  pruritus. 

Toxic  pruritus  or  itching  includes  all  those  forms  of  pruritus 
in  which  the  cause  seems  to  be  actually  some  change  in  the  tissue 
fluids  or  blood,  whether  this  change  be  metabolic  (autotoxic)  in 
nature,  or  a  true  intoxication  of  food  or  drug  origin  (exotoxic). 

Autotoxic  metabolic  pruritus  is  extremely  common.  It  is 
met  with  in  diabetes  {diabetic  pruritus),  in  gout,  in  uremia,  in  ster- 
coremia  (constipation),  in  cholemia  (itching  in  jaundice),  in  arter- 
iosclerosis {senile  pruritus),  in  dyspepsia,  and  in  dysmenorrhea.  Its 
outstanding  feature  is  plainly  the  conception  of  an  altered  humoral 
state  consequent  upon  the  insufficiency  of  the  liver  and  kidneys 
which  is  characteristic  of  most  of  the  above  mentioned  disorders. 

Pruritus  of  alimentary  origin  is  no  less  common,  and  the 
large  number  of  the  persons  predisposed  to  it  is  well  known.  The 
more  particularly  prurigenous  articles  of  food  are  crustaceans  and 
Other  shell  fish,  preserved  and  salted  meats,  gam-e,  stale  fish, 
spices,  an  excessive  meat  diet,  fermented  cheeses,  and  strawberries.  * 
A  partial  insufficiency  of  the  liver  and  kidneys  seems  to  be  at 
the  bottom  of  these  various  types  of  food  intolerance.  Possibly 
(1106) 


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ITCHING.  1107 

the  factor  of  anaphylaxis  is  also  concerned,  as  in  the  succeeding 
group  of  cases. 

Pruritus  of  pharmaceutic  origin,  due  to  coffee,  tea,  alcohol, 
belladonna,  cocaine,  antipyrine,  mercury,  bromides,  chloral  hydrate, 
opium  and  its  derivatives,  and  the  balsamic  remedies.  Abuse  of 
these  drugs  in  some  persons,  and  their  use  in  ordinary  dosage  in 
many,  may  be  the  source  of  itching  with  or  without  actual  skin 
disease. 

Pruritus  of  hydatid  origin  should  also  receive  recognition  in 
this  group. 

Dermatosic  pruritos  comprises  all  the  skin  aflfections  which 
give  rise  to  itching.  The  commonest  are:  Prurigo,  urticaria, 
lichen,  eczema,  mycosis  fungoides,  chicken-pox,  seborrhea,  hy- 
peridrosis,  Duhring's  dermatitis  herpetiformis,  the  ringworms, 
etc.  One  cannot  resist  the  temptation  to  reproduce  in  extenso 
Rrocq's  lecture  on  the  topic  of  pruriginous  skin  disorders : 

"I  am  reviewing  for  you  briefly  how  one  may  understand  and 
classify  the  pruriginous  dermatoses  which  fall  into  the  group 
I  term  that  of  the  simple  skin  reactions  with  pre-emptive  pruritus 
(Jacquet). 

"1.  When  a  patient  is  seized  with  pruritus  and  scratches  him- 
self, the  integument,  even  though  exposed  to  the  trauma  of 
scratching  and  rubbing,  may  retain  its  normal  appearance,  show- 
ing no  structural  change  appreciable  to  the  naked  eye,  i.e.,  no 
eruption.  One  may  thus  say  that  it  is  not  reacting  in  a  visible  man- 
ner.  This  constitutes  simple  pruritus  or  pruritus  sine  materia. 
This  is  the  so-called  idiopathic  pruritus,  a  rather  frequent  condition 
in  private  practice,  especially  among  neurotics;  senile  pruritus  be- 
longs in  this  group. 

"2.  Under  the  influence  of  scratching  and  rubbing,  the  skin 
may  more  or  less  rapidly  exhibit  a  changed  appearance ;  it  may 
assume  a  slightly  brownish  tint;  the  creases  in  it  become  en- 
hanced and  more  readily  visible,  deeper,  and  cross  one  another 
in  diamond-shaped  fi.gures  of  varying  regularity ;  the  appearance 
at  first  becomes  velvety,  then  rugose,  owing  to  accentuation  of 
the  dermal  papillae  and  of  the  epidermis ;  histologically,  indeed, 
there  is  produced  a  very  marked  hyperacanthosis.    The  process 


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1108  SYMPTOMS, 

may  stop  at  this  point,  as  is  nearly  always  the  case  when  the 
pruritus  is  of  general  distribution;  when  it  is  circumscribed, 
however,  the  skin  lesions  undergo  further  development,  suggest- 
ing at  first  species  of  papules  arising  through  papillary  and  epi- 
dermal hypertrophy,  and  later  infiltrated,  thickened,  cross-hatched 
plaques,  more  or  less  scaly  and  excoriated.  These  are  the  changes 
characteristic  of  simple  lichenification,  2l  process  which,  like  pruri- 
tus itself,  may  be  either  diffuse  or  circumscribed;  and  as  I 
showed  twenty-two  years  ago  while  attempting  a  complete  dif- 
ferentiation of  these  morbid  types,  these  are  lesions  of  a  purely 
traumatic  origin,  which  may  be  either  primary,  i.e.,  show  initial  de- 
velopment on  a  healthy  skin,  or  secondary,  i.e.,  become  superimposed 
upon  any  other  pre-existing  pruriginous  skin  disorder.  When  pri- 
mary, the  condition  constitutes  the  lichen  simplex  of  the  older  au- 
thors, or,  in  our  own  nomenclature,  diffuse  pruritus  or  circum- 
scribed pruritus  with  lichenification, 

"3.  Under  the  influence  of  scratching  and  rubbing  the  skin  may 
react  by  the  production  of  an  ordinary  urticaria;  it  may  react  with 
the  so-called  urticaria  papulosa,  characterized  by  small,  papular 
lesions,  and  the  resulting  sequence  of  changes  tends  toward  the  ap- 
pearance of  prurigo  (see  below)  ;  again,  it  may  react  with  urticaria 
bullosa,  and  the  resulting  sequence  of  changes  tends  toward  the 
appearance  of  dermatitis  multiformis  (see  below). 

"4.  Under  the  influence  of  scratching  and  rubbing,  especially 
when  the  pruritus  is  localized  on  the  inner  aspects  of  the  fingers, 
the  patient  may  note  almost  immediately  the  formation  of  certain 
elevations  of  the  epidermis  filled  with  citrine,  clear,  serous  fluid 
and  free  of  surrounding  redness,  the  result  being  that  the  skin 
appears  as  though  peppered  with  boiled  sago  grains,  closely 
Siggr^gSited  and  sometimes  so  confluent  as  to  form  rather  exten- 
sive areas  of  raised  epidermis,  almost  always  discrete,  or  merely 
in  apposition.  This  is  the  clinical  picture  for  which  the  term  dys- 
idrosis  should  properly  be  reserved;  frequently,  however,  it  is 
present  in  combination  with  the  following  type  of  disturbance, 
whence  unfortunate  mistakes  are  apt  to  result. 

"5.  Under  the  influence  of  scratching  and  rubbing,  there  de- 
velop on  the  skin,  sometimes  without  redness,  but  nearly  al- 
ways with  a  more  or  less  striking  erythema,  fine  vesicles  of  un- 


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ITCHING,  1109 

equal  size,  of  the  average  size  of  a  pinhead,  and  which  dot  the 
epidermis  in  highly  irregular  fashion.  The  best  plan  for  observ- 
ing them  plainly  is  to  first  dry  the  skin  either  with  a  piece  of 
fine  cloth  or  with  cotton  impregnated  with  sulphuric  ether,  then 
apply  over  the  affected  surface  a  piece  of  cigarette  paper,  over 
which  is  placed  a  piece  of  glass  to  exert  pressure.  Serous  fluid 
from  the  vesicles  is  then  seen  through  the  glass  to  ooze  out  and 
be  absorbed  by  the  paper,  thus  showing  very  clearly  the  shape 
and  arrangement  of  the  little  vesicles.  If  the  latter  have  not  yet 
ruptured,  one  need  merely  make  a  few  very  light  strokes  with  a 
curette  and  then  apply  the  cigarette  paper  and  pressure  glass. 
To  this  objective  morbid  condition,  definitely  characterized  by 
the  peculiar  fundamental  skin  lesion  just  referred  to,  I  apply  the 
term  eczema  vulgaris,  true  vesicular  eczema,  or  amorphous  eczema, 

"6.  Under  the  influence  of  scratching  and  rubbing  there  de- 
velop minute  lesions  of  a  rather  bright  red  color,  slightly  ele- 
vated above  the  surrounding  skin  surface,  exhibiting  at  their 
center  a  slight  lifting  up  of  the  epidermal  layer  by  citrine  serous 
fluid,  i.e.,  a  small  vesicle.  These  lesions  may  be  scattered  here 
and  there  in  complete  disorder,  especially  on  the  extremities,  but 
exhibit  a  marked  tendency  to  become  agminated  and  confluent, 
thus  giving  rise  to  red  patches,  dotted  with  minute  vesicles  simi- 
lar to  those  of  the  preceding  type  and  oozing  more  or  less  freely. 
This  is  the  disorder  to  which  the  term  papulovesi<:ular  eczema  is 
peculiarly  applicable.  It  is  made  up  of  a  number  of  transitional 
stages  which  insensibly  merge  the  true,  common  or  amorphous 
vesicular  eczema  with  the  true  prurigoes  to  be  next  described. 

"7.  Under  the  influence  of  scratching  and  rubbing,  the  skin 
reacts  with  bright  red,  acuminate,  more  or  less  urticarial  papules, 
exhibiting  at  their  apices  a  slight  tendency  to  elevation  of  the 
epidermal  layer  by  a  little  citrine  serous  fluid.  As  the  attendant 
itching  is  very  marked,  these  urticarial  papulovesicles  (Tomma- 
soH's  seropapules)  are  nearly  always  found  ruptured  by  the  pa- 
tient's finger  nails;  where,  however,  the  lesion  is  permitted  to  run 
Its  course  without  traumatic  interference,  there  arises  spontane- 
ously at  its  summit  a  minute  brownish-yellow  crust  formed 
through  desiccation  of  the  little  apical  vesicle.  Such  is  the  char- 
acteristic fundamental  lesion  of  prurigo.    As  I  already  stated  in 


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1110  SYMPTOMS. 

discussing  the  diflferential  diagnosis  of  one  of  our  cases,  if  these 
eruptive  units  remain  separate  and  discrete,  the  morbid  type 
known  as  prurigo  simplex  exists ;  if  they  show  a  tendency  to  come 
together  in  clusters  and  form  eczematized  and  lichenified 
plaques,  the  condition  is  that  known  as  Hehra's  prurigo;  if  they  are 
very  large,  the  condition  present  is  prurigo  ferox  Vidali, 

"8.  Following  scratching  and  rubbing  there  may  be  produced 
in  certain  patients  only  a  more  or  less  marked  lichenification  of 
various  extent,  together  with  acute  out-croppings  of  eczema  ves- 
icles. E.  Eesnier  long  ago  classified  this  disorder  among  the 
'diathetic  prurigoes.'  According  to  the  nomenclature  personally 
adopted,  it  cannot  be  spoken  of  as  a  form  of  prurigo,  since  it 
fails  to  exhibit  the  fundamental  urticarial  papulovesical  charac- 
teristic of  this  group.  For  it  I  shall  therefore  retain  the  term 
pruritus  with  lichenification  and  ecsematous  transformation. 

"9.  Under  the  influence  of  scratching  and  rubbing,  the  skin  may 
finally  react  in  a  much  more  complex  manner.  In  some  places  there 
form  patches  of  erythema,  elsewhere  urticarial  lesions,  elsewhere, 
either  on  healthy  skin  or  over  pre-existing  patches  of  erythema, 
vesicles  or  blebs  of  varying  size,  and  sometimes  even  pustules. 
These  various  eruptive  types  may  be  simultaneously  present  in  the 
same  individual,  constituting  the  multiform  eruption  par  excellence; 
they  may  instead  occur  in  succession,  one  eruptive  outburst  being, 
e.g.,  urticarial,  another  erythematous,  another  erythematovesicular, 
another  bullous,  another  actually  multiform,  etc.  Furthermore,  the 
various  eruptive  lesions  may  be  scattered  in  disorderly  fashion; 
they  may  be  grouped  together,  and  suggest  either  herpes,  vulgaris  or 
the  circinate  lesions  of  ringworm,  in  which  event  the  term  derma- 
titis herpetiformis  (Duhring)  is  particularly  applicable.  The  clin- 
ical group  as  a  whole  should  be  termed  that  of  dermatitis  muHi 
formis. 

"Such,  briefly  summarized,  is  the  vast  series  of  the  pruriginous 
skin  disorders  with  pre-eruptive  pruritus  (Jacquet)  belonging  to 
the  group  of  the  primary  skin  reactions. 

"It  should  be  added,  however,  that  under  the  influence  of  itch- 
ing and  the  attendant  scratching,  other  eruptions,  which  cannot,  for 
the  present  at  least,  be  classed  simply  among  the  skin  disorders  with 
pre-eruptive  itching,  may  likewise  develop  with  extreme  ease  and 


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ITCHING.  1111 

rapidity.  In  the  front  rank  among  these  should  be  mentioned  those 
peculiar  disturbances,  intermediate  between  eczema  and  psoriasis, 
which  have  been  the  subject  of  such  extensive  discussion  of  late 
and  to  which  we  have  applied  the  term  psoriasiform  parakeratoses; 
now,  among  these  psoriasiform  parakeratoses  there  is  one  particu- 
lar form  which  is  frequently  seen  to  develop  under  the  circum- 


Fig.  798.— Scabies.    Places  of  election  for  burrows.    None 
are  ever  noted  on  the  face  or  scalp. 

stances  alluded  to:  This  variety  is  chiefly  characterized,  objectively, 
by  the  presence  of  patches  of  varying  extent  of  a  more  or  less 
bright  red  color,  sometimes  pale,  sometimes  rather  dark,  scaly,  and 
over  which  are  formed  vesicles  similar  to  those  of  true  vesicular 
eczema.  This  condition  is  therefore  actually  deserving  of  the 
appellation  eczema;  it  is  what  most  authors  term  seborrheic  psori- 
asiform eczema,  but  what  I  have  referred  to  as  eczematized  psori- 
asiform parakeratosis,  wishing  thereby  to  imply  that  in  many  in- 
stances this  clinical  condition  is  in  no  wise  related  to  seborrhea/' 


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1112  SYMPTOMS. 

Along  with  these  various  forms  of  dermatosic  pruritus  should 
be  mentioned  the  itching  due  to  varicose  conditions  of  the  lower 
extremities.  These  are  always  accompanied  by  trophic  disturb- 
ances. 

The  same  applies  to  the  localized  forms  of  pruritus,  such  as 
vulvar  or  perianal  pruritus  due  to  some  local  uterine,  vaginal 
(leucorrheal),  urethral,  anal  or  perianal  (fistula  or  hemorrhoids) 
discharge. 

Parasitic  pruritos  is  clinically  represented  chiefly  by  scabies 
and  the  several  varieties  of  pediculosis.  These  conditions  should 
always  be  kept  in  mind,  though  little  should  be  said  about  them, 


Fig.  799. — Burrow  containing  a  female  itch-mite  and  her  ova. 

even  after  the  diagnosis  is  certain.  The  diagnosis  of  scabies — ^an 
important  one  to  render — should  be  basied  chiefly  on  the  transmis^ 
sion  of  an  itching  disorder  (the  patient  "having  slept  with  some  one 
who  was  frequently  scratching  himself"),  on  the  special  localisation 
of  the  itching  at  the  points  of  election  shown  in  the  annexed  illus- 
tration, and  if  necessary,  by  microscopic  identification  of  the  paror- 
sites  themselves.  For  the  latter  purpose  one  of  the  little  burrows  in 
the  skin  should  be  opened  up  with  a  needle  and  the  minute  white 
object  at  the  bottom  of  it  removed,  likewise  with  the  needle;  the 
female  parasite  is  thus  secured  and  may  be  examined  with  a  hand 
lens  or  microscope. 

The  following  description  of  one  of  these  burrows  is  reproduced 
from  Sabouraud:^ 

"The  Burrow. — I  am  for  the  first  time  thus  alluding  to  the 
familiar  burrow  of  scabies.    This  is  because  in  any  fairly  extensive 


1  Presse  medicale,  June  21,  1917. 


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ITCHING,  1113 

dispensary  practice,  the  dermatologist  will  have  twenty  times  made 
a  diagnosis  of  scabies  on  the  basis  of  the  localizations,  of  the  dis- 
order before  having  searched  for  a  single  burrow.  The  burrow  is 
•  looked  for  in  recent  or  doubtful,  cases  in  which  no  light  is  thrown 
on  the  condition  by  the  history.  What,  then,  is  the  scabies  burrow  ? 
A  homely  comparison  will  give  an  idea  of  it  at  once,  for  every  one 
is  familiar,  from  repeated  observation,  with  the  burrow  of  a  mole 
projecting  above  the  surface  of  the  ground  in  a  field.  The  burrows 
of  the  itch-mite  are  constructed  similarly.    They  are  most  readily 


Fig.  800. — Sarcoptes  scabiei,  female,      Fig.  801. — Sarcoptes  scabiei,  female, 
dorsal  aspect  (R.  Blanchard).  ventral  aspect  {R.  Blanchard). 

observed  in  uncleanly  individuals  working  in  dirty  liquids,  since 
these  liquids,  entering  the  burrows  by  capillarity,  stain  them  black. 
To  see  them  well  when  one  is  not  familiar  with  them,  the  palm 
of  the  hand  in  the  children  of  the  very  poor  should  be  selected. 
The  burrows  may  be  accurately  compared  to  the  outline  of  the 
spirochete  of  syphilis  stained  with  silver  nitrate,  now  a  familiar 
object  owing  to  its  frequent  reproduction  by  photography  as  well 
as  by  delineation.  It  appears  as  a  wavy  black  line.  Where  the 
burrow  is  not  blackened  with  dirt,  howerer,  it  is  so  hard  to  see 
that  the  observer,  in  order  to  remove  all  doubt,  should  stain  it 
by  placing  a  drop  of  ink  or  tincture  of  iodine  over  it,  wiping  it 
off  a  moment  later — a  simple,  but  often  useful  procedure. 


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1114  SYMPTOMS, 

"The  unblackened  burrow  is  even  harder  to  describe  than  to 
descry.  X-et  the  reader  imagine  that  he  has  pushed  a  needle 
through  thick,  horny  epidermis,  e.g.,  at  the  finger  tip,  without 


Fig.    S02.—Pediculus    capitis,    male.  Fig.  803.— Ovum  of  Pediculus  cap- 

Enlarged  25 X    (Brumpt),  itis  attached   to   a   hair.     Enlarged. 

(Brumpt), 

drawing  any  blood.     When  the  needle  is  withdrawn,  the  track 
made  by  it  will  be  visible,  the  raised  epidermis  having  been  ren- 


Fig.  SOi.—Phthirius  pubis.    Enlarged  25  X.    St.  Stigma.    Tr.  Air-duct. 

dered  dull  and  whitish;  the  channel  thus  made  is,  however,  a 
straight  one,  while  that  of  the  itch-mite  is  always  wavy.  Other- 
wise, the  white,  dull  condition  of  the  epidermis  induced  is  exactly 
the  same.    Such  a  channel  is  quite  hard  to  see,  and  this  is  what 


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ITCHING.  1115 

makes  the  diagnosis  of  the  disease  so  difficult,  except  under  hos- 
pital conditions.  More  commonly  the  lesions  of  scabies  are  ele- 
vations, papules,  or  vesicles  often  opened  by  scratching,  and  the 
long  axis  of  which  exhibits  the  same  direction  as  the  skin  fold 
at  that  point." 

The  diagnosis  of  pediculosis  (phthiriasis)  is  similarly  based  on 
the  situation  of  the  skin  lesions  (see  illustration)  and  direct  exami- 
nation of  the  parasite.    It  should  not  be  overlooked  that  these  para- 


Fig.  805. — Pediculosis  or  phthiriasis.    Areas  of  election. 

sites  are  not  only  unpleasant,  but  also  dangerous,  being  known  car- 
riers of  many  instances  of  relapsing  fever  and  of  typhus  fever. 
The  well-known  maculce  carulece  above  the  pubis,  characteristic  of 
pediculosis  pubis,  should  be  kept  in  mind. 

Neurotic  pruritus  is  met  with  chiefly  under  the  three  following 
circumstances : 

(a)  In  psychoses,  neuroses,  exophthalmic  goiter,  and  as  a  sequel 
to  overwork,  sorrow,  and  severe  emotional  impressions. 

(&)  In  lesions  of  the  peripheral  nerves  (causalgia). 

(c)  As  a  reflex  manifestation  of  some  deep-seated  visceral  irri- 
tation, as  exemplified  in  the  itching  of  intestinal  helminthiasis. 


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1116  SYMPTOMS. 

To  recapitulate:  Itching  may,  for  practical  purposes,  be  divided 
into  the  following  five  gfroups  of  causes,  which  account  for  at 
least  95  per  cent  of  all  cases: 

1.  Parasites:  Scabies  and  pediculosis;  in  these  cases  the 
diagnosis  is  based  on: 

(a)  Localization  of  the  itching:  Head  and  neck  in  ordinary 
pediculosis;  dorsal  surfaces  of  the  hands  and  forearms,  anterior 
aspect  of  the  axillae,  inguinal  regions,  and  penis  in  scabies;  pubic 
region  in  pediculosis  pubis. 

(fr)  The  skin  lesions  due  to  scratching. 

(c)  Direct  observation  of  the  parasite  concerned  with  a  good 
hand  lens  or  microscope. 

2.  Itching  skin  affections:  Observation  of  the  type  of  skin 
disorder  present  enables  the  experienced  dermatologist  to  ren- 
der an  immediate  diagnosis. 

3.  Hepatic  and  renal  insufficiency:    Cholemia  and  azotemia, 
(a)  Blood-pressure  estimation,  uranalysis,  the  presence  of  other 

evidences  of  azotemia  (vertigo,  cramps,  epistaxis,  and  nycturia), 
and  in  particular,  determination  of  the  blood  urea  will  lead  unmis- 
takably to  the  diagnosis  of  azotemia, 

(fc)  The  itching  attending  jaundice  is  a  familiar  symptom.  One 
should  be  able,  however,  to  detect  even  an  early  cholemia,  of 
which  itching  is  itself  a  valuable  indication. 

4.  Metabolic  disorders,  in  the  front  rank  of  which  should  be 
placed  diabetes.  Pruritus  in  certain  regions,  e.g.,  the  inveterate 
pruritus  vulvce  of  women,  is  particularly  significant.  One  should 
never  omit  examining  the  urine  in  a  case  of  pruritus,  for  four  dis- 
tinct reasons — sugar,  albumin,  bile,  and  acidity.  Glycosuria,  nephr- 
itis, cholemia,  and  acidosis  are  extremely  common  causes  of  itching. 

5.  Neuropathic  states  in  which  pruritus  is  an  actual  cutaneous 
dysesthesia,  accompanied  by  the  usual  characteristic  evidences 
of  neurosis.  The  diagnosis  of  neuropathic  pruritus  should,  how- 
ever, be  made  only  by  exclusion,  after  having  systematically 
eliminated  the  causes  already  mentioned,  %nz.,  parasites,  skin 
disorders,  cholemia,  azotemia,  glycosuria,  and  dietetic  or  phar- 
maceutic intoxication. 


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ITCHING. 
ITCHING. 


1117 


Cad  SIS. 

Special   Pbatcbbs 
AND  Location 

or    ITCHING. 

Urini 
Examination. 

Obnbral  Condition. 

Associated  Clinical 

Signs. 

Parasitic. 

Pediculosis. 

Scabies 
(burrows). 

Scratch  marks. 
Special  parasite. 
Head    and    back    of 
neck. 

Dorsal   aspect    of 
hands  and  forearms. 

Anterior     aspect     of 
axillx. 

Prepuce ; inguinal 
regions. 

Pubes. 

Nocturnal  paroxysms. 

0 

0 

Denna- 
toaic 

Typical     skin     affec- 
tions,  such   as   pru- 
rigo, urticaria,  lichen, 
eczema,  seborrhea, 
ringworm,     chicken- 
pox,  mycosis,  etc. 

Sometimes    al- 
bumin   if    the 
skin     disorder 
is  generalized. 

0 

Cholemic 

Generalized    itching 
sine  materia,  some- 
times  predominantly 
on    the    lower    ex- 
tremities. 

Scratch   lesions    late 
in  appearing. 

Sometimes  bile 
pigments. 

Nearly    always 
urobilin,     and 
frequently  ali- 
mentary    gly- 
cosuria. 

Established  or  in- 
cipient jaundice. 
Bradycardia. 
Familial  cholemia. 

Azotemic 

Generalized    itching 

sine  materia. 
Sometimes  nocturnal 

paroxysms. 
Scratch    lesions    late 

in  appearing. 

Frequently 
albumin. 

Evidences  of  Bright's 
disease  and  arterio- 
sclerosis. 

High  blood-pressure. 

Headache,    vertigo, 
epistaxis,      nycturia, 
etc. 

Diabetic 

Itching  often  localized 
at  the  vulva,  or  skin 
folds  on  flexor  sur- 
faces;    extremely 
marked    and    obsti- 
nate. 

Glycosuria. 

The    usual    signs    of 

diabetes : 
Polyuria,     polydipsia, 

poyphagia,  etc. 

Toxic 

Generalized   itching 
sine  materia,  or  urti- 
carial, or  dermatitis 
medicamentosa  (Ex. : 
Exfoliative     derma- 
titis    of     mercurial 
origin). 

0 
Or  transitory 

albuminuria. 
Or  transitory 

urobilinuria. 

Dietetic    or    pharma- 
ceutic     intoxication, 
more  or  less  obvious. 

Yields  more  or  less 
quickly  to  removal 
of  the  cause. 

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1118 


SYMPTOMS. 
ITCHING   (conHnued). 


Special  Features 

Ubinb 

GENERAL    CONDITION. 

Causes. 

AND  LOCATION 

BXAM I  NATION. 

Associated  Clinical 

OF  Itch  I  NO. 

SIGNS. 

Neuro- 

General or  local 

0 

(a)  Psychopathic 

pathic 

itching  sine  materia. 

disorder,   neurosis, 
exophthalmic 
goiter,   emotions, 
overwork,  etc. 

(b)  Peripheral  neu- 
ritis (causalgia). 

(c)  Remote  visceral 
irritation  (helmin- 
thiasis). 

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JAUNDICE  (ICTERUS). 


The  term  icterus  is  applied  in  all  cases  in  which — whether  the 
urine  and  stools  are  or  are  not  aflfected — the  conjunctivae  and 
skin  exhibit  a  yellow  or  yellowish  hue.  In  this  work  the  word 
icterus,  in  conformity  with  its  etymologic  derivation  (from 
lyTfpog,  jaundice),  will  be  taken  as  synonymous  with  jaundice 
and  as  being  free  of  any  implication  that  the  discoloration  is  of 
biliar>%  hepatic,  or  other  origin. 

Icterus  or  jaundice  may  be  caused : 

1.  By  retention  and  reabsorption  of  the  bile  and  of  the  normal 
biliary  pigments :    Hepatic  jaundice. 

2.  Through  a  special  change  in  the  blood  (hemolysis)  :  Hematic 
(hemolytic)  jaundice. 

3.  Through  a  special  kind  of  intoxication  (picric  acid)  :  Picric 
jaundice. 

I.— HEPATIC  JAUNDICE. 

Hepatic  jaundice,  dependent  upon  retention  and  reabsorption  of 
bile  and  biliary  pigments,  is  that  which  displays  in  its  greatest  inten- 
sity the  well-known  symptom-group  of  jaundice  with  its  cardinal 
symptoms,  viz,,  jaundice  of  the  skin  and  conjunctivae  and  urinary 
jaundice  (from  canary  yellow  to  mahogany  color,  with  more  or  less 
pronoimced  decolorization  of  the  stools),  and  its  associated  symp- 
toms due  to  bile  intoxication,  viz.,  slow  pulse,  itching,  loss  of  weight, 
depression,  oozing  of  wounds,  etc. 

It  should  be  at  once  pointed  out  that  this  classical  symptom- 
group,  which,  as  we  shall  see,  is  of  markedly  variable  origin,  ex- 
hibits a  diminishing  degree  of  intensity  of  the  jaundiced  color 
of  the  skin,  conjunctivae,  and  urine  in  the  following  three  classes 
of  cases : 

Maximum  intensity:  Cholelithiasis,  cancer  of  the  pancreas, 
and  chronic  obstruction  of  the  bile  duct. 

(1119)  ' 


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1120  SYMPTOMS. 

Intermediate  intensity:  Catarrhal  jaundice,  benign  infectious 
jaundice,  and  picric  jaundice^ 

Minimum  intensity:  Infectious,  cirrhotic,  syphilitic,  and 
hemolytic  forms  of  jaundice. 

Hepatic  jaundice  may  be  the  result  either  of  an  obstruction  or 
impediment  to  the  flow  of  bile  or  of  disease  of  the  hepatic  lobules  or 
dyshepatia. 

Intrinsic  (Intracanaliculobiliary)  Causes  of  Obstruction. — 
Cholelithiasis,  affecting  the  gall-bladder,  but  more  particularly 
the  biliary  canal  or  bile-duct,  is  by  far  the  most  important  among 
the  possible  causes  of  jaundice;  tenderness  of  the  gall-bladder, 
acute  attacks  suggestive  of  hepatic  colic,  and  the  history  will 
generally  point  directly  to  the  diagnosis. 

Catarrhal  jaundice  comes  next,  with  its  usual  accompaniment 
of  febrile  gastric  disturbance  and  running  its  course  in  one  or 
two  weeks;  as  a  rule  the  diagnosis  of  these  cases  occasions  no 
difficulty. 

Exceptionally  there  have  been  reported  instances  of  foreign 
bodies  that  had  passed  out  through  the  walls  of  the  intestine  (fruit 
stones,  grape  seeds,  and  parasitic  ascarides  or  hydatid  disease) ;  in 
such  cases  the  diagnosis  can  be  made  only  as  an  unexpected  finding 
during  an  operation  or  at  the  autopsy.  In  the  case  of  a  cicatricial 
stenosis  following  duodenal  ulcer,  the  diagnosis  would  be  made  on 
the  basis  of  the  history  and  the  symptoms  of  duodenal  disease. 

Extrinsic  (Extracanalicular)  Causes  of  Obstruction. — 1.  Out- 
side  of  the  liver:  Usually,  cancer  of  the  head  of  the  pancreas, 
which  is  by  far  the  commonest  cause  of  jaundice  of  extrahepatic 
origin.  Exceptionally :  Secondary  tuberculous  or  malignant  gland- 
ular involvement  at  the  hilum  of  the  liver,  peritoneal  bands,  ad- 
hesions of  the  biliary  channels,  lower  hepatic  surface  and  colon  on 
the  right  side,  tumors  of  the  kidney,  and  aneurysm  of  the  abdominal 
aorta. 

2.  Within  the  liver:  Cancer  of  the  biliary  ducts  and  liver, 
hepatic  abscess,  and  cysts  of  the  liver. 

Disease  of  the  lobules  of  the  liver,  or  dyshepatia,  may  result 
from  some  intoxication  or  infection  acting  injuriously  upon  the  liver 
cells.  It  is  generally  manifest  in  the  lengthy  chain  of  infectious 
jaundiced  states,  a  mere  enumeration  of  which  will  here  suffice : 


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JAUNDICE,  1121 

Catarrhal  jaundice,  simple  or  prolonged,  always  benign,  and 
occurring  sporadically  and  indigenously. 

Benign  infectious  jaundice,  or  pseudocatarrhal  infectious  icterus. 

Pleiochromic  jaundice. 

Recurring  infectious  jaundice. 

Grave  icterus,  usually  secondary  to  some  pre-existing  liver  dis.- 
turbance,  such  as  cirrhosis,  etc.,  or  to  an  infectious  disease,  such  as 
typhoid  fever,  staphylococcic  infection,  malaria,  etc.;  exceptionally 
as  a  primary  disorder,  as  in  phosphorus  poisoning,  yellow  fever, 
icterohemorrhagic  spirochetosis,  etc. 

This  type  of  jaundice  is  essentially  characterized  clinically  by 
a  certain  symptomatic  triad,  viz.,  (1)  jaundice;  (2)  typhoid  state, 
and  (3)  various  sorts  of  hemorrhage.  According  to  the  kind  of 
case  the  condition  may  be  attended  with  hypothermia,  as  in 
colon  bacillus  infection  and  phosphorus  poisoning,  or  with  fever, 
as  in   yellow  fever  and  staphylococcic  or  streptococcic  infection. 

Larrey,  in  his  Memoires,  already  wrote  of  an  "icteroid  typhus" 
which  assailed  the  troops  of  the  Army  of  Egypt  in  1800.  Dur- 
ing the  War  of  the  Rebellion,  over  70,000  American  soldiers  be- 
came afflicted  with  jaundice.  More  recently,  in  Macedonia,  the 
belligerent  armies  developed  many  cases  of  grave  malarial 
bilious  fever  (intermittent  bilious  fever,  hemorrhagic  bilious 
fever,  hemoglobinuric  bilious  fever,  etc.). 

Special  mention  may  here  be  appropriately  made  of  an  appar- 
ently primary  variety  of  infectious  jaundice  which  has  only  of  late 
come  to  notice.  It  is  manifested  in  a  recurring  febrile  infectious 
jaundice,  ordinarily  accompanied  by  myalgia  and  hemorrhage,  and 
brought  on  by  a  spirochete  discovered  and  studied  in  1913-1915  by 
two  Japanese  authors,  Inada  and  Ido,  whence  the  term  ictero- 
hemorrhagic spirochetosis  now  generally  applied  to  the  disease. 

This  form'  of  infectious  jaundice,  often  a  grave  disorder,  is 
probably  identical  with  Larrey's  icteroid  typhus,  with  the  epi- 
demic remittent  bilious  fever  of  Laveran,  and  with  the  idiopathic 
grave  icterus  of  Kelsch. 

It  is  manifested  in  a  symptom-group  characterized  by  sudden 
onset,  high  fever  (39-40**  C),  a  pronounced  typhoid  state,  a  pro- 
gressive jaundice  of  variable  intensity,  pains  in  the  extremities, 
myalgia  (especially  in  the  thighs  and  calves),  and  joint  pains, 

71 


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1122  SYMPTOMS. 

albuminuria,  and  a  progressive  azotemia  which  may  attain  to  a 
very  high  degree.  In  one  of  our  fatal  cases,  the  azotemia  ulti- 
mately rose  to  6.80.  The  provisional  diagnosis  of  spirochetosis 
can  be  definitely  established  only  by  microscopic  examination 
for  the  causative  germ. 

As  a  matter  of  fact,  icterohemorrhagic  spirochetosis  may  ex- 
hibit any  grade  of  severity,  from  the  form  suggesting  catarrhal 
jaundice  to  that  representing  grave  icterus.  On  the  whole  one 
may,  however,  make  out  three  stages  in  the  course  of  the  disease : 
(1)  A  preicteric  stage,  with  predominance  of  constitutional  symp- 
toms ranging  from  simple  diffuse  pains  to  continuous  fever  sug- 
gesting typhoid;  (2)  an  icteric  stage,  with  more  or  less  in- 
tense and  persistent  jaundice  and  almost  constant  albuminuria; 
(3)  a  stage  of  slow  restoration,  with  gradual  return  to  normal, 
or,  on  the  contrary,  aggravation  of  the  disease  vrith  progressive 
azotemia  and  a  fatal  termination. 

A  positive  diagnosis  manifestly  requires  examination  for  the 
spirochete.  Its  presence  is  best  demonstrated  by  guinea-pig  in- 
oculations. Into  one  guinea-pig  5  cubic  centimeters  of  blood  are 
injected  and  into  another,  5  cubic  centimeters  of  urine.  Where 
the  result  is  positive,  the  animal  dies  in  about  a  week,  exhibiting 
a  yellow  color  of  the  scler3e,  ears,  and  mucous  membranes,  and 
bile  pigment,  albumin,  and  spirochetes  in  large  numbers  in  the 
urine  and  in  sections  of  internal  organs. 

In  hepatic,  mechanical  jaundice  of  the  retention  type,  the  bile 
pigments  retained  in  the  blood  and  passing  out  in  the  urine  are  nor- 
mal bile  pigments  (see  Technical  procedures) ,  and  the  icterus  may 
be  said  to  be  orthopigmentary. 

In  infectious,  dyshepatic  jaundice,  the  result  of  cell  disturbance 
and  pathologic  change,  the  bile  pigments  retained  in  the  blood  and 
passing  out  in  the  urine  are  normal  as  well  as  abnonnal  bile  pig- 
ments (see  Technical  procedures),  and  the  icterus  may  be  said  to 
be  metapigmentary, 

XL— HEMATIC  JAUNDICE. 

The  hematic  forms  of  jaundice,  mainly  dependent,  apparently, 
upon  some  disturbance  of  the  blood,  or  at  least  accompanied  and 
characterized  by  such  a  disturbance,  were  already  clearly  discerned 


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JAUNDICE.  1123 

in  the  eighteenth  century.  Bianchi's  concise  reference  to  the  matter 
(1710),  quoted  by  Boix,  leaves  no  room  for  doubt  in  this  connec- 
tion: **Sunt  duo  primaria  icteri  genera:  prima  classis  icterus  e 
tntio  hepatis,  alterius  speciei  uteri  a  causa  solutiva  sanguinis."  The 
profound  studies  of  Giibler  on  hemapheic  icterus  are  well-known  to 
all.  The  subject  has,  however,  in  late  years  been  completely  recast, 
thanks  particularly  to  the  labors  of  the  French  clinicians  Chauffard, 
Gilbert,  Widal,  and  their  followers  on  the  hemolytic  forms 
of  icterus.. 

Clinical  characteristics  of  hemol3rtic  icterus : 

1.  Jaundice  generally  of  slight  or  intermediate  intensity. 

2.  Coloration  of  the  stools. 

3.  Hemapheic  character  of  the  urine  (see  Urine)  :  Absence  of 
true  bile  pigments,  presence  of  urobilin  (acholemic,  orthopigmentary 
jaundice). 

4.  Absence  of  the  ordinary  signs  of  bile  intoxication,  in:^.,  ab- 
sence of  slow  pulse,  itching,  xanthelasma,  and  loss  of  weight. 

Characteristics  referable  to  the  blood: 

1.  Anemia. 

2.  Lowered  resistance  of  the  red  cells  (hemolytic  reaction). 

3.  Granular  red  cells  and  autoagglutination  of  these  cells. 
Clinical   varieties    (the    least    obscure    ones)    of   hemolytic 

icterus : 

1.  Congenital,  familial  hemolytic  jaundice  (Gilbert's  familial 
cholemia;  Chauffard's  congenital  icterus  of  the  adult).  As  a  mat- 
ter of  fact,  all  cases  of  congenital  icterus  in  the  adult  should  be 
presumed  to  be  of  non-hepatic  origin. 

2.  Acquired  hemolytic  jaundice:  Simple  jaundice  of  the 
newborn,  simple  post-infectious  hemolytic  jaundice,  hemolytic 
jaundice  of  the  type  of  pernicious  anemia,  and  the  jaundice  of 
idiopathic  paroxysmal  hemoglobinuria.  ^ 

III.— PICRIC  JAUNDICE. 

Picric  jaundice  results,  as  the  term  implies,  from  picric  intox- 
ication, by  the  ingestion  of  picric  acid.    It  is  characterized : 

1.  By  a  yellow,  icteric  hue  of  the  skin,  conjunctivae  and  urine. 

2.  By  coloration  of  the  stools. 


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1124  SYMPTOMS. 

3.  By  the  usual  absence  of  bile  pigments  from  the  urine  and 
blood  serum,  picric  acid  being,  however,  present  in  these  fluids  (see 
Uranalysis). 

4.  By  the  usual  absence  of  the  classic  signs  of  bile  intoxication, 
vi::.,  by  the  absence  of  slow  pulse,  itching,  and  loss  of  weight. 

The  procedure  described  by  Castaigne  and  Desmoulins,  which 
permits  the  detection  of  picric  acid  in  the  serum  of  patients  with 
jaundice,  is  particularly  serviceable  by  reason  of  its  simplicity, 
reliability,  and  speed:  Fifteen  to  20  cubic  centimeters  of  blood 
are  collected  by  wet  cupping  or  vein  puncture  and  placed  in  a 
test-tube.  An  equal  volume  of  a  25  per  cent,  aqueous  solution 
of  trichloracetic  acid  is  added.  The  tube  is  then  closed  with  the 
thumb  and  thoroughly  shaken,  the  mixture  poured  on  an  ordinary 
pleated  filter,  and  the  filtrate  collected  in  a  well  cleaned  test-tube. 

In  the  absence  of  picric  acid  the  filtrate  is  clear  and  colorless. 

The  presence  of  picric  acid  is  shown  by  a  yellow  picric  tint 
of  varying  intensity  upon  inspection  against  a  white  background. 

IV.— SYPHILITIC  JAUNDICE  AND  JAUNDICE  DUE 
TO  ARSPHENAMIN. 

The  relative  frequency  of  jaundice  occurring  during  arsphenamin 
treatment  has  led  to  the  publication  of  many  contributions  on  the 
subject  which  are  rather  contradictory,  some  considering  the  jaun- 
dice as  a  syphilitic  jaundice  or  hepato- recurrence  awakened  by  the 
treatment  and  amenable  to  more  intensive  medication,  while  others 
look  upon  it  as  a  toxic  arsenical  jaundice. 

In  truth,  it  would  seem  most  extraordinary  if  the  drugs  of  the 
arsphenamin  series  were  the  only  arsenical  compounds  which  might 
not,  in  high  dosage,  act  prejudicially  on  the  liver,  and  certainly 
nothing  is  less  definitely  proven  at  the  present  time  than  that  arsen- 
ical treatment  is  indicated  and  effectual  in  these  cases.  For  the 
present  it  seems  prudent  to  consider  the  jaundice  which  occurs  un- 
der these  conditions  as  of  toxic,  arsenical  nature,  and  to  interrupt  the 
treatment  or  replace  it  by  mercurial  medication. 

As  for  chronic  jaundice,  it  should  be  recalled  that  Hanot's  syn- 
drome and  the  hemolytic  types  of  jaundice  particularly  call  for  a 
search  for  acquired  syphilis  in  the  former  case  and  for  syphilis  or 
inherited  syphilis  in  the  latter. 


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JAUNDICE.  1125 

V.~R£LATIV£  FREQUENCY  OF  THE  SEVERAL 
FORMS  OF  JAUNDICE 

Clinically,  the  order  of  frequency  of  the  several  vareties  of 
jaundice  above  mentioned  appears  to  be  as  follows: 

Infectious  jaundice,  ranging  from  catarrhal  to  grave. 

Cholelithiasis,  simple  or  with  complications. 

Hemolytic  icterus. 

Tumors  of  the  liver. 

Cirrhosis  and  syphilis  of  the  liver. 

Cancer  of  the  pancreas  and  biliary  tract,  etc.  (extrahepatic 
tumors). 

Abscess  and  hydatid  cyst. 

Picric  jaundice. 

Consideration  of  the  differential  diagnosis  of  jaundice  in  the 
subjoined  table  will  be  limited  to  the  varieties  just  given. 


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1126 


SYMPTOMS. 


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JOINT  PAINS. 

ARTHRALGIA. 

RHEUMATISM. 


(>6VfMrv(yfi6g^  from  (>ev[ia,  flux. 
Rheumatism. 


Pains  in  the  joints  (arthralgia)  occur  so  often,  in  such  a  va- 
riety of  situations,  and  in  so  many  forms  that  an  analytic  and 
synthetic  presentation  of  the  subject  would  seem  to  be  almost 
an  impracticable  task,  particularly  since  it  brings  up  the  ques- 
tion, as  yet  obscure  in  many  respects,  of  "rheumatism."  Hence 
the  author's  belief,  departing  from  the  plan  followed  in  other 
chapters  of  this  work,  that  it  is  best  here  not  to  analyze  the 
"innumerable  and  protean  joint  disturbances,"  but  to  arrange 
them  in  logfical  grouping's  from  the  standpoint  of  pathologic  phy- 
siology and  to  recall  the  general  clinical  rules  which  permit  of 
the  makmg  of  a  concrete  diagnosis  in  these  cases. 

To  give  an  idea  of  the  frequency  with  which  the  term  "rheu- 
matism" is  improperly  applied  to  the  most  varying  clinical  con- 
ditions, one  need  merely  recall  the  figures  published  by  Deaderick, 
analyzingi  100  cases  labelled  "rheumatism"  and  detecting  53 
mistaken  diagnoses  which  were  grouped  thus: 

Eighteen  cases  of  syphilis  with  positive  Wassermann  reaction, 
8  cases  of  neuritis,  4  cases  of  tuberculosis,  4  of  flat  foot,  2  of 
neurasthenia,  2  of  arteriosclerosis,  2  of  tabes  dorsalis,  1  of  chronic 
nephritis,  1  of  chronic  gastritis,  1  of  progressive  muscular 
atrophy,  1  of  malaria,  1  of  pernicious  anemia,  and  1  of  myelitis. 

Joint  Pains. — Rheumatism. — Whereas  practically  definite 
pathologic  and  clinical  concepts  are  expressed  in  the  terms  dia- 
betes, gout,  and  obesity,  this  is  far  from  being  the  case  with  the 
term  rheumatism.  Usage  has  given  to  this  word  a  vague,  inac- 
curate, extremely  defective  meaning  because  it  is  far  too  com- 
prehensive ;  this  term  we  shall  accept,  however,  without  attempt- 
ing useless  explanations  of  it,  the  essentially  practical  aim  of  the 
work  making  it  necessary  to  exclude  all  hair-splitting  and  fruit- 
less terminologic  discussions. 
(1128) 


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JOINT  PAINS.       ARTHRALGIA.       RHEUMATISM.      1129 

Medical  men  are  constantly  speaking,  then,  of  acute  articular 
rheumatism,  of  gonorrheal  rheumatism,  of  tuberculous  rheumatism, 
of  gouty  rheumatism,  of  deforming  rheumatism,  of  trophoneurotic 
rheumatism,  of  muscular  rheumatism,  etc.  There  is  no  doubt  that  it 
would  be  much  better  to  use  in  most  instances  strictly  concrete  and 
determinate  pathologic  terms  such  as  arthritis,  osteoarthritis,  neu- 
ralgia, myalgia,  etc.,  following  them  with  special  qualifying  words 
such  as  gouty,  gonococcic,  tuberculous,  saturnine,  traumatic,  etc., 
and  to  make  of  the  qualifying  term  rheumatic  itself  a  specific  desig- 
nation applying  to  certain  relatively  well  defined  clinical  entities 
such  as  acute,  frank,  rheumatic  multiple  arthritis,  or  progressive, 
deforming,  rheumatic  multiple  arthritis.  Yet,  we  repeat,  nosologic 
usage  has  already  settled  the  matter  otherwise  and  has  given  to  the 
term  rheumatism  the  very  vague  signification  of  a  disorder  charac- 
terised especially  by  pains  in  the  joints;  we  shall  accept  it  thus, 
faulty  as  it  is — and  all  the  more  willingly  since  in  practical  work  the 
often  difficult  question  of  diagnosis  between  most  varied  sorts  of 
joint  disturbance,  infectious  and  metabolic,  is  continually  arising 
and  it  seems  useful  and  eminently  practical  to  attempt  a  compre- 
hensive classification  and  general  review  of  the  clinical  features  of 
the  joint  disorders  most  commonly  encountered. 

To  find  and  keep  to  the  proper  path  in  the  maze  of  joint  dis- 
turbances, it  is  necessary  to  refer  back  to  the  etiology  whenever 
the  pathogenic  cause  of  the  condition  can  be  determined.  This 
is,  of  course,  not  always,  nor  even  often,  the  case;  hence  the 
need  of  accepting,  in  lieu  of  a  better  one,  the  following*  hybrid 
classification,  based  partly  on  the  etiology  and  partly  on  the 
clinical  features. 

I.  Acute  joint  disorders. 

A.  Acute  articular  rheumatism. 

B.  Infectious  pseudorheumatism,  or  better,  infectious  arthritis 
{ordinary  joint  infections,  or  specific,  toxic-infectious  disorders)  : 

gonorrheal,  miscellaneous    (post-influenzal, 

tuberculous,  post-pneumonic,      puerperal, 

syphilitic,  post-anginal,      post-typhoid, 

scarlatinal,  etc.). 

polymicrobic, 


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1130  SYMPTOMS. 

C  Acute  gouty  arthritis. 

II.  Chronic  arthritides. 

A.  Chronic  gouty  arthritides, 

B.  Generalised  chronic  rheumatism, 

(a)  With  erratic  manifestations  (articular,  muscular,  neural- 
gic, etc.). 

(&)  With  local  manifestations  (Heberden's  nodes,  campto- 
dactylia,  drumstick  fingers,  rhizomclic  spondylosis,  etc.). 

(c)  Progressive  deforming  rhetunatic  polyarthritis  (nodular 
rheumatism). 

C.  Arthritis  deformans,  mono-  or  oHgo-  articular. 

III.  Trophoneurotic. — Neurotrophic. 

(a)  Joint  disorders  following  neuritus  (z(ma),  myelitis  (tabes), 
encephalopathy  (hemiplegia),  etc. 

(&)  Amyotrophic  arthropathies  due  to  spinal  lesion,  the  latter 
either  primary  or  secondary  to  the  reaction;  of  the  joint  inflammation 
upon  the  neuraxis. 

(c)  Generalized  dystrophy. 

IV.  Traumatic. 

(Sprains,  fractures  near  joints,  wounds,  and  foreign  bodies.) 
The  latter  group  is  of  interest  in  this  connection  only  when 
the  traumatism  results  in  local  infectious  or  nutritional  disturb- 
ance. 

The  above  simple  classification  is  of  real  practical  service ;  it 
is  sufficiently  clinical  in  type  and  seems  deserving  of  recommen- 
dation provided  its  somewhat  restricted  scientific  basis  is  always 
kept  in  mind.  In  other  words,  clinical  use  of  this  tabular  scheme 
necessitates  familiarity  with  the  three  following  clinical  laws: 

I.  There  is  not  necessarily  any  relationship  between  the  cause 
of  a  joint  disturbance  and  its  clinical  modality. — ^Thus,  gonor- 
rheal joint  disease  may  occur  in  any  of  the  following  forms : 
Acute  febrile  arthritis  (gonorrheal  rheumatism). 
Suppurative  arthritis. 
Plastic,  fibrous,  ankylosing  polyarthritis. 
Again,  tuberculous  joint  disease  may  occur  as: 
Acute  febrile  arthritis  (tuberculous  rheumatism). 


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JOINT  PAINS.       ARTHRALGIA.       RHEUMATISM.       1131 

Subacute  serous  arthritis  (hydrarthrosis). 

Suppurative  osteoarthritis  (white  swelling). 

Fibrous,  ankylosing  osteoarthritis. 
Even  the  term  tuberculous  arthritism  has  been  used  by  some. 
Consequently : 

II.  A  given  clinical  type  of  joint  disturbance  may  result  from 
different  pathogenic  causes. — Thus,  progressive  deforming  poly- 
arthritis may  be  the  end-result  of  acute  rheumatism,  of  gonococcic 
infection,  of  tubercle  bacillus  infection,  and,  even  more  frequently,  of 
as  yet  imperfectly  defined  causes,  among  which  are  mentioned  pre- 
eminently exposure  to  cold  and  dampness  and,  as  a  subsidiary  fac- 
tor, thyroid  insufficiency. 

Again,  acute  exudative  febrile  arthritis  may  be  brought  on,  ordi- 
narily by  acute  rheumatism,  rather  frequently  by  gonococcic  infec- 
tion, exceptionally  by  tubercle  infection,  etc. 

III.  There  is  no  definite  line  of  demarcation  between  the  three 
t3rpes  of  joint  disturbance  (toxic-infectious,  dyscrasic,  and  neuro- 
trophic).— Or  at  least,  if  a  few  perfectly  definite  clinical  species 
do  exist,  such  as  acute  rheumatism,  the  gouty  arthropathies,  and 
rhe  tabetic  arthropathies,  most  of  the  above  mentioned  clinical 
species,  of  obscure  and  diverse  etiology,  do  not  constitute  definite 
clinical  identities,  but  mere  syndromes  which  may  be  brought  on 
by  different  pathogenic  causes  [toxic-infectious,  humoral  (ex- 
ogenous and  endogenous),  or  neurotrophic]. 

Further,  it  is  readily  conceived  that  some  toxic-infectious  dis- 
order, reacting  upon  the  functions  of  the  endocrin  glands,  for 
example,  or  upon  the  neurotrophic  cells,  might  actually  bring  about 
the  humoral  or  trophoneurotic  degenerative  changes  which 
are  recognized  or  suspected  as  being  at  the  bottom  of  the  major- 
ity of  the  so-called  diathetic  chronic  joint  disorders — ^the  various 
forms  of  chronic  rheumatism. 

As  in  the  case  of  diabetes  or  obesity,  one  is  led,  then,  to  the  con- 
ception of  chronic  rheumatism  as  a  trophoneurotic  clinical  syndrome 
affecting  particularly  the  joints,  of  toxic-infectious  or  dyscrasic 
origin,  these  tzvo  pathogenic  factors  being  present  either  separately, 
in  combination,  or  as  a  subordinate  cause. 

On  the  whole,  the  joint  tissues  react,  whatever  pathogenic 
agent  they  may  be  subjected  to,  in  but  a  few  ways,  vu:.,  pain, 


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1132  SYMPTOMS. 

congestion,  inflammation,  serous  exudation,  suppuration,  and 
fibrosis. 

Any  joint  disorder,  of  whatever  cause  (traumatic,  infectious, 
dyscrasic,  or  nervous)  may  pass  through  three  distinct  stages: 
Acute  stage,  chronic  stage,  and  stage  of  deformity. 

Some  forms  stop  in  the  acute  stage,  as  is  generally  the  case 
in  rheimiatic  fever;  others  in  the  chronic  stage,  as  is  frequently 
the  case  in  tuberculous  arthritis ;  a  few  begin  in  an.  acute  stage 
and  terminate  in  the  deforming  stage,  as  is  frequently  the  case  in 
gonorrheal  joint  disease;  certain  disturbances,  moreover,  cause 
deformity  from  the  start,  as  in  nodular  rheumatism.  All  these 
varieties  are  commonly  met  with. 

The  disease  may  attack  from  the  start  or  in  succession  the 
synovial  membrane,  the  periarticular  aponeuroses,  the  muscles 
and  tendons  in  the  vicinity  of  the  joint,  the  periarticular  bony 
surfaces,  the  nerves,  and  the  marrow ;  all  the  tissues,  in  fact,  in- 
cluding the.  skin,  cellular  tissues,  and  vessels,  may  undergo  tro- 
phoneurotic degeneration — a  matter  of  common  observation  in 
chronic  forms  of  rheumatism. 

It  seems  not  inappropriate  here  to  present  an  excerpt  from 
the  communication  of  P.  Le  Gendre  to  the  Academic  de  medecine 
on  May  9,  1911,  regarding  the  pathogenesis  and  prophylaxis  of 
the  so-called  "rheumatic"  affections: 

To  explain  the  origin  of  the  rheumatic  disorders  and  their  re- 
crudescences, it  is  necessary  to  bring  in  two  parallel  series  of 
factors,  zns.,  (1^  the  intoxications  and  toxic-infectious  states,  and 
(2)  faulty  hygiene  of  the  locomotor  apparatus. 

The  latter  might  be  said  to  be  the  initial  and  primary  factor, 
producing  a  favorable  soil  for  the  activities  of  the  former;  it 
would  thus  underlie  the  entire  clinical  history  of  rheumatism  in 
all  its  forms,  both  those  set  apart  under  the  term  pseudorheuma- 
tism,  and  the  gradually  decreasing  number  which  are  still  con- 
sidered instances  of  true  rheumatism. 

In  the  case  of  the  latter,  Bouchard,  through  his  studies  of  their 
concurrence  with  other  morbid  conditions,  brought  out  their  rela- 
tionship ivith  the  diseases  due  to  slowing  of  the  nutritive  process, 
such  as  obesity,  diabetes,  gout,  migraine,  calculous  disorders,  asthma, 
etc.,  and  with  the  so-called  arthritic  diseases.    This  implies  that  they 


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JOINT  PAINS,       ARTHRALGIA.       RHEUMATISM.       1133 

are  likewise  dependent  upon  arthritism — the  bradytrophic  diathesis 
of  Landouzy,  or  dystrophic  diathesis,  if  one  uses  the  term  proposed 
by  Fernet  This  relationship  seems  also  to  be  shown  by  clinical 
observation  of  the  post  histories  of  the  patients  themselves  and  their 
family  histories. 

Might  one  not  conceive  of  this  relationship,  however,  as  being  the 
result  of  the  influence  of  faulty  hygiene  of  the  locomotor  apparatus 
upon  general  nutrition? 

It  is  impossible  that  an  apparatus  of  such  importance  in  the 
living  system  should  not  play  a  very  prominent  role  in  the  ac- 
tivity of  interstitial  metabolism.  In  it,  along  with  the  digestive 
tract  and  the  nervous  system,  are  to  be  found  the  three  great 
sources  of  nutritive  disturbances — acting  through  different 
mechanisms  but  frequently  in  combination. 

A  diet  which  is  defective  through  excess  or  improper  selection 
of  foods,  imperfect  elaboration  of  the  latter  owing  to  impaired 
digestive  functions,  autointoxication  by  poisons  of  gastrointestinal 
origin  resulting  from  prolonged  stasis  of  the  digestive  residue  in 
one  or  another  portion  of  the  alimentary  tract  (dilatation  of  the 
stomach,  dyspepsia  with  ileocecal  stasis,  and  coprostasis  either  of 
liquid  or  solid  matters  in  the  colon),  and  defective  functioning  of 
the  liver — ^these,  doubtless,  are  the  causes  of  arthritism. 

An  excessive,  disturbed  functioning  of  the  nervous  system,  in- 
hibiting tissue  metabolism  or  secretion  by  the  endocrin  glands  which 
supply  the  ferments  indispensable  for  such  metabolism,  should  also 
be  taken  into  account  in  the  production  of  certain  arthritic  diseases, 
and  it  has  been  necessary  to  appeal  to  it  in  the  pathogenesis  of 
obesity,  of  diabetes,  and  of  gout,  according  as  the  metabolic  proc- 
esses concerned  were  those  of  fat,  sugar,  or  uric  acid  production,  or 
fat,  sugar,  or  uric  acid  de3truction. 

As  a  counterpart  to  these  factors,  we  shall  accept  the  view  that 
there  occurs  also  a  group  of  disorders  characterized  by  slowed 
nutrition  which  is  dependent  upon  a  primary  disturbance  of  the 
locomotor  apparatus  and  that  it  is  this  disturbance  which  is  at  the 
bottom  of  the  so-called  true  rheumatic  disorders — predisposing  the 
various  constituent  parts  of  this  apparatusi  to  become  unduly  sensi- 
tive to  cosmic  factors  as  well  as  to  endogenous  toxic  influences,  and 


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1134  SYMPTOMS, 

to  react  against  them  by  such  manifestations  as  pain,  hyperemia, 
exudation,  or  proliferation. 

Perhaps  this  dystrophic  state  of  the  serous,  fibro-connective, 
osteo-cartilaginous,  and  muscular  systems  also  predisposes  them 
to  being  more  easily  injured  by  exogenous  bacterial  or  toxic 
attacks  and  to  reacting  against  the  latter  by  various  local  changes 
which  may  progress  to  the  point  of  actual  suppuration. 

Among  the  characteristic  effects  of  the  bradytrophic  diathesis 
is  an  excessive  sensitiveness  of  the  vasomotor  system;  as  Cazalis 
and  Senac  have  stated,  it  is  a  congestive  diathesis,  which  favors 
hyperemia,  edema,  and  oversecretion ;  it  also  exhibits  an  exces- 
sive tendency  to  painful  manifestations  or  algias.  Thus,  it  carries 
with  it  a  tendency  to  react  excessively  to  cosmic  factors  in  the 
production  of  congestion,  edema,  and  exudation  in  the  serous 
membranes  of  the  joints  and  the  synovial  coverings,  and  to  trans- 
late into  pain  all  functional  disturbances  of  the  various  constitu- 
ent parts  of  the  locomotor  apparatus. 

To  recapitulate,  the  motor  apparatus  contributes  in  two  re- 
spects to  the  general  functioning  of  the  system. 

Through  its  serous  membranes,  connective  and  fibrous  tissues, 
and  marrow  tissue,  it  constitutes  a  part  of  the  connective  tissue, 
lymphatic,  and  leucocytic  defensive  system;  it  serves  as  a  locus  for 
the  unloading  and  destruction  of  bacterial  agents  and  the  soluble, 
organic  or  mineral  poisons  of  bacteria. 

By  the  functioning  of  its  masses  of  muscle  tissue,  it  takes  part 
in  the  processes  of  nutrition;  it  uses  up  glycogen  and  forms  lactic 
acid  and  many  other  products  of  disintegration. 

From  the  first  of  these  standpoints,  it  is  destined  to  be  the  seat 
of  infectious  rheumatic  disorders,  or  pseudorheumatism. 

From  the  second  standpoint,  it  may  contribute  to  the  production 
of  the  bradytrophic  diathesis,  and  when  it  itself  takes  the  conse- 
quences of  the  latter,  becomes  the  seat  of  what  is  still  termed  true 
rheumatism,  with  the  associated  extraordinary  sensitiveness  to  cos- 
mic influences. 

Always  at  the  bottom  of  the  condition,  however,  is  faulty 
hygiene  of  the  motor  apparatus. 

This  pathogenetic  conception  is  perhaps  not  actually  a  new 
theory ;  it  is,  at  least,  a  more  comprehensive  interpretation  of 


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JOINT  PAINS.       ARTHRALGIA,       RHEUMATISM.       1135 

known  facts  and  current  views,  capable  of  serving  as  a  link  be- 
tween the  older  theories  which  are  only  apparently  in  disaccord — 
it  is  thus  a  common  meeting-ground  for  purposes  of  conciliation. 

It  offers  the  particular  advantage  of  serving  as  a  basis  for 
therapeutic,  and  especially  prophylactic,  indications. 

In  the  prophylaxis  of  the  arthritic  dystrophy  and  of  the  nu- 
tritive diseases — apart  from  the  regulations  concerning  dietetic 
hygiene,  so  much  emphasized,  and  justifiably  so,  in  modem  con- 
tributions, and  apart  from  the  hygiene  of  the  nervous  system, 
which  has  been  rather  more  neglected — highly  important  indica- 
tions appear  to  the  author  to  be  as  follows : 

1.  One  should  regulate  the  hygiene  of  the  motor  apparatus  with 
the  greatest  care,  beginning  in  early  childhood,  in  all  children,  but 
more  especially  those  the  offspring  of  rheumatic  individuals.  There 
should  be  sufficient,  but  never  excessive — ^particularly  regular — daily 
exercise  of  all  the  motor  structures. 

2.  One  should  place  these  structures  in  a  state  of  defence  against 
cosmic  agencies,  particularly  exposure  to  cold,  by  a  systematic,  pro- 
gressive training  toward  tolerance  of  cold,  by  stimulation  of  the 
skin  functions.  Instead  of  defending  one's  self  passively  against 
cosmic  influences,  it  is  better  to  activate  the  play  of  the  vasomotor 
reflexes  and  skin  excretions  by  dry  rubbing  or  rubbing  with  alcohol, 
cold  affusions,  and  hydrotherapy  of  the  "hardening"  type. 

Again,  when  the  rheumatic  tendency,  i.e.,  the  state  of  lowered 
resistance  of  the  motor  apparatus  to  cosmic  agencies  and  endogen- 
ous onslaughts,  has  actually  shown  itself,  one  should  look  for  and 
overcome,  insofar  as  is  possible,  any  sources  of  infection  and  in- 
toxication which  the  body  may  be  harboring.  These  are  detected  by 
a  careful  clinical  study  of  the  functional  activities  of  the  digestive 
tract  and  the  annexed  glandular  organs,  the  nasopharyngeal  cavities, 
the  genital  organs,  and  the  endocrin  glands,  and  by  analysis  of  the 
blood  and  urine.  Though  there  are  rheumatic  subjects  with  excessive 
uric,  lactic,  or  oxalic  acidity,  there  appear  also  to  be  some  with 
lowered  acidity. 

Sources  of  intoxication  should  be  removed  by  the  use  of  the 
best  procedures  now  known ;  the  emunctories  should  be  assisted,  and 
insofar  as  is  practicable,  the  faulty  chemical  state  of  the  body 
fluids  should  be  corrected. 


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1136  SYMPTOMS. 

All  this  can  be  done  without  neglecting  the  use  of  remedies 
that  may  allay  the  rheumatic  symptoms  or  influence  the  patho- 
logic results  of  the  disorder — ^measures. selected  from  the  phar- 
maceutic realm  and  especially  from  physical  therapy. 

It  is  well  to  emphasize  again  the  marked  importance  of  look- 
ing for  some  chronic  or  subacute  focus  of  infection  in  the  pres- 
ence of  cryptogenic  joint  affections.  The  nasopharynx  and  teeth 
(caries  or  infectious  processes)  should,  in  particular,  be  investi- 
gated. In  the  course  of  a  study  of  1000  cases  of  acute  joint 
disturbance  more  or  less  closely  suggesting  acute  rheumatism, 
Lambert  {Jour,  Amer,  Med,  Assoc,  Apr.  10,  1920)  found  253  in- 
stances of  inflammation  of  the  nasopharynx  and  683  of  dental 
infection.  Such  infections  are  of  frequent  occurrence  in  chronic 
joint  disorders.  Indeed,  the  author  has  personally  seen  some 
cases  of  subacute  or  chronic  joint  involvement  clear  up  after  ap- 
propriate treatment  of  the  teeth  and  nasopharynx  had  been  given. 


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LOSS  OF  WEIGHT. 


The  body  weight  is  a  factor  of  considerable  clinical  import- 
ance. The  scales  are  to  be  thought  of  as  an  essential  piece  of 
medical  equipment,  as  necessary  as  the  clinical  thermometer. 
Along  with  the  blood-pressure  instrument,  they  constitute  the 


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Fig.  806.— Case  2500.    F.,  1860,  154  cm.    Loss  of  weight. 

thermometer  of  chronic  cases,  which  will  detect  many  instances 
of  as  yet  latent  functional  failure,  and  permit  of  accurately  trac- 
ing the  course  of  many  morbid  states. 

Experience  has  shown  that  for  each  individual  there  is  a  nor- 
mal weight  characteristic  of  health,  which,  in  the  event  of  perfect 
functional  equilibrium,  ranges  only  between  rather  restricted 
limits.  The  author's  normal  weight,  as  recorded  for  nearly  thirty 
years,  has  always  ranged  between  74  and  75  kilograms.  Below 
73,  there  appear  unquestionable  evidences  of  physical  and  mental 
weakness  (such  a  test  was  made  ten  times  in  the  course  of  re- 

72  (1137) 


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1138  SYMPTOMS. 

peated  reduction  cures)  ;  above  76,  manifestations  of  plethora 
develop. 

Theoretic  expressions  of  this  physiologic  body  weight  have 
been  vouchsafed,  the  simplest  of  which  consists  in  the  assump- 
tion that  the  normal  weight  is  equal  in  kilograms  to  the  number 


Fig.  807. — Case  252,  49  years,  160  cm.    Gradual  retrogression  In  a 
cardiorenal  case  with  good  compensation. 

of  centimeters  of  height  above  one  meter.  Thus,  for  a  person 
measuring  170  centimeters  it  would  be  70  kilograms,  and  for  one 
measuring  154  centimeters,  54  kilograms,  etc.^ 

Observation  shows  that  this  rule  is  correct  only  for  medio- 


1  One  hundred  centimeters  =  39.37  inches ;  one  kilogram  =  2.2046  pounds 
Avoirdupois. 


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LOSS  OF   WEIGHT. 


1139 


linear  individuals,  of  intermediate  morphologic  type,  i.e.,  persons 
the  ratio  of  whose  height  to  the  biaxillary  diameter  is  in  the 
neighborhood  of  5.8  (5.6  to  6),  as  in  the  subject  referred  to  below : 

(Case  3049).  Mediolinear,  IJ^  (5.85),  whose  normal  weight 
is  68  kilograms. 

In  a  brevilinear  or  stocky  individual,  with  a  broad  biaxillary 
diameter  and  in  whom  the  ratio  referred  to  is  below  5.6,  the 


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70 

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Fig.  808. — Case  467.    Cardio-arterio-renal  sclerosis. 

normal  weight  generally  exceeds  by  a  few  kilograms  the  figure 

obtained  by  the  preceding  calculation,  as  in  the  following  subject: 

(Case  399).     Brevilinear,  ^J^^-   (5.44),  whose  normal  weight 

31  cm. 

is  74  kilograms. 

In  a  longilinear  individual,  on  the  other  hand,  the  preceding 
ratio  being  above  6,  observation  of  subjects  in  a  state  of  perfect 
nutritive  equilibrium  yields  lower  figures,  as  in  the  following 
case: 

(Case  3207).  Longilinear,  Ms^  (6.20),  whose  normal  weight 
is  73  kilograms. 

These  three  concrete,  not  theoretic,  examples  point  clearly  to  the 
necessity  of  taking  into  account  at  least  the  vertical  and  transverse 


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1140  SYMPTOMS, 

measurements  in  calculating  theoretically  the  normal  weight  of  an 
individual. 

The  theoretic  normal  weight  of  a  subject  who  is: 

Mediolinear,  is  expressed  approximately  in  kilograms  by  the 
number  of  centimeters  by  which  his  height  exceeds  one  meter, 

Mediolinear:    Height,  170  centimeters  =  weight,  70  kilograms. 

Brevilinear :  May  exceed  the  above  figure,  the  correction  some- 
times reaching  one-tenth  of  the  whole. 

Brevilinear:  Height,  170  centimeters  =  weight,  70  to  77 
{70 +  f^)  kilograms. 

Longilinear:  Should  be  lower  than  the  figure  in  mediolinear 
subjects,  the  correction  sometimes  reaching  one-tenth  of  the  whole. 

Longilinear:  Height,  170  centimeters  =  weight,  70  to  63 
(70  — p  kilograms. 


Even  with  due  corrections,  however,  such  theoretic,  approxi- 
mate results  hold  good  only  in  subjects  who  are  nearly  normal; 
continued  concrete  observation  without  preconceived  notions 
leads  to  the  conclusion  that  in  individuals  with  inherited  con- 
stitutional defects  the  foregoing  rules  do  not  hold  good.  There 
are  some  constitutionally  lean  persons  whose  normal  weight  in 
a  state  of  physiologic  equilibrium  may  be  much  below  the  theo- 
retic figures  previously  mentioned ;  again,  there  are  constitution- 
ally stout  (obese)  persons  whose  normal  weight  may  be  decidedly 
above  these  figures.  One  of  the  author's  patients  (Case  2510), 
an  adult  (bom  in  1885),  an  unusually  longilinear  subject  with 
inherited  dystrophy  (g^™-.  Index :  7.05 !)  was  observed  to  vary 
from  52.8  to  61  kilograms.  He  could  never  be  brought  to  weigh 
more  than  61  kilograms.  This  is,  of  course,  a  subject  suffering 
from  constitutional  hyposphyxia,  asthenia,  varicose  vessels,  etc., 
with  a  diabetic  family  history. 

In  this  connection  one  might  discuss  the  ethnic,  familial,  and 
pathologic  factors  resulting  in  the  development  of  special  types 
of  constitution ;  such  a  discussion,  however,  would  lead  us  too 
far  afield. 


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LOSS  OF   WEIGHT.  1141 

Loss  of  weight  may  thus  constitute  a  favorable  process,  and 
one  which  the  therapeutist  will  seek  to  obtain  in  many  instances 
where  the  patient's  weight  is  above  normal  and  this  condition 
is  accompanied  by  pronounced  disturbances  such  as  plethora  and 
evidences  of  cardiovascular  inadequacy.    (See  Plethora.) 

At  this  point  mention  may  be  made  of  the  remarkable  rela- 
tionship generally  existing  between  the  body  weight  and  the 
blood-pressure.  In  a  high  pressure  case  (plethoric  or  cardiorenal) 
undergoing  improvement,  the  weight  and  blood-pressure  go  hand 
in  hand  (Figs.  806  and  807).  In  a  low  pressure  case  (anemia, 
asthenia,  and  certain  forms  of  hyposphyxia),  the  weight  and 
blood-pressure  rise  simultaneously.  This  is  a  point  both  of  prog- 
nostic significance  and  of  actual  practical  import. 

In  the  course  of  certain  cases  of  arteriosclerosis  the  corres- 
pondence of  the  weight  and  pressure  is  most  striking,  and  where 
this  correspondence  is  observed  to  cease,  the  weight  falling  while 
the  blood-pressure  is  rising,  certain  aggravation  of  the  sclerotic 
process  is  indicated  and  the  prognosis  rendered  less  favorable. 
This  condition  was  noted  in  the  case  represented  in  Fig.  808, 
which  was  under  observation  for  a  prolonged  period. 

In  short,  loss  of  weight  generally  goes  hand  in  hand  with  dinti- 
nution  of  blood-pressure,  and  gain  in  weight  with  elevation  of  blood- 
pressure  {at  least  in  well  compensated  subjects).  Lack  of  accord  in 
the  progression  of  these  two  factors  is  of  marked  prognostic 
significance. 


Loss  of  weight  is  a  very  common  clinical  event,  the  cause  of 
which  should  be  inquired  into  with  great  care.  Its  import  is 
sometimes  obvious,  as,  for  example,  in  the  case  of  an  individual 
whose  work  has  increased  while  the  amount  of  food  taken  has  dimin- 
ished. The  same  is  likewise  frequently  true  where  the  loss  of 
weight  is  accompanied  by  manifest  signs  of  some  disease,  such 
as  tuberculosis,  typhoid  fever,  acute  infections,  gastric  disorders, 
enteritis,  etc.  But  much  oftener  still,  a  careful  inquiry  to  ascer- 
tain the  cause  is  required. 

The  author  has  made  note  of  the  various  clinical  cases  which 
came  to  him  complaining  chiefly  of  loss  of  weight  which  had 


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1142  SYMPTOMS. 

excited  their  apprehension.    These  cases  may  be  classified  in  the 
following  groups,  given  in  the  order  of  frequency : 

1 .  Gastrointestinal  disorders,  and  more  particularly  the  frequent 
and  common  forms  of  atonic  (hyposthenic)  gastrointestinal  dyspep- 
sia and  acute  or  chronic  enteritis.  The  main  diagnostic  features 
connected  with  this  group  of  cases  will  be  found  in  the  section  on 
Dyspepsia, 

2.  Infections,  especially  those  of  tuberculous  and  influenzal 
nature,  and  secondarily  all  acute  or  chronic  infections  (choleroid 
states  and  typhoid  fever  at  one  extreme  and  syphilis  at  the 
other).  The  sequence  of  events  in  these  cases  is  too  obvious  to 
require  further  comment  than  the  following,  to  wit:  Where 
the  occasion  presents,  one  should  examine  systematically  for 
the  characteristic  evidences  of  the  infections  (auscultatory  signs, 
sputum  examination,  leucocyte  count,  temperature  curve,  etc.), 
and  carefully  avoid  making  the  least  premattwe  statement  involv- 
ing the  serious  risk  of  a  mistaken  diagnosis. 

3.  Depressive  psychoneuroses,  together  with  exophthalmic 
goiter  and  Addison's  disease.  During  the  course  of  the  year  1918, 
a  large  number  of  persons  sought  the  author's  advice  on  account  of 
loss  of  weight,  in  some  instances  very  marked,  e,g.,  8  to  12  kilo- 
grams (20  to  30  pounds)  or  more.  In  a  few  cases  food  restrictions, 
particularly  that  referring  to  bread,  seemed  to  be  the  main  cause. 
In  the  greatest  number  of  instances,  the  loss  of  weight  was  accom- 
panied by  numerous  evidences  of  general  depression  (insomnia, 
weakness,  exaggerated  emotivity,  pessimism,  despairing  thoughts, 
"cafard,"  etc.).  Examination  of  the  body  itself  yielded  practically 
negative  results,  revealing,  however,  a  reduction  of  blood-pressure 
which  was  often  very  pronounced.  The  anxiety  and  worries  under- 
gone in  that  trying  year  were  unquestionably  the  exciting  cause  of 
this  morbid  condition,  which  the  author  is  disposed  to  term  depres- 
sive psychoneurosis  with  impaired  nutrition  and  low  blood-pressure. 
All  these  patients  recovered  under  the  threefold  influence  of  tonic 
medication,  optimistic  psychotherapy,  and  the  final  triumphant  vic- 
tory of  the  Allied  cause. 

Exophthalmic  goiter  is  sometimes  the  source  of  a  most  striking 
loss  of  weight,  amounting  practically  to  cachexia.  The  same  is  true 
of  Addison's  disease. 


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LOSS  OF   WEIGHT,  1143 

4.  Comparable  with  the  foregoing  types  of  cases  are  certain  in- 
,  stances  of  loss  of  weight  accompanied  by  temporary  glycosuria  in 

overworked  individuals,  especially  intellectual  workers.  The 
author  has  seen  a  number  of  these  cases  among  his  colleagues  in  the 
course  of  the  last  few  years. 

Such  a  loss  of  weight  may,  however,  as  is  well  known,  be  an 
initial  indication  of  diabetes,  particularly  the  grave  cases  of  pan- 
creatic diabetes,  but  also  sometimes  in  the  so-called  neuroarthritic, 
hepatic,  and  nervous  forms  of  diabetes. 

Practical  conclusion :  Never  omit  uranalysis  in  a  case  of  loss 
of  weight. 

5.  Tumors,  in  whatever  situation,  though  more  especially 
tumors  of  the  digestive  tract,  constitute  the  most  dangerous 
factor  of  loss  of  weight.  Tumor  should  always  be  thought  of  in 
an  elderly  person  who  begins  to  lose  weight  and  whose  general 
condition  exhibits  continuous  and  inexorable  deterioration.  At 
the  least  suspicion  of  trouble,  a  systematic  examination  must  be 
carried  out,  including  inquiry  for  occult  bleeding  from  the  ali- 
mentary canal  through  examination  of  the  stools,  careful  exam- 
ination of  this  canal  by  fluoroscopy  after  ingestion  of  a  bismuth 
meal,  etc.,  and  will  very  often  settle  the  question.  Pyloric  steno- 
sis, cancer  of  the  large  bowel  and  rectum,  and  cancer  of  the  liver 
are  by  far  the  commonest  medical  tumors ;  the  possibility  of  their 
presence  should  always  be  borne  in  mind,  and  in  particular,  one 
should  never  forget  to  palpate  the  rectum  in  all  suspected 
cases. 

6.  Arteriosclerosis  is  also  a  common  cause  of  impaired  nutri- 
tion. The  age  of  the  patient,  the  high  blood-pressure  generally 
existing,  and  the  coexisting  signs,  generally  multiple  (tortuous 
temporal  vessels,  signs  elicited  upon  auscultation  over  the  aorta, 
nycturia,  etc.),  without  taking  into  account  the  state  of  hydremia 
frequently  present  and  manifesting  itself  in  lowered  viscosity  of 
the  blood,  will  insure  the  correct  diagnosis. 

7.  Again,  mention  may  be  made,  as  regards  more  exceptional 
C3^es,  of  certain  intoxications,  vis.,  alcohol  in  large  amounts, 
through  the  resulting  gastrointestinal  dyspepsia  and  hepatic  cir- 
rhosis, and  morphine  in  chronic  poisoning,  both  of  which  condi- 
tions generally  cause  loss  of  weight. 


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1144  SYMPTOMS. 

8.  Lastly,  mention  may  be  made,  as  a  species  of  clinical  curi- 
osity, of  a  condition  which,  while  rather  common  in  an  attenu- 
ated form  in  women,  is  very  uncommon  in  its  well-marked  form, 
vis,,  progressive  lipodystrophy  (Barraquer-Simons's  disease), 
characterized  by  a  gradual  and  almost  complete  disappearance 
of  adipose  tissue  and  subcutaneous  cellular  tissue  from  the  upper 
portions  of  the  body,  combined  with  adiposity  of  the  parts  from 
the  umbilicus  down.  In  its  attenuated  form  it  sometimes  leads 
to  a  singular  conformation  which  might  be  described  thus : 
Venus  de  Milo  above  the  umbilicus  and  the  Hottentot  Venus 
below  it.  In  its  pronounced  form  the  face,  chest,  and  abdomen 
present  a  skeletal  aspect,  while  the  more  dependent  parts  become 
so  overburdened  with  fat  as  to  suggest  elephantiasis.  Whether 
this  condition  is  of  endocrin  or  nervous  origin  has  not  as  yet  been 
ascertained. 


In  brief,  in  cases  of  marked  and  persistent  loss  of  weight,  a 
comprehensive  examination  is,  as  always,  indicated ;  the  essential 
procedures  of  examination,  however,  the  various  combinations 
of  which  with  the  factor,  loss  of  weight,  will  permit  of  definitely 
grouping"  95  per  cent,  of  the  cases  are  the  following : 

(a)  Blood-pressure  determinations. 

(b)  The  temperature  curve. 

(c)  Uranaly sis  (amount,  specific  gravity,  sugar,  and  albumin). 

(d)  Careful  examination  of  the  digestive  tract. 


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LOW  BLCX)D-PRESSURE. 


Inclusion  in  this  work  of  a  short  section  on  low  blood-pres- 
sure as  a  counterpart  to  that  on'  high  blood-pressure  already  pre- 
sented is  warranted:  1.  Because  this  condition  is  very  fre- 
quently met  with.  2.  Because  it  is  often  one  of  marked  clinical 
significance.  3.  Because  among  chronic  cases,  at  least,  deter- 
mination of  the  blood-pressure  now  appears  to  the  author  just 
as  essential  as  that  of  the  temperature  or  pulse  in  acute  cases. 

In  this  section  consideration  of  the  subject  of  low  blood-pressure 
will  be  limited  to  a  short  discussion  of  the  symptomatic  import  of 
low  systolic,  diastolic,  and  pulse  pressures,  the  reader  being  referred 
for  the  definition  of  the  terms  systolic,  diastolic,  and  pulse  pressure 
to  the  section  on  High  blood-pressure. 

Low  systolic  pressure  may  be  put  down  as  commencing  at 
120  to  130  millimeters  of  mercury,  as  determined  with  the  Pachon 
blood-pressure  instrument.  [The  readings  with  this  instrument 
are  somewhat  higher  than  those  afforded  by  the  ordinary  mer- 
cury sphygmomanometer. — Translator.]  The  lowest  readings 
the  author  has  met  with  in  adults  were  70  and  80  millimeters. 

A  continuous  low  systolic  pressure  is  found  almost  exclusively 
in  anemias,  in  the  tuberculous,  in  neurasthenics,  in  adrenal  insuffi- 
ciency (Addison's  disease,  post-infectious  adrenalitis,  etc.),  and  in 
a  rather  important  group  of  cases  not  specifically  grouped  until 
lately,  vis,,  cases  of  low  blood-pressure  through  debility  of  the  car- 
dio-arterial  functions,  congenital  or  familial,  perpetuated  or  made 
worse  by  a  mode  of  life  excluding  all  physical  exercise — ^a  condition 
the  author  has  described  under  the  term  hyposphyxia. 

Low  blood-pressure  is  one  of  the  almost  constant  attributes  of 
the  disorders  causing  cachexia,  viz.,  tuberculosis,  cancer,  and  de- 
fective nutrition ;  a  progressive  and  inveterate  low  blood-pressure  is 
generally  a  forerunner  of  death. 

(1145) 


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1146  SYMPTOMS, 

A  temporary  reduction  of  systolic  pressure  may  be  observed  in 
the  course  of  infectious  diseases  and  during  convalescence  from 
them,  as  well  as  after  hemorrhage  or  operative  shock.  The  prog- 
nostic importance  of  low  pressure  in  the  last-named  class  of  cases  is 
well  known ;  in  thoraco-abdominal  wounds,  progressive  reduction  of 
blood-pressure  points  to  a  continuing  hemorrhage. 

Traumatic  shock  is  a  general  somatic  state  met  with  after 
wounds  and  characterized  by  a  pronounced  and  persistent  deficiency 
of  blood-pressure,  with  frequent  pulse,  pallor,  sweating,  shallow  and 
frequent  respiration,  and  extreme  weakness  with  a  tendency  to 
syncope. 

Low  diastolic  pressure,  80  millimeters  or  below  (oscillometric 
or  auscultatory  methods),  is  met  with  only  in  conjunction  with  the 
low  systolic  pressure  of  anemic  and  cachectic  cases  and  in  aortic  re- 
gurgitation. The  lowest  reading  obtained  by  the  author  in  an  adult 
was  50  millimeters,  in  a  case  of  pernicious  anemia.  Low  diastolic 
pressure  is  of  diagnostic  import  only  in  aortic  regurgitation,  but  in 
this  condition  its  significance  is  very  clear-cut  and  may  be  expressed 
as  a  definite  rule :  The  combination  of  low  diastolic  pressure  (80  mm, 
or  below)  with  high  systolic  pressure  (170  mm,  or  above)  is 
pathognomonic  of  aortic  regurgitation. 

As  for  the  significance  of  the  pulse  or  differential  pressure, 
following  are  certain  justifiable  statements  on  this  subject:  The 
pulse  pressure  is  in  a  measure  a  sphygmomanometric  reflection  or 
expression  of  cardiac  power.  Persons  with  constitutional  debility 
and  congenitally  small  hearts  exhibit  a  low  pulse  pressure  (20  to 
40  mm.),  while  well  compensated  arteriosclerotic  cases  with  hyper- 
trophied  "ox  hearts"  show  a  very  high  pulse  pressure  (100  to  250 
mm.).  In  cases  of  cardiac  insufficiency  with  low  pulse  pressure  the 
pulse  pressure  rises  in  proportion  as  the  heart  regains  its  functional 
power  and  diuresis  takes  place,  etc. 

In  some  cases  of  ''shock,"  the  pulse  pressure  may  be  completely 
obliterated.  In  these  cases  a  fatal  termination  has,  so  far,  always 
occurred.  The  prognosis  of  "shock"  is  the  less  favorable  in  propor- 
tion as  the  pulse  pressure  sinks  lower  and  the  oscillometric  index 
falls  more  rapidly. 

Three  points  relating  to  low  blood-pressure  seem  to  require 
further  discussion  from  the  practical  standpoint,  7A2,: 


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LOW  BLOOD-PRESSURE,  1147 

1.  Low  blood-pressure  in  tuberculosis. 

2.  Low  blood-pressure  in  adrenal  insufficiency. 

3.  Low  blood-pressure  in  hyposphyxia. 

1.  Low  pressure  is  so  constantly  present  in  tuberculous  cases 
that:  (1)  It  may  be  considered  an  evidence  of  tuberculosis  to 
the  same  degree  as  cough,  loss  of  weight,  fever,  anorexia,  lassi- 
tude, etc.;  taken  alone,  it  is  of  very  little  symptomatic  value,  but 
in  conjunction  with  the  preceding  manifestations  it  assumes 
marked  significance.  (2)  The  finding  of  a  normal  or  increased 
pressure  warrants  the  conclusion  that  either  tuberculosis  is  ab- 
sent or  some  complication,  generally  renal,  is  present;  all  the 
tuberculous  subjects  in  whom  the  author  found  high  blood-pres- 
sure were  also  suffering  from  nephritis. 

Nevertheless — and  this  statement  applies  whenever  one  is  deal- 
ing with  low  pressure — one  must  always  take  into  account  the  hyper- 
tensive reaction  of  nervous  origin  which  inevitably  occurs  at  the 
first  blood-pressure  examination.  Whence  the  following  ad- 
monitions : 

(1)  At  the  first  examination,  one  should  make  two  successive 
pressure  determinations  at  a  few  minutes'  interval.  [The  dis- 
crepancy, often  pronounced,  between  the  first  and  second  read- 
ings (the  latter  always  being  lower)  affords  a  good  index  of  the 
emotivity  of  the  patient  concerned.]  (2)  Further  blood-pressure 
determinations  should  be  made  at  later  examinations.  The  emo- 
tional and  accidental,  temporary,  hypertensive  factor  is  thus 
eliminated,  and  the  morbid,  essential,  and  permanent  factor  alone 
kept  in  view. 

2.  Low  blood-pressure  is  one  of  the  three  permanent  evidences  of 
adrenal  insufficiency  (h3rpoadrenia).  One  may  state  that  the 
symptom-group  low  pressure,  asthenia,  and  Sergent's  white  line  is 
pathognomonic  of  adrenal  insufficiency,  the  extremely  frequent 
clinical  occurrence  of  which  has  been  discovered  through  recent 
investigations.  In  its  highest  expression  this  condition  is  mani- 
fested by  the  well-known  classic  syndrome  of  Addison's  disease, 
long  since  ascribed  to  degenerative  changes  in  the  adrenal  glands 
and  accompanied  by  characteristic  pigment  changes  in  the  skin  and 
mucous  membranes.     The  conclusion   from  the  recent  investiga- 


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1148  SYMPTOMS. 

tions  referred  to  seems  to  be  that  most  instances  of  infectious, 
post-infectious,  or  cachectic  low  blood-pressur^  are  wholly  or 
partly  the  result  of  adrenal  insufficiency,  whether  there  exists  an 
actual  adrenalitis  or  merely  a  temporary  insufficiency  (Loeper). 
This  interpretation,  however,  is  still  a  moot  point. 

3.  Hyposphyxia  is  a  circulatory  symptom-group  a  short  dis- 
cussion of  which  seems  warranted  in  view  of  the  fact  that  it  has 
been  known  and  described  only  in  relatively  recent  years. 

Blood-pressure  and  blood  viscosity, — The  author  has  shown  in 
the  course  of  the  last  few  years  that  in  subjects  whose  cardiovas- 
cular system  is  well  balanced  and  at  no  point  impaired  there  exists 
a  rather  close  relationship  between  the  differential  or  pulse  pres- 
sure, an  expression  of  the  power  of  the  heart  beat,  and  the  viscosity 
of  the  blood,  an  expression  of  the  resistance  opposed  by  the  blood 
to  the  circulation.  With  a  low  viscosity,  as  in  anemics,  there  cor- 
responds a  low  pressure;  with  a  moderate  viscosity,  as  in  normal 
subjects,  a  moderate  pressure,  and  with  a  high  viscosity,  as  in  ple- 
thoric, full-blooded  persons,  a  high  pressure.  In  short,  in  the  per- 
son who  is  normal  from  the  cardiovascular,  or  better  the  circula- 
tory standpoint,  the  pressure  goes  hand  in  hand  with  the  viscosity. 
The  converse,  however,  is  not  always  true,  for  reasons  set  forth 
at  length  in  an  earlier  work  of  the  author's^  devoted  to  a  study  of 
this  question. 

Furthermore,  this  relationship,  which  the  author  was  enabled 
to  demonstrate  only  after  extensive  observations,  will  seem  ob- 
vious to  any  one  who  will  call  to  mind  the  fact  that  the  energy 
required  to  cause  a  fluid  to  circulate  in  a  given  canal  system  is 
proportionate  to  the  resistance  offered  by  the  fluid,  vis,,  to  its 
viscosity. 

Such  is  the  natural  relationship  of  the  pulse  pressure  and 
blood  viscosity. 

Clinical  observation  leads  to  the  detection  of  two  radically 
opposed  abnormal  sphygmoviscosimetric  types  of  cases  in  which 
there  is  disharmony  between^  the  pulse  pressure  and  the  blood 
viscosity. 


1  Alfred  Martinet  :    "Pressions  arterielles  et  viscosite  sanguine,"    Paris, 
Masson,  1912. 


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LOW  BLOOD-PRESSURE.  II49 

The  first  type  exhibits  a  pulse  pressure  which  is  high  in  com- 
parison to  the  normal  or  low  blood  viscosity;  these  are  hyper- 
systolic,  hypersphyxic  cases,  the  permanent  hypersphyxia  being 
represented  by  arteriorenal  sclerosis. 

The  second  type,  which  is  the  subject  of  the  following  brief 
study,  shows,  on  the  other  hand,  a  viscosity  which  is  high  as 
compared  with  a  normal  or  low  pulse  pressure :  These  are  hy- 
posphyxic  cases. 

The  h5rposph)rxic  syndrome. — Hyposphyxia  consists  of  the 
combination  of  an  absolutely  or  relatively  low  pulse  pressure  with 
a  high  blood  viscosity.  These  two  factors,  simultaneously  present, 
constitute  the  highest  expression  of  the  condition  of  sluggish  cir- 
culation so  frequently  noted  in  young  girls,  sedentary  indiznduals, 
pretuberculous  subjects,  etc.,  and  characterized  especially  by  weak 
pulse,  a  liznd  skin  surface,  habitual  coldness  and  cyanosis  of  the 
extremities,  a  tendency  to  venous  plethora,  varicose  veins,  enlarge- 
ment of  the  liver,  unusual  sensitiveness  to  cold,  etc. 

Hyposphyxia  is  almost  constantly  associated  with  pluriglandu- 
lar insufficiency,  of  which  it  is  a  dominant  feature  and  upon  which 
it  depends.  In  hyposphyxics  there  are  noted,  indeed,  gastrointes- 
tinal dyspepsia  due  'to  inadequacy  of  the  several  digestive  glands, 
various  disturbances  long  since  attributed  to  insufficiency  of  the 
endocrin  glands  (thyroid,  ovaries,  adrenals,  pituitary,  etc.),  vis., 
headache,  migraine,  dysmenorrhea,  asthenia,  asthma,  disturbed 
nutrition  of  the  hair,  etc. 

The  hyposphyxic  syndrome  is  specifically  mentioned  in  many 
descriptions  of  the  syndromes  due  to  insufficiency  of  glandular 
functions. 

Stress  is  to  be  laid  on  the  fact  that  hyposphyxia  is  only  a  symp- 
tom-group and  not  a  definite  disease  entity,  and  that  one  may  dis- 
tinguish organic  and  functional  forms  of  hyposphyxia,  as  well  as 
constitutional  inherited,  and  accidental  {e.g.,  post-infectious)  forms. 
Precisely  the  same  is  true  of  the  syndrome  of  pluriglandular  in- 
sufficiency. 

This  ascendancy  of  the  circulatory  factor  over  the  neuro-mus- 
culo-trophic  factor  had  already  been  clearly  expressed  by  Bris- 
saud  in  relation  to  feeble  children  (Bauer)  and  to  mitral  dwarf- 
ism.   "As  soon  as  a  certain  degree  of  narrowness  of  the  arteries 


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1150  SYMPTOMS, 

exists,"  he  wrote,  "the  poorly  nourished  tissues  and  organs  may 
actually  undergo  development,  but  remain  small  and  weak.  The 
stunted  individual  that  results  does  attain  complete  development, 
but  without  proper  growth."     (Henry  Meige.) 

From  the  standpoint  of  pathogenesis,  this  syndrome  consti- 
tutes, in  last  analysis,  the  outward  manifestation  of  a  circulatory 
disturbance  characterized  by  high  venous  pressure  with  stasis  de- 
pendent either  upon  some  obstruction  in  the  left  heart  (mitral  dis- 
orders) or  in  the  right  heart  (tricuspid  disorders),  or,  as  is  more 
usually  the  case,  upon  a  congenital  underdevelopment  of  the  heart 
(constitutional  cardiac  debility),  or  an  obstruction  in  the  lung 
(chronic  tuberculous  lung  disorders),  liver  (cirrhosis  or  passive 
congestion),  or  veins  (varicose  veins,  phlebitis,  and  cutaneous 
cyanosis). 

Absolute  or  relative  weakness  of  the  cardiac  contraction,  peri- 
pheral circulatory  weakness  through  vascular  myasthenia,  and 
respiratory  weakness  are  met  with  in  all  these  conditions. 

The  above  state  of  circulatory  dynamism,  with  a  low  pulse 
pressure  and  high  viscosity,  points  directly  either  to  a  congenital 
weakness  or  underdevelopment  of  the  cardioarterial  system  (con- 
stitutional cardiac  debility)  or  to  an  obstacle  to  the  circulation 
behind  the  left  heart  (mitral  valve,  lungs,  right  heart,  or  liver). 
Venous  plethora  is  the  inevitable  result  and  constitutes  a  mode 
of  adaptation  or  defensive  reaction  to  an  unusual  condition  of 
the  circulation. 

The  presence  of  this  syndrome  in  a  chronic  form,  constituting 
an  habitual  circulatory  state,  chronic  hyposphyxia,  has  been  clin- 
ically obsen^ed  by  the  writer: 

1.  In  subjects  with  certain  lesions,  chiefly  obvious  cardio- 
pulmonary conditions  and  corresponding  with  clearly  defined 
nosologic  entities,  to  which  the  term  secondary  organic  hypo- 
sphyxia  is  applicable. 

.  2.  In  subjects  apparently  free  of  any  organic  heart  or  lung 
disorder  so  far  described,  the  appellation  protopathic  functional 
hyposphyxia  (neurocirculatory  asthenia)  may  be  used. 

3.  Occurrence  of  the  syndrome  as  an  acute  or  subacute,  acci- 
dental and  temporary  condition,  acute  ten:4)orary  hyposphyxia, 
has  also  been  noted. 


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LOW  BLOOD-PRESSURE.  HSl 

Organic  hyposphyxia  has  been  observed  by  the  writer : 

1.  In  acute  or  chronic  tuberculous  cases,  with  the  exception  of 
those  with  added  renal  complications. 

2.  In  mitral  disease,  with  or  without  compensation.  Congenital 
or  acquired  mitral  stenosis  affords  the  most  striking  examples  of 
this  group.    Doubtless  the  same  applies  to  tricuspid  stenosis. 

3.  In  the  majority  of  cases  of  chronic  lung  disturbance  with 
emphysema  and  bronchitis, 

4.  In  kyphotic  patients, 

5.  In  some  cases  of  uremia,  or  more  correctly,  azotemia. 
Functional  hyposphyxia  has  been  very  frequently  witnessed. 
This  type  is  almost  the  rule  in  young  girls  and  a  large  number 

of  women  leading  sedentary  lives  by  choice  or  occupation  (dress- 
makers, pianists,  clerks,  etc.),  with  low  breathing  capacities  and 
weak  musculatures.  The  author  has  also  come  across  it  in  a 
number  of  youths,  scholars  or  students  not  interested  in  sports. 

Often  it  is  an  inherited  condition,  dependent  upon  an  actual, 
congenital  and  familial  cardiovascular  hypoplasia.  In  one  such 
family,  the  grandfather,  suffering  from  varicose  veins,  had  al- 
ways exhibited  cyanosis  and  had  cold,  moist  extremities;  the 
mother,  also  varicose,  was  likewise  hyposystolic  and  showed  a 
high  blood  viscosity;  the  uncle  had  varicose  veins  and  cyanosis 
of  the  face,  lips,  and  extremities;  an  aunt,  cyanotic  and  with 
varicose  ulcers,  was  looked  upon  as  having  heart  disease;  another 
aunt  was  in  a  similar  state;  as  for  the  patient  himself,  he  was  a 
cyanotic,  sedentary  individual  with  poor  musculature,  cold,  moist 
extremities,  and  a  congested  liver;  his  pulse  pressure  was  30 
millimeters  and  his  viscosity  5.5. 

This  type  of  disturbed  nutrition,  accompanied  by  many  other 
states  of  maldevelopment  (dental,  palatal,  abdominal,  etc.),  fre- 
quently forms  part  of  the  symptom-group  of  congenital  syphilis. 


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1152 


SYMPTOMS. 
LOW  BLOOD-PRESSURE. 


Anemias. 
Hemorrhages. 

Neurasthenia. 

Cachectic  states. 
Tuberculosis. 


Adrenal  insuffi- 
ciency. 


Hjrposphyxia. 


Organic 


Functional 


Low  cell  count;  pallor  of  mucous  membranes; 
functional  cardioarterial  murmurs. 


Traumatic  or  post-operative. 

(Progressive   reduction   of   blood-pressure   after 

trauma  or  an  operation  is  always  an  indication 

of  persistent  hemorrhage). 


Neuropathic    syndrome:      Headache,    insomnia, 
constipation,  asthenia,  anxiety. 


Cancer;  senility;  phthisic  conditions. 


Cough,  fever,  loss  of  weight,  auscultatory  signs. 
'  either   lead   to   exclusion   of 
the    diagnosis     of    tuber- 
culosis, 
or  lead  to  the  detection  of 
a  renal  complication. 


High  blood-pres- 
sure should 


Padiognomonic    ssrmptom-group:      Low    blood- 
pressure,  asthenia,  and  Sergent's  white  line.  . 

'  from  Addison's  disease  or  acute  ad- 
renalitis  with  rapid  death, 
All  grades  {  to   the  temporary  and  mild  forms 
of  post-infectious  adrenal  insuffi- 
ciency. 


Slow  circulation  (low  pressure,  high  viscosity), 
very  often  associated  with  pluriglandular  in- 
sufficiency (hypocrinia). 

(Pulse  small  and  frequent,  lividity,  sensitiveness 
to  cold,  coldness  and  cyanosis  of  the  extremi- 
ties, venous  plethora,  etc.). 


1.  Tuberculous  cases. 

2.  Mitral  cases. 

3.  Chronic  pneumopaths. 

4.  Kyphotics. 

5.  Azotemics. 

6.  Congenital   cardiovascular   dystrophy    (includ- 
ing congenital  syphilis). 


Sedentary  life,  cardiomuscular  debility,  etc. 
Neurocirculatory  asthenia. 


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LOWER  EXTREMITIES,  PAIN  IN. 


The  causal  diagnosis  of  pain  in  the  lower  limbs  is  often  ob- 
vious, as  in  rheumatic  arthritis,  post-infectious  phlebitis,  acute 
gouty  attacks,  etc. ;  yet  sometimes  it  presents  insuperable  diffi- 
culties. Few  portions  of  the  body  are  more  accessible  and  read- 
ily examined;  yet  few  are  more  complex,  and  none  is  the  seat  of 
pains  that  may  be  due  to  such  a  large  variety  of  causes. 

Any  of  the  tissues  of  the  extremity,  bones,  joints,  muscles, 
veins,  arteries,  or  nerves,  may  be  the  starting-point  of  painful 
affections;  the  spinal  cord,  vertebral  column,  various  trophoneu- 
rotic disturbances,  and  various  abdominopelvic  disorders  may 
^  likewise  cause  more  or  less  obstinate  pain  in  the  lower  extremi- 
ties. Proper  diagnosis  sometimes  demands  an  extremely  pains- 
taking clinical  investigation  and  penetrating  analysis. 

Any  of  the  tissues,  as  we  have  seen,  may  be  the  starting-point 
of  painful  affections.  A  succinct  reference  to  each  kind  of  tissue 
may  prove  serviceable: 

I.  The  Bones. — Traumatic  conditions,  such  as  fractures,  con- 
tusions, and  sprains,  generally  self-evident,  may  be  dismissed  from 
the  start,  leaving  for  our  consideration  osteoperiostitis;  osteomye- 
litis; osteosarcoma;  an  extremely  common  skeletal  deformity,  flat 
foot,  which  should  always  be  kept  in  mind  precisely  because  of  its 
common  occurrence,  and  the  disorders  of  the  bony  spinal  column, 
foremost  among  which  is  Potfs  disease. 

(a)  Osteoperiostitis. — This  condition  is  characterized  by  the 
presence  of  a  more  or  less  localized  painful  area  along  the  shaft 
of  one  of  the  bones  of  the  lower  limb,  usually  the  femur  or  tibia, 
together  with  a  variable  degree  of  swelling.  Osteoperiostitis 
may  be : 

Syphilitic,  as  suggested  by  the  history,  recurrence  of  the  pain  at 
night  (osteocopic  pains),  a  positive  Wassermann,  and  the  efficacy 
of  mixed  treatment. 

78  (1153) 


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1154.  SYMPTOMS. 

Tuberculous,  though  this  form  of  osteoperiostitis  is  actually 
much   less  common  than  tuberculous  osteoarthritis. 

Post-infectious,  e.g,,  post-typhoid;  staphylococcic  in  the  pres- 
ence of  recurring  furunculosis  or  after  sore  throat. 

(6)  Osteomyelitis. — This  is  characterized  by  more  severe  and 
more  diffuse  pains  and  larger  oscillations  of  temperature;  it  is 
generally  post-infectious,  e.g.,  typhoid  (post-typhoid)  or  staphy- 
lococcic (following  sore  throat  or  furunculosis). 

(r)  Osteosarcoma. — This  is  fortunately  much  less  common,  in 
fact  exceptional,  and  is  characterized  by  a  rapidly  progressive  and 
generally  painful  enlargement  involving  the  shaft  of  the  femur.  , 
A  mere  mention  of  the  condition  would  suffice  were  it  not  neces- 
sary to  point  out  that  it  may  sometimes  be  confounded  with  a 
syphilitic  gumma  of  the  bone.  Indeed,  in  a  case  of  sciatica  resist- 
ant to  all  forms  of  treatment,  in  which  the  progressive  develop- 
ment of  a  swelling  of  the  femur  had  led  to  a  diagnosis  of  osteosar- 
coma and  a  decision  to  amputate  the  limb,  and  the  denials  of  the 
intelligent  patient,  answering  questions  in  good  faith,  the  absence 
of  evidence  of  venereal  diseasfe,  and  the  existence  of  nearly  adoles- 
cent children  free  of  any  appreciable  stigmata  had  seemed  to  war- 
rant exclusion  of  the  diagnosis  of  syphilis,  the  swelling  was  ob- 
served to  melt  away  like  butter  before  the  sun's  direct  rays  as  a 
result  of  mercurial  inunctions. 

(d)  Painful  valgus  flat  foot  should  be  thought  of  in  any  ado- 
lescent complaining  of  pains  in  the  legs  and  muscular  contrac- 
tures when  he  is  fatigued,  and  the  diagnosis  may  be  made  by  the 
print  method,  which  consists  in  having  the  patient  place  his  feet 
over  sheets  of  paper  covered  with  lampblack.  The  footprints 
thus  obtained  show,  in  such  cases,  that  the  inner  border  of  the 
foot  is  completely  sagged  down  and  that  the  foot  is  resting  on 
the  ground  over  the  entire  extent  of  the  sole  and  not  on  its  three 
normal  pillars — posterior  (os  calcis),  anterior  (toes),  and  ex- 
ternal (outer  border  of  the  foot). 

(e)  In  this  essential  examination  of  the  bony  framework  the 
spinal  column,  particularly  in  its  dorsolumbar  region,  should  not 
be  neglected.  This  step  in  the  examination  is  made  necessary 
chiefly  by  the  possibility  of  Pott's  disease: 


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LOWER  EXTREMITIES,  PAIN  IN.  1155 

Whether  the  case  be  that  of  a  child  with  unsteadiness  of  gait, 
weakness  of  the  legs,  more  or  less  definite  pains  in  the  lower 
extremities,  and  impairment  of  general  health ; 

Whether  it  be  that  of  a  subject  whose  parents  have  them- 
selves detected  a  lateral  deviation  of  the  spinal  column  giving 
rise  to  pain ; 

Or  whether,  especially  in  an  adult  complaining  of  pain,  an 
abscess  pointing  in  the  inguinal  region  brings  definitely  to  light 
a  Pott's  disease  which  careful  examination  of  the  spinal  column 
by  inspection,  percussion,  motion,  and  fluoroscopy  might  have 
disclosed  many  months  before. 

(/)  Lastly,  one  should  bear  in  mind  the  rare  possibility  of  an 
incipient  osteomalacia,  which  would  later  be  confirmed  by  charac- 
teristic deformities,  with  exaggeration  of  the  normal  curves  of  the 
bones,  disordered  locomotion,  and  pain  on  walking,  becoming 
fatigued,  or  local  pressure. 

II.  The  Joints. — It  will  not  be  necessary  here  to  review  all  the 
possible  causes  of  joint  pains,  a  special  section  having  already  been 
included  on  thisi  subject  (see  Joint  pains).  Systematic  examina- 
tion by  inspection,  palpation,  mobilization,  and  if  necessary  fluoros- 
copy, will  in  the  first  place  locate  the  pain  in  one  of  the  joints  of 
the  extremity.  The  special  features  of  the  joint  disturbance,  the 
history,  onset,  course,  and  simultaneous  presence  of  other  abnormal 
conditions  will,  as  a  rule,  lead  quickly  to  classification  of  the  dis- 
order in  one  of  the  following  groups :  Acute  articular  rheumatism, 
gonorrheal  rheumatism,  post-infectious  rheumatism  (scarlatinal, 
typhoid,  etc.),  or  rheumatism  due  to  some  metabolic  disorder 
(gout,  arthritis  deformans,  etc.).  Too  much  stress  cannot  be  laid, 
here  as  elsewhere,  upon  the  advisability  of  examining  the  seat  of 
pain  carefully  and  by  direct  inspection,  of  palpating  and  passively 
moving  it,  in  short,  of  locating  with  care  the  pain  and  the  seat  of 
pathologic  change,  of  precisely  determining  its  nature,  if  possible, 
and  of  not  resting  content  with  the  vague  term  "rheumatism," 
which  is  just  as  devoid  of  true  diagnostic  meaning  as  "headache" 
or  "pain  in  the  side." 

Some  joint  involvements  exhibit  a  rather  pronounced  selective 
tendency. 


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1156  SYMPTOMS, 

Gout  very  frequently  occurs  in  the  joints  of  the  great  toe  (meta- 
tarsophalangeal joints). 

Acute  rheumatism  of  the  lower  extremities  is  located  in  the 
knees  in  four  cases  out  of  five.  The  same  is  true  of  gonorrheal 
arthritis. 


Fig.  809.— Bilateral  tabetic  knee-Joints.    (Glorieux  and  Van 
Gehuchten,  Revue  neurologique,  1895). 

Tuberculosis  involves  almost  indifferently  any  of  the  joints; 
yet  its  predilection  for  the  knee  (white  swelling)  and  the  hip 
(coxalgia)  is  well  known. 

Malum  cox(V  senilis,  the  pathogenesis  of  which  is  as  yet  ob- 
scure, involves,  as  the  term  implies,  the  hip  in  elderly  subjects. 

Nor  should  one  forget  the  characteristic  tabetic  or  Charcot 
joints,  with  the  attendant  marked  deformity,  extreme  laxity  of  the 


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LOWER  EXTREMITIES,  PAIN  IN.  II57 

involved  joints  and  painlessness.  If  the  condition  is  only  kept  in 
mind,  the  diagnosis  can  be  made  by  observation  of  the  other  indi- 
cations of  tabes — specific  history,  reflex  disturbances  (Argyll- 
Robertson  pupil),  loss  of  the  patellar  reflex,  etc.;  astasia,  abasia, 
ataxia,  lightning  pains,  sphincter  disturbances,  etc. 

III.  The  Muscles. — Disorders  of  the  muscles,  tendons,  and 
serous  membranes,  occurring,  respectively,  in  the  form  of  myo- 
sitis, tenositis,  and  bursitis,  constitute  possible  localizations  of 
rather  indefinite  painful  processes  the  origin  of  which  may  be 
that  described  by  Le  Gendre,  vie,  "a  defective  functioning  of  the 
locomotor  apparatus  either  through  lack  of  activity  (sedentary 
mode  of  life)  or  through  excessive  activity  (overstrain),"  which 
renders  it  sensitive  particularly  to  cosmic  [meteorologic]  influ- 
ences that  are  normally  not  felt. 

Mention  may  here  be  made  of  the  myalgias,  often  accom- 
panied by  arthralgias  without  objective  manifestations,  which, 
attended  with  an  apparent  typhoid  state  with  sudden  onset  and 
albuminuria,  frequently  features  the  first  or  preicteric  stage  of 
primary  infectious  jaundice  (hemorrhagic  spirochetosis).  Such 
pains  may  dominate  the  clinical  picture  sufficiently  to  mislead  an 
inexperienced  practitioner.  Thus,  the  author  saw  a  fatal  case  of 
primary  infectious  jaundice  which  was  admitted  tp  a  hospital  on 
the  third  day  of  the  illness  with  a  diagnosis  of  ** rheumatism." 
The  patient,  indeed,  complained  almost  exclusively  of  pain  and 
cramps  in  the  thighs  and  a  feeling  in  the  knees  as  of  constriction 
in  a  vice,  without  any  redness  or  swelling  but  with  a  temperature 
of  40°  C,  a  pulse  rate  of  136,  albuminuria,  a  small  liver,  and 
incipient  jaundice.  This  case  succumbed  in  ten  days  with  the 
complete  clinical  picture  of  grave  primary  infectious  jaundice — 
small  liver,  progressive  jaundice,  albuminuria,  hemorrhages,  and 
increasing  hypothermia.  The  pains  in  the  muscles  subsided  as  the 
jaundice  grew  more  marked.  A  few  spirochetes  were  found  in  the 
blood  and  the  urine. 

To  complete  the  enumeration,  mention  may  be  made  of  the 
painful  muscular  spasms  of  nervous  diseases,  of  tetanus,  etc. 

IV.  The  Veins. — Inflammations  of  the  veins  play  a  far  more 
important  role  in  pain  in  the  lower  extremities  than  they  do  in  the 


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1158  SYMPTOMS. 


case  of  pain  of  the  upper  limbs.  Here  phlebitis  is  much  more 
common,  being  either  of  chronic  nature,  as  in  chronic  degenerative 
phlebitis  (varicose  veins)  or  ck:ute  or  subacute  infectious  phlebitis. 


^*  Superior 

mesent. 
plexus 


gf  Inferior 

mesent. 
plexus 

Hy 


moid 
(xure 


sclati 


idder 


Fig.  810. — Lumbosacral  and  hypogastric  plexuses  in  the  male 
(sources  of  the  sciatic  nerve)   {Hirschfeld). 

the  latter  especially  post-infectious,  post-operative  or  puerperal  in 
origin.  The  diagnosis  of  the  condition  is,  as  a  rule,  easy.  The 
mere  finding  of  dilated  veins,  which  in  the  chronic  forms  are  par- 
ticularly prominent  with  the  patient  in  the  standing  posture,  the 
observation  upon  palpation  of  phlebosclerosis  and   frequently  of 


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LOWER  EXTREMITIES,  PAIN  IN.  1159 

induration  around  the  vein,  and  the  presence  of  trophic  changes  of 
the  skin  lead  to  the  proper  diagnosis  in  chronic  forms.  In  acute 
and  subacute  phlebitis,  the  history  (as  of  infection,  a  surgical  pro- 
cedure,  or  parturition),   the   fever,   edema,   special   sensitiveness 


1st  saci 
gangli 


Hypogaatric 
plexus 


Great 
sciatic 
nenre 

Visceral 
nenres 


Uterine 
plexus 


Fig.  811.— Lumbosacral  and  hypogastric  plexuses  in  the  female 
(sources  of  the  sciatic  nerve)   (Hirschfeld). 

along  the  course  of  the  vein,  and  sometimes  the  finding  of  a  hard, 
cord-like  vein  insure  recognition  of  the  existing  disorder. 

V.  The  Arteries. — Pain  attending  disease  of  the  arteries  in 
the  lower  extremities  is  not  of  very  frequent  occurrence,  but 
when  present  is  very  obstinate.  It  is  the  result  of  arteritis  of  the 
femoral  or  of  the  tibial  or  peroneal  vessels.     Arteriosclerosis, 


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1160  SYMPTOMS. 

gout,  specific  disease,  and  infections,  especially  typhoid  fever,  are 
by  far  the  most  frequent  causes — in  fact,  the  only  oties  met  with 
in  the  author's  experience. 

As  serviceable  diagnostic  indications  of  such  a  condition  the 
following  features  may  be  mentioned : 

A  distinct  difference  of  blood-pressure  in  the  two  limbs ;  grad- 
ual diminution  of  the  beats  below  the  involved  portion  of  the 
artery;  intermittent  claudication  (in  the  chronic  forms) ;  lowered 
local  temperature  of  the  affected  limb ;  coldness  and  pallor ;  some- 
times, where  the  vascular  distribution  from  a  certain  trunk  is 
actually  obliterated  and  no  collateral  circulation  forms,  hypo- 
thermia, vasomotor  disturbances,  and  cyanosis  occur  and  are  fol- 
lowed by  the  appearance  of  areas  of  necrosis  of  varying  extent, 
which  may  later  result  in  mutilation  of  the  part. 

VI.  The  Nerves. — The  sciatic  nerve  is  the  one  by  far  the  most 
frequently  involved  in  the  lower  extremities.  One  should  remember 
that  the  course  of  the  sciatic  nerve  comprises  a  spinal  portion,  origi- 
nating in  the  anterior  branches  of  the  last  two  lumbar  and  first  four 
sacral  nerves;  a  pelvic  portion,  in  which  the  sacral  plexus,  formed 
by  the  convergence  and  subsequent  fusion  of  the  foregoing  nerve- 
roots,  enters  into  direct  or  indirect  anatomical  relationship  with 
nearly  all  the  pelvic  organs;  a  gluteal  portion,  beginning  at  the 
great  sacro-sciatic  notch,  from  which  the  single,  combined  trunk 
of  the  sciatic  issues  at  the  gluteal  fold,  being  ensconced  in  this 
region  in  a  musculo-osseous  recess  bounded  within  by  the 
ischium  and  externally  by  the  greater  trochanter;  a  deep,  intra- 
muscular femoral  portion,  in  which  the  nerve  is  lodged  in  a  ver- 
tical muscular  trough  bounded  externally  by  the  long  head  of  the 
triceps  and  internally  by  the  semitendinosus  and  semimembran- 
osus, and  finally,  a  terminal  portion,  in  which  it  divides,  four 
fingerbreadths  above  the  plane  of  the  tibiofemoral  joint,  into  its 
two  terminal  branches,  the  external  popliteal  nerve,  which,  after 
having  passed  around  the  external  condyle  of  the  femur  and  the 
inner  surface  of  the  head  of  the  fibula,  continues  through  the 
thickness  of  the  peroneus  longus  and  along  the  external  and  dor- 
sal aspects  of  the  foot,  and  the  internal  popliteal  nerve,  which 
crosses    the    popliteal    space    obliquely,    passes    above   the    soleus 


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LOWER   EXTREMITIES,  PAIN  IN. 


1161 


(posterior  tibial  nerve)  and  extends  to  the  plantar  surface  of  the 
foot,  nearly  the  whole  of  which  is  innervated  by  it. 

Brief  reference  to  these  anatomic  facts  was  necessary  because: 


Sup.  gluteal  nerye 
Nerve  to  pyriformla 
Inf.  gluteal  nerye  | 

Post,  cutaneous  ner 

Post,  cutaneous  neri^ 
of  the  thigh 


Inf.  gluteal  nerye 
Sciatic  nerye 


Nerve  to  semitendinosui 


Nerve  to  semimem- J 
branosus  ] 


Nenre  to  semitendinosui 


Nerve  to  short  head  of 
biceps 


^erve  to  long  head  of 
biceps 


,  popliteal  nerve 


Int.  popliteal  ner 


Nerve  to  int.  gastrc 
nenoiius 


;>opliteal   nerve 
to  plantarls 

to  ext.   gastroc- 
us 


Ext   saphenous   e 


Fig.  812.— The  greater  sciatic  nerve  (Sappey).  The  small  sciatic  nerve 
consists  of  the  two  small  trunks  designated  above  as  the  inferior  gluteal 
nerve  and  the  posterior  cutaneous  nerve  of  the  thigh. 

1.  The  sciatic  nerve  must  be  investigated  in  every  portion  of 
its  course,  from  the  lumbosacral  vertebrae  to  the  os  calcis  and  the 
sole  of  the  foot.  There  are  certain  points  which,  on  account  of 
their  regional  anatomic  relationships,  lend  themselves  especially 
well  to  examination  and  the  eliciting  of  tenderness.  Valleix  made 
a  special  study  of  these  elective  points,  whence  the  designation 


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1162 


SYMPTOMS. 


"Valleix^s  points"  which  has  remained  attached  to  them.     These 

points  are  shown  in  the  annexed  diagram. 

Mention  should  be  made  of  Lasegue's  well-known,  simple  and 
rapid  maneuver,  which  consists  in  flexing  the 
thigh  on  the  pelvis  with  the  leg  extended. 
During  this  procedure  the  sciatic  nerve,  after 
running  a  practically  straight  course  with  the 
limb  in  complete  extension,  is  forced  into  a 
sharp  curve  in  its  gluteal  course  by  the  flexion 
of  the  limb,  and  is  thereby  stretched  like  a 
violin  string  when  the  bridge  is  raised  into 
position.  The  resulting  tension  at  once  excites 
a  characteristic  pain  along  the  nerve  in  the 
presence  of  sciatica. 

Lasegue's  test  is  merely  the  simplest  and 
most  commonly  used  of  the  various  pro- 
cedures of  stretching  the  sciatic,  which  brings 
on  pain  where  there  is  disorder  of  the  nerve. 
It  is  plain  that  any  form  of  motion,  whether 
active  or  passive,  which  causes  stretching  will 
excite  the  same  sort  of  pain  or  a  character- 
istic posture  of  the  limb  having  for  its  pur- 
pose to  obviate  the  stretching  of  the  nerve. 
When  the  patient  is  standing  and  is  asked  to 
pick  up  an  object  from  the  floor,  keeping  the 
legs  extended  on  the  thighs,  he  will  in- 
stinctively and  necessarily  flex  the  involved 
limb  or  move  it  backward  in  order  to  avoid 
tension  on  the  nerve. 

When  the  patient  is  recumbent  and  is  re- 
quested to  sit  up,  keeping  his  legs  straight,  he 
will  similarly,  and  for  the  same  reason,  flex 
the    affected    limb     (Sicard's    ^'raised    knee 
V  11  •  '      ^^9^")*   thus   exhibiting  what  appears   as  a 

points  on  the  poste-     unilateral  Kemig  sign  (G.  Roussy). 

rior    aspect    of    the  2.  The  origin  of  the  nerve  pain  may  be  at 

lower  extremity,  and  j^^^    ^^  ^^^    ^^^^^    ^^    ^j^^    ^^^^ 

their    relationship    to      _  ^ 

the  bony  skeleton.         The  whole  course  of  the  nerve  should  be 


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LOWER  EXTREMITIES,  PAIN  IN.  1163 

examined  just  as  carefully  to  discover  the  cause  as  from  the 
symptomatic  standpoint 

Along  the  spinal  portion  of  the  sciatic  bony  changes  should 
especially  be  looked  for,  vis.,  Pott's  disease,  exostoses,  spondylitis, 
gumma,  or  cancer  of  the  vertebrae ;  and  likewise  meningeal  disturb- 
ances, such  as  acute  or  chronic  meningomyelitis  or  the  common  con- 
dition termed  meningeal  hyperemia.  An  undemonstrable,  but 
seemingly  probable  and  frequent  cause,  judging  from  the  percent- 
age of  cases  in  which  the  author  found  it  and  the  therapeutic  efficacy 


Fig.  814. — ^Left-sided  sciatica.    Forward  bending  of  the  body  is  possible 
only  if  the  knee  of  the  affected  side  is  flexed  (G.  Roussy). 

of  hamamelis  in  large  doses,  is  intraspinal  venous  hyperemia  or  the 
"intraspinal  varicose  state,"  causing  pressure  upon  and  strangula- 
tion of  the  nerve-roots  upon  their  emergence  from  the  bone  (see 
Lumbar  pain). 

Along  the  pelvic  portion  of  the  sciatic,  disorders  of  the  rectum, 
prostate,  bladder,  Fallopian  tubes  and  ovaries,  and  uterus  may 
be  and  frequently  are  the  source  of  sciatic  neuralgia  or  neuritis 
through  one  of  the  four  following  factors:  1.  Pressure,  as  by 
primary  new  growths  or  secondary  glandular  enlargements.  2. 
Hyperemia,  as  in  inflammatory  pelvic  congestion  or  acute  con- 
gestion of  hemorrhoids.  3.  Reflex  irritation  from  a  remote  struc- 
ture, as  in  urethritis  or  orchitis.  4.  Direct  involvement  in  malig- 
nancy or  inflammation,  as  in  tumor  of  the  rectum  or  uterus. 


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1164  SYMPTOMS. 

From  the  above  considerations  the  importance  of  a  systematic 
examination  of  the  pelvic  structures  in  the  presence  of  sciatica 
will  readily  be  seen. 

Along  the  femoral  portion  of  the  nerve,  in  the  buttock,  the  con- 
ditions oftenest  met  with  as  exciting  causes  of  sciatica  are  trauma- 
tism  (falls,  sudden  impacts  or  blows)  and  coxofemoral  arthritis  and 
periarthritis.  In  the  femoral  region  a  special  search  should  be  made 
for  factors  resulting  in  compression,  chiefly  by  bone,  such  as  osteo- 
periostitis, gumma,  and  osteosarcoma;  in  the  popliteal  space,  the 


Fig.  815. — Right-sided  sciatica.  In  some  instances,  when  the  body 
is  being  bent  forward,  the  patient  spontaneously  tilts  the  affected  lower 
limb  backward  (G.  Roussy), 

commonest  exciting  causes  are  crypts,  aneurysm,  and  fungous  joint 
inflammation. 

Where,  however,  all  these  local  causes  of  neuralgia  and  neu- 
ritis can  be  excluded,  an  inquiry  should  be  made  for  general 
causes,  some  of  which  are  still  rather  obscure : 

Neuralgia  a  f rigor e  (following  exposure  to  cold). 

Rheumatic  (?)  neuralgia. 

Diathetic  neuralgia ;  diabetes  should  be  remembered  as  a  fre- 
quent cause  of  obstinate  sciatica. 

Post-infectious  neuralgia. 

Toxic  neuralgia;  in  this  connection  special  attention  should  be 
paid  to  alcoholism,  with  the  attendant  diffuse  pains,  lack  of  febrile 


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LOWER  EXTREMITIES,  PAIN  IN.  1165 

temperature,  absence  of  local  inflammation  and  of  signs  of  tabes 
dorsalis,  and  sometimes  the  steppage  gait  in  an  inveterate  alcoholic. 

If  still  nothing  can  be  found,  the  condition  may  be  labelled 
a  simple,  primary,  or  idiopathic  sciatica,  the  physician  thus 
escaping  the  necessity  of  committing  himself  concerning  the 
actual  nature  of  the  disturbance. 

It  is  plain  that,  apart  from  symptomatic,  palliative  treatment 
of  the  neuralgia,  which,  indeed,  is  frequently  all  that  is  required, 
an  accurate  causal  diagnosis  can  alone  supply  a  reliable  basis  for 
curative  treatment. 


Fig.  816.— Right-sided  sciatica.    The  patient,  when  in  the  sitting  position, 
is  unable  to  extend  the  aflFected  limb  completely  (G.  Roussy). 

One  should  always  carefully  examine  for  muscular  atrophy 
and  electric  reactions,  which  afford  a  distinction  between  neu- 
ralgic sciatica,  ordinarily  a  mild  condition,  and  neuritic  sciatica, 
which  is  always  serious  and  sometimes  incurable. 


The  lumbar  plexus,  formed  by  anastomoses  of  the  anterior 
divisions  of  the  last  four  lumbar  nerves,  and  its  branches — the 
ilio-hypogastric,  ilio-inguinal,  external  cutaneous,  genito-crural, 
obturator,  and  especially,  the  anterior  crural — is,  apparently,  much 
less  frequently  affected  than  the  sdatic.    Yet  lumboabdofninal  neur- 


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1166  SYMPTOMS. 

algia  with  its  painful  points  (lumbar,  iliac,  abdominal  and  scrotal), 
frequently  encountered  in  pyelonephritic  disorders ;  external  cutane- 
ous neuralgia  with  its  superior  interiliac  painful  point,  and  especially 
anterior  crural  neuralgiCy  with  its  painful  points  dispersed  along 
the  anterointernal  aspect  of  the  thigh,  leg,  and  foot  (tender  points  in 


Qi 


12th  doraal 

2d   lumbar 

3d  lumbar 

4th  lumbar 
Bxte: 

Genlto-crural 

Lumbosacral  trunk 
^  Sacral  plexus 


Fig.  817. — The  lumbar  plexus. 

the  inguinal  region,  the  crural  region,  over  the  internal  condyle,  the 
internal  malleolus  and  the  inner  margin  of  the  foot)  are  not  very 
uncommon,  particularly  that  last  mentioned. 

Lumboabdominal  neuralgia,  as  we  have  just  seen,  15  an  almost 
constant  clinical  appurtenance  of  many  pyelonephritic  infections, 
especially  renal  colic. 

In  anterior  crural  neuralgia  a  special  examination  should  be 
made  for  Pott's  disease,  psoas  inflammation,  appendicitis,  typh- 
litis, inguinal  and  femoral  hernia,  and  in  a  general  way  for  affec- 


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LOWER  EXTREMITIES,  PAIN  IN,  1167 

tions  in  the  pelvis,  especially  those  involving  the  Fallopian  tubes 
or  the  ovaries. 

Lastly,  mention  should  be  made  of  the  lightning  pains  of  tabes 
dorsalis,  exhibiting  definite  features  in  their  paroxysmal  occurrence, 
lancinating,  fulgurant,  and  boring  character,  but  the  diagnosis  of 
which  should,  in  short,  be  based  mainly  on  the  major  symptom- 
group  of  tabes,  vis,,  specific  history;  reflex  disturbances,  such  as 


Transve 

ntervertehral 
oramina 


Articulai 


Fig.  818. — Relations  of  the  intervertebral  foramina  of  the  lower  lumbar 
region  with  the  lumbar  spinal  ganglia. 

loss  of  the  patellar  reflex  and  the  Argyll-Robertson  pupil ;  disturb- 
ances of  station  and  equilibrium  (astasia),  disturbances  of  motion 
(ataxia),  sphincter  disturbances,  etc. 


In  a  striking  synthetic  study  concerning  cases  of  neurodocitis 
and  vertebral  funiculitis,  Sicard  (Presse  med.,  Jan.  7,  1918),  gave  a 
good  general  account  and  excellent  anatomic  classification  of  the 
changes  occurring  in  the  spinal  nerves  from  their  point  of  issue  in 
the  spinal  cord  to  their  rearrangement  in  separate  fascicular  groups. 
A  good  diagram  condensing  the  essential  facts  in  this  connection 
seems  adequate  at  this  point.    Neurodocitis  is  a  general  term  desig- 


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1168  SYMPTOMS, 

nating  the  changes  resulting  from  compression  of  certain  nerve- 
trunks  in  the  natural  osseous,, fibro-osseous,  or  fascial  canals.  The 
word  funiculitis  is  here  taken  to  signify  a  neurodocitis  of  the  tis- 
sues surrounding  the  intervertebral  foramina. 

Ordinary  sciatic  neuralgia  is  either  a  neurodocitis  resulting 
trom  compression  of  the  nerve  at  the  great  sacrosciatic  notch,  in 


sma/f  htanehes 

Fig.  819. — ^The  several  sections  of  the  nerve  paths  from  the  spinal 
cord  to  the  periphery.  Ordinary  sciatica  is  a  funiculitis  at  the  inter- 
vertebral foramen. 

the  ischiotrochanteric  space,  or  on  the  outer  aspect  of  the  fibula, 
or  a  funiculitis  of  the  intervertebral  foramen  of  rheumatic,  gouty, 
or  arthritic  origin. 

True  lumbago  is  a  bilateral  rheumatic  funiculitis  involving  the 
2d,  3d,  and  4th  lumbar  nerves. 

Syphilis  usually  causes  radiculitis  and  myelitis,  while  tuber- 
culosis and  cancer  oftenest  lead  to  funiculitis. 


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LOl^BR  EXTREMITIES,  PAIN  IN.  1169 

However  long  and  tedious  the  preceding  enumeration  may 
have  been,  it  constitutes  only  an  incomplete  list  of  the  local  dis- 
orders; yet  it  includes  the  majority,  at  least,  of  the  painful  con- 
ditions met  with  in  the  lower  extremities.  (In  addition  there  are 
to  be  thought  of  such  discomforts  as  may  arise  from  tight  leggings, 
corns,  perforating  ulcers,  ill-fitting  footwear,  abscesses,  lymph- 
angitis, suppurative  processes  and  the  corresponding  glandular 
enlargements,  etc. — all  self-evident  local  disorders.) 

As  a  parting  piece  of  counsel,  it  may  be  stated  that  whatever 
variety  of  pain  in  the  lower  extremity  is  complained  of,  one 
should  never  fail  to  examine : 

(a)  The  spinal  column. 

(b)  The  hip  joint 

(c)  The  region  of  the  appendix, 
(rf)  The  kidney  region. 

(e)  The  urine. 


74 


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LUMBAR  PAIN. 
BACKACHE. 


Few  symptoms  are  so  frequently  misinterpretea  as  lumbar 
pain,  backache,  or,  as  popularly  termed,  **kidney  pains."    The 


bar  muBcles 
HUB  dorsl 
mediuB 

maxlmus 


Fig.  820. — Lumbar  musculature.  The  spinal  muscles  on  the  side 
opposite  to  that  of  flexion  are  in  contraction.  The  transverse  folds  of 
skin  over  the  spinal  muscles  on  the  relaxed  side  are  readily  seen  (P. 
Desfosses), 

author  has  f)ersonally  seen — ^an  instance  almost  unbelievable,  yet 
absolutely  authentic — a  case  of  ordinary  lumbago  labelled  Bright's 
disease  (needless  to  state,  examination  showed  neither  albumin, 
casts,  high  pressure,  nor  any  increase  in  blood  urea),  and  con- 

(1170) 


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LUMBAR  PAIN.       BACKACHE.  1171 

versely,  an  obvious  case  of  Pott's  disease  of  the  lower  dorsal 
region  with  abscess  formation,  labelled  lumbago. 

Such  mistakes  may  be  accounted  for  in  many  ways. 

First  and  foremost  is  the  unfortunate  habit  of  not  examining 
the  painful  region  directly  and  by  inspection.  Only  exception- 
ally, indeed,  is  the  lumbar  region  actually  subjected  to  a  sys- 
tematic examination  in  a  patient  complaining  of  "kidney  pains." 


laliB  colli 
lUocoBtalis   cerrl  Icalla  descendens 


Longisslmus  dors! 

Sacrolumbal  is 
niocofltalis  dorsl 

Spdnalis  dorai 


lumbalis 
niocofltalis  lumb< 

inaliB 


Fig.  821. — ^The  spinal  muscles. 

As  a  matter  of  fact,  there  are  few  regions  of  the  body  that  de- 
mand a  more  thorough  and  systematic  local  examination,  since 
very  few  regions  exhibit  painful  manifestations  originating  in 
such  diverse  and  variously  situated  disturbances.  While  one 
of  the  anatomic  peculiarities  of  the  region  is  the  pres- 
ence of  the  thick  sacrolumbar  masses  of  muscular  tissue,  which 
act,  to  all"  intents  and  purposes,  as  the  muscles  governing  the 
erect  posture  and  are  so  frequently  rendered  painful  by  the  most 
varied  pathologic  states,  the  following  regional  anatomic  divi- 
sions should  be  kept  in  mind : 

1.  Muscular  region :    The  sacrolumbar  mass  of  muscle  tissue. 
*    2.  The  bony  spine  and  the  sacroiliac  joints. 


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1172  SYMPTOMS. 

3.  The  spinal  cord  and  nervous  system. 

4.  Paravertebral  organs :    The  aorta  and  lymphatic  structures. 

5.  The  abdominal  viscera,  including  especially  the  kidneys, 
spleen,  liver,  colon,  and  uterus. 

When  a  patient  comes  complaining  of  "kidney  pains"  or  back- 
ache, the  lumbar  region  should  be  exposed  and  a  systematic  ex- 
amination of  the  structures  above  enumerated  proceeded  with. 

1.  The  skin. — This  is  sometimes  the  seat  of  herpes  zoster 
(zona)  covering  a  varying  extent  of  surface. 


dominis 
Peritoneum 

Small  IntesUne  '"»  extemus 

Iquus  Internus 

Abdominal  i  ransversalis 

Inferior  vena 

>  Psoas 

Right  kidney 
Lumbar  vertebra  "(covered  with 

peritoneum 
Spinal  coi  anterioriy) 

scending  colon 

IratuB  lumborum 


Longisslmus  dor 

Spinal  «'"""  «° 

-lumbalis 


Fig.  822. — Transverse  section  through  the  lumbar  region. 

2.  The  sacrolumbar  muscular  system. — Palpation  and  inspec- 
tion with  the  patient  in  various  positions,  especially  the  erect 
posture,  together  with  movements  of  anteflexion,  extension,  tor- 
sion, and  lateral  bending  will  often  lead  to  the  discovery  that  the 
seat  of  pain  is  actually  in  the  muscle  tissue,  the  condition  being 
a  true  lumbar  muscular  pain  for  which,  seemingly,  the  term  lum- 
bago should  be  set  apart,  but  which  may  yet  be  encountered 
under  very  variable  clinical  circumstances,  to  wit : 

(a)  Acute  lumbago,  following  a  forceful  straightening  of  the 
flexed  body,  as  in  lifting  a  heavy  v/eight,  such  as  a  trunk. 

(&)  Subacute  lumbago,  following  a  prolonged  march,  with 
fatigue  and  exhaustion.  This  represents  a  "forcing^*  of  the 
muscle,  which  becomes  painful  because  of  overwork, — a  tondi- 


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LUMBAR   PAIN.       BACKACHE,  1173 

tion  that  might  without  impropriety  be  placed  in  the  group  of 
**rheumatic  disturbances  the  result  of  defective  functioning  of 
the  locomotor  apparatus,"  masterfully  described  by  Le  Gendre.^ 
Undoubtedly  there  occurs,  moreover,  an  acute  or  subacute  lum- 
bago of  rheumatic  origin  which  is  very  favorably  influenced  by 
sodium  salicylate. 


Fig.  823. — Posterior  relations  of  the  kidneys.  On  the  left  side  is  seen 
the  main  mass  of  spinal  muscle  (shaded),  and  projecting  beyond  it  below, 
the  quadratus  lumborum.  On  the  right  side  the  main  spinal  muscle 
mass  has  been  removed,  exposing  the  quadratus  lumborum  and  the  lum- 
bocostal ligament. 

(f )  Subacute  or  chronic  lumbago  of  psychoneurotic  cases,  ap- 
parently the  local  clinical  expression  of  an  actual  constitutional  neu- 
romuscular asthenia,  and  which  may  occur  either  as:  1.  A  localized 
pain  constituting  an  actual  topoalgia.  2.  A  regional  dysesthesia,  with 
morbid  sensations  of  pressure,  of  sharp,  fleeting  pains,  of  heat,  or  of 
cold,  frequently  with  abnormal  sensitiveness  of  the  region  to  pal- 


iLeGendre:    Acad,  de  med.,  May  9,  1911. 


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1174 


SYMPTOMS, 


pation,  the  whole  constituting  a  vague  neuromuscular  syndrome.  3. 
Deep  pain,  weakness,  and  exhaustion  with  lumbar  muscle  pains  fol- 
lowing strong  emotional  impressions;  an  actual  paroxysmal  emo- 
tional lumbago  superimposed  upon  a  chronic  psychoneurotic  lum- 
bago attending  habitual  asthenia. 

The  absence  of  definite  local  lesions,  the  history,  the  neurotic 
stigmata,  the  habitual  psychasthenia,  the  chronic  course  of  the 
morbid  manifestations,  and  their  recrudescence  after  emotional 


Figs.  824  and  825. — Osteospondylitis  of  the  vertebrse. 

impressions  are  the  most  reliable  diagnostic  features  of  these 
cases. 

3.  The  spinal  column,  and  more  particularly  the  lumbar  verte- 
brae, with  which  we  are  here  especially  concerned,  may  be  the  seat 
of  many  pathologic  conditions  causing  lumbar  pain. 

(a)  First  and  foremost  should  be  placed  the  chronic  inflamma- 
tory states-  or  spondylitis  of  the  vertebrae,  their  periosteum,  and  the 
intervertebral  joints,  leading  to  the  exostoses,  adhesions,  and  anky- 
loses frequently  encountered  in  sedentary  individuals  after  the 
fourth  decade  of  life.  Some  rough  sketches  illustrating  these  con- 
ditions are  presented  herewith.  Such  instances  of  spondylitis  are 
met  with  among  all  the  usual  cases  of  arthritis  deformans,  and  post- 
infectious rheumatism,   e,g,,  after  pneumonia,  tonsillitis,  typhoid 


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LUMBAR  PAIN,       BACKACHE, 


1175 


fever,  etc.  The  condition  is,  in  short,  a  vertebral  osteoarthritis,  or 
a  deforming  or  post-infectious  lumbarthritis.  Nor  is  post-traumatic 
spondylitis  a  rare  affection. 

The  limitation  of  motion,  the  stiffness  in  the  lumbar  region,  the 
pain  induced  in  the  lumbar  spine  by  flexion  or  torsion  of  the  body, 
the  cracking  sensations  experienced  by  the  patients  themselves,  the 
chronic  or  subacute  course  of  the  disorder,  the  history,  and  espe- 
cially the  x-ray  examination,  will  lead  to  the  diagnosis.^  The  dis- 
order particularly  to  be  excluded  in  these  cases  is  Pott's  disease. 

(b)  Pott's  disease,  the  recognized  evidences  of  which  need 
here  scarcely  be  recalled:  Localized  pain,  most  marked  in  one 
vertebra ;  radiation  of  pain  to  the  lower  extremities ;  cessation  of 
pain  upon  rest  in  recumbency  and  immobilization  of  the  affected 
region ;  and  ultimately,  angular  deformity  at  the  point  of  involve- 
ment and  paretic  disturbances  of  the  sphincters  and  lower  extremi- 
ties, with  exaggerated  reflexes,  abscess  formation,  etc. 

Pott's  disease  should  always  be  thought  of  in  the  presence  of 
chrdnic  lumbar  pain, 

(r)  Diac  and  sacroiliac  osteoarthritis,  the  location  of  which 
is  determined  by  careful  palpation. 


1  Beclere,  quoted  by  Leri  (Presse  nUd,,  Feb.  28,  1918),  had  already  pub- 
lished in  1906  the  following  differential  table  relating  to  chronic  rheumatism 
of  the  vertebrae  and  rhizomelic  spondylosis : 


1.  Chronic  vertebral  rheumatism. 

First  feature:  Distortion  of  the 
bodies  of  the  vertebra  consisting  of 
a  broadening  of  the  upper  and  lower 
surfaces  and  exaggeration  of  the 
circular  concavity. 

Second  feature:  The  interver- 
tebral discs  are  distinctly  more 
transparent  than  the  bodies. 

Third  feature:  Little  or  no  sug- 
gestion of  a  vertical  opaque  band 
corresponding  to  the  ligaments  is 
present 


2.  Rhizomelic  spondylosis. 

First  feature:  No  distortion  of 
the  bodies  of  the  vertebra,  which 
are  almost  cylindrical  in  shape. 


Second  feature:  The  discs  are 
not  more  transparent  than  the 
bodies. 

Third  feature:  Both  the  bodies 
and  discs  are  covered  by  a  broad 
band  with  parallel  borders;  the 
outermost  portions  of  the  verte- 
bral bodies  project  beyond  this 
band;  the  processes  of  the  verte- 
bra exhibit  a  remarkable  and  un- 
usual degree  of  transparency. 


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1176  SYMPTOMS. 

4.  Inflammatory  conditions  of  the  spinal  cord  and  vertebral 
column  cause  well-known  forms  of  backache.  They  are  met  with 
chiefly  in  the  following  disorders. 

(a)  In  acute  meningomyelitis  (acute  meningitis;  cerebro- 
spinal meningitis),  the  diagnosis  of  which  is  based  on  the  simul- 
taneous presence  of  constitutional  signs  of  infection,  such  as 
fever  and  leucocytosis,  in  conjunction  with  the  meningeal  symp- 
tom-group (headache,  backache,  Kemig's  sign,  etc.),  and  is  con- 
firmed by  examination  of  the  cerebrospinal  fluid,  showing  an  ex- 
cess of  lymphocytes  or  polynuclears,  the  presence  of  meningo- 
cocci, etc. 

(6)  The  onset  of  many  infectious  diseases,  particularly  influ- 
enza, smallpox,  and  pneumonia,  is,  as  is  well  known,  frequently 
marked  by  extremely  severe  backache.  Examination  of  a  num- 
ber of  specimens  of  cerebrospinal  fluid  obtained  under  these  con- 
ditions led  to  the  surmise  that  the  beginning  of  these  disorders 
is  often  accompanied  by  a  sharp  but  temporary  meningeal  con- 
gestion, which  later  passes  off  along  with  the  backache  which 
is  its  clinical  manifestation. 

(c)  Mention  may  here  be  made  of  an  expression  used  in  military 
medicine,  ins,,  backache  with  fever  {courbaiure  febrile) — on  the 
whole  a  rather  happy  expression  since  it  combines  both  the  symp- 
toms, backache  and  fever,  which  feature  the  clinical  state  to  which 
it  refers.  Unquestionably  this  term  comprises  a  number  of  diflFerent 
conditions  and  careful  investigation  would  lead  frequently  to  the 
discovery  of  cases  of  "incomplete"  paraityphoid  or  even  typhoid 
cases.  On  the  other  hand,  it  is  certainly  true  that  if  the  clinical 
entities  now  recognized  are  eliminated  from  it  there  remains  a  large 
percentage  of  undetermined,  cryptogenic  infections,  usually  tran- 
sient and  mild,  but  for  which  an  accurate  designation  would  be 
hard  to  find. 

(rf)  The  same  sort  of  a  sharp,  temporary  meningeal  reaction 
with  backache  and  fever  has  been  noted  by  the  author  in  certain 
cases  of  secondary  syphilis  running  an  acute,  febrile  course. 

{e)  The  author  has  been  led  to  consider  as  symptomatic  of 
venous  congestion  of  the  spinal  and  perispinal  plexuses  certain  in- 
stances of  chronic  lumbago  in  subjects  suflFering  from  hemorrhoids, 
with  high  venous  pressure  and  low  arterial  pressure,  the  lumbar  pain 


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LUMBAR  PAIN,       BACKACHE.  1177 

showing  daily,  almost  periodic  exacerbations;  these  cases  were,  as 
a  matter  of  fact,  greatly  relieved  by  counterirritation  with  fly  blisters 
and  wet  cupping  over  the  lumbar  region  and  medication  directed 
toward  overcoming  the  venous  congestion,  vis.,  adrenalin,  strych- 
nine, and  hamamelis.  This  condition  must  play  an  important  role 
in  the  lumbago  of  psychoneurotic  subjects. 


Lateral  ant. 
plexus 

ant 


irse 

lexus  iBverae 

.  plexus 


us  of  the 

jrvert 

unen 


iteral  ant. 
lexuB 


Figs.  826  and  827. — Intraspinal  venous  plexuses. 

(/)  Lastly,  it  should  not  be  forgotten  that  the  spontaneous  or 
artificially  induced  pain  in  some  cases  of  sciaticalgia  may  ascend 
above  the  great  sacrosciatic  notch  to  the  vicinity  of  the  sacroiliac 
joint  or  of  the  transverse  processes  of  the  lumbar  vertebrae  and  the 
lumbosacral  masses  of  muscle  tissue. 

Examination  for  Lasegue's  sign  is  of  the  greatest  service  in 
these  cases. 

In  the  frequent  instances  of  sciatica  combined  with  kypho- 
scoliosis or  scoliosis,  hyperesthesia  and  hyperkinesia  of  the  lum- 


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1178  SYMPTOMS, 

bosacral  muscular  mass  are  constantly  present.  It  is  noteworthy, 
however,  that  this  hyperesthesia  and  hyperkinesia  are  in  some 
instances  homologous  {i.e.,  present  on  the  same  side  as  the  sciatic 
pain),  while  in  others  they  are  on  the  opposite  side;  no  reliable 
explanation  of  this  fact  can  at  present  be  vouchsafed. 

This  peculiarity  is  of  importance  in  the  exposure  of  maling- 
erers. Where,  in  conjunction  with  the  symptoms  of  sciatica, 
there  is  noted  spontaneous  or  induced  hyperesthesia  of  the  lum- 
bar region  on  the  opposite  side,  one  may  aimost  certainly,  unless 


Fig.  828. — Diploic  veins  in  the  body  of  a  vertebra. 

the  subject  is  thoroughly  familiar  with  the  clinical  features  of 
sciatica,  exclude  the  possibility  of  malingering. 

5.  The  popular  exp-ression  "pain  in  the  kidneys"  correctly 
suggests  the  anatomic  relationships  of  the  kidneys  to  the  lumbar 
regions.  It  is  an  actual  fact  that  many  renal  disorders  are  accom- 
panied by  lumbar  pain,  the  following  succinct  description  of 
which  is  borrowed  from  Cathelin : 

"The  first  indication  of  reno-ureteral  affections  which  plays 
a  predominant  role  in  the  patient's  own  estimation  is  pain,  which 
may  be  either  spontaneous  or  artificially  brought  on  by  motion 
or  by  pressure  in  the  costovertebral  angle,  particularly  at  the 
apex  of  this  angle.  It  is  seldom  present  anteriorly,  yet  radiates 
either  in  the  direction  of  the  ureter  obliquely  downward  and  in- 


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LUMBAR   PAIN,        BACKACHE,  1179 

ward  or  along  the  iliohypogastric  and  ilioinguinal  nerves,  extend- 
ing around  the  body. 

**In  other  instances,  it  radiates  even  to  the  neck  of  the  bladder 
or  the  spermatic  cord,  as  in  stone,  a  fact  accounted  for  by  the 
existence  of  the  genital  fibers  of  the  ilioinguinal  nerve. 

"The  pain  may  be  located  sympathetically  (Guyon's  reno-renal 
reflex)  in  the  opposite  kidney,  thus  bringing  in  a  disturbing  factor 
in  the  interpretation  of  the  case.  A  patient  with  a  stone  in  the  right 
kidney  often  experiences  pain  in  the  left  kidney.  The  same  sort  of 
thing  is  observed  in  renal  congestion. 

**The  pain  may  be  either  slight,  dull,  and  deep-seated  or  occur 
in  paroxysms  introducing  the  symptom-group  of  renal  colic  (hydro- 
nephrosis) or  of  nephritic  colic  (descent  of  a  stone)  ;  while  gen- 
erally wanting  in  nephritis,  in  cancer,  and  in  some  common  forms 
of  renal  tuberculosis,  it  is  present  especially  in  certain  cases  of 
movable  kidney,  in  hydronephrosis,  and  in  lithiasis,  in  which  it  is 
increased  by  walking,  riding  in  vehicles,  violent  exercise,  and 
motion  in  general," 

Physical  examination  of  the  kidneys,  which  should  be  com- 
bined with  the  study  of  the  functional  signs,  consists  chiefly  of  pal- 
pation and  the  finding  of  either  a  movable,  a  distended,  a  subcostal, 
or  a  cancerous  kidney,  the  organ,  in  the  latter  instance,  being  often 
hard,  irregular,  and  mobile. 

Such  a  clinical  investigation  for  tumor  in  the  hypochondriac 
regions  is  sometimes  hard  to  interpret,  on  account  of  the  pres- 
ence of  the  liver  on  the  right  side  and  the  spleen  on  the  left. 

By  this  procedure,  however,  one  is  enabled  to  ascertain  the 
exact  position  of  the  enlarged  kidney,  whether,  thoracic  or  sub- 
costal, its  mobility,  its  smooth  or  lobulated  surface,  its  consist- 
ency (hard  or  soft;  fluctuation  in  hydronephrosis),  and  its  irreg- 
ular shape  (in  certain  instances  of  malignancy). 

Among  the  further  sources  of  information  that  may  be  availed 
of  by  palpation  are  the  three  ureteral  points  of  tenderness,  viz.,  the 
superior  or  paraumbilical  point,  corresponding  to  the  renal  pelvis; 
the  intermediate  or  iliac  point,  corresponding  to  the  crossing  of  the 
external  iliac  vessels,  and  the  inferior  or  z*esical  point,  corresponding 
to   the    interstitial,    intravesical    portion    of    the    ureter,    palpable 


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1180  SYMPTOMS. 

through  the  vagina  in  women  and  through  the  rectum  in  the  male 
subject. 

6.  Abdominal  ptosis,  various  uterine  disorders,  and  pregnancy 
are  the  cause^ — frequently  obvious— of  many  instances  of  lumbago. 
The  mere  thought  of  them  is  often  sufficient  to  make  plain  their 
causal  relationship  to  the  lumbar  discomfort.  The  author  has  seen 
very  many  cases  of  obstinate  lumbago  yield  to  the  wearing  of  a 
suitable  abdominal  belt. 

7.  Exceptional  forms. — Mention  may  be  made  of  certain  truly 
exceptional  causes  of  lumbar  pain,  viz.,  cholelithiasis,  aortic  aneu- 
rysm, and  vertebral  and  paravertebral  tumors.  The  presence  of 
a  painful  point  in  the  right  lower  lumbar  region  with  contraction 
of  the  muscles  of  the  posterior  wall  in  attacks  of  acute  appendi- 
citis has  been  pointed  out  by  a  number  of  authors. 


Brief  clinical  examination  will  often  discover  very  easily  the 
actual  cause  of  lumbar  pain.  The  following  few  questions  are 
sometimes  conclusive  in  this  connection : 

1.  How  long  has  the  patient  been  suffering  from  backache? 

(a)  The  patient  may  have  had  it  for  a  few  days,  the  onset  hav- 
ing been  sudden,  after  exertion  or  a  forced  march :  True  or  rheu- 
matic muscular  lumbago, 

(b)  He  may  suffer  from  it  in  chronic  fashion,  with  exacerba- 
tions, and  exhibit  an  asthenic  appearance:  Depressive  psychoneii- 
roses,  spondylitis,  Pott's  disease,  spinal  and  perispinal  venous  con- 
gestion, chronic  abdominal  affections,  or  chronic  nephritis. 

2.  The  backache  is  closely  accompanied  by  an  infectious  dis- 
order: Meningomyelitis,  onset  of  infectious  diseases  (such  as  in- 
fluenza, small-pox,  pneumonia,  etc.),  backache  with  fever,  etc. 

3.  The  lumbar  pain  is  increased  by  the  standing  posture  and 
by  flexor  and  extensor  movements  of  the  body :  The  seat  of  pain 
may  be  in  the  spinal  column  (Pott's  disease,  vertebral  osteoar- 
thritis, etc.)  or  the  lumbosacral  muscle  mass  (traumatism,  strained 
back,  rheumatism). 

4.  Is  there  pain  on  pressure  or  percussion,  and  if  so,  where? 
In  a  vertebra :    Vertebral  osteoarthritis.  Pott's  disease. 


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LUMBAR  PAIN,       BACKACHE.  1181 

In  the  costovertebral  angle :    A  renal  disorder. 

In  a  sacroiliac  joint:    Sacroiliac  osteoarthritis. 

Involving  the  last  lumbar  nerves  and  along  the  sciatic  nerve: 
Sciatic  aigia. 

5.  Does  the  urine  contain  albumin,  blood,  or  pus?  A  renal 
disorder. 


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NECK,  SWELLINGS  IN  THE, 


The  limits  of  that  which  constitutes  the  neck  are  rather  hard 
to  define.  Anteriorly,  it  is  bounded  below  by  the  angle  formed 
by  the  clavicles  and  sternum,  above  by  the  lower  jaw  and  an 
imaginary  line  extending  from  the  angle  of  the  jaw  to  the  mast- 
oid process.  Posteriorly,  it  is  bounded  above  by  the  mastoid 
processes  and,  the  external  occipital  protuberance,  while  below 
its  limits  are  indefinite ;  it  forms  a  continuous  surface,  in  the  ab- 
sence of  any  prominent  landmarks,  with  the  dorsal  region.  This 
constitutes  the  nuchal  region,  which  is  one  of  subsidiary  import- 
ance from  the  medical  aspect.  The  anterior  and  lateral  surfaces 
of  the  neck,  on  the  other  hand,  are  frequently  the  seat  of  swell- 
ings concerning  which  the  practitioner's  opinion  is  often  in  de- 
mand, and  although  by  far  the  greater  number  of  these  belong 
rather  to  the  domain  of  surgery,  it  seems  essential  to  refer  to 
them  briefly.  The  subject  being,  however,  somewhat  out  of  the 
exact  limits  of  the  field  covered  by  this  work,  the  data  presented 
will  be  given  merely  in  a  brief,  suggestive  form,  with  just  suffi- 
cient detail  properly  to  recall  the  various  possibilities  to  the 
reader's  mind. 

For  convenience  of  description,  it  is  advisable  to  divide  the 
anterolateral  region  of  the  neck  into  two  median  parts,  the  supra- 
and  infra-hyoid,  and  two  lateral  parts,  the  sternomastoid  and  the 
supraclavicular,  as  represented  in  Fig.  829. 


The  patient  comes  to  seek  the  practitioner's  advice: 

Either  on  account  of  a  local  or  diffuse  swelling  in  the  neck,  of  an 
acute  and  painful  inflammatory  type. 

Or  on  account  of  a  chronic  enlargement  of  non-inflanimatory 
nature.     A  swelling  in  the  neck  may  even  be  discovered  by  the 
physician  in  the  course  of  a  systematic  examination  without  the 
patient  having  previously  been  aware  of  its  presence. 
(1182) 


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NECK,  SWELLINGS  IN   THE.  1183 

The  acute  inflammatory  swellings  in  the  neck  comprise  ade- 
nitis, thyroiditis,  and  cellulitis  of  the  neck. 

Submaxillary  adenitis,  a  frequent  condition  in  children,  is 
generally  of  dental  origin. 

Adenitis  below  the  angle  of  the  jaw  either  originates  from  the 
pharynx  or  occurs  in  conjunction  with  disturbances  localized  in  the 
unsdom  tooth. 

In  suprahyoid  adenitis  a  primary  inflammatory  condition 
should  be  examined  for  in  the  lower  lip  and  suprahyoid  superficial 


Diga8trl( 
Mylotayoi< 


Inten  ,     .     ^, 

Externa  ^«^**^  <^"^^ 

Oi  »«® 

Sternoi  ige 

Stemc 
Cleidoma 
Trapeziu 


«v^»««-, (cut) 

Fig.  829. — Anterior  surface  of  the  neck,  showing  the  regional  sub-    ' 
divisions  and  underlying  structures. 

tissues.  Allied  to  this  is  the  serious  condition  known  as  suprahyoid 
cellulitis,  following  Ludwig's  angina,  the  primary  source  of  which  is 
an  inflammation  of  the  floor  of  the  mouth  in  the  form  of  a  sub- 
lingual abscess. 

In  the  infrahyoid  region,  an  inflammatory  swelling  is  neces- 
sarily associated  with  laryngeal  manifestations  such  as  aphonia' 
dyspnea,  and  suflFocative  attacks.  It  follows  an  abscess  of  the 
thyrohyoid  and  thyroepiglottic  spaces,  detected  by  palpation 
from  the  pharynx:  On  following  down  the  base  of  the  tongue, 
an  edematous,  tender,  and  sometimes  fluctuating  swelling  is 
found  in  front  of  and  on  the  lateral  surfaces  of  the  epiglottis. 


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1184  SYMPTOMS. 

Stemomastoid  adenitis  is  almost  inevitably  accompanied  by 
symptomatic  torticollis,  Tha  source  of  infection  is  to  be  looked  for 
in  the  regions  of  the  mastoid  (mastoiditis)  and  of  the  pharynx 
(phlegmonous  angina). 

DiflFuse  cellulitis  of  the  neck  sometimes  follows  the  form  of 
adenitis  referred  to ;  much  oftener,  however,  it  develops  directly, 
in  a  predisposed  subject,  as  a  result  of  some  infection  of  the 
mouth  or  pharynx. 

All  of  the  above  conditions  are  mainly  surgicaL 

Thyroiditis  is  chiefly  a  medical  disorder.  It  appears  in  the 
form  of  a  uni-  or  bi-  lateral  swelling  in  the  infrahyoid  region  repre- 
senting the  thyroid  gland,  the  shape  of  which  is  reproduced 
thereby;  the  enlargement  is  sensitive  rather  than  painful,  of 
elastic  consistency,  and  covered  with  healthy  skin  of  normal  hue 
but  crossed  by  dilated  veins.  The  condition  is  accompanied  by 
dyspnea,  cough,  a  rough  quality  of  the  voice,  and  sometimes  by 
frothy,  blood-stained  expectoration.  The  pain  is  worse  on  swal- 
lowing. The  disorder  develops  either  spontaneously,  with  a  sud- 
den onset  marked  by  a  chill  and  fever,  or  in  consequence  of  an 
infectious  disease.  Resolution  is  the  rule,  and  suppuration 
exceptional. 


Chronic  Enlargements  in  the  Neck. — ^These  are  by  far  the 

more  important  from  the  medical  standpoint. 

A  regional  classification  is  necessary  for  practical  clinical  pur- 
poses :  A  swelling  may  exist  either  on  one  of  the  lateral  aspects 
of  the  neck  or  in  the  median  region. 

Enlargements  on  the  Lateral  Aspects  of  the  Neck. 

1.  Glandular  enlargements. — Here  again,  involvement  of 
glands  supplies  the  greatest  number  of  enlargements. 
•  The  usual  causes  of  such  enlargements  are  tuberculosis,  syph- 
ilis, lymphatic  hypertrophy,  and  neoplasm;  the  main  diagnostic 
features  of  these  conditions  have  already  been  given  under  Glandular 
enlargements  (q.v.). 

Softened  tuberculous  l5miph-nodes  are  identified  by  their 
fluctuation  and  non-reducibility.     Where  there  is  periadenitis, 


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NECK,  SWELLINGS  IN   THE.  1185 


Fig.  830. — Lymphatics  of  the  head  and  neck   (Sappey). 

/,  /.  Lymphatic  vessels  leading  to  the  parotid  nodes.  -?,  2.  Inferior 
frontal  lymphatics,  j,  S.  Superior  frontal  lymphatics.  4,  4.  Parietal 
lymphatic  vessels ;  these  pass  vertically  downward,  anastomosing  with  the 
neighboring  vessels,  and  end  in  the  mastoid  nodes.  5,  5.  Origin  of  these 
vessels.  6,  6.  Anterior  suboccipital  vessels,  converging  to  form  a  single 
trunk  which,  after  a  prolonged  course,  terminates  in  one  of  the  lowest 
cervical  nodes.  7.  Trunk  resulting  from  coalescence  of  these  vessels.  8. 
Node  in  which  this  trunk  terminates.  9,  9.  Posterior  suboccipital  vessels, 
terminating  in  two  nodes  located  at  the  anterior  border  of  the  trapezius 
muscle.  70,  10.  The  above  two  nodes.  //.  Large  horizontal  trunk  start- 
ing from  the  uppermost  of  these  nodes  and  passing  beneath  the  splenius 
muscle  to  end  in  the  submastoid  nodes.  12.  Vessels  originating  in  the 
superior  mastoid  nodes  and  passing  through  the  sternomastoid  to  end  in 
the  nodes  located  beneath  this  muscle,  /j?.  Parotid  nodes.  14.  ^4-  Cer- 
vical nodes  and  their  afferent  vessels.  /%  13.  Lymphatic  vessels  originat- 
ing in  the  integument  of  the  nose.  r6,  16.  Lymphatic  vessels  of  the  lips. 
77.  Subn)axillary  nodes.  7^.  Lymphatic  vessels  from  the  middle  portion 
of  the  lower  lip.  19.  Suprahyoid  node  in  which  the  above  vessels  ter- 
minate.   ^.  Large  lymphatic  vein. 

75 


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1186 


SYMPTOMS. 


with  adhesion  to  the  reddeiled  and  tense  overlying  skin,  the  diag- 
nosis is  extremely  easy. 

The  differential  diagnosis  between  tuberculous  lymphadenitis 
and  lymphadenoma  sometimes  occasions  difficulty:  'These  two 
forms  of  enlargement  at  first  present  common  features.  They  may 
be  of  the  same  size  and  shape,  in  either  case  consisting  of  several 
lymph-glands;   they   are   movable   in   respect  of   the   skin   and 


Fig.  831. — Adenolipomatosis   {Launois  and  Bensaude), 

deeper  tissues,  though  in  some  instances  fixed  by  contraction  of 
the  sternomastoid  muscle;  they  have  the  same  seat  of  predilec- 
tion (angle  of  the  jaw,  submaxillary  region,  and  carotid  chain)  ; 
they  may  be  symmetrically  placed,  and  also  appear  at  the  same 
age,  though  scrofulous  adenitis  is  more  frequent  in  early  life. 
Yet  each  of  the  conditions  has  its  own  particular  features.  Thus, 
lymphadenoma  is  relatively  uncommon,  while  tuberculous  ade- 
nitis is  by  far  the  commonest  form  of  enlargement  met  with  in 
the  neck.  Lymphadenoma  is  of  an  even  consistency  and  imparts 
to  the  fingers  a  sensation  similar  to  that  of  renal  parenchyma. 


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NECK,  SWELLINGS  IN    THE.  1187 

Tuberculous  adenitis,  on  the  other  hand,  may  be  of  uneven  con- 
sistency and  present  some  hard  spots  and  other  areas  of  soft- 
ening. Tuberculous  adenitis  imdergoes  suppiuration,  while  lym- 
phadenoma  never  does.  Consequently,  whenever  fluctuation,  or 
even  periadenitis,  is  detected,  or  a  sinus  or  the  scar  of  a  former 


In 


>tid 

vical  ganglion 

t>Ud 
tery 

LStoid  muscle 
Hypoi 


Middl 

trie  nerve 

Con 
Inferio 


in  artery 


Fig.  832. — Deep  structures  of  the  neck  (vessels). 

abscess  observed,  a  definite  diagnosis  of  tuberculous  adenitis 
may  be  made.  Finally,  although  lymphadenoma  affords  only 
negutive  signs,  since  at  one  period  the  same  evidences  are  found 
as  in  lymphatic  tuberculosis,  it  should  be  borne  in  mind  that 
lymphadenoma  may  be  diagnosed  where  an  enlargement  of  con- 
siderable size  IS  present;  where  lymph-nodes  similarly  affected 
are  found  in  the  axillae  and  the  inguinal  and  other  lymphatic 
regions;  where  an  enlargement  of  the  same  nature  is  found  in 
another  organ,  either  the  testicle  or  the  skin   (mycosis  fung- 


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1188  SYMPTOMS. 

oides) ;  where  enlargement  of  the  spleen,  tonsils,  or  thyroid  gland 
is  simultaneously  found,  and  finally,  where  the  blood  count 
shows  an  increase  of  the  leucocytes. 

"If  the  swelling  has  developed  rapidly  and  attained  a  consid- 
erable size  within  a  few  months;  if  it  forms  a  rounded  prominence, 
covered  by  a  marked  venous  network,  and  especially  if  its  surface 
has  become  ulcerated  and  gives  rise  to  free  hemorrhages  from  time 


Fig.  833. — Exophthalmic  goiter. 

to  time,  one  should  think  of  sarcoma,  which  may  originate  in  any 
of  the  structures  constituting  the  neck  and  even  the  submaxillary 
gland,  but  which,  as  a  rule,  starts  in  the  lymph-nodes,  or  results 
merely  from  transformation  of  a  lymphadenoma,  in  which  event  it 
is  termed  lymphosarcoma"  (Rochard  and  Demoulin,  "Manuel  de 
diagn  ostic  ch  iru  rgical"  ) . 

2.  Mention  should  be  made  of  the  ossifluent  abscesses  (ab- 
scesses from  congestion  with  breaking  down  of  bone  tissue),  the 
existence  of  which  is  shown  by  the  fluctuating  character  of  the 
swelling  with  slight  reducibility   (liquid  tumor),  the  fact  that 


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NECK,  SWELLINGS  IN   THE.  Ugg 

motion  of  the  head  generally  causes  pain,  and  examination  of  the 
spine,  which  reveals  either  a  bony  deformity  or  the  presence  of 
a  well  localized  point  of  tenderness. 

3.  Lipoma,  including  the  supraclavicular  pseudolipoma  of  the 
emphysematous  and  adenolipoma,  probably  comes  next  after  gland- 
ular swellings  in  frequency.  A  mere  mention  of  lipoma  is  here 
sufficient.  An  illustration  of  typical  adenolipomatosis  is  presented 
herewith  (Fig.  831). 

4.  Finally,  there  are  the  vascular  enlargements,  or  more 
specifically,  aneurysm,  which  is,  however,  an  uncommon  disorder, 
even  though  the  supraclaviculocarotid  region  is  a  point  of  election 
for  it.  Aneurysms  present  four  pathognomonic  signs :  They  are  of 
fluid  consistency,  reducible,  and  pulsating,  whether  their  beats,  which 
synchronize  with  those  of  the  pulse,  be  visible  or  merely  palpable; 
lastly,  they  are  the  seat  of  a  systolic  blowing  bruit  which  is  audible 
on  auscultation.  These  are  the  well-known  signs  of  arterial  aneur- 
ysms. Arteriovenous  aneurysms  are  always  consequent  upon 
traumatism,  e.g.,  a  bullet  or  stab  wound;  the  bruit  is  continuous 
with  reduplication,  and  palpation  yields  the  so-called  "thrill,"  a 
species  of  fremitus  with  periodic  accentuation. 

It  is  the.  custom  to  explain  how  to  differentiate  aneurysm 
from  vascular  goiter.  A  single  sign  is  ordinarily  sufficient  for 
the  purpose:  A  p:oiter,  even  when  vascular,  ascends  with  the 
larynx  during  deglutition  while  an  aneurysm  remains  motionless. 

Recognition  of  the  site  of  an  aneurysm  is  of  marked  import- 
ance as  regards  operative  intervention. 

Carotid  aneurysm  is  located  in  the  sternomastoid  region.  The 
bruit  is  transmitted  in  the  cervical  region.  Only  the  temporal 
pulse  is  interfered  with. 

Subclavian  aneurysm  is  located  in  the  infraclavicular  region, 
at  a  point  lateral  to  the  sternomastoid.  The  enlargement  is  elon- 
gated in  the  transverse  direction.  The  bruit  is  transmitted  to- 
ward the  axilla.    The  radial  pulse  is  interfered  with. 

Aneurysm  of  the  innominate  artery  and  aortic  arch  is  located 
in  the  suprasternal  region,  between  the  sternomastoid  muscles. 
Both  the  radial  and  temporal  pulses  are  interfered  with.  The 
bruit  is  transmitted  toward  both  the  neck  and  the  axilla. 


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1190  SYMPTOMS, 

5.  Sebaceous  cysts,  uncommon  in  this  region,  contained 
within  the  skin,  painless,  and  of  firm  consistency,  could  hardly  be 
mistaken  for  anything  except  a  small  encapsulated  lipoma,  and  the 
untoward  result  of  such  a  mistake  would  be  slight. 

Exophthalmic  Goiter 

Nervous  Factor  Thyroid  Factors 


Sympathetic  l^eurosis  Dysthyroidia 

C&€broytfikmf9V8tem 

tAaAnos} 


Vasomotor 
nervtm  io 
skin  9t*d  i 
Sfmatgknds 
(Swan  and 


a. 

^5) 


StomBch 

Uver  (intfrmiH^nt 

htestina  (di^rrheB) 
^fCtr}eys(pofyuna) 


Fig.  834. — Graves's  disease.    Exophthalmic  goiter. 
Symptoms  and  pathogenesis. 

Enlargements  in  the  Median  Region  of  the  Neck. 

The  suprahyoid  region  being  rapidly  dealt  with  by  simple 
enumeration  of  adcnolipoma  and  suprahyoid  glandular  swellings 
(syphilis,  lymphatic  hypertrophy,  or  neoplasm),  there  remains  to  be 
considered : 

The  infrahyoid  region,  in  which,  the  exceptional  eventualities 
of  cysts,  tuberculous  lymphadenitis,  and  cancer  of  the  larynx  (dis- 
turbances of  voice  production  and  deglutition,  blood-stained  and 
mucopurulent  salivation,  and  laryngoscopic  examination)  having 


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NECK,  SWELLINGS   IN   THE.  Il91 

been  likewise  —  and  readily  —  eliminated,  the  remaining  con- 
dition is : 

Enlargement  of  the  thyroid  gland,  situated  definitely  below 
the  larynx,  generally  bilateral,  and  moving  upward  upon  swal- 
lowing owing  to  the  fact  that  the  gland  is  attached  to  the  laryn- 
gotracheal canal. 

Congestion  of  the  thyroid  with  temporary  swelling  of  the 
neck  may,  as  is  well  known,  be  witnessed  in  pregnancy,  after  pro- 
longed exertion,  and  in  the  course  of  infectious  diseases  (small-pox, 
typhoid  fever,  eruptive  fevers,  etc.).  It  is  essentially  a  transient 
condition,  as  is  true  likewise  of  thyroiditis,  but  it  may  at  times  be 
associated  with  the  symptomatic  picture  of  mild  and  fugacious 
Graves's  disease. 

True,  lasting  enlargements  of  the  thyroid  (cysts  and  solid 
enlargements)  are,  from  the  medical  aspect,  dominated  by  the  ques- 
tion of  Grofves's  disease  and  dysthyroidia.  The  problem  which 
arises,  and  which  is  the  most  important  to  the  physician,  is  as 
follows : 

Is  the  condition  a  simple  goiter  (solid  or  cystic)  without  appre- 
ciable disturbance  of  the  function  of  the  gland — without  dys- 
thyroidia? 

Or  is  it  a  goiter  with  overfunctioning  of  the  thyroid  or  hyper- 
thyroidia  (exophthalmic  goiter)  or  with  reduced  function  or 
hypothyroidia  (myxedema)  ? 

Briefly,  in  every  goiter  case,  of  whatever  degree  and  variety, 
one  should  look  carefully  for  the  signs  of  hyperthyroidia  given 
in  the  subjoined  table,  which  covers  concisely  the  main  clinical 
features  and  probable  pathogenesis  of  the  disturbances  of  thyroid 
function. 


Mention  may  here  appropriately  be  made  of  the  profound  dis- 
turbances of  metabolism  which  generally  accompany  exophthal- 
mic goiter  and  of  which  the  metabolism  of  glucose  serves  as  a 
rather  satisfactory  index.  In  this  connection  one  may  also  refer 
to  the  possibility  of  the  simultaneous  presence  of  exophthalmic 
goiter  and  diabetes,  as  emphasized  by  Marcel  Labbe,  and  the 
frequency  of  intermittent  glycosuria  and  of  alimentary  glyco- 


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1192  SYMPTOMS, 

suria.  Hyperglycemia  is  the  rule  in  Graves's  disease.  American 
writers  (Goetsch  and  Lueders)  have,  moreover,  called  attention 
to  the  fact  that  intramuscular  injection  of  0.5  cubic  centimeters 
of  1 :  1000  adrenalin  solution  in  hyperthyroid  subjects  causes  not 
only  a  marked  pulse  acceleration  and  rise  of  blood-pressure  but 
also,  as  a  rule,  in  the  succeeding  two  hours,  a  varying  degree  of 
glycosuria. 


Chief  Clinical  Signs  of  Exophthalmic  Goiter. 

1.  Enlargement  of  the  thjrroid  gland  (goiter). 

2.  Exophdialmos  and  the  associated  ocular  signs:     Staring  expres- 

sion (Stellwag);  failure  of  upper  lid  to  move  with  the  eyeball  in 
looking  downward  (von  Graefe);  deficient  convergence 
(Mobius). 

3.  Permanent  tachycardia,  respiratory  arhythmia,  palpitations,  vaso- 

motor manifestations  (transient  erythema,  dermographia), 
sphygmolability,  and  febricula. 

4.  Static  tremor,  exaggerated  reflexes,  nervousness,  subjective  sen- 

sation of  heat,  and  various  spasmodic  disturbances  (asthmatoid 
attacks,  gastrospasm,  spastic  constipation,  etc.). 

5.  Profuse  sweats,  unusual  salivary  secretion,  and  tendency  to  diar- 

rhea on  slight  provocation. 

6.  Polyuria,  frequent  urination,  and  intermittent  glycosuria. 

7.  Sexual  perturbations. 

Chief  Clinical  Signs  of  Hypothsrroidia. 

1.  Atrophy  and  sclerosis  of  the  thsrroid,  possibly,  though  rarely,  in 

conjunction  with  apparent  hypertrophy,  or,  more  frequently, 
with  a  doughy  condition  of  the  tissues  of  the  neck. 

2.  Doughy  condition  of  the  tissues,  thickening  of  the  integument, 

with  a  swollen,  waxy,  myxedematous  appearance  (false  edema, 
firm  and  resilient). 

3.  Phjrsical   torpor,   sluggishness,   inertia,   sloA^ness   of   the   move- 

ments, and  sensitiveness  to  cold. 

4.  Mental  torpor,  apathy,  tendency  to  backwardness,  and  slowness 

of  mental  reactions. 

5.  Diminution  of  the  sweat  and  sebaceous  secretions;  skin  dry  and 

scaly.     Impaired  nutrition  of  the  skin  and  hairy  covering. 

6.  Reduced  urinary  output  (oliguria). 

7.  Sexual  anorexia. 


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NERVOUSNESS. 


A  definition  of  the  term  '^nervousness"  is  badly  needed  for 
the  very  reason  that  it  is  so  commonly  used.  What  is  the  meaning 
of  the  term  "being  nervous?"  One  may  be  nervous  in  a  variety 
of  different  ways,  and  the  mere  attempt  to  have  patients  who 
describe  themselves  as  being  "nervous"  give  a  definite  account 
of  their  symptoms  (often  an  impossible  task)  is  enough  to  show 
that  this  term,  as  commonly  used,  is  possessed  of  either  vague  or 
variable  meanings  which  make  it  unsuitable  for  legitimate  clinical 
use. 

Unquestionably  the  proper  thing  to  do  is  to  decompose  "nen^ous- 
ness^'  into  its  several  primary  factors  and  to  make  a  systematic 
search,  in  a  patient  considered  "nervous,"  for  the  typical  stigmata 
and  symptoms,  both  motor,  sensory  and  special  sense,  mental,  vis- 
ceral and  vasomotor. 

I.  Motor  nervousness  is  manifested  especially  in  restlessness 
and  exaggeration  of  motor  responses.  In  one  group  of  cases  the 
patient  is  shifty,  restless,  unable  to  keep  still,  and  actually  has  "the 
fidgets."  Such  motor  excitement  is,  as  is  well  known,  practically 
a  normal  condition  in  children.  In  the  adult  it  is  often  associated 
with  mental  excitement,  insomnia,  anxious  states,  etc.  It  is  one  of 
the  attributes  of  the  emotive  or  nervous  constitution. 

In  a  second  group  of  cases,  the  patient  exhibits  uncontrollable 
contractions  of  var)ring  frequency  in  some  portion  of  the  body: 
Twitchings,  contractures,  tics,  or  tremor  (see  Tremor), 

This  form  of  motor  nervousness  is  met  with  in  chorea  and  the 
choreiform  states,  in  tics,  and  in  many  neurotic  disturbances.  A 
particular  search  should  be  made  for: 

Somatic  causes,  foremost  among  which  are : 

1.  Intoxications,  principally  alcoholism,  less  frequently  cocaino- 
mania,  opium  habit,  lead  poisoning,  etc. 

2;  Hyperthyroidia:  Graves's  disease,  exophthalmic  goiter,  in- 
complete (fruste)  Graves's  disease,  and,  in  a  general  way,  over- 

(1193) 


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1194  SYMPTOMS. 

activity  of  the  internal  secretions — thyroid  and  ovarian  or  testicular, 
and  hypercrinia. 

Mental  causes:  Strong  emotional  impressions,  overwork,  and 
passional  states  inducing  psychoneurotic  disturbances.  Such 
motor  nervousness  is  often  the  external  expression  of  a  deep 
mental  injury.  The  patient  has  some  poignant  burden  in  his 
heart;  he  rebels,  and  the  pain  experienced  induces  lasting  nerv- 
ousness. A  historic  example  of  this  is  that  of  the  wandering,  ill- 
used  Empress  of  Austria,  Elizabeth. 

II.  General  sensory  and  special  sense  nervousness  is  mani- 
fested in  an  hyperesthesia,  either  general  or  selective,  toward  exter- 
nal stimuli, — whether  tactile,  gustatory,  auditory,  olfactory,  visual, 
or  cutaneous  impressions  be  felt  to  an  excessive  or  actually  pain- 
ful degree,  or  even  awaken  distressful  motor  or  visceral  reflexes. 

The  disturbance  is  especially  evident  as  regards  the  auditory 
function.  The  subject  is  startled  by  the  least  sound,  jumps  when 
a  door  is  opened,  and  complains  of  hyperacusis.  Frequently  such 
a  patient  is,  moreover,  unable  to  stand  bright  illumination  or 
direct  sunlight  (as  exemplified  in  the  obstinate  facial  neuralgia 
sometimes  experienced  on  the  Southern  Coast  of  France).  At 
times  olfactory  hyperesthesia  is  manifest  in  that  the  subject  is 
able  to  perceive  odors  which  persons  considered  normal  cannot 
smell,  yet  which  analytic  procedures  show  to  be  actually  present. 
Not  rarely  one  observes  in  these  cases  a  cutaneous  hyperesthesia, 
demonstrated  by  pricking  with  a  pin  or  by  mere  grazing  of  the 
skin  surface,  as  well  as  a  heightening  of  the  tendon  and  skin 
reflexes. 

This  "general  sensory  and  special  sense  nervousness"  is  fre- 
quently accompanied  by  neuralgia  of  varying  kinds.  There  is  thus 
present  an  actual  diathesis — an  actual  algic,  hyperesthesic  con- 
stituHon, 

Special  mention  should  be  made  of  the  "general  sensory  and 
special  sense  nervousness**  manifest  in  a  "meteorologic  (cosmic) 
hyperesthesia."  These  patients  are  actual  meteorologic  esthe- 
siometers  or,  as  they  frequently  describe  themselves,  "regular 
barometers."  They  are  oversensitive  to  variations  of  tempera- 
ture, of  barometric  pressure,  and  of  humidity,  to  electro-magnetic 


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NEK  I/O  US  NESS.  1 195 

variations,  and  unquestionably  also  to  many  other  cosmic  varia- 
tions as  yet  unknown  to  us.  Some  forecast  and  feel  changes  in 
the  weather,  sharp  changes  of  barometric  pressure,  shifting  of 
the  direction  of  the  wind,  the  precipitation  of  mist,  etc.,  with 
extreme  accuracy  and  under  such  conditions  as  exclude  all  pos- 
sibility of  fraud.  The  author  has  often  had  occasion  to  witness 
a  rheumatic,  neuralgic  patient,  sitting  in  the  evening  in  a  closed 
room  with  the  shutters  drawn  and  curtains  pulled  together,  shut 
off  from  any  direct  or  indirect  contact  with  the  outer  air,  an- 
nounce with  infallible  precision  a  rise  or  fall  of  barometric  pres- 
sure of  moderate  extent  (5  to  10  millimeters)  or  a  shift  in  the 
direction  of  the  wind  or  the  onset  of  snowfall,  etc.  Every  one 
may  readily  observe  phenomena  of  this  type  among  his  associates. 
The  events  are  such  as  would  suggest  that  the  majority  of  meteoro- 
logic  changes  cause  a  disturbance  of  balance  of  the  body  fluids, 
objectively  manifested  in  various  physical  effects  and  subject- 
ively in  pain. 

Whatever  explanation  be  conceived  as  to  the  intimate  causation 
of  these  disturbances,  it  is  hard  not  to  think  of  them  as  being  de- 
pendent upon  an  unusually  unstable  electrochemical  balance  in  the 
body  fluids,  a  species  of  supersaturated  state  on  the  threshold  of 
precipitation  and  in  relation  to  which  the  least  shock  or  perturbation 
suffices  to  bring  on  an  intra-organic  reaction  involving  the  precipita- 
tion of  some  noxious  agent  either  at  the  nerve-terminals  (neuralgia), 
the  joints  (arthralgia) ,  or  certain  internal  organs  (visceralgia).  In 
this  way  may  be  roughly  described  the  relationships  existing  be- 
tween the  as  yet  rather  poorly  defined  groups  of  patients  with  "a 
tendency  to"  rheumatism  or  neuralgia,  at  present  loosely  combined 
under  the  term  "neuro-arthritism." 

III.  Psychic  nervousness  is  perhaps  a  commoner  condition. 
Its  outstanding  feature,  on  the  whole,  is  mental  instability  in  all 
its  different  expressions.  The  subject  is  emotional,  and  the  least 
untoward  event  causes  him  to  lose  his  self-possession ;  he  is  not 
"master  of  his  own  acts."  Often  periods  of  enthusiastic  excite- 
ment and  exaggerated  optimism  alternate  with  periods  of  depres- 
sion and  unwarranted  pessimism. 

In  the  condition  characterized  by  excitement  the  subject  is 


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1196  SYMPTOMS. 

irritable  and  even  impulsive ;  he  quickly  becomes  angry  and  even 
violent. 

In  the  depressed  condition,  he  is  morose,  anxious,  aboulic,  and 
is  readily  seized  with  apprehension  or  actual  fear. 

The  question  of  the  "neuroses"  and  "psychoneuroses"  might 
appropriately  be  taken  up  here.  We  shall  not  do  so,  however, 
merely  reminding  the  reader  that  in  these  cases  the  chief  aim  of 
the  practitioner  should,  seemingly,  be  to  ascertain : 

1.  Whether  the  existing  psychopathic  disorder  is  not  the  ex- 
pression of  a  concrete  somatic  condition,  the  most  important  dis- 
ease in  this  connection  being  general  paralysis,  as  well  as  some 
common,  latent  or  overlooked  morbid  state  such  as  diabetes,  ar- 
teriosclerosis, intoxication  (as  by  alcohol,  etc.),  tuberculosis  in 
its  insidious  stage,  malaria,  etc. 

2.  Whether  the  psychopathic  disorder  is  not  the  necessary 
and  perhaps  inevitable  consequence  of  some  conscious  mental 
stress,  such  as  secret  sorrow,  frequently  present  in  young  girls 
and  women,  or  professional  difficulties  or  disappointments,  which 
are  responsible  for  a  high  percentage  of  embittered,  anxious, 
nervous  individuals,  etc.  Political,  literary,  and  even  medical 
pursuits  yield  a  host  of  such  cases. 

3.  Whether  the  psychic  nervousness  is  not,  properly  speaking, 
a  constitutional,  congenital,  and  frequently  inherited  state. 
Nothing  could  be  more  illuminating  in  this  connection  than  the 
simultaneous  examination  of  a  mother  and  her  daughter,  the 
latter  showing  the  same  psychopathic  manifestations  as  the 
former,  but  with  twofold  or  even  threefold  intensity. 

The  highly  suggestive  psychologic  conception  of  hysteria 
considered  as  a  disorder  characterized  essentially  by  a  contrac- 
tion of  the  "field  of  consciousness"  which  allows  the  subject  to 
group  together  at  a  given  moment  only  an  extremely  restricted 
number  of  sensations  and  recollections  accounts  satisfactorily 
for  this  variety  of  "psychic  nervousness,"  with  its  expressions 
in  the  form  of  instability,  impulsiveness,  psychic  and  moral  in- 
coordination, suggestibility,  etc.,  a  single  idea,  image,  or  sensa- 
tion sufficing  to  overcrowd  the  field  of  consciousness,  so  that 
one  idea  drives  out  another. 


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NERVO  USNESS.  1 197 

IV.  Visceral  and  vasomotor  nervousness. — The  ''spasmodic" 
and  ''paretic"  manifestations  predominate  in  this  group,  whether 
the  spasmophilia  be  chiefly  visceral,  and  capable  of  causing  very 
various  phenomena  such  as  spasm  of  the  esophagus,  meteorism,  re- 
gurgitation of  food,  dyspepsia,  constipation,  retention  of  urine,  etc., 
or  cardiovascular,  being  represented  by  the  anginal  symptom-group, 
neurocardiac  erethism,  the  tachycardiac  neurosis,  spasm  of  the  ves- 
sels, hyperidrosis,  dermographism,  acrocyanosis,  disturbances  of 
skin  temperature,  etc.  In  these  cases  sympathetic  disturbances 
predominate. 

In  some  subjects  there  is  observed  an  actual  vasomotor  ataxia 
characterized  by  evidences  either  of  vasodilation  or  vasocon- 
striction or  of  a  mixture  of  these  two  varieties  of  vascular  dis- 
order. Graves's  disease  represents  the  extreme  vasodilator  type, 
and  Raynaud's  disease,  the  extreme  vasoconstrictor  type.  Be- 
tween these  two  are  found  many  intervening  varieties,  of  vary- 
ing intensity  and  location,  such  as  simple  urticaria,  dermograph- 
ism, nervous  edema,  drug  idiosyncrasies,  hay  fever,  intermittent 
albuminuria,  a  tendency  to  purpura  and  petechiae,  multiple  angio- 
mata  of  the  skin,  and  paroxysmal  tachycardia.  The  disturbances 
at  the  menopause  present  essentially  this  condition  of  vasomotor 
ataxia. 

Clinical  tests. — There  are  available,  indeed,  certain  elementary 
clinical  tests  which  enable  the  practitioner  to  detect  such  exces- 
sive irritability  of  the  sympathetic  system : 

(a)  The  vasomotor  skin  reactions  induced  by  rubbing  or  by  the 
application  of  heat  or  cold.  When  exaggerated,  these  lead  to  der- 
mographism, as  in  the  "meningeal  line";  when  perverted,  to  re- 
actions in  the  opposite  sense,  vis.,  redness  after  the  application  of 
cold  and  pallor  following  the  application  of  heat. 

(b)  The  reactions  as  to  heart  frequency  induced  by  the  respira- 
tion. Normally,  the  influence  of  the  respiration  on  the  pulse  is  prac- 
tically nil.  Under  abnormal  conditions,  however,  the  pulse  becomes 
irregular  and  arhythmic  during  respiration;  this  constitutes  the  so- 
called  "respiratory  arhythmia"  met  with  in  young  subjects  and 
many  neuropathic  patients. 

(c)  The  trigemino-cardiac  reactions,  the  one  most  investigated 
so  far  being  the  oculocardiac  reflex.     Normally,  slowing  of  the 


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1198  SYMPTOMS, 

pulse  rate  results  from  pressure  upon  the  eyeballs.  Under  abnor- 
mal conditions,  the  pulse-rate  is  unchanged  or  even  accelerated. 

These  tests  are  of  exceedingly  great  importance  in  the  frequently 
difficult  diagnosis  of  the  cardiac  neuroses  (tachycardiac  neuroses). 

Whether  present  singly  or  in  combination,  the  various  nervous 
symptoms  above  referred  to,  sometimes  associated  with  insomnia, 
paretic  or  convulsive  disturbances,  headache,  asthenia,  mental  cloud- 
ing, various  disorders  of  the  tendon-  and  skin-  reflexes,  and  some- 
times even  states  of  mental  confusion  with  amnesia,  delirium,  and 
hallucinatory  restlessness,  constitute  the  main  factors  in  the  neuroses 
and  psychoneuroses — hysteria,  neurasthenia,  Krishaber's  cerebro- 
cardiac  neuropathy,  Dupre's  emotive  constitution,  the  anxiety  neu- 
rosis, cardiac  neurosis,  and  Grasset*s  psychosplanchnic  neuropathy. 
Sometimes  the  clinical  symptom-groups  given  in  text-books  as 
characteristic  of  these  various  neuroses  and  psychoneuroses  are 
sufficiently  well  marked  and  differentiated  as  to  permit  of  actually 
applying  to  the  case  a  fairly  precise  designation,  such  as  neuras- 
thenia (with  its  stigmata:  type  of  special  headache,  amyosthenia, 
brain  depression,  etc.)  ;  hysteria  (with  its  characteristic  pithiatism)  ; 
neuropathy  (with  its  stigmata:  special  type  of  headache,  amyos- 
thenia,  brain  depression,  etc.)  ;  psychosplanchnic  neuropathy  (with 
its  debility  of  the  higher  mental  processes,  hyperkinesthesia,  and 
psychosplanchnic  interdependence)  ;  the  emotive  constitution,  and 
the  anxiety  neurosis;  but  the  symptoms  of  these  disorders  are 
dovetailed  and  superimposed,  with  the  result  that  differentiation  is 

often  a  very  difficult  task. 

*     *    * 

Somewhat  recent  investigations  have  drawn  the  attention  of 
the  profession  to  two  types  of  nervousness — which,  as  a  matter 
of  fact,  overlap — the  emotive  or  emotional  constitution  and  the 
anxiety  neurosis.  Both  of  these  are  of  marked  clinical  import- 
ance ;  hence  it  is  deemed  advisable  to  present  a  short  account  of 
each,  the  first  as  described  by  Dupre,  and  the  second,  by  Heckel. 

I.— THE  EMOTIVE  CONSTITUTION. 

Dupre^  proposed  some  years  ago  to  set  apart,  under  the  appel- 
lation  emotive  constitution,   a   special  type   of   imbalance  of   the 


1  DupRf: :    Acad,  de  med.,  Apr.  2,  1918. 


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NERVO  USNESS,  1 199 

nervous  system,  characterized  by  diffuse  erethism  of  general, 
special  sense,  and  psychic  sensitiveness;  by  inadequacy  of  motor 
inhibition,  reflex  as  well  as  voluntary,  and  clinically  manifested  by 
responses  abnormal  in  degree,  diffusion,  duration,  and  lack  of  pro- 
portion to  their  exciting  causes. 

Hyperemotivity,  a  normal  condition  in  infants  and  very  fre- 
quently present  in  older  children  (infantile  nervousness)  dis- 
appears in  the  adult  owing  to  the  gradual  development  of  the 
inhibitory  nerve  paths,  which  insure  balance  and  stability  of  the 
nervous  system.  Abnormal  emotivity,  usually  constitutionally 
inherent  and  inherited,  may  be  an  acquired  state  and  be  the  re- 
sult of  infectious,  toxic,  and  especially  traumatic  factors,  such 
as  intense  or  repeated  body  commotions  or  emotions. 

Emotion,  indeed,  often  sensitizes  the  nervous  system  to  subse- 
quent emotional  stresses,  and  through  a  species  of  emotive  ana- 
phylaxis may  bring  about  a  constitutional  emotivity.  In  contrast 
to  such  cases  one  may,  on  the  other  hand,  observe  in  well  balanced 
subjects  a  gradual  habituation  to  an  entire  group  of  emotions,  a 
rather  remarkable  emotive  immunity  being  thus  conferred  through 
repetition  of  like  emotional  stresses. 

The  emotive  constitution  is  characterized  by  two  groups  of 
permanent  signs,  the  physical  and  the  mental: 

Physical  signs. — Exaggerated  reflex  action,  diffuse  and  involv- 
ing both  the  tendon,  skin,  and  pupillary  reflexes.  Sensory  hyper- 
esthesia, with  sharp,  extensive,  and  protracted  motor  responses, 
principally  as  regards  gestures  and  speech.  Loss  of  motor  equi- 
Ubritim,  manifested  in  spasm  of  viscera,  as  in  pharyngo-esophageal 
spasm,  gastroenterospasm,  bladder  spasm  with  frequent  urination, 
and  palpitations.  Emotive  tremor  in  all  its  numerous  expressions, 
such  as  tremor  of  the  extremities,  shuddering,  quivering,  shivering, 
chattering  of  the  teeth,  stammering,  transient  myoclonic  move- 
ments, tics,  etc.  Functional  inhibition  and  loss  of  power  of  motor 
structures,  of  a  transient  nature,  as  in  sudden  giving  way  of  the 
knees,  inability  to  speak,  or  relaxation  of  the  sphincters.  Loss  of 
circulatory  equilibrium,  manifested  in  tachycardia,  sometimes  occa- 
sional but  often  permanent  and  paroxysmal;  instability  of  the 
pulse.  Alternate  peripheral  vasoconstriction  and  vasodilation ; 
dermographism.      The    relationship    of   these   circulatory    disturb- 


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1200  SYMPTOMS. 

ances,  chiefly  permanent  tachycardia,  with  certain  types  of  high 
blood-pressure  remains  to  be  ascertained,  especially  in  the  subjects 
free  of  arteriosclerosis  and  renal  disease.  Loss  of  thermal  equi- 
librium, as  shown  in  objective  variations  of  temperature,  detected 
by  local  thermometric  tests,  and  subjective  sensations  of  heat  and 
cold,  chiefly  in  the  extremities.  Loss  of  glandular  equilibrium, 
with  spontaneous  or  emotionally  induced  variations  of  the  sweat, 
salivary,  lacrymal,  gastrointestinal,  urinary,  genital,  and  biliary 
secretions.  Disturbances  of  intennsceral  reflex  action,  taking 
place,  in  the  major  systems  of  the  body,  through  association  of 
spasmodic  conditions,  secretory  disorders,  and  functional  stimula- 
tion or  inhibition,  brought  about  through  abnormal  reflex  eflFects 
exerted  upon  one  organ  by  another  along  the  vagosympathetic  or 
cerebrospinal  nerve  paths. 

Mental  signs. — Undue  impressionability,  a  distraught  condi- 
tion, apprehensiveness,  anxiety,  irritability,  and  impulsiveness. 
More  or  less  constant  or  remittent,  and  frequently  paroxysmal, 
these  morbid  conditions  appear  in  alternation  or  combination  and 
form  a  permanent  basis  or  soil  upon  which  appear  and  develop 
the  emotive  symptom-groups,  timidity,  scruples,  doubts,  obses- 
sions, phobias,  simple  or  delirious  states  of  anxiety,  and  psycho- 
sexual  emotive  abnormalities.  In  the  more  severe  cases  there 
appear  attacks  of  anxious  melancholia,  and  chronic  states  of  ob- 
session with  ultimate  development  of  incurable  delusions  of  self- 
accusation,  hypochondria,  or  negation. 

Constitutional  emotivity,  which,  to  be  sure,  is  not  incom- 
patible with  normal  or  unusual  intellectual  attainments  and  af- 
fectivity,  is  frequently  combined  with  other  neuro-psychopathic 
states,  notably  neurasthenia  and  hysteria,  with  which  it  exhibits 
certain  interesting  relationships  as  regards  combination  or  se- 
quence, but  from  which  it  should  be  clearly  distinguished. 

II.— THE  ANXIETY  NEUROSIS. 

The  following  data  concerning  the  semeiology  of  anxiety  and 
more  particularly  of  the  anxiety  neurosis  are  based  on  Heckel's 
monograph  on  this  subject^ : 

Pathologic  physiology. — Anxiety  and  angor  (angoisse)  occur 


1  H ECKEL :    Ncvrosc  d* angoisse,  Masson,  pub!.,  1917. 


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NERVOUSNESS,  1201 

normally  as  physiologic,  functional  manifestations.  The  former, 
anxiety,  characterized  by  disquiet,  restlessness,  and  mental  disturb- 
ance of  varying  degree,  is  produced  normally  and  casually  under  the 
influence  of  emotional  stresses,  fear,  and  under  all  circumstances 
in  which  life  and  the  preservation  of  the  individual  are  menaced. 
It  is  ordinarily  accompanied  by  certain  xoncomitant  manifesta- 
tions, physical,  organic,  or  somatic.  It  is  these  concomitant 
manifestations  which  characterize  angor,  i.e.,  a  distressful  sensa- 
tion of  constriction  (from  the  Greek  word,  ayyeiv,  to  choke) 
involving  various  systems  of  the  body.    We  thus  have: 

(a)  Respiratory  angor,  consisting  of  a  feeling  of  thoracic  dis- 
comfort, of  pressure  on  the  sternum,  of  tightening  of  the  inner 
and  outer  musculature  of  the  chest,  and  of  tightening  of  the 
bronchi;  whence,  oppression,  fear  of  asphyxiation,  terror,  respira- 
tory spasms,  sighing,  aphonia,  and  cough — all  of  emotive  and 
anxious  origin. 

(b)  Cardiovascular  angor,  simulating  angina  pectoris  in  all 
its  grades  of  intensity  (emotive  or  anxious  pseudoangina  pectoris), 
manifested  in  sensations  of  gripping  at  the  heart,  of  constricted 
heart,  or  of  unduly  large  heart,  by  subjectively  noticeable  heart- 
beats, palpitation,  arhythmia,  faintness  preceded  by  vertigo,  vas- 
cular phenomena,  resulting  in  coldness  of  the  extremities,  beating 
arteries,  and  flushing  or  pallor  of  the  face  or  body. 

(r)  Digestive  angor,  characterized  by  interference  with  swal- 
lowing, the  emotive  '^globus,"  epigastric  discomfort  with  a  feeling 
of  weight  on  the  stomach,  anxious  gastralgia  with  or  without 
pyrosis,  nausea  and  even  vomiting,  colicky  pains,  tenesmus,  consti- 
pation or  diarrhea,  arrest  or  excess  of  bile  secretion,  white  or  un- 
duly colored  stools,  and  cholemia  or  sometimes  jaundice. 

(d)  Cerebral  angor,  associated  with  a  feeling  of  constriction  of 
the  temples,  of  narrowing  of  the  skull,  and  of  emptiness  in  the 
head  with  consequent  inability  to  maintain  thought.  There  is  also 
a  typical  facial  expression.  The  facies  of  anxious  emotivity  is 
characterized  by  a  transversely  wrinkled  forehead  with  two  vertical 
folds  due  to  the  muscles  of  the  supraorbital  ridges  and  by  accen- 
tuation of  the  nasolabial  folds,  descent  of  the  labial  and  palpebral 
commissures,  and  sometimes,  in  the  presence  of  marked  terror, 
protrusion  of  the  eyeballs.     The  expression  of  preoccupied  con- 

76 


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1202  SYMPTOMS, 

centration,  of  g^ief ,  or  of  fear  and  the  preoccupied  or  tragic  facics 
of  the  anxious  patient  are  due  to  constriction  of  the  nasal,  ocular, 
and  oral  orifices  by  the  contracted  muscles,  to  a  narrowing  of  the 
face  as  a  whole,  and  to  the  vertical  traction  exerted  along  the 
facial  lines  and  muscular  furrows,  as  well  as  to  the  subject's  shift- 
ing, worried,  distracted  glances  and  at  times  to  dilatation  of  the 
pupils.  This  anxious  facies  is  most  striking  under  marked  emo- 
tional stress  or  in  the  presence  of  abject  fear. 

Lastly,  cerebral  angor  or  anxiety  is  associated  with  a  psychic 
state  expressed  in  manifestations  which  are: 

1.  Mental,  inz.,  worry,  disordered  thought,  incoherence  of  men- 
tal association  or  even  marked  mental  impairment  with  amnesia 
and  delirium. 

2.  Such  anxiety  is  also  expressed  in  motor  phenomena,  such  as 
restlessness  of  the  body  as  a  whole,  inability  to  remain  in  one 
place;  sudden,  purposeless,  contradictory,  jerky,  discontinuous 
movements ;  stamping  on  the  floor ;  sometimes  limited  or  exuberant 
gesticulations;  at  other  times  headlong  flight  or,  on  the  contrary, 
motionlessness,  stupor,  and  retirement;  there  may  also  be  exclama- 
tions, complaints,  and  sobs. 

Motor  reactions  may  also  be  manifested  in  spasm  or  contrac- 
ture of  smooth  as  well  as  striped  muscles,  local  or  general  tremor 
with  chattering  of  the  teeth,  and  even  tonic  and  clonic  convulsions, 
constituting  the  spasmodic  attack  of  anxious  emotivity,  which  is 
nothing  other  than  the  well-known  nervous  ^pell  formerly  con- 
founded with  hysterical  seizures. 

3.  The  attack  of  anxiety  also  exhibits  a  secretory  manifestation 
in  the  form  of  lacrymation,  profuse  sweats,  emission  of  ordinary 
or  colorless  urine,  salivation,  and  diarrhea,  where  there  is  secre- 
tory stimulation,  or,  on  the  other  hand,  inhibition  of  secretion  as 
shown  by  dryness  of  the  mouth,  constipation,  acholia,  anorexia, 
apepsia,  etc. 

All  these  motor  and  secretory  manifestations,  which  are  an 
expression  of  the  lowest  ebb  of  anxious  depression,  lead  to  ces- 
sation of  the  latter  through  an  actual  process  of  "release." 

4.  Lastly,  the  sensory  manifestations  of  anxiety  are  neuralgic 
pains  along  the  thoracic  nerve-trunks,  intercostals,  sciatics.  tri- 
geminals,   etc.,    headache,    and    rheumatoid    pains,    which,    when 


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NERVOUSNESS.  1203 

present  alone,  in  incipient  forms,  cannot  be  specifically  recognized 
and  lead  to  numerous  diagnostic  errors. 

It  will  have  been  noted,  then,  that  anxiety  is  an  emotive  state, 
especially  of  a  conscious  sort,  made  up  of  mental  distress,  worry, 
and  doubt,  together  with  a  senscUion  of  physical  constriction  to 
which  the  term  angor  is  particularly  applied.  The  essential  fea- 
tures of  the  latter  are,  in  the  first  place,  a  feeling  of  contracture  or 
spasmodic  condition  not  only  of  the  voluntary  muscles  but  more 
especially  of  the  visceral  involuntary  muscles,  and  secondly,  of 
a  distressful  modification  of  the  internal  sensibility  or  cenesthesia. 


Under  normal  conditions  anxiety  follows  any  sort  of  emo- 
tional stress  brought  about  by  external  or  internal  conflicts,  to 
which  it  remains  sufficient  and  proportionate. 

Under  abnormal  conditions  the  reactions  from  morbid  emo- 
tions are  excessive  and  unduly  prolonged,  whereas  the  causes 
responsible  for  them  are  futile  and  seemingly  absent;  in  the 
latter  instance,  anxious  emotivity  or  anxiety  would  appear,  then, 
to  be  spontaneous,  but  this  is  not  actually  the  case,  as  the  mech- 
anism of  emotive  sensibility  is  always  set  in  motion  by  stimuli, 
often  reflex  and  unconscious,  some  of  which  are  of  psychic  and 
others  of  organic  origin. 

In  short,  angor  is  a  condition  of  bulbar  origin,  manifested  in 
reactions  of  the  body  dependent  upon  disturbance  of  the  nuclei 
of  the  vagus  or,  more  exactly,  the  bulbar  origin  of  the  vagus 
and  of  the  sympathetic.  This  disturbance  may  reach  the 
medulla  by  descent  from  the  cerebrum  where  it  orig^inated  in 
the  psychic  sphere — in  which  event  the  condition  is  a  descend- 
ing angor  of  psychic  origin ; — or  it  may  ascend  from  the  depths 
of  the  organism  toward  the  bulbar  center  of  angor  along  the 
visceral  branches  of  the  vagus  and  of  the  sympathetic — in  which 
event  the  condition  is  an  ascending  angor  of  organic  (visceral) 
origin.  Often  both  routes  of  ascending,  vagosympathetic  trans- 
mission are  simultaneously  stimulated  by  the  group  of  slight 
visceral  commotions  the  knowledge  of  which  as  a  whole  by  the 
brain  constitutes  cenesthesia   (obscure  consciousness  of  favor- 


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1204  SYMPTOMS. 

able  or  unfavorable  conditions  of  intimate  functioning  of  the 
body  organs). 

Yet,  while  bulbar  angor  of  psychic  origin  is  dependent  upon 
a  brain  primarily  disturbed  through  some  external  emotion 
causing  cerebral  anxiety,  it  may  also  be  initiated  through  the 
transmission  to  the  brain  of  an  organic  ascending  angor.  In 
most  instances,  psychic  cerebral  angor  or  anxiety  is  so  closely 
combined  with  bulbar  angor  of  somatic  and  visceral  origin  that 
it  is  sometimes  hard  to  distinguish  the  origin  of  these  manifes- 
tations. 

Anxiety  and  angor  are  symptoms  of  marked  clinical  interest 
from  which  every  physician  should  be  able  to  obtain  diagnos- 
tic and  therapeutic  indications  of  prime  importance  in  practice. 

Clinical  conclusions. — Heckers  investigations  lead  to  the 
conclusion  that  the  physician  should,  for  purposes  of  diagnostic 
guidance,  recognize  three  main  classes  of  angor  and  anxious 
states:  1.  Angor  consequent  upon  functional  disturbances  or 
pathologic  conditions  of  internal  organs.  2.  Angor  present  in 
disturbances  of  general  nutrition.  3.  Essential  angor  or  the 
angor  neurosis. 

Etiologic  resume. — Aside  from  the  favoring  influence  of 
heredity  (Dupre's  emotive  constitution)  and  of  race  (Semitics 
and  Latins  of  the  Mediterranean  division),  symptomatic  angor 
and  anxiety,  in  common  with  the  anxiety  neurosis,  may  be  conse- 
quent upon  inherited  tendencies  of  the  metabolic  type  (gout, 
diabetes,  obesity,  etc. ;  hereditary  arthritism)  and  upon  all  fac- 
tors causing  emotion  (sentimental  emotion  or  ungratified  sexual 
desire).  Emotional  shocks,  traumatism,  nervous  impressions, 
overwork,  and  fatigue  are  the  usual  causes  of  acquired  angor 
and  anxiety,  certain  infectious  diseases  or  intoxications  are  pre- 
disposing factors.  Heckel  has  demonstrated  the  relationship  of 
tuberculosis  and  the  metabolic  diseases  to  angor.  Casual  slight 
causes,  such  as  anger  and  changes  in  the  weather  suffice  to  bring 
on  attacks  in  those  predisposed. 


Let  it  be  repeated,  in  conclusion,  and  even  more  earnestly  than 
in  earlier  sections,  that  a  diagnosis  of  neurosis  or  of  psychoneur- 


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NERyOUSNESS.  1205 

osis,  even  with  a  special  symptom-group  attached,  but  without 
etiologic  qualification,  is  a  diagnosis  *'by  exclusion"  or  "makeshift" 
diagnosis  with  which  one  cannot  rest  satisfied.  The  physician  should 
always  make  a  systematic  attempt  to  ascertain  the  casual,  provoca- 
tive or  exciting  cause  of  the  "psychoneuropathic"  syndrome. 

The  methodical  examination  to  which  the  patient  is  subjected 
should,  as  always,  be  thoroughgoing,  though  dealing  more  par- 
ticularly with  the  nervous  system,  blood-pressure,  urine  (always  an 
indispensable  procedure),  blood  (urea  and  Wassermann),  thyroid 
gland,  etc. 

In  patients  below  forty  the  practitioner  should  think  especially 
of  anemia,  latent  tuberculosis,  syphilis,  exophthalmic  goiter,  sex- 
ual excesses,  and  nutritional  disturbances. 

In  patients  past  forty  he  should  think  especially  of  arterio- 
sclerosis, diabetes,  the  menopause,  and  general  paralysis. 

Both  before  and  after  forty  years  a  careful  inquiry  should 
be  made  for  psycho-emotive  causes,  such  as  overwork,  psycho- 
venereal  excesses,  and  emotional  shocks.^ 


*  Regarding  the  war  neuroses  and  psychoneuroses  and  the  anxiety  neu- 
rosis, the  following  works  may  be  consulted : 

Grasset:  "Les  grands  types  cliniques  des  psychon^vroses  de  guerre 
{Reunion  medico-chir.  de  la  XF/«  region,  Jan.  22,  1917;  abstracted  in  Presse 
mid,,  Aug.  22,  1917,  p.  495). 

DuPRfe:    Constitution  ^motive  {Acad,  de  med.,  Apr.  2,  1918). 

J.  Babinski  and  J.  Froment:  Hysteria,  pithiatisme,  et  troubles  nerveux 
d'ordre  rcflexe  en  neurologie  de  guerre  (Masson,  pub!..  1916). 

F.  Heckel:    La  nevrose  d'angoisse  (Masson,  1917). 

Devaux  and  Logre:    Les  anxieux  (Masson,  1916). 

Roussy:    Traitement  des  psychonevroses  de  guerre  (Masson,  1918). 


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OBEiSITY.  [Obesus,  stout;  ovemourished.] 


Obesity  is  derived  from  the  Latin  word  obesus,  meaning  an 
ovemourished  individual.  It  is  a  poor  term,  since  obesity  is  not 
always  due  to  an  excessive  intake  of  food. 

Obesity  is  essentially  characterized  by  a  general  overgrowth 
of  adipose  tissue  as  compared  to  the  other  kinds  of  tissue  (espe- 
cially the  muscles). 

It  will  not  be  inappropriate  to  note  that  there  exists  a  cer- 
tain affinity  between  the  processes  of  fat  accumulation  in  the 
system  and  the  processes  of  sugar  accumulation,  as  in  diabetes, 
or  of  protein  accumulation,  as  in  gout.  All  these  metabolic 
changes  are  effected  through  the  agency  of  special  ferments. 
Three  oxidizing  ferments  or  oxidases  preside  over  the  chemical 
transformations  to  which  sugar,  fat,  and  proteins  are  subjected. 
If  one  of  these  is  lacking  or  becomes  insufficient,  there  results 
a  disturbance  of  nutrition  featured  by  the  appearance  of  dia- 
betes, gout,  or  obesity.  Thus,  gout,  diabetes,  and  obesity  may 
be  ascribed  to  such  causes  as  react  upon  the  production  of  fer- 
ments by  the  internal  organs  and  to  conflicts  between  the  fer- 
ments and  the  substances  they  transform.  In  truth,  however, 
the  anaerobic  life  of  cells  and  the  conception  of  the  endocrin  hor- 
mones and  hormozones  has  in  late  years  lent  a  considerable 
added  complexity  to  the  question.  The  etiology  and  pathogenesis 
of  obesity  seem  in  some  respects  analogous  to  those  of  diabetes  and 
of  gout ;  one  is  led  to  ascribe  the  disorder  partly  to  the  endocrin  or 
ductless  glands  and  in  a  larger  measure  to  the  nervous  system. 

As  Heckel  has  very  clearly  shown,  obesity  is  a  progressively 
developing  symptom-group,  easily  corrected  in  its  initial  stage 
(minor  obesity),  which  is  due  to  exogenous  and  endogenous  dis- 
turbances of  fat  regulation  and  is  characterized  by : 

(a)   Fatty  infiltration  and  degeneration,  more  or  less   pro- 
nounced, of  the  connective  and  even  other  tissues. 
(1206) 


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OBESITY,  1207 

(b)  Concomitant .  functional  disturbances  (with  or  without 
pathologic  changes)  in  the  nervous  system,  digestive  tract,  en- 
docrin  glands,  cardiovascular  system,  kidneys,  etc. 

(c)  A  rise  in  the  adipomuscular  coefficient,  i.e,,  of  the  ratio 
fat      which  is  normally  1 :  10. 

muscle  '' 

The  prognostic  significance  of  obesity  is  dependent  upon  the 
importance,  progression,  and  seriousness  of  the  concomitant 
functional  disturbances. 

Obesity  is  a  clinical  s3n(idrome  and  not  a  disease,  since  it  is 
dependent  upon  no  single  cause  and  has  no  constant  patho- 
genesis. 

There  may  occur  a  temporary  or  permanent  obesity : 

1.  From  superalimentation,  through  hyperphagia  or  overeating, 
since  fat  may  accumulate  in  the  tissues  after  excessive  ingestion  of 
food  rich  in  proteins  and  carbohydrates. 

Through  hypolipolysis  in  the  muscles  and  blood :  Insufficient  ex- 
ercise in  sedentary  or  invalid  persons,  etc. — insufficient  oxygenation 
and  anoxemia  among  hyposphyxics,  anemics,  sedentary  individuals 
confined  in  rooms,  etc. 

2.  From  disturbances  in  various  organs: 

(a)  Inadequacy  of  the  digestive  functions  and  gastrointestinal 
dyspepsia.  The  fats,  in  this  event,  being  insufficiently  or  not  at  all 
converted,  remain  in  the  form  of  neutral  fats  which  are  less  readily 
oxidizable  and  accumulate  more  readily  in  the  tissues. 

(b)  Insufficiency  of  the  endocrin  glands  as  a  group,  though 
principally  of  the  thyroid,  thus  unequal  to  their  r61e  as  oxidizing  or 
fat-splitting  glands. 

The  role  of  thyroid  insufficiency  in  obesity  is  unquestionable,  as 
exemplified  in  the  obesity  of  thyroidectomized  animals,  the  obesity 
of  the  earlier  stages  of  myxedema,  and  the  sometimes  marked  loss 
of  weight  caused  by  thyroid  administration. 

The  role  of  the  reproductible  glands  is  even  more  obvious,  as  in 
the  obesity  of  castrated  animals  (capons  and  hogs),  the  obesity  of 
eunuchs,  and  the  obesity  associated  with  ovarian  insufficiency  (Der- 
cum's  disease,  obesity  of  the  menopause,  obesity  after  ovariectomy, 
obesity  of  puberty  in  chlorotics  with  irregular  menstruation,  obesity 
of  the  early  months  of  pregnancy,  etc.). 


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1208  SYMPTOMS, 

3.  From  disturbances  of  the  nervous  system. — This  cause  is 
obvious  at  least  in  certain  localized  adipose  states,  such  as  Grasset's 
nen'ous  adiposis  (Duchenne's  pseudohypertrophic  paralysis,  sym- 
metric lipomatosis,  adiposis  dolorosa  or  Dercum's  disease,  etc.). 

It  is  probably  present  in  certain  forms  of  obesity  associated 
with  other  nervous  symptoms  (herpes  zoster,  joint  disorders, 
scleroderma,  exophthalmic  goiter,  etc.). 

4.  From  disturbed  general  nutrition: 

(a)  Neuro-arthriiic  obesity,  dependent  upon  a  chronic  general 
nutritional  disorder,  usually  inherited  and  associated  or  variously 
combined  with  the  several  morbid  states  termed  arthritis,  with  gout, 
diabetes,  lithiasis,  etc.  The  word  "neuroarthritic"  is  here  used  as  an 
accepted  makeshift,  without  attempting  to  conceal  the  fact  that,  to 
the  author,  arthritism  is  merely  a  nutritional  symptom-group  devoid 
of  specificity. 

(6)  Intoxications. — Certain  intoxications,  particularly  of  the 
mild  but  repeated  variety,  lead  to  obesity.  First  place  may  here  be 
given  to  alcoholism,  and  after  it  come,  in  the  order  of  decreasing 
frequency,  arsenic,  phosphorus,  and  lead, 

(c)  Infections, — Those  of  greatest  interest  are  the  typhoid  and 
tuberculous  infections.  The  increase  of  weight,  sometimes  exces- 
sive, witnessed  during  convalescence  of  typhoid  cases  is  a  matter  of 
common  observation.  Tuberculous  obesity — a  less,  exceptional  con- 
dition than  is  generally  thought — is  due  to  three  factors,  vis,,  irra- 
tional overfeeding  (when  it  is  readily  curable,  at  least  at  first), 
neuroarthritic  heredity,  and  the  complex  action  of  the  tubercle 
bacillus  itself  or  its  toxins  in  certain  forms  of  the  disease  and  in 
certain  predisposed  individuals  (Carnot's  experimental  tuberculous 
obesity). 

If  all  clinical  and  experimental  data  are  taken  into  account,  it 
becomes  necessary,  broadening  our  earlier  conceptions  of  the  patho- 
genesis, to  recognize  that  obesity  is  the  outward  expression  of  the 
organic  response  to  a  lesion  or  functional  disturbance  at  some  point 
in  the  lipotrophic  nutritional  system. 

This  lipotrophic  nutritional  system,  which  is  extremely  complex, 
is  governed  and  coordinated  by  the  cerebrospinal  and  sympathetic 
nervous  system,  which  insures  functional  cooperation  in  this  system ; 
whence  the  possibility  of  a  hyperadiposis  of  nervous  origin  through 


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OBESITY.  1209 

lipotrophic  incoordination  (the  fact  is  clinically  certain  as  regards 
localized  or  symmetric  hyperadiposes,  and  probable  as  regards 
obesity).  The  system  is  mainly  constituted  of  a  group  of  glandular 
organs,  vis.,  the  gastrointestinal  mucosa,  liver,  pancreas,  thyroid, 
reproductive  glands,  etc.,  which  are  charged  with  the  task  of  elab- 
orating the  fats  and  governing  their  conservation  (lipogenesis)  and 
destruction  (lipolysis),  and  overactivity  or  insufficiency  of  which, 
constituting  a  lipodystrophy,  induces  obesity  of  glandular  origin. 

This  lipolytic  activity,  however,  though  devolving  especially  on 
certain  organs  or  tissues,  appears  to  be  a  functional  attribute  of 
living  cells  in  general,  so  that  any  general  disturbance  of  cell  nutri- 
tion, while  usually  combined,  indeed,  with  the  above  mentioned 
glandular  disturbances,  may  induce  obesity:  dystrophic  obesity  of 
neuroarthritic  or  toxic-infectious  origin. 


Sometimes  obesity  is  obvious.  The  most  casual  inspection 
shows  that  the  individual  is  too  stout  for  his  height.  Such  a 
diagnosis,  however,  brings  in  too  much  of  the  subjective  ele- 
ment. A  person  is  obese  when  his  weight  exceeds  the  normal 
as  compared  to  hi^  height.  What  is  this  normal  weight?  To 
find  out,  one  may  turn  to  the  tables  prepared  by  Quetelet  and 
by  Bouchard. 

It  is  more  convenient,  however,  to  adopt  the  following 
simple,  elementary  rule :  The  normal  weight  of  an  adult  equals 
in  kilograms  the  number  of  centimeters  by  which  his  height  ex- 
ceeds one  meter.  Thus,  154  centimeter?  =  54  kilograms;  165 
centimeters  =  65  kilograms;  172  centimeters ^^ 72  kilograms. 

This  rule  and  the  tables  mentioned  are  quite  sufficient  for 
clinical  purposes  provided  the  following  corrections  required 
because  of  individual  peculiarities  of  physique  are  taken  into 
account.  Human  subjects  may  be  roughly  classed  in  three 
groups : 

Mediolinear:  The  average  type,  in  which  the  transverse  and 
vertical  measurements  exhibit  a  mean,  normal  ratio: 

Height 


Biaxillary  diameter 


=  5.6  to  6. 


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SYMPTOMS. 


Longilinear:  An  unusually  elongated  type,  in  which  the  vertical 
measurements  are  manifestly  excessive  as  compared  to  the 
transverse : 


Fig.  835. — Longilinear  subject. 
Height 


>6. 


Biaxillary  diameter 
Brezilinear:    An  unusually  short  type,  in  which  the  transverse 
measurements  are  relatively  excessive  as  compared  to  'the  vertical : 

Height 


Biaxillary  diameter 


<5.6. 


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OBESITY. 


1211 


In  medioHnear  subjects  the  rule  that  the  weight  in  kilograms 
equals  the  number  of  centimeters  over  one  meter  is  quite  suffi- 
cient in  practical  work.  Example:  169  centimeters;  normal 
weight,  69  kilograms. 


Fig.  836. — MedioHnear  subject. 


Fig.  837. — Brevilinear  subject. 


In  longilinear  subjects  one  should  allow,  in  calculating  the 
normal  weight,  a  reduction  which  may  reach  -\.  Example :  169 
centimeters  (longilinear) ;  normal  weight,  from  69  kilograms  to 
69  — -J|-  =  62.1  kilograms. 


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1212  SYMPTOMS, 

In  brevilinear  subjects  one  should  allow,  on  the  other  hand, 
an  excess  which  may  reach  JL.  Example:  169  centimeters 
(brevilinear);  normal  weight,  from  69  kilograms  to  69  +-^  = 
75.9  kilograms. 

After  these  corrections  have  been  deliberately  introduced,  if 
the  subject's  weight  is  distinctly  above  the  theoretic  weight,  the 
diagnosis  of  obesity  may  be  rendered. 

The  only  features  that  are  of  actual  importance  from  the 
practical  standpoint  are : 

1.  The  type  of  obesity  (plethoric  or  anemic). 

2.  Its  association  with  some  allied  symptom-group: 
(a)  Gout,  diabetes,  or  lithiasis. 

{b)  Hyposphyxia,  polyglandular  insufficiency,  or  dysthyroidia. 
(c)  Asthma,  emphysema,  or  hay  fever. 

3.  The  presence  of  some  complication  which,  as  a  matter  of  fact, 
is  a  natural  consequence  in  the  course  of  the  disorder. 

(a)  Cardiac  or  cardiovascular. 

{b)   Pulmonary  or  cardiopulmonary. 

(c)  Renal  or  zxisculorenal, 

(d)  Hepatic. 

These  are  the  data  upon  which  the  treatment  of  the  case  depends. 

Clinical  classification. — From  the  purely  clinical  standpoint 
the  following  classification  appears  to  be  the  best  because  it  auto- 
matically specifies  the  therapeutic  indications — ^which  is,  after  all, 
the  essential  point  Obese  subjects  may  be  divided  into  two  dia- 
metrically opposed  groups: 

Florid,  plethoric,  ftdl-blooded  obese  subjects. 

Atonic,  asthenic,  anemic  obese  subjects. 

In  either  of  these  two  groups,  obesity  may  exist  in  the  pure 
state,  i,e,,  without  any  associated  morbid  state  or  complication, 
or  it  may  occur  in  combination  with  the  morbid  syndromes 
affiliated  with  it,  or  with  complications.  Thus,  with  all  possi- 
bilities taken  into  account,  the  following  classification  is  offered 
the  clinician: 

I.  Simple  plethoric  obesity. 

Plethoric  obesity  associated  with  gout,  diabetes,  lithiasis,  etc. 

II.  Simple  atonic  obesity. 


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OBESITY, 


1213 


1.    Table  Showing  the  Average  Height  and  Weight  at 
Different  Ages  (after  Quitelet)A 


Age. 

Males. 

A. 

Females. 

Height. 

Weight. 

Height. 

Weight. 

0  year  

1  year  

2  years  

3  ..... 

4  "      

5  "      

6  "      

7  "      

8  "      

9  "      

10  "      

11  "      

12  "      

13  "      

14  "      

15  "      

16  "      

17  "      

18  "      ..... 

20      "      

25      "      

30     "      

40      "       

50      "       

60      "       

70      "      

meters. 

0.500 
0.698 
0.771 
0.864 
0.928 
0.988 
1.047 
1.105 
1.162 
1.219 
1.275 
1.330 
1.385 
1.439 
1.493 
1.546 
1.594 
1.634 
1.658 
1.674 
1.6»} 
1.684 
1.684 
1.674 
1.6,39 
1.623 

kilograms. 

3.20 

9.45 
11.34 
12.47 
14.23 
15.77 
17.24 
19.10 
20.76 
22.65 
24.52 
27.10 
29.82 
34.38 
38.76 
43.62 
49.67 
52.85 
57.85 
60.06 
62.93 
63.65 
63.67 
63.46 
62.94 
59.52 

meters. 

0.490 
0.690 
0.780 
0.852 
0.915 
0.974 
1.103 
1.146 
1.181 
1.195 
1.248 
1.299 
1.353 
1.403 
1.453 
1.499 
1.535 
1.555 
1.564 
1.572 
1.577 
1.579 
1.579 
1.536 
1.516 
1.514 

kilograms. 

2.91 

8.99 
10.67 
11.79 
13.00 
14.36 
16.01 
17.54 
19.08 
21.36 
23.52 
25.65 
29.82 
32.94 
36.70 
40.39 
43.57 
47.31 
51.83 
52.28 
53.28 
54.33 
55.23 
56.16      • 
54.30 
51.51 

Atonic  obesity  associated  with  polyglandular  insufficiency  or 
hyposphyxia. 

III.  Complicated  plethoric  or  atonic  obesity  (with  cardiac, 
pulmonary,  renal,  or  other  complications). 

It  is  true,  to  be  sure,  that  the  majority  of  these  "complica- 
tions" are  absolutely  certain  to  set  in  at  some  stage  in  the 
course  of  obesity,  if  the  latter  is  not  corrected  in  time. 

I.  Simple  plethoric  obesity  is  characterized  by  a  simple,  ua- 
complicated  plethora.  The  plethoric  is  a  supernormal  individual  all 
of  whose  functions  or  other  features  are  of  the  "hyper"  variety, 
but  preserve  a  normal  mutual  balance.  Thus,  he  exhibits  over- 
weight, hypertension,  hyperviscosity,  polyphagia,  polydipsia,  and 


1  One  meter  =  39.370  inches.    One  kilogram  =  2.20462  pounds  Avoirdupois. 


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1214  SYMPTOMS, 

polyuria.  He  is  a  florid-complexioned,  full-blooded,  obese  subject 
whose  digestive,  nutritive,  circulatory,  urinary,  and  other  functions 
are  of  an  exaggerated  type  but  nevertheless  very  satisfactorily  car- 
ried out ;  bodily  vigor  and  the  mental  faculties  are  unimpaired. 

It  cannot  be  too  often  repeated,  how^ever,  that  such  a  subject 
is  predisposed  to  the  so-called  neuro-arthritic  disorders,  z*ic^ 
gout,  diabetes,  lithiasis,  etc.,  and  a  likely  victim  of  connective 
tissue  deposit  in  the  viscera,  especially  the  arteries  and  kidneys. 

This  fact  should  be  duly  borne  in  mind  when  the  diagnosis 
is  made,  and  the  necessary  precautions  taken,  even  in  the  **minor 
obesity"  stressed  by  Heckel,  for,  as  this  observer  correctly 
writes:  "It  is  ridiculous  to  wait,  in  order  to  obtain  a  suitable 
label,  until  a  person  is  deformed  with  fatty  accumulations  be- 
fore warning  him  of  the  risk  he  is  running." 

Ovemutrition  and  an  arthritic  family  tendency  are  generally 
met  with  as  etiologic  factors  in  these  cases. 

Plethoric  obesity  is  very  frequently  associated  with  gout,  dia- 
betes, and  lithiasis,  the  pathogenesis  of  which  seems  to  be  closely 
related  to  plethora.  All  plethoric  obese  subjects  should  therefore  be 
gone  over  carefully  in  this  connection,  being  examined  for  evidences 
of  gout  in  the  joints  or  internal  organs,  of  diabetes  (glycosuria), 
and  of  lithiasis  (high  specific  gravity,  acidity,  and  uric  acid  con- 
tent of  the  urine ) ,  and  warned  against  these  possible  complications. 

IL  Anemic,  atonic,  asthenic  obesity,  on  the  other  hand,  is 
manifested  in  a  pale  complexion  and  at  times  a  waxy  appear- 
ance; the  appetite  is  often  poor,  the  digestive  functions  are  im- 
paired, constipation  is  frequent,  bodily  vigor  is  below  normal, 
indolence  and  apathy  are  habitual,  the  circulation  is  deficient, 
hyposphyxia  frequent,  and  the  elimination  of  chlorides  often 
disturbed.  All  test  features  are  of  the  "hypo"  variety,  Wr.,  hy- 
potension, hypopepsia,  etc.,  with  the  exception  of  the  body 
weight  and  viscosity,  which  are  increased. 
'  In  these  cases  the  etiologic  factors  most  often  met  with  are 
dyspepsia,  anoxemia,  intoxications,  infections,  and  degeneration 
of  glandular  organs,  such  as  the  thyroid  and  testicles.  Typhoid 
and  tuberculous  obesity  belong  in  this  category. 

Anemic,  atonic  obesity,  usually  attended  with  slowed  and  vitiated 
nutritive  processes  and  circulation,  is  very  frequently,  if  not  always, 


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OBESITY.  1215 

combined  with  polyglandular  insufficiency  and  hyposphyxia,  for  evi- 
dences of  which  a  systernatic  search  should  always  be  made  (goiter, 
genital  dystrophies,  myxedema,  etc.,  on  the  one  hand;  low  blood- 
pressure,  high  viscosity,  lividity,  cryesthesia,  and  dyspnea  on  exer- 
tion, on  the  other).  Highly  serviceable  indications  concerning  the 
pathogenesis  and  hence  also  as  to  the  treatment  are  thus  obtained 

III.  Cardiac,  renal,  and  pulmonary  complications. — Either 
one  of  the  foregoing  types  of  obesity  may,  and  frequently  does,  be- 
come complicated  with  other  disorders.  The  heart,  kidneys,  and 
lungs  are  the  organs  most  frequently  affected,  and  investigation  of 
these  organs  is  therefore  particularly  necessary  in  all  obese  patients. 

(a)  Cardiorenal  Disturbances. — Subjects  with  plethoric 
obesity  are,  as  already  pointed  out,  likely  victims  of  cardio-arterio- 
renal  fibrosis  (arteriosclerosis  and  interstitial  nephritis),  which  is 
detected  through  blood-pressure  determinations  (hypertension)  and 
examination  of  the  urine  (albuminuria  and  lowering  of  the  hydruric 
coefficient  — )  and  the  heart  (hypertrophy,  gallop  rhythm). 

Atonic  obese  cases  are  predisposed  to  venous  stasis  (varicose 
veins  and  edema),  to  dilatation  of  the  heart  and  cardiac  insuffi- 
ciency (tachycardia,  low  blood-pressure,  dyspnea  on  exertion, 
cyanosis,  and  reduced  urinary  output),  and  to  chlorine  retention. 

Both  types  terminate  in  heart  failure  and  uremia  the  result  of 
progressive  cardiorenal  inadequacy. 

Heckel,  in  his  book  on  obesity,  was  the  first  to  lay  stress  on 
the  marked  frequency  of  the  chronic  nephritides  among  the 
obese,  stating  that  "nearly  all  the  obese  are  incipient  uremics." 
Marcel  Labbe  reached  the  following  conclusions :  "The  ratio  of 
interstitial  nephritis  among  the  obese  is  22  per  cent,  before  the 
age  of  fifty  years  and  77  per  cent,  after  fifty  years.  This  means 
that  in  all  old  obese  subjects  renal  sclerosis  is  almost  inevitable." 
The  author  of  the  present  work  has  demonstrated  the  above- 
mentioned  relationship  of  the  plethora  of  obese  cases  to  chronic 
hydremic  (hypertensive)  and  azotemic  (uremigenous)  nephritis, 
and  has  formulated  rules,  based  on  observation  of  the  blood- 
pressure,  blood  viscosity,  and  daily  output  of  urine  which  en- 
able the  physician  to  discern  the  moment  when  patients  are 
passing  from  the  sta^e  of  simple  plethora  to  that  of  chronic 
nephritis  (see  High  blood-pressure). 


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1216 


SYMPTOMS. 


(b)  Pulmonary  Disturbances. — Obese  persons  are  exposed  to 
numerous  complications: 

Respiratory  insufficiency,  anoxemia,  asthma,  and  emphysema 
— almost  constant  features  at  a  certain  stage  of  obesity. 

Active  hyperemia,  congestive  attacks,  and  acute  edema  of  the 
lungs  in  plethorics,  and  more  especially  in  the  cardiorenal  stage. 

Passive  hyperemia,  edema  of  the  bases  of  the  lungs,  and  hy- 
drothorax  in  the  atonic  cases  and  more  especially  in  the  stage 
of  cardiac  insufficiency.  In  this  group,  as  a  matter  of  fact,  a 
cardiopulmonary  trend  of  the  disease  is  much  commoner  than 
cardiorenal  complication. 

This  diagnosis  of  the  complications  of  obesity  constitutes, 
on  the  whole,  in  conjunction  with  the  causal  diagnosis,  the  essen- 
tial feature  in  the  diagnosis  of  obesity,  and  one  should  not  wait, 
to  render  it,  until  irreparable  tissue  lesions  have  set  in.  To  wait 
for  the  appearance  of  gallop  rhythm  before  rendering  a  diagno- 
sis of  interstitial  nephritis  is  like  waiting  for  the  police  before 
cutting  down  a  man  who  has  just  been  hung.  As  Heckel  writes : 
"It  is  not  the  amount  of  fat  accumulated  which  allows  of  the 
prognosis  being  made,  but  the  intensity  of  the  functional  disturb- 
ances accompanying  the  obesity,  whether  the  latter  be  of  the 
major  or  minor  variety."^ 

2.  Height,  Weight,  Average  Anthropometric  Segments,  Fat  per 
Segment,  Fat  in  the  Whole  Body  (after  Bouchard).^ 


Height  in 

Weight  of 

Centim- 

Weight in 

THE   Segment 

Fat  per 

Fat  in 

eters 

Kilograms 

w. 

Segment 

THE  Whole 

H. 

W. 

H 

in  Grams. 

Body. 

140 

45.81 

3.27 

425 

5.955 

141 

46.66 

3.31 

430 

6.066 

142 

47.50 

3.35 

435 

6.175 

143 

48.36 

3.38 

440 

6.292 

144 

49.18 

3.42 

444 

6.394 

145 

50.05 

3.45 

449 

6.506 

146 

50.88 

3.49 

453 

6.614 

147 

51.73 

3.52 

462 

6.725 

148 

52.58 

3.55 

462 

6.835 

1  For  additional  data  on  this  question,  see  F.  Heckel  :    Grandes  et  petites 
ohesith,  Masson,  2d  Ed.,  1920. 

2  One  hundred  centimeters  =  39.370  inches.     One  kilogram  =  220462 
pounds  Avoirdupois. 


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OBESITY. 


1217 


2.  Height,  Weight,  Average  Anthropometric  Segments,  Fat  per 
Segment,  Fat  in  the  Whole  Body  (after  Bouchard),  continued. 


Height  in 

Weight  of 

Centim- 

Weight in 

the  Segment 

Fat  per 

Fat  in 

eters 

Kilograms 

W 

Segment 

THE  Whole 

H. 

W. 

H* 

in  Grams. 

Body. 

149 

53.45 

3.59 

466 

6.948 

150 

54.32 

3.62 

471 

7.062 

151 

55.21 

3.66 

475 

7.173 

152 

56.09 

3.69 

480 

7292 

153 

56.93 

3.72 

483 

7.401 

154 

57.78 

3.75 

488 

7.511 

155 

58.64 

3.78 

492 

7.623 

156 

59.50 

3.81 

496 

7.735 

157 

60.38 

3.85 

500 

7.849 

158 

6126 

3.88 

504 

7.964 

159 

62.15 

3.91 

508 

8.080 

160 

62.91 

3.93 

511 

8.178 

161 

63.76 

3.96 

515  . 

8291 

162 

64.61 

3.99 

518 

8.392 

163 

65.46 

4.02 

522 

8.509 

164 

66.26 

4.04 

525 

8.610 

165 

67.06 

4.06 

528 

8.712 

166 

67.79 

4.08 

531 

8.815 

167 

68.55 

4.11 

534 

8.912 

168 

69.30 

4.13 

536 

9.005 

169 

69.98 

4.14 

538 

9.092 

170 

70.69 

4.16 

541 

9.197 

171 

71.38 

4.17 

543 

9.285 

172 

72.07 

4.19 

545 

9.374 

173 

72.78 

4.21 

547 

9.463 

174 

73.48 

4.22 

549 

9.552 

175 

74.11 

424 

551 

9.642 

176 

74.77 

4.25 

552 

9.715 

177 

75.40 

4.26 

554 

9.806 

178 

76.04 

427 

555 

9.879 

179 

76.77 

4.29 

558 

9.988 

180 

77.42 

4.30 

559 

10,062 

181 

78.08 

4.31 

561 

10.150 

182 

78.73 

4.33 

562 

10228 

183 

79.40 

4.34 

564 

10.321 

184 

80.06 

4.35 

566 

10.414 

185 

80.73 

4.36 

567 

10.489 

186 

81.39 

4.38 

569 

10.583 

187 

82.07 

4.39 

571 

10.678 

188 

82.76 

4.40 

572 

10.759 

189 

83.43 

4.41 

574 

10.849 

190 

84.11 

4.43 

576    . 

10.944 

191 

84.79 

4.44 

577 

11,021 

192 

85.48 

4.45 

579 

11.117 

193 

86.17 

4.47 

581 

11213 

194 

86.85 

4.48 

582 

11.291 

195 

87.48 

4.49 

583 

11.372 

196 

88.06 

4.49 

584 

11.446 

197 

88.81 

4.51 

586 

11.544 

198 

89.32 

4.51 

586 

11.603 

199 

89.87 

4.52 

587 

11.681 

200 

90.40 

4.52 

588 

11.752 

77 


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OLIGURIA  r  ^^^'  scanty;  oiJpor,  wine;  ] 

'  [diminished  secretion  of  urine.] 


In  a  normal  adult  person  on  a  normal  diet,  the  average  daily 
output  of  urine  is  from  1250  to  1500  cubic  centimeters,  the  out- 
put in  the  daytime,  from  9  a.m.  to  9  p.m.  (750  to  1000  cubic  cen- 
timeters), being  always  distinctly  greater  than  the  nocturnal  out- 
put, from  9  P.M.  to  9  a.m.  (500  to  400  cubic  centimeters). 

Oliguria  is  present  when  the  amounts  excreted  are  distinctly 
below  the  above  mentioned  average  figures.  Oliguria  is  said  to 
be  total,  diurnal,  or  nocturnal  according  as  the  reduction  affects 
the  daily  output  or  only  that  in  the  daytime  or  at  night. 


Diuresis  being  closely  and  obviously  dependent  both  upon  the 
amount  of  water  ingested  either  in  beverages  or  in  solid  food  and 
upon  the  various  excretions  other  than  the  urine  (cutaneous,  intes- 
tinal, and  pulmonary),  many  factors  may,  singly  or  in  combination, 
induce  under  physiologic  circumstances  a  definite  diminution  of  the 
output  of  urine.  Such  factors  should  be  thought  of  from  the  start, 
in  order  that  they  may  be  excluded :  Habitual  restriction  of  fluids, 
whether  spontaneous  or  under  the  physician's  direction  (dry 
regime)  ;  one  should  always  ascertain  approximately  the  intake  as 
well  as  the  output  of  fluid ;  spontaneous  free  szveats,  as  from  violent 
and  sustained  exertion  or  from  summer  temperatures  (oliguria  in 
the  summer  is  almost  constant  in  normal  individuals)  ;  free  evacua- 
tions of  the  bowels,  spontaneous  (transient  diarrhea)  or  induced 
(purgation),  etc. 

The  foregoing  brief  and  elementary  inquiry  having  been  gone 
through,  there  remain: 

1.  Oliguria  of  a  transient,  temporary,  accidental  type. 

2.  Oliguria  of  a  lasting,  permanent,  habitual  type. 

(1218) 


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OUGURIA.  1219 

TRANSIENT,  TEMPORARY,  ACCIDENTAL  OLIGURIA. 

After  evacuation  of  an  extensive  collection  of  fluid,  as  in 
cysts,  ascites,  or  pleurisy,  it  is  the  rule  to  observe  a  distinct  re- 
duction in  the  amount  of  urine.  An  actual  drainage  of  water 
occurs  toward  the  affected  structures.  The  oliguria  is  less 
marked  at  the  time  of  spontaneous  reabsorption  of  an  exudate, 
which  process  may  instead  be  associated  with  a  relative 
polyuria. 

In  cholera,  amebic  and  bacillary  dysentery,  infantile  enteritis, 
yellow  fetter,  cholera  morbus,  etc.,  intense  oliguria  may  occur  on 
account  of  repeated,  copious  bowel  movements,  and  the  usual 
presence  of  albumin  in  the  urine  indicates  that  even  apart  from 
the  withdrawal  of  water  through  the  intestine  the  kidneys  are 
more  or  less  affected  by  the  existing  toxic-infectious  disorder. 

In  another  group  of  cases,  oliguria  appears  to  be  the  consequence 
of  a  reflex  inhibition  of  diuresis,  which  may  originate  either  in 
the  urinary  system  itself  or  elsewhere.  Reference  may  here  be  made 
to  the  reflex  oliguria  of  renal  colic,  which  involves  not  only  the  dis- 
eased but  also  the  opposite  kidney ;  to  calculous  anuria,  which  passes 
off  upon  catheterization  on  the  affected  side,  and  to  the  oliguria  fre- 
quently induced  by  urethral  and  ureteral  catheterization. 

Peripheral  stimuli,  burns,  traumatic  injuries,  neuroses  such  as 
hysteria  and  neurasthenia,  painful  conditions  {hepatic  colic),  peri- 
tonitis, appendicitis,  and  laparotomy  may,  as  is  well  known,  like- 
wise induce  a  temporary  oliguria,  with  excretion  of  clear  urine  of 
high  specific  gravity,  of  good  concentration,  and  free  of  any  ab- 
normal constituents. 

In  a  final  group  of  cases,  oliguria  appears  in  the  presence  of 
some  infectious  process,  and  this  type  of  oliguria  forms  part,  in 
conjunction  with  the  temperature  and  the  quality  and  rate  of 
the  pulse,  of  the  most  characteristic  symptomatic  triad  giving 
information  as  to  the  course  of  the  infection.  A  moderate  de- 
gree of  oliguria,  with  a  full,  regular,  and  moderately  accelerated 
pulse,  and  a  temperature  of  varying  height,  but  with  good  morn- 
ing remissions,  points  to  a  favorable  course  and  termination. 
Excessive  oliguria,  with  a  frequent,  small,  irregular  pulse  and 


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1220  SYMPTOMS. 

sustained  hyperthermia  with  but  slight  or  no  remissions,  points 
to  the  necessity  of  a  very  guarded  prognosis. 

Upon  defervescence  one  observes  a  more  or  less  marked  out- 
burst of  polyuria,  with  emission  of  urine  of  high  specific  gravity, 
poor  in  chlorides  but  rich  in  urates,  phosphates,  urea,  urobilin, 
pigments,  etc.,  imparting  to  the  highly  colored  urine,  with  its 
abundant  brick  dust  sediment,  a  highly  characteristic  appearance. 

LASTING,  HABITUAL,  PERMANENT,  OR  AT  LEAST 
EASILY  RECURRING  OLIGURIA. 

Of  far  greater  import  from  the  standpoints  of  semeiology 
and  treatment  are  the  lasting,  habitual  or  recurring  forms  of 
oliguria.  The  major  systems  most  frequently  responsible  are 
the  circulatory  and  renal  systems.  Oliguria  is  one  of  the  cardi- 
nal evidences  of  cardiorenal  inadequacy,  and  the  heart  and  kid- 
neys are  always  the  organs  to  be  investigated  above  all  else  in 
these  cases. 

Cardiac  insufficiency. — Reduced  urinary  output  is,  mith  dyspnea 
on  exertion,  one  of  the  earliest  signs  of  incipient  cardiac  inadequacy, 
hyposystoly,  or  circulatory  decompensation.  One  cannot  emphasize 
too  strongly  the  following  fundamental  features:  The  output  of 
urine  is  dependent  upon  renal  permeability  (and  more  probably, 
glomerular  permeability)  and  upon  the  blood-pressure  (especially 
the  differential  or  pulse  pressure).  Where  compensation  for  the 
cardiac  or  renal  or  cardiorenal  disorder  has  been  lost;  when  the 
cardiac  fiber,  no  longer  equal  to  its  task,  shows  signs  of  becoming 
fatigued,  the  kidney,  no  longer  receiving  blood  under  the  required 
degree  of  pressure,  becomes  oliguric ;  if,  however,  the  heart  is  alone 
at  fault,  the  urine  is  more  markedly  reduced  in  amount,  but  is  of 
high  specific  gravity,  well  concentrated,  and  free  of  foreign  con- 
stituents. 

For  a  long  time,  as  a  matter  of  fact,  oliguria  is  manifest  only 
when  the  patient  is  in  the  standing  posture  {orthostatic  oliguria), 
and  is  counterbalanced  by  the  relative  polyuria  existing  when  he  is 
recumbent  (clinostatic  relative  polyuria,  or  nycturia),  so  that  in  the 
earliest  stages,  diurnal  oliguria  is  compensated  for  by  nocturnal 
polyuria,  and  the  daily  intake  and  outgo  of  fluid  are  in  equilibrium. 


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OLIGURIA.  1221 

Gradually  cardiac  decompensation  becomes  more  marked,  and 
with  it  appear  continuous  total  oliguria,  permanent  and  paroxysmal 
dyspnea,  edema,  hypostatic  congestion  of  viscera,  cardiac  insuffi- 
ciency, and  cardiac  failure.  The  importance  of  watching  the  out- 
put of  urine  in  heart  disease  and  its  value  in  connection  with  the 
prognosis  and  treatment  are  well  known;  the  urine  graduate 
serves  in  such  cases  as  does  the  thermometer  elsewhere. 

Oliguria  of  cardiopulmonary  origin. — Whether  primary  or 
Secondary,  decompensation  or  cardiac  insufficiency  is  sooner  or 
later  complicated  with  stasis  in  the  pulmonary  circulation,  anox- 
emia, hyposphyxia,  and  even  asphyxia;  the  viscosity  of  the  blood 
rises  in  the  absence  of  any  compensatory  ascent  of  blood-pres- 
sure, renal  stasis  becomes  more  mark^  on  this  account,  and 
consequently,  oliguria  increases. 

As  is  well  known,  an  opposite  sequence  of  events  may  occur 
instead,  some  respiratory  disorder,  such  as  chronic  bronchitis, 
emphysema,  capillary  bronchitis,  etc.,  bringing  on  cardiac  in- 
sufficiency and  the  syndrome  of  cardiopulmonary  insufficiency 
causing  oliguria. 

So  long  as  the  kidneys  remain  uninvolved,  the  urine  remains 
scanty,  of  high  specific  gravity,  deeply  colored,  and  highly  con- 
centrated. 

Oliguria  of  cardiorenal  origin. — Participation  of  the  kidneys 
in  the  reduction  of  urinary  secretion  is  shown  by  a  definite,  pathog- 
nomonic sign:  The  ratio  of  the  absolute  daily  output  of  urine  to 
the  number  of  centimeters  of  mercury  of  differential  or  pulse  pres- 
sure, as  determined  with  the  Pachon  instrument,  shows  a  reduction. 
In  a  normal  subject  this  ratio  (of  the  daily  output  of  urine,  H,  to 
the  differential  pressure,  p)  is  equal  to  or  exceeds  250.  In  a  subject 
with  interstitial  or  congestive  renal  involvement  it  is  below  200  (law 
of  Martinet). 

Simultaneously  there  are  observed  to  appear  more  or  less 
rapidly : 

Either  the  evidences  of  hydremic,  hypertensive  nephritis — 
high  blood-pressure,  low  viscosity,  hydremia,  gallop  rhythm, 
hemorrhages,  false  polyuria  with  elimination  of  urine  of  low 
specific  gravity,  a  slight  degree  of  albuminuria,  etc. 


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1222  SYMPTOMS. 

Or  those  of  uremigenous  nephritis — headache,  dyspnea,  som- 
nolence, excess  of  blood  urea,  etc. 

Or  those  of  hydropigenous  nephritis— ed^ma,  serous  exu- 
dates, diminished  chlorides  in  the  urine,  etc. 

Or  the  combined  indications  of  a  pan-nephritis,  combining 
in  greater  or  less  degree  the  above  several  deficiencies  of  renal 
functioning. 

In  some  instances — in  fact,  generally — this  primary  renal  im- 
pairment, relatively  well  compensated  for  a  varying  period  of 
time  through  compensatory  cardiac  hypertrophy,  becomes  as- 
sociated with  evidences  of  heart  weakness  only  in  a  relatively 
late  stage. 

In  other  instances  the  heart  weakness  is  primary  and  the 
renal  inadequacy  secondary. 

Present  methods  of  determining  the  functional  capacities  of 
the  heart  and  kidneys  ordinarily  yield  sufficient  information  as 
to  the  comparative  parts  played  by  the  two  symptoms,  and  such 
information  is  of  far  more  than  mere  academic  interest,  since  it 
gives  a  clue  to  an  efficient  line  of  treatment. 

Oliguria  of  cardiopneumorenal  origin. — In  the  final  stage  of 
cardiac,  pulmonary,  or  renal  disease,  the  disorder  is  no  longer 
limited  to  the  heart,  lungs,  or  kidneys.  A  combined  insufficiency 
of  these  major  systems,  closely  united  as  they  are  through  the 
circulation,  exists.  There  is  present  a  cardiopneumorenal  in- 
sufficiency :  Heart  failure,  asphyxia,  and  uremia  are  conjointly 
operative,  each  engendering  and  aggravating  the  others,  and  an 
extreme  degree  of  oliguria  is  produced.  But  however  serious — 
and  frequent — such  a  condition  may  be,  it  is  not  necessarily 
fatal,  at  least  at  the  outset.  Active,  energetic,  and  judicious  treat- 
ment often  insures  to  sucb  patients  an  additional  more  or  less 
prolonged  lease  of  life. 

Oliguria  of  hepatic  origin. — Hepatic  obstruction  is  likewise  a 
factor  in  the  production  of  lowered  urinary  excretion,  and  in  diflfer- 
ent  ways,  vie,  through  high  pressure  in  the  portal  circulation  and 
abdominal  venous  stasis,  and  through  pressure  upon  the  vena  cava 
above  the  renal  veins  and  passive  hyperemia  of  the  kidneys. 
Oliguria  of  hepatic  origin  is  known  sometimes  to  show  the  char- 
acteristic feature  termed  opsiuria,  or  delayed  excretion  of  ingested 


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OUGURIA.  1223 

fluid,  of  which  clinostatic  polyuria  (nocturnal  polyuria  or  nycturia) 
is,  as  a  matter  of  fact,  merely  one  variety. 


Oliguria  of  renal  origin  is  also  deserving  of  some  considera- 
tion. 

The  oliguria  of  rend  congestion,  constantly  present  in  acute 
nephritis,  is  generally  accompanied,  at  least  in  the  more  serious 
cases,  by  severe  lumbago  with  dense,  highly-colored,  albuminous, 
and  acid  urine,  yielding  a  sediment  containing  more  or  less  dis- 
organized red  blood  cells  and  exhibiting  renal  epithelia,  granular 
and  blood  casts,  etc.  It  may  be  the  result  of  poisoning  by  a  drug, 
typically  cantharides,  of  an  infection,  as  in  beginning  grippe  with 
backache,  or  of  an  autointoxication,  as  exemplified  in  gout. 

In  gouty  nephritis,  the  marked  accumulation  of  urates  along  the 
uriniferous  tubules  checks  diuresis  and  may  induce  renal  congestion 
and  oliguria,  which  may  in  turn  progress  to  complete  anuria. 

Hyperemia  of  the  kidneys  may  find  its  expression  in  the  course 
of  chronic  renal  disorders  in  the  appearance  of  a  more  pronounced 
oliguria. 


A  separate  place  in  the  classification  should  be  made  -for 
oliguria  with  cloudy  urine,  whether  the  latter  contains  an  excess 
of  readily  deposited  crystalloid  compounds,  such  as  phosphates 
and  carbophosphates,  blood  cells  that  have  passed  out  from  the 
vessels  during  acute  hyperemia,  or  pus. 

Oliguria  with  cloudy  urine  containing  pus  may  follow  or  even 
alternate  with  cloudy  polyuria.  Polyuria  is,  as  is  well  known,  a 
customary  reaction  of  the  kidney  to  extrarenal  urinary  infection,  as 
in  prostatic  hypertrophy,  cystitis,  or  pyelonephritis;  in  these  cases 
the  urine  is  of  low  specific  gravity  and  low  in  urea  and  chlorides. 
Cloudy  oliguria  following  cloudy  polyuria  indicates  that  extension 
of  the  infectious  process  to  the  kidney  itself  has  occurred,  nephritis 
following  pyelonephritis. 

At  times,  in  some  cases  of  nephritis,  the  urine  becomes 
cloudy  owing  to  the  passage  of  pus  and  blood  cells  into  it;  un- 
der these  circumstances,  either  the  kidney  has  undergone  certain 


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1224  SYMPTOMS. 

changes  owing  to  the  toxic  effect  of  faulty  metabolism,  or  the 
changes  in  it  are  of  infectious  origin.  In  the  former  event,  the 
urine  is  readily  rendered  clear  by  dietetic  measures;  in  the 
latter,  its  cloudy  condition  is  harder  to  overcome. 

Bacteria  may  harm  the  kidneys  either  directly  (in  situ),  or  in- 
directly through  the  action  of  their  toxins  and  altered  metabolism. 
Tuberculous  infection  affords  many  instances  of  this  kind ;  outside  of 
what  is  properly  termed  tuberculous  nephritis,  there  are  many  cases 
in  which  tuberculous  disease  of  the  lungs,  intestine,  or  even  the 
joints  leads  to  the  appearance  of  the  signs  of  nephritis  with  reduced 
output  of  cloudy  urine — and  sometimes  slight  hematuria— even 
though  no  tubercle  bacilli  can  be  found  at  the  time  by  the  most 
advanced  methods ;  tuberculosis  of  the  kidneys  often  sets  in  in  this 
manner. 

Later,  the  urine,  reduced  in  amount,  becomes  .increasingly 
cloudy  through  secondary  development  of  many  varieties  of 
germs,  especially  the  colon  bacillus,  in  a  kidney  with  lowered 
powers  of  resistance. 


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PAIN  IN  THE  SIDE. 


The  expression  "pain  in  the  side"  is  not  infrequently  used  to 
designate  acute  pains  in  the  region  of  the  chest  which  may  be 
compared  to  those  induced  by  the  impact  of  a  pointed  instru^ 
ment  in  this  vicinity.  This  is  a  common  symptom  in  many 
thoracic  affections,  yet  one  which  may  be  practically  pathogno- 
monic in  pleurisy  and  pneumonia. 

For  practical  purposes  it  is  convenient  to  group  such  "pains 
in  the  side"  into  those  of  visceral  origin  and  those  of  parietal 
origin. 

Thoracic  pain  of  visceral  origin  is  typically  referable  to  the 
pleura  or  lung. 

Pleurisy  is  a  common  cause  of  such  pain. 

Acute  serofibrinous  pleurisy  induces,  in  general,  a  rather  diffuse 
pain,  sometimes  extending  over  an  entire  half  of  the  thorax,  of 
variable  intensity,  and  increased  by  cough,  deep  inspiration,  sneez- 
ing, and  often  by  motion  and  lying  on  the  affected  side.  It  inter- 
feres with  the  breathing,  which  becomes  more  superficial.  The 
usual  signs  of  pleurisy  should  be  examined  for,  vis.,  dulness,  loss 
of  fremitus,  muffled  breath-sounds,  egophony,  etc. ;  in  the  event  of 
doubt,  exploratory  puncture  will  settle  the  diagnosis. 

Suppurative  pleurisy,  aside  from  the  usual  signs  of  pyemia,  in- 
cluding the  severe  constitutional  disturbance  and  the  special  charac- 
teristics of  the  temperature  curve,  is  sometimes  marked  by  a  more 
superficial  location  of  the  pain  and  greater  sensitiveness  to  digital 
pressure.  Here  again  exploratory  puncture  will  eliminate  all  un- 
certainty. 

The  advent  of  pneumothorax  is  generally  marked  by  a  sharp, 
intense,  sudden  pain,  almost  causing  syncope  and  attended  with  ex- 
treme dyspnea. 

Pain  is  most  violent,  however,  in  diaphragmatic  pleurisy,  caus- 
ing the  patient  to  cry  out  and  literally  cutting  short  his  respiration. 

(1225) 


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1226  SYMPTOMS, 


Figs.  838  to  841. — Anterior,  posterior,  and  lateral  topographic  fea- 
tures of  the  chest,  showing  the  pleural  culs-de-sac  and  the  interlobar 
fissures. 


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PAIN  IN   THE   SIDE.  1227 

The  pain  is  situated  lower  down  than  in  ordinary  pleurisy.  The 
five  cardinal  points  of  tenderness  emphasized  by  Peter  and  Gueneau 
de  Mussy  should  be  investigated  in  these  cases: 

1.  Between  the  two  heads  of  the  sternocleidomastoid. 


Fig.  842. — Relations  of  the  heart  as  shown  in  a  horizontal  section 
through  the  chest  of  a  new-born  infant  (Poirier).  a.  Right  auricle,  b. 
Left  auricle,  c.  Right  ventricle,  d.  Left  ventricle,  e.  Phrenic  nerve.  /. 
Elsophagus.    g.  Aorta,    h.  Vena  azygos. 

2.  Along  the  border  of  the  sternum  in  the  upper  costal  in- 
terspaces. 

3.  The  diaphragmatic  point,  at  the  junction  of  the  sternal 
line  (right  or  left  sternal  margin)  and  the  line  of  prolongation 
of  the  bony  portion  of  the  tenth  rib. 

4.  The  insertions  of  the  diaphragm  at  the  base  of  the  thorax. 


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1228  SYMPTOMS. 

5.  The  spinous  processes  of  the  upper  cervical  vertebrae. 

These  points,  which  constitute, 'as  a  matter  of  fact,  the 
points  for  stimulation  of  the,  phrenic  nerve,  are  of  service,  ac- 
cording to  Peter,  not  only  to  ascertain  the  condition  of  the  dia- 
phragmatic pleura  but  also  that  of  the  peritoneal  covering  of 
the  diaphragm. 

Interlobar  pleurisy  is  marked  in  particular  by  "fissured  points" 
which  Sabourin  describes  as  follows :  "On  either  side,  at  the  level 
where  the  third  and  fourth  ribs  mark  the  beginning  of  the  chief 


Fig.  843. — Anatomic  relations  of  the  intercostal  nerves. 

fissure,  is  the  vertebral  point;  at  the  anterior  end  of  the  chief  fissure, 
at  about  the  sixth  rib,  is  the  antero-inferior  point.  In  addition,  on 
the  right  side,  owing  to  the  differentiation  of  the  middle  lobe,  there 
is  a  post-axillary  point  corresponding  to  the  beginning  of  the  hori- 
zontal secondary  fissure  and  an  antero-superior  point  corresponding 
to  the  axillary  end  of  this  secondary  fissure.  These  are  actually  the 
only  marginal  foci  of  clinical  interest." 

At  these  points  there  is  spontaneous  pain,  which  is  accentu- 
ated by  motion,  deep  inspiration,  coughing  spells,  etc.;  pain  is 
also  induced  by  digital  pressure. 

Special  mention  should  be  made  of  localised  dry  pleurisy  in  the 
precordial  cul-de-sac,  giving  rise  to  a  precordial  painful  point  and 


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PAIN  IN  THE  SIDE.  1229 

frequently  attended  with  angor,  dyspnea,  and  premature  beats — in 
short,  with  pseudocardiac  neighborhood  manifestations.  Careful 
and  accurately  directed  auscultation  elicits  characteristic  friction 
sounds  corresponding  with  the  respiratory  movements;  one  might 
at  times  be  in  doubt  as  to  the  possible  presence  of  dry  pericarditis, 


Figs.  844  and  845.— Head's  zones. 

which  may,  indeed,  be  combined  with  the  pleural  disturbance  (see 
Precordial  pain). 

Inflammatory  conditions  of  the  lung  likewise  induce  pain  in 
the  side.  Whether  the  disturbance  present  is  pneumonia  or  tuber- 
culosis, these  inflammatory  states  are  very  often  in  the  nature  of  a 
pleuropulmonary  "corticalitis,"  and  the  pleura  participates,  as  al- 
ready mentioned,  in  the  production  of  the  pain. 


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1230  SYMPTOMS, 

Acute  frank  lobar  pneumonia  represents  the  type  of  the  diseases 
attended,  with  pain  in  the  side.  The  pain  is  generally  more  violent 
and  situated  more  anteriorly  (often  in  the  nipple  line),  more 
"stabbing,"  and  hence  more  intolerable  than  that  of  pleurisy.    It  is 


Figs.  846  and  847. — Head's  zones. 

usually  accompanied  with  a  marked  chill,  followed  by  a  rapid  rise 
of  temperature,  which  lead  the  physician  to  look  for  the  usual  local 
evidences  of  pneumonia  (dulness,  exaggerated  fremitus,  bronchial 
breathing,  crepitant  rales,  and  characteristic  sputum),  the  appear- 
ance of  which  is,  however,  often  postponed  until  much  later,  par- 
ticularly in  central   pneumonia.     In  the  latter   form,  the   disease 


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PAIN  IN   THE  SIDE. 


1231 


;CS. 


;*^ 


sometimes  takes  several  days  to  reach  the  cortex  and  to  become 
objectively  noticeable  through  manifest  auscultatory  signs. 

As  is  well  known,  however,  this  "dra- 
matic" onset  is  lacking  in  aged  subjects, 
in  whom  one  should  arbitrarily  look  for 
the  signs  of  pneumonia,  often  practically 
latent;  the  same  is  true,  but  for  opposite 
reasons,  in  children. 

Congestion  of  the  lungs  and  broncho- 
pneumonia may,  in  a  varying  degree,  give 
rise  to  variously  situated  pains  in  the 
chest. 

The  old-fashioned  notion  of  a  "chest 
flux"  (fluxion  de  poitrine)  had  to  do  with 
an  inflammatory  condition  in  the  chest 
involving  both  the  muscles  (pleurodynia), 
the  nerves  (neuralgia),  the  pleura  (pleu- 
risy), and  the  lung  (pneumonia,  inflam- 
matory congestion).  While  this  syn- 
drome is  not  specifically  dealt  with  in  our 
text-books,  it  certainly  occurs  clinically. 

An  investigation  of  "pains  in  the  side" 
is  especially  indicated  in  pulmonary  tuber- 
culosis. Such  pains  occur  under  two 
entirely  different  circumstances:  1.  In 
connection  with  acute  pneumonic  and  bron- 
chopneumonic  attacks  (with  especial  in- 
volvement of  the  apex),  in  which  they  are 
not  notably  different  from  the  pains  of 
ordinary  pneumonia  and  bronchopneu- 
monia. 

2.  In  a  practically  permanent  and  chrOnic 
form,  in  any  stage  of  the  disease,  even 
when  latent.  The  pain  is  sometimes  spon- 
taneous and  intermittent,  but  is  nearly 
always  induced  or  augmented  by  pressure 
upon  or  percussion  over  the  supraclavicular  and  supraspinous 
regions,  corresponding  to  the  apex  of  the  lung.    It  is  undoubtedly 


./i" 


\ 


\ 


,\ 


Fig.  848.— Sesni^ental 
cutaneous  distributions 
of  the  nerves  of  the 
trunk  (after  Head). 


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1232  SYMPTOMS. 

due  to  a  plcuro pulmonary  corticalitis  or  apical  plctiritis,  which  is 
practically  a  constant  accompaniment  of  tuberculosis. 

Lastly,  pneumothorax  likewise  begins  with  a  sudden,  severe  pain 
in  the  side,  generally  starting  in  a  coughing  spell  or  upon  exertion, 
situated  in  the  vicinity  of  the  inferior  angle  of  the  scapula  or  the 


I  ntercostohumeral 

cut.  br.  of  II  N. 

Lat.   cut.   br.   of   II   N  cut.  br.  of  I  N. 

Lat  cut  br.  of  III  N. 

N.  to  serratus  magnua 


\.nt.  cut  br.  of  VI  N. 


Int  cut  br.  of  X  N. 
Lat.  cut  br.  of  XII  N. 
I  lumbar  N. 


nguinal 


Fig.  849. — Cutaneous  branches  of  the  intercostal  nerves  (after  Poirier). 

nipple,  and  accompanied  by  severe  dyspnea  with  marked  accelera- 
tion of  the  respiration.  Tympany,  loss  of  vocal  fremitus,  disap- 
pearance of  the  vesicular  murmur,  sometimes  amphoric  breathing, 
the  coin  test,  metallic  tinkle,  and  the  usual  history  of  tuberculosis  or 
emphysema  (though  sometimes  wholly  negative  in  this  respect), 
generally  permit  of  a  rapid  diagnostic  decision  in  these  cases. 

Various   abdominal   affections,    especially   subdiaphragmatic 
disorders,  may  give  rise  to  pain  in  the  side.    Mention  need  here 


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PAIN  IN   THE  SIDE,  1233 

only  be  made  of  the  right  scapular  point  in  gaJl-stones,  the  left  in- 
ferior thoracic  and  precordial  points  in  flatulence  and  especially  in 
aerophagia,  and  the  right  or  left  inferior  thoracic  points  encountered 
in  the  different  varieties  of  subdiaphragmatic  abscess. 

Thoracic  pain  of  parietal  origin  may  arise  from  any  one  of 
the  several  layers  of  tissue  constituting  the  thoracic  wall : 

1.  The  skin,  in  which  herpes  zoster  may  occur  as  an  outward 
expression  of  a  deep-seated  nervous  disturbance. 

2.  The  muscles,  inflammation  of  which  causes  pleurodynia,  or 
pains  accentuated  particularly  by  motion  or  palpation  of  the  muscles 
concerned;  pains  diffuse  in  distribution,  involving  muscular  rather 
than  nervous  structures,  or  at  least  exhibiting  neither  the  character- 
istics nor  the  distribution  of  intercostal  neuralgia. 

3.  The  bones — ribs  and  spinal  column :  Osteitis,  osteoperiostitis 
(generally  tuberculous  or  specific),  or  chondrostemal  or  costoverte- 
bral osteoarthritis,  actually  giving  rise  rather  to  a  locali/ed  area  of 
painful  exacerbation  on  pressure  than  to  a  true  "pain  in  the  side." 
Involvements  of  the  spinal  column  will  be  briefly  considered  below. 

4.  The  nerves. — (a)  Intercostal  neuralgia,  outlining  a  costal 
interspace  with  the  three  classic  Valleix's  points  of  hyperesthesia: 
1.  Posterior,  just  lateral  to  the  corresponding  spinous  process.  2. 
Intermediate,  in  the  axillary  line.  3.  Anterior,  slightly  lateral  to 
the  sternum. 

(&)  Herpes  zoster  (zona;  shingles),  referred  to  above  as  a  skin 
manifestation,  is  as  a  matter  of  fact  **a  neuralgia-neuritis  with  neur- 
itid  or  nervous  (nerve),  radicular  (ganglion),  or  segmental  (hori- 
zontal zone)  distribution,  and  with  herpetic  vesicles  forming  a  burn- 
ing half-girdle"  (Grasset). 

(c)  The  pseudoneuralgia  (neuritis)  of  Pott's  disease,  of  verte- 
bral cancer,  of  vertebral  spondylitis,  of  aneurysm  of  the  abdominal 
aorta,  and  of  cancer  cases  uithout  spinal  involvement,  is  generally 
bilateral  and  associated  with  hyperesthesia  and  accentuation  of  the 
pain  by  percussion  of  a  definite  vertebral  zone. 

5.  Lastly,  in  the  spinal  cord,  tabes  and  dorsal  meningomyelitis 
may  give  rise  to  girdle  pains  or  to  thoracic  constriction  with  or 
without  lightning  pains,  gastric  crises,  and  the  usual  signs  of  tabes 
(Argyll-Robertson  pupil,  ataxia,  astasia,  loss  of  knee-jerks,  etc.). 

78 


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SYMPTOMS. 


Exceptional  cases. — One  cannot  conclude  a  discussion  of  the 
symptom,  "pain  in  the  side/'  without  referring  to  Head's  cones  of 
cutaneous  hyperesthesia.  Head  showed  that  in  many  disorders  of 
internal  organs  investigation  of  skin  sensitiveness  demonstrates  the 
existence  of  corresponding,  well-defined  hyperesthetic  (hyperal- 
gesic)  zones,  and  on  the  basis  of  natural  sequence  and  reciprocity, 
concluded  that  the  observation  of  such  a  zone  erf  hyperalgesia  in 
any  given  case  definitely  means  the  existence  of  some  disturbance 
of  the  underlying  deep  organ.  His  conceptions  do  account  for 
many  otherwise  inexplicable  pains  and  are  of  considerable  service 
in  the  clinical  study  of  many  more  or  less  latent  affections  of 
viscera.  It  seems  advisable,  therefore,  to  recall  here  the  various 
associations  of  skin  regions  to  the  viscera  of  the  chest  and  ab- 
domen, as  established  by  Head.  Through  their  agency  the  author 
has  frequently  been  enabled  to  announce  the  existence  of  other- 
wise completely  latent  foci  of  inflammation  in  the  pleura  and  lung. 

The  subject  appears  of  sufficient  practical  importance  to  war- 
rant the  reproduction  in  extenso  from  Head  of  a  complete  table 
showing  the  areas  of  pain  referred  to  the  skin  surface  from  vis- 
ceral disease. 

Table  Showing  the  Relationships  Between  the  Thoracic  and  Abdominal 

Viscera,  the  Spinal  Segments,  and  the  Peripheral  Nerves  of  the 

Trunk.    (After  Head,  in  Poirier's  "Anatomy.'*) 

[The  question  marks  following  certain  pairs  of  nerves  in  the  table  are 
intended  to  call  attention  to  the  fact  that  the  transmission  of  pain  does 
not  occur  constantly  in  the  field  of  distribution  of  these  nerves]. 


nbrye8    along    which    pain    is 
Orqans.  rbfbrrbd  to  the  pabibtes   in 

VISCERAL  DISEASE. 


Remarks. 


Heart  and  aorta 


Lungs 


In  angina  pectoris  the  referred  pain 
extends  down  the  arm  to  the  area  of  dis- 
tribution of  Di,  D2,  and  D3,  and  also  in 
the  thoracic  region  in  the  segments  D5, 
De.  D7,  Dg,  and  D9. 

The  pain  in  pneumonia  is  more  •espe- 
cially localized  in  the  4th  and  5th  costal 
interspaces;  collaterally  the  area  of  re- 
ferred pain  may  extend  into  the  segmen- 
tal distributions  De  and  D7. 


Esophagus 


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PAIN  IN  THE  SIDE. 


1235 


NERVES     ALONG     WHICH     PAIN     18 
OBOANS.  RBrEUBED    TO    THE    PARIETES    IN 

VISCERAL   DISEASE. 


REMARKS. 


I  Cardiac 
p;.rc" 
region 

Small  and  large  in* 
testine 


Xiphoid  point  and  spinal  point  in  gas- 
tric ulcer. 


Dorsolumbar  pain  in  cancer  of  the  in- 
testine or  mesentery. 


Rectum 


Liver 


Gall-bladder 


Kidney  and  renal 
pelvis 


Ureter 


Muscular 
layer  . . 


Bladder 


Mucous 
layer  . 


In  gall-stones  pain  is  referred  mainly 
in  the  8th  and  9th  costal  interspaces,  less 
frequently  in  the  9th  and  10th. 


Girdle  pains  in  malignant  disease  of 
the  kidney. 

Girdle  pains  and  pain  referred  toward 
the  nerves  of  the  lumbar  plexus  in  neph- 
ritic colic. 

Y       Dorsolumbar  pain  in  cystitis. 

I        Pain  the  result  of  irritation  by  foreign 
f  bodies  (stones,  etc.). 


Uterus 


Body  . 
Cervix 


Testicle  or  ovary 


Dorsolumbar  pain  in  parturient  women. 


Dio 


}Pain  due  to  inflammatory  states  and 
tumors  of  the  cervix. 

(Dorsolumbar  pain  in  tumors  or  tuber- 
culosis of  the  reproductive  glands. 
Referred   girdle-pain   in   cysts   of   the 
ovary. 

Epididymis |    ^^    I       Dorsolumbar  pain  in  orchitis,  epididy- 

Fallopian  tube  |    V^^    f  mitis,  or  suppurative  salpingitis. 

f  ^"         f    sf  ? 
Prostate  j    D12  and  j     ^ 

^  ^^  I    S3 

r>i^„^o-  o«^  ^«^;  f         Referred  pains  extend  along  the  course  of  the 

fnn^Tim  \  Peripheral  nerves,   and  are  associated  with   deep- 

loneum ^  seated  pain  confined  to  the  area  actually  involved. 


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PLETHORA.  InXrideLv,  to  be  full] 


The  terms  "plethora"  and  "plethoric,"  freely  used  in  the  clin- 
ical medicine  of  olden  times,  are  not  to  be  found  in  the  standard 
treatises  and  text-books  published  in  the  course  of  the  last  forty 
years.  In  this  fact  lies  one  of  the  inevitable  weaknesses  of  the 
prevailing  nosology,  which,  soundly  based  as  it  was  upon  the 
pathologic  conception  of  a  certain  clinical  picture  corresponding 
exactly  to  a  certain  definite  organic  lesion,  found  itself  com- 
pletely at  a  loss  when  required  to  classify  correctly  the  func- 
tional symptom-complexes  attendant  upon  morbid  physiology. 
It  was  obliged  to  yield,  unwillingly,  in  some  instances,  and  at- 
tempted to  associate  a  symptom-group  with  a  definite  lesion — not 
always,  nor  even  frequently,  succeeding  in  its  endeavor.  One 
need  merely  recall  the  countless  "lestonal"  theories  of  angor  pec- 
toris, such  as  the  neuritis  theory  and  the  theories  of  coronary 
arteritis,  of  aortitis,  of  myocarditis,  etc.  As  for  certain  other 
conceptions,  such  as  the  morbid  temperaments,  constitutional 
morbid  predispositions,  the  "preorganic"  stages  of  various  dis- 
eases, and  the  "boundaries  of  the  disease,"  according  to  Heri- 
court's  very  justifiable  expression  they  were  deliberately  jetti- 
soned from  the  nosological  field  as  it  was  formerly  accepted. 

This  opposition  between  that  which  the  author  has  deliber- 
ately— and  without  overlooking  the  inaccuracy  of  the  terms 
when  taken  in  the  strict  sense— designated  as  functional  nos- 
ology and  the  realm  of  lesional  or  organic  nosology  accounts  in 
part  for  the  frequently  recorded  lack  of  harmony  between  hos- 
pital practice  and  private  practice.  Hospital  practice  deals  al- 
most exclusively  with  lesional  cases  suflFering  either  from  acute 
disorders  or  from  chronic,  long-standing,  lesional,  inveterate,  in- 
curable disorders  that  have  reached  the  stage  of  organic  decom- 
pensation, such  as  advanced  tuberculosis,  arteriosclerosis,  inter- 
stitial nephritis,  cirrhosis  of  the  liver,  tumors,  etc.  Private  prac- 
(1236) 


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PLETHORA,  1237 

tice,  on  the  other  hand,  deals  chiefly  with  functional  cases  suf- 
fering from  morbid  affections. or  tendencies  of  relatively  recent 
advent  and  generally  curable,  such  as  pretuberculosis,  hypo- 
sphyxia,  plethora,  transient  or  mild  forms  of  cardiorenal  insuffi- 
ciency, active  or  passive  congestion  of  the  liver,  etc.  Hospital 
medicine,  which  hitherto  has  afforded  the  most  clearcut  material 
utilized  in  standard  systems,  deals  mainly  with  extreme  forms 
of  disease,  very  often  perfectly  established  and  with  highly  de- 
finite outlines.  Private  practice  generally  supplies  for  the  physi- 
cian's observation  incipient  clinical  types,  an  infinitely  greater 
range  of  abnormal  conditions,  and  morbid  tendencies  sometimes 
as  yet  barely  outlined;  yet  any  one  can  see  that  it  is  precisely 
upon  the  detection  of  these  premonitory  stages  of  presclerosis, 
of  pretuberculosis,  of  cardiac,  renal,  or  hepatic  insufficiency,  etc., 
latent  or  incipient,  that  the  efficacy  of  our  therapeutic  endeavors 
depends. 

A  concise  consideration  of  plethora  will  illustrate  this  assertion 
as  a  concrete  clinical  example. 

Plethora  {Tdkri^is^^  from  TtXyjOeiv,  to  be  full)  constitutes  a 
very  distinct  and  common  clinical  type.  In  its  simple,  uncompli- 
cated form,  it  strikes  the  eye  by  virtue  of  the  subject's  flourishing, 
often  ruddy,  supernormal,  "overfilled,*'  "plethoric"  appearance^ 

The  plethoric  subject  is,  in  truth,  by  no  means  a  sick  person  in 
the  ordinary  sense  of  the  term ;  on  the  contrary,  apart  from  certain 
minor,  intermittent  ailments  such  as  skia  disturbances,  hemor- 
rhoids, etc.,  he  enjoys  a  flourishing,  seemingly  perfect  state  of 
health ;  he  even  shows  an  unusual  functional  activity  character- 
istic of  more  intense  vitality ;  he  is  polyphagic  and  his  digestive 
functions  are  admirably  carried  out  (as,  indeed,  they  are  in  dia- 
betic, gouty,  and  obese  subjects)  ;  he  is  polydipsic  and  polyuric 
(like  the  diabetic  and  gouty)  ;  his  skin  is  ruddy  and  his  general 
appearance  robust ;  without  his  being  actually  obese,  his  weight 
is  nevertheless  above  the  normal  (96  kilograms  with  a  height 
of  187  centimeters,  74  kilograms  to  166  centimeters,  etc.)  ;  his 
powers  of  endurance  are  great;  he  is  unusually  active  and  the 
amount  of  work  he  does  may  be  far  above  the  average  (as  in 
many  gouty  and  diabetic  individuals). 


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1238  SYMPTOMS. 

In  short,  in  the  absence  of  any  sort  of  illness  on  his  part, 
one  would  almost  be  apt  to  state  that  the  plethoric  is  a  super- 
normal person  or  "superman"  from  the  standpoint  of  body 
physiology.  His  more  powerful,  hypertrophied  heart  contracts 
more  forcibly,  leading  to  an  unusually  high  systolic  and  differ- 
ential blood-pressure.  His  blood,  more  rich  and  less  dilute, 
exhibits  a  higher  viscosity  and  frequently  an  enhanced  number 
of  blood  cells.  His  kidneys,  adapted  to  more  active  circulation 
and  nutrition,  excrete  unusually  large  amounts  of  water,  salt, 
urea,  uric  acid,  etc.,  and  of  urine,  which  often  shows  high  acidity 
and  high  specific  gravity.  His  digestive  glands,  copiously  sup- 
plied with  blood,  produce  unusually  laxge  amounts  of  secretion, 
causing  polyphagia,  polydipsia,  polyuria,  plethora,  etc. 

The  plethoric  subject  is  thus  not,  strictly  speaking,  an  abnor- 
mal, but  rather  a  supernormal  individual,  clinically  characterized 
by  his  flourishing  appearance,  his  supernormal  body  weight,  and 
his  high  blood-pressure  and  blood  viscosity. 

He  is  predisposed,  however,  to  obesity,  to  diabetes,  to  gout, 
and  to  urinary  lithiasis,  of  which  he  already  presents  certain  typ- 
ical features  as  regards  body  conformation  and  functionation. 
He  is  predisposed  to  the  development,  sooner  or  later,  of  cardio- 
vascular-renal fibrosis.  The  chief  advantage,  indeed,  of  'a  diag- 
nosis of  true  plethora  founded  on  the  symptomatic  triad,  over- 
weight, high  blood-pressure,  and  high  viscosity  (with  their  corol- 
laries, high  urinary  acidity  and  specific  gravity),  is  that  it  points, 
long  before  any  recognized  and  ordinarily  listed  morbid  mani- 
festation has  appeared,  to  the  presence  of  an  abnormal  tendency 
which,  at  the  time,  is  still  susceptible  of  relatively  easy  correc- 
tion before  any  irreparable  organic  change  has  become  estab- 
lished (see  High  blood- pressure). 

In  over  one-half  of  all  cases  of  plethora  duly  substantiated  by 
the  presence  of  overweight  and  high  blood-pressure  and  viscosity, 
the  plethoric  state  will  be  found  associated  with  a  recognized 
metabolic  disease,  inc.,  diabetes  (see  Glycosuria),  obesity  (q.v.), 
gout  (see  Joint  pains),  or  urinary  lithiasis  (see  Lumbar  region, 
pain  in). 

Plethora  constitutes,  furthermore,  a  premonitory  stage  in 
arteriorenal  fibrosis  or  arteriosclerosis,  which  it  precedes,  heralds. 


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PLETHORA,  1239 

and  elaborates.  When  the,  plethoric  subject  has  exhausted  the 
cardio-arterio-renal  reserve  powers  which  have  up  to  that  time 
maintained  and  insured  his  abnormally  high  level  of  physiologic 
performance,  he  passes  gradually  into  a  stage  of  angiospastic  pre- 
sclerosis,  during  which  he  experiences  intermittent  attacks  of  renal 
insufficiency  with  retention,  clinically  expressed  in  paroxysmal  high 
blood-pressure,  hydremia,  and  their  consequences — anginose 
pains,  suffocative  sensations,  pseudoasthma,  transient  reduction  of 
urinary  output,  etc.  If  this  condition  of  presclerosis,  which  is 
still  in  large  measure  a  reducible  condition,  is  not  set  right,  a 
definitive  and  practically  irremediable  arteriorenal  sclerosis  becomes 
established.  The  subject  is  no  longer  merely  a  patient,  but  a  per- 
manent invalid. 

The  foregoing  concise  account  will  have  set  before  the  reader 
the  prime  importance  of  the  syndrome,  plethora,  which,  correctly 
interpreted  and  treated,  will  obviate  in  many  instances  an  other- 
wise refractory  condition  of  general  tissue  deterioration.  ^ 


ipor  further  details,  see  Martinet:  Pressions  artirielUs  et  viscositi 
sanguine,  Masson,  1912 ;  Clinique  et  thSrapeutique  circulatoires,  Masson,  1914, 
and  in  the  present  work,  the  section  on  High  blood-pressure. 


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POLYURIA.  [7toXi;$,  much;  oipov,  urine.] 


The  first  thing  to  do  in  a  patient  who  states  that  he  passes 
much  urine  or  in  whose  case  there  is  reason  to  believe  that 
polyuria  exists  is  to  make  sure  that  the  condition  is  actually 
present.  Many  patients  confuse  the  terms  frequent  urination  (pol- 
lakuria)  and  free  urination  (polyuria).  As  a  matter  of  fact,  no 
necessary  and  intimate  relationship  exists  between  these  two  mani- 
festations. The  practitioner  should  therefore  have  the  patient 
carefully  and  systematically  collect  the  twenty-four  hour  urine  in 
one  or  more  two-liter  (or  two-quart)  containers.  Polyuria  can- 
not be  said  to  exist  unless  the  twenty- four  hour  output  (e,g.,  from 
8  A.M.  to  the  following  8  a.m.)  materially  exceeds  1.5  liters,  which 
is  the  normal  average  amount  in  an  adult  on  a  normal  diet.  The 
average  degree  of  polyuria  which  is  by  far  the  most  frequently 
met  with  is  that  ranging  between  1.750  and  3  liters.  In  exceptional 
instances,  such  amounts  as  4  to  6,  8,  10  liters,  or  even  more,  have 
been  and  are  encountered. 


Little  space  will  be  devoted  to  the  subject  of  induced  polyuria, 
whether  of  physiologic  origin  and  due  to  spontaneous  ingestion  of 
fluid  in  large  amounts,  as  in  polydipsic  subjects,  or  of  therapeutic 
origin,  in  conformity  with  the  physician's  orders.  Where  this  form 
of  polyuria  exists  care  should  be  taken  at  least  to  ascertain  s^proxi- 
mately  the  total  amounts  of  fluid  ingested  and  of  urine  excreted. 
Only  by  a  comparison  of  these  two  amounts  can  a  reliable  conclu- 
sion be  reached  as  to  the  eliminatory  power  of  the  kidneys  as 
regards  water  (see  Functional  examination  of  the  kidneys:  In- 
duced diuresis). 

This  applies  to  plethoric  subjects ;  they  eat  much  food  and  drink 
much  fluid  and  consequently  pass  a  large  volume  of  urine,  and  if  a 
careful  comparison  of  their  ingesta  and  excreta  is  made,  a  satis- 
(1240) 


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POLYURIA.  1241 

factory  balance  between  the  two  is  noted.  Their  urinary  output 
per  centimeter  of  differential  or  pulse  pressure  is,  moreover,  nor- 
mal, zfis.,  250  cubic  centimeters  (see  High  blood-pressure). 

Polyuria  following  injections  of  saline  or  glucose  solutions,  the 
administration  of  diuretic  agents,  or  the  institution  of  other 
diuretic  measures  likewise  presents  an  obvious  exciting  cause,  but 
should  stimulate  the  physician  to  record  accurate  and  carefully 
made  observations  such  as  will  ultimately  permit  of  our  formulat- 
ing a  practical  and  rational  system  of  pharmacodynamics  as  related 
to  the  diuretic  agents. 

♦    ♦    ♦ 

Spontaneous,  accidental,  temporary  polyuria  is  met  with  par- 
ticularly under  two  well-defined  conditions : 

1.  After  paroxysmal  nervous  attacks,  especially  among  hys- 
teric subjects,  epileptics,  and  exophthalmic  goiter  (post-hysteric, 
post-epileptic,  and  hyperthyroid  polyuria),  and  even  after  ordi- 
nary spells  of  nervous  excitement  among  naturally  "nervous" 
subjects,  ue.,  persons  with  unusual,  excessive  nervous  reactions 
to  stimuli. 

2.  In  the  critical  stage  of  febrile  diseases  and  more  particu- 
larly in  the  stage  of  resolution  in  pneumonia,  influenza,  broncho- 
pneumonia, pleurisy,  etc.  In  these  it  constitutes,  as  a  rule,  a 
favorable  prognostic  sign  of  the  greatest  importance  and  which 
generally  marks  the  change  of  trend  of  the  disease  from  a  fatal 
to  a  favorable  termination. 

The  foregoing  types  of  polyuria  are,  as  will  have  been  noticed,  of 
considerable  practical  importance,  but  those  to  follow  are  far 
more  significant  still. 


Spontaneons,  habitnal,  chronic,  or  at  least  recurring,  polyuria. 

— The  most  commonly  encountered  forms  are  those  of  renal  fibro- 
sis (interstitial  nephritis),  diabetes,  and  chronic  diseases  of  the 
urinary  tract.  The  several  different  forms  may  be  intermingled, 
but  ordinarily  they  are  completely  dissociated  and  their  recogni- 
tion is  easy,  rapid,  and  elementary. 


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1242  SYMPTOMS, 

1.  Polyuria  in  renal  fibrosis  (interstitial  nephritis). — ^The 
patient  is  of  ripe  or  advanced  age.  Usually  he  has  a  moderate 
degree  of  polyuria  (1800  to  2000  cubic  centimeters),  with  pol- 
lakuria  and  nycturia.  The  urine  passed  is  light  colored,  of  low 
specific  gravity  (1014  or  less),  with  small  proportions  of  urea  and 
chlorides,  and  traces  of  albumin,  frequently  so  small  as  to  pre- 
clude determination,  or  even  entire  absence  of  albumin. 

Sometimes,  and  even  often,  the  polyuria  is  accompanied  by 
the  ordinary  signs  of  arteriosclerosis :  Cardiac  hypertrophy,  ac- 
centuation of  the  second  sound  at  the  base,  or  even  gallop  rhythm, 
together  with  sinuous  or  sometimes  actually  hardened  peripheral 
arteries;  at  a  more  advanced  stage:  Hemorrhages  in  various 
situations,  as  in  the  retina,  from  the  nose  (epistaxis),  etc. 

There  exists,  furthermore,  a  sign  which  in  the  author's  view 
is  pathc^nomonic  of  renal  fibrosis  in  the  stage  of  eusystoly,  i.e,, 
of  adequate  cardiac  compensation.  In  this  stage  there  is  always  a 
high  systolic  pressure,  a  high  pulse  pressure,  and  also  frequently  a 
high  diastolic  pressure.  Determination  of  the  quotient  ^  of  the 
actual  twenty-four  hour  output  of  urine,  H,  over  the  pulse  pressure, 
p,  as  estimated  with  the  Pachon  instrument  in  the  sitting  patient 
in  the  later  morning  hours  or  in  the  afternoon,  yieldst  in  the 
normal  subject  a^  result  equal  or  superior  to  250  cubic  centim- 
eters. In  the  patient  with  interstitial  nephritis  the  same  cal- 
culation yields  constantly  and  permanently  a  result  more  or  less 
inferior  to  250  cubic  centimeters,  and  the  lower  the  figure,  the 
more  pronounced  the  process  of  sclerosis.  By  accident  and  in  a 
strictly  transient  m.anner,  such  a  figure  may  be  recorded  in  an 
angio-spastic  case,  but- never  lastingly  and  permanently. 

2.  Polyuria  in  diabetics. — The  patient  is  generally  in  middle 
adult  life  and  presents  a  flourishing  appearance.  The  pol3ruria  is 
usually  more  marked  than  in  interstitial  nephritis,  amounting  to  2 
liters  or  more.  The  urine  is  more  highly  colored,  and  at  times  even 
deeply  tinted;  it  is  always  of  high  specific  gravity,  viz,,  1020  or 
above,  1030,  1034,  etc.  Whether  glycosuria  is  present  or  absent, 
this  feature  alone  is  almost  sufficient  to  differentiate  the  polyuria 
of  low  specific  gravity  of  nephritis  from  the  diabetic  polyuria 
with  high  specific  gravity. 


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POLYURIA.  1243 

(a)  In  9  cases  out  of  10  there  is  glycosuria,  signifying  diabetes 
mellitus,  the  cause  of  which  is  thereupon  to  be  sought. 

(b)  In  1  case  out  of  10  glycosuria  is  absent,  but  there  is  excess 
of  nitrogen,  of  chlorides,  of  phosphates,  etc.  In  this  event  the 
condition  is  termed  diabetes  insipidus,  and  in  this  connection  one 
is  confronted  with  one  of  the  more  complex  aspects  of  polyuria, 
since  it  borders  on  the  condition  known  as  renal  hyperpermeability 
— a  syndrome  exactly  opposite  to  the  hypopermeability  which  re- 
sults from  renal  fibrosis^ — as  well  as  on  amyloid  degeneration  of 
the  kidney,  on  idiopathic  (or  cryptogenic)  polyuria,  sometimes  of 
hysteric  origin  (and  what  now  remains  of  hysteria?),  and  on  poly- 
uria symptomatic  of  nervous  disorders,  especially  bulbar,  tumors 
of  the  medulla,  disseminated  sclerosis,  general  paralysis,  hemor- 
rhage, softening,  tumors  of  the  pituitary,  etc.  Discussion  of  all 
these  allied  and  varied  conditions  would  lead  us  too  far  afield ;  let 
the  mere  mention  of  their  possible  clinical  occurrence  here  suffice. 

3.  Polyuria  in  "urinary"  cases. — In  this  group  are  included 
the  instances  of  polyuria  almost  constantly  met  with  in  the 
course  of  the  chronic  diseases  of  the  urinary  tract,  such  as  hyper- 
trophied  prostate,  stone  in  the  bladder,  chronic  cystitis,  pyelo- 
nephritis (especially  of  calculous  origin),  etc. 

Its  mode  of  production  is  undoubtedly  complex,  the  symptom 
being  the  result  of  a  reflex  stimulation  (possibly  vasodilator),  of 
secondary  interstitial  changes  in  the  kidney  with  secondary  high 
blood-pressure,  and  probably  of  other  as  yet  poorly  understood 
factors. 

At  all  events,  such  a  polyuria  seldom  exceeds  2  or  2^^  liters. 
Only  very  exceptionally  is  the  urine  passed  clear  as  in  the  pre- 
ceding categories.  The  associated  infection  of  the  urinary  tract 
makes  of  it  a  cloudy  polyuria,  in  which  the  turbidity  is  due  to  pus 
in  the  urine  and  sometimes,  likewise,  to  alkalinity  (or  hypoacidity) 
and  phosphaturia.  In  relatively  recent  cases  the  urine  clears  up  on 
standing,  the  pus  and  other  solid  substances  forming  a  voluminous 
deposit  at  the  bottom  of  the  receptacle ;  in  inveterate  cases,  on  the 
other  hand,  with  more  advanced  renal  lesions,  the  urine  remains 
cloudy,  with  a  much  less  abundant  sediment. 


1  See   Martinet  :     *'Clinique  et   therapeutique   circulatoires"  section   on 
Renal  hyperpermeability. 


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1244  SYMPTOMS. 

This  cloudy  form  of  polyuria  may  be  met  with  in  renal  tuber- 
culosis, especially  when  in  an  advanced  stage.  At  the  beginning  a 
copious,  clear  polyuria  is  more  frequently  observed,  with  traces  of 
albumin,  phosphaturia,  and  quite  frequently  with  slight,  mani- 
fest or  occult  hematuria,  the  latter  being  examined  for  by  centrifu- 
gation  and  examination  of  the  sediment  for  red  blood  cells. 


Such  are,  for  practical  purposes,  the  three  main  varieties  of 
chronic,  persistent,  lasting  polyuria.  Yet,  as  in  all  other  clinical 
groupings,  there  remains,  in  last  analysis,  a  residue  of  cases  still 
obscure  and  which  lend  themselves  poorly  to  any  satisfactory 
didactic  description.  This  is  the  g^oup  alluded  to  above  in  con- 
nection with  the  polyuria  of  diabetes  insipidus,  vis.,  the  essential 
or  idiopathic  polyurias,  or  better,  the  cryptogenic  polyurias,  the 
latter  term  being  more  in  accord  with  our  present  state  of  knowl- 
edge, since  we  are  ignorant  of  their  cause  and  even  of  their  prob- 
able mode  of  production.  Most  of  the  case  reports  refer  to  young 
subjects,  twenty  to  forty  years  of  age,  frequently  alcoholic,  and 
nearly  always  hysteric.  The  onset  is  almost  abrupt,  with  frequent 
urination.  The  amounts  reported  by  many  of  the  authors  are  so 
amazing,  e.g,,  10  liters,  15  liters,  or  even  30  liters,  that  they  in- 
evitably suggest  the  "Tales  of  Hoffmann"  and  that  it  is  difficult 
to  believe  that  there  are  not  among  them  some  instances  of  "colos- 
sal" faking.  Personally,  the  author  has  never  observed  any 
amount  approaching  the  above  figures.  The  highest  amount  recorded 
has  been  7  liters,  already  a  remarkable  figure,  and  even  in  this  case 
the  circumstances  as  regards  supervision  of  the  patient,  although  a 
rather  close  watch  was  kept,  were  not  such  as  to  exclude  all  pos- 
sibility of  faking  on  the  part  of  the  patient — an  irresistible  tendency 
in  such  subjects,  who  are  always  going  after  that  which  is  excessive 
and  extraordinary  and  seeking  mainly,  like  the  members  of  certain 
schools  of  art,  to  "astound  the  physician."  "The  spider,"  said  Mar- 
cus Aurelius,  "takes  pride  in  catching  a  fly ;  another  creature  takes 
pride  in  catching  a  hare ;  another,  in  catching  a  sardine ;  another,  in 
destroying  a  wild  boar;  another,  in  killing  Sarmatians."  Another, 
we  may  add,  in     .      .      . 

Where  will  pride  not  seek  its  outlet ! 


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PRECORDIAL  PAIN. 


There  are  many  patients  who  complain  of  pains  in  the  region 
of  the  heart  and  believe,  therefore,  that  their  heart  must  be  af- 
fected.' As  a  matter  of  fact,  precordial  pain,  while  sometimes 
of  cardiac  origin,  is  far  more  frequently  of  extracardiac  origin. 
The  commonest  among  these  extra-cardiac  causes  are  dyspepsia, 
aerophagia,  neuroses,  and  more  particularly  the  so-called  "psy- 
chosplanchnic  neurosis;'*  in  addition,  a  host  of  other  factors  may 
on  occasion  be  operative. 

The  fact  is  that  the  precordial  region  is  anatomically  highly 
complex. 

The  precordial  parietes  comprisie,  from  before  backward : 

1.  The  skin,  subcutaneous  cellular  tissue,  mammary  gland,  and 
subjacent  muscles,  in  particular  the  pectoralis  major, 

2.  The  chest  wall  proper,  consisting  of  muscle,  bone,  and  car- 
tilage, and  including  the  sternum,  ribs,  costal  cartilages,  together  with 
the  costal  interspaces  and  their  vessels  and  nerves, 

3.  The  pericardium  and  heart. 

4.  Anteriorly,  the  tongue-like  projections  of  the  pleurcc  and  lungs 
between  the  pericardium  and  the  thoracic  wall. 

5.  Posteriorly,  the  heart  is  ensconced  in  its  medic^tinal  recess 
in  more  or  less  direct  relationship  zvith  the  esophc^us,  the  descend- 
ing aorta,  and  the  mediastinal  lymph-glands. 

6.  Above,  it  is  prolonged  by  the  great  vessels  at  the  base,  viz,, 
the  aorta  and  the  pulmonary  vessels, 

7.  Below,  it  rests  on  the  thin  diaphragm,  which  alone  separates 
it  from  the  fundus  of  the  stomach. 

8.  Laterally,  it  is  in  relationship  with  the  mediastinal  pleura,  the 
lungs,  the  phrenic  nerves,  and  the  vessels  to  the  diaphragm. 

There  is  not  one  of  these  structures  which  may  not  be  the 
source  of  pain  in  the  precordial  region,  some  commonly,  like  the 
stomach,  others  exceptionally,  like  the  mammary  glands. 

(1245) 


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1246  SYMPTOMS. 

Clinically,  a  correct  dia^osis  can,  as  a  rule,  be  quickly 
reached  on  the  basis  of  three  circumstances,  viz.,  the  nature  of  the 
pain,  the  time  at  which  it  appears,  and  the  associated  signs. 

Vena  azygoB  Aorta  ISsophagus  Phrenic  nerve 


Right  auricle     Left  auricle       Right  ventricle  Left  ventricle 

Fig.  850. — Horizontal  cross-section  of  the  chest  of  a  new-born  infant 
through  the  eighth  dorsal  vertebra  (Poirier). 

(a)  NATURE  OF  THE  PAIN. 

This  may,  for  practical  convenience,  be  divided  into  the  fol- 
lowing six  varieties : 

1.  A  sensation  as  of  a  '"misstep"  or  momentary  arrest  of  the 
heart,  frequently  accompanied  by  a  precordial  thump  with  a 
slight  feeling  of  constriction  at  the  apex  of  the  heart  and  of 
transient  faintness,  and  sometimes  preceded  by  a  sensation  of 
constriction  in  the  esophagus. 


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PRECORDIAL  PAIN,  /         1247 

This  is  the  ordinary  extra-systole  or  premature  beat,  a  condi- 
tion frequently  encountered  and  recorded.  It  is  rather  a  transitory 
discomfort  than  an  actual  pain.  For  its  clinical  interpretation  the 
reader  is  referred  to  the  section  on  Arhythmia. 

2.  Pain  localized  about  the  apex  of  the  heart,  recrudescent 
with  each  cardiac  contraction,  and  with  an  exacerbation  at  the 
same  point  when  a  rather  deep  inspiration  is  taken.  This  is  the 
typical  pain  of  pleurisy  involving  the  precordial  cul-de-sac,  often 
leadily  detected  by  auscultation  (localized  rub  during  inspira- 
tion and  expiration,  ceasing  during  the  periods  of  apnea). 

The  pain  of  pericarditis  sicca,  sometimes  rather  similar,  is,  as  a 
rule,  easily  differentiated  by  the  persistence  of  the  friction  sounds 
even  during  apnea  and  their  synchronism  with  the  heart  beats. 

They  may  be  accompanied  by  local  tenderness. 

3.  Pain  more  or  less  localized  at  the  apex,  with  superficial 
darts  and  radiation  toward  the  left  lateral  "^nd  posterior  portion 
of  the  chest.  This  is  the  typical  pain  of  intercostal  neuralgia. 
The  three  characteristic  points  of  tenderness  should  be  examined 
for. 

The  various  possible  causes  of  the  pain  should  be  sought,  vis., 
rheumatic  fever,  Pott's  disease,  beginning  meningomyelitis, 
osteoperiostitis,  etc. 

4.  Pain  as  of  a  surface  bruise  or  muscle  cramp  in  the  left  side 
of  the  thorax,  accompanied  by  tenderness  on  pressure  or  pinch- 
ing of  the  muscles,  accentuated  by  movements  of  the  left  arm, 
and  allayed  by  rest  of  the  extremity.  This  may  be  a  myalgia  of 
the  pectoral  muscles  due  to  overuse  of  these  muscles,  trauma- 
tism, or  exposure  to  cold. 

5.  A  sensation  of  intrathoracic  distention,  of  a  **large  heart,"  of 
a  too  narrow  chest,  frequently  accompanied  by  some  degree  of 
anginose  discomfort  and  by  dyspnea  increasing  upon  exertion, 
walking,  and  climbing.  All  grades  may  be  encountered,  from  a 
slight,  transient  pain  behind  the  sternum  coming  on  upon  marked 
exertion  and  ceasing  upon  termination  of  the,  latter,  to  a  continued 
pain  with  persistent  anginose  discomfort  and  increasing  dyspnea. 
In  these  cases  the  physician's  attention  should  be  definitely  directed 
tcl  the  myocardium;  the  condition  is  probably  a  myocardialgia ;  the 
well-known  dyspnea  on  exertion  is  present ;  only  a  concrete  clinical 


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1248  SYMPTOMS.    , 

study  and  the  use  of  appropriate  tests  will,  however,  permit  of 
estimation  of  its  degree,  significance,  and  seriousness.  It  may  just 
as  well  be  the  result  of  aerophagia,  interfering  by  direct  pressure 
with  expansion  of  the  myocardium,  as  the  result  of  cardiac  neurosis, 
bringing  about  an  angiospastic  attack  with  excess  of  work  imposed 
upon  the  heart,  or  as  the  result  of  true  myocardial  degeneration 
leading  to  progressive  cardiac  insufficiency. 

6.  A  sensation  of  violent  constriction  of  the  thorax,  of  squeez- 
ing of  the  chest  as  in  a  vice,  with  a  constricting  pain,  clawing 
sensation,  spasm,  or  strangling  extending  from  the  post-sternal 
area  to  the  upper  part  of  the  chest,  sometimes  with  radiation  to 
the  left  arm  on  its  ulnar  aspect,  more  rarely  along  both,  arms  or 
only  on  the  right,  paroxysmal,  and  accompanied  by  anginose  dis- 
tress o£  varying  degree  which  may  go  so  far  as  to  yield  a  sub- 
jective impression  as  of  imminent  death.  This  is  the  typical  pain 
of  angina  pectoris,  which  may  be  encountered  in  varying  degrees. 
As  in  the  preceding  type,  its  significance,  degree  and  seriousness 
can  be  determined  only  by  accurate  clinical  analysis.  Angina 
pectoris,  or  better  the  anginose  syndrome,  is,  indeed,  not  only 
witnessed  in  all  grades  but  may  be  brought  on  by  the  most 
varied  causes,  f  com  the  mildest  kind  of  aerophagia  to  the  most  seri- 
ous aortitis  with  coronary  disease  and  myocarditis.  Hence  the 
much  criticized  classification  of  olden  times  into  pseudoangina 
pectoris  which  does  not  threaten  life  and  true  angina  pectoris 
which  kills  the  patient.  This  simple  conception  is  incorrect  in 
that  such  a  clean-cut  division  is  a  practical  impossibility  and  by 
no  means  harmonizes  with  clinically  observed  facts.  What  is 
true,  however,  is  that  it  is  the  physician's  duty  to  a.scertain,  by- 
painstaking  clinical  analysis,  that  which  underlies  the  anginose 
syndrome  and,  together  with  its  intensity  and  its  cause,  its  mild- 
ness or  seriousness,  to  estimate  its  gravity  in  the  individual  case 
— an  extremely  variable  quantity. 

The  diagnosis  of  angina  pectoris  is  often  made  with  discon- 
certing freedom.  One  cannot  sufficiently  warn  the  practitioner 
of  the  twofold  moral  responsibility  he  undertakes  either  in  over- 
looking the  seriousness  of  an  singinose  syndrome  which  is  the 
clinical  expression  of  a  lethal  cardioaortic  disease  or  in  holding 
the  terrible  sword  of  Damocles  of  sudden  death  over  the  head 


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PRECORDIAL  PAIN.  1249 

of  a  neurotic  or  aerophagic  patient  Hence,  he  should  carefully 
analyze  the  symptom  before  making,  even  merely  in  his  own 
mind,  a  diagnosis  of  angina,  and  should  avoid  expressing  any 
sort  of  a  prognosis  imtil  after  painstaking,  repeated,  and  pro- 
longed examination.  The  author  has  seen  patients  with  exten- 
sive aortic  lesions  and  subject  to  apparently  alarming  anginose 
attacks  live  ten,  twelve,  fifteen  years  or  longer,  in  some  instances 
evert  with  complete  intermissions  of  several  years'  duration. 

The  reader  may  have  noted)  how  difficult  it  has  been  to  dis- 
sociate in  a  clear-cut  manner  the  pains  of  the  myocardialgic  type 
from  those  of  the  type  of  angina  pectoris.  Indeed,  the  relation- 
ship between  the  two  is  very  close  and  there  are  insensible  gra- 
dations. This  has  been  well  and  forcefully  expressed  by  Esmein 
as  follows: 

"There  now  appears  the  cardinal  symptom  of  insufficiency  of  the 
left  ventricle,  painful  dyspnea.  This  term,  which  certain  methodical 
minds  might  be  tempted  to  criticize,  is  the  one  most  appropriate  for 
designating  the  underlying  functional  disturbance  existing  in  these 
subjects.  From  the  beginning,  the  dyspnea  on  exertion  (manifest 
upon  climbing  stairs,  hilly  streets,  etc.)  is  accompanied  by  painful 
sensations  behind  the  sternum  and  in  the  epigastrium,  and  these 
painful  sensations  are,  from  the  start,  of  a  subjectively  alarming 
character,  although  ephemeral  and  rapidly  allayed  by  rest. 

"Then,  there  appears  the  dyspnea  of  recumbency,  coming  on  ab- 
ruptly on  the  approach  of  or  during  sleep,  and  likewise  accompanied 
by  subjectively  alarming  precordial  pains,  frequently  radiating  to 
the  back,  shoulders,  and  arms.  Sometimes  the  dyspneic  factor  dis- 
tinctly predominates  over  the  pain  factor;  there  exists  then  an 
asthmatoid  dyspnea  or,  employing  the  questionable  term  which  is 
nevertheless  consecrated  by  usage,  a  cardiac  pseudoasthma. 

"When  the  main  features  of  these  painful  manifestations  are  re- 
flected upon,  a  single  word  at  once  comes  to  mind,  viz,,  angina  pec- 
toris: Shall  we,  on  the  basis  of  slight  symptomatic  variations  relat- 
ing to  the  duration  and  intensity  of  a  symptom,  perpetuate  former 
errors  and  separate  these  anginose  pains,  this  alleged  angina  minor 
(from  which  one  is  not  expected  to  succumb!),  from  true  angina 
pectoris,  which  causes  death  ?  The  clinical  course  of  the  disturbance, 
here  again,  will  bring  us  back  to  the  truth.    It  is  not  rare,  indeed,  to 

70 


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1250  SYMPTOMS, 

find  appearing,  in  subjects  who  had  previously  presented  merely  this 
rather  attenuated  syndrome,  the  major  disturbances  of  insufficiency 
of  the  left  ventricle:  Angina  pectoris,  the  most  characteristic,  and 
also  pulmonary  edema,  a  description  of  which  need  not  here  be  given. 
Since  the  investigations  of  Merklen,  it  is  no  longer  possible  to  over- 
look the  bond  which  unites  the  painful  dyspnea  of  high  pressure 
cases,  angina  pectoris,  and  pulmonary  edema,  as  well  as  the  relation- 
ship of  these  symptom-groups  to  left  ventricular  insufficiency/* 

Yet,  in  the  anginose  syndrome,  while  it  appears  that  one  may 
ordinarily  attribute  the  anxiety,  dyspnea,  and  sensation  of  thoracic 
constriction  to  left  ventricular  insufficiency  with  dilatation  or  a 
tendency  to  dilatation,  the  clawing  sensation  beneath  the  sternum, 
the  strangling,  and  the  interscapular  pain  radiating  to  the  trachea 
seem  rather  dependent  upon  traction  on  the  nerve  plexuses  around 
the  aorta.  The  anginose  syndrome,  as  a  rule,  does  actually  result 
from  a  combination  of  these  two  factors,  vis,,  the  aorticonervous 
factor  and  the  myocardial  factor. 

(b)  TIME  OP  APPEARANCE  OF  THE  PAIN. 

The  time  relations  of  the  pain,  and  the  circumstances  under 
which  it  occurs,  sometimes  supply  extremely  valuable  diagnostic 
indications. 

Precordial  pain  accompanied  by  dyspnea,  appearing  only  upon 
exertion  (walking  up  inclines,  carrying  heavy  weights,  etc.)  and  dis- 
appearing upon  rest,  nearly  always  indicates  an  at  least  relative  in- 
sufficiency of  the  myocardium.  The  same  is  frequently  true  of  con- 
tinuous dyspnea  with  a  sensation  of  pressure  in  the  chest,  increased 
by  exertion;  this  is  the  form  regularly  met  with  in  the  advanced 
stages  of  decompensation  in  cardiopulmonary  disorders,  such  as 
emphysema,  tuberculosis,  chronic  bronchitis,  chronic  endocarditis, 
cardiorenal  fibrosis,  etc.  This  long  accepted  conception  of  a 
"dyspnea  on  exertion"  is  of  the  greatest  clinical  service  provided  it 
is  accurately  observed,  seen,  and  even  measured  (see  Functional 
heart  tests), 

A  hearty  meal  acts  in  the  same  way  as  marked  exertion,  and 
may  lead  to  the  appearance,  in  cases  of  cardiac  insufficiency,  of 
dyspnea,  a  sensation  of  pressure  in  the  chest,  subjective  alarm,  and 
even  an  attack  of  angina.    Thus,  post-prandial  dyspnea  may  have 


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PRECORDIAL  PAIN,  1251 

the  same  meaning  as  dyspnea  on  exertion.  Much  oftener,  however, 
it  is  merely  the  symptomatic  expression  of  a  neurotic  dyspepsia  in 
which  contact  of  food  with- a  hyperesthetic  mucous  membrane  re- 
flexly  brings  on  various  cardiac  disturbances,  such  as  palpitation, 
painful  tachycardia,  premature  beats,  angor,  dyspnea,  and  anginose 
attacks,  or  of  a'erophagia  giving  rise,  through  pressure  on  the  heart 
through  the  diaphragm,  to  a  mechanical  hindrance  to  relaxation  of 
the  heart  in  diastole. 

Emotional  factors  act  similarly  through  angiospasm,  which 
is  one  of  their  essential  manifestations.    The  sensation  as  of  a 


bubble. 


Fig.  851.— Case  1279.    H.,  1900;   178  cm.;  80.5  kilogr.     Pulse  rate,  92. 
Pressures,  i*%o.    Aerophagia.    Dyspnea  on  exertion.    Precordialgia. 

*4arge  heart'*  or  of  a  "constricted  heart"  is  one  of  the  constant 
attributes  of  depressing  emotions  such  as  worry,  apprehension, 
grief,  and  pain.  Painful  tachycardia,  with  the  heart  "palpita- 
ting" and  "driven,"  is  one  of  the  constant  attributes  of  abrupt, 
violent  emotions  such  as  surprise,  emotional  shock,  fear,  etc. 
The  angina  syndrome  and  mental  anguish  often  form  a  reversible 
couple.  This  amounts  to  saying  that  painful  emotional  dyspnea  is 
a  common,  physiologic  occurrence  devoid  of  any  marked  pathologic 
meaning.  Yet,  upon  analysis,  it  may  reveal  itself  as  meaning 
myocardial  asthenia,  in  common  with  dyspnea  on  exertion,  or  as 
meaning  a  neurotic  visceral  pain.  It  is  only  upon  supplementary 


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1252  SYMPTOMS. 

clinical  analysis  and  by  bringing  together  the  coexisting  morbid 
signs,  however,  that  such  a  distinction  can  be  made. 

Finally,  there  remains  the  highly  important  subject  of  pains 
occurring  mainly  in  the  daytime  or  at  night  This  question  is 
often  rather  hard  to  interpret.  While,  in  its  earlier  stages,  the 
painful  dyspnea  of  incipient  cardiac  insufficiency  is  relieved 
by  rest  and  recumbency,  at  a  later  period  one  may,  on  the 
contrary,  observe  the  appearance,  especially  in  cardiorenal  cases, 
of  a  decubital  dyspnea  coming  on  abruptly  at  the  approach  of  or 
during  sleep  and  sometimes  accompanied  by  subjective  alarm 
and  asthmatoid  attacks. 

Again,  these  nocturnal  manifestations,  insomnia,  subjective 
alarm,  dyspnea,  or  even  angina  and  cardiac  pseudoasthma  are 
ordinarily  far  more  frequent,  striking  and  dramatic  in  neurotics 
(cardiac  neuroses)  than  in  organic  heart  cases.  Such  psycho- 
somatic nocturnal  disturbances  are  especially  characteristic  in 
neurocardiac  patients  (see  below). 

Consequently,  this  analysis  of  the  subjective  aspects  of  precor- 
dial pain  and  its  several  modalities,  however  valuable  it  may  be  and 
however  systematically  it  should  be  carried  out,  must,  from  the 
standpoints  of  diagnosis,  prognosis,  and  treatment,  give  place  to  the 
concrete,  objective  examination  of  the  case,  and  to  the  search  for 
coexisting  signs,  observation  and  correlation  of  which  can  alone 
permit  of  a  well-founded  and  firm  conclusion. 

(c)  ASSOCIATED  SIGNS  ALONG  WITH  PRECORDIAL  PAIN. 

The  three  least  distressing  varieties  of  precordial  pain, 
myalgic,  neuralgic,  and  pleuropericardial,  having  been  rapidly, 
and  as  a  rule  very  readily,  excluded,  there  remain  the  three 
standard  forms  previously  described:  1.  Extra-systoles.  2. 
Dyspnea  on  exertion.  3.  Anginose  syndrome.  Taken  singly 
these  conditions  sometimes,  in  fact  frequently,  offer  marked  dif- 
ficulties as  regards  a  causal  diagnosis. 

The  associated  signs  alone  will  permit  of  making  such  a 
diagnosis,  the  symptoms  themselves  possessing  only  a  very  re- 
stricted meaning. 

Extra-systoles  are  of  no  definite  diagnostic  significance;  all 
depends  upon  the  circulatory  symptoms  accompanying  them. 


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PRECORDIAL  PAIN,  1253 

In  practice  the  following  varieties  are  more  or  less  readily 
distinguished : 

Functional  extra-systoles,  reflex  (aerophagia,  dyspepsia,  or 
neurosis)  or  toxic  (gout),  intermittent  temporary  extra-systoles, 
unaccompanied  by  any  general  circulatory  disturbance,  are 
devoid  of  any  significance  as  regards  the  heart  and  circulation. 
They  diminish  or  even  disappear  upon  exercise.  They  are 
generally  the  symptomatic  expression  of  a  cardiac  neurosis  or 
dyspepsia,  or  of  both.  They  constitute  one  of  the  most  frequent 
attributes  of  the  psychosplanchnic  neurosis. 

Organic  extra-systoles,  as  a  rule  practically  permanent,  are 
the  outward  expression  of  myocardial  disease  and  are  accom- 
panied by  the  ordinary  signs  of  myocardial  and  vascular  de- 
generation already  repeatedly  enumerated  (changes  in  blood 
pressure,  stasis  symptoms,  dyspnea  on  exertion,  evidences  of 
aortic  degeneration,  orthostatic  oliguria,  nycturia,  stasis  edema, 
etc.).  They  are  increased  or  brought  on  by  exercise  and  exer- 
tion. In  this  event  the  extra-systole  is  an  evidence  of  myocardial 
degeneration  which,  taken  in  conjunction  with  other  evidences, 
points  toward  the  customary  prognosis  of  myocarditis. 

Dyspnea  on  exertion,  from  the  very  fact  of  being  so  common, 
is  of  significance  only  by  reason  of  the  objective  signs  with 
which  it  is  accompanied.  It  may  be  and  frequently  is  the  sub- 
jective manifestation  of  an  organic  cardiopulmonary  insufficiency 
due,  e.g.,  to  an  endocardial  lesion  (valvular  disease),  myocardial 
disturbance  (fibrous  degeneration),  or  pulmonary  disorder  (em- 
physema, chronic  bronchitis,  etc.) ;  it  may,  however,  be  merely 
the  outward  expression  of  aerophagia  or  of  a  neurosis. 

A  care'ful  search  should  therefore  be  made  for: 

1.  The  usual  signs  of  valvular  disorders,  particularly  mitroaortic 
(se^  Circulatory  procedures). 

2.  The  usual  signs  of  pulmonary  disorders,  such  as  emphysema, 
chronic  bronchitis,  and  lung  congestion  (see  Respiratory  procedures). 

3.  The  usual  signs  of  cardiac  decompensation,  zia.,  vesperal 
edema,  latent  edema  at  the  bases  of  the  lungs,  ortho§tatic  tachy- 
cardia, and  orthostatic  oliguria.  In  this  investigation  one  should, 
if  need  be,  seek  assistance  from  the  circulatory  functional  test  (see 
Circulatory  procedures) . 


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1254  SYMPTOMS. 

As  in  the  case  of  the  extra-systoles,  this  systematic  and  necessary 
investigation  will  lead  to  the  differentiation  of  : 

Functional  dyspnea  on  exertion,  in  the  absence  of  organic  disease 
of  the  heart  or  lungs  (as  in  aerophagia,  dyspepsia,  and  neurosis), 
the  result  of  mechanical  pressure  on  the  heart  (gastric  air  bubble), 
of  reflex  excitation  (dyspepsia),  or  of  an  erethistic  psychosplanchnic 
predisposition  (psychosplanchnic  neurosis). 

Organic  dyspnea  on  exertion,  due  to  cardiopulmonary  insuffi- 
ciency, the  result,  in  turn,  of  an  appreciable,  tangible  lesion  in  the 
cardiopulmonary  system,  associated  with  the  hyposphyxic  syndrome 
(see  Low  blood-pressure). 

The  previously  emphasized  relationship  of  dyspnea  on  exertion 
and  the  anginose  syndrome  suggests  a  priori  that  the  same  con- 
siderations shall  apply  to  angor,  and  at  bottom  this  is  in  all  likeli- 
hood what  the  older  authors  understood  without  actually  expressing 
it  in  their  much-criticized  division  into  the  pseudoanginas  and  the 
true  anginas.  The  author  will  take  good  care  not  to  enter  into  any 
doctrinal  discussion  in  this  purely  practical  work. 

The  following  exclusively  clinical  classification  seems  ad- 
vantageous : 

1.  Angina  pectoris  dependent  upon  an  aortic  lesion  (aortic 
aneurysm,  aortic  valvular  disease,  interstitial  or  specific  aortitis, 
arteriosclerotic  degeneration,  or  cardiorenal  sclerosis),  very  fre- 
quently combined  with  chronic  degeneration  of  the  myocardium, 
yields  a  first  rather  homogeneous  group  of  cases — cases  of  serious 
angina  which  may  prove  fatal,  and  always  necessitating  a  very 
guarded  prognosis,  although  the  author  has  witnessed  survival  for 
ten,  fifteen,  or  more  years,  even  in  the  presence  of  very  advanced 
aortic  lesions  (see  High  blood-pressure), 

2.  Angina  pectoris  occurring  in  plethora,  presclerosis,  angio- 
spasm, nicotinism,  or  gout,  generally  much  less  serious  than  the 
preceding  type,  and  very  often  curable  provided  the  patient  will 
submit  to  appropriate  hygienic  regulation  (see  Plethora,  High  blood- 
pressure,  etc.). 

3.  Angina  pectoris  in  aerophagia,  well  described  by  Robin 
and  Fiessinger,  and  actually  rather  often  encountered  by  the 
author.  While  occurring  alone,  such  angina  rarely  assumes  the 
form  of  true  major  angina. 


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PRECORDIAL  PAIN.  1255 

4.  Angina  pectoris  in  neuroses  and  psychoneuroses,  eminently 
benign  as  regards  the  heart,  but  of  such  practical  importance  that  it 
seems  advisable  to  devote  considerable  space  in  this  section  to  its 
discussion  and  to  reproduce  in  extenso  an  article  on  the  cardiac 
neuroses  published  by  the  author  some  years  ago  (Presse  tned., 
Nov.  4,  1915). 

id)  THE  CARDIAC  NEUROSES. 

Special  significance!  was  lent  to  the  question  of  the  cardiac 
neuroses  by  the  late  war.  More  than  two-thirds  of  the  hospital 
cases  labelled  **heart  disorder"  belonged  in  this  category. 

And  first  of  all,  what  is  meant  by  the  term  cardiac  neurosis? 
The  practical,  clinical  definition  of  thq  condition  seems  simple: 
Cardiac  neurotics  are  those  subjects  who,  in  the  absence  of  any  acute 
or  chronic  organic  lesion  of  the  heart  or  its  coverings  (endocarditis, 
pericarditis,  or  myocarditis)^  in  the  absence  even  of  any  true  myo- 
cardial weakness,  e,g.,  congenital  or  constitutional  weakness,  or  of 
any  recognized  lesion  of  the  nervous  system,  suffer  from  a  symp- 
tom-complex involving  mainly  the  heart.  This  definition  excludes 
all  the  organic  disorders  of  the  heart,  all  cardiac  manifestations  de- 
pendent upon  some  organic  nervous  disorder,  central  or  peripheral, 
and  all  temporary  and  evanescent  cardiac  manifestations  of  reflex 
origin  and  extra-systoles,  e.g.,  of  digestive  origin. 

With  the  ground  thus  cleared  by  a  relatively  easy  process  of 
clinical  elimination,  there  yet  remains  an  extensive,  rather  homo- 
geneous group  of  cases — although  further  study  of  the  cause 
may  easily  resolve  it  into  sub-groups  very  variable  in  their 
pathogenesis  and  clinical  course  (cardiac  neurasthenia,  Graves's 
disease,  etc.).  All  these  subjects  have  in  common  the  fact  of 
suffering  from  severe,  manifold,  and  refractory  manifestations  in 
the  cardiac  region,  and  more  generally,  of  disturbances  of  a  cir- 
culatory nature,  while  nevertheless  presenting  upon  examina- 
tion an  apparently  complete  integrity  of  the  system  referred  to. 

As  a  matter  of  fact,  it  is  these  self-same  cardiac  neuroses  which 
are  accompanied  by  the  most  numerous  and  distressing  cardiac  or 
pseudocardiac  symptoms:  Squeezing  or  constriction  of  the  heart,  a 
distressful  sensation  of  beatmg  arteries  or  of  "missteps"  of  the 
heart,  an  anginose  feeling  with  pains  radiating  in  the  arm  and  neck 


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1256  SYMPTOMS. 

(nervous  angor,  dyspnea,  constriction  of  the  esophagus  and  neck, 
choking  sensations,  etc.),  as  well  as  by  equally  numerous,  if  not 
alarming,  objective  signs,  such  as  tachycardia,  tachy-arhythmia, 
extra-systoles,  marked  vasomotor  instability  (involving  both  the 
pulse  frequency  and  the  blood-pressure),  fainting  spells,  profuse 
sweats,  frequently  cardiac  hypertrophy,  with  a  special  vibrant 
quality  of  the  first  sound,  at  times  even  an  intermittent  systolic 
apical  murmur  transmitted  toward  the  axilla  and  the  left  sternal 
border,  and  frequently  accentuation,  sometimes  reduplication,  of 
the  second  pulmonic  sound,  etc. 

Finally,  these  conditions  are  ordinarily  combined  with  unques- 
tionable neuropathic  manifestations,  such  as  insomnia,  nervousness, 
exaggeration  of  emotive  reactions  and  of  the  reflexes,  cenesthesic 
instability,  headache  or  actual  migraine,  asthenia  and  abnormal  ex- 
citability (irritable  weakness  of  the  nervous  system,  etc.),  and 
sometimes  manifestations  of  asthenic  nervous  overexcitability  of 
other  systems,  as  evidenced,  e,g,,  by  gastrointestinal  dyspepsia, 
asthmatoid  phenomena,  dermographia,  and  paroxysmal  sweating. 

This  clinical  picture,  which  is  of  exceedingly  frequent  occur- 
rence, whether  existing  merely  in  faint  outline  or  with  its  salient 
features  pushed  to  their  ultimate  conclusion  as  in  exophthalmic 
goiter,  betokens  and  outwardly  manifests  better  than  could  the 
most  perfect  experiment  in  physiology  the  intimate  relationship 
existing  between  the  nervous  and  circulatory  systems.  In  the 
present  state  of  our  knowledge,  this  neurocirculatory  interde- 
pendence may  be  outlined  as  follows: 

Cardiovascular  activity  is  controlled  and  regulated  as  a  whole 
by  the  so-called  vegetative  nervous  system,  which  consists,  as  is 
well  known,  of  the  vagus  and  the  sympathetic  with  their  bulbar 
centers.  The  vagus  and  the  sympathetic  are  in  a  large  measure 
mutually  antagonistic.  Stimulation  of  the  sympathetic  causes 
acceleration  of  the  pulse  (tachycardia),  elevation  of  the  systolic 
blood-pressure,  and  shortening  of  cardiac  systole;  when  very 
marked  it  is  capable  of  inducing  an  excessive,  or  even  extra- 
systolic,  pulse  acceleration  of  the  type  of  paroxysmal  tachycardia. 
Stimulation  of  the  vagus  causes,  on  the  other  hand,  slowing  of  the 
pulse   (bradycardia);  reduction  of  the  systolic  blood-pressure, 


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PRECORDIAL  PAIN. 


1257 


and  lengthening  of  both  ventricular  diastole  and  systole;  when 
very  marked  it  is  capable  of  inducing  a  pronounced  slowing  of 
intracardiac  conduction  or  even  auriculoventricular  dissociation 
through  inhibition  of  the  bundle  of  His,  aa  in  the  bradycardia 
and  dissociation  produced  by  digitalis.  Inhibition  of  the  centers 
referred  to  leads  to  opposite  results — a  fact  which  by  no  means 
tends  to  facilitate,  in  clinical  studies,  inquiries  as  to  that  portion 
of  the  eflFects  relating  to  each  one  of  these  nerves. 

ryng.   nerve. 


Pneumog. 


Recurrent 
Middle  ai 
cardiac  i 

Phrenic  nei 


•yng.  nerve, 
g.  nerve. 

iCUSSCDii. 

rdiac  nerve. 

nt  nerve, 
plexus. 

irenic    nerve. 

ronch.  plexus. 

at.  cardiac 
plexus. 


Fig.  852.— The  nerves  of  the  heart  (Hirschfeld) . 

It  should  be  added  that  the  actions  of  both  nerves  extend 
to  the  peripheral  circulatory  structures,  giving  rise,  as  the  case 
may  be,  to  vasoconstrictor  phenomena  (or  even  angiospasm)  or 
to  vasodilator  phenomena  (or  even  vagoparesis),  reacting,  in 
turn,  upon  the  heart  either  in  a  direct  mechanical  manner  or 
indirectly  and  reflexly. 

The  medullary  centers,  on  the  one  hand,  and  the  myelogang- 
lionic  nerve  paths,  on  the  other,  are  manifestly  influenced  alike 
by  stimuli  of  psychic  and  special  sensory  origin  (special  sen- 
sory stimuli  and  concepts,  images,  recollections,  emotions,  etc.) 


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1258 


SYMPTOMS. 


and  by  cenesthesic  stimuli  arising  through  visceral  sensation, 
which  may  be  pleasant  or  unpleasant,  or  even  painful. 

The  result  of  all  this  is  an  exceedingly  close  interdependence 
of  the  nervous  and  circulatory  systems,  which  leads  the  circu- 
lation to  react  with  extreme  sensitiveness  to  any  nervous  stimu- 
lus, whether  latent  or  manifest,  conscious  or  unconscious. 
Clearly,  the  circulation  reacts,  perhaps  more  than  any  other 
system,  to  such  incessant  nervous  traumatism  as  characterized 
the  late  war.  How  does  it  react  under  such  conditions?  Actual- 
ly, in  very  diverse  fashion,  according  to  the  individual. 


Heart 


Fig.  853. — The  nervous  system  as  related 
to  the  circulation.  Connections  of  the  vag^us 
nerve  and  the  sympathetic  system. 


In  most  ostensibly  normal  persons  the  neurocardiac,  or  bet- 
ter, neurocirculatory  reaction  does  not  extend  beyond  a  condi- 
tion of  temporary  insomnia  with  accelerated  pulse  rate,  nervous 
overexcitability  with  exaggerated  reflexes,  transient  subjective 
alarm  and  tremor,  and  a  few  evanescent  vasomotor  and  secre- 
tory manifestations,  such  as  pallor  or  hot  flushes,  "goose  flesh," 
sweats,  temporary  diarrhea,  etc.  Within  a  few  days  a  more  or 
less  complete  tolerance  becomes  established,  the  vegetative  nerv- 
ous system  adapts  itself  to  the  new  conditions,  and  the  cardiac 
and  vasomotor  reactions  are  reduced  to  a  physiologic  minimum. 

In  others  the  emotional  shock  persists,  leading  to  a  pro- 
tracted or  permanent  loss  of  neurocirculatory  balance  charac- 
terized by  appearance  of  the  symptoms  already  mentioned  as 
constituting  the  cardiac  neurosis. 


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PRECORDIAL  PAIN.  1259 

As  in  the  case  of  the  reserve  power  of  the  heart-muscle  itself, 
so  the  reserve  power  of  the  nervous  system  in  these  cases,  in- 
cluding the  capacity  of  resisting  without  collapse  or  even  adapt- 
ing itself  to  certain  psychophysiologic  stresses,  varies  exceedingly 
in  different  individuals.  Some  nervous  systems  resist  and  adapt 
themselves  even  to  the  most  severe  trials,  as  in  the  case  of  the 
peasant  who  was  buried  for  twenty-five  days  among  the  debris 
in  a  landslide  and  whose  first  words  when  finally  set  free  were : 
"Have  the  animals  been  saved?"  In  other  instances  the  mere 
fact  of  entering  the  barracks  is  enough  to  upset  the  nervous 
system  completely. 

As  a  matter  of  fact,  the  author  saw  just  as  many,  if  not  more 
cases  of  cardiac  neurosis  among  subjects  on  duty  far  from  the 
scenes  of  military  action  than  among  those  who  had  actually 
been  subjected  to  the  gruelling  life  at  the  front. 

Huchard  used  to  remark  that  "the  physical  heart  is  lined  with 
a  mental  heart."  The  author  some  years  ago  read  in  an  Italian 
periodical^  the  following  naive  yet  truthful  statement  concerning 
subjects  suffering  from  organic  heart  disorders  and  fully  conscious 
of  their  infirmity:  "Sustained  by  small  doses  of  digitalis  and  more 
particularly  by  their  valorous  spirits,  they  were  able  to  perform  long 
and  fatiguing  missions,  even  as  aviators." 

This  statement  serves  as  a  good  paraphrase  of  Turenne's 
sublime  remark  to  his  own  "beast"  or  body.  "You  are  trembling, 
carcass ;  5'ou  would  be  trembling  much  more  if  you  knew  where 
I  am  going  to  take  you."  A  penetrating  statement  this  was 
from  the  standpoint  of  body  physiology :  We  are  powerless  to 
restrain  the  reflexes  of  our  medullary  and  spinal  vegetative 
system,  but  an  "energetic,  valorous  spirit"  can  always  make  its 
"beast"  of  a  body  advance,  even  if  it  is  "shivering"  and  "palpita- 
ting" at  the  time. 

Cases  even  occur  in  which  the  stimulus  afforded  by  constant 
danger  exerts  a  favorable  effect  on  a  preexisting  cardiac  neurosis. 
Such  is  the  personal  case  of  Longhi,  the  Italian  translator  of 
Stokes's^  classic  work,  which  he  describes  as  follows  in  his  trans- 
lation : 

1  Mendes  :    Manuale  di  medicina  chirurgia  di  guerra,  Rome,  1915. 

2  Stokes  :  Malattie  del  cuore  c  delV  aorta.  Prima  traduzione  italiana  del 
dott.  A.  Longhi,  Turin,  1858,  p.  223. 


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1260  SYMPTOMS, 

**In  the  course  of  the  winter  of  1848,  I  was  constantly  troubled 
with  palpitations  and  with  the  dejection  of  spirits  which  neariy 
always  occurs  in  heart  disorders.  Tired  of  suflFering,  I  went  to 
see  a  distinguished  colleague,  a  specialist  in  chest  disorders, 
who  told  me  that  I  had  a  hypertrophied  heart — not  a  very  serious 
condition  in  itself,  but  one  which  is  incurable  like  any  other 
dependent  upon  an  organic  lesion.  He  prescribed  for  me  a  line 
of  treatment  calculated  to  moderate  the  heart  action  and  advised 
me  not  to  give  way  to  melancholia,  as  the  disorder  was  not 
serious  and  would  allow  me  to  continue  living  a  long  time,  even 
though  I  might  experience  slight  discomforts  from  it. 

**On  the  very  next  day  after  my  visit  the  revolution  broke  out 
in  Milan,  and  in  it  I  took  a  rather  active  part.  At  the  first 
gunshots  that  I  saw  and  heard,  my  heart  began  to  beat  so 
strongly  that  I  almost  fell  to  the  ground  and  feared  lest  I  might 
be  obliged  to  retire  from  the  fight,  not  through  cowardice,  but 
from  physical  weakness.  Shortly  after,  my  heart  became  more 
quiet  and  I  found  myself  drawn  into  a  skirmish  in  the  course 
of  which  I  had  no  opportunity  to  think  of  it.  Subsequent  to 
that  day  I  led  a  very  active  life  at  the  camp,  at  first  as  a  volun- 
teer and  later  as  a  Piedmontese  officer  of  the  bersaglieri,  without 
ever  being  conscious  of  my  heart  action.  During  the  last  nine 
years  I  have  been  in  excellent  health  and  have  had  no  precordial 
pain.  I  am  convinced  that .  in  1848  my  discomforts  were  due 
principally  to  a  temporary  engorgement  of  the  heart  resulting" 
from  the  sedentary  life  I  led  at  tl\at  time,  spending  eight  or  ten 
hours  at  my  desk  each  day,  whereas  in  my  youth  I  had  been 
accustomed  to  a  very  active  life." 

The  author  knows  of  many  neuro-cardiac  subjects  who  no 
longer  "felt  their  hearts"  after  the  mobilization,  as  exemplified 
by  an  artillery  officer  aged  forty-eight  who,  afflicted  with  palpita- 
tion, precordial  pain,  and  angor,  had  been  living  since  1908 
obsessed  with  the  fear  of  aneurysm  or  angina  pectoris  and  had, 
to  the  author's  own  knowledge,  consulted  about  ten  physicians 
in  Paris,  none  of  whom  had  found  anything  more  than  neurocardiac 
erethism  and  a  moderate  degree  of  hypertrophy.  The  author 
saw  him  again  after  he  had  been  one  year  at  the  front,  including 
three  months  in  the  trenches  with  the  infantry,  at  which  time  he 


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PRECORDIAL  PAIN,  1261 

had  entirely  forgotten  his  cardiac  discomforts  and  experienced 
merely  slight  dyspnea  on  running. 

Such  a  turn  of  affairs  is  not  exceptional,  although,  as  a  mat- 
ter of  fact,  much  less  common  than  the  converse  sequence  of 
events. 

Considering  only  the  heart  S3miptoms,  the  diagnosis  between  car- 
diac neurosis  and  organic  disease  is  not  always  easy.  Auscultation 
may  be  puzzling  and  misleading,  and  various  forms  of  arhythmia 
(extrasystoles,  sinus  arhythmia,  etc.)  may  be  observed  in  either 
instance;  the  same  consideration  applies  to  the  customary  hyper- 
trophy of  the  left  ventricle  and  even  more  strikingly  to  the  sub- 
jective manifestations,  vis,,  dyspnea  on  exertion,  sensation  of  con- 
striction or  actual  angina,  palpitation,  phrenocardia,  etc.  Yet  there 
are  a  number  of  differential  signs: 

(a)  The  first  and  most  important,  perhaps,  is  the  neurotic  sub- 
strate upon  which  the  cardiac  neurosis  always  develops.  The  car- 
diac symptom-group  above  referred  to  merely  forms  part  of  an 
always  more  or  less  pronounced  neuropathic  clinical  picture,  which 
is  confirmed,  in  turn,  by  the  family  history  and  by  extracardiac  neur- 
opathic manifestations,  digestive  and  mental  in  particular. 

(&)  The  second  is  the  relative  frequency  and  importance  of 
nocturnal  symptoms,  such  as  insomnia,  subjective  alarm,  dyspnea, 
and  even  anginose  discomfort  and  cardiac  pseudoasthma,  which  are 
far  more  common  and  striking  and  generally  more  dramatic  than  in 
subjects  with  organic  heart  disease.  These  characteristic  and  inter- 
esting nocturnal  psychosomatic  disturbances  among  neurocardiacs 
are  in  themselves  deserving  of  a  thorough  study. 

(r)  The  neurocardiovascular  instability  and  lability  constituting 
an  outward  expression  of  abnormal  emotivity.  The  pulse  frequency 
and  blood-pressure  exhibit  surprising  variations  from  the  slightest 
disturbing  causes.  This  is  often  true  likewise  even  of  the  ausculta- 
tory signs  which  are  far  from  presenting  the  relatively  high  degree 
of  permanency  and  constancy  of  those  of  organic  lesions.  The 
changeableness  as  regards  arhythmias  is  perhaps  even  more  char- 
acteristic (Fig.  854). 

(d)  There  may  frequently  be  noted  an  absence  of  the  usual 
etiologic  factors  of  organic  heart  conditions,  such  as  rheumatic. 


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1262  SYMPTOMS, 

typhoid,  syphilitic,  diphtheritic,  and  other  infections ;  plethora  and 
autointoxication,  gout,  uricemia,  etc. 


m  e  If    e9          m 

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H15.17  8  IS 

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Rr 

Fig.  854.— Cardiac  neurosis.    H.,  1885;  174  cm.;  73.6  kilogr.; 
pulse,  %;  pressures,  *'^91oo;  viscosity,  4. 

The  two  above  tracings  were  taken  about  V/i  minutes  apart.  The 
first  shows  premature  contractions  imparting  to  the  pulse  tracing  a  bi- 
geminal ,  aspect.  In  the  second,  all  premature  contractions  have  dis- 
appeared. 

{e)  High  blood-pressure,  systolic  as  well  as  diastolic,  is  noted  in 
the  great  majority  of  cases,  in  spite  of  the  widely  held  view  to  the 


S  S    SItUng 
^^••■M    Recumbent 
I    I  I    Standing 
L  L  L    Dipping  exercises 
1*2*3'.  Time  in  minutes 

Blood-pressures 
■>■■■■■»  Pulse  frequency 

Fig.  855.— Normal  individual.    H.,  1893;  173  cm.;  70  kilogr. 

(Mx  =  systolic  pressure;  Mn  =  diastolic  pressure;  pressures 

given  in  centimeters  of  mercury). 

contrary.  There  do  occur,  however,  a  few  cases  of  cardiac  neurosis 
with  low  blood-pressure;  thefee  are  of  two  varieties,  as  the  author 
proposes  to  show  elsewhere. 

(/)  Lastly,  the  functional  test  of  the  circulation,  which  consists 
in  recording  the  changes  in  pulse  frequency  and  systolic  and  dias- 


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PRECORDIAL  PAIN.  1263 

tolic  blood-pressure  occurring  when  the  subject  rises  from  recum- 
bency to  the  standing  posture  as  well  as  after  a  series  of  carefully 
standardized  exercises  (20  dips  with  flexion  of  the  lower  extremi- 


Fig.  856. — Normal  subject  as  re-  Fig.  857. — Heart  weakness, 

gards  the  circulation.  H.,   1893,   165  cm.;  60  kilogr. 

H.,  1875;   169  cm.;  7:^  kilogr. 

ties),   demonstrates   clearly   the   exaggerated   vasomotor   reactions 
(reflex  overexcitability)  in  well-marked  cases,  as  well  as  the  con- 


Fig.  858. — Cardiac  neurosis.  Fig.  859. — Cardiac  neurosis. 

H.,  1878,  169  cm.;  67  kilogr.  H.,  1895,  169  cm.;  64^  kilogr. 

siderable  margin  of  reserve  myocardial  power  usually  present,  as 
exemplified  in  the  five  annexed  illustrations,  two  of  which  are  from 
normal  subjects,  one  from  a  case  of  weak  heart,  and  two  from  car- 
diac neurotics  (Figs.  855-859). 


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1264  SYMPTOMS. 

In  short,  the  true,  organic  heart  case,  when  well  compensated, 
reacts  like  a  normal  individual;  when  poorly  compensated,  he 
reacts  like  a  case  of  heart  weakness  and  yields  a  typical  curve  de- 
noting cardiac  insufficiency,  vis.,  a  weak  blood-pressure  reaction,  or 
even  a  reversed  reaction,  with  slow  return  to  the  original  state  of 
equilibrium. 

The  cardiac  neurotic  reacts  to  an  exaggerated  extent  both  as 
regards  pulse  rate  and  rise  of  blood-pressure,  thereby  affording  an 
outward  manifestation  of  his  reflex  cardiac  and  vasomotor  over- 
excitability;  on  the  other  hand,  his  blood-pressure  test  shows  no 
tendency  toward  myocardial  insufficiency. 

To  be  sure,  an  organic  heart  ca^e  may  also  be  neurotic,  and  a 
true  neurotic  may  be  found  suffering  from  cardiac  debility,  plethora, 
or  even  organic  heart  disease.  In  such  cases  the  functional  test 
alone  is  frequently  sufficient  to  demonstrate  the  simultaneous  pres- 
ence of  the  two  disorders;  when  used  in  conjunction  with  the  other 
methods  of  clinical  investigation  it  nearly  always  enables  the  ob- 
server to  distinguish  that  which  attaches  to  the  nervous  system  from 
that  which  is  referable  to  the  circulation,  and  thus  to  render  a  well- 
founded  prognosis  and  institute  a  rational  line  of  treatment  based 
on  a  reliable  physiopathologic  conception  of  the  case. 

As  far  as  the  patient's  availability  for  military  service  is  con- 
cerned, it  is  not,  as  will  readily  be  seen,  the  reserve  power  of 
the  heart  which  is  the  criterion  in  the  matter,  ample  reserve 
power  being,  as  a  rule,  available.  It  is  rather  the  power  of 
nervous  resistance  and  reaction  that  should  be  investigated  by 
appropriate  methods. 

The  cardiovascular  symptom-complex  here  constitutes  but  a 
single  outward  manifestation,  albeit  a  highly  important  one,  of 
an  abnormal  psychoneurotic  state  which  dominates  and  governs 
the  entire  symptomatology  as  well  as  the  prognosis. 


From  the  foregoing  description  the  reader  will,  it  is  hoped, 
have  been  led  to  realize  both  the  complexity  and  the  relative 
simplicity  of  the  diagnostic  problem  which  arises  in  connection 
with  the  precordial  pains.  Its  solution  may,  on  the  whole,  be 
concretely  stated  as  follows : 


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PRECORDIAL  PAIN,  1265 

1.  One  should  make  a  careful  analysis  of  the  characteristics  and 
nature  of  the  precordial  pain  present.  This  initial  procedure  will 
orient  the  investigation  a  priori  in  some  particular  direction,  but 
however  searching  the  analysis  may  have  been,  it  will  never  lead  to 
a  sound  diagnosis,  which  can  only  be  established  by  objective  exami- 
nation of  the  patient. 

2.  Only  a  complete  objective  examination  (carried  out  as  des- 
cribed in  the  section  on  Systematized  clinical  examination)  zvill  per- 
mit of  obtaining  a  more  or  less  prompt  solution  of  the  diagnostic 
puzzle  presented. 

In  concluding  this  section  it  seems  advisable  to  go  over  the  sub- 
ject of  precordial  pain  summarily  from  a  different  aspect,  viz.^  by 
starting  with  the  clinical  conditions  themselves  and  correlating  with 
them  the  various  forms  of  pain. 

DISORDERS  OF  THE  HEART  AND  AORTA. 

1.  DiBorders  of  the  Cardiac  Orifices.  Endocarditis.— (a)  Dur- 
ing the  stage  of  adequate  compensation,  endocarditis  can  hardly 
be  said  to  cause  pain.  The  frequency  with  which  patients  are 
unaware  of  their  condition  apart  from  periods  of  lost  compensa- 
tion is  well  known.  Yet  the  possibility  must  be  recognized  that 
among  some  nervous  and  hyperesthetic  subjects  there  may 
eventually  occur  extra-systoles  and  a  sensation  as  of  cardiac 
distention,  precordial  hyperesthesia,  or  chronic  precordialgia. 
Mackenzie  doubtless  had  these  cases  in  mind  when  he  wrote: 
"Many  subjects  suffering  from  an  actual  heart  lesion,  such  as 
may  involve  the  mitral  or  aortic  valve,  exhibit  evidences  of  ex- 
aggerated precordial  sensitiveness.  This  sort  of  thing  is  witnessed 

more  particularly  in  women Attacks  of  very  severe 

pain  in  the  chest  may  be  experienced.     .     .     .      More  frequently 

there  is  an  unpleasant  dull  sensation The  hyperalgesia 

may  extend  over  a  very  large  area  and  is  sometimes  very  marked. 
....  The  pain  may  not  be  as  distressing  as  in  the  more  severe 
instances  of  angina  pectoris,  but  it  persists  a  longer  time. 
....  It  is  often  associated  with  extreme  tenderness  of  the 
tissues  of  the  neck  or  left  side  of  the  chest,  especially  the  left 
breast.     Where  the  condition  of  tenderness  of  the  skin  and 

80 


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1266  SYMPTOMS. 

muscles  has  been  tested  by  pinching  them  ^between  the  thumb 
and  forefinger,  the  part  remains  sensitive  for  several  hours." 

As  a  niatter  of  fact,  this  type  of  chronic  precordialgia  has 
seemed  to  the  author  quite  exceptional  among  well  compensated  and 
non-neurotic  cases  of  endocarditis.  It  is  the  rule,  on  the  other  hand, 
in  the  cardiac  neuroses  (see  above),  hyposphyxia  (see  Low  blood- 
pressure),  and  cardiac  insufficiency  of  whatever  cause.  In  the  latter 
type  of  case,  the  mechanical  factor,  distention  of  the  heart,  seems 
to  be  more  particularly  concerned  in  its  causation. 

(&)  During  the  stage  of  lost  compensation,  ranging  from  a 
mere  reduction  in  the  reserve  power  of  the  heart  to  actual  heart 
failure,  the  picture  witnessed  is  mainly  that  of  the  dyspneic 
syndrome,  from  dyspnea  on  exertion  to  continuous  dyspnea  with 
more  or  less  pronounced  anginoid  phenomena  and  with  the  usual 
signs  of  impaired  heart  action,  such  as  orthostatic  oliguria, 
cyanosis,  edema,  etc. 

2.  MyocarditiB. — Here  the  signs  of  lost  compensation  and 
cardiac  insufficiency  already  enumerated  constitute  the  main 
feature,  sometimes  with  extra-systoles  and  attaicks  of  angina. 

3.  Pericarditis. — Pericarditis  may  either  be  completely  latent 
or  be  accompanied  by  pain  so  slight  and  evanescent  that  some  pa- 
tients pay  no  attention  to  it.  In  the  majority  of  cases  pericarditis, 
especially  when  of  the  "dry*'  variety,  induces  precordial  pain  which  is 
localized  in  the  region  about  the  apex  or  the  sternum  and  is  some- 
times recurrent  with  the  successive  heart-beats.  Examination  may 
demonstrate  the  presence  of  tender  points  the  result  of  radiation 
along  the  phrenic  nerve  (Gueneau  de  Musses  points),  vis.,  the 
lower  point,  between  the  ensiform  appendix  and  the  border  of  the 
costal  cartilages  on  the  left  side;  the  intermediate  points,  at  the 
anterointemal  portion  of  the  left  costal  interspaces,  along  the  sternal 
border,  and  the  upper  point,  between  the  sternal  and  clavicular  heads 
of  the  sternocleidomastoid  muscle. 

4.  Aortitis. — Dilated  Aorta. — ^AneiUTsm.— This  disorder  may 
be  accompanied  by  three  sorts  of  pain : 

(a)  Pain  behind  the  sternum  and  in  the  chest,  with  or  with- 
out radiation,  either,  as  is  most  often  the  case,  toward  the  axilla  and 


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Precordial  pain,  1267 

left  arm,  or  toward  the  right  axilla  and  arm,  or  toward  both  arms, 
in  accordance  with  the  location  and  size  of  the  aortic  deformation. 
This  pain  appears  to  be  mainly  of  periaortic,  neurovascular  origin, 
being  related  to  an  inflammatory  condition  and  distention  of  the 
nerve  plexuses  around  the  aorta.  ■ 

(b)  Pain  as  of  constriction  of  the  chest,  with  a  squeezing  sen- 
sation, subjective  alarm,  a  sensation  as  of  impending  death,  the 
whole  constituting  the  essential  factor  in  the  syndrome, known  as 
angina  pectoris,  while  the  preceding  type,  which  so  often  accom- 


Fig.  860. — Aortic  aneurysm  resulting  in  an  elevated  pulsating  tumor 
on  the  left  side. 

panics  it,  is  merely  an  auxiliary  factor.  This  pain  seems  to  be  de- 
pendent upon  deficient  functioning  of  the  heart  muscle,  or  more 
specifically,  an  cu:ute  insufficiency  of  the  left  ventricle,  which  is 
painfully  striving  to  overcome  a  resistance  so  marked  as  to  exhaust 
its  reserve  power. 

Dyspnea  on  exertion  necessarily  accompanies  this  t^'pe  of 
pain.  The  author  has  noted  its  absence,  however,  with  the  pre- 
ceding type,  in  particular  in  a  case  of  aneurysm  of  the  ascending 
aorta  which  had  eaten  away  the  sternum,  formed  a  pulsating 
tumor  of  the  size  of  a  hen's  egg,  and  induced  pain  on  the  right 
side  of  the  chest  radiating  to  the  right  axilla  and  arm. 


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1268  SYMPTOMS, 

(c)  In  the  stage  of  lost  compensation  are  added  permanent 
paroxysmal  dyspnea  and  the  usual  signs  of  heart  failure. 

5.  Arteriosclerosis.  Disorders  Attended  with  High  Blood- 
Pressure. — ^The  forms  of  pain  experienced  in  these  cases  are 
very  similar  "to  those  referred  to  in  connection  with  diseases  of 
the  aorta,  which,  indeed,  is  itself  often  involved  in  the  process. 
Thus,  there  occur: 


Fig.  861.— Aortic  aneurysm  with  precordial  pulsating  tumor. 

(a)  Pain  of  the  type  of  dyspnea  on  exertion,  which  is  the 
first  to  appear. 

(b)  Pain  of  the  type  of  permanent  paroxysmal  precordialgia 
with  dyspnea,  subjective  alarm,  etc.,  of  myocardial  origin. 

(r)  Clawing  pains  behind  the  sternum,  radiating  to  the 
periaortic  region. 

Interstitial  nephritis  and  uremia  are  frequently  accompanied 
by  similar  manifestations. 

6.  Vasomotor  Angiospastic  Attacks. — The  attacks  of  high 
blood-pressure  from  vasoconstriction  induced  in  some  subjects 
by  overwork,  emotional  impressions^  or  abuse  of  tobacco  may 
eventually  be  accompanied  by  manifestations  of  precordial  pain 


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PRECORDIAL  PAIN,  1269 

and  angina  in  all  respects  similar  to  those  already  described. 
Again  it  should  be  emphasized  that  it  is  only  through  the 
anamnesis  and  especially  by  systematic  and  thorough  clinical 
examination  that  these  subjective  disturbances  can  be  traced  to 
their  actual  causes. 

7.  Cardiac  Neuroses. — This  subject  has  already  been  referred 
to  at  such  length  that  it  seems  unnecessary  to  discuss  it  again 
here.  Any  form  of  disturbance  may  be  witnessed,  from  dyspnea 
on  exertion  to  the  anginal  attack  and  from  extra-systoles  to 
permanent  paroxysmal  dyspnea. 

DISORDERS  OF  STRUCTURES  ADJACENT  TO  THE  HEART. 

1.  Pleurisy  of  the  Precordial  Diverticulum  of  the  Pleura. — 

In  this  condition  there  is  pain  localized  at  the  cardiac  apex, 
recurring  with  each  heart  beat  and  increased  by  rather  deep 
breathing. 

In  nervous  subjects  it  may  lead  to  the  production  of  reflex 
extra-systoles. 

2.  Aerophagia  and  Dyspepsia  with  Gastric  Distention. — This  is 
one  of  the  commonest  and  yet  one  of  the  most  frequently  over- 
looked causes  of  precordial  pain,  the  individuals  concerned  often 
being  neurotic. 

Dyspnea  on  exertion,  most  marked  after  meals,  feelings  of 
painful  distention  in  the  vicinity  of  the  cardiac  apex,  extra- 
systoles,  and  attacks  of  pseudo-angina  (angina  pectoris  of 
aerophagics),  may  be  observed.  The  time  of  occurrence  of  the 
pain  (after  meals),  the  tympany  and  increased  size  of  Traube*s 
space,  actual  observation  of  the  aerophagia,  and  the  absence  of 
objective  heart  signs  easily  lead  to  the  correct  diagnosis  if  they 
are  merely  thought  of. 

The  orthoradioscopic  view  shown  in  Fig.  851  gives  a  good 
idea  of  the  extent  to  which  the  heart  can  be  pushed  aside  by  the 
air  content  of  the  stomach. 

3.  Gaseous  Distention  of  the  Colon. — The  rather  frequently 
encountered  accumulation  of  gas  in  the  splenic  flexure  brings 
about  the  same  symptoms  as  have  already  been  enumerated,  and 
through  the  same  process  of  mechanical  displacement  of  the 


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1270  SYMPTOMS, 

diaphragm.  The  patients  concerned  suffer  from  spastic  constipa- 
tion; percussion  elicits  exaggerated  resonance  over  the  colon, 
and  fluoroscopy  sometimes  yields  an  actual  view  of  the  gaseous 
accumulations.  Liquid  petrolatum  and  extract  of  belladonna  are, 
as  a  rule,  both  diagnostically  and  therapeutically  su<:cessful  in 
these  cases. 

4.  Mastodynia,  when  localized  in  the  left  breast,  may  suggest, 
albeit  only  approximately,  precordial  pain.  Any  possibility  of  a 
mistake  is  readily  obviated  by  the  most  superficial  examination, 
including  palpation  of  the  breast  and  the  observation  of  diffuse 
induration  or  of  small  scattered  nodules,  in  conjunction  with  the 
absence  of  all  true  cardiac  manifestations. 

5.  Intercostal  neuralgia  is  usually  distinguished  by  virtue  of 
the  three  characteristic  points  of  Valleix :  Anterior,  by  the  side  of 
the  sternum ;  lateral,  in  the  axillary  line,  and  posterior  or  paraverte- 
bral. The  neuralgia,  moreover,  would  hardly  tend  to  mislead  unless 
located  exactly  in  the  precordial  region.  It  should  be  borne  in  mind 
that  the  term  intercostal  neuralgia,  purely  an  anatomic  expression, 
implies  nothing  as  to  the  cause,  which  should  be  sought  and  may 
be  either  toxic,  as  in  lead  fK)isoning,  gout,  etc.;  infectious,  as  in 
rheumatism,  typhoid  fever,  etc.;  osseous,  as  in  osteoperiostitis, 
Pott's  disease,  etc. ;  pleuro pulmonary,  as  in  pleurisy,  pneumonia,  etc., 
or  even  cardiomedic^tinal,  as  in  aortic  aneurysm,  hypertrophy  of  the 
heart,  mediastinal  tumor,  etc.  One  should  never  hesitate  to  resort 
to  fluoroscopy  in  obscure  cases. 

6.  As  an  exceptional  cause,  mention  should  be  made  of 
tabetic  pains.  Tabes  dorsalis  is  frequently  associated,  as  is  well 
known,  with  more  or  less  pronounced  pathologic  changes  in  the 
aorta,  and  some  tabetics,  quite  naturally,  may  experience  attacks 
of  angina  pectoris  definitely  of  aortic  origin.  In  at  least  two 
tabetic  cases,  however,  the  author  has  observed  paroxysmal  and 
transient  attacks  of  precordial  pain  which,  since  they  occurred 
in  alternation  with  other  paroxysmal  attacks  of  pain  referred  to 
the  gastric  region  and  lower  extremities,  were  necessarily  con- 
sidered of  tabetic  origin. 


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SLEEP,  MORBID. 


To  die,  to  sleep; 
To  sleep:    perchance  to  dream, 
(Shakespeare,  Hamlet, 
Act  III,  Scene  I.) 


The  crude  analogy  existing  between  sleep  and  death  is 
obvious.  It  would  lend  itself  most  readily  to  a  fascinating  meta- 
physico-poetic  discourse,  most  concisely  and  suggestively  ex- 
pressed in  the  Shakespearean  epigram  at  the  head  of  this  sec- 
tion. Such  a  discourse  would,  however,  far  transcend  the  definite 
purposes  underlying  the  present  work,  and  we  shall  have  to 
preserve  due  limitations  in  this  connection. 


Sleep  may  occur  in  very  variable  degrees  and  modalities. 

It  may  be  divided,  according  to  its  intensity,  into  somnolence,  light 
sleep,  profound  sleep,  and  coma,  the  latter,  on  the  whole,  being 
diflferent  from  profound  sleep  only  in  a  more  complete  loss  of 
sensibility,  in  the  impossibility  of  rousing  the  subject  by  artificial 
stimulation,  and  frequently  in  paralysis  of  the  sphincters.  The 
differential  diagnosis  of  the  several  forms  of  coma  has  already  been 
dealt  with  in  a  special  section  (see  Coma). 

To  base  conclusions  on  the  degree  of  sleep  present  is  not  of 
great  clinical  value,  for  in  general  one  sees  no  definite  lines  of  de- 
marcation between  the  different  grades  of  sleep  and  the  same 
morbid  cause — e.g.,  toxic — may,  according  to  the  individual  and  the 
extent  of  the  morbid  influence  present,  yield  any  degree  of  hyper- 
somnia, from  simple  somnolence  to  the  most  profound  coma.  This 
is  true,  for  example,  in  the  case  of  alcohol,  opium,  and  azotemia. 

It  seems  more  in  keeping  with  clinical  conditions  and  even  cur- 
sory observation  to  base  our  interpretation  of  the  hypersomnias  upon 
their  clinical  features,  and  to  divide  them  as  follows : 

Hypersomnia  presenting  the  appearances  of  normal  sleep  and 
differing  from  it  only  in  its  time  relations,  duration,  or  depth. 

(1271) 


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1272  SYMPTOMS. 

Hypersomnia  of  the  lethargic  type,  prolonged  and  profound, 
with  pronounced  slowing  of  the  circulatory  and  respiratory 
functions. 

Hypersomnia  accompanied  by  more  or  less  definite  symptom- 
groups  : 

Infectious  states. 
Meningeal  conditions. 
Toxic  states. 
Hypersomnia  accompanied  by  motor  manifestations. 

I. — ^Hypersomnia  presenting  the  appearances  of  normal  sleep 

and  differing  from  it  only  in  the  depth  or  duration  of  sleep  may 
be  due  to  such  a  variety  of  causes — exhaustion,  intoxications, 
infections — that  its  diagnostic  significance  is  thereby  greatly  re- 
duced. 

The  semeiology  of  profound  sleep  partially  merges  with  that  of 
the  lethargic  states  (see  below)  and  that  of  coma  (see  Coma).  It 
will,  therefore,  be  necessary  here  only  to  recall  briefly  that  of 
morbid  somnolence  or  narcolepsy,  manifested  in  an  abnormal  and 
practically  irresistible  tendency  to  sleep,  sometimes  only  of  short 
duration,  but  at  others  almost  permanent,  as,  e.g.,  in  the  sleeping 
sickness. 

This  variety  is  met  with  in  most  of  the  meningoenccphalic  states 
(sleeping  sickness,  lethargic  encephalitis,  various  meningeal  disturb- 
ances, and  brain  tumor)   (see  below). 

It  is  certainly  caused  oftenest  by  toxic-infectious  conditions, 
which  may  be  enumerated  for  purposes  of  memorization  as  follows : 

Heterotoxic  hypnogenotis  intoxications:  Opium,  chloral  hydrate, 
alcohol,  cannabis,  chloroform,  ether,  and  various  h)rpnotics  (barbital, 
sulphonethylmethane,  etc.). 

Autotoxic  hypnogenous  intoxications:  Acetonemia  (diabetes), 
azotemia  (uremia),  ill-defined  autointoxications  due  to  hepatorenal 
insufficiency,  intestinal  fermentations,  or  slowing  of  tissue  oxida- 
tion (hyposphyxic  states;  cardiopulmonary  insufficiency). 

Less  frequently,  these  narcoleptic  states  are  witnessed  during  the 
period  of  decline  in  general  infections;  some  of  them,  such  as  the 
narcolepsies  of  convalescence,  are  actually  of  the  nature  of  repara- 
tive sleep. 


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SLEEP,  MORBID.  1273 

Hysteria  and  epilepsy  claim  a  large  proportion  of  these  hypnotic 
conditions. 

Lastly,  after,  as  in  the  comas,  careful,  systematic  clinical  inquiry 
(history,  physical  examination,  uranalysis,  and  investigations  of  the 
blood  and  cerebrospinal  fluid)  has  been  carried  out  and  one  of  the 
foregoing  hypnotic  factors  discovered,  there  remains  a  small  num- 
ber of  unclassable  cases  for  which  must  be  preserved,  until  further 
light  is  shed  on  the  subject,  the  term  essential  or  idiopathic  narco- 
lepsy, probably  of  constitutional  origin,  encountered  most  often  in 
neuropsychopathic  families,  and  the  most  characteristic  feature  of 
which  is  that  of  being  chronic,  wholly  incurable,  and  not  accounted 
for  by  any  clinically  expressible  cause. 


II. — ^The  lethargic  states,  in  the  commonly  accepted  sense 
of  the  term,  i,e,,  states  featured  by  morbidly  prolonged  sleep 
(persisting  for  days,  weeks,  months,  or  even  years),  and  at- 
tended with  pronotinced  slowing  of  the  circulation  and  of  nutri- 
tion, impose  upon  the  practitioner  two  serious  tasks  : 

1.  In  the  presence  of  an  actual  lethargic  state,  to  ascertain  its 
nature. 

2.  In  the  presence  of  an  actual  state  of  death,  to  distinguish 
it  from  a  lethargic  state,  and  vice  versa. 

Only  exceptionally  is  a  lethargic  state  attended  with  inhibi- 
tion of  the  circulatory  and  respiratory  functions  to  such  an 
extent  as  to  lead  actually  to  apparent  death  as  seen  by  a  careful 
and  trained  observer.  Ordinarily,  indeed,  an  obscure  grade  of 
consciousness  is  still  present  and  the  taking  of  food  is  frequently 
possible.  The  lethal  appearance,  however,  is  the  thing  that  proves 
striking  to  bystanders  and  is  expressed  in  Ambrose  Fare's  defini- 
tion :  **Sleep  by  virtue  of  which  the  faculties  and  powers  of  the 
mind  lare  buried,  in  such  wise  that  it  seems  as  if  one  were  dead." 

Death  having  been  excluded  by  the  findings  later  to  be  men- 
tioned, the  nature  of  the  lethargic  condition  remains  to  be  ascer- 
tained. Singular  complications  have  been  injected  into  the  ques- 
tion by  the  doctrinal  discussions  concerning  hysteria.  Lethargy 
has  been  and  is  still  considered  by  a  few  authors  as  a  specific 
manifestation  of  hysteria;  it  has  been  termed,  comatose  hysteria. 


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1274  SYMPTOMS. 

attacks  of  hysteric  sleep,  and  hysteric  apoplexy.  While  due 
account  has  to  be  taken  of  the  possibility  of  simulation;  while 
one  sTiould  be  on  his  guard,  and  while  it  is  prudent  to  question, 
with  Dupre  and  Meige,  whether  certain  cases  recorded  and  ad- 
vertised in  the  public  press  are  not  "simply  fantasies  of  my- 
thomaniacs  desirous  of  drawing  attention  to  themselves/'  there 
seems  to  be  no  doubt  but  that  "hysteric  sleep"  probably  comprises 
the  majority  of  the  true  lethargic  states. 

Yet  it  does  not  appear  to  the  author  that  lethargy  is  exclusively 
an  attribute  of  hysteria.  Lethargic  states  may  seemingly  be  brought 
on  by  many  other  causes,  in  particular  through  intoxication  by 
hypnotics,  the  resulting  lethargic  state  being  sometimes  sufficiently 
profound  even  to  induce  a  state  of  apparent  death,  as  illustrated  in 
the  following  case,  recorded  in  the  Deutsche  medizinische  Wochen- 
schrift  for  November  13,  1919,  page  1277.  A  nurse  aged  23 
took,  on  October  27,  1919,  1.7  grams  of  morphine  and  5  grams  of 
veronal.  She  was  found  the  next  day  in  a  park,  life  being  almost 
extinct.  In  the  ambulance  she  was  thought  to  be  dead.  The  exist- 
ing signs  of  death  were,  rigidity,  extreme  pallor,  and  absence  of 
reflexes,  of  the  pulse,  of  breathing,  and  of  the  heart-beats.  Appli- 
cation of  hot  sealing  wax  over  the  skin  caused  no  reaction.  After 
she  had  been  in  the  Morgue  for  fourteen  hours,  the  coffin  was 
opened  on  October  29,  a  medical  official  wishing  to  identify  the 
body.  The  cheeks  were  seen  to  be  slightly  roseate  and  slight  move- 
ments of  the  larynx  were  observed.  No  respiratory  movements 
nor  pulse  beats  were  noted,  but  obscure  heart  sounds  were  audible. 
At  10  o'clock  in  the  morning  the  i>atient  was  taken  to  the  hospital ; 
hypodermic  injections  of  caffeine  and  camphor  in  oil  were  adminis- 
tered and  the  stomach  washed  out.  A  hot  bath  was  then  given, 
with  vigorous  rubbing,  followed  by  artificial  respiration  and  oxygen 
inhalation.  At  11  o'clock  the  pulse  was  perceptible  and  a  few  brief 
inspiratory  movements  were  noted;  the  rigidity  of  tlie  limbs  was 
passing  off.  At  noon  the  pulse  was  distinctly  noticeable,  with  a 
rate  of  50  per  minute.  On  October  30,  the  patient  regained  con- 
sciousness and  made  short  verbal  statements.  She  gradually  re- 
covered, but  exhibited  a  persistent  leucopenia. 

In  this  case  the  arrest  of  the  circulation  and  respiration  with 
continuance  of  life  appears  to  have  lasted  over  twenty-four  hours. 


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SLEEP,  MORBID,  1275 

Perhaps  the  explanation  of  this  anomalous  occurrence  is  to  be 
found  in  the  combined  action  of  cold  and  of  the  narcotic  causing 
general  vasomotor  paralysis  with  marked  reduction  in  the  organic 
demand  for  oxygen — a  condition  similar  to  that  of  hibernation 
in  certain  animal  species. 

Was  this  a  hysteric  subject?  The  history  does  not  mention 
it,  but  it  is  plain  that  the  condition  of  lethargy  and  even  appar- 
ent death  was  here  brought  about  through  the  combined  action 
of  intoxication  by  a  hypnotic  and  of  exposure  to  cold. 

While  undue  weight  is  not  to  be  laid  on  literary  documenta- 
tion, the  case  of  Juliet — which  is  naturally  brought  to  mind — 
seems  to  show  that  these  toxicolethargic  states  were  well  known  and 
had  been  accurately  observed  even  before*  Shakespeare's  time.  At 
all  events,  a  more  precise  description  of  them  would  be  hard  to  find : 

.   .   .  out,  alas!  she*s  cold; 
Her  blood  is  settled,  and  her  joints  are  stiff. 

(Romeo  and  Juliet,  Act  IV,  Sc.  V). 

•  Take  thou  this  vial,  being  then  in  bed, 

And  this  distilled  liquor  drink  thou  off; 
When  presently  through  all  thy  veins  shall  run 
A  cold  and  drowsy  humour,  for  no  pulse 
Shall  keep  his  native  progress,  but  surcease: 
No  warmth,  no  breath,  shall  testify  thou  livest; 
The  roses  in  thy  lips  and  cheeks  shall  fade 
To  paly  ashes,  thy  eyes*  windows  fall. 
Like  death,  when  he  shuts  up  the  day  of  life. 
Each  part,  deprived  of  subtle  government. 
Shall,  stiff  and  stark  and  cold,  appear  like  death: 
And  in  this  borrow'd  likeness  of  shrunk  death 
Thou  shalt  continue  two  and  forty  hours. 
And  then  awake  as  from  a  pleasant  sleep, 

{Romeo  and  Juliet,  Act  IV,  Sc.  I). 

Incidentally  and  without  further  discussion,  the  mysterious 
and  disturbing  spirit  of  Lazarus  may  here  be  alluded  to. 

The  deep  sleep  of  convalescents  and  of  the  depressive  form  of 
melancholic  stupor  rarely  assumes  actual  lethargic  characteristics, 
though  a  marked  similarity  may  exist. 

In  all  such  instances  the  diagnosis  is  indicated  by  the  history 
far  more  than  by  direct  observation  of  the  case. 


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1276 


SYMPTOMS. 


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SLEEP,  MORBID,  1277 

Mors  certa,  mors  incerta, 
Moriendum  esse  certutn  omnino, 
Mortum  esse  incertum  aliquando, 
(WiNSLOw,  1740). 

Thus,  profound  sleep,  and  especially  certain  morbid  forms 
of  sleep,  may  be  confused,  at  least  by  hasty  observers,  with 
actual  death.  A  few  instances  of  unwarranted  burial  have  been 
recorded,  but  the  number  of  such  cases  has  been  singularly 
amplified  through  popular  imagination.  While  such  occurrences 
have  doubtless  been  rather  frequent  in  backward  and  some- 
what savage  countries,  it  should  be  repeatedly  emphasized  that 
very  few  authentic  instances  exist  in  civilized  nations  and  that 
in  Paris  not  a  single  case  of  this  kind  in  the  last  thirty  years  has 
come  to  the  author's  notice.  Yet  the  instance  above  referred  to 
shows  that  such  an  occurrence  is  not  an  absolute  impossibility. 

The  fact  remains,  therefore,  that  in  the  case  of  the  practi- 
tioner and  more  particularly  the  coroner's  physician,  professional 
conscience  and  the  anxiety  of  relatives  often  place  before  him 
with  singular  force  the  question  of  apparent  death  and  actual 
death.  It  is  therefore  appropriate  to  recall  here  the  definite  signs 
of  death. 

These  indications  are,  on  the  whole,  drawn  just  as  they  were 
a  century  ago,  from  the  direct  or  indirect  observation  of  perma- 
nent cessation  of  circulation,  respiration,  heat  production,  and 
the  functions  of  the  nervous  system.  Modem  observers  have 
merely  devised  a  few  improved  procedures  which  permit  of  as- 
certaining more  accurately  or  more  promptly  the  cessation  of 
function  of  the  systems  referred  to. 

A  concise  summary  of  these  procedures,  with  brief  descrip- 
tions of  the  technic,  is  given  in  the  annexed  table. 

♦    ♦     ♦ 

III.  Hypersomnia  Associated  With  Definite  Clinical  Syn- 
dromes.— Meningeal  disturbances  in  which  somnolence  or  sleep 
of  varying  depth  and  obstinacy  is  one  of  the  chief  features  are 
extremely  common.    Coma  is  a  usual  ultimate  manifestation. 

Special  mention  must  be  made,  however,  of  three  meningo- 
encephalic  conditions,  now   rather  well-defined   clinically,   and 


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1278  SYMPTOMS. 

constituting  actual  examples  of  a  narcoleptic  meningo-encepha- 
litis,  vis.,  the  sleeping  sickness,  lethargic  encephalitis,  and  post- 
influenzal meningeal  disorders  with  narcolepsy. 

The  true  sleeping  sickness  is,  as  is  well  known,  endemic  in 
the  African  territories  near  the  equator,  and  is  specifically  caused 
by  primary  development  in  the  blood  and  secondary  development  in 
the  cerebrospinal  fluid  of  the  parasite  known  as  Trypanosoma  gam- 
biense.  In  its  primary  stage  of  blood  infection,  clinically  manifested 
in  trypanosomic  fever  and  glandular  enlargement,  somnolence  is 
absent  or  slight,  and  the  disturbance  might  be  mistaken  for  malaria 
or  filariasis ;  under  these  conditions  blood  examination  is  necessary, 
and  will  remove  all  doubt  by  revealing  either  the  trypanosome, 
Plasmodium,  or  filaria. 

In  its  secondary  or  cerebrospinal  stage,  somnolence  becomes 
pronounced.  In  the  waking  state  the  patient  is  confused,  sleepy, 
with  drooping  lids,  a  dull  expression,  sluggish,  benumbed  men- 
tality, and  an  unsteady  gait.  Somnolence  is  invincible,  irresistible, 
and  permanent;  sleep  is  constant  or  nearly  so,  but  is  relatively 
light,  the  patient  being  easily  roused  by  the  slightest  sound. 
Fever,  weakness,  tremor,  asthenia,  emaciation,  and  progressive 
cachexia  complete  the  clinical  picture.  If  the  diagnosis  was  not 
confirmed  by  blood  examination  in  the  preceding  stage,  examina- 
tion of  the  cerebrospinal  fluid  now  clinches  it  by  revealing  the 
trypanosome. 

Lethargic  encephalitis  has  been  the  subject  of  a  large  mass  of 
literature  in  the  last  few  years,  whence  it  appears  that  the  con- 
dition is  characterized  by  three  main  symptoms : 

1.  Fever,  39**  to  40**  C,  associated  with  weakness  and  loss  of 
weight. 

2.  Dissociated  ocular  paralyses,  sometimes  combined  with  facial 
paralysis.  This  would  appear  to  be,  perhaps,  the  most  constant  and 
striking  manifestation  of  the  disease,  the  patients  frequently  seek- 
ing medical  advice  because  of  seeing  double  (diplopia),  because  of 
squint  (strabismus),  or  because  the  lids  fail  to  stay  open  (ptosis). 
Upon  examination  there  may  be  observed  inequality  of  the  pupils, 
paralysis  of  accommodation,  ptosis,  and  dissociated  paralyses  of  the 
motor  nerves  resulting  in  disturbed  movements  of  the  eyeballs. 


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SLEEP,  MORBID.  1279 

3.  A  condition  of  sleep,  a  hypersomnia,  ranging,  as  in  trypano- 
somiasis, from  simple  somnolence  to  constant,  deep,  lethargic  sleep, 
— without  actual  coma,  however,  as  it  is  nearly  always  possible  to 
rouse  the  patient. 

As  subsidiary  manifestations  one  may  note  depressive  states, 
paralysis  of  the  extremities  of  hemiplegic  type,  sensory  disturb- 
ances, pain,  mental  disturbances,  or  signs  of  excitement,  such  as 
muttering  delirium,  tremor,  contractures,  convulsions,  and  vaso- 
motor disturbances. 

Examination  of  the  cerebrospinal  fluid  yields  two  important 
signs: 

1.  Low  cell  content  or  absence  of  cells. 

2.  High  sugar  content,  0.7  to  1  gram  to  the  liter,  probably  due  to 
stimulation  of  Claude  Bernard's  glycobulbar  center. 

3.  Exceptionally  the  cerebrospinal  fluid  may  be  hemorrhagic. 
In  truth,  the  pathogenic  agent  in  lethargic  encephalitis  is  as 

yet  unknown,  and  its  specificity  not  wholly  demonstrated.  While 
the  diagnosis  is  clinically  obvious  in  cases  combining  typically 
the  triad  of  symptoms  already  mentioned,  it  is  far  more  difficult 
in  the  atypical,  incomplete  forms.  It  seems  wise,  therefore,  tem- 
porarily to  maintain,  with  Claude,  a  clihical  subdivision  for : 

Meningeal  conditions  with  narcolepsy,  in  which  the  chief  symp- 
tom is  somnolence,  present  in  association  with  fever,  spinal 
rigidity,  Kemig^s  sign,  retention  of  urine,  diminished  reflexes, 
excess  of  albumin  and  lymphocytes  in  the  cerebrospinal  fluid,  and 
sometimes  headache,  squint,  and  inequality  of  the  pupils. 

Claude  cautiously  concludes:  "The  concurrence  of  these 
narcolepsies  attended  by  very  pronounced  meningeal  reactions 
with  an  epidemic  of  influenza  would  seem  to  justify  the  view  of 
some  etiologic  relationship  between  the  two  conditions." 

As  a  matter  of  fact,  narcolepsy  may  be  met  with  in  the  majority 
of  meningeal  disorders,  including  tuberculous  meningitis  in  par- 
ticular. 

Brain  tumor  is  associated  with  insomnia  much  more  frequent- 
ly than  w^ith  narcolepsy,  which,  in  any  case,  is  here  of  but  slight 
diagnostic  service  and  of  no  localizing  value. 


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1280  SYMPTOMS. 

IV.   Morbid  Sleep  Associated  With  Motor  Manifestations. 

— This  subject  is  highly  complex  and  covers  a  singularly  large 
field,  as  it  brings  up  the  question  of  ambulatory  automatism, 
somnambulism,  and  the  cataleptic  states;  leads,  without  undue 
extension,  to  the  interpretation  of  insane  delusions  and  wander- 
ing tendencies,  to  which  it  bears  an  obvious  connection,  and 
brings  up  in  last  analysis  the  vexing  problems  of  hypnotic  sug- 
gestion, dual  personality,  and  responsibility  of  the  human  indi- 
vidual. 

One  need  here  merely  point  out  the  interrelationship  of  these 
questions  and  briefly  recall  the  clinical  significance  of  somnam- 
bulism, which  is  obviously  inseparable  from  ambulatory  automatism. 
The  definition,  limits,  and  meaning  of  the  term  somnambulism  have 
been  rendered  singularly  vague  through-  the  conflicts  between  dif- 
ferent schools  of  thought  concerning  the  nature  and  even  the  exist- 
ence of  hysteria.  From  the  standfK)int  of  elementary  clinical  com- 
mon sense,  somnambulism  is  constituted  of  the  fact  that  a  sleeping 
person  may  carry  out  more  or  less  complex  motor  acts  of  which 
he  loses  all  remembrance  upon  awakening. 

The  MINOR  SOMNAMBULISTIC  STATES  are  commonly  observed 
conditions  and  may  be  witnessed  in  practically  normal  subjects  under 
the  influence  of  some  ratfier  compelling  thought  or  mild  intoxica- 
tion ;  constitutional  neuropsychopathic  states  predispose  to  these 
manifestations.  Their  frequency  is  surprising  if  they  are  looked 
for  at  all  carefully.  A  person  with  simple  nervousness,  not  des- 
cribed by  any  definite  clinical  term,  after  a  rather  strenuous  and 
difficult  voyage,  during  which  a  single  obsessive  thought  had  kept 
him  almost  awake  for  a  whole  week,  and  in  which,  as  he  bore 
with  him  a  rather  large  sum  of  money,  he  h^d  naturally  had  to 
take  certain  precautions  against  being  robbed,  was  led  for  months 
to  brief  somnambulistic  practices  which  consisted  in  his  getting  up 
to  see  that  the  door  of  his  room  was  closed  and  his  wallet  safe  in  his 
inner  coat  pocket.  The  obsessive  thought  by  which  he  had  been 
dominated  for  a  whole  week  left  an  impression  that  wore  off  only 
after  several  months. 

Alcoholic  somnambulism,  met  with  especially  m  persons  with 
inherited  psychopathic  taint,  is  to  be  compared  with  the  alcoholic 
delusional  state  known  as  delirium  tremens.    In  these  minor  somn- 


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SLEEP,  MORBID,  1281 

ambulistic  conditions  inquiry  should  be  made  for  some  obsession, 
hitoxication,  or  a  neuropsychopathic  predisposition.  It  seems  diffi- 
cult to  set  up  an  absolute  line  of  demarcation  between  true  somn- 
ambulism and  the  clear-cut,  active  dream-states  in  which  insane 
illusion,  continuing  for  a  time  "after  the  awakening,"  leads  the 
subject  to  carry  out  unconscious,  absurd  motor  acts. 

Attacks  of  MAJOR  SOMNAMBULISM,  featured  by  the  duration 
and  complexity  of  the  motor  acts  carried  out,  or  by  their  repetition, 
are  of  more  definite  clinical  significance.  They  are  hardly  met  with 
in  any  conditions  other  than  epilepsy  and  hysteria,  and  according  to 
some  authors  in  neurasthenia  and  alcoholism.  The  forms  en- 
countered are  sometimes  sufficiently  distinct  to  permit  of  the  making 
of  a  differential  diagnosis. 

Epileptic  somnambulism  (and  fugue,  or  wandering  tendencies) 
is  characterized  sometimes  by  sudden  onset,  imperious,  blind  im- 
pulses, the  absence  of  any  definite  purpose,  and  complete  amnesia. 

Hysteric  somnambulism  (and  fugue)  frequently  reflects  the  un- 
conscious influence  of  a  previous  idea,  whence  there  results  some 
degree  of  logical  coherence  of  motor  acts  directed  to  some  more  or 
less  definite  purpose,  a  vague  consciousness  of  which  may  persist 
after  awakening. 

Neurasthenic,  or  better,  psychasthenic  somnambulism  (and 
fugue),  the  occurrence  of  which  is  doubted  by  some  writers,  is 
claimed  to  be  associated  with  relative  consciousness  of  the  obsessive 
idea,  logical  sequence  in  the  motor  acts  carried  out,  and  almost 
complete  remembrance  upon  awakening. 

Alcoholic  somnambulism  is  described  as  usually  occurring  only 
among  congenitally  psychopathic  subjects,  and  as  exhibiting  the 
features  of  epileptic  or  neurasthenic  somnambulism,  according  to 
the  individual  case. 

Brief  mention  may  here  be  made  of  a  condition  of  limited  clin- 
ical diagnostic  interest,  zns,,  somnambulism  indited  during  hyp- 
nosis, which  has  been  and  still  is  the  subject  of  acrimonious  discus^ 
sions.  This  practice  obviously  serves  the  purposes  of  therapeusis 
rather  than  of  diagnosis. 

♦    ♦    ♦ 

It  has  always  been  a  matter  of  surprise  to  the  author,  and  par- 
ticularly so  while  writing  this  section,  that  most  of  the  terms 

81 


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1282  SYMPTOMS. 

relating  to  sleep,  and  especially  its  abnormal  forms,  are  so  vague 
and  ill-defined  in  their  meanings.  Thus,  the  terms  catalepsy, 
lethargy,  and  somnambulism  each  have  two  entirely  different  ac- 
cepted meanings,  popular  and  scientific,  and  even  the  latter  is  far 
from  being  uniform  as  used  by  different  writers.  It  has  seemed  in- 
dispensable, therefore,  to  prepare  a  short  glossary  of  hypnotic 
terms: 

Catalepsy. 

1.  A  disorder  featured  by  the  ability  of  the  limbs,  and  even  the  trunk, 
to  maintain  throughout  the  attack  positions  which  they  had  previously  occu- 
pied or  had  been  placed  in. 

2.  A  condition  in  the  presence  of  which  the  subject  is  unable  to  move,  al- 
though consciousness  and  sensation  are  retained. 

[Historical  (16th  century)  :  "And  if  said  vapors  ascend  to  the  brain, 
they  cause  epilepsy  or  catalepsy,  which  is  when  the  whole  body  remains  stiflF 
and  cold  and  in  the  same  attitude  which  it  was  in  before  the  illness,  the  eyes 
being  open  without  seeing  and  without  hearing."  (Ambrose  Pare,  xviii,  52.)]. 

Derivation:  KordXiT^tt,  from  Kard,  down,  and  X^tt,  seizure. 

Dream. 

An  involuntary  combination  of  images  or  ideas,  generally  without  sequence, 
sometimes  very  distinct  and  well  co-ordinated,  occurring  during  sleep. 

Hjrpnosis. 

Commonly:     Artificial   sleep.     Example:     Chloroform  hjrpnosis.     [Also 
abnormal  sleep,  and  the  approach  or  production  of  sleep.] 
Derivation:  *Tirivj,   sleep. 

Hsrpnagogue. 

Something  which  leads  to  sleep.  Hypnagogue  hallucinations:  Visions 
experienced  when  half  asleep. 

Derivation:  "TirpoSf  sleep,  and  dywyitt  leading. 

Hjrpnology. 

The  study  of  sleep.     Xcfyot,  treatise. 

Hsrpnophobia. 

Fear  of  sleeping:  <f>6^s,  fear  or  terror  during  sleep. 
Derivative  words:    Hypnotic,  hypnotism,  and  hypnolepsy. 

Lethargy. 

Deep  and  continued  sleep  in  which  the  patient  will  talk  if  awakened  but 
does  not  know  what  he  says,  forgets  what  he  has  said,  and  sinks  again  into 
slumber. 

Derivation:   X^a/ryto,  TutOapyos,  see  Lethargus. 

Lethargus. 

A  term  applied  by  the  old  Greek  physicians  to  a  remittent  type  of  fever 
featured  by  drowsiness. 


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SLEEP,  MORBID,  1283 

\ifiafnfoty  as  adjective,  one  who  is  somnolent ;  as  noun,  the  desire  to  sleep ; 
from  XiJ^,  forgetfulness,  without  exact  knowledge  of  the  mode  of  derivation. 
Common  acceptance  of  the  term : 

1.  A  state  of  apparent  death  characterized  by  almost  complete  suspension 
of  respiration  and  circulation. 

2.  Profound,  irresistible,  uninterrupted  sleep,  lasting  several  hours  or  days. 

Narcosis. 

Stupor  due  to  the  action  of  a  narcotic. 
Derivation:  lSiapx<»fTix6s,  from  i^pxv»  stupor. 

Narcotic 

That  which  produces  stupor,  like  opium,  hyoscyamus,  belladonna,  etc. 

Narcotism. 

The  aggregate  of  the  effects  caused  by  narcotic  substances.  Same  deriva- 
tion. 

Narcotin. 

A  chemical  term.    An  alkaloid  discovered  in  opium  by  Derosne  in  1803; 
also  known  as  Derosne's  salt. 
Derivation :    N arpptic. 

Narcotico-acrid. 

An  adjective  and  toxicologic  term.  A  word  applied  to  the  poisons  which, 
like  aconite,  helleborus,  etc.,  induce  both  narcotism  and  inflammatory  effects 
in  the  intestine. 

Derivative  words:    Narcolepsy,  narcomania,  etc. 

Oneiric. 

From  6p€tpos,  a  dream.  Something  in  the  nature  of  a  dream.  Oneiric  de- 
lirium :    Dream-like  delirium. 

Derivative  words:  Oneirocritia  (the  art  of  interpreting  dreams)  ;  onei- 
romancy  (divination  or  diagnosis  through  dreams). 

Sleepw 

Complete  stupor  of  the  senses,  or,  in  physiologic  terms,  a  temporary  cess- 
ation of  the  activity  inherent  in  animal  life. 

Somnifacient 

Something  which  induces  sleep. 

Derivation:    From  the  Latin,  somnus,  sleep,  and  facere,  to  make. 

Sonmiloquy  (somniloquence). 

The  habit  of  talking  during  sleep. 

Derivation:  From  the  Latin,  somnus,  sleep,  and  loqui,  to  speak. 

Somnolence. 

Slight  drowsiness  which  is  unpleasant  but  irresistible. 
Derivation:    Latin,  somnolentia,  from  somnus. 

Somnolent 

Affected  with  somnolence. 

Derivation:    Latin,  somnolcntus,  from  somnus. 


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1284  SYMPTOMS, 

Somnambulism. 

i.  A  disorder  of  the  cerebral  functions  featured  by  a  tendency  to  repeat 
during  sleep  acts  that  have  become  customary,  or  of  walking  and  carrying 
out  various  motor  acts  without  retaining  any  memory  of  them  on  awakening. 

2.  Magnetic  somnambulism :  A  special  nervous  state  into  which  highly 
susceptible  persons,  especially  hysteric  women,  can  be  thrown  by  a  species 
of  psychic  influence. 

3.  Commonly  accepted  meaning :  A  nervous  state  during  which  a  sleeping 
person  rises  from  bed  and  carries  out  certain  motor  acts  which  he  fails  to 
remember  on  awakening. 

Derivation:    Latin,  somnus,  sleep,  and  ambulare,  to  walk. 

Soporific. 

Something  which  induces  profound  sleep. 
Derivation:    Latin,  soporificus,  from  sopor,  sleep. 


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SLOW  PULSE  r/?pa5i5$,  alow,  ^ap^w^t,  heart;! 

L       slowing  of  the  heart.       J 


(BRADYCARDIA). 


True  bradycardia  is  attended  by  a  slowing  of  the  rate  of  car- 
diac contraction  to  56  per  minute  or  lower.     Palpation  of  the 

/5       1    I    I    f    I    I    I    I    I    I    I    I    I    (    I    I    I    ,    I    ,    I 

A 

F 


^  normal 


Fig.  862.— Normal  heart-rhythm. 


^J\jjJ\;r^AjJ\}j^ 


Fig.  863. — Tendency  to  auriculoventricular  dissociation.    Delayed 
conduction.     Prolongation  of  the  a-c  period. 

pulse  in  combination  with  auscultation  of  the  heart  is  essential 
for  the  recognition  of  true  bradycardia.  Pseudo-bradycardia,  or 
bradysphygmia,  i.e.,  slowing  of  the  pulse  rate  without  actual 

(1285) 


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1286 


SYMPTOMS. 


-  slowing  of  the  heart  rate,  may  occur  in  the  alternating  pulse  and 
in  the  bigeminal  pulse  of  extra-systole  when  the  second  pulsation 
is  too  weak  to  be  perceptible  at  the  wrist;  under  these  conditions 

I  I   I  I  I  I  I   I   I  I  I  •  I   I  I  I  a  I  I  I   I   I   I  I  I  I   I. 


II       II 


II      II 


Fig.  864. — Partial  heart-block.     Incomplete  auriculoven- 
tricular  dissociation. 

only  one  pulsation  is  felt  for  every  two  beats  of  the  heart  (see 
Arhythmia). 

•  I  I  I  I  I  I  I  I  f  f  I  »  I  I  I  I  I  I  I  I  1  1  I  I  I  I  I  t  1 

\  \  \  \  \  \  \ 
\   \   \    \ 


Fig.  865. — Complete  auriculoventricular  dissociation.     Co-ordination  be- 
tween the  contractions  of  the  auricles  and  ventricles  is  wholly  lost. 

Although  recent  investigations,  such  as  those  of  Daniel 
Routier,  of  Frederiq,  and  Petzetakis,  in  particular,  have  shown 
that  the  accepted  division  of  bradycardia  into  several  varieties  is 


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SLOW  PULSE  (BRADYCARDIA), 


1287 


not  literally  valid  and  that  rather  numerous  ambiguous  or 
transitional  conditions  occur,  the  subjoined  synoptic  table  is 
available  for  practical  purposes. 


DIFFERENT  TYPES  OF  BRADYCARDIA. 

Clinical 

Graphic 

Various. 

Features. 

Features. 

Reactions. 

History. 

Due  to  Intracardiac  Disease. 

Disease  of  the  bundle  of  His  (gumma).    Ventricular  myocardial 

disease  (uncommon)  (fibrous  or  rheumatic  myocarditis). 

Bradycardia. 

Complete  indepen- 

No reaction  to  Specific  history  most   | 

1.  Very  pro- 
nounced (30 

dence     of     the 

atropine. 

frequently. 

auricular    beats, 

No  reaction  to 

Sometimes    com- 

or 40  beats 

the  rate  of  which 

the  respiratory 

bined  jaundice  and 

per  minute,  or 

remains     practic- 

movements, to 

uremia. 

less). 

ally  normal,  from 

exertion    and 

During    the    initial 

2.  Continuous 

the      ventricular 

posture,  nor  to 

period    (paroxys- 

or paroxys- 

beats,  with   their 

fever. 

mal    bradycardia), 

mal. 

markedly  reduced 

severe     and     pro- 

rate. 

longed    epileptoid 

(Heart-block. 

seizures    (Stokes- 

Auriculo- ventric- 

Adams disease). 

ular  dissociation.) 

Due  to  Pathologic  Change  or  Functional  Defect  in  the  Vagus. 

Bradjrcardia. 

Usually    a    total  Marked  reac- 

Nervous  depression : 

1.  Moderate: 

bradycardia  with- 

tion (accelera- 

Lassitude,   exhaus- 

56 to  40. 

out  auriculo-ven- 

tion)   to  atro- 

tion, shock,  neuras- 

2. Transient 

tricular    dissocia- 

pine. 

thenia,     and     psy- 

tion. 

Positive  reac- 

choses. 

tion  (acceler- 

Hepatic:   Jaundice. 

ation)  to  mo- 

Pharmaceutic: 

tion,  posture, 

Strophanthus,  digi- 

respiration, 

talis. 

exertion,     and 

Autointoxication : 

fever. 

Uremia. 

Nervous  lesions  in- 
volving : 

Medullary  center: 
Hemorrhages,  soft- 
ening,    arterioscle- 
rosis, etc. 

Points      of      emer- 
gence :  Meningitis. 

Nerve  -  trunk :     En- 
larged  tracheo- 
bronchial glands, 
mediastinal     turn- 

ors,  or  aneurysm.      1 

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1288 


SYMPTOMS. 


The  above  schematic  classification  is  clinically  convenient,  but 
the  fact  that  there  are  still  many  obscure  and  as  yet  incompletely 
elucidated  points  should  be  kept  in  mind. 


"■vnr^^^r-^rv^  ^r'v^nr- 


r^r^'Vy  v^»'V''^>-7r'^^^^p'v^' 


Fig.  866.— Delayed  conduction  (RouHer), 

1.  Anatomic:  There  exist  auriculo- ventricular  bundles  inde- 
pendent of  the  bundle  of  His  (Stanley  Kent). 


Fig.  867.— Partial  heart-block  (Routier), 

2.  Physiologic :  Persistence  of  auriculo-ventricular  conduction 
after  section  of  the  bundle  of  His  (Stanley  Kent). 


i.5J3.DiSioc  complete 

Fig.  868. — Complete  dissociation  (Routier). 

3.  Physiopathologic :  (a)  Removal  of  block  from  some  hearts 
by  adrenalin  (D.  Routier). 


Fig.  869.— Total  bradycardia  (Routier). 

(b)  Block  in  some  hearts  upon  compression  of  the  eyeballs 
(Petzetakis). 


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SLOPy  PULSE  (BRADYCARDIA), 


1289 


The  atrc^ine  test  consists  in  injecting-  into  the  bradycardic 
subject  0.001  gram  of  atropine  sulphate  (1  cubic  centimeter  of 
a  1:1000  solution),  and  later,  in  the  succeeding  days,  2  cubic 
centimeters  if  the  first  test  was  negative  and  well  borne  by 
the  patient. 


•  c 


Fig.  870. — Bradycardia   due  to   auriculoventricular   dissociation   the 

result  of  a  gumma  of  the  bundle  of  His. 

Case  1257.    H.,  1855 ;  pulse,  27 ;  pressures,  25%o.    Former 

specific  infection.     Wassermann  +. 

The  test  is  considered  negative  if,  in  the  hour  following  the 
injection,  acceleration  occurs  to  the  extent  of  less  than  ten  beats 
per  minute. 

The  test  is  considered  positive  if,  in  the  hour  following  injec- 
tion, acceleration  greater  than  twenty  beats  per  minute  occurs. 

The  test  is  considered  doubtful  if,  in  the  hour  following  in- 
jection, an  acceleration  ranging  between  ten  and  twenty  beats 
per  minute  takes  place. 


|M 


19l7.2t.1f 


Fig.  871.— Total  bradycardia  due  to  depressive  psychoneurosis. 

It  is  held  that  any  bradycardia  which  is  not  changed  in  the 
atropine  test  cannot  be  considered  a  nenous  bradycardia.  Atro- 
pine, termed  by  Frangois-Franck  *'the  curare  of  the  nerves  of 
the  heart,"  prevents  the  inhibitory,  bradycardic  action  of  the 
vagus.  This  rule,  however,  is  still  under  widespread  discussion, 
and  can  be  accepted  only  provisionally  and  as  being  subject  to 
change  upon  further  investigation. 


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SORE  THROAT  FAngina,  frcm  angere,] 

(ANGINA).  L         to  mffocate.         J 


No  classification  of  sore  throat  (angina)  that  is  both  rational 
and  clinically  serviceable  can  as  yet  be  presented.  A  classifica- 
tion based  on  bacteriologic  grounds  alone,  while  theoretically  at- 
tractive, is  soon  found  inadequate  for  practical  needs,  i.e.,  for  the 
securing  of  well-founded  indications  for  rational  treatment;  pre- 
cisely the  same  is  true  of  a  purely  clinical  classification,  although 
such  a  division  is  practically  simple  of  attainment.  None  of  the 
outlines  based  on  but  a  single  feature  will  stand  the  test  of 
clinical  usa^e,  all  being  at  fault  in  more  than  one  respect ;  all  one 
can  do  is  to  combine  in  the  least  objectionable  manner  the 
clinical  and  bacteriologic  data  as  well  as  those  relating  to  the 
course  of  the  disease.  The  plan  of  division  hereinafter  followed, 
which  is  in  rather  general  use,  is  one  of  the  least  defective  in 
the  present  state  of  our  knowledge. 

Acute  angina  may  be  primary,  ue.,  occur  as  the  outward 
evidence  of  an  infection  involving  the  pharynx  first,  or  secondary, 
i,e,,  occur  as  the  pharyngeal  manifestation  of  a  more  general  infec- 
tion, whether  constituting  its  first  or  its  last  symptom. 

Whether  primary  or  secondary,  sore  throat  appears  to  the  ob- 
server either  in  the  form  of  a  red  throat  (red  angina),  attended  with 
more  or  less  diffuse  and  intense  redness  of  the  tonsils  and  pharynx, 
without  white  patches; 

Or  in  the  form  of  a  white  throat  (white  angina),  attended 
with  the  presence  of  whitish  or  grayish  exudates,  which  vary  in 
conspicuousness  according  to  the  degree  of  contrast  with  the 
red  background  of  inflamed  pharyngeal  mucous  membrane. 

Such  white  anginas  occur  in  the  following  four  types : 

(a)  Pultaceous. — The  tonsil  shows  disseminated  white  points 
or  is  covered  with  a  grayish,  creamy,  puriform,  friable,  non- 
adherent exudate  which  can  be  detached  merely  by  contact  of 
the  tongue  depressor  or  of  cotton  on  an  applicator. 
(1290) 


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SORE  THROAT  (ANGINA).  1291 

(&)  Vesicular. — The  pharynx,  soft  palate,  and  tonsils  are  at 
first  the  seat  of  a  more  or  less  extensive  and  confluent  vesicular 
eruption,  rupture  of  which  results  in  the  formation  of  small  cir- 
cular ulcerations  or  small  patches  of  false  membrane 

(c)  Pseudomembranous. — Thfe  pharynx,  red  and  swollen,  is 
covered  with  grayish  yellow  false  membrane  which  is  adherent 
tOj  the  mucous  membrane,  thick,  detached  only  with  difficulty, 
causing  the  mucous  membrane  to  bleed,  and  recurring  more  or 
less  rapidly  after  removal. 

(d)  Ulceromembranous. —  This  type  runs  a  two-stage  course : 
First  stage:  False   membrane  on   the  tonsil,  whitish,   only 

slightly  adherent,  and  readily  reproduced. 

Second  stage:  Ulcers  with  punched-out  margins  encroach- 
ing upon  the  pillar  and  digging  into  the  tonsil,  the  base  contain- 
ing a  pseudomembranous  exudate;  no  induration. 


(1)  Bacteriologic  examination,  especially  necessary  in  the 
pseudomembranous  and  ulceromembranous  forms  (see  Bacteriol- 
ogy) ;  (2)  the  associated  clinical  signs,  and  (3)  the  visible  features 
,  just  referred  to,  allow,  as  shown  in  the  subjoined  table,  of  a  rather 
thorough  and  clinically  serviceable  discrimination  between  the  vari- 
ous forms  of  acute  angina. 


Lastly,  reference  may  be  made  to  the  probably  unsuspected 
frequency  of  chronic  or  subacute  pharyngeal  infections  as  the 
underlying  cause  of  '*cr>^ptogenic"  fevers,  refractory  rheumatoid 
manifestations  of  undetermined  nature,  and  of  inveterate,  vague 
deficiencies  in  the  general  condition  of  the  body.  The  pharynx 
and  nasopharynx  certainly  constitute  one  of  the  great  foci  of 
systemic  infection.  They  should  always  be  subjected  to  ex- 
amination, especially  in  the  presence  of  subacute  or  chronic 
febrile  states  and  erratic  joint  manifestations  the  true  source  of 
which  has  not  previously  been  revealed. 


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1292 


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SORE  THROAT  (ANGINA), 


1293 


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TINNITUS  AURIUM.  [Tinnitus,  "a  tinkling:'] 


"De  minimis  non  curat  praetor"  is  a  well  known  adage.  It  would 
be  unwise,  however,  to  apply  it  to  the  minor  symptom  known  as 
tinnitus  aurium,  or  ringing  in  the  ears.  While  sometimes  really  of 
negligible  clinical  significance,  it  may,  on  the  other  hand,  be  an 
indication  of  previously  unsuspected  morbid  conditions.  When 
persistent,  it  becomes  to  the  patient  an  unbearable  obsession, 
which  may  lead  to  what  amounts  practically  to  a  delirium. 

In  a  patient  who  comes  complaining  of  distressing  and  obstinate 
tinnitus,  whether  in  the  form  of  whistling  sounds,  cockle-shell 
sounds,  or  buzzing  sounds,  the  proper  procedure  is  to  examine 
first  of  all  the  ear  and  make  a  systematic  search  for  any  lesion 
of  the  external,  middle,  or  internal  ear  which  might  be  the  cause 
of  the  tinnitus. 

Tinnitus  due  to  quinine,  subjectively  resembling  the  ringing 
of  bells  and  accompanied  \>y  hardness  of  hearing  and  a  heavy  feel- 
ing in  the  head  is  practically  a  normal  condition  which  passes  oflF 
completely  in  a  few  hours.  It  occurs  so  constantly  after  quinine 
that  it  serves,  in  a  measure,  as  a  control  of  quinine  exhibition. 
Where  it  is  lacking  the  physician  should  carefully  inquire:  1.  As 
to  whether  the  patient  has  actually  taken  the  dose  prescribed.  2. 
Whether  the  salt  supplied  was  actually  the  salt  ordered,  3.  Whether 
the  medicine  was  taken  in  the  manner  specified  (with  an  acid 
beverage). 

When  intense,  these  aimcular  disturbances  may  become 
abnormal  and  alarming,  or  even  progress  toward  a  highly  severe 
vertigo  comparable  to  that  of  Meniere's  disease.  According  to 
Lermoyez,  "all  depends  on  the  condition  of  the  labyrinth,  and 
if  there  is  the  least  labyrinthine  lesion,  the  least  dose  of  drug  is 
sufficient  to  produce  manifestations  of  vertigo,"  and  the  adminis- 
tration of  quinine  is  contraindicated. 

Such  marked  disturbances  are  seldom  induced  by  sodium  sali- 
cylate; yet  one  should  take  into  account  the  possibility  of  a  tem- 
(1294) 


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TINNITUS  AURIUM.  1295 

porary  brain  congestion   with  tinnitus,  transient  deafness,   slight 
dizziness,  flushing  of  the  face,  and  even  epistaxis.         i 

The  frequency  of  tinnitus  aurium  in  chronic  aortitis  and 
arteriosclerosis  is  well  known;  it  may  even  induce  giddiness  or 
fainting  spells.  It  is  often,  a  preliminary  indication  of  further 
trouble  to  come.  In  any  elderly  patient  complaining  of  tinnitus 
and  dizziness  a  careful  examination  of  the  cardiovascular  system 
and  kidneys  should  be  made,  including  auscultation,  blood-pres- 
sure determinations,  and  uranalysis.    The  pathogenesis  is  com- 


4 
3 


Fig.  872. — Mode  of  production  of  tinnitus  aurium  (G,  Laurens), 

Tinnitus  is  the  result  of  irritation  of  the  internal  ear.  The  latter  may 
be  due,  in  turn,  to  a  disturbance:  (o)  Of  the  external  ear  (wax),  ex- 
erting pressure  on  the  drumhead,  ossicles,  and  endolabyrinthine  fluid  (1). 
(b)  Of  the  middle  ear  (3),  eg.,  otitis  or  catarrh  or  disease  of  the 
Eustachian  tube  (2),  in  the  same  way  as  the  preceding  condition,  (c) 
Of  the  internal  ear  (4),  e.g^,  disturbed  circulation,  anemia,  congestion, 
constitutional  disorders,  arteriosclerosis,  etc 

plex,  but  the  condition  is  probably  dependent  largely  upon  reflex 
spasm  of  the  capillaries  in  the  brain,  probably  due,  in  turn,  to 
the  irritation  to  which  the  intima  of  the  aorta  is  subjected 
through  changes  in  the  blood-pressure  caused  in  aortic  and 
arteriosclerotic  cases  by  changes  of  posture,  locomotion,  and 
exertion. 

Tinnitus   aurium   and   vertigo   are   very   closely   allied    (see 
Vertigo). 


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1296  SYMPTOMS. 

Usual  Causes  of  Tinnitus  Aurium. 

External  car:    Impacted  cerumen  or  a  foreign  body. 

Middle  ear:  Otitis  media,  especially  with  exudation  and  pressure  on 
the  stapes,  or  obstruction  of  the  Eustachian  tube. 

Internal  ear:  The  exciting  cause  of  tinnitus  is  always  actually  some 
form  of  irritation  of  the  internal  ear,  some  disturbance  in  its  circu- 
lation (hyperemia  or  ischemia) ,  or  an  increase  or  decrease  of  in- 
tralabyrinthine  pressure. 

In  the  absence  of  any  apparent  disease  of  the  internal  or  middle  ear: 

An  examination  should  be  made  for  degeneration  of  vessels,  dia- 
thetic disorders,  and  pharmaceutic  or  autogenous  toxic  states.   These 
conditions  induce  tinnitus  through  the  hyperemia  or  ischemia,  or 
the  rise  or  fall  of  pressure  which  they  cause  in  the  internal  ear. 
The  following  conditions  should  be  looked  for : 

Arteriorenal  degenerative  changes:  Arteriosclerosis  or  Bright's  dis- 
ease. 

Diathetic  disorders  of  the  neuroarthritic  type:    Gout  or  diabetes. 

Drug  intoxications:    Quinine  or  sodium  salicylate. 


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TONGUE,  DIAGNOSTIC  FEATURES 
RELATING  TO  THE. 


The  tongue  has  been  aptly  said  to  "mirror  the  stomach  ;*'  but 
it  also  supplies  a  clue  to  the  fimctional  state  of  many  other 
structures,  when  inspected  by  a  practised  eye. 

I.  Examination  of  the  Tongue  Reveals  Neither  Ulcerations 
nor  Tumor-like  Formations. — Aside  from  all  malformations, 
ulcerations,  and  tumors  of  the  tongue,  to  which  brief  reference 
will  be  made  later,  the  appearance  of  the  lingual  mucous  mem- 
brane is  in  itself  highly  informative.  The  normal  roseate  and  moist 
appearance,  with  the  characteristic  leaf-like  oblique  striations  and 
the  posteriorly  situated  V-shaped  angle,  are  too  familiar  to  require 
mention.  It  may  be  pointed  out,  however,  that  even  under  physio- 
logic conditions  the  lingual  mucous  membrane  is  frequently  covered 
with  a  light  grayish  normal  coating  resulting  from  the  continuous 
desquamation  of  the  superficial  epithelia.  This  coating  accumulates 
as  the  interval  since  the  preceding  meal  increases ;  mastication  of 
solid  food,  on  the  other  hand,  is  generally  sufficient  to  cause  it  to  dis- 
appear. One  may  therefore  expect  to  find  this  coating  thicker  and 
more  persistent  in  persons  on  a  diet,  taking  liquid  food,  as  well  as  in 
the  morning  on  awakening.  The  presence  of  such  a  coating  in  the 
morning  obsesses  some  patients  to  such  an  extent  that  they  scrape 
their  tongues  every  morning  with  some  scraping  instrument. 

On  the  other  hand,  in  sialorrhea  the  tongue  is  red,  moist,  and 
glistening;  it  is,  in  fact,  too  clean-looking,  and  should  lead  to  the 
discovery  of  excessive  salivation,  the  cause  of  which  is  thereupon  to 
be  inquired  into. 

With  the  practically  normal  coating  is  combined  an  almost  rasp- 
like  dryness  in  heavy  smokers  and  especially  in  mouth-breathers 
(coryza  or  adenoid  vegetations). 

The  whitish  or  grayish  color  of  the  coating  may  be  changed  as  a 
result  of  the  ingestion  of  certain  foods  or  drugs.  It  may  turn  to  a 

82  (1297) 


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1298  SYMPTOMS. 

color  ranging  from  purplish  red  to  dark  brown  upon  ingestion  of 
red  wine,  of  blackberries,  of  chocolate,  of  extract  of  licorice,  of 
catechu,  of  cinchona,  of  fresh  nuts,  of  tobacco,  etc.;  it  becomes 
saffron  yellow  upon  ingestion  of  laudanum  or  rhubarb,  and  creamy 
white  in  persons  on  a  milk  diet. 


Epiglottis 

Median    glosso- 
epiglotUc    fold 

Faucial   tonsil 

Lingual  follicle 

Foramen 

ClrcumTallate 
papilla. 

Fungiform 
papilla 

Median 


Fig.  873.— Dorsal  surface  of  the  relaxed  tongue  (Poirier), 

Certain  peculiarities  the  result  of  defective  functioning  of  the 
digestive  tract  are  universally  known,  in  particular  the  dirty  yel- 
low brown  coating  of  dyspepsia  and  indigestion.  In  gastric  dis- 
orders the  brown  coating  is  thick  and  the  tongue  flattened  out, 
with  its  margins  sho\ying  imprints  of  the  teeth,  sometimes  with 
small  red  elevations,  consisting  of  the  papillae,  when  clearing 
begins. 

Some  infectious  diseases  affect  the  tongue  in  almost  patho- 
gnomonic fashion: 


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TONGUE,  DIAGNOSTIC  FEATURES.  1299 

The  "strawberry''  or  "raspberry/*  scarlet  red,  bare  tongue  of 
scarlet  fever. 

The  varnished,  porcelain-like  tongue,  with  a  red  band  at  its 
margins,  of  grippe  at  its  height. 

The  parched,  dry,  fissured  tongue,  covered  with  dry  and  black- 
ened mucus,  of  the  typhoid  patient  (when  poorly  cared  for,  one 
might  add,  i.e,,  where  the  ordinary  measures  of  oral  hygiene  are  not 
carried  out). 

The  "sooty,"  dry,  black,  rough,  "parrot  tongue''  of  grave  infec- 
tions of  the  typhoid  type  and  of  certain  varieties  of  uremia. 

The  phrase  "certain  varieties"  is  used  in  reference  to  uremia  be- 
cause in  some  other  forms,  in  particular  in  certain  instances  of  acute 
azotemia,  the  author  has  had  occasion  to  observe  a  thick,  **viscou^' 
tongue,  with  excessive  flow  of  viscid  saliva  containing  a  large 
amount  of  urea. 

II.  True  glossitis  is  reached  by  insensible  gradations  from  the 
preceding  group. 

1.  Thrush  is  the  most  frequent  disorder  in  infancy,  being  a  re- 
sult of  poor  quality  of  the  milk  or  unclean  bottles.  In  the  adult  and 
elderly,  it  may  occur  as  a  complication  of  grave  infectious  states  and 
of  cachexias,  as  in  advanced  tuberculosis,  severe  typhoid  fever, 
infections  of  the  urinary  tract,  etc.  The  tongue,  at  first  red  and 
"varnished,"  becomes  covered  with  small  grayish  masses  like  milk 
curds,  which  thereupon  draw  together,  fuse,  and  expand  into  creamy 
patches  which  can  be  detached  rather  easily  by  rubbing. 

2.  In  the  mercurial  stomatitis  of  patients  intolerant  of  mer- 
cury and  ignorant  of  oral  hygiene,  the  tongue  is  swollen,  viscous, 
of  a  dirty  gray  color,  and  bearing  imprints  of  the  teeth  on  its 
margins.  The  malodorous  breath,  the  ptyalism,  the  coexisting 
stomatitis,  and  the  history  of  having  taken  liiercury  lead  directly 
to  the  diagnosis. 

3.  Aphthous  fever  is,  as  a  rule,  rather  discretely  manifested  on 
the  tongue.  Aphthw  may  be  noted  at  the  tip  and  along  the  margins 
of  the  tongue  in  the  form  of  vesicles  similar  to  those  of  skin  herpes 
or  of  a  circle  of  swollen  mucous  membrane;  the  vesicles  rupture 
after  a  few  days,  leaving  small  circular  ulcers  of  the  size  of  a  pin- 


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1300  SYMPTOMS. 

head  up  to  that  of  a  lentil,  with  grayish  bases  and  irregular 
margins. 

4.  Marginal  exfoliative  glossitis  is  a  chronic,  recurrent  affec- 
tion of  the  tongue  characterized  by  desquamation  of  plate-like 
scales  with  circinate,  ^'geographic"  margins,  usually  with  their 
convexity  directed  outward. 

The  very  multiplicity  of  the  terms  applied,  vis,,  pityriasis 
linguae  (Rayer),  geographic  tongue  (Bergeron),  marginal  ex- 
foliative glossitis  (Fournier),  eczema  desquamatif  lingual  en 
aires,  margine  (Besnier),  psoriasis  linguae,  etc.,  is  sufficient  proof 
of  our  ignorance  of  its  nature — which  may  perhaps  be  variable 
and  complex.  It  does  not  seem  to  be  of  syphilitic  origin;  at 
least  it  is  not  amenable  to  specific  treatment.  Yet,  as  in  the 
case  of  leukoplakia,  to  be  next  discussed,  the  distinction  to  be 
made  from  syphilitic  glossitis  is  most  difficult,  and  how  many  derma- 
tologists have — as  of  yore  in  connection  with  tabes  and  general 
paralysis — used  the  phrase  **parasyphilitic  manifestation"  in  this 
connection?  The  "What  do  I  know?"  attitude  of  Montaigne  is 
alone  justifiable  at  the  present  time. 

5.  Leukoplakia  buccalis  appears  in  the  form  of  amorphous, 
pearl-white,  patches  on  the  tongue,  without  any  special  marginal 
band;  the  patches  are  irregularly  dispersed,  thin,  bluish,  trans- 
lucent, discrete  at  first,  and  show  an  almost  invincible  tendency 
to  extend,  thicken,  and  undergo  hardening,  with  resulting  for- 
mation of  whitish,  thick,  adherent  patches,  which  become  fissured 
and  cracked  through  desquamation.  Such  patches  may  also  be 
observed  on  the  mucous  membrane  of  the  lips  and  on  the  inner 
surface  of  the  cheeks. 

Syphilis  is  noted  in  a  very  grtat  many  of  these  cases,  and  it 
seems  likely  that  a  large  number  of  leukoplakias  are  of  syphilitic 
origin.  Yet  such  exciting,  provocative,  or  predisposing  causes  as 
tobacco  (nicotinic  leukoplakia),  traumatism  (dental  leukoplakia, 
with  dental  caries  or  poorly  made  dentures),  neuroarthritism 
(irritative  neuroarthritic  leukoplakia  of  Brocq),  etc.,  play  a  role 
in  their  production  which  is  not  negligible. 

The  marked  clinical  interest  of  leukoplakia  resides  in  its  rela- 
tionship to  syphilitic  glossitis  and  the  possibility  of  the  occur- 
rence in  it  of  epitheliomatous  degeneration. 


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TONGUE,  DIAGNOSTIC  FEATURES.  1301 

Brocq,  with  his  usual  ability,  discussed  this  question,  which 
is  of  prime  clinical  importance,  in  1919.^  The  following  three 
points  are  worth  quoting  here: 

(a)  There  occurs  a  buccal  lichen  planus  which  is  sometimes 
hard  to  distinguish  from  other  conditions.  It  is  marked  by  the 
presence,  on  the  inner  aspect  of  the  cheeks,  of  white  striae  exhibiting 
occasional  small  nodular  elevations;  on  the  tongue  one  observes 
instead  opalescent  spots,  which  coalesce  to  form  more  extensive 
patches. 

(&)  Leukoplakia  nearly  always  develops  on  a  syphilitic  substrate, 
but  not  always.    Non-syphilitic  leukoplakic^  do  occur. 

These  two  propositions  are  of  marked  practical  import,  for 
while  they  justify  antisyphilitic  treatment  in  the  majority  of 
cases,  they  condemn  the  blind  tendency  to  institute  intensive  and 
repeated  antisyphilitic  treatments  in  all  persons  with  ordinary 
white  patches.  In  playing  the  part  of  the  wise  and  well-versed 
clinician,  it  is  well  to  make  a  careful  diagnosis  in  these  cases 
(discrimination  from  lichen  planus,  or  syphilis — manifest,  prob- 
able, or  non-existent)  and  to  act  accordingly  as  regards  treat- 
ment. 

(c)  It  is  certain  that  many  leukoplakias  undergo  epitheliomatous 
degeneration.  "Yet,  many  subjects  harboring  leukoplakial  patches 
do  not  show  degeneration  of  the  disorder  into  cancer;  such  degener- 
ation of  the  disorder  is  even  relatively  rare  when  the  patients, 
warned  in  good  time,  carry  out  and  persistently  continue  all  the 
required  hygienic  measures."  (Brocq,  loc.  cit.) 

6.  Syphilitic  glossitis  is  of  greater  importance  in  the  adult 
than  any  of  the  preceding  varieties.  It  is  well  established,  to  be 
sure,  that  the  majority  of  instances  of  leukoplakia  and  a  few  in- 
stances of  marginal  exfoliative  glossitis  are  syphilitic. 

Syphilis  may  yield  lingual  manifestations  in  any  of  its  stages : 
Primary  (chantre  of  the  tongue) ;  secondary  (various  forms  of 
secondary  glossitis,  mucous  patches)  ;  tertiary  (gummas,  tertiary 
syphilomas). 

Some  varieties  are  merely  exudative  and  exfoliative,  like  the 
majority   of  the   secondary  manifestations;  others   are  tumor- 


1  Brocq  :    Presse  mid.,  May  22,  1919. 


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1302  SYMPTOMS. 

producing  and  ulcer-forming  (gummas).  They  consequently  oc- 
cupy a  border-line  position  in  the  didactic  classification  herein 
followed.  Yet  they  will  be  placed  in  the  present  group.  They 
serve  for  purposes  of  transition  to  the  clinical  cases  of  glossitis 
associated  with  ulcers  or  tumor-formations. 

Chancre  of  the  tongue  is  relatively  uncommon,  representing 
hardly  more  than  10  per  cent,  of  the  cephalic  chancres.  It  is  gen- 
erally located  at  the  tip  of  the  tongue,  and  exhibits  either  an  erosive, 
papulo-erosive,  or  ulcerative  character  with  diffuse  induration.  The 
submaxillary  lymph-glands  are  always  and  the  sternoid  mastoid 
glands  sometimes  involved,  and  exhibit  the  usual  features  of  pri- 


Fig.    874. — Extensive    gummatous  Fig.  875. — Tertiary  syphilitic  scle- 

ulceratiou  of  the  tongue  (Musee  de  rosis  of  the  tongue  (Musce  de  Saint- 
Saint-Louis).  Louis). 

mary  syphilitic  glandular  enlargements  (one  large  node  with  sur- 
rounding smaller  nodes,  practically  painless;  see  Neck,  glandular 
enlargements  in).  The  history  of  infectious  contact,  the  examina- 
tion for  the  spirochete,  and  eventually  the  appearance  of  the  roseola 
constitute,  as  always,  the  chief  diagnostic  factors. 

Secondary  lingual  syphilides  (mucous  patches)  are  usually 
discrete  and  demand  a  careful  search.  They  occur  in  the  form  of 
round  or  elliptical  patches,  of  smooth  "depapillated"  appearance, 
contrasting  with  the  normal  granular  background  of  the  lingual 
mucous  membrane. 

Tertiary  syphilides  occur  in  two  main  clinical  forms,  7^'c.,  the 
sclerous  and  the  gummatous,  which  in  exceptional  instances  arc 
combined  in  a  mixed  sclero-gummatous  form. 


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TONGUE,  DIAGNOSTIC  FEATURES.  1303 

Gumma  of  the  tongue  may  be  superficial  or  deep.  When 
superficial,  it  causes  local  elevations  of  the  dorsum  in  the  form  of 
multiple  small  nodosities  varying  in  size  from  a  leaden  shot  to  a 
pea,  and  sometimes  arranged  in  a  horse-shoe-shaped  figure.  If 
tuitreated,  it  softens  and  ulcerates,  leaving  a  relatively  deep,  cyclic 
or  polycyclic  ulcer  with  clear-cut  margins.  When  deep,  it  is  situated 
in  the  midst  of  the  muscles  of  the  tongue,  forming  there  a  hard 
node,  nearly  spheric  or  ovoid  in  shape,  of  hazelnut  to  walnut  size, 
painless,  and  unaccompanied  by  any  glandular  reaction.  If  allowed 
to  progress  unopposed,  it  enlarges  and  involves  the  dorsal  surface  of 
the  tongue,  softens,  and  ulcerates,  discharging  a  characteristic 
gummy  fluid.  This  constitutes  the  deep  tertiary  syphilitic  ulcer,  with 
punched  out  margins,  discharging  base,  not  bleeding,  and  unattended 
with  any  glandular  reaction  unless  infection  or  secondary  degenera- 
tion sets  in. 

Fibrous  glossitis,  like  gumma,  may  be  either  superficial  or 
deep-seated. 

When  superficial,  the  cords  and  patches  of  fibrous  tissue  form 
irregular  islets  of  superficial  induration,  sometimes  smooth,  at 
other  times  leucoplastic,  the  tongue  at  times  assuming  a  stringy- 
appearance  owing  to  the  presence  of  a  network  of  shallow  fissures 
lined  with  fibrous  tissue. 

When  deep-seated,  they  infiltrate  the  major  portion  of  the 
tongue,  especially  its  anterior  region,  imparting  to  it  a  hard, 
wood-like  consistency.  The  simultaneous  presence  of  large  and 
small  knob-like  elevations,  lobulated,  smooth,  and  devoid  of  papillae, 
gives  to  the  tongue  an  absolutely  pathognomonic  aspect  (lingual 
cirrhosis).  Like  gummatous  glossitis,  fibrous  glossitis  is  not 
accompanied  by  any  secondary  glandular  enlargement  and  is 
practically  painless.  These  two  features  should  never  be  over- 
looked, as  they  are  of  capital  diagnostic  import. 

III.  A  Tumor-like  Enlargement  is  Present— In  most  instances 
the  patient  first  notices  that  certain  movements  of  the  tongiie  are 
somewhat  hard  to  execute.  Clinical  examination  thereupon  re- 
veals some  abnormality  in  the  size  and  consistency  of  the  organ. 

Brief  reference  may  be  made,  as  an  altogether  exceptional  pos- 
sibility, to  cysts  (either  parasitic,  glandular,  or  congenital),  which 


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1304  SYMPTOMS. 

are  very  hard  to  diagnose.  Unless  an  exploratory  puncture  is  made, 
there  can  be  nothing  more  than  a  mere  presumption  of  the  presence 
of  a  cyst,  based  on  its  fluid  consistency — ^which  is,  however,  not  easy 
to  detect — and  on  the  history.  The  same  is  true  of  the  connective 
tissue  tumors,  viz,,  lipoma,  fibroma,  fibrosarcoma,  and  chondroma. 

In  the  presence  of  a  tumor-like  enlargement  of  the  tongue,  the 
chief  possibilities  which  should  come  to  the  physician's  mind  are 
syphiloma,  epithelioma,  tuberculoma,  and  actinomycosis. 

Nothing  more  need  be  said  concerning  the  syphilomas,  the 
customary  features  of  which  have  already  been  briefly  referred  to 
— gumma  and  fibrous  glossitis,  characterized  by  painlessness  and 
the  absence  o4  glandular  enlargement. 

The  condition  which  has  most  often  to  be  differentiated  is 
epithelioma.  In  theory  such  differentiation  is  easy.  The  epi- 
thelial induration  present  shows  a  special  consistency;  it  is 
imperfectly  circumscribed,  having  a  tendency  to  infiltrate  the 
neighboring  tissues ;  it  is  attended  with  a  varying  degree  of  ten- 
derness, or  may  cause  actual  pain ;  the  accompanying  glandular 
enlargement  consists  at  first  of  small  separate  nodes,  which  roll 
beneath  the  finger  and  coalesce  only  at  a  late  stage  of  the  dis- 
order; finally,  the  condition  occurs  only  in  elderly  subjects  and 
its  tendency  toward  progressive  extension  to  surrounding  tissues 
is  manifest  and  obstinate.  Nevertheless,  the  actual  distinction  of 
certain  hypertrophic  forms  of  epithelioma  of  the  tongue  from 
fibrous  glossitis  is  sometimes  a  matter  of  great  difficulty  and 
baffles  even  the  most  astute  clinicians,  particularly  in  view  of 
the  fact  that  there  occur  mixed  forms  giving  rise  to  a  hybrid 
cancerosyphilitic  glossitis — a  condition  which  has  been  carefully- 
studied  by  Verneuil.  The  physician  is  thus  easily  induced  to 
institute  the  therapeutic  test  by  brief  but  active  administration 
of  potassium  iodide  and  mercury  or  potassium  iodide  and  arsenic- 
als — a  procedure  which  rapidly  dissipates  the  disease  if  it  is 
syphilitic  or,  on  the  other  hand,  stimulates  it  temporarily  to 
greater  activity  if  epithelioma  is  present 

Tuberculomas,  which  are  very  uncommon  in  the  tongue  as 
compared  to  the  syphilomas  and  epitheliomas,  appear  usually 
on  the  upper  surface  of  the  organ.  They  are  sensitive  or  pain- 
ful on  pressure,  engorgement  of  lymph-nodes  is  exceptional,  the 


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TONGUE,  DIAGNOSTIC  FEATURES.  1305 

patient  is  always  a  tuberculous  individual,  and,  if  necessary,  ex- 
cision of  a  bit  of  the  tumor  tissue  for  examination  and  injection 
of  the  diseased  tissue  into  a  guinea-pig  will  lead  to  recognition 
of  the  presence  of  the  tubercle  bacillus. 

Lingual  actinomycosis  may  so  resemble  fibrogummatous 
syphilis  or  a  deep  tuberculoma  as  to  be  readily  mistaken  for  it. 
If  the  condition  is  only  thought  of,  however,  the  diagnosis  may 
be  settled  by  exploratory  puncture  and  examination  on  a  slide 
(with  cover-slip)  of  the  characteristic  small  yellow  granules,  sug- 


Fig4  876. — Actinomycosis. 

gesting  powdered  iodoform,  which  the  fluid  withdrawn  allows 
to  settle  on  the  walls  of  the  tube  into  which  it  has  been  ex- 
pressed. When  stained  with  picrpcarmin  they  appear  as  if 
made  up  of  a  central  felt-like  central  mass  consisting  of  mycelial 
filaments  and  surrounded  by  a  radiating  zone  of  ovoid  bodies 
disposed  like  petals,  the  whole  resembling  to  some  extent  a 
daisy. 

Lastly,  mention  may  be  made  of  a  congenital  anomaly,  for- 
tunately very  rare,  constituting  a  real  pathologic  curiosity,  viz,, 
macroglossia,  which,  undergoing  development  during  later  child- 
hood and  even  the  period  of  puberty,  may  lead  to  permanent 
prolapse  of  the  tongue,  which  has  become  too  large  for  the  buccal 
cavity. 


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1306  SYMPTOM!^', 

IV.  Ulcerations  are  Present. — Small  ulcers  on  the  tongue  may 
be  observed : 

1.  During  an  attack  of  whooping-cough;  there  is  ulceration 
of  the  lower  surface  of  the  tongue  and  its  frenum,  due  to  forcible 
projection  of  the  tongue  against  the  teeth  during  cough. 

2.  As  a  result  of  biting  of  the  tongue ;  there  is  present  a  cut- 
like ulceration  along  the  margins  of  the  organ,  e,g.,  in  epilepsy. 

3.  As  a  result  of  dental  traumatism,  the  ulcer  being  situated 
opposite  a  badly  decayed,  broken,  or  deviated  tooth. 


Fig.  877. — Macroglossia   {Mikulicz  and  Kiimmel), 

The  more  extensive  ulcerations  of  the  tongue  are  due  to  the  four 
following  major  causes  of  tumor  formation : 

Syphilitic  ulcers.  Tuberculous  ulcers. 

Neoplastic  ulcers.  Actinomycotic  ulcers. 

Syphilitic  ulcers  are  represented  mainly  by  ulcerated  gum- 
mas; mention  need  here  be  made  only  of  their  characteristic 
depth,  perpendicular  margins,  sloughing  base,  absence  of  bleed- 
ing, and  relative  painlessness,  as  well  as  the  usual  absence  of 
glandular  enlargements  and  the  history.  In  the  event  of  doubt 
the  therapeutic  test  will  settle  the  diagnosis. 

Neoplastic  ulcers,  or  epitheliomatous  ulcers,  show  lacerated, 
irregular  margins,  with  suppurating  bases,  and  oozing  of  blood, 
and  are  superimposed  on  an  indurated  mass  which  infiltrates  the 


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TONGUE,  DIAGNOSTIC  FEATURES,  1307 

neighboring  tissues.  There  is  copious  salivation  and  a  malodorous 
breath.  Such  ulcers  give  .rise  to  pain,  sometimes  of  marked 
severity,  radiating  toward  the  ears.  The  submaxillary  lymphatic 
ganglia  are  involved. 

Tuberculous  ulcers  are  generally  broad  and  superficial,  multi- 
ple, writh  clear-cut,  but  only  slightly  elevated  margins,  with  a 


Fig.  878.— Tuberculosis  of  the  tongue. 

pale,  grayish  base,  not  prone  to  bleed,  but  causing  much  pain. 
Sometimes  they  are  surrounded  by  discrete  yellowish  points  or 
granulations  resembling  millet  seeds,  constituting  actual  small 
tuberculomas,  which  would  be  pathognomonic  were  similar  mani- 
festations not  sometimes  observed  in  actinomycosis. 

Actinomycotic  ulcers  may  present  an  appearance  similar  to 
that  of  the  preceding  type  of  ukers ;  they  exude  serous  pus,  in 
which  the  characteristic  yellow  granules  already  referred  to 
should  be  sought. 


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TREMOR.  [Tremulare,  to  tremble.^ 


Tremor   consists   of   regular  oscillatory   movements   taking 

^  place  at  a  varying  rate  and  with  varying  amplitude,  involving  the 

entire  body  or  an  extremity,  and  symmetric  in  both  directions 

from  the  resting  position.     The  mode  of  production  of  tremor 

is  still  obscure  and  a  mooted  subject. 

Tremor  may  be  either  accidental  (transitory)  or  essential 
(permanent). 

I.  Accidental  (transitory)  tremor  is  chiefly : 

(a)  Emotional,  in  which  it  is  easily  traced  to  its  cause,  e.g., 
fear  or  other  emotional  stress. 

(fc)  Pyrexial,  frequently  marking  the  onset  of  an  acute  infec- 
tion (see  Chills). 

The  initial  chill  of  pneumonia  and  that  occurring  in  the  first 
stage  of  the  malarial  paroxysm  are  well-known  examples,  both 
of  which  are  as  a  rule  traceable  to  their  cause. 

(r)  Cryogenic,  or  brought  on  by  cold,  and  in  the  initial  stage 
of  fevers.  "You  are  trembling,  Bailly? — Yes,  but  it's  because 
Tmcold!" 

II.  Permanent  tremor  occurs  in  two  forms : 

Tremor  during  the  execution  of  volitional  movements  (kinetic 
or  intention  tremor),  typically  exemplified  in  disseminated  sclerosis. 

Tremor  at  rest  (static  tremor),  exemplified  in  paralysis  agitans. 

A.  Tremor  during  voluntary  motion. — Charcot  ascribed  this 
form  of  tremor  to  the  usual  persistence  of  the  axis  cylinder  de- 
prived of  its  myelin  sheath  in  the  midst  of  the  areas  of  sclerosis. 
Pierre  Marie  compares  such  an  axis  cylinder  to  an  electric  wire 
from  which  the  insulation  has  been  removed  and  along  which 
an  escape  of  electricity  occurs  causing  the  tremor. 

(a)  This  type  of  tremor  is  illustrated  in  the  highest  degree  and 
in  the  utmost  state  of  purity  in  disseminated  sclerosis.  While 
(1308) 


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TREMOR.  1309 

absent  during  rest,  it  starts  up  when  movements  are  undertaken.  It 
quickens,  develops,  and  exhibits  increased  amplitude  during  the 
execution  or  repetition  of  the  motor  act.  The  rate  of  vibration  is 
always  moderate,  vi::.,  six  or  seven  vibrations  per  second.  The 
amplitude,  which  increases  during  the  performance  of  the  motor  act, 
may  become  very  great — 5,  10,  or  even  30  or  40  centimeters. 

In  this  disease  the  tremor  is  accompanied  by  vertigo  or  apoplecti- 
form seizures,  by  ocular  disturbances  and  nystagmus,  by  exaggerated 
reflexes,  and  sometimes  by  spastic  paralysis  and  slow,  scanning 
speech. 

(b)  Hereditary  tremor  (with  a  similar  tremor  or  merely  a  neu- 
rotic tendency  in  the  parents)  may  be  considered  to  be  present  when 
the  tremor  is  absent  during  complete  rest,  exhibits  a  rapid  rate  of 
vibration,  develops  with  movements  but  does  not  increase  during 
their  execution,  involves  particularly  the  upper  extremities,  eyelids, 
lips,  and  face,  and  set  in  slowly  during  childhood  or  adult  life.  It  is 
sometimes  present  to  a  slight  extent  during  rest. 

(c)  -Toxic  tremor,  due  to  alcohol,  coflFee,  tea,  lead,  mercury,  etc., 
is  remittent  and  of  the  intentional  type,  of  intermediate  rate,  and 
but  slightly  marked  or  absent  during  rest.  A  brief  inquiry  as  to  the 
subject's  past  history  will  generally  settle  the  diagnosis.  This  is  by 
far  the  commonest  kind  of  tremor. 

(d)  Tremor  is  said  to  have  been  observed  sometimes  in  the 
secondary  stage  of  malaria, 

B.  Tremor  during  rest  (static  tremor)  is  but  slightly  or  not 
at  all  aflFected  by  voluntary  movements. 

(a)  This  variety  of  tremor  is  most  characteristically  exempli- 
fied in  paralysis  agitans  (Parkinson's  disease).  In  contrast  with 
the  preceding  variety,  it  is  continuously  present  during  rest  and 
ceases — at  least  in  the  earlier  stage  of  the  disease — during  the 
performance  of  voluntary  movements.  It  is  a  slow  tremor,  ex- 
hibiting four  or  five  vibrations  per  second,  of  slight  amplitude, 
and  coordinated,  simulating  the  endless  repetition  of  voluntary 
movements — pill  rolling,  thread  winding,  crumbling  of  bread, 
masturbation,  etc. 

It  involves  chiefly  the  uppei^  extremities,  the  head  and  neck 
being  relatively  free.  It  is  accompanied  by  a  special  kind  of 
muscular  rigidity  (waxy  flexibility)  and  a  slowness  in  starting 


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1310  SYMPTOMS. 

locomotion  which  impart  to  the  act  of  walking  a  very  typical 
slow  and  scanning  appearance.  There  are  also  noted  a  subjec- 
tive sensation  of  heat  and  a  morbid  desire  for  locomotion. 

Grasset  called  attention  to  two  anatomic  regions  often  found 
the  seat  of  morbid  changes  in  this  disease: 

1.  The  region  of  peri-ependymal  myelitis,  with  obliteration 
of  the  central  canal. 

2.  The  automatic  pontobulbar  centers  and  the  capsulotha- 
lamic  region. 

(fc)  The  commonest  form  in  this  class  of  tremors  is  perhaps 
senile  tremor,  which,  as  the  term  implies,  occurs  particularly  in 
old  persons,  is  of  comparatively  slow  rate  and,  affecting  mainly 
the  head  and  neck,  imparts  to  the  tremor  the  peculiar  suggestion 
of  an  indefinitely  repeated  nod  of  affirmation  or  shake  of  nega- 
tion. 

(r)  Graves's  (Basedow's)  disease. — Here  the  tremor  shows  a 
rapid  rate.  It  generally  occurs  in  conjunction  with  the  sympto- 
matic triad,  tachycardia,  goiter,  and  exophthalmos.  This  triad 
may,  however,  be  absent  or  only  partially  represented,  in  which 
event  one  should  look  for  the  other  signs  of  hyperthyroidia — 
frequent  pulse,  tremor,  hyperidrosis,  exaggerated  reflexes,  and 
diarrhea. 

(d)  Tumors  of  the  cerebral  peduncle. — In  tumors  of  the  cms, 
the  tremor  presents  the  same  features  as  in  Parkinson's  disease, 
but  is  generally  unilateral. 

(e)  Post-hemiplegic  tremor  is  sufficiently  characterized  by 
the  history  of  hemiplegia  and  exaggeration  of  the  reflexes. 

(/)  The  tremor  of  progressive  general  paralysis  exhibits  a 
rapid  rate;  it  is  accompanied  by  a  special  difficulty  of  speech, 
by  pupillary  disturbances  (Argyll-Robertson  pupil),  and  by 
special,  characteristic  changes  of  mentality. 

(g)  Meige  has  called  attention  to  the  occurrence  of  tremor  of 
the  type  of  paralysis  agitans  in  wound  cases. 

III.  Hysteric  Tremor. — A  special  division  is  required  for  hysteric 
tremors.  These  do  not  belong  in  any  of  the  foregoing  categories. 
Their  various  modalities  closely  imitate  most  of  the  other  forms  of 
tremor.    How  are  they  to  be  differentiated,  then,  from  such  tremors, 


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TREMOR.  1311 

and  in  particular,  from  toxic,  exophthalmic,  Parkinsonian  tremors, 
etc.?  Such  differentiation  is" often  rendered  all  the  more  difficult 
in  that  hysteria  is  frequently  combined  with  most  varied  forms  of 
intoxication  and  neurosis. 

On  the  whole,  the  diagnosis  of  hysteric  tremor  is  founded  on 
two  groups  of  symptomatic  features : 

1.  Positive  indications:  Sudden  onset,  following  convulsive 
seizures,  in  a  subject  exhibiting  sensory  and  special  sense  stigmata 
of  hysteria;  possibility  of  change  in  the  type  of  tremor  present; 
curative  influence  of  suggestion. 

2.  Negative  indications:  Absence  of  the  usual  signs  of  hyper- 
thyroidia,  of  disseminated  sclerosis,  of  exaggeration  of  the 
reflexes,  etc. 

*     *     * 

The  clinical  course  exhibited  by  the  tremor  may  also  be  of 
diagnostic  assistance : 

1.  Progressive  tremor,  at  first  localized  in  one  limb  or  portion  of 
a  limb,  progressively  extends  to  one  or  more  other  limbs.  Such 
is  the  case  in  the  tremor  of  paralysis  agitans. 

2.  Retrogressive  tremor,  generalized  at  the  start,  tends  gradu- 
ally to  become  localized  in  one  limb  or  portion  of  a  limb.  This  kind 
of  a  clinical  course  obtains  particularly  in  tremor  of  neuropathic 
origin. 

3.  Migratory  tremor,  exhibiting  variable  localizations  both  as 
regards  space  and  time.  Such  changes  in  the  situation  of  the 
tremor  may  come  on  spontaneously;  they  are  rendered  more  dis- 
tinct by  changing  the  positions  of  the  limbs  or  immobilizing  one  or 
more  portions  of  the  limbs.  This  is  frequently  the  case  in  hysteric 
tremor. 

4c       4t       4t 

The  relative  order  of  frequency  of  the  various  types  of  tremor 
as  encountered  in  practice  appears  to  be  as  follows : 


1.  Toxic   tremor    (alcohol,   tea, 
and  coffee). 

2.  Tremor  of  Graves's  disease. 

3.  Neurotic,  hysteric  tremor. 

4.  Senile  tremor. 


5.  Hereditary  tremor. 

6.  Tremor  of  paralysis  agitans. 

7.  Sclerotic     tremor     (dissemi- 
nated sclerosis). 


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1312 


SYMPTOMS. 
TREMOR. 


I. — Accidental. 

Readily  referred  to  its  cause: 

(a)  Elmotional:    Fear,  pleasure,  or  other  pronounced  emotion. 

(b)  Febrile:    (See  Chills.) 

(c)  A  frigore:    Shivering. 

II. — Permanent 
A.  During  motion  (as  typified  in  Disseminated  sclerosis). 


(a)  Disseminated 
sclerosis. 


(b)  Hereditary 
tremor. 


(c)  Toxic  tremor 
(tea,  coffee,  akohol, 
etc.)  (by  far  the 
most  frequent 
form). 


1.  Tremor  absent  during  rest;  sets  in  and  in- 
creases with  voluntary  motion. 

2.  Dizziness,  apoplectiform  attacks,  nystagmus, 
exaggerated  reflexes,  and  scanning  speech. 

1.  Absent  or  slight  during  rest;  sets  in,  with- 
out accentuation,  during  voluntary  motion. 

2.  None  of  the  above  associated  signs;  often 
sets  in  in  childhood. 

1.  Less  extensive,  but  more  rapid  tremor  than 
in  the  preceding  disorders. 

2.  History  of  toxic  poisoning. 


B.  During  rest  (as  typified  in  Paralysis  agitans). 


(a)  Paralysis  agi- 
tans. 


(b)  Graves's  dis- 
ease. 

(r)  Post-hemiplegic 
tremor. 

(d)  Progressive 
general  paralysis. 


1.  Persistent  during  rest ;  lessens  or  disappears 
during  voluntary  motion. 

2.  Special  kinds  of  muscular  rigidity ;  slow, 
jerky  locomotion;  characteristic  facies  and 
posture. 

Tremor  associated  with  frequent  pulse,  goiter, 
and  exophthalmos. 

History  of  hemiplegia;  exaggerated  reflexes. 


Special  speech  disorder;  pupillary  disturbances 
(Argyll-Robertson  pupil)  ;  special  and  char- 
acteristic mental  changes ;  history  of  syphilis. 


in. — Hysteric. 

(a)  Abrupt  onset  after  a  convulsive  seizure;   sensory  and 

special  sense  stigmata;  variability  of  the  type  of  tremor. 
(5)  Absence  of  concrete  somatic  evidences, 
(f)  Mythomania. 


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UPPER  EXTREMITIES,  PAIN  IN. 


This  section  on  pains  in  the  upper  extremities  is  undertaken  by 
the  author  with  some  degree  of  trepidation,  as  such  pains  have 
seemingly  little  to  do  with  "internal  medicine."  Yet  the  author 
has  frequently  found  him3elf  embarrassed  in  the  interpretation 
of  some  of  these  pains.  While  often  of  obvious  causation,  as  in 
herpes  zoster  or  acute  articular  rheumatism,  they  are  at  times 


In  the  succeeding  illustra- 
tions, borrowed  from  the  writ- 
ings of  Mme.  Benisty,  and 
showing  diagrammatically  the 
innervation  of  the  upper  ex- 
tremity, the  fields  of  distribu- 
tions of  the  different  nerves 
are  to  be  recognized  by  the 
kind  of  shading,  as  follows: 


Median  nerve, 

Musculospiral  nerve. 

Musculocutaneous  nerve. 

^^H    Ulnar  nerve. 

^^^    Circumflex  nerve. 
Fig.  879. 

very  obscure,  as  in  many  vasomotor  disturbances  concerning 
which  little  is  as  yet  known. 

In  such  cases,  it  is  necessary  to  carry  out  a  careful,  syste- 
matic anatomo-clinical  analysis,  which,  while  indispensable,  un- 
fortunately does  not  always  yield  clear-cut  information.. 

Any  of  the  tissues  forming  part  of  the  upper  limb  may  be 
the  source  of  painful  disturbances ;  many  brachialgias  constitute 
the  outward  manifestations  of  some  spinal  or  deep  visceral  dis- 
order, ordinarily  mediastinal  and  in  the  majority  of  instances 
aortic  or  peri-aortic. 

Aside  from  the  post-traumatic  affections  (fractures,  luxations, 
sprains,  wounds,  and  contusions),  the  diagnosis  of  which  is  gen- 
erally obvious,  the  joint  disorders  greatly  predominate  as  causes  of 
pain  in  the  upper  extremity,  whether  localized  in  the  shoulder, 

«3  (1313) 


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1314  SYMPTOMS. 

elbow,  the  joints  of  the  carpus  or  metacarpus,  or  the  phalanges. 
Reference  need  not  here  be  made  to  all  the  possible  causes  of 
articular  pains,  a  special  section  having  been  devoted  to  the  subject 
(see  Joint  pains).    Systematic  examination  by  inspection,  palpation, 


Supraclavicular 


Circumflex 


MuBculoapiral 


Musculocuta- 
neous 


Radial 


Median 


Fig.  880. — Peripheral  sensory  dis-  Fig.  881. — Peripheral  sensory  dis- 

tribution in  the  upper  extremity  tribution  in  the  upper  extremity 
(posterior  aspect).  (lateral  aspect). 

and  passive  motion  will  first  of  all  localize  the  pain  in  one  of  the 
above  mentioned  joints.  The  special  features  of  the  joint  disturb- 
ance, the  history,  the  mode  of  onset,  and  the  subsequent  course  will, 
as  a  rule,  enable  the  observer  quickly  to  class  the  condition  under 
one  of  the  following  heads,  viz,,  acute  articular  rheumatism,  gonor- 
rheal rheumatism,  tuberculous  rheumatism,  post-infectious  {e.g,, 
post-typhoid)  rheumatism,  gout,  arthritis  deformans,  etc.    One  can- 


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UPPER  EXTREMITIES,  PAIN  IN. 


1315 


not  too  earnestly  recommend  to  the  practitioner,  as  in  other  dis- 
orders, to  examine  the  painful  region  carefully  and  by  actual  in- 
spection, to  palpate  and  mobilize  it;  in  short,  to  localize  with  care 
the  pain  and  the  actual  local  condition  present,  to  determine  its 
nature  if  possible,  and  especially,  not  to  rest  content  with  the  in- 
definite term  "rheumatism," — a  temi  just  as  devoid  of  true  diag- 
nostic meaning  as  "headache"  or  "pain  in  the  side." 

The  examiner  should  not  forget  the  possibility  of  tabetic  joint 
disease,  which,  while  an  exceptional  disorder,  presents  characteristic 


Figs.  882  and  883. — Two  common  types  of  distribution  of  the  sensory 
disturbances  in  complete  section  of  the  radial  nerve.  Black  area: 
Anesthesia  to  all  stimuli  except  deep  pricking,  which  is  often  felt  as  a 
mere  contact  with  the  tissues.  Gray  area:  Marked  hyperesthesia  to 
pricking,  anesthesia  to  heat,  cold,  and  very  superficial  tactile  stimuli. 
Dotted  area :  Slight  hypoesthesia  to  tactile  stimuli  and  to  heat  and  cold. 
(Mtne.  Benisty). 

features  consisting  of  a  striking  degree  of  deformity,  extreme  re- 
laxation of  the  joint,  and  painlessness.  If  only  the  condition  is  kept 
in  mind,  the  diagnosis  can  be  made  by  observation  of  the  other 
signs  of  tabes,  vis.,  specific  history,  reflex  disturbances  (Argyll- 
Robertson  pupils  and  loss  of  knee-jerks),  astasia,  ataxia,  lightning 
pains,  sphincter  disturbances,  etc. 

Disorders  of  bones — osteitis,  osteoperiostitis,  osteoarthritis, 
and  osteomyelitis — are,  in  the  order  of  their  frequency : 

Tuberculous:  Periostitis  and  osteoarthritis  (white  swelling). 

Syphilitic:    Osteoperiostitis  and  gumma. 


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1316  SYMPTOMS. 

Post-infectious:    Staphylococcic  (osteomyelitis) . 
Neoplastic :    Osteosarcoma. 

The  following  features  will  insure  a  proper  diagnosis: 
1.  The  history :    Lymphatic  diathesis,  specific  taint,  infection 
(typhoid  fever  or  staphylococcic  infection). 


Superficial  cenrlcal  plexus 


Circumflex 


Intercostal  branches* 


External  cutaneous/ 
Intercostohumeral . 
Internal  cutaneous] 


Musculocutaneous/ 


Ulnar 
Radial  (external  branch) 

Median  (palmar  cutaneous  branch) 

Median    (digital   branches) 
Ulnar  (terminal  superficial  branch)  • 

Fig.  884. — Peripheral  sensory  distribution  in  the  upper 
extremity  (anterior  aspect). 

2.  Fever  (generally  wanting  in  syphilis  and  neoplasms). 

3.  Localization  particularly  around  the  joint  in  tuberculous 
disease. 

4.  A    rather    sluggish    clinical    course    in    tuberculosis    and 
syphilis. 

5.  The  nature  of  the  pain,  with  nocturnal  exacerbations  in 
syphilis. 


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UPPER  EXTREMITIES,  PAIN  IN, 


1317 


6.  special  tests  such  as  the  Wassermann  reaction  and  the 
successful  therapeutic  test  (mercury  and  iodide)  in  syphilis. 

Disorders  of  the  muscles  and  serous  surfaces,  viz.,  myositis, 
subacromial  bursitis,  and  deltoid  rheumatism,  are  possible  localiza- 
tions of  rather  poorly  defined  painful  manifestations,  the  origin  of 
which,  however,  seems  actually  to  be  that  mentioned  by  Le  Gendre: 
"Deficient  functioning  of  the  locomotor  apparatus,  either  through 
lack  of  exercise  (sedentary  mode  of  life)  or  through  excessive  mus- 
cular labor."    Such  a  deficiency  through  loss  of  functional  balance. 


Fig.  885.— Palm  of  the  hand.  ^ig.  886.— Dorsum  of  the  hand. 


EWstribution  of  the  disturbances  of  sensation  in  severe  injuries  of 
the  median  nerve.  Black  area:  Complete  anesthesia  of  all  types.  Gray 
area:  Hypoesthesia  to  pricking  and  anesthesia  to  heat  and  cold.  Dot- 
ted area:    Less  marked  hypoesthesia. 

''when  it  has  been  present  in  patients,  necessarily  places  the  various 
component  parts  of  the  locomotor  apparatus  in  a  weakened  state  in 
which  it  becomes  susceptible  to  influences  ordinarily  not  noticed  by 
well  persons;  these  are  the  influences  to  which  we  are  constantly 
exposed,  inc.,  the  cosmic  influences.  Among  these  influences,  the 
best  studied  has  been  that  of  cold,  which  is  even  considered  an 
etiologic  factor — especially  damp  cold  and  long-continued  cold  or 
exposure.'* 

The  upper  extremity  may  be,  and  manifestly  is,  the  seat  of 
neuralgia  and  neuritis  variously  situated  (e.g.,  ulnar,  radial,  or 
median)  and  of  varying  cause:    Traumatic  (contusions,  open  sur- 


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1318  SYMPTOMS. 

faces  and  wounds),  toxic  (lead  poisoning,  alcohol,  etc.),  pressure 
(osteoperiostitis,  osteosarcoma,  or  defective  callus  of  the  humerus, 
radial  paralysis  of  lovers,  etc.),  and  infections.  Careful  examina- 
tion for  local  sensitiveness  (see  illustration  showing  the  distribu- 
tion of  the  sensory  nerves),  as  well  as  of  mobility  (paralysis;  see 
illustration  showing  distribution  of  the  motor  nerve  fibers)  will 
soon  lead  to  discovery  of  the  site  of  the  lesion.  The  history  and 
even  the  location  of  the  neuritis  will  frequently  permit  of  tracing 
the  cause  of  the  disturbance. 

Lastly,  mention  may  be  made  of  vasomotor  disturbances, 
represented  in  the  highest  degree  by  Raynaud's  disease  (local 
asphyxia  of  the  extremities),  and  seemingly  often  of  specific 
origin,  whether  acquired,  inherited,  or  secondary  to  a  mitral 
malformation. 

Exceptionally,  in  particular  among  the  Senegalese,  there  may  be 
noted  evidences  of  leprosy  of  the  nervous  or  anesthetic  types,  the 
nerve  symptoms  being  manifest  in  a  prodromal  stage  by  a  monili- 
form  enlargement,  frequently  of  considerable  size,  of  the  nerve 
trunks,  which  are  very  sensitive  to  pressure;  later,  the  pain,  of 
neuralgic  t3rpe,  is  constant  and  spontaneous,*  with  repeated  violent 
paroxysms;  it  is  accompanied  by  dysesthesias  (itching,  etc.)  and  by 
vasomotor  disturbances  ("dead  finger"  sign),  and  ends  in  anes- 
thesia, with  trophic  disorders,  atrophy  of  muscles,  and  deformity. 
These  manifestations  of  leprosy  exhibit  great  clinical  analogy  with 
syringomyelia  and  with  ''Morgan's  disease'*  or  panaritium  analgicum. 

Pain  in  the  arm  occurring  in  the  absence  of  any  local  lesion, 
whether  muscular,  articular,  'osseous,  nervous,  or  vascular,  may 
constitute  the  outward  expression  of  remote  lesions,  the  most  im- 
portant of  which  are : 

(a)  Aortic  and  periaortic  lesions  (radiation  of  the  pains  of 
angina  pectoris  and  aneurysm  to  the  arm). 

(fc)  Certain  *'high"  forms  of  degeneration  of  the  posterior 
columns  (lightning  pains  of  cervical  tabes). 

(c)  Lesions  of  the  brachial  plexus. 

(d)  Certain  mediastinal  tumors. 

(a)  The  pain  of  angina  and  of  aortic  and  periaortic  disorders  in 
general  is,  as  a  rule,  felt  in  the  area  of  distribution  of  the  fourth 


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UPPER  EXTREMITIES,  PAIN  IN.  1319 

left  dorsal  nerve  over  the  chest  and  arm.  It  may  descend  and 
radiate  as  far  as  the  epigastrium  in  the  areas  of  distribution  of  the 
fiftband  sixth  dorsal  nerves.  More  often,  however,  it  ascends  and 
radiates  along  the  first,  second,  and  third  dorsal  or  even  the  seventh 
and  eighth  cervical  nerves,  being  felt,  therefore,  along  the  ulnar 


Muscles  Nerves  Roots 

Deltoid  Circumflex  C,*  C.« 

Fectoralls  major  Circumflex  C,*  C,«  C.^ 

Triceps  Musculosplr.  C,"  CJ 

Biceps  MuBculocut.  C,^  C* 

Bracbialis  ant      Musculocut.  C,'  C." 

Pronator  teres       Median  C,«  C' 

Supinator  longus  Musculosplr.  C,*^  C* 

Ext.    carpi  rad.     Musculosplr.  C,*  C 
long,  and  brev. 


Flexor  carpi 
rad. 

Median 

C  c,»  d: 

Palmaris  longus 

Median 

C,8  D.i 

Flexor  sublim. 
dig. 

Median 

C,8  D.i 

Flexor   carpi 
uln. 

Ulnar 

0,8  D.i 

Thenar  muscles 

Median 

c.«  c.f 

Hypothenar 
muscles 

Ulnar 

C,«  D.i 

Fig.  887. — Nerve-supply  of  the  muscles  of  the  upper  extremity 
(anterior  aspect). 

border  of  the  forearm  and  hand.  This  constitutes  the  typical  area 
of  distribution  of  anginose  pain,  vie.,  precordial  (mammillary),  left 
upper  thoracic  (axillary),  and  ulnar. 

Exceptionally,  the  pain  extends  to  the  corresponding  areas 
on  the  right  side  (chiefly  in  cases  with  aortic  dilatation)  and  to 
the  neck,  including  its  posterior  aspect  (nuchal  region). 


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1320  SYMPTOMS. 

Such  pain  is,  as  is  well  known,  when  present  in  conjunction  with 
a  feeling  of  constriction  of  the  chest  (squeezing  sensation  or  suffo- 
cation) and  a  fear  of  impending  death,  the  cardinal  indication  of 
angina  pectoris.  It  should  always  be  borne  in  mind,  however,  that 
many  neuropathic  states,  whether  or  not  based  on  some  cardioaortic 
disease,  may  lead  to  a  syndrome  of  "anxiety  neurosis"  similar  in  all 
respects  to  the  anginose  syndrome,  yet  far  more  favorable  from  the 
standpoint  of  prognosis.     For  a  discussion  of  the  differential  diag- 


Fig.  888. — Distribution  of  the  pain  and  cutaneous  hyperalgesia  after 
repeated  attacks  of  angina  pectoris. 

nosis  in  this  connection  the  reader  is  referred  to  the  section  on 
Precordial  pain. 

(b)  Aortic  aneurysm  may  cause  pain  in  the  arm  of  threefold 
origin :  \ 

1.  Anginose  pain  of  the  type  above  described. 

2.  Neuralgic  or  neuritic  pressure  pain. 

3.  Pain  due  to  stasis  on  account  of  pressure  on  venous  trunks. 
These  pains  may  be  of  unbearable  intensity  and  necessitate 

the  use  of   morphine.      Oftea   the    clinical    evidences,    such    as 
aneurysmal  swelling  and  signs  of  pressure  on  the  veins  (visible 


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UPPER  EXTREMITIES,  PAIN  IN.  1321 

venous  network  in  the  superior  caval  area,  swelling  of  the  neck, 
edema  of  the  face,  and  inequality  of  the  pulse  on  the  two  sides, 
etc.),  are  obvious;  fluoroscopic  examination  will  remove  all 
doubt  as  to  the  condition  present. 

(c)  The  same  is  true  in  tumors  of  the  medidstinum.  The  coex- 
istence of  pain  in  one  or  both  upper  extremities  with  evidences  of 
interference  with  the  return  circulation  in  the  superior  caval  area 
(cyanosis,  visible  superficial  venous  circulation,  swelling  of  the  neck 
and  face,  prominence  of  the  eyeballs,  and  facial  edema)  is  almost 
pathognomonic  of  mediastinal  tumor,  e.g.,  dilatation  of  the  aorta, 
pericarditis  with  effusion,  enlarged  lymphatic  glands,  etc. 

((/)  The  pains  of  tabes,  although  much  less  common  in  the  upper 
than  in  the  lower  extremities — the  latter  constituting  the  site  of 
election — ^may  occur  as  the  usual  "lightning  pains,"  sharp,  abrupt, 
and  fulgurant,  like  lightning.  Sometimes  they  occur  singly,  at 
others  grouped  in  paroxysmal  attacks  of  varying  duration — from 
one  to  several  days.  They  are  felt  more  particularly  along  the  inner 
border  of  the  forearm  and  the  fifth  and  fourth  fingers.  They  may 
be  of  the  piercing,  burning,  lancinating  type ;  at  times,  however, 
they  are  of  the  nature  of  a  constriction,  squeezing,  or  ring-like  pain. 
This  special  characteristic  of  the  pains  of  tabes — ^though  not  an 
exclusive  attribute,  since  it  may  be  met  with  likewise  in  peripheral 
neuritis  (due,  e.g.,  to  alcoholism  or  leprosy)  and  in  pressure  on 
nerve-roots — is  nevertheless,  as  a  rule,  highly  suggestive.  Let  the 
observer  merely  recollect  the  possibility  of  tabes — and  how  could  he 
fail  to  think  of  it  in  such  cases? — and  the  diagnosis  will  bo  quickly 
confirmed  by  examination  for  the  typical  tabetic  indications  (specific 
history,  reflex  disturbances,  motor  disturbances,  visceral  disturb- 
ances, particularly  genitourinary,  etc.). 


The  foregoing  review  by  no  means  exhausts  the  possibilities  as 
regards  pain  in  the  upper  limbs.  Various  exceptional  clinical  con- 
ditions, such  as  supernumerary  cervical  rib,  poliomyelitis,  etc.,  have 
been  designedly  omitted  in  order  not  to  make  the  present  section  too 
unwieldy. 

The  same  applies  to  abscesses,  felons,  lymphangitis,  phlegmonous 
inflammations,  and  the  attendant  glandular  enlargements — all  con- 


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1322  SYMPTOMS. 

ditions  met  with  in  everyday  practice,  but  the  diagnosis  of  which  is 
ordinarily  devoid  of  difficulty  and  to  which  reference  is  here  made 
merely  to  call  them  to  the  reader's  mind. 

In  conclusion,  the  hope  may  be  expressed  that  the  reader  will 
find  lessi  difficulty  in  reading  and  reflecting  on  this  section  than 
the  author  experienced  in  writing  it. 


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VERTIGO.  [Vertigo,  frcm  vertere,  to  ium.'\ 


Vertigo  is  characterized  by  a  mistaken  subjective  sensation  in 
virtue  of  which  the  patient  believes  himself  to  be  rotating  al- 
though he  is  motionless,  or  sees  surrounding  objects  turning 
about  him  although  they  are  at  rest.  When  vertigo  is  persistent 
or  very  marked,  it  may  induce  loss  of  equilibrium  and  a  fall  to 
the  ground  if  the  subject  is  in  the  standing  position  at  the  time. 
It  may  be,  and  frequently  is,  attended  with  nausea,  or  even 
vomiting,  and  by  nystagmus  or  even  deviation  of  the  eyes. 

The  highly  complex  pathogenesis  of  this  symptom  seems,  at  the 
present  time,  to  be  rather  well  condensed  in  the  following  definition 
formulated  by  Grasset:  Vertigo  is  the  symptom  of  functional  in- 
sufficiency (intermittent  claudication)  of  the  automatic  centers 
(mesencephalic  and  cerebellar)  of  equilibration.  Bonnier,  as  is  well 
known,  has  made  a  profound  study  of  vertigo  from  the  physio- 
pathologic,  clinical,  and  therapeutic  standpoints. 

These  automatic  mesencephalic  and  cerebellar  centers  of 
equilibration: 

1.  Receive: 

(a)  Vestibular  fibers  coming  from  the  semicircular  canals 
through  the  auditory  nerve. 

(b)  Visual  fibers  coming  from  the  retina  through  the  optic 
nerve. 

(c)  Muscle-sense  fibers  from  Clarke's  columns  and  the  posterior 
columns. 

2.  Send: 

(a)  Fibers  terminating  in  the  Rolandic  area  on  the  opposite  side 
and  acting  on  the  motor  centers. 

(b)  Fibers  terminating  in  the  nucleus  of  Deiters,  which  is  con- 
nected with  the  oculomotor  nerves,  these  in  turn  governing  the 
ocular  muscles. 

(c)  Fibers  terminating  in  the  anterior  horns  of  the  spinal  cord, 
whence  radiate  motor  fibers  to  the  voluntary  muscles. 

(1323) 


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1324  SYMPTOMS. 

(rf)  Fibers  to  other  bulbar  centers  (glossopharyngeal  and  pneu- 
mogastric). 

These  anatomic  and  physiologic  connections  of  the  mesen- 
cephalic  and  cerebellar  centers  account  for  the  following: 

(a)  The  clinical  combination  of  vertigo,  disturbances  of  equilib- 
rium, nausea,  and  ocular  disturbances  (nystagmus  and  deviation  of 
the  eyeballs).  (Normal  equilibrium  is  the  result  of  harmony  of  the 
retinal,  labyrinthine,  and  muscular  impressions). 


AflFerent  paths. 
EflFerent  paths. 


1.  Vestibular  fibers. 

2.  Semicircular  canals. 

3.  Acoustic    nuclei    of    Bech- 

terew  and  Deiters. 

4.  Visual  fibers. 

5.  Corpora  quadrigemina. 

6.  Sensory  fibers. 

7.  Columns  of  Clarke. 

8.  Cerebello-rolandic  commis- 

sural fibers. 

9.  Cerebello-auditory  fibers. 

10.  Cerebello-oculomotor  fibers. 

11.  Cerebello-spinal  fibers. 

12.  Cerebello-bulbar  fibers. 

13.  Muscles. 

14.  Retina. 


Fig.  889.— -Pathogenesis  of  vertigo  (Bonnier),  The  cerebellum  ap- 
pears as  the  "vertigo  center,"  whence  the  frequency,  if  not  the  uniform 
presence,  of  vertigo  in  cerebellar  disorders. 

(fc)  The  factors  generally  causative  in  vertigo: 

1.  Disorders  and  pathologic  changes  in  the  centers  of  equili- 
bration (cerebellum  and  crura). 

2.  Wrong  or  disharmonious  impressions  supplied  from  the 
receptive  structures  (retina,  labyrinth,  and  muscle-sense). 

3.  Morbid  stimuli  in  the  field  of  the  pneumogastric  nerve 
(gastric  disorders,  helminthiasis,  etc). 

From  the    foregoing    brief    and    synoptic    enumeration    the 
reader  will  readily  conceive  how  common  vertigx)  may  be  and 


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VERTIGO.  1325 

in  how  many  different  varieties  it  may  occur,  and  what  powers 
of  clinical  analysis  will  frequently  have  to  be  brought  to  bear 
in  seeking  its  causes  (auricular  vertigo,  arteriosclerotic  vertigo, 
cerebral  vertigo,  neurotic  vertigo,  migrainous  vertigo,  ocular 
vertigo,  epileptic  vertigo,  toxic  vertigo,  etc.) 

Under  physiologic  conditions,  vertigo  may  be  brought  on  by 
abrupt  change  in  the  position  of  the  body,  e.g,,  rising  from  re- 
cumbency to  the  standing  posture,  by  an  abrupt  change  of  di- 
rection or  motion,  by  rapid  rotation,  by  an  ascent,  and  by  looking 
down  from  a  high  place.  Travelling  in  a  railway  or  trolley  car 
suffices,  as  is  well  known,  to  induce  vertigo  in  some  persons. 
Vertigo  is  an  essential  component  of  seasickness.  •  The  electric 
current,  in  particular  the  application  of  the  galvanic  current  to 
the  head,  or  sharp  percussion  of  the  middle  ear  by  use  of  the 
aural  syringe,  will  induce  vertigo  in  predisposed  individuals. 

Clinically,  one  cannot  here  do  more  than  recall  in  a  concise 
table  the  more  usual  causes  of  vertigo,  which  investigation  of 
the  concomitant  symptoms  will  alone  identify : 

L— CENTRAL  VERTIGO. 

Central  vertigo  occurs  mainly  when  the  position  of  the  body  is 
changed,  e.g.,  upon  passage  from  the  horizontal  to  the  vertical 
position. 

Arteriosclerosis. — ^The  highest  degree  of  importance  should 
be  attached  to  vertigo  coming  on  without  apparent  cause  in 
elderly  individuals  previously  never  afHicted  with  it.  Old  age, 
vertigo  and  high  blood-pressure,  present  in  combination,  nearly 
always  mean  arteriosclerosis.  The  vertigo  may  be  of  mild  de- 
gree, even  in  this  type  of  case,  and  remain  so  for  years ;  some- 
times— too  often — it  is  an  alarm  signal  betokening  an  approach- 
ing and  threatening  attack  of  apoplexy. 

Cerebral  tumor. — Vertigo  is  observed  in  the  majority  of 
cases  of  frontal  tumor  and  in  over  one-third  of  cases  of  tumor  in 
other  regions  of  the  cerebrum ;  the  attacks  of  vertigo  seem  to 
correspond  to  the  periods  of  enlargement  of  the  tumor.  Examin- 
ation of  the  eyegrounds  for  choked  disc  should  never  be  neglected 


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1326  SYMPTOMS. 

in  suspected  cases,  and  other  signs  of  brain  tumor,  such  as 
vomiting,  etc.,  should  be  inquired  for. 

Cerebellar  tumor. — Vertigo  is  almost  constant  in  tumors  of 
the  cerebellum;  in  nearly  all  instances  it  is  associated  with  dis- 
turbances of  equilibriiun  which  lead  to  a  staggering  gait,  latero- 
pulsion,  a  gait  as  of  "pseudo-intoxication" — ^the  cerebellar  gait, 
which  is  highly  significant  to  a  practised  eye. 

Disseminated  sclerosis. — Vertigo  is  one  of  the  most  frequent 
signs  of  disseminated  sclerosis,  being  combined  with  nystagmus 
and  the  intention  tremor  characteristic  of  this  disorder. 

Paretic  dementia. — Vertigo  occurs  in  two  stages  of  this  in- 
curable affection,  zis,,  at  the  start,  in  the  preliminary  stage,  and 
in  the  advanced  stage,  as  a  precursor  of  some  acute  complicatibn, 
such  as  coma,  convulsions,  or  hemiplegia. 

Disturbed  circulation  in  the  centers,  whether  of  hyperemic  or 
anemic  type,  and  whether  dependent  upon  actual  congestion, 
actual  anemia,  or  vasomotor  disturbances,  may  be  an  exciting 
cause  of  vertigo.  Such  is  the  vertigo  of  syncope  (in  its  premoni- 
tory stage),  of  the  menopause,  of  chloroneurosis,  of  the  anemias, 
of  hemorrhage,  of  heart  disorders,  etc. 

II.— AURAL  VERTIGO. 
M6nidre*8  verti^^o. — Labyrinthine  vertigo.! 
(By  G.  Laurens,  M.D.) 

What  is  meant  by  aural  vertigo? — One  portion  of  the 
ear,  as  is  well  known,  is  concerned  in  audition,  and  the  other  in 
equilibration,  i.e.,  in  orientation  of  the  head,  which  plays  an  im- 
portant role  in  the  maintenance  of  bcdy  balance.  These  two  por- 
tions are  independent: 

Disease  of  the  one  causes  deafness  and  .tinnitus. 

Disease  of  the  other  causes  vertigo. 

What  is  M6niire's  disease? — About  fifty  years  ago  Meniere 
described  a  disorder  characterized  by  the  following  three  symptoms: 
vertigo,  deafness,  and  tinnitus,  and  on  post-mortem  examination  of 
the  few  cases  upon  which  his  contribution  was  based,  observed 


1  From  Laurens  :    Loc.  cit.,  p.  132  ff. 


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VERTIGO.  1327 

hemorrhage  into  the  internal  ear.^    Thus,  only  a  very  small  number 
of  cases  served  in  the  earliest  description  of  this  disease. 

Since  then,  the  meaning  of  the  term  has  been  expanded,  and 
whenever  a  patient  presents  aural  vertigo  he  is  said  to  be 
suffering  from  Meniere's  disease.  This  is  a  mistake,  however,  for 
while  the  symptom  is  the  samie,  the  underlying  pathologic  con- 
dition is  entirely  different,  and  it  is  well  to  bear  in  mind  that 
any  disease  of  the  ear  (external,  middle,  internal,  Eustachian 
tube,  tympanic  membrane,  and  tympanic  cavity,  .  .  .  e.g.,  an 
ordinary  impaction  of  earwax,  or  suppurative  otitis)  is  capable 
of  bringing  on  vertigo  with  deafness  and  tinnitus.  This  occurs 
through  irritation  of  the  labyrinth.  Thus,  given  a  plug  of  wax  in 
contact  with  the  tympanic  membrane  and  forcing  in  the  latter, 
and  consequently  also  the  chain  of  ossicles,  irritation  of  the 
labyrinth  results;  and  the  same  is  true  when  there  is  increased 
tension  of  the  labyrinthine  fluid  from  the  presence  of  pus  in 
otitis,  and  where  there  is  anemia,  congestions  or  infection  of  the 
internal  ear  in  certain  constitutional  disorders  or  through  poison- 
ing by  drug^  such  as  quinine  and  sodium  salicylate. 

To  recapitulate: 

1.  The  term  Meniere's  disease  should  be  exclusively  set  apart  for 
vertigo  induced  by  an  actual  hemorrhage  into  the  labyrinth.  This 
condition  is  very  uncommon. 


1  Meniere's  initial  case  is  deserving  of  reproduction ;  he  studied  it  in 
Chomers  service,  being  at  that  time  on  the  staflF  of  the  Hotel-Dieu. 

"A  young  girl,  having  travelled  at  night  on  the  top  of  a  stage-coach  dur- 
ing her  menstrual  period,  was  seized,  after  considerable  exposure  to  cold, 
with  sudden  and  complete  deafness.  Upon  admission  in  Qiomer's  service 
she  showed  constant  vertigo  as  the  chief  symptom ;  the  least  attempt  to  move 
brought  on  vomiting,  and  death  took  place  on  the  fifth  day. 

"The  necropsy  showed  the  cerebrum,  cerebellum,  and  spinal  cord  to  be 
completely  free  of  any  patholbgio  change;  but  inasmuch  as  the  patient  had 
become  suddenly  deaf  after  having  always  enjoyed  good  hearing,  I  removed 
the  temporal  bones  in  order  to  make  a  careful  inquiry  into  what  might  be 
the  cause  of  this  complete  deafness  of  such  sudden  advent.  I  found  nothing 
in  the  way  of  a  pathologic  change  save  the  filling  of  the  semicircular  canals 
with  a  plastic  red  material,  a  species  of  bloody  exudation,  of  which  only 
traces  could  be  seen  in  the  vestibule  and  which  was  entirely  absent  from  the 
cochlea.  Careful  investigation  enabled  me  to  establish  with  all  necessary 
accuracy  that  the  semicircular  canals  were  the  only  structures  exhibiting  an 
abnormal  condition  in  this  case.'' 


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1328 


SYMPTOMS. 


2.  There  occurs  also  a  syndrome  of  Miniere,  or,  more  com- 
monly, aural  vertigo,  when  there  is  irritation  of  the  internal  ear 
from  any  cause. 

How  is  one  to  recognize  the  existence  of  aural  vertigo? 

1.  From  the  nature  of  the  disturbances  complained  of  by  the 
patient. 

2.  By  otoscopic  examination. 


Cerebral  cortex 


I 

2 


6 


Fig.  890. — Diagram  illustrating  aural  vertigo. 

The  two  portions  of  the  internal  ear:  1.  The  auditory  portion,  rep- 
resented by  the  cochlea  and  related  to  the  cochlear  nerve.  2.  The  organ 
of  equilibration  or  of  the  spacial  sense,  represented  by  the  vestibule  and 
semicircular  canals  and  related  to  the  vestibular  nerve. 

1.  From  the  Nature  of  the  Disturbances  Complained  of  by 
the  Patient.. 

(a)  Sometimes  he  will  tell  you  that  while  in  perfect  health, 
without  any  noticeable  cause,  he  felt  a  sort  of  explosion  or  intense 
sound  in  the  ear.  At  the  same  moment,  there  was  tinnitus,  dizziness, 
sometimes  an  actual  fall  to  the  floor,  with  or  without  nausea  and 
vomiting.  This  attack  lasted  from  a  few  minutes  to  a  few  hours; 
as  soon  as  it  ended,  the  patient  noticed  that  he  was  deaf.  This 
major  attack  sometimes  recurs,  but  in  a  much  less  pronounced  form. 

Such  is  a  typical  case  of  Meniere's  disease. 


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VERTIGO,  1329 

(&)  In  some  instances,  the  subject  is  a  person  in  good  health  in 
whom  vertigo  appears  without  the  least  apparent  cause — and  this 
is  frequently  the  case ; — in  other  instances  he  is  already  deaf,  suffer- 
ing from  otosclerosis,  or  acute  or  chronic  suppurative  otitis;  or, 
again,  in  the  course  of  some  general  infectious  disease,  or  some- 
times following  ingestion  of  drugs,  such  as  quinine  and  salicylates, 
he  was  seized  with  the  symptoms  already  mentioned,  ins,: 

Vertigo,  causing  staggering,  failing  to  disappear  in  recumbency 
or  upon  closure  of  the  eyes,  drawing  the  patient  toward  the  side 
of  the  affected  ear,  and  lasting  a  few  hours ;  sometimes  inducing 
a  continuous  state  of  malaise  with  dizziness;  acute  tinnitus,  with 


8.^ 


Fig.  891.— The  causes  of  aural  vertigo.  Aural  vertigo  may  be  the 
result  of  a  disorder  of  the  external  ear  (/)  (foreign  body,  wax  in  con- 
tact with  the  drum,  etc.)  ;  of  otitis  media  (2)  ;  of  hemorrhage  in  the 
labyrinth  (Meniere's  disease),  or  of  anemia,  hyperemia,  or  suppuration 
of  the  labyrinth,  intoxication  by  drugs,  or  general,  infectious  diseases. 
This  is  the  common  form  of  aural  vertigo. 

loud  whistling  soimds;  increasing  deafness.  This  symptom- 
group  is  at  times  supplemented  by  bilious  vomiting,  appearing 
spontaneously,  without  the  least  exertion,  and  which  the  physi- 
cian is  led  to  ascribe  to  dyspepsia. 

Such  is  the  ordinary  type  of  aural  vertigo.  Its  existence  must 
be  confirmed : 

2.  By  Otoscopic  Examination. 

The  observer  finds  in  some  instances  a  plug  of  wax,  sometimes 
an  otitis,  and  in  still  others  an  absolutely  normal  tympanic  memr- 
brane:  this  last  means  that  the  vertigo  is  of  labyrinthine  origin. 

S4 


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1330  SYMPTOMS. 

IIL— NEUROPATHIC  VERTIGO. 

1.  In  a  first  group  should  be  plax:ed  neurasthenia,  psychoneu- 
roses,  and  the  neuroses  of  congenital  origin,  in  which  there  seems 
to  be  operative  a  congenital  or  acquired  hypersensitiveness  to 
stimuli  and  impressions  of  all  kinds,  sometimes  with  an  added 
autosuggestibility  which,  for  example,  may  automatically  start 
an  attack  of  vertigo  in  the  presence  of  some  factor — such  as  an 
odor,  railway  travel,  riding  in  a  carriage,  etc. — ^which  had  already 
been  previously  associated  with  vertigo. 

2.  In  a  second  group  we  shall  place  epilepsy,  in  which  vertigo 
may  be  encountered  either  as  a  premonitory  aura  or  as  an  equiv- 
alent of  the  epileptic  seizure. 

IV.— TOXIC  VERTIGO. 

This  may  be  due  to. alcohol,  tobacco,  carbon  monoxide,  qui- 
nine, sodium  salicylate,  or  cannabis.  The  pathogenesis  seems  to 
be  complex — angiospastic  conditions  in  the  brain,  congestion  of 
the  internal  ear,  transient  cerebral  anemia,  etc. 

The  influence  of  renal  disease  has  been  clearly  shown  by  Bonnier, 
who  called  attention  to  the  frequent  occurrence  of  vertigo  in  renal 
cases  and  proposed  as  a  suitable  term  in  this  connection  the  word 
otobrightism.  Here  is  another  circumstance  showing  how  impor- 
tant it  is  to  test  the  blood-pressure  and  examine  the  urine  (and  the 
renal  functions  more  generally)  in  all  patients,  and  in  cases  of 
vertigo  in  particular.  The  practitioner  should  keep  in  mind,  at 
least,  that  vertigo  may  be  dependent  upon  high  blood-pressure, 
arteriosclerosis,  and  uremia. 

v.— REFLEX  VERTIGO. 

Perhaps  it  is  best  to  place  under  this  heading  the  so-called 
"gastric  vertigo"  or  'Vertigo  a  stomacho  laeso"  of  older  authors. 
These  cases  have  been  rather  overlooked  of  late.  One  should, 
however,  bear  in  mind — in  general  practice — that  vertigo,  what- 
ever be  its  precise  mode  of  production,  is  with  exceeding  fre- 
quency, if  not  constantly,  associated  with  nausea  and  vomiting; 
that  it  is  often  manifested  in  "gastric  upsets"  of  varying  cause 
and  origin,  and  that  it  frequently  yields  in  these  cases  to  treat- 


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VERTIGO.  1331 

ment  directed  toward  the  alimentary  tract,  vis.,  diet,  purgation, 
and  stomach  washing. 

It  is  a  fact  that  vertigo  and  vomiting  or  nausea,  present  in 
combination,  may  be  obviously  dependent  upon  a  single  cause 
which  brings  them  on  at  the  same  time  and  is  associated  with 
and  regulates  them,  as  in  seasickness,  mountain  sickness,  car 
sickness,  and,  as  we  have  already  seen,  brain  tumors. 

VL— VERTIGO  WHICH  RESTORES  THE  SENSE 
OF  *H  EARING. 

In  a  well-grounded  and  highly  suggestive  article  entitled 
"Vertigo  which  restores  the  sense  of  hearing; — labyrinthine  an- 
giospasm,'' Lermoyez^  described  a  curious  vertiginous  symptom- 
group  characterized  by  abrupt  and  violent  onset  with  recovery 
within  a  few  hours  of  hearing  in  subjects  whose  auditory  func- 
tion had  previously  seemed  hopelessly  lost. 

"It  appears  to  me,"  he  wrote,  "that  one  has  to  deal  in  these  cases 
with  local  angiospasms  in  neuroarthritic  (or,  as  I  would  rather  put 
it,  gouty)  subjects  possessed  of  exaggerated  sensitiveness  of  the 
internal  ear,  both  as  regards  external  stimuli  (clattering  sounds, 
violent  and  prolonged  movements)  and  internal  irritants  (various 
intoxications  and  especially  gastric  autointoxications) — which  ex- 
cuses Trousseau  for  having  conceived  his  celebrated  vertigo  a  stotn- 
acho  laeso!" 

Lermoyez  compares  the  condition  to  the  local  asphyxia  of  the 
extremities  with  the  characteristic  painful  numbness  (onglee) 
which  precedes  restoration  of  circulation  through  the  tissues. 

"Similar  phenomena  occur  in  the  ears,  and  it  would  not  be 
an  exaggeration  to  speak  of  a  'painful  numbness  of  the  laby- 
rinth.' The  closure  of  the  internal  auditory  artery,  which  took 
place  slowly,  induced  gradual  anesthesia  of  the  ear,  i.e.,  deafness. 
But  now  the  spasm  abruptly  relaxes;  the  blood  rushes  anew 
into  the  labyrinth,  which  it  stuns;  and  this  excessively  sudden 
influx,  which,  in  the  fingers,  causes  the  well-known  pain,  here 
induces  simultaneously  the  special  pain  of  the  cochlear  organ, 
which  is  tinnitus,  and  the  suffering  of  the  vestibular  organ, 
which  is  vertigo ;  in  addition,  it  causes  disappearance  of  the  an- 
esthesia of  the  ear,  i.e.,  of  the  deafness." 

1  Presse  mSd.,  Jan.  2,  1919. 


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VOMITING.  [From  vomere,  to  vomit.] 


Vomiting  consists  of  the  evacuation  of  the  stomach  contents 
by  way  of  the  esophagus  and  mouth.  It  constitutes  a  "reversed 
deglutition"  during  which,  as  in  deglutition,  the  openings  of  the 
larynx  and  nasal  cavities  into  the  pharynx  are  closed.  As  a 
matter  of  fact,  esophageal  vomiting  is  also  a  possibility.  In  con- 
trast with  the  preceding  variety,  it  is  not  generally  accompanied 
by  nausea  and  always  results  in  the  ejection  of  food,  though 
sometimes  also  of  varying  amounts  of  blood. 

True  (gastric)  vomiting  is  a  reflex  of  which : 

The  center  is  in  the  medulla,  in  the  vicinity  of  the  respiratory 
center. 

The  afferent,  sensory  nerve-paths  arise  mainly: 

From  the  pneumogastric  (abdominal  stimuli). 

From  the  glossopharyngeal  (pharyngeal  stimuli). 

From  the  trigeminal  (nasal  stimuli). 

From  the  cerebral  cortex  (cerebral  stimuli,  inflammatory,  toxic, 
or  psychic). 

The  efferent,  motor  nerve-paths  follow  chiefly: 

The  phrenic  nerve  (diaphragm). 

The  pneumogastric  nerve  (stomach). 

The  spinal  nerves  (muscles  of  the  abdominal  parietes,  recti,  etc.). 

The  above  anatomic  and  physiologic  features  account  for  the 
fact  that  vomiting  may  be  either  of  central  origin  (meningitis, 
apomorphine,  or  revolting  impressions)  or  of  peripheral  origin 
(appendicitis,  indigestion,  pregnancy,  or  tickling  of  the  uvula). 

The  vomited  material  may  be  either: 

1.  Alimentary.  It  is  extremely  important  to  note  the  degree  of 
previous  digestion  of  the  food  vomited,  its  more  or  less  acid  or 
alcoholic  odor,  its  nature,  and  especially  the  greater  or  less  interval 
between  its  ingestion  and  evacuation.  The  mere  fact  of  the  pres- 
ence of  food  ingested  on  the  preceding  day,  and  especially  on  the 
(1332) 


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VOMITING.  1333 

second  preceding  day,  is  a  serious  indication  of  stasis  with  marked 
probability  of  pyloric  stenosis. 

2.  Bilious. 

3.  Mucous,  as  in  the  morning  vomiting  of  alcoholics. 

4.  Bloody  (see  Hematemesis), 

VOMITING 


Efferent  Vomiting  center  in  meduUa  Afferent  paths  of 

motor  paths  xt       *u  •    .  .  stimulation 

^^^, . Near  the  respiratory  center. 


SI 


;Musc 
lAbdoi 

•oUiqi 
!   vers 


Fig.  892.— Pathogenesis  of  vomiting. 

5.  Fecal  Old,  detected  at  once  by  the  odor,  or  if  necessary  by  the 
pigment  tests.  Such  vomitus  is  of  grave  portent.  It  is  nearly 
always  an  evidence  of  intestinal  obstruction  or  occlusion  (peritonitis, 
strangulated  hernia,  etc.). 

The  history  is  always  of  great  importance : 

In  some  subjects,  vomiting  (rangirfg  from  simple  regurgitation 
to  true  vomiting)  is  an  ordinary,  habitual  event,  which  occurs 
almost  without  effort  and  with  the  greatest  ease.  This  is  the  case 
in  many  children,  in  many  alcoholics,  in  some  hearty  eaters,  and  in 
many  gastric  neuroses.  It  is  important  to  record  the  symptom,  but 
it  is  usually  devoid  of  any  serious  significance. 

In  others,  on  the  contrary,  vomiting  is  diflficult,  distressing,  and 
unusual.    Its  significance  is  much  greater ;  the  physician  must  know 


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1334 


SYMPTOMS. 


that  he  is  not  to  rest  content  with  the  superficial  and  common- 
place explanation  of  indigestion,  but  is  to  make  a  careful  examina- 
tion for  the  obscure  and  serious  causes  of  certain  cases  of  vomiting, 
such  as  uremia,  acetonemia,  brain  tumor,  etc. 

In  other  words,  there  are  some  persons  in  whom  quasi-habit- 
ual vomiting  is  almost  a  negligible  event;  there  are  others,  how- 
ever, in  whom  vomiting  is  exceptional  and  of  marked  clinical 
significance. 

In  regard  to  the  approximate  relative  frequency  of  the  com- 
moner causes  of  vomiting,  Cabot  g^ves  the  following  table : 


Toxemia  of  pregnancy. 

"Acute  dyspepsia'*   (indigestion). 

Alcoholism. 

Seasickness. 

Onset  of  infectious  diseases. 

Postoperative  shock. 

"Gastritis." 
Gastric  neurosis. 
Acute  appendicitis. 
Cardiac  disease. 
Peptic  ulcer. 


Cases  too  many  and  too  vaguely 
enumerable  for  accurate  estima- 
tion. 


Intestinal  obstruction. 
Gastric  cancer. 
Uremia. 
Tabes. 


Diseases  of  the  brain  (meningitis,  abscess,  tumor)  are  not  in- 
cluded; as  a  matter  of  fact,  the  percentage  of  such  cases  in  the 
total  number  of  instances  of  vomiting  is  very  low.  The  foregoing 
list,  moreover,  is  by  no  means  complete;  it  is  well,  at  all  events,  to 
mention  the  vomiting  of  meningitis,  of  acetonemia  (precursor  of 
diabetic  coma),  and  of  hepatic  and  renal  colic. 

It  is  not  in  the  scope  of  this  work  to  review  all  the  possible 
causes  of  vomiting  and  analyze  their  "diflferential  clinical  feat- 
ures ;  it  w^ill  be  sufficient  to  present  a  synoptic  table  of  the  more 
common  causes  with  their  diagnostic  signs. 

Some  space  will,  however,  be  devoted  to  certain  facts  chiefly 
culled  from  an  article  by  Professor  Marfan,*  relating  to  a  peculi- 
arly difficult  task  of  diflferential  diagnosis,  in::.,  that  of  dis- 
tinguishing the  periodic  acetonemic  vomiting  of  children  and 
the  vomiting  symptomatic  of  acute  appendicitis. 


^Presse  med.,  Sept.  11,  1916. 


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VOMITING.  1335 

Periodic  Vomiting  with  Acetonemia  is  not  a  Form  of  Appen- 
dicitis.— The  phrase  **periodic  vomiting  with  acetonemia"  is  ap- 
plied to  a  disorder  of  childhood  characterized  by  attacks  of 
vomiting,  accompanied  from  the  start  with  pronounced  elimina- 
tion of  acetone  with  the  urine  and  expired  air,  such  attacks  gen- 
erally coming  on  during  apparently  satisfactory  general  health, 
lasting  from  a  few  hours  to  a  few  days,  and  stopping  abruptly, 
being  replaced  by  a  state  of  perfect  tolerance  of  food. 

They  occur  almost  exclusively  in  the  children  of  neuroar- 
thritic  parents  (migrainous,  asthmatic,  eczematous,  lithiasic, 
obese,  gouty,  diabetic,  and  hemorrhoidal).  Their  occurrence  is 
favored  by  a  diet  rich  in  fats. 

Some  have  asserted  that  such  periodic  vomiting  with  aceton- 
emia is  due  to  an  acute  attack  of  appendicitis,  constituting  an 
exacerbation  of  chronic  appendicitis.  The  falsity  of  this  view  is 
shown  by  the  fact  that  the  periodic  vomiting  may  occur  in  chil- 
dren whose  appendix  has  already  been  removed. 

Marfan  has  long  been  emphasizing  the  differential  features  of 
these  two  disorders.  The  following  discussion  is  borrowed  from 
his  writings  on  the  subject: 

"Is  the  diagnosis  between  an  attack  of  periodic  vomiting  and 
one  of  appendicitis  a  matter  of  great  difficulty?  In  many  cases 
it  is  not  difficult;  in  a  few,  it  is;  occasionally,  it  is  impossible. 
This  is  what  the  writer  now  wishes  to  prove  by  a  consideration 
of  the  various  features  on  which  the  diagnosis  may  be  based. 

"In  distinguishing  periodic  vomiting  from  the  vomiting 
caused  by  acute  appendicitis,  chief  stress  is  laid  on  the  results 
of  examination  of  the  ileocecal  region.  One  should  not,  however, 
neglect  any  of  the  other  symptoms,  although  they  are  of  less 
value. 

"In  acute 'appendicitis  the  temperature  is,  in  general,  higher 
than  in  the  attacks  of  periodic  vomiting,  in  which  it  is  often 
normal  and  in  which  it  is  high  only  under  exceptional  circum- 
stances and  for  a  short  time.  In  acute  appendicitis,  acetonemia 
is  inconstant,  late  in  appearing,  and  often  slight,  as  it  is  due  to 
the  inanition  resulting  from  the  vomiting  or  from  the  diet  or- 
dered by  the  physician ;  in  periodic  vomiting,  acetonemia  is  con- 
stant and  pronounced,  and  appears  early;  it  may  even  be  ob- 


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1336  SYMPTOMS, 

served  before  the  attax:k.  In  acute  appendicitis  the  vomiting  and 
nausea  are  generally  less  marked  than  in  the  attack  of  aceton- 
emia. In  acute  appendicitis,  the  abdomen  is  frequently  dis- 
tended; in  periodic  vomiting,  very  seldom;  on  the  contrary,  in 
the  latter  disorder  it  is  usually  flat  and  sometimes  scaphoid  as 
in  meningitis.  It  should  not  be  forgotten  that  below  the  age  of 
five  years  appendicitis  is  a  comparatively  rare  aflfection,  being 
more  uncommon  in  that  period  of  life  than  periodic  vomiting. 

**The  decisive  factors  in  the  diagnosis  are,  however,  supplied 
by  examination  of  the  ileocecal  region.  If  superficial  touch 
elicits  cutaneous  hyperesthesia  of  this  entire  region ;  if  forcible, 
deep  palpation  reveals  a  painful  contracture  of  the  muscles  of 
the  abdominal  wall,  and  if  it  induces  a  well  localized  or  dis- 
tinctly more  pronounced  pain  at  McBumey's  point  (the  middle 
point  of  a  line  joining  the  umbilicus  and  the  anterior  superior 
spine  of  the  ilium,  or  slightly  outside  this  point),  the  disorder 
present  is  acute  appendicitis.  We  are  not  referring  to  the  cases 
in  which  the  diagnosis  is  rendered  still  more  obvious  by  the  pres- 
ence of  a  swelling  in  the  ileocecal  region  or  by  symptoms  of 
diffuse  peritonitis.  Of  the  foregoing  signs,  cutaneous  hyperes- 
thesia and  rigidity  are  the  most  important ;  they  are  possessed, 
to  my  mind,  of  greater  significance  even  than  pain  on  deep  pal- 
pation, which  is  often  hard  to  localize  at  McBurney's  point  on 
account  of  the  resistance  oflfered  by  the  abdominal  muscles. 

"In  the  attack  of  periodic  vomiting,  the  abdomen  is  not  pain- 
ful at  any  point ;  it  is  only  after  the  attack  has  lasted  some  days 
that  the  muscles  of  the  abdominal  wall,  having  been  repeatedly 
dragged  upon  by  attempts  at  vomiting,  may  become  the  seat,  not  of 
actual  pain,  but  of  a  feeling  of  soreness,  especially  at  their  points 
of  insertion  on  the  ribs. 

"As  a  rule,  the  examination  of  the  abdomen  permits  of  readily 
making  a  diagnosis  between  periodic  vomiting  and  appendicitis. 
But  such  is  not  always  the  case.  There  are  cases  in  which  one 
is  in  doubt,  and  in  which  one  has  a  right  to  be  in  doubt.  Following 
is  an  example  of  such  a  case :  A  child  is  seized  with  vomiting  and 
slight  fever,  hardly  exceeding  38**  C. ;  the  ileocecal  region  is  ex- 
amined ;  cutaneous  hyperesthesia  is  absent,  and  rigidity  is  lacking  or 
is  very  slight  and  diffused  over  the  entire  abdomen ;  deep  palpation 


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VOMITING,  1337 

elicits  only  trifling  pain,  without  distinct  localization,  so  that  the  phy- 
sician questions  whether  the  sensitiveness  elicited  is  not  merely  due 
to  the  pressure  exerted  by  the  examining  finger;  finally,  aceton- 
emia appears  early  and  is  pronounced.  In  a  case  of  this  sort 
it  is  very  hard  to  come  to  any  definite  diagnostic  decision. 

**True,  sometimes  rectal  palpation  will  remove  the  doubt;  if 
such  palpation  leads  the  examiner  to  feel  a  tender  infiltrated  area 
at  the  upper  portion  of  the  wall  of  the  pelvic  cavity  on  the  right 
side,  a  decision  in  favor  of  the  presence  of  appendicitis  should  be 
made.  But  this  sign  is  frequently  lacking,  and  if  it  cannot  be 
elicited,  the  original  doubts  persist. 

**There  is  another  class  of  cases  in  which  the  diagnosis  re- 
mains in  suspense;  these  are  the  cases  in  which  the  results 
of  examination  of  the  ileocecal  region  change  from  one  attack 
to  the  next:  In  one  attack  there  is  nothing  wrong  in  the  ileo- 
cecal region,  acetonemia  appears  early,  and  a  diagnosis  of  peri- 
odic vomiting  is  made.  In  the  next  succeeding  attack,  there  are 
found  abdominal  evidences  pointing  to  inflammation  of  the  ap- 
pendix. 

"These  cases  are  readily  explained.  The  same  subject  may 
be  suffering  both  from  periodic  vomiting  and  from  appendicitis. 
An  appendicular  attack  in  a  predisposed  subject  may,  like  any 
other  acute  febrile  disorder,  bring  on  an  attack  of  periodic  vomit- 
ing with  pronounced  acetonemia. 

"To  recapitulate,  in  the  majority  of  cases  periodic  vomiting 
and  acute  appendicitis  appear  in  a  typical  form  and  are  rather 
easily  distinguished.  Sometimes,  however,  such  diflferentiation 
is  very  difficult,  and  occasionally  it  is  impossible.  The  common- 
est cause  of  such  difficulties  consists  in  the  possible  coexistence 
of  the  two  affections  in  the  same  subject.  In  the  event  of  doubt, 
the  case  should  be  dealt  with  as  though  appendicitis  were  known 
to  exist,  i.e.,  if  the  patient  is  a  child,  one  should  nearly  always 
recommend  subsequent  removal  of  the  appendix. 

"In  the  foregoing  presentation,  we  have  referred  to  cases  in 
which  the  physician  is  called  upon  to  settle  the  question  of  diag- 
nosis during  the  attack  of  vomiting.  But  it  may  happen  that  he 
must  make  a  retrospective  diagnosis,  i.e.,  one  made  a  variable 
time  after  the  occurrence  of  an  attack  which  he  did  not  witness. 


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1338  SYMPTOMS, 

We  believe  that  it  is  often  very  hazardous  to  make  a  decision 
under  such  circumstances.  No  doubt  there  are  cases  in  which 
examination  of  the  ileocecal  region  will  yield  unmistakable  evi- 
dences ;  where,  the  attack  of  vomiting  having  terminated  a  vari- 
able time  before,  deep  palpation  nevertheless  reveals  distinct 
tenderness  clearly  localized  at  McBurney's  point,  and  where 
such  palpation  also  reveals  the  presence  of  some  degree  of  mus- 
cular contracture  strkrrty  confined  to  the  abdominal  wall  in  the 
right  iliac  fossa  aniT^cking  in  the  left  iliac  fossa,  one  may  con- 
clude that^^lbere  ha&  ^^urred  an  attack  of  acute  appendicitis 
which  has  left  behiad  it  some  degree  of  subacute  or  chronic  in- 
liammation  of  the  appendix.  But  such  cases  are  rather  uncom- 
mon. Usually  examination  of  the  right  iliac  fossa  after  the  at- 
tack shows  no  abnormal  condition,  or  else,  examination  for 
tenderness  at  McBumey's  point  or  for  rigidity  gives  such 
indefinite  and  inconclusive  results  that  they  cannot  be  inter- 
preted without  risk  of  error.  Hence,  where  the  practitioner  has 
not  actually  seen  the  attack,  he  should  leave  to  the  physician 
who  may  have  seen  it  the  responsibility  of  reaching  a  definite 
decision.  If,  however,  circumstances  are  such  that  a  decision 
must  be  made  even  under  the  conditions  already  described,  the 
family  should  be  carefully  apprised  of  the  fact  that  the  decision 
made  can  be  based  only  upon  conjecture." 


It  seems  impracticable  to  conclude  an  article  on  the  semeiology 
of  vomiting  without  a  brief  additional  consideration  of  the  subject  of 
"Vomica."  By  the  term  vomica  is  meant  the  evacuation  through 
the  respiratory  tract  of  an  accumulation  of  pus  in  such  amount 
that  it  suggests  vomiting  {vomere,  to  vomit). 

The  condition  is  entirely  different  from  vomiting,  inasmuch 
as  the  evacuation  of  fluid  takes  place  through  the  respiratory 
tract.  A  vomica  is,  strictly  speaking,  an  expectoration  of  pus 
in  large  amount.  But  from  the  standpoint  of  gross  symptoma- 
tology the  occurrence  is  a  vomiting  of  pus — a  sudden  ejection 
through  the  mouth  of  a  considerable  amount  of  purulent  fluid, 
generally  accompanied  by  paroxysmal  cough  and  a  degree  of 
suflFocation  sometimes  bordering  on  complete  asphyxia. 


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VOMITING.  1339 

By  far  the  commonest  kind  of  vomica  is  the  pleural  vomica, 
which  constitutes  a  possible  termination  of  suppurative  pleurisy, 
interlobar,  mediastinal,  diaphragmatic,  or  encysted,  sometimes 
with  formation  of  a  pyopneumothorax. 

The  pulmonary  vomica,  much  less  common,  follows,  as  the 
term  implies,  abscess  of  the  lung  or  gray  hepatization  (suppurative 
pneumonia) ;  the  germ  found  in  the  evacuated  pus  is  nearly  always 
the  pneumococcus.  Some  cavities  in  fA^liteiifijaildiSQme  bronchiec- 
tatic  cavities  may  lead  to  purulent  expectaration  in  ^uch  amount  as 
to  suggest  a  vomica. 

As  an  exceptional  condition,  reference  may  be  imade  to  the 
hydatid  pulmonary  vomica,  or  suppurative  pulmonary  hydatids, 
which  simulate  the  pleural  vomica  and  can  be  differentiated  from 
it  only  by  the  finding  of  pieces  of  hydatid  membrane  and  of 
echinococcic  booklets  in  the  ejected  material. 

Finally,  any  variety  of  subdiaphragmatic  abscess,  whether  of 
hepatic,  renal,  gastric,  or  splenic  origin,  may  under  exceptional  cir- 
cumstances burrow  through  the  diaphragm  and  pleura  and  appear 
externally  in  the  form  of  a  vomica. 

In  all  these  disturbances  the  history  of  the  case  arid  systematic 
examination  will,  as  a  rule,  enable  the  physician  very  easily  to 
trace  back  from  the  symptom,  vomica,  to  its  pleural,  pulmonary,  or 
subdiaphragmatic  (hepatic,  gastric,  renal,  or  splenic)  source. 


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1340 


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INDEX  OF  THE  PRINCIPAL  CLINICAL 

SIGNS.^ 

ARRANGED  ACCORDING  TO  THE  NAMES  OF  THE 
AUTHORS  CONCERNED. 


Abderhalden  Reaction. 

Biochemistry, 
A  reaction  having  for  its  purpose 
to  demonstrate  the  proteolytic  fer- 
ments set  free  in  the  blood  upon  in- 
troduction into  the  system  of  incom- 
pletely elaborated  organic  products. 
Has  been  used  for  the  diagnosis  of 
pregnancy.  Technic  difficult.  Re- 
sults questionable. 

Abrams's  Reflexes.  Physiology. 

Cardiopulmonary  reflexes  awakened 
by  peripheral  stimulation  (skin,  mus- 
cles, and  mucous  membranes).  Per- 
cussion over  the  precordium  causes  a 
reduction  of  the  area  of  heart  dull- 
ness through  dilatation  of  the  lungs 
and  contraction  of  the  heart. 

Adams-Stokes  Disease.  Syndrome. 
Featured  by  a  marked  slowing  of 
the  pulse  rate  (to  30  or  40)  with  diz- 
ziness, epileptoid  seizures,  and  some- 
times actual  syncope.  Due  to  auricu- 
loventricular  dissociation,  and  is  be- 
lieved usually  the  result  of  disease  of 
the  bundle  of  His. 

Addison's  Disease.  Endocrinology. 
Characterized  by  a  variable  degree 
of  asthenia,  brown  pigmentation  of 
the  skin  and  mucous  membranes,  and 
low  blood-pressure.  It  is  due  to  dis- 
ease of  the  adrenal  glands. 

Anui-Duchenne  Type.      Neurology, 

Progressive  muscular  atrophy  be- 
ginning with  the  muscles  of  the 
hands. 

Argyll-Robertson  PupiL  Neurology. 
An  early  sign  of  tabes  dorsalis,  con- 
sisting of  disappearance  of  the  pupil- 
lary light  reflex  with  conservation  of 
the  accommodation  reflex. 


Arthus's  Phenomenon.       Serology. 
Local  skin  disturbances  (eruptions, 
erythema,  edema)  following  repeated 
injections  of  foreign  serums. 

Aschner's  Sign.  Neurology. 

The  oculocardiac  reflex,  consisting 
of  a  slowing  of  the  pulse  rate  by  5 
to  15  or  20  beats  per  minute  upon 
compression  of  the  eyeball.  The  re- 
flex is  enhanced  in  vagotonic  states. 
Acceleration  of  the  pulse  rate  (inver- 
sion of  the  reflex)  occurs  in  sym- 
patheticotonic  states. 

Avellis's  Ssmdrome.  Neurology. 

Hemiplegia  of  the  soft  palate  and 
paralysis  of  the  recurrent  nerve  on 
the  same  side. 

B 
Babinski's  Sign.  Neurology. 

This  sign  of  disease  of  the  spinal 
cord  (pyramidal  tract)  consists  in 
extension  of  the  big  toe  when  the 
sole  of  the  foot  is  mechanically  stim- 
ulated by  drawing  the  point  of  a  pin 
over  it. 

Baccelli's  Sign.  Lungs. 

Whispering  pectoriloquy.  Distinct 
transmission  of  the  whispered  voice 
to  the  ausculting  ear  on  the  side  of 
a  pleural  eflusion. 

Baccelli's  Anguloscapular  Sign. 

Lungs. 
Reduced    motion    of    the    scapula 
during  deep   inspiration   in  tubercu- 
losis of  the  apex. 

Balfour's  Disease; 

Osseous  sarcomatosis  aflecting 
chiefly  the  bones  of  the  cranium  and 
face  and  attended  with  greenish  dis- 
coloration  (chloroma  ) . 


1  Prepared  with  the  assistance  of  Dr.  Prevel. 


(1343) 


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1344 


PRINCIPAL  CLINICAL  SIGNS. 


Bamberger's  Sign.  Neurology, 

A  disturbance  of  sensation  in  ta- 
betics. Stimulation  of  a  restricted 
area  of  skin  is  referred  by  the  pa- 
tient to  the  opposite  side  of  the 
body   (allochiria). 

Banti's  Disease.  Liver. 

Hepatic  cirrhosis  with  ascites,  pro- 
gressive anemia,  and  enlargement  of 
the  spleen. 

Baranjr's  Sign.  Otology, 

Disappearance  of  hydro-caloric  ves- 
tibular nystagmus  in  severe  disease 
of  the  internal  ear. 

Bard  and  Pic's  Syndrome. 

Pancreas, 
In  cancer  of  the  head  of  the  pan- 
creas the  following  conditions  are 
present  in  combination:  Chronic, 
progressive  jaundice,  cachectic  ema- 
ciation, and  dilatation  of  the  gall- 
bladder. 

Bard's  Sign.  Neurology. 

Serves  to  distinguish  organic  from 
congenital  nystagmus.  In  the  first 
instance,  the  oscillations  of  the  we 
increase  as  the  patient  follows  the 
physician's  finger  moved  before  his 
eye  from  right  to  left  and  then  from 
left  to  right.  In  the  second  instance, 
the  oscillations  disappear. 

Barlow's  Disease.  Pediatrics, 

A  disease  of  early  childhood  char- 
acterized by  anemia  with  bone  pains 
(subperiosteal  hemorrhages). 

Basedow's  Disease.    Endocrinology, 
Thyroid   enlargement   with   tachy- 
cardia, exophthalmos,  and  tremor. 

Baum^s,  Law  of.  Syphilography, 
A  S3^hilitic  father  may  procreate 
a  syphilitic  child  without  the  appear- 
ance of  specific  manifestations  in 
the  mother  and  without  risk  to  her 
in  nursing  her  infant. 

Beard's  Disease.  Neurology, 

Neurasthenia.  A  neuropathic  symp- 
tom-complex consisting  of  a  variable 
degree  of  insufficiency  of  the  muscu- 
lar, circulatory,  secretory,  and  digest- 
ive functions,  with  insomnia  and  gen- 
eral asthenia.  Met  with  in  over- 
worked individuals. 


BeU's  Sign.  Neurology. 

Displacement  of  the  eyeball  upward 
and  outward  when  the  patient  at- 
tempts to  lower  the  paralyzed  upper 
eyelid  (peripheral  facial  paralysis). 

Bence- Jones's  Disease.       Sarcoma. 
Concomitant  albumosuria  and  sar- 
coma. 

Benedikfs  Syndrome;      Neurology, 
Hemiplegia   with  paralysis  of  the 
oculomotor  nerve  of  the  opposite  side 
(disease  of  the  cerebral  peduncle). 

Bergeron's  Disease.  Pediatrics. 

Infantile  chorea  with  rhythmic 
movements  in  more  or  less  rapid  rep- 
etition. 

Besredka's  Method. 

Vaccine  therapy. 
Antianaphylactic  vaccination  car- 
ried out  by  administering  an  injection 
of  0.1  cubic  centimeter  of  scrum  two 
hours  before  the  therapeutic  injec- 
tion. 

Bier^s  Method.  Therapeutics, 

Use,  in  the  treatment  of  inflamma- 
tory conditions,  of  venous  hyperemia 
induced  by  elastic  constriction  of 
the  veins  (in  the  extremities)  or  by 
application  of  suction  cups  of  vary- 
ing shape  and  size. 

Biett's  Ring.  Dermatology. 

A  small  ring  of  white  epidermis 
frequently  present  about  the  skin 
lesions  of  secondary  syphilis. 

Bird's  Disease.  Metabolism. 

The  sum  of  the  digestive,  urinary, 
circulatory,  and  nervous  disturbances 
resulting  from  the  oxalic  diathesis. 

Bockhart's  Impetigo.    Dermatology, 
Vesiculopustules  always  developing 
about  a  hair  follicle.   A  skin  disorder 
of  childhood. 

Bonfils's  Disease.  Blood. 

Proliferation  of  the  lymphoid  tissue 
without  increase  in  the  white  blood 
cells  (aleukemic  or  simple  lympha- 
denia). 

Bordet  and  Gengou  Reaction. 

Serology, 
A  complete  specific  serum  (contain- 
ing antibodies  following  injection  of 
an  antigen :  bacteria,  cells,  or  toxins) 
yields  a  specific  reaction  (hemolysis, 


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PRINCIPAL  CLINICAL  SIGNS, 


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bacteriolysis,  etc.)  with  the  corres- 
ponding antigen. 

When  heated  to  55°  C.  the  specific 
serum  loses  its  specific  reacting  power. 
Brought  in  contact  with  the  antigen, 
it  is  inactivated. 

It  is  reactivated  by  the  addition  of 
normal  serum,  which  supplies  to  it 
what  it  lacks,  Tnsf,,  complement. 
Brought  in  contact  with  the  antigen, 
it  now  again  yields  the  specific  re- 
action. 

The  complement  of  the  normal 
serum  thus  utilized  is  permanently 
fixed  in  the  reaction,  i.e.,  it  is  deviated 
and  cannot  serve  again  for  further 
reactivation. 

Bouchard's  Nodes.  Metabolism. 

Thickening  of  the  second  joints  of 
the  fingers  in  certain  subjects  with 
dilatation  of  the  stomach. 

Boudin's  Law.  Tuberculosis. 

Antagonism  of  malaria  and  tuber- 
culosis, possibly  dependent  upon  hy- 
pertrophy of  the  liver. 

Bouillaud's  Laws.  Rheumatism. 

Endocarditis  and  joint  inflamma- 
tion are  usually  concomitant  in  acute 
articular  rheumatism  with  severe  and 
multiple  manifestations. 

They  are  not  concomitant  in  cases 
with  only  partial  or  mild  manifesta- 
tions. 

Bouveret's  Disease.  Cardiology. 

Marked  tachycardia  (180,  200,  or 
higher)  accompanied  by  low  blood- 
pressure  and  elevation  of 'tempera- 
ture, coming  on  in  sudden  attacks  of 
variable  duration,  from  a  few 
minutes  to  several  days  (heart  fail- 
ure).    Paroxysmal  tachycardia. 

Bozzolo's  Siga  Cardiology. 

Visible  pulsations  of  the  nostrils 
in  some  cases  of  thoracic  aneurysm. 

Brandt's  Method.  Therapeutics. 

Treatment  of  typhoid  fever  by  the 
systematic  use  of  cold  baths. 

Bright's  Disease.  Kidneys. 

Chronic  nephritis  with  albuminuria, 
high  blood-pressure,  and  terminal 
edema. 

Bright's  Siga  Peritonitis. 

Peritoneal  friction  sounds. 


85 


Briquet's  Gangrene.  Lungs. 

Gangrene  of  the  bronchi  in  the 
course  of  bronchiectasis. 

Brissaud  and  Sicard,  Syndrome  of. 

Neurology. 
Motor  disturbances  on  one  side  of 
the  body  with   facial  hemispasm  on 
the  opposite  side. 

Broadbent's  Siga  Cardiology. 

Systolic  retraction  of  the  left  pos- 
terior aspect  of  the  chest  at  the  level 
of  the  diaphragm;  a  sign  of  peri- 
cardial adhesion. 

Broca's  Aphasia.  Neurology. 

Motor  aphasia  resulting  from  dis- 
ease of  the  lower  portion  of  the  left 
third  frontal  convolution. 

Brown-S6quard'8  Mediod. 

Endocrinology. 
Opotherapy.  The  administratic«i  of 
extracts  of  organs  in  disease  of  the 
identical  organs  to  make  up  for  their 
deficiencies  or  to  stimulate  them.  A 
procedure  based  on  the  fact  that  the 
vascular  glands  produce  an  internal 
secretion. 

Brown-S6quard's  Sjoidrome. 

Neurology. 
Unilateral  disease  of  the  spinal  cord 
causing    hemiparaplegia    with    hemi- 
anesthesia on  the  opposite  side. 

Brudzinski's  Signs.  Neurology. 

Signs  of  meningitis.  A  reflex 
movement  of  flexion  or  extension  of 
the  lower  extremity  is  obtained  by 
strongly  flexing  the  limb  of  the  op- 
posite side   (contralateral  reflex). 

Flexion  of  the  lower  extremities  is 
obtained  upon  flexing  the  neck. 

Bryson's  Siga         Graves^s  disease. 
Deficient    chest    expansion    during 
inspiration  in  cases  of  Graves's  dis- 
ease. 


Charcot's  Disease.  Neurology. 

Spastic    paralysis    in    conjunction 
with  progressive  muscular  atrophy. 

Charcot-Marie's  Siga      Neurology. 
The  rapid  tremor  of  exophthalmic 
goiter. 


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PRINCIPAL  CLINICAL  SIGNS. 


Chesme-Stokes  Breathing.  Lungs. 
A  type  of  breathing  comprising  a 
series  of  respirations  of  increasing 
amplitude,  then  of  decreasing  ampli- 
tude, followed  by  a  varying  period  of 
apnea  and  resumption  of  the  increas- 
ing respirations. 

Chvostek,  Jr.'s  Sign.  Tetany. 

Increased  mechanical  irritability  of 
the  motor  nerves  in  tetany. 

Clapton's  Sign,      Copper  poisoning. 
A  greenish   line  on  the   gums  in 
copper  poisoning. 

A  sympathetic  ocular  syndrome 
characterized  by  enophthalmos,  my- 
osis,  and  vasomotor  disturbances  on 
the  same  side  of  the  face  (elevation 
of  local  temperature  and  sweating). 

Colrafs  Test  Liver. 

Alfmentary  glycosuria,  demon- 
strated by  having  the  patient  take 
150  grams  of  glucose  on  an  empty 
stomach  and  tracing  the  sugar  in  the 
urine  on  the  same  dav  (an  indica- 
tion of  insufficiency  of  the  liver). 

Conigan's  Disease.  Cardiology. 

Aortic  insufficiency  of  rheumatic 
origin. 

Corrigan  Pulse.  Cardiology. 

A  bounding  and  brief  pulse.  Ab- 
rupt ascent,  rapid  turn,  and  quick 
descent  of  the  pulse  tracing.  Aortic 
insufficiency  due  to  endocarditis. 


Courvoisier  and  .Terrier, 
Law  of. 


Liver. 


Atrophy  of  the  gall-bladder  in  the 
presence  of  obstruction  of  the  com- 
mon bile-duct  by  a  stone;  dilatation 
of  the  gall-bladder  in  other  kinds  of 
obstruction. 


Cruveilhier's  Disease. 

Gastric  ulcer. 


Stomach. 


Damoiseau's  Curve.  Pleura. 

A  curve  with  its  convexity  upper- 
most, formed  by  the  surface  of 
pleural   effusions. 


Dehio's  Test.  Cardiology. 

Testing  for  cardiac  acceleration  in 
bradycardia  upon  injection  of  1  mil- 
ligram of  atropine  sulphate.  If  the 
test  is  positive,  the  bradycardia  is  of 
nervous  origin ;  if  negative,  of  car- 
diac origin. 

Dejerine-Klumpke,  Sjoidrome  of. 

Neurology. 

Paralysis  of  the  lower  nerve-roots 
of  the  brachial  plexus,  accompanied 
by  myosis  and  enophthalmos. 

Dubini's  Chorea.  Neurology. 

Chorea  marked  by  convulsive  at- 
tacks which  are  followed  by  para- 
lysis and  coma. 


Duchenne's  Disease. 
Tabes  dorsalis. 


Neurology. 


Duguet's  Sign.  Cardiology. 

Ulcers  on  the  pillars  of  the  soft 
palate  in  typhoid  fever. 

Duroziez's  Disease.  Cardiology. 

Uncomplicated  mitral  stenosis. 

Duroziez's  Sign.  Typhoid  fever, 

A  double  murmur  heard  with  a 
stethoscope  exerting  gentle  pressure 
over  the  femoral  artery. 

A  sign  of  aortic  regurgitation. 


Auscultation. 
the    whispered 


D'EsfHne's  Siga 

Bronchophony  of 
voice  elicited  by  auscultation  over 
the  spinal  column  between  the  scap- 
ulae (a  sign  of  intertracheobronchial 
glandular  enlargement). 

Erb's  Siga  Neurology. 

Enhanced  electric  excitability  of 
the   muscles    and    nerves    in    tetany. 

Disappearance  of  the  pupillary  re- 
sponse to  pain  in  tabes. 


Fallot's  Disease.  Cardiology. 

Congenital  malformations  of  the 
heart  in  "blue  babies:"  Stenosis  of 
the  pulmonary  artery,  interventricu- 
lar communication,  hypertrophied 
right  ventricle,  and  displacement  of 
the  aorta  to  the  right. 


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PRINCIPAL  CLINICAL  SIGNS, 


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Finsen's  Method.  Therapeutics, 

Treatment    of    skin    disorders    by 
means  of  selected  light  rays. 

Fochier*8  Method.         Therapeutics. 

Treatment   by   means   of   artificial 

aseptic  abscesses  (fixation  abscesses). 

Friedreich's  Disease.         Neurology. 
Hereditary    locomotor    ataxia    ap- 
pearing in  childhood  and  persisting 
indefinitely. 

Frdhlich's  Sjmdrome. 

Endocrinology, 
Obesity  associated  with  an  infan- 
tile condition  of  the  sexual  organs, 
due  to  pituitary  insufficiency. 

Fiirbringer's  Siga 

Subphrenic  abscess. 
Serves  to  differentiate  subdia- 
phragmatic abscess  from  abscess  in 
the  chest.  A  needle  passed  into  the 
abscess  cavity  is  displaced  with  the 
respiratory  movements  in  the  former 
case  and  not  in  the  latter. 


Gaucher's  Disease.  Spleen. 

Primary  epithelioma  of  the  spleen. 

Gerhardt's  Test  Urine. 

Portwine  color  of  the  urine  upon 
addition  of  ferric  chloride,  pointing 
to  the  presence  of  diacetic  acid. 

Gmelin's  Test  Urine. 

An  emerald  green  rinu:  formed  at 
the  surface  of  contact  between  urine 
and  nitric  acid  without  application  of 
heat;  points  to  the  presence  of  bile 
pigments  in  the  urine. 

Godelier's  Law.  Tuberculosis. 

Tuberculization  of  the  pleura  al- 
ways occurs  when  tuberculosis  of  the 
peritoneum  exists. 

Gordon's  Siga  Neurology. 

Extension  of  the  great  toe  upon 
compression  of  the  muscles  of  the 
calf;  points  to  disease  of  the  pyra- 
midal tract. 

Gradenigo's  Sjmdrome.        Otology. 

Paralysis  of  the  sixth  cranial  nerve 

(abducens)  during  acute  otitis  media. 


Graefe's  Sign.  Endocrinology. 

Dissociation  of  the  movements  of 
the  upper  lid  and  eyeball  when  the 
eye  glances  downward.  A  sign  of 
exophthalmic  goiter. 

Grancher's  Disease.  Lungs. 

Massive  congestion  of  the  lung 
without  pleural  effusion,  but  )nelding 
clinical  signs  similar  to  those  of 
pleurisy. 

Graves's  Disease.  Gaiter. 

Exophthalmic  goiter  or  Basedow's 
disease. 

Graves's  Sign.  Gout. 

Abnormal  sensitiveness  of  the 
dental  nerves  in  gouty  individuals, 
causing  them  to  grind  the  teeth. 

Grocco's  Triangle.  Percussion. 

A  triangular  area  of  paravertebral 
dullness  at  the  base  of  the  thorax  on 
the  side  opposite  that  of  pleurisy. 
Ascribed  to  displacement  of  the 
mediastinal  structures. 

Gu6rin's  Law.  Rachitis. 

Rachitic  deformities  begin  in  the 
lower  portions  of  the  body. 

H 

Hahnemann's  Method.  Therapeutics. 
Homeopathy. 

Hanot's  Disease.  Liver. 

Hypertrophic  cirrhosis  with  chronic 
jaundice. 

Harley's  Disease.  Blood. 

Paroxysmal  hemoglobinuria  com- 
ing on  on  account  of  exposure  to 
cold. 

Harrison's  Groove.  Rickets. 

Observed  in  rachitic  Subjects  dur- 
ing deep  inspiration,  between  the 
chest  and  the  upper  portion  of  the 
abdomen,  at  the  level  of  insertion 
of  the  diaphragm. 

Head's  Zones.  Neurology. 

Innervation  of  the  visceral  struc- 
tures and  skin  surface  in  correspond- 
ing zones.  Cutaneous  hyperesthesia 
in  definite  zones  points  to  disease  of 
the  corresponding  deep-seated  or- 
gans. 


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1348 


PRINCIPAL  CLINICAL  SIGNS. 


Heberden's  Nodes.         Rheumatism. 
Nodes  about  the  terminal  phalan- 
geal joint  in  chronic  rheumatism. 

Heine-Kreysig's  Sign. 

Pericardial  adhesion. 
Systolic    depression    of   the   inter- 
costal   spaces    indicating    pericardial 
adhesion    (cardiac  symphysis). 

Heine-Medin's  Disease.    Infections. 
An    infectious,    epidemic    disorder 
resembling  infantile  paralysis. 

Heine-Sanders'  Sign. 

Pericardial  adhesion. 
Wave-like  motion  of  the  chest- 
wall  extending  beyond  the  bound- 
aries of  cardiac  dullness  and  most 
marked  in  the  epigastric  region. 
Characteristic  of  pericardial  adhesion. 

Herxheimer's  Reaction.        Syphilis. 
Temporary  accentuation  of  syphi- 
litic   manifestations    as    a    result    of 
mercurial  or  arsenical  treatment. 

Hirschsprung's  Disease.         Colon, 
Congenital  megacolon  accompanied 
by    constipation    and   abdominal    en- 
largement in  young  children. 

Hodgson's  Disease.         Cardiology. 
Aortic     insufficiency     of     arterial 
origin. 

Hutchinson  Teeth.  Teeth. 

Dental  deformity  characterized  by 
semicircular  notches  in  the  free 
margins  of  the  median  upper  incisors 
with  narrowing  of  the  necks  of  the 
teeth.    A  sign  of  congenital  syphilis. 


Jaccoud's  Siga  Cardiology. 

A  sign  of  pericardial  adhesion  con- 
sisting of  a  rolling  movement  in  the 
precordial  region, 

Jellineck's  Siga  Dermatology. 

Discoloration  of  the  eyelids  in 
Basedow  or  nervous  subjects. 


Karell's  Treatment  Therapeutics. 
Marked  reduction  in  the  intake  of 
fiolid  and  liquid  food  (800  grams  of 
milk  per  diem)  ;  used  in  certain 
cases  of  heart  weakness. 


Kemig's  Sign.  Neurology. 

l^lexion  of  the  legs  on  the  thighs 
when  the  lower  limbs  are  placed  at 
a  right  angle  with  the  trunk  (sit- 
ting posture  in  bed).  A  sign  of 
spinal  meningitis. 

Kienbock's  Siga  Pleura. 

Fluoroscopy  showing  a  rise  of  the 
diaphragm  at  the  time  of  inspiration 
on  the  side  of  an  effusion  of  fluid 
and  air  in  the  pleura. 

Klippel's  Disease.  Neurology. 

A  species  of  rapidly  progressive 
general  paralysis  occurring  in  old 
men  (dementia,  stroke,  and  paralytic 
phenomena). 

Kussmaul  Breathing.  Respiration. 
A  kind  of  breathing  characterized 
by  a  prolonged  inspiration  followed 
by  a  pause  and  a  brief  expiration, 
followed  by  a  second  pause.  Met 
with  in  diabetic  coma. 


Laennec's  Cirrhosis.  Liver. 

Atrophic  cirrhosis. 

Landouzy-Dejerine  Tsrpc.  Myology. 
A    form   of   progressive   muscular 
atrophy  of  childhood  beginning  with 
the  face,  shoulders,  and  arms. 

Landry's  Disease.  Neurology. 

Paralysis  of  the  lower  extremities 
of  an  acute  t)rpe,  soon  involving  the 
trunk  and  causing  death  within  a 
few  days. 

Lasdgue's  Siga  Neurology. 

A  sharp  pain  elicited  in  the  but- 
tock by  flexion  of  the  thigh  on  the 
pelvis  with  the  lower  extremity 
extended.    An  indication  of  sciatica. 

Leyden-Mobius  Typt.         Myology. 
Muscular  atrophy  beginning  in  the 
lower  limbs  and  later  gradually  in- 
volving the  upper  extremities. 

Litten's  Siga  Lungs. 

Reduced  mobility  of  the  diaphragm 
on  the  affected  side  in  pulmonary 
tuberculosis. 

Little^s  Disease.  Neurology. 

Congenital  spastic  paraplegia  oc- 
curring in  premature  infants  or  fol- 
lowing unusually  difficult  labor. 


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PRINCIPAL  CLINICAL  SIGNS. 


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Ludwig's  Angina.  Mouth, 

Infectious  cellulitis  of  the  floor  of 

the  mouth. 

M 

Madelung's  Disease. 
Hand  in  the  valgus  position,  with 

prominence  of  the  head  of  the  ulna 

and  palmar  subluxation  of  the  hand. 


Marejr's  Law. 

Tachycardia  generally 
low  blood-pressure  and 
high  blood-pressure. 

Marie's  Disease. 

Enlargement    of    the 
and  face. 


Cardiology. 
accompanies 
bradycardia 

Dystrophy. 
hands,    feet, 


Martinet's  Laws.  Circulation. 

Dividing  the  daily  output  of  urine 
by  the  mean  differential  (pulse) 
pressure  gives  a  result  equal  to  or 
exceeding  one-fourth  liter  in  the 
healthy  subject  on  a  normal  diet. 

Persistence  of  the  result  below 
0.200  liter  is  characteristic  of  renal 
sclerosis. 

Martinet's  Ssmdrome.  Circulation. 
Hyposphyxia,  characterized  by  low 
blood-pressure  and  an  absolutely  or 
relatively  high  blood  viscosity,  with 
small  pulse  and  slowed  circulation. 

Menetrier's  Ssmdrome. 

Thoracic  duct. 
Signs  of  pressure  upon  the  thor- 
acic duct:  Firm  edema  of  the  lower 
portion  of  the  body,  the  chest  and 
the  left  arm,  with  peritoneal  and 
pleural  effusions  on  the  left  side. 

M6nidre's  Sjmdromc.  Otology. 

Vertigo,  with  various  sounds  heard 
by  the  patient.  Reduction  of  audi- 
tory acuity.  An  indication  of  in- 
ternal ear  disease. 

Mikulicz's  Disease.  Glands. 

Enlargement  of  the  lacrymal  and 
salivary  glands  on  both  sides,  with 
suppression  of  their  secretion  but 
without  local  pain;  believed  fre- 
quently due  to  leukemia. 

Millard-Gubler  Ssmdrome. 

Neurology. 
Hemiplegia  on  one  side  with  facial 
paralysis  on  the  other. 

Mbbius's  Disease.  Neurology. 

Ophthalmoplegic  migraine. 


Mobius's  Sign.  Endocrinology. 

Difficulty  of  convergence  of  the 
eyes  in  exophthalmic  goiter. 

Morton's  Disease.  Feet. 

Metatarsalgia  frequently  following 
fatigue. 

Morvan's  Disease.  Leprosy. 

Felon  accompanied  by  anesthesia 
of  the  fingers;  considered  of  leprous 
nature. 

Murphy's  Method.  Therapeutics. 
Rectal  administration,  drop  by 
drop,  of  glucose  or  saline  solution 
in  high  fever  or  after  surgical  oper- 
ations. 

Musset's  Sign,  Cardiology. 

Rhythmic  jerking  movements  of 
the  head,  synchronous  with  the  heart 
beats,  in  patients  with  aortic  regur- 
gitation. [Alfred  de  Musset  is  said 
to  have  exemplified  this  sign.] 

N 
Negri  Bodies.  Rabies. 

Found  in  the  central  nerve  cells  of 
animals  that  have  succumbed  to 
rabies.  Considered  specifically  re- 
lated to  the  disease. 

Negro's  Sign.  Neurology, 

A  sign  of  peripheral  facial  paral- 
ysis :  Elevation  of  the  eyeball  is 
more  marked  on  the  paralyzed  side 
when  the  patient  looks  upward  with 
the  head  motionless. 


Ocrtcl's  Method.  Therapeutics. 

Treatment  by  graded  exercise 
(walking  on  level  ground  or  in- 
clines) in  chronic  heart  disorders. 

Oliver's  Sign.  Aortic  aneurysm. 

Movements  of  the  larynx  from 
below  upward,  synchronous  with  car- 
diac systole,  in  subjects  suffering 
from  aneurysm  of  the  arch  of  the 
aorta. 

Oppenheim's  Sign.  Neurology. 

A  sign  of  disease  of  the  pyramidal 
tracts.  Ascent  of  the  great  toe  when 
pression  is  exerted  from  above  down- 
ward over  the  muscles  of  the  antero- 
external  aspect  of  the  leg. 


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1350 


PRINCIPAL  CLINICAL  SIGNS. 


Paget's  Disease  of  the  Bones. 

Bones. 
Marked  thickening  of  the  bones  of 
the  skull  and  extremities.     Believed 
an  indication  of  inherited  syphilis. 

Paget's  Disease  of  the  Nipple. 

Breast. 
A  malignant  tumor  starting  at  the 
nipple,  in  old  women. 

Parkinson's  Disease.  Neurology. 
A  disease  characterized  by  rigid 
posture  of  the  body,  a  facies  as  of 
surprise,  and  a  peculiar  (pill-rolling) 
tremor  of  the  fingers. 

Parrot's  Disease.  Bones. 

Syphilitic  epiphyseal  detachment. 

Parrot's  Law.  Tuberculosis. 

A  tuberculous  lesion  of  the  bron- 
chial lymph-nodes  is  always  accom- 
panied by  a  pulmonary  lesion  of  the 
same  nature. 

Parrot's  Siga  Meningitis. 

Dilatation  of  the  pupil  when  the 
skin  is  pinched  in  meningitis. 

Pavy's  Disease.  Albuminuria. 

Intermittent  cyclic  albuminuria  in 
young  subjects,  occurring  in  the  day- 
time. 

Perret  and  Devic,  Signs  of.  Pleura. 
Signs  of  pleurisy  at  the  base  of  the 
left  lung,  posteriorly;  they  disappear 
in  the  knee-chest  posture,  and  are 
met  with  particularly  in  children 
suffering  from  pericarditis  with 
effusion. 

Pettenkoffer's  Test  Urine. 

Purple  violet  color  of  the  urine 
when  treated  with  sulphuric  acid  in 
the  presence  of  sugar;  points  to  the 
presence  of  bile  acids. 

Pfuhl's  Sign.  Pleura. 

Shows  whether  an  effusion  is 
above  or  below  the  diaphragm.  In 
the  first  instance  the  pressure  in  the 
manometer  connected  with  the  trocar 
rises  during  inspiration;  in  the  sec- 
ond instance,  it  falls. 

Porgds's  Reaction.  Serology. 

Precipitation  of  serum  in  the  pres- 
ence of  a  solution  of  sodium  glyco- 
cholate.   Claimed  to  indicate  syphilis. 


Pott's  Disease.  Bones. 

Tuberculosis  of  the  vertebrae. 
Profeta,  Law  of.  Syphilis. 

A  syphilitic  mother  may  nurse  her 
healthy  infant  without  risk  of  in- 
fecting it. 

Q 

Quincke's  Disease.       Dermatology. 
Hereditary  acute  paroxysmal  ede- 
ma,   unattended    with    constitutional 
disturbance. 

R 

Raynaud's  Disease.  Circulation. 

Disturbances  of  the  circulation  in 
the  extremities  (cyanosis,  local  as- 
phyxia, "dead  finger"),  which  may 
lead  to  dry  gangrene. 

Recklinghausen's  Disease. 

Dermatology. 

Cutaneous  and  nervous  tumors 
(neurofibromata)  accompanied  by 
pigmentation  of  the  skin. 

Reclus's  Disease.  Breast. 

Presence  of  many  small  shot-like 
cysts  in  the  breast. 

Revilliod's  Phenomenon. 

Hemiplegia. 

Inability,  in  organic  hemiplegia,  to 

close  the  eye  on  the  paralyzed  side 

without    at    the    same    time    closing 

that  on  the  well  side. 

Rinn^'s  Test  Otology. 

Rinne  positive  when  the  sound  of 
the  tuning-fork  is  heard  better  by 
air  conduction  than  by  mastoid 
(bone)  conduction.  Rinne  negative 
when  the  sound  is  better  conducted 
by  bone  than  by  air. 

Rivalta's  Test  Serology. 

A  few  drops  of  effused  fluid  cause 
a  turbidity  when  dropped  in  water 
acidulated  with  acetic  acid  if  the  ef- 
fusion is  of  inflammatory  nature. 

Roger's  Disease.  Cardiology. 

Congenital  communication  between 
the  ventricles  of  the  heart,  unat- 
tended with  dyspnea  nor  cyanosis 
when  the  subject  is  at  rest. 

Romberg's  Sign.  Neurology. 

An  indication  of  tabes  dorsalis : 
Loss  of  equilibrium  when,  with  the 
eyes  closed,  the  heels  are  brought 
together. 


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PRINCIPAL  CLINICAL  SIGNS. 


1351 


Rosenbach's  Sign.  Neurology, 

Persistence  of  the  abdominal  reflex 
in  hysteric  hemiplegia,  in  spite  of 
the  anesthesia  of  the  skin. 

Rosenheim's  Siga         Perigastritis, 
Friction   sounds  heard  on  auscul- 
tation  over  the  left  hypochondrium 
in  cases  of  fibrous  perigastritis. 

Ruault's  Siga  Respiration, 

Diminished  amplitude  of  respira- 
tion on  the  affected  side  in  incipient 
pulmonary  tuberculosis. 


Sahli's  Test  Pancreas, 

Where  the  pancreas  is  functionat- 
ing normally,  iodine  appears  in  the 
urine  six  hours  after  ingestion  of  a 
gluten-coated  iodoform  pill. 

Sicard's  Method.  Neurology, 

Treatment  of  certain  disorders  by 
the  introduction  of  solutions  of 
drugs  into  the  epidural  space. 

Sieur's  Siga  Pleurisy. 

A  ringing,  metallic  sound  elicited 
in  pleural  effusion  by  percussing  the 
opposite  point  with  two  coins,  the 
one  placed  against  the  thorax  and 
the  other  used  as  pleximeter. 

Souques's  Siga  Neurology, 

Spreading  of  the  fingers  when  a 
patient  with  organic  hemiplegia  at- 
tempts to  raise  the  paralyzed  arm 
(incomplete  flaccid   hemiplegia). 

Stellwag's  Siga  Endocrinology, 

Incomplete  closure  of  the  eyes  in 
exophthalmic  goiter. 

Stokes-Chopart,  Law  of. 

Inflammation, 
The    muscles    underlying    an    in- 
flamed mucous  membrane  or  serous 
surface  are  in  a  paralyzed  state. 

Straus's  Siga  Neurology. 

In  severe  peripheral  facial  paral- 
ysis the  sweating  induced  by  pilocar- 
pine is  delayed. 


Thomsen's  Disease.  Myology, 

Spastic  contraction  of  the  muscles 
when  voluntary  movements  are  at- 
tempted. 


Thure-Brandt  Posture.  Abdomen, 
Posture  in  which  the  abdominal 
wall  is  relaxed.  Dorsal  decubitus, 
lower  extremities  flexed,  and  but- 
tocks raised,  the  patient  taking  deep 
inspirations. 

Traube's  Law.  Circulation, 

Interstitial  nephritis  always  tends 
to  bring  about  hypertrophy  of  the 
left  ventricle. 

Troisier's  Ganglioa        Lymphatics, 
Glandular   enlargement   above   the 
clavicle  on  the  left  side  in  cancer  of 
the  stomach. 

Trousseau's  Siga  Neurology, 

Contracture  obtained  by  exerting 
pressure  on  nerves  or  vessels  in 
tetany. 

V 
Valleix's  Laws.  Neurology, 

Governing  the  location  of  pain  in 
neuralgia:  The  painful  areas  are  to 
be  found  at  the  points  of  emergence 
and  in  regions  where  the  nerve  rami- 
fications become  superficial. 

Valsalva  Test  Otology. 

By  attempting  to  blow  out  air  with 
the  mouth  and  nose  closed  the  pa- 
tient inflates  the  t)rmpanic  cavity. 

Vaquez's  Disease.  Blood. 

A  disorder  characterized  by  a 
marked  increase  in  the  number  of 
red  cells,  together  with  cyanosis  and 
splenic  enlargement. 

Vincent's  Angina.  Tonsils, 

Subacute  tonsillitis  with  a  diph- 
theroid exudate  and  associated  with 
the  presence  of  fusiform  bacilli. 

Vulpian's  Law.  Neurology. 

In  hemiplegia  the  patient  turns  his 

head  and  eyes  toward  the  side  of  the 

lesion,  which  he  appears  to  look  at. 

W 
Wassermann  Reactioa       Serology, 
The   Bordet  and  Gengou   reaction 
of  fixation  applied  in  the  diagnosis 
of  syphilis. 

Weber's  Test  Blood. 

A  test  for  traces  of  blood  in  the 
feces  or  in  vomitus.  Acetic  acid, 
ether,  fresh  tincture  of  guaiac,  and 
hydrogen  peroxide  solution  yield  a 
blue  color. 


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1352 


PRINCIPAL  CLINICAL  SIGNS. 


Weber's  Test  Otology, 

A  test  of  the  hearinpr  carried  out 
by  applying  a  tuning-fork  over  the 
forehead.  If  conduction  is  better  on 
the  affected  side,  there  is  middle  ear 
disease.  If  conduction  is  better  on 
the  opposite  side,  there  is  internal 
ear  disease. 

Werlhoff's  Disease.  Blood. 

Cryptogenic  purpura  and  hemor- 
rhages, unattended  with  fever  and 
prognostically  favorable. 

Wernicke's  Siga  Neurology. 

Consists  in  that,  in  a  subject  with 

bilateral    homonymous    hemianopsia, 


pupillary  response  when  a  beam  of 
light  strikes  the  blind  half  of  the 
retina  occurs  only  when  the  lesion 
involves  the  optic  fibers  beyond  the 
thalamus.  In  the  opposite  event,  a 
response  is  obtained  only  by  stimu- 
lating the  normal  half  of  the  retina. 

Westphall's  Sign.  Neurology, 

An  early  sign  of  tabes  dorsalis : 
Loss  of  the  patellar  reflex. 

Woillex's  Disease.  Lungs. 

Acute  pulmonary  congestion  giv- 
ing rise  to  symptoms  similar  to  those 
of  pneumonia. 


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INDEX  TO  VOLUMES  I  AND  II. 


Abderhalden  test,  1343 
Abdomen,  80;   sec  also  the  various 
organs. 

fluoroscopy  of,  81 

inspection  of,  80,  IZl,  1089 

palpation  of.  81,  738,  1091 

percussion  of,  81,  738,  1094 

prominent,  80 

rigid,  1093 

scaphoid,  81 

succussion  of,  81 
Abdominal  angina,  835,  841 

ptosis,  lumbar  pain  of,  1180 

reflex,  475 

wall,  edema  of,  739 
Abdominocardiac  reflex,  281 
Abducens  paralysis   in   otitis   media, 

1347 
Abortion  of  syphilitic  origin,  856 
Abrams's  reflexes,  1343 
Abscess,  brain,  headache  of.  983 

of  the  liver,  1069,  1082,  1120,  1127 

ossifluent,  1188 

perinephric,  1061,  1066,  1070,  1072 

subdiaphragmatic,  1062,  1074,  1339, 
1347 
Accentuated  aortic  second  sound,  208 
Accommodation,  paralysis  of,  in  en- 
cephalitis, 1278 
Acetonemia,  dyspnea  of,  810,  823 

sleep  of,  1272 

vomiting  of,  1334 
Acetonuria,  425 
Achilles  reflex,  468 
Achondroplasia,  604,  606 
Achorion  Schcenleinii,  504 
Achylia  gastrica,  793 
Acidosis,  convulsions  of,  771,  772 

dyspnea  of,  824 

itching  of,  1116 
Acrocyanosis,  1197 
Acromegaly,  605,  606,  912 


Actinomycosis,  586 

of  the  skin,  956 

of  the  tongue,  1305,  1307 
Adams-Stokes    disease,   2,    722,   776, 

927,  1343 
Addison's  disease,  1343 

asthenia  of,  754 

loss  of  weight  in,  1142 

low  blood-pressure  of,  1147 
Adenoid  vegetations,  150 

coated  tongue  in,  1297 
Adhesion,  pericardial,  1348 
Adhesions,  jaundice  due  to,  1120 
Adiposis  dolorosa,  1208 

nervous,  1208 
Adrenal  diabetes,  970 

insufficiency,   754,   928,    1145,    1147, 
1152 
Aerophagia,     805,    1039,    1058,    1233, 

1251,  1254,  1269 
Agglutination  test  for  typhoid  fever, 

548 
Agraphia,  484 
Agrypnia,  1101 
Albumin,  qualitative  tests  for,  409 

quantitative  determination  of,  411 

test  (sputum),  196 
Albuminuria,  649 

acute,  650 

artificial,  412 

cardiac,  655 

chronic,  652 

cryptogenic,  658 

cyclic,  658,  1350 

diabetic,  655 

digestive,  658 

functional,  658 

gouty,  655 

intermittent,  659 

neuromotor,  658 

of  autointoxications,  655 

of  chronic  infections,  654 

(1353) 


Digitized  by 


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1354 


INDEX  TO  yOLUMES  I  AND  II. 


Albuminuria  of  intoxications,  654 
of  pregnancy,  655 
of  fatigue,  658 
orthostatic,  659 
simulated,  659 
Tabular  Synopsis,  656-657 
Alcoholism,  convulsions  of,  773,  774, 
776 

cough  of,  784 

edema  of,  830 

eye  disturbances  of,  922 

gastritis  of,  803,  1000 

loss  of  weight  of,  1143 

nervousness  of,  1193 

neuritis  of,  1318 

obesity  of,  1208 

sleep  of,  1271 

somnambulism  of,  1281 

tremor  of,  1309 

vertigo  of,  1330 

vomiting  of,  1334,  1340 
Alimentary  chloriduria,  440 

enterocolitis,  791 

glycosuria.  125,  970,  1346 

pruritus,  1106 

tract,  41 
ulceration    in,   topographic   diag 
nosis  of,  102 
Allochiria,  1344 
Alopecia,  661 

areata,  661 

cicatricial,  668,  673 

congenital,  661,  668 

in  the  adult,  669 

in  the  child,  661 

in  the  elderly,  673 

in  the  nursling,  669 

infectious,  668 

occipital,  661 

pityrodcs,  670 

senile.  673 

syphilitic,  672 

temporal,  668 

x-ray,  668 
Alternating  pulse,  726,  1286 
Amaurosis,  915,  919 
Ambard's  coefficient,  443 

ureometer,  293 
Amblyopia,  913 
Ambulatory  automatism,  1280 


Ambulatory  case  examination,  627 
Amebae  in  stools,  108,  541 
Amebic  dysentery,  diarrhea  of,  790 
Amphoric  breathing,  166 

voice,  166 
Anemia,  675 

asthenia  of,  754 
epistaxis  of,  845 
low  systolic  pressure  of,  1145 
vertigo  of,  1326 
aplastic,  676 
.    autotoxic,  677 
by  spoliation,  676 
cancerous,  677 

cholemic,  679  , 

infections,  677 
pernicious,  676,  793 

edema  of,  828 
plastic,  676 
toxic,  678 
Aneurysm,  1189 
aortic,  226,  228,  237,  685 
arm  pain  of,  1318,  1320 
bradycardia  of,  1287 
cough  of.  783 
edema  of,  830 
hematemesis  of,  1035 
hemoptysis  of,  1035 
hiccough  of,  1040 
intercostal  pain  of,  1270 
lumbar  pain  of,  1180 
Oliver's  sign  of,  1349 
precordial  pain  of,  1266 
pulsation  of  nostrils  in,  1345 
recurrent  nerve  paralysis  in.  685 
arteriovenous,,  1189 
carotid,  1189 
innominate,  1189 
of  abdominal  aorta,  842,  1120 

pain  in  side  in,  1233 
subclavian.  1189 
Angina  (sore  throat),  1290 
abdominalis,  835,  841 
pectoris,  840,  1248 
arm  pain  of,  1318 
dyspnea  of,  817 
epigastric  pain  of,  800 
pseudo-,  1201 
phlegmonous,  1184 


Digitized  by 


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INDEX  TO  VOLUMES  I  AND  II. 


1355 


Anginoid  syndrome,  1065,  1254 
Angiocholitis,  937 
Angiomata,  multiple,  1197 
Angioneurotic  edema,  831 
Angiospasm,    237,    238,    1051,    1056, 
1257,  1268 
angina  pectoris  in,  1254 
labyrinthine,  1331 
Angiospastic  presclerosis,  1239 
Angor,  1201 

Anguillula  intestinalis,  117 
Aniline  violet,  517 
Ankylostoma,  112,  113 
Anthrax  bacillus,  534 
Anthropomorphic  measurements,  596 
Antianaphylactic  vaccination,   1344 
Antiformin  method  for  sputum,  521 
Antipyrin  in  urine,  427 
Anuria,  651 

calculous,  1219 
Anxiety  neurosis,  1200,  1320 
Aorta,  atheroma  of,  208 
dilatation   of,  225,  227.  237,   1266, 

1319 
diseases  of.  237 

relations  of,  to  body  morphology, 
600 
Aortic  insufficiency,  201,  202,  204 
chronologic  diagrams  of,  202,  204 
Corrigan  pulse  in,  1346 
epistaxis  of,  844 
low  diastolic  pressure  of,  1146 
Musset's  sign  of,  1349 
stenosis,  203,  204 
chronologic  diagrams  of,  203,  204 
Aortitis,  237,  238,  1040 
angina  pectoris  in.  1254 
hiccough  of,  1040 
pain  of,  1266 
tinnitus  of,  1295 
Aphasia,  484,  803 

bundle,  1017 
Aphonia,  680 
acute.  680 
chronic,  680 
hysterical,  692 
simulated,  692 
Tabular  Synopsis,  686-690 
Aphtha,  1299 


Aphthous  fever,  1299 
Apical  pleuritis,  1232 

systolic  murmurs,  209 
Apomorphine,  vomiting  due  to,  1332 
Apoplexy,  see  Coma,  759,  and  Hemi- 
plegia, 1014 
Appendicitis,  dyspepsia  of,  804 

epigastric  pain  of,  842 

left  hypochondriac  pain  of,  1059 

right  hypochondriac  pain  of,  1070, 
1084 
ilac  pain  of,  1089 

yomiting  of,  1332,  1334,  1335,  1340 
Aran-Duchenne     type     of     muscular 

atrophy,  1343 
Argyll-Robertson  pupil,  481,  1343 
Arhsrthjnia,  693 

perpetual,  728 

respiratory  (sinus),  710.  1197 

Tabular  Synopsis,  732-733 
Arm,  see  Upper  extremities. 
Ameth's    neutrophilic    blood-picture, 

175,  315 
Arsenic,^diarrhea  due  to,  791 

hematemesis  due  to,  996 

obesity  due  to,  1208 
Arsphenamin,  jaundice  due  to,  1124 
Arterial  stupor,  traumatic,  245 
Arteries,  239,  1159 
Arteriosclerosis,  927,  1024,  1146 

asthenia  of,  755 

dyspepsia  of,  803 

epistaxis  of,  844 

high  bIo6d-pressure  of,  1053 

in  obesity,  1215 

itching  of,  1106 

loss  of  weight  of,  1143 

plethora  preceding,  1238 

precordial  pain  of,  1268 

tinnitus  of,  1295 

vertigo  of,  1325 

vomiting  of,  1342 
Arteritis,  1159 

syphilitic,  1025.  1026 
Arthralgia,  1128.  1157 
Arthritides,  acute,  1129 

chronic,  1130 

traumatic,  1130 

trophoneurotic,  1130 


Digitized  by 


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1356 


INDEX  TO  VOLUMES  I  AND  II. 


Arthritis,  coxo femoral,  1164 

deformans,  1130 
eye  disorders  of,  915 

gonorrheal,  1156 

tuberculous,  1156 
Arthus's  phenomenon,  1343 
Ascaris,  112,  117 
Aschner's  sign,  1343 
Ascites,  324.  737,  1071 

Tabular  Synopsis,  748,  749 
Ascitic  fluid,  743 
Astasia,  458 
Asphyxia,   local,  of  the  extremities, 

1318 
Asphyxiating  gases,  824 
Asthenia,  751 

humoral,  754 

infectious,  755 

myocardial,  281 

nervous.  752 

vasomotor,  281 

Tabular  Synopsis,  753 
Asthma,  bronchial,  189,  809,  811,  815 

cardiac,  819 
Astigmatism,  879,  904,  985 
Ataxia,  458 

differentiation  of,  498 

locomotor,  see  Tabes  dorsalis. 
Atheroma  of  aorta,  208 
Atrophy,  progressive  muscular,  1343 
Atropine  test,  1289.  1346 
Aura,  vertigo  as,  1330 
Aural  vertigo,  1326 
Auricular  fibrillation,  728 
Auriculoventricular  conduction,   1288 

dissociation,  714,  1286 
Auscultation   of   bronchi   and   lungs, 
166-190 

of  heart.  199-215 
Avellis's  syndrome,  1343 
Azotemia,   442,    755,   823.   980,    1116, 
1151,  1271,  1299 

Babinski  sign,  474,  1343 

induced  vertigo  sign,  494 
Baccelli*s  sign,  1343 

anguloscapular  sign,  1343 
Bacillus  anthracis,  534 

coli,  543 


Bacillus  cholerae  Asiaticae,  540 

diphtheriae,  535 

dysenteriae,  541 

influenzas,  526 

of  Ducrey,  534 

of  Hoffmann,  545 

tetani,  535 

tuberculosis,  525 
Backache,  1170,  1180 

with  fever,  1176 
Bacteria,  classification  of,  524 

in  urine,  434 
Bacteriology,  513 
Balanitis,  955 
Baldness,  669 
Balfour's  disease,  1343 
Bamberger's  sign  in  tabes,  1344 
Bands,  jaundice  due  to,  1120 
Banti's  disease,  1071,  1344 
Barany  sign,  496,  1344 
Bard  and  Pic's  syndrome,  1344 
Barlow's  disease,  1344 
Barraquer-Simons's  disease,  1144 
Bartholin's  glands,  385 
Basedow's  disease,  see  Goiter,  ex- 
ophthalmic. 
Baumes,  law  of,  in  syphilis,  1344 
Beard's  disease,  1344 
Bedside  case  examination,  619 
Bell's  sign  in  facial  paralysis,  1344 
Belladonna,  itching  due  to,  1107 
Bence-Jones's  disease,  1344 
Benedikt's  syndrome,  1344 
Bergeron's  disease,  1344 
Besredka's  method,  1344 
Bier's  method,  1344 
Biett's    ring    in    secondary    syphilis, 

1344 
Bile  acids  in  urine,  420 

in  blood,  124 

pigments,  albumin  reaction,  101 
in  blood,  299 
in  urine,  417 
Triboulet's  reaction,  100 
Bilharzia,  113,  1010 
Bilioseptic  fever,  937,  940 
Bilious  headache,  980 
Bilirubin  in  blood,  299 

in  urine,  418 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1357 


Bird's  disease,  1344 
Biting  of  the  tongue,  1306 
Bladder,  351 
capacity,  353 
cystoscopic  appearances  in  disease, 

360 
hematuria,  1006.  1013 
stone  in,  353,  361 
tumors  of,  361 
ulcerations  of,  360 
Blastocystis  hominis,  111 
Bleeding  time,  289 
Blepharitis,  919 
Blistering  test  of  death,  1276 
Blood,  282,  963 
bacteriologic  examination,  520 
bile,  124 

chemical  examination,  292 
bile  pigments,  299 
chlorides,  298 
picric  acid,  301 
urea,  292,  442,  764 
cultures,  318,  543,  552 
cytologic  examination,  301 
collecting  blood  samples,  301 
cell  counts,  305 
red  cells,  308 
white  cells,  310 
differential,  312 
dry  blood  smear,  311 
filarial  larvae,  320 
malarial  parasite,  319 
hemoglobin,  310 
in  alimentary  canal,  102 
stools,  101,  330 
urine,  330,  424,  433 
physical  examination,  282 
coagulability,  288 
resistance  of  red  cells,  290 
spectroscopy,  282,  588 
viscosity,  282,  1148,  1238 
plasma,  collection  of,  303 
serum,  collection  of,  303 
stains,  detection  of,  589 
Blood-presure  estimation,  239 
auscultatory  method,  243 
oscillatory  (Pachon)  method,  240 
palpatory  method,  239 
high,  1043 


Blood-pressure,  high,  in  nephritis,  653 
low,  981,  1145 

relationship     of,     to    body-weight, 
1141 

Blurred  vision,  904 

Bockhart's  impetigo,   1344 

Body  weight,   1138 

Bones,    disorders    of,    in    upper    ex- 
tremity, 1315 

Bonfils's  disease,  1344 

Bordet-Gengou   complement    fixation 
test,  551,  565,  1344 

Bothriocephalus,  113,  115 

Botulism,  791,  793,  923 

Bouchard's  nodes  in  dilatation  of  the 
stomach,  1345 

Boudin's  law  concerning  malaria  and 
tuberculosis,  1345 

Bouillaud's    laws    concerning    rheu- 
matism, 1345 

Bouveret's  disease,  1345 

Bozzolo's  sign  in  aneurysm,  1345 

Brachial  plexus,  pain  in  disease  of, 
1318 

Brachyalgia,  1313 

Bradycardia,  717,  718,  776,  927,  1256, 
1285 

Bradysphygmia,  1285 

Bradytrophic  diathesis,  1133 

Brain  abscess,  headache  of,  983 
congestion,  1295 
diseases,  eye  disturbances  in,  921 

vomiting  in,  1344 
softening,  484.  1014  . 
tumor,  984,  991,  1279,  1325 

Brandt's  method,  1345 

Brass  sound,  166 

Breast,  pain  in,  1270 

Breathing  capacity,  193 

Bright's  disease,  see  Nephritis, 
sign  in  peritonitis,  1345 

Briquet's  gangrene,  1345 

Brissaud   and    Sicard,    syndrome   of, 
1345 

Broadbent's    sign    in   pericardial   ad- 
hesion, 1345 

Broca's  aphasia.  1345 

Brocq's  pseudopelade  variety  of  fol- 
liculitis decalvans,  673 


Digitized  by 


Google 


1358 


INDEX  TO  VOLUMES  I  AXD  II. 


Bromides  in  urine,  427 
Bronchial  breathing,  166 

glands,  enlarged,  170,  171 
Bronchiectasis,    184,    783,    784,    1339, 

1345 
Bronchitis,   170,  868,  869,  872,   1151, 
1250 
capillary,  171 
chronic,  868,  869 
dyspnea  of,  812 
hemoptysis  of,  1033 
hemorrhagic,  866 
Bronchophony,  166,  1346 
Bronchopneumonia,  186 

pain  of,   1231 
Bronchopulmonary  infections,  cough 

of.  782 
Bronchospirochetosis,      hemorrhagic, 

866 
Brown-Sequard's  method,  1345 

syndrome,  1021,  1023,  1345 
Bnidzinski's  signs,  1345 
Bruit,  aneurysmal,  1189 

d'airain,  166 
Bryson's    sign    in    Graves's    disease, 

1345 
Bubo.  953 

Bulbar  hemiplegia,  1020,  1022 
Bullous  eruptions,  849 
Bundle  of  His,  gumma  of,  1287,  1289 
Bursitis,  subacromial,  1317 

Cachexia,  ascites  of,  746 

edema  of,  828,  832 

low  blood-pressure  of,  1145 
Cadaveric  cooling,  1276 

hypostasis,  1276 

putrefaction,  1276 

rigidity,  1276 
Calculi,   urinary,   350,   353,   361 ;    see 
also       Nephrolithiasis      and 
Stone  in  bladder  and  ureter. 
Calmette's  tuberculin  test,  557 
Caloric  test,  496 
Cancer  of  esophagus,  685 

of  gall-bladder,  1080 

of  intestine,  diarrhea  of,  791,  793 
dyspepsia  of,  802 

of  kidney,  1008 


Cancer  of  larynx,  681,  689,  1190 

of  liver,  1069,  1071,  1083,  1120,  1127 

of  pancreas,  1071.  1120 

of  prostate,  380 

of  splenic  flexure,  1063 

of  stomach,  106.  807 
edema  of,  826,  838 
epigastric  pain  of,  837 
hematemesis  of,  997,  1000 
vomiting  of,  1334,  1341 

of  tongue,  1304 

of  vertebrae,  1233 
Cannabis,  vertigo  due  to,  1330 
Cantharis    poisoning,    hematuria    of, 

1010 
Car  sickness,  vertigo  of,  1331 
Carbol-fuchsin,  517 

-thionin,  517 
Carbon  monoxide  anemia,  678 

vertigo,  1330 
Cardiac  asthma,  819 

disorders    (see   also   Heart),   etio- 
logic  diagnosis,  236 

edema,  827 

hypertrophy,  1270 

neuroses,  821,  1252,  1255 
differentiation  from  organic  dis- 
ease, 1261 
high  blood-pressure  in.  1262 
Cardiography,  261 
Cardiorenal  sclerosis,  1055,  1057,  1139 

in  obesity,  1215 
Casts  in  urine,  430 
Catalepsy,  1282 
Cataract,  902.  923 
Catheterization,  of  bladder,  362,  1219 

ureteral,  340,  1010,  1219 
Causalgia.  1115 
Cavernous  breathing,  166 
Cavities  in  lung,  1339 
Cell  counts,  blood,  305 
Cells  in  exudates,  320 
Cellulitis,  diffuse,  of  the  neck,  1184 

suprahyoid,  1183 
Cephalalgia,  976 

Cerebellar  tumor,  vertigo  of,  1326 
Cerebral  abscess,  headache  of,  983 

arteritis,  484 

embolism,  1014-1026 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1359 


Cerebral     hemorrhage,     see     Hemi- 
plegia, 
eye  disturbances  of,  921 
peduncle,  disease  of,  1344 

tremor  in  tumor  of,  1310 
softening,  1014 
tumor,  Babinski  sign  in,  475 
vertigo  of,  1325 
Cerebrocardiac  neuropathy,  983 
Cerebrospinal  fluid,  324,  492 
bacteriologic  and  biologic  examina- 
tion, 330 
chemical  examination,  327 
cytologic  examination,  329 
in  lethargic  encephalitis,  1279 
physical  features,  324 
Cerumen,  impacted,  tinnitus'  due  to, 
1296 
vertigo  due  to,  1327 
Cervical  glands,  enlarged,  960 
rib.  1321 
tabes,  1318 
Chancre,  885,  952,  953,  960 

of  tongue,  1302 
Chancroid,  952,  953 

bacillus  of,  534,  952 
Charcot  joint,  1156,  1315 
Charcot's  disease,  1345 
Charcot-Marie*s  sign  in  exophthalmic 

goiter,  1345 
Chauflfard's  congenital  icterus,  1123 
Chest  circumference,  191 
constriction,  1267 
expansion,  192 
Cheyne-Stokes    breathing,    167,    714, 

813,  1346 
Chicken-pox,  861,  916 
Chills,  757 

Chloral  hydrate,  hypnotic  use  of,  1103 
Chloride  balance,  441 

retention,  440 
Chlorides  in  blood,  determination  of, 
298 
in  urine,  406,  439 
Chloroform  syncope,  927 
Chloroma,  1343 
Chlorosis,  679 

Cholelithiasis,    1069,    1082    (see    also 
Gall-stones). 


Cholelithiasis,  epigastric  pain  of,  799, 
835,838 

gaseous  distention  of,  1059 

jaundice  of,  1120 

lumbar  pain  of,  1180 
Cholemia,  familial,  1123 
Cholera,  bacillus  of,  540 

diarrhea  of,  790,  794 

oliguria  of,  1219 
Choleroid  state,  791 
Choluria,  419 

Chvostek,  Jr.'s,  sign  in  tetany,  1346 
Chylous  ascites,  746 
Circulatory  system,   199 

functional  tests,  270,  1262 

relationship     to     nervous     system, 
1258 
Cirrhosis    of    liver;    see    Liver,    cir- 
rhosis of. 
Clapton's   sign   in   copper  poisoning, 

1346 
Claude     Bernard-Homer    syndrome, 

918,  919,  1346 
Clinical    examination,    guiding    prin- 
ciples of,  609 

signs,  index  of,  1343 
Coagulability  of  blood,  288 
Coenurosis,  507 
Coffee  intoxication,  950,  1102,  1107 

tremor  of,  1309 
Cogwheel  breathing,  167 
Coin  test,  167 
Cold  abscess,  959 
Colitis,  mucous,  1086 
Colon  bacilluria,  1224 

bacillus  diarrhea,  790 
gaseous  distention  of,  1269 

tumors  of,  1063,  1087,  1271 
Color  vision,  disturbances  of,  906 
Colrat's  test,  1346 
Coma,  759 

Tabular  Synopsis,  762-763 
Comma  bacillus,  540 
Complement  deviation,  565 
in  hydatid  disease,  511 

fixation  test,  551 
Congenital  alopecia,  661 

heart  defects,  1346 

syphilis,  856 


Digitized  by 


Google 


1360 


INDEX  TO  VOLUMES  I  AND  II. 


Conjunctiva,  diseases  of,  896 
Conjunctival  tuberculin  test,  557 
Conjunctivopalpebral  reflex,  476 
Constipation,  766,  804 

headache  of,  980 

itching  of,  1106 

right  iliac  pain  of,  1100 
Contusions,  neuritis  due  to,  1317 
Convalescence,  narcolepsy  of,  1272 
Convulsions,  770 

acute,  771 

chronic,  774 

simulated,  770 
Copaiba  in  urine,  427 
Copper  poisoning,  1346 
Cornea,  886,  898,  920 
Corneal  reflex,  476 
Corrigan  pulse,  1346 
Corrigan's  disease,  1346 
Cosmic  influences,  1317 
Cough,  777 

clinical  features,  778 

mode  of  production,  779 

therapeutic  indications,  780 

varieties,  782 
Courvoisier's  law,  1080,  1346 
Cowper's  glands,  381 
Coxalgia,  1156 
Cracked  pot  sound,  167 
Crackling  sounds,  167 
Cremasteric  reflex.  475 
Croup,  see  Diphtheria. 

false,  783 
Cruveilhier's  disease,  1346 
Culs-de-sac,  pelvic,  388 
Culture  media,  541 
inoculation,  543 
preparation,  542 
Cultures,  544 

blood,  318,  543,  552 
Cupping,  wet,  302 
Cutaneomuscular  reflexes,  474 

symptomatic  significance,  475 
Cutaneovasomotor  reflexes,  476 
Cuti-reaction,  556 
Cyclic  albuminuria,  658,  1350 

vomiting  in  children,  1334 
Cylindroids,  433 
Cvrtometric  mensuration,  192 


Cyst,  cervical,  1190 

hydatid,  508,  1071,  1079,  1107 

ovarian,  740,  832,  1088,  1098 

sebaceous,  956,  1190 
Cysticercosis,  506 
Cystitis,  1007,  1012 

polyuria  of,  1223,  1243 
Cystocele,  385 
Cystoscopy,  340,  355 
Cytologic  examination  of  blood,  301 

of  cerebrospinal  fluid,  329 

of  exudates,  320 

of  gastric  fluids,  64 

Damoiseau's   curve    in    pleural   effu- 
sion, 1346 
Dandruff,  504 

Dark-ground  illumination,  513 
Dead  finger  sign,  1318,  1350 
Death,  signs  of,  923,  1276 

apparent,  1277 
Dehio's  test  in  bradycardia,  1346 
Dejerine-Klumpke,  syndrome  of,  1346 
Delirium,  785 

autotoxic,  789 

cordis,  728 

dream-like,  785 

infectious,  786,  789 

of  interpretation,  788 

oniric,  785 

systematized,  786 

toxic,  786,  789 

tremens,  1280 
Delusional  interpretations,  788 
Delusions,  785 
Deltoid  rheumatism,  1317 
Dementia,  787 

Deplasmatized  red  cell  method,  292 
Depressive  psychoneuroses.  752 
Dercum's  disease,  1207,  1208 
Dermatitis  herpetiformis,   1110 

multiformis,  1110 
Dermographism,  478,  1197,  1256 
D'Espine*s   sign   of   tracheobronchial 

adenopathy,  1346 
Diabetes  insipidus,  1243 

mellitus,  969,  1191 
acetonemia  of,  823 
albuminuria  of,  655 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1361 


Diabetes  mellitus,  asthenia  of,  754 
coma  of,  764 
convulsions  of,  773,  775 
diarrhea  of,  791 
dyspnea  of,  823 
eye  disorders  of,  915 
high  blood-pressure  of,  1045 
itching  of,  1106,  1116,  1117 
loss  of  weight  of,  1143 
obesity  with,  1214 
polyuria  of,  1242 
specific  gravity  of  urine  in,  395 
tinnitus  of,  1296 
vomiting  of,  1342 
Diabetides,  955 
Diacetic  acid  in  urine,  426 
Diagnosis,  causal,  4 
clinical,  4 

errors  of  judgment  in,  25 
functional,  4 
lesional,  4 
Diagnostic  science,  evolution  of,  1 
Diaphanoscopy,  889 
Diaphragmatic  pleurisy,  hiccough  of, 
1040 
pain  of,  1225 
Diarrhea,  790 
circulatory.  792,  1258 
digestive,  793 
emotional,  792 
infectious,  790 
nervous,  791 
toxic,  791 
vasomotor,  791 
Diastolic  blood-pressure,  1043 
low,  1146 
murmurs,  202,  204,  206,  207 
Diathetic  disorders,  tinnitus  in,  1296 
Differential  leucocyte  count,  312,  963 

pressure,  1043,  1146 
Digestive  albuminuria,  658 
activity  in  stomach,  67 
residues,  57 
tract,  41 
Digitalis,  bradycardia  due  to,  1287 
Dionin  test  of  death,  924,  1276 
Diphtheria,  1293 
bacillus,  535,  545 
bacteriologic  procedures,  545 


Diphtheria,  cough  of,  783 

eye  disturbances  of,  916 
Diplopia,  906 

in  encephalitis,  1278 
Disseminated  sclerosis,  472,  475,  484 

eye  disturbances  of,  922 

polyuria  of,  1243 

tremor  of,  1308 

vertigo  of,  1326 
Dissociation,  auriculoventricular,  see 
Heart-block. 

thermo-analgesic,  458 
Distention  of  colon,  gaseous,  1269 
Diuresis,  induced,  434,  1240 
Dizziness,  see  Vertigo. 
Double  vision,  906 
Dream  states,  1281,  1282 
Drug  intoxications,  discolored  tongue 
of,  1297 

dyspepsia  of,  798 

edema  of,  831 

eruptions  of,  848,  849 

eye  disturbances  of,  922 

hematuria  of,  1011 

insomnia  of,  1102 

itching  of,  1107 

nervousness  of,  1193 

oliguria  of,  1223 

sleep  due  to,  1272 

tinnitus  of.  1296 

tremor  of,  1309 

vertigo  of,  1329,  1330 
Dry  blood  smear,  311 
Dubini's  chorea,  1346 
Duchenne's  disease,  1346 
Ducrey,  bacillus  of,  534,  952 
Ductless  glands,  eye  disturbances  in 

disorders  of,  919 
Duguet's  sign  in  typhoid  fever,  1346 
Duodenal  kink,  1073 

ulcer,  75,  77,  82,  105,  998 
fluoroscopy  in,  77,  82 
jaundice  of,  1120 
right     hypochondriac     pain     of, 

1070,  1083 
topographic  diagnosis  in,  105 
Duodenum,  75 
Duroziez's  disease,  1346 


80 


Digitized  by 


Google 


1362 


INDEX  TO  VOLUMES  I  AND  II. 


Durozicz's    signs    in    typhoid    fever 
and      aortic      regurgitation, 
1346 
Dwarfs.  604,  606 
Dyschromia,  850 
Dysentery,  ameba  of,  106,  541 

bacillus  of,  541 

diarrhea  of,  790 

oliguria  of,  1219 
Dysesthesia,  457 
Dysidrosis,  1108 
Dysmenorrhea,  1088 
Dyspepsia,  796,  837 

atonic,  constipation  of,  768 

coated  tongue  of,  1298 

cough  of,  778 

neurotic,  dyspnea  of,  1250 

precordial  pain  of,  1269 

vomiting  of.  1334,  1340 
Dysphagia,  1292 
Dyspnea,  809 

cardiac,  817 

decubital,  817,  1252 

dyscrasic,  822 

emotional,  1251 

neurotic,  810,  824 

of  respiratory  origin.  815 

on  exertion,  811,  1250,  1253,  1267 

paroxysmal,  1268 

p09t-prandial,  1250 

toxic,  810     . 

Ear,  external,   foreign  body  in,  1296 

internal,  493 
hemorrhage  into,  1327 
tinnitus  in  disorders  of,  1296 

middle,    tinnitus    in    disorders    of, 
1296 
Echinococcosis,  507,  508 
Eclampsia,  infantile,  771 

puerperal,  773 
Ectropion,  895 
Eczema,  830,  848,  1109 

marginatum,  504 

seborrheicum,  504 
Edema,  825 

angioneurotic,  831 

cardiac,  827 

dyscrasic,  828 


Edema,  dystrophic,  829 

hemic,  828 

hepatic,  829 

in  nephritis,  651 

nervous,  829 

of  abdominal  wall,  739 

of  face,  830,  1321 

of  lids,  830 

of  lower  extremities,  831 

of  upper  extremities,  831 

paroxysmal,   1350 

preascitic,  829 

renal,  651,  827 
Effort  cough,  783 
Egg  albumin  in  urine,  412 
Egophony,  167 
Einhorn's  bead  method,  131 
Electrocardiography,  264,  721,  729 
Electrodiagnosis,  460 
Embolism,  998,  1014 

pulmonary,  190 
Emotional  angiospasm,  1268 

chill,  758 
Emotive  constitution,  1198 
Emphysema,    pulmonary,     188,     189, 
1151 

dyspnea  of,  811,  812,  1250 

pseudolipoma  of,  1189 
Empyema,  181,  182 

pain  of,  1225 
Encephalitis,  lethargic.  328,  921,  1278 
Endocarditis,    236,    934,    943,     1025. 
1040.  1250,  1253 

pain  of,  1265 
Endocrine  glands  in  diabetes,  971 
Endostethoscopy,  43 
Enophthalmus,  896,  918 
Enteritis,  793 
Enterocolitis,  infectious.  790 

mucomembranous,  1086 

toxic,  791 
Enteroptosis,    constipation    of,    767, 

804 
Enuresis,  775 
Eosin,  517 

Eosinophilia,  506,  509 
Epidermal  scales,  500 
Epidermophyton,  504 
Epididymis,  382 


Digitized  by 


Google 


INDEX  TO  VOLUMES  1  AMD  11. 


1363 


Epidural  treatment,  Sicard's  method 

of,  1351 
Epigastric  pain,  833 

Tabular  Synopsis.  840-841 

reflex,  475 
Epilepsy,  773,  775,  926 

biting  of  tongue  in,  1306 

eye  disturbances  of,  921 

narcolepsy  of,  1273 

polyuria  of,  1241 

somnambulism  of,  1281 

vertigo  of,  1330 
Epistaxis,  843,  1029,  1055 

Tabular  Synopsis,  846 
Epithelioma  of  tongue,  1304 
Equilibration,  disturbances  of,  1323 
Erb*s  signs  in  tetany  and  tabes,  1346 
Eruptions,  skin,  847 
Erysipelas,  849,  863 

edema  of,  830 

eye  disturbances  of,  917 

insomnia  of,  1103 

of  the  newborn,  863 

of  throat,  1292 
Erythema  multiforme  in  eyeball,  919 
Erythematous  eruptions,  849 

throat,  1292 
Erythrasma,  503,  504 
Erythrocyte  count,  308 
Erythrocytes  in  urine,  433 
Erythrodermias,  849 
Esbach's  albuminometer,  412 
Esophagoscopy,  46 

contraindications,  50 
Esophagus,  41 

anatomical  considerations,  41 

auscultation  of,  42 

bleeding  from,  994,  999 

cancer  of,  685 

disorders  of,  999 

diverticulum  of,  46 

examination  of,  with  sounds,  43 

fluoroscopy  of,  43 

palpation  of,  42 

stenosis  of,  42 

stricture  of,  46 

varicose  vessels  of.  999 
Ether  pearl  method,  67 


Ethylmorphine  hydrochloride  test  of 

death,  1276 
Eustachian  tube,  tinnitus^  in  obstruc- 
tion of,  1296 
Examination,  medical,  guiding  prin- 
ciples in,  609 
Exanthemata,  847 
Tabular    Synopses,   848-850,   855- 
863 
Exhaustion,  751 

Exophthalmic  goiter,  see  Goiter,  ex- 
ophthalmic. 
Exophthalmus,  896,  918,  920 
Expectoration,  865 
of  pus,  1339 

Tabular    Synopses,   868-869,   872- 
873 
Expression  sound  in  esophagus,  42 
Extra-uterine  pregnancy,  1088,  1099 
Exudate,  pharyngeal,  544,  1290 

pleural,  182 
Exudates,  cells  in,  320 
differentiation  of,  by  Rivalta's  test, 
331 
Eyeball,    compression    of    (oculocar- 
diac reflex),  213 
prominence  of,  896,  918,  920,  1321 
retraction  of,  896 
Eyelids,  discoloration  of,  1348 
disorders  of,  895 
eversion  of,  883 
Eyes,  disorders  of,  894 
headache  in,  984 
in  general  disease^,  913 
examination    and   symptomatology, 

876,  893 
pain  in,  903 

Facial  neuralgia,  982 

paralysis,  1025 
in  encephalitis,  1278 
peripheral,  Straus's  sign  of,  1351 
Fainting,  925 
Fallot's  disease,  1346 
Fats  in  stools,  99,  130,  794 

intolerance  of,  793 

normal  assimilation  of,  100 
Fatigue,  751 

humoral,  754 


Digitized  by 


Google 


1364 


INDEX  TO  VOLUMES  I  AND  II. 


Fatigue,  infectious,  754 

nervous,  752 
Favus,  5()4,  666 
Febricula,  936 
Fecal  obstruction,  802 
Fecaloid  vomiting,  1333 
Feces,  examination   of,  91 ;  see  also 

Stools. 
Fehling's  solution,  415 
Female  reproductive  organs,  384 
Fever,  929,  948 

Tabular  Synopsis,  938-939 
Fibrillation,  auricular,  728 
Fibrous  glossitis,  1303 
Field  of  vision,  891,  910 
Filaria,  320 
Filiform  bougies,  365 
Finsen's  method,  1347 
Fissural  points  in  interlobar  pleurisy, 

1228 
Fixation  abscess,  1347 

methods  of,  522 
Flask  bacillus,  503,  504 
Flat  foot,  1153,  1154 
Flatulence,  1058,  1065,  1066,  1233 
Flatulent  dyspepsia,  804 
Flexor  reflex  of  forearm,  469 
Flint  murmur,  201 
Fluorescin  death  test,  923,  1276 
Fochier's  method,  1347 
Folliculitis  decalvans,  Brocq's,  673 
Food  intoxication,  793,  848 

residue  in  stomach,  59 
Forcipressure  test  of  death,  1276 
Fosse  method  of  urea  determination, 

296 
Fracture    of    skull,    hemiplegia    of, 

1027 
Frequent  pulse,  942 

Tabular  Synopsis,  950 
Fresh  blood  preparation,  304 
Friction,  pericardial,  212 

pleural,  168 
Friedreich's  ataxia,   1347 

eye  disturbances  of,  922 
Frohlich's  syndrome,  1347 
Frontal  tumor,  vertigo  of,  1325 
Functional  capacity  of  kidneys.  346 

tests  of  circulation,  270,  1262 


Funiculitis,  vertebral,  1167,  1168 
Mirbringer's  sign,  1347 
Fusiform  bacillus,  538,  1351 
Future  of  medicine,  640 

Gall-bladder,  cancer  of.  1080 
perforation  of,  1075 
point,  117 
Gall-stones,  1068,  1080,  1082  (see  also 
Cholelithiasis), 
dyspepsia  of,  799 
epigastric  pain  of,  835 
hypochondriac  pain  of,  1068,  1082 
jaundice  of,  1120 
Gallop  rhythm,  201 
Gaseous  distention  of  colon,  1269 
Gastralgic  crises  of  tabes,  801,  842 
Gastric  analyses,  61 
atony,  55 

cancer  (see  Cancer  of  stomach), 
contents,  examination  of,  58 
acid,  62 
bile,  64 
blood,  64 
cells,  64 
fatty  acids,  64 
free  HCl,  63 
lactic  acid,  64 
protein  substances,  64 
removal  of,  55 
cough,  778 

distention,  precordial  pain  of,  1269 
esthesiometer,  54 
neuroses,  836,  837,  1340 
points  of  tenderness,  54 
residues,  57 

secretion,  study  of,  without  stom- 
ach tube,  65 
ulcer,  6,  104,  837 
differentiation   from  cancer,   106, 
807,  808,  837 
from  duodenal  ulcer,  105 
hematemesis  of,  997,  1000 
right  hypochondriac  pain  of,  1083 
topographic  diagnosis,  104 
vomiting  of,  1341 
Gastritis,  alcoholic,  803 
vomiting  of,  1334.  1340 
medicamentosa.  798 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1365 


Gastrointestinal     disorders,    loss    of 

weight  in,  1142 
Gaucher's  disease,  1347 
Gel  reaction  in  syphilis,  579 
General  considerations,  1 
paralysis,  see  Paralysis,  progres- 
sive general. 
Genital  ulcerations,  951 

Tabular  Synopses,  953,  955 
Genitourinary  tract,  332 
Geographic  tongue.  1300 
Gerhardt's  test,  426,  1347 
German  measles,  860 
Giddiness,  see  Vertigo. 
Giemsa  stain,  518 
Gigantism,  605,  606 
Gilbert's  familial  cholemia,   1123 
Gilbert    and    Herscher    method    for 

urobilin  in  blood,  301 
Glandular  enlargements,  956 
chancroidal,  953 
in  the  neck,  960,  1184 
neoplastic,  961 
syphilitic,  855,  953.  958.  960 
Glaucoma,  899,  900,  908,  910,  983 
Glenard's  procedure  in  kidney  palpa- 
tion, 338 
test,  52 
Glossitis,  1299 
cancerosyphilitic,  1204 
fibrous.  1303 

marginal  exfoliative,  13(X),  1301 
syphilitic,  1301,  1303 
Glucose  solution,  polyuria  following 

administration  of,  1241 
Glycosuria,  969,  1191 
alimentary,  125,  970,  1346 
and  loss  of  weight,  1143 
traumatic,  974 
Gmelin's  test,  300,  417,  1347 
Godelier's   law    in    tuberculous   peri- 
tonitis, 1347 
Goetsch's  test,  1192 
Goiter,    exophthalmic,    5,    896,    1191, 
1197,  1344 
chief  clinical  signs  of,  1192 
diarrhea  of,  792 
eye  disturbances  of,  919 
fever  of,  936 


Goiter,     exophthalmic,     itching     of, 
1115 
loss  of  weight  of,  1142 
polyuria  of,  1241 
tachycardia  of,  944 
tremor  of,  1310 
simple,   1191 
cough  of,  783 
dyspnea  of,  810 
Gonococcus,  527 
Gonorrhea,  375,  939 

urethrovaginal,  384 
Gonorrheal  arthritis,  1156 

urethritis,  378 
Goose  flesh,  1258 
Gordon's  sign  in  pyramidal   disease, 

1347 
Gout,  albuminuria  of.  655 
angina  pectoris  of,  1254 
arthritis  of,  1130,  1156 
diarrhea  of,  791 
edema  of,  831,  832 
extra-systoles  of,  1253 
eye  disorders  of,  915 
grinding  of  teeth  in,  1347 
hemoptysis  of,  1035 
high  blood-pressure  of,  1045 
intercostal  neuralgia  of,  1270 
itching  of,  1106 
obesity  in,  1214 
tinnitus  of,  1296 
Gradenigo's  syndrome,  1347 
Graefe's  sign,  919,  1347 
Gram's  method,  523 

solution,  518 
Gram-negative  germs,  524 

-positive  germs,  524 
Grancher's  disease,  1347 
Graphic  methods,  249 
Grave  icterus,  1121 
Graves's    disease,    see    Goiter,    ex- 
ophthalmic, 
sign  in  gout,  1347 
Grimbert    method     for    albumin    in 
urine,  411 
test  for  bile  in  urine.  418 
Grocco's  triangle  of  dulness,  1347 
Guaiac  test  for  blood  in  urine,  424 
Gueneau  de  Mussy's  points,  1266 


Digitized  by 


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1366 


INDEX  TO  VOLUMES  I  AND  II, 


Guerin's  law  in  rickets,  1347 
Gumma,  852,  856,  953 

of  bone,  1154,  1315 

of  bundle  of  His,  1287,  1289 

of  tongue,  1301,  1303 
Gums,  bleeding  from,  1030 
Guyon's  procedure  of  kidney  palpa- 
tion, 336 

reno-renal  reflex  pain,  1179 

Habit  cough,  783 
Hair,  diseases  of,  499 
Hallucinations,  786 
Hanot's  disease,  1347 
Harley's   disease,    1347* 
Harrison's   groove,    1347 
Hay  fever,  1197 
Hay's  test,  420 
Hayem's  hematinieter,  306 

hemochromometer,  310 

solution,  306 
Head's  cranial  zones,  977,  978,  986, 
1347 

zones   of   cutaneous   hyperesthesia, 
1234 
Headache,  976,  989 

alcohol,  981 

bilious,  980 

muscular,  987 

nasal,  986 

nervous,  981,  1256   • 

ocular,  984 

of  constipation,  980 

pressure,  983 

prodromal,  979 

syphilitic,  984 

tobacco,  981 

toxic,  979 

uremic,  980 

utero-ovarian,  987 

winter,  981 

Tabular  Synopsis,  990-991 
Heart  action,  weak,  274,  278 

arhythmia,  693 

block,  714,  1286 

cough,  783 

defects,  congenital,  1346 

disorders,    anginose    syndrome    of, 
1250 


Heart    disorders,    blood-pressure    in, 
1046,  1047 
dyspnea  of,  812,  1250 
edema  of,  826,  827 
epigastric  pain  of,  836 
etiologic  diagnosis,  236 
eye  disorders  of,  915 
frequent  pulse  of,  942 
hemoptysis  of,  1031 
oliguria  of.  1220 
vertigo  of.  1326 
vomiting  of,   1334,   1341 
distention,  1266 
failure,  ascites  of,  745 
bradycardia  of,  1287 
hematemesis  of,  1001 
hypochondriac  pain  of,  1069 
insomnia  of,  1103 
low  pulse  pressure  of,  1146 
irregularities,  693 
landmarks  on  chest  wall,  211 
murmurs,  201-207,  209 
pains  in  region  of,  1245 
percussion,  215 

.  relations  to  body  morphology,  600 
sounds,  200,  208 
underdeveloped,  1150 
weakness,    187,  274,  812,  817,  827, 

1220 
x-ray  examination  of,  219 
fluoroscopy,  220 
orthodiagraphy,  222 
orthofluoroscopy,  225 
teleradiography.  230 
Heberden's  nodes,  1348 
Height,  596 
Heinc-Kreysig's    sign    in    pericardial 

adhesion,  1348 
Heine-Medin's  disease,   1348 
Heine-Sanders's    sign    in    pericardial 

adhesion,  1348 
Helminthiasis,  506,  1039 

vertigo  of,  1324 
Hematemesis,  993,  1030,  1055 

Tabular  Synopsis,  1000-1001 
Hematin,  588 
Hematology,  282 
Hematoxylin,  518,  519 
Hematuria,  1003 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1367 


Hematuria,  cryptogenic,  1010,  1013 

false  (drugs).  1011 

hemic.  1009 

parasitic,  1010 

prostatic,  1005 

renal,  1007 

toxic,  1010 

ureteral,  1007 

urethral,  1005 

vesical,  1006 

Tabular  Synopsis,  1012-1013 
Hemeralopia,  905 
Hemianopsia,  911 

Wernicke's  sign  in,  1352 
Hemiplegia,  761,  1014,  1343 

organic,  Revilliod  s  phenomenon  in, 
1350 
Souques's  sign  of,  1351 
Vulpian's  law  in,  1351 

Tabular  Synopsis,  1026-1027 
Hemoconia,  125 
Hemoglobin  estimation,  310 

spectroscopic  determination,  594 
examination,  588 
Hemoglobinuria,  paroxysmal,   1347 
Hemolysis,  290 
Hemolytic  jaundice,  1123,  1126 

reaction,  565 
Hemophilia,  cpistaxis  of,  845 

hematuria  of,  1009 

hemoptysis  of,  1035 
Hemoptysis,  994,  1029,  1055 
Hemorrhage,  anemia  due  to,  676 

cerebral,  765,  1015. 

eye  disorders  in,  915 

hematemesis.  993 

hematuria.  1003 

hemoptysis,  1029 

syncope  in,  928 

vertigo  of.  1326 
Hemorrhagic       bronchospirochetosis. 

866 
Hemorrhoids,  blood  from,  105 

lumbago  in,  1176 

pelvic  pain  in,  1163 
Hepatic  colic,  see  Cholelithiasis, 
oliguria  of,  1219 
vomiting  of,  1334,  1340 

diabetes,  970 


Hepatic  obstruction,  oliguria  of,  1222 
Hepatitis,  742 

Hepatization,  gray,  pulmonary  vom- 
ica in,  1339 
Hepatoptosis,  1071 
Hereditary  tremor,  1309 
Hernia,   inguinal,   left   iliac   pain   in, 
1088 
right  iliac  pain  in,  1089,  1099 
scrotal,  382 

strangulated,  hematemesis  of,  997 
vomiting  of,  1333,  1341 
Herpes,  genital,  954,  955 
zoster,  1078,  1172,  1233,  1313 
of  pharynx,  1292 
Herpetic  angina,  1292 
Herxheimer's  reaction,  1348 
Hesperanopia.  905,  919 
Hiccough,  1039 
High  blood-pressure,  1043 

diseases  attended  with,  844 
epistaxis  of,  844 
vertigo  of,  1330 
Tabular  Synopsis,  1056-1057 
portal  pressure,  436.  742,  1000,  1046 
Hip  disease,  1156 

Hippocratic  succussion  sound,  167 
Hirschsprung's  disease,  1348 
Hoarseness,  ^80 
Hodgkin's  disease,  961,  962 

edema  of,  830 
Hodgson's  disease,  1348 
Hookworm  (ankylostoma),  112,  113 
Hot  flushes,  1258 
Hourglass  stomach,  801 
Hunger  pain,  76 
Hutchinson  teeth,  1348 
Hydatid  disease,  508.  1107 
of  liver,  1071,  1079 
pulmonary  vomica,  1339 
Hydremia,  653 
Hydrocele,  324.  326,  73H 
Hydrocephalus,  eye   disturbances   of, 

921 
Hydronephrosis,   1060.   1066 
Hydruria,  436 

Hydrurimetric  coefficient,  439 
Hydrurimetry,  390,  434 


Digitized  by 


Google 


1368 


INDEX  TO  VOLUMES  I  AND  II. 


Hyperchlorhydria,  epigastric  pain  of. 

836 
Hyperesthesia,  1194 

lumbar,  1178 
Hyperidrosis,  1177 
Hyperopia,  904,  985 
Hypersomnia,  1271 
Hypertension,  1043 

intraocular,  899 

portal,  436,  742.  1000,  1046 
Hypertensive  diseases,  844 
Hyperthermia,  929 
Hyperthyroidia,   1193,  1310;  see  also 

Goiter,  exophthalmic. 
Hypertrophy  of  heart,  pain  of,  1270 

of  prostate,  380,  1223,  1243 
Hyphema,  898 
Hypnophobia,  1282 
Hypnosis,  1282 

somnambulism  during,  1281 
Hypnotics,  sleep  due  to,  1274 
Hypoadrenia,  1147 
Hypochondria,  dyspepsia  in,  806 
Hjrpochondrium,  left,  pain  in,  1058 
Tabular  Synopsis,  1066-1067 

right,  pain  in,  1068 

points  of  tenderness  in,  1076 
Tabular  Synopsio,  1082-1084 
Hypopyon,  898 
Hyposphyxia,  227,  1140,  1148 

asthenia  of,  754 

dyspnea  of,  823 

headache  of,  981 

low  systolic  pressure  of,  1145 

obesity  and,  1215 

sleep  of,  1272 
Hypotension,  see  Low  blood-pres- 
sure. 
Hypothyroidia,  chief  clinical  signs  of, 

1192,  1207 
Hysteria,  1198 

differentiation    of,    from    epilepsy, 
475 
Hysterical  aphonia,  692 

coma,  928 

convulsions,  774.  775 

cough,  780 

headache,  982 

hematemesis,  996 


Hysterical  hemiplegia,  1023,  1026 
Rosenbach's  sign  of,  1351 

hiccough,  1040 

pain,  1091 

polypnea,  824 

polyuria,  1241 

sleep.  759,  1273 

somnambulism,  1281 

tremor,  1310 
Hysterometry,  389 

Hysteropithiatism,    eye    disturbances 
of,  920 

Icard*s  fluorescein  formula,  1276 
Icterohemorrhagic  spirochetosis,  1121, 

1157 
Icterus,  998,  1119 

grave,  1121,  1126 

hematic,  1122 

hepatic,  1119 

infectious,  1121,  1126 

picric,  1123 
Idiocy,  eye  disturbances  of,  921 
Iliac  fossa,  left,  pain  in,  1085 

Tabular  Synopsis,  1088 
Iliac  fossa,  right,  pain  in,  1089 

Tabular  Synopsis,  1098-1099 
Illuminating  gas,  glycosuria  due  to, 

971 
Impetigo,  Bockhart's,  1344 

bullosa,  504 
Inanition,  dyspepsia  due  to,  798 
Incubators,  543 
India-ink  method;  519 
Indican  in  urine,  421 
Indigestion,  796  (see  also  Dyspepsia). 

coated  tongue  in,  1298 

diarrhea  in,  795 

vomiting  in,  1332,  1340 
Indurative    muscular   headache,   988, 

991 
Inequality   of  pulse  in  aortic  aneu- 
rysm, 1321 

of  pupils,  915,  1278 
Infantile    eclampsia,   convulsions   of, 
771 

giants,  606 
Infarction  of  lung,  190 


Digitized  by 


Google 


INDEX  TO  i  OLUMES  I  AND  11. 


1369 


Infectious  diseases,  see  articles  on 
Asthenia,     Delirium,    Fever, 
Frequent    pulse,     Headache, 
Lumbar  pain,  and  Oliguria, 
jaundice,  1120,  1126 
Influenza,  935,  938 
bacillus,  526 
headache  of,  979 
loss  of  weight  in,  1142 
tongue  of,  1299 
Inoculation   test   for  tubercle   infec- 
tion, 558,  561 
Insanity,  see  Delirium,  785 

eye  disturbances  of,  921 
Insomnia,  1101,  1258 
due     to     circulatory     disturbances, 

1103 
due    to    nervous    overexcitability, 

1102 
due  to  pain,  1101 

due    to    respiratory    disturbances, 
1103 
Intercostal  neuralgia,  1270 
Intermittent  albuminuria,  1197 
claudication,  1160 
fevers,  940 

hepatic  fever,  937,  940 
pulse,    see    Premature   beats   and 
Sinus  arhythmia. 
Internal  ear,  493 

hemorrhage  into,  1327 
Intestinal    fermentations,    sleep    due 
to,  1272 
obstruction,  vomiting  of,  1333,  1341 
parasites,  111-117 
Intestine,  80,  105 
cancer  of,  791,  793,  802 
x-ray  examination  of,  82 
Intoxication    (see   also   Drug  intox- 
ications),  delirium   of,   789 
Intraocular  tension,  887,  899 
Iodides  in  urine,  428 
Iridonesis,  901 
Iris,  diseases  of,  899 

examination  of,  886 
Irregularities  of  heart  action,  693 
Israel's   procedure   of   kidney  palpa- 
tion, 337 
Isuria,  434 


Itch,  1112 
Itching,  1106 

dermatosic,  1107 

neurotic,  1115 

parasitic,   1112 

toxic,  1106 

Tabular  Synopsis,  1106 

Jaccoud's    sign     in    pericardial    ad- 
hesion, 1348 
Jaundice,  1119 

bradycardia  of,  1287 

catarrhal,  1120 

due  to  arsphenamin,  1124 

hematic,  1122 

hemolytic,  1123,  1126 

hepatic,  1119 

infectious,  1120,  1126,  1157 
hemoptysis  of,  1034 

itching  of,  lll6 

picric,  1123 

relapsing,    temperature    curve    in, 
937 

syphilitic,  1124 

Tabular  Synopsis,  1126-1127 
Jejunum,  75 
Jellineck's  sign,  1348 
Joint  pains,  1128 

in  lower  extremities,  1155 

in  upper  extremities,  1313 

KarelFs  treatment,  1348 
Keratitis,  898 
Kerion  of  Celsus,  667,  668 
Kemig's  sign,  485,  1279,  1348 
Kidney,  amyloid  degeneration,  poly- 
uria of,  1243 

anatomic  relations  of,  1073 

eye    involvement    in    disorders    of, 
914 

functional  tests  of,  434,  452 

inspection  of,  334 

pain,  1172,  1178 

painful  enlargements  of,  1179 

palpation  of,  336 

percussion  of,  339 

permeability  of,  448,  651 

physiologic  laws  relating  to,  446 

points  of  tenderness,  335 


Digitized  by 


Google 


1370 


INDEX  TO  VOLUMES  I  AND  II. 


Kidney  stone,  350,  1008,  1060,  1066; 

see  also  Nephrolithiasis, 
tuberculosis  of,  see  Tuberculosis, 

renal, 
tumor  of,  1012   - 
x-ray  examination  of,  344,  349 
Kienbock's     sign    in     hydropneumo- 

thorax,  1348 
Killian's  tracheoscope,  47 
Kink,  767 
Kiva  method   for  urobilin  in  blood, 

300 
Klebs-Loffler  bacillus,  545 
Klippel's  disease,  1348 
Knee-jerk.  467     . 
Koplik's  spots,  859 
Kraurosis  vulvae,  385 
Kussmaul  breathing,  1348 
Kyphosis,  hyposphyxia  in,  1151 

Labioglossolaryngeal  paralysis,  10^2 

Labyrinth.  493 

Labyrinthine  angiospasm,  1331 

vertigo,  493,  1326 
Lacrymal  duct,  885 
Lacrymation,  894 
Laennec's  cirrhosis,  1348 
Lamblia  intestinalis,  111 
Landouzy-Dejerine  type  of  muscular 

atrophy,  1348 
Landry's  disease,  1348 
Lanz's  point,  1097 
Larval  worms,  parasitic,  506 
Laryngismus  stridulus,  783 
Laryngitis,  acute,  680,  686 

chronic,  680,  686 
Laryngoscopic  picture.  160 
Larynx,  cancer  of,  681,  689,  1190 

diseases  of,  680 

examination  of,  155 

hemorrhage  into,  1030 

paralyses  of,  6^2,  689 

syphilis  of,  681,  688 

tuberculosis  of,  681,  687 

tumors  of,  680,  688 
Lasegue's  sign  in  sciatica,  1162, 1177, 

1348 
Lead  acetate  as  test  of  death,  1276 

anemia,  678 


Lead  colic,  1096 

constipation,  766 

convulsions,  773 

dyspepsia,  801 

eye  disturbances,  923 

gastralgia.  801 

hemiplegia,  1027 

intercostal  neuralgia,  1270 

nervousness,  1193 

neuritis,  1318 

right  iliac  pain,  1096 

tremor*  1309 
Left  ventricle,  acute  insufficiency  of, 

1267 
Leg,  see  Lower  extremities. 
Lematte*s  test  of  renal  activity,  452 
Lens,  crystalline,  888 
Leprosy,  anesthetic,  1318 

eye  disturbances  of,  917 

nervous,  1318 
Lethargic  encephalitis,  328,  1278 

states,  1273 
Lethargus,  1283 
Lethargy,  1283 
Leucocyte  count,  310 
differential,  312 
Leucocytes  in  urine,  434 
Leucoma,  898 
Leucopenia,  676 
Leukemia,  939,  964 

epistaxis  of,  845 

hematuria  of,  1009 
Leukoplakia  buccalis,  1300 

epitheliomatous     degeneration     of, 
.1301 
Lcyden-Mobius     type     of     muscular 

atrophy,  1348 
Lichen  planus,  buccal,  1301 
Lichenification,  1108 
Lids,  edema  of,  830,  831 
Lieben's  test,  425 
Lingual  syphilides,  1302 
Lipemia,  alimentary,  125 
Lipodystrophy,  progressive,  1144 
Lipoma,  956.  1189,  1190 
Litten's    sign    in    pulmonary    tuber- 
culosis, 1348 
Little's  disease,  1348 

eye  disturbances  of,  922 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II, 


1371 


Liver,  117,  742,  1068 
abscess  of,  1069,  1082,  1120.  1127 
cancer  of,  1069,  1083,  1120,  1127 
cirrhosis    of,    atrophic,    742,    1071, 
1127,  1150,  1348 
edema  of,  829 
epistaxis  of,  846 
hematemesis  of,  998 
tympanites  of,  792 
hypertrophic,  1071 
disorders,  epistaxis  in,  845 
eye  disturbances  in,  919 
fluoroscopy  of,  124 
hydatid  disease  of,  1079 
inspection  of,  117 
outline  of,  117 
overactivity  of,  793* 
palpation  of,  120 
ChaufFard's  procedure,   120 
Gilbert's  procedure,  121 
Glenard's  thumb  procedure,  121 
Mathieu's  procedure,  121 
two-thumb  procedure,  122 
passive    congestion,    pain    of,    835, 

1068,  1082 
percussion  of,  118 
suprahepatic  ballottement,  119 
transthoracic    hydatid     fremitus, 
119 
wave,  119 
points  of  tenderness,  124 
radiography  of,  124 
syphilis  of,  1069,  1083,  1127 
Locomotor  ataxia,  see  Tabes  dor- 

salis. 
Loss  of  weight,  1137 
Lovers,  radial  paralysis  of,  1318 
Low  blood-pressure,  1145 
headache  of,  981 
in  adrenal  insufficiency,  1147 
in  hyposphyxia,  1148 
in  tuberculosis,  1147 
Tabular  Synorsis,  1152 
Lower  extremities,  pain  in,  1153 
Ludwig's  angina,  1349 
dyspnea  of,  810 
edema  of,  830 
Lumbago,  1168,  1172,  1176,  1180 
Lumbar  pain,  1170 


Lumbar  plexus,  1165 

puncture,  487 
Lumbarthritis,  1175 
Lung,  abscess  of,  184,  1033 

pulmonary  vomica  in,  1339 

congestion  of,   1352 
massive,  1347 
pain  in  the  side  in,  1231 
passive,  187 

emphysema  of,  188 

fibrosis,  dyspnea  of,  812,  818 

gangrene  of,  184,  1034 

hydatid  cysts  of,  184 

infarction,  hemoptysis  of,   1031 

inflammation,  pain  of,  1229 

syphilis  of,  1034 

tuberculosis  of,  see  Tuberculosis, 
pulmonary. 

tumors  of,  184,  1034 
Lymphadenitis,  956 

cervical,  960,  1184 

tuberculous,  959,  1185 
Lymphadenoma,  1186 
Lymphangitis,  1321 

edema  of,  826 
Lymphatic  temperament,  967 
Lymphosarcoma,  967,   1188 

MacDonagh  reaction  in  syphilis,  579 
Macroglossia,  1305 
Macular  eruptions,  849 
Madelung's  disease,  1349 
Malaria,  eye  disturbances  of,  917 

headache  of,  979 

hemoptysis  of,  1034 

temperature  curve  in,  935 

tremor  of,  1309 
Malarial  parasite,  319 
Malum  coxae  senilis,  1156 
Marey's  law,  1349 
Marie's  disease,  1349 
Martinet's  laws,  1349 

syndrome,  1349 
Masseter  reflex,  472 
Mastodynia,  1270 
Maurel's  reagent  for  egg  albumin  in 

urine,  413 
McBurney's  point,  1094,  1097 
Measles,  858 


Digitized  by 


Google 


1372 


INDEX  TO  VOLUMES  I  AND  II, 


Measles,  epistaxis  of,  846 
eye  disturbances  of,  916 
German,  860 
sore  throat  of,  1292 
Median   nerve,   sensory   disturbances 

in  injuries  of,  1317 
Mediastinal    tumors,    arm    pain    of, 
1318,  1321 
bradycardia  of,  1287 
cough  of,  783 
edema  of,  830 
intercostal  pain  of,  1270 
Medical  organization,  640 
Megacolon,  congenital,  1348 
Melancholic  stupor,  1275 
Menetrier's  syndrome,  1349 
Meniere's  disease,  1326 
syndrome,  1328,  1349 
vertigo,  1326 
Meningeal     hemorrhage,     hemiplegia 
of,  1027 
hyperemia,  486 
states,  328 
cell  findings  in,  329 
convulsions  of,  771 
eye  disturbances  of,  921 
headache  of,  983,  991 
hiccough  of,  1040 
hypersomnia  of,  1277,  1279 
insomnia  of,  1102 
tache  cerebrale  of,  478 
vomiting  of,  1332,  1342 
Meningitic  line,  478 
Meningitis,  cerebrospinal,  4,  528,  939, 
948,  1176 
Brudzinski's  signs  of,  1345 
Parrot's  sign  of,  1350 
tuberculous,  326,  1027.  1279 
Meningococcus,  528 
Meningomyelitis,  acute,  1176 

girdle  pains  of,  1233 
Menopause,    vasomotor    disturbances 
of,  1197 
vertigo  of,  1326 
Menstruation,  vicarious,  844,  1036 
Mensuration,  597 

of  chest,  191 
Mercurial  anemia,  678 
diarrhea,  791 


Mercurial  stomatitis,  1299 

tremor,  1309 
Mercury  ureometer,  294 
Metabolic  disturbances  in  exophthal- 
mic goiter,  1191 
Metallic  tinkle,  167 
Metatarsalgia.  1349 
Meteorism,  739,  1058 
Meteorologic  hyperesthesia,  1194 
Methemoglobin,  588 
Methylene  blue,  517.  523 

test  for  renal  permeability,  448 
Meyer's  test  for  blood  in  urine,  424 
Microsporia,  502,  663 
Microsporon  Audouini,  504 
furfur,  503,  504 
minutissimum,  503,  504 
Migraine,  981,  988 
ophthalmic,  903 
ophthalmoplegic,  909 
vomiting  of,  1342 
Mikulicz's  disease,   1349 
Millard-Gubler  syndrome,  909,   1017, 

1019,  1349 
Mistaken  diagnoses,  causes  of,  15 
Mitral  insufficiency,  205,  207,  238 
chronologic     diagrams    of,    205, 
207 
stenosis,    201,    206,    207,    238,    735, 
1151 
chronologic    diagrams    of,     206, 

207 
dyspnea  of,  818 
hemoptysis  of,  1031 
Mobius's  disease,  1349 

sign  in  exophthalmic  goiter,  1349 
Morbid  sleep,  1271 

Morphine   and    veronal    intoxication. 
1274 
hypnotic  use  of,  1103 
in  urine,  428 

intoxication,  chronic,  loss  of  weight 
in,  1143 
Morphologic  indices,  599 
Morris's  point,  1097 
Morton's  disease,  1349 
Morvan's  disease,  1318,  1349 
Motion,  examination  of,  458 
Mountain  sickness,  vertigo  of,  1331 


Digitized  by  VjOOQIC 


INDEX  TO  VOLUMES  I  AND  II. 


1373 


Mouth  breathers,  coated  tongue  of, 

1297 
Mucous  enteritis,  792 

patches,  855,  1302 
Mumps,  eye  disturbances  of,  917 
Murmurs,  heart,  201-207,  209 
features  differentiating  organic  and 

functional,  212 
ocular  compression  in,  213 
Murphy's  method,  1349 
Muscae  volitantes,  905 
Muscles  of  lower  extremities,  pain- 
ful disturbances  of,  1157 
of  upper  extremities,  painful  dis- 
turbances of,  1317 
Muscular  power,  testing,  459 
Musset's    sign    in    aortic    regurgita- 
tion, 1349 
Myalgia,  1157 

pectoral,  1247 
Mycoses,  584,  918 
Mydriasis,  901,  918 
Myelitis,  1024 
eye  disturbances  in,  922 
peri-ependymal,  1310 
Myocardial  asthenia,  281,  1250 
Myocardialgia,  1247 
Myocarditis.  274,  275,  942,  1040,  1266, 

1287 
Myopia,  904,  985 
Myosis,  901,  918 
Myositis,  1157,  1317 
Myxedema,  asthenia  in,  754 
Myxedematous  dwarfs,  604,  606 

Nanism,  606 
Narcolepsy,  1272,  1279 

idiopathic,  1273 
Narcosis,  1283 
Narcotin,  1283 
Nasal  cough,  778 

fossae,  136 

headache,  986 
Nasopharynx,  digital  examination  of, 

149 
Nausea  in  aural  vertigo,  1328 
Neck,  swellings  in  the,  1182 

acute,  1183 

chronic,  1184 


Neck,    swellings    in    the,    in    aortic 

aneurysm,  1321 
Negri  bodies,  1349 
Negro's    sign    of    peripheral    facial 

paralysis,  1349 
Nephritis,  anemia  of,  678 
ascites  of,  746 
edema  of,  826,  827 
epis taxis  of,  844 
eye  disorders  of,  914 
hemiplegia  of,  1024 
high    blood-pressure    of,    1053, 

1056 
oliguria  of,  1221,  1223 
polyuria  of,  1242 
precordial  pain  of,  1268 
tinnitus  of,  1296 
vertigo  of,  1330 
acute,  650 
azotemic,  653 
chloridemic,  653 
chronic,  653 
gouty,  1223 
hematuric,  1008,  1012 
hydremic,  653 
hyperacute,  651 
in  obesity,  1215 
interstitial,  439,  1045,  1242 
Traube's  law  in,  1351 
Nephrolithiasis,  350,  1008,  1060,  1070, 
1083,  1238 
oliguria  of,  1219 
polyuria  of,  1243 
x-ray  examination  in,  350 
Nephroptosis,  1073 

Nervous     angiospastic     cases,     high 
blood -pressure  of,  1051 
cough,  783 
diabetes,  974 
diarrhea,  792 
disorders,  dyspepsia  of,  803 

eye  disturbances  of,  920 
edema,  829 
erethism,  1053,  1056 
fatigue,  752 
headache,  981 
insomnia,  1102 
system,  457 
Nenrousness,  1193 


Digitized  by 


Google 


1374 


INDEX  TO  VOLUMES  I  ANITIL 


Nervousness,  motor,  1193 

psychic,  1195 

sensory,  1194 

vasomotor,  1197 

visceral,  1197 
Neuralgia,  988,  1164,  1317 

anterior  crural,  1166 

external  cutaneous,  1166 

facial,  982 

in  lower  extremities,  1164,  1168 

in  upper  extremities,  1317 

intercostal,  1233,  1247,  127D 

lumboabdominal,   1165 

sciatic,  1168 

Valleix's  laws  in,  1351 
Neurasthenia,  755,   1344 

constipation  of,  769 

eye  disturbances  of,  921 

headache  of,  982 

low  systolic  pressure  of,  1145 

somnambulism  of,  1281 

vertigo  of,  1330 
Neuritis,  1317 

lead,  1318 

multiple,  458 

pressure,  1318 
Neuroarthritism,  1195 
Neurodocitis,  1167 
Neurosis,  1196 

angina  pectoris  of,  1255 

anxiety,   1200 

cardiac,  279,  821,  944,  1198,  1255 

gastric,  836,  837,  1340 

intestinal,  791,  793 
•    tachycardic,  944,  950 

vertigo  of,  1330 
Neurotic  dyspnea,  810 

itching,  1116.  1118 

lumbago,  11?3 

vomiting,  1340 
Nicotinism,  angina  pectoris  of,  1254 

leukoplakia  of,  1300 
Night  terrors,  775 
Nitrogen  retention,  442 
Nose,  135 
Nosebleed,  843 
Nosology,  6 
Nostrils,  136 
Nutritive  balance,  455 


Nyctalopia,  904 
Nycturia,  435,  1220 
Nystagmus,  493,  917,  1309,  1324 
induced,  496 

Obesity,  1206,  1347 

anemic,  1214 

asthenia  of,  754 

high  blood-pressure  of,  1045 

ovarian,  1207 

plethoric,  1213 

with  cardiorenal  or  other  compli- 
cations,  1215 
Obstruction,  fecal,  802 

intestinal,  vomiting  of,  1333,  1341 
Ocular     functions,    examination    of, 
890 

headache,  984 

paralyses  in  encephalitis,  1278 
Oculocardiac  reflex,  213,  482 
Oculomotor  paralysis.  907,  1016 
Odors,  vertigo  due  to,  1330 
Oertel's  method  in  chronic  heart  dis- 
orders, 1349 
Office  equipment,  special,  630 
Oil  of  santal  in  urine,  427 
Oliguria,  435,  1218 

lasting,  1220 

orthostatic,  435,  1220 

transient,  1219 
Olive-tipped  sound,  43 
Oliver's  sign  in  aortic  aneurysm,  1349 
Oneiric  states,  1283 
Opacity,  898 
Opaque  enema,  86 

meal,  82 
Ophthalmic  disorders,  894 

migraine,  903 
Ophthalmoplegia,  909 
Ophthalmo-reaction    in    tuberculosis, 

557 
Opium,  hypnotic  use  of,  1105 

sleep  from,  1271 
Opotherapy,  1345 

Oppenheim's  sign  of  pyramidal  dis- 
ease, 1349 
Opsiuria,  126,  434,  1222 
Orbitoscopy,  890 
Orthodiagraphy  of  heart,  222  . 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1375 


Orthofluoroscopy  of  heart,  225 
Orthopnea,  809 
Orthostatic  albuminuria,  659 
oliguria,  435 
tachycardia,  281 
Ossifluent  abscesses,  1188 
Osteoarthritis,  iliac,  1175 
sacroiliac,  1175 
vertebral,  1175 
Osteomalacia,  1155 
Osteomyelitis,  1154,  1316 
Osteoperiostitis,  1153,  1315 
intercostal,  1270 
post-infectious,  1154,  1316 
staphylococcic,  1154 
syphilitic,  1153,  1315 
Osteosarcoma,  1154,  1315 
Otitis  media,  abducens  paralysis  in, 
1347 
convulsions  of,  771 
eye  disturbances  in,  918 
headache  of,  991 
suppurative,  vertigo  of,  1327,  1329 
Otobrightism.  1330 
Otosclerosis,  1329 
Otoscopic    examination    in    vertigo, 

1329 
Ova,  parasitic,  in  stools,  112 
Ovarian  cyst,  740 
edema  in,  832 
left  iliac  pain  of,  1088 
right  iliac  pain  of,  1098 
obesity,  1207 
Overeating,  793,  798 
Overwork,    angiospastic   attacks    due 
to,  1268 
dyspepsia  due  to.  806 
Oxalic  diathesis,  1344 
Oxyuris  vermicularis,  113,  116 

Pachon's  sphygmomanometer,  240 

Pachymeningitis,  1025 

Paget's  disease  of  the  bones,  1350 

of  the  nipples,  1350 
Pain,  epigastric,  833 

in  duodenal  ulcer,  76 

in  the  hypochondrium,  left,  1058 
right,  1068 

in  the  iliac  fossa,  left,  1085 


Pain,  in  the  iliac  fossa,  right,  1089 

in  the  joints,  1128 

in  the  lower  extremities,  1153 

in  the  lumbar  region,  1170 

in  the  side,  1225 

in  the  upper  extremities,  1313 

interlobar,  185 

precordial,  1245 

(See  also  Neuralgia). 
Pallor,  1258 

anemic,  675 
Palpitations,  1059,  1251 
Panaritium  analgicum,  1318 
Pancreas,  126 

cancer  of,  1071,  1120 

inspection  of,  126 

palpation  of,  126 
tenderness,  127 

percussion  of,  128 
Pancreatic  diabetes,  970 

disorders,  epigastric  pain  of,  838 
stools  in,  130 
chemical  analysis,  130 
Einhorn*s  bead  method,  131 
Schmidt's  nucleus  test,  130 

function,  Sahli's  test  of,  1351 

point  of  tenderness,  127 
Pancreaticobiliary  syndrome,  838 
Pancreatitis,  839 
Pannus,  898 

Papular  skin  affections,  848 
Paracentesis  pericardii,  231 
Paralysis,  459 

abducens,  1347 

agitans,  tremor  of,  1309 

facial,  1025,  1278,  1349 

hemiplegic.  1014 

laryngeal,  681 

ocular,  907,  1016,  1278 

progressive  general,  776,  787,  856, 
922,  927,  1243 
tremor  of,  1310 
vertigo  of,  1326 

radial,  1318 
Paranoia,  786 

Paraphasic  disturbances,  484 
Paraplegia,  spastic,  472,  475 
Parasites,  intestinal,  111-117 
Parasitic  fungi,  584 


Digitized  by 


Google 


1376 


INDEX  TO  VOLUMES  I  AND  II. 


Parasitology,  505 
Paratyphoid  infections,  549,  552 
Paresthesias  in  arteriosclerosis,  803 
Parkinson's  disease,  1350 

tremor  of,  1309 
Parotid  glands,  131 
Paroxysmal  cough,  778 

hemoglobinuria,  1347 

tachycardia,  260,  707,  946 
Parrot's  disease,  1350 

law  in  tuberculous  bronchial  lymph- 
adenitis, 1350 

sign  in  meningitis,  1350 
Passive  congestion  of  lungs,  187 
Patellar  reflex,  467 
Pavy's  disease,  1350 
Pectoriloquy,  167 

whispering,  168 
Pediculosis,  1115 
Pelvic  pain,  sciatic,  1163 

suppuration,  pain  of,  1088 
Pemphigoid  eruptions,  849,  919 
Penis,  375,  952,  954 
Percussion,  see  the  various  separate 

organs  or  structures. 
Pericardial  friction,  212 

puncture,  231 
Pericarditis,  933,  943,  948,  1040,  1266 

arm  pain  of,  1321 

diagnostic  considerations,  235,  238 

edema  of,  830 

posterior.  226 

sicca,  212.  235 
pain  of,  1247 

with  effusion,  235 
Perigastritis,    Rosenheim's    sign    of, 

1351 
Perinephric  abscess,  1061,  1066,  1070, 

1072 
Peristalsis,  visible,  81 
Peritoneum,  ascites  in  cancer  of,  744 
Peritonitis,  948,  1039 

tuberculous,  ascites  in,  581,  745 

vomiting  of,  1333,  1341 
Permeability   of  kidneys,  448 
Pernicious  anemia,  676 
Perret  and  Devic,  signs  of,  in  peri- 
carditis, 1350 


Pettenkoffer's    test     for    bile    acids, 

420,  1350 
Pezzer  catheter,  27Z 
Pfeiffer  bacillus,  526 
Pfuhl's  sign  in  effusion,  1350 
Pharyngeal  cough,  778,  784 

exudate,  544 

infections,  1291 
Pharynx,  examination  of,  150 
Phenols  in  urine,  428 
Phenolsulphonephthalein  test,  452 
Phlebitis,  827,  831,  832,  1031,  1158 

puerperal,  edema  of,  826,  832 
Phlegmasia  alba  dolens,  827,  832 
Phosphates  in  urine,  395,  409 
Phosphaturia,  1243 
Phosphenes,  905 

Phosphorus  poisoning,  996,  1010 
Photophobia,  895,  906 
Phthiriasis,  1115 
Physical  examination,  systematic,  621, 

629,  634 
Picric  acid  in  blood,  test  for,  301 

jaundice,  1123 
Pignet's  index,  603 
Pill-rolling  movements,  1309 
Pituitary  disease,  eye  disturbances  of, 
912,  920 
headache  of,  982 

tumors,  polyuria  of,  1243 
Pityriasis  linguae,  1300 
Plague  bacillus,  539 
Plantar  reflex,  474 
Plethora,  1213,  1236,  1254 

epistaxis  of,  844 

high  blood-pressure  of,  1049 
Pleura,  diseases  of,  180 

exploratory  puncture  of,  194 
Pleural  effusion,  181,  322 
syncope  of,  928 

exudates,  cells  in,  322,  323 

fluid,  cells  in,  182 

friction,  168 

vomica,  1339 
Pleurisy,  181,  322,  1065,  1084,  1339 

cough  of,  778 

dry,  183 

encysted,  184 

fainting  in,  928 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  11. 


1377 


Pleurisy,  hiccough  of,  1040 
interlobar,  184,  1228 
pain  of,  1225 
painful  points  in,  185 
precordial,  1228,  1247,  1269 
right  hypochondriac  pain  of,  1072, 

1074 
suppurative,  see  Emphysema. 
Pleuritis,  adhesive,  dyspnea  of,  818 

apical,  1232 
Pleurodynia,  1231,  1233 
Pluriglandular      insufficiency,      1149, 

1215 
Pneumococcus,  526 
Pneumonia,   172 

expectoration  in,  872 
hemoptysis  of,  1033 
left  hypochondriac  pain  of,  1065 
right     hypochondriac     pain     of, 
1072,  1084 
bronchial,  186 
lobar,  4,  872 
pain  of,  1230 
vomiting  of,  1341 
Pneumonokonioses,  873 
Pneumothorax,  179 

pain  of,  1225,  1232 
Polarimeter,  for  sugar  in  urine,  417 
Polioencephalomyelitis,  1022 
Poliomyelitis,  arm  pain  of,  1321 
Pollakuria,  1240 
Polyglandular  insufficiency,  1149 

in  obesity,  1215 
Polygrams,  695,  731      • 
Polygraph,  Jacquet's,  252 

Mackenzie's,  256 
Polypnea,  809 

hysterical,  824 
Polyuria,  435,  1223,  1240 
clinostatic,  1220  , 
cryptogenic,  1244 
experimental,  347 
induced,  1240 
of  diabetes,  1242 
of  nephritis,  1242 
of  urinary  cases,  1243 
Popliteal  space,  painful  disturbances 

in,  1164 
Porges's  reaction  in  syphilis,  1350 


Portal   hypertension,  436,  742,   1000,- 

1046 
Post-hemiplegic  tremor,  1310 
Potain  on  heart  percussion,  215 
Pott's  disease,  1154,  1175,  1233,  1270 
Precordial  pain,  1245 
Pregnancy,  740 

albuminuria  of,  655 

edema  of,  830 

extra-uterine,  1088.  1099 

indigestion  of,  797 

obesity  of,  1207 

pyelonephritis  of,  655 

vomiting  of,  1340 
Premature  beats,  700,  1247 
Presclerosis,  1051,  1254 

angiospastic,  1239 
Presystolic  murmur.  201,  206,  207 
Proctoscopy,  88 
Prodromal  headache,  979 
Profeta,  law  of,  1350 
Projection  sound  in  esophagus,  43 
Prolonged  expiration,  168 
Proportions  of  the  human  body,  597 
Prostate,  378 

abnormal  findings  on  palpation  of, 
380 

blood  from,  1005 

cancer  of,  380 

expression  of,  380 

massage  of,  380 
Prostatic  catheter,  368 

hypertrophy,  380 

polyuria  of,  1223,  1243 
Prostatitis,  377,  380 
Protozoa  in  the  stools,  108,  111 
Prurigo,  848,  1109 
Pruritus,  1106,  1107 

insomnia  of,  1101 
Pseudoangina  of  aerophagics,  1269 
Pseudocasts,  433 
Pseudodiptheria  organisms,  545 
Pseudomembranous  sore  throat,  1291, 

1293 
Psoas  inflammation,  1166 
Psoriasiform  parakeratoses,  1111 
Psoriasis,  6 

linguae,  1300 
Psychoneuroses,  depressive,  752,  1142 


87 


Digitized  byV^OOQlC 


1378 


INDEX  TO  VOLUMES  I  AND  II. 


Psychoneuroses,  dyspepsia  of,  806 

headache  of,  990 

insomnia  of,  1102 

loss  of  weight  of,  1142 

lumbago  of,  1173 

slow  pulse  of,  1287 

vertigo  of,  1330 
Psychoneurosis.  1196,  1204 

appendiceal,  1099 
Psychosplanchnic    neuropathy,    1198, 

1253 
Pterygium,  896 
Ptomain  poisoning,  793 
Ptosis,  895,  1278 

abdominal,  1180 
Puberty,  epistaxis  of,  845 
Puerile  breathing,  168 
Pulmonary  abscess,  184,  1033 

apoplexy,  190 

complications  in  obesity,  1216 

congestion,  187,  1347,  1352 

disturbances  in  obesity,  1216 

embolism,  190 

emphysema,   188 

fibrosis,  dyspnea  of,  812,  818 

gangrene,  184,  1034 

infarction,  1031 

syphilis,  1034 

thrombosis,  190 

tuberculosis,     see     Tuberculosis, 
pulmonary. 

tumors,  184,  1034 

valve  lesions,  2^ 

vomica,  1339 
Pulse,  1043 

alternating,  726 

bigeminal,  704 

Corrigan,  1346 

frequent,  942 

intermittent,  702 

pressure,  1146 

records,  249 

slow,  see  Bradycardia. 
Puncture,  lumbar,  487 

of  finger-tip,  301 

of  pericardium,  231 

of  pleura,  194 

venous.  248,  302 
Pupil,  Argyll-Robertson.  481,  901 


Pupil,  abnormalities  of,  900 
Pupillary  reflexes.  479,  887 
Pupils,  inequality  of,  915,  1278 
Purpura,  849,  1352 

epistaxis  of,  845 

hematuria  of,  1009 

hemoptysis  of,  1034 
Pus,  521 

Pustular  skin  affections,  849 
Pyelography,  344 
Pyelonephritis,  polyuria  of,  1223 

calculous,  hematuria  of,  1012 
Pylephlebitis,  ascites  In,  743.  750 
Pyonephrosis,  1050,  1066,  1070.  1072 
Pyopneumothorax,  178,  1339 
Pyramidon  in  urine,  427 
Pyuria,  333,  394,  394  1223 

Quincke's  disease,  831,  1350 
Quinine,  eye  disturbances  due  to,  923 

in  urine,  4?8 

tinnitus  due  to,  1294 

vertigo  due  to,  1329,  1330 

Rabies,  772,  1349 

Rachitic  dwarfs,  604,  606 

Rachitis,  1347 

Radial  nerve,  sensory  disturbances  in 

section  of,  1315 
Radiculitis,  1168 

Radioscopy,  see  X-ray  examination. 
Railway  travel,  vertigo  in,  1330 
Rales,  bubbling,  166 

crepitant,  167 

sibilant,  168 

sonorous,  168 

subcrepitant.  168 
Rapid  eating,  805 

pulse,  942 
Raynaud's  disease,  1197,  1318,  1350 
Reaction  of  degeneration,  462 
Recklinghausen's  disease,  1350 
Reclus's  disease,  1350 
Rectocele,  385 
Rectum,  87 

endoscopy  of,  90 

fluoroscopy  of,  90 

palpation  of,  87 

proctoscopy,  88 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  II. 


1379 


Rectum,  radiography  of,  90 
Recurrent  nerve  paralyses,  683,  689 
Red  blood  cells,  count  of,  308 

in  anemias,  675 

in  urine,  433 

resistance  of,  290 
Reflex  convulsions,  771 

cough,  777 

dyspepsia,  804 

headache,  978,  984 
Reflexes,  462 

circulatory,  482 

cutaneomuscular,  474 

cutaneovasomotor,  476 

oculocardiac,  213,  482 

pupillary,  479 

tendinomuscular,  466 
Refraction,  disorders  of,  904 

headache  of,  984 
Regurgitation  of  food,  803 
Renal  ballottement,  336 

calculus,   1008    (see   also   Nephro- 
lithiasis). 

cancer,  1008 

colic,  oliguria  of.  1219 
vomiting  of,  1334,  1340 

congestion,  oliguria  of,  1223 

diabetes.  970 

disease,  see  Nephritis. 

function,  tests  of.  434,  452 

hematuria,  1007,  1012 

hyperpermeability,  1243 

pain,  1172,  1178 

permeability,  448,  651 

points  of  tenderness,  335 

stone,  350,  1008,  1060,  1066;  see  also 
Nephrolithiasis. 

tub e r  c u  1  o s i s ,  see  Tuberculosis, 
renal. 

tumor,  1012 
Renault's  test  for  indican,  421 
Reproductive    system,    eye    disturb- 
ances in  disorders  of,  920 

role  of,  in  obesity,  1207 
Respiratory  arhythmia,  710 

tract,  133 
extrathoracic  (upper),  133 
intrathoracic   (lower),  164 
physical  signs.  164 


Respiratory  tract,  x-ray  examination 
of,    170,    172,    176,   178,    182, 
184,  187,  188,  191 
Retained  catheter,  373 
Retention  of  urine,  352,  740 
Retinitis  pigmentosa,  905,  910 

prealbuminuric,  914 
Retropharyngeal  abscess,  dyspnea  of, 

810 
Revolting  impressions,  vomiting  due 

to,  1332 
Revilliod's    phenomenon    in    organic 

hemiplegia,  1350 
Rheumatic  pleurisy,  181 
Rheumatism,    236,    938,    1128,    1156, 
1174 
chronic  vertebral,  1175 
cryptogenic,  1136 
eye  disturbances  of,  917 
gonorrheal,  1130 
Heberden's  nodes  in,  1348 
insomnia  of,  1103 
intercostal  neuralgia  of.  1270 
pain  in  upper  extremities  in,  1313, 

1317 
tuberculous,  1130 
Rhinitis,  986 
Rhinoscopy,  anterior,  136.  147 

posterior,  141,  147 
Rhizomelic  spondylosis,  1175 
Rhonchi,  168 
Ribs,  pain  in,  1233 
Rigidity,  abdominal,  1093 

muscular,  in  paralysis  agitans,  1309 
Ringing  in  the  ears,  1294 
Ringworm,  501,  502,  663 
Rinne's  test  in  otology,  1350 
Rivalta's  test  of  effused  fluids.  331, 

1350 
Roger's  disease,  227,  1350 
Romberg's  sign,  438,  494,  1350 
Rosenbach's  sign  of  hysterical  hemi- 
plegia, 1351 
Rosenheim's  sign  of  fibrous  perigas- 
tritis, 1351 
Roseola,  syphilitic,  855 
Rotation  test,  497 
Rough  breathing,  168 
Roux's  stain,  518 


Digitized  by 


Google 


1380 


INDEX  TO  VOLUMES  I  AND  II. 


Ruault's     sigii     of     incipient    tuber- 
culosis, 1351 
Rubella,  860 

Sacroiliac  osteoarthritis,  1175 

Sacrolumbar  pain,  1172 

Sahli's   test   of   pancreatic    function, 

1351 
Salicylates  in  urine,  428 

tinnitus  due  to,  1294 

vertigo  due  to,  1329 
Saliva,  132 
Salivary  glands,  131 
Salol  in  urine,  428 
Salpingitis,  pain  of.  1088,  1098 

and  appendicitis,  1093 
Sarcomatosis,  osseous,  1343 
Sarcoptes  scabiei,  1113 
Scabies,  954,  955,  1112 
Scanning  speech,  1309 
Scarlet  fever,  858 

eye  disturbances  in,  916 

sore  throat  of,  1292,  1293 

tongue  of,  1299 

vomiting  of,  1341 
Schick  test,  547 
Sciatica,  1160,  1177 
Sclera,  diseases  of,  898 
Scleroderma,  850 
Scoliosis,  pain  in,  1177 
Scotoma,  892,  912 

scintillating,  905 
Scrofula,  960 
Scrotum,  382 

Scurvy,  hematuria  of,  1009 
Seasickness,  vertigo  of,  1331 

vomiting  of,  1334 
Sebaceous  cyst,  956,  1190 
Seborrhea,  503 

decalvans,  669 
Seborrheic  psoriasiform  eczema,  1111 
Segregation,  urinary,  340 
Seminal  vesicles,  380 
Senile  alopecia,  673 

tremor,  1310 
Sensation,  457 
Septic  affections,  934,  938 

edema  of,  831,  832 
Sergent's  white  line,  478,  754 


Serous  surfaces  in  upper  extremity, 

disorders  of,  1317 
Shingles,  see  Herpes  zoster. 
Shock,   post-operative,   vomiting   of, 
1334 

traumatic,  1146 
Shreds  in  urine,  376 
Sialorrhea,  1059 

tongue  in,  1297 
Sicard's  raised  knee  sign  in  sciatica, 
1162 

method  of  epidural  treatment,  1351 
Sieur's  sign  of  pleural  effusion,  1351 
Sigmoid,  tumors  of,  1087,  1088 
Sigmoiditis,  left  iliac  pain  in,  1068 
Sigmoidoscopy,  88 
Signs,  index  of  clinical,  1343 
Silent  breathing,  168 
Singultus,  1039 
Sinus  arhythmia,  710 
Sinusitis,  eye  involvement  in,  918 

headache  of,  986 
Skene's  glands,  384 
Skin  discolorations,  850 

eruptions,  847 
artificial,.  851 

reflexes,  474 

tumors,  850 
Skodaic  resonance,  168 
Skull  fracture,  hemiplegia  of,   1027 
Sleep,  morbid,  1271 
Sleeping   sickness,   lethargic   enceph- 
alitis, 328,  1278 
trjrpanosomiasis,  1278 
Slow  iNilse,  1285 
Small-pox,  860 

eye  disturbances  of,  916 

sore  throat  of,  1293 

vomiting  of,  1341 
Smokers*  tongue,  1297 
Softening  of  brain,  484,  1014 
Solar  plexus,  hyperesthesia  of,  837 
Somnambulism,  1280 
Somniloquy,  1283 
Somnolence,  morbid,  1272 
Sore  throat,  1290 

erythematous,  1292 

pseudomembranous,  1291,  1293 

pultaceous,  1290,  1292 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  IL 


1381 


Sore  throat,  streptococcic,  1293 

ulceromembranous,  1291,  1293 

vesicular,  1291,  1292 
Souques's  sign  of  organic  hemiplegia, 

1351 
Spasmophilia,  771 

Spastic    contraction    of    muscles    in 
Thomsen*s  disease,  1351 

paraplegia,  472,  475 
Special    medical    diagnostic    proced- 
ures, 41 
Spectroscopy,  587 

of  blood,  424 
Speech  disturbances,  484 
Spermatic  cord,  382 
Sphygmography,  249,  1043 
Sphygmohydruric  coefficient,  437 
Sphygmomanometer,  239,  621 
Spinal  cancer,  1233  ' 

hemiplegia,  1021,  1023 

localizations  of  skin  reflexes,  475 
of  tendon  reflexes,  473 

pains,  1163,  1167,  1174,  1176 
Spirochaeta  bronchialis,  527,  875 

pallida,  528,  563 
Spirochetosis,  icterohemorrhagic,  1121, 

1157 
Spirometry,  193 
Spiroscope,  193 

Spleen,  enlargements  of,  1062,   1067, 
1071 

primary  epithelioma  of,  1347 

topographic  features  of,  1059 
Splenic  flexure,  1063.  1067 
Splenomegaly  with  chronic  polycyth- 
emia, see  Vaquez's  disease, 
1351 
Spondylitis,  1174,  1233 
Spondylosis,  rhizomelic,  1175 
Sporotrichosis,  584 
Sputum,  albumin  test,  196 

examination  of,  196,  521 

semeiologic  significance  of,  865 
Squamous  skin  affections,  848 
Staining  methods,  523 
Stains,  bacteriologic,  515 

blood,  589 
Stammering,  484 
Staphylococcic  osteomyelitis,  1316 


Staphylococcus,  538 

Steatorrhea,  95,  129,  794 

Stellwag's     sign      of     exophthalmic 

goiter,  1351 
Sternum,  pain  behind  the,  1266,  1268 
Stethoscopic  glossary,  166 
Stokes-Adams    disease,    2,    722,    764, 

776,  927,  1343 
Stokes-Chopart,  law  of,  1351 
Stomach,  50 

anatomical  considerations,  50 

auscultation  of,  54 

cancer  of,  see  Cancer  of  stomach. 

contents,  57 

digestive  activity,  estimation  of,  67 

dilatation  of,  Bouchard's  nodes  in, 
1345 

eye   disturbances   in   affections   of, 
919 

fluoroscopy  of,  69 

gaseous  distention  of,  1058,  1065 

hematemesis  in  affections  of,  997 

hiccough  in  affections  of,  1039 

hourglass,  801 

inflation  of,  54 

inspection  of,  55 

introduction  of  stomach  tube,  55 

pains,  836 

palpation  of,  52 

percussion  of,  54 

radiography  of,  75 

residues,  57 

succussion. sounds,  52 

test  meal,  57 

tube,  55 

ulcer  of,  see  Gastric  ulcer. 

x-ray  examination  of,  69 
Stomatitis,  mercurial,  tongue  of,  1299 
Stone  in  bladder,  353,  361 

in  kidney,  see  Nephrolithiasis. 

in  ureter,  1088,  1099 
Stools,  examination  of,  91,  126,  129, 
794 

bacteriologic,  106 
bacillus  of  dysentery,  106 
cholera  bacillus,  107 

chemical,  99,  130 
bile  pigments,  100 
blood.  101,  330,  794,  795 


Digitized  by 


Google 


1382 


INDEX  TO  VOLUMES  I  AND  II, 


Stools,    examination    of,    chemical, 
fats,  99,  130,  794 
mucus,  794 

ratio   of   dry    to   moist   constit- 
uents, 99 
reaction,  99,  795 
macroscopic,  94,  794 
amount,  794 
color,  94,  794 
concretions,  95 
consistency,  794 
food  remnants,  94 
odor,  95,  794 
rice  bodies,  795 
sand,  795 
tapewonn,  114 
microscopic,  95 
amebse,  108 
connective  tissue,  97 
crystals,  98 
debris,  98 
elastic  fibers,  98 
fats,  98 

muscle  fibers,  96 
Nothnagel's  yellow  granules,  97 
parasitic  cysts,  110 

ova,  112 
pus,  794,  795 
starch,  95 
vegetable  cells,  95 
Strabismus,  907,  920,  985 

in  encephalitis,  1278 
Strangulated    hernia,    vomiting    of, 

1333,  1341 
Straus's    sign    of    peripheral    facial 

paralysis,  1351 
Streptococcic  sore  throat,  1293 
Streptococcus,  538 
Stricture  of  esophagus,  46 

of  urethra,  364,  378 
Strongyloides  stercorals,  116,  117 
Strophanthus,    bradycardia    due    to, 

1287 
Strychnine  poisoning,  772 
Subacromial  bursitis,  1317 
Subcutaneous  tuberculin  test,  555 
Subdiaphragmatic  abscess,  1062,  1074, 
1339,  1347 
disorders,  pain  of,  1232 


Sublingual  glands,  132 
Submaxillary  glands,  132 

lymphadenitis,  960,  1183 
Succussion  sound,  Hippocratic,  167 

splash,  in  abdomen,  81 
in  stomach,  52 
Sugar  in  cerebrospinal  fluid,  328 

in  urine,  415 
Supraclavicular  glands,  957 
Suprarenal,  see  Adrenal. 
Sweating,  paroxysmal,  1256 
Symblepharon,  895,  919 
Sympathetic  disturbances,  1197 

excessive  irritability,  clinical  tests 
of,  1197 

excitation,  945 
Symptoms,  analysis  of,  647 
Syncope,  722,  760,  925 

vertigo  of,  1326 
Synechia,  899,  900 
Syphilis,  853,  953 

alopecia  of,  672 

backache  of,  1176 

bacteriologic  diagnosis  of,  528,  563 

bone  pains  of,  1153 

chancre  of,  885,  952,  953,  960.  1302 

clinical  features  of,  855-857 

congenital,  856,  1151 
Wassermann  reaction  in,  575 

eruptions  of,  855,  8^6,  857 

eye  disorders  of,  916,  917 

gland   enlargements   of,   855,   953. 
958,  960 

headache  of,  984,  991 

heart  disorders  of,  237 

jaundice  of,  1124 

leukoplakia  of,  1300 

lingual     manifestations     of.     1300, 
1301,  1302 

lumbar  pain  of,  1176 

MacDonagh  reaction  in,  579 

mucous  patches  of,  855,  1302 

Porges's  reaction  in,  1350 

of  larynx,  681,  688 

of  liver.  1069,  1083,  1127 

of  lungs,  1034 

secondary   meningeal    reaction    of, 
1176 

skin  manifestations  of,  855 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  IL 


1383 


Syphilis,  sore  throat  of,  1292,  1293 

spirochete  of.  528,  563 

Vernes  phenomenon  in,  582 

Wassermann  reaction  in,  563,  583 
Syphilitic  epiphyseal  detachment,  1350 

osteoperiostitis,  1315 

sclerosis  of  tongue,  1302 

urethritis,  377 
Syphilometry,  583  , 
Syringomyelia,  1318 
Systematic  medical  examination,  609 
Systolic  blood-pressure,  1043 
low,  1145 

murmurs,  203,  205,  207 

Tabes  dorsalis,  458,  481 

arm  pains  of,  1321 

cervical,  1318 

Erb's  sign  of,  1346 

eye  disturbances  of,  481,  922,  1343 

gastralgic  crises  of,  801,  835,  842 

girdle  pains  of,  1233 

hemiplegia  of,  1027 

lightning  pains  of,  1167 

precordial  pain  of,  1270 

right  hypochondriac  pain  of,  1078 

Romberg's  sign  in,  494 

vomiting  of,  1334,  1342 
Tabetic  joints,  1156,  1315 
Tache  cerebrale,  478 
Tachycardia,  942,  950,  1200,  1256 

emotional,  949 

orthostatic,  281,  949 

painful,  1251 

paroxysmal,  260,  707.  946 
Taenia  saginata,  114,  505 

solium,  114,  505 
Tallqvist's  hemoglobin  scale,  311 
Tanret's  reagent  for  albuminuria,  410 
Tapeworm,  114,  505 

itching  of,  115 
Taylor  principle,  610 
Tea  intoxication,  tremor  of,  1309 
Teleradiography,  230 
Temperature,  929 
Tendinomuscular  reflexes,  466 

symptomatic  significance  of,  472 
Tertiary    syphilides    of    the    tongue, 
1302 


Test  chart  for  eye  examination,  879, 

890 
Test  diet  for  renal  function,  452 
Test  meal,  57,  93 
Testicles,  381,  920 

tumor  of,  382 
Tetanus,  772 

bacillus,  535 
Tetany,  Trousseau's  sign  in,  1351 
Tetramitus  mesnili.  111 
Theobrominism,  950 
Thermo-analgesic  dissociation,  458 
Thionin,  518,  523 
Thomsen's  disease,  1351 
Thoracentesis,  194 

Thoracic  duct,  compression  of,  1349 
fluctuation,  168 
mensuration,  191 
pain,  1233 
Throat  exudates.  522,  543,  544 

sore,  see  Sore  throat 
Thrombosis,  pulmonary,  190 
with  hemiplegia,  1014,  1026 
Thrush,  1299 

Thure-Brandt  posture,  1351 
Thyroid,  congestion  of,  1191 
disorders,  eye  disturbances  in.  919 
enlargement,    685,    1191    (see    also 
Goiter), 
recurrent     laryngeal     paralysis 
due  to,  685 
glycosuria,  970 
insufliciency,  1192,  1207 
obesity,  1207 
Thyroiditis,  1184,  1191 
Tic  cough,  783 

hiccough,  1040 
Tinea,  499 
favosa,  504,  666 
tonsurans,  501,  502,  663 
versicolor,  503,  504 
Tinnitus  aurium,  1294 

in  Meniere's  disease,  1326,  1328 
mode  of  production  of,  1295 
Tobacco  abuse,   angiospastic   attacks 
of,  1268 
eye  disturbances  of,  922 
headache  of,  981 
sore  throat  of,  1292 


Digitized  by 


Google 


1384 


INDEX  TO  VOLUMES  I  AND  II. 


Tobacxro  abuse,  vertigo  of,  1330 
Toison's  fluid,  306 

Tongue,  diagnostic  features  relating 
to,  1297 

actinomycosis  of»  1305 

chancre  of,  1302 

cysts  of,  1303 

discolorations  of,  1297 

epithelioma  of,  1304 

gumma  of,  1301,  1303 

tuberculoma  of,  1304,  1307 

tumors  of,  1304 
Tonsil,  tuberculosis  of,  1293 
Tonsillitis,  1290 
Torticollis,  symptomatic,  1184 
Toxemic  dyspnea,  813 
Toxic  glycosuria,  970 

hematuria,  1010 

insomnia,  1102 

neuritis,  1318 

sleep,  1272 

tinnitus,  1296 

tremor,  1309 
Tracheobronchial     adenopathy,     170, 
171,  685 
bradycardia  of,  1287 
recurrent  laryngeal  paralysis  of, 
685      . 
Transudates,  Rivalta*s  test  for,  331 
Traube's  law  in  nephritis.  1351 
Traumatic  diabetes,  974 

neuralgia  and  neuritis,  1317 

shock,  1146 
Tremor,  1308 

accidental,  1308 

hereditary,  1309 

hysteric,  1310 

intention,  1308 

migratory,  1311 

permanent,  1308 

post-hemiplegic,   1310 

progressive,  1311 

regressive,  1311 

senile,  1310 

Tabular  Synopsis,  1312 
Treponema  pallidum,  528,  563 
Triacid  stain,  518 
Triceps  reflex,  469 
Trichiasis,  895 


Trichocephalus,  113 

Trichomonas,  diarrhea  due  to,  791 

Trichophyton,  502,  665 

Tricuspid  lesions,  238,  735,  1150 

Troisier's  ganglion  in  gastric  cancer, 

1351 
Trophedema,  829 
Trousseau's  sign  in  tetany,  1351 
Trypanosomiasis,  1278 
Tube  casts,  430 
Tubercle  bacillus,  525,  558 

in  urinary  sediment,  558 
Tuberculin,  555 

tests,  555 
Tuberculoma  of  the  tongue,  1304 
Tuberculosis,  934,  938 
diagnostic  bacteriologic  procedures 

in,  555 
lingual,  1304,  1307 
of  joints,  1156 
of  tonsils,  1293 

pericecal,  right  iliac  pain  of,  1098 
pulmonary,  174,  869,  872 
alarm  zone  in,  175 
Ameth's  neutrophilic  blood  pic- 
ture in,  175 
asthenia  of,  755 
dyspepsia  of,  798 
dyspnea  of,  1250 
eye  disorders  in,  917 
fluoroscopy  in,  176 
hemoptysis  of,  1031 
hyposphyxia  in,  1151 
loss  of  weight  of,  1142 
low   systolic    pressure   of,    1145, 

1147 
pain  of,  1231 

physical  signs  of,  174-179 
renal,    bacteriologic    diagnosis    of, 
558 
hematuria  of  1008 
hypochondriac  pain  in,  1060,  1066 
urine  in,  333,  346,  558,  1008,  1012, 
1224,  1244 
tests  for,  555 
Tuberculous  diarrhea,  791 
laryngitis,  681,  687 
lymphadenitis,  959,  1185 
meningitis,  326,  1027,  1279 


Digitized  by 


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INDEX  TO  rOLUMES  I  AND  II. 


1385 


Tuberculous  obesity,  1208 

osteoarthritis,  1315 

periostitis,  1315 

peritonitis,  ascites  of,  581,  745 
pleural  involvement  in,  1347 

prostatitis,  380 

urethritis,  377 
Tubular  breathing,  168 
Tumors,  see  various  structures  con- 
cerned. 

loss  of  weight  in,  1143 
Tunica  vaginalis,  382 
Tuning-fork  test,  Weber's,  1352 
Tympanic   cavity,   Valsalva   inflation 

of,  1351 
Tympanites  in  hepatic  cirrhosis,  792 
Typhlocolitis,  1098 
Typhoid  fever,  936,  938 

agglutination  test  f^,  548 

blood  cultures  in,  552 

delirium  of,  786 

diarrhea  of,  790 

Duguet*s  sign  of,  1346 

Duroziez's  sign  of,  1346 

epistaxis  of,  846 

eye  disturbances  of,  917 

fever  of,  934,  936,  938 

headache  of,  979 

hemolytic  tests  for,  550 

hemoptysis  of,  1034 

insomnia  of,  1103 

intercostal  neuralgia  of,  1270 

temperature  curve  in,  934 

tongue  of,  1299 

Widal  test  for,  548 

Uffelmann's  reagent,  64 

Ulcer,  duodenal,  see  Duodenal  ulcer. 

gastric,  see  Gastric  ulcer. 
Ulcerations,  genital,  951 

lingual,  1306 
Ulnopronator  reflex,  472 
Ultra-microscope,  513 
Upper  extremities,  pain  in,  1313 
post-traumatic,  1313 
nerve-supply  to  muscles  of,  1319 
peripheral    sensory    disturbances 
in,  1314,  1316 
Uranalysis,  390,  429 


Urea  in  blood,  292,  442 

in  urine,  398 
Uremia,  653 
asthenia  of,  755 
bradycardia  of,  1287 
coma  of,  764 
convulsions  of,  773y  775 
diarrhea  of,  791 
dyspepsia  of,  797 
dyspnea  of,  810,  813,  823 
headache  of,  980 
hematemesis  of,  997 
hemoptysis  of,  1035 
high  diastolic  pressure  of,  1046 
hyposphyxia  of,  1151 
in  obesity,  1215 
itching  of,  1106 
precordial  pain  of,  1267 
tongue  of,  1299 
vertigo  of,  1330 
vomiting  of,  1334,  1342 
Ureter,  blood  from,  1007 
stone  in,  1068,  1099 
x-ray  examination  of,  349 
Ureteral  catheterization,  340 

cytologic  and  bacteriologic  ex- 
amination of  urine,  345 
points  of  tenderness,  1179 
Urethra,  female,  383 
male,  362 
catheterization  of,  362 
spasm  of,  367 
stricture  of,  364 
urethritis.  365,  375,  377 
Urethral  discharge,  varieties  of,  377 

hematuria,  1005 
Urethrorrhagia,  1006 
Urinary  secretion,  rhythm  of,  126 
segregation,  340 
tract,  332 
Urine,  abnormalities  of,  333 
chemical  analysis  of,  396 
acetone,  425 
acidity,  396,  425 
albumin,  409 

quantitative  determination,  411 
bile  acids,  420 

pigments,  410,  417 
blood,  330,  424,  1003 


Digitized  by  VjOOQIC 


1386 


INDEX  TO  VOLUMES  I  AND  II. 


Urine,  chemical  analysis  of,  chlorides, 
406,439 

diacetic  acid,  426 

indican,  421 

phosphates,  395,  409 

sugar,  415,  969 

urates,  395 

urea,  398 

uric  acid,  395 

urobilin,  420 
drugs  in,  427 

antipyrin,  427 

bromine  (bromides),  427 

copaiba,  427 

iodine  (iodides),  428 

morphine,  428 

oil  of  santal,  427 

phenols,  428 

pyramidon,  427 

quinine,  428 

salicylates,  428 

salols,  428 
macroscopic  examination  of,  390 

amount,  390,  434,  1218 

color,  394 

odor,  394 

pus,  333,  394,  395,  1223 

sediment,  395 

shreds,  376 

specific  gravity,  395 
microscopic  examination  of,  430 

bacteria,  434 

casts,  430 

cylindroids,  433 

erythrocytes,  433 

leucocytes,  434 

parasites,  434 

pseudo-casts,  433 

red  cells,  433 

tubercle  bacilli,  558 
retention  of,  352 
Urobilin  in  blood,  300 

in  urine,  420 
Uroseptic  fever,  940 
Urticaria,  848,  849,  1108 
bullosa,  11C8 
papulosa,  1108 
Uterus,  386 
displacements  of,  387 


Uterus,  examination  of,  with  specu- 
lum, 388 
with  retractors,  389 
hysterometry,  389 
Uvula,  vomiting  due  to  tickling  of, 
1332 

Vaccine,  862  » 

Vagina,  385 

Vaginismus,  385 

Vaginitis,  385 

Vagus  nerve,  disease  of,  1287 

Valleix's  laws  in  neuralgia,  1351 

points,  1162,  1270 
Valsalva's  test,  1351 
Vaquez's  disease,  1351 
Varicella,  861,  916 
Varicocele,  382 
Varicose  eden^,  832 

veins,  1150,  1158 
Variola,  860 

eye  disturbances  of,  916 

sore  throat  of,  1293 

vomiting  of,  1341 
Vas  deferens,  3S2 
Vasomotor  angiospastic  attacks,  1268 

asthenia,  281 

ataxia,  1197 

disturbances,  1318 

instability,  1256 

nervousness,  1197 

reflexes,  476,  1263 
Vegetations,  adenoid,  150 

on  penis,  954,  955 
Vegetative  nervous  system,  1256 
Veins,  248 

inflammation    of.    1157    (sec    also 
Phlebitis). 
Venous  network,  visible,  1321 

pressure,  248 
high,  1150 

puncture,  248.  302 
Ventricle,  acute  insufficiency  of  left, 

1267 
Vernes  phenomenon  in  syphilis,  582 
Veronal   and   morphine  intoxication, 

1274 
Vertebral  cancer,  pain  of,  1233 


Digitized  by 


Google 


INDEX  TO  VOLUMES  I  AND  11, 


1387 


Vertebral  column,  inflammatory  con- 
ditions of,  1176 

funiculitis,  1167,  1168 
Vertigo,  493,  1323 

a  stomacho  laeso,  1330 

arteriosclerotic,  1325 

aural,  1326 

central,  1325 

cerebral,  1325 

gastric,  1330 

induced,  494 

labyrinthine,  1326 

neuropathic,  1330 

ocular,  906 

pathogenesis  of,  1323 

reflex,  1330 

toxic,  1329,  1330 

which  restores  the  sense  of  hear- 
ing, 1331 
Vesical  disorders,  see  Bladder. 
Vesicular  skin  affections,  848 
Vicarious  menstruation,  844,  1036 
Vincent's  angina,  538,  1293,  1351 
Visceralgia,  1195 
Visceroptosis,  949 
Viscosity  of  blood,  282 
in  hyposphyxia,  1148 

Cuvier  viscosimeter,  287,  288 

Hess  viscosimeter,  284 
Vision,  colored,  906 

double,  906 

iridescent,  906 
Visual  acuity,  890 

field,  891,  910 
Vitreous  body,  888 
Voice  disturbances,  484 
Vomica,  1338 

pleural,  1339 

pulmonary,  1339 
Vomitiiig,  1332 

alimentary,  1332 

bilious,  1333 

bloody,  see  Hematemesis. 

central,  1332 

fecaloid,  1333 

habitual,  1333 

in  aural  vertigo,  1328 

in  children,  1333,  1334 
periodic  acetonemic,  1334 


Vomiting,  mechanism  of,  1332 

mucous,  1333 

pathogenesis  of,  1333 

peripheral,  1332 
Von  Graefe's  sign,  919,  1347 
Von  Pirquet's  test,  556 
Vulpian's  law  in  hemiplegia,  1351 
Vulva,  384 

kraurosis  of,  385 
Vulvitis,  385 

Wassermann  reaction,  564,  764,  855, 

1351 
Weber's  syndrome,  909,  1016,  1019 

test  for  blood  in  stools  or  vomitus, 
101,  1351 
in  otology,  1352 
Weight,  590,  1209 

relationship  to  blood-pressure,  1141 
Weil-Mathieu's  disease,  937 
Wen,  956,  1190 
Werlhoff's  disease,  1352 
Wernicke's  sign  in  bilateral  homo- 
nymous hemianopsia,   1325 
Westphal's  sign  of  tabes,  498,  1352 
Whistling  sounds  in  the  ears,  1329 
White  line,  479 
Whooping-cough,  ulceration  of  tongue 

in,  1306 
Widal  test  in  typhoid  fever,  548 
Woillez's  disease,  1352 
Word  blindness,  484 

deafness,  484 
Worm  cough,  778 

parasites,  114,  505 
Wounds,  tremor  in,  1310 

Xanthelasma,  1123 
X-ray  alopecia,  668 
examination  in  duodenal  ulcer,  77, 
82 
in  gastric  cancer,  807 

ulcer,  807 
in  nephrolithiasis,  350 
in  pulmonary  tuberculosis,  176 
of  abdomen,  81 
of  duodenum,  77,  82 
of  esophagus,  43 
of  heart,  220 


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1388 


INDEX  TO  VOLUMES  I  AND  II. 


X-ray   examination    of   kidney,   344, 
349 
of  liver,  124 
of  rectum,  90 

of  respiratory  tract,  170-191 
of  stomach,  69,  75 
of  ureter,  349 
opaque  enema  in,  86 
meal  in,  82 


Yeasts,  504 

Ynnurigaro's      esophageal      sounds, 
43 

Ziehrs  carbol-fuchsin,  517,  521,  525, 

531,  559 
Zona,  see  Herpes  zoster. 
Zuber's   sign    of   simulated  aphonia, 

692 


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